Clinicians' evaluation and management of mental health, substance abuse, and chronic pain conditions in the intensive care unit.
OBJECTIVE
The purpose of this study was to describe clinicians' evaluation and management of co-existing mental health, substance abuse (MHSA), and chronic pain (CP) conditions in patients with prolonged critical illness. Little is known about the evaluation and management of these conditions in the intensive care unit, and practice guidelines do not address management in the context of critical illness, optimal sedation/analgesia, or ventilator weaning.


METHODS
Longitudinal qualitative description.


METHODS
Intensive care unit of an urban academic medical center.


METHODS
Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation.


METHODS
Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks.


RESULTS
Transcribed interviews, field notes, and clinical records, representing >400 documents, were reviewed and coded using constant comparative analysis to identify the facilitators, barriers, contextual factors, and consequences associated with the evaluation and management of MHSA and CP conditions. Numeric clinical data supplemented and clarified thematic findings. Facilitators of MHSA and CP evaluation and management included family as history keepers, the use of subspecialty consultations, and anticipated alcohol withdrawal. Barriers included limited history taking and assessment of MHSA and CP conditions and the use of cognitive shortcuts. Consequences included nonintegration of MHSA and CP medications and diagnoses, episodic pharmacologic responses to psychobehavioral symptoms, and clinician-patient interpersonal tension. Contextual factors involved ambiguous psychobehavioral symptomatology, patients' critical illness and inability to speak, and competing clinical goals.


CONCLUSIONS
The explicit evaluation and management of MHSA and CP conditions was highly variable and inconsistent across cases. Findings suggest that MHSA and CP conditions require monitoring and management similar to that required for other chronic conditions. Multidisciplinary, individual-level, and system-level responses are warranted to address the complex interplay of barriers, consequences, and context.
Broyles
Lauren M
LM
Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA. lmb18@pitt.edu
Colbert
Alison M
AM
Tate
Judith A
JA
Swigart
Valerie A
VA
Happ
Mary Beth
MB
D002908:Chronic Disease; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008137:Longitudinal Studies; D008297:Male; D008487:Medical History Taking; D008511:Medicine; D001523:Mental Disorders / Q000175:diagnosis* / Q000628:therapy*; D008875:Middle Aged; D010146:Pain / Q000175:diagnosis*; D059408:Pain Management; D010414:Pennsylvania; D010818:Practice Patterns, Physicians'; D011369:Professional-Patient Relations; D036301:Qualitative Research; D012017:Referral and Consultation; D013038:Specialization; D019966:Substance-Related Disorders / Q000175:diagnosis* / Q000628:therapy*