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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Dear Editor&#44;</span><p id="par0005" class="elsevierStylePara elsevierViewall">A characteristic of Departments of Intensive Care Medicine that have a post-intensive care syndrome follow-up program is the testimony of the evaluated patients&#44; with the documentation of phrases such as&#58; &#8220;It was as if it weren&#8217;t me&#8221;&#44; &#8220;I thought I was living a series in which they were interacting with me&#8221;&#59; or &#8220;I was like an actor in a film&#44; in which a woman congratulated me on my way of acting&#8221;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Survivors of critical illness often suffer cognitive and psychiatric problems&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Depersonalization and derealization episodes such as those described can entail behavioral changes in the acute phase&#44; that can be interpreted as delirium and&#47;or leave psychological sequelae&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Many variables can contribute to these phenomena&#46; The structuring of most Intensive Care Units &#40;ICUs&#41; allows many patients to be visualized simultaneously&#44; but limits the visual field of the patients to the &#8220;control area&#8221;&#46; The patients do not perceive what is happening around them&#44; and this contributes to the sensation of being controlled&#44; as <span class="elsevierStyleItalic">Foucault</span> would say&#44; enhancing the feeling of invisible omniscience associated with derealization&#46; Monitoring&#44; usually not visible to the patient and involving acoustic alarms&#44; implies continued and frequent displacement of the healthcare staff inside and outside the visual range of the patient&#44; which can favor depersonalization&#46; Likewise&#44; the lack of familiarity with the environment&#44; communication difficulties and loneliness can activate feelings of sequestration and prejudice that in turn result in fear and loss of control and autonomy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thanks to <span class="elsevierStyleItalic">Wallon</span> and <span class="elsevierStyleItalic">Lacan</span>&#44; we know that mirrors are involved in human development&#44; favoring self-perception capacity by facilitating the integration of one&#8217;s own body image&#46; On examining the therapeutic utilities of mirrors&#44; we find that they have been employed in the patient rehabilitation setting to improve motor function following stroke&#44; with moderate evidence in favor of their use&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Mirrors have been postulated as a supporting tool in neurological evaluations&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and their effects have been studied in a sample of critically ill surgical patients&#44; with no conclusive results regarding the reduction of delirium&#44; though with the documentation of a lesser incidence of traumatic memories&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> A qualitative study in the ICU concluded that the use of mirrors could improve patient self-perception&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> No robust studies are available on the short and long-term psychological-psychiatric implications of the use of mirrors in critical patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Considering the above&#44; we hypothesize that the use of mirrors in the ICU could contribute to avoiding the abovementioned phenomena&#46; However&#44; we would like to open debate on their applicability&#58; What would be the right moment for introducing mirrors&#63; Who should apply them and to what patients&#63; Is patient autonomy respected&#63; Would it be an act of beneficence for all critical patients&#63; In the case of burn or facial trauma patients&#44; when would the principle of non-maleficence be considered&#63; Would consent be required&#44; or could a legal representative provide consent&#63;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We feel that mirrors may have a place in application to certain critical patients&#46; However&#44; there are not enough studies on their applicability in the ICU&#44; where their implantation could give rise to ethical considerations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have received no financial support in relation to the present study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Journal Information
Vol. 48. Issue 3.
Pages 183-184 (March 2024)
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466
Vol. 48. Issue 3.
Pages 183-184 (March 2024)
Letter to the Editor
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Use of mirrors in the critically ill patient admitted to the Intensive Care Unit, do they have a place?
Uso del espejo en el paciente crítico ingresado en la Unidad de Cuidados Intensivos, ¿tiene cabida?
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466
Kapil Laxman Nanwani Nanwania,b,c,
Corresponding author
kapilnanwani@gmail.com

Corresponding author.
, María Victoria Bonanb,c
a Servicio de Medicina Intensiva, Hospital Universitario La Paz, Madrid, Spain
b Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
c Servicio de Psiquiatría, Hospital Universitario La Paz, Madrid, Spain
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Dear Editor,

A characteristic of Departments of Intensive Care Medicine that have a post-intensive care syndrome follow-up program is the testimony of the evaluated patients, with the documentation of phrases such as: “It was as if it weren’t me”, “I thought I was living a series in which they were interacting with me”; or “I was like an actor in a film, in which a woman congratulated me on my way of acting”.

