Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial

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

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

A randomized clinical trial to evaluate the effect of post-intensive care multidisciplinary consultations on mortality and the quality of life at 1 year

PURPOSE

Critical illness is associated with long-term increased mortality and impaired quality of life (QoL). We assessed whether multidisciplinary consultations would improve outcome at 12 months (M12) after intensive care unit (ICU) discharge.

METHODS

We performed an open, multicenter, parallel-group, randomized clinical trial. Eligible are patients discharged alive from ICU in 11 French hospitals between 2012 and 2018. The intervention group had a multidisciplinary face-to-face consultation involving an intensivist, a psychologist, and a social worker at ICU discharge and then at M3 and M6 (optional). The control group had standard post-ICU follow-up. A consultation was scheduled at M12 for all patients. The QoL was assessed using the EuroQol-5 Dimensions-5 Level (Euro-QoL-5D-5L) which includes five dimensions (mobility, self-care, usual activities, pain, and anxiety/depression), each ranging from 1 to 5 (1: no, 2: slight, 3: moderate, 4: severe, and 5: extreme problems). The primary endpoint was poor clinical outcome defined as death or severe-to-extreme impairment of at least one EuroQoL-5D-5L dimension at M12. The information was collected by a blinded investigator by phone. Secondary outcomes were functional, psychological, and cognitive status at M12 consultation.

RESULTS

540 patients were included (standard, n = 272; multidisciplinary, n = 268). The risk for a poor outcome was significantly greater in the multidisciplinary group than in the standard group [adjusted odds ratio 1.49 (95% confidence interval, (1.04-2.13)]. Seventy-two (13.3%) patients died at M12 (standard, n = 32; multidisciplinary, n = 40). The functional, psychological, and cognitive scores at M12 did not statistically differ between groups.

CONCLUSIONS

A hospital-based, face-to-face, intensivist-led multidisciplinary consultation at ICU discharge then at 3 and 6 months was associated with poor outcome 1 year after ICU.

A randomised controlled trial of a nurse facilitator to promote communication for family members of critically ill patients

PURPOSE

Suboptimal communication with clinicians, fragmented care and failure to align with patients' preferences are determinants of post intensive care unit (ICU) burden in family members. Our aim was to evaluate the impact of a nurse facilitator on family psychological burden.

METHODS

We carried out a randomised controlled trial in five ICUs in France comparing standard communication by ICU clinicians to additional communication and support by nurse facilitators. We included patients > 18 years, with expected ICU length of stay > 2 days, chronic life-limiting illness, and their family members. Facilitators were trained to help families to secure care in line with patient's goals, beginning in ICU and continuing for 3 months. Assessments were made at baseline and 1, 3 and 6 months post-randomisation. Primary outcome was the evolution of family symptoms of depression over 6 months using a linear mixed effects model on the depression subscale of the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included HADS-Anxiety, Impact of Event Scale-6, goal-concordant care and experience of serious illness (QUAL-E).

RESULTS

385 patients and family members were enrolled. Follow-up at 1-, 3- and 6-month was completed by 284 (74%), 264 (68.6%) and 260 (67.5%) family members respectively. The intervention was associated with significantly more formal meetings between the ICU team and the family (1 [1-3] vs 2 [1-4]; p < 0.001). There was no significant difference between the intervention and control groups in evolution of symptoms of depression over 6 months (p = 0.91), nor in symptoms of depression at 6 months [0.53 95% CI (- 0.48; 1.55)]. There were no significant differences in secondary outcomes.

CONCLUSION

This study does not support the use of facilitators for family members of ICU patients.

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.

Prediction of post-traumatic stress disorder in family members of ICU patients: a machine learning approach

PURPOSE

Post-traumatic stress disorder (PTSD) can affect family members of patients admitted to the intensive care unit (ICU). Easily accessible patient's and relative's information may help develop accurate risk stratification tools to direct relatives at higher risk of PTSD toward appropriate management.

METHODS

PTSD was measured 90 days after ICU discharge using validated instruments (Impact of Event Scale and Impact of Event Scale-Revised) in 2374 family members. Various supervised machine learning approaches were used to predict PTSD in family members and evaluated on an independent held-out test dataset. To better understand variables' contributions to PTSD predicted probability, we used machine learning interpretability methods on the best predictive algorithm.

