We do not yet know precisely the outcomes that survivors of covid-19 will face, but we should be ready with support for those experiencing the psychiatric sequelae of intensive care, say Daniela Lamas and colleagues
As the threat posed by covid-19 soared, healthcare workers scrambled to address the crises moment by moment: respiratory failure and its management, rationed personal protective equipment, an anticipated shortage of essential medications and ventilators. Intensive care units have been full and providers are anxious, balancing their own fear with the drive to provide high quality care. It has been hard to see what comes after.
Yet there will be an after. Patients will survive coronavirus—but that survival will likely come at a cost for some. Research on similar populations suggests that at least 50% of people who survive admission to an intensive care unit (ICU) can be left with what researchers now call “post-intensive care syndrome,” a constellation of emotional, cognitive, and physical symptoms that limit their functioning. Survivors of critical illness can often return to the world with memory problems and difficulty planning and processing that is similar to those with moderate traumatic brain injury or mild dementia. Other survivors experience post-traumatic stress disorder (PTSD), at an incidence ranging from 10% to 50%. Their caregivers, too, will often experience a cluster of adverse outcomes, including anxiety, PTSD, and depression. As we await the next surge of patients—now one of survivors—there is a clear need for interventions to improve the quality of life of this growing population.
To begin to fill this gap, before the covid-19 pandemic, we had designed a clinic at our quaternary care referral center at Brigham and Women’s Hospital to see patients at high risk of developing post-intensive care syndrome. As we have already seen an increase in referrals, we expect that this clinic—with its heavy emphasis on the neuropsychiatric sequelae of intensive care—will be particularly useful to survivors of coronavirus.
We designed our clinic using an approach influenced by a trauma-informed care framework. This recognizes that an individual’s history before being admitted to intensive care and social determinants of health will impact their experience and outcomes, and also that the medical interventions themselves can be potentially traumatizing for patients and their families. Given that framework, the clinic is staffed by critical care clinicians, a critical care social worker, and a consult liaison psychiatrist. We offer education and an opportunity for patients to fill in some of their missing memories with fact, screening for post-intensive care syndrome, and appropriate referrals. Some patients will even elect to visit the intensive care unit they were in and we will help to arrange this.
Of the patients we have seen, many describe having experienced challenges in all domains of functioning, and feeling misunderstood or alone through that process. There is a central expectation by those around them—and even by the survivors themselves—that since they are lucky to be alive, there is little room for resentment at the change in their quality of life at the other end of this life threatening experience. The opportunity to process this with experts offers both qualitative relief and an opportunity to feel more engaged in their recovery.
We do not yet know precisely what outcomes the survivors of covid-19 will face. We can hope that they will face fewer long term consequences than those whose outcomes have been studied. We worry, however, that the deep and prolonged sedation these patients often require to tolerate ventilator maneuvers like proning will lead to long term cognitive and physical dysfunction. Furthermore, the isolation from family and other forms of support during admission, and a possible related increase in delirium, might worsen their cognitive and psychological sequelae, including post-traumatic stress symptoms. We eagerly await the results of studies examining these questions. But we cannot wait for those results to begin to act.
We need to start scaling up systems now to screen patients after their ICU discharges, and to provide support to primary care doctors already swamped with patients trying to navigate through varying levels of both covid and non-covid related issues. This might mean building multidisciplinary teams that include critical care doctors, hospitalists, and nurses, alongside social workers and psychiatrists, to provide patients and their families with a central source of information and supportive therapies.
We were unprepared for this pandemic and will have to live with that tragedy. But we still have time to mitigate foreseeable components of its aftermath, including the needs of those who have survived the most aggressive interventions we have to offer in critical care. Raising awareness among healthcare professionals to support early screening and intervention for these patients is a feasible and scalable next step in this disaster response.
Daniela Lamas is a pulmonary and critical care doctor at Brigham & Women’s Hospital in Boston, Massachusetts.
Nomi Levy-Carrick is a consult-liaison psychiatrist who currently serves as associate vice chair of ambulatory services in the Department of Psychiatry, also at Brigham & Women’s Hospital.
Stacey Salomon is a social worker in the intensive care unit at Brigham & Women’s Hospital.
Gerald Weinhouse is a pulmonary and critical care doctor at Brigham & Women’s Hospital.
Competing interests: We have read and understood BMJ policy on declaration of interests and have nothing to declare.
Acknowledgement: The authors also thank Lauren Nisotel, Ariadne Labs project manager, for her help with the design and development of our Critical Illness Recovery Program.
Funding acknowledgement added on 24 June at the authors’ request: Much of the work described in this article was funded by Ariadne Labs Spark Program underwritten by the Paul G. Allen Family Foundation.