Patient Care Vignette
A 64-year-old patient presented to the emergency department with dyspnea, fever, and malaise 1 week following a motor vehicle collision resulting in six right-sided rib fractures and a pulmonary contusion. Discharged from an outside facility, the patient presented to the hospital yesterday, and rapidly progressed to demonstrating septic shock with a diagnosis of an ipsilateral pneumonia and worsening hypoxia. Though unaccompanied on arrival by private vehicle, the patient reports being in a long-term relationship with a partner of 26 years. The patient did not come with documentation from the outside facility but was able to report that he is a transgender man and is taking gender-affirming hormone therapy in the form of topical testosterone. The patient quickly became obtunded in the emergency department and was intubated.
The last 24 hours have resulted in intubation and mechanical ventilation, broad-spectrum antimicrobial coverage, multiple vasoactive agents, and worsening hemodynamics, leading to multiple organ system dysfunction. His partner arrived at the hospital with more documentation, including home medications for hypertension and Type II diabetes mellitus, which he reported to be in good control. The patient’s partner identified himself as the patient’s husband, but also reported that they never married legally. The patient has adult children from his previous marriage, and is estranged from his adult son, but does communicate with his adult daughter periodically. The other father of his children died 3 years ago following a prolonged intensive care stay, resulting from an intracranial hemorrhage, where he lingered with a tracheostomy for 10 days before succumbing. The adult children are his only other relatives. After 3 days in the hospital, the patient is proving challenging to liberate from the ventilator, and a family meeting is requested to discuss further future measures, including possible tracheostomy. The patient’s partner says, “he would never want that,” citing that watching his first husband’s death was terrifying for the patient. The patient’s daughter, however, feels that he would want everything done after all that was put in to medically and socially affirming his gender. He eventually undergoes tracheostomy and recovers sufficiently to return home from rehabilitation. He demonstrates signs of significant cognitive decline and may be depressed, leading to a lack of interest in improvement.
Patients in the lesbian, gay, bisexual, transgender, queer, intersex, asexual, “plus” (LGBTQIA+) community have historically encountered challenges in the healthcare system that undermine care, weaken trust, and compromise outcomes. Given this, it is important to understand the concerns of patients and families who identify with this community, as these concerns influence critical illness recovery from both clinical and social perspectives. In this chapter, we present some considerations unique to LGBTQIA+ care and support during critical illness recovery, starting with a discussion of stigma and language, then discussing transgender people, preexisting health status in specific LGBTQIA+ subgroups, and social and family needs for LGBTQIA+ patients. The chapter concludes with post-ICU care considerations for LGBTQIA+ patients. Key terms relevant to the ...