Intensive care unit (ICU) admissions create immense psychological challenges for patients and their loved ones. With increasing recognition of the psychological impact of an ICU admission, qualified psychologists have been incorporated into the care team both to address acute psychological stress during the admission and to help prevent continuing psychological difficulties after hospital discharge. This chapter describes the direct work that ICU psychologists do with patients, the support they provide for families, and other indirect ways they contribute to improving communication, psychological understanding, and the therapeutic environment in the ICU. Psychologists use a range of evidence-based approaches in their ICU work, including interventions based on cognitive behavioral therapy (CBT). Research into the most effective ways of delivering psychological interventions in the ICU is still in its infancy and should be prioritized now that psychological professionals are increasingly engaged with ICU teams.

Post-Intensive Care Syndrome (PICS) refers to the wide array of physical, cognitive, and psychological symptoms that a patient may experience following an acute illness. Persistent dysphagia is one significant concern that may remain following a patient’s discharge from the hospital. In these instances, the patient will be referred to a speech-language pathologist for outpatient dysphagia therapy services. Swallowing rehabilitation following discharge from the ICU is managed by a team of medical professionals, with the SLP acting as a coordinator for the interdisciplinary team. Referrals may be placed to psychologists, dietitians, and neurologists, amongst other professionals. Outpatient services begin with an initial evaluation that involves several components, including medical chart review, case history, oral mechanism exam, and bedside swallow exam. The patient may also be referred for an instrumental swallowing assessment to allow for direct visualization of the oral and pharyngeal phases of the swallow. Based on the evaluation results, a comprehensive treatment plan will be developed that includes restorative swallowing exercises, compensatory strategies, and diet modifications. Technology may also be incorporated into therapy sessions for maximum benefit.

In medical ethics, there is a well-established debate about the authority of advance directives over people living with dementia, a dispute often cast as a clash between two principles: respecting autonomy and beneficence toward patients. This chapter, in highlighting underexplored issues of power and social status, argues that there need be only one principle in substitute decision-making: determining authenticity. This principle favours a substituted judgment standard in all cases and instructs decision-makers to determine what the patient would authentically prefer to happen – based not merely on the patient’s decisions but also on their present settled dispositions. Adhering to this principle entails that, in a significant range of cases, an advance directive can (and indeed ought to) be overruled.

Postvention describes the support offered after suicide bereavement to mitigate the risk of suicide in those affected by the loss. In this chapter we describe the international epidemiological evidence about the impact of suicide on relatives, friends, and other close contacts of the deceased. This includes an elevated risk of depression and suicide, and other adverse physical health and social outcomes. We describe the practice of postvention as it applies to recommended responses to suicide in clinical and community settings, and the evidence to support this. Whilst there is a lack of evidence to support the effectiveness of postvention in preventing suicide specifically, there is evidence that it improves the mental health and social outcomes likely to mediate suicide risk. Clinicians who encounter suicide-bereaved individuals should be aware of resources available to people affected by suicide loss, described here, including digital resources in the public domain.

Post-COVID condition (PCC) describes new or worsening symptoms that develop after initial SARS-CoV-2 infection and are persistent for months without alternative explanations. Common PCC symptoms include post-exertional malaise, fatigue, breathlessness, cough, dizziness, “brain fog,” and gastrointestinal symptoms, and they may occur in upwards of 10% of patients infected with SARS-CoV-2. The physical, cognitive, and mental health sequalae seen in post-intensive care syndrome (PICS) are also common in PCC, particularly in COVID-19 patients that have survived critical illness. The pathophysiology of PCC remains poorly understood. Patients’ symptoms should be managed aggressively; management has significant overlap with the treatment approach to PICS patients. Dedicated PCC clinics or combined PICS/PCC clinics should include specific expertise in the diagnosis and management of symptoms relating to COVID-19, including fatigue, dyspnea, exertional intolerance, GI discomfort, psychological sequelae, and cognitive dysfunction, and actively collaborate with an interdisciplinary team of clinicians and staff with PCC expertise.

The introductory chapter outlines the book’s central premise: disabled people have as much right to live in the world as the non-disabled. It introduces the human rights and critical disability studies methods used to interrogate the problem of disability discrimination throughout the life cycle, especially at the beginning and end of life. Along with providing an overview, the introductory chapter argues that the book is particularly needed because disability equal rights struggles remain marginal in mainstream bioethics and law.

Suicide is a global phenomenon, with implications for HICs and LMICs alike, bec,ause of interconnectedness. Social injustice increases societies’ suicide risk and it is easily and frequently exported. Suicide is preventable but not always individually. Suicide prediction is difficult or impossible, so those measures that effect everyone work best. Hence assuring good quality, timely mental health coverage for the whole population is important. Those with the least resources must be targeted, as they are at greatest risk..

Suicide prevention requires a systematic approach to develop a framework that brings together different elements of a prevention strategy, including surveillance, mental health service access, restriction of lethal means, and public awareness campaigns. Originating with Finland's pioneering efforts in the 1980s, such strategies have since expanded worldwide, driven by the World Health Organization's call for action and alignment with the Sustainable Development Goals. It is imperative that these programmes/strategies are evidence-based, informed by local research, continuously monitored and regularly evaluated for effectiveness. By developing suicide prevention programmes/strategies, governments around the world show their commitment to mitigating preventable deaths, underscoring the need for sustained funding, leadership, and research-driven implementation.

