General Themes and Guidelines

The psychiatric consultant in the pediatric critical care setting needs to employ a variety of diagnostic, treatment, and consultation skills and can benefit from an eclectic approach. Due to the critical nature of patients' physical health and the overall ecology of crisis and trauma, the consultant is often under overt pressure to intervene quickly and effectively in a rapidly changing clinical situation (Colville 2001). Swift assessment skills and the ability to establish a therapeutic alliance are invaluable given these inherent pressures and constraints (Hazzard and Henderson 2004). Often, the consultant's mere arrival and calm, nonanxious presence can help to contain intense affect on the part of patients, families, and staff members alike and can have a de-escalating and soothing effect, underscoring the importance of prompt and responsive action following a referral (Meyer et al. 1996). Referral questions may be vague, often with limited information regarding psychosocial history (DeMaso and Meyer 1996), and the mental health consultant should prioritize assessment and interventions. A successful consultant addresses the immediate issues at hand, offers practical and feasible suggestions, models good communication and family-staff relationships, and fosters a climate of emotional safety and well-being. Written documentation is best when practical, focused, and succinct (Meyer et al. 1996).

By its nature, the PICU offers little privacy, and consultants must be flexible and creative about where, when, and how long to meet with patients and parents, balancing family members' wishes to remain at the bedside, the need for privacy, and the demands of critical care (DeMaso and Meyer 1996). The consultant should be vigilant to ensure that care delivery does not impinge on the ability of other staff to provide for critical medical needs (Small and Melnyk 2006). Given the emotional intensity of the PICU environment, the consultant may at times intuit the need to deviate from traditional boundary setting, anonymity, and neutrality (DeMaso and Meyer 1996).

Close interdisciplinary collaboration with other psychosocial care providers, including those in child life, social work, and chaplaincy, is invaluable, as are ongoing consultation and liaison with medical providers. Regularly scheduled psychosocial rounds may allow clinicians to "keep a finger on the pulse" of the unit, case find, and proactively address complex situations. Interdisciplinary collaboration can also be helpful in the context of highly complex ethical issues and decision making that often characterize the PICU environment (Colville 2001; Gill 2005).

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