What is an ICU and Neurologic Critical Care? Tips and a Guide for Everyone

Episode Transcript

Dr. Daniel Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Katy Peters:
And I am Dr. Katy Peters, and this is the Brain & Life podcast.

Dr. Daniel Correa:
When any of us might enter the hospital, there is just a long list of vocabulary terms that come up in those urgent moments. Things like nasogastric tube and PEG tube or feeding tubes, and there's all kinds of different wires people will talk about and lines, not just the IV that gets placed in the ER. But sometimes, even things called central lines and other venous lines. There's a lot to figure out.
Katy, we encounter these discussions as doctors, but have you ever been in the position as the family member and navigating the decisions about feeding tubes and all these ICU level interventions?

Dr. Katy Peters:
Daniel, I agree. As a physician, you and I have both had to deal with this to discuss with our patients about feeding tubes or lines or other intensive care issues, whether those tubes are being placed in a vein and artery or in stomach or our nose. And thank you for asking. My father passed in 2021 from cardiac issues, and I did have to discuss code status with him, my mother, our extended family, and also the providers in the intensive care unit. And needless to say, it was really, really tough.

Dr. Daniel Correa:
Katy, my heart goes out to you and your family. I imagine even in that difficult time; it brought you all closer together. It's an incredibly challenging time for everyone in our families, not only to be struck with the surprise of that unexpected phone call about someone we love being urgently ill, but then to try and process all the different things that are going on, the tests, the procedures, the different decisions that come up that could impact someone both in the short-term and in their long-term needs.
This week we're featuring a discussion with Dr. Casey Albin. She's a neurologic intensive care specialist. And we're going to be discussing with her the different terms and decisions that any of us might encounter when someone in our family or ourselves might need ICU type care.
Be sure to follow and subscribe, so you don't miss our next interview and discussion with author and humorist, Samantha Irby, who joins us to share her experience of being a caregiver to her mother and who was diagnosed with multiple sclerosis.

Dr. Katy Peters:
The holidays are just around the corner and we want to hear from you. Our listeners, call into the Brain & Life podcast phone number by December 1st and record a short message sharing with us what you are grateful for in 2023, for an opportunity to be featured in a future episode. Don't forget to tell us who you are and where you're calling from.

Dr. Daniel Correa:
We also want to answer questions that you have about conditions we've not included before. Tell us what you want to know, and maybe what topics you want to hear about in the future. You can record a voicemail at 612-928-6206, and we also have an email address you can email us at in the show notes.
Welcome back to the Brain & Life podcast. I'm really excited to be joined today by a colleague and neurologist, and to build on some of the episodes that we've talked about, different brain health topics and give you the community tools not only to understand more about your medical conditions, but to help make medical decisions with the whole team of doctors and all the decision makers along with you, whether it's inside the hospital or outside.
Dr. Casey Albin is an assistant professor of neurology and neurosurgery at Emory University, School of Medicine in Atlanta and is trained as a specialist in the neurologic intensive care units. When she isn't working in the Neuro ICU, Casey is passionate about digital education, the teaching and education of doctors in training and our colleagues already working in medicine, but she also works to improve shared decision-making with the families of people in the ICU. Casey, thank you so much for joining us today.

Dr. Casey Albin:
It's really a delight to be here. Thank you so much for having me.

Dr. Daniel Correa:
Now, I talked about you being a neurointensivist or a Neuro ICU doctor, and there's just the other idea of intensive care units. Why is the intensive care unit a different thing for someone who comes into the hospital or to the ER than just every other floor or bed in the hospital?