This chapter provides an overview of suicidal behaviours and suicide prevention strategies among minority groups, including refugees, migrants, asylum seekers, and internally displaced persons (IDPs). The chapter highlights the interplay of cultural and gender diversity in shaping suicidal behaviours and emphasizes the need for tailored interventions that address the specific challenges faced by these populations. It reviews the existing literature on the prevalence of suicide among minority groups in both high-income countries (HICs) and low- and middle-income countries (LMICs), examining the role of cultural factors, gender-based violence, and mental health issues. The chapter also discusses suicide prevention strategies in humanitarian settings, such as community engagement, gatekeeper training, cultural adaptation of interventions, and the importance of integrating mental health services into primary healthcare services. The chapter highlights evidence-based practices recommended by research, the Inter-Agency Standing Committee (IASC), and the World Health Organization (WHO). The conclusion underscores the need of a comprehensive, culturally sensitive approach and calls for further research, increased investment in mental health infrastructure, and the development of gender-sensitive strategies to reduce the burden of suicide among minority groups in humanitarian contexts.

Advocacy for Post-Intensive Care Syndrome (PICS) is a critical component of supporting the recovery of survivors of critical illness. Despite its importance, a shared understanding of PICS advocacy remains underrepresented in medical literature. This chapter defines PICS advocacy as an ethical commitment to patient- and caregiver-centered care, encompassing three key dimensions: supporting individuals living with PICS, promoting awareness and prevention within medical and lay communities, and advancing the science surrounding this condition. Current advocacy efforts occur across various levels, including local communities, national organizations, and global collaborations. Central to these efforts is awareness, facilitated by a growing array of educational resources such as books, podcasts, and websites. However, PICS advocacy can further benefit from large-scale public awareness campaigns modeled after successful initiatives by organizations like the American Heart Association and the American Cancer Society. These efforts could amplify public understanding and drive systemic change. Individuals are encouraged to take an active role in PICS advocacy, and this chapter offers practical strategies for engagement. By empowering individuals to champion PICS awareness and support, the healthcare community can foster a more inclusive approach to addressing this condition. Advocacy for PICS is not just a responsibility–it is an opportunity to transform care and improve outcomes for survivors and their families.

Delirium, which is an important risk factor for post-intensive care syndrome (PICS), is common during critical illness, affecting between 20% and 80% of patients. It is associated with numerous adverse outcomes, including longer time on mechanical ventilation, longer time in the intensive care unit (ICU) and hospital, death, and long-term cognitive impairment. Delirium in the ICU can be reliably detected using multiple tools, including the Confusion Assessment Method in the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). The exact cause of delirium, however, remains elusive even though there are many purported mechanisms, including neuroinflammation, metabolic insufficiency, neuronal dysfunction, and neurotransmitter disturbances. Due to knowledge gaps regarding the mechanism(s) of delirium, effective medical treatments for delirium also remains elusive. Current practice involves the prevention of delirium through the recognition and management of modifiable risk factors. The well-studied ABCDEF bundle is one such strategy, which is primarily non-pharmacologic, to prevent or mitigate delirium and thus limit its adverse outcomes. Unfortunately, delirium still occurs at a high rate, and the work to understand the underlying mechanism and its varied manifestations and to develop an effective treatment continues.

Pediatric critical illness survival has soared in high-income countries while intensive care infrastructure is improving in lower- and middle-income countries. The framework of Post-Intensive Care Syndrome- pediatrics (PICS-p) encompasses new impairments in cognitive, emotional, physical, social, and family health of the critically ill child across the developmental span. Notably caregivers and siblings may additionally experience PICS-p as a result of their relationship with critically ill children. Single or multi-domain impairments occur in the face of pre-existing, ICU-based, and post-ICU risk factors and may be long-lasting and affect development. Prevention and treatment interventional evidence is growing but key knowledge gaps and validation trials are lacking.

After discharge from the intensive care unit (ICU), it is often assumed that a patient’s appetite, weight, and nutritional status will return to premorbid levels with minimal intervention. Malnutrition is common following critical illness, and multiple barriers exist to nutrition rehabilitation following hospital discharge, which are often recognized and understood in this vulnerable patient population. Such barriers include appetite and weight loss, early satiety, gastrointestinal disturbances, altered taste and smell, dysphagia, and the constellation of physical, functional, cognitive, and psychosocial challenges known as the post-intensive care syndrome (PICS). Registered dietitians (RD) can direct the continuity of nutrition care essential to supporting recovery from critical illness, with the goal of helping patients regain muscle mass, strength, and independence. Education and partnership with the patient, family, and medical team are required for the best outcomes in nutrition recovery. Nutrition rehabilitation will be explored after discharge from the hospital by addressing the barriers and strategies to guide the patient toward success.

Chapter 6 examines the regulation of access to controlled and prohibited substances for symptomatic relief and palliative care. It argues that restrictive drug control policies, especially uniform drug prohibition, are incompatible with disability rights because they are discriminatory against disabled people in pain. The chapter concludes that permitting a wider range of controlled substances to be accessed by people with impairments, especially those eligible for assisted dying, strengthens their right to live in the world by giving them greater options to live with their conditions.