Intensive Care Med (2005) 31:611–620
DOI 10.1007/s00134-005-2592-6
David W. Dowdy
Mark P. Eid
Artyom Sedrakyan
Pedro A. Mendez-Tellez
Peter J. Pronovost
Margaret S. Herridge
Dale M. Needham
Received: 11 November 2004
Accepted: 17 February 2005
Published online: 1 April 2005

Springer-Verlag 2005
D. W. Dowdy
Department of Epidemiology,
Johns Hopkins Bloomberg
School of Public Health,
Baltimore, MD, USA
A. Sedrakyan · P. J. Pronovost
Department of Health Policy
and Management,
Johns Hopkins Bloomberg School
of Public Health,
Baltimore, MD, USA
D. W. Dowdy · M. P. Eid
School of Medicine,
Johns Hopkins University,
Baltimore, MD, USA
P. A. Mendez-Tellez · P. J. Pronovost
Department of Anesthesiology
& Critical Care Medicine,
Johns Hopkins University,
Baltimore, MD, USA
P. J. Pronovost
Department of Surgery,
Johns Hopkins University,
Baltimore, MD, USA
D. M. Needham ())
Division of Pulmonary
& Critical Care Medicine,
Johns Hopkins University,
1830 E. Monument Street, 5th floor,
Baltimore, MD, 21205, USA
e-mail: dale.needham@utoronto.ca
M. S. Herridge
Interdepartmental Division
of Critical Care Medicine,
University of Toronto,
Toronto, Ontario, Canada
SYSTEMATIC REVIEW
Quality of life in adult survivors
of critical illness: A systematic review
of the literature
Abstract Objective: To determine tion, ICU survivors report lower QOL
how the quality of life (QOL) of in- prior to ICU admission. After hospi-
tensive care unit (ICU) survivors tal discharge, QOL in ICU survivors
compares with the general popula- improves but remains lower than
tion, changes over time, and is pre- general population levels. Age and
dicted by baseline characteristics. severity of illness are predictors of
Design: Systematic literature review physical functioning. This systematic
including MEDLINE, EMBASE, CI- review provides a general under-
NAHL and Cochrane Library. Eligi- standing of QOL following critical
ble studies measured QOL
30 days illness and can serve as a standard of
after ICU discharge using the Medi- comparison for QOL studies in spe-
cal Outcomes Study 36-item Short cific ICU subpopulations.
Form (SF-36), EuroQol-5D, Sickness
Impact Profile, or Nottingham Health Keywords Critical care · Critical
Profile in representative populations illness · Health status indicators ·
of adult ICU survivors. Disease-spe- Intensive care units · Outcome
cific studies were excluded. Mea- assessment (health care) · Quality
surements and results: Of 8,894 ci- of life
tations identified, 21 independent
studies with 7,320 patients were re-
viewed. Three of three studies found
that ICU survivors had significantly
lower QOL prior to admission than
did a matched general population.
During post-discharge follow-up,
ICU survivors had significantly lower
QOL scores than the general popu-
lation in each SF-36 domain (except
bodily pain) in at least four of seven
studies. Over 1–12 months of follow-
up, at least two of four studies found
clinically meaningful improvement in
each SF-36 domain except mental
health and general health perceptions.
A majority of studies found that age
and severity of illness predicted
physical functioning. Conclusions:
Compared with the general popula-
612
Introduction
As more patients survive critical illness, assessing quality
of life (QOL) among intensive care unit (ICU) survivors
has become a research priority [1, 2]. Despite a rapidly
growing body of literature, previous reviews of QOL in
ICU survivors have been descriptive [3–7] or method-
ological [8], and have not broadly synthesized research
findings. Specifically, there has been no systematic re-
view of how QOL in ICU survivors (1) compares with the
general population, (2) changes over time, and (3) is
predicted by baseline characteristics.
Ultimately, it is important to understand QOL in spe-
cific ICU subpopulations (e.g., acute respiratory distress
syndrome (ARDS) and severe sepsis) in order to assess
the impact of specific interventions on these patients [9].
