Post‐intensive care syndrome: survival, but at what cost?

Abstract

Twitter/X: @caz_sampson More than 30 years ago a report from the Kings Fund on intensive care in the UK stated the simple fact that ``there is more to life than measuring death´´ [1]. Twenty-five years ago, the National Institute for Health and Care Excellence published guidance on rehabilitation after critical illness stating, ``Given the individual impact on patients, and ripple effects on families and society in general, poor-quality rehabilitation and impaired recovery from severe illness should be regarded as a major public health issue´´[2]. Critical care `survivorship´, defined as the return to a good quality of life as assessed by the critical care survivor themselves, and simple `survival´are not synonymous. It is imperative that critical care and wider healthcare teams focus on optimal survivorship for our patients. With any healthcare intervention, we need to consider morbidity alongside mortality. Decisions on candidacy for critical care admission in an emergency or as part of advanced planning for patients with chronic diseases, must be undertaken with due consideration and communication of the benefits and risks. As clinicians, we need to focus on what matters most to each individual patient and accept that prioritising quantity of life (i.e. survival at all costs) over quality of life-years left is rarely a patient-centred goal. Historically, most critical care research has focused on short-(up to 30 days) or medium-term (up to 90 days) mortality as a primary outcome measure, either individually or as part of a composite measure. Advances in critical care medicine over the last 50 years have led to huge improvements in these relatively short-term metrics. Driven by both the improvements in short-term mortality and our ageing population, the number of patients admitted to critical care is increasing. The demographics of the intensive care patient population are also changing, with critical care offered more routinely to patients who are older and who have a higher burden of pre-existing comorbidities and frailty. The number of adult critical care beds in England rose from 3550 in 2010/2011 (mean occupancy 84.1%) to 4123 in 2019/2020 (mean occupancy 80.3%) [3]. During the same decade, data from the Intensive Care National Audit and Research Centre (ICNARC) shows an increase in survival to hospital discharge in adult patients admitted to critical care units in England, Wales and Northern Ireland from 76.0% in 2010/2011 to 79.6% in 2019/2020 [4, 5].The objective binary outcome `alive vs. dead´is easy to obtain and verify. Survival is undoubtedly a crucial metric but with this now being the case for the majoirity of patients admitted to critical care, arguably these questions are just as important: `what will my quality of life be like post intensive care?´; `will I recover to the same level of health and baseline functioning?´; `will I face repeated admissions to hospital?´; `will I be able to return to my own home and current employment?´; and `what will be the effect on my family, social life and fin...