Survivors of critical illness often suffer cognitive and psychiatric problems.1 Depersonalization and derealization episodes such as those described can entail behavioral changes in the acute phase, that can be interpreted as delirium and/or leave psychological sequelae.

Many variables can contribute to these phenomena. The structuring of most Intensive Care Units (ICUs) allows many patients to be visualized simultaneously, but limits the visual field of the patients to the “control area”. The patients do not perceive what is happening around them, and this contributes to the sensation of being controlled, as Foucault would say, enhancing the feeling of invisible omniscience associated with derealization. Monitoring, usually not visible to the patient and involving acoustic alarms, implies continued and frequent displacement of the healthcare staff inside and outside the visual range of the patient, which can favor depersonalization. Likewise, the lack of familiarity with the environment, communication difficulties and loneliness can activate feelings of sequestration and prejudice that in turn result in fear and loss of control and autonomy.

Thanks to Wallon and Lacan, we know that mirrors are involved in human development, favoring self-perception capacity by facilitating the integration of one’s own body image. On examining the therapeutic utilities of mirrors, we find that they have been employed in the patient rehabilitation setting to improve motor function following stroke, with moderate evidence in favor of their use.2 Mirrors have been postulated as a supporting tool in neurological evaluations,3 and their effects have been studied in a sample of critically ill surgical patients, with no conclusive results regarding the reduction of delirium, though with the documentation of a lesser incidence of traumatic memories.4 A qualitative study in the ICU concluded that the use of mirrors could improve patient self-perception.5 No robust studies are available on the short and long-term psychological-psychiatric implications of the use of mirrors in critical patients.

Considering the above, we hypothesize that the use of mirrors in the ICU could contribute to avoiding the abovementioned phenomena. However, we would like to open debate on their applicability: What would be the right moment for introducing mirrors? Who should apply them and to what patients? Is patient autonomy respected? Would it be an act of beneficence for all critical patients? In the case of burn or facial trauma patients, when would the principle of non-maleficence be considered? Would consent be required, or could a legal representative provide consent?

We feel that mirrors may have a place in application to certain critical patients. However, there are not enough studies on their applicability in the ICU, where their implantation could give rise to ethical considerations.

Financial support

The authors declare that they have received no financial support in relation to the present study.

Conflicts of interest

The authors declare that they have no conflicts of interest.

References
[1]
K. Nanwani-Nanwani, L. López-Pérez, C. Giménez-Esparza, I. Ruiz-Barranco, E. Carrillo, M.S. Arellano, et al.
Prevalence of post-intensive care syndrome in mechanically ventilated patients with COVID-19.
[2]
H. Thieme, N. Morkisch, J. Mehrholz, M. Pohl, J. Behrens, B. Borgetto, et al.
Mirror therapy for improving motor function after stroke.
Cochrane Database of Syst Rev, 7 (2018),
[3]
A. Vanhaudenhuyse, C. Schnakers, S. Brédart, S. Laureys.
Assessment of visual pursuit in post-comatose states: use a mirror.
J Neurol Neurosurg Psychiatry, 79 (2008), pp. 223
[4]
K. Giraud, M. Pontin, L.D. Sharples, P. Fletcher, T. Dalgleish, A. Eden, et al.
Use of a structured mirrors intervention does not reduce delirium incidence but may improve factual memory encoding in cardiac surgical ICU patients aged over 70 years: a pilot time-cluster randomized controlled trial.
Front Aging Neurosci, 8 (2016), pp. 228
[5]
W.M. Freysteinson.
The use of mirrors in critical care nursing.
Crit Care Nurs Q, 32 (2009), pp. 89-93
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