Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU

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

OBJECTIVES

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

DESIGN

Prospective, longitudinal, observational study.

SETTING

Medical ICUs at two academically affiliated medical centers in Taiwan.

PATIENTS/PARTICIPANTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication

Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.

Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives

BACKGROUND

In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard.

METHODS

A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data.

RESULTS

Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role.

CONCLUSIONS

As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.

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.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Advances in post intensive care unit care: A narrative review

As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-Care and Family/Surrogate Decision-Maker Data

BACKGROUND

To facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDEs) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC.

METHODS

To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the National Institutes of Health/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core", "basic", "exploratory", or "supplemental", as well as their use for studying the acute or chronic phase of DoC, or both.

RESULTS

We identified 32 relevant preexisting National Institutes of Health CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup.

CONCLUSIONS

Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application

In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.

Cognitive Biases and Shared Decision Making in Acute Brain Injury

Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-care and Family/Surrogate Decision-Maker Data

INTRODUCTION

In order to facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDE) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC.

METHODS

To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the NIH/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core," "basic," "exploratory," or "supplemental," as well as their utility for studying the acute or chronic phase of DoC, or both.

RESULTS

We identified 32 relevant pre-existing NIH CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup.

CONCLUSIONS

Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.

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

BACKGROUND/OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician

BACKGROUND

Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting.

RESEARCH QUESTION

Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician?

STUDY DESIGN AND METHODS

A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores.

RESULTS

In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model.

INTERPRETATION

The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.

Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time

BACKGROUND

Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time.

OBJECTIVE

Assess caregivers' EOL care goal for PWSDs and change in these goals over time.

METHODS

Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point.

RESULTS

At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals.

CONCLUSION

Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.

Associations between Mental Health and COVID-19 Status among 18- and 19-Year-Old Adolescents: A Multi-Country Study

The aim of this study was to describe the mental health status of 18- and 19-year-old adolescents who were infected or affected by COVID-19 during the first wave of the COVID-19 pandemic. This was a secondary analysis of a dataset collected from 152 countries between July and December 2020. Dependent variables were anxiety, depression, and post-traumatic stress symptoms. The independent variable was COVID-19 status (tested positive for COVID-19, had COVID-19 symptoms but did not test, had a close friend who tested positive for COVID-19, knew someone who died from COVID-19). Three multivariable logistic regression analyses were conducted to determine the associations between the dependent and independent variables while adjusting for confounding variables (sex—male, female, and country income level). Data of 547 participants were extracted, and 98 (17.9%) had experienced depression, 130 (23.8%) had experienced anxiety, and 219 (40.0%) had experienced post-traumatic stress symptoms. Knowing someone who died from COVID-19 was associated with significantly lower odds of having post-traumatic stress symptoms (AOR: 0.608). Having COVID-19 symptoms but not getting tested was associated with significantly higher odds of having anxiety symptoms (AOR: 2.473). Results indicate diverse mental health responses among adolescents aged 18–19-years old as a sequela of COVID-19. This needs to be studied further.

Differences in Physical Activity, Sedentary Behavior, and Mental Health of the Older Population in South Korea Based on Marital Status and Gender

The primary purpose of the present study was to assess differences in physical activity (PA), sedentary behavior (SB), and mental health (i.e., depression, suicidal thoughts, and cognitive function) by marital status (i.e., married and widowed) within an aging population in South Korea. PA, SB, and mental health were evaluated in 9092 older adults by comparing the married group (n = 5773, 73.2 ± 5.9 years, 63.5%) to the widowed group (n = 3319, 75.8 ± 6.8 years, 36.5%). Between-group differences in PA, SB, depression, and cognitive function were tested using independent t-tests, and the association between marital status and gender was evaluated using two-way ANOVA. Suicidal thoughts were analyzed using a Mann-Whitney U-test. Older adults in the widowed group participated in significantly less PA (p < 0.001) and had higher SB (p < 0.001) per week, especially the widows, who had significantly less PA (p < 0.01) and had higher SB (p < 0.001) compared to married women. Participants in the widowed group experienced more depression (p < 0.001) and suicidal thoughts (p < 0.001) and had significantly lower cognitive function compared to participants in the married group (p < 0.001). Between the two groups, widowers were more vulnerable to all mental health factors compared to those in the married group. At the same time, widows were only more vulnerable to depression and cognitive function compared to women in the married group. Findings indicated that the presence of a spouse is strongly associated with higher PA levels, lower SB, and better mental health among older adults. Spouses are the primary social supports and play a major role in the health and emotional well-being of the aging population. Given the importance of the spouse, our study suggests that health educators working with older widows should prioritize several different forms of social support to benefit their physical and mental health.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life

BACKGROUND

The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL.

