Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine. Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com. And now your host, Dr. Sergio Zanotti.
Speaker: Critical care clinicians focus on saving lives and treating complex diseases, including multi-organ failure. We celebrate as a team when our patients leave the ICU. However, we now recognize that the road after the ICU for critical illness survivors is long and complicated.
Speaker: In recent years, attention has increased toward post-intensive care syndrome, or PICS. In today's episode, we will discuss how to communicate with patients and families about post-intensive care syndrome.
Speaker: Our guest is Dr. Carla Savin. Dr. Savin is an Associate Professor of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center, where she serves as Director of the Pulmonary Patient Care Center and Director of the ICU Recovery Center.
Speaker: Her research interests include long-term outcomes after critical illness, post-intensive care syndrome, and ICU survivorship. She has been instrumental in developing ICU recovery centers and post-ICU clinics to address PICs. a prolific author.
Speaker: She co-authored multiple papers, including a recent one entitled Communicating to Patients and Families about Post-Intensive Care Syndrome, published in CHEST. Carla, welcome back to Critical Matters.
Speaker: Thank you. Thank you for having me. The first question is why should listeners care about this topic of communicating to families and patients about PICS?
Speaker: It's such a good question. i think, um you know, from my perspective, probably most of your audience is involved in critical care. and survivorship really is the defining issue of critical care in the next 100 years. You know, we're pretty young specialty and we're just beginning to even figure out what the long term outcomes are after critical illness and how our care in the ICU can affect those outcomes. What we do in the ICU really matters and it's an extremely common problem. So probably almost 6 million patients are admitted to an ICU every year in the U.S. s alone and at least half of those will have some sort of post-ICU sequelae.
Speaker: Perfect. And as we start our our discussion and dive into the topic, with your permission, Carla, I would love to read verbatim two clinical cases that you've used to frame this discussion in the wonderful chess paper on this topic. Would that be okay?
Speaker: Yes, that would be great. I do want to mention, though, that all credit really goes to Mark Rolfson, who's first author on this paper and who was my fellow now faculty at Scripps, He I think we first started talking about this at his fellowship interview. So before he even came to Vanderbilt, he was so fired up and motivated about this topic and really brought this this paper to to its publication and them could not be prouder to be a part of it.
Speaker: Excellent. And we definitely will obviously link the the paper itself in the show notes. And I encourage all listeners to listen to the podcast and then go read the paper. So case number one, a 41 year old previously healthy woman is admitted to the ICU for ARDS.
Speaker: She's mechanically ventilated for 10 days during which she receives deep sedation and neuromuscular blockade and remains immobilized. During and after mechanical ventilation, she suffers from hypoactive delirium.
Speaker: She is ultimately discharged to an inpatient rehab facility where she spends two weeks before returning home. On returning home, she can dress and bathe her two young children but battles nightmares from her ICU stay and unrelenting intrusive memories that months later will be diagnosed as post-traumatic stress disorder, PTSD.
Speaker: Concentration is a challenge for her, and returning to her prior full-time job as a computer programmer is not possible. This places her household in financial peril. A primary care note reports normal abbreviated neurologic examination, and she subsequently denied disability claims.
Speaker: Her general practitioner attempts to have her focus on being grateful for her survival and reassures her that all will be well if she just gives it time. Case number two.
Speaker: An 81-year-old man is admitted from home and diagnosed with septic shock from a biliary source. He requires mechanical ventilation and moderate doses of vasopressors. After six days, he is extubated but remains delirious for four more days.
Speaker: He is discharged two weeks later to an acute rehabilitation facility. Although he previously enjoyed long walks with his dog, he is now unable to walk 10 feet without a walker.
Speaker: He cannot remember his grandchildren's names or do his daily crossword puzzle despite being sharp as tack before his critical illness. The family is surprised at how challenging his life has become after critical illness, and many of them feel overwhelmed with new caregiver responsibilities.
Speaker: When they ask his primary care physician for an explanation of his problems and survivorship, they are told he might be getting Alzheimer's disease. The patient's daughter, who did not leave the ICU for most of his admission, experiences symptoms of depression with her increased caregiver responsibilities, which impedes her own life and functioning.
Speaker: So on one hand, these are very common, Carla. On the other hand, it's like, whoa, right? i mean, let's pause for a second. And I think it's it's a great it's a great a introduction, and maybe we can use these to frame our discussion. But as we dive in, maybe we could start with a PICS overview.
Speaker: What is the post-intensive care syndrome? Sure. um First of all i love these cases because they are so typical. And i love also that one of them illustrates that even a very young, previously healthy person can have serious sequelae from critical illness. and older people who were previously well-functioning may struggle even more, but it's certainly not limited to our older population. ah The post-intensive care syndrome was really, know,
Speaker: you know it was developed 2012 to come up with a name to sort of this nebulous constellation of symptoms that we were seeing patients after they were critically ill. And there was no syndrome or diagnosis that could be given ah to help people find resources. So as one of our patients said many years ago, there was I didn't even know what to Google when I left the hospital and I was having all these problems. So for partially for research purposes and partially to help people find resources for clinical care, this this term was
Speaker: generated and it's defined as new or worsening impairments in you know one or more of three domains, physical, ah mental health, and um and ah cognitive after the ICU. So um some patients may have all of all of these types of problems. Some may only have problems in one domain.
