Despite the trend to having all medical care delivered by a primary care provider, critical care is not just internal medicine, pediatrics, or general surgery
plus a few procedures. The ICU poses a wide range of potentially lethal problems and uses sophisticated technology to which the primary care provider typically has limited exposure. Because of the rapid pace of illness and events in the ICU, decisions must be made quickly, often using incomplete information. The non-ICU practitioner typically has little experience with inevitable diagnostic uncertainty in this setting.

Ideally, physicians working in ICUs should be critical care trained and readily available, yet less than 5% of ICUs have a senior physician present around the clock, and less than one third of all ICUs have even continuous “resident” level coverage. More striking is the fact that fewer than 20% of hospitals have a critical care trained physician on-site continuously even during daylight hours. This situation is unfortunate because numerous studies indicate that establishing a “closed unit,” where patients are cared for by a critical care physician, reduces the length of stay, mortality, and costs. There are several potential reasons for improved outcomes with intensivist staffing. ICU physicians are more likely to be on-site without the distraction of a busy clinic or operating room schedule. The advantages of dedicated intensivists are eroded when physicians are not physically present, for example, when they provide care in geographically widely separated units. Benefit may also result from the fact that intensivists have a body of experience which allows them to anticipate and preempt serious problems before they become fatal or costly. For example, to an intensivist at the bedside, subtle increases in airway pressure and modest declines in saturation and blood pressure are likely to signal an early pneumothorax that can be successfully treated long before it results in serious injury. An off-site physician is less likely to appreciate and promptly act upon these very same findings. The presence of a dedicated intensivist also increases consistency of care and compliance with recommended practices. Examples abound: when no standards exist, deep venous thrombosis prophylaxis, fluid resuscitation for septic shock, glucose control, nutrition, and normal tidal volume ventilation are inconsistent in method and application. When a different method is used for every patient, it is likely that the therapy will be overlooked for some patients and suboptimal in others. Despite fierce arguments for physician autonomy and “customization” of care, there, usually, is a best way to begin treating the typical patient and reducing unnecessary variation contributes to improved quality. Furthermore, knowing which treatments have succeeded or failed in a given patient leads to more efficient and less costly care. In an era in which patient turnover is rapid, and staff changes are frequent, well-crafted policies, protocols, and checklists are essential to maintain consistent care. Variability in care can be magnified in teaching hospitals where trainee duty hours are now tightly constrained, necessitating frequent handoffs. Another potential advantage of the on-site critical care physician is that he or she is less likely to summon multiple consultants. Care is inefficient, costly, and potentially dangerous when a physician, especially one off-site, “practices” using multiple consultants. In this model, each consultant responds at a pace dictated by his or her schedule, and the communication between the consultants, the primary physician, and the family is often suboptimal. The intensivist is the best person to adjudicate and coordinate the consultant recommendations and to communicate with the family and with the physicians who will provide care after ICU discharge. Without effective coordination, it is possible for numerous, often redundant, diagnostic tests to be ordered as subspecialists attempt to justify their involvement by searching for evermore obscure conditions. An even worse situation occurs when the therapeutic goals of consultants are at odds or when one consultant is oblivious to the thoughts of another.

Perhaps no one is better attuned to the potential for and limitations of the ICU than the intensivist, the person who is most qualified to identify patients who cannot benefit from ICU care because they either are not sufficiently ill or are unsalvageable. Patients at low risk of death or complications tie-up needed beds and are more likely to experience an adverse event as a result of ICU admission than they are to experience benefit. Hence, “low risk admissions” should be avoided. Likewise, moribund patients are not well served by ICU admission, where they occupy beds that could be used for salvageable patients, may suffer isolation from family and friends, are exposed to nosocomial hazards, and pay a high financial price. Even with all the difficulty in determining what “futile” care is, reasonable limits can be developed on a case- by-case basis. The intensivist is the best person to help the patient and family develop these boundaries by having honest, open, and recurring discussions of expectations. Regular, preferably daily, consultation with the patient and family is important to maintain common goals. Such consultations often require 30 to 60 min/patient each day, a time requirement that
few physicians with responsibilities outside the ICU can manage. Beginning routine family discussions early in the ICU stay makes later meetings when weighty decisions must be made much less daunting. This plan of communication has other benefits: patient and family satisfaction is enhanced by communication with fewer physicians delivering a consistent message.

