Restricted Mobility and Recumbency

Hospitalization, particularly in the ICU, is associated with a considerable reduction in mobility (i.e., loss of exercise stimulus) and recumbency (i.e., loss of gravitational stimulus) (see Chapters 18 and 20).^11–13 These two factors are essential for normal oxygen transport; thus their removal has dire consequences for the patient with or without cardiovascular and pulmonary dysfunction.

In terms of a physiological hierarchy of treatment interventions (see Chapter 17), exploiting the physiological effects of acute mobilization, upright positioning, and their combination is the most physiologically justifiable primary intervention to maximize oxygen transport and prevent its impairment in patients who are critically ill.

Recumbency is nonphysiological; it is a position in which, all too often, most patients are injudiciously confined. Changing the position of the body from erect to supine positions results in significant physiological changes that may jeopardize the patient’s already compromised or threatened oxygen transport system (Box 33-2) (see Chapter 20).

The culmination of these deleterious effects offsets the increased homogeneity of ventilation and perfusion and their matching in the supine position. These effects compound the superimposed factors of restricted mobility, recumbency-induced central fluid shifts, prolonged lying without the normal stimulation or will to turn the body, and underlying pathophysiology or trauma that may contribute to impaired cardiovascular and pulmonary function and oxygen transport. Theoretically, the more compromised the patient, the greater the priority to maximize time spent in the upright position in conjunction with exploiting the benefits of acute mobilization.

Specificity of Cardiovascular and Pulmonary Physical Therapy

Physical therapy interventions in the ICU (see Chapter 17 and Part III) are more specifically geared toward the status of each organ system, taking into consideration the pathophysiological basis for the patient’s signs and symptoms, the rationale for each intervention, and the physiological and scientific evidence supporting the effectiveness of the intervention.¹⁴ Physical therapy provides both prophylactic and therapeutic interventions for the patient in the ICU. Conservative, noninvasive measures constitute initial treatments of choice to avert or delay the need for additional invasive monitoring and treatment including supplemental oxygen, pharmacological agents, and the need for intubation and mechanical ventilation. The physical therapist aims to avoid, reduce, or postpone for as long as possible the need for respiratory support. Even if the patient is mechanically ventilated, maintaining some level of spontaneous breathing, no matter how minimal, is associated with improved oxygenation and outcomes.¹⁵ In addition, the physical therapist helps to prevent the multitude of side effects of restricted mobility and recumbency during bed rest. A summary of general information required before treatment of the patient in the ICU is presented in Box 33-3. This provides the basis for establishing a patient’s readiness to be mobilized and the progressive steps for doing so (Box 33-4 and Figure 33-2).

Maximizing Function

Maximizing function refers to maximizing the capacity to participate in one’s life roles and associated activities. This necessitates promotion of optimal physiological functioning at an organ system level, as well as promoting maximal functioning of the patient as a whole. In critical care, primary goals related to function optimization are initially focused on cardiovascular and pulmonary function. With improvement in oxygen transport, increased attention is given to optimal functioning of the patient with respect to self-care, self-positioning, sitting up, and walking. General physical therapy goals related to function optimization are shown in Box 33-5. Outcomes can be tracked objectively by recording the length of time a patient sits over the edge of the bed, sits in a chair at bedside, stands, and walks. Also, the weight a patient lifts as well as the number of repetitions and sets he or she performs can be readily quantified.

Consistent with being primarily a noninvasive practitioner, the physical therapist exploits noninvasive interventions to achieve therapeutic goals. Outcomes related to reduced reliance on invasive interventions are important physical therapy outcomes. These include reducing FIO₂; avoiding mechanical ventilation; minimizing mechanical ventilator support; increasing the amount of spontaneous breathing, even minimally, if the patient is mechanically ventilated; and reducing medication (e.g., bronchodilators, inotropes, chronotropes, sedation, narcotics, and analgesics).

