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When patients get into ICU and apply mechanical ventilation, they are treated continuously by applying nursing treatment in critical condition, covering assessment up to evaluation. For patients in ICU, mechanical ventilation is an effective medication to survive acute illnesses and increase survival rate. Nurses have their own role which is different from medical rehabilitation team in the process of pulmonary rehabilitation in patients with applied mechanical ventilation, one of which is by performing continuing care program. This research aims to find out how the perception of nurses, patients and families is, as well as to describe how the system in ICU is pertained to continuing care program in patients with applied mechanical ventilation by conducting in-depth interview with semi-structured interview guidance. The themes resulted from this research are: 1) The continuing care program in the implementation of pulmonary rehabilitation in hospitals has not run systematically well, 2) The nurses- perception of continuing care program has not fit the concept of continuing care, 3) Families need continuing care in pulmonary rehabilitation process in patients with mechanical ventilation. This research concludes that it is necessary to perform a continuing care program in hospitals, especially in patients with mechanical ventilation who are in the process of pulmonary rehabilitation, to get a synergy in treatment service.