Plenary Articles

Humanizing Intensive Care: Toward a Human-

Centered Care ICU Model
Nicolas Nin Vaeza, MD, PhD1,2,3; María Cruz Martin Delgado, MD2,4,5; Gabriel Heras La Calle, MD2,3,4,5

Key Words: human-centered care; humanization; intensive The professional and technical development of the ICUs is
care unit remarkable. Proof of this is the high survival statistics that sup-
Downloaded from http://journals.lww.com/ccmjournal by BhDMf5ePHKbH4TTImqenVB5cXIaDaihKo5sAHhY02mLo8bbr6ZBhkK4UI17JS1pb//zNuUYmiOg= on 02/15/2020

port its excellent results (4). Nevertheless, humanistic aspects

of care have not developed as effectively as technological
advancements, thereby affecting these three relevant groups

“I
f you could choose, how would you like the Inten-
sive Care Units (ICUs) to be?” The Humanization of
Intensive Care movement (Proyecto HU-CI) arose
after we asked this simple question in our blog, receiving sug-
gestions from more 10,000 people (1). Created in Spain on
February 2014, the Humanization of Intensive Care move-
ment is an international research project that seeks, using ev-
idence-based medicine, to answer that same question, thus
creating a paradigm shift in the way we deliver our care toward
a more friendly and human-centered model (2). Although
many may be surprised and feel a contradiction toward this
humanistic model, is an essential skill in health professionals
that should have never been lost. When professionals are face
with the reality of being patients or a family member of criti-
cally ill patient, it is then, when they appreciate how it works.
“Yet many professionals cite lack of humanistic care as a cause
for burnout, an epidemic among health professions today” (3).
Displaying kindness and concern for all the individuals that
are part of the healthcare environment, not only patients and
its families, is a necessity and the path toward building an ex-
cellent healthcare system. We will not be able to cure all people,
but surely, we can improve the care we provide by focusing on
the dignity of people.
1
Intensive Care Unit, Hospital Español, Montevideo, Uruguay.
2
Member of the International Research Project for the Humanization of
Intensive Care Units (Proyecto HU-CI), Madrid, Spain.
3
Member of Latin American Intensive Care Network (Red LIVEN).
4
Intensive Care Unit, Hospital Universitario de Torrejón, Madrid, Spain.
5
Universidad Francisco de Vitoria, Madrid, Spain.
Dr. Heras La Calle received funding from lecturing for Proyecto HU-CI,
Pfizer, Orion Pharma, Fundación Lilly, Quality Resources International, and
Roche. The remaining authors have disclosed that they do not have any
potential conflicts of interest.
For information regarding this article, E-mail: niconin@hotmail.com
Copyright © 2019 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000004191
(patients, families, healthcare personnel). In many places, the
organizational and architectural characteristics of the ICUs
create hostile environments for all: that is why humanization
must also require structural changes (5).
Humanizing means, “everything that has to be done to
promote and protect health, cure diseases and guarantee an
environment that favors a healthy and harmonious life on
a physical, emotional, social and spiritual level in people.”
"Talking about humanization demands the intrinsic dignity of
every human being and the rights that derive from it, and this
makes it a necessity of vital importance and transcendence"(6).
Humanizing also involves individualizing care by paying
attention to what patients and family members need, even if
they do not agree with the manner in which we deliver care
and turning this into a clinical process, where attitude is fun-
damental. Humanizing is also understanding and accepting
that professionals are fallible and vulnerable and that we need
to be contemplate since we are the cornerstone to humanize
healthcare.
Care requires professional competence and training, but
also individuality, emotion, solidarity, sensitivity, and ethics. It
requires excellent social and communication skills, empathy,
active listening, respect, and compassion to others. However,
historically, healthcare professionals have curricular flaws in
their training of “human tools,” the so-called “soft skills.”
Through a multicenter and international collaborative re-
search, Proyecto HU-CI aims to evaluate different areas and
carry out the implementation of the corresponding improve-
ment actions. These areas of improvement and research (Fig. 1)
were identified through active listening and shared reflection
on the opinions thousands of healthcare professionals (1). This
initiative generated an ICU Humanization plan (7) where each
item is explained below, was recognized as a paradigm shift in
the healthcare model (8) and has laid the foundations for the
ICU Manual of Good Practices in Humanization (9), including
160 actions to transform the healthcare management model
(Table 1). To date, Proyecto HU-CI has evaluated compliance

