Posttraumatic stress and complicated grief in family members of patients in the intensive care unit

Gastrointestinal complications requiring operative intervention after cardiovascular surgery: Predictors of in-hospital mortality

BACKGROUND

Risk factors for in-hospital mortality related to gastrointestinal complications requiring operative intervention after cardiovascular surgery have not been previously described.

METHODS

Adult patients who underwent cardiovascular surgery followed by gastrointestinal surgery during the same admission between January 2010 and June 2023 were included. Multivariable logistic regression was used to identify predictors of in-hospital mortality. Kaplan-Meier survival analysis was performed to assess overall survival based on identified risk factors.

RESULTS

Gastrointestinal complications requiring operative intervention after cardiac surgery occurred in 151 patients, with an overall in-hospital mortality of 35.76% (n = 54). The most common diagnosis was bowel ischemia (50.33%). On multivariable logistic regression, the history of cirrhosis (odds ratio: 37.96, 95% confidence interval: 3.57-543.90) and the clinical condition at the time of emergency general surgery consultation, described by elevated lactate (odds ratio: 5.76, 95% confidence interval: 1.71-22.82), platelets <50 × 109/L (odds ratio: 11.34, 95% confidence interval: 1.60-162.37), ≥3 vasoactive medications (odds ratio: 4.93, 95% CI: 1.29-20.14), and the need for renal replacement therapy (odds ratio: 5.18, 95% confidence interval: 1.46-20.79) were predictive of in-hospital mortality. In-hospital mortality was low when none of the risk factors identified on multivariable analysis were present (2.38%, n = 1 of 42), but in-hospital mortality was universal among patients with 4-5 risk factors (100%, n = 8 of 8).

CONCLUSIONS

Gastrointestinal complications after cardiac surgery are disastrous when patient illness becomes severe. Clinicians should maintain a high index of suspicion for gastrointestinal complications to promote early involvement of general surgery. Knowledge of these risk factors could help guide discussions among the multidisciplinary care team, patients, and their families.

Post-Intensive Care Syndrome Family

Family members of patients admitted to intensive care units often experience psychological distress, including depression, anxiety, and trauma symptoms, known as post-intensive care syndrome-family (PICS-F), due to the stress from having a critically ill loved one and resultant caregiver burden. Awareness of this syndrome is needed, as are prevention and management strategies, to improve outcomes.

Clinical Comparison of Post-intensive Care Syndrome and Long Coronavirus Disease

Post-intensive care syndrome (PICS) encompasses persistent physical, psychological, and cognitive impairments. The coronavirus disease of 2019 (COVID-19) pandemic highlighted parallels between PICS and "long COVID". There is an overlap between the 2 in risk factors, symptoms, and pathophysiology. Physical impairments in both include weakness and fatigue. Cognitive impairments include executive dysfunction in PICS and "brain fog" in long COVID. Mental health issues consist of depression, anxiety, and posttraumatic stress disorder in both disease states. Long COVID and PICS impact families, with multifaceted effects on physical health, mental well-being, and socioeconomic stability. Understanding these syndromes is crucial for comprehensive patient care and family support.

Medical Decision-Making and Bereavement Experiences After Cardiac Arrest: Qualitative Insights From Surrogates

BACKGROUND

Surrogates of incapacitated patients in the intensive care unit (ICU) face decisions related to life-sustaining treatments. Decisional conflict is understudied.

OBJECTIVES

To compare experiences of ICU surrogates by reported level of decisional conflict related to treatment decisions after a patient's cardiac arrest preceding death.

METHODS

Convergent mixed methods were used. Bereaved surrogates recruited from a single northeastern US academic medical center completed surveys including the low-literacy Decisional Conflict Scale (moderate-to-high cut point >25) and individual interviews about 1 month after the patient's death. Interview data were analyzed by directed and conventional content analysis. Surrogates were stratified by median total survey score, and interview findings were compared by decisional conflict level.

RESULTS

Of 16 surrogates, 7 reported some decisional conflict (median survey score, 0; range, 0-25). About two-thirds decided to withdraw treatments. Three themes emerged from interviews: 2 reflecting decision-making experiences ("the ultimate act"; "the legacy of clinician communication") and 1 reflecting bereavement experiences ("I wish there was a handbook"). Surrogates reporting decisional conflict included those who first pursued but later withdrew treatments after a patient's in-hospital cardiac arrest. Surrogates with decisional conflict described suboptimal support, poor medical understanding, and lack of clarity about patients' treatment preferences.

CONCLUSIONS

These findings provide insight into bereaved ICU surrogates' experiences. The low overall survey scores may reflect retrospective measurement. Surrogates who pursued treatment were underrepresented. Novel approaches to support bereaved surrogates are warranted.

Anxiety and depression following critical illness: A comparison of the recovery trajectories of patients and caregivers

BACKGROUND

Following critical illness, family members are often required to adopt caregiving responsibilities. Anxiety and depression are common long term problems for both patients and caregivers. However, at present, it is not known how the trajectories of these symptoms compare between patients and caregivers.

OBJECTIVES

The aim of this study was to investigate and compare the trajectories of anxiety and depression in patients and caregivers in the first year following critical illness.

METHODS

This study analyses data from a prospective multicentre cohort study of patients and caregivers who underwent a complex recovery intervention following critical illness. Paired patients and caregivers were recruited. The Hospital Anxiety and Depression Scale was used to evaluate symptoms of anxiety and depression at three timepoints: baseline; 3 months; and 12 months in both patient and caregivers. A linear mixed-effects regression model was used to evaluate the trajectories of these symptoms over the first year following critical illness.

RESULTS

115 paired patients and caregivers, who received the complex recovery intervention, were recruited. There was no significant difference in the relative trajectory of depressive symptoms between patients and caregivers in the first 12 months following critical illness (p = 0.08). There was, however, a significant difference in the trajectory of anxiety symptoms between patients and caregivers during this time period (p = 0.04), with caregivers seeing reduced resolution of symptoms in comparison to patients.

CONCLUSIONS

Following critical illness, symptoms of anxiety and depression are common in both patients and caregivers. The trajectory of symptoms of depression was similar between caregivers and patients; however, there was a significantly different recovery trajectory in symptoms of anxiety. Further research is required to understand the recovery pathway of caregivers in order to design effective interventions.

Grief and coping among relatives of patients who died of COVID-19 in intensive care during the height of the COVID-19 pandemic

BACKGROUND

The grief of relatives of patients who died of COVID-19 in an intensive care unit (ICU) has exacted an enormous toll worldwide.