AIM

To assess whether the 3WP is associated with improved ratings of EOL care.

PROGRAM DESCRIPTION

In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families.

SETTING

2-hospital academic healthcare system.

PARTICIPANTS

Dying patients in the ICU and their families.

PROGRAM EVALUATION

A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care).

RESULTS

Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups.

DISCUSSION

The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.

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

Introduction

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

Materials and Methods

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

Results

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

Conclusions

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

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.

Determinants of Adherence to Best Practice in Severe Traumatic Brain Injury: A Qualitative Study

Background

Management of patients with severe traumatic brain injury (sTBI) is highly variable and inconsistently aligned with evidence derived from high-quality trials, including those examining intravenous fluid resuscitation and use of decompressive craniectomy surgery. This study explored the barriers and facilitators of general and specific evidence-based practices in sTBI from the perspectives of stakeholder clinicians.

Methods

This was a qualitative study of semistructured interviews conducted with specialist clinicians responsible for acute care of patients with sTBI. Interview analysis was guided by the Theoretical domains framework (TDF), and key themes were mapped to relevant TDF behavioral domains.

Results

Ten neurosurgeons, 12 intensive care specialists, and three trauma physicians from six high-income countries participated between May 2020 and May 2021. Key TDF domains were environmental context and resources, social influences, and beliefs about consequences. Evidence-aligned management of patients with sTBI is perceived to be facilitated by admission to academic research-oriented hospitals, development of local practice protocols, and interdisciplinary collaboration. Determinants of specific practices varied and included health policy change for fluid resuscitation and development of patient-centered goals for surgical decision-making.

Conclusions

In choosing interventions for patients with sTBI, clinicians integrate local environmental, social, professional, and emotional influences with evidence and associated clinical practice guideline recommendations. This study highlights determinants of evidence-based practice that may inform implementation efforts and thereby improve outcomes for patients with sTBI.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-022-01551-x.

The relationships between adverse life events, depression, economic activities, and human capital investment in Nigeria

This paper examines the links between adverse events, depression, and decision-making in Nigeria. It investigates how events such as conflicts, shocks, and deaths of family members can affect short-term mental health, as well as longer-term decisions on economic activities and human capital investments. First, the findings show that exposure to conflict has the largest and strongest relationship with depression, associated with a 21-26 percentage point increase in the probability of depressive symptomatology. Second, depression is associated with lower labour force participation, child educational investment, and annual per capita income, holding constant covariates such as exposure to adverse events. People with depressive symptoms are 8 percentage points less likely to work. In addition, parents exhibiting depressive symptoms spend 18% less on their children's education. These findings show the links between adverse events and important outcomes such as labour and education through mental health. As such, policymakers must consider both the direct and indirect effects that adverse events - particularly conflicts - and depression can have on welfare.

Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication

Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.

Postintensive Care Syndrome-Family Associated With COVID-19 Infection

To assess the prevalence of and risk factors for postintensive care syndrome in family (PICS-F) in the COVID-19 era.

Surrogates of Patients With Severe Acute Brain Injury Experience Persistent Anxiety and Depression Over the 6 Months After ICU Admission

CONTEXT

Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty.

OBJECTIVES

To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV).

METHODS

We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons.

RESULTS

Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2-6.0).

CONCLUSION

Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population.

Stress-Related Disorders of Family Members of Patients Admitted to the Intensive Care Unit With COVID-19

IMPORTANCE

The psychological symptoms associated with having a family member admitted to the intensive care unit (ICU) during the COVID-19 pandemic are not well defined.

