Because of advances in technology and the provision of critical care, an increasing number of patients are surviving critical illness; this growing population of survivors of critical illness is characterized by heightened vulnerability to a host of adverse health outcomes and by the development of multidimensional impairments that significantly impact their quality of life and societal participation. Post-intensive care syndrome (PICS) is defined as new or worsening impairments in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. PICS-Family describes the psychological and social impairments that family members, loved ones, and caregivers can develop as a consequence of their loved one’s critical illness. Survivors of critical illness are a heterogeneous patient population, and considerable variation exists with respect to the breadth, depth, duration, and mutability of their symptoms and impairments. This chapter explores the clinical manifestations of PICS, its incidence and prevalence, the co-occurrence of impairments in multiple domains, duration and severity of impairments, risk factors for its development, prediction tools, prevention strategies, screening and diagnosis, and treatment options. Additional topics include the biophysical model of disability, functional trajectories following critical illness, and the lack of communication about post-ICU problems.

In addition to symptoms classically associated with the post-intensive care syndrome (PICS), survivors of critical illness often report debilitating physical symptoms affecting their comfort and appearance. Fatigue and chronic pain are among the most common symptoms, and standardized scoring systems have been developed to measure these symptoms in survivors. Moreover, patients who undergo intensive care are at risk for joint contractures, heterotopic ossification, pressure injuries and ulcerations, sexual dysfunction, urinaruy complications, sensory deficits, and skin, hair, and nail changes. A thorough review of systems can identify patients in need of specialty care. Early identification and prompt treatment of symptoms may improve the quality of life for many survivors of critical illness.

This chapter describes the significant role that spiritual support plays for both the ICU patient and their loved ones. A hospital stay is a stressful time, and an ICU experience is traumatic. The severity of illness and the uncertainty of healing can precipitate existential questioning and increase reliance on faith. Intervention by a trained non-denominational chaplain can be an asset to an ICU team, offering patients and loved one’s psycho-spiritual support to diverse kinds of needs. As a spiritual care specialist, a chaplain can distinguish between spirituality – an internal search for meaning – and religiosity, often rooted in a structured belief system. Tools like the FICA model are used by chaplains to assess spiritual distress, and chaplains can train the ICU staff as “spiritual care generalists,” who can then identify spiritual distress and reach out to a chaplain if needed. The chapter also addresses the need for spiritual support in patients with Post Intensive Care Syndrome (PICS) and Post Intensive Care Syndrome – Family (PICS-F). Chaplains can be beneficial for both diagnoses.

This chapter serves to identify barriers and solutions for PICS clinic formation and success. Systematic identification of patients with PICS risk factors and their stakeholders in care can facilitate education about the pathophysiology of PICS during hospitalization. Early clinic team contact with the patient and their care stakeholders increases clinic recruitment and reduces attrition through clarifying the need and purpose of the clinic. Secondary to the patient’s medical complexity and progression through hospitalization, rehabilitation, and home, there are inherent risks for gaps in care. These gaps can be bridged with an interdisciplinary screening process and transition of care plan.

Survivors of critical illness are at increased risk for the development of functional impairments, including difficulties performing activities of daily living and instrumental activities of daily living. This chapter explores the role of occupational therapy (OT) in the rehabilitation of patients impacted by post intensive care syndrome (PICS). Specific evaluation tools used by occupational therapists that can be assess PICS patients to identify their impairments in the key areas of physical, cognitive, and mental health are described. Thereafter, interventions used by occupational therapists to remediate identified impairments and maximize independence are described, derived from a combination of evidence-informed practice in similar patient populations and current empirical evidence for PICS rehabilitation.

Age-Friendly Health Systems include hospitals, clinics, and long-term care facilities that provide state-of-the art care to older adults. They organize care around 5 core principles known as the 5Ms: Mobility, Mentation, Medications, Multicomplexity, and What Matters Most. The 5Ms have not been applied previously to care delivery for older adults with post-intensive care syndrome (PICS); thus, this chapter offers a novel, interprofessional 5Ms approach to evidence-based care delivery for older adults with PICS. The first section provides essential background on interpreting evidence about PICS through the lenses of ageism (bias related to age) and ableism (bias related to disability status). Each of the next five sections explains one of the 5Ms constructs and summarizes relevant evidence related to PICS. The final section summarizes offers a vision linking Age-Friendly Healthcare, Age-Friendly Communities, and Age-Friendly Public Health after critical illness.