To place this knowledge in context, however, an under-
standing of QOL among the general population of criti-
cally ill patients is needed as a standard against which to
compare outcomes in ICU subpopulations. Consequently,
in this systematic review, we studied QOL in patient
populations representative of all adult ICU survivors.
Methods
Search strategy
To identify studies eligible for the systematic review, we searched
Medline (1966–2004), EMBASE (1974–2004), CINAHL (1982–
2004), pre-CINAHL, and the Cochrane Library (2004, Issue 3) on
August 13, 2004. The following search strategy was used, with all
terms mapped to the appropriate MeSH/EMTREE subject headings
and “exploded”: (“quality of life” OR “health status indicators”)
AND (“intensive care units” OR “critical care” OR “critical illness”
OR “sepsis” OR “adult respiratory distress syndrome”). Sepsis and
ARDS were included in the strategy because one eligible study
identified before conducting the search was not captured using the
initial search terms. No limits regarding language or publication
type were applied. We also hand-searched personal files and the
reference lists of relevant review articles [3–8]. For all articles
included in the systematic review, we reviewed the reference lists
and conducted an Expanded Science Citation Index (ISI Web of
Knowledge, Thomson Corporation) search of publications citing
the articles.
Study selection
Two authors (D.W.D., M.P.E.) independently reviewed citations,
abstracts, and full articles to select eligible studies for review. All
citations selected by either author for abstract review were in-
cluded, and subsequent disagreement regarding eligibility was re-
solved by consensus. Agreement between the two reviewers was
calculated by percentage agreement and the kappa statistic. For all
foreign language articles, English translations of abstracts were
reviewed. Eligible articles written in German, French, and Spanish
were reviewed, in full, by a single author (D.W.D.). One potentially
eligible article written in Czech [10] was excluded without full-text
review.
Studies were selected for review if they met two inclusion
criteria: (1) study of a representative population of adult ICU sur-
vivors (defined as a population consisting entirely of medical and/
or surgical ICU patients
14 years old and representing a majority
of all patients with an ICU length of stay >24 h), and (2) mea-
surement of QOL
30 days after ICU discharge, using one of four
widely used instruments: Medical Outcomes Study 36-item Short
Form General Health Survey (SF-36) [11], EuroQol-5D (EQ-5D)
[12], Sickness Impact Profile (SIP) [13], or Nottingham Health
Profile (NHP) [14]. In order to minimize heterogeneity, studies
focusing on specific diseases (e.g., ARDS), treatments (e.g., par-
enteral nutrition), or conditions (e.g., length of stay >7 days) were
excluded.
Description of measurement instruments
SF-36, EQ-5D, SIP, and NHP are measures of health-related quality
of life commonly used in critical care research. Patrick’s Perceived
Quality of Life (PQOL) questionnaire [15] was excluded because it
measures qualitatively different QOL domains (e.g., family, com-
munity, leisure, help, income, and respect) than the four selected
instruments, thereby precluding a meaningful synthesis of results.
Other instruments, such as the Fernandez questionnaire [16], were
excluded because they lacked specific domains or because they
were used in
5 critical care studies, including studies of specific
subpopulations [3].
SF-36 [11] uses 36 items to measure eight QOL domains:
physical functioning, role limitations due to physical problems,
bodily pain, general health perceptions, energy/vitality, social
functioning, role limitations due to emotional problems, and mental
health. SIP [13] uses 136 questions to evaluate twelve QOL do-
mains: work, recreation, emotional behavior, alertness, home
management, sleep, body care, eating, ambulation, mobility, com-
munication, and social interaction. Both SF-36 and SIP allow cal-
culation of summary scores from their multiple domains: physical
and mental component scores for SF-36, and physical and psy-
chosocial summary scores for SIP. SF-36 and SIP have been
comprehensively validated in critically ill patients [17,18].
