Reported burden on informal caregivers of ICU survivors: a literature review

Financial Hardship: A Qualitative Study Exploring Perspectives of Seriously Ill Patients and Their Family

CONTEXT

Seriously ill patients, such as those who experience critical illness, and their families experience a variety of poor outcomes, including financial hardship. However, little is known about the ways in which these seriously ill patients and their families experience financial hardship.

OBJECTIVE

To examine seriously ill patients' and families' experiences of financial hardship and perspectives on addressing these concerns during and after critical illness.

METHODS

We conducted a thematic analysis of semi-structured interviews with seriously ill patients who recently experienced a critical care hospitalization (n=15) and family caregivers of these patients (n=18).

RESULTS

Our analysis revealed three themes: 1) Prioritizing Survival and Recovery; 2) Living with Uncertainty-including experiences of prolonged uncertainty, navigating bureaucratic barriers, and long-term worries; and 3) Preferences for Financial Guidance. Our results suggest patients and families prioritize survival over financial hardship initially, and feelings of uncertainty about finances persist. However, patients and family caregivers are reluctant to have their physicians address financial hardship.

CONCLUSIONS

Our findings suggest that the acute and time sensitive nature of treatment decisions in critical care settings provides a unique context for experiences of financial hardship. Additional research is needed to better understand these experiences and design context-sensitive interventions to mitigate financial hardship and associated poor patient- and family-centered outcomes.

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.

Effects of Wab-WPPEP on post-intensive care syndrome-family in family caregivers of heart valve replacement patients: A randomized controlled trial

OBJECTIVES

To evaluate the effects of a WeChat applet-based whole process psychological empowerment program (Wab-WPPEP) on post-intensive care syndrome-family in family caregivers of heart valve replacement patients.

DESIGN

Two-arm, parallel, randomized controlled clinical trial.

SETTINGS

A tertiary general hospital in Fuzhou, China.

METHODS

Participants were randomly assigned to two groups. The intervention group received Wab-WPPEP, while the control group received routine care. The intervention was implemented from ICU admission to one month post-discharge. The primary outcome was anxiety, while secondary outcomes included depression, post-traumatic stress disorder (PTSD), and quality of life. Outcomes were assessed at baseline (T0), before ICU transfer (T1), pre-discharge (T2), and one month post-discharge (T3) using standardized questionnaires. Generalized estimating equations were used to analyze the repeated-measures data.

RESULTS

The intervention group exhibited greater improvements in anxiety (T1: β = -1.92, 95 % CI: -2.35 to -1.49, P < 0.001; T2: β = -1.66, 95 % CI: -2.03 to -1.29, P < 0.001; T3: β = -3.98, 95 % CI: -4.34 to -3.62, P < 0.001), depression (T1: β = -1.32, 95 % CI: -1.79 to -0.85, P < 0.001; T2: β = -1.70, 95 % CI: -2.08 to -1.32, P < 0.001), and quality of life (T2: β = 31.16, 95 % CI: 21.35 to 40.98, P < 0.001) compared to the routine-care group. PTSD scores were also significantly lower in the intervention group (t = -6.454, P < 0.001).

CONCLUSIONS

Wab-WPPEP significantly reduced anxiety and depression, improved quality of life, and alleviated PTSD symptoms in family caregivers of heart valve replacement patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Comprehensive psychological interventions should be implemented throughout the ICU stay and recovery period to improve family caregiver well-being.

How and when post intensive care syndrome-family is measured: A scoping review

OBJECTIVES

Family members of Intensive Care Unit (ICU) patients can experience mental health difficulties. These are collectively described as Post Intensive Care Syndrome-Family (PICS-F). There are no standardised outcome measures to benchmark the impact of PICS-F. This scoping review aimed to map and characterise interventions, outcomes, and outcome instruments related to PICS-F.

METHODS

Eight databases were searched in June 2023: Pubmed, CINAHL, Ovid Medline, EMBASE, PsycInfo, AMED, Emcare and Cochrane. The grey literature was also searched. Studies published after 2012 related to PICS-F were included. Search strategy included: (Population) family members of adult ICU patients, (Concept) PICS-F, (Context) ICU settings. Frequency analysis of outcomes was performed, and instruments were mapped to describe the characteristics.

RESULTS

Of the identified 4848 records, 46 papers representing 44 unique studies met the inclusion criteria and were retained for analysis. In total, 8008 family members were represented across 15 countries in four continents worldwide. The number of studies reporting PICS-F interventions increased rapidly over the past 12 years and were performed in ICUs treating mixed conditions. Studies were randomised control trials (n = 33), before-and-after design (n = 6) and non-randomised trials (n = 5). A total of 18 outcome instruments were used measuring predominantly anxiety, with complicated grief measured only once. The identified instruments were mostly validated for clinical and disease specific populations but not validated among relatives of ICU patients.

CONCLUSION

There is a plethora of instruments measuring PICS-F outcomes. No core outcome set is currently available for PICS-F. To reduce heterogeneity of how PICS-F is measured, a core outcome set with validated measurements is recommended to allow benchmarking and to document the impact of PICS-F interventions.

IMPLICATIONS FOR CLINICAL PRACTICE

Recognising PICS-F symptoms and understanding how to assess them could help clinicians to develop interventions to improve family outcomes. Validated instruments are needed to evaluate these interventions.

Patient safety in the intensive care department

Patient safety is a priority for all healthcare systems. Despite this, too many patients still suffer harm as a consequence of healthcare. Furthermore, it has a significant impact on family members, professionals and healthcare institutions, resulting in considerable economic costs. The critically ill patient is particularly vulnerable to adverse events. Numerous safe practices have been implemented, acknowledging the influence of human factors on safety and the significance of the well-being of professionals, as well as the impact of critical episodes at hospital discharge on patients and their families. Training and engagement of professionals, patients and families are of paramount importance. Recently, artificial intelligence has demonstrated its ability to enhance clinical safety. This update on "Patient Safety" reviews all these aspects related to one of the most pivotal dimensions of healthcare quality.

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.

AIIMS ICU Rehabilitation (AIR): development and description of intervention for home rehabilitation of chronically ill tracheostomized patients

Background

The paucity of state-supported rehabilitation for chronically ill patients with long-term tracheostomies has ramifications of prolonged hospital-stay, increased burden on acute-care resources, and nosocomial infections. Few interventions describe home rehabilitation of adult tracheostomized patients. Almost none involve stakeholders. This paper describes the All-India Institute of Medical Sciences (AIIMS) ICU rehabilitation (AIR) healthcare intervention developed to facilitate home rehabilitation of chronically ill tracheostomized patients.

Methods

The AIR intervention development was based on the experience-based codesign theory (EBCD). A core research-committee studied prevalent knowledge and gaps in the area. Patients-carer and health-care stakeholders' experiences of barriers and facilitators to home care resulted in an intervention with interlinked components: family-carer training, equipment bank, m-health application, and follow-up, guided by the Medical Research Council (MRC) framework. Healthcare stakeholders (doctors, nurses, medical equipment vendors) and patient-carer dyads were engaged to gather experiences at various stages to form smaller codesign teams for each component. Multiple codesign meetings iteratively allowed refinement of the intervention over one year. The Template for Intervention Description and Replication (TIDieR) checklist was used to report the AIR intervention.

