The prevalence of post-traumatic stress disorder symptoms in relatives of severe trauma patients admitted to the intensive care unit

Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study

Background

Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care.

Materials and methods

A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire.

Results

Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients' family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test).

Conclusion

Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay.

How to cite this article

Atri V, Bhatt MT, Chaudhuri S, Mitra A, Maddani SS, Ravindranath S. Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study. Indian J Crit Care Med 2024;28(5):483-494.

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.

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.

Prevalence and course of posttraumatic stress disorder symptoms in partners of burn survivors

Background: Partners of burn survivors may develop posttraumatic stress disorder (PTSD) symptoms in response to the potential life threatening nature of the burn event and the burn survivor's medical treatment. Objective: This longitudinal study examined the prevalence, course and potential predictors of partners' PTSD symptoms up to 18 months post-burn. Methods: Participants were 111 partners of adult burn survivors. In a multi-centre study, PTSD symptoms were assessed with the Impact of Event Scale-Revised during the acute phase and subsequently at 3, 6, 12 and 18 months post-burn. Partners' appraisal of life threat, anger, guilt and level of rumination were assessed as potential predictors of PTSD symptoms in an exploratory piecewise latent growth model. Results: Acute PTSD symptoms in the clinical range were reported by 30% of the partners, which decreased to 4% at 18 months post-burn. Higher acute PTSD symptoms were related to perceived life threat and higher levels of anger, guilt, and rumination. Over time, mean symptom levels decreased, especially in partners with high levels of acute PTSD symptoms, perceived life threat and rumination. From three months onward, PTSD symptoms decreased less in partners of more severely burned survivors. At 18 months post-burn, higher levels of PTSD symptoms were related to higher acute PTSD symptoms and more severe burns. Conclusions: One in three partners reported clinical levels of acute PTSD symptoms, of which the majority recovered over time. Perceived life threat, feelings of anger and guilt, and rumination may indicate the presence of acute PTSD symptoms, whereas more severe burns predict long-term PTSD symptom levels. The results highlight the need to screen for acute PTSD symptoms and offer psychological help to partners to alleviate acute elevated stress levels if indicated.

Partial Least Squares Structural Equation Path Modelling Determined Predictors of Students Reported Human Cadaver Dissection Activity

Human cadaver dissection remains a core and preferred method of anatomical instruction at most low- and middle-income health professional training institutions. Dissection, which is both traumatic and stressful, sets the tone of the students’ responses to later and or similar stressful learning opportunities like the post-mortems or care for terminally ill patients. Partial least squares structural equation modelling was used to determine the effect of the students’: personality, perception of the learning environment, learning approach, and effect of the environment on the student, on undergraduate health professional student’s activity in the human cadaver dissection room. This was a secondary analysis of previously collected data from a cross sectional survey of undergraduate health professional students. We found that personality type and perception of the environment had a positive effect on dissection room activity. Approach to learning and being affected by the dissection room experience (impact), had a negative effect on dissection room activity. All the above effects on dissection room activity were not significant. This study showed that personality, perception of the learning environment, learning approach and effect of the environment on the student, had effects on undergraduate health professional student’s activity in the human cadaver dissection room. The modelled effects are opportunities for educational interventions aimed at increasing student activity in the dissection room.

Post-traumatic stress symptoms in family caregivers of intensive care unit patients: A longitudinal study

OBJECTIVES

To describe the prevalence and trajectory of family caregivers' post-traumatic stress symptoms during the first year after a patient's admission to the intensive care unit and identify associations between family caregivers' background characteristics, hope and post-traumatic stress symptoms.

RESEARCH METHODOLOGY/DESIGNS

Family caregivers of intensive care unit patients (n = 211) completed questionnaires at patient admission to the intensive care unit and thereafter at 1, 3, 6, and 12 months. Mixed-model analyses were performed.

SETTING

Four intensive care units in a university hospital in Norway.

MAIN OUTCOME MEASURES

Impact of Event Scale-Revised and Herth Hope Index.