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Nin Vaeza et al

personal hygiene, food man-

agement, early mobilization,
or rehabilitation), under the
training and supervision of
healthcare professionals.
The presence of family
members during specific pro-
cedures can produce changes
in the attitude of profession-
als, concerning privacy, dig-
nity, and pain management,
as well as greater family sat-
isfaction and higher accept-
ance of the situation favoring
the grieving process (14).
The main concerns conveyed
are the possible psychologic
trauma and anxiety that
affects the family, interference
during procedures, distrac-
tion, and finally, the possible
impact on the healthcare
team. The presence and par-
ticipation of family members
during daily rounds also con-
tribute to the improvement
of communication and favors
the information process,
increasing their satisfaction
(15). The effective incorpora-
tion of the family as a member
of the ICU team can reduce
anxiety and stress, improving
satisfaction, and decreasing
Figure 1. The H-Evolution of ICUs.
post-intensive care syndrome
(PICS) (16). Interventions
in Humanization Good Practices in more than 200 ICUs in that facilitate family support improve outcomes in critically
Spain and Latin America. These units have submitted their ill patients (17).
self-assessments with global compliance between 40% and
60% of those good practices.
COMMUNICATION
Communication skills constitute a crucial element in the human-
OPEN DOORS ICU. FAMILY PRESENCE AND ization process (18). Excellent communication is fundamental
PARTICIPATION in recognizing the patient as a person and place him or her at
Despite the available scientific evidence, most ICUs have a re- the center of the system (19). Effective communication between
strictive visiting hours policy (10, 11). In reality, this restriction professionals and multidisciplinary teams is essential to improve
is mainly customary, lacking critical reflection of its inconve- patient outcomes in and increase families’ and professionals’ sat-
niences (12) and focused more on professional needs, than on isfaction (20). Different tools improve communication and facil-
those of patients and family members. Currently, the available itate teamwork, while including the patient and family as team
evidence suggests that the flexibility of schedules or the estab- members is still a pending task in many ICUs (21).
lishment of “open doors” is feasible and beneficial to patients, Conflicts between professionals in the ICU are frequent,
family members, and professionals (13). The existing barriers many of them due to communication failures. Furthermore,
to transform the visiting policy respond to the physical struc- they threaten the concept of teamwork and directly influence
ture of the units and the mental structure of the profession- the wellbeing of the patient and their family, generate pro-
als. It requires transforming the concept from “visitor” to that fessional burnout, and negatively influence outcomes (22).
of “partner in care,” restoring the role of caregivers to family Specific training is required, especially in stressful situations.
members and integrating them, if they wish, into the care (e.g., Clinical simulation facilitates the development of nontechnical

