Exploring long-term impacts on ICU survivors: A concept analysis of post-intensive care syndrome
Brookelyn Hussey, MN, RN and Connie Schumacher, PhD, RN
Abstract
Post-intensive care syndrome (PICS) has emerged as a concern for intensive care unit (ICU) survivors, particularly in the context of the increasing survival rates of patients with severe illness. This syndrome encompasses a range of physical, cognitive, and psychological impairments that can continue long after ICU discharge. PICS impacts survivors’ quality of life, with common manifestations including muscle weakness, memory deficits, and depression. Despite growing awareness, PICS remains underexplored in clinical practice, with ongoing research focused on identifying its risk factors and effective management strategies. Risk factors such as prolonged mechanical ventilation, extended ICU stays, and delirium contribute to its development, particularly among older adults who face heightened vulnerability to long-term complications. This concept analysis, using the Walker and Avant (2011) method, aims to clarify the defining attributes, antecedents, and consequences of PICS, offering a framework to improve understanding, clinical management, and intervention. Through an extensive review of literature from 2012 to 2024, key elements of PICS are identified, and their implications for both healthcare providers and patients are discussed. The analysis highlights the need for standardized care pathways, including psychological support, physical rehabilitation, and follow-up care, and highlights the importance of early detection and intervention in the ICU and post-ICU settings. This paper contributes to the growing body of knowledge on PICS, offering a solid foundation for further research, clinical guidelines, and care protocols that will improve the long-term recovery, quality of life, and overall well-being of ICU survivors, ultimately improving patient outcomes and enhancing recovery strategies for all.
Keywords: post-intensive care syndrome, ICU survivors, long-term recovery, critical care, concept analysis
Nursing Implications
- Early identification and assessment: Nurses should remain alert in identifying early signs of post-intensive care syndrome (PICS) in ICU survivors. Implementing screening tools and regular assessments in the post-ICU follow-up phase can facilitate early intervention.
- Multidisciplinary collaboration: Addressing PICS requires a collaborative approach among healthcare teams. Nurses have an important role in coordinating care and advocating for adequate treatment plans.
- Patient and caregiver education: Nurses should educate ICU survivors and their caregivers about the potential-long term effects of critical illness, including PICS.
- Advocacy for policy development: Nurses should advocate for healthcare policies that prioritize long-term follow-up care for ICU survivors, including regular screening for PICS and access to rehabilitation services.
Background
In recent years, rising survival rates for intensive care unit (ICU) patients have highlighted the long-term consequences of critical illness. Post-intensive care syndrome (PICS), characterized by impairments in cognition, psychology, and physical health, is among the most concerning outcomes (Smith & Rahman, 2023). PICS significantly impacts survivors’ quality of life, necessitating multidisciplinary care beyond ICU discharge (Voiriot et al., 2022). Despite its recognition as a distinct condition, PICS remains underexplored (Smith & Rahman, 2023).
PICS encompasses symptoms that extend beyond the acute care phase, often lasting weeks to years post-ICU. Symptoms include muscle weakness, memory and concentration deficits, anxiety, depression, and post-traumatic stress disorder (PTSD) (Hiser et al., 2023). Cognitive impairments similar to moderate traumatic brain injury and Alzheimer’s dementia have been seen in patients up to one-year post-ICU stay (Pandharipande et al., 2013). Studies estimate 50-70% of ICU survivors experience some form of PICS (He et al., 2024; Schwitzer et al., 2023; Wang et al., 2018). Care challenges are exacerbated by limited screening tools and insufficient follow-up care (Pant et al., 2023; Wang et al., 2022). PICS demands standardized approaches to prevention, early detection, and management.
Risk factors for PICS include prolonged mechanical ventilation, extended ICU stays, delirium, and sedative exposure(Needham et al., 2012). A Canadian study identified a lack of care availability, which would typically be provided in post-ICU follow-up clinics (Stapleton et al., 2020). Addressing ICU survivors’ long-term challenges is increasingly relevant. This concept analysis explores the complex nature of PICS, focusing on its implications for survivors and care needs, particularly in older adults. By clarifying the defining attributes, antecedents, and consequences of PICS, this analysis aims to inform clinical practice and future research.
Design / Methodology
This concept analysis followed Walker and Avant’s (2011) framework. First, the concept was selected, and relevant literature was reviewed to define its purpose. Key elements, including defining attributes, antecedents, and consequences were identified. Model, borderline, and contrary cases were developed to illustrate the concept. Empirical referents were identified, and research gaps highlighted.
Data Collection
Relevant literature was sourced from CINAHL, PubMed, and Google Scholar. Search terms included “post-intensive care syndrome,” “PICS,” and “ICU survivors.” Articles from 2012 to 2024 were prioritized. Only peer-reviewed studies in English focusing on PICS’ long-term effects were included. Studies on pediatric populations or unrelated interventions were excluded. A total of 43 articles were analyzed.
