Parental Perspectives on Roles in End-of-Life Decision Making in the Pediatric Intensive Care Unit: An Integrative Review

A Rapid Review on Shared Decision Making in Pediatric Palliative Care and End-of-Life Care: Implications for Clinical Practice, Research, and Policy

Shared decision making is a concept essential to establishing meaningful goals of care that reflect one's preferences, values, beliefs, culture, and quality of life. This rapid review considered shared decision making from the perspective of seriously ill or medically complex children receiving inpatient palliative or end-of-life care, where shared decision making is made on behalf of and in the child's best interest. A total of 118 articles were screened, resulting in the selection of 12 articles using a systematic process. Emergent themes noted and discussed include the roles of family and clinicians, explorative communication, transparency, cultural implications, and ethical challenges.

Humanisation in paediatric intensive care units: A narrative review

OBJECTIVE

To identify findings in the scientific literature relevant to the strategic lines proposed by the Humanising Intensive Care Project in the context of paediatric intensive care units.

DESIGN

Narrative review.

METHODS

A literature search was conducted in the databases PubMed, Scopus, CINHAL, and Cochrane Library. Specific indexing terms and search strategies adapted to each database were designed. The inclusion of publications was based on two criteria: 1) related to the paediatric intensive care unit and 2) addresses at least one of the topics related to the strategic lines of the Humanising Intensive Care Project. Study selection was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the quality of the included studies was assessed using the Mixed Method Appraisal tool.

RESULTS

A total of 100 articles from 19 different countries were included, covering the period between 2019 and 2021. Nineteen different design types were identified. Thirty-two studies were cross-sectional observational studies, while 15 had an experimental approach. The articles were distributed among the seven strategic lines of the Humanising Intensive Care Project.

CONCLUSIONS

Synthesising the knowledge related to humanisation in paediatric intensive care units will allow progress to be made in improving quality in these units. However, there is disparity in the amount of experimental research overall.

IMPLICATIONS FOR CLINICAL PRACTICE

There is a disparity in the available research related to the different strategic lines, and it is necessary to carry out more exhaustive research on topics such as the presence and participation of the family in care or the management of post-paediatric intensive care syndrome.

The elements of end-of-life care provision in paediatric intensive care units: a systematic integrative review

BACKGROUND

Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families.

METHODS

A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method.

RESULTS

Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death.

CONCLUSION

The focus of end-of-life care in PICUs varies depending on HCPs' and families' preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families' beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care.

Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review

OBJECTIVES

This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes.

METHODS

The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement.

RESULTS

This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.

Parents' experiences of being involved in medical decision-making for their child with a life-limiting condition: A systematic review with narrative synthesis

BACKGROUND

Parental involvement in the decision-making processes about medical treatment for children with life-limiting conditions is recognised as good practice. Previous research highlighted factors affecting the decision-making process, but little is known about how parents experience their participation.

AIM

To explore how parents experience their participation in the process of decision-making about treatment and future care for their children with life-limiting conditions.

DESIGN

A systematically constructed review using narrative synthesis. The PRISMA guidelines were followed to report the findings. Databases Medline, EMBASE, SCOPUS, CINAHL and PsycINFO were searched up to December 2023. The study protocol was registered at PROSPERO (RN CRD42021215863).

RESULTS

From the initial 2512 citations identified, 28 papers met the inclusion criteria and were included in the review. A wide range of medical decisions was identified; stopping general or life-sustaining treatment was most frequent. Narrative synthesis revealed six themes: (1) Temporal aspects affecting the experience with decision-making; (2) Losing control of the situation; (3) Transferring the power to decide to doctors; (4) To be a 'good' parent and protect the child; (5) The emotional state of parents and (6) Sources of support to alleviate the parental experience.

CONCLUSIONS

Parental experiences with decision-making are complex and multifactorial. Parents' ability to effectively participate in the process is limited, as they are not empowered to do so and the circumstances in which the decisions are taking place are challenging. Healthcare professionals need to support parental involvement in an effective way instead of just formally asking them to participate.

