Improving patient care through the prism of psychology: application of Maslow's hierarchy to sedation, delirium, and early mobility in the intensive care unit

Abstract

The intensive care unit (ICU) is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and although the overall number of hospital beds remains stable in the United States, the percentage of that total devoted to ICU beds is rising. These 2 realities engender a demographic imperative to address patient safety in the critical care setting. This article addresses the medical community's resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This article is not intended to provide a comprehensive review of the literature but rather a framework to rethink our currently outdated culture of critical care by employing Maslow's hierarchy of needs, along with a few novel analogies. Application of Maslow's hierarchy will help propel health care professionals toward comprehensive care of the whole person not merely for survival but toward restoration of pre-illness function of mind, body, and spirit.

Keywords: Cognitive impairment; Critical care; Patient safety; Psychology; Rehabilitation.

Figure 1a

Maslow’s Hierarchy of Needs^, – the original depiction of the hierarchy of human needs as described by Maslow in 1943. One does not move into upper tiers of human needs until the levels of needs are met at each consecutive lower level (i.e., one moves from bottom to top in a stepwise fashion).

Figure 1b

Maslow’s Hierarchy of Needs adapted for the ICU (see also Table 1) – an adaption of Maslow’s depiction of the hierarchy of human needs as viewed through the prism of critical care. Maslow’s time-tested truths make it evident that the ICU first had to deal with the lowest level of “needs” (i.e., basic elements of survival such as cardiovascular stability, nutrition, and pain control). The persistence of that mindset as “sufficient goals for ICU care” has retarded the maturation of the culture of critical care. We must move actively towards the higher levels of human needs shown in Maslow’s Hierarchy in order to restore or preserve the patient fully to his/her pre-illness mind, body, and spirit.

Figure 2

Executive Function performance scores (measured via the Tower Test) among ICU survivors were randomized following hospital discharge in the RETURN trial [48] to receive either usual care (control patients) or a cognitive rehabilitation plus physical rehabilitation program for 12 weeks (intervention patients). Scores were measured at the time of enrollment (i.e., baseline assessment at hospital discharge) and again at 3-month follow-up when the rehabilitation program was complete. Higher scores reflect better cognitive performance. In this pilot study, both groups were similar in executive function at the time of enrollment. At the time of 3-month follow-up, as compared to the control group, the patients who received the intervention were statistically superior in their executive function as compared to the control group (p<0.01).