SAJCC March 2023, Vol. 39, No. 1 3
SOAPBOX
They are standing around my bed talking about my heart rate and blood
pressure, concerned because it is so high. I know why it is high.
The alarms are going off.
I can feel my heart pumping.
They don’t know I can’t breathe when I am flat.
They have not asked me if I am ok.
They say I am anxious.
I have pain and can’t breathe.
My hands are tied to the bed.
I can’t move.
I can’t breathe.
Please lift me up so I can breathe.
Someone … please … ask me what is wrong.
(Adult critically ill patient with multiple rib fractures)
The intensive care unit offers lifesaving interventions, but these
interventions are often accompanied by loss of patient autonomy
and, at times, even dignity.[1] Loss of control over one’s body, inability
to communicate needs, fear, and loss of identity, to name just a few,
contribute to patients’ vulnerability, suffering and dehumanisation in
the ICU.[1-4] Unless we specifically and intentionally attend to these, how
are autonomy, non-maleficence and beneficence applied in our care?[5]
The harm that may arise is from the neglect of adequate respect and in
turn the erosion of one’s dignity.[2,6] Perhaps one of the biggest dangers
of dehumanisation is that it can occur slowly and silently over time and
is perpetuated by a lack of respect of persons – patients, families and
staff alike.[1]
The negative effects of such ‘care’ may be significant and last well
beyond the ICU.[3,7,8]
There is growing evidence that measuring survival is not sufficient to
determine the effectiveness of our ICU care – is it about the quality of
the life saved or the death died?[9] While there many unpreventable risk
factors for morbidity following an ICU stay, many are preventable and
are care/culture-induced risk factors. A recent systematic review looking
at risk factors for increased morbidity following an ICU stay found that
a negative patient experience is one of these preventable risk factors.
[10] Surely we can all play a role in rehumanising the ICU and returning
dignity to the people entrusted to our care?[2]
Communication, and where possible dialogue, is probably the
simplest tool we can use to return some dignity, autonomy and identity
to the person.[2-4,11] This communication enables healthcare providers
to see Bed 5 as more than the polytrauma patient, as someone with a
past, present and future; and this communication is essential to person-
centred care and to mitigate many of the negative experiences in the
ICU.[2,12] When engaging in such communication, we as healthcare
providers need to be cognisant of the inevitable power relationship that
occurs when one member in the conversation is limited.[13] It is not,
however, merely speaking to and listening to the person, but speaking
and listening with empathy – engaging with them with compassion from
and between all members of the interdisciplinary team.[4,14]
Admittedly ICU environments are not the most personal
environments, and as Francis Peabody asked, how one can be more
personal (person centred) in an impersonal environment?[15] Perhaps
the first port of call is to stand back and look at ourselves. What are
we as healthcare providers bringing to our interactions? What are our
biases, attitudes and assumptions that we carry with us?[4] How are
these impacting on our behaviour?[4] Are we reflective in our practice
– aware of our assumptions and behaviours, and able to acknowledge
and remedy these?[4] What are our contributions to the environment
and the culture in which we work? However, in the same breath, we also
need to acknowledge how the environment and culture impact on us as
healthcare providers.
As much as the ICU is a stressful environment for patients and
family members, its toll on healthcare providers is increasingly being
recognised.[16] In our post-pandemic world today, a pandemic during
which healthcare providers had little time to breathe, the effects of the
ICU environment on staff are likely to be amplified. Disengagement as
a result of self-preservation or emotional fatigue may contribute to a
decline in empathy, and consequently to the dehumanisation one may
experience in the ICU.[2,14] Increasing cynicism around one’s job related
to systemic culture, process and infrastructure may further perpetuate
the healthcare provider’s approach to patient care.[1-3,14] To what degree
do we feel seen, heard and respected in our environments?[1] The
aforementioned factors are likely to be symptoms and/or contributors
to staff burnout, which further impacts on the care we provide.[3,16,17] As
healthcare workers we need to recognise that we too are human, and part
of humanising the ICU is humanising it for us also.[2] Improving care to
patients may start with improving care for staff, and calls for leaders and
advocates to sound the alarm, and calls for change at systems level as
well as with us as individuals.[1,2,4]
How are we embodying care to ourselves, our colleagues and, most
importantly, those entrusted to our care?