Results

The first component comprised a minimum of three bedside hands-on training sessions for carers relating to tracheostomy suction, catheter care, monitoring oxygenation, enteral feeding, skincare, and physiotherapy, buttressed by pictorial-books and videos embedded in a mobile-application. The second was an equipment-bank involving a rental-retrieval model. The third component was a novel m-health tool for two-way communication with the core group and community of other patient-carers in the project for follow-up and troubleshooting. Home visits on days 7 and 21 post-discharge assessed patient hygiene, nutrition, physiotherapy, and established contact with the nearest primary healthcare facility for the future.

Conclusions

Findings support the EBCD-based development using active feedback from stakeholders. Assessment of feasibility, process and effectiveness evaluation will follow.

Association of baseline muscle mass with functional outcomes in intensive care unit survivors: A single-center retrospective cohort study in Korea

In critical care settings, ultrasound (US) of the quadriceps muscle and Bioelectrical Impedance Analysis (BIA) are noninvasive and widely available tools to evaluate muscle mass. We studied whether baseline muscle mass affects physical function in intensive care unit (ICU) survivors after discharge. This retrospective review of a prospective cohort enrolled 30 patients admitted to the medical ICU between April 2016 and June 2018. On ICU admission, quadriceps muscle thickness and skeletal muscle mass were measured using US and BIA, respectively. Muscle strength and physical function were measured using handgrip dynamometry, the 6-min walk test, and the Barthel index questionnaire survey during every clinic visit at 1, 3, 6, and 12 months after hospital discharge. Skeletal muscle mass at ICU admission was statistically correlated with the 6-min walk distance (6MWD) and Barthel index score. The segmental lean mass of the right arm was also positively correlated with handgrip muscle strength at 6 months after discharge. Likewise, the correlation between quadriceps muscle thickness at ICU admission and 6MWD at 6 months after discharge was positive and statistically significant. Multivariate regression analysis showed that skeletal muscle mass was associated with a reduced 6MWD, but the length of ICU stay was not. The segmental lean mass of the right arm also showed a significant association with handgrip strength after discharge. Low muscle mass on ICU admission is associated with reduced muscle strength, causing impaired physical function after hospital discharge in ICU survivors.

Exploring critically ill patients' functional recovery through family partnerships: A descriptive qualitative study

BACKGROUND

Early mobilisation interventions play a role in preventing intensive care unit-acquired weakness in critically ill patients and may contribute to improved recovery. Patient-and-family-centred care includes collaborative partnerships between healthcare professionals and families and is a potential strategy to promote early mobilisation in critical care; however, we currently do not know family member preferences for partnering and involvement in early mobilisation interventions.

OBJECTIVES

The objective of this study was to explore family member perspectives on the acceptability and feasibility of partnering with healthcare professionals in early mobilisation interventions for adult critically ill patients.

METHODS

A descriptive qualitative design. Semistructured interviews were conducted with family members of adult critically ill patients admitted to an intensive care unit. Data were collected through individual audio-recorded interviews. Interview data were analysed using the six phases of thematic analysis described by Braun and Clark. This study is reported following the Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

Most family members of critically ill patients found the idea of partnering with healthcare professionals in early mobilisation interventions acceptable and feasible, although none had ever considered a partnership before. Participants thought their involvement in early mobilisation would have a positive impact on both the patient's and their own wellbeing. Themes uncovered showed that understanding family-member readiness and their need to feel welcome and included in the unfamiliar critical care environment are required before family member and healthcare professional partnerships in early mobilisation interventions can be enacted.

CONCLUSIONS

Family members found partnering with healthcare professionals in early mobilisation interventions acceptable and feasible to enact, but implementation is influenced by their readiness and sense of belonging.

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

Factors affecting perceived caregiver burden: caregivers of trauma patients discharged from the intensive care unit

Background

Caregivers to intensive care unit survivors are vulnerable to caregiver burden, which has been demonstrated to have consequences to patients' and caregivers' mental and physical health. Potentially modifiable factors should be explored so that interventions may be developed.

Methods

Ninety-one anticipated caregivers were prospectively assessed both at a southwestern trauma intensive care unit during their patient's admission and at home via remote interview 3 months after intensive care unit admission. Caregiver depression, posttraumatic stress symptoms, experiences, and perceived burden were assessed.

Results

At follow up, there was a significant negative correlation between caregiver burden and understanding of their patient's condition (P < 0.001) and intensive care unit events (P = 0.008). Caregivers with lower understanding of their patient's injury/illness had significantly greater depressive symptoms (P = 0.04).

Conclusions

Education and knowledge of intensive care unit events regarding their patient may influence perceived burden among caregivers. Interventions to orient caregivers to intensive care unit events are suggested to reduce caregiver and healthcare system burden.

The facilitators and barriers to implementing virtual visits in intensive care units: A mixed-methods systematic review

BACKGROUND

Visitation has a positive effect on patients and families, yet, it can disrupt intensive care unit (ICU) care and increase the risk of patient infections, which previously favoured face-to-face visits. The coronavirus disease 2019 (COVID-19) pandemic has raised the importance of virtual visits and led to their widespread adoption globally, there are still many implementation barriers that need to be improved. Therefore, this review aimed to explore the use of ICU virtual visit technology during the COVID-19 pandemic and the barriers and facilitators of virtual visits to improve virtual visits in ICUs.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases (CINAHL, China National Knowledge Infrastructure [CNKI], PubMed, Cochrane, VIP and Wang Fang databases) were searched for empirical studies published between 1 January 2020 and 22 October 2023. Studies that investigated and reported barriers to and facilitators of implementing virtual visits in ICUs during the COVID-19 pandemic were included. Evidence from the included studies was identified and thematically analysed using Thomas and Harden's three-step approach. Study quality was appraised with the Mixed-Methods Appraisal Tool.

RESULTS

A total of 6770 references were screened, of which 35 studies met the inclusion criteria after a full-text review. Eight main barriers to virtual visits use were identified: technical difficulties; insufficient resources; lack of physical presence and nonverbal information; low technical literacy; differences in families' perceptions of visual cues; privacy and ethics issues; inequitable access and use of virtual visit technology; and lack of advance preparation. Four facilitating factors of virtual visit use were identified: providing multidimensional professional support; strengthening coordination services; understanding the preferences of patients and their families; and enhancing privacy and security protection. In the quality appraisal of 35 studies, 12 studies were rated as low, five as medium and 18 as high methodological quality.

CONCLUSION

This review identified key facilitating factors and barriers to ICU virtual visits, which can foster the development of infrastructure, virtual visiting workflows, guidelines, policies and visiting systems to improve ICU virtual visiting services. Further studies are necessary to identify potential solutions to the identified barriers.

The Experiences of Family Members of Patients Discharged from Intensive Care Unit: A Systematic Review of Qualitative Studies

BACKGROUND

Improving the understanding of the post-discharge experiences of family members after their loved ones leave the Intensive Care Unit (ICU) is essential for developing effective follow-up strategies. These strategies are crucial for mitigating potential negative outcomes for both patients and their families. The aim of this study was to explore the lived experiences of family members after the discharge of their loved ones from the ICU.

METHODS

In September 2023, we conducted a systematic search of qualitative studies across the following databases: CINAHL, MEDLINE, Scopus and Web of Science. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used to guide this review.

RESULTS

Eight articles met the inclusion criteria. Four themes were identified following evidence synthesis: (1) grappling with a weighty burden; (2) recognizing and confronting adversities along the way; (3) seeking support beyond one's own resources; and (4) addressing comprehensive care requirements.