Prophylaxis

General aspects of patient care related to physical therapy practice include the role of prophylaxis or prevention. The complications of restricted mobility and recumbency are described in Chapter 18 and relate primarily to the status of the cardiovascular and pulmonary, neuromuscular, and musculoskeletal systems and overall functional capacity. In the ICU the negative physiological effects of restricted mobility are amplified in patients who are severely ill and older. A primary objective of the physical therapist therefore is to avoid or reduce these untoward effects on the patient’s recovery and the patient’s length of stay in the ICU. Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the ICU and is associated with poor outcomes and high cost of ICU care.

Preventive physical therapy goals include reducing the deleterious effects of restricted mobility and pathology on cardiovascular and pulmonary and neuromuscular function and reducing the risk of musculoskeletal deformity, neurological dysfunction, and decubitus ulcers over pressure areas (back of the head, shoulders, elbows, sacrum, and heels). Special mattresses or a special bed may be indicated. The negative sequelae of recumbency and restricted mobility, which can be life-threatening in people who are critically ill, are largely preventable. Particular care must be taken to avoid pressure sores because these increase the risk of infection and deterioration and can be life-threatening. Physical therapists as well as nurses need to pay particular attention to individuals at risk and to examine routinely for sites of redness, pressure, and potential skin lesions in every patient, regardless of expected length of stay in the ICU.¹⁶ The texture of bed covers, their smoothness, bunching of the bed gown, and irritation from lines and catheters to the patient must be routinely monitored. Prevention is key, given the potentially reduced immunity and capacity to heal of patients in the ICU.¹⁷ Although pressure sores are largely preventable, the need to be vigilant remains, given the deleterious consequences they may have on recovery. Unrelieved pressure and equipment failure have been identified as key causes of pressure sores in the patient after trauma.¹⁸ These causes of pressure sores are 100% avoidable with vigilance and monitoring. Physical therapists have a role for making recommendations about patient positioning between treatments in the interest of preventing deleterious sequelae of recumbency and restricted mobility.

Preparation for Treating the Patient in the Intensive Care Unit

Patients in the ICU are generally characterized by some degree of life-threatening medical instability or its risk. Before treating a given patient in the ICU, the physical therapist should be thoroughly familiar with the specific information shown in Box 33-6. Depending on the level of care in the ICU, nursing care is usually 1 : 1 or 1 : 2. Coordinating treatment with nursing interventions is efficient. It is helpful to have the nurse at hand to assist as required, particularly if the patient is beginning physical therapy. Alternatively, if the nursing care proved strenuous for the patient, physical therapy may be more beneficial if delayed.

Monitoring

Maximizing the effects of physical therapy treatment depends on exploiting information from the ICU monitoring systems. Monitoring systems can be used to establish the indications and contraindications for treatment as well as parameters of the treatment prescription and progression, and to assess the patient. Physical therapy uses of monitoring systems in the ICU are summarized in Box 33-7. Physical therapists need to exploit the considerable amount of objective data available to them in patient management. A thorough knowledge and routine use of monitoring systems for each patient in the ICU cannot be overemphasized in terms of contributing to improved quality of care with less risk to the patient. Subjective responses of the patient are particularly important in the ICU, where the patient’s power and self-responsibility are compromised. Eliciting subjective responses can be achieved through a sign system, use of analog scales, and communication devices. The patient needs to be able to communicate basic needs if possible (e.g., discomfort or /pain, anxiety, fear, and general distress). Patients have been reported to experience significant levels of stress when being managed in the ICU—in turn, worsening outcomes.¹⁹

The monitoring systems described in Chapter 16 provide essential information with respect to the management of the patient in the ICU. Information regarding arousal, acid-base imbalance, and fluid and electrolyte balance helps to establish specific treatment goals. The Swan-Ganz catheter in situ permits measurement of pulmonary artery pressure and wedge pressure, which provide an index of myocardial sufficiency and specifically left-sided heart function. Central venous pressure gives an indication of fluid loading and the ability of the right side of the heart to cope with changes in circulating body fluids. Pressures related to heart function give the physical therapist an indication of pulmonary status and help to determine whether heart dysfunction is affecting lung function or lung dysfunction is affecting heart function, or both. Cardiovascular and pulmonary stress alerts the physical therapist to modify workloads or the physical demands of treatment to keep the patient medically stable and avoid undue fatigue and deterioration. The physical therapist conducts ongoing monitoring of the patient’s responses to invasive care in the ICU (e.g., responses to medication and fluid resuscitation, indications for intervention and refinement of its prescription) to ensure patient safety.

