Perspectives and wishes for patient and family centred care as expressed by adult intensive care survivors and family-members: A qualitative interview study

Digital health interventions in adult intensive care and recovery after critical illness to promote survivorship care

Digital health refers to the field of using and developing technology to improve health outcomes. Digital health and digital health interventions (DHIs) within the area of intensive care and critical illness survivorship are rapidly evolving. Digital health interventions refer to technologies in clinical interventional format. A DHI could support clinicians with increasing clinical demands to have improved oversight of their patients' recovery trajectory or potential for deterioration, improve efficiency of healthcare delivery, and/or predict patient outcomes. In this narrative review, DHIs are explored across the continuum from in the ICU (recognising and managing clinical deterioration, identifying individuals at risk of poor recovery outcomes, tailoring care of the ICU patient and supporting the emotional needs of their family) through to integration in the primary care setting (adjuncts to ICU follow-up clinics and tracking, coaching and remote monitoring). Some of the DHIs discussed in this narrative review (to name a few) include interventions delivered via: Telehealth, artificial intelligence, wearable devices, virtual reality, and mobile phone applications (apps). Additionally, exploration of DHIs used successfully in other health fields are discussed to highlight potential opportunities for adaptation to the ICU context. Finally, the review provides an overview of considerations needed in the development of new DHIs. Development should consider the intended user, barriers to technology engagement and design. In the implementation of a new DHI, the World Health Organization (WHO) Global Strategy on Digital Health and appropriate evaluation should be considered prior to scaling up. Optimal implementation of DHIs could help address the key challenges of the ICU field.

Family involvement in preventing delirium in critically ill patients: A systematic review and meta-analysis

BACKGROUND

Humanized care is a novel concept in the prevention of delirium, with family involvement being a crucial component. Currently, there is controversy regarding the effectiveness of family involvement in preventing delirium among critically ill patients, and the impact of varying levels of family involvement on delirium prevention remains unclear.

OBJECTIVE

The purpose of this study is twofold: (a) to investigate the influence of family involvement on delirium among critically ill patients, and (b) to explore the effectiveness of different levels of family involvement in preventing delirium in these patients.

DESIGN

A systematic review and meta-analysis.

METHODS

From database inception to July 2024, a comprehensive search was conducted across PubMed, EMBASE, CINAHL, Web of Science, and the Cochrane CENTRAL database. Randomized controlled trials that examined family involvement were included in the review.

RESULTS

This review included a total of 11 randomized controlled trials, encompassing 3113 critically ill patients. Family involvement was found to significantly reduce the incidence of delirium among critically ill patients (RR = 0.46, 95%CI = 0.31 to 0.69), decrease the duration of delirium (WMD = -2.18, 95 % CI = -4.14 to -0.22), and shorten the length of Intensive Care Unit (ICU) stay (WMD = -1.46, 95%CI = -2.43 to -0.50). Three different levels of family involvement-direct participation in care (RR = 0.37, 95%CI = 0.26 to 0.51), family visits and companionship (RR = 0.56, 95 % CI = 0.25 to 1.25), and indirect participation (RR = 0.77, 95 % CI = 0.29 to 2.07)-varies in their effectiveness for delirium prevention.

CONCLUSIONS

Family involvement significantly impacts delirium prevention in critically ill patients. The effectiveness of delirium prevention varies depending on the level of family involvement, with direct participation of family members in caregiving demonstrating a more pronounced effect in reducing delirium incidence among critically ill patients.

REGISTRATION

The review protocol has been registered in the PROSPERO International prospective register of systematic reviews (CRD42024563095).

Patient- and family-centered care in adult ICU (FAM-ICU): A protocol for a feasibility study

BACKGROUND

In the intensive care unit (ICU), delirium in patients and long-term mental health challenges in both patients and their family members are highly prevalent. To address these issues, patient- and family-centered care has been recommended to alleviate the burdens associated with critical illness and ICU admission. We have developed the patient- and FAMily-centered care in the adult ICU intervention (FAM-ICU intervention). This multi-component intervention comprises several concrete and manageable components and operationalizing patient- and family-centered care principles in clinical practice. In this protocol, we describe a study aiming to evaluate the feasibility and acceptability of the FAM-ICU intervention in the adult ICU setting, including the feasibility of collecting relevant patient- and family-member outcome data.

