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

Predictors of Complicated Grief in Caregivers of Palliative Care Patients

Introduction: It is important to identify the factors s associated with complicated grief (CG) in order to prevent it. Objective: To determine the factors associated with CG in the end-of-life phase within the palliative care context. Method: The PRISMA model was followed for the review. We accessed the following databases: PUBMED, SCOPUS, and PsycoINFO, to review publications from 2006. Results: A total of 17 studies were obtained. A direct relationship between factors prior to bereavement and CG is established: intensity of anticipated grief, previous mental and physical health of the caregiver, social support; quality of patient care, communication at the end-of-life, preparation for death, spirituality, and sociodemographic factors. Conclusions: Previous mental health and level of anticipatory grief in the main caregiver are shown to be the most powerful predictors of CG. Patient age and quality of care are factors considered as strong predictors of CG in almost every study.

Strategies for Coping With Complicated Grief in Relatives of Patients Who Are Critically Ill: An Observational Single-Center Cohort Study

BACKGROUND

Relatives of patients who are critically ill who die are at high risk for symptoms of complicated grief (CG) with potential individual and social burdens. The prevalence and predictors of CG, and in particular the involvement of individual facets of relatives' coping strategies, are not well understood.

RESEARCH QUESTION

How high is the prevalence and what are the predictors of CG, and how are coping strategies associated with CG symptoms?

STUDY DESIGN AND METHODS

In this observational single-center cohort study, relatives of patients who are critically ill who died while in the ICU were surveyed 6 months later, using the Inventory of Complicated Grief (ICG) and the Brief Coping Orientation to Problems Experienced questionnaire, to assess CG symptoms and coping strategies, respectively. Patients' and relatives' characteristics were obtained. The primary outcome was the ICG sum score.

RESULTS

Relatives of 89 of the 298 patients who died in the ICU during the study period were included. The mean ± SD ICG sum score was 41.6 ± 10.9. Eighty-four relatives (94.4%) had an ICG score ≥ 25. Multivariable analysis revealed that being a partner significantly affected the ICG sum score (coefficient, 4.9; 95% CI, 1.8 to 8.0; P = .003), as did the coping strategies of self-distraction (coefficient, 4.4; 95% CI, 2.5 to 6.3; P < .001), acceptance (coefficient, -4.4; 95% CI, -6.3 to -2.5; P < .001), and self-blame (coefficient, 3.8; 95% CI, 1.4 to 6.3; P = .002).

INTERPRETATION

Almost all relatives of deceased patients who are critically ill exhibit symptoms of CG. Relatives' functional and dysfunctional coping strategies may be associated with their CG symptoms. Knowledge of individual relatives' coping strategies may be helpful in supporting them. Adequate supportive interventions should be developed.

Development and evaluation of a Hospice Foundation of Taiwan Bereavement Assessment Scale: A psychometric properties test

OBJECTIVES

Supporting family caregivers (FCs) is a critical core function of palliative care. Brief, reliable tools suitable for busy clinical work in Taiwan are needed to assess bereavement risk factors accurately. The aim is to develop and evaluate a brief bereavement scale completed by FCs and applicable to medical staff.

METHODS

This study adopted convenience sampling. Participants were approached through an intentional sampling of patients' FCs at 1 palliative care center in Taiwan. This cross-sectional study referred to 4 theories to generate the initial version of the Hospice Foundation of Taiwan Bereavement Assessment Scale (HFT-BAS). A 9-item questionnaire was initially developed by 12 palliative care experts through Delphi and verified by content validity. A combination of exploratory factor analysis (EFA), reliability measures including items analysis, Cronbach's alpha and inter-subscale correlations, and confirmatory factor analysis (CFA) was employed to test its psychometric properties.

RESULTS

Two hundred seventy-eight participants conducted the questionnaire. Three dimensions were subsequently extracted by EFA: "Intimate relationship," "Existential meaning," and "Disorganization." The Cronbach's alpha of the HFT-BAS scale was 0.70, while the 3 dimensions were all significantly correlated with total scores. CFA was the measurement model: chi-squared/degrees of freedom ratio = 1.9, Goodness of Fit Index = 0.93, Comparative Fit Index = 0.92, root mean square error of approximation = 0.08. CFA confirmed the scale's construct validity with a good model fit.