NHP [14] measures QOL with two parts. Part I evaluates sub-
jective functional status with 38 yes/no statements in six domains:
physical mobility, pain, sleep, energy, emotional reactions, and
social isolation. Part II is no longer recommended for use by its
developers, due to poor measurement properties, and is therefore
excluded from this review. EQ-5D [12] is a brief, two-part instru-
ment. The EQ-5D self-classifier is a five-item questionnaire that
elicits one of three responses (“no”, “some”, or “extreme”) for
problems with mobility, self-care, usual activities, pain/discomfort,
and anxiety/depression; the EQ-VAS assesses self-rated health
status using a single visual analogue scale (VAS) scored from 0 to
100. Although some studies [19,20] have examined limited aspects
of NHP validity, NHP and EQ-5D have not been comprehensively
validated for ICU patients.
Data extraction, synthesis, and study quality
For each eligible study, two authors (D.W.D., M.P.E.) indepen-
dently abstracted measures of study quality, baseline variables (age,
severity of illness, gender, ICU length of stay, and admission di-
agnosis), QOL instrument, method of administration, and QOL
outcomes in an unmasked manner [21] with differences resolved by
consensus.
Due to quantitative and qualitative heterogeneity in the re-
porting of QOL results, a quantitative synthesis was not possible.
We therefore summarized study results as either statistically sig-
nificant ( p <0.05) or nonsignificant. In addition, differences in SF-
36 scores of more than 5 points were reported as clinically mean-
ingful [11]; comparable measures of clinical meaning were not
available for the other instruments.

Fig. 1 Flow diagram of litera-
ture search results
We assessed study quality using four criteria adapted from the
United States Preventive Services Task Force [22]: (1) no sys-
tematic exclusion of >10% of the adult ICU population; (2) de-
scription of patients lost to follow-up and comparison with those
remaining in the study; (3) measurement and reporting of specific
QOL domains at baseline and follow-up; and (4) adjustment for
confounders—including age—by stratification, statistical adjust-
ment, or comparison with a matched population. Each criterion was
assessed independently without reporting an overall score. Quality
criteria were not used in decisions regarding inclusion or exclusion
of eligible studies.
Results
Search results and study characteristics
We identified 8,894 citations, of which 352 abstracts and
111 full-text publications were reviewed (Fig. 1). A total
of 26 reports (25 articles and one dissertation) describing
21 independent patient populations were eligible for the
review (Table 1). Reviewer agreement on selection of
eligible citations was 97.4% (kappa=0.71), and on selec-
613
tion of publications for final review was 99.0% (kap-
pa=0.97).
Of the 21 independent studies reviewed, five were
multicenter studies [17, 19, 25, 40,45]; 16 were conducted
in Europe [17, 19, 23,26–34,36–40, 45,46], three in the
United States [25, 43,44], one in Australia [35], and one
in Hong Kong [42]. Ten studies used SF-36, four used
EQ-5D, five used SIP, and two used NHP (Table 1).
Thirteen of 14 (93%) studies using SF-36 or EQ-5D were
published in 2000 or later, vs one of seven (14%) using
SIP or NHP. One study [33] had a mean patient age of 33,
while the mean or median age in all other studies ranged
from 45 to 65. Three studies (14%) had a mean ICU
length of stay >5 days [19, 26,40]. Nineteen studies (90%)
had a follow-up period ranging from 3–24 months, while
the remaining two studies had extended follow-up periods
of 6 years [24] and 12 years [33]. The median follow-up
time was 7 months. QOL was assessed at follow-up by
mailed survey in 16 studies, by telephone in three [26,
36,39], and by personal interview in two [28,37].