METHOD

We will conduct a pre-/post two-group study design. We plan to recruit 30 adult ICU patients and their close family members at Herlev University Hospital in Denmark. The pre-group (n = 15) will receive usual care and the post-group (n = 15) will receive the FAM-ICU intervention. The FAM-ICU intervention involves interdisciplinary training of the ICU team and a systematic approach to information sharing and consultations with the patients and their family. Feasibility outcomes will include recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Acceptability will be assessed through questionnaires and interviews with clinicians, patients, and family members. Data collection is scheduled to begin in January 2025.

DISCUSSION

This study will assess the feasibility and acceptability when implementing the FAM-ICU intervention and the feasibility of conducting a main trial to investigate its effectiveness on delirium in patients and the mental health of patients and family members. The data from the feasibility study will be used to guide sample size calculations, trial design, and final data collection methods for a subsequent stepped-wedge randomized controlled trial.

Long-term prevalence of PTSD symptom in family members of severe COVID-19 patients: a serial follow-up study extending to 18 months after ICU discharge

BACKGROUND

Experiencing a loved one's stay in the intensive care unit (ICU) can profoundly affect families, often leading to post-intensive care syndrome-family (PICS-F), a condition particularly exacerbated during the COVID-19 pandemic. While PICS-F significantly impacts the mental health of families of ICU patients, especially in the context of COVID-19, the long-term effects beyond 12 months remain understudied. This study aims to explore the prevalence of PTSD-related symptoms and health-related quality of life (HRQOL) in family members up to 18 months after ICU discharge.

METHODS

This prospective study, conducted in a tertiary university hospital in Tokyo, enrolled family members of severe COVID-19 ICU patients (July 2020 to June 2022 with final follow-up ending in December 2023). The primary outcome was family member symptoms of PTSD at 6, 12 and 18 months after ICU discharge, measured by the Impact of Events Scale-Revised (presence of PTSD symptoms defined by score > 24). Secondary outcomes were family member symptoms of anxiety and depression, sleep disorders, and health-related quality of life (HRQOL) at the same timepoint.

RESULTS

Among 97 enrolled family members, 68 participated. At least one PTSD-related symptom was reported by 26% of family members, persisting over 18 months post-discharge (16% at 6 months, 23% at 12 months, and 25% at 18 months). A subgroup (15%) exhibited delayed-onset PTSD symptoms. Family members with PTSD-related symptoms reported lower HRQOL, especially in mental and social components.

CONCLUSIONS

The study underscores the importance of long-term support for family members post-ICU discharge, given the sustained prevalence of PTSD-related symptoms among family members of severe COVID-19 patients.

Establishing consensus on patient- and family-centered care in adult intensive care units: A Delphi survey

PURPOSE

To establish consensus between intensive care unit (ICU) experts on concrete patient- and family-centered care statements for adult patients and relatives in the ICU.

MATERIALS AND METHODS

We did a three-round Delphi survey with a panel of ICU health care professionals from 23 ICUs in Denmark. In round 1, participants answered 20 open-ended questions, based on existing evidence. Analysis of their responses generated close-ended statements, which participants primary rated on a five-point-Likert-scale, from very important to not important at all. In rounds 2 and 3., consensus was predefined as ≥75% of participants rating a statement important.

RESULTS

Sixty-nine participated: 38 nurses, 24 physicians, and four occupational and physiotherapists. In total 96%, 90% and 72% answered the first, second, and third rounds, respectively. In round 1, participants answers resulted in >3000 statements that were analyzed into 82 condensed statements. After participants rated the statements in round 2 and 3, 47 statements reached consensus as important.

CONCLUSIONS

The 47 statements rated to be important included interdisciplinary approaches to systematic information sharing and consultations with patients and family-members, with the aim being to accommodate patients and family-members´ individual needs throughout the ICU stay.