OBJECTIVE

To examine the prevalence of symptoms of stress-related disorders, primarily posttraumatic stress disorder (PTSD), in family members of patients admitted to the ICU with COVID-19 approximately 90 days after admission.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multisite, mixed-methods observational cohort study assessed 330 family members of patients admitted to the ICU (except in New York City, which had a random sample of 25% of all admitted patients per month) between February 1 and July 31, 2020, at 8 academic-affiliated and 4 community-based hospitals in 5 US states.

EXPOSURE

Having a family member in the ICU with COVID-19.

MAIN OUTCOMES AND MEASURES

Symptoms of PTSD at 3 months, as defined by a score of 10 or higher on the Impact of Events Scale 6 (IES-6).

RESULTS

A total of 330 participants (mean [SD] age, 51.2 [15.1] years; 228 [69.1%] women; 150 [52.8%] White; 92 [29.8%] Hispanic) were surveyed at the 3-month time point. Most individuals were the patients' child (129 [40.6%]) or spouse or partner (81 [25.5%]). The mean (SD) IES-6 score at 3 months was 11.9 (6.1), with 201 of 316 respondents (63.6%) having scores of 10 or higher, indicating significant symptoms of PTSD. Female participants had an adjusted mean IES-6 score of 2.6 points higher (95% CI, 1.4-3.8; P < .001) than male participants, whereas Hispanic participants scored a mean of 2.7 points higher compared with non-Hispanic participants (95% CI, 1.0-4.3; P = .002). Those with graduate school experience had an adjusted mean score of 3.3 points lower (95% CI, 1.5-5.1; P < .001) compared with those with up to a high school degree or equivalent. Qualitative analyses found no substantive differences in the emotional or communication-related experiences between those with high vs low PTSD scores, but those with higher scores exhibited more distrust of practitioners.

CONCLUSIONS AND RELEVANCE

In this cohort study, symptoms of PTSD among family members of ICU patients with COVID-19 were high. Hispanic ethnicity and female gender were associated with higher symptoms. Those with higher scores reported more distrust of practitioners.

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study

BACKGROUND

During the Coronavirus disease 2019 (COVID-19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL).

AIM

The primary aim was to describe EoL care for COVID-19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death-related stress in family members.

DESIGN

Single centre cross-sectional study. The setting was the ICU of a COVID-19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death-related stress on their family members was measured using the Impact of Event Scale-Revised (IES-R). The statistical association was tested by means of logistic regression.

RESULTS

The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High-stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES-R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89).

CONCLUSIONS

During the first year of the COVID-19 pandemic, patients died without their family members at the bedside while on life-sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death-related stress.

RELEVANCE FOR CLINICAL PRACTICE

During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death-related stress, especially for the patient's spouse.

Access to Mental Healthcare in the 21st Century: An Evolutionary Concept Analysis

BACKGROUND

One of the most important aspects of receiving medical care is access to that care. For people with mental illness who have greater healthcare needs and are at risk for poor health outcomes, reduced access to care constitutes a crisis. While the COVID-19 (coronavirus disease 2019) pandemic continues to affect the United States, specifying what it means to have access to mental healthcare is more critical than ever.

AIMS

The aims of this concept analysis are to review definitions and descriptions of access to mental healthcare in the literature and to synthesize the relevance of these findings to inform future research, theory development, policy, and practice.

METHODS

The concept of access to mental healthcare was analyzed using Rodgers's evolutionary concept analysis method. CINAHL, PsycINFO, and MEDLINE were queried for peer-reviewed articles about access to mental healthcare published from January 2010 to April 2020 (n = 72). Data were reviewed for concept antecedents, attributes, consequences, surrogate, and related terms.

RESULTS

Five models of access to mental healthcare were identified, with several antecedents and consequences: utilization, economic loss/gain, incarceration, and patient/provider satisfaction. Cross-sectional and predictive studies highlighted three interrelated attributes: clinical management, healthcare delivery, and connectedness.

CONCLUSIONS

The concept of access to mental healthcare is often used stagnantly across disciplines to create health policies, yet the concept is transformative. Future research requires up-to-date operational definitions of access to mental healthcare to target interdisciplinary approaches.

