CLINICAL PERSPECTIVESAssistant Editors: Michael S. [ellinek, MD.

Joseph Biederman, MD.

A Psychiatric Consultant's Survival Guide to thePediatric Intensive Care Unit

DAVID RAY DEMASO, M.D., AND ELAINE C. MEYER, PH.D., R.N.

"Intensive care" generally evokes a visceral response in peo­ple, and the psychiatric consultant is no exception. Thedegree ofpatient acuity, uncertainty ofprognoses, and ethicaldilemmas make the pediatric intensive care unit (PICU)especially stressful. Woolston (1994) identifies the sourcesof emotional intensity as the constant exposure to death,disfigurement, loss,and dehumanization and likens the PICUto participating in "active warfare." Survival strategies forpsychiatric consultation in this arena are detailed in the fourimportant domains of the patient, family, staff, andconsultant.

The PICU provides high-volume acute care with preserva­tion of life as its most critical function (Gilkerson, 1990).This setting is dominated by advanced technology, anxiousfamilies, and large numbers of urgently busy staff. Thesickest, most unstable, technology-dependent children areadmitted to the unit. The starkest of alternatives-life anddeath of children-are focused into sharp relief in the PICU.

The consultant may be called in the midst of crisis andfeel pressured to "do something." The psychiatrist needs toresist the pressure to act immediately and tty to clarify thereason for the consult (Lewis, 1994). This information maybe difficult to ascertain, and it is not unusual for theconsultant to arrive on the unit with only minimal informa­tion. The consultant may initially need to tolerate consider­able ambiguity about the referral reasons. Do not expectprecise referral questions or detailed psychosocial historiesgiven the atmosphere of crisis. At the same time, do not"push the system too hard," for the staff may truly notknow how to articulate the problem.

Accepted November 29, 1995.Dr. DeMaso is with the Departments of Psychiatry and Cardiology and

Dr. Meyer is with the Departments of Psychiatry, Nursing, and Anesthesia,ChildrensHospital and. Harvard Medical Schoo!' Boston.

The authors thank Laura Basili, Ph.D., LeslieBiron Campis, Ph.D., GeraldP. Koocber, Ph.D., and Stuart J Goldman, M.D., jor their clinical insightsand manuscript review.

Reprint requests to Dr. DeMaso, Department of Psychiatry, ChildrensHospital, 300 Longwood Avenue, Boston, MA 02115.

0890-8567/96/3510-1411$03.0010©1996 by the American Academyof Child and Adolescent Psychiatry.

Respond promptly when summoned to the PICU. Often,knowing that the consultant is "on the way" can help toquell unit anxiety, thereby facilitating patient care. Providinga calming presence and helping to contain intense affect areimportant roles for the consultant. Psychiatric consultantsserveto sanction the legitimacy ofpsychosocialcare, acknowl­edge and model affectiveexpression, and provide a structuredapproach to addressing emotional issues.

Focusing on the Patient

The consultant is immediately challenged with assessingthe patient's mental status.

In the face of complex medical conditions, patients areoften difficult to examine as well as to diagnosis and manage.The consultant needs to be highly vigilant for medicalconditions and/or medications that can affect mental status.The staff may attribute a child's presentation to "ICUpsychosis," which means to them that the patient is havinga "reaction" to the unit. The consultant must educate staffabout important underlying biological contributors to achild's behavior, in addition to the environmental aspectsof the PICU that may influence the child's presentation.

Patients in the PICU can be fully alert, some having beenhospitalized for weeks or even months. Daily structure,mobilization within the limits of the child's medical illness,supportive and behavioral psychotherapy, and child lifereferrals are recommended to deal with the ever-presentstressors (Pearson et al., 1980; Pollin and Kanaan, 1995).The patient who is intubated poses a major challenge,but with the aid of parents and staff, the consultant maycommunicate via gestures and lipreading. In such cases,helpful recommendations include consistency of care provid­ers, providing the patient with accurate information andsome control of his or her care, and consultation withspeech/language pathologists for augmentative communica­tion systems.