RESULTS

On admission, 54% of family caregivers reported high post-traumatic stress symptom levels, which decreased during the first six  months after patient discharge. Lower levels of hope, being younger, having more comorbidities and being on sick leave were associated with higher post-traumatic stress symptom levels. Being the parent of the patient was associated with decreased post-traumatic stress symptom levels.

CONCLUSIONS

Family caregivers of intensive care unit patients report high levels of post-traumatic stress symptoms. Higher levels of hope were associated with fewer post-traumatic stress symptoms.

Anxiety and depression symptoms in family members of icu patients

<p><strong>Objective:</strong> This study investigated symptoms of anxiety and depression in relatives of patients admitted in the Intensive Care Unit and determined whether these symptoms were associated to the seriousness of the patients’ condition.</p><p><strong>Metodology:</strong> A total of 102 patients’ relatives were surveyed<br />during the study. They were given a self-report questionnaire in order to assess demographic data, anxiety and depression symptoms. The symptoms of anxiety and depression were evaluated with the Hospital Anxiety and Depression Scale (hads). Patient’s condition was evaluated with a.p.a.ch.e ii Score.</p><p><strong>Results:</strong> More than 60% of patients’ relatives presented severe symptoms of anxiety and depression. No relation was found between symptoms of anxiety and depression of the relatives of patients and patients’ condition of health. On the<br />contrary, these feelings used to exist regardless of the seriousness of patient’s condition.</p><p><strong>Conclusions:</strong> The assessment of these patients is recommended in order serious problems of anxiety<br />and depression to be prevented. </p>

Coping Strategies and Posttraumatic Stress Symptoms in Post-ICU Family Decision Makers

OBJECTIVE

To assess the coping strategies used by family decision makers of adult critical care patients during and after the critical care experience and the relationship of coping strategies to posttraumatic stress symptoms experienced 60 days after hospitalization.

DESIGN

A single-group descriptive longitudinal correlational study.

SETTING

Medical, surgical, and neurological ICUs in a large tertiary care university hospital.

PATIENTS

Consecutive family decision makers of adult critical care patients from August 2012 to November 2013. Study inclusion occurred after the patient's fifth day in the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family decision makers of incapacitated adult ICU patients completed the Brief COPE instrument assessing coping strategy use 5 days after ICU admission and 30 days after hospital discharge or death of the patient and completed the Impact of Event Scale-Revised assessing posttraumatic stress symptoms 60 days after hospital discharge. Seventy-seven family decision makers of the eligible 176 completed all data collection time points of this study. The use of problem-focused (p=0.01) and emotion-focused (p<0.01) coping decreased over time while avoidant coping (p=0.20) use remained stable. Coping strategies 30 days after hospitalization (R2=0.50, p<0.001) were better predictors of later posttraumatic stress symptoms than coping strategies 5 days after ICU admission (R2=0.30, p=0.001) controlling for patient and decision-maker characteristics. The role of decision maker for a parent and patient death were the only noncoping predictors of posttraumatic stress symptoms. Avoidant coping use 30 days after hospitalization mediated the relationship between patient death and later posttraumatic stress symptom severity.

CONCLUSIONS

Coping strategy use is a significant predictor of posttraumatic stress symptom severity 60 days after hospitalization in family decision makers of ICU patients.

Psychological distress and psychiatric diagnoses among primary caregivers of children undergoing hematopoietic stem cell transplant: an examination of prevalence, correlates, and racial/ethnic differences

OBJECTIVE

The aims of the study were to examine the prevalence of self-reported psychological distress, examine the prevalence of interview-rated psychiatric diagnoses, identify correlates of psychological distress and psychiatric diagnosis and examine racial/ethnic group differences on measures of psychological distress among primary caregivers of children preparing to undergo hematopoietic stem cell transplant (HSCT).

