Original article
Psychological wellbeing, health related quality of life and memories of intensive care and a specialised weaning centre reported by survivors of prolonged mechanical ventilation

https://doi.org/10.1016/j.iccn.2013.11.002Get rights and content

Summary

Objective

To compare memories and recall of intensive care unit and specialised weaning centre admission, characterise health-related quality of life and psychological morbidity, and examine the relationship between delusional memories and psychological outcomes.

Methods

We recruited participants following hospitalisation that included ICU admission and subsequent weaning in a specialised centre. We administered validated questionnaires to assess memory and recall of both care locations, anxiety, depression, post-traumatic stress symptomatology and health-related quality of life.

Results

Of 53 eligible patients discharged from the weaning centre over seven years, we recruited 27 participants. Participants had similar numbers of factual and feeling memories but reported more delusional memories for ICU than the weaning centre (1.6 vs. 0.7, P = 0.004). Nine (39%) participants scored ≥11 on the hospital anxiety and depression scale (anxiety) and were more likely to experience delusional memories (P = 0.008). Thirst (70%), no control (70%), noise (65%) were most frequently recalled ICU experiences. Procedures (83%), night awakening (70%), inability to sleep (70%) most frequently recalled from the weaning centre.

Conclusion

Delusional memories and anxiety disorder were prevalent and associated suggesting interventions to ameliorate delusional memories may reduce anxiety. Difficulty sleeping and thirst were common experiences.

Introduction

Patients experiencing prolonged mechanical ventilation (PMV) are at risk of psychological morbidity due to difficulty communicating, anxiety and dyspnoea during weaning trials, and concerns about long-term prognosis (Arslanian-Engoren and Scott, 2003, Engström et al., 2013). Jubran and colleagues found 42% of 336 PMV patients undergoing daily weaning trials had depressive disorders (Jubran et al., 2010a) and in a sub-study of 41 successfully weaned patients, 12% met diagnostic criteria for posttraumatic stress disorder (PTSD) (Jubran et al., 2010b). Anxiety is also highly prevalent when undergoing mechanical ventilation (Chlan, 2003), during weaning trials, and in intensive care unit (ICU) survivors (Kress et al., 2003, Tate et al., 2012). Emotional distress and psychological morbidity remain a significant problem for ICU survivors for months to years after hospital discharge (Adhikari et al., 2011, Myhren et al., 2010, Ringdal et al., 2010).

In addition to fear and panic associated with dyspnoea and weaning, patients report anxiety due to distorted perceptions and delusional memories of ICU admission (Engström et al., 2013). Unpleasant and sometimes delusional memories have been reported by 25–75% of ICU survivors (Jones et al., 2001, Ringdal et al., 2006, Samuelson, 2011). Studies in trauma (Ringdal et al., 2009, Ringdal et al., 2010) and mixed ICU populations (Badia-Castello et al., 2006, Jones et al., 2001, Jones et al., 2007) demonstrate an association between delusional memories and worse psychological outcomes including anxiety, depression, and PTSD. Delusional memories also have been associated with prolonged ICU stay and PMV (Myhren et al., 2009), worse baseline severity of illness, increased sedation (Ringdal et al., 2009, Samuelson et al., 2006, Samuelson et al., 2008) and analgesic medications, infections, and fever (Capuzzo et al., 2004). Conversely, facilitation of increased factual memories using strategies such as sedation minimisation, sleep promotion, and restoration of day-night cycle may decrease delusional memories and reduce psychological morbidity (Jones et al., 2001).

Specialised weaning centres (SWCs) admit patients from ICUs experiencing PMV, generally more than 21 days, and multiple failed weaning attempts. Their objective is to provide an alternative care venue to the ICU that not only facilitates weaning but also improves psychological well-being (MacIntyre et al., 2005). In comparison to ICUs, characteristics of SWCs likely to ameliorate the possible psychological impact of ICU admission include: restoration of the day–night cycle, minimal or no sedation, less exposure to potentially disturbing events occurring to other patients, increased privacy, liberal visitation policies, promotion of independence and individuality, and greater access to psychological services (MacIntyre et al., 2005, Rose and Fraser, 2012). For these reasons survivors of admission to both an ICU and SWC may have different memories and recall of stressful experiences which may impact psychological wellbeing. Our objectives were to describe memories and recall of stressful experiences of the ICU and the SWC, to characterise health related quality of life (HrQoL) and psychological morbidity, and to examine the relationship between delusional memories and psychological outcome.

Section snippets

Patient selection and study sample

Potential participants were identified through the Prolonged-ventilation Weaning Centre (PWC) database. The PWC is an 8-bed unit within an acute care hospital (Toronto East General Hospital (TEGH)) situated in Ontario, Canada that accepts referrals from ICUs across the province. Admission criteria comprise prior ventilation for ≥21 days in an ICU, medical stability, and considered ‘weanable’ within 90 days (maximum programme duration) (Rose and Fraser, 2012). The interprofessional programme

Results

Of the 136 patients receiving an episode of care in the PWC from inception to June 2011, 66 had died and a further 17 had phone contact details no longer in service meaning we were unable to confirm if they were alive. Of the remaining 53 patients, 12 did not respond to recruitment strategies, 13 refused and 1 did not return mailed questionnaires, resulting in 27 participants. Median participant age was 68 years, 41% were female. The median time from PWC discharge to questionnaire completion

Discussion

This study identified delusional memories and psychological morbidity were prevalent in this small cohort of ICU survivors experiencing care transition to a SWC. To our knowledge, this is the only study to describe prevalence of delusional memories from two care environments in the trajectory of recovery from critical illness. Delusional memories of the ICU were more common than of the SWC. This may be because patients are less severely ill and no longer receive sedative agents after transfer,

Conclusion

This study adds to the growing body of literature documenting considerable psychological morbidity in ICU survivors. Delusional memories and anxiety were prevalent and associated with each other suggesting interventions designed to ameliorate delusional memories may reduce anxiety. Difficulty sleeping, thirst, missing family/friends and trouble communicating were common experiences suggesting patient and family centred interventions are needed. Participants continued to experience anxiety for

Funding

This study was funded by the Toronto East General Hospital Community Based Research Fund. The funder had no role in the design and conduct of the study, data analysis or preparation of this manuscript.

Conflict of interest statement

The authors have no conflict of interest to declare.

Acknowledgement

We would like to thank Dr Alex Kiss for his assistance with statistical analysis.

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