The role of the “hospitalist” in the care of the critically ill patient remains to be defined. Although one would expect that a hospitalist providing around-the-clock care would be superior to no inhouse physician, the training, experience, and scope of responsibilities of the hospitalists are heterogeneous and results unknown. For example, many hospitalists are internists with no formal critical care training who have chosen to limit their practice to inpatient medicine. It is also not clear if a physician providing coverage for many patients throughout the hospital provides the same level of care as a physician dedicated to the ICU.

Similarly, the role of the “tele-physician” remains uncertain, and the implementation of a telemedicine program is quite expensive. In practice settings lacking any organized critical care presence, the addition of telemedicine oversight could be imagined to produce significant improvements in outcome. However, in settings where critical care physicians are already present during the day, improved outcomes have not been demonstrated. Interestingly, it is not clear if the benefits of telemedicine come from the oversight function of the service or from establishing the standardized methods of dealing with common issues.

Undoubtedly, an experienced on-site critical care trained physician is the best person to care for critically ill patients with the input of necessary consultants. Unfortunately this ideal model is currently impractical because even in large tertiary care centers, there are rarely sufficient numbers of critical care physicians to provide in-house, 24-h-a-day coverage.

Critical care nurses are the patient’s lifeline and family’s salvation. Today’s nurses are being asked to do more highly technical, labor-intensive tasks with a greater level of independence than ever before. In this environment, making sure that nurses are not overburdened is as important as making sure that they are well educated and current in their training. Given the intensity of ICU activity, anytime a nurse is asked to care for more than two (sometimes more than one) critically ill patient(s), it is likely that less than ideal care is being delivered. When task saturation occurs, it is common for nurses to keep performing essential patient-centered work but care of the family and documentation suffer. Although a heretical idea to some, lapses in documentation are usually unimportant, unless a critical event or adverse occurrence is inadequately described, leading to its repetition. Nonetheless, it is best to avoid any inconsistency in care or documentation by providing adequate staffing. To this end, bedside nurses, ICU leaders, and administrators must work together to ensure that the process of care is efficient. New programs and initiatives should be thoroughly vetted before implementation to make sure that additional work or documentation requirements do not detract from care of the patient or family. Common examples of process of care changes that can impose substantial burdens are institution of intensive glucose control, early mobilization programs, and continuous renal replacement therapy. Sometimes seemingly trivial requirements can impose significant work; for example, simply documenting that mouth care and repositioning have been done every few hours can be time intensive, especially if the system for documentation is inefficient.

ICU nurses are not interchangeable cogs in a large critical care machine. They develop specialized skills to serve the most common problems they see and become familiar with the policies, procedures, and layout of the unit in which they most often work. Simply not knowing where supplies or equipment are stored in an unfamiliar unit results in inefficiency and, in some cases, even danger. In addition, the teamwork and camaraderie that develops among nurses who work consistently together provide physical and emotional support to complete the difficult tasks they are called upon to do. For these reasons, the use of temporary nurses or rotating nurses between ICUs of different disciplines should be discouraged.

Nursing excellence requires much more than a caring attitude, technical knowledge, and careful documentation; experience brings priceless insight, intuition, or judgment. Every savvy critical care physician knows the folly of not promptly responding to an experienced nurse who says “I’m not sure what’s wrong, but the patient just doesn’t look right.” Not only can one not buy experience, but it is also very expensive to retrain or orient a nurse to a new ICU; some have estimated costs at tens of
thousands of dollars. Hence, it makes sense to do everything reasonably possible to retain quality nurses. While nurses certainly care about salary, benefits, and work hours, satisfaction at work is a much more important factor for staff stability. There are numerous ways to improve nurse’s job satisfaction. The first and probably the most important factor to enhance satisfaction is to treat nurses as the indispensible elements of a team providing care. Just like the copilot of an aircraft, nurses provide critical information and accomplish crucial tasks for successful mission completion. Airlines long ago recognized that an intimidating, unapproachable captain was a dangerous and divisive employee; the same is true of a dictatorial ICU physician who disregards a nurse’s ideas or observations. Although it is clear that one person (the attending physician) must make the key decisions, there is no room for paternalism, patronization, or dismission. For satisfaction, but more importantly for patient safety, everyone caring for patients should understand the plans for care and must feel free to speak up when a course of action appears to be not working. Another method to promote staff satisfaction is to develop an environment where learning and teaching are valued and inquiry is welcomed. Conducting formal clinical trials or quality control projects helps establish an environment where questions are welcomed and a culture of discovery flourishes. Conducting regular educational programs designed to answer the questions that arise during patient care is also valuable and vastly superior to an arbitrary or irrelevant schedule of topics. By having all members of the health care team present at educational sessions, the knowledge of the group is boosted, the stature of the presenter is enhanced, and, as a result, care improves.