While much of this book has been focused on describing post-intensive care syndrome (PICS) in objective terms, is if often the personal stories of survivors of critical illness and their loved ones that are so much more revealing than the distance walked during 6 minutes or a score on a cognitive test. It was not until I began seeing patients in my ICU follow-up clinic that I truly appreciated how life-changing an experience surviving critical illness could be. Understanding the real-life impact of the physical, functional, cognitive, psychiatric, and social impairments that those suffering from PICS face is a profoundly moving and motivating experience. For that reason, I wanted to close this book with stories of survivors of critical illness and their loved ones, allowing the reader to synthesize and contextualize the objective data that has heretofore been presented in neatly parsed, individual chapters and to more deeply appreciate how that data translates into a much more impactful lived experience.

Survivors of critical illness are at risk for severe negative health outcomes, including an increased risk for mortality in the first several years following their index hospitalization and an increased risk for hospital readmission. recovery trajectories among survivors of critical illness vary considerably, with some patients recovering to near baseline functional status and others entering a cycle of readmissions, disease exacerbations, and prolonged chronic critical illness. Moreover, critical illness has been found to be associated with an increased risk of the development of new chronic diseases, including cardiovascular, pulmonary, neuroloigcal, and renal diseases, as well as worsesning of pre-existing chronic conditions. Given these increased risks, it is no wonder that survivors of critical illness–many of whom may spend more time in a hospital-like setting than at home–have high rates of healthcare utilization. Recognizing these risks can provide a basis for early diagnostic testing and referral for specialty care as needed. Understanding the association of critical illness with subsequent mortality, chronic illness, and healthcare utilization can provide a foundation for the skilled care of survivors of critical illness.

Advocacy for Post-Intensive Care Syndrome (PICS) is a critical component of supporting the recovery of survivors of critical illness. Despite its importance, a shared understanding of PICS advocacy remains underrepresented in medical literature. This chapter defines PICS advocacy as an ethical commitment to patient- and caregiver-centered care, encompassing three key dimensions: supporting individuals living with PICS, promoting awareness and prevention within medical and lay communities, and advancing the science surrounding this condition. Current advocacy efforts occur across various levels, including local communities, national organizations, and global collaborations. Central to these efforts is awareness, facilitated by a growing array of educational resources such as books, podcasts, and websites. However, PICS advocacy can further benefit from large-scale public awareness campaigns modeled after successful initiatives by organizations like the American Heart Association and the American Cancer Society. These efforts could amplify public understanding and drive systemic change. Individuals are encouraged to take an active role in PICS advocacy, and this chapter offers practical strategies for engagement. By empowering individuals to champion PICS awareness and support, the healthcare community can foster a more inclusive approach to addressing this condition. Advocacy for PICS is not just a responsibility–it is an opportunity to transform care and improve outcomes for survivors and their families.

After discharge from the intensive care unit (ICU), it is often assumed that a patient’s appetite, weight, and nutritional status will return to premorbid levels with minimal intervention. Malnutrition is common following critical illness, and multiple barriers exist to nutrition rehabilitation following hospital discharge, which are often recognized and understood in this vulnerable patient population. Such barriers include appetite and weight loss, early satiety, gastrointestinal disturbances, altered taste and smell, dysphagia, and the constellation of physical, functional, cognitive, and psychosocial challenges known as the post-intensive care syndrome (PICS). Registered dietitians (RD) can direct the continuity of nutrition care essential to supporting recovery from critical illness, with the goal of helping patients regain muscle mass, strength, and independence. Education and partnership with the patient, family, and medical team are required for the best outcomes in nutrition recovery. Nutrition rehabilitation will be explored after discharge from the hospital by addressing the barriers and strategies to guide the patient toward success.