614

Table 1 Characteristics of studies measuring quality of life in Form General Health Survey, EQ-5D EuroQol-5D, SIP Sickness
adult ICU survivors (ICU intensive care unit, LOS intensive care Impact Profile, NHP Nottingham Health Profile, CABG coronary
unit length of stay, SF-36 Medical Outcomes Study 36-item Short artery bypass graft)
First author (year) Na Key exclusion criteria Patient age ICU LOS Follow-up
(years) b (days) b (months) c
SF-36
Pettila (2000) [23] 298 None 53 (16) 5 (6) 12, 72
and Kaarlola (2003) [24]
Kleinpell (2003) [25] 199 <45 years old; LOS <24 h >45 yearsd 3 (3) 1, 3, 6, 12
Wehler (2003) [26] 171 LOS 24 h 57 (17) 11 (19) 6
Graf (2003) [27] 164 Delirious/comatose; 64 (13) – 1, 9
LOS <24 h
Eddleston (2000) [28] 136 None 49 (12) 4 (1–13) 3
Kvale (2003) [29,30] 126 LOS 24 h 52 (16) 3 (mean) 6, 24
Vedio (2000) [31] 115 Overnight stay 65 (56–70) 2 (1–4) 6
Ridley (1997) [32] 95 “Precipitous” discharge 62 (mean) 1 (1–1) 6
Flaaten (2001) [33] 51 Cardiac surgery 33 (22) 5 (7) 12 years
and Kvale (2002) [34]
Chaboyer (2002) [35] 16 No family proxy 61 (18) 3 (4) 6, 12
EQ-5D
Badia (2001) [36] 334 Proxy not available; 57 (44–65) 5 (3–16) 12
LOS <12 h
Granja (2002) [37] 275 LOS <24 h [37] 57 (median) 2 (median) 6
and Granja (2004) [38]
Garcia Lizana (2003) [39] 96 Uncomplicated 60 (42–75) 3 (3–6) 18
elective surgery
Sznajder (2001) [40] 64 None 55 (20) 8 (11) 6
SIP
Tian (1995) [17] 3,655 LOS <24 h 60 (15) 3 (4) 6
and Miranda (1994) [41]
Short (1999) [42] 853 None 45 (32–62) 2 (1–4) 12
Kleinpell (1991) [43] 164 <45 years old >45 yearse 4 (6) 7
Sage (1986) [44] 140 CABG patients 56 (mean) 4 (mean) 15
Frick (2002) [45] 85 None 65 (median) 2 (median) 6
NHP
Hurel (1997) [19] 223 None 52 (18) 9 (10) 6
Bell (1994) [46] 60 Transferred elsewhere 54 (mean) 3 (mean) 3
a
Sample size at first follow-up visit after hospital discharge
b
Data are reported as median (interquartile range) or mean (standard deviation) if not specified.
c
Length of time from ICU or hospital discharge until quality of life measurement
d
53% of patients were 45–64 years old, and 47% were 65–86 years old.
e
22% were 45–64 years old, 46% were 65–79, and 32% were
80 years old.

Assessment of study quality
A majority of the studies met each of the four quality
criteria (Table 2). However, pre-admission QOL domains
were measured in only five studies (24%). Four studies
excluded >10% of the eligible adult ICU population;
these exclusions were based on age <45 years [25,43] and
cardiac surgery status [33,44]. Two studies [42,44] re-
ported only a summary QOL measure, instead of specific
domains. Agreement on assessment of study quality was
93.0% (kappa=0.85).
Comparing quality of life in ICU survivors versus
the general population
Seven studies [23, 24, 26, 27,31–33] compared QOL in
ICU survivors versus a matched general population (Ta-
ble 3). All studies used the SF-36 survey. Three of these
studies retrospectively examined QOL prior to ICU ad-
mission, with each study reporting statistically significant
( p <0.05) and clinically meaningful (>5 points) decre-
ments in all eight QOL domains.
QOL was measured at 6 months to 14 years after ICU
admission in eight patient populations (Table 3). For each
domain, except bodily pain, a majority of populations
reported significant and meaningful decrements in QOL
versus the general population. For bodily pain, a clinically
meaningful decrement was observed in four populations
(50%), but this finding was statistically significant in only
one study (14%). Compared with the general population,
no study reported a statistically significant or clinically
meaningful increase in any QOL domain among its
complete population of ICU survivors.