CONCLUSIONS

Family members face significant psychological and physical challenges while caring for their loved ones recovering from an ICU stay. Adequate formal and informal help is imperative to provide support both during hospitalization and after discharge. A refined understanding of the distinct requirements and experiences of family members can serve as a strategic framework for informing educational interventions and follow-up programs during the transition from hospital settings to community-based care. This study was not registered.

Caregiver burden and impact on COVID-19 patient participation and quality of life one year after ICU discharge - A prospective cohort study

OBJECTIVES

to investigate changes in caregiver strain, mental health complaints and QoL in caregivers of COVID-19 ICU survivors in the first year after discharge, and their associations with patients' participation and quality of life.

METHODS

Post-ICU COVID-19 survivors, needing inpatient rehabilitation and their informal caregivers were included. Caregiver self-administered questionnaires included quality of life, self-rated health, caregiver strain, anxiety and depression symptoms, post-traumatic stress and coping style. Patients' participation in society was assessed and quality of life.

RESULTS

67 patients (78% male) and 57 caregivers (23.6% male) were included. Three months post-ICU, caregivers experienced caregiver strain (32%), anxiety (41%), depressive symptoms (16%) and PTSD (24%). One year post-ICU, rates decreased, still being 11%, 26%, 10% and 5%, respectively. Caregiver anxiety symptoms and self-rated health at three months were associated with worse patient levels of participation and quality of life one year after ICU discharge (p < 0.05).

CONCLUSIONS

COVID-19 caregivers experience high levels of mental health complaints one year after a patient's ICU discharge. Furthermore, our results indicate that patient participation levels and quality of life one year after ICU discharge may be negatively associated by caregiver complaints.

PRACTICAL IMPLICATIONS

Counselling and routine assessment of emotional complaints and unmet needs of the informal caregiver should be incorporated and addressed in the rehabilitation treatment of (COVID-19) post-ICU patients.

Parents' Experiences Caring for a Child after a Critical Illness: A Qualitative Study

Objectives  This article described parents' experience and identifies outcomes important to parents following their child's critical illness. Methods  Semistructured interviews with 22 female and 4 male parents representing 26 critically ill children with predominately neurologic and respiratory diagnoses. Most children were younger than 5 years at discharge with a median (interquartile range) of 2 (2.0-3.0) years from discharge to interview. Results  Many children returned home with life-altering physical and cognitive disabilities requiring months to years of rehabilitation. Parents remembered feeling unprepared and facing an intense, chaotic time when the child first returned home. They described how they suddenly had to center their daily activities around the child's needs amidst competing needs of siblings and partners, and in some cases, the medicalization of the home. They recounted negotiating adjustments almost daily with insurance agencies, medical doctors and therapists, employers, the child, and other family members to keep the family functioning. In the long term, families developed a new norm, choosing to focus on what the child could still do rather than what they could not. Even if the child returned to baseline, parents remembered the adjustments made to keep the child alive and the family functioning. Conclusion  Heightened awareness of family experiences after pediatric critical illness will allow health care providers to improve family preparedness for the transition from hospital to home.

[Relatives after a stay on the intensive care unit: a care gap to be closed]

Structures for the care of relatives after a stay on the intensive care unit are present in principle, but no systematic interfaces between the different types of care and the care sectors exists. Therefore, in a first step, the needs of relatives during intensive care treatment should be continuously assessed and addressed as early as possible. Furthermore, proactive provision of information regarding aftercare services is necessary throughout the entire course of hospitalization and rehabilitation, but also in the phase of general practitioner care. The patient's hospital discharge letter with a detailed social history can serve information transfer at the interfaces.

Translation and Psychometric Validation of the German Version of the Iceland-Family Perceived Support Questionnaire (ICE-FPSQ): A Cross-Sectional Study

Supporting families experiencing critical illness through family interventions is essential to ease illness burden, enable family management, and reduce their risk for adverse health. Thus far, there is no validated German instrument to measure the perceived support families receive from nurses. We translated the 14-item Iceland-Family Perceived Support Questionnaire (ICE-FPSQ) and tested its psychometric properties with 77 family members of intensive care patients. Compared with the original instrument, the construct validity of the German ICE-FPSQ (FPSQ-G) showed unstable results with a partially divergent structure, most likely caused by the limited sample size. The first two principal components explained 61% of the overall variance and a good internal consistency with a Cronbach's alpha of .92. The FPSQ-G is a promising instrument to measure family members' perceptions of the support they received from nurses in the acute critical care setting but requires further validation.

Early mobility and family partnerships in the intensive care unit: A scoping review of reviews

BACKGROUND

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

AIM

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

STUDY DESIGN

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

RESULTS

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

CONCLUSIONS

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

RELEVANCE TO CLINICAL PRACTICE

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

Family Members' Engagement in Symptom Communication, Assessment, and Management in the Intensive Care Unit: A Qualitative Study

BACKGROUND

Opportunities for communication and participation in decision making are limited for critically ill patients, but family members serving as surrogates enable empowerment of these patients.

OBJECTIVE

The aim of this study was to explore family members' engagement in symptom communication in the intensive care unit.

METHODS

A qualitative descriptive design using fieldwork methodology with triangulation of participant observation and individual interviews was conducted. Nine mechanically ventilated patients were observed in interaction with family members and clinicians in the intensive care unit. Six of the observed patients, 6 family members, and 9 clinicians were interviewed after participant observation. Field notes and transcripts were analyzed using Braun and Clarke's method of thematic analysis.

RESULTS

Family members engaged actively in symptom communication, assessment, and management, and there were barriers and facilitators to family engagement. Three main themes and 9 subthemes describing family engagement emerged: (1) intermediary role (recognize and report symptoms, provide patient information, and assist in communication), (2) independent role (provide familiarity, manage symptoms, and promote patient communication), and (3) conditions for family engagement (intensive care unit environment, relationship with the patient, and patient preferences).

DISCUSSION

Family members have unique knowledge of the patient that differs from and complement the competence of the staff, and might contribute to improved symptom communication. Future research should examine how family members can contribute to symptom communication, assessment, and management.

An environmental scan of online resources for informal family caregivers of ICU survivors

PURPOSE

To collate a comprehensive repository of online resources for family caregivers of intensive care survivors to inform a recovery website and digital peer support programme.

MATERIALS AND METHODS

To identify resources, we conducted an environmental scan using processes recommended by the Canadian Agency for Drugs and Technologies in Health and guided by clinical experts, former patients, and family members. We searched internet sources, professional society websites, social media, and contacted our professional networks.

RESULTS

Through expert consultation we identified 16 information categories and found 301 online resources. Five categories with the most resources were: how to look after yourself/recognise anxiety or post-traumatic stress/getting mental health support (n = 63); information specific to conditions necessitating ICU admission (n = 49); multiple category resources (n = 46); symptoms of post-intensive care syndrome (n = 44); stories of lived experience (n = 23). Five categories with the least resources were physical, emotional and cognitive symptoms of post-intensive care syndrome-family (n = 1); interacting with primary care (n = 2); medical deterioration (how to recognise/what to do) (n = 2); driving and accessing the community (n = 3); end-of-life and bereavement (n = 5). Of these resources, we included 45 on our recovery website.

CONCLUSION

This environmental scan identifies multiple resources addressing informational needs of family caregivers and highlights areas for resource development.

