Names and numbers: How COVID-19 impacted on de-humanization of ICU patients

Dear Editor,

The recent COVID-19 outbreak in Northern Italy and the great number of critical patients requiring mechanical ventilation outnumbered available intensive care resources. Hospitals' original structures have undergone great changes to face this emergency: wards, operating theatres and recovery rooms were rapidly converted into intensive care units (ICU), doubling or tripling intensive care beds.

Healthcare professionals had to reconsider their working habits, learning new skills in different settings. Intensivists and critical care nurses were involved in multiple roles, trying to overcome the shortage of medical workers skilled in intensive care, educating them and redefining strategies to optimize workload and assistance. It is a time of profound changes, and probably hospitals and intensive care will never be the same again.

But what about patients and their families? In the last years, ICU visiting policies were completely revisited, including patients and relatives as active members of the care process, reducing anxiety and agitation and increasing patient and family satisfaction. ¹ The path for intensive care humanization and family engagement was not easy, but now the advantages are well recognised by most operators. ² With the outbreak of COVID-19, we had to give up to most of the achievements in terms of patient-centered care. Lockdown measures adopted by Italian government limited hospital visiting policies and particularly ICU visits had to be restricted to protect patients, visitors and operators. Information, one of the primary needs expressed by ICU patients and relatives, is often limited to a daily call about clinical conditions. ³

COVID-19 patients usually leave their homes and greet their families when ambulance personnel accompany them to the Emergency Department; in most cases, they enter the hospital alone and they are alone even in the end of life. A mobile phone remains the last link with their loved ones; for many patients, a phone call just before being intubated is the last greeting to their families.

Personal protective equipment, even if necessary to prevent SARS-CoV-2 spread and to protect medical workers, represents an obstacle for communication; wearing a mask requires to raise the voice and hides face expressions, including a smile. The touch of a hand, protected by two or three gloves, is often the last human contact.

The need to assist critical patients wearing protective equipment increase workload and represent a stressing condition for ICU personnel. The urgency for tracheal intubation, mechanical ventilation and invasive procedures in such a great number of critical patients leaves intensivists and nurses with limited time to communicate, to explain clinical conditions and therapeutic options but particularly to consider their history, their personal identity and their names. Admitting several patients in a shift, all with similar clinical conditions, treatments and same therapies, like in an assembly line, could lead to forget names reducing patients to numbers.

Even in a critical situation, with incredible workload and limited resources, healthcare professionals should insist in their efforts, preserving patients' dignity and humanizing the intensive care setting. Even if it is difficult, we must not allow that patients become numbers.