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Patient Care Vignette

A 53-year-old male with past medical history of hypertension, diabetes mellitus, and anxiety was admitted to the medical intensive care unit (MICU) with acute hypoxemic (low oxygen saturation) respiratory failure due to Legionella pneumonia that resulted in the acute respiratory distress syndrome (ARDS; see the chapter on the Respiratory Therapist). On hospital day 2, the patient’s oxygenation worsened despite corticosteroids and high-flow nasal cannula O2, and he required a breathing tube (i.e., intubation) and was supported with invasive mechanical ventilation. On hospital day 3, the patient was sedated, received a neuromuscular blocking medication, and underwent prone position therapy while on the ventilator.

The patient’s wife was able to join and participate in multiprofessional rounds in the MICU. By the end of rounds, she had developed a reasonable understanding of her husband’s diagnosis and prognosis. When asked how she was doing, she acknowledged being scared and having a difficult time sleeping. She asked whether the patient’s preexisting anxiety would worsen and what could be done to mitigate psychological distress after critical illness.

The clinical team introduced her to the ICU’s diary program, known as a Healing Journal. The patient’s wife agreed to participate, and the MICU pharmacist wrote an initial entry. After 12 days in the MICU, the patient was transferred to the acute care unit to continue his recovery. The clinical team placed 18 entries during his time in the MICU, and the patient’s family and friends provided many more separate entries. The patient and his wife visited the MICU 2 months later to express their gratitude for the care and support they received. They were also grateful for the Healing Journal which he read several times since he did not remember most of his MICU stay. He found that the entries helped him to better understand what he experienced. His physical strength has recovered to where he is independent. He acknowledges that he had difficulty sleeping for several weeks, and at times felt anxious that he would fall ill again. Fortunately, these symptoms have decreased in frequency and intensity in recent weeks which he takes as a sign of continued recovery.

Millions of patients each year are admitted to an intensive care unit (ICU), many of whom require invasive mechanical ventilation. While ventilated, intravenous sedation is frequently administered to patients to facilitate synchrony with the ventilator and to manage agitation, anxiety, or delirium. Sedatives are often combined with intravenous analgesics, especially when pain is anticipated to be present (i.e., after procedures including surgery). As patients recover, these medications are reduced in dose and then either stopped or replaced with an oral agent depending on the patient’s need.

Upon awakening, many patients struggle to recall what occurred to them and to make sense of their lived or perceived experience. In the weeks and months after critical illness, many survivors experience difficulties with cognition, mental health, and physical functioning. These difficulties ...

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