SUMMARY

High levels of anxiety and the development of posttraumatic stress disorder (PTSD) are being recognized as significant problems occurring after a stay in an intensive care unit (ICU) and may be related to traumatic experiences during ICU therapy. The severity of the symptoms varies and ranges from anxiety, nightmares and fears, to depression and posttraumatic syndrome which prevents patients to carry on a normal life.

Family members of patients who died in ICU may present even more symptoms of anxiety and serious depressions. Although the exact cause of these alterations is not yet well established, some studies suggest that they may be related to both the traumatic episodes and the memory of the experiences lived by the patient.

The aim of this paper is to consider some aspects of the life in ICU and to examine how the suffering of the patients and their relatives is usually forgotten while communication problems can make the situation worse.

The attitude adopted by the professionals can play an important role on the way in which the experience is lived and also on the impact that it can have regarding later life according to clinical observations and recent published studies.

Critically ill patients are the ones who have an actual risk of a close death and due to this fact, they become fragile and easily vulnerable. Patients in ICU live painful situations (needles, catheters, thirst or sleep deprivation), but they also feel isolated, scared and alone and they may experience a lot of suffering and anxiety caused by the proximity of death. Moreover, the disease itself or the administration of sedative drugs (being essential in order to tolerate certain therapeutic procedures) can cause semi-unconscious states (delirium) which can prevent the perception of the limits of reality. This confusion between fantasy and reality can be the origin of disquieting emotions capable to last for a long time even after the operation.

The patient in these circumstances asks for two types of help. First of all, he asks for a solution for his medical problem that will be solved by the modern medicine in most of cases (but not always). Secondly, the patient will need a more subtle, less explicit, but equally important aid: the understanding of the situation he lives, the empathy with his pain, frustration and even irrationality, and the attention to his person as a whole and not only to his ill organs.

The therapeutic power of an effective communication is out of doubt. We should understand communication in the broad sense of the word, and not only as the verbal components that it contains. The real communication process is the one capable of giving the necessary aid to the patient, the one which can deal without fear with emotions, attitudes, respect, attention and real interest for the other.

Although the needs of the patient are the primary focus of caregivers, there is a growing consensus that a family-centered approach is particularly important. Family members of critically ill patients admitted to an ICU experience symptoms of anxiety or depression as well. These symptoms are even more prevalent than the ones presented by the patients (families do not have delusional memories and their recall of the situation is vivid and real), especially among those relatives who have endured the death of the patient after sharing the decision to limit his treatment with the professionals who took care of him.

Involvement of families in decisions regarding the end of life is common. Critically ill patients are usually unconscious and they cannot decide by themselves. In those cases, conversations are usually complex and difficult and they take place in an atmosphere of high emotional tension. Along this shared decision-making process, the professional is required to foment a confidence climate allowing the values and preferences of the patient to be freely expressed and articulated. These conversations can lead to the family’s satisfaction or not, it will always depend on the degree of emotional support they receive. We have the opportunity to listen and respond to the patient’s relatives, to acknowledge and address their emotions and the opportunity to explore patients’ preferences, thus assuring non-abandonment. There has been an increasing amount of research on the content of clinical family communication in the ICU, and many efforts have been made in order to find out ways to improve communication. Some results suggest that clinicians should spend less time talking and much more listening. In fact, levels of anxiety are clearly lower in families that spent more time talking.

We suggest some difficulties we find in practice which could explain the existence of a bad communication due to a lack of listening. Firstly, working routines in critical care units have always been more worried about the organic processes and the application of technology than about the patients’ experiences. Secondly, hurrying and impatient ways of acting do not allow professionals to have a talk in a careful, reflective and sensitive way. Thirdly, the idea of professionalism seems to prefer scientific and technical abilities rather than skills for relationship, communication and empathy. In addition, the fear towards uncontrolled situations can also move professionals away from conversations with their patients.

Moreover, one can also highlight some items in order to improve the state of the question. Teaching should appear in the first place. It is necessary for students to get familiarized with some topics (ethics, philosophy, law or communication skills) as soon as possible, in order to become more sensitive towards the patient. They should learn how to consider the patient in a broad dimension, trying to relieve his suffering but also being curious and interested in his ideas, values and concerns. They obviously need tools to deal with all that and this is exactly what professionals should teach them besides all the other medical subjects.

To conclude, some other proposals should be pointed out, such as: promoting the existence of calmed atmospheres in hospitals, without unnecessary noises and with cosy and more comfortable waiting rooms; sensitizing the managers about the importance of the time dedicated to communication and the possibility to consider it as part of the medical aid; and finally making the visiting schedules in ICU more flexible in order to create less artificial spaces of communication between professionals and relatives.