Thus, important questions are raised about both the issue of disclosure of uncertain prognostic information and about just what interventions might be appropriate for those patients who are experiencing cognitive difficulties after being gravelly ill.In 1998 I spent weeks in an intensive care unit (ICU) with an invasive infection, severe thenthereby ARDS, and an alarming number of organs in failure. I am also an academic philosopher and found much that was of genuine ethical and methodological interest in that first-hand experience. I shall draw on this experience in what follows, keeping alert to the danger of making unwarranted generalizations.Measuring cognitive impairment: intensive care unit delirium as a confounding factorDelirium is a frequent phenomenon in critically ill patient populations.
Ely and coworkers [2] found that 18.5% of 275 mechanically ventilated patients had persistent coma, and of the remaining patients 81.7% developed delirium. Similar findings have been reported by other investigators [3-6]. The delirium tends to involve bizarre and terrifying nightmares, hallucinations, and paranoid delusions �C often of the clinical staff trying to rape, murder, or otherwise harm the patient [7,8]. I have suggested that what makes ICU delirium especially insidious is that, unlike nightmares and more like paranoid delusions, it tends to occur in real time and hook onto slices of external reality [9,10]. One takes actual people in the ICU, whips up what is often a violent fantasy around them, and then has the fantasy play itself out in the midst of actual conversations and medical procedures.
One loses one’s grip on what is true and what is false because the true and the false are mixed together in one mess of experience.Kapfhammer and coworkers [11] surmised that the process of traumatization in ARDS patients has to do with the initial immediate threat of death by suffocation, the fact that patients must be at least partially awake and cooperative during weaning, the limited ability to communicate, and the lack of possibilities to flee. However, Jones and colleagues [12] have found that it is not memories of terrible real events during critical illness that are related to the stress disorders which can plague ex-ICU patients. It is the memories of the delusions [12-14]. Only these memories were strenuously retained over time �C recall of unpleasant factual events, such as suctioning and pain declined. Also, trauma patients, who might be expected to experience increased psychological distress because of memories of horrific actual events, did not have higher levels of anxiety if they did not have memories of delusions. It seems that the mental horrors Drug_discovery experienced by ICU patients are more traumatizing than the physical ones.