Speaker: But most of the patients that we see in our clinic have something that we can help them with. Okay. So even if they don't have an impairment in you know, a specific impairment in one of these domains, most of them do, there's something that we can help them with.
Speaker: Often it's because our system our health system is just not built to take care of patients after the ICU. So they have all these problems. Often a patient will come out of the ICU with 10, 11, 12 brand new problems. You can imagine them marching into their primary care doctor's office with 10 new problems and 20 minutes to solve them. Assuming we even tell the primary care doctor what the 12 problems are, which we usually do not because of logistic challenges.
Speaker: and um And our healthcare care system, you know, like post-intensive care syndrome is not an ICD-10. It was not really designed to be a diagnostic code. There is now a code for sepsis aftercare, thanks to efforts of other folks in in the post-ICU community.
Speaker: But um it's really hard for for people to transition from this really high-intensity you know, intensive care, it's called intensive care. We're given intensive care. And then they transition back to home where could not be less intensive. um And they really struggle ah to get their meds and return to work and find you know mental health counseling and there's family conflict. And so there are all these things that are not even necessarily one of those domains.
Speaker: Unsurprisingly, the family members are also affected by this. And in many cases, the families were with them in the ICU. And so that's where the terms pick the term PICS-F comes from or PICS family in an attempt to also address the the problems that that family members are experiencing after a critical illness.
Speaker: Excellent. And I think in relation to the PICS-FM, I've also had the chance to talk on the podcast with and family members of cardiac arrest survivors and the the the concept of the forgotten patient, how they are i actually have serious needs during and after a critical illness of a loved one and recognizing that and being able to counsel them appropriately, I believe is also part of this whole conversation.
Speaker: Absolutely. And I think we have a long way to go there also. I mean, i can't tell you how many times a patient came into post ICU clinic and they're like, I'm fine because they have no recollection of the ICU stay. And the family member is there like literally quivering with fear and anxiety and has a suitcase packed, you know, next to the door ready to go back to the ER at the drop of a hat and you know, when, when that dyad comes in, you know, that patient and the family member comes to see me in clinic, I don't have a chart on them. I can't order them consults or, or medications. And yet they are my patient too, in a way. And, um, you know,
Speaker: at Vanderbilt, at least we're lucky to have, um, pretty extensive collection of peer support groups, um, including ones that are dedicated to family members. So we can at least, um, provide some peer support. And of course we give advice, informally um, and, and try to hook people up with resources, but it really is, uh, another patient in the room with you that, you know, whose needs and, and, um,
Speaker: and situation need to be taken into consideration, not least because the the successful recovery of the patient hinges so absolutely on the family members. you know If you are completely alone after a critical illness, it is very difficult to have a complete recovery. The family members are absolutely crucial to that.
Speaker: How frequent is PICS? Could you talk a little bit about the epidemiology?
Speaker: Of the data that we have, um you know, which is... in my opinion, incomplete. We could certainly have, it's of of the areas that I practice in critical care medicine, I feel like this is this is the one that really has the the least data. But of the data that we have, it ah suggests that patients surviving a critical illness have at least one domain impaired and it probably 50 60% of the patients.
Speaker: of the patients who actually come to clinic, which admittedly is something of a self-selected population, the the incidence is much higher. You can argue that they wouldn't come to clinic if they didn't think they needed something. But patients also don't know what they don't know, and family members don't know what they don't know. And this is where communicating with patients and families about PICS before they even leave the hospital is so important.
Speaker: They will not be able to fathom what kind of problems they may have until they actually get home and start to – try to return to their usual routines. And then they'll be like, why is this so hard? So if we give them some information about it on the front end, you know, they can be like, oh, okay, I i do have some big recollection that I heard about this and that there are resources um available. But if we don't do that,
Speaker: Most of these patients are thinking like this is that they're alone in the universe and they're the only ones who are experiencing these problems, especially things like post-traumatic stress, anxiety, depression, memory cognitive impairment. These things are really fly under the radar and often do not even strike the patient as something that they would talk to their doctor about.
Speaker: What are the risk factors for developing PICs?
Speaker: Yeah, that's a ah ah great question. Certainly anybody can develop PICs, but a critical illness is not going to improve any problems that you had before the ICU. So um frailty, ah pre-existing um post-traumatic stress, pre-existing depression, anxiety, cognitive impairment, basically anything that fits one of those domains that you had an issue with beforehand will be puts you at higher risk for a post-intensive care syndrome afterwards. But again, a completely healthy person, completely healthy young person can come into the ICU and have even ah a relatively, what we would consider a relatively brief critical illness of three days or something like that and have really significant impairments, enduring impairments after that.
Speaker: And obviously a lot of the the risk factors you mentioned are pre-ICU status and not modified by the ICU team. But what about in-hospital factors? And I presume some of these are modifiable and some are not, but could you mention some of those?