Results
Examining the Applications of the Concept
Examining the applications of the concept of PICS reveals its role in enhancing the care of ICU survivors. PICS ,as a concept, informs healthcare providers about the diverse challenges ICU survivors face, guiding interventions (Hiser et al., 2023). For instance, PICS is applied in creating care pathways that facilitate psychological support and rehabilitation, addressing the cognitive and emotional needs of survivors (Renner et al., 2023). In clinical settings, the concept is often used to develop educational programs aimed at equipping healthcare professionals with the knowledge to recognize and manage PICS (Zhang et al., 2023). Furthermore, PICS informs policy decisions regarding follow-up care, advocating for integrated healthcare models that promote long-term recovery (Schwitzer et al., 2023).
Defining Attributes
In conducting a concept analysis of PICS using the Walker and Avant (2011) framework, the defining attributes represent the characteristics that distinguish this concept. A literature review revealed three key attributes consistently associated with PICS: neurocognitive impairment, physical debilitation, and emotional disturbances.
Neurocognitive impairment, a defining attribute of PICS, includes memory loss, attention difficulties, and executive functioning challenges. These deficits can significantly impact ICU survivors’ daily lives, as studies have shown declines in concentration, information recall, and decision-making abilities post-ICU (Alro et al., 2022; Kohler et al., 2019; Pereira et al., 2024). Mart et al. (2022) noted that cognitive difficulties often persist long after discharge, sometimes resembling early dementia.
Physical debilitation encompasses fatigue, muscle weakness, weight loss, pain, and functional impairment (Boelens et al., 2022; Makinen et al., 2020; Wischmeyer & San-Millan, 2014). Prolonged immobility, combined with sedation and mechanical ventilation, often leads to muscle atrophy and diminished physical endurance (Boelens et al., 2022; Lad et al., 2020). Goddard et al. (2024) documented challenges with activities like walking or climbing stairs months or years post-discharge. Recovery through physical rehabilitation is critical, though outcomes vary based on illness severity and length of ICU stay (Boelens et al., 2022).
Emotional disturbances including anxiety, depression, and PTSD are a third key attribute (Abdelbaky & Eldelpshany, 2024; Hatch et al., 2018). Survivors often experience distress from life-threatening situations, invasive procedures, and isolation during their ICU stay (Vrettou et al., 2022). Abdelbaky & Eldelpshany (2024) identified PTSD-like symptoms prevalent in patients who underwent prolonged sedation or mechanical ventilation, exacerbating their emotional challenges. These psychological aspects of PICS significantly affect survivors’ quality of life and engagement in rehabilitation (He et al., 2024).
Antecedents
Several factors contribute to the development of PICS in ICU survivors. Prolonged mechanical ventilation is a key antecedent, linked to physical and cognitive declines post-ICU (Bulic et al., 2020; Huang et al., 2022; Jubran et al., 2018). Extended sedation, often required for ventilated patients, frequently leads to delirium, another contributor to PICS (Ceric et al., 2024). Patients with ICU delirium are at increased risk for long-term cognitive impairment, highlighting the importance of sedation management (Goldberg et al., 2020; Schwitzer et al., 2023).
The length of ICU stay is another critical factor, with long stays correlating to greater risks of physical, psychological, and cognitive impairments (Fiani et al., 2022). Prolonged exposure to invasive procedures, immobility, and stress in the ICU environment exacerbates these risks (Inoue et al., 2019). Additionally, pre-existing comorbidities in older adults increase their susceptibility to PICS due to underlying frailty and functional declines (Green et al., 2021; Inoue et al., 2019). Understanding these antecedents is essential to reducing PICS incidence and improving outcomes for ICU survivors.
Consequences
Consequences are the outcomes resulting from the concept of PICS (Walker & Avant, 2011). While primarily adverse, some positive outcomes have been observed. A notable positive consequence is that some ICU survivors adapt to a “new normal” and become advocates for others transitioning out of the ICU (Hirshberg et al., 2020).
Adverse consequences are more common, including diminished quality of life due to physical, cognitive, and psychological impairments (Geense et al., 2021; Hofhuis et al., 2021). PICS often leads to long-term issues such as muscle weakness, memory loss, anxiety, and depression, impacting survivors’ health-related quality of life (Smith & Rahman, 2023). These challenges also extend to caregivers, many of whom face significant emotional and physical burdens. Nearly 50% of caregivers report feeling overburdened when caring for PICS survivors (Van Beusekom et al., 2016; Van Sleeuwen et al., 2020). These outcomes emphasize the widespread impact of PICS on individuals, their support networks, and healthcare systems.
Insert Figure 1
Model Case
This model case illustrates the concept of PICS and serves as an example for understanding and explaining it.
John, a 70-year-old man, is discharged from the ICU after being treated for severe pneumonia. After his discharge, he experiences physical weakness, memory loss, and depression. His wife, overwhelmed by his needs and behavioural changes, struggles as his primary caregiver. Despite follow-up care, John’s recovery is slow, and his quality-of-life declines. Eventually, John and his wife join a support group for ICU survivors, where they gain tools for managing symptoms and supporting others. Over time, John adapts to his “post-normal” life. This case demonstrates the key attributes of PICS and its impact on patients and caregivers.
