An intensivist is a physician who provides special care for critically ill patients. Also known as a critical care physician, the intensivist has advanced training and experience in treating this complex type of patient.
An intensivist, also known as an intensive care unit (ICU) or critical care physician, provides specialist care for critically ill patients. This is usually within the setting of an ICU in a major hospital, where there will be access to many investigative specialities, such as radiology and laboratory testing. The aim of an ICU is to provide life-sustaining therapy to a critically ill patient in order to maintain or restore organ function. The advent of critical care occurred during the polio epidemic of the 1950s, as the development of effective ventilators and advances in circulatory support meant that more complex surgery became possible and patient survival improved.
Comprehensive approach
Rather than focusing on one specific body system, as, for example, a cardiologist or pulmonologist would, an intensivist takes a more comprehensive approach to patient care. Critical care medicine crosses the boundaries of many medical specialities, which have traditionally been based on age, technique, organ or disease. Therefore, an intensivist must have knowledge of all those fields. He or she has the primary responsibility for an ICU patient’s care and leads a team of caregivers, whose role is to act as consultants, who are experts in different specialist fields. As such, the intensivist is responsible for overseeing the many decisions needed in the care of a critically ill patient and for coordinating all the other specialist services that the patient may need, so that the opinions and knowledge offered are complementary, rather than contradictory. Thus, along with the knowledge and judgement gained through training and experience, an intensivist must also possess excellent interpersonal skills, along with a willingness to question their own actions in order to achieve the best outcome for the patient.
Types of treatment
Intensivists treat any patient who has a major life-threatening illness or operation, where high-level support is required. ICU patients are intensively monitored and supported and can expect to have their condition reviewed by an intensivist several times each day. Treatment almost always follows a multidisciplinary approach. The types of procedures that an intensivist might be required to undertake include intubation, ventilation, dialysis, tracheostomy, central venous access and arterial cannulation.
Difficult decisions
While the advent of new technology has made it possible to prolong life almost indefinitely, this may not be desirable if there is no hope of recovery to an acceptable level. Where critical illness does not respond to treatment, or when treatment is out of proportion to the expected prognosis, an intensivist may need to make a judgement about withholding or withdrawing treatment. It is part of the intensivist’s job to realise when this point has been reached and to involve the patient’s family in making difficult decisions. Intensivists have an unrivalled understanding of critical illness and the limits of vital organ support and can explain to patients and family members what these might be in any specific clinical situation. Once the decision has been made to remove life-supporting therapy, it is the intensivist’s responsibility to manage the patient in a way that combines pain control, comfort, and support both the patient and their family.
The role of an intensivist
Numerous studies have shown that ICU patients who are managed by a intensivist have improved survival rates, particularly in patients whose condition is in the middle range of severity. It was first reported as far back as 1972 that patients cared for in ICUs, as opposed to wards, had a higher survival rate. A further significant improvement in survival rate can be obtained by the provision of 24-hour access to an intensivist, compared to cover provided by a non-specialist anaesthetist who may also be covering other hospital departments. Patient survival appears to be highest in ICUs with carefully designed clinical protocols, comprehensive nursing support and good nurse/physician communication. However, the role of an intensivist is not just about saving lives but should also involve saving a patient’s quality of life. Further documented benefits of involving an intensivist include a reduction in the rate of complications suffered by patients, a shorter length of stay in the ICU, a reduction in the number of procedures required and increased medication safety.
Medico-legal challenges
In the medicolegal setting, an intensivist is most likely to be called upon to provide an expert opinion in cases where medical negligence has been alleged. This can cover a wide spectrum of cases, with the most common being related to nursing care, particularly pressure sores caused by poor positioning. However, the relatively high number of this type of case may be partly due to the increased contact between nurses and patients in the environment of close monitoring provided by an ICU. Other case types frequently seen include hospital-acquired infections, such as sepsis or MRSA; respiratory conditions; missed or delayed diagnosis or treatment; and a failure identify deterioration. Due to the complex and varied nature of the conditions presenting in critically ill patients, and the wide-ranging knowledge and skills needed to practice in this field, an intensivist is ideally placed to offer an opinion in such cases.
About Dr Marlice van Dyk
Dr van Dyk is a Consultant in Intensive Care and Anaesthesia at Unitas Hospital in Centurion, where she leads a multi-disciplinary team. Dr van Dyk is also an Expert witness in Intensive Care Medicine (Intensivist) and can provide expert opinion on a range of cases relating to the clinical management of critically ill patients.