 615

Table 2 Assessment of study Source No major Losses Specific QOL domains Adjusted
methods and reporting for exclusion to follow-up measured for age
quality of life in adult ICU criteriaa described and gender
survivors (ICU intensive care Pre-ICU Post-ICU
unit, QOL quality of life, SF-36
Medical Outcomes Study 36- SF-36 p p p p
item Short Form General Health Pettila [23] p –p p p
Survey, EQ-5D EuroQol-5D, Kleinpell [25] p– p p p
SIP Sickness Impact Profile, Wehler [26] p p– p p
NHP Nottingham Health Pro- Graf [27] p p p p–
file) Eddleston [28] p p – p
Kvale [29] p p – p p–
Vedio [31] p –
p p p
Ridley [32] p– p p
Flaaten [33] p– – p
Chaboyer [35] – – –
EQ-5D p p p
Badia [36] p p– p p–
Granja [37] p p – p
Garcia Lizana [39] p – p p–
Sznajder [40] – –
SIP p p p
Tian [17] p p – p–
Short [42] p – p– p
Kleinpell [43] – p –
Sage [44] p– – p– –
Frick [45] – – –
NHP p p p
Hurel [19] p p– – p
Bell [46] – –
Total 17 14 5 19 12
(of 21 studies)
a
Defined as systematic exclusion of >10% of the adult ICU population with a length of stay >24 h

Table 3 Quality of life measurements in adult ICU survivors versus age- and gender-matched general population (ICU intensive care unit,
QOL quality of life)
Source Na Follow-up Physical QOL domainsc Mental QOL domainsc
timeb
Physical Role Bodily General Vitality Social Role emo- Mental
function physical pain health function tional health
Studies of QOL prior to ICU admissiond
Wehler [26] 318 – #* #* #* #* #* #* #* #*
Graf [27] 153 – #* #* #* #* #* #* #* #*
Ridley [32] e 75 – #* #* #* #* #* #* #* #*
Studies of QOL after ICU stay
Wehler [26] 171 6 months #* #* – #* #* #* #* #*
Ridley [32] e 75 6 months #* #* #* #* #* #* #* #*
Vedio [31] f
Elective 66 6 months – #* " – – – – –
Emergency 49 6 months #* #* # – #* #* – #*
Graf [27] 153 9 months #* #* – #* #* #* #* #*
Pettila [23] 298 12 months #* #* # #* #* # #* #
g
Kaarlola [24] 169 6 years # # – # – – – –
Flaatten [33] 51 13–14 years #* #* # #* # #* #* #*
a
Sample size at the time of follow-up
b
Length of time from ICU or hospital discharge until quality of life measurement
c
#/" clinically meaningful (i.e., >5-point) decrement/improvement in quality of life; #*clinically meaningful and statistically significant
(p<0.05) decrement in quality of life; – non-clinically meaningful (i.e., 5-point) change in quality of life
d
QOL prior to ICU admission was measured retrospectively from patient or proxy.
e
Includes only patients <65 years old
f
Separately analyzed patients with emergency and elective diagnoses on ICU admission
g
The study population in [24] is a subset of that in [23]. No measure of significance was reported in [24].
616

a
Table 4 Change in quality of life from baseline for adult ICU survivors ( ICU intensive care unit, QOL quality of life)
b
Domain Follow-up time
1 month 6 months 9 months 12 months
Kleinpell [25] Graf [27] Kleinpell [25] Wehler [26] Ridley [32] Graf [27] Kleinpell [25]
Physical domains
Physical functioning "* "* "* – – "* "*
Role – physical #* #* " " – "* "*
Bodily pain – "* " – "* "* "
General health – – – – – – –
Mental domains
Vitality – – " – "* "* "
Social functioning – # "* "* "* – "*
Role – emotional – #* " "* – – "
Mental health – "* – – – "* –
a
Baseline measurements were obtained retrospectively by interview with patient [25–27, 32] or proxy [25, 26,32]. Follow-up times are
from ICU or hospital discharge.
b
"/#clinically meaningful (i.e., >5-point) improvement/decline in quality of life; "*/#*clinically meaningful and statistically significant
(p<0.05) improvement/decline in quality of life; – non-clinically meaningful (i.e., 5-point) change in quality of life. All quality of life
measurements at follow-up are compared against baseline.