Development of the perceived miscommunication measure in the pediatric intensive care unit

PURPOSE

Miscommunication between parents and healthcare providers in the Pediatric Intensive Care Unit (PICU) can affect family-provider relationships and outcomes. This paper reports on the development and psychometric testing of a measure for parent perceived miscommunication, defined as the failure to communicate clearly as perceived by relevant stakeholders in the PICU.

DESIGN AND METHODS

Miscommunication items were identified through a review of the literature with interdisciplinary experts. In a cross-sectional quantitative survey, the scale was tested with 200 parents of children discharged from a PICU at a large Northeastern Level 1 Pediatric hospital. The psychometric properties of a 6-item miscommunication measure were assessed using exploratory factor analysis and internal consistency reliability.

RESULTS

Exploratory factor analysis yielded one factor explaining 66.09% of the variance. Internal consistency reliability in the PICU sample was α = 0.89. As hypothesized, there was a significant correlation between parental stress, trust, and perceived miscommunication in the PICU (p < .001). Confirmatory factor analysis supported good fit indices in testing the measurement model (χ2/df = 2.57, Goodness of Fit Index (GFI) = 0.979, Confirmatory Fit Index (CFI) =0.993 and Standardized Mean Residual (SMR) = 0.0136).

CONCLUSIONS

This new six-item miscommunication measure shows promising psychometric properties including content and construct validity, which can be further tested and refined in future studies of miscommunication and outcomes in PICU.

PRACTICE IMPLICATIONS

Awareness of perceived miscommunication in the PICU can benefit stakeholders within the clinical environment by recognizing the importance of clear and effective communication and how language affects the parent-child-provider relationship.

Shared responsibility for decision-making in NICU: A scoping review

BACKGROUND

Shared responsibility is an essential part of family-centred care and it characterizes the relationship between parents and healthcare professionals. Despite this, little is known about their shared responsibility for decision-making in neonatal intensive care units.

AIM

The aim of this scoping review was to identify previous studies on the subject and to summarize the knowledge that has been published so far.

METHOD

The review was conducted using electronic searches in the CINAHL, PubMed, Scopus and PsycINFO databases and manual searches of the reference lists of the selected papers. The searches were limited to peer-reviewed papers that had been published in English from 2010 to September 2021. The data were selected based on inclusion and exclusion criteria and the findings were inductively summarized. We identified eight papers that met the inclusion criteria.

ETHICAL CONSIDERATIONS

The scoping review was conducted according to good scientific practice by respecting authorship and reporting the study processes accurately, honestly and transparently.

RESULTS

The results showed that shared responsibility for decision-making was based on the parents' intentions, but the degree to which they were willing to take responsibility varied. The facilitating and inhibiting factors for shared responsibility for decision-making were related to the communication between parents and professionals. The impact was related to the parents' emotions.

CONCLUSION

It is essential that parents and professionals negotiate how both parties will contribute to their shared responsibility for decision-making. This will enable them to reach a mutual understanding of what is in the infants' best interests and to mitigate the emotional burden of decisions in neonatal intensive care units. More research is needed to clarify the concept of shared responsibility for decision-making in this intensive care context.

Understanding parent experiences of end-of-life care for children: A systematic review and qualitative evidence synthesis

BACKGROUND

An estimated 21 million children worldwide would benefit from palliative care input and over 7 million die each year. For parents of these children this is an intensely emotional and painful time through which they will need support. There is a lack of synthesised research about how parents experience the care delivered to their child at the end of life.

AIM

To systematically identify and synthesise qualitative research on parents' experiences of end-of-life care of their child.

DESIGN

A qualitative evidence synthesis was conducted. The review protocol was registered in PROSPERO (CRD42021242946).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science databases were searched for qualitative studies published post-2000 to April 2020. Studies were appraised for methodological quality and data richness. Confidence in findings was assessed by GRADE-CERQual.

RESULTS

About 95 studies met the eligibility criteria. A purposive sample of 25 studies was taken, of good-quality papers with rich data describing the experience of over 470 parents. There were two overarching themes: parents of children receiving end-of-life care experienced a profound need to fulfil the parental role; and care of the parent. Subthemes included establishing their role, maintaining identity, ultimate responsibility, reconstructing the parental role, and continuing parenting after death.

