244

Injury, 7, 244-245

Social work in an intensive

care unit

Catherine Cole Medical

Social Worker, Birmingham Accident Hospital

AT THEBirmingham Accident Hospital the social worker is informed of the admission of a severely injured patient and, while the medical and nursing staff concentrate upon the treatment of the patient, she will be responsible for the care of the relatives. Most people have difficulty in adjusting to the shock of an accident and need considerable help if they are to be able to cope with their own feelings as well as the distress of the patient. The speed with which the social worker gains access to the relatives is important, for experience shows that it is easier to establish rapport with the people concerned if they are seen shortly after the patient is admitted. It is particularly helpful if the social worker can be present when the relatives are interviewed by the doctor, for they may often listen to the information given to them but fail to absorb it because they are too upset. If the social worker knows what has been said she can assess how realistic an interpretation the relatives have been able to make, and she can then reinforce and perhaps further explain what the doctor has previously said. Indeed, it is often easier for people to discuss their anxieties with a non-medical person. This initial contact with the relatives when they are in a distressed state allows the social worker to plan appropriate help for the family while the patient is receiving treatment. It may be that the accident has happened at a particularly troublesome time for the family and it exacerbates problems not necessarily caused by the incident. David A, the teenage son of a couple in their late SOS,was admitted to the major injuries unit following a road traffic accident. This happened at a time when Mr and Mrs A. were coping with several problems connected with their marriage and Mr A.3 employment and David’s accident proved to be ‘the last

straw’ for them. Instead of being able to help David, Mr and Mrs A. were in need of support and advice

themselves. As their relationship became stronger it was possible for them to help and encourage their son. In other cases the accident itself may arouse strong feelings of guilt on the part of the relatives. For instance, if a child is badly injured whilst running an errand it is understandable that the distraught parents should blame themselves for the accident. However, these feelings of selfrecrimination may have a less obvious explanation. There may, for example, have been a heated argument shortly before the accident and it may then seem to the parents that harsh words previously uttered have in some ways been responsible for the accident. The task of the medical social worker is not confined to the first few hours or days after the shock of the accident, or even to the time spent in the hospital by the victim. Emotional and practical problems associated with an accident may continue and develop long after the patient is well enough to leave. Difficulties about returning to work may need a social worker’s help in the form of contact with employers or rehabilitation centres and it may be necessary for the social worker to assist in the application for appropriate financial and other benefits and to ensure that they are duly received. When it seems that the patient will never be able to return to ‘normal’ life, the social worker can encourage and support the family and help them to replace an attitude of pessimistic resignation with one more conducive to successful recovery. The responsibility of discussing the prognosis of a patient with a severely injured brain and perhaps deciding how long he should remain on a ventilator can also cause feelings of guilt among

Cole : Social Work

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the family. Some people are strong enough to cope with this decision and often help medical staff by making it clear that they would not want the patient to remain dependent upon a machine for the rest of his life. Others, and usually these are people who are emotionally dependent upon the patient and cannot envisage a future without him, cannot face the inevitability of death and require a lot of help from the social worker in order to accept what has happened. She has an important supportive role in helping the relatives to adjust to the idea of life without the patient, and also to come to terms with any guilty feelings they may have if they consider they have sanctioned the patient’s death by agreeing to the machine being switched off. The acceptance of death can be made more difficult by the speed with which death sometimes occurs. The initial contact made between the social worker and the relatives is an invaluable basis upon which future help can be planned. It may be some time before the relatives are able to accept that the patient has died and start the usual grieving process. They may attempt to deny that death has taken place and become angry with those ‘who should have cured him’, with themselves if they feel they should have done more during the patient’s life, and even with the patient for allowing himself to be killed. Support and understanding at this stage can be used to help the family to acce t what has happened. Although the social war+Zer first sees the family in the major injuries unit she may well visit them at their home for several months following the accident. Simon B., an old man, was an alcoholic and died as a result of injuries received in a fall when he was drunk. He and his wife had been separated for 7 years after her own health had begun to suffer from the strain of coping with his alcoholism and frequently violent behaviour. When he died she mourned not only for her husband, but also for the life they might have had together. Contact was maintained by the social worker for 12 months afterwards and this enabled her to adjust her feelings and come to terms with her husband’s death.

The social worker may also provide a source of help for the patient who may feel frightened and overwhelmed by the atmosphere of an intensive care unit. This can occasionally cause Requests&-

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Peter C. sustained multiple fractures in a car accident. He was an anxious, elderly man who tended to relate to the other people being treated in the unit and assume their problems as well as his own. Unfortunately, the other patients in the unit died and Mr C. became convinced that his turn was next, so much so that he completed the final details of his will and waited to die. His wife, a similarly anxious individual,

was also sure that her husband’s death was imminent (although they had never discussed this). Having ascertained what was happening, the social worker was able to encourage Mr and Mrs C. to discuss the possibility of Mr C.‘s death and then to point out, with the aid of the medical staff, that Mr C. was, in fact, improving. Arrangements for his future discharge were discussed so that Mr C. could see that the staff regarded him as capable of recovering and gradually he became less depressed and improved enough to be transferred to another ward. Even with patients who have nothing but admiration for and a feeling of trust in the intensive care unit it may be comforting to talk to someone who is not a member of the medical or nursing staff, especially if it is possible to discuss the family and give a reassurance that they, too, are being cared for. At this early stage of treatment it may also be appropriate to start working towards the gradual realization and acceptance of a mutilating injury such as an amputation. It is widely accepted that the staff in an intensive care unit are continually subjected to severe pressures, not least those applied by the distressed relatives of the patients they are treating. ‘Care of distressed families seems to be a major source of stress. Partly because they are nobody’s responsibility they tend to get left out and therefore become even more anxious.’ (Baxter, 1974.) By using the social worker’s skills to help with this aspect of the care provided by the unit, the stress on other members of staff may be substantially reduced, the relatives are reassured and provided with accurate information and the patient’s peace of mind is stabilized.

REFERENCE

BAXTERS. (1974) Psychological problems of intensive care. Br. J. Hosp. Med. 11, 75.

Miss Catherine Cole, Social Services Department,

High Street, King’s Heath, Birmingham

14.

Social work in an intensive care unit.

244 Injury, 7, 244-245 Social work in an intensive care unit Catherine Cole Medical Social Worker, Birmingham Accident Hospital AT THEBirmingham...
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