A journey through transitional care-family members' experiences post a life-threatening situation: A qualitative study

BACKGROUND

Being a family member to someone who suffers from a serious illness can change one's perspectives about life. A sudden and severe illness can result in a demanding journey that involves acute admission to hospital, intensive care, post-care, and finally, returning home.

AIM

To describe the experience of staying beside a next of kin throughout the healthcare journey, from the onset of illness at home, to the intensive care unit, post-care, and returning home.

METHODS

The study employed a qualitative design, with data collected via semi-structured interviews and analysed using reflexive thematic analysis. A purposive sampling was used to recruit participants (n = 14), who had experiences of staying beside a next of kin throughout the healthcare journey from the onset of illness to discharge from the hospital.

FINDINGS

Family members' experiences were captured under the overarching theme Journey through an emotional turmoil and the themes Entering a new world, Continuing the journey towards something unknown, and Striving for the new normal at home. They described going through a non-linear process, characterised by transitions or changes in several aspects. The transitions included shifts in the roles that the family members played, in the various environments they found themselves in, and in the progression of the patient's illness or injury.

CONCLUSION

The study suggested that family members with a next of kin who experienced life-threatening situations undergo challenging transitions. The informal caregiver role placed on family members of intensive care unit-survivors significantly impacts their lives and the healthcare systems should prioritise providing high-quality support to family members throughout the entire healthcare journey. Elevating the importance of nursing care within the healthcare system can contribute to delivering holistic care and facilitating transitions. Further research should focus on understanding the support that family members perceive as necessary to facilitate their transition and enhance their well-being.

Ethical considerations related to virtual visiting for families and critically ill patients in intensive care: a qualitative descriptive study

BACKGROUND

During the COVID-19 pandemic, virtual visiting technologies were rapidly integrated into the care offered by intensive care units (ICUs) in the UK and across the globe. Today, these technologies offer a necessary adjunct to in-person visits for those with ICU access limited by geography, work/caregiving commitments, or frailty. However, few empirical studies explore the ethical issues associated with virtual visiting. This study aimed to explore the anticipated or unanticipated ethical issues raised by using virtual visiting in the ICU, such that healthcare professionals can be informed about how to carry out virtual visits ethically, safely and productively.

METHODS

We used a descriptive exploratory qualitative research approach recruiting a convenience sample of newly-graduated junior doctors facilitating ICU virtual visits in a tertiary academic centre. Eight newly graduated junior doctors, seven female and one male, aged 23-27, participated in semi-structured interviews. We analysed transcripts using an inductive coding approach.

RESULTS

Five overarching themes emerged. Two of the themes namely, 'fulfilling a moral instinct to connect families' and 'promoting autonomy', arose from participants' descriptions of how virtual visits aligned with healthcare standards and practices they considered ethical. Three further themes, 'preserving dignity and privacy', 'managing emotional distress', and 'providing equitable access' to virtual visiting technologies, highlight how virtual visits might exacerbate ethical issues related to family communications.

CONCLUSION

Virtual visiting may potentially both ameliorate and exacerbate aspects of ethical healthcare delivery for ICU patients and family members. ICU team members should consider unique ethical considerations related to using virtual visiting. We recommend virtual communications skills training for staff and advocate for the use of easily accessible educational resources for families who wish to visit critically unwell patients remotely.

Health care providers' perceptions of family participation in essential care in the intensive care unit: A qualitative study

BACKGROUND

Family participation in essential care may benefit patients and relatives.

AIMS

To examine the needs, perceptions and preferences of health care providers about family participation in essential care in the adult intensive care unit.

STUDY DESIGN

A qualitative descriptive study using inductive thematic analysis. Three focus group interviews with a total of 30 intensive care unit health care providers, consisting of 20 critical care nurses, one nursing assistant, five physicians, three physical therapists and one speech therapist working in three Dutch intensive care units.