RESULTS

Non-linear ensemble learning tree-based methods showed better predictive performances (Random Forest-area under curve, AUC = 0.73 [0.68-0.77] and XGBoost-AUC = 0.73 [0.69-0.78]) than regularized linear models, kernel-based models, or deep learning models. In the best performing algorithm, most important features that positively contributed to PTSD's predicted probability were all non-modifiable factors, namely, lower patient's age, longer duration of ICU stay, relative's female sex, lower relative's age, relative being a spouse/child, and patient's death in ICU. A sensitivity analysis in bereaved relatives did not alter the algorithm's predictive performance.

CONCLUSION

We propose a machine learning-based approach to predict PTSD in relatives of ICU patients at an individual level. In this model, PTSD is mostly influenced by non-modifiable factors.

Finding the right words: A focus group investigation of nurses' experiences of writing diaries for intensive care patients with a poor prognosis

BACKGROUND

The overall purpose of diaries written during an intensive care stay is to help patients fill in memory gaps from the illness trajectory, which might promote long-term psychological recovery. Diaries have also been shown to benefit nurses in maintaining a view of the patient as a person in the highly technical environment and to promote reflection. There is a lack of research on how nurses might be affected by writing a diary for critically ill patients with a poor prognosis.

OBJECTIVES

The aim of this study was to investigate nurses' experience of writing diaries for intensive care patients with a poor prognosis.

METHODS

This study has a qualitative descriptive design and was inspired by the methodology of interpretive description. Twenty-three nurses from three Norwegian hospitals with a well-established practice of writing diaries participated in four focus groups. Reflexive thematic analysis was used. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

FINDINGS

The overarching theme resulting from our analysis was "Finding the right words". This theme represents the challenge of writing in view of the uncertainty of the patient's survival and of who would read the diary. It was important to strike the right tone with these uncertainties in mind. When the patient's life could not be saved, the purpose of the diary expanded to comforting the family. To put an extra effort into making the diary something special when the patient was dying was also a meaningful activity for the nurses.

CONCLUSIONS

Diaries may serve other purposes than helping patients to understand their critical illness trajectory. In cases of a poor prognosis, nurses adapted their writing to comfort the family rather than informing the patient. Diary writing was meaningful for the nurses in managing care of the dying patient.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Memory making in critical care: A qualitative thematic synthesis

BACKGROUND

Caring for bereaved families is an important aspect of the nursing role in critical care. Memory making practices are one way in which dying, death and bereavement can be acknowledged and supported within critical care. Memory making was introduced into the care of stillborn babies and neonatal deaths to improve parents' experiences of bereavement, and has since become common practice in adult critical care.

AIMS

The aim of this qualitative thematic synthesis was to explore families' experiences of memory making in critical care, with a view of gaining greater understanding of the ways in which memory making impacts bereaved families.

METHODS

A systematic search strategy was developed, and five databases were searched (Medline, CINAHL, PsychINFO, Embase and ASSIA). Seven qualitative studies were included: four were conducted in adult and three in paediatric critical care settings in which memory making was initiated between 2014 and 2020. Memory making practices included, patient diaries, general keepsakes, word clouds and photography.

RESULTS

The thematic synthesis generated four main themes to describe families' experience of memory making in critical care: 'connection', 'compassion', 'engagement and creation' and 'continuation'.

CONCLUSIONS

Memory making is a meaningful activity for families whose loved one dies in critical care; it brings focus and meaning during a devastating process in a highly technical environment. Families rely heavily on nursing staff for support and guidance. The creation of memories and/or keepsakes can have a positive impact on the bereavement experience for families and can facilitate a continuing bond with their loved one.

RELEVANCE TO CLINICAL PRACTICE

Memory making is a worthwhile practice to support and guide family bereavement within critical care. It can provide structure and purpose during an emotionally challenging transition, by supporting families to focus on a meaningful activity during a devasting time.

Differences between responders and nonresponders in intensive care unit (ICU) related survey studies

BACKGROUND

In survey research studies, there are often a proportion of non-responders, that is patients or relatives of patients who do not want to fill in a survey. Especially in intensive care medicine, these proportions of non-responders can be relatively high. However, with the increasing incidence of post-intensive care syndrome (PICS), it can be beneficial to know what the predisposing factors are.