Family burden after critical illness: the forgotten caregivers

OBJECTIVE

To determine the incidence of primary caregiver burden in a cohort of family members of critically ill patients admitted to ICU and to identify risk factors related to its development in both the patient and the family member.

DESIGN

Prospective observational cohort study was conducted for 24 months.

SETTING

Hospital Universitario Clínico San Cecilio, Granada.

PATIENTS

The sample was the primary caregivers of all patients with risk factors for development of PICS (Post-Intensive Care Syndrome).

INTERVENTIONS

The follow-up protocol consisted of evaluation 3 months after discharge from the ICU in a specific consultation.

MAIN VARIABLES OF INTEREST

The scales used in patients were Barthel, SF-12, HADS, Pfeiffer, IES-6 and in relatives the Apgar and Zarit.

RESULTS

A total of 93 patients and caregivers were included in the follow-up. 15 relatives did not complete the follow-up questionnaires and were excluded from the study. The incidence of PICS-F (Family Post Intensive Care Syndrome) defined by the presence of primary caregiver burden in our cohort of patients is 34.6% (n=27), 95% CI 25.0-45.7. The risk factors for the development of caregiver burden are the presence of physical impairment, anxiety or post-traumatic stress in the patient, with no relationship found with the characteristics studied in the family member.

CONCLUSIONS

One out of 3 relatives of patients with risk factors for the development of PICS presents at 3 months caregiver burden. This is related to factors dependent on the patient's state of health.

Quality of Life and Incidence of Clinical Signs and Symptoms among Caregivers of Persons with Mental Disorders: A Cross-Sectional Study

BACKGROUND

Caring for individuals with mental disorders poses significant challenges for caregivers, often leading to compromised quality of life and mental health issues such as stress, anxiety, and depression. This study aims to assess the extent of these challenges among caregivers in Greece, identifying which demographic factors influence their well-being.

METHOD

A total of 157 caregivers were surveyed using the SF-12 Health Survey for quality-of-life assessment and the DASS-21 questionnaire for evaluating stress, anxiety, and depression symptoms. t-tests, Kruskal-Wallis tests, Pearson's correlation coefficients, and regression analyses were applied to understand the associations between demographics, quality of life, and mental health outcomes.

RESULTS

The study found that caregivers, especially women and younger individuals, faced high levels of mental health challenges. Marital status, educational level, and employment status also significantly influenced caregivers' well-being. Depression was the most significant factor negatively correlating with the mental component of quality of life. The magnitude of the burden experienced by caregivers highlighted the urgency for targeted social and financial support, as well as strategic treatment programs that consider caregiver well-being.

CONCLUSIONS

Caregivers of individuals with mental disorders endure significant stress, anxiety, and depression, influencing their quality of life. Demographic factors such as age, gender, marital status, education, and employment status have notable impacts. Findings emphasize the need for society-wide recognition of caregivers' roles and the creation of comprehensive support and intervention programs to alleviate their burden, particularly in the context of the COVID-19 pandemic.

Adaptation of Caregivers of Individuals on Mechanical Ventilation to Caregiving Role

Aim

The aim of this study is to investigate the adaptation of caregivers of individuals on mechanical ventilation (MV) at home to their caregiver role.

Study design

The phenomenological research method, one of the qualitative research methods, was employed in the study.

Materials and methods

The sample consisted of 21 individuals who agreed to participate in the research. Necessary legal permissions were obtained to conduct the study.

Results

The data were analyzed according to the Roy adaptation model (RAM). Accordingly, the domains of the RAM were expressed with the following themes: Physiologic domain: The effects of care on the caregiver (reluctance toward self-care, psychological fatigue, insomnia, and limitation of social life); Self-concept domain: Supportive situations (trust in God and spiritual practices) and non-supportive situations (fear of losing and self-blame); Role-function domain: Adaptation of the caregiver role (thinking no one else can give similar care) and maladaptation of the caregiver role (fear of failing to cope with suddenly emerging situations, failing to fulfill roles and responsibilities, and economic inadequacy); Interdependence domain: Receiving support (support of healthcare professionals and support of family members) and lack of support (inadequacy of health services and loneliness).

Conclusion

It was concluded that individuals who provided care for patients on MV experienced many difficulties and that these difficulties increased their care burden and made it difficult to adapt to their caregiving roles.

How to cite this article

Aydin M, Bulut TY, Avcİ İA. Adaptation of Caregivers of Individuals on Mechanical Ventilation to Caregiving Role. Indian J Crit Care Med 2024;28(1):41-47.

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.

When chronic critical illness is a family affair: A multi-perspective qualitative study of family involvement in long-term care

OBJECTIVE

Those with chronic critical illness (CCI) remain dependent on life-sustaining treatments and increasingly reside in long-term care facilities equipped to meet their needs. The nature of family involvement in care remains undetermined thwarting approaches to mitigate poor family outcomes. The research objective was to explicate family involvement in the care of an individual with CCI who resides in long-term care.

METHODS

In this qualitative research, we used thematic analysis and constant comparative techniques to analyze data from interviews with 38 participants: 11 family members, 6 residents with CCI, and 21 healthcare providers.

RESULTS

Involvement in care entailed family: (1) reorienting their life despite the stress and emotional toll; (2) assuming responsibility for meaningful activities and management of practical matters, yet struggling alone; (3) advocating for care by being present, reminding and pushing, and picking their battles; and (4) figuring out how to contribute to nursing care, but with unclear expectations.

DISCUSSION

The burden of family caregiving was substantial, contrasting the assumption that family are relieved of their caregiver responsibilities when the patient with CCI is in a care facility. Research to address unmet family needs specific to their roles and responsibilities could potentially improve family outcomes and is warranted.

Being devastated by critical illness journey in the family: A grounded theory approach of post-intensive care syndrome-family

OBJECTIVES

This study aimed to explore the meaning and structure of postintensive care syndrome experienced by families of critically ill patients.

METHODS

This qualitative study applied the constructivist grounded theory approach and conducted one or two interviews with eight participants with postintensive care syndrome-family for a total of 12 interviews. The contents of the interviews were analysed through line-by-line coding, focused coding, and categorisation. Data collection and analysis were iterative, to enable continuous comparative analysis.

FINDINGS

The core category of postintensive care syndrome experienced by families was 'being devastated by the critical illness journey in the family' and comprised the interactions of four categories: 'overwhelming intensive care experience', 'taking responsibility for the recovery trajectory of critical illness', 'life devastated by the trauma of intensive care and family caregiving', and 'balancing and compromising'.

CONCLUSION

Based on this grounded theory approach, postintensive care syndrome experienced by families is a complex and ongoing phenomenon that arises from the recovery trajectory of a critical illness. It involves mental, physical, social and familial aspects, particularly the impact on the patient's family.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings can guide critical care nurses to understand postintensive care syndrome experienced by families in providing patient or family-centred care. To improve the long-term outcomes and quality of life for families, it is necessary to assess their unique needs within the continuum of post-intensive care syndrome experienced by the family and to propose interventions to satisfy those needs.

Impact of hospitalisation on behavioural and physiological stress responses associated with cardiovascular risk in visiting family members

BACKGROUND

The hospitalisation of a patient in intensive care impacts the psychological health of family members, with a high prevalence of anxiety, depression, and post-traumatic stress symptoms reported among families of critically ill patients. Understanding of the behavioural and physiological impact is limited and presents a new area of focus.