Additional Cases
Examining borderline, related, and contrary cases clarifies PICS attributes. Borderline cases exhibit most but not all attributes, related cases share some similarities but lack critical features, and contrary cases lack PICS entirely (Walker & Avant, 2011).
Borderline Case
A 68-year-old man, recently discharged from the ICU following a cardiac event, experiences fatigue and occasional confusion but retains physical function and manages daily activities independently. His memory issues cause minor frustrations but do not require formal rehabilitation. While his symptoms align partially with PICS, they are mild and manageable, missing the severity and functional impact characteristic of the condition.
Related Case
A 74-year-old woman is discharged from the hospital after a lengthy stay for pneumonia but was never admitted to the ICU. She experiences fatigue and a reduced quality of life. Although she finds daily tasks more tiring, she has no cognitive impairments and can still perform her routine activities with minimal physical assistance. Her symptoms stem from post-hospital syndrome rather than PICS, lacking ICU-specific factors and the significant impairments of the syndrome. 
Contrary Case
A 55-year-old man is admitted to the ICU for several days after a traumatic accident but makes a full recovery upon discharge, with no cognitive, physical, or psychological complications. He returns to his pre-ICU routine without assistance or lasting symptoms. This case contrasts with PICS, as it involves a complete recovery without residual challenges.
Empirical Referents of PICS
Empirical referents are measurable indicators that confirm a concept’s real-world presence (Walker & Avant, 2011). For PICS, they translate the concept into observable terms, aiding in developing valid assessment tools.
Existing assessments often measure isolated aspects of PICS, such as physical limitations or psychological distress, but lack the breadth required for a holistic evaluation (Pant et al., 2023). Tools like the Medical Research Council Scale for Muscle Strength and Activities of Daily Living (ADL) measure physical dysfunction (Edemekong et al., 2023), while the Hospital Anxiety and Depression Scale (HADS) and Posttraumatic Stress Symptoms-14 (PTSS-14) assess psychological symptoms (Milton et al., 2018). However, these tools rarely address the interplay between PICS domains, limiting their ability to capture the full scope of its impact.
The Post-Intensive Care Syndrome Questionnaire (PICSQ) uses an 18-item, four-point Likert scale to evaluate cognition, physical function, and psychological status (Jeong & Kang, 2019). While it addresses core cognitive concerns, it insufficiently accounts for the social and community impacts critical to understanding PICS. This highlights a gap in current tools, which restricts providers’ ability to assess the syndrome’s complete effects on survivors’ lives.
Discussion
This concept analysis highlights PICS as a multidimensional phenomenon profoundly impacting ICU survivors’ quality of life. Defined by neurocognitive impairment, physical debilitation, and emotional disturbances, PICS presents diverse challenges that persist after ICU discharge (Boelens et al., 2022; Mart et al., 2022). Older adults are particularly vulnerable, as age-related factors exacerbate recovery challenges, underscoring the need for specialized interventions (Fiani et al., 2022). Antecedents such as prolonged mechanical ventilation, extended ICU stays, and sedation exposure increase the risk of PICS, emphasizing opportunities for preventative strategies (Green, Rochwerg, & Wang, 2022; Huang et al., 2022; Schwitzer et al., 2023).
PICS consequences extend beyond patients, significantly impacting caregivers and healthcare systems. Caregivers often face emotional and physical strain, while healthcare systems bear costs related to extended rehabilitation (Van Sleeuwen et al., 2020). Interdisciplinary follow-up care and referrals to post-ICU clinics are essential for supporting survivors and their caregivers, ensuring adequate treatment and rehabilitation (Stapleton et al., 2020). This concept analysis underscores the importance of standardized care models and protocols to address PICS effectively. Future research should prioritize refining nursing interventions, particularly for high-risk groups such as older adults, to enhance post-ICU quality of care.
Conclusion
This analysis of PICS offers foundational insights to enhance its understanding and management in critical care settings. By clarifying essential attributes, antecedents, and consequences, this concept analysis supports a framework that can guide education, patient care, and future research across healthcare disciplines. The findings contribute to a growing body of knowledge on PICS and provide practical groundwork for healthcare providers and educators to develop targeted interventions, assessment tools, and policies.
Author Notes
Brookelyn Hussey, MN, RN, Department of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
Connie Schumacher, PhD, RN, Department of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
Corresponding Author
Brookelyn Hussey, MN, RN, Department of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada. Email: bh22ks@brocku.ca
Funding and Conflict of Interest
No funding was provided for this research from the public, commercial, and/or not-for-profit sectors. The authors declare no conflicts of interest.
Acknowledgements
The authors express our gratitude to Dr. Joanne Crawford of Brock University for her guidance and advice on research methodologies. Her feedback throughout provided a solid foundation for the topic of this concept analysis.
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Figure 1: Antecedents, Attributes, and Consequences of PICS