METHODS

We performed a sub analysis of a recent survey study we have conducted on relatives of deceased ICU patients. Of the 219 eligible relatives, 139 were willing to fill in the questionnaires and 95 of them actually returned the questionnaire, which raises the question whether there are differences between the 95 relatives who did fill in the questionnaires and the 44 relatives who did not. We collected information from the medical records of deceased patients whose relatives did and did not fill in the questionnaires, that is responders and non-responders.

RESULTS

Patient's whose relatives did not fill in the questionnaire had a significantly lower median age compared with patients whose relatives returned the questionnaires (64 [56-75] vs. 71 [65-76] years, respectively, p = .039). The non-responders were two relatives of a deceased patient below 60 years in 34.1% of the cases, whereas this percentage was 14.7% in the responders. The distribution of men and women was comparable between the groups (p = .54) as well as the length of ICU stay (p = .48).

CONCLUSION

Our findings suggest that ICU-related variables did not influence response rate, but the age of the deceased ICU patient does: The non-responders are related to deceased ICU patients with a significantly lower age.

An integrative literature review examining the key elements of bereavement follow-up interventions in critical care

PURPOSE OF REVIEW

The aim of this review is to examine bereavement follow-up intervention studies in critical care, with the purpose of integrating results on the timing, content, aims and outcomes of interventions. The impact of a death in critical care is well documented, and bereavement follow-up is recognised as an important topic, but there is limited research with little consensus on the content and structure of interventions.

RECENT FINDINGS

A total of 18 papers were selected; 11 are intervention studies, with only one randomised control trial. Six papers were from national surveys and are not the focus of this review. Bereavement follow-up mainly consisted of information giving, condolence interventions, telephone calls and meetings with families. The timing, content, aims and outcomes depended on the intervention and were influenced by the design of the study.

SUMMARY

Overall, bereavement follow-up is acceptable for relatives but outcomes are mixed. Calls for more research are valid, but how do we utilise the current research to better inform the critical care community? Researchers suggest that bereavement follow-up interventions need to be designed with specific aims and outcomes, in collaboration with bereaved families that are appropriate to the intervention.

Follow-up focused on psychological intervention initiated after intensive care unit in adult patients and informal caregivers: a systematic review and meta-analysis

Psychological dysfunction is one of the considerable health-related outcomes among critically-ill patients and their informal caregivers. Follow-up of intensive care unit (ICU) survivors has been conducted in a variety of different ways, with different timing after discharge, targets of interest (physical, psychological, social) and measures used. Of diverse ICU follow-up, the effects of follow-ups which focused on psychological interventions are unknown. Our research question was whether follow-up with patients and their informal caregivers after ICU discharge improved mental health compared to usual care. We published a protocol for this systematic review and meta-analysis in https://www.protocols.io/ (https://dx.doi.org/10.17504/protocols.io.bvjwn4pe). We searched PubMed, Cochrane Library, EMBASE, CINAHL and PsycInfo from their inception to May 2022. We included randomized controlled trials for follow-ups after ICU discharge and focused on psychological intervention for critically ill adult patients and their informal caregivers. We synthesized primary outcomes, including depression, post-traumatic stress disorder (PTSD), and adverse events using the random-effects method. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the certainty of evidence. From the 10,471 records, we identified 13 studies (n = 3, 366) focusing on patients and four (n = 538) focusing on informal caregivers. ICU follow-up for patients resulted in little to no difference in the prevalence of depression (RR 0.89, 95% CI [0.59-1.34]; low-certainty evidence) and PTSD (RR 0.84, 95% CI [0.55-1.30]; low-certainty evidence) among patients; however, it increased the prevalence of depression (RR 1.58 95% CI [1.01-2.46]; very low-certainty evidence), PTSD (RR 1.36, 95% CI [0.91-2.03]; very low-certainty evidence) among informal caregivers. The evidence for the effect of ICU follow-up on adverse events among patients was insufficient. Eligible studies for informal caregivers did not define any adverse event. The effect of follow-ups after ICU discharge that focused on psychological intervention should be uncertain.