Table 5 Predictors of quality of life using SF-36 ( SF-36 Medical Failure Assessment, APACHE Acute Physiology and Chronic
Outcomes Study 36-item Short Form General Health Survey, ICU Health Evaluation, SAPS Simplified Acute Physiologic Score)
intensive care unit, QOL quality of life, SOFA Sequential Organ
Source Follow- Measure Physical QOL domainsb Mental QOL domainsb
Upa
Physical Role Bodily General Vitality Social Role Mental
function physical pain health function emotional health
Age
Eddleston [28] 3 months >65 vs. 65 years * – – – – – – –
of age
Kleinpell [25] 6 months
65 vs. <65 years – – – – – – – –
of age
Wehler [26] 6 months 4 strata of age * * * * * * – –
Graf [27] 9 months
66 vs. <66 years * – – – – – – –
of age
Pettila [23] 12 months Agec * * * * * – * –
Severity of Illness
c
Kleinpell [25] 6 months APACHE III * – – * – – – –
Wehler [26] 6 months SOFA
6 vs. <6 * – – * – – – –
Vedio [31] 6 months “Chronic * – – * * – – –
problem” on
APACHE II
Graf [27] 9 months SAPS II and – – – – – – – –
SOFAc, d
Pettila [23] 12 months SOFA
6 vs. <6 * * * * * * * *
Kvale [29] 24 months SAPS IIc – – – – – – – –
a
Length of time from ICU or hospital discharge until quality of life measurement
b
*Statistically significant ( p <0.05) decrease in quality of life with increase in age or severity of illness; – No statistically significant
change in quality of life ( p >0.05)
c
Measured as a continuous variable
d
Both measures were independently studied, and neither showed a significant association.

Changes in quality of life over time
Five studies compared QOL at follow-up with pre-ad-
mission baseline QOL measured retrospectively. Four of
these studies [25, 26, 32,36] used proxies to obtain
baseline QOL for patients who were unable to respond,
and one study [27] excluded such patients. Four studies
used the SF-36 survey (Table 4). Social functioning and
role performance due to both physical and emotional
problems showed clinically meaningful decreases from
baseline at 1-month follow-up, but clinically meaningful
increases from baseline at 6 months and 12 months. Vi-
 617

Table 6 Predictors of quality of life using EuroQol-5D and SIP ( subscore, Psych psychosocial subscore, APACHE Acute Physiolo-
SIP Sickness Impact Profile, NHP Nottingham Health Profile, ICU gy and Chronic Health Evaluation, SAPS Simplified Acute Physi-
intensive care unit, Activ. activities, Pain pain/discomfort, Anx. ologic Score)
Depr. anxiety/depression, VAS visual analogue scale, Phys physical
Source Measure Follow- EuroQol-5Db SIPb
Upa
Mobility Self Usual Pain Anx. VAS Phys Psych Total
Care Activ. Depr.
Age
Granja [37] Agec 6 months * * * * – * – – –
Garcia [39] Agec 18 months – – * – – – – – –
Tian [17] 6 strata of age 6 months – – – – – – * – *
Kleinpell [43] 3 strata of age 7 months – – – – – – * – *
Short [42] 3 strata of age 12 months – – – – – – – – *
Sage [44] 3 strata of age 15 months – – – – – – – – *
Severity of Illness
Granja [37] APACHE IIc 6 months * * * – – * – – –
Garcia [39] APACHE IIc 18 months – – * – * – – – –
Tian [17] APACHE IIc 6 months – – – – – – – – –
Kleinpell [43] APACHE IIc 7 months – – – – – – – – –
Short [42] APACHE II 12 months – – – – – – – – *
(4 strata)
Sage [44] APACHE IIc 15 months – – – – – – – – –
a
Length of time from ICU or hospital discharge until quality of life measurement
b
* Statistically significant ( p <0.05) decrease in quality of life with increase in age or severity of illness; – no statistically significant
change in quality of life ( p >0.05)
c
Measured as a continuous variable

tality also showed clinically meaningful improvement
between 1 and 6 months, between 1 and 9 months, and
between 1 and 12 months follow-up [25,27]. For both
physical functioning and bodily pain, clinically mean-
ingful improvement from baseline was observed by
1 month and seen throughout follow-up in five of seven
measurements. Only one study [26] showed a clinically
meaningful change in mental health, and no study showed
a meaningful change in general health perceptions.