Speaker: Yes. and And there's sort of this little bit of a gray area that I think ah we as ICU clinicians are a little bit blind to, which is the pre, sort of like the pre-hospital, pre-ICU illness. So they're already sick, but they're, you know,
Speaker: they have arrest at home or they have to call an ambulance or they have to get an emergent chest tube in the ER. All of that happened before they came it up to the ICU, but certainly early a awake memories, frightening memories of ICU experiences can increase the risk of PTSD. We know that. um the Probably the the thing that I worry about the most is the is delirium. So duration of delirium,
Speaker: is the biggest predictor of post-ICU cognitive impairment. Again, probably the problem that's the least well-addressed, but most affecting patients and families after the ICU. And that is something that we ah we certainly can't control 100%, but we can do a lot of things to make it less bad. So the A to F bundle, the ABCDF bundle, which helps us minimize sedation and improve mobility and keep patients awake as much as possible and off the ventilator as soon as possible. All of those things all of those things may help us decrease the risk of delirium and decrease the risk of post-ICU cognitive impairment. I had an interesting experience a few years ago when we were giving a
Speaker: a talk at a conference and somebody stood up in the audience and said, well, if we just adhere to the ADF bundle, then we wouldn't have any post ICU syndrome because we wouldn't have any delirium. That I wish that were true. That is, you know, certainly delirium is a marker of a lot of the diagnoses that bring you to the ICU in the first place. So, you know, se sepsis and and so forth. um So I don't think we're gonna get it down to zero, there are certainly things that we can be doing aggressively in the ICU. And you know I think like many doctors, I probably suffer from high self-esteem and I feel like I'm gonna make the best decision for my patients you know on an individual basis. But this is an area where where protocolized care, I mean, ICU care is team care. So having protocols in place, To, you know, make it easy to do the right thing, to minimize sedation, to um have an awakening and breathing trial every single day, just like automatically before rounds even start.
Speaker: These are the things that can really make a huge difference in your ICU care and in your post-ICU outcomes. Absolutely. and And I do believe that in the power of marginal gains, right, every little thing we do can add up to a huge compound impact. And especially when we talk about the A to F bundle, no matter how well people think they're doing it, there's opportunity to make it better and to keep pushing forward. but also it probably can have an impact that is dose responsive down the road when we don't see these patients anymore. So really having that focus in the day-to-day, I believe is super important.
Speaker: Yes, it's so true. Atul Gawande wrote a great article, and I think it was in the New Yorker years ago, called The the Heroism of Incremental Care. I think that was the title. And um i think the one of the examples was a migraine clinic. And they just like tiny tweaks and tiny tweaks and tiny tweaks. and this intractable problem. And then eventually one day the patient's like, oh, I'm better. You know, like it's not, it's not um open heart surgery. You know, it's not level one trauma center, but it's this, this persistent attention to detail in the pursuit of reducing suffering. And that is what we have to do both in and after the ICU. Yeah. Yeah, and that ultimately ah along the Atulga one, the kind of concept is the difference between a truly world-class ICU and their A to F bundle versus a good A to F bundle implementation, right? And it's like those little details, those little things, I mean, they don't take no for an answer. They're always pushing the envelope, pushing the envelope and trying to to maximize the impact. So that's super important. Yeah.
Speaker: Carla, we'd like to move on to better communication in the ICU about PICS. And a maybe we could start with discussion on communication and empathy in the ICU.
Speaker: Could you just define for our listeners sympathy versus empathy and maybe throw in the difference with compassion there? Sure. um so and i And I love words and etymology, so this is a perfect question for me. Sympathy, you know, is is when you feel for somebody. You see somebody in the in the ICU and you feel bad for them because they are having a real rough day and they're sick and their family members are tearful.
Speaker: You feel sorry for them. Empathy is to really feel with somebody, you are also feeling the suffering that they are feeling, which I think is, you know, can be a little a little bit of empathy is important. um You can have too much empathy, but you can have too little empathy as ah as a critical care doctor, I think. um And compassion is um where you're, you know, you you feel,
Speaker: with the person, for the person, but you are so are also taking action to improve their plight. So probably of the three, I think that's the best description for what we're doing as ICU um clinicians. and And actually the what ah the other thing I love about compassion is that the the passion part is from the Latin root pati, to suffer um or endure.
Speaker: And that's also the same root word for patient. So in some cases, you know, if you consider compassion, calm, being with patients. So compassion is being with the patient, walking with the patient, seeing what they need and taking action to improve their situation.
Speaker: Before we talk about the components of empathy and ICU communication, i want to ask you about compassion fatigue or empathy fatigue. Do you think that sometimes it can be too much for a clinician or how would you recommend handling that?
Speaker: Because it seems that it's the right thing for our patients.
Speaker: Yes. I mean, this is something I talked to my trainees about a fair amount. and You can... You can certainly have too much empathy um if it burns you out and makes it impossible for you to do your job. I mean, you so you've got to protect yourself enough to live to fight another day. um But too little empathy is also a problem. I think the dose makes the poison. Most people who are working in the ICU are not doing, you know, 52 consecutive weeks of critical care a year. The dose makes the poison. so Um, you know, here at my institution, we generally do a week at a time on service and that lets me just pour my whole heart into it and, um, you know, feel,
Speaker: with the patients and with the family members. And yeah, it's, it's, it's hard and it's straining. But it's also um a calling and gives, gives us purpose and, and I think guides us to do do the right thing for the patient, even when we have system limitations and and things like that.
