Lived Experiences of COVID-19 Intensive Care Unit Survivors.

The COVID-19 pandemic can be considered one of the worst ‘nightmares’ of the century for both the general public as well as the health care workers (HCWs). Every day the world is seeing an increase in the death tally, despite all possible steps such as lockdown and other infection control measures.[1] Even though about 80% of COVID-19 cases remain asymptomatic or have minimal upper respiratory symptoms, about 5% become seriously ill, requiring admission to the intensive care units (ICUs) and mechanical ventilation.[2]

Being admitted in an ICU setting has been considered a traumatic event, and the existing literature suggests that ICU survivors suffer from several psychological/mental health problems, the most common ones being post-traumatic stress disorder (PTSD), depression, anxiety disorders, and cognitive impairment.[3, 4] A diagnosis of COVID-19 infection, by itself, leads to significant anxiety and distress in the individual[5], which may be amplified by being admitted to an ICU.[6] This may be attributed to reports of mortality related to COVID-19 infection.[7, 8] These detailed descriptions often induce more anxiety in the minds of the COVID-19 sufferer battling for life in the ICUs.

A few blogs and newspaper articles mention the long-term disability and prolonged recovery in COVID ICU survivors,[9, 10] and some news reports are also available.[11] In this context, we discuss the lived experiences of three persons who were admitted to the ICU with COVID-19, all of whom had given verbal consent for publishing the same.

Narrative Experience-1: “Will I Be Able to Survive, Will I Be Able to See my Family Again?”

A 52-year-old lady, diagnosed with COVID-19, who had uncontrolled diabetes mellitus, was initially admitted in our COVID isolation ward and developed shortness of breath within hours of admission, with a drop in her oxygen saturation,[12] for which she had to be shifted to the COVID ICU. In the ICU, she was stabilized with nasal prongs and did not require ventilator support. However, she was found to be extremely anxious, was sweating despite maintaining normal oxygen saturation, and would appear worried. She was not able to sleep properly and would frequently ask “Will I be able to survive? Will I be able to meet my family again?” She would ask the HCWs to inform her if she was going to die soon, so that she can have a last-minute conversation with her husband, and would often become tearful. She would be comforted and reassured by the HCWs, which would make her feel relaxed for a few minutes. However, this would immediately be followed by re-emergence of the symptoms she had prior to being reassured. She remained in the ICU for five days in the same state. After that, she was shifted out of the ICU, following which her anxiety reduced, but she continued to have sleep disturbances and, therefore, was referred to the psychiatric services for telephonic consultation.

On probing deeper during the consultation, she revealed that after she came to know about the diagnosis of COVID-19, she developed severe anxiety and, after a few hours, had shortness of breath. Thereafter, she was admitted to the ICU owing to the oxygen saturation dropping to 93%. She reported that as she had seen in the news and read in the newspapers that having shortness of breath and being supported on oxygen were some of the signs of severe COVID-19, and after she had to be shifted to ICU, she started having recurrent thoughts that she was going to die. She further described that she had thoughts of being intubated, catheterized, tracheotomized, and so on, which were based on her knowledge about what usually happens with patients admitted to ICU, which led to further increase in the anxiety, shortness of breath, feeling of choking, and sense of being close to death. Whenever the HCWs would approach her, it would lead to a further increase in the anxiety and the apprehension of being intubated. Further, she reported that whenever she was approached for any kind of blood investigation, she would feel that she was very close to dying. After coming out of the ICU, she continued to have these memories and, resultantly, continued to remain anxious and, thus, was not able to sleep. Based on these, a possibility of acute stress reaction was considered.

Supportive sessions were started by a psychiatrist, with eight years of experience, on a daily basis for 15–20 minutes. Additionally, she was asked to maintain a schedule, keep herself active in the room, maintain sleep hygiene, communicate with her family members using audio and video calls, and follow her religious practices. Over the next 3-4 days, her anxiety came down, and her preoccupation with the experience of ICU reduced. During this period, her son, who was also diagnosed with COVID-19, was shifted close to her room, which led to further reduction in her anxiety. At the time of writing this report, she was currently waiting for her COVID-19 status to be declared negative so that she can be discharged. In the meanwhile, the psychological interventions have been planned to be continued. No psychopharmacological agents were started.

Narrative Experience 2: “Happy that I Am with My Wife in ICU, We Will Die Together”

A 58-year-old man, who was diagnosed with diabetes mellitus and had morbid obesity, was shifted from the isolation ward to the COVID ICU upon a drop in oxygen saturation below 92%. His wife was admitted to COVID ICU three days prior. He improved with oxygen support and conservative management and was again shifted back to the isolation ward after three days of ICU stay.

