What to Expect in a Hospital Intensive Care Unit (ICU)0 USER TIPS ADD YOUR TIP
Most people who have watched medical shows on TV associate a hospital intensive care unit (ICU) with beeping monitors and doctors and nurses racing to perform life-saving acts on dying patients and trauma victims. While the ICU is not quite that dramatic in real life, this specialized critical care unit does house the most medically vulnerable, with the goal to keep patients alive at all costs.
However, certain critical care experts such as Jessica Zitter, MD, the author of Extreme Measures: Finding a Better Path to the End of Life, believe that for patients who have serious chronic or debilitating illnesses, the life-saving measures of the ICU such as intubation and resuscitation may not be in line with their end-of-life wishes. And so while no one plans for an admission to the ICU, advance planning, along with knowledge of the treatment patients can expect in the unit, can help patients and their families make informed decisions about their health care—before a medical crisis hits.
Why patients end up in the ICU
“Hospitals admit patients to the ICU because they usually suffer from what we call ‘hemodynamic instability,’” explains Audrey Radin, MD, a palliative care physician with VNA/Barnabas Health Home Care and Hospice in New Jersey. “That means the patients’ vital signs, especially their heart rate or breathing, are compromised, blood is not pumping sufficiently, and they need some degree of care, such as ventilation or constant monitoring, that can’t be provided in another setting.”
Hemodynamic instability can result from any number of conditions: an acute health problem such as a heart attack; an escalating infection including pneumonia or sepsis (an infection of the blood); or trauma, such as a car accident. Naturally, acute problems can also arise from chronic illnesses such as cancer, congestive heart failure, or Parkinson’s disease. “The goal of the ICU is to stabilize the patient’s vital signs, so tests and treatment focus entirely on restoring breathing or the heart rate to a manageable level,” Radin notes.
While the ICU team will routinely check blood levels and conduct other tests at the patient’s bedside, for the patient’s safety, they will only conduct tests directly related to the condition that brought them to the ICU. “A cancer patient in the ICU with an infection may go for a scan to root out the cause of the infection,” Radin explains, “but the medical team will wait to schedule tests to determine whether the cancer has spread, for instance, until the patient has left the ICU.” However, the ICU team remains in contact with the patient’s primary care physician and other medical specialists throughout the ICU stay so the patient’s team can monitor his or her health and plan for further testing and procedures afterward.
Once the ICU patient is stabilized, he or she is rarely discharged from the hospital to return home right away. Most patients remain in the hospital, with many entering “step-down” units where they remain closely monitored around the clock until they recover more fully.
Treatment in the ICU
With its focus on stabilizing the medically fragile patient, the ICU administers treatment that patients generally cannot receive elsewhere in the hospital. For example, the ICU team will treat patients suffering from hypotension—abnormally low blood pressure—with vasopressors, commonly known as “pressors,” which constrict blood vessels to raise the blood pressure. Additionally, patients with critical illness, especially those recovering from blood diseases such as sepsis, may remain in the ICU as they receive continuous renal replacement therapy (CRRT), a type of dialysis which takes hours to administer and requires the ICU team to monitor the patient’s heart throughout the process.
The ICU team commonly administers treatment to ease patients’ breathing and provide nutrition for patients who cannot eat or digest food properly. These can include:
Someone who suffers shortness of breath due to weakness or an obstruction will most likely receive intubation, in which a breathing tube is placed in the patient’s trachea, the tube that runs down the throat to the lungs. The tube may also be attached to a ventilator, a machine that helps regulate the patient’s breathing. The patient’s oxygen and carbon dioxide levels are monitored, and periodically, the medical team may try to “extubate” the patient, or remove the breathing tube, to test whether the patient can breathe on their own. Intubated patients are not able to eat or talk and are often sedated to ease discomfort and anxiety.
Intubation usually lasts less than a week, but if the patient must remain on a ventilator past the two-week mark, the ICU team may recommend that the patient undergo a tracheotomy, also called a “trach,” in which an incision is made at the base of the patient’s throat to insert a tube for the long term.
“A patient in need of a tracheotomy, especially after spending two weeks on a ventilator, is probably facing a complex set of medical problems that may not be cured or resolved,” Radin notes. “Naturally, a tube in the throat will also affect talking and eating. Prior to the placement of the trach, the medical team will have a frank discussion with the patient and his or her family to discuss the prognosis and consider the patient’s quality of life. Depending on whether the patient also has a serious, incurable illness, this may be an appropriate time to explore hospice.”