Speaker: yeah and So it is, it it is a balance yeah that I think will change for people over, over the course of their career too. You know, when you start, In the ICU, everything is like so so shocking and overwhelming and terrible. And you're like, oh, my gosh, how am I going to keep doing this in some cases? And, you know, you you you learn over time to sort of titrate how much how much empathy you can you can survive.
Speaker: I agree. and And I do believe that and along the same discussion of compassion for our colleagues, self-compassion is extremely important, right? And giving us a little bit more love to ourselves when things don't go as well. And and the other aspect of what you were saying in terms of balance, I'm a believer in presence, right? More than balance. So when you are in the ICU, you're fully in the ICU. And when you're out of the ICU, you're fully in your other activities, with your family with other things to recharge so that you can be what but your patients need when you come back. And and I agree, it's it's a great way to to think about it.
Speaker: What are the components of empathy and ICU communication? you You have a very nice figure in in the paper, but I do believe it's nice to kind of break up these these important these skills into steps and things that you should be considering. Can you talk about that?
Speaker: Yes, the the arc of recovery is really long for these patients. So it's you're not going to be ah able to provide all things at all stages and and the patient and the family are not going to be receptive to all things at all stages. So, you know, when somebody first comes in and they're critically ill and multiple organ failure and they're on the ventilator, and you're just trying to you know, get them to survive through the day, that is not the time to be um talking about long-term outcomes necessarily. Although often families will ask things like, you know, if if is is is he going to be okay? Is he going to be himself again? what What will survival look like? So certainly we want to have those conversations if they're invited by the family, but it's so overwhelming um for them and if, and also for the patient, if the patient is awake. So, you know, generally we, my preference is to give as much information as I can, that's going to help them and get through the day um or or the hour as it were. um And, you know, address each new sort of set of problem of problems as they, as they come up. And that,
Speaker: then includes, you know, when somebody is getting ready to potentially improve enough to leave the ICU and we think they're going to survive, that's the time to start talking about, um you know, what the long-term outcomes may be and what we would like or recommend for them to do after they um leave the ICU, because most people will have a lot of transitions of care before they even get home. So we're not We're often not the team that's doing the discharge discussions, the discharge planning. And even if we are talking about things like LTAC or inpatient rehab, um those plans can often ah change after the the patient leaves our care. So they're sort of giving folks ah a general overview and just kind of a warning shot that we're so delighted that your person is getting better. And, you know, if they have XYZ problems when they get home, that would be super common. And we know all about it and we have resources to help. And, you know, please call, come back, ah come to post ICU clinic
Speaker: It's a very overwhelming time for patients and families. Most of our patients, well, I don't know most, but a lot of patients, even when they leave the ICU, are still delirious. So they are not receiving information and they're certainly not retaining information. So having some written information about post post-intensive care syndrome, some written um resources, we have a little a little brochure that we made, well, it looks nicer now because some of our colleagues in the Sib Center have have buffed it up, but the first iteration of it was really, was just me Googling how to make a brochure and, you know, putting a little info brochure together, that they have some language to, back to what that patient said many years ago, that they have something to Google to actually help them find some resources and then have some way to get back to, know,
Speaker: to us to, if you have a post-ICU clinic, back to the post-ICU clinic, because they may have many transitions of care between ICU and when they get home. And it might be even longer before they realize they have problems. I know we the the the discharge paperwork is another um area where we probably put too little information about post-intensive care syndrome and too much information about other things that aren't as important to Patients, we had ah we did a qualitative study um some years ago where patients said there was a lot of information about wound care, but like nothing else. And when they had you know these higher level problems, they didn't know where to turn. And when we started our clinic, which was back in 2012, one of the first patients we asked to come back,
Speaker: did not wanna come back. She was upset about her hospitalization and perhaps her her situation. But we had put her post ICU clinic appointment on her discharge paperwork with phone number for the clinic And she didn't come to clinic, but seven years later, she called the clinic ah number and made an appointment because she was still having um problems, which were probably some post-traumatic stress related issues. So the discharge paperwork is powerful. Written information is powerful. And of course now everything's electronic, but I enjoy putting a ah ah solid piece of paper in front of somebody with the information that they need. Yeah. And like you said, I think giving people information and being very intentional about how we design these brochures, it doesn't have to be a lot, but if it's the right information, it can be really a transformative. Just knowing that some of the things that your family member is going through or that you're going through are not unique to you and that a lot of other people are going through and that there might be places where you could go for for more support are are super, I believe, ah powerful and and useful.
Speaker: One of the things you you talk about in in the paper is like the different phases of care. And you alluded to some of that, Carla, like the acute critical illness, then you have early recover, ICU discharge, and then the post-hospital support, which what we can talk about each one of these. But in terms of the the focus, how do you tie everything together, not only the communication, but also what we're doing for for each patient at that stage? So I guess for the acute critical illness,
Speaker: The best we can do, as you mentioned, to prevent this is implement ADF bundles, work on the ISO liberation protocols, a just giving them the information they need to make the day, right? At that point, we're just trying to move the patient forward, get them get them get them better. But as they start to recover, what are other things that that you you start incorporating in terms of your discussions with the family and maybe during rounds As you start seeing that, okay, now I'm going to start weeding them from the ventilator and what what comes down the road.