Consultations following suicide attempts are often accom­panied by an urgency by staff to move the patient "out ofthe unit." This response is fueled, in part, by the frustrationof staff tending for children who have "intentionally" tried

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DEMASO AND MEYER

to end their lives, while other patients are "fighting for theirlives." The consultant can be the recipient of this angerparticularly if the disposition process is slow. Suicide precau­tions are important given the multitude of means availableto hurt oneself in the PICU.

Finally, the consultant can be helpful in understandingand responding to age-related behaviors and responses tostress (Camp is et al., 1990). The consultant can enhancethe staffs empathic responses to a child and improve careby providing a premorbid description of the child and anunderstanding of the expected responses to hospitalization.

Family Issues

Families are under enormous stress when their child ishospitalized in the PICU (LaMontagne and Pawlak, 1990;Rothstein, 1980). Parents face complex and life-threateningmedical situations and, in many cases, need to understandthese issues well enough to provide consent for treatmentand/or surgery and to participate in decision-making withthe PICU staff. The essential and urgent questions, "Willmy child get better?" and "How long will it take?" are alltoo often not answerable. Given the technological focus ofthe unit, parents and staff may have long discussions aboutthe diagnosis or laboratory results; however, the outcomeof the illness and the bottom-line questions may remainunanswered. The consultant should also be alert to areas ofuncertainty and potential conflict between staff and families,especially when a child does not respond to treatment asexpected or when medical options are limited. Parents oftenappreciate the consultant's listening, acknowledgment, andunderstanding when they do no seem to be "getting anyanswers" or when the child's progress has plateaued.

The traditional parental roles of protector and decision­maker are surrendered out of urgent necessity (Zaner andBliton, 1991). Affleck and Tennen (1991) found that parentsrarely desire exclusive control over their child's care, notingthat only 25% of mothers in an intensive care setting soughtan active role in decision-making. About half of the parentswere reported to be uninterested in participatory control inthe medical treatment. These parents willingly relinquishedcontrol to the staff, whom they trusted for their competence.The final group of parents were reluctant to cede controlof medical decisions yet were unable to achieve a satisfactorylevel of participatory care. Such parents may present similarlyto Groves' (1975) "entitled demanding" patients who charac­teristically make demeaning and entitled statements regard­ing their child's care. This behavior can compromise thecare and unnerve staff, who are generally more comfortablewith sad and worried parents. The consultant needs toidentify the breakdown in the treatment alliance and theparents' fearfulness, which often lies behind their behavior.The consultant should facilitate parent and staff meetings

to acknowledge their mutual goals of good care and delineateappropriate roles, while at the same time setting limits. Theconsultant's understanding of the PICU culture and thewide range of parental coping styles can help to enhance thetreatment alliance between family and staff at difficult times.

Consultants may also arrive on the unit to find themselvesconfronting the imminent death of a patient. Parents maybe experiencing the shock, anger, and/or disbelief associatedwith the early grieving process (Miles and Perry, 1985;Rando, 1986). The consultant can facilitate mourning bylistening to the parents, ensuring privacy, offering adviceregarding siblings, and facilitating supportive interventionsby staff. Recommendations regarding follow-up with com­munity physicians, family and friends, religious personnel,and/or psychiatric referral are helpful.

Staff Issues

PICU staff must be supported in order to meet thepsychosocial needs of children and their families (Meyerand Sands, 1995). Staff members bear witness to criticalillness and death, which may exact a heavy emotional toll(Downey et al., 1995; Lewis and Schonfeld, 1994). Theyare often abruptly confronted with the intimate emotionallives of strangers in considerable distress. The most intenseemotions elicited in the PICU are those related to intimacyand loss (Jellinek et al., 1993). The emotional cost to staffmembers is likely to increase the longer involvement witha family continues or when there is personal identificationwith a child or family. Identification with patients is height­ened and the sense of professional immunity eroded whenstaff care for children who are similar in age or characteristicsto their own children or other beloved patients.