“It’s proven that people who have good nutritional status do better in the ICU,” Radin says. “Just about every patient receives fluids intravenously (IV), but the team will also look to provide nutrition as soon as possible to help the patient feel stronger.” For instance, the team may insert a nasogastric (NG) tube via a nostril, though Radin also notes that that most ICU patients also have a “central” line inserted in an artery near the neck (subclavian line) or groin (femoral line) to receive nutrition or medication, such as antibiotics, more efficiently.
If the patient needs to receive artificial nutrition for a longer period of time, the ICU team may recommend a peripherally inserted central catheter (PICC line) inserted in a vein for medication or nutrition, or a percutaneous endoscopic gastrostomy (PEG), in which a line is inserted directly into the stomach. All IV lines may be removed if the patient is able to resume eating and digesting food, though if necessary, the PEG may remain permanently.
Visitors at the hospital may hear the call for a “code blue” over the loudspeaker, which summons all assigned medical staff to attempt to resuscitate a patient whose heart has stopped, also called “coding.” The team may use cardiopulmonary resuscitation (CPR), in which they apply rhythmic chest compressions to stimulate blood flow, or they may try defibrillation and stimulate the heart through an electric current delivered via paddles placed on the chest.
A medical team will attempt resuscitation unless the patient, or the patient’s designated health care proxy who can make decisions on the patient’s behalf, has signed a “do not attempt to resuscitate” status, also called a DNR. Some hospitals may refer to this code status as “allow a natural death” or AND. If there is no DNR or AND in place, the patient remains a “full code” and will be subject to CPR and other forms of resuscitation if the patient’s heart were to stop in the ICU.
When the ICU isn’t the best place to be treated
Though the ICU treats patients with unexpected and serious medical issues, Radin recommends that patients consider their health care options well before a crisis arises. This is especially vital for older adults or others with chronic or serious illness.
“ICUs are meant for the relatively healthy person who has suffered an acute health event or trauma, and there is a full expectation they will return to their original state of health, or close to where they were before,” Radin explains.
However, many patients, especially older adults, enter the ICU due to complications from a chronic or debilitating illness and face diminished quality of life once they leave the unit. In this case, it is vital for the medical team, often with the help of a palliative care physician, to look at the patient’s overall health condition rather than focus solely on heart rate or other single organ functioning.
“In a hospital setting we look at escalation of care,” Radin explains. “They go from needing outpatient care—say, they have pneumonia and receive a prescription for oral antibiotics because we want to use the least powerful medication that will work. If they don’t respond, then they are admitted to the hospital and are given IV antibiotics. If they are still not responding, that’s the point at which we need to consider whether the patient should escalate to the ICU. We should ask ourselves, what is happening to the entire person?”
As Radin points out, “The ICU experience can be grueling for older people with other illnesses. Every IV line the team inserts creates another risk for infection for people whose conditions are already compromised. These patients may be diabetic, they may have congestive heart failure or they just had a hip fracture, and when they contract an infection they may not have the reserves to fight it.”
It is often at this juncture, when the patient admitted for a serious condition subsequently suffers shortness of breath, that an impending trip to the ICU triggers a discussion about whether the patient would want to be resuscitated if his or her heart were to stop. “CPR, intubation, and artificial nutrition can cause more discomfort than the older patient might be able to endure given their condition and prognosis, and when weighed against potential benefits,” Radin emphasizes. “We should not wait until patients are on the verge of going into the ICU to have that conversation for the first time.”
What can the patient do? “For younger, healthier patients, at the very least it is important to designate a health care proxy who can make decisions on your behalf,” Dr. Radin advised. “Everyone has to name beneficiaries for the life insurance policies or their retirement plans, and choosing a health care proxy, and putting that decision in writing, is no different.”
Radin recommends that older patients, especially those with a chronic or serious medical condition, meet with their doctors to complete a POLST form (Physician Orders for Life Sustaining Treatment) and discuss the treatment options that may arise in an emergency room or ICU scenario. “The physician will make recommendations based on your diagnosis, your prognosis, and the medical issues you are likely to encounter down the line,” Radin says. “These decisions are difficult to make in the moment, especially when that moment takes place in the ICU where patients and family members are truly at their most vulnerable. An advance care plan gives patients the opportunity to learn what to expect, so they can make healthcare decisions from a position of strength.”