The Impact of Randomized Family-Centered Interventions on Family-Centered Outcomes in the Adult Intensive Care Unit: A Systematic Review

Objective: To review the literature for randomized family-centered interventions with family-centered outcomes in the adult intensive care unit (ICU). Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library database from inception until February 2023. Study Selection: We included articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting family-centered outcomes. Data Extraction: We extracted data on author, year of publication, setting, number of participants, intervention category, intervention, and family-centered outcomes. Data Synthesis: There were 52 RCTs included in the analysis, mostly involving communication and receiving information (38%) and receiving care and meeting family member needs (38%). Nearly two-thirds of studies (N = 35; 67.3%) found improvements in at least 1 family-centered outcome. Most studies (N = 24/40; 60%) exploring the impact of family-centered interventions on mental health outcomes showed improvement. Improvements in patient-centered outcomes (N = 7/17; 41%) and healthcare worker outcomes (N = 1/5; 20%) were less commonly found. Conclusions: Family-centered interventions improve family-centered outcomes in the adult ICU and may be beneficial to patients and healthcare workers.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions to improve well-being among children and youth aged 6-17 years during the COVID-19 pandemic: a systematic review

BACKGROUND

The COVID-19 pandemic is an example of a global infectious disease outbreak that poses a threat to the well-being of children and youth (e.g., physical infection, psychological impacts). The consequences of challenges faced during COVID-19 may be longstanding and newly developed interventions are being deployed. We present a narrative synthesis of available evidence from the first 2 years of the COVID-19 pandemic on the feasibility, accessibility, and effects of interventions to improve well-being among children and youth to inform the development and refinement of interventions relevant to post-pandemic recovery.

METHODS

Six databases were searched from inception to August 2022. A total of 5484 records were screened, 39 were reviewed in full text, and 19 studies were included. The definition of well-being and the five domains of well-being as defined by the Partnership for Maternal, Newborn & Child Health and the World Health Organization in collaboration with the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being were used.

RESULTS

Nineteen studies (74% randomized controlled trials) from 10 countries were identified, involving a total of 7492 children and youth (age range: 8.2-17.2 years; 27.8-75.2% males) and 954 parents that occurred during the COVID-19 pandemic (March 2020 to March 2021). Nearly all interventions (n = 18, 95%) targeted health and nutrition, followed by connectedness (n = 6, 32%), while fewer studies targeted agency and resilience (n = 5, 23%), learning and competence (n = 2, 11%), or safety and support (n = 1, 3%). Five interventions (26%) were self-guided while 13 interventions (68%) were guided synchronous by a trained professional, all of which targeted physical and mental health subdomains within health and nutrition; one intervention (5%) was unclear.

CONCLUSIONS

Studies deploying synchronous interventions most often reported improved well-being among children and youth largely in the domain of health and nutrition, specifically physical and mental health. Targeted approaches will be crucial to reach sub-groups of children and youth who are most at risk of negative well-being outcomes. Further research is needed to determine how interventions that best supported children and youth early in the pandemic are different from interventions that are required now as we enter into the post-pandemic phase.

Incidence and risk factors of prolonged grief in relatives of patients with terminal cancer in French palliative care units: The Fami-Life multicenter cohort study

OBJECTIVES

Psychological consequences of grief among relatives are insufficiently known. We reported incidence of prolonged grief among relatives of deceased patients with cancer.

METHODS

Prospective cohort study of 611 relatives of 531 patients with cancer hospitalized for more than 72 hours and who died in 26 palliative care units was conducted. The primary outcome was prolonged grief in relatives 6 months after patient death, measured with the Inventory Complicated Grief (ICG > 25, range 0-76, a higher score indicates more severe symptoms) score. Secondary outcomes in relatives 6 months after patient death were anxiety and depression symptoms based on Hospital Anxiety and Depression Scale (HADS) score (range 0 [best]-42 [worst]), higher scores indicate more severe symptoms, minimally important difference 2.5. Post-traumatic stress disorder symptoms were defined by an Impact Event Scale-Revised score >22 (range 0-88, a higher score indicates more severe symptoms).

RESULTS

Among 611 included relatives, 608 (99.5%) completed the trial. At 6 months, significant ICG scores were reported by 32.7% relatives (199/608, 95% CI, 29.0-36.4). The median (interquartile range ICG score) was 20.0 (11.5-29.0). The incidence of HADS symptoms was 87.5% (95% CI, 84.8-90.2%) at Days 3-5 and 68.7% (95% CI, 65.0-72.4) 6 months after patient's death, with a median (interquartile range) difference of -4 (-10 to 0) between these 2 time points. Improvement in HADS anxiety and depression scores were reported by 62.5% (362/579) relatives.