The World Health Organization recognizes disability as part of being human. The fact that people with PICS are a part of a global disabled population at high risk of disparities due to disability itself is underrecognized.To better explore PICS as a subgroup within a larger disabled community, this chapter reviews international consensus on human rights and disability; the difference between equality and equity; the Biomedical and Social Models of Disability; application of the Social Model of Disability to the lived experiences of people with PICS; and practical strategies to make care more just and inclusive for people with PICS based on strategies that have been successful for other communities with disabilities.

Critical illness often results in profound cognitive, physical, and psychological challenges that can significantly affect an individual’s ability to resume employment and driving. This chapter provides an extensive review of the literature regarding returning to work and driving post-critical illness, focusing on the multifaceted nature of impairments and the implications for rehabilitation. Cognitive deficits, encompassing attention, memory, executive function, and visuospatial skills, pose significant barriers to both returning to work and driving. Physical limitations such as weakness, decreased coordination, and balance issues further compound these challenges. Additionally, psychological sequelae, such as anxiety, depression, and post-traumatic stress disorder, can prolong the return to work and driving. Assessment tools, including neuropsychological tests, driving simulators, and on-road evaluations, play a pivotal role in identifying impairments and guiding rehabilitation strategies. Rehabilitation interventions must adopt a holistic approach, integrating cognitive rehabilitation, physical therapy, and psychological support to address the diverse needs of affected individuals. Further research is warranted to establish standardized assessment protocols and evidence-based rehabilitation interventions tailored to the unique needs of individuals recovering from critical illness.

For decades, the belief in the critical care community was that survival alone was a good outcome, and although that remains relatively true, it is also clear that survivors of critical illness face numerous debilitating symptoms, physical and neuropsychological morbidities, and functional impairments that require long-term management. As both the number of survivors and recognition of the burden of survivorship have increased significantly over the last 25 years, clinicians and researchers have paid considerably more attention to outcomes beyond mortality. The late 1990s and the early 2000s witnessed a period of significant growth in recognition of and research interest in long-term outcomes after critical illness. Major scientific meetings included significant content on survivorship following critical illness, particularly after the 2002 Brussels Roundtable issued a call to improve critical care research by investigating long-term, patient-centered outcomes beyond mortality alone. The field took a significant leap forward in 2010, when the term post-intensive care syndrome (PICS) was coined to describe the impairments in physical, cognitive, and mental health arising after a critical illness and persisting beyond hospital discharge. Although important in focusing the field, the definition of PICS does not address severity, duration, or impact on other domains of health.

Developing and sustaining ICU follow-up clinics to address PICS in survivors of critical illness and their loved ones pose significant challenges, and clinics need to be tailored to the physical, personnel, and financial resources available at a given institution. Although no standard recipe guarantees a successful ICU aftercare program, emerging clinics need to address a common set of hurdles, including securing an adequate space; assembling an invested, multidisciplinary staff; and procuring the necessary equipment, technological, and financial support to be successful. Although certain risk factors for the development of PICS are defined, there remains no consensus on screening tools to determine which patients would derive most benefit, and recruitment strategies for clinic participants remain institution-dependent. Although there is expert consensus on some screening tools to detect PICS, significant additional investigation is needed to refine these recommendations. Benefits derived by patients and their families, feedback mechanisms to improve in-ICU care at the organizational and clinician level, and the general lack of awareness of PICS among the critical care, medical, and lay communities demand that motivated clinicians with a commitment to interprofessional teamwork, defined operational processes, and creative problem-solving skills continue their efforts to further refine the promise of ICU follow-up clinics.

This chapter tells the story of the long struggle to overturn Plessy v. Ferguson and desegregate American schools - culminating with the Supreme Court’s unanimous opinion Brown v. Board of Education. The chapter then examines the application of Brown, detailing how subsequent rulings purporting to stem from Brown have, in fact, failed to carry out its central command to desegregate all American schools. Much of this checkered legal history arose due to the Court’s insistence on delineating between de jure (legally mandated) and de facto (arising incidentally as a result of non-legally mandated conduct) segregation This distinction led to the 2007 PICS ruling, which dramatically circumscribes the use of race to achieve a desegregated educational environment for districts which experience de facto rather than de jure discrimination. The chapter concludes with an analysis of the growing “resegregation” of American schools, tracing its deleterious effects on all students.