Sleep disturbances frequently precede and are exacerbated by critical illness, persisting well into the recovery phase. These issues are prevalent among ICU survivors and can aggravate physical, cognitive, and psychosocial symptoms associated with Post-Intensive Care Syndrome (PICS). This chapter reviews the outpatient evaluation of patients experiencing sleep problems after ICU discharge, emphasizing the importance of addressing sleep issues as part of a comprehensive PICS assessment. Recent studies reveal high prevalence of sleep disturbances following the ICU, with symptoms such as difficulty falling asleep, poor sleep quality, and nightmares. Insomnia, excessive daytime sleepiness, and obstructive sleep apnea (OSA) are also common post-ICU issues. Evaluation should include assessing sleep quality, reviewing medications, and screening for common sleep disorders. Cognitive Behavioral Therapy for Insomnia (CBT-i) is recommended for chronic insomnia, while imagery rehearsal therapy is suggested for PTSD-related nightmares. Additionally, OSA screening is crucial due to its potential impact on recovery and quality of life. Addressing these concerns through an ICU follow-up clinic may improve patient outcomes, enhance recovery, and mitigate the long-term effects of critical illness on sleep and overall health.

The refusal and withdrawal of life-sustaining treatment and care by, and on behalf of, people with impairments are the focus of Chapter 4. The chapter argues that greater attention must be given to the socio-economic contexts in which these non-treatment decisions are made. It also argues that the selective non-treatment of disabled infants and the non-consensual withholding and withdrawal of life-sustaining care from people with disorders of consciousness are incompatible with disability rights. The chapter concludes that disabled people, and their health care proxies, should not simply have rights to refuse or withdraw life-sustaining interventions, they must also have rights to request life support.

With advances in critical care technology, survival of acute critical illness has risen drastically, and many of these patients experience persistent deficits in physical and cognitive functioning, termed post-intensive care syndrome (PICS). This chapter provides a comprehensive overview of the pathophysiologic underpinnings of PICS. Perturbations during acute critical illness and early in recovery can have downstream and long-lasting effects. The immune response response is dysregulated with perturbations in both proinflammatory and immunosuppressive pathways. This dysregulation is more pronounced in patients who go on to have worse functional outcomes. Immune dysregulation also contributes to neuroinflammation, blood-brain barrier dysfunction, and disruptions in brain white matter leading to cognitive impairment. Transcriptomic analyses reveal massive shifts in gene expression, with aberrant expression of many genes related to the inflammatory response and extracellular matrix deposition, which clincially correlate with ICU-related complications, such as ICU-acquired weakness. Furthermore, sepsis and inflammation act together to disrupt the microvasculature, which further contributes to organ failure and ICU-acquired weakness. Mitochondrial dysfunction and ubiquitin-proteasome overactivation accelerate skeletal muscle catabolism and can also contribute to weakness. Finally, disruptions in the gut microbiome can disturb blood-brain barrier permeability and alter gene transcription associated with skeletal muscle growth and function. These perturbations interact deleteriously, resulting in the phenotype of PICS.

More than five million individuals in North America experience an episode of critical illness annually, and among those who survive, as many as a third experience substantial cognitive impairment, which often lasts long after discharge and can be permanent. While cognitive impairment after critical illness has been widely studied for two decades, much remains unknown, and the insights that have been generated by research often fail to inform clinical care. Key issues germane to understanding and optimally treating ICU survivors with cognitive deficits include: improving methods of early detection and screening, honing and implementing cognitive rehabilitation strategies, and better understanding the trajectories of impairments observed in patients. Prioritizing the brain health of individuals after critical care both through prevention and thoughtful interventional efforts remains a key public health goal and one that can only be accomplished through careful and deliberate interdisciplinary efforts.

