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More and more ICU teams have come to value the role that palliative care can play in the critical care setting and to understand that it is not only for when a patient is dying. Wes Ely, Every Deep-Drawn Breath

Patient Care Vignette

Ms. Jones is a 31-year-old female who collapsed at work after significant coughing. For weeks she experienced progressive breathlessness, finger ulcers, and joint pain. When the ambulance arrived, she was profoundly hypoxemic and was immediately intubated, connected to a portable ventilator, and transported to the local hospital. After initial evaluation in the Emergency Department, she was admitted to the ICU where she was treated with high-dose steroids and invasive ventilator support for a newly diagnosed severe lung disease. Her lung function was so poor that she was rapidly evaluated for extracorporeal membrane oxygenation (ECMO) rescue as a bridge to life-saving lung transplantation. However, as the sole provider for three young children (who were now being cared for by a neighbor) with recurrent housing and food instability and a limited support system, the medical and surgical teams viewed her as a poor candidate. Therefore, a long ICU course to try to improve her lung function was anticipated.

In the ICU, she felt trapped in her body and was unable to effectively communicate due to the endotracheal tube, medications for pain and anxiety, and the use of safety restraints so that she did not dislodge critical life support devices. Because ECMO rescue was not offered, the ICU team consulted Palliative Care Medicine (PCM), who helped address her needs in conjunction with the ICU team. Importantly, as she was recovering and could be more engaged, the PCM team also helped address emotional and spiritual aspects of her recovery. After being able to breathe on her own, she shared her concerns with the PCM team. If she became critically ill again in the future, she could not imagine going through another ICU stay again, but found it too anxiety provoking and stressful to discuss care planning while she was still in the hospital, even though she was outside of the ICU. After leaving the ICU, she suffered from intractable cough, severe dyspnea (shortness of breath), anxiety, posttraumatic stress disorder (PTSD), and persistent hypoxemia needing supplemental oxygen. She required rehabilitation for critical illness myopathy and polyneuropathy (weakness) acquired during her critical illness. She needed to file for disability as she could not meet the physical and cognitive demands of her job. Finally, regular outpatient follow-up for her new serious respiratory illness and complicated care transitions along her long road to recovery defined a new course for her daily life that impacted her children as well (Fig. 8-1).


Care Transitions in Serious or Critical Illness. Patients with serious illness often experience complicated transitions of care across the continuum. Patients and families are frequently unprepared for the complexities of these transitions.

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