Dr. Casey Albin:
So, when we think about intensive care medicine, I think there are three main buckets of patients that I would see who need my specialty and my training. So, what neurointensivists are trained to do within the Neuro ICU is care for patients who cannot receive the type of therapy needed that can't be done on a floor.
Most commonly, that's because a patient needs a breathing tube. Sometimes, it's because they need a medication that supports their blood pressure. And then, other times, it's because the trajectory of their course is so uncertain that we just really need to keep a very close eye on them. And what makes the neuro ICU different than the floor is that the nursing ratios are a little bit different.
On the floor, one nurse typically caress for about four patients, where in the ICU, we have the ability to have a nurse either take care of just one patient or two patients. So, they are just able to follow that patient a lot more closely. And so, patients who we just totally aren't quite sure how they're going to do and we really need to keep a close eye on them, they might need intensive care. Anyone who's on a breathing machine needs an intensive care unit or patients who have the need for stronger drugs that we can deliver on a floor, they would end up in the ICU.
So, most of our patients are quite sick, but not all of our patients. And sometimes, we're monitoring neurosurgical patients after they've had a procedure. Many of those patients do just fine, but because they've just had a big surgery, we'd like for our nursing colleagues to have just a better ability to watch them. So, not everyone in the Neuro ICU is very, very sick. But certainly, we are caring for the sickest patients with more serious neurologic injuries than the floor does.

Dr. Daniel Correa:
Now, I could see some members of my family or people that I talked to, we'd be discussing this, and they might find the experience of coming into the ER into the hospital, so scary. And then, they hear your description and could think, "Well, why can't all of us get that amount of nursing care? And isn't that important for everybody?" So, why might it be better for someone not to be in the ICU?

Dr. Casey Albin:
Oh, absolutely. I think of the ICU as a place that we want to get people out of as fast as possible. If you think of the ICU, there are a lot of noises all the time. Most of our patients are in glass doors, so there's no privacy and we are disrupting their sleep all the time. It is not a healing, resting place. It is a place where critical care can be done, but we want brain recovery. And brain recovery, I really think happens when the patient is able to get out of this very disorienting environment.
So, being able to monitor a patient is certainly wonderful and they should have that when they have a critical illness that they need that type of monitoring. But I absolutely want our patients to get out of the ICU as fast as possible because they can do more physical therapy on the floor, because they can rest more on the floor, because they have more privacy on the floor, because they're going to be able to focus on that recovery and that next stage of getting better on the floor so much better than they can in a hectic environment of the ICU. And that doesn't even get into some of the risk factors like delirium, much more prevalent in the ICU than on the floor or infections much more likely to acquire in the ICU than on the floor.
So, the ICU is an amazing place for critical care, and I absolutely want any loved one to stay there until they're out of that critical phase of illness. But healing really takes place on the floor, and I'm a big proponent that as soon as a patient can get out of the ICU, we should get them out.

Dr. Daniel Correa:
Now, we talked about this idea of shared medical decision-making. What does that really mean for you as being one of the care team leaders and partners for the patients and families?

Dr. Casey Albin:
This is really I think, the cornerstone of critical care medicine because our patients are often critically ill need to make a lot of decisions about how aggressive we're going to be. Will they get procedures? Will they be put on a breathing machine? We in ICU are constantly working with families to understand what the patient would want in these situations.
And so, when I think of shared decision-making, I think I'm bringing a certain specialized knowledge to the table that knowledge is mostly about what the next couple of days or weeks might look like for that patient as they face whatever has brought them into the ICU.
So, I'm bringing with me the experience of having cared for patients over that trajectory and understanding quite a lot about the neuropathology, but I know usually nothing or very little about who your loved one was before they came to the ICU. So, unlike a neurologist in the community who might have had the opportunity to get to know your loved one and your family over many, many visits, usually this is the first time I'm going to know that patient. And so, I am not an expert at all in what your loved one or you as the patient would want in a critical care situation.
And so, the family members really coming in with the expertise of their loved one. And so, when I think of shared decision-making, I think of it as exchanging expertise knowledge that I have the expertise of this medical condition and you have the expertise of who your loved one was as a person. And together, we're taking your knowledge of who they are and my knowledge of what this disease is to come up with a plan that is personalized for your loved one or for you as the patient.

Dr. Daniel Correa:
So, let's walk through a situation or an example, and let's talk about some of the key decision points when someone's coming into the ICU. And hopefully, graduating and leaving.

