Delusions in intensive care: How can healthcare professionals help?

BBC Radio 4 recently aired the series The History of Delusions. One episode focused on delusions specific to people who had been patients on intensive care units.

An intensive care unit (ICU) is a highly specialised area of secondary care. They provide technology-driven treatment for patients in multi-organ failure. Until recently, little attention was paid to the psychological impact of admission to ICU. Delirium, previously referred to as ICU Syndrome or ICU Psychosis, affects around 60% of ICU patients (Brummel and Girard, 2013). Delirium is thought to be caused by critical illness, sleep deprivation, and sedative drugs such as Benzodiazepines. Delirious patients may appear agitated or withdrawn; or display both states alternately. The syndrome is associated with poor post-discharge outcomes, including anxiety and depression (Salluh et al., 2015) and reduced socio-economic function (Griffiths et al., 2013).

“Delusions are false beliefs stemming from an incorrect perception of reality.”

Delusions are one element of delirium and are false beliefs stemming from an incorrect perception of reality. Delusions can also be experienced by non-delirious patients. Post-discharge, former ICU patients report vivid memories of their delusions, often over-powering actual ‘factual’ memories of intensive care. These ‘false’ memories have been linked to the development of post-traumatic stress disorder (Jones, 2010).

Patients report experiencing feelings of motion and of being moved (Svenningsen et al., 2016), which can perhaps be linked to the use of pressure-relieving air mattresses together with the way patients are frequently moved around the unit to accommodate new admissions. As a former ICU sister, I heard numerous beliefs and stories from my patients. One lady accused staff of stealing her organs, one by one, night after night. Another was convinced her sons had left her in intensive care so we could murder her and they could receive their inheritance. Another patient wrote to staff to tell them about his delusions, the memory of which persisted a year after his discharge. He recalled how ‘Satan and his helpers’ visited each patient. I interpreted this as a reference to the consultants’ ward round.

“One lady accused staff of stealing her organs, one by one, night after night.”

The journalist David Aaronovitch reportedly fought off nurses who he believed were using oxygen to tenderise his flesh prior to eating him. Many patients report believing that they are involved in games or challenges, where they feel compelled to do certain tasks ‘or else’.  Such delusions may explain some of the agitation and hypervigilance seen amongst ICU patients. Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing and asked his bemused relatives to bring in his passport and dinner jacket.

“Not all delusions are persecutory, however: one patient told me that he was on a cruise with the greats of Formula 1 motor racing…”

So how can healthcare professionals help?

We have written about how discharged patients value diaries written by their family and ICU staff. The diaries help patients reclaim ownership of lost time and reconstruct their illness narrative. Such diaries should be used alongside multi-disciplinary follow-up support (Teece and Baker, 2017). The recent POPPI Trial explored the use of nurse-led interventions to provide a calm environment and detect signs of psychological distress in patients, and future phases will trial the effectiveness of other interventions. The bedside nurse has an important role to play in screening for delirium, re-orientating, reassuring, and comforting frightened and vulnerable patients.

Do you have any experience of caring for delirious patients, or supporting discharged patients who have experienced delirium whilst in hospital? Comments and questions are very welcome. You can
contact Angela Teece directly or use the comments form below.

References

BRUMMEL, N. E. & GIRARD, T. D. 2013. Preventing delirium in the intensive care unit. Critical Care Clinics, 29, 51-65.

GRIFFITHS, J., HATCH, R. A., BISHOP, J., MORGAN, K., JENKINSON, C., CUTHBERTSON, B. H. & BRETT, S. J. 2013. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Critical Care, 17, 1-12.

JONES, C. 2010. Post-traumatic stress disorder in ICU survivors. Journal of the Intensive Care Society, 11, 12-14.

SALLUH, J. I. F., WANG, H., SCHNEIDER, E. B., NAGARAJA, N., YENOKYAN, G., DAMLUJI, A., SERAFIM, R. B. & STEVENS, R. D. 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal, 350.

SVENNINGSEN, H., EGEROD, I. & DREYER, P. 2016. Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur’s interpretation theory. Journal of Clinical Nursing, 25, 2807-2815. h

TEECE, A. & BAKER, J. 2017. Thematic Analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing, 41, 50-56.

Artwork credit: original artist unknown, but sourced from the Delirium Care Network @deliriumcare