OBJECTIVES

The objective of this study was to evaluate behavioural and physiological stress responses of visiting family members following hospitalisation of their adult relative.

METHODS

Prospective longitudinal evaluation included 40 family members of adult patients with admission to intensive or coronary care in a large tertiary care metropolitan hospital. Assessments were conducted at three timepoints: in-hospital within 1 week of admission and 2 weeks and 3 months post discharge. Assessments included duration and quality of sleep (self-reported and actigraphy measured), physical activity, dietary and alcohol patterns, resting heart rate and blood pressure, and morning blood cortisol and lipid levels. Assessment of a reference group of 40 non-hospital-exposed control participants was also conducted.

RESULTS

At the in-hospital assessment, study participants reported lower sleep time, altered 24-h physical activity patterns, reduced dietary and alcohol intake, and higher systolic and diastolic blood pressure than a nonhospitalised reference group. Compared to in-hospital assessment, these altered behavioural and physiological responses improved over time except for systolic blood pressures which remained unchanged at 3 months post family member discharge.

CONCLUSION

Hospitalisation is associated with altered behavioural and physiological responses in family members. These findings contribute to understanding of the impact of unexpected hospitalisation on family members' cardiovascular risk factors and provide insights into potential mechanisms for the proposed increased risk during this time. Elevated systolic blood pressure at 3 months post discharge suggests a prolonged cardiovascular stress response in many family members of critical care patients that requires further study, with a focus on contributing and potential modifiable factors.

Health-related quality of life among critically ill patients after discharge from the ICU-A systematic review protocol

The impact of critical illness on patients is profound, resulting in physical, mental, and social consequences and poor health-related quality of life (HRQOL). Several studies investigated HRQOL among patients discharged from the intensive care unit (ICU). However, few systematic reviews cover studies conducted in the last decade or using valid instruments for measuring HRQOL in general ICU survivor populations. Herein, we conduct a systematic review of these studies that followed PRISMA guidelines. We will search PubMed, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, and Open Grey for papers. We will search for articles reporting the HRQOL of ICU survivors that were written in English and published from 01 January 2012 onward from the date of this protocol's publication. We will also extract HRQOL data and analyze associate factors. The risk of bias will be measured with a standard quality assessment tool. The strength of the results will depend on the number of studies and the consistency of their results. Trial registration number: PROSPERO CRD 42022304279.

Exploring family functioning and - hardiness in families' experiencing adult intensive care - A cross-sectional study

Being cared for in an intensive care unit affects both the patient being cared for and the family in various ways. The family is of great importance for the recovery of the former intensive-care patient. The aim is to explore family functioning and family hardiness in families of former intensive care patients. A cross-sectional study using two self-reported questionnaires. Former adult intensive care patients and their family were recruited to participate between December 2017 and June 2019. The data were coded and entered the Statistical Package for the Social Sciences version 25, for analysis. To explore questionnaire data, descriptive and inferential statistical analyses were performed. Scale values were calculated on, both family wise and between the patients and the family members. STROBE checklist was used. Data was collected from 60 families (60 former intensive cared patients and 85 family members) and showed that 50 families scored healthy family functioning and 52 high strengths in hardiness. The data showed small variations between and within families for family functioning and family hardiness, there were only two families scoring low for both family functioning and hardiness. The variation was higher within the families, but there was no significance level.The conclusions were that family functioning and hardiness was, to a large extent, assessed as good by the families. Nevertheless, it is important to help the family obtain information and support. So, the family need to continue to communicate, finding coping abilities and strengths in adopting new strategies to protect the family unit. The family are very important for members' mental and physical recovery as the health of one family member affects the family as a unit.

Association between psychosocial factors and satisfaction with communication in family members of intensive care unit patients during COVID-19 pandemic: An exploratory cross-sectional study

OBJECTIVE

To investigate the relationship between satisfaction with communication and perceived stress, depressive symptoms and perceived social support among family members of critically ill.

RESEARCH METHODOLOGY/DESIGN

Exploratory, cross-sectional study was conducted.

SETTING

Private teaching hospital in Santiago, Chile.

MAIN OUTCOMES MEASURES

Family members of critically ill patients with 3-7 days of stay and respiratory support were approached. Questionnaires were used to assess satisfaction with communication (Family Satisfaction in the Intensive Care Unit-24), perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9) and perceived social support (Medical Outcomes Study Social Support Survey). The relationship between satisfaction with communication and relevant variables was investigated using bivariate analyses and a beta regression.

RESULTS

The study included 42 family members, with 71.4% being female and 52.4% having prior critical care experience. There was a positive correlation between perceived stress and depressive symptoms (r = 0.32, p = 0.039). According to the beta regression, perceived social support (B; 95% confidence interval, 0.44 [1.05-2.29]) and the number of calls with unit staff (0.17 [1.06-1.32]) were positively associated with satisfaction with communication but negatively with college education (-1.86 [0.04-0.64]) and perceived stress (-0.07 [0.87-0.99]).

CONCLUSION

Psychosocial factors, such as higher educational level, perceived stress and perceived social support, can influence family members' evaluation of communication with staff. Current communication practices in acute care settings should be adapted to family members' psychosocial context to improve their satisfaction with the communication process.

IMPLICATIONS FOR CLINICAL PRACTICE

Critical care professionals must be aware of the influence of family member-related factors on the quality and effectiveness of the communication process. Psychosocial features of the family members are likely to impact their satisfaction with communication and should be assessed on admission and during their stay to assist clinicians to adjust and improve their communication practices.

Understanding the Challenges of Intensive Care Staff in Communicating With Patients and Patients' Families During the COVID-19 Crisis: A Qualitative Exploration

Background Coronavirus disease 2019 (COVID-19) isolation protocols in India restricted family members of COVID-19 patients from visiting them in hospitals and in intensive care units, especially during the peak of the pandemic. This along with the elaborate personal protective equipment (PPE) created challenges for intensivists and nurses in COVID ICUs in effectively communicating with patients and patients' families, especially in shared decision-making processes. Methods This article is the outcome of a qualitative study using in-depth one-on-one interviews with 10 intensivists and four intensive care nurses in two teaching hospitals in Bengaluru, South India. Each participant, purposively selected till data saturation was reached, had spent extensive periods of time in a COVID ICU during both COVID-19 waves in 2020 and 2021. A framework of descriptive phenomenology led to the design of the study in which varied experiences and insights of participants were captured using an interview guide to understand their lived reality. The interviews were conducted online or in person between July 2021 and October 2021 and were audio recorded and transcribed verbatim. Coding of transcripts using the NVivo 12 (Burlington, MA: QSR International Pty Ltd) software helped with the thematic analysis. This was guided by interpretive phenomenological methods that derived meaning from participants' life experiences. Results Four themes involving challenges in effective communication in the COVID ICU emerged as follows: physical barriers, emotional and mental stressors, infrastructural challenges, and ethical and moral dilemmas. Sub-themes included personal protective equipment as a barrier, reduced energy levels, and isolation of family from patients under the domain of physical challenges; fears of the unknown, handling death of patients in isolation, and the frustrations of families were challenges under the emotional and mental domain. Infrastructural/systemic challenges included poor connectivity and insufficient mobile phones, and the absence of rules to handle interruptions. Privacy breaches, taking consent over the phone, end-of-life discussions, and medico-legal risks emerged as the subthemes under the domain of ethical and moral challenges. A mobile phone communication policy specifying usage times and operating methods, a mandatory communication and counseling training module for intensivists and intensive care nurses, and a set of protocols for highly restrictive, intensive care units in pandemic situations were recommendations and lessons learned. Conclusions The lack of face-to-face interactions was a serious barrier to communication between ICU staff and patients and their caregivers. It had a bearing on trust levels and had emotional and ethical consequences for healthcare teams to handle. Opportunities for self-care, venting of anxiety and distress, and opportunities to celebrate and reward special efforts and cooperation between consultants, residents, nurses, and technicians in stressful environments like a pandemic ICU were important to sustain empathy and keep care and communication humane.

