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We discuss the field of rehabilitation psychology, and how it can help patients with persistent critical illness, with Dr. Megan Hosey (@DrMeganHoseyPhD), clinical psychologist and assistant professor at Johns Hopkins School of Medicine, where she practices in the medical ICU.
Takeaway lessons
- Rehabilitation psychology is a specialty of clinical psychology that generally partners with patients who have acute illness or injury, and helps them adapt to life in these new circumstances. They discuss health behaviors, values and priorities, help patients find paths back to what they love, and assess cognitive and behavioral changes that accompany new illness. In the ICU, they can assist with the psychological aspects of care, particularly in patients with a prolonged stay where psychological factors play an important role in recovery, or for treatment-refractory delirium.
- Delirium often dominates the patient experience of the ICU. This is primarily an experience of inattention, with relatively little awareness of their circumstances, the day, the context for events, and the presence of often-vivid hallucinations and delusions.
- ICU care is highly anxiety provoking, with common questions of “when,” “why,” and many other (often unanswerable) questions. The more certainty and structure you can provide, the better.
- Depression is common as well in longstanding inpatients, and is often better characterized as “hospital demoralization,” a fairly appropriate response to prolonged confinement and limited access to their regular life. This can lead to sensations of helplessness and hopelessness.
- Motivation can be improved by strategies to reduce the emotional barriers to engagement, while also strengthening their sense of meaning—i.e. what matters to them, and how will their involvement help move towards that?
- Effective psychological care relies on communication with the patient, and medical measures like tracheostomies and endotracheal tubes can be a barrier. Good care that minimizes sedation and delirium, close involvement from respiratory therapy and speech therapy (with tools like speaking valves), and non-verbal tools like speech boards, eye gaze, yes/nos, etc. are key.
- Patients with persistent/chronic critical illness appreciate having their schedule set out for the day, to give them a clear sense for what to expect and reduce anxiety.
- Try to build pleasurable activities into their day, aka “behavioral activation.” Doing things that are meaningful and pleasurable creates a positive feedback loop that enables more activity. Animal therapy, “sunshine therapy” (getting outside), music therapy (or just playing preferred music) are all valuable. Merely asking patients their preferred music and playing it can reduce anxiety and sedation requirement (see Linda Chlan’s work on this)
- Relaxation strategies can be learned, and in the ICU setting, vital sign monitoring can even be used as a form of biofeedback to appreciate changes in heart rate or respiratory rate in response to stress.
- Motivational interviewing emphasizes taking control over the aspects of their life that can be controlled.
- Normalize and validate the difficulty of being in the hospital. (“It is very common for people to feel frustrated, scared, or down in the hospital. This makes sense as you’re away from the people and things that you love, all while not feeling well. We can work together to find ways to help you feel like yourself.”)
- Create a schedule for the day to establish predictability and reduce anxiety. When possible, getting patient preferences (eg, morning rehab therapies, sitting up to chair for favorite tv show, evening wash up, recreate parts of bedtime routine from home, view church service remotely on Sundays via ipad, etc)
- Give patients choice over some activities (what time of day rehab therapies? Preferred positions for peri care? pick a length of time to do trach collar trial vs. go as long as you can?)
- Benzodiazepines as a treatment for anxiety in the hospitalized patient tend to be a short-term solution only, and may ultimately contribute to delirium. SSRIs or similar drugs might be a useful adjunct for patients who describe depressive symptoms like helplessness, hopelessness, worthlessness, guilt, etc.
- Gentle attempts at reorientation are appropriate for the delirious patient. In more agitated patients, emphatic and repetitive attempts at reorientation are usually not helpful. “Join the journey” (or as the improv comics say, “Yes, and…”) by redirecting benign delusions toward productive ends rather than disputing them. Floridly delirious patients generally cannot comprehend, even if they are able to parrot back information to please the interrogator.
- Consider implementing a “Get to Know Me” board; see Ognjen Gajic’s work
Resources
- The Conversation Project: good questions about end of life care wishes
- Vital Talk: quick guides on effective communication at end of life
- American Psychological Association, Division for Rehabilitation psychology: for anyone who has interest about what a rehab psychologist is and what they do
- PADIS Guidelines
- ABCDEF Bundle