This chapter illustrates the harmful impact of bed rest and immobilization on body systems, including the cardiovascular, respiratory, metabolic, neurological, and musculoskeletal systems. These changes are likely to contribute to Intensive Care Unit Acquired Weakness (ICUAW), which is an umbrella term for critical illness polyneuropathy, myopathy, and muscle atrophy. Other risk factors include illness severity, baseline characteristics, and social determinants of health, along with drug use and organ support during critical illness. ICUAW is currently diagnosed using the Medical Research Council Sum-Score which rates 6 bilateral muscle groups from 0 (no contraction) to 5 (normal strength); a score of less than 48 points out of 60 defines clinical weakness. ICUAW is associated with increased short- and long-term morbidity and mortality, making it a substantial contributor to poor outcomes after the ICU, including post-intensive care syndrome.

Because of advances in technology and the provision of critical care, an increasing number of patients are surviving critical illness; this growing population of survivors of critical illness is characterized by heightened vulnerability to a host of adverse health outcomes and by the development of multidimensional impairments that significantly impact their quality of life and societal participation. Post-intensive care syndrome (PICS) is defined as new or worsening impairments in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. PICS-Family describes the psychological and social impairments that family members, loved ones, and caregivers can develop as a consequence of their loved one’s critical illness. Survivors of critical illness are a heterogeneous patient population, and considerable variation exists with respect to the breadth, depth, duration, and mutability of their symptoms and impairments. This chapter explores the clinical manifestations of PICS, its incidence and prevalence, the co-occurrence of impairments in multiple domains, duration and severity of impairments, risk factors for its development, prediction tools, prevention strategies, screening and diagnosis, and treatment options. Additional topics include the biophysical model of disability, functional trajectories following critical illness, and the lack of communication about post-ICU problems.

In addition to symptoms classically associated with the post-intensive care syndrome (PICS), survivors of critical illness often report debilitating physical symptoms affecting their comfort and appearance. Fatigue and chronic pain are among the most common symptoms, and standardized scoring systems have been developed to measure these symptoms in survivors. Moreover, patients who undergo intensive care are at risk for joint contractures, heterotopic ossification, pressure injuries and ulcerations, sexual dysfunction, urinaruy complications, sensory deficits, and skin, hair, and nail changes. A thorough review of systems can identify patients in need of specialty care. Early identification and prompt treatment of symptoms may improve the quality of life for many survivors of critical illness.

This chapter describes the significant role that spiritual support plays for both the ICU patient and their loved ones. A hospital stay is a stressful time, and an ICU experience is traumatic. The severity of illness and the uncertainty of healing can precipitate existential questioning and increase reliance on faith. Intervention by a trained non-denominational chaplain can be an asset to an ICU team, offering patients and loved one’s psycho-spiritual support to diverse kinds of needs. As a spiritual care specialist, a chaplain can distinguish between spirituality – an internal search for meaning – and religiosity, often rooted in a structured belief system. Tools like the FICA model are used by chaplains to assess spiritual distress, and chaplains can train the ICU staff as “spiritual care generalists,” who can then identify spiritual distress and reach out to a chaplain if needed. The chapter also addresses the need for spiritual support in patients with Post Intensive Care Syndrome (PICS) and Post Intensive Care Syndrome – Family (PICS-F). Chaplains can be beneficial for both diagnoses.

Cognitive impairment in the ICU can have long-term, life-altering impacts well beyond the ICU and hospital stay. Cognitive impairment can be hard to identify in the complex medical setting of the ICU, but the systematic use of standardized screens and assessments can alert the write as healthcare team to cognitive impairment. Patients with disorders of consciousness benefit from cognitive stimulation interventions. For patients awake and alert, cognitive intervention strategies include cognitive training (e.g., word search, memory match) and cognitive rehabilitation (e.g., ADL and IADL performance). Early engagement in activity in the ICU can help improve overall performance. One component of rehabilitation is functional cognition, defined as the process of utilizing and integrating thinking and processing skills to accomplish everyday activities. Assistive technology is another tool that can help patients with tasks from communication to complex problem solving and executive functioning. Cognitive stimulation, training, and rehabilitation all work toward decreasing the impact of cognitive impairments and improving overall function and quality of life. Examining patients’ performance through real-life functional tasks help to generalize these skills.

This chapter provides insights on physical rehabilitation in the intensive care unit (ICU) and on the general wards, covering the current evidence based on landmark randomized controlled trials and systematic reviews of the field. Progressive mobilization and the use of assistive technology devices provide opportunities for physical rehabilitation in the ICU and across the hospitalization, including strategies such as stepwise mobility, active exercises, passive mobilization, cycling, and neuromuscular electrical stimulation. Physical rehabilitation of patients in the ICU comes with inherent risks, and the identification of safety criteria is critical to mitigate the occurrence of adverse events related to mobilization. The use of physical functioning instruments as a component of rehabilitation is important to screen patients at risk of poor physical outcomes, monitor rehabilitation efficacy, and predict recovery trajectories.

From a panel of leading experts in the late 1980s to modern day international consortiums, ICU follow-up clinics have experienced significant growth and have been a catalyst for much of the research that continues to drive this field forward. This chapter details the origins of the first ICU follow-up clinics through to conteomporary global collaborations of clinics designed to enhance clinical care, patient and provider education, and research.

This chapter serves to identify barriers and solutions for PICS clinic formation and success. Systematic identification of patients with PICS risk factors and their stakeholders in care can facilitate education about the pathophysiology of PICS during hospitalization. Early clinic team contact with the patient and their care stakeholders increases clinic recruitment and reduces attrition through clarifying the need and purpose of the clinic. Secondary to the patient’s medical complexity and progression through hospitalization, rehabilitation, and home, there are inherent risks for gaps in care. These gaps can be bridged with an interdisciplinary screening process and transition of care plan.