The Caregiver Pathway, a Model for the Systematic and Individualized Follow-up of Family Caregivers at Intensive Care Units: Development Study

BACKGROUND

Family caregivers of patients who are critically ill have a high prevalence of short- and long-term symptoms, such as fatigue, anxiety, depression, symptoms of posttraumatic stress, and complicated grief. These adverse consequences following a loved one's admission to an intensive care unit (ICU) are also known as post-intensive care syndrome-family. Approaches such as family-centered care provide recommendations for improving the care of patients and families, but models for family caregiver follow-up are often lacking.

OBJECTIVE

This study aims to develop a model for structuring and individualizing the follow-up of family caregivers of patients who are critically ill, starting from the patients' ICU admission to after their discharge or death.

METHODS

The model was developed through a participatory co-design approach using a 2-phased iterative process. First, the preparation phase included a meeting with stakeholders (n=4) for organizational anchoring and planning, a literature search, and interviews with former family caregivers (n=8). In the subsequent development phase, the model was iteratively created through workshops with stakeholders (n=10) and user testing with former family caregivers (n=4) and experienced ICU nurses (n=11).

RESULTS

The interviews revealed how being present with the patient and receiving adequate information and emotional care were highly important for family caregivers at an ICU. The literature search underlined the overwhelming and uncertain situation for the family caregivers and identified recommendations for follow-up. On the basis of these recommendations and findings from the interviews, workshops, and user testing, The Caregiver Pathway model was developed, encompassing 4 steps: within the first few days of the patient's ICU stay, the family caregivers will be offered to complete a digital assessment tool mapping their needs and challenges, followed by a conversation with an ICU nurse; when the patient leaves the ICU, a card containing information and support will be handed out to the family caregivers; shortly after the ICU stay, family caregivers will be offered a discharge conversation by phone, focusing on how they are doing and whether they have any questions or concerns; and within 3 months after the ICU stay, an individual follow-up conversation will be offered. Family caregivers will be invited to talk about memories from the ICU and reflect upon the ICU stay, and they will also be able to talk about their current situation and receive information about relevant support.

CONCLUSIONS

This study illustrates how existing evidence and stakeholder input can be combined to create a model for family caregiver follow-up at an ICU. The Caregiver Pathway can help ICU nurses improve family caregiver follow-up and aid in promoting family-centered care, potentially also being transferrable to other types of family caregiver follow-up.

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

OBJECTIVES

To explore perspectives and wishes for patient and family centred care among adult patients and family-members with recent experience of admission to an adult intensive care unit.

RESEARCH DESIGN

An explorative descriptive study using an inductive thematic analysis. Semi-structured interviews with adults (≥18 years) who had experienced admission ≥48 hours to an adult intensive care unit as a patient or family-member within the previous three months. Interview data were analysed used the six phases of thematic analysis, described by Braun and Clarke. Semi-structured interviews with adults (≥18 years) who had experienced admission ≥48 hours to an adult intensive care unit as a patient or family-member within the previous three months. Interview data were analysed used the six phases of thematic analysis, described by Braun and Clarke.

SETTING

Participants were recruited from six general (mixed surgical and medical) units in the Capital Region of Denmark.

FINDINGS

From fifteen interviews a total of 23 participants (8 patients and 15 family-members) described their perspectives and wishes for patient- and family-centred care. Three main themes were identified: 1) Ongoing dialogue is fundamental. Both scheduled and spontaneous information-sharing is important. 2) Humanizing. High-quality treatment was especially evident for participants when staff maintain a humanized attitude. 3) Equipping family to navigate. We found a range of specific suggestions of attention that may help patients and family-members to navigate during admission.

CONCLUSIONS

We found that patients' and family-members' perspectives and wishes for PFCC centred around ongoing dialogue with staff and the importance of humanizing the ICU environment. Patients and family members needed to share and have their knowledge, concerns and perspectives brought forth and acknowledged by staff. Participants emphasized the pivotal role staff have in equipping patients and family-members to cope in the unit and supporting specifically family-members in fulfilling their role as advocates and supporters of the patient.

Physical, social, mental and spiritual functioning of COVID-19 intensive care unit-survivors and their family members one year after intensive care unit-discharge: A prospective cohort study

OBJECTIVE

To describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain.

DESIGN

A single-centre, prospective cohort study with a mixed-methods design.

SETTING

The intensive care unit of the University Medical Center Groningen in the Netherlands.

MAIN OUTCOME MEASURES

To study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members.

RESULTS

A total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0-68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43-66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was 'returning to normal' in the interviews with survivors and 'if the patient is well, I am well' in the interviews with family members.

CONCLUSIONS

One year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members' well-being is strongly impacted by the health of the survivor.

Cultural adaptation and psychometric properties of the Chilean-Spanish version of the Family Satisfaction in the Intensive Care Unit - 24 questionnaire

OBJECTIVE

To adapt and validate the Spanish version of the Family Satisfaction in the Intensive Care Unit - 24 (FS ICU-24) questionnaire among relatives of critically ill patients in a teaching hospital in Chile.

DESIGN

Prospective observational study aimed to validate a measuring instrument.

SETTING

Medical-surgical intensive care unit (ICU) of a teaching hospital in Chile.

PATIENTS OR PARTICIPANTS

Two hundred and forty relatives of critically ill patients with at least48 h in the ICU, older than 18 years, and with at least one visit to the patient.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Content validity, construct validity, and reliability analysis of the Spanish version of the FS ICU-24 were evaluated.

RESULTS

The Spanish version of the FS ICU-24 was adapted, improving its understanding and clarity. The factor analysis showed an optimal solution of 3 factors for the Chilean-Spanish version of the FS ICU-24, which explain 51% of the total variance. Reliability was adequate for the global scale (α = 0.93) and the dimensions of satisfaction with patient and family care (α = 0.82), satisfaction with communication (α = 0.91) and satisfaction with decision-making (α = 0.71).

CONCLUSIONS

The Chilean-Spanish version of the FS ICU-24 proved to be valid and reliable for the evaluation of family satisfaction in the ICU. Having a valid instrument will allow health institutions to accurately identify areas for improvement in the care of the family members and the critically ill patient.

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

IMPORTANCE

Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness.

OBJECTIVE

To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients.

DESIGN, SETTING, AND PARTICIPANTS

The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022.

EXPOSURES

Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90).

MAIN OUTCOMES AND MEASURES

Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality.

RESULTS

The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28.

CONCLUSIONS AND RELEVANCE

In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.

Factors Affecting Psychological Distress in Family Caregivers of Critically Ill Patients: A Qualitative Study

BACKGROUND

Family caregivers often experience psychological distress during a critical care hospitalization, potentially compromising their ability to function effectively in a supportive role. A better understanding of the sources of family caregiver distress is needed to inform strategies to mitigate its development and impact.