The ICU pharmacist is pivotal for optimal patient outcomes and cost control. The role of pharmacists and methods to optimize pharmacotherapy are covered in detail in Table 19-1 and Chapter 15. Similarly, the ICU dietitian or nutritionist provides valuable guidance for nutritional requirements and is essential to help navigate the dizzying variety and the number of products available. While clearly an oversimplification, merely having someone on rounds each day to prompt the team to begin enteral feeding and to discourage irrational interruptions in support is valuable. Attention to immediate life-threatening concerns often lowers the perceived importance of problems that can affect the long-term quality of life. Perhaps no better example exists than lack of attention to physical therapy or occupational therapy needs. Saving the life of a young severe sepsis patient is profoundly rewarding until it is realized that the patient is left with the potentially avoidable problems of foot drop and wrist contractures which prevent return to employment and recreation. In addition, it has recently been recognized that early mobilization of some critically ill patients may even accelerate ventilator weaning and ICU discharge. Therefore, it is important to involve physical and occupational therapists as soon as feasible during the ICU stay.

An automobile journey would prove long, expensive, and potentially dangerous if there were no clear destination, defined route, or even a map and numerous people took turns driving. In the same way, successfully negotiating the path through the ICU becomes perilous and expensive if the “driver” does not understand the route or destination. It is also impossible to plan an efficient route without knowing all the relevant trip information. For most of the day, bedside nurses “drive,” and if the plan and priorities are not clear, a wandering route is likely. For the ICU patient, confusion is manifest as redundant or irrelevant diagnostic testing, inappropriate therapeutic interventions, missed critical opportunities, and miscommunication.

The most practical solution to such problems is to have a senior physician lead the ICU team to execute a carefully developed plan. To accomplish this goal, it is essential to have at least daily multidisciplinary bedside rounds where participation
(not just attendance) of key team members is required. This group should include the physician, nurse, pharmacist, dietician, and respiratory therapist. Attendance of consultant physicians is desirable but often not feasible. When circumstances suggest that they would be beneficial, occupational/physical therapists, social workers, case managers, palliative care specialists, and clergy should be included. Each day, the success or failure to achieve goals set the previous day should be evaluated. New problems and organ system function should be reviewed. Diagnostic information gained since the previous day and its implications should be discussed. The need for all medications, tubes, and catheters should be questioned. Changes in therapy should be agreed upon (not just what to do, but in what order to do it, with contingency plans for unexpected events). The information to be communicated to the patient, family, and referring physicians should be discussed, and plans for transfer or discharge should be finalized. Following these steps all but guarantees that members of the team move efficiently in the same direction. This cooperative process offers the physician in charge the most current and accurate information upon which to make decisions, and as a major benefit, the staff becomes more cohesive, knowledgeable, happy, and respectful of one another.

In most hospitals, nursing and respiratory therapy personnel change shifts two or three times daily while physicians typically trade responsibilities less often. Personnel changes have advantages and disadvantages. While a new caregiver provides a rested body and mind, the oncoming provider lacks key information and recent experience with the patient. The process of “handing off” a patient may occur much more frequently though than just once or twice daily as personnel may differ during transport of patients to or from the CT scanner, operating room, recovery room, or general care floor. It is important that transfers be done in an orderly and systematic way to prevent miscommunication. The oncoming staff must be made aware of the patient’s history, life support technology, medications, recent events and problems, and future plans. This review is often accomplished at two levels as bedside nurses exchange information and review medications, indwelling lines, and pertinent examination features. Separately, charge nurses review critical elements of illness and care to plan which nurses might need help or which patients are likely to require higher or lower levels of staffing. In the handoff process, respiratory therapists likewise review ventilator settings, treatment requirements, and recent problems and plans for weaning. For physicians, the process of care transfer often involves making formal beside rounds together daily in teaching institutions. In nonteaching hospitals, a face-to-face or telephone exchange of information is often conducted.