Changes in ECG may reflect heart disease, lung disease, altered acid-base, and electrolyte and fluid balance. The physical therapist is responsible for identifying the patient’s heart rhythm and ECG changes, which can be expected with improvement or deterioration in oxygen transport and secondary to medical management, drug intervention, changes in the course of the disease, and response to treatment generally.

Pharmacological Agents

The physical therapist needs a thorough knowledge of the common pharmacological agents used in intensive care (see Chapter 45). With this knowledge, the physical therapist can augment the effects of these agents and optimize physical therapy treatment response when treatments are coordinated with medication schedules. Most medications have optimal dosages for any given patient, optimal sensitivity, and peak response time. Most medications have side effects. Side effects may cause deterioration in the patient’s condition, create apparent signs and symptoms suggestive of other disorders, or alter response to treatment. The physical therapist therefore needs to identify the medications each patient is taking and their side effects. Medication that contributes to suboptimal therapeutic outcomes warrants discussion with the team in terms of finding an alternative. One physical therapy outcome is the minimization of medication with effective physical therapy.

Certain medications, such as anxiolytics, bronchodilators, sedatives, mucolytic agents, antianginal medications, and analgesics, help the patient to cooperate and tolerate treatment. Special consideration must always be given to the different peak response times of different medications. The patient can cooperate more actively in the treatment if pain and anxiety are reduced and breathing is easy. An enhanced treatment effect is therefore more likely. These advantages can result in shorter, more cost-effective treatment and more effective use of the physical therapist’s time.

Some medication can attenuate a patient’s response to mobilization and exercise and activity. Patients on beta-blocking agents, for example, may not show the normal changes in heart rate and blood pressure in response to exercise. In addition, beta-blockers contribute to fatigue. Therefore, caution needs to be observed when prescribing exercise for patients taking beta-blockers. Another classification of drugs called vasopressor agents regulates blood pressure and heart rate. Patients taking these agents may also exhibit abnormal mobilization and exercise responses. Monitoring is essential; however, vital signs to assess treatment response may be rather limited for patients taking drugs that act on the cardiovascular system.

Narcotics are a commonly used classification of drug in the ICU and are often administered for their analgesic effects jointly with sedatives and tranquilizers. Despite pain relief, narcotics, particularly in combination with other sedative-type drugs, interfere with physical therapy treatments because of the patient’s reduced arousal, monotonous ventilation, and inability to cooperate with treatment. Furthermore, narcotics tend to have multisystem effects rather than localized effects. Because physical therapy is the most physiological and noninvasive intervention available to the patient in the ICU, it behooves the physical therapist to ensure that pharmacological agents that are effective and more selective than narcotics in achieving the desired effect have been considered. Thus as a team member the physical therapist has a major role during rounds to ensure an integrative management program for each patient.

Supplemental Oxygen

Supplemental oxygen is usually administered continuously, whether the patient is ventilated or not, to maintain PaO₂ level within an optimal range.²⁶ Oxygen concentrations can be increased before treatment to help compensate for associated stress. Oxygen, however, should always be increased to 100% and inspired for at least 3 minutes before and after suctioning. Should arterial desaturation be apparent during treatment, oxygen may need to be increased. If the patient is spontaneously breathing without oxygen, supplemental oxygen may also be indicated during treatment to avoid desaturation. Oxygen administration is regulated by the ICU team based on arterial blood gas levels including arterial saturation and subjective distress. Severe hypoxemia is known to result in irreversible tissue damage within minutes, but hyperoxia can also produce harmful effects within hours. By maximizing alveolar ventilation, gas exchange, and ventilation and perfusion matching, supplemental oxygen can be optimally used and the effects of acidemia minimized.