SIGNIFICANCE OF RESULTS

These findings support the importance of screening relatives having risk factors of developing prolonged grief in the palliative unit and 6 months after patient's death.

Piloting Group-Based Behavioral Activation Therapy for Families of Deceased COVID-19 Patients

Surrogate decision-making is a stressful process for many family members of critically ill patients. The COVID-19 pandemic may have amplified the risk for anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms in ICU surrogates.

OBJECTIVES

This study piloted an online group-based behavioral intervention with family members of deceased COVID-19 patients. Participant engagement, perceptions, and responses related to the intervention were assessed.

DESIGN

A single-arm pilot study was conducted with bereaved families. Quantitative analysis of measures of anxiety, depression, and PTSD symptoms was conducted with mixed models. Qualitative data were analyzed to identify themes in surrogates' experiences with the intervention.

SETTING

Participants were recruited from ICUs at a tertiary academic medical center. Participants completed the intervention, measures, and interviews online.

SUBJECTS

Participants were family members of patients who died from COVID-19.

INTERVENTIONS

The intervention involved six online group-based behavioral activation sessions. Sessions covered topics pertinent to grieving and engagement in personally meaningful activities.

MEASUREMENTS AND MAIN RESULTS

Semi-structured interviews explored participants' experiences with the intervention. Surrogates also completed measures of anxiety, depression, and PTSD symptoms before and after the intervention. Nineteen of 26 participants (73.1%) completed the study. Thematic analysis suggested that surrogates found the group helpful for overcoming perceived isolation, receiving validation, and developing coping skills. Significant pre-to-post reductions were observed in symptoms of Hospital and Anxiety Disorder Scale (HADS) anxiety (pre-mean = 9.27, sd = 5.30 vs post-mean = 6.80, sd = 4.16; p = 0.0271), HADS depression (pre-mean =6 .65, sd = 4.58 vs post- mean = 4.89, sd = 3.40; p = 0.0436), and Impact of Events Scale-Revised PTSD (pre-mean = 36.86, sd = 16.97 vs post-mean = 24.14, sd = 13.49; p = 0.0008).

LIMITATIONS

This was a preliminary study based on qualitative and self-report measures. Future studies should include a control group.

CONCLUSIONS

Online group-based behavioral activation therapy appears to be a potentially useful intervention for family members of ICU patients who died from COVID-19.

Improving the intensive care experience from the perspectives of different stakeholders

The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel’s suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

OBJECTIVES

Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions.

DATA SOURCES

MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022.

STUDY SELECTION

Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified.

DATA EXTRACTION

Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose.

CONCLUSIONS

Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

Bereavement Support Programs in the Intensive Care Unit: A Systematic Review

OBJECTIVES

The death of a loved one in the intensive care unit (ICU) may have a psychological impact on relatives of deceased ICU patients. The first aim of this review is to give an overview of different bereavement support strategies and possible different effects on anxiety, depression, Post-traumatic Stress Disorder (PTSD), and complicated grief. Secondly to assess if there is a difference in organization among bereavement support strategies mentioned in literature.

METHODS

A multi-database search (Pubmed, Web of Science, PsychInfo, Medline, and Embase) was conducted until February 6, 2021. Articles were screened and selected by two independent researchers. Methodological quality of the included articles was assessed using the Delphi List for Quality Assessment of Randomized Clinical Trials and the Newcastle-Ottawa scale (NOS) for nonrandomized trials.

RESULTS

The primary literature search revealed 1668 articles, including 769 duplicates. Seven articles were included in this review, of which six were randomized controlled trials and one was a prospective cross-sectional study. We found that a bereavement strategy consisting of a communication strategy and a brochure lowered the appearance of symptoms of PTSD, anxiety, and depression. A brochure, condolence card, and phone call as bereavement support can lower the risk of prolonged grief. Receiving information about CPR and getting the choice to attend CPR led to fewer frequencies of PTSD, depression, and traumatic/complicated grief.