Speaker: Yeah, I think this is where it's really... wonderful to have family on rounds because we're accomplishing a lot of things at once. We're we're advancing the patient's care forward, hopefully, perhaps weaning the ventilator, you know doing a breathing trial, turning off sedation. We're educating the the patient and the family about what we're doing and giving them a heads up for the next steps. And we're providing we're educating on you know we're educating our our teams and our our trainees all at the same time. So having that family presence on rounds is great. um I think in the paper, it it it does make it sound like we are super awesome at counseling about post-intensive care syndrome and every single patient hears that phrase before they leave the hospital. But even we, with our hyper-awareness of the situation, are not... ah
Speaker: ah We are not reaching every patient with this this counseling. And it was when Mark was doing this companion study where he's interviewing patients and providers about their awareness of PICS.
Speaker: which was published in the, I think it was February, 2026 chest. um I, I think it was that study where one of my, he, he recruited one of my patients who I have seen post ICU clinics several times. And they said they had never heard of the phrase picks. So, um you know, we can, we, everybody can do better by ah using, incorporating this terminology so that patients are not caught. um off guard when they start to have these problems. But, you know, as clinicians, we're often like deep in the weeds trying to make sure that every detail of this person's care is being taken care of and um You know, the long term outcome counseling can can fall by the wayside. So just like you would do your physical exam the same, you know, you kind of have the same physical exam procedure every time you examine a patient. So should should you try to work in this concept of post ICU or transfer treatment? counseling when when patients are getting ready to transfer to the floor. And even if you did remember it every single time, the patient is not going remember it every single time. the um,
Speaker: the family member may not, you know, be there. They're being overwhelmed by information again, where written information is really helpful. And in that study I mentioned where, where Mark Rolfson interviewed all these, he also interviewed providers to see how,
Speaker: how many of them even had awareness of PICS and how often they were counseling patients. I thought the numbers were kind of high. There was a study a few years ago in Australian critical care, um first author, R-A-I in 2020, where very few of the clinicians who are actually doing the discharge planning, meaning the floor clinicians, actually had first of all, any awareness of post-intensive care care syndrome. And obviously, if you're not aware of it, you're not going to be able to counsel about it. So back to sort of the protocolized care, if if you can work it into into the workflow somehow in a protocolized way, ah you know, a checkbox that you don't forget to talk about it or everybody gets a brochure or whatever the case is right for your unit, um
Speaker: Building a system where you're not depending on an individual person's brain to remember everything about ah the patient's care is probably the key to success. For sure. And one of the aspects of of empathy and of communication that I believe is undervalued is curiosity and asking questions and questions that are ah based on deep curiosity, right?
Speaker: But... I think that we we we talk about goals of care. We talk about what what the patient would want at some situations. But even in survivors, understanding their values, understanding what they do for for a life, who's at home, right? Who cares for them or who do they care for are probably questions that we should be asking more often. Any any comments on that?
Speaker: Yes, I... i I think a lot of times we're afraid of the answer. And so we don't ask these questions or it's just, you know, again, not, not the most pressing thing that's going to happen in the next, you know, two hours or six hours. And so it falls by the wayside, but with some very um few questions, you can really ah find out a lot of illuminating stuff. That's going to open your, your your care plan for this patient. And, um and also it's pretty interesting. I think a lot of,
Speaker: Clinicians go into intensive care because they don't really enjoy having clinic and sitting in clinic and and and listening to um a long list of of problems. But um I have found it absolutely fascinating to talk to patients after the ICU. So especially if it's somebody that you took care of in the ICU and then you get to see them in clinic, it's really changed experience.
Speaker: my way of practicing critical care. And, um and I think part of that is when, when somebody is critically ill, it's you're, you're leaning so hard on their family members depiction of their home life and what they think their wishes are. And it's, you know, kind of like a game of telephone. You really can't always get what the patient wants or what's important to the patient.
Speaker: And nowhere is this more important than when we're, we're, you know, counseling about, end of life care, which is, you know, obviously something we also do a lot of. So if you do not survive the ICU, then you are not going to be coming to post ICU clinic, but it's not always clear on the front end, which patients are going to survive and, and which are not. And if you don't see patients post ICU, I think you also have a much more limited understanding of what is survivable. And to your point about patients wishes, what, what is a desirable survival? So, um you know, that, that is something that,
Speaker: you know especially if you're ah young ICU doctor, it's kind of hard to imagine you're you know you're you're you're at peak performance. So it's really hard to imagine living um and with any kind of impairments and and that being a satisfying life. But that's just not our decision to make. And and many patients may be, and family members may be actually quite content to have a survival with some amount of impairments. um and that So that's not something that we can depict on the front end.