Using EQ-5D to measure change in QOL from base-
line to 12 months after ICU discharge, Badia et al. [36]
found a significant increase in mobility, significant de-
creases in self-care and usual activities, and no significant
change in pain/discomfort, anxiety/depression, or the vi-
sual analogue scale.
Predictors of quality of life
Seventeen studies investigated associations of patient age,
severity of illness, admission type, gender, or ICU length
of stay with QOL in ICU survivors. Regarding age, a
majority of studies found significantly lower physical
functioning (SF-36, Table 5), usual activities (EQ-5D,
Table 6), and physical or total QOL (SIP, Table 6) in
older versus younger ICU survivors. No study found a
significant association between age and mental health
(SF-36), anxiety/depression (EQ-5D) or psychosocial
QOL (SIP).
Of six studies investigating severity of illness and
QOL measured by SF-36, four (67%) found a significant
association between severity of illness and lower physical
functioning or general health perceptions (Table 5).
Similarly, both EQ-5D studies measuring usual activities
and the one study measuring EQ-VAS found significant
associations in these domains with severity of illness
(Table 6). There was no significant association of severity
of illness with the total QOL score in three of four studies
using SIP (Table 6) and one study using NHP [38].
Five studies [19, 29, 36, 42,46] examined QOL in ICU
survivors with medical versus surgical diagnoses. Only
one study [19] found a significant difference in more than
one QOL domain. In patients surviving trauma, three
studies (100%) [36, 37,39] demonstrated significantly
worse pain/discomfort on EQ-5D, compared with other
ICU survivors, at 6–18 months after discharge.
Six studies [19, 31, 36, 37, 42,44] evaluated survivors
of elective versus emergency surgical procedures. At 6–
18 months after ICU discharge, three studies [19, 42,44]
found no significant association between surgical status
and overall QOL, and two [31,37] found that emergency
surgical patients had significantly worse quality of life in
a minority of domains. Two studies [31,36] evaluated
changes in QOL over time. Badia et al. [36] observed
significant improvements from baseline to 12 months in
four of five EQ-5D domains (mobility, usual activities,
pain/discomfort, and anxiety/depression) among sched-
uled, but not unscheduled, surgical patients. Similarly,
Vedio et al. [31] found that 76% of elective, vs. 31% of
emergency, surgical patients reported an improved QOL
from baseline after 6-months follow-up.
618
Of nine studies investigating associations between
QOL and gender, only two studies [26,39] found a sig-
nificant association of gender with any domain. Of eight
studies investigating ICU length of stay, only one [23]
found a significant association with any QOL domain.
Discussion
This systematic review of quality of life in 7,320 adult
ICU survivors has three major findings. First, compared
with the general population, ICU survivors have lower
QOL for all domains (except bodily pain) at baseline and
at 6 months to 14 years after discharge. Second, QOL in
ICU survivors improves with over time after discharge,
but this improvement is not uniform across domains. At
6–12 months, clinically meaningful improvements from
pre-admission baseline occur in six SF-36 domains;
however, general health perceptions and mental health do
not consistently demonstrate any clinically meaningful
difference from baseline. Third, regarding predictors of
QOL, older age and increased severity of illness may be
associated with poorer physical function and general
health perceptions (severity of illness only), but are not
consistently associated with decrements in other QOL
domains. Lower QOL at baseline may explain this find-
ing. Wehler et al. [26] found that older patients, compared
with younger patients, did not have a significantly worse
change in QOL after discharge. Patient gender, ICU
length of stay, and medical versus surgical diagnosis do
not appear to be important predictors of QOL. Survival
after trauma is associated with worse pain/discomfort, and
elective surgical patients are more likely than emergency
patients to improve their QOL from pre-admission values.
Similarly, one excluded study of patients with prolonged
ICU stay [47] found QOL at 6 months post-discharge to
be lowest in respiratory and trauma patients and highest in
patients undergoing cardiac surgery.
Our finding of high study quality contrasts with Hey-
land et al.’s previous methodologic assessment [8].