OBJECTIVE

To explore sources of family caregiver psychological distress during a critical care hospitalization and how caregivers' experiences may differ by their anxiety level.

METHODS

Forty adult family members of patients receiving mechanical ventilation for more than 72 hours in 2 intensive care units at an academic medical center were interviewed. A qualitative directed content analysis was done. Experiences were compared by anxiety level group, defined using the Hospital Anxiety and Depression Scale: anxiety (n = 15), borderline anxiety (n = 11), and low anxiety (n=14).

RESULTS

Most family members (32%) were adult children; no major demographic differences were noted across anxiety groups. Among caregivers in the anxiety group, salient factors included early unknowns around critical illness, health care team processes, care decisions made, financial and housing concerns, family dysfunction, and new responsibilities. In general, low-anxiety family caregivers did not express their concerns using language of distress but rather expressed emotion and disappointment and often took action to process their concerns.

CONCLUSIONS

Factors influencing family caregiver distress during the critical care stay were wide-ranging and varied by level of anxiety. The findings highlight several key areas and potential interventions to reduce psychological distress, especially among caregivers with anxiety.

Experience of relatives in the first three months after a non-COVID-19 Intensive Care Unit discharge: a qualitative study

Background

The novel coronavirus brought Intensive Care Units (ICUs) back to their past when they were closed to family members. The difficulties of family caregivers encountered after the ICU discharge might have been increased during the coronavirus disease 2019 (COVID-19) pandemic. However, no traces of their experience have been documented to date. The objective of this study is to explore the everyday life experience of relatives in the first three months after a non-COVID-19 ICU discharge.

Methods

A descriptive qualitative study was conducted in 2020–2021. Two Italian general non-COVID-19 ICUs were approached. Follow-up telephone interviews were conducted three months after the ICU discharge. The study has been conducted according to the COnsolidated criteria for REporting Qualitative research principles.

Results

A total of 14 family members were interviewed. Participants were mostly females (n = 11; 78.6%), with an average age of 53.9 years. After three months of care of their beloved at home, relatives’ experience is summarised in three themes: “Being shaken following the ICU discharge”, as experiencing negative and positive feelings; “Returning to our life that is no longer the same”, as realising that nothing can be as before; and “Feeling powerless due to the COVID-19 pandemic”, given the missed care from community services and the restrictions imposed.

Conclusions

Relatives seem to have experienced a bilateral restriction of opportunities – at the hospital without any engagement in care activities and their limited possibility to visit the ICU, and at home in terms of formal and informal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01720-z.

The impact of an intensive care unit admission on the health status of relatives of intensive care survivors: A prospective cohort study in primary care

Background

Relatives of intensive care unit (ICU) survivors may suffer from various symptoms after ICU admittance of their relative, known as post-intensive care syndrome-family (PICS-F). Studies regarding PICS-F have been performed but its impact in primary care is unknown.

Objectives

To explore health problems of relatives of ICU survivors in primary care.

Methods

This is an exploratory prospective cohort study in which we combined data from two hospitals and a primary care research network in the Netherlands. ICU survivors who had been admitted between January 2005 and July 2017 were identified and matched by sex and age with up to four chronically ill (e.g. COPD, cardiovascular disease) patients. In both groups, relatives living in the same household were identified and included in this study. Primary outcome was the number of new episodes of care (International Classification of Primary Care-2) for up to five years. Hazard ratios (HRs) for the total number of new episodes were calculated.

Results

Relatives of ICU survivors (n = 267, mean age 38.1 years, 41.0% male) had significantly more new care episodes compared to the reference group (n = 705, mean age 36.3 years, 41.1% male) 1–2 years (median 0.11 vs. 0.08, HR 1.26; 95% confidence interval (CI) 1.03–1.54) and 2–5 years (median 0.18 vs. 0.13, HR 1.28; 95%CI 1.06–1.56) after ICU discharge. No differences were found in the period before ICU admission.

Conclusion

Relatives of ICU survivors present more morbidity in primary care than relatives of chronically ill patients up to five years after ICU discharge.

Prevalence and factors associated with symptoms of depression in family members of people hospitalized in the intensive care unit

OBJECTIVE

To evaluate the prevalence and factors associated with depression in family members of people hospitalized in intensive care units.

METHODS

A cross-sectional study was conducted with 980 family members of patients admitted to the intensive care units of a large public hospital in the interior of Bahia. Depression was measured using the Patient Health Questionnaire-8. The multivariate model consisted of the following variables: sex and age of the patient, sex and age of the family member, education level, religion, living with the family member, previous mental illness and anxiety.

RESULTS

Depression had a prevalence of 43.5%. In the multivariate analysis, the model with the best representativeness indicated that factors associated with a higher prevalence of depression were being female (39%), age younger than 40 years (26%) and previous mental illness (38%). A higher education level was associated with a 19% lower prevalence of depression in family members.

CONCLUSION

The increase in the prevalence of depression was associated with female sex, age younger than 40 years and previous psychological problems. Such elements should be valued in actions aimed at family members of people hospitalized in intensive care.

The influence of nurse characteristics on practice skills and attitudes towards working with families in critical care: A regression analysis

OBJECTIVES

The study aimed to identify nurse characteristics that influence their self-perceived practice skills in working with families and their attitudes towards engaging families in adult and neonatal intensive care units.

RESEARCH METHODOLOGY/DESIGN

Secondary data analysis using a descriptive, cross-sectional design.

SETTING

An online survey was completed by 256 nurses from six adult intensive (73% response rate) and two neonatal intensive and one intermediate care unit (27% response rate) in a Swiss, university affiliated hospital.

MAIN OUTCOME MEASURES

Nurses' self-perceived practice skills in working with families were assessed with the "Family Nursing Practice Scale". Attitudes towards families were measured with the "Families' Importance in Nursing Care - Nurses' Attitudes Scale". Data were analysed with multiple linear regression models.

RESULTS

Prior education in family nursing significantly influenced nurses' self-perceived practice skills in working with families. Nurses' clinical speciality had a significant influence on their attitudes towards overall, and on the subscale "family as a burden". Neonatal intensive care nurses showed more open attitudes towards families overall, but perceived family more often as a burden than nurses in adult intensive care. Nurses' perceived skills and attitudes in family engagement significantly influenced each other.

CONCLUSION

The results suggest that nurses' prior education in family nursing and clinical speciality determine their ability to work with and engage families in critical care. Our study suggests that integration of family nursing engagement practices in critical care requires educational implementation strategies combined with culture change efforts.

Patient Experiences after Physical Trauma: The Negative Effect of the COVID-19 Pandemic on Recovery

The coronavirus disease 2019 (COVID-19) pandemic generated a crisis within the healthcare system, during which acute, COVID-19-related health needs were prioritized over less urgent needs, including vulnerable subgroups. This study explored experiences of recovery among survivors of physical injuries associated with severe pain during the COVID-19 pandemic in Norway. In-depth interviews were conducted among 13 participants. Findings generated by a thematic analysis revealed that the pandemic, including the contagion control measures and interrupted healthcare, were of negative consequence for the participants' recovery experiences and mental and physical health. Despite experiencing severe pain and perceived needs for support, the participants experienced being deprioritized by the healthcare system. They experienced a reduced capacity to cope with pandemic-related stress and to perform everyday tasks, which they perceived as generating an additional burden for their loved ones. Alcohol was reported to be used in an effort to relieve the associated mental distress. As suggested by this study, injury survivors constitute a vulnerable subgroup for whom the continuity of rehabilitation services during a national crisis, as well as the integration of mental health support, can be essential for mitigating the negative impact of the crisis on recovery and for promoting optimal long-term health outcomes.