Speaker: I think that the reason I'm bringing this up is because, um you know, we also do a a lot of prognosticating in the ICU. And um I have been surprised by some of the patients that I've seen back in post-ICU clinic, what is survivable and with what kind of impairments people can be happy and satisfied with with their post-ICU life. So certainly there there are a lot of downsides to having post-ICU syndrome. I'm not suggesting that you know people are glad to have impairments and we should be doing everything that we can to avoid those. But having impairments is not necessarily a barrier to having a happy and satisfying ah life and seeing patients um after the ICU. I can think of a couple of examples where
Speaker: I counseled the family to discontinue life support because I did not think that the patient could survive. And I was wrong. And the patient came back to clinic and I was shocked and humbled. It's a humbling, it's a humbling um experience and also so, so valuable. um in In one case, the patient really had a great recovery. And even though she was um older, um she went back to work and it was just great. The other patient was quite young, had persistent cognitive deficits, had um was, was not living independently, was living with his family, but actually it had a ah complete change in his personality. His family was delighted and, you know, they were all living together happily. so you know, that's not really for us to decide, but I think it's,
Speaker: In retrospect now, I think it would be really difficult to to have these conversations, having these prognostic conversations with families and not have that data where I could see what is possible. It goes both ways. We have patients who have much worse recovery than anticipated and we have patients who have better recovery than anticipated. But the point is that we we don't know for sure what the recovery is going to be and we have to be honest in that in that reality when we're counseling families. I agree. ah And I do believe that a lot of intensivist colleagues, including myself, probably at at some stages just stages of my career, in
Speaker: think they have answers when we we should really have is more doubt and more questions. and and And especially when we're trying to pronosticate and talk about what lies ahead, it's very hard to know what each individual person would want. And that can change over time as well.
Speaker: there's There's a book I read many years ago, Carla, maybe you read it called The Diving Bell and the Butterfly. And it's about a, it's a true story about ah ah a young editor, French editor who gets a huge stroke in his 40s and is locked in.
Speaker: And, and everybody was trying to convince the family nothing else to do. And then he wrote the book. Yeah. So it's amazing. So just more more, more, more, more questions. I agree. In terms of, uh, of the, the recovery or the post-hospital phase, um, your group at Vanderbilt and, uh, and under your leadership and, and your whole team has done a lot in terms of developing the, um,
Speaker: The recovery center, the post ICU clinic. and Tell me a little bit more. Does every patient who leaves the ICU get referred to the post ICU clinic or do you have criteria?
Speaker: We have criteria and um the the criteria are the clinical criteria are really the same that ah that we started out with in 2012, which is you know any mechanical ventilation, um any shock, and any delirium. So you don't have to have all of those. You can have any of those. And we have also seen patients who did not strictly meet those criteria. we had We've seen patients who...
Speaker: weren't even technically in the ICU, but, you know, we're septic on the floor, but we're referred by somebody. um ah During COVID, we really, ah you know, again, these are these are sort of like guideline criteria for seeing back the patients that we think are most likely to have problems. So during COVID, you know, i had a patient who was on BiPAP for six weeks. I mean, that's not, she wasn't intubated, but it wasn't a good time. um So she, you know, we were delighted to see her back. um
Speaker: we We do have some exclusions, but they're also a little soft. So if somebody has some other multidisciplinary care, like, you know, a team that's really ah managing every aspect of their care and has access to multidisciplinary resources like transplant or our HIV care center, for example, here. um or if they have you know active cancer and they're being managed by their oncology team, we we generally exclude those patients. But of course, if they want to be seen and there's something that we can offer that they can't get elsewhere, we're we're happy to see them. But you know I um lead a post-ICU clinic collaborative through CHIRO, the critical and acute illness recovery organization. So we have calls every month with folks who are doing post ICU clinic all over the world. And we often talk about recruitment and selection criteria because it, you know, the, the selection criteria may vary. Some folks look at ICU length of stay or you know, severity score, this or that. um But really the biggest barrier to getting folks back is just the logistics of first of all, trying to,
Speaker: educate about a problem and then provide a potential solution for the problem when they may not understand that there's a problem. And then just trying to get folks scheduled and back to clinic um during a high need period after they go through, you know, two, three, four other transitions of care. And this is a high risk population. So the chances of them being readmitted before they come back to clinic are high. And then, you know, that ah appointment falls off. So,
Speaker: These are all things that are seemingly solvable with either systems or manpower. um So far, we have not solved them with systems in a satisfactory way. So it does require some some human capital. But again, I think there are also benefits to to seeing these patients back that improve our ICU care and improve us as clinicians. It may even decrease burnout in in clinicians who are, you know, they have a hard job and they see a lot of cases that don't survive, and that's rough. So to see a patient back who's actually improving and came came back from the brink, that can be very renewing and rejuvenating for
Speaker: for people who work in the ICU. And if that decreases your, your turnover, that would be great. Excellent. So a lot of our listeners might be asking themselves, well, I don't have a post ICU clinic.
Speaker: What should I do to move the needle at this point? Yeah. Well, i think ah what this paper really shows is that there's certainly things that you can do in um in the ICU and in the hospital for, before patients leave the hospital that may,
Speaker: um You know, information is power. So that, you know, if you're if you're giving information to patients and families, that can certainly um help them either find the care that they need or at least recognize, okay, these problem they told me this was going to happen and, you know, it may improve with time. And if it doesn't, I need to get it checked out and it's related to my ICU care or my ICU, my critical illness. um So there are some...