There is no blanket approach to family communication, rather it is best to learn about the patient, family, and their preferences for receiving information and making decisions and then attempt to meet their goals. For example, do they want to attend rounds, have a face-to-face meeting daily, or talk by phone at a specified time? Including families in daily rounds is not an unreasonable option but can be time consuming and has met with mixed results. If done, it takes special physician talent to translate medical issues to lay-language and answer questions accurately but efficiently while avoiding the appearance of haste. Some family desires cannot be met; no physician can meet or even call multiple family members at a set time each day. For large, especially large involved families, it is a very good idea to have them appoint a spokesperson with whom communication will occur if the entire clan is not in attendance. This practice is obviously not to withhold information from others who wish to be present for such discussions but rather to prevent physicians and nurses from being inundated by sometimes dozens of calls or visits each day requesting the same information. Furthermore, even when the exact same words are spoken to different family members, their interpretations are often dissimilar. As typically happens, after several family members compare what they “heard,” yet more calls are placed to the doctor or nurse to reconcile seemingly discordant communications. Even when the message provided is consistent, the perception of the family is often one of inconsistency leading to dissatisfaction. In addition to scheduled discussions, families should be notified in a reasonable time frame of major changes in status including procedural complications, significant clinical deterioration or improvement, and certainly if the patient is being transferred from the unit. Because the time shortly after admission is particularly stressful, it is important not to let families languish without information during the period of initial evaluation and stabilization. Even a brief visit from the patient’s nurse, the charge nurse, a doctor, or even a receptionist can be soothing. Keeping families updated on the progress of procedures and
surgery is very comforting, especially if a procedure takes longer than planned or does not start when scheduled. Providing families a phone number that can be called at all times to obtain information should be a standard practice. It is important to respect the patient’s right of confidentiality; hence, it is essential to find out if there are family members or friends who should not receive information—a practice that is facilitated by issuing passwords to persons authorized to receive information.

The policies surrounding visitation are highly variable, but more than two thirds of hospitals have some restrictions regarding the number of visitors and hours for visitation. While some of these policies may simply be tradition, a sound case can be made for some periods of each day being visitor free (or limited). For example, space limitations in many ICUs practically limit the number of visitors at one time. Restricting visiting times can also be justified to guard the privacy of the patient being visited and other patients as they undergo physician examinations, bathing, and procedures. The presence of visitors can also hinder some important but routine duties such as handoffs, teaching rounds, and housekeeping functions.

Some family members have a driving need for physical proximity to the patient, wanting to stay at the hospital, sleep in the patient’s room, and even help provide nursing care. Just as many family members care as deeply but cannot stand the sights, sounds, and smells of the ICU. For others, despite the strong desire to be present, their wishes cannot be fulfilled because of work or family obligations or simply geographic remoteness, and for them, a great guilt can result. Having families stay with patients for extended periods has good and bad aspects. Visitors can be very helpful in the care of patients or can be dangerous disruptions. Because of their familiarity with the patient, vigilant visitors can alert the staff to subtle findings which may presage a true physiologic crisis. A helpful visitor can also provide valuable information such as a patient’s usual medications, allergies, and previous illnesses and therapeutic misadventures. In theory, visitors could even prevent problems like drug dosing errors, taking the wrong patient for a procedure, or performing an operation at the wrong site. Helpful visitors can offer the patient comfort and familiarity and sometimes can even be a care extender. When visitors participate in the care of the patient, valuable knowledge can be transferred that may be needed for a successful transition home (e.g., tracheostomy care) and they also get a realistic sense of how hard staff work and how many things must be done to care for a critically ill patient. Having a family member present can also enhance communication with other relatives who are not at the hospital.

On the other hand, a hyper-vigilant visitor can be a profound disruption if he or she obsesses over each beep or buzzer resulting from a cough on the ventilator, the completion of a medication infusion, or artifactual heart rate alarm. Similarly, if visitors prevent patient rest, or cause frustration by repeatedly asking the same question of a patient with delirium or impaired communication, they can impair care. The continuous presence of visitors in the ICU can also present significant challenges to patient confidentiality and privacy. Special care should be taken to prevent visitors from overhearing conversations or seeing things from other patients that should remain confidential. Visitors also present important infection control issues, especially for patients in contact isolation because of transmissible infections. Visitors’ failure to comply with isolation procedures can contaminate themselves and other visitors in the waiting area. Finally, the continuous presence of the same family member or visitor also presents a real problem of exhaustion and sleep deprivation for the visitor since facilities for rest and nourishment are rarely adequate.

