Returning to work following critical illness: milestone or millstone?

Abstract

The journey of survivorship for patients following critical illness is often lengthy, complex and characterised by an individualised spectrum of multidomain impairment. Returning to work may be viewed as an important landmark for patients in their recovery journey, a metric of success that distinguishes those patients recovering sufficiently ‘well’ from those in whom continued restorative rehabilitation is required. For many of us, our jobs, our professional roles or trades, are closely linked to our sense of selfidentity and responsibility within our families and society. Work can provide a feeling of purpose, motivation, and value, as well as being a financial necessity, and for patients successfully returning to work following critical illness, a sense of being ‘back to normal’ may resonate. Conceptually, return to work (RTW) is a marker of societal participation, involvement in a ‘life situation’. However, for many patients, the persistent legacy of physical, cognitive, psychological, and other sequelae associated with their critical illness experience represents such a burden of disability, that returning to work feels like, and often is, a distant and unachievable task. Less a milestone indicating onward progression along the survivorship road, and more like the proverbial millstone, weighing heavily as another indicator that the life before critical illness is far removed from the life that exists after. Certainly, data from recent years bear witness to this scenario. Prevalence of RTW in previously employed survivors of critical illness ranges from 36% (95% CI 23% to 49%) at 1–3 months following hospitalisation, to 68% (95% CI 51% to 85%) at 42–60 months. Other pooled data suggest the proportion of employment at 5 years may be even lower, at less than half of the patients (44%, 95% CI 0.25 to 0.76). Influencing RTW include critical illnessrelated, postcritical illness impairmentrelated, and socioeconomic factors, as well as extent of disability support policies. Broader fiscal consequences of failure to RTW can be profound for both patients and families/caregivers—loss of earnings, reliance on savings, the need to borrow money or seek charitable aid, refinancing property to pay for care, seeking new or increased state support benefits, greater caring responsibilities in turn leading to reduced working opportunity (either fewer hours, taking longterm leave or leaving employment completely) and associated financial toxicity. 6 These consequences need to be particularly considered in the context of different higherincome and lowerincome countries, where sociopolitical factors can further exacerbate conditions. That these circumstances negatively affect psychosocial health and wellbeing for both patients and families/caregivers is unsurprising. Even where RTW is possible for survivors, this may fail to resemble preillness employment in terms of nature, status, and/or permanency. 4 6 Su and colleagues further our understanding of RTW in survivors of acute respiratory distress syndrome (ARDS) by exploring the association of imbalance between job workload and functional ability with RTW. Patients from a prospective multicentre cohort study who were in fulltime or parttime employment preillness, and who survived to 6 (n=341) and 12 (n=301) months with complete followup employment and functional ability outcome data, were included. Cognitive, emotional, interpersonal, and physical workloads of survivors’ preARDS employment were estimated by matching their job title to a validated national database (the Occupational Information Network (O*NET)). Occupations listed in O*NET are measured by descriptors rating specific domains, for example, knowledge, skills, abilities on a scale of 1–5, where higher scores are more important for that particular occupation, and recommended thresholds of ≤2 and >2 for low and high workloads, respectively, were adopted. Cognitive, emotional, interpersonal and physical functional abilities were measured using the MiniMental State Exam (scores of <24 indicating impairment) and the Short Form-36 Survey mental health, social functioning and physical function subscales, respectively (normalised scores of ≤40 indicating impairment). Imbalance in work ability was described as an ARDS survivor whose job had high workload demands but with low individual functional ability in that area. Cognitive, emotional and interpersonal imbalances were further collapsed into ‘psychosocial’ imbalance (defined as ≥1 imbalance in the three areas), resulting in four categories of imbalance in work ability: (1) no imbalance, (2) psychosocial alone, (3) physical alone and (4) both physical and psychosocial. Key findings from the authors include that 88% (n=152 and n=144, respectively) of patients who had RTW at 6 and 12 months had physical or psychosocial imbalance in work ability, those with both physical and psychosocial imbalances in work ability had a decreased adjusted odds of RTW at 6 and 12 months, and that of the 202 survivors who ever had RTW during the first years postARDS, nearly 20% were unable to sustain this RTW to 12 months, with onethird demonstrating an imbalance in both physical and psychosocial work ability at followup. These data speak to the challenges of managing RTW in survivors of critical illness. First, it is postcritical illness impairment that may matter more than preillness job characteristics (previous data from the same authors show that workload prior to ARDS does not influence RTW). Second, it is multidomain, rather than singular, impairment that is adverse to a RTW outcome (individual imbalances in physical or psychosocial work ability did not influence RTW). Third, how much postcritical illness impairment is sufficiently modifiable to facilitate RTW (around half of patients in the current dataset had not RTW by 6 and 12 months). Vocational rehabilitation interventions—strategies that support individuals with health conditions to stay at, return to, and remain in, work—may provide the holistic, multiprofessional, and individualised approach to managing RTW in survivors of illness that is required to address these challenges. Already there are examples of how these complex interventions could be beneficial in an outpatient setting, although there is a pressing need for greater research in this space that also considers factors such as healthcare jurisdiction and available social support infrastructure (which may differ internationally and according to income status), WellcomeWolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia Lane Fox Respiratory Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Centre for Human & Applied Physiological Sciences, King’s College London, London, UK