Speaker: some like I said, if you if you have a brochure some sort of information that you can give to the to the patient and the family, that can be very helpful. Communicating to their primary care physician, hopefully they have a primary care provider, communicating to that person like, hey, this person had XYZ, their risk of, you know,
Speaker: Cognitive impairment is high, sort of depending on the patient. We do a lot of, for example, return to work counseling. So if somebody is a CEO or brain surgeon or some something that requires a lot of um cognitive reserve to do their job safely, then you can, you know, at least give the the PCP resources for, you know, cognitive testing and and things like that. um
Speaker: So I think all that information is is power. In severe cases, we've had patients come visit us from other states, ah patients are desperate for this kind of care. And so we do have on the, on the Cairo website, it's chirorecovery.com. There's a post ICU clinic directory. It is not complete because we need to update it. And we're always adding new, new members, but um I always encourage like, you know, if somebody last week I had a,
Speaker: I had a message from somebody in Texas who wanted to come to our post ICU clinic. I'm like, absolutely, you can come, but here's some post ICU clinics in Texas in case you don't wanna travel that far.
Speaker: um So that's a nice network, nice network and nice resource to to send to have folks find the care that they need closer to to their home. um I will also say we have some, there's some peer support options all our peer support groups here are virtual and sometimes we do accept patients from other places i think mayo clinic connect has some asynchronous advice sort of like a message board resource for post-icu care so there's there are other ways to to access it and and sometimes there are very specific cases i think in one of the cases in the paper you know like you mentioned
Speaker: This young woman, she couldn't go back to work as a computer programmer, but her like a brief neuro exam was fine. Like if she knew what day it was. But that doesn't mean you can go back to work in in a high, you know, cognitive reserve type job. And in in that sort of case, a neuropsychological testing can be really helpful. to both to sort of like demonstrate what the det deficits are. So if you do have to do something like, you know, look into disability that can help your case, but also maybe something that can be managed or, you know, therapize with cognitive rehab and rehabilitated um so that somebody can go back to work perhaps with supports or in a related field or what have you. So there's some very specific um cases
Speaker: that maybe require ah a pretty tertiary opinion. But in most cases, i think some information and just asking the patient what their goals are like, do you want to go back to work or you know what what are you trying to do? What are you trying to accomplish? And then tailoring their intervention to that to those goals.
Speaker: Perfect. As we close, Carla, could you give us two clinical pearls and two pitfalls to avoid? when communicating with patients and families on a PICS?
Speaker: Well, I think the the the top one is what we've we've talked about here is just, you know, talk about it, teach about it, um let everyone know about it, the patient, the family, the other um clinicians in your circle, the primary care physician, and, um you know, put it on the discharge summary, write it down, and provide written resources so that folks don't have to remember stuff and that if they come to some stepping stone in their recovery arc in
Speaker: two weeks or two months or two years, they can reach back um and and and make contact with the resources that they need.
Speaker: and And I guess that would be one of the top pitfalls to avoid too, like make sure patients have some way to reach back to the ICU because most of the times, most of the time, you know, it's it can be actually very difficult for the patient to see even who their care team was in the ICU. And so when they have sort of ICU specific problems that they have questions about, they don't have somebody that they can reach out to.
Speaker: And i I do think we sell ourselves a little bit short as a subspecialty. Like we were subspecialty critical care, and there are things that are going to be obvious to us that are not obvious to non-critical care doctors. And so we really owe it to the patient for them to get that that specialty opinion when they need it.
Speaker: perfect um I think that the other pitfall is just um being aware that, as I mentioned, there's this recovery arc and the patient may not be ready to engage all aspects of recovery at the same time. So, for example, the early post um discharge period is very heavy with, you know, wound care and getting my, you know, PICC line out and, you know, sort of like medical needs and physical rehab. And, you know, for even for folks who might have had an ICU diary, which is something we we didn't talk about, but that everybody can provide in in in the ICU for very little cost. The patient may not be ready to engage that until, you
Speaker: you know, six months later. um So we frequently, like right now we're doing a telemedicine study called Teleport and the first visits at three weeks.
Speaker: And there's a one week assessment of their cognitive function and things like that. And then three week visit and a three month visit. And many times the three week visit is like, this is fine. This is fine. And then the three month visit, it's like, oh yeah, I did crash my wife's car and I, and I can't remember where my keys are. And you know, like the the truth comes out. um So there's really being available to, to patients to meet them where they are at the time that they are able to receive that help is, is important. And so having that frequent touch. Yeah.
Speaker: can be useful. But it can be also very disruptive to to patients to revisit their ICU memories, especially in the early post-ICU period. And for example, in that study, we had a a patient drop out recently after her one-week assessment because, you know, so she was asked some questions about her experiences. And it was just so overwhelming. She's like, I can't even be in this study. I can't talk to you anymore. Um, which is sad. I hope she comes back. We, well, we left our number. Um, but just tell the patient, you know, you may not be ready to, to talk about things in, in this timeframe, but we are available. And I also try to give people
Speaker: a timeline expectation for recovery. I'm saying, you know, so glad you're getting better. um You know, sometimes people ask me, you know, can they go back to work or things like that? And I'll say something along the lines of, you know, this is going to be a long recovery.
Speaker: Don't be frustrated if things aren't going as fast as you want them to go. it may be a year, you know, before you and start to feel like yourself again. So giving that 12 month time point, really, i think sort of Lowers expectations, low expectations being the key to happiness and, and, and take some pressure off the patient to go back to work in three weeks or whatever they need to do. Yep. Whatever they think they're going to be able to do.