Survivors of critical illness are at increased risk for the development of functional impairments, including difficulties performing activities of daily living and instrumental activities of daily living. This chapter explores the role of occupational therapy (OT) in the rehabilitation of patients impacted by post intensive care syndrome (PICS). Specific evaluation tools used by occupational therapists that can be assess PICS patients to identify their impairments in the key areas of physical, cognitive, and mental health are described. Thereafter, interventions used by occupational therapists to remediate identified impairments and maximize independence are described, derived from a combination of evidence-informed practice in similar patient populations and current empirical evidence for PICS rehabilitation.

Age-Friendly Health Systems include hospitals, clinics, and long-term care facilities that provide state-of-the art care to older adults. They organize care around 5 core principles known as the 5Ms: Mobility, Mentation, Medications, Multicomplexity, and What Matters Most. The 5Ms have not been applied previously to care delivery for older adults with post-intensive care syndrome (PICS); thus, this chapter offers a novel, interprofessional 5Ms approach to evidence-based care delivery for older adults with PICS. The first section provides essential background on interpreting evidence about PICS through the lenses of ageism (bias related to age) and ableism (bias related to disability status). Each of the next five sections explains one of the 5Ms constructs and summarizes relevant evidence related to PICS. The final section summarizes offers a vision linking Age-Friendly Healthcare, Age-Friendly Communities, and Age-Friendly Public Health after critical illness.

Critical illness is a life-altering experience for both patients and families. Although patients and families have shared priorities for recovery, they also have unique lived experiences that require individualized attention and validation after critical illness. Patient and family needs are dynamic and evolve over successive phases of critical illness recovery. In general, patients and families desire structured, proactive supports that address distinct informational, emotional, appraisal, instrumental, social, and spiritual needs. Timely, consistent, and clear communication across all phases of recovery is key to fostering trust and resilience. The “Timing-it-Right” framework is a useful model to guide recovery-oriented care programs from the hospital ward to community setting. Critical illness recovery programs should be holistic, coordinated, and prioritize functional goals and quality of life. Future research on critical illness recovery should engage diverse patient and family perspectives and incorporate quality of life outcomes that matter to patients and families. Common themes in patient and family experience may provide guidance for clinicians, researchers, and health systems looking to support critical illness recovery.

While much of this book has been focused on describing post-intensive care syndrome (PICS) in objective terms, is if often the personal stories of survivors of critical illness and their loved ones that are so much more revealing than the distance walked during 6 minutes or a score on a cognitive test. It was not until I began seeing patients in my ICU follow-up clinic that I truly appreciated how life-changing an experience surviving critical illness could be. Understanding the real-life impact of the physical, functional, cognitive, psychiatric, and social impairments that those suffering from PICS face is a profoundly moving and motivating experience. For that reason, I wanted to close this book with stories of survivors of critical illness and their loved ones, allowing the reader to synthesize and contextualize the objective data that has heretofore been presented in neatly parsed, individual chapters and to more deeply appreciate how that data translates into a much more impactful lived experience.

Effective post-ICU recovery requires empathetic exploration of the ICU experience and a detailed evaluation of the unique challenges and symptoms faced by survivors of critical illness. Utilizing palliative care techniques in this evaluation helps clinicians identify unmet needs and coordinate post-ICU management around patient-centered goals. Several palliative care tools and techniques may be used by ICU follow-up clinic providers without specialized palliative care training. Screening tools like the Edmonton Symptom Assessment Scale and Palliative Performance Scale may help clarify post-intensive care syndrome (PICS) symptoms and prognosis, while communication techniques like Ask-Tell-Ask and NURSE emotional response statements may offer insight into patient values and expectations in the post-ICU setting. The implementation of primary palliative care techniques in ICU follow-up clinics may additionally aid in the completion of documents like Advance Directives, which help clarify patient wishes. Specialized palliative care referral may be considered in situations with unmet needs, such as severe physical symptoms, existential distress, and prognosis less than one year. Integration of palliative care principles into the evaluation and management of PICS may ultimately facilitate meaningful recovery in survivors while fostering the concept of post-traumatic growth after critical illness.

Cardiac arrest survivorship is a burgeoning phenomenon, largely driven by advances in intensive care and widespread public health campaigns aimed at improving resuscitation outcomes. However, the specific risk factors, mediators, and effective interventions that support long-term survivorship and recovery remain insufficiently understood and are the focus of ongoing research. Survivors of cardiac arrest face multifaceted challenges that affect various aspects of health, including physical, cognitive, psychological, and social well-being. Psychological distress, cardiac anxiety, and the stability of the family unit following cardiac arrest emerge as key factors influencing recovery. Targeted interventions that address the distinct phases of critical illness and recovery following cardiac arrest are crucial and warrant further investigation and implementation.

Survivors of critical illness are at risk for severe negative health outcomes, including an increased risk for mortality in the first several years following their index hospitalization and an increased risk for hospital readmission. recovery trajectories among survivors of critical illness vary considerably, with some patients recovering to near baseline functional status and others entering a cycle of readmissions, disease exacerbations, and prolonged chronic critical illness. Moreover, critical illness has been found to be associated with an increased risk of the development of new chronic diseases, including cardiovascular, pulmonary, neuroloigcal, and renal diseases, as well as worsesning of pre-existing chronic conditions. Given these increased risks, it is no wonder that survivors of critical illness–many of whom may spend more time in a hospital-like setting than at home–have high rates of healthcare utilization. Recognizing these risks can provide a basis for early diagnostic testing and referral for specialty care as needed. Understanding the association of critical illness with subsequent mortality, chronic illness, and healthcare utilization can provide a foundation for the skilled care of survivors of critical illness.