SIGNIFICANCE OF RESULTS

A bereavement strategy consisting of multiple parts, including family participation and a brochure may reduce the levels of anxiety, depression, PTSD, and/or complicated bereavement in family members of deceased ICU patients.

Effectiveness of Brief Contact Interventions for Bereavement: A Systematic Review

Brief contact interventions are an efficient and cost-effective way of providing support to individuals. Whether they are an effective bereavement intervention is not clear. This systematic review included articles from 2014 to 2021.711 studies were identified, with 15 meeting inclusion criteria. The brief contact interventions included informational and emotional supports. Narrative synthesis identified that participants valued brief contact interventions, however some did not find them helpful. Exposure to a brief contact intervention was typically associated with improvements in wellbeing. Studies with comparison groups typically found significant but modest improvements in grief, depression symptoms and wellbeing associated with the intervention. However, one intervention was associated with significant deterioration of depression symptoms. Existing brief contact interventions for bereavement appear feasible, generally acceptable to the target population and are associated with improvements in wellbeing. Further development and evaluation to account for why improvements occur, and to identify any unintended impacts, is required.

Integrating palliative care into the modern cardiac intensive care unit: a review

The modern cardiac intensive care unit (CICU) specializes in the care of a broad range of critically ill patients with both cardiac and non-cardiac serious illnesses. Despite advances, most conditions that necessitate CICU admission such as cardiogenic shock, continue to have a high burden of morbidity and mortality. The CICU often serves as the final destination for patients with end-stage disease, with one study reporting that one in five patients in the USA die in an intensive care unit (ICU) or shortly after an ICU admission. Palliative care is a broad subspecialty of medicine with an interdisciplinary approach that focuses on optimizing patient and family quality of life (QoL), decision-making, and experience. Palliative care has been shown to improve the QoL and symptom burden in patients at various stages of illness, however, the integration of palliative care in the CICU has not been well-studied. In this review, we outline the fundamental principles of high-quality palliative care in the ICU, focused on timeliness, goal-concordant decision-making, and family-centred care. We differentiate between primary palliative care, which is delivered by the primary CICU team, and secondary palliative care, which is provided by the consulting palliative care team, and delineate their responsibilities and domains. We propose clinical triggers that might spur serious illness communication and reappraisal of patient preferences. More research is needed to test different models that integrate palliative care in the modern CICU.

Communication with bereaved family members after death in the ICU: the CATHARTIC randomised clinical trial

Objective: It is uncertain whether psychological distress in the family members of patients who die during an intensive care unit (ICU) admission may be improved by bereavement interventions. In this trial, relatives' symptoms of anxiety and depression after 6 months were measured when allocated to three commonly used bereavement follow-up strategies. Design: Single-centre, randomised, three parallel-group trial. Setting: A tertiary ICU in Australia. Participants: Relatives of patients who died in the ICU. Interventions: Relatives received bereavement follow-up 4 weeks after the death using a condolence letter, short telephone call or no contact. Main outcome measures: The primary outcome was the total Hospital Anxiety and Depression Scale (HADS-T) score. Secondary outcomes estimated anxiety, depression, complicated grief, post-traumatic stress, and satisfaction with ICU care. Results: Seventy-one relatives participated (24 had no contact, 19 were contacted by letter and 28 by telephone 4 weeks after the death). The mean HADS-T score for no contact was 16.1 (95% CI, 12.4-19.8). Receipt of a letter was associated with a mean HADS-T increase of 1.4 (4.0 decrease to 6.8 increase), and a condolence call was accompanied by a mean decrease of 1.6 (6.6 decrease to 3.4 increase; P > 0.5). Non-significant differences were observed for all secondary outcomes. Conclusions: Anxiety and depression at 6 months in the relatives of patients who died in the ICU was not meaningfully alleviated by receipt of either a condolence letter or telephone call. Trial registration: Australia New Zealand Clinical Trials Registry (ACTRN12619000917134).

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

Background

Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.

Materials and methods

MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.

Results

Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.

Conclusion

This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503)

In-Hospital Bereavement Services as an Act of Care and a Challenge: An Integrative Review

CONTEXT

Globally, people most often die within hospitals. As such, healthcare providers in hospitals are frequently confronted with dying persons and their bereaved relatives.