AIMS

To determine the prevalence of probable prolonged grief disorder (PGD) at 12 months post-loss and beyond. We also sought to examine circumstances of the death during the COVID-19 pandemic that might pose a heightened risk of PGD, and the associations between probable PGD diagnosis, quality of life and social disconnection.

METHOD

We conducted an observational, cross-sectional multicentre study of the next of kin of those who died of COVID-19 between March 2020 and December 2021. Participants were recruited from ICUs in South-East London. The Prolonged Grief Disorder Scale (PG-13-R), Quality-of-Life Scale (QOLS) and Oxford Grief-Social Disconnection Scale (OG-SD) were used.

RESULTS

A total of 73 relatives were recruited and assessed, all of them over a year after their loss. Twenty-five (34.2%; 95% CI 23.1-45.4%) relatives of patients who died in the ICU met the criteria for PGD. Those who met the criteria had significantly worse quality of life (QOLS score mean difference 26; 95% CI 17-34; P < 0.001) and endorsed greater social disconnection (OG-SD score means difference 41; 95% CI 27-54; P < 0.001).

CONCLUSIONS

The findings suggest that rates of PGD are elevated among relatives of patients who died of COVID-19 in the ICU. This, coupled with worse quality of life and greater social disconnection experienced by those meeting the criteria, suggests the need to attend to the social deprivations and social dysfunctions of this population group.

Associations between Post-Intensive Care Syndrome Domains in Cardiac Arrest Survivors and Their Families One Month Post-Event

Background: Post-intensive care syndrome (PICS) affects many critical care survivors and family members. Nevertheless, the relationship between PICS-relevant domains in cardiac arrest (CA) survivors and psychological distress in their family members (henceforth, PICS-F) remains underexplored. Methods: We enrolled consecutive CA patients admitted between 16 August 2021 and 28 June 2023 to an academic medical center, along with their close family members, in prospective studies. Survivors' PICS domains were: physical dependence (Physical Self-Maintenance Scale, PSMS), cognitive impairments (Modified Telephone Interview for Cognitive Status, TICS-M), and post-traumatic stress disorder (PTSS) symptoms (PTSD Checklist-PCL 5), as well as PICS-F (PCL-5 Total Score). Hierarchical multivariate linear regressions examined associations between PICS-F and survivors' PICS domains. Results: Of 74 dyads (n = 148), survivors had a mean (SD) age of 56 ± 16 years, with 61% being male and with a median hospital stay of 28 days. Family members (43% spouses) were slightly younger (52 ± 14 years), predominantly female (72%), and of minority race/ethnicity (62%). A high prevalence of PICS assessed 28.5 days (interquartile range 10-63) post-CA was observed in survivors (78% physical dependence, 54% cognitive impairment, 30% PTSS) and in family members (30% PTSS). Survivor PTSS was significantly associated with family member distress (β = 0.3, p = 0.02), independent of physical dependence (β = 0.0, p = 0.9), cognitive impairment (β = -0.1, p = 0.5), family member characteristics, and duration of hospitalization. Conclusions: Both CA survivors and their family members showed substantial evidence of likely PICS. Survivor PTSS is notably associated with family member distress, highlighting the need for dyadic interventions to enhance psychosocial outcomes.

Evaluating the impact of a standardised intervention for announcing decisions of withholding and withdrawing life-sustaining treatments on the stress of relatives in emergency departments (DISCUSS): protocol for a stepped-wedge randomised controlled trial

INTRODUCTION

The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives.

METHODS AND ANALYSIS

The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06071078.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

The experiences of the families of patients admitted to the intensive care unit

BACKGROUND

The admission of close family members to intensive care units can cause significant stress and anxiety for both patients and their families. The sudden and unexpected nature of such admissions often leaves families feeling worried, confused, and shocked. This study aimed to explore the experiences of families with loved ones admitted to the intensive care unit.

METHOD

The current qualitative study used conventional content analysis. The researchers purposefully selected 11 close family members of patients admitted to the intensive care unit. Semi-structured in-depth face-to-face interviews were conducted with the participants. These interviews were recorded, transcribed, and analyzed the data.

FINDINGS

After reviewing and analyzing the data, three themes and nine categories emerged. These themes included the search for support resources, psychological consequences within the family, and the presence of various needs within the families.

CONCLUSION

The study findings revealed that families, when present in the intensive care unit, actively sought support resources due to their fear of their loved one's mortality. The interactions with the healthcare team and the fulfillment of their needs could significantly affect their sense of hope and confidence in the patient's condition. It is recommended that nurse managers, who possess a genuine perception of the family's needs, implement family-oriented measures and interventions to provide the necessary support.

Associations Between Family-Assessed Quality-of-Dying-and-Death Latent Classes and Bereavement Outcomes for Family Surrogates of ICU Decedents

OBJECTIVES

To examine associations between family surrogates' bereavement outcomes and four previously determined quality of dying and death (QODD) latent classes (high, moderate, poor-to-uncertain, and worst).

DESIGN

Prospective, longitudinal, observational study.

SETTING

Medical ICUs at two academically affiliated medical centers in Taiwan.

PATIENTS/PARTICIPANTS

Three hundred nine family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Health Evaluation II scores > 20) from a disease.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants were assessed by the depression and anxiety subscales of the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, 11 items of the Prolonged Grief Disorder (PGD) scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey at 1, 3, 6, 13, 18, and 24 months post-loss. We simultaneously examined associations of four QODD latent classes with physical and mental health-related quality of life (HRQOL) and symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and PGD assessed over 24 bereavement months using multivariate hierarchical linear modeling. Surrogates' distinct QODD latent classes assessed at 1-month post-loss were significantly associated with bereavement outcomes, except for physical HRQOL and PGD symptoms. Significantly more depressive symptoms and worse mental HRQOL (β [95% CI]) were reported by bereaved surrogates in the moderate (1.958 [1.144-2.772], -2.245 [-3.961 to -0.529]), poor-to-uncertain (2.224 [1.438-3.010], -7.026 [-8.683 to -5.369]), and worst (2.081 [1.215-2.964], -4.268 [-6.096 to -2.440]) QODD classes than those in the high QODD class. Bereaved surrogates in the moderate (2.095 [1.392-2.798]) and poor-to-uncertain (0.801 [0.123-1.480]) QODD classes reported more anxiety symptoms, whereas those in the poor-to-uncertain QODD class suffered more PTSD symptoms (2.889 [1.005-4.774]) than those in the high QODD class.

