American College of Physicians: Internal Medicine — Doctors for Adults ®

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ICU patients suffer symptoms silently

From the July ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Stacey Butterfield

By the time a patient gets to the intensive care unit, his symptoms aren't usually the focus of diagnostics or treatment. But that doesn't mean they aren't still bothering him.

A new study of very sick ICU patients (22% of them died before discharge) found they were significantly affected by a number of symptoms. The symptoms were not necessarily the ones a physician might expect, either. The most common complaints were tiredness, thirst, anxiety, restlessness and hunger; pain, on the other hand, was an issue for fewer than half the patients. Researchers also asked the patients which was the most distressing of their symptoms, and the top answer was shortness of breath, which more than 40% of patients reported experiencing.

To find out more about how physicians can elicit, and ideally eliminate, these symptoms from their ICU patients, ACP Hospitalist recently spoke with the lead author of the study, which was published in the November 2010 Critical Care Medicine. Kathleen A. Puntillo, RN, DNSc, is professor emeritus of nursing at the University of California, San Francisco.

Q: How did the results of the study compare to your expectations?

A: There were some surprises in that we found that thirst, for example, was the second most prevalent symptom and it was the most intense symptom for patients that had it. This was quite a surprise. To our knowledge, no one had really looked at the prevalence of thirst. Thirst had been identified on some surveys ICU patients had completed in previous studies, but that was really the extent of our knowledge.

Another surprise was related to pain. It was more or less a pleasant surprise—only 40% of the patients in this study said they were having pain. Pain, traditionally ever since we started studying it, has been identified as a very prevalent symptom with patients. When we found that only 40% of our patients reported it, we thought what's happened? [It] could be that the patients who were having pain weren't able to report, so we may be underestimating. The other possibility is that all the work that we have done in pain research and education about pain and patients in ICUs may be paying off. I do know, clinically, we are more attentive to pain than we were when I started my research.

Q: As has been done with pain, could ICUs do more to treat these other symptoms?

A: Clearly yes. As a result of these findings, I actually did a pilot study to test some interventions for thirst. Because the findings from the pilot study were favorable, I wrote a grant to the NIH, which was funded, to study an intervention for thirst on a larger scale. I'm about midway through that study. There are certainly other findings that really could use some follow-up— for example, the distress that's associated with shortness of breath or dyspnea. That was the most distressful of the symptoms for the patients and I think we can pay attention to that as well.

Q: How do we pay attention? Should ICUs be screening patients?

A: Yes. Put that into the mix of all of the other work that needs to be done for patients in ICU. Maybe we can't screen for all of these symptoms that we screened for, but perhaps the ones that were at the top of the list with regard to prevalence or intensity or distress. I don't think clinicians mean to not pay attention to symptoms but it's very difficult to assess symptoms in ICU patients, particularly because a lot of the patients have communication problems. There are ways that we could try to assess for these symptoms. You don't know what the patient is experiencing unless you ask the patient.

Q: How do you ask patients who aren't able to speak?

A: Try to see if your patients…are able to self-report, and by self-report I mean not just to speak out loud, but to be able to point to a list of symptoms if they can't speak out loud and shake their heads yes or no. Offer patients that opportunity to let the clinicians know what is bothering them. Because I think there are some things we can do to make patients' experiences in ICU—whether they live or die—more comfortable and less distressing, both for them and their family members.

Q: What can be done for patients who really can't self-report?

A: That's a real challenge. As far as pain is concerned, we know more about pain and pain assessment because there's been a lot of good research over the past 10 years to look at the other types of instruments that don't require the patient report. They are observations of patient behaviors that could be indicative of pain. We now are moving into using these observational pain behavior scales and really promoting their use in ICUs so that we can get a sense of [whether] patients are experiencing pain. If they are and we can diagnose it, then we can go on to institute some treatments.

With the other symptoms, we're just at the beginning. There's beginning work on behavioral scales for distress, and there are scales for identifying delirium, but there's a whole lot more work that needs to be done.

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