In his routine telephonic psychiatric evaluation, he reported that earlier he was anxious when his wife was shifted to the ICU and would worry if he would ever be able to see her again; this would lead to frequent night time awakenings. Later, when he was informed that he too would be shifted to the ICU, he had mixed feelings. He experienced rise in anxiety with respect to what is going to happen next, what will the doctors do with him—will they insert various tubings in his nose and mouth, etc., yet somewhere he felt relieved too, as shifting to the ICU was giving him an opportunity to have a glimpse of his wife: “I was happy that I am going to meet my wife; I will die with my wife with whom I have spent my entire life. Would pray to God for death before my wife, so that I don’t have to see her dying in ICU (on the bed next to mine) and at the same time would thank God for sending me near my wife at this critical point of life, which I had never imagined.” He further reported having thoughts that the ICU bed was his death bed. He would get thoughts about whether they both would be cremated with respect by their family members or not. These thoughts were based on his knowledge from the media reports of the piling of dead bodies of COVID patients in European countries, due to the inability of the family members to join the death rituals.[13] However, after coming out of the ICU and knowing about the improvement in his wife’s condition in the ICU, he reported that he was quite hopeful of recovery and was less worried. At the time of writing this report, both the partners were stable physically and were waiting for their discharge. No specific psychiatric diagnosis could be ascertained based on the current nosological system. The plan ahead is to follow up with both of them for the emergence of any mental health morbidity and address their mental distress.

Narrative Experience 3: “I Am Not Afraid of My Death, but What Will Happen to My Children and Wife After Me?”

A 40-year-old male, diagnosed with diabetes mellitus, was admitted to COVID ICU upon a drop in his oxygen saturation to 90%. His eight-year-old daughter and 62-year-old mother were also admitted with him in the isolation ward. After six days of stabilization with oxygen and conservative management, he was shifted back to the isolation ward.

On routine telephonic mental health screening, he described that when he was shifted to the ICU, he started getting recurring thoughts that “my future is doomed; I may die or may get paralyzed; I may be bedridden for my entire life.” He further reported that he was not afraid of dying but was worried about his family—would get recurring thoughts related to the future of his family and see images of his children and wife crying whenever he would try to sleep. He would be worried about their situation and future after his death. All of this would lead to severe anxiety. He would try to cope with his anxiety and worries by chanting the name of God, which would help him to ward off these negative thoughts. He would recollect the various investments and insurance policies he had made and wonder if he would be able to tell about them to his wife before his death. He would frequently ask the HCWs if he would survive or not. He would ask to be allowed to make a last call to his wife, to give her the details of his investments. The treating team would reassure him. He reported having many sleepless nights in ICU but, later on, he was hopeful of recovery, and upon being shifted back to ward, he was relaxed. However, he reported that he would never be able to forget those few days in the ICU and was quite thankful to the entire team of HCWs.

No specific psychiatric diagnosis could be ascertained based on the current nosological system. He had been discharged after being tested negative for COVID-19 after a hospital stay of 18 days and is being followed-up.

Discussion

These three narratives of lived experiences of the COVID-19 ICU survivors depict the mental agony they went through upon being admitted to the ICU. A few studies that explored the experiences of ICU survivors (non-COVID/general ICU patients) reported being bedridden, pain, general discomfort, daily needle punctures, family worries, fear of death, and uncertainty about the future as some of the common stressful experiences.[14] Some studies have also documented delusional memories (mostly related to delirium).[15]

However, when we compare the experiences documented in this report, it is evident that the experiences of COVID-19 ICU survivors had predominant themes of fear of being intubated, dying alone, or being away from family; concern whether they will be given respect after their death or not; feeling insecure about their families if they die; wish for a death prior to their near ones (admitted in the same ICU) and; worrying about the family. The different new experiences (other than those usually reported) could be because of the hype of information about high mortality rates of COVID-19, which induces a significant fear in the mind of people diagnosed with the disease and gets further exacerbated when they are shifted to the ICU. Further, none of the patients had an earlier experience of being admitted in an ICU setup, which could have possibly increased their anxiety in the background of COVID-19-related anxiety.

Further, in ICUs, generally, caregivers are allowed to meet the patient from a few minutes to a few hours a day, but in the case of COVID ICUs, considering the risk of infection, family members are not allowed to visit. This further adds to the fear and mental trauma of the COVID ICU patients. Fortunately, none of the above three patients required mechanical ventilation and they recovered quickly. Therefore, these lived experiences may not be generalized to all COVID ICU survivors.

These cases suggest that there is a pressing need to evaluate all the COVID survivors for the psychological consequence of their hospital stay. Another fact, apparent from the description of the first case, is that, possibly, the patient have had a panic attack, which was considered as the reason for the worsening of her physical health status resulting in ICU admission. Hence, all patients admitted to the COVID ward and ICU should be routinely screened by mental health professionals, telephonically or by video calling, for any emerging mental health issues. These must be addressed on priority in order to prevent apparent worsening of the clinical condition.

Although we assessed these patients very early during their recovery from the COVID-19, it can still be said that the narrative provided by the patients was retrospective and could have some amount of recall bias.

This case series of narrative experiences highlights the importance of evaluating the experiences of COVID ICU survivors, which may be different from those of general ICU survivors in terms of themes and lived experiences. The current ICU management recommendations of COVID-19 should also include psychological support, which is equally important for the individuals admitted into ICUs.[12]

Based on the findings, it can be suggested that all the patients admitted to the COVID ward should be counselled about the possible outcomes, with a special focus on providing information about the fact that shifting to ICU does not necessarily mean death. The decision to shift to ICU is based on their physical parameters. Further, they should be informed that all the patients shifted to ICU are not necessarily intubated. These can help in allaying the anxiety, as COVID-19 is associated with a fear of death.