Dr. Casey Albin:
A couple of the major things where we often sit down are thinking about, does the patient want to be on a breathing machine? That is a really fundamental cornerstone of critical care medicine. Many of our patients are in the ICU because they can't protect their airway on their own.
And so, we are able to get them through that phase of their illness with a breathing machine. Many times, that breathing machine is a short-term treatment. They need the support of the ventilator while they are recovering from the most severe part of their neurologic injury. But sometimes, they can need it for quite some time.
So, one of the first phases is this patient looks like maybe they aren't protecting their airway, they have a severe brain injury, should we intubate them? Sometimes, this even happens in the emergency department where they make that decision because we operate in medicine assuming that you want us to do all the things.
So, oftentimes, patients come to me and they've already been intubated. And we're helping to work with the family to understand if that's an acceptable place for the patient to be as they recover. And I think most people want to say, "Let's see how things go." So, I think that's decision number one in the ICU, is a breathing tube acceptable? And if they come to me with a breathing tube, is it okay if they stay in this condition?

Dr. Daniel Correa:
When you say intubate, we mean the placement of that breathing tube in?

Dr. Casey Albin:
That's correct. Absolutely. So, intubation is the procedure in which a breathing tube or an endotracheal tube that's the breathing tube, is placed in the airway and that allows the breathing machine to deliver breaths to your loved one. Now, many patients with neurologic issues, it's not the breathing that's the issue. It's not their lungs that are injured. It's that, whatever the acute brain injury is, it's caused them to be so sleepy that they may not do a good enough job breathing or they may not be able to cough appropriately.
And so, the breathing machine is preventing them from getting pneumonias or from not breathing well enough. So, you may say, "Oh, it looks like they're doing fine. They don't have a pneumonia." Patients who end up in the Neuro ICU, we're usually giving them a breathing tube to help protect them from developing pneumonias because they're just a little too sleepy to do the breathing on their own.

Dr. Daniel Correa:
And then, the ventilator is that breathing machine?

Dr. Casey Albin:
Absolutely, yup.

Dr. Daniel Correa:
Now, we both know there's also some nerve and muscle conditions where people might end up in the Neuro ICU because that condition is affecting how well the nerves and the muscles can even pump the chest to breathe. In some of those situations, we might talk about that ventilator before they get to the point where they absolutely need it, but there's also these other machines that we talk to them about sometimes called BiPAP and CPAP. What are those machines and how are they different?

Dr. Casey Albin:
Yeah, a lot of people are familiar with CPAP because this is what people use at home if they have obstructive sleep apnea. CPAP is where we help give the lungs a little bit of pressure to stay open all the time, regardless of you're taking a breath in or taking a breath out, it's giving a little bit of pressure that helps keep the lungs expanded to decrease a little bit of the work that you need to do to do the breathing that is so fundamental for keeping us alive.
I think of BiPAP is a step-up. It's going to give you a little bit more pressure when you're trying to take that breath in to even further decrease that work of breathing. The good thing about both of these treatments is that they can be done without a tube that goes into your body. We call this noninvasive ventilation because they are supporting your breathing through a mask, so that pressure is delivered through a mask, and that can help with diminishing how much work the patient has to do to breathe.
Sometimes, that can be used as a temporizing measure. Now, if we think that your loved one or you as the patient are going to need that support for a long period of time, this is not going to be a good option. You can't eat or drink, if you're using this machine. It can certainly, help for maybe a day, maybe a little bit longer, but this is not really a good long-term solution.
So, sometimes, we'll give it a shot. We want to see like, can we help your loved one turn the corner or you as the patient turn the corner with this non-invasive before we have to think about, "Well, this might be a longer issue." The breathing tube has the advantage of being more durable and allows for a longer support.

Dr. Daniel Correa:
And in both of those situations, it's the lungs themselves have to be healthy and working on their own. It's not as much the situation where the ventilator can help overcome an injury.

Dr. Casey Albin:
Yeah, exactly. The lungs and the diaphragmatic muscles that we need to breathe until those have recovered, you need that support.

Dr. Daniel Correa:
There's one other aspect, if you have that ventilator helping you with assisted breathing and you have that tube down your throat, it can't stay there for a very long time. Sometimes, we move the tube position, and what's that called? How do you get into that decision making?