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 Plenary Articles

TABLE 1. Humanization Plan Objectives in ICU

Open-door policy
  Make professionals aware of the benefits for patients, relatives, professionals in implementing the ICU open-doors policy
  Facilitate ICU accessibility to patients’ relatives
  Promote contact between patients and their families during their stay in ICU
Communication
  Develop tools that ensure the correct transfer of relevant information on a patient among all team members and that improve
teamwork
  Facilitate aspects that help establish appropriate and empathetic communication with relatives on behalf of all team members, in
order to reach a satisfactorily helpful relationship, and facilitate the accessibility of information
  Facilitate the giving out of information to patients and promote the use of augmentative and/or alternative communication
systems where necessary
  Psychologic and spiritual comfort: Promote actions that lead a reduction in the patient’s psychologic suffering and attend to
spiritual demands
  Patient autonomy: Establish measures that promote patient autonomy and facilitate his/her connection to the outside world
  Environmental comfort: Promote measures that facilitate waking-sleeping rhythms and nighttime rest, as well as other
environmental wellbeing measures
Presence and participation of relatives in intensive care
  Offer the family the opportunity to participate in the primary care of the patient and specific procedures
  Detect and support the emotional and psychologic needs of the families
Care for the healthcare professional
  Improve knowledge on professional burnout syndrome and work to make it more visible
  Evaluate the impact of professional burnout syndrome in ICU
  Analyze the factors related to professional burnout syndrome, such as job satisfaction, anxiety, depression, and engagement in
the work
Prevention, management, and monitoring of PICS
  Prevent and detect the appearance of PICS early
  Improve the quality of life of patients identified to be pre-discharge from the ICU while they are monitoring on the ward and/or
when they are discharged and sent home
  Assess and implement possible organizational measures appropriate to the situation in each hospital
Humanized infrastructure
  Ensure the patient’s privacy
  Ensure the patient’s environmental comfort
  Foster communication and focus on the patient
  Encourage entertainment for the patient
  Make available spaces in gardens or patios and ensure patient access to them
  Guarantee the education process for school-age patients during their stay in ICU
  Ensure comfort and functionality in the treatment area
EOL care
  Have an EOL protocol
  Control physical symptoms of patients in EOL situations
  Facilitate the accompaniment of patients in EOL situations
  Cover the emotional and spiritual needs of patients and family members in EOL situations
  Have a LST protocol that follows the recommendations of scientific communities
  Ensure that patients’ needs and autonomy in LST decision-making are respected
  Ensure the participation of all the professionals involved in the LST
EOL = end of life, LST = life-sustaining treatment, PICS = post-intensive care syndrome.

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Nin Vaeza et al
skills, training them in an interdisciplinary way to apply results
into clinical practice (23).
Information is one of the primary needs expressed by
patients and relatives in the ICU (24). Critically ill patients may
be often incapacitated, and the information is frequently given
to their relatives (25). Reporting accurately in situations of sig-
nificant emotional burden requires communication skills, for
which many professionals have not been trained. Correct com-
munication with patients and family requires a climate of trust
and respect and facilitates accurate decision-making (26).
The inability to communicate with many critically ill
patients generates negative feelings and is an essential source of
stress and frustration for patients, family members, and profes-
sionals (27). Fostering communication, adapted to the specific
needs of each patient, through augmentative and alternative
communication systems, is essential to humanize care and
allows the patient to participate in the critical process (28, 29).
PATIENT WELLBEING
Many factors cause suffering and discomfort to patients, such as
pain, thirst, cold, heat, and insomnia, among others (30). All this
added to the proper management of pain and sedation and the
prevention and management of delirium are essential pieces to
improve comfort and perceived ICU experience of patients and
their families (31). The psychologic and emotional distress can
be very high, especially, and sometimes healthcare personnel are
not taken into account. Patients experience feelings of loneliness,
isolation, fear, loss of identity, intimacy, and dignity, feeling of de-
pendence, uncertainty due to poor communication and misun-
derstanding, among others (32). The evaluation and support of
these needs is a crucial element of the quality of care (33).
HEALTHCARE PROFESSIONAL CARE
In 1970, Mc Grath defined for the first time the word work
stress. Four years later, Freundeberger introduced the word
burnout and described its risk factors. Furthermore in 1984,
Maslach classified the three classical dimensions: feelings of en-
ergy depletion or exhaustion; increased mental distance from
one’s job, or feelings of negativism or cynicism related to one’s
job; and reduced professional efficacy (34, 35). We are currently
facing a complicated and less simplistic occupational disease
that can affect professionals in different ways, such as burnout
itself (being overworked), bore out (being bored at work), and
finally, compassion fatigue (loss of meaning) (9).
In ICUs, the natural stressors of patient care are augment by
the suffering and death, fear, and uncertainty of the patients.
In turn, when we add work overload, chronic staff fatigue,
and increased comorbidities and patient length stay, the risk
can increase even more. The natural adaptation to burnout is
emotional, family, and social isolation and, later on, deperson-
alization, depression or anxiety, and finally, the expression of
disruptive or self-destructive behaviors.
Consequently, burnout produces work absenteeism,
increases medical errors, decrease in quality of care, and low
satisfaction rates in-patient and their families.
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Among its contributing factors, individual personal charac-
teristics, environmental and organizational factors stand out,
among them, lack of time, and a dysfunctional workplace with
low leadership and the balance or not of family life where di-
vorce rates can be very high.
Recently, different scientific societies have sought to bring
attention to this syndrome, and the way to approach it is to
diagnose the situation, understand the factors, and general
action plans to mitigate it (36). Several studies reveal that
different interventions prevent and reduce this syndrome,
including improving communication at all levels, strength-
ening leadership, improving working conditions, and per-
sonal and group tools to increase psychologic resilience,
among others.
POST-INTENSIVE CARE SYNDROME
On many occasions, after discharge from the ICU patients ex-
perience physical, cognition, and mental impairments Table 2.
Identified as PICS, these problems affect a significant number
of patients (30 to 50%) (37). Its mid- and long-term sequela,
affect the quality of life of patients and families.
Minimizing the development of PICS requires preventive
activities, as well as proper management and monitoring of
known alterations (38). For this, multi-professional and co-
ordinated work is essential in the detection, monitoring, and
treatment. The family is a fundamental piece in the manage-
ment of the PICS. Caregivers may also be affected by feelings of
worry and confusion that can lead them to neglect their health
(39). The healthcare team must be aware of this to meet the
needs of the patient-family wellbeing.
TABLE 2. Post-Intensive Care Syndrome
Physical impairments
  Persistent pain
  ICU-acquired weakness
 Malnutrition
  Pressure ulcers
  Sleep disturbances
  Need to use devices
  Impaired lung function
Cognition impairments
  Cognitive deficits
  Memory disorders
 Attention
  Mental processing speed
Mental impairments
 Anxiety
 Depression
  Post-traumatic stress disorder