Treatment for respiratory acidosis in individuals with chronic pulmonary disease is aimed at increasing alveolar ventilation to improve the exchange of carbon dioxide and oxygen. Because the respiratory center is depressed by increased amounts of carbon dioxide (carbon dioxide narcosis), the lowered oxygen tension of the blood becomes the stimulus for respiration. If the patient inhales high concentrations of oxygen, the stimulation for respiration may be removed. For this reason, oxygen is never given to patients with carbon dioxide narcosis.

Low-flow oxygen (1 to 3 L/min) is given to a patient with chronic pulmonary disease who maintains a chronically elevated arterial PCO₂ in the presence of arterial hypoxemia. If intermittent positive pressure breathing is indicated, compressed or room air is used instead of oxygen.

Severe hypoxemia usually suppresses cardiac output to some degree. Cardiac output may be further compromised immediately after a patient has been placed on a mechanical ventilator because of impaired venous return resulting from the elevated transpulmonary pressure.²⁷ An attempt is made to carefully balance ventilation with an optimal or adequate cardiac output by shortening inspiratory time and minimizing transpulmonary pressures by using lower tidal volumes.

Breathing and Coughing Maneuvers

If the patient is nonventilated or was recently extubated, breathing and coughing maneuvers in conjunction with moving and body positioning are emphasized to promote ventilation, flow rates, and secretion clearance; decrease minute ventilation and respiratory rate; increase tidal volume; and improve arterial blood gases. Breathing exercises for individuals who breathe with long-time constants (e.g., patients with chronic pulmonary disease) are believed to be most effective if pursed-lip breathing is performed in conjunction with mechanical pressure applied over the abdomen. To derive the maximum benefits, breathing and coughing maneuvers should be performed in body positions that are most mechanically and physiologically optimal. In addition, they can be performed in the postural drainage positions to augment mucociliary clearance. To avoid airway closure, patients should not breathe below the end of normal tidal ventilation.

Mucociliary Transport and Secretion Clearance

The patient in the ICU needs special attention regarding fluid balance to carefully regulate hydration and fluid volume. Inhaled humidified air is a significant additional source of body fluid. Normally the alveolar gas is saturated with water vapor. The lining of the tracheobronchial tree is therefore protected from erosion and potential infection. This is particularly important in the patient who requires frequent suctioning. The effect of humidification can be assessed by the consistency of the patient’s secretions. Thick secretions suggest humidification may be inadequate, and the patient may be dehydrated.

If the effects of mobilization on mucociliary transport and secretion accumulation have been exploited and further secretion clearance is warranted, postural drainage may be indicated. Postural drainage may be contraindicated in patients with unstable vital signs and is usually contraindicated immediately after feedings and meals. In some institutions, however, patients on continuous 24-hour tube feedings are tipped after feeding has been discontinued for 15 minutes. The cuff in the artificial airway is inflated to avoid aspiration. The specific postural drainage positions to be used are determined on the basis of the pathology, radiographs, and clinical examination. The recommended positions for the bronchopulmonary segments involved should be approximated as closely as possible (see Chapter 21) and modified as needed. Frequently, specific positioning in the ICU is compromised as a result of the patient’s status, intolerance to lying flat or being tipped, or limitations imposed by the monitoring apparatus or ventilator.