CONCLUSIONS

Services delivering end-of-life care for children need to recognise the importance for parents of being able to fulfil their parental role and consider how they enable this. What the parental role consists of, and how it's expressed, differs for individuals. Guidance should acknowledge the need to enable parents to parent at their child's end of life.

Attitudes Toward Neonatal Palliative Care Among Turkish Nurses and Physicians: A Comparative Cross-sectional Study

Few studies have examined and compared neonatal physicians' and nurses' attitudes toward palliative care. This comparative study sought to evaluate attitudes toward neonatal palliative care in neonatal nurses and physicians and identify associated facilitators and barriers. This comparative, cross-sectional study included 173 neonatal intensive care unit staff (149 neonatal nurses and 24 neonatal physicians) in 2 hospitals in Istanbul, Turkey. Data were collected using the Turkish version of the Neonatal Palliative Care Attitude Scale. The results of the study revealed 8 facilitators and 9 barriers to neonatal palliative care. Nurses were significantly more likely than physicians to agree that parents are informed about palliative care options in their unit ( P = .008), that caring for dying infants is traumatic ( P = .007), and that their willingness to provide palliative care is influenced by their personal attitudes toward death ( P = .015). This study demonstrates the importance of parents' active involvement in the palliative care process, the establishment of standard policies and guidelines, and the provision of vocational and in-service education programs to support palliative care. Initiatives to strengthen facilitators and mitigate barriers are needed to optimize the implementation of palliative care in NICUs.

How Physicians Discuss Uncertainty With Parents in Intensive Care Units

BACKGROUND AND OBJECTIVES

Physicians and parents of critically ill neonates and children receiving intensive care have to make decisions on the child's behalf. Throughout the child's illness and treatment trajectory, adequately discussing uncertainties with parents is pivotal because this enhances the quality of the decision-making process and may positively affect the child's and parents' well-being. We investigated how physicians discuss uncertainty with parents and how this discussion evolves over time during the trajectory.

METHODS

We asked physicians working in the NICU and PICU of 3 university medical centers to audio record their conversations with parents of critically ill children from the moment doubts arose whether treatment was in the child's best interests. We qualitatively coded and analyzed the anonymized transcripts, thereby using the software tool MAXQDA 2020.

RESULTS

Physicians were found to adapt the way they discussed uncertainty with parents to the specific phase of the child's illness and treatment trajectory. When treatment options were still available, physicians primarily focused on uncertainty related to diagnostic procedures, treatment options, and associated risks and effects. Particularly when the child's death was imminent, physicians had less "scientific" guidance to offer. They eliminated most uncertainty and primarily addressed practical uncertainties regarding the child's dying process to offer parents guidance.

CONCLUSIONS

Our insights may increase physicians' awareness and enhance their skills in discussing uncertainties with parents tailored to the phase of the child's illness and treatment trajectory and to parental needs in each specific phase.

Nurses and nursing students' experiences on pediatric end-of-life care and death: A qualitative systematic review

BACKGROUND

End-of-Life care and experiencing death of infants, children, and teenagers remain one of the most difficult and traumatic events for nurses and nursing students, potentially leading to personal and professional distress. Although efforts have been made to alleviate stressors in these settings, improvements remain slow. Understanding nurses and nursing students' experiences of pediatric End-of-Life care and death in multiple care settings may direct interventions to better support quality of care and healthcare professionals in these areas.

OBJECTIVE

This review aimed to qualitatively synthesize existing literature to examine the nurses and nursing students' experiences of providing End-of-Life care to children and the death of pediatric patients.

DESIGN

The qualitative systematic review was conducted using Sandelowski and Barroso's guidelines. The included studies were appraised using the Critical Appraisal Skill Program.

DATA SOURCES

This qualitative systematic review was registered with the International Prospective Register of Systematic Reviews. Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from the database inception date through May 2021.

RESULTS

Thirty articles were included to form three key themes: (1) Emotional impact of pediatric End-of-Life care and death, (2) Perspective of delivering optimal care: What works and what does not, and (3) The complex role of nurses in pediatric End-of-Life care. Overall, the findings suggested that in an emotionally taxing environment, clinical and emotional support were paramount. Furthermore, there is a need to examine nurses' role in End-of-Life decision making and provide more discussion on professional boundaries.