CONCLUSIONS

The four distinct QODD latent classes were significantly associated with ICU family surrogates' bereavement outcomes, suggesting targets to improve end-of-life care quality in ICUs.

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

CONTEXT

Little is known about Veterans who die during a short terminal admission, which renders them ineligible for the Department of Veterans Affairs (VA) Bereaved Family Survey.

OBJECTIVES

We sought to describe this population and identify opportunities to improve end-of-life (EOL) care quality.

METHODS

Retrospective, cohort analysis of Veteran decedents who died in a VA inpatient setting between October 2018-September 2019. Veterans were dichotomized by short (<24 hours) and long (≥24 hours) terminal admissions; sociodemographics, clinical characteristics, VA and non-VA healthcare use, and EOL care quality indicators were compared.

RESULTS

Among 17,033 inpatient decedents, 723 (4%) had short terminal admissions. Patients with short compared to long terminal admissions were less likely to have a VA hospitalization (38% vs. 54%) in the last 90 days of life and were more likely to die in an intensive care (49% vs 21%) or acute care (27% vs 18%) unit. Patients with a short compared to long admission were about half as likely to receive hospice (33% vs 64%) or palliative care (33% vs 69%). Most patients with short admissions (76%) had a life-limiting condition (e.g., cancer, chronic obstructive pulmonary disease) and those with cancer were more likely to receive palliative care compared to those with non-cancer conditions.

CONCLUSION

Veterans with short terminal admissions are less likely to receive hospice or palliative care compared to patients with long terminal admissions. Many patients with short terminal admissions, such as those with life-limiting conditions (especially cancer), receive aspects of high-quality EOL care, however, opportunities for improvement exist.

Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study

Background

Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care.

Materials and methods

A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire.

Results

Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients' family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test).

Conclusion

Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay.

How to cite this article

Atri V, Bhatt MT, Chaudhuri S, Mitra A, Maddani SS, Ravindranath S. Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study. Indian J Crit Care Med 2024;28(5):483-494.

Psychological impact of medical evacuation for ICU saturation in Covid-19-related ARDS patients

PURPOSE

Psychological impact of Medical Evacuation (MEDEVAC) in Covid-19 patients is undetermined. The objectives were to evaluate: Post-traumatic Stress Disorder (PTSD) in MEDEVAC patients hospitalized in ICU for Covid-19-related acute respiratory distress syndrome (ARDS) compared to control group; anxiety, depression rates and outcomes in patients and PTSD in relatives.

MATERIAL AND METHODS

This is a retrospective multicentric 1/1 paired cohort performed in 10 ICUs in the West of France. Evaluation was performed 18 months after discharge. Patients and closest relatives performed IES-R (Impact and Event Scale-Revised) and/or HADS (Hospital Anxiety and Depression Scale) scales.

RESULTS

Twenty-six patients were included in each group. Patients were 64 ± 11 years old, with 83% male. We report 12 vs 20% of PTSD in control vs MEDEVAC groups (p = 0.7). Anxiety disorder affected 43.5 vs 28.0% (p = 0.26) and depression 12.5 vs 14.3% (p > 0.99) in control vs MEDEVAC groups. PTSD affects 33.3 vs 42.1% of closest relatives (p = 0.55). Ways of communication were adapted: video calls were more frequent in MEDEVAC patients (8.7 vs 60.9%, p < 0.01) whereas physical visits concerned more control group (45.8 vs 13.0%, p = 0.01).

CONCLUSIONS

PTSD rate were similar between groups. Adaptive ways of communication, restricted visits and global uncertainties could explain the absence of differences.

Development and initial validation of a family activation measure for acute care

BACKGROUND

Activation of a family member refers to their desire, knowledge, confidence, and skills that can inform engagement in healthcare. Family activation combined with opportunity can lead to engagement in care. No tool currently exists to measure family activation in acute care. Therefore, we aimed to develop and validate a tool to measure family activation in acute care.

METHODS

An interdisciplinary team of content experts developed the FAMily Activation Measure (FAM-Activate) through an iterative process. The FAM-Activate tool is a 4-item questionnaire with 5 Likert-type response options (ranging from strongly agree to strongly disagree). Scale scores are converted to a 0-100 point scoring range so that higher FAM-Activate scores indicate increased family activation. An overall FAM-Activate score (range 0-100) is calculated by adding the scores for each item and dividing by 4. We conducted reliability and predictive validity assessments to validate the instrument by administering the FAM-Activate tool to family members of patients in an acute cardiac unit at a tertiary care hospital. We obtained preliminary estimates of family engagement and satisfaction with care.

RESULTS

We surveyed 124 family participants (age 54.1±14.4; 73% women; 34% non-white). Participants were predominantly the adult child (38%) or spouse/partner (36%) of patients. The mean FAM-Activate score during hospitalization was 84.1±16.1. FAM-Activate had acceptable internal consistency (Cronbach's a = 0.74) and showed test-retest responsiveness. FAM-Activate was moderately correlated with engagement behavior (Pearson's correlation r = 0.47, P <0.0001). The FAM-Activate score was an independent predictor of family satisfaction, after adjusting for age, gender, relationship, and living status.

CONCLUSION

The FAM-Activate tool was reliable and had predictive validity in the acute cardiac population. Further research is needed to explore whether improving family activation can lead to improved family engagement in care.

Postintensive care syndrome family: A comprehensive review

Families of critically ill patients are predisposed to tremendous burdens when their relatives are admitted to the intensive care unit (ICU). Postintensive care syndrome family (PICS-F) can be described as a devastated life, encompassing psychological, physical, and socioeconomical burdens that begin with the emotional impact experienced by the family when the patient is admitted to the ICU. PICS-F was primarily proposed as a clinically significant psychological impairment, but it needs to be extended beyond the psychological impairment of the family to include physical and socioeconomical impairments in the future. The prevalence of physiological problems including depression, anxiety and post-traumatic syndrome is 20-40%, and that of non-physiological problems including fatigue is 15% at 6 months after the ICU stay. Assessment of PICS-F was frequently conducted at 3- or 6-month points, although the beginning of the evaluation was based on different assessment points among each of the studies. Families of ICU patients need to be given and understand accurate information, such as the patient's diagnosis, planned care, and prognosis. Prevention of PICS-F requires a continuous bundle of multifaceted and/or multidisciplinary interventions including providing a family information leaflet, ICU diary, communication facilitators, supportive grief care, and follow-up, for the patient and families from during the ICU stay to after discharge from the ICU. This is the first comprehensive review of PICS-F to address the concept, risk factors, assessment tools, prevalence, and management to prevent PICS-F to facilitate acute care physicians' understanding of PICS-F.