SIGNIFICANCE OF RESULTS

This study developed an HFT-BAS and assessed its psychometric properties. The scale can evaluate the bereavement risk factors of FCs in clinical palliative care.

Psychological symptoms, quality of life and dyadic relations in family members of intensive care survivors: a multicentre, prospective longitudinal cohort study

BACKGROUND

There is scarce literature evaluating long term psychological or Quality of Life (QoL) outcomes in family members of ICU survivors, who have not experienced invasive ventilation. The objective was to compare long-term psychological symptoms and QoL outcomes in family members of intubated versus non-intubated ICU survivors and to evaluate dyadic relationships between paired family members and survivors.

METHODS

Prospective, multicentre cohort study among four medical-surgical ICUs in Australia. Adult family members of ICU survivors and family-survivor dyads had follow-up assessments (3 and 12 months after ICU discharge), using Impact of Event Scale-Revised; Depression, Anxiety Stress Scales-21; EQ-5D-5L. Dyadic relationships examined associations of psychological symptoms or QoL impairments.

RESULTS

Of 144 family members (75% female, 54% partners/spouses) recruited, 59% cared for previously intubated survivors. Overall, 83% (110/132) of eligible family members completed ≥ 1 follow-up. In family members of intubated vs non-intubated survivors, clinically significant psychological symptoms (PTSD/depression/anxiety) were reported by 48% vs 33% at 3-months (p = 0.15); and 39% vs 25% at 12-months (p = 0.23). Family self-rated their QoL with a mean score of 83 (SD 13) on a visual analogue scale (range 0-100), and > 30% reported problems in pain/discomfort or anxiety/depression domains at 12-months. Family members were more likely to have persistent psychological symptoms of PTSD [OR 4.9, 95% CI (1.47-16.1), p = 0.01] or depression [OR 14.6, 95% CI (2.9-72.6), p = 0.001]; or QoL domain problems with pain/discomfort [OR 6.5, 95% CI (1.14-36.8), p = 0.03] or anxiety/depression [OR 3.5, 95% CI (1.02-12.1), p = 0.04], when the paired survivor also reported the same symptoms.

CONCLUSIONS

Almost one-third of the family members of ICU survivors reported persistent psychological symptoms and QoL problems at 12-months. There was a noticeable dyad effect with family members more likely to have persistent symptoms of PTSD, depression, and problems in QoL domains when the paired ICU survivors experienced similar symptoms. The family members of non-intubated ICU survivors had an equal propensity to develop long-term psychological distress and should be included in long-term outcome studies. Future recovery intervention trials should be aimed at ICU family-survivor dyads. Trial registration ACTRN12615000880549.

The Grief of Older Parents Over the Loss of a Child: A Scoping Review

Aging brings physical, psychological, and social changes, often accompanied by significant life events like the death of a loved one. One of the most devastating losses is the death of a child, which profoundly impacts older parents. This scoping review examines 47 studies on the effects of such grief, highlighting increased death anxiety, elevated mortality risk, psychological distress, and the role of social isolation in intensifying grief. Cultural factors, including stigma, further complicate the mourning process. The findings reveal that prolonged grief, social withdrawal, and declining health are common among bereaved older parents. These results underscore the urgent need for tailored interventions and support networks to mitigate the psychological and social consequences of this profound loss. Addressing this critical issue can improve the well-being of older parents, making it a vital area for further research and intervention.

How bereaved families conceptualise good care and communication in intensive care in South Australia

Since 2018, DonateLife South Australia and the Royal Adelaide Hospital (RAH) have collaborated to deliver routine family follow-up after bereavement in the intensive care unit (ICU). This follow-up includes a telephone interview that invites bereaved family members to comment on the quality of care and communication experienced in the ICU. To identify bereaved families' experiences, including how they conceptualise good care and communication in intensive care, an analysis was conducted on all qualitative data collected during 118 interviews completed between 1 February 2018 and 30 May 2019. Reflexive thematic analysis was undertaken in an inductive and semantic way, with coding and theme generation being directed by the explicit content of the data, as conceptualised by Braun and Clarke. Initial codes were based on the interview questions, then additional codes were created during data analysis. Coding was informed by philosophical insights about concepts and the spirit of interpersonal engagement developed by Wittgenstein and Cordner, respectively. A concept map of the relationships observed between patterns of meaning in the data was created. Participants deeply appreciated staff providing them and their loved one with practical expressions of care and hospitality, however modest. These, along with staff sometimes crossing professional boundaries, expressed staff's spirit of engagement, which in turn helped to maintain the patient's dignity. Private space also helped to maintain the patient's dignity, and it helped family to have enough time to say goodbye. Family not feeling rushed and being informed about their loved one dying also helped family to have enough time to say goodbye. Being informed depended on the quality of doctors' communication. When family were not clearly informed, or had to wait long periods, they felt rushed and that they did not have enough time to say goodbye. Documents written to guide the assessment of intensive care comment on almost all of these matters, but the present study newly maps how they interact based on the extensive empirical evidence that it collected. Guidance documents should comment on giving staff scope to occasionally traverse a boundary, such as an institutional border or rule, to better support the patient and family, since families experience exceptionless practice insensitive to context as callous or disruptive of care.

Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates

BACKGROUND

Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates' PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care.

METHODS

Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors.

RESULTS

Most surrogates were female (59.1%), the patient's adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult-child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class.

CONCLUSIONS

Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support.

The role of women in the field of early intervention

This study examines the intersection of early intervention and the role of women as primary caregivers for children with disabilities. Studies for this analysis were collected through a meticulous search in the Web of Science (WoS) and Scopus databases. This process ensured the inclusion of a wide range of relevant literature from the field of study. A rigorous procedure of identification, selection, eligibility assessment, and inclusion of potentially relevant studies in this research area was conducted. We analyzed 130 articles, identifying 8 key research areas. Significant factors include the impact on parental interactions, communication skills, the role of women in developmental disabilities, mothers' understanding of their children's disabilities, emotional overload, parental stress, and psychological aspects. These factors significantly affect the well-being and development of mothers and children with disabilities. The study also considers the impact on women's careers. While research on psychological aspects and maternal overload is well-developed, establishing early intervention systems to optimize resources for proper child development is a challenge. The findings have high social value, paving the way for improving the quality of early childhood services.

Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe.

AIM

Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12-18 months post-death.

DESIGN

Prospective matched cohort study.

SETTINGS/PARTICIPANTS

Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID -ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG).

RESULTS

Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12-18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID -ve, pre-COVID) or physical presence of the family member in the final 48 h of life.

CONCLUSIONS

Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.

Factors associated with grief in informal carers of people living with Motor Neuron Disease: A mixed methods systematic review

The purpose of this mixed methods systematic review was to identify factors associated with anticipatory grief, post-death grief, and prolonged grief in informal carers of people living with Motor Neuron Disease (MND) to inform future research and practice. Six electronic databases were searched and two quantitative and eight qualitative studies were identified. Five overarching themes were generated through thematic synthesis. The findings suggest that there are factors that may affect different grieving processes. It might be particularly important to target some factors prior and after the death of the person living with MND such as the knowledge about the progression of the disease, changes in relationships, anxiety and depressive symptoms of carers, and planning for death of the care recipient. Factors that may affect all three grieving processes were also identified such as negative experiences of caregiving, experiences of losses, end of life and psychological support, and emotional avoidance coping.

Risk factors for prolonged grief symptoms: A systematic review and meta-analysis

BACKGROUND

The diagnosis Prolonged Grief Disorder (PGD) has recently been included in ICD-11 and DSM-5-TR. To identify individuals who need help coping with grief, knowledge is needed about who is at risk of developing PGD. We, therefore, conducted a comprehensive systematic review and meta-analysis of the available literature on risk factors for prolonged grief symptoms (PGS).

METHODS

Based on a literature search in PsycInfo, PubMed, Web of Science, and CINAHL, we included the most frequently investigated risk factors in a meta-analysis. The effect size correlation was used as the standardized measure of the strength of the association between the risk factor and PGS.

RESULTS

Based on 120 studies of 61.580 participants published between 1989 and 2023, 19 risk factors were included in the meta-analysis. For the adjusted associations, the strongest associations with PGS were pre-loss grief symptoms (ESr = 0.39, 95%CI[0.24-0.53]) and depression (ESr = 0.30, 95%CI[0.13-0.44]). Small, but statistically significant associations were observed for unexpected death, violent/unnatural death, low educational level, low income, female gender, anxious attachment style, and death of a child or partner.

CONCLUSIONS

An updated overview of risk factors for PGS is presented, including their predictive strength. The results offer knowledge that can aid prevention and early identification of people at risk of PGD.

Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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