One of the essential qualities of the clinician is interest in humanity, for
the secret of the care of the patient is caring for the patient.
(Francis Peabody,[15] 1927)
Alison Lupton-Smith, PhD, BSc (Physiotherapy)
Division of Physiotherapy, Faculty of Medicine and Health Sciences,
Stellenbosch University, Cape Town, South Africa
aluptonsmith@sun.ac.za
1. Brown SM, Azoulay E, Benoit D, et al. The practice of respect in the ICU. Am J Respir Crit Care
Med 2018;197(11):1389-1395. https://doi.org/10.1164/rccm.201708-1676CP
2. Vaeza NN, Martin Delgado MC, la Calle GH. Humanizing intensive care: Toward a human-
centered care ICU model. Crit Care Med 2020;48(3):385-390. https://doi.org/10.1097/
CCM.0000000000004191
3. Wilson ME, Beesley S, Grow A, et al. Humanizing the intensive care unit. Crit Care 2019;23(1):32.
https://doi.org/10.1186/S13054-019-2327-7
4. Chochinov H. Dignity and the essence of medicine: The A, B, C, and D of dignity conserving care.
BMJ 2007;335(7612):184-187. https://doi.org/10.1136/bmj.39244.650926.47
5. Thompson DR. Principles of ethics: In managing a critical care unit. Crit Care Med 2007;35(2
Suppl):S2-S10. https://doi.org/10.1097/01.CCM.0000252912.09497.17
6. Sokol-Hessner L, Folcarelli PH, Sands KEF. Emotional harm from disrespect: The neglected
preventable harm. BMJ Qual Saf 2015;24(9):550-553. https://doi.org/10.1136/bmjqs-2015-004034
7. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from
intensive care unit: Report from a stakeholders’ conference. Crit Care Med 2012;40(2):502-509.
https://doi.org/10.1097/CCM.0b013e318232da75
8. Harvey MA, Davidson JE. Postintensive care syndrome: Right care, right now … and later. Crit
Care Med 2016;44(2):381-385. https://doi.org/10.1097/CCM.0000000000001531
9. Dunstan GR. Hard questions in intensive care. A moralist answers questions put to him at a
meeting of the Intensive Care Society, Autumn, 1984. Anaesthesia 1985;40(5):479-482.
10. Lee M, Kang J, Jeong YJ. Risk factors for post–intensive care syndrome: A systematic review and
meta-analysis. Aust Crit Care 2020;33(3):287-294. https://doi.org/10.1016/j.aucc.2019.10.004
11. Koksvik GH. Silent subjects, loud diseases: Enactment of personhood in intensive care. Health
(London) 2016;20(2):127-142. https://doi.org/10.1177/1363459314567792
SOAPBOX
The missed art of care?
4 SAJCC March 2023, Vol. 39, No. 1
SOAPBOX
12. Cutler LR, Hayter M, Ryan T. A critical review and synthesis of qualitative research on
patient experiences of critical illness. Intensive Crit Care Nurs 2013;29(3):147-157. https://doi.
org/10.1016/J.ICCN.2012.12.001
13. Holm A, Dreyer P. Nurse-patient communication within the context of non-sedated mechanical
ventilation: A hermeneutic-phenomenological study. Nurs Crit Care 2018;23(2):88-94. https://
doi.org/10.1111/nicc.12297
14. Haslam N. Humanising medical practice: The role of empathy. Med J Aust 2007;187(7):381-382.
https://doi.org/10.5694/j.1326-5377.2007.tb01305.x
15. Peabody FW. The care of the patient. JAMA 1927;88(12):877-882. https://doi.org/10.1001/
jama.1927.02680380001001
16. Kerlin MP, McPeake J, Mikkelsen ME. Burnout and joy in the profession of critical care medicine.
Crit Care 2020;24(1):98. https://doi.org/10.1186/S13054-020-2784-z
17. Pastores SM, Kvetan V, Coopersmith CM, et al. Workforce, workload, and burnout among
intensivists and advanced practice providers. Crit Care Med 2019;47(4):550-557. https://doi.
org/10.1097/CCM.0000000000003637
South Afr J Crit Care 2023:39(1):XXX. https://doi.org/10.7196/SAJCC.2023.v39i1.563