RESULTS

One overarching theme, balancing interests, and four main themes emerged: looking after the patient's interests, taking the relatives' perspective into account, looking after interests of intensive care unit health care providers and conditions for family participation. The first theme, looking after the patient's interests, included three sub-themes: insecurity about patient's wishes and needs, patient safety concerns and potential benefits for the patient. The second theme, taking the relatives' perspective into account, was also characterized by three sub-themes: concerns about the relatives' possible burden, potential benefits for the relative and the relationship between patient and relative. The third theme, looking after interests of intensive care unit health care providers, included three sub-themes: attitude towards family participation in essential care, differing perceptions of essential care and concerns about intensive care unit health care provider's burden. The last theme, conditions for family participation, included two sub-themes: establishing a relationship and considering family participation in essential care as a process.

CONCLUSIONS

Health care providers' perceptions and preferences regarding family participation in essential care in the intensive care unit are summarized in the overarching theme balancing interests. This overarching theme also reflects the needs and perceptions of patients and relatives.

RELEVANCE TO CLINICAL PRACTICE

These findings may support critical care nurses and other health care providers when encouraging family participation in essential care.

Informal caregivers' experiences of support from a tailored primary healthcare unit for older adults - A focus group study

BACKGROUND

Informal caregivers are an essential part of health and social care systems worldwide. As such, they may need professional support.

AIM

The aim of this study was to describe informal caregivers' experiences and need for support from a tailored primary health care (PHC) unit.

METHODS

This is a qualitative descriptive study using data collected from five semi-structured focus group discussions with a purposeful sample of 16 informal caregivers of older relatives. Respondents were recruited from a tailored PHC unit for people aged 75 years or older in a region in central Sweden. The data were analysed by qualitative content analysis with an abductive approach, based on the principles of the patient- and family-centred care framework.

RESULTS

The overarching theme was 'Striving for partnership'. The findings indicate that informal caregivers to some extent felt supported by the healthcare professionals. However, the caregivers expressed a need to be further acknowledged by the professionals in order to participate in the care of their older relatives in the way they wanted. Moreover, insufficient information regarding the older adult's health condition and care provided by the professionals had a negative impact on the caregiver's participation in care.

CONCLUSIONS

Informal caregivers have unmet needs for support and strive for a partnership with the PHC professionals. PHC professionals should be more attentive and invite informal caregivers to participate in the care of the older adult in order to meet their support needs and build an equal partnership. The patient- and family-centred care framework may be of guidance when providing care for older adults in a PHC context.

A Case Report and Review of the Literature of ICU Delirium

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

The spectrum of psychological disorders in family members of patients suffering from delirium associated with critical illness: a prospective, observational study

During intensive care unit admission, relatives of critically ill patients can experience emotional distress. The authors hypothesized that families of patients who are diagnosed with intensive care unit (ICU) delirium experience more profound depression and anxiety disorders related to stress than do families of patients without delirium. We performed a prospective observational single-center study including families of adult patients (age above 18 years) hospitalized in a 17-bed ICU of a university hospital for at least 48 h who completed research questionnaires at day 2 after admission and day 30 after initial evaluation using dedicated questionnaires (HADS, CECS, IES, PTSD-C). A total of 98 family members of patients hospitalized in the ICU were included in the final analysis (50 family members whose relatives were CAM-ICU positive (DEL+), and 48 family members of patients without delirium (DEL-)). No statistically significant differences in demographics and psychosocial data were found between the groups. In the follow-up 30 days after the first conversation with a family member, the mean PTSD score for the relatives of patients with delirium was 11.02 (Me = 13.0; SD = 5.74), and the mean score for nondelirious patients' family members was 6.42 (Me = 5.5; SD = 5.50; p < 0.001). A statistically significant increase in IES scores for family members of patients with delirium was observed for total PTSD (p = 0.001), IES-intrusion (p < 0.001), and IES-hyperarousal (p = 0.002). The prevalence of anxiety symptoms, depression, and posttraumatic stress disorder (PTSD) was higher in families of patients diagnosed with ICU delirium within 48 h of admission to the ICU. No factors increasing the depth of these disorders in family members of patients with ICU delirium were identified. Taking appropriate actions and thus providing families with appropriate support will contribute to the understanding of unfavorable emotional states, including anxiety, stress, depression, anger, agitation, or avoidance.