The role of manual techniques has long been questioned because they have been associated with desaturation, atelectasis, musculoskeletal trauma, discomfort, cardiac dysrhythmias, and cardiac arrest.²⁸ Thus these techniques must be applied rationally, with appropriate monitoring, and modified accordingly. The precise sequence, duration, intensity, and frequency of treatment are based on treatment outcome rather than time. Oxygen demand has been shown to increase with manual airway techniques, and the hemodynamic and metabolic responses have been reported to resemble the response to exercise.²⁴ The increases in cardiac output and blood pressure are thought to reflect increased sympathetic activity from stress as well as the exercise-like response.²⁵ The stressful responses to ICU procedures as well as conventional airway clearance procedures have been reported to be effectively modulated with medication.²⁹ A recent study reported no significant changes in and mean arterial pressure with conventional airway clearance interventions compared with undisturbed side-lying positions.³⁰ These discrepant findings may reflect differences in the intervention and subjects studied (stable patients who are ventilated). The application of manual techniques in the head-down position is contraindicated in patients with acute myocardial infarction and increased ICP. Relative contraindications include hemorrhage, bronchopulmonary fistula, acute chest trauma, lung abscess, and gastric reflux.³¹ Given the adverse effects of manual airway clearance interventions that have been reported, the physical therapist needs to ensure that more physiological alternatives associated with fewer risks have been exploited.

Weaning from the Mechanical Ventilator

Depending on the institution and country, the physical therapist, the respiratory therapist, or both are often responsible for assisting physicians in weaning the patient from mechanical ventilation. Coordinating goals and working with the ICU team to ensure that the weaning process is carried out expediently and with the least risk of weaning complications (e.g., postextubation atelectasis, aspiration, and hypoxemia) are priorities. Expediting weaning is an important ICU goal, as patient outcomes improve with shorter periods of mechanical ventilation.³³ Evidence-based guidelines have been documented.

Weaning can increase cardiovascular and psychological stress, and in turn . Patients at particular risk of weaning failure must be identified and monitored by the physical therapist during this process. One study reported that cardiovascular responses to weaning in patients after heart surgery depended on the type of surgery.³⁴ Cardiac index, for example, was greater after abdominal aortic surgery than after bypass or transplantation surgery. Although the oxygen extraction ratio remained stable after aortic surgery, it increased somewhat after bypass surgery and markedly after transplantation surgery. Weaning patients with cardiac dysfunction from mechanical ventilation can lead to pulmonary edema because of increased venous return and release of catecholamines, reduced left ventricular compliance, compression of the heart by the lungs, and increased left ventricular afterload.

Because of its profound effect on pulmonary function and gas exchange, body position must be optimized for weaning to maximize weaning success and avoid the need for reintubation because of weaning failure. Patients who are overweight warrant particular attention. Low tidal volume and high respiratory rates can jeopardize weaning success. In patients who are obese, a semirecumbent position may favor weaning, compared with a 90-degree upright position, which may cause the abdomen to encroach on the underside of the diaphragm and limit its excursion.³⁵

Blood gas analysis and pulmonary function provide the indications for weaning. Ideally the patient’s spontaneous tidal volume should approximate that delivered by the ventilator. Forced vital capacity should be two to three times the patient’s required tidal volume. Weaning is not usually indicated if the patient requires positive end-expiratory pressure greater than 5 cm H₂O or if FIO₂ is greater than 0.4. In addition, patients who are unable to generate a negative inspiratory pressure of −20 mm Hg or greater are unlikely to be able to generate sufficient intrathoracic pressures for deep breathing and airway clearance and thus are poor candidates for weaning. Minute ventilation and maximum voluntary ventilation can be measured at bedside and contribute to the decision regarding whether to wean. Although weaning protocols differ depending on the patient and the ventilatory mode used, general guidelines for this common ICU procedure are outlined in Box 33-8.

Special Noninvasive Intensive Care Unit Priorities and Considerations

Intubation and mechanical ventilation are usually delayed as long as possible, particularly in individuals with COPD. These individuals have poor blood gas levels in combination with poor CO₂ ventilatory drive. Once mechanically ventilated, the patient tends to deteriorate rapidly, and the risk of failure to wean is increased. Noninvasive mechanical ventilation (see Chapter 44) has been a more recent advance to provide low-risk ventilatory support as a means of avoiding associated risks of invasive ventilation. It is used for patients in whom short-term mechanical ventilation is anticipated.