An intensive care unit admission (ICU) can have a profound impact on patients and their families and loved ones. Most people experience heightened emotions, both negative and positive, during their time in the ICU. We know that the experiences that patients have in the ICU affect their psychological recovery and quality of life after hospital discharge. Risk factors for later psychological difficulties include acute stress and disturbing memories associated with the ICU; clinical factors, such as duration of sedation and delirium; and socio-demographic factors, such as age, gender, and socio-economic status. Patients have to deal with a range of challenges in the ICU, including illness-related, environment-related, and interpersonal stressors. ICU staff, including psychologists, should recognize common sources of distress and aim to alleviate patients’ stress through enhanced communication techniques and psychological interventions. Studying the coping strategies of patients who have a more positive experience during their time in the ICU is a promising way to help reduce stress and improve outcomes of intensive care.

Chapter 2 focuses on the regulation of selective abortion following prenatal screening and testing. It argues that disability-selective abortion bans may appear to be compatible with disability rights but that such bans are ultimately misguided because they fail to recognise the socio-economic context in which reproductive decisions are made by prospective parents. The chapter concludes that disability-inclusive abortion laws would not legally entrench differential time limits for pregnancy termination based on foetal impairment: if disabled foetuses can be aborted until birth, then the same should apply to non-disabled foetuses.

Intensive care has been one of the marvels of modern medicine. For centuries, many conditions like septic shock, major trauma, or acute decompensations of chronic pulmonary, cardiac, or liver disease, carried a terrible prognosis. But, with the development and dissemination of modern intensive care systems, the ability to rapidly evaluate and resuscitate patients and to provide vital organ support, such as mechanical ventilation, has led to dramatic reductions in hospital mortality rates. A side-effect of this success, however, is the ever-growing population of individuals who survive life-threatening illness only to face a long and protracted road to recovery.

The scope of this chapter is to provide an overview of the relationship of substance use disorders (SUD) and suicidal behaviour. The epidemiology of substance use disorders and suicidal behaviour is extensively and critically reviewed in general and clinical populations. The mediating mechanisms for this association are examined.

The findings strongly indicate that SUD is a robust risk factor for suicidal behaviour: It is remarkable that the contribution of SUD to suicidal behaviour is universal except for few variations in the association of SUD with suicidal behaviour between high-income and low-income and middle-income countries.

The regulation of embryo testing, selection, and gene editing, as part of assisted reproduction, is the focus of Chapter 3. The chapter argues that restricting or prohibiting the transfer of embryos with impairments during assisted reproduction is incompatible with disability rights. It also argues that if embryos can have their impairments removed through gene editing, then preventing the creation of disabled embryos would be incompatible with regulating assisted reproduction in a disability-inclusive manner.

Social determinants of health (SDOH) are defined as the non-medical factors that influence health outcomes. As the conditions in which people are born, live, learn, work, play, and worship, SDOH can impact risk for critical illness, the experience of critical illness, and their prognosis and recovery. SDOH may further impact survival after critical illness given the risks of vocational disability, loss of income, familial and financial costs of medical care, and social isolation. A holistic approach to treating critical illness facilitates coordination of collaborative care to identify and address SDOH. Social workers have particularly essential roles in critical illness, and can contribute to the research, policy, and practice efforts to improve the recovery process and outcomes for survivors of critical illness. This chapter summarizes the relationship of SDOH to survivorship following critical illness, and prioritizes the role of the social worker to identify and address SDOH.

Post-Intensive Care Syndrome (PICS) has rarely been studied in survivors of acute neurologic injury (ANI) due to the difficulty in determining what is attributable to the neurological injury versus what is attributable to the hazards of hospitalization and critical illness. Nevertheless, patients and their families do likely still experience PICS and PICS-Family (PICS-F). There is a growing movement to address the experiences of these patients along the care continuum giving rise to post-ICU neurorecovery clinics. We first focus on discussing the specific recovery trajectories and chronic sequelae of common neuro ICU admissions, including subarachnoid hemorrhage (SAH), status epilepticus (SE), traumatic brain injury (TBI), and spinal cord injury (SCI). Following this, we describe the specific utility of a post-ICU clinic to address the unique challenges of neuro ICU survivors.