However, we restricted our analysis to four specific QOL
instruments and used different quality assessment criteria.
In their review, Heyland et al. [8] noted that few QOL
instruments have been adequately validated in ICU pop-
ulations; this remains true of EQ-5D and NHP, and rep-
resents an important focus for future methodologic re-
search.
This systematic review has a number of methodologic
limitations. First, in order to reduce heterogeneity be-
tween studies, we excluded QOL studies that examined
only specific subsets of ICU survivors. QOL outcomes in
these subsets may differ in important ways from general
ICU populations [19]. Thus, this systematic review cannot
provide a comprehensive picture of QOL in all patient
groups. However, this review does provide a general
understanding of QOL after critical illness and serves as a
foundation for comparison with future reviews of QOL in
specific ICU patient subsets.
Second, in this review, we evaluated only four QOL
instruments commonly used in critical care research. The
exclusion of Patrick’s PQOL [15] and other instruments
reduces the comprehensiveness of this review. However,
our selection of QOL instruments allowed for greater
comparability and more meaningful synthesis of study
findings than would have been possible under a more
comprehensive review. Standardizing the instrument(s)
used for QOL assessment in critical care research would
enable more effective comparison between studies [1].
Third, scores for some QOL domains reflect a greater
number of survey items, and are thus more precise, than
other domains. For example, on SF-36, physical func-
tioning reflects ten items, whereas social functioning re-
flects two items. A 5-point difference on the latter domain
may therefore be less meaningful than a 5-point differ-
ence on the former. However, our findings generally ad-
dressed the most precise domains (i.e., physical func-
tioning, mental health, and general health perceptions on
SF-36). Thus, we believe that our synthesized findings do
not simply reflect precision differences between QOL
domains. We caution, however, that distribution-based
measures, such as statistical significance and 5-point
change, are problematic in translating QOL changes into
clinically meaningful terms [48]. Validation of instru-
ments with anchor-based methods in ICU populations is
required to assist in making inference regarding clinically
meaningful changes [48].
In addition to methodological concerns, our findings
are limited by the infrequent collection of baseline data
and inconsistent reporting methods among reviewed
studies. Only five studies [25–27, 32,36] examined QOL
prior to ICU admission, and each demonstrated marked
impairments in baseline QOL compared with the general
population. As a result, it is difficult to determine whether
QOL decrements at follow-up reflect the impact of criti-
cal illness or simply a lower baseline QOL. Baseline QOL
measurement is needed to control for preexisting im-
pairment, but is difficult to perform since it must be ob-
tained retrospectively from the ICU survivor (subject to
recall bias) or from his/her proxy (subject to measurement
error). Prior studies [49,50] have found fair to good
agreement between proxy and patient responses on the
SF-36. Further research comparing methods of estimating
baseline QOL is needed to assist with future study design.
Due to inconsistent reporting methods, we were unable
to quantitatively synthesize results. QOL scores, even
from the same instrument, were reported in a heteroge-
neous fashion (e.g., absolute scores, z -scores, semi-
quantitative figures). Standardization of reporting meth-
ods for QOL scores, specifically reporting the mean score
and standard deviation for each domain, would allow
improved comparison and synthesis of study findings.
 619

In conclusion, our systematic review of 21 studies
involving 7,320 patients demonstrates that ICU survivors
report a lower baseline (pre-admission) quality of life that
improves over time in most domains, but remains lower
than general population levels throughout long-term fol-
low-up. In particular, physical functioning shows rapid
improvement and is associated with patient age and
severity of illness, whereas mental health shows no im-
provement and is independent of baseline characteristics.
This synthesis provides a general understanding of quality
of life following critical illness and can serve as a stan-
dard of comparison for QOL studies in specific ICU
subpopulations.
Acknowledgements This research is supported by the National
Institutes of Health (ALI SCCOR Grant # P050 HL 73994–01). Dr.
Needham is supported by Clinician-Scientist Awards from the
Canadian Institutes of Health Research and the University of
Toronto, and a Detweiler Fellowship from the Royal College of
Physicians and Surgeons of Canada

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