CONCLUSION

This review offered nurses' and nursing students' perceptions of pediatric End-of Life care and death in the nursing profession. Findings can provide useful insights towards the planning of educational programs and institutional changes that supports nurses and nursing students in these settings.

Parents' perspectives on conflict in paediatric healthcare: a scoping review

BACKGROUND

Conflict in paediatric healthcare is becoming increasingly prevalent, in particular relation to paediatric end of life. This is damaging to patients, families, professionals and healthcare resources. Current research has begun to explore perspectives of healthcare professionals (HCPs), but the parental views on conflict are lacking.

OBJECTIVES

This scoping review explores parental views on conflict during a child's end of life. In addition, parental views are mapped onto HCPs' views.

METHODS

A search was completed of the databases CINAHL, PubMed, Web of Science, Embase and Medline between 1997 and 2019, focused on parents of children with involvement with palliative or end-of-life care referring to conflict or disagreements.

RESULTS

The review found 10 papers that included parental views on conflict. Data on conflict were categorised into the following seven themes: communication breakdown, trust, suffering, different understanding of 'best interest', disagreements over treatment, spirituality and types of decision-making. In particular, parental expertise, perspectives on suffering and ways of making decisions were significant themes. A subset of themes mirror those of HCPs. However, parents identified views of conflict unique to their perspective.

CONCLUSIONS

Parents identified important themes, in particular their perspective of what constitutes suffering and 'best interest'. In addition, parents highlight the importance of being recognised as an expert.

Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review

BACKGROUND

Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP).

METHODS

To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA).

RESULTS

Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents.

CONCLUSION

In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.

Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations

In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.

Focuses and trends of the studies on pediatric palliative care：A bibliometric analysis from 2004 to 2018

OBJECTIVES

To investigate the focuses and trends of the studies on pediatric palliative care (PPC) and provide directions for future research.

METHODS

Relevant papers about PPC published from 2004 to 2018 were analyzed using bibliometric analysis methods, including co-word analysis, biclustering analysis, and strategic diagram analysis. The included papers were divided into three groups based on the publication time, including 2004-2008, 2009-2013, and 2014-2018.

RESULTS

A total of 1132 papers were published between 2004 and 2018, and there were 293 papers published between 2004 and 2008, 396 between 2009 and 2013, and 443 between 2014 and 2018. There were 42 high-frequency MeSH terms/MeSH subheadings in papers published between 2004 and 2018, including 12 between 2004 and 2008, 13 between 2009 and 2013, and 17 between 2014 and 2018.

CONCLUSION

Studies on PPC were making progress, with the increasing number, expanding scope, and uneven global distribution. Integration palliative care into pediatrics, cancer treatments in pediatric oncology, education methods on PPC, and establishment of professional teams were the major themes during 2004-2008, then the themes changed into establishing interventions to enhance the quality of life of the patients and parents, building professional-family relationship, and investigating attitude of health personnel in PPC during 2009-2013 and subsequently turned into communication skills, end-of-life decision making, and guidelines making on PPC during 2014-2018. Underdeveloped and protential themes including effective approaches to deal with the ethical dilemmas, training programs on communication skills, family support and guideline making are worth studying in the future.

Identifying as a Good Parent: Considering the Communication Theory of Identity for Parents of Children Receiving Palliative Care

Background: Parents of seriously ill children are at risk of psychosocial morbidity, which may be mitigated by competent family-centered communication and role-affirming conversations. Parent caregivers describe a guiding desire to do a good job in their parenting role but also depict struggling under the intense weight of parental duty. Objectives and Design: Through this case study, the Communication Theory of Identity (CTI) provides a framework for conceptualizing how palliative care teams can help parents cope with this reality. CTI views communication with care teams as formative in the development and enablement of parental perceptions of their "good parenting" role. Results: Palliative care teams may consider the four frames of identity (personal, enacted, relational, and communal) as meaningful dimensions of the parental pursuit to care well for an ill child. Conclusion: Palliative care teams may consider compassionate communication about parental roles to support the directional virtues of multilayered dynamic parental identity.