Role Mismatch in Medical Decision-Making Participation Is Associated with Anxiety and Depression in Family Members of Patients in the Intensive Care Unit

This study aimed to investigate the mismatch between the preferred and actual roles in the medical decision-making of intensive care unit (ICU) patients' family members and the relationship between the role mismatch of family members' decisions and anxiety and depression syndromes. A total of 223 family members of ICU patients in the Affiliated Hospital of Jiangnan University in China were enrolled. The simple Chinese version of the Control Preference Scale was used to complete the surveys to assess the preferred and actual roles, and anxiety and depression syndromes were measured using the Generalized Anxiety Disorder-7 scale and Patient Health Questionnaire-9, respectively. For the preferred and actual roles, the active role rates were 16.1% and 8.1%, the cooperative role rates were 49.3% and 31.4%, and the passive role rates were 34.5% and 60.5%, respectively. The incidence of mismatch was 43.0% between the preferred and actual roles, and the consistency between their preferred and actual decision-making roles was poor (kappa = 0.309, P < 0.001). Family members with mismatched decision-making roles had significantly higher incidence rates of anxiety (90.6% vs. 57.5%, P < 0.001) and depression (86.5% vs. 63.0%, P < 0.001). Logistic regression analysis revealed that mismatches in decision-making roles remained independently associated with these outcomes after adjustment for family members' sociodemographic features. The results of the present study demonstrate that the preferred role of ICU patients' family members is mainly cooperative, and the actual role is mainly passive. The mismatch between the preferred and actual roles is associated with anxiety and depression among the ICU patients' family members.

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

Background/objective

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

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

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

Bereavement Experiences of Families in the Cardiac Intensive Care Unit

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delivering Cognitive Behavioral Therapy for Post-Intensive Care Syndrome-Family via a Mobile Health App

BACKGROUND

Family members of intensive care unit (ICU) patients are at risk for post-intensive care syndrome- family (PICS-F), including symptoms of anxiety, depression, and posttraumatic stress. Cognitive behavioral therapy is the first-line nonpharmacologic treatment for many psychological symptoms and has been successfully delivered by use of mobile technology for symptom self-management.

OBJECTIVES

To determine the feasibility of delivering cognitive behavioral therapy through a smartphone app to family members of critically ill patients.

METHODS

This was a prospective longitudinal cohort study with a consecutive sample of patients admitted to 2 adult ICUs and their family members. The control group period was followed by the intervention group period. The intervention consisted of a mobile health app preloaded on a smartphone provided to family members. The study time points were enrollment (within 5 days of ICU admission), 30 days after admission, and 60 days after admission. Study measures included demographic data, app use, satisfaction with the app, mental health self-efficacy, and measures of PICS-F symptoms.

RESULTS

The study sample consisted of 49 predominantly White (92%) and female (82%) family members (24 intervention, 25 control). Smartphone ownership was 88%. Completion rates for study measures were 92% in the control group and 79% in the intervention group. Family members logged in to the app a mean of 18.58 times (range 2-89) and spent a mean of 81.29 minutes (range 4.93-426.63 minutes) using the app.

CONCLUSIONS

The study results confirm the feasibility of implementing app-based delivery of cognitive behavioral therapy to family members of ICU patients.

Association between intensive care unit admission of a patient and mental disorders in the spouse: a retrospective matched-pair cohort study

Background

Previous prospective studies have suggested that spouses of patients who are admitted to the intensive care unit (ICU) have a high prevalence of mental disorders, termed post-intensive care syndrome-family (PICS-F). However, it remains unclear whether the patient’s ICU admission is associated with the occurrence of mental disorders in the spouse outside of the prospective study setting. We therefore investigated the proportion of ICU patients’ spouses who visited medical facilities for mental disorders and the association between ICU admission of a patient and mental disorders in the spouse using real-world data.