Dr. Casey Albin:
So, this is I think one of the most common points where we will have a family meeting. What Daniel's referring to is what's called a tracheostomy. That's when the breathing tube is moved from a patient's mouth and to a small hole. That is a procedure that's done usually at the bedside, but sometimes in the operating room that allows the patient to have an even more durable airway.
So, when I describe a tracheostomy, what I describe is that your loved one we've determined still needs support of the ventilator as they recover either as their muscles get stronger or as their brain recovers. And during this recovery, we want them to have the support of the breathing machine. Now, the breathing tube that goes in the mouth, that's a pretty easy procedure to do, but you can imagine that could get dislodged more easily or that's not very comfortable.
All of our gag reflexes are at the back of our mouth. And so, the breathing tube that we put in the mouth can aggravate those gagging responses. And so, often, patients need to be a little sedated, so that they're not uncomfortable with the breathing machine. However, the tracheostomy after the initial procedure, it's actually a much more comfortable way to ventilate a patient. It's also safer. Once it's matured, that's really a durable airway
So, it offers the long-term support, but in a safer and more comfortable way for the patient. So, I think of it as a really important time for us to pause and have that discussion. But I always like to walk families through like, what does this look like? And what does it mean? The procedure itself, for the most part, goes pretty well. It is not a very hard or complicated procedure, and most places have teams that are experienced in doing lots of these.
What we have to think about is not so much, can we do the procedure or not? Usually, we can, but is committing your loved one to the longer-term recovery part of their goals of care? And so, this is really the time that we like to meet with families to just do a pulse check, but also an update. Most of the time, we will use the breathing tube in the mouth for about two weeks.
This allows us to get to know you as a family, to get to know your loved one, to get a sense of how they're recovering from their acute illness or if it's a neuromuscular problem, like a lung breathing problem, how they're recovering from that. That two weeks allows us to get some data points on what does recovery going to look like? Is this going to be maybe another two weeks? Is this going to be probably, we're looking at months? Is this going to be a longer-term state of being more dependent?
And so, I like to have the meeting at this point to have a shared knowledge with the family. Here's what I as a neurologist am seeing, and here's what I can do the best I can to predict where we're going to be in a week, in a month or a year. And let's meet with you as a family, so you can give me your expertise about, if your loved one would be alright, being in a more state of dependency for that week's, month's, or year's duration. The reason we have to think about this is because if you have a tracheostomy almost all of the time, you are not going directly home. It is nearly impossible to take a ventilator home, and all except long-term sort of ALS situations with really multidisciplinary care.
Most patients who need a tracheostomy because of a severe brain injury, they need to be in a hospital-like environment until they have recovered to the point where that tracheostomy is no longer needed, and that really is going to be a hospital environment. Some people say, "Absolutely my loved one, however long it takes for him to make this recovery, our goal is that whatever his recovery looks like, we're here to support it for as long as it takes."
Other families will say, "So-and-so would never want to be dependent in a nursing home." That's just not acceptable for his or her quality of life. And if they can't breathe well enough on their own, we don't know that we want to continue with this degree of aggressive care. And I can't answer that question. And I think that that's one of the things that is so important about this process is that the family member is really the expert in what the patient is willing to tolerate and the hope of a good outcome.
And so, when we have these meetings, a lot of what I'm doing is getting information from the family about what would be considered an acceptable outcome? Would being able to sit and watch TV be acceptable? Or is it that the patient needs to live independently, care for himself, be able to drive to the grocery store, do all of his grocery shopping independently? If that's the quality, those are two very different outcomes, neither is right or wrong. But that's what we're trying to assess with your knowledge of either the patient or your family's comfort with neurologic illness.

Dr. Daniel Correa:
And that really gets back to such a key discussion that we all should be having with our family members, our loved ones, anyone involved in our medical care decision-making at whatever age. We've mentioned this before in our episode with an interview with a palliative care doctor, and we'll make sure also that that episode will be included in the show notes because if our family is going to have a good discussion with Casey about this, they need to already occur and know in the ICU what we would actually want in these situations, whether we're a 14-year-old or an 84-year-old, because otherwise you're left trying to figure that out from some recollection and memories of conversations you've had.