Speaker: Perfect. As we close, Carla, you've been on the podcast before. We like to ask a couple of questions unrelated to the clinical topic. Would that be okay? Yes. So the the first question relates to book. Is there a book that you have read recently that has had a big impact on you?
Speaker: Well, I have two because the first one's kind of a small impact. that ah Like a recent book that I read was – The Correspondent um by Virginia Evans, pretty recent book. It's all written in letters.
Speaker: ah The whole book's in letters, which was um didn't sound like I would enjoy it, but I really did. And it also sort of brought me back to my joy of writing and sort of, ruin I was like, I'm going to write some letters and I'm going to use my fancy pens and everything's digital now. And I really hate that. And I feel like we've lost something when we don't write by hand. So when you write a letter or a card or something or a novel, I guess, haven't written one yet, but if I did, it probably would be longhand because there's some connection between the brain and and the hands that just it gives a different sense
Speaker: a different level of thought. Uh, so i it was very, it was just like very peaceful and relaxing to read that book. And then, um, I got some more fancy pens, which I probably didn't need, but I'm enjoying them a lot.
Speaker: And, um, the book that really is kind of haunting me I don't i don't know if i can recommend it to the readers because I'm still thinking about it it's been a few years since I read it um is The Wall Die Wand and it was originally written in German um Marlene Haushofer I think I read it I i don't know where i picked it up I think I read it in some other interview where somebody said it affected them and um it was it was written in the 60s and it's it's
Speaker: I guess it's kind of science fiction. It's about a woman who is just a hunting lodge, visiting friends in Austria um, they go off to dinner in town or something, she wakes up the next morning and there's just like ah an invisible wall around this forest, when this launch is, and she just has to survive there by herself. And, you know, there's no explanation for why there's an invisible wall there. And it seems like the end of the world has occurred, but you don't know that. And, um, I guess it's just about survival and solitude um,
Speaker: I do think about it in the context of ICU recovery because it can be very lonely to be an ICU survivor. I think that's part of why we have so much empathy and compassion for this population.
Speaker: But obviously the book is not about that. It's about survival and sort of the meaning that she finds in just everyday tasks and I don't know if you if you want to suffer a little bit, but also think hard. It's a good book. the all I have not read that one, but it sounds intriguing.
Speaker: And the the second question is, could you tell us something you have changed your mind about in the last few years?
Speaker: Yeah, I think it's really been been the end of life counseling, those patients that that came back and it really made me think, um you know, I think there are a lot of times in, in our job where we're like, this is hopeless. Like this, everybody's suffering, the patient's suffering, the family's suffering. Like there's no hope for recovery. and um I've really, i really think I really slowed that down in the last few
Speaker: 15 years or so, 20 years, maybe. um and really just allowed myself to live with that discomfort that we don't, you know, we don't know everything and we can only counsel what we know about. and um, and, um, just, we have to let ourselves be open to continue to learn and improve and be able to,
Speaker: yeah, live with that dis discomfort in order to provide the best care. And, you know, even if somebody is going to die to make sure that their family knows that we've, you know, we did absolutely everything that we could.
Speaker: And to close, could you give us and just a thought of what would you want every listener to know?
Speaker: Well, specifically around the the idea of post-ICU recovery and trying to see patients post-ICU and ah learn more about them. i i talked to a lot of centers who are trying to start clinics and, you know, like we talked about new service lines and stuff and they... do a lot of preparation, which is great. That's how we are. We're type A people. we want to like make sure all our ducks are in a row and before we start anything. um but I would say just do it. Just like, you know, see some patients. If you have some other kind of outpatient part of your job, just bring some of these patients back. You don't have to have a huge team. um
Speaker: Just sit with them ask them questions. We have, our post ICU clinics on Friday afternoon. So there's a little bit less time pressure to like see a ton of patients in a short amount of time. And i really love that. Just, you know, sitting with patients, hearing their stories, asking the right questions. And then when you ask the right question and uncover something, you're like,
Speaker: wow, I can really help with this. It's great. um And by doing that, you will learn more about your patients and your health system and where the gaps are and what is you know fixable and what is not fixable. And um that's a really satisfying aspect of my practice. Can highly recommend.
Speaker: Carla, just want to thank you again for your time, your willingness to share your expertise with with us through the podcast. And also thank you and the whole Vanderbilt team for the leadership and such an important topic. I always think about...
Speaker: ICU liberation, PICS, and recognize that when I was a fellow, it wasn't even on anybody's radar. Nobody talked about this, right? So of all the things that are so relevant to our day-to-day practices, it was really, I mean, in the last couple of decades, it's it's emerged as a new thing. And I think there's so much to to be done, but so much good that can be it can come out of it for our patients. So thank you. Thank you very much.
Speaker: it's It's absolutely our pleasure and ah and our joy. And i'll just I'll just mention that the motto of Vanderbilt Medical School is, Ars Longa Vida Brevis, which is, the art is long, life is short. So...
Speaker: We each only have, you know, some finite decades to dedicate to the fields, but there's a lot to do. So just doing what you can in the place where you are um and keep doing it for as long as you can. i think you and I can both look back at our our careers thus far and just see how much change has occurred in this field. It's so steep um and we have a lot more to do. So good for us.
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Speaker: To learn more, visit www.soundphysicians.com.
