Care of the Caregiver in the ICU and After Critical Illness

KEY POINTS

Fifty percent (50%) of physicians and nurse caregivers working in intensive care units (ICUs) are reported to experience burnout. Physician burnout is attributable to the number of working hours (number of night shifts, and vacation time and frequency), whereas burnout among ICU nurses is mainly related to ICU organization and end-of-life care policy.
ICU conflicts are independent predictors of burnout for both physicians and nurses. Recent studies identify potentially effective preventive measures. Despite identification of associations and triggers, no prospective study addresses the issues of impact on quality of care or caregiver outcome, or effective management strategies once burnout occurs.
Standardized communication strategies appear key to ensure safety, effective functioning, and harmonious end-of-life decision making and care; physicians may not be natural leaders in establishing interprofessional intensive care communication strategies. Communication should be considered a safety feature on par with infection control, and requires organization and buy-in from all stakeholders.
The specific context of pandemics and natural disasters impose a greater burden on critical care staff and require planning and postevent debriefing and caregiver follow-up.
The stress experienced by trainees exposed to critical care is essential to learning. Reflexive learning and the use of the narrative are useful in contexts where emotion and morality are part of the critical caregiver’s experience.

INTRODUCTION

Caring for the sick can strain critical care caregivers. Long working hours and sleep deprivation can exhaust even the most energetic physicians. Death is a constant companion to all critical care nurses, trainees, and doctors. Treatments are proffered, and decisions made that alter whether patients live or die. Families accompany patients, bringing with them their sorrow, anxieties, and conflicts. Teamwork, which is at the center of caring for the critically ill, can be disturbed by individuals, local culture, and demands exceeding the physical or organizational capacities of its members.

Although the stress experienced by critical care nurses has been explored in the nursing literature for decades, the first publication addressing stress lived by intensive care unit (ICU) physicians only appeared in 1986.¹ Burnout, a negative consequence of stress, and of the individual’s response to it, is now understood to affect ICU physicians² and nurses³ frequently. Its incidence among physicians is roughly 50% and correlates with overall burnout rates among all (critical care and noncritical care) physicians. This correlation suggests that despite stressors inherent to critical illness and its technology-focused environment, the balance between effort and reward⁴ may be no different than in other environments.

The correlation between stressors, burnout, and job dissatisfaction, and the personnel shortages in critical care should make stress and burnout a policy-driving issue, in addition to a caregiver’s health issue. Calls for recognition by professional societies, better organization, and proactive resolution of stressors within individual intensive care units⁵ have not affected the daily challenges faced by caregivers. No prospective studies have validated the effectiveness of interventions that aim to minimize ICU physician burnout. Although several studies describe the point prevalence or self-report⁶ of burnout symptoms—with the limitation that self-reported angst may not correlate with psychological health⁷—no longitudinal studies of the natural history of burnout over time could be found at the time of this writing. Some data suggest that nurses can gain insight into stress and coping with it from educational seminars,⁸ but whether this translates into long-term benefit to them, physician trainees, or other medical staff is not clear.

Nurses report futility in aggressive care as an important stressor,⁹ and conflict and lack of communication as important determinants of professional well-being. Physicians, on the other hand, are more affected by workload, conflict and communication issues with peers, but not by communication with nurses.¹⁰ Caregiver gender,¹¹ resilience,¹² and personality¹³ probably play a role in handling work-related challenges and developing burnout as well. A healthy work climate can improve personnel retention and professional satisfaction in all team members.¹⁴ Effective multidisciplinary teams are associated with lower patient mortality.¹⁵ Conversely, and in the context of the medical crises that characterize critical care, entire team performances and perceptions can be affected by one or more individuals.¹⁶ A healthy professional environment thus seems a sensible goal from every perspective. Strategic implementation of communication strategies around end-of-life issues minimize conflict and appear to improve burnout rates.¹⁷ Once burnout occurs, no intervention has unequivocally been shown to be effective.¹⁸

Additional tension can be placed upon entire health care delivery systems in situations of natural disaster, such as those experienced by caregivers during Hurricane Katrina in New Orleans in 2005, or during outbreaks of infectious diseases during which more patients require mechanical ventilation, such as those experienced by Toronto teams during the SARS outbreak in 2004, or the H1N1virus in Montreal and Winnipeg in 2009. Such situations place two specific kinds of pressure on caregivers. The first is related to the sudden increase in the gap between demand and the capacity to accommodate critically ill patients. Triage of patients to select those most likely to benefit from critical care resources is in direct conflict with the covenant of trust between physicians and their patients. Models of triage, including third-party decision making, have been developed with the hope of aiding health care professionals with these difficult choices.¹⁹ The failure of these models to predict outcome accurately²⁰ mirrors the poor performance of clinicians in predicting outcome in individual patients,²¹ and adds to the potentially challenging uncertainty that critical care caregivers face daily. The second stressor is the risk of exposure to infection during outbreaks such as SARS and H1N1, and the variety of responses among physicians and nurses. Moral and professional obligation should apply to all members of an ICU team and to those providing them with protective equipment equally. When some workers come in to work and others do not, and some caregivers are infected with the epidemic virus, considerable tension emerges in the postcrisis period. Both of these situations (disasters and pandemics) constitute a small proportion of what critical care caregivers will face in a professional life span, but warrant mentioning because they have all the elements to provoke strain beyond that experienced under “normal” circumstances. Whether critical care caregivers are at risk for developing posttraumatic stress disorder or other adaptation difficulties, much like caregivers returning from war zones, is not clear.

This chapter will focus on two common areas described as challenging by nurses and physicians alike and which are specific to the critical care setting. These two areas are chosen empirically from a review of stressors in the critical care literature associated with burnout and caregiver distress, because of their frequent occurrence and relative importance in the context of the critically ill. The first is establishing the level of care in a critically ill patient—withholding, withdrawing, or limiting critical care support. The second relates to effective communication.

In ICUs, considerable time and effort are devoted to delivering bad news, discussing the level of care to be provided to patients, discussing end-of-life (EOL) topics²²

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