Dr. Casey Albin:
I really do think these are really important discussions to not even just have once, but to check in. And there are hard discussions to have, right? We don't like to confront our own mortality or we don't like to think that something like a severe brain injury could happen. Our vast hope is that it doesn't. But I think, when families come prepared and say, "We've had this discussion, and I know my loved one does want to stay on the ventilator as long as possible, even if it means that they're in a nursing home, it's really important for them to prioritize being alive. Or we've had this discussion and my loved one said that if they ever had to be in a nursing home where they were dependent on care for any amount of time, they really wouldn't want that type of care."
And again, there is no value. And I think one of the things that's important for us as physicians is to let you know we don't come with a value. We're going to do our very best to give you the probability of a good outcome in terms of what you've defined for your loved one as that good outcome. We're going to do our best knowing that we are all limited in terms of being able to prognosticate. But we'll do the best we can.
But it is really the family that defines what a good outcome is. Not me, not any of the literature. You having a conversation and telling me, "This is what our loved one would consider a good quality of life." That's the baseline that we're going to use. And that's why when we talk about shared decision making, I think of it as two experts coming to the table, one with an expertise in neurologic illness, and one with the expertise and who their family member is.

Dr. Daniel Correa:
When a family member comes to you, this was the level of quality of life that they wanted and expected if they ever got sick or for the rest of their lives at least in what they want. And how then do you turn that around to give them a sense of the likelihood of that occurring and bringing some clarity into what's going on?

Dr. Casey Albin:
This is a great question Daniel, and I think it's one that we as neurologists just do the best that we can, and I hope that all families know that we are not perfect at this. I have loved the work that Susanne Muehlschlegel's group has done. She's now at Johns Hopkins. But she's really looked at the language that clinicians use.
It turns out that we're not the greatest at giving probability outcomes. But I think that that is really what you as a family member should ask about. What is the probability? Sometimes, we really may not know. We can give you our best guess. The reason why we're not perfect at this is because we don't have the literature that really shows us all natural outcomes.
Let me give you an example of this. If I were to tell you a patient with this degree of brain injury is really unlikely to do well, they are probably going to live in a nursing home and they may not be able to speak or eat or move on their own. I think many patients would hear that and say, "That's not the kind of long-term life that my loved one wants." And they end up saying, "You know what? We're going to discontinue life support and we want to focus instead on their comfort." That's completely appropriate.
But, then we start to say, "Well, we've seen the literature that people with that degree of illness, they end up passing away." Would they have passed away? Or did they pass away because we shifted their care to more comfort focused care? What that's called in the medical literature is the self-fulfilling prophecy, that if I tell you something and I forecast a bad outcome, you're going to use that and you're going to probably say, "Oh, they may not want that bad outcome. I'm going to focus on their comfort." And they end up passing away.
A lot of our long-term literature is unfortunately impacted by the fact that people do how we predict, and then we are reinforced in saying, "Well, they did as we predicted that they would do." And so, we as a Neuro ICU community are trying really hard to get data that doesn't take into account the prophecy that you weren't going to do well, and so you didn't. But not all of our literature is without that bias.
This is a complicated topic, but I think it really gets to the heart of why sometimes we're not able to say how your loved one might do is because the population data that we work with is really affected by how physicians say the patient's going to do.

Dr. Daniel Correa:
Yeah, I think you clarified that very well, and it's just the challenge. We bring the experience and expertise that we may have, and that has already been developed out of the science and the research that's out there. But it's a great point to discuss and show that it's limited, and that's all we can work from.

Dr. Casey Albin:
What I always do when we're having these family meetings is share my best case, worst case. I think that that's a helpful thing that if you're going into one of these conversations with your neurologist, I think it's helpful to ask, "Dr. So-and-So, what do you think is the best-case scenario? Then, Dr. So-and-So what do you think is the worst-case scenario? And what do you think is the most likely scenario?" I think I try to offer that to our families, "This is the best case, this is the worst case. Here's what I think is most likely," because that gives you really the full range.
So, if they don't say that, you can always ask, "What do you think is the best case? What do you think is the worst case? What do you think is most likely?" That I think allows us to still have that diagnostic humility that we are not perfect. The longer I do this, the more I realize that we just don't have a crystal ball. Some patients are going to do better than we predicted. Some are going to do worse, and then we can only share the most likely outcome.

Dr. Daniel Correa:
Now, there's one other big decision that also comes up. But another one that comes up often is my family member's been in the ICU for several days now, they're not eating. And how do we address nutrition in the ICU and in these critical situations?