Long-term psychiatric disorders in families of severe COVID-19 patients

Aim

The present study aimed to describe in detail the changes to and assess the risk factors for poor long-term outcomes of psychiatric disorders in families of COVID-19 patients.

Methods

A single-center, retrospective study using questionnaires. Family members of patients admitted to the intensive care unit (ICU) with severe COVID-19 participated. Psychiatric disorders refer to the psychological distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient's family.

Results

Forty-six family members completed the survey and were analyzed. Anxiety, depression, and PTSD occurred in 24%, 33%, and 2% of family members, respectively, and psychiatric disorders occurred in 39%. On multivariable analysis, living in the same house with the patient was independently associated with a lower risk of psychiatric disorders in families of COVID-19 patients (OR, 0.180; 95% CI, 0.036-0.908; p = 0.038). Furthermore, four family members overcame psychiatric disorders, and six family members newly developed psychiatric disorders during the one-year follow-up period.

Conclusion

Approximately 40% of family members had long-term psychiatric disorders, and some of them overcame the psychiatric disorders, and some newly developed psychiatric disorders over the one-year follow-up. Living in the same house with the patient was possibly significantly associated with the reduction of long-term symptoms of psychiatric disorders, but this result must be interpreted with care. Further large studies are needed to examine the factors associated with the long-term mental status of family members.

Prediction of post-traumatic stress disorder in family members of ICU patients: a machine learning approach

PURPOSE

Post-traumatic stress disorder (PTSD) can affect family members of patients admitted to the intensive care unit (ICU). Easily accessible patient's and relative's information may help develop accurate risk stratification tools to direct relatives at higher risk of PTSD toward appropriate management.

METHODS

PTSD was measured 90 days after ICU discharge using validated instruments (Impact of Event Scale and Impact of Event Scale-Revised) in 2374 family members. Various supervised machine learning approaches were used to predict PTSD in family members and evaluated on an independent held-out test dataset. To better understand variables' contributions to PTSD predicted probability, we used machine learning interpretability methods on the best predictive algorithm.

RESULTS

Non-linear ensemble learning tree-based methods showed better predictive performances (Random Forest-area under curve, AUC = 0.73 [0.68-0.77] and XGBoost-AUC = 0.73 [0.69-0.78]) than regularized linear models, kernel-based models, or deep learning models. In the best performing algorithm, most important features that positively contributed to PTSD's predicted probability were all non-modifiable factors, namely, lower patient's age, longer duration of ICU stay, relative's female sex, lower relative's age, relative being a spouse/child, and patient's death in ICU. A sensitivity analysis in bereaved relatives did not alter the algorithm's predictive performance.

CONCLUSION

We propose a machine learning-based approach to predict PTSD in relatives of ICU patients at an individual level. In this model, PTSD is mostly influenced by non-modifiable factors.

Self-Care Mental Health App Intervention for Post-Intensive Care Syndrome-Family: A Randomized Pilot Study

BACKGROUND

Post-intensive care syndrome-family (PICS-F) is a constellation of adverse psychological symptoms experienced by family members of critically ill patients during and after acute illness. Cognitive behavioral therapy delivered using smartphone technology is a novel approach for PICS-F symptom self-management.

OBJECTIVE

To determine the efficacy of smartphone delivery of cognitive behavioral therapy in reducing the prevalence and severity of PICS-F symptoms in family members of critically ill patients.

METHODS

The study had a randomized controlled longitudinal design with control and intervention groups composed of family members of patients admitted to 2 adult intensive care units. The intervention consisted of a mental health app loaded on participants' personal smartphones. The study time points were upon enrollment (within 5 days of intensive care unit admission; time 1), 30 days after enrollment (time 2), and 60 days after enrollment (time 3). Study measures included demographic data, PICS-F symptoms, mental health self-efficacy, health-related quality of life, and app use.

RESULTS

The study sample consisted of 60 predominantly White (72%) and female (78%) family members (30 intervention, 30 control). Anxiety and depression symptom severity decreased significantly over time in the intervention group but not in the control group. Family members logged in to the app a mean of 11.4 times (range, 1-53 times) and spent a mean of 50.16 minutes (range, 1.87-245.92 minutes) using the app.

CONCLUSIONS

Delivery of cognitive behavioral therapy to family members of critically ill patients via a smartphone app shows some efficacy in reducing PICS-F symptoms.

An integrative literature review examining the key elements of bereavement follow-up interventions in critical care

PURPOSE OF REVIEW

The aim of this review is to examine bereavement follow-up intervention studies in critical care, with the purpose of integrating results on the timing, content, aims and outcomes of interventions. The impact of a death in critical care is well documented, and bereavement follow-up is recognised as an important topic, but there is limited research with little consensus on the content and structure of interventions.

RECENT FINDINGS

A total of 18 papers were selected; 11 are intervention studies, with only one randomised control trial. Six papers were from national surveys and are not the focus of this review. Bereavement follow-up mainly consisted of information giving, condolence interventions, telephone calls and meetings with families. The timing, content, aims and outcomes depended on the intervention and were influenced by the design of the study.

SUMMARY

Overall, bereavement follow-up is acceptable for relatives but outcomes are mixed. Calls for more research are valid, but how do we utilise the current research to better inform the critical care community? Researchers suggest that bereavement follow-up interventions need to be designed with specific aims and outcomes, in collaboration with bereaved families that are appropriate to the intervention.

Temporal reciprocal relationships among anxiety, depression, and posttraumatic stress disorder for family surrogates from intensive care units over their first two bereavement years

BACKGROUND/OBJECTIVE

Bereaved family surrogates from intensive care units (ICU) are at risk of comorbid anxiety, depression, and post-traumatic stress disorder (PTSD), but the temporal reciprocal relationships among them have only been examined once among veterans. This study aimed to longitudinally investigate these never-before-examined temporal reciprocal relationships for ICU family members over their first two bereavement years.

METHODS

In this prospective, longitudinal, observational study, symptoms of anxiety, depression, and PTSD were assessed among 321 family surrogates of ICU decedents from 2 academically affiliated hospitals in Taiwan by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised, respectively at 1, 3, 6, 13, 18, and 24 months postloss. Cross-lagged panel modeling was conducted to longitudinally examine the temporal reciprocal relationships among anxiety, depression, and PTSD.