Nurses' experiences of managing cognitive problems in intensive care unit patients: A qualitative study

OBJECTIVES

Nurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses' perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit. The objective of this study was to explore nurses' experiences of cognitive problems in patients admitted to an intensive care unit.

RESEARCH METHODOLOGY

A phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation.

FINDINGS

Three themes related to nurses' experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment.

CONCLUSIONS

The interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives' knowledge to assess patients' cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients' cognition, which involved "shielding" patients from the noisy and disruptive intensive care unit environment.

IMPLICATIONS FOR CLINICAL PRACTICE

Effective communication methods, coupled with family involvement may aid nurses in identifying patients' cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients' cognition. Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

Exploring patients' and relatives' needs and perceptions regarding family participation in essential care in the intensive care unit: A qualitative study

OBJECTIVES

To examine the needs, perceptions and influencing factors according to former adult intensive care unit patients and relatives with regard to family participation in essential care in the unit.

RESEARCH DESIGN

A qualitative interpretive descriptive study using inductive thematic analysis.

SETTING

Twelve pairs of former Dutch patients and their relatives were interviewed within two months after the patient's discharge from the unit between December 2017 and April 2018.

FINDINGS

Four themes emerged: the family's history, the patient's condition, supporting the patient and supporting the relative. The family's history, in particular the relationship with the patient and former experience with care, determined the level of participation in essential care. The level of participation was also influenced by the patient's condition, more specifically level of consciousness, stability of the patient's situation and length of the patient's stay. The third theme, supporting the patient, related to presence/being able to 'be there' for the patient and a mostly positive attitude towards family participation. The last theme was supporting the relative, with three subthemes associated with relatives' needs and perceptions: (dis)comfort with participation in essential care, need for invitation and support, and concern about the possible strain experienced by relatives.

CONCLUSION

Supporting the patient and supporting the relative are reflecting the needs and perceptions of patients and relatives regarding family participation in essential care. Both the family's history and the patient's condition influence the relative's level of participation. Intensive care unit nurses and other healthcare providers could take these themes into account when encouraging family participation in essential care.

IMPLICATIONS FOR CLINICAL PRACTICE

Patients' and relatives' needs and perceptions of family participation in essential care in the intensive care unit vary. Family participation in essential care is influenced by the family's history and the patient's condition. Healthcare providers could take these findings into account when implementing family participation in essential care.

Effects of an online information tool on post-traumatic stress disorder in relatives of intensive care unit patients: a multicenter double-blind, randomized, placebo-controlled trial (ICU-Families-Study)

PURPOSE

Intensive care unit (ICU) hospitalization is challenging for the family members of the patients. Most family members report some level of anxiety and depression, sometimes even resulting in post-traumatic stress disorder (PTSD). An association has been reported between lack of information and PTSD. This study had three aims: to quantify the psychological burden of family members of critically ill patients, to explore whether a website with specific information could reduce PTSD symptoms, and to ascertain whether a website with information about intensive care would be used.

METHOD

A multicenter double-blind, randomized, placebo-controlled trial was carried out in Austria and Switzerland.

RESULTS

In total, 89 members of families of critically ill patients (mean age 47.3 ± 12.9 years, female n = 59, 66.3%) were included in the study. 46 relatives were allocated to the intervention website and 43 to the control website. Baseline Impact of Event Scale (IES) score was 27.5 ± 12.7. Overall, 50% showed clinically relevant PTSD symptoms at baseline. Mean IES score for the primary endpoint (~ 30 days after inclusion, T1) was 24 ± 15.8 (intervention 23.9 ± 17.9 vs. control 24.1 ± 13.5, p = 0.892). Hospital Anxiety and Depression Scale (HADS - Deutsch (D)) score at T1 was 12.2 ± 6.1 (min. 3, max. 31) and did not differ between groups. Use of the website differed between the groups (intervention min. 1, max. 14 vs. min. 1, max. 3; total 1386 "clicks" on the website, intervention 1021 vs. control 365). Recruitment was prematurely stopped in February 2020 due to coronavirus disease 2019 (COVID-19).

CONCLUSION

Family members of critically ill patients often have significant PTSD symptoms and online information on critical illness did not result in reduced PTSD symptoms.