During The Stay


Resources to help yourself or your loved one during ICU stay




Useful Information


- What is the routine?

If the patient is in a Surgical ICU, he/she is seen by the ICU and Primary Surgical Teams in the morning and afternoon. In the Medical ICU, the patient is generally cared for by the ICU Team only. During ward rounds, most hospitals will request for visitors to wait until the round is completed. At the same time, the events over the day is recounted and plans are made for the day. After the round is completed, the Teams will carry out the plans and visitors are then allowed into the ICU.

The Teams may contact the Next of Kin to discuss the treatment plans or obtain acknowledgment regarding certain procedures, such as the placement of breathing tubes, special intravenous drips, etc.

Family conferences or meetings may take place at variable frequency. During these meetings, the doctors will discuss and update the patients’ conditions and reach a consensus on the treatment plans and goals.

- What common procedures are done?

A wide variety of procedures may be performed as part of the patient’s treatment, but the commonest include the endotracheal intubation, placement of central venous catheters and intra-arterial cannulas, placement of urine catheters, bronchoscopy, paracentesis and chest drain insertion or thoracentesis.

- What complications may arise from the procedure?

Complications vary from minor to severe and life threatening. The commonest risk include bleeding and infection. Specific risks can be found here.

- What does the doctor mean when he/she says “….”?

Although doctors try hard to explain things in simple terms, medical terminology may slip into the conversation. Always attempt to clarify on the spot, otherwise you can find a glossary of terminology here.


Common ICU Conditions


With modern ICU care, it's becoming less common for patients to die acutely. What is becoming more common is the patient who survives the acute phase of critical illness but develops numerous complications and may never make recover completely.

This is a list of commonly encountered complications within the ICU. In general, the occurrence of these complications increase with duration of hospitalisation and ICU stay.


Confusion or Delirium

Delirium may include periods of confusion with intermittent periods of normal function, poor memory and lack of attention, excessive sleepiness, agitation or hallucinations. The exact cause of delirium is not known but elderly age, severe illness, major surgery, lack of sleep, medications or infection may all contribute. The treatment is aimed at correcting reversible medical conditions and protecting the patient from being injured. If general care fails to control the agitation, medications and temporary restraints may be required to protect the patient from harming himself or herself. Delirium may vary in duration. Some patients may suffer from permanent mental changes after severe illness.

Weakness 


ICU patients are at risk of becoming weak very quickly, due to problems with nerves (known as neuropathy) or wasting of the muscles (known as myopathy).  Weakness may mean that the patient will be dependent on the breathing machine for longer than expected. The exact cause of this type of acute weakness is not known, but it is likely related to widespread inflammation, certain types of drugs (such as steroids), and high blood sugar levels. The focus is on prevention by good nutrition and physiotherapy. There is no specific treatment for ICU related weakness and recovery is known to be slow.

Heart Failure

Heart failure may be the cause of the ICU admission, or it might be affected by other conditions and contribution to the patient’s deterioration. Severe infection is well known to cause heart malfunction. This is usually reversible if the patient recovers from the underlying condition. Drugs are used to boost the blood pressure and improve heart function, but may also cause unwanted side effects.

Infections



Infection means invasion of the body by bacteria, viruses or fungus that cause harm to a person. Many different parts of the body can be infected, but in ICU the most common sites include the lungs, IV tubes, surgical wounds and the bladder.  



Lung or chest infection: Ventilator-associated pneumonia


The main risk factor for a lung infection (also known as pneumonia) is being on a breathing machine. The likelihood of this increase with the duration of breathing support.

IV tube infection: Central line-associated bloodstream infection


The main risk factor for a IV tube infection is the duration in which the tube is in place. Unfortunately these tubes are essential, especially when the patient is very sick.

Surgical site infection


 Many factors contribute to wound infection and repeat surgery may be necessary to control the situation.

Bladder or urine tube: Catheter-associated urinary tract infection


The main risk factor for a bladder infection is the duration in which the urine tube is in place. Unfortunately the urine tube may be essential to ensure that the bladder can empty and for monitoring of urine production.



Treatment: When an infection is suspected, tests are performed and infections are usually treated with antibiotics. In some cases, removal (and replacement) of infected tubes are required.

“Hole in the lung” or Pneumothorax


This condition may arise as a complication of a procedure (central line insertion), due to existing poor lungs or due to high pressures generated by the breathing machine to ensure adequate air exchange. Imagine the lung as a deflated balloon. This condition may be quickly life threatening and is treated by placing a tube into the chest cavity to drain the accumulated gas outside the lung and allowing the deflated lung to re-expand.