RESULTS

Examined psychological-distress levels were markedly stable over the first 2 bereavement years: autoregressive coefficients for symptoms of anxiety, depression, and PTSD were 0.585-0.770, 0.546-0.780, and 0.440-0.780, respectively. Cross-lag coefficients showed depressive symptoms predicted PTSD symptoms in the first bereavement year, whereas PTSD symptoms predicted depressive symptoms in the second bereavement year. Anxiety symptoms predicted symptoms of depression and PTSD at 13 and 24 months postloss, whereas depressive symptoms predicted anxiety symptoms at 3 and 6 months postloss while PTSD symptoms predicted anxiety symptoms during the second bereavement year.

CONCLUSIONS

Different patterns of temporal relationships among symptoms of anxiety, depression, and PTSD over the first 2 bereavement years present important opportunities to target symptoms of specific psychological distress at different points during bereavement to prevent the onset, exacerbation, or maintenance of subsequent psychological distress.

Prolonged Grief in Times of Lockdown During the COVID-19 Pandemic

This study aimed to estimate the prevalence of prolonged grief (PG) during the COVID-19 pandemic and to analyze associated variables. 142 family members of patients who died during the lockdown at a hospital were surveyed 6 months after the death. Prolonged grief, depression and anxiety, grief rumination, and loss-related variables were captured. Logistic regression analyses were conducted to detect the associated variables of PG symptoms. Prolonged grief was present in 44.4% of the bereaved. 76.2% of the relatives reported feeling distressed due to visitor restrictions, and the majority of them were unable to bid farewell to their family member at the time of death. Pastoral or psychological care was also lacking. Low education (p < 0.001), emotional closeness (p = 0.007), loss of a spouse (p < 0.001), inability to bid farewell after death (p = 0.024), feeling of threat due to the pandemic (p < 0.001), depression (p = 0.014), and anxiety (p = 0.028) were significantly associated with prolonged grief.

The Impact of Randomized Family-Centered Interventions on Family-Centered Outcomes in the Adult Intensive Care Unit: A Systematic Review

Objective: To review the literature for randomized family-centered interventions with family-centered outcomes in the adult intensive care unit (ICU). Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library database from inception until February 2023. Study Selection: We included articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting family-centered outcomes. Data Extraction: We extracted data on author, year of publication, setting, number of participants, intervention category, intervention, and family-centered outcomes. Data Synthesis: There were 52 RCTs included in the analysis, mostly involving communication and receiving information (38%) and receiving care and meeting family member needs (38%). Nearly two-thirds of studies (N = 35; 67.3%) found improvements in at least 1 family-centered outcome. Most studies (N = 24/40; 60%) exploring the impact of family-centered interventions on mental health outcomes showed improvement. Improvements in patient-centered outcomes (N = 7/17; 41%) and healthcare worker outcomes (N = 1/5; 20%) were less commonly found. Conclusions: Family-centered interventions improve family-centered outcomes in the adult ICU and may be beneficial to patients and healthcare workers.

Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic

INTRODUCTION

In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time.

METHODS

This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed.

FINDINGS

Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected.

CONCLUSION

Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

Identification of Palliative Care Needs and Mental Health Outcomes Among Family Members of Patients With Severe Acute Brain Injury

Importance

Family members of patients with severe acute brain injury (SABI) are at risk for poor psychological outcomes.

Objective

To explore the utility of the early use of a palliative care needs checklist in identifying care needs of patients with SABI and family members who are at risk of poor psychological outcomes.

Design, Setting, and Participants

This prospective cohort study included patients with SABI in an intensive care unit (ICU) for 2 days or more and a Glasgow Coma Scale score of 12 or lower and their family members. This single-center study was conducted at an academic hospital in Seattle, Washington, from January 2018 to June 2021. Data were analyzed from July 2021 to July 2022.

Exposure

At enrollment, a 4-item palliative care needs checklist was completed separately by clinicians and family members.

Main Outcomes and Measures

A single family member for each enrolled patient completed questionnaires assessing symptoms of depression and anxiety, perception of goal-concordant care, and satisfaction in the ICU. Six months later, family members assessed their psychological symptoms, decisional regret, patient functional outcome, and patient quality of life (QOL).

Results

A total of 209 patient-family member pairs (family member mean [SD] age, 51 [16] years; 133 women [64%]; 18 Asian [9%], 21 Black [10%], 20 [10%] Hispanic, and 153 White [73%] participants) were included. Patients had experienced stroke (126 [60%]), traumatic brain injury (62 [30%]), and hypoxic-ischemic encephalopathy (21 [10%]). At least 1 need was identified for 185 patients or their families (88%) by family members and 110 (53%) by clinicians (κ = -0.007; 52% agreement). Symptoms of at least moderate anxiety or depression were present in 50% of family members at enrollment (87 with anxiety and 94 with depression) and 20% at follow-up (33 with anxiety and 29 with depression). After adjustment for patient age, diagnosis, and disease severity and family race and ethnicity, clinician identification of any need was associated with greater goal discordance (203 participants; relative risk = 1.7 [95% CI, 1.2 to 2.5]) and family decisional regret (144 participants; difference in means, 17 [95% CI, 5 to 29] points). Family member identification of any need was associated with greater symptoms of depression at follow-up (150 participants; difference in means of Patient Health Questionnaire-2, 0.8 [95% CI, 0.2 to 1.3] points) and worse perceived patient QOL (78 participants; difference in means, -17.1 [95% CI, -33.6 to -0.5] points).

Conclusions and Relevance

In this prospective cohort study of patients with SABI and their families, palliative care needs were common, although agreement on needs was poor between clinicians and family members. A palliative care needs checklist completed by clinicians and family members may improve communication and promote timely, targeted management of needs.

Anxiety and Depression Symptoms of Family Members of Intensive Care Unit Patients: A Prospective Observational Study and the Lived Experiences of the Family Members

Background  The aim of this study is to investigate the factors affecting symptoms of anxiety and depression in the family members of critically ill patients. Methods  This prospective cohort study was conducted in an adult tertiary care mixed medical-surgical intensive care unit (ICU) at a tertiary-level teaching hospital. The symptoms of anxiety and depression of first-degree adult relatives were evaluated with the Hospital Anxiety and Depression Scale. Four family members were interviewed and asked about their experiences during the ICU process. Results  A total of 84 patients and their family members were included in the study. The symptoms of anxiety were present in 44/84 (52.4%), and depression was present in 57/84 (67.9%) family members. A nasogastric tube was found to be related to anxiety ( p  = 0.005) and depressive symptoms ( p  = 0.002). The family members of the patients with an acute developed illness had 3.9 (95% confidence interval [CI]: 1.4-10.9) times the odds of having the symptoms of anxiety and 6.2 (95% CI: 1.7-21.7) times the odds of having the symptoms of depression than the family members of the patients with an illness developed on a chronic basis. The family members of the patients who died in the ICU had 5.0 (95% CI: 1.0-24.5) times the odds of being depressed than the patients discharged from the ICU. All interviewees stated having difficulty understanding and remembering what was told. The common feelings of all the interviewees were desperation and fear. Conclusions  Awareness of the emotional stress of family members can help develop interventions and attitudes to alleviate symptom burden.

Spiritual Care in the Intensive Care Unit: Experiences of Dutch Intensive Care Unit Patients and Relatives

BACKGROUND/OBJECTIVE

To gain insight into both patients' and relatives' experiences with spiritual care (SC) in the intensive care unit (ICU).

METHODS

Method used was qualitative interviewing. This was a thematic, topic-centered, biographical, and narrative approach, using semistructured interviews with thematic analysis. A purposive sampling method was used to select a sample of ICU patients and ICU patients' relatives. An interview guide facilitated individual, semistructured interviews. The interview data were recorded by means of note-taking and audio-recording. Verbatim transcripts were compiled for analysis and interpretation.

RESULTS

All 12 participants-7 ICU patients and 5 family members of 5 other ICU patients-experienced ICU admission as an existential crisis. Participants would appreciate the signaling of their spiritual needs by ICU health care professionals (HCPs) at an early stage of ICU admission and subsequent SC provision by a spiritual caregiver. They regarded the spiritual caregiver as the preferred professional to address spiritual needs, navigate during their search for meaning and understanding, and provide SC training in signaling spiritual needs to ICU HCPs.

DISCUSSION

Early detection of existential crisis signals with ICU patients and relatives contributes to the mapping of spiritual and religious needs. Spiritual care training of ICU HCPs in signaling spiritual needs by ICU patients and relatives is recommended. Effective SC contributes to creating room for processing emotions, spiritual well-being, and satisfaction with integrated SC as part of daily ICU care.

Effect size estimates of risk factors for post-intensive care syndrome-family: A systematic review and meta-analysis

BACKGROUND

Families of patients admitted to ICUs often experience post-intensive care syndrome-family, and previous studies have reported several possible risk factors. However, to date, no meta-analyses have been conducted on the numerous risk factors associated with the development of post-intensive care syndrome-family and how strongly these factors are in association with post-intensive care syndrome-family.

OBJECTIVES

To identify risk factors for post-intensive care syndrome-family and determine the effect size of individual risk factors.

METHODS

This systematic review used MEDLINE, CINAHL, PsycINFO, and EMBASE databases to search all studies through December 1, 2021, that reported risk factors for anxiety, depression, PTSD, and prolonged grief disorder in the families of adult patients in ICUs. A meta-analysis was conducted to calculate an overall estimate for key risk factors, and odds ratio and 95% confidence intervals were used as summary statistics using the random-effects model.

RESULTS

Of 2964 identified studies, 17 were included. Nine factors for anxiety, eight for depression, and three for PTSD were assessed using results from 13 studies. The risk factor with the largest effect size was "history of mental illness," which, along with "female sex," was a significant risk factor common to anxiety, depression, and PTSD. "Poor communication with ICU staff," "severely ill patient," and "patients' spouse" were common risk factors for anxiety and depression.

CONCLUSIONS

We identified several risk factors related to patient and family demographic characteristics. Further research is required to identify and validate modifiable risk factors for the psychosocial experiences of families of ICU patients.

Identification of risk factors for post-intensive care syndrome in family members (PICS-F) among adult patients: a systematic review

INTRODUCTION

Relatives of critically ill patients who either die or survive the intensive care unit (ICU) may develop substantial mental health problems that are collectively defined as post-intensive care syndrome in family (PICS-F).

MATERIAL AND METHODS

By using a systematised search strategy we included studies that focused on PICS-F in relatives of adult ICU patients and reported the risk factors associated with its development. The search was conducted within PubMed, Embase, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 23 August 2022. PRISMA 2020 guidelines were implemented for appropriate reporting. The objective was to document all possible risk factors associated with the development of PICS-F.

RESULTS

We included 51 papers covering 9302 relatives. The frequency of PICS-F varied between 2.5 and 69%. We identified 51 different risk factors of PICS-F, among which we distinguished patient-related ( n = 16), relative-related ( n = 27), and medical staff-related ( n = 8) risk factors. Among 21 studies of the highest quality, we identified the 33 variables associated with the development of PICS-F, of which younger age of a patient, death of a patient, depression in relatives during the ICU stay, history of mental disorders in relatives, being a female relative, being a spouse, and having low satisfaction with communication and care in the ICU were the most commonly reported risk factors.

CONCLUSIONS

PICS-F is a highly frequent phenomenon that can be exacerbated by several risk factors. Special attention should be paid to relatives of younger patients with worse prognosis and with the following relative-related risk factors: female sex, being a spouse, and history of mental health disorders. Finally, the medical staff play a role in preventing the PICS-F development, not only by maintenance of proper communication, but also by early identification of relatives prone to PICS-F.

Family Burden of ICU Survivors and Correlations with Patient Quality of Life and Psychometric Scores – A Pilot Study

Introduction

Post intensive care syndrome (PICS) affects an increasing number of critical illness survivors and their families, with serious physical and psychological sequelae. Since little is known about the burden of critical illness on ICU survivor families, we conducted a prospective observational study aiming to assess this, and investigate correlations of the patients’ psychometric and health-related quality of life (HRQOL) scores with family burden.

Materials and Methods

Twenty-nine patients were evaluated in the presence of a family member. Participants were assessed with the use of validated scales for anxiety, depression, post-traumatic stress disorder, cognitive decline, and the family burden scale (FBS).

Results

High burden was present in 27.6% of family members. Statistically significant correlations were observed between the FBS score and trait anxiety, depression, and the physical and psychological components of HRQOL.

Conclusions

Our results suggest that family burden following critical illness is common, suggesting that its assessment should be incorporated in the evaluation of PICS-family in large observational studies.

Family Presence on Rounds in Adult Critical Care: A Scoping Review

Family presence on rounds involves allowing family members to participate in daily healthcare team rounds and is recommended by critical care professional societies. Yet, family presence on rounds is not performed in many institutions. There is a need to synthesize the current evidence base for this practice to inform healthcare providers of the potential benefits and challenges of this approach. The main objective of this study was to explore the impact of family presence on adult ICU rounds on family and healthcare providers.

DATA SOURCES

Ovid Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and PubMed databases were last searched on January 28, 2022. Studies published during the COVID-19 pandemic were included.

STUDY SELECTION

Studies involving family presence during rounds that included family or healthcare provider perspectives or outcomes were selected. There were no limitations on study design.

DATA EXTRACTION

Qualitative and quantitative family and provider perspectives, barriers and challenges to family presence, and study outcomes were extracted from studies. The JBI Manual for Evidence Synthesis published guidelines were followed.

DATA SYNTHESIS

There were 16 studies included. Family reported family presence on rounds as a means of information transfer and an opportunity to ask care-related questions. Family presence on rounds was associated with increased family satisfaction with care, physician comfort, and improved physician-family relationship. Healthcare providers reported a positive perception of family presence on rounds but were concerned about patient confidentiality and perceived efficacy of rounds. Family presence was found to increase rounding time and was felt to negatively impact teaching and opportunities for academic discussions.

CONCLUSIONS

Family presence on rounds has potential advantages for family and healthcare providers, but important challenges exist. Further studies are needed to understand how to best implement family presence on adult ICU rounds.

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

OBJECTIVES

Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions.

DATA SOURCES

MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022.

STUDY SELECTION

Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified.

DATA EXTRACTION

Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose.

CONCLUSIONS

Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury

BACKGROUND AND OBJECTIVES

Breakdowns in clinician-family communication in neurologic intensive care units (neuroICUs) are common, particularly for goals-of-care decisions to continue or withdraw life-sustaining treatments while considering long-term prognoses. Shared decision-making interventions (decision aids [DAs]) may prevent this problem and increase patient-centered care, yet none are currently available. We assessed the feasibility, acceptability, and perceived usefulness of a DA for goals-of-care communication with surrogate decision makers for critically ill patients with severe acute brain injury (SABI) after hemispheric acute ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.

METHODS

We conducted a parallel-arm, unblinded, patient-level randomized, controlled pilot trial at 2 tertiary care US neuroICUs and randomized surrogate participants 1:1 to a tailored paper-based DA provided to surrogates before clinician-family goals-of-care meetings or usual care (no intervention before clinician-family meetings). The primary outcomes were feasibility of deploying the DA (recruitment, participation, and retention), acceptability, and perceived usefulness of the DA among surrogates. Exploratory outcomes included outcome of surrogate goals-of-care decision, code status changes during admission, patients' 3-month functional outcome, and surrogates' 3-month validated psychological outcomes.

RESULTS

We approached 83 surrogates of 58 patients and enrolled 66 surrogates of 41 patients (80% consent rate). Of 66 surrogates, 45 remained in the study at 3 months (68% retention). Of the 33 surrogates randomized to intervention, 27 were able to receive the DA, and 25 subsequently read the DA (93% participation). Eighty-two percent rated the DA's acceptability as good or excellent (median acceptability score 2 [IQR 2-3]); 96% found it useful for goals-of-care decision making. In the DA group, there was a trend toward fewer comfort care decisions (27% vs 56%, p = 0.1) and fewer code status changes (no change, 73% vs 44%, p = 0.02). At 3 months, fewer patients in the DA group had died (33% vs 69%, p = 0.05; median Glasgow Outcome Scale 3 vs1, p = 0.05). Regardless of intervention, 3-month psychological outcomes were significantly worse among surrogates who had chosen continuation of care.

DISCUSSION

A goals-of-care DA to support ICU shared decision making for patients with SABI is feasible to deploy and well perceived by surrogates. A larger trial is feasible to conduct, although surrogates who select continuation of care deserve additional psychosocial support.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov NCT03833375.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that the use of a DA explaining the goals-of-care decision and the treatment options is acceptable and useful to surrogates of incapacitated critically ill patients with ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.

Psychological Attachment Orientation and Long-Term Posttraumatic Stress Symptoms Among Family Members of ICU Patients

To determine the degree to which an ICU patient’s family member having an “anxious” psychologic attachment orientation is a risk factor for developing long-term posttraumatic stress disorder (PTSD) symptoms following patient ICU discharge or death.

An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness

BACKGROUND

Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support.

OBJECTIVE

To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness.

METHODS

A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively.

RESULTS

Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training.

CONCLUSIONS

Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.

ICU bereaved surrogates' comorbid psychological-distress states and their associations with prolonged grief disorder

Background/objective

Bereaved ICU family surrogates’ psychological distress, e.g., anxiety, depression, and post-traumatic stress disorder (PTSD), is usually examined independently, despite the well-recognized comorbidity of these symptoms. Furthermore, the few studies exploring impact of psychological distress on development of prolonged grief disorder (PGD) did not consider the dynamic impact of symptom evolution. We identified surrogates’ distinct patterns/states of comorbid psychological distress and their evolution over the first 3 months of bereavement and evaluated their associations with PGD at 6-month postloss.

Methods

A longitudinal observational study was conducted on 319 bereaved surrogates. Symptoms of anxiety, depression, PTSD, and PGD were measured by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised scale, and the PGD-13, respectively. Distinct psychological-distress states and their evolution were examined by latent transition analysis. Association between psychological-distress states and PGD symptoms was examined by logistic regression.

Results

Three distinct comorbid psychological-distress states (prevalence) were initially identified: no distress (56.3%), severe-depressive/borderline-anxiety distress (30.5%), and severe-anxiety/depressive/PTSD distress (13.3%). Except for those in the stable no-distress state, surrogates tended to regress to states of less psychological distress at the subsequent assessment. The proportion of participants in each psychological-distress state changed to no distress (76.8%), severe-depressive/borderline-anxiety distress (18.6%), and severe-anxiety/depressive/PTSD distress (4.6%) at 3-month postloss. Surrogates in the severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD-distress state at 3-month postloss were more likely to develop PGD at 6-month postloss (OR [95%] = 14.58 [1.48, 143.54] and 104.50 [10.45, 1044.66], respectively).

Conclusions

A minority of family surrogates of ICU decedents suffered comorbid severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD symptoms during early bereavement, but they were more likely to progress into PGD at 6-month postloss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03981-7.

Prognostication and shared decision making in neurocritical care

Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.

Risk factors for complicated grief among family members bereaved in intensive care unit settings: A systematic review

BACKGROUND

Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.

MATERIALS AND METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.

RESULTS

Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.

CONCLUSION

This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503).

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

Bereavement Experiences of Families in the Cardiac Intensive Care Unit

BACKGROUND

Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit.

OBJECTIVE

To describe the bereavement experiences of families of patients in the cardiac intensive care unit.

METHODS

In this secondary analysis, an exploratory, descriptive design was used to understand the families' bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient's death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes.

RESULTS

Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families' bereavement work included both practical tasks and emotional processing; (2) families' bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient's death influenced families' bereavement experiences; and (5) families' experiences in the intensive care unit affected their bereavement.

CONCLUSIONS

This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support.

Caregiver burden and emotional wellbeing in informal caregivers to ICU survivors-A prospective cohort study

BACKGROUND

Informal caregivers to intensive care unit (ICU) survivors may develop post-intensive care syndrome family (PICS-F), including depression, anxiety and post-traumatic stress (PTS). Our primary aim was to investigate associations between caregiver burden in informal caregivers cohabiting with ICU survivors and patients' physical and psychological outcomes.

METHODS

A prospective, multicentre cohort study in four ICUs in Sweden. Adults cohabiting with ICU patients included in a previous study were eligible for inclusion. Three months post-ICU, informal caregivers received questionnaires assessing caregiver burden, health-related quality of life (HRQL) and symptoms of depression, anxiety and PTS. In parallel, patients reported their three-month physical and psychological status via validated questionnaires. The primary outcome of this study was to compare caregiver burden in informal caregivers to patients with and without adverse physical and psychological outcomes 3 months post-ICU. Secondary outcomes were correlations between caregiver burden and informal caregivers' mental HRQL.

RESULTS

Among 62 included informal caregivers, 55 (89%) responded to the follow-up questionnaires. Caregiver burden was higher among informal caregivers to patients with an adverse outcome, compared to informal caregivers to patients without an adverse outcome, caregiver burden scale score mean (±standard deviation) 52 (11) and 41 (13) respectively (p = 0.003). There was strong negative correlation between caregiver burden and informal caregivers' mental HRQL (r_s -0.74, p < 0.001).

CONCLUSION

Informal caregivers to ICU survivors with adverse physical or psychological outcome experience a higher caregiver burden. A higher caregiver burden correlates with worse caregiver mental HRQL. ICU follow-up programs should consider screening and follow-up of informal caregivers for mental health problems.

Initiating and integrating a personalized end of life care project in a community hospital intensive care unit: A qualitative study of clinician and implementation team perspectives

RATIONALE

The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing for patients, families, and clinicians. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described.

OBJECTIVES

To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and implementation team perspective.

METHODS

This qualitative descriptive study evaluated the implementation of the 3WP in a 20-bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life-sustaining therapy. Following the qualitative descriptive approach, semi-structured interviews were conducted with purposively sampled clinicians and implementation team. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis.

RESULTS

Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but suggested more non-clinical project support for orientation, continuing education, and data collection. A majority of wishes focused on physical resources including keepsakes, which helped facilitate project spread when clinician capacity was attenuated by competing duties.

CONCLUSIONS

In this community hospital, ICU clinicians and implementation team members report perceived improved EOL care for patients, families, and clinicians following 3WP initiation and integration. Implementing individualized and meaningful wishes at EOL for dying patients in a community ICU requires adequate planning and time dedicated to optimizing clinician education. Adapting key features of an intervention to local expertise and capacity may facilitate spread during project initiation and integration.

Heart rate variability and subsequent psychological distress among family members of intensive care unit patients

Objective

To determine whether heart rate variability (HRV; a physiological measure of acute stress) is associated with persistent psychological distress among family members of adult intensive care unit (ICU) patients.

Methods

This prospective study investigated family members of patients admitted to a study ICU. Participants’ variability in heart rate tracings were measured by low frequency (LF)/high frequency (HF) ratio and detrended fluctuation analysis (DFA). Questionnaires were completed 3 months after enrollment to ascertain outcome rates of anxiety, depression, and post-traumatic stress disorder (PTSD).

Results

Ninety-nine participants were enrolled (median LF/HF ratio, 0.92 [interquartile range, 0.64–1.38]). Of 92 participants who completed the 3-month follow-up, 29 (32%) had persistent anxiety. Logistic regression showed that LF/HF ratio (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.43, 1.53) was not associated with 3-month outcomes. In an exploratory analysis, DFA α (OR 0.93, 95% CI 0.87, 0.99), α₁ (OR 0.97, 95% CI 0.94, 0.99), and α₂ (OR 0.94, 95% CI 0.88, 0.99) scaling components were associated with PTSD development.

Conclusion

Almost one-third of family members experienced anxiety at three months after enrollment. HRV, measured by LF/HF ratio, was not a predictor of psychologic distress, however, exploratory analyses indicated that DFA may be associated with PTSD outcomes.

Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges

This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.

The Association between Patient Health Status and Surrogate Decision Maker Post-Traumatic Stress Disorder Symptoms in Chronic Critical Illness

Rationale: Surrogate decision-makers of patients with chronic critical illness (CCI) are at high risk for symptoms of post-traumatic stress disorder (PTSD). Whether patient health status after hospital discharge is a risk factor for surrogate PTSD symptoms is not known. Objectives: To determine the association between patient health status 90 days after the onset of CCI and surrogate symptoms of PTSD. Methods: We performed a secondary analysis of the data from a multicenter randomized trial of a communication intervention for adult patients with CCI and their surrogate decision-makers. Results: Surrogate PTSD symptoms were measured at 90 days using the Impact of Events Scale-Revised. For patients who were alive at 90 days, location was used as a marker of health status and included the following categories: 1) home (relatively good health and low acuity), 2) acute rehabilitation (moderate care needs and impairments, generally expected to improve), 3) skilled nursing facility (moderate care needs and impairments, generally not expected to improve significantly or quickly), 4) long-term acute care facility (persistently high acute care needs and functional impairment), and 5) readmission to an acute care hospital (suggesting the highest acuity of illness and care needs of the cohort). Patients who died before 90 days were categorized as deceased. In the analyses, 365 surrogates and 256 patients were included. Among patients, 49% were female, and the mean age was 59 years. Among surrogates, 71% were female, and the mean age was 51 years. A directed acyclic graph was constructed to identify covariates to be included in the model. Compared with symptoms seen among surrogates of patients living at home, heightened PTSD symptoms were seen among surrogates of patients who were readmitted to an acute care hospital (β coefficient, 15.9; 95% confidence interval [CI], 4.5 to 27.3) or had died (β coefficient, 14.8; 95% CI, 8.8 to 20.9) at 90 days. Conclusions: Surrogates of patients with CCI who have died or have been readmitted to an acute care hospital at 90 days experience increased PTSD symptoms as compared with surrogates of patients who are living at home. These patients and surrogates represent a readily identifiable group who may benefit from enhanced emotional support.