OBJECTIVES

To provide an overview of the current role hospitals take in providing bereavement care. Furthermore, we want to present an operational definition of bereavement care, the way it is currently implemented, relatives' satisfaction of receiving these services, and finally barriers and facilitators regarding the provision of bereavement care.

METHODS

An integrative review was conducted by searching four electronic databases, from January 2011 to December 2020, resulting in 47 studies. Different study designs were included and results were reported in accordance with the theoretical framework of Whittemore and Knafl (2005).

RESULTS

Only four articles defined bereavement care: two as services offered solely post loss and the other two as services offered pre and post loss. Although different bereavement services were delivered the time surrounding the death, the follow-up of bereaved relatives was less routinely offered. Relatives appreciated all bereavement services, which were rather informally and ad-hoc provided to them. Healthcare providers perceived bereavement care as important, but the provision was challenged by numerous factors (such as insufficient education and time).

CONCLUSION

Current in-hospital bereavement care can be seen as an act of care that is provided ad-hoc, resulting from the good-will of individual staff members. A tiered or stepped approach based on needs is preferred, as it allocates funds towards individuals-at-risk. Effective partnerships between hospitals and the community can be a useful, sustainable and cost-effective strategy.

A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trial

BACKGROUND

In relatives of patients dying in intensive care units (ICUs), inadequate team support can increase the prevalence of prolonged grief and other psychological harm. We aimed to evaluate whether a proactive communication and support intervention would improve relatives' outcomes.

METHODS

We undertook a prospective, multicentre, cluster randomised controlled trial in 34 ICUs in France, to compare standard care with a physician-driven, nurse-aided, three-step support strategy for families throughout the dying process, following a decision to withdraw or withhold life support. Inclusion criteria were relatives of patients older than 18 years with an ICU length of stay 2 days or longer. Participating ICUs were randomly assigned (1:1 ratio) into an intervention cluster and a control cluster. The randomisation scheme was generated centrally by a statistician not otherwise involved in the study, using permutation blocks of non-released size. In the intervention group, three meetings were held with relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after the patient's death to offer condolences and closure. ICUs randomly assigned to the control group applied their best standard of care in terms of support and communication with relatives of dying patients. The primary endpoint was the proportion of relatives with prolonged grief (measured with PG-13, score ≥30) 6 months after the death. Analysis was by intention to treat, with the bereaved relatives as the unit of observation. The study is registered with ClinicalTrials.gov, NCT02955992.

FINDINGS

Between Feb 23, 2017, and Oct 8, 2019, we enrolled 484 relatives of ICU patients to the intervention group and 391 to the control group. 379 (78%) relatives in the intervention group and 309 (79%) in the control group completed the 6-month interview to measure the primary endpoint. The intervention significantly reduced the number of relatives with prolonged grief symptoms (66 [21%] vs 57 [15%]; p=0·035) and the median PG-13 score was significantly lower in the intervention group than in the control group (19 [IQR 14-26] vs 21 [15-29], mean difference 2·5, 95% CI 1·04-3·95).

INTERPRETATION

Among relatives of patients dying in the ICU, a physician-driven, nurse-aided, three-step support strategy significantly reduced prolonged grief symptoms.

FUNDING

French Ministry of Health.

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.

Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges

This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.

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.

Service evaluation of the bereavement care delivered in a UK intensive care unit

BACKGROUND

Losing a loved one in the intensive care unit (ICU) can be a traumatic experience. The literature highlights that relatives of those who have died in ICU can experience symptoms of stress, anxiety, depression, post-traumatic stress disorder (PTSD) and prolonged grief.

AIM

To evaluate the service delivery of the bereavement care that is provided on a 20-bed general ICU.

METHODS AND ANALYSIS

A literature review informing and supporting the service evaluation and development of the questionnaire. Thematic analysis was undertaken using the six-phase framework.

FINDINGS

Five main themes were found: timing; care, dignity and respect; support; information; and memory making. Bereavement care is described as after-death care. However, the participants stipulated that bereavement care should be discussed prior to the death. Participants described using a range of interventions, such as memorial services, condolence letters, follow-up meetings and diaries.

CONCLUSION

Bereavement care was regarded as an important aspect of the care delivered in ICU. It was evident that participants strived to deliver an holistic approach, yet some found this difficult to achieve.