Stomach or Stress Ulcers



This occur when the lining of the stomach breaks down due to severe illness and can lead to life threatening bleeding. To prevent this, most ICU patients are treated with medications which lower the amount of acid in the stomach. 
If bleeding occurs, treatment involves medication to reduce the acidity of the stomach or direct treatment using a special camera inserted into the stomach through the mouth. In some situations, surgery may be required to stop the bleeding. 

Ileus or gut failure

Disease of the intestine, severe infection and drugs are some common causes of ileus, also known as gut failure or malfunction. Normally, food and nutrients move from the stomach towards to rectum in an organised fashion.

In ileus, the intestine fail to coordinate and nutrition cannot be absorbed. If there is a surgical cause (for example, blocked intestines), an operation may be needed. If there is no physical blockage, then treating the underlying disease, and the use of some medications to encourage intestinal movement is used.

Dead intestine or ischemic bowel


This is a life threatening condition in which part of the intestine do not receive enough blood supply and die as a result. The dead intestine causes severe pain, low blood pressure and may burst, releasing food material in the abdomen. This is an emergency and urgent surgery is often needed.

Deep Vein Thrombosis (DVT)

A DVT is a blood clot in the deep veins of the leg or groin. It can affect any immobilised patient and is increased in patients with injury, cancer, infections, or genetic reasons. The most serious complication of DVT is pulmonary embolism (PE), when the clot travels into the lung and may be cause death. To prevent DVT, patients are treated with low dose blood thinners, special stockings or machine to compress the calf intermittently.

Kidney Failure

Kidney failure is the inability of the kidneys to remove toxins and fluid from the body resulting in accumulation. There are many causes of kidney failure, including prolonged low blood pressure, infections, or medications. It may be temporary or may become permanent. Toxins and fluid may be removed from the body using machines (dialysis).

Please click here for additional information.

Skin ulcers (pressure ulcers or bed sores)

These are ulcers that are caused by pressure on the skin, especially in the buttock, heel or elbow areas where bones are close to the skin. The main risk factor for developing pressure sores is prolonged immobilisation. Thin patients who have chronic muscle weakness, or who have been hospitalised for prolonged periods of time are at higher risk. This is prevented by frequent turning in bed to relief the pressure on the skin.

Please click here for additional information.

Medication Side Effects


All medications have the potential to cause harmful effects which are not intended. Side effects can be mild (skin rash or diarrhoea) or severe (bleeding, severe allergy or death) and maybe unpredictable.

Please click here for additional information.

Procedural Complications


Most patients in the ICU require procedures to be performed at regular intervals. Most commonly, such procedures involve the placement of lines or tubes, such as feeding tubes, breathing tubes, drainage tubes, or IVs into the deep or superficial veins.

All procedures carry a small risk of complications. All possible measures are taken to reduce the risk of such complications, but the risk is never zero. In the event that a patient requires a procedure (beyond the normal procedures that all patients require), the situation will be discussed with the patient or their family.


Help From Family


Recommended Actions

 

1. Take care of yourself. Remember to eat, drink and sleep.



2. Communication
  • - It is common for patients to be frustrated, or not be interested in communicating. Be patient.
  • - Avoid asking questions that cannot be answered easily, especially when intubated - link to glossary.
  • - Use a board so that the patient can point to words such as “pain”, “thirsty”, or “tired”.
  • - Simple hand gestures may work equally well: thumbs up and thumbs down.
  • - Repeat the date and time of day to orientate the patient.
  • - Communicate with rest of family, communicate with ICU team.



3. Assurance

Although the patient may be sedated with medication, there is no harm talking to him or her to assure her.

  • - Speak in a calm, clear manner.
  • - Make short positive statements. “I am here with you and you are doing better and making progress.”.
  • - Acknowledge the discomfort your loved one may be experiencing. "You're are in the ICU and you have a tube to help you breath. This is temporary and the nurses will give you medication to make you more comfortable.”
  • - Touch or hold hands.
  • - Describe what the different noises mean to help ease any fear or anxiety.
  • - Music to ease anxiety.



4. Protection
  • - Wash hands or use disinfectant hand wash to reduce infection risk.
  • - Wear provided gowns or mask if requested by the ICU team.

The Child with a Loved One in the ICU


Recommended Actions

 These suggestions should be modified to meet the needs of the child and circumstances surrounding the patient’s ICU admission. Age specific guidelines are difficult as many factors come into play. The information conveyed to a child needs to be appropriate for the child's maturity and be determined by a responsible adult.

 
Should a child be told of the patient’s ICU admission?

Yes.

Many experts are of the opinion that trying to protect a child by withholding information is not in the child's best interest. Children possess strong observational skills but do not possess the maturity to correctly interpret all of their observations. It is ideal to have a close relative provide accurate explanation with as much information as appropriate so that the interpretation is not left up to the child's imagination. The child should have the opportunity to ask questions and be provided with honest answers which is crucial in maintaining the child's trust in the family.

Should a child be allowed to visit?

There are 2 angles to consider: benefits to the child and benefits to the patient. We will only consider the child’s in this section.

Appropriate information should be provided to the child and if the adult responsible for the child feels a visit would be appropriate and the child is capable of making the decision, the child should be given the opportunity to decide whether or not he/she wants to visit. The child's decision should be honoured. It is important to ensure that the child's imagination is not leading them to inappropriate conclusions by having frequent frank conversations with the child.

If the child wants to visit?

Check with the medical staff prior to the visit: this is always a good idea to make sure that it is safe for both the child and patient. Many ICU's have visiting policies pertaining to children and the ICU staff may have additional suggestions for you regarding the visit. Some children may want to meet the nurse or doctor caring for their loved one and this can be arranged.

Prepare the child for the visit: the child should have a reasonable understanding of what he/she may encounter as the experience may be frightening and overwhelming. The child should be told in advance whether or not the patient will be able to respond. The patient’s appearance should be described, including the presence of tubes and catheters, mechanical ventilators, and other medical equipment. The child's increased understanding that the devices in the room are to make the patient better or more comfortable will make the experience more reassuring and gives them specific ways to relate to the patient.

Prepare the patient for the visit: If possible, the child's visit should be discussed with and approved in advance by the patient.

Plan a brief visit of 5-10 minutes: during which the adult should support and guide the child and answer any questions he/she may have.

After the visit: allow some quiet time to sit with the child and ask if he or she has any questions regarding the visit. Answer honestly with as much information as deemed appropriate.

What if the child does not want to visit?

If the child decides that he/she does not want to visit at this time, engage the child with alternatives to visiting such as making a card or sketch, writing, or sending an object. Avoid forcing a visit as it may be traumatising to the child.

When is it better not to visit?

When the patient’s appearance is markedly different or if the child is handling the situation poorly, you may decide to discourage the visit unless this is the last opportunity that the child will have to see their loved one.

Should a child be told about the death of the patient?

Yes.

There is no "right" or “best” way to do this. Do not shy away from using the words "death" and "die" in the conversation. The child must sense the support of the parent or close family member when dealing with this. The response of a child to the loss of a loved one is similar to an adult's response. Children do grieve and may feel anger, guilt, rejection, anxiety, and frustration, although the manifestation may differ from an adults. There are some local resources available to help in this website’s “Resources” section. 


Should a child attend the funeral?

Yes.

Like the visit, the child should be offered the opportunity to attend the funeral. The funeral may transfer denial into reality and offer the opportunity to say good-bye.


What If Things Don't Go Right


Life Choices

Medical technology can prolong life in many situation, but if the underlying condition cannot be reversed it does nothing but to prolong suffering by artificially delaying death and resulting in a huge financial drain that leave the living to suffer. In such situations, a decision needs to be made to determine the extent of care.

It is important for you to know that you and your loved one have options. In Singapore, the decision to limit or withdraw care is often made in conjunction with the family. When faced with critical questions such as these, it becomes very important to put your own feelings aside and to consider the wishes of the patient. The healthcare team will make recommendations regarding the limitation or withdrawal of care. This comes in several forms:

1. Withdrawing of artificial life support.

The patient may be kept alive only by artificial means (with drugs or machines). Withdrawal of life support does not mean giving up. Stopping these artificial interventions is to allow nature to take its course. The patient is still cared for but with the focus on keeping comfortable and as pain-free as possible.

2. Limitation of artificial life support.

There are situations where limitation of the amount or type of life support is reasonable. This can include avoiding high or toxic doses of medications or starting treatment that may cause harm. Treatment limitation may include the limited use of fluid drips and antibiotics.