Critical illness is frightening, and each family member has a different desire for knowledge and a different way of coping with the stress. For some, acquisition of information is comforting. These family members relish participating in rounds, search the internet, read informational pamphlets, ask probing questions about the diseases and procedures, and may even investigate the training and qualifications of the physicians and nurses. They often want to be present during procedures or sometimes even during cardiopulmonary resuscitation. Such family members appreciate the discussions of the risks and benefits of various possible courses of action. However, for just as many family members, the very same information is terrifying, incomprehensible, or overwhelming. For them, hearing the problems of even minor transient instability and the seemingly infinite number of laboratory and radiographic abnormalities is disconcerting. Similarly, team discussions of the likely next events or complications produce a sense of dread. All they want to know are answers to simple questions like are the lungs getting better? Family members also have vastly different responses to the
inherent uncertainty of much of medicine, especially critical care. Learning that there may be disagreement about the best path to take or that some questions just cannot be answered can erode confidence in providers and sometimes even produces anger. “How could there not be an answer?”

Prognostication is difficult, yet it is one of the most desired features of family-physician communication. For some families, precision is important, insisting on specific “percentages,” but for others, questions are much more general: Do you think she will make it? Predicting outcomes is hard because except at the extremes of illness, survivability is uncertain. Because survival data are derived from populations not individuals, it makes little sense to communicate prognosis with precision. No person has 55% mortality—survival is dichotomous. For this reason, without being evasive, many clinicians use nonnumerical phrases like “hardly ever,” “very unlikely,” “more likely than not,” and “almost certainly” when describing outcomes. Another reasonable approach is to emphasize that outcome predictions come from populations using phrases like “Of 100 patients with a condition similar to your mother 85 will survive.” The obvious problem is that there are not 100 patients sufficiently similar to anyone’s mother to make such a comparison meaningful. Along similar lines, it is a folly to provide families precise timelines for improvement, deterioration, or even death; doing so is doomed to failure. For example, any precise time is probably going to be wrong, and when wrong confidence in the providers is undermined not just for the patient at hand but also for future health care encounters. All experienced providers have heard something along the lines of: “Five years ago the doctors told me my brother would not live through the night but lived almost a week, so why should I believe you now?” Again the best course of action is to be as honest as possible in providing estimates of outcomes and timing while avoiding false precision.

It is important to explore cultural and religious issues with the family. In some cultures, life support is viewed as interference with the natural order, for others not providing full support is akin to suicide. For some patients, a successful outcome is defined as a well-functioning mind regardless of the state of the body; for others, physical limitations define failure. Some cultures find it incomprehensible that the patient is provided all the information regarding his or her condition, especially if the diagnosis is a terminal one like metastatic cancer. In other cultures, some diagnoses (e.g., severe sepsis) imply personal or moral failure and are therefore poorly accepted. For some patients, avoidance of transfusion and transplant are paramount, whereas others have specific prohibitions against use of recombinant or animal-derived medications. The only way to cope with the wide variety of beliefs and preferences is to talk openly with patients and families exploring these issues. A spiritual leader or clergyman of the patient’s faith can be very useful to help the providers understand the patient’s beliefs.

Before performing nonemergent procedures or surgery, seeking informed consent from patients or ascent from families is a common but far-from-uniform practice. Which risks are discussed and who carries out the discussion are highly variable. In addition, the procedures by which consent is sought vary by location with some hospitals seeking consent for transfusion, others for HIV testing, and some only for mechanical or surgical interventions. By contrast, formal consent or ascent discussions using a detailed approved consent form are almost always required for the conduct of prospective human research. Regardless of this, in both settings, the risks, benefits, and alternatives to the proposed intervention should be discussed and questions answered. It is best to think of consent as a process rather than an event where continuing discussions occur sometimes over hours or perhaps even days until the risks and benefits are clear. There is general agreement that consent is not required to perform immediately necessary life-saving procedures (i.e., chest tube placement for tension pneumothorax). Despite the expectation to seek consent, there is a huge variability in the depth of information families seek during discussions, and little is known about what is actually understood. In fact, it is likely that no matter how well the discussion is conducted, there will be some knowledge deficit on the part of the patient or the family. In addition, there is legitimate debate about the value or need to seek reconsent for a third or fourth central line during a long ICU stay. Accordingly, some ICUs have instituted the concept of “preconsent” where families are provided information regarding all commonly performed procedures at or near the time of admission and provide a single consent or assent for care. While this practice makes sense in many ways, some practical issues can be envisioned. First, the sheer volume of information
presented all at once might be overwhelming. Second, since the risks and benefits of any given procedure change somewhat over time, a discussion closer to the time of a given procedure might provide a more accurate assessment of the risk-benefit ratio. Moreover, a patient’s or a family’s acceptance of a given procedure may change over time as the patient improves or deteriorates, even if the risks and benefits have not changed. And finally, who knows what the legal interpretation of a single consent is.