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.

Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France

BACKGROUND

Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help.

DESIGN AND INTERVENTION

We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months.

PARTICIPANTS

We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less.

OUTCOMES

We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries.

CONCLUSIONS

We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.

The impact of bereavement support on psychological distress in family members: a systematic review and meta-analysis

Background: Persistent psychological distress occurs frequently in family members of patients who die in an intensive care unit (ICU). Objective: To determine the effectiveness of bereavement interventions in reducing persisting psychological distress in bereaved family members after death in an adult ICU. Design: Systematic review and meta-analysis of studies that assessed the effect of bereavement interventions on persisting psychological distress in bereaved family members of ICU patients. Data sources: MEDLINE and APA PsycInfo databases were searched until April 2020. Review methods: Two of us independently screened titles and abstracts of identified studies, and then completed full text evaluation of selected studies. We assessed risk of bias using version 2 of the Cochrane risk-of-bias tool for randomised trials and the Newcastle-Ottawa Scale, which is designed to assess the quality of non-randomised studies in meta-analyses. We also used random effects meta-analysis to assess the effect of various interventions on total Hospital Anxiety and Depression Scale (HADS) scores. Results: From 664 citations, five studies were included - three multicentre randomised clinical trials and two single centre observational studies. Three studies tested the intervention of written bereavement support materials and two studies used narration of family members' experiences in the ICU. All studies reported HADS scores. Scores for Impact of Event Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief were measured in some but not all studies. There was no effect of an intervention on HADS scores (weighted mean difference, -0.79 [95% confidence interval, -3.81 to 2.23]; I2 = 65.8%). Conclusions: Owing to limited data, and clinical and statistical heterogeneity, there is considerable uncertainty regarding whether bereavement support strategies reduce, increase or have no effect on psychological distress in bereaved family members.

Interventions in Post-Intensive Care Syndrome-Family: A Systematic Literature Review

OBJECTIVES

Data show that family members of ICU patients may have high levels of anxiety, depression, posttraumatic stress disorders, and/or complicated grief. This was previously referred to as post-intensive care syndrome-family. We systematically review randomized controlled trials for post-intensive care syndrome-family.

DATA SOURCES

Systematic research in databases (Pubmed, EMBASE, PsycINFO, CINHAL for articles published between January 2000 and October 2019).

STUDY SELECTION

Interventions in randomized controlled trials for post-intensive care syndrome-family in relatives of adult ICU patients.

DATA EXTRACTION

Review, quality assessment, and risk assessment for bias of eligible publications were performed along recommended guidelines for each investigation. Quality assessment graded studies into "strong" (n = 5), "moderate" (n = 4), and "weak" (n = 2).

DATA SYNTHESIS

Out of 2,399 publications, 11 investigations were found eligible (3,183 relatives of ICU patients). Studies addressed interventions during ICU stay (n = 6), during the post-ICU period (n = 4), or both (n = 1). Two studies included relatives of dying/deceased patients. One study implemented end-of-life conferences and showed reduced prevalence of posttraumatic stress disorder (45% vs 69%; p = 0.01), anxiety (45% vs 67%; p = 0.02), and depression (29% vs 56%; p = 0.003). Family conferences with a physician and proactive participation of a nurse reduced anxiety-scores (p = 0.01) without reducing anxiety prevalence (33.3% vs 52.3%; p = 0.08). Other studies failed to improve symptoms or reduce prevalence of post-intensive care syndrome-family. Interestingly, condolence letters may even increase prevalence of posttraumatic stress disorder (52.4% vs 37.1%; p = 0.03). Meetings without the presence of ICU physicians were shown to increase Impact of Event Scale-Revised scores (25.9 vs 21.3; p = 0.0495).

CONCLUSIONS

Only few data are available on interventions for post-intensive care syndrome-family. It appears that proactive communication and provision of information seems pivotal for post-intensive care syndrome-family treatment. Interestingly, some interventions may even worsen post-intensive care syndrome-family. In the light of the relevance of post-intensive care syndrome-family in daily ICU care, more high-quality data seems urgently needed.

Bereavement interventions to support informal caregivers in the intensive care unit: a systematic review

Background

Informal caregivers of critically ill patients in intensive care unit (ICUs) experience negative psychological sