Objective To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom reports. Design Prospective, observational study of patients' symptoms. Setting Two intensive care units in a tertiary medical center in the western United States. Patients One hundred seventy-one intensive care unit patients at high risk of dying. Interventions None. Measurements and Main Results Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method–Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients. Conclusions Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.

Critically ill patients often have distressful episodes of severe thirst, but the underlying complex biochemical, neurohormonal regulatory controls that regulate this primal sensation have rarely been addressed by clinicians. Subtle changes in plasma osmolality are the most potent stimulus for thirst. In response to increases in osmolality, osmoreceptors activate release of the neurohormone vasopressin (also known as antidiuretic hormone). The released vasopressin acts on the kidneys to conserve water to correct the hyperosmolar state. If this compensatory mechanism is unsuccessful, thirst arises to promote drinking. Thirst induced by marked volume loss, in contrast, is more closely related to the volemic and pressure changes regulated by the renin-angiotensin aldosterone system. Understanding the physiological mechanisms of thirst will help in understanding the pathophysiological consequences of underlying thirst-related disease and treatments in critically ill patients. Further clinical research is needed to elucidate the multiple inhibitory and excitatory neurohormonal stimuli that motivate patients’ intense desire for water.

Purpose To test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and under-treated symptoms in ICU patients, but for which data-based interventions are lacking. Methods Single-blinded, randomized clinical trial in three ICUs in a tertiary medical center in urban California. 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥ 3 on 0–10 numeric rating scales (NRS) were randomized to Intervention or Usual Care groups. A Research Team Nurse (RTN#1) obtained patients’ pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the Intervention group: oral swab wipes, sterile ice cold water sprays, and a lip moisturizer, or observed patients in the Usual Care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to 6 sessions per patient were conducted across two days. Results Multilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the Intervention group (2.3 and 1.8 NRS points, respectively) versus the Usual Care group (0.6 and 0.4 points, respectively) (p < 0.05). The Usual Care group was 1.9 times more likely than the Intervention group to report dry mouth for each additional session on Day 1. Conclusion This simple, inexpensive thirst bundle significantly decreased ICU patients’ thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst. Clinical trial registered with www.clinicalTrials.gov (NCT01015755).

Family members are important to patient care in the ICU. They perform multiple roles that are often not valued or go unrecognized by ICU health care providers. More support and appreciation of family members' contributions to care may provide families opportunities for intimacy and promote a sense of belonging in the highly technical environment of an ICU.

The CONSORT-EHEALTH checklist is intended for authors of randomized trials evaluating webbased and Internet-based applications/interventions, including mobile interventions, electronic games (incl multiplayer games), social media, certain telehealth applications, and other interactive and/or networked electronic applications. Some of the items (e.g. all subitems under item 5 -description of the intervention) may also be applicable for other study designs.The goal of the CONSORT EHEALTH checklist and guideline is to be a) a guide for reporting for authors of RCTs, b) to form a basis for appraisal of an ehealth trial (in terms of validity)CONSORT-EHEALTH items/subitems are MANDATORY reporting items for studies published in the Journal of Medical Internet Research and other journals / scientiUc societies endorsing the checklist.Items numbered 1., 2., 3., 4a., 4b etc are original CONSORT or CONSORT-NPT (non-pharmacologic treatment) items. Items with Roman numerals (i., ii, iii, iv etc.) are CONSORT-EHEALTH extensions/clariUcations.As the CONSORT-EHEALTH checklist is still considered in a formative stage, we would ask that you also RATE ON A SCALE OF 1-5 how important/useful you feel each item is FOR THE PURPOSE OF THE CHECKLIST and reporting guideline (optional).Mandatory reporting items are marked with a red *. In the textboxes, either copy & paste the relevant sections from your manuscript into this formplease include any quotes from your manuscript in QUOTATION MARKS, or answer directly by providing additional information not in the manuscript, or elaborating on why the item was not relevant for this study. YOUR ANSWERS WILL BE PUBLISHED AS A SUPPLEMENTARY FILE TO YOUR PUBLICATION IN JMIR AND ARE CONSIDERED PART OF YOUR PUBLICATION (IF ACCEPTED) 1a-i) Identify the mode of delivery in the titleIdentify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if ooine products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms. 1 2 3 4 5 subitem not at all important essential Does your paper address subitem 1a-i? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briepy explain why the item is not applicable/relevant for your study participants eligibility -must own mobile-phone, tablet or computer because part of the intervention study design incorporated participant use of Fitbit Zip and Fitbit app 1a-ii...