3. Do not resuscitate (DNR) order.

This means that in the event that the heart stops, chest compressions will not be used to attempt to resuscitate as it may prolong the dying process and cause pain or harm.

We all hope and work towards the full recovery of the patient, but there will be a time where it is difficult or impossible to reverse disease conditions. In this situation, it is important not to cause more pain and suffering by persisting with unnecessary and ultimately futile treatment.

 

End of Life Care

How long does this stage last?

Each person’s situation is different, and it may vary from days to months. Your ICU Team may be able to give you more information about this based on their experience.

Goals of care at the End-of-Life

The goals of care shifts from curative towards palliative, where the ICU Team help your loved one stay comfortable and safe during his/her last days.

End-Of-Life Care Options

There are three options available for end-of-life care:

  • Home Hospice Service
  • Hospice Day Care Centre
  • Inpatient Hospice Care

There are many considerations to make when making a choice. These may include the wishes of the patient, medical needs of the patient, availability of help at home and affordability.

The ICU Team, Medical Social Worker and/or Palliative Care Team can help explore these options with you and decide on the most suitable course of action.

Practical Preparation for End-of-Life

As the patient, preparation for end-of-life care can greatly relieve the burden and stress on your family. You may want to indicate your choices and preferences with Advance Care Planning. You may consider drawing up documents such as a will, Lasting Power of Attorney and Advance Medical Directive. These will help your carers to ensure that your wishes are carried out.

As the family or friends, you can provide support for the patient by being honest and open. You may want to encourage the patient to consider the options listed above. The focus is on the well being of the patient in his/her last days and this can be achieved with thoughtful communication (if/when the patient is able to) or simply with your presence and touch. Be aware of your own physical and emotional needs. Take care of yourself. Remember to eat, drink and sleep.

 

Organ Donation

What is organ donation?
  • Organ donation are divided into two categories: living donation and cadaveric donation.
  • Living donation occurs when a healthy person donates an organ (usually kidney) or part of an organ (usually liver) to another person.
  • Cadaveric donation occurs when a person donates his or her organs after the diagnosis of death.
  • Donated organs are transplanted into patients in need and can save or improve lives.

Why donate organs?
  • Organ donation allows the deceased to leave a living legacy. It is also often considered as the “greatest gift one can make”.
  • Organ donation is an act of altruism and can save or improve lives of others. When an individual’s actions are focused mainly on the beneficial impact to others, without regard to the consequences to the individual, the actions are regarded as “altruistic”. Saving a life is regarded as one of greatest good man can achieve.
  • Some experts and philosophers believe that everyone should want to donate organs as it is for the good of the society. In fact, some believe that it is immoral for an individual to decline consent for donation of his or her organs, especially when they no longer have use for them.
  • Major religions encourage altruistic acts, and specifically include organ donation.

Additional resources on organ donation: https://www.liveon.sg/content/moh_liveon/en/index.html


Does my religion encourage or even allow organ donation?

- Yes. All major religions in Singapore approve of organ donation. Some resources include:
Organ Transplant In Islam
Does the Catholic Church allow organ donation?

What is the law of the land?

In Singapore, the Human Organ Transplant Act (HOTA) is based on “implicit consent”, that is to say: consent without some specific move denoting consent, and inaction is itself a sign of consent. In simpler terms, everyone who qualifies is a potential organ donor if they are diagnosed with brain death and have not previously registered their objection officially.

HOTA covers all Singapore Citizens and Permanent Residents 21 years old and above, who are not mentally disordered and to come into effect when the diagnosis of brain death is made. The criteria of brain death is stringent and internationally recognized to protect the interest of the patient.The only organs covered under this Act are the kidneys, liver, heart and corneas.

Actual HOTA document: Human Organ Transplant Act (CHAPTER 131A)

The Medical (Therapy, Education and Research) Act (MTERA) is based on based on “explicit consent”, that is to say an opt-in scheme, where people pledge to donate their organs and tissues (e.g. kidney, liver, heart, cornea, lung, bone, skin, heart valves, etc) for the purposes of transplantation, education or research after they pass away.

Anyone 18 years old and above, and are not mentally disordered can pledge to donate all his or her organs or specify which to donate. In cases where a person had not pledged his/her organs under MTERA before passing away, the family members donate the organs on their behalf under MTERA if they wish to do so.

Actual MTERA document: Medical (Therapy, Education and Research) Act (CHAPTER 175)