Discharge from the Intensive Care Unit

Every ICU should have and use admission and discharge criteria. The criteria may differ from ICU to ICU and hospital to hospital. The discharge criteria are likely to be met in situations in which there is no need for mechanical ventilation, airway protection, or invasive hemodynamic monitoring and there is resolution of the medical problems that necessitated the admission.

The physical therapist is responsible for documenting the physical therapy treatment priorities and frequent progress notes during the ICU stay so that the team responsible for the patient after discharge can continue management with reduced risk of disruption of care or regression of the patient’s condition. The patient should be informed continually of his or her progress and the plans made by the team and family.³⁶ The patient should be given as many choices as possible about his or her care and should be actively involved in long-term management planning.

Nutrition

Patients who are critically ill are hypermetabolic. Metabolic demand and oxygen consumption are increased after surgery and secondary to healing and repair, increased temperature, and altered thermoregulation. Patients with chronic cardiovascular and pulmonary limitation who are admitted to the ICU are often undernourished because of the effort required to purchase, prepare, and consume food. Furthermore, these patients have increased and energy expenditure secondary to the increased work of breathing. Without adequate nutrition, patients incur the effects of deconditioning faster and are debilitated, less capable of responding optimally to therapy, and more susceptible to infection. Intravenous or external hyperalimentation is typically instituted early to maintain optimal nutritional status and avoid excessive physical wasting and deterioration. If a tracheostomy has been performed, the patient is able to eat normally, provided risk of aspiration is minimal.

Regardless of the means by which nutritional support is provided, carbohydrate may be limited because of the increased CO₂ production resulting from its metabolism.

Infection Control

Infection control has become an even greater concern in hospitals and particularly ICUs now that “superbugs” have become prevalent. Superbugs are microorganisms that are resistant to broad-spectrum antibiotics. The prevalence of these microorganisms has been attributed to the fact that many people today, over the course of their lives, have taken antibiotics, which has made them more susceptible to certain microorganisms and less sensitive to antibiotics. In addition, more patients with critical illness are surviving owing to advances in management. Personal hygiene and good hygienic practice on the part of the physical therapist are mandatory because of the inherently high rate of infection in the ICU and compromised immunity of the patients. Patients in the ICU are prone to infection. Meticulous hand washing with an antiseptic detergent between patients is essential. Soaping for 30 seconds or more with a thorough scrubbing motion followed by thorough rinsing should be carried out. After contact with infected wounds, saliva, blood, pus, vomit, urine, or stool, the physical therapist must be particularly conscientious about washing immediately. Physical protection, including gowning, gloving, capping, and masking, is often required, given the concerns regarding infection, and has in fact become routine practice in many ICUs.

There are several levels of infection control, and there may be differences across ICUs in different hospitals. Some patients need to be protected from infection transmitted across patients in the ICU by health care staff—hence the need for meticulous hand washing. Some patients have types of infections from which the health care staff need protection. Often a combination of both types of precautions is indicated. The physical therapist needs to know the different level of infection control and precautions for each patient. In respiratory isolation, the patient remains in an isolated room for treatment. Masking and gloving will be required, and possibly gowning. Depending on the patient’s diagnoses, eye protection may also be required. Contact isolation requires maximal infection control by those who come into contact with the patient; however, the patient can leave the room or restricted area according to the hospital’s policies.

The Patient as a Person

Although constraints do exist in the high technology environment of the ICU, the patient’s dignity is observed as much as possible regardless of the reason for admission, the level of consciousness, or combative behavior directed toward the ICU staff. Gestures such as using the patient’s preferred name, explaining aspects of the patient’s care, continually orienting the patient regarding person, place, time, and day, and having an interpreter available if necessary are widely practiced. A supportive caring atmosphere is created in which the patient is free to make choices and ask questions as much as possible. With endotracheal intubation, patients are unable to talk. Communication strategies are assessed to ensure the patient is maximally able to communicate his or her needs and maintain a sense of perceived control. Some strategies include mouthing (silent speech), use of a spelling board, writing, pointing to pictures, and responding with yes and no signs.