Methods

This was a retrospective matched-pair cohort study using commercially available, routinely collected administrative claims data. As the study population, we identified all married couples (both wife and husband) who were registered in the database from 1 April 2012 to 31 August 2018 using family identification codes. We identified spouses of patients who were admitted to the ICU for more than 2 days as the exposure group and defined the date of admission to the ICU as the index date. We randomly matched four individuals in the non-exposure group with one individual in the exposure group. The primary outcome was any PICS-F–related mental disorder in the spouses within 6 months from the index date. As a sensitivity analysis, we also investigated the proportion and association of individuals (excluding spouses) with a history of mental disorders.

Results

Among 1,082,208 married couples, we identified 8490 spouses of ICU patients, and they were matched with 33,946 individuals. The proportion of any PICS-F–related mental disorder within 6 months from the index date was 12.8% in ICU patients’ spouses and 11.3% in the matched individuals (adjusted odds ratio, 1.29; 95% confidence interval, 1.03–1.42). The sensitivity analysis showed significant associations between ICU admission and spouses’ mental disorders.

Conclusions

Spouses of patients who were admitted to the ICU had a slightly higher risk of mental disorders within 6 months than spouses of patients who were not admitted to the ICU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00583-3.

Symptoms of post-traumatic stress disorder (PTSD) in next of kin during suspension of ICU visits during the COVID-19 pandemic: a prospective observational study

BACKGROUND

During the COVID-19 pandemic, suspension of visits by next of kin to patients in intensive care units (ICU), to prevent spread of the SARS-CoV-2 virus, has been a common practice. This could impede established family-centered care and may affect the mental health of the next of kin. The aim of this study was to explore symptoms of post-traumatic stress syndrome (PTSD) in the next of kin of ICU patients.

METHODS

In this prospective observational single-center study, next of kin of ICU patients were interviewed by telephone, using the Impact of Event Scale-Revised (IES-R), to assess symptoms of acute stress disorder during the ICU stay and PTSD symptoms at 3 months after the ICU stay. The primary outcome was the prevalence of severe PTSD symptoms (IES-R score ≥ 33) at 3 months. The secondary outcomes comprised the IES-R scores during the ICU stay, at 3 months, and the prevalence of severe symptoms of acute stress disorder during ICU stay. An inductive content analysis was performed of the next of kin's comments regarding satisfaction with patient care and the information they were given.

RESULTS

Of the 411 ICU patients admitted during the study period, 62 patients were included together with their next of kin. An IES-R score > 33 was observed in 90.3% (56/62) of next of kin during the ICU stay and in 69.4% (43/62) 3 months later. The median IES-R score was 49 (IQR 40-61) during the ICU stay and 41 (IQR 30-55) at 3 months. The inductive content analysis showed that communication/information (55%), support (40%), distressing emotions (32%), and suspension of ICU visits (24%) were mentioned as relevant aspects by the next of kin.

CONCLUSIONS

During the suspension of ICU visits in the COVID-19 pandemic, high prevalence and severity of both symptoms of acute stress disorder during the ICU stay and PTSD symptoms 3 months later were observed in the next of kin of ICU patients.

End-of-Life Care Decision-Making in Stroke

Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.

Virtual reality for relatives of ICU patients to improve psychological sequelae: study protocol for a multicentre, randomised controlled trial

INTRODUCTION

Intensive care unit (ICU) admission of a relative might lead to psychological distress and complicated grief (post-intensive care syndrome-family; PICS-F). Evidence suggests that increased distress during ICU stay increases risk of PICS-F, resulting in difficulty returning to their normal lives after the ICU experience. Effective interventions to improve PICS-F are currently lacking. In the present trial, we hypothesised that information provision using ICU-specific Virtual Reality for Family members/relatives (ICU-VR-F) may improve understanding of the ICU and subsequently improve psychological well-being and quality of life in relatives of patients admitted to the ICU.

METHODS AND ANALYSIS

This multicentre, clustered randomised controlled trial will be conducted from January to December 2021 in the mixed medical-surgical ICUs of four hospitals in Rotterdam, the Netherlands. We aim to include adult relatives of 160 ICU patients with an expected ICU length of stay over 72 hours. Participants will be randomised clustered per patient in a 1:1 ratio to either the intervention or control group. Participants allocated to the intervention group will receive ICU-VR-F, an information video that can be watched in VR, while the control group will receive usual care. Initiation of ICU-VR-F will be during their hospital visit unless participants cannot visit the hospital due to COVID-19 regulations, then VR can be watched digitally at home. The primary objective is to study the effect of ICU-VR-F on psychological well-being and quality of life up to 6 months after the patients' ICU discharge. The secondary outcome is the degree of understanding of ICU treatment and ICU modalities.

