Intensive care units (ICU) are places in the hospital where the most seriously ill patients are cared for by specially trained staff. The staff consists of doctors, nurses, respiratory therapists, nutritionists, physical therapists, pharmacists, case workers and clergy. They work closely together as a team to provide the best possible humane care. Two things that make care in the ICU different than in a regular hospital care area are the nursing support and the special type of equipment in use. The level of nursing care in the ICU is higher than care in other parts of the hospital. ICU nurses are specially trained to care for the most ill patients. There are more nurses for patients than on regular hospital wards. The second thing that distinguishes an ICU is the use of advanced technology. The ICU team uses a number of specialized machines and devices, called monitors, to frequently check the heartbeat, blood pressure and breathing. There are machines that help patients breathe called mechanical ventilators. While it can be overwhelming to see so many machines, wires and tubes, each does its job to help the patient.
There are many diseases and injuries that can lead to critical illness. Examples of problems that may require the special and expensive care in an ICU include:
- Problems with the heart and blood vessels - such as very high blood pressure, very low blood pressure (called shock), abnormal heart beats, or a heart attack.
- Problems with the lungs - such as asthma, severe pneumonia, or pulmonary embolism (blood clots in the lung). Difficulty with breathing that is so severe that the patient may need a machine to help or take over breathing until the problem is corrected.
- Problems with salts, chemicals, or minerals in the bloodstream - The body's cells require a number of substances that must be present in the correct balance for the body to work properly. Levels of substances such as sodium (salt), potassium and glucose (sugar) must be kept within a very narrow range. A level that is too high or too low can threaten life, and immediate treatment may be necessary.
- Brain injuries - Severe brain injuries including bleeding, stroke and head trauma, may cause loss of consciousness, also called coma. Patients who are in a coma or who are at a high risk of coma are often watched and treated in the ICU until their condition becomes stable.
- Severe trauma - such as auto accidents, gunshot wounds and burns. These patients may have multiple injuries that require specialized treatment and monitoring.
- Major surgery - Patients undergoing major surgery, who need special monitoring or who are at high risk of having problems after the operation. They may have other serious health problems that can complicate care after surgery.
To the casual observer, the ICU would seem a good place for patients to stay all the time they are in hospital because of the high level of care. This is not the case, however, for the following reasons:
- Risks - ICU care involves a number of risks, especially of getting new infections. Since severe infections are common in critically ill patients, the longer a patient stays in an ICU, the greater is the risk of picking up an infection from other patients. Also, the bacteria causing these infections sometimes do not respond to antibiotics as well (these bacteria are called resistant strains).
- Expense - It is very expensive to provide constant nursing attention for patients who are getting better. Most ICUs have rules for deciding which patients need this special form of care and when they can be transferred to another hospital ward. This change is part of recovery.
Families should understand a simple fact: modern medicine has produced many amazing breakthroughs in the past 20-30 years, but there are many diseases that cannot be treated. Patients are treated in the ICU because they are at risk of dying without such care. Many people mistakenly believe that physicians, by using the most modern machines, are able to reverse the dying process. There are always patients who cannot be saved even by the most advanced care that is available. Doctors may be able to offer a rough idea of a patient's chance of surviving, but with much less than 100% accuracy. We stress that Medicine doesn't have all the answers. Also, the dedicated health care team providing this art and science are only human and as such are imperfect beings.
Critically ill patients and their families will have expectations of the health care workers. The following are among reasonable expectations:
- To Be Informed - It is reasonable to get the doctor's assessment of the problems which caused the need for care in the ICU. It is important to understand that it is not always possible to know the cause for an illness or why a disease worsens. Medical knowledge is incomplete despite new advances. Also, it often takes hours or days to get test results and to fit all the information together to make a diagnosis. You should expect to be told about major changes in your condition. You may ask about the assessment and treatment plan.
- To Speak with the Doctors - It is reasonable to have a chance to speak with the doctor on a regular basis. You should expect daily, or even more often, updates if you are very sick. While many doctors are involved, one primary attending doctor is always in charge and organizes the care plan.
- To Decide Whether Procedures Should be Performed - When you go into the hospital, you usually sign a paper, called a consent form, which allows doctors and hospital staff to give basic treatments (for example intravenous tubes, called catheters, placed into the veins of the body, blood draws, and administration of medicines). Critically ill patients may need certain procedures that require additional permissions. These procedures may be tests to help figure out what is wrong or treatments to relieve symptoms or resolve problems. To help you decide if you want a procedure, you should be told (or "informed") of the benefits and common risks. This process is called "informed consent." All procedures have risks and the doctor performing the procedure can review the common risks. The benefits are what good is expected to come from the procedure. This information may be provided by word of mouth, but is best to also have it in writing. Occasionally, life-saving procedures are performed in an emergency when delay would harm the patient and there is not enough time to contact family members for consent.
- To Ask for Second Opinions - In some hospitals, an ICU doctor who is "on-call" takes care of patients in the unit. In other ICUs, patients are cared for by their primary (family) doctor with the help of specialists. Occasionally, patients and the families may feel more comfortable if they can get a "second opinion." Most doctors will not be insulted if a patient or family member asks politely for another doctor to give a second opinion.
Sometimes, it is possible to have doctors and other health workers meet with the family in a group - what we call a "family meeting." Family meetings can be held at the bedside of the patient, when the patient is able to help in decision-making. A family meeting is a chance for family members to ask questions and discuss care with doctors and nurses. Such a meeting helps to ensure that everyone has a common understanding of the problems and current plan. The meeting may help family members make decisions about care, especially when the patient is too sick to make decisions.
Patients and families also have the obligation to conduct themselves in a courteous manner that is not disruptive to the ICU and the care of other critically ill patients.