After an end-of-life decision: Parents' reflections on living with an end-of-life decision for their child

AIM

Parents' role as end-of-life decision-makers for their child has become largely accepted Western health-care practice. How parents subsequently view and live with the end-of-life decision (ELD) they made has not been extensively examined. To help extend understanding of this phenomenon and contribute to care, as a part of a study on end-of-life decision-making, bereaved parents were asked about the aftermath of their decision-making.

METHODS

A qualitative methodology was used. Semi-structured interviews were conducted with parents who had discussed ELDs for their child who had a life-limiting condition and had died. Data were thematically analysed.

RESULTS

Twenty-five bereaved parents participated. Results indicate that parents hold multi-faceted views about their decision-making experiences. An ELD was viewed as weighty in nature, with decisions judged against the circumstances that the child and parents found themselves in. Despite the weightiness, parents reflected positively on their decisions, regarding themselves as making the right decision. Consequently, parents' comments demonstrated being able to live with their decision. When expressed, regret related to needing an ELD, rather than the actual decision. The few parents who did not perceive themselves as their child's decision-maker subsequently articulated negative reactions. Enduring concerns held by some parents mostly related to non-decisional matters, such as the child's suffering or not knowing the cause of death.

CONCLUSION

Results suggest that parents can live well with the ELDs they made for their child. End-of-life decision-making knowledge is confirmed and extended, and clinical support for parents informed.

A Scoping Review of Nursing Research Priorities in Pediatric Care

PROBLEM

Priority setting for pediatric nursing is important to plan, coordinate and direct future research. The aim of this scoping review was to systematically identify and synthesise the nature, range and extent of published pediatric nursing research priorities.

ELIGIBILITY CRITERIA

English language full text publications focusing generic nursing research priorities for the child or adolescent, indexed in CINAHL, EMBASE, The Cochrane Database of Systematic Reviews, AMED, MEDLINE and PsycINFO and published from 2008 to 2019.

SAMPLE

A total of 789 citations were identified, 44 full text articles were retrieved and assessed for eligibility and eight studies were finally reviewed, quality assessed (CREDES) and synthesised.

RESULTS

All eight studies used a consensus building method to identify research priorities reported by nurses. Six used Delphi technique, one Nominal Group Technique (NGT) and one consensus workshop. CREDES score range was 10-14 of a possible 16. Synthesis of the 234 nursing research priorities generated four themes; evidenced-based practice, pediatric context, child and family-centered care; pediatric nursing, with 14 subthemes.

CONCLUSION

The nursing research priorities reported appear to be still current and important to nurses. There was a focus on acute care, with fewer priorities reflecting areas of child-, school-, or mental- health. Consumer and community priorities have not been reported.

IMPLICATIONS

These nursing research priorities can be used to inform the national or local research agenda, although there is a need to establish priorities from the perspective of all stakeholders and in particular, identify what is important to consumers.

Family Outcomes and Perceptions of End-of-Life Care in the Intensive Care Unit: A Mixed-Methods Review

The purpose of this review was to evaluate end-of-life care (EOLC) in the intensive care unit (ICU) from the perspective of family members. Sandelowski's segregated approach from Joanna Briggs Institute (JBI) Mixed-Methods Systematic Reviews guided this review. A search was conducted in PubMed, CINAHL, PsycINFO, EMBASE, and ProQuest databases and identified 50 papers (33 quantitative, 15 qualitative, and 2 mixed-methodology studies). Five synthesized themes (distressing emotions, shared decision-making, proactive communication, personalized end-of- life care, and valuing of nursing care) were identified. For quantitative results, study methodologies and interventions were heterogeneous and did not always improve family members' perceived quality of care and family members' psychological distress. Configuration of qualitative and quantitative data revealed ICU end-of-life interventions were ineffective because they were not guided by family members' reported needs and perceptions. To fulfill the family members' needs for the patients' EOLC in the ICU, researchers should develop a theory to explicitly explain how the family members experience ICU EOLC and implement a theory-based intervention to improve family psychological outcomes.