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To describe 4-year mortality, patient-reported functional status and health-related quality of life (HRQoL) among ICU-treated COVID-19 ARDS patients, and to explore early factors associated with short- and long-term mortality as well as long-term recovery. Single-center retrospective\u2013prospective cohort study with structured 4-year telephone follow-up. 283 adults treated in the Temporary ICU Hospital in Zielona G\u00f3ra, Poland (December 2020\u2013July 2021). Follow-up interviews were completed in 81 of 157 confirmed 4-year survivors. Associations with 30-day mortality and late mortality (among 30-day survivors) were explored using multivariable logistic regression. Survivors completed a structured interview assessing HRQoL (EQ-5D-5\u00a0L\/EQ-VAS), dyspnoea severity assessed with the mMRC scale, functional status assessed with PCFS, fatigue, brief cognitive screening items, return to work, rehabilitation use, and financial burden. A cumulative post-ICU impairment score (0\u20136 domains) was constructed. Cost estimates were exploratory and based on public ICU reimbursement rates and patient-reported rehabilitation burden. Thirty-day mortality was 29.0%, and cumulative 4-year mortality was 45%. In adjusted analyses, older age and higher white blood cell count at ICU admission were associated with mortality endpoints (model discrimination up to AUC 0.86, depending on endpoint). Among 4-year survivors, 27.5% reported clinically relevant fatigue, 46.8% insomnia, and a substantial proportion reported persistent limitations across functional and EQ-5D domains. Rehabilitation was reported by 39% and was associated with lower QALY, likely reflecting greater baseline impairment. Median 4-year QALY was 3.7, varying significantly by fatigue, dyspnoea, return-to-work status, and subjective cognitive complaints. Among ICU-treated COVID-19 ARDS patients, long-term mortality remained high and many survivors reported persistent multidomain impairment years after discharge. These findings support structured post-ICU follow-up pathways and targeted rehabilitation and occupational support for long-COVID survivors.<\/jats:p>","DOI":"10.1038\/s41598-026-42341-1","type":"journal-article","created":{"date-parts":[[2026,3,1]],"date-time":"2026-03-01T07:45:00Z","timestamp":1772351100000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Four year mortality and quality of life after ICU treatment for COVID 19 related acute respiratory distress syndrome"],"prefix":"10.1038","volume":"16","author":[{"given":"Jacek","family":"Zawadzki","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jagoda","family":"Kania","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Magdalena","family":"Murkos","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dominika","family":"Zgo\u0142a","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna","family":"Noga","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pawe\u0142","family":"Nowak","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wiktoria","family":"Kuli\u0144ska","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Piotr","family":"Pawlik","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bartosz","family":"Kudli\u0144ski","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,3,1]]},"reference":[{"issue":"16","key":"42341_CR1","doi-asserted-by":"publisher","first-page":"1574","DOI":"10.1001\/jama.2020.5394","volume":"323","author":"G Grasselli","year":"2020","unstructured":"Grasselli, G., Pesenti, A. & Cecconi, M. 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This manuscript does not contain any individual-level identifiable data (including personal details, images, or videos). No identifiable patient quotations are included.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"Ethical approval for this study was obtained from the Bioethics Committee of the Regional Medical Chamber in Zielona G\u00f3ra, Poland (ref: 03\/165\/2021). The study comprised two components with different consent requirements. For the retrospective ICU-phase component, anonymized clinical and laboratory data were extracted from routine electronic medical records under an ethics-approved waiver of written informed consent, in accordance with applicable Polish regulations and GDPR provisions for research using de-identified retrospective data. 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