ETHICS AND DISSEMINATION

The Medical Ethics Committee of the Erasmus Medical Centre, Rotterdam, the Netherlands, approved the study and local approval was obtained from each participating centre (NL73670.078.20). Our findings will be disseminated by presentation of the results at (inter)national conferences and publication in scientific, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (TrialRegister.nl, NL9220).

Voices From the Pandemic: A Qualitative Study of Family Experiences and Suggestions Regarding the Care of Critically Ill Patients

Rationale

Intensive care unit (ICU) visitation restrictions during the coronavirus disease (COVID-19) pandemic have drastically reduced family-engaged care. Understanding the impact of physical distancing on family members of ICU patients is needed to inform future policies.

Objectives

To understand the experiences of family members of critically ill patients with COVID-19 when physically distanced from their loved ones and to explore ways clinicians may support them.

Methods

This qualitative study of an observational cohort study reports data from 74 family members of ICU patients with COVID-19 at 10 United States hospitals in four states, chosen based on geographic and demographic diversity. Adult family members of patients admitted to the ICU with COVID-19 during the early phase of the pandemic (February–June 2020) were invited to participate in a phone interview. Interviews followed a semistructured guide to assess four constructs: illness narrative, stress experiences, communication experiences, and satisfaction with care. Interviews were transcribed verbatim and analyzed using an inductive approach to thematic analysis.

Results

Among 74 interviewees, the mean age was 53.0 years, 55% were white, and 76% were female. Physical distancing contributed to substantial stress and harms (nine themes). Participants described profound suffering and psychological illness, unfavorable perceptions of care, and weakened therapeutic relationship between family members and clinicians. Three communication principles emerged as those most valued by family members: contact, consistency, and compassion (the 3Cs). Family members offered suggestions to guide clinicians faced with communicating with physically distanced families.

Conclusions

Visitation restrictions impose substantial psychological harms upon family members of critically ill patients. Derived from the voics of family members, our findings warrant strong consideration when implementing visitation restrictions in the ICU and advocate for investment in infrastructure (including staffing and videoconferencing) to support communication. This study offers family-derived recommendations to operationalize the 3Cs to guide and improve communication in times of physical distancing during the COVID-19 pandemic and beyond.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Course and predictors of posttraumatic stress-related symptoms among family members of deceased ICU patients during the first year of bereavement

Background/Objective

Death in intensive care units (ICUs) may increase bereaved family members’ risk for posttraumatic stress disorder (PTSD). However, posttraumatic stress-related symptoms (hereafter as PTSD symptoms) and their precipitating factors were seldom examined among bereaved family members and primarily focused on associations between PTSD symptoms and patient/family characteristics. We aimed to investigate the course and predictors of clinically significant PTSD symptoms among family members of deceased ICU patients by focusing on modifiable quality indicators for end-of-life ICU care.

Method

In this longitudinal observational study, 319 family members of deceased ICU patients were consecutively recruited from medical ICUs from two Taiwanese medical centers. PTSD symptoms were assessed at 1, 3, 6, and 13 months post-loss using the Impact of Event Scale-Revised (IES-R). Family satisfaction with end-of-life care in ICUs was assessed at 1 month post-loss. End-of-life care received in ICUs was documented over the patient’s ICU stay. Predictors for developing clinically significant PTSD symptoms (IES-R score ≥ 33) were identified by multivariate logistic regression with generalized estimating equation modeling.

Results

The prevalence of clinically significant PTSD symptoms decreased significantly over time (from 11.0% at 1 month to 1.6% at 13 months post-loss). Longer ICU stays (adjusted odds ratio [95% confidence interval] = 1.036 [1.006, 1.066]), financial insufficiency (3.166 [1.159, 8.647]), and reported use of pain medications (3.408 [1.230, 9.441]) by family members were associated with a higher likelihood of clinically significant PTSD symptoms among family members during bereavement. Stronger perceived social support (0.937 [0.911, 0.965]) and having a Do-Not-Resuscitate (DNR) order issued before the patient’s death (0.073 [0.011, 0.490]) were associated with a lower likelihood of clinically significant PTSD symptoms. No significant association was observed for family members’ satisfaction with end-of-life care (0.988 [0.944, 1.034]) or decision-making in ICUs (0.980 [0.944, 1.018]).

Conclusions

The likelihood of clinically significant PTSD symptoms among family members decreased significantly over the first bereavement year and was lower when a DNR order was issued before death. Enhancing social support and facilitating a DNR order may reduce the trauma of ICU death of a beloved for family members at risk for developing clinically significant PTSD symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03719-x.

Smartphone Delivery of Cognitive Behavioral Therapy for Postintensive Care Syndrome-Family: Protocol for a Pilot Study

BACKGROUND

Family members of critically ill patients experience symptoms of postintensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder. Postintensive care syndrome-family reduces the quality of life of the families of critically ill patients and may impede the recovery of such patients. Cognitive behavioral therapy has become a first-line nonpharmacological treatment of many psychological symptoms and disorders, including anxiety, depression, and posttraumatic stress. With regard to managing mild-to-moderate symptoms, the delivery of cognitive behavioral therapy via mobile technology without input from a clinician has been found to be feasible and well accepted, and its efficacy rivals that of face-to-face therapy.

OBJECTIVE

The purpose of our pilot study is to examine the efficacy of using a smartphone mobile health (mHealth) app to deliver cognitive behavioral therapy and diminish the severity and prevalence of PICS-F symptoms in family members of critically ill patients.

METHODS

For our pilot study, 60 family members of critically ill patients will be recruited. A repeated-measures longitudinal study design that involves the randomization of participants to 2 groups (the control and intervention groups) will be used. The intervention group will receive cognitive behavioral therapy, which will be delivered via a smartphone mHealth app. Bandura's social cognitive theory and an emphasis on mental health self-efficacy form the theoretical framework of the study.

RESULTS

Recruitment for the study began in August 2020. Data collection and analysis are expected to be completed by March 2022.

CONCLUSIONS

The proposed study represents a novel approach to the treatment of PICS-F symptoms and is an extension of previous work conducted by the research team. The study will be used to plan a fully powered randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04316767; https://clinicaltrials.gov/ct2/show/NCT04316767.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30813.

Psychological Symptoms in Relatives of Critically Ill Patients: A Longitudinal Cohort Study

OBJECTIVES

To explore the psychologic impact of an ICU stay on relatives and to determine patient and relative factors, including their pre-ICU mental health status, associated with psychologic symptoms 3 months after ICU admission.

DESIGN

A prospective, exploratory, longitudinal cohort study.

SETTING

A 12-bed ICU in a Dutch tertiary teaching hospital.

PATIENTS

The relatives of ICU patients admitted between March 2018 and December 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Relatives completed the Hospital Anxiety and Depression Scale shortly after patients' ICU admission referring to the week before ICU admission and 3 months later, together with the Impact of Event Scale-Revised, assessing posttraumatic stress. A total of 387 were eligible of which 78 (20%) responded. Almost a quarter reported an increase of anxiety (23.1%) and depression (24.4%) between baseline and 3 months follow-up. One in six (17.9%) reported posttraumatic stress. Anxiety, depression, and posttraumatic stress at 3 months follow-up were significantly associated with preexisting anxiety and depression. Patients' factor associated with depression 3 months follow-up in relatives was length of ICU stay (odds ratio, 1.09; 95% CI, 1.02-1.16).

CONCLUSIONS

Relatives with preexisting psychologic symptoms before ICU admission are at risk to develop anxiety, depression, or posttraumatic stress shortly after ICU discharge of the patient. Screening and identification in an early stage enables early interventions to prevent relatives from worsening mental health during and after ICU admission.

Practice Recommendations for End-of-Life Care in the Intensive Care Unit

TOPIC

A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices.

CLINICAL RELEVANCE

Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members.

PURPOSE OF PAPER

To provide recommendations for high-quality end-of-life care for patients and family members.

CONTENT COVERED

This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.

[Post-intensive care syndrome]

Post-intensive care syndrome is an entity defined in 2010 and covering any sequelae following an extended hospitalization in intensive care unit. It comprises psychological, cognitive and physical disorders (neuromyopathy, respiratory dysfunction, joint stiffness, among others). These sequelae have important consequences on autonomy and quality of life of these patients, as well as on their healthcare consumption and on mortality. Psychological sequelae can also be seen in hospitalized patients' relatives. Screening and management of these disorders is more and more frequent but no method has formally proven effective. The number of patients surviving an intensive care unit hospitalization is increasing, and management of post-intensive care syndrome is a major issue. It seems important that the internist be aware of this syndrome, given his pivotal role in global management of patients and frequent implication into care after the intensive care unit.

A Whirlpool of Stress in Families of Intensive Care Unit Patients: A Qualitative Multicenter Study

BACKGROUND

Family members of patients admitted to the intensive care unit must tolerate high levels of stress, making them emotionally and physically vulnerable. However, little is known about the kinds of stress family members may experience.

OBJECTIVE

To explore perceived stress in the families of patients admitted to the intensive care unit.

METHODS

This qualitative content analysis study involved 23 family members of patients admitted to intensive care units. Participants were drawn from family members of patients hospitalized in intensive care units of 3 public and 2 private hospitals. Data were collected through semistructured interviews.

RESULTS

Three themes emerged from the data: "distrust," "repeated stress exposure," and "a whirlpool of persistent negative emotional-physical state." The first theme had 2 categories: "fearful mindset" and "negative beliefs about professional caregivers." The second theme also had 2 categories: "fear of the future" and "sustained accumulation of tensions." The third theme had 3 categories: "impaired mental health," "impaired physical health," and "impaired family function."

CONCLUSIONS

The findings of this study may help critical care nurses better understand the nature and sources of family stresses during a patient's intensive care unit stay. Supervisory nurses should alert their staff to these issues so that family care programs can address them, thereby reducing family members' risk of posttraumatic stress disorder and post-intensive care syndrome-family.

Lived Experiences of Family Members of Patients With Severe COVID-19 Who Died in Intensive Care Units in France

IMPORTANCE

During the initial surge of the COVID-19 pandemic, family members were often separated from their loved ones admitted to intensive care units (ICUs), with a potential for negative experiences and psychological burden.

OBJECTIVE

To better understand the experiences of bereaved family members of patients who died in an ICU during the COVID-19 pandemic, from the time of hospital admission until after the patient's death.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used semistructured, in-depth interviews to collect experiences from bereaved family members of patients who died from severe COVID-19 in 12 ICUs during the first wave of the pandemic in France. Purposeful sampling was used to ensure the diversity of study participants with respect to sex, age, relationship with the patient, and geographic location. All data were collected between June and September 2020, and data analysis was performed from August to November 2020.

MAIN OUTCOMES AND MEASURES

Interviews were conducted 3 to 4 months after the patient's death and were audio-recorded and analyzed using thematic analysis.

RESULTS

Among 19 family members interviewed (median [range] age, 46 [23-75] years; 14 [74%] women), 3 major themes emerged from qualitative analysis. The first was the difficulty in building a relationship with the ICU clinicians and dealing with the experience of solitude: family members experienced difficulties in establishing rapport and bonding with the ICU team as well as understanding the medical information. Distance communication was not sufficient, and participants felt it increased the feeling of solitude. The second involved the patient in the ICU and the risks of separation: because of restricted access to the ICU, family members experienced discontinuity and interruptions in the relationship with their loved one, which were associated with feelings of powerlessness, abandonment, and unreality. The third was regarding disruptions in end-of-life rituals: family members described "stolen moments" after the patient's death, generating strong feelings of disbelief that may lead to complicated grief.

CONCLUSIONS AND RELEVANCE

This qualitative study found that during the initial wave of the COVID-19 pandemic in France, bereaved family members described a disturbed experience, both during the ICU stay and after the patient's death. Specific family-centered crisis guidelines are needed to improve experiences for patients, families, and clinicians experiences.