HUMANIZED INFRASTRUCTURE
A high percentage of ICUs were constructed in the last cen-
tury, with large open spaces where the dignity and privacy of
patients were not taken into account. Others have small rooms
with little space to allow family support and foster personal-
ized relationships between professionals and patients, and in
some places, ICUs have no access to natural light.
From this line of work, it is proposed and promoted the
creation of functional spaces where technical effectiveness is
linked to the quality of care and comfort of all users. There are
recommendations focused on reducing stress and promoting
comfort, focusing on the architectural and structural improve-
ments of the ICUs. Changes must consider an appropriate loca-
tion, as also improved light conditions, temperature, humidity,
noise, furniture, and decoration among others (40). The in-
corporation of vinyl, artificial windows when natural light is
not available, decorative elements, and others that facilitate the
time-space orientation of the patients, require minimal invest-
ments and can significantly increase the wellbeing of all those
involved. These modifications can positively influence the feel-
ings and emotions favoring human spaces adapted to the func-
tionality of the units. These concepts are equally applicable to
waiting rooms, which must be redesign so that they become
“living rooms” and offer greater comfort and functionality to
families; and improving workspace and staff rest areas.
END OF LIFE CARE
Palliative and intensive care must coexist throughout the
critical care process (41). Palliative medicine seeks to provide
comprehensive care to the patient and his/her environment
by reducing the discomfort and suffering of the patient and
family at the end of life. The limitation of life support, com-
mon in critically ill patients, should follow the guidelines
and recommendations established by Scientific Societies (42,
43). It must integrate a palliative care plan, in a multidisci-
plinary way to cover the physical, psychosocial, and spiritual
needs of patients and relatives (44). The existence of specific
protocols and the periodic evaluation of the care offered are
necessary requirements. The complex decisions made around
critically ill patients at the end of life can produce discrep-
ancies between health professionals and between them and
their families. Moral suffering (45), care perceived as inap-
propriate (46), compassion fatigue (47) are frequent in these
situations and may favor professional attrition with negative
consequences for the patient, family, and especially for pro-
fessionals and own institutions (48). Professionals must have
the necessary skills and tools to solve these conflicts by incor-
porating open and constructive discussions in these situa-
tions with coping strategies to reduce the emotional burden
derived from them.
IN SUMMARY
This change in the management model is transforming the re-
ality of the ICUs, adding value to the experience of patients,
families, and professionals. There is still a long way to go, but
Critical Care Medicine www.ccmjournal.org 389
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Plenary Articles
we are moving toward evolving into human-centered ICU
model.
ACKNOWLEDGMENTS
We would like to thank Gloria Rodríguez-Vega for their critical
grammatical review of the article.
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