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.

Psychological distress and morbidity of family members experiencing virtual visiting in intensive care during COVID-19: an observational cohort study

Purpose

During the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world introduced virtual visiting to mediate the psychological impact of in-person visiting restrictions. Our objective was to evaluate levels of distress, depression, anxiety, and stress among family members experiencing virtual visits.

Methods

Multi-centre prospective observational study recruiting adult family members of critically ill patients in the United Kingdom (UK) using a bespoke virtual visiting solution (aTouchAway). We recruited participants and administered validated questionnaires digitally via their aTouchAway account. Prior to first virtual visit, participants completed the Distress Thermometer (score range 0–10) and the Depression, Anxiety and Stress Scale (DASS)-21. Following first and subsequent virtual visits, participants repeated the Distress Thermometer and completed the Discrete Emotions Questionnaire.

Results

We recruited 2166 adult family members of ICU patients in 37 UK hospitals. Most were grown up children (33%) or spouses/partners (23%). Most (91%) were ≤ 65 years. Mean (SD) pre-virtual-visit Distress Thermometer score was 7 (2.6) with 1349/2153 (62%) reporting severe distress. Pre-visit Distress Thermometer scores were associated with relationship type (spouse/partner OR 1.65, 95% CI 1.27–2.12) but not family member age, or length of ICU stay. Mean (SD) post-visit Distress Thermometer score provided by 762 (35%) participants was 1.6 (3.2) points lower than pre-visit (P < 0.001). Of participants experiencing multiple visits, 22% continued to report severe distress. Median (IQR) pre-visit DASS-21 score was 18 (2–42) (1754 participants). Severe-to-extremely severe depression, anxiety, or stress were reported by 249 (14%), 321 (18%), and 165 (9%) participants, respectively. Participants reported a range of emotions with reassurance being the most common, anger being the least.

Conclusion

Family members exposed to COVID-19 pandemic ICU visiting restrictions experienced severe distress. One fifth of family members reported severe-to-extremely sever anxiety or depression. Distress score magnitude and prevalence of severe distress decreased after undertaking one or more virtual visits.

A multicomponent family support intervention in intensive care units: study protocol for a multicenter cluster-randomized trial (FICUS Trial)

BACKGROUND

Family members of critically ill patients face considerable uncertainty and distress during their close others' intensive care unit (ICU) stay. About 20-60% of family members experience adverse mental health outcomes post-ICU, such as symptoms of anxiety, depression, and posttraumatic stress. Guidelines recommend structured family inclusion, communication, and support, but the existing evidence base around protocolized family support interventions is modest and requires substantiation.

METHODS

To test the clinical effectiveness and explore the implementation of a multicomponent, nurse-led family support intervention in ICUs, we will undertake a parallel, cluster-randomized, controlled, multicenter superiority hybrid-type 1 trial. It will include eight clusters (ICUs) per study arm, with a projected total sample size of 896 family members of adult, critically ill patients treated in the German-speaking part of Switzerland. The trial targets family members of critically ill patients with an expected ICU stay of 48 h or longer. Families in the intervention arm will receive a family support intervention in addition to usual care. The intervention consists of specialist nurse support that is mapped to the patient pathway with follow-up care and includes psycho-educational and relationship-focused family interventions, and structured, interprofessional communication, and shared decision-making with families. Families in the control arm will receive usual care. The primary study endpoint is quality of family care, operationalized as family members' satisfaction with ICU care at discharge. Secondary endpoints include quality of communication and nurse support, family management of critical illness (functioning, resilience), and family members' mental health (well-being, psychological distress) measured at admission, discharge, and after 3, 6, and 12 months. Data of all participants, regardless of protocol adherence, will be analyzed using linear mixed-effects models, with the individual participant as the unit of inference.

DISCUSSION

This trial will examine the effectiveness of the family support intervention and generate knowledge of its implementability. Both types of evidence are necessary to determine whether the intervention works as intended in clinical practice and could be scaled up to other ICUs. The study findings will make a significant contribution to the current body of knowledge on effective ICU care that promotes family participation and well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05280691 . Prospectively registered on 20 February 2022.

Experiences of nurses with an innovative digital diary intervention in the intensive care unit: A qualitative exploration

INTRODUCTION

Diaries have been used regularly in various intensive care units (ICUs) in international settings. Hard copy diaries written by relatives became impractical during the COVID-19 pandemic due to ICU visiting restrictions and infection control considerations. The implementation of a web based application, named the "Post-ICU" diary, offered relatives the ability to collaboratively write in a digital diary, to easily upload photos, video and audio clips and to feel engaged with the patient at a safe distance. In addition it allowed nurses to easily provide up-to-date information. The aim of this pilot study was to explore the experiences of ICU nurses with the implementation process and application of the Post-ICU diary.

METHODS

A multicentre qualitative design with focus group interviews was used with ICU nurses in November 2020. Interview data were audiotaped and transcribed verbatim, and then a thematic analysis was performed to categorize the data.

RESULTS

Participants from three hospitals (n = 14), 57% of whom were women, with a mean age of 40.6 years, described their experiences with the Post-ICU diary. The following themes emerged: implementation process, COVID-19, integration, and motivation. The results showed that ICU nurses perceived the Post-ICU diary to be applicable in daily care and endorsed the added value of the digital Post-ICU diary as a new opportunity to improve interhuman connectedness. However, the nurses also experienced barriers such as non-user-friendly access, lack of time and hesitance to write short messages.

CONCLUSION

ICU nurses reported that the Post-ICU diary had added value for patients and their relatives. However, in the beginning they also experienced barriers such as lack of time, insufficient integration with their own work processes, and challenges regarding writing short messages themselves. For structural embedding of the intervention, tailored strategies are needed to support ICU nurses in using this innovative Post-ICU diary.

Professionals' narratives of interactions with patients' families in intensive care

Background: ICU patients' family members are in a new, uncertain, and vulnerable situation due to the patient's critical illness and complete dependence on the ICU nurses and physicians. Family members' feeling of being cared for is closely linked to clinicians' attitudes and behavior.Aim: To explore ICU nurses' and physicians' bedside interaction with critically ill ICU patients´ families and discuss this in light of the ethics of care.Research design: A qualitative study using participant observation, focus groups, and thematic narrative analysis.Participants and research context: Data were gathered from July 2017 to August 2019, in four ICUs in Norway through 270 h of fieldwork and seven focus groups with ICU nurses and physicians.Ethical considerations: The Regional Committee for Medical and Health Research Ethics and the Norwegian Centre for Research Data approved the study. Findings: Quality of ICU family care depends on nurses' and physicians' attitudes, behavior, and personality traits. Three main themes were identified: being attentive, an active approach, and degree of tolerance.Discussion: The findings are discussed in light of the ethics of care and empirical research from the intensive care environment.Conclusions: This study shows that attentive, active, and tolerant clinicians represent a culture of ethical care that gives families greater freedom of action and active participation in patient care. Clinicians must not bear sole responsibility for this culture; it must have a firm basis in the hospital and ICU and be established through training, interprofessional reflection, and support of clinicians.