Difficult issues can arise when staff must provide care fordistraught, demanding, or grieving families. Feelings ofbeingunderappreciated, frustration at having little else to offer,or multiple deaths can translate into feelings of failure as astaff (Whitt et al., 1981). Asa means to cope, staff membersmay avoid or deny the situation, be reluctant to provideinformation to family members, or detach themselves emo­tionally. Be alert to signs of staff over- or underinvolvementthat can compromise the quality of care. Support groupscan provide opportunities for sharing work-related concerns,mutual peer support, and multidisciplinary problem-solving(Beardslee and DeMaso, 1982). In our own setting, we havenoted that when staff support groups are offered there aremore appropriate and timely requests for psychiatricconsultation.

When consulted, enlist staff members to share their per­ceptions and concerns about the situation and assess staffinteractions with the child and family. It is in the consultant'sinterest to enlist staff input early, for staff compliance withsubsequent recommendations may hang in the balance.

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Listen carefully for opportunities to clarify staff perspectives,support staff, normalize their distress, and offer practicalsuggestions for coping. Multidisciplinary meetings are oftenuseful in resolving intense emotions, uncertainties, and dis­agreements that can ariseamong the staff. If needed, consulta­tion with the hospital's ethics committee and legal counselcan be recommended.

Issues for the Consultant

The magnitude of illness and suffering in the Pl'Cl.Icombined with the unfamiliar advanced medical technologiesmay generate anxiery within the consultant. The unit pacedemands quick responses and formulations that differ frommuch of psychiatry. Frequently there is an unstated pressureto "fix it." The consultant is expected to assess patientswith virtually none of the privacy afforded in an office.Moreover, the consultant must be prepared for the occasionaldemeaning comments from staff who directly or implicitlydevalue psychiatric understanding and management (Jellineket al., 1981).

These stresses can evoke significant countertransferentialresponses in the consultant, ranging from anger at being"inappropriately consulted," to frustration with the staff'sapparent lack of emotional concern, to avoidance ofpatients.The consultant may experience the sense of being a "for­eigner, alone among others who do not speak his language"(Fritz, 1990). Additional stress may come from fundingpressures as a psychiatry consultant is usually the last andleast paid (Fritz, 1990), and consultation duties may be atime-consuming addition to some job descriptions.

To have therapeutic impact, the consultant must assumean engaging, spontaneous "therapeutic stance," and deviatefrom the more traditional anonymiry, abstinence, and neu­trality (Geist, 1977; Perry and Viederman, 1981). Thisstance can help to assuage the consultant's sense of being a"foreigner." The consultant is well served to follow Sperling'striad of advice: be available, be practical, and be understand­able (Rothenberg, 1979). This approach will help the consul­tant to implement effective treatment plans and educatestaff regarding their patients' important psychological issues.Following this triad of advice typically generates more fre­quent referrals and may eventually lead to funding supportfrom medical and/or surgical services.

The consultant is not immune to the unit's sadness andgrief. The consultant who is accessible may gain beneficialmutual support from the unit's staff. However, given thelikelihood of potential emotional responses, the consultantwould be wise to seek ongoing support and supervisionfrom psychiatric colleagues.

Conclusion

While many of the principles of good consultation areapplicable, the Pl'Cl.J presents the psychiatrist with a uniqueand challenging environment. The PlCl.l is a setting where

CLINICAL PERSPECTIVES

mental health needs are many, the clinical pace is demanding,and opportunities for rewarding consultative work are plenti­ful. The PleU consultant should keep in mind the fourinterrelated domains of patient, family, staff, and consultant.The integration of these domains into the formulation andplanning of treatment has the potential to enhance thepsychiatric consultant's survival and success.

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