Dr. Casey Albin:
A lot of times, if a patient has a breathing tube, we will also place a feeding tube in their nose that's called a Dobhoff tube, and they can get their nutrition through that. We really care about nutrition in the ICU. In fact, a lot of times, we'll have a nutritionist round with us. We know that good nutrition is imperative in terms of helping your loved one get better.
Some patients, we have our speech and language pathologists work with them. Sometimes, the breathing tube can come out, but those muscles of swallowing, they're still not quite strong enough to have the patient support their nutritional intake by themselves. And so, one of the other conversations that we may have is around a percutaneous gastrostomy tube. That is a more permanent, although easily reversible tube that goes directly into your loved one's stomach.
If a patient is going to have a tracheostomy, we will place a percutaneous gastrostomy at the same time or in the same couple of days. Those two tend to go hand in hand. Although, we focus a little bit more on the tracheostomy, as you can get up and walk around, you can do your rehab. The PEG tube is not going to hold you back.
The breathing machine and being hooked up to a breathing machine and relying on a breathing machine, that certainly does impair what your loved one's able to do. And so, that tends to drive the conversation about, would this be an acceptable quality of life?
Now, the percutaneous gastrostomy tube, like the tracheostomy, the procedure itself is very simple. There are few complications, although the surgeons themselves will talk to you about what to expect, good analgesia is given during the procedure. Typically, this is not procedurally a big deal. The conversation may be about, if your loved one isn't able to eat for themselves, how does that factor in to their overall assessment of quality of life?
So, very commonly in the early states of an ICU admission, you'll see that your loved one has a little something in their nose. That tube is called a Dobhoff tube, and it's giving them the good nutrition that we really want them to have while they recover. If we feel like over time they're still not able to swallow, then we have that conversation about moving to a semi-permanent, again, reversible, but much more durable tube that goes directly into your loved one's stomach.

Dr. Daniel Correa:
In most situations you find that the tube that goes directly into the stomach or as we've mentioned, the PEG tube, is that really necessary to get enough nutrition? Is it necessary just because someone can't swallow and protect their lungs? What are some of the reasons why someone's actually going to need that?

Dr. Casey Albin:
Most of it I think, is driven by the fact that we need you to get a good amount of nutrition while you're recovering from a critical illness. It turns out, critical illness is actually really hard on the body. Your body is working really hard to recover, and it needs a lot of nutritional support.
So, most of the time, we are focused on the PEG needing for nutrition. Sometimes, the patient is able to eat some, but when they swallow, they might choke a little bit or they may gag a little bit and we worry, again, I rely on my speech and language pathologist to assess this, that even though they seem to be swallowing, some of it is going actually down the wrong pipe.
We've all had that experience where you choose something and oop, you swallow it, and then you're coughing and you're choking and you feel like, "Oh, gosh, it went down the wrong pipe." Sometimes, when you're recovering from a neurologic illness, those muscles that protect you from swallowing down the wrong pipe, they're just not strong enough.
And so, what this can do is put the patient at risk of getting pneumonia, and we certainly don't want your loved one to get a pneumonia while they are recovering from their brain injury. We want them to be focused on recovering from their brain injury.
So, sometimes, the PEG tube is placed not because your loved one isn't able to eat at all, but because we worry that those swallowing muscles just haven't quite recovered and no one wants pneumonia to set them back.

Dr. Daniel Correa:
A question I've often gotten from individuals or families is, "I have the IV in, why can't I just get my food in the IV?"

Dr. Casey Albin:
Every now and then, we do use the IV to give nutrition. However, that is the form of nutrition that is the last resort, and I'll tell you why. One is that, it's not complete nutrition as what can be given in the stomach. Two, you could imagine that when you are getting nutritious fluid that sometimes we use an IV to deliver while it is full of nutrition, it also puts the patient at higher risk of getting a bloodstream infection.
You could imagine bacteria likes that nutrients too. And so, one of the reasons we don't like to use the IV to deliver nutrition is that, it can put your loved one at risk of an infection. And again, we've talked about like we want your loved one to focus on their brain recovery, not fighting infections in the bloodstream or in the lungs.
And so, while there is a subset of patients for whom we will select the IV nutrition, we always want to use the gut if it works. If your stomach is working, if your small intestines are working, that's where your body is going to get the most nutrients and that's going to be the most nourishing for your body. We really use the IV as a last resort.