METHODS

Caregivers (N = 215) completed the Beck Anxiety Inventory, Beck Depression Inventory (BDI), Impact of Events Scale, and a psychiatric interview assessing major depressive disorder, generalized anxiety disorder and panic disorder. Regression analyses examined correlates of distress and psychiatric diagnosis. Comparisons were made between racial/ethnic groups.

RESULTS

Posttraumatic stress symptoms were reported by 54% of caregivers during the time preparing for the child's HSCT. Twenty-seven percent of caregivers met diagnostic criteria for at least one of the psychiatric diagnoses during this time. Few factors were associated with distress or psychiatric diagnosis, except the child scheduled for allogeneic transplant, being married and prior psychological/psychiatric care. Sociodemographic factors accounted for racial/ethnic group differences, except that Hispanic/Latino caregivers reported higher BDI scores than non-Hispanic white caregivers.

CONCLUSION

Caregivers may be at greater risk of posttraumatic stress symptoms than anxiety or depression. Prior psychological/psychiatric treatment is a risk factor for greater psychological distress and psychiatric diagnosis during this time. Racial differences are mostly due to sociodemographic factors.

Post-Traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004 to 2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing.

Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital

Context:

An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown.

Aims:

The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital.

Settings and Design:

A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India.

Materials and Methods:

A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response.

Statistical Analysis:

Statistical analysis was done using the Mann-Whitney and chi-square tests.

Results:

Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding “change in the patient's condition” compared to the objective change in severity of illness. “Change in worry” was incongruous compared to the perception of improvement of the patient's condition in 78% of relatives.

Conclusions:

Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.

Can we predict intensive care relatives at risk for posttraumatic stress disorder?

Aims:

To identify the relatives of the intensive care unit (ICU) patients at risk for developing symptoms of posttraumatic stress disorders.

Setting:

A multidisciplinary hospital ICU.

Design:

Prospective single center observational study.

Material and Methods:

Relatives of patients admitted in the ICU (May06-Nov06) who consented to answer the questionnaire participated in the study. Anxiety was assessed by using the Hospital Anxiety and Depression Scale (HAD) and vulnerability to posttraumatic disorder (PTSD) by using the Impact of Event Scale Revised (IES-R) which was administered on the fifth day of admission and at two months following discharge or death.

Results:

During admission, 48% of the relatives had a HAD score >11 and 72% showed IES-R score >26. There was no association of HAD with gender, patient outcome, working status, age of the patient, or mode of payment of the bills. There was significant association of IES-R >26 with trauma admission, HAD score >11 and mode of payment with the relatives of insured being more stressed as compared to those who settled their bills personally. A total of 35% relatives showed symptoms of posttraumatic stress reaction consistent with a high risk of PTSD after two months. Death in the hospital resulted in elevated HAD and IES-R score during admission and at the two month follow-up. Persistence of stress symptoms was more in school drop outs, working relatives, parents and those with initial anxiety score >11.

Conclusions:

HAD score greater than 11 was the only factor at admission which could statistically predict a higher PTSD score on follow-up. Adequate counseling of this group of relatives may prevent lasting psychological sequelae of an ICU admission in the relatives of critically ill.

Posttraumatic stress disorder among bereaved relatives of cancer patients

The aim of this study was to assess post-traumatic stress disorder (PTSD) and predictors of PTSD in individuals who experienced the loss of a close relative to cancer. A total of 251 bereaved relatives ages 14 to 76 (M = 41.3, SD = 16.8) were recruited at a counseling service for cancer patients and their relatives. The prevalence of current probable PTSD was 40% in the bereaved sample. A hierarchical logistic regression analysis indicated that full-time employment, perceived control, and a secure attachment style moderated the risk for PTSD. Moreover, a long period of caretaking, high levels of somatization, and dissociation were all associated with an increased risk of PTSD.

Short- and long-term impact of critical illness on relatives: literature review

AIM

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives.

BACKGROUND

Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care.

DATA SOURCES

The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials.

SEARCH METHODS

Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'.

RESULTS

Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives.

CONCLUSION

Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.