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Thinesh Dahanayake, MD.

Director of the Intensive Care Unit and Palliative Care

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