2018 MEDICAL DIRECTORSHIPS AT THE WILLIAM W.
BACKUS HOSPITAL
Thinesh Dahanayake, MD.
Director of the Intensive Care Unit and Palliative Care
Intensive care units (ICU) were first established in the 1950s when it
was recognized that the most severely ill patients in hospital could
benefit from specialized care, or at least closer attention than what
was provided to less ill patients. The ICU in days past was isolated
and to some a frightening place with limited visiting hours where
all staff were gowned from head to toe. Early on in the history
of intensive care medicine many interventions, such as invasive
hemodynamic monitoring and heavy sedation of mechanically
ventilated patients, were dogma despite relatively weak or
nonexistent evidence to support their necessity.
As the decades passed, the ICU has become less interventional and
more humane for patients and their families. Critical care research,
especially in the early 1990s, began to question the unproven
practices of certain intensive interventions. Routine therapies
such as insertion of pulmonary artery catheters, blood transfusion
triggers at a Hg of 10, aggressive blood sugar control and heavy
sedation of mechanically ventilated patients were refuted by
evidence-based studies. Guidelines for the management of
syndromes such as sepsis and ARDS were formulated based on new
research. Point-of-care ultrasound has since become commonplace.
The introduction of a multidisciplinary approach to care was
made possible with the dedicated involvement of doctors, nurses,
respiratory therapists, care managers, nutrition specialists,
pharmacists, physical therapists, and palliative care specialists. It
is now recognized as a standard of quality care in the ICU. With the
advent of rapid response teams to facilitate care of patients who
become critically ill on the general medical floors, intensive care
has evolved beyond the fixed walls of the ICU.
As much as critical care medicine has grown, it has many hurdles
in the present and future. Intensive care plays an increasingly
larger role at the center of acute hospital support as millions of
baby boomers age. With healthcare encompassing approximately
6 THE OPEN JOURNAL
18% of the gross domestic product and Medicare growing at
more than the twice the rate of inflation, methods of pushing
acute treatment (once hospital based) to outpatient management
are being emphasized and there may be potentially less need for
overall hospital beds. However, ICU beds and services will grow
as technologies improve, supporting older and sicker patients.
The number of intensivists trained and experienced ICU nurses
is declining in stark contrast to the rising critical care patient
population. ICU staffing shortages are likely to be the greatest
challenge to maintain the high level of care demanded in treating
the critically ill. Additionally, intensivists and ICU nurses suffer from
higher levels of burnout in comparison to other physician specialists,
with up to 47% of ICU professionals scoring high on burnout
indicators in one study. Factors contributing to this professional
exhaustion include caring for the most ill and complex patients, long
work hours, and compassion fatigue with frequent exposure to end
of life situations.
Just as treatment protocol dogmas have changed in the ICU, so
has the concept that palliative care and critical care are mutually
exclusive. Palliative care is based not on prognosis and estimated
survival, but on symptom management, and it is an is an essential
component for treatment of critically ill patients in the ICU.
Palliative care also overlaps with hospice care, the later confined to
end of life.
As the processes of care have evolved in ICU treatment with
evidence based medicine and a constantly growing focus on
palliative care, the major challenge will be finding a solution to the
ever widening gap between the demand for critical care and the
supply of intensivists and critical care nurses and palliative care
providers in order to maintain the highest standards of care. n