Patient suffering and the humanized ICU: where do non-pharmacological interventions fit?
To aid in conceptualizing non-pharmacologic interventions in the ICU, we propose an adaptation of the Loeser pain and suffering model . This model highlights the inter-relatedness of physiologic and emotional suffering, and the importance of interdisciplinary care in recovery from disease (Fig. 1). In the model, the innermost circle represents physiologic burden where patients sustain physiologic changes, such as hypoxia or hypotension, and require medical interventions, such as mechanical ventilation or vasopressors. The second circle represents suffering, which includes the patient’s thoughts (e.g., “I am short of breath. I am dying;” “I am a burden and worthless;” “Walking while critically ill will harm me”) and emotions (e.g., anxiety, sadness, and loneliness) about their physiologic and environmental experience. Non-pharmacologic interventions to alleviate suffering can include education, psychological support, and other methods to reduce distress (e.g., cognitive-behavioral therapy, animal-assisted intervention, and music intervention). The third circle represents behavior, wherein worsening of physiologic burden and suffering can change patient engagement in medical and/or rehabilitation care (e.g., disengagement in rehabilitation, avoidance of medical information, declining recommended medical interventions). In the behavior realm, interventions (e.g., early mobility and motivational interviewing) move patients toward action and reinforce their role as participants in their own recovery.
Interventions in one circle have the potential to influence outcomes in other domains. Equally important is acknowledging that the patients’ experiences at each level are real even if they are difficult to observe and measure. Increased attention to both patient suffering and behavior domains ensures comprehensive care and potentially better long-term outcomes.