Dr. Daniel Correa:
Now, lastly, I just wanted to get a sense, are there any other key points that you think those family members who are making those medical decisions and their caregivers should have when they're thinking about their approach to discussing things with the team, and really just helping conceive the care that their family member needs in the ICU. And as they make that transition home, hopefully.

Dr. Casey Albin:
I always like to tell families that as we get to know your loved one, every day we have a little bit better picture of what's going on. I can only imagine just how scary it can be to have your loved one admitted to a Neuro ICU. And I would certainly, have a lot of questions from the start. What will their recovery look like? What's their brain function going to be? How long are they going to stay? All of those things are things that I would want to know.
And I try to be very upfront with family members that it's going to take us some time to know. Right in that initial 24, 48, even the first week, we may really be just getting a sense of what degree of injury we're dealing with, and trying to stabilize that, getting to know the patient and you. And so, we may not have answers to those really important questions at the beginning of the hospitalization.
We always do the best we can to try to predict where things are going and what direction we're heading. But I think a lot of it is unfortunately, being patient while we try to get through that initial resuscitation and really get to know your family member. And every day, we get a little bit more data about where they have been and where they're going. But at the beginning, it can be really challenging for us to have a good sense of what will the next day, week, month, year look like?

Dr. Daniel Correa:
I've learned so much from you, and I've learned so much from the patients and families that I get a chance to work with. Is there something that you've learned from the individuals and the families that you've helped take care of that has changed the way you've discussed your own medical decision making with your family?

Dr. Casey Albin:
Having seen how much of a struggle it is to try to guess what your loved one would want? That has made me want to take a more active role in understanding what the people in my life would want in this situation of critical illness.
I also do know that things change and that we need to check back in with our loved ones as years go by. What may be true one year may not be true the next year. And so, I think that actually the families that seem to have the most peace in the ICU are the ones that had these conversations on a rolling basis, and we're very open with understanding what their loved ones would want.
And certainly, that's more feasible if a patient has a chronic condition. But even the families that have had these conversations when an acute illness happens, I think they're better prepared, and I think that really cannot be overstated how important those conversations can be.

Dr. Daniel Correa:
They can be tough conversations, but maybe we should all hope for the privilege of having them many, many times with our family members year-after-year. Casey, thank you so much for joining us and for sharing your expertise and everything that you've learned from the experts of the families that you've worked with.

Dr. Casey Albin:
Absolutely. Thank you so much, Daniel for having me. I love that there's this platform that I hopefully, will inspire a lot of people to go in and have some decision-making discussions.

Dr. Daniel Correa:
Thank you again for joining us today on the Brain & Life podcast. Follow and subscribe to this podcast, so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life magazine for free at brainandlife.org. Don't forget about Brain & Life en Español.

Dr. Katy Peters:
Also, for each episode, you can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in an email to BLpodcast@brandandlife.org and leave us a message at 612-928-6206.

Dr. Daniel Correa:
You can also find that information in our show notes, and you can follow Katy and me and the Brain & Life magazine on any of your preferred social media channels.

Dr. Katy Peters:
And these episodes would not be possible without the Brain & Life podcast team.

Dr. Daniel Correa:
Including Nicole Lussier, our Senior Manager of Public Engagement.

Dr. Katy Peters:
Rachel Robertson, our Public Engagement Coordinator. And Twin Cities Sound, our audio editing partner.

Dr. Daniel Correa:
We are your hosts, Dr. Daniel Correa, connecting with you from New York City and online @NeuroDrCorrea.

Dr. Katy Peters:
And Dr. Katy Peters joining you from Durham, North Carolina and online @KatyPetersMDPhD.

Dr. Daniel Correa:
Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

Dr. Katy Peters:
We hope together we can take steps to better brain health and each thrive with our own abilities every day.

Dr. Daniel Correa:
Before you start the next episode, we would appreciate if you could give us five stars and leave a review. This helps others find the Brain & Life podcast. See you next week.

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