Other considerations that must be observed are related to disrobing, modesty, and privacy. These may reflect sex, age, physical image, culture, and individual differences. The patient needs to be asked about his or her comfort level with these and also whether he or she is more comfortable with family present during treatment. Accommodating these individual differences is extremely important if the patient is to be maximally motivated to participate in treatment and adhere to recommendations between treatment sessions.

Patients may be in varying stages of cognitive awareness, from completely comatose to semicomatose to a reduced state of arousal. Patients who are comatose have been reported to have some awareness of their environment and later can recall having been talked about or wanting to communicate and having been unable to do so. In addition, mechanical ventilation is a barrier to communication; thus methods of communicating need to be identified.

The Intensive Care Unit as a Healing Environment

The physical environment of the ICU has a profound effect on the patient’s recovery independent of the level of care received. Outside windows with daylight orient the patient to day and night. Other benefits include reduced number and types of complications and reduced length of stay in the ICU and in the hospital overall.37,38 Also, exposure to daylight may reduce the need for analgesia.³⁹ Minimizing the sense of social isolation is important, so family is encouraged to be present as much as permitted by the ICU visiting policy. Pet therapy may have some role in the ICU, as it has been shown to have benefits in other care settings.⁴⁰ Circadian rhythms are associated with fluctuations in physiological and hormonal functions important to the patient’s healing, recovery, and well-being, and these are compromised with bed rest deconditioning. Normalizing circadian rhythms can be achieved by optimizing a sleep schedule with more wakeful periods during the day and reduction of noise at night.⁴¹

Principles of Physical Therapy Management

The family and friends of the patient who is dying have special needs that must be considered, and in fact constitute an integral part of the patient’s overall care. In general the physical comfort and personal hygiene of the patient, as well as the quality of the immediate psychosocial environment, are paramount concerns. Optimal functional capacity is maintained as much as possible⁴⁴ and has been shown to improve even in patients whose course is unstable.⁴⁵ Nonetheless, the individual’s priorities and needs may change quickly. The physical therapist needs to be flexible to accommodate these fluctuations and sensitive to indications for no intervention. This may be a time for providing support and touching, if the patient wishes. Compassion, understanding, and respect for the patient and the family must be forthcoming from the ICU team as a whole. The ability to be attentive, comforting, and compassionate is an invaluable personal quality that needs to be developed to a high degree in the critical care area. The team members need to attend to how the patient, if sufficiently alert, is dealing with the possibility of dying and must take their cues from the patient with respect to the role they need to play. If requested by the patient or family, spiritual care leaders are summoned.

If life support systems are being continued, the physical therapist may provide treatment to keep the patient as comfortable as possible. Conservative prophylactic cardiovascular and pulmonary physical therapy may be provided to reduce the work of breathing (body positioning and stress reduction, both of which can minimize oxygen cost). Treatments are kept to a minimum in terms of number and duration if death is inevitable. Range-of-motion exercises and skin care may help to reduce the discomfort of restricted mobility, facilitate nursing management and the basic care of the patient, and prevent complications. Analgesics may be continued along with other medications to reduce pain and suffering and maximize comfort. If so, these are prudently coordinated with treatments, if appropriate. In the presence of life supports the patient’s needs may have to be anticipated somewhat more than without life supports because they severely limit communication. The dignity and modesty of the patient continue to be observed even after death.

The patient who has had life supports removed receives the same level of palliative care as the patient with supports. Weakness and wasting may contribute to the fatigue induced by treatment and coughing. Facilitated and supported coughing may help reduce the effort required to cough productively.

One’s humanity is one of the most important attributes a health care provider can bring to the care of patients, and this is particularly true in palliative care. The use of human touch and talking (or being silent) may be the most important means of communicating with and providing support to the patient who is dying and may be unable to communicate or disinterested in doing so. Supportive touching and hand-holding may be even more important to the patient on life support systems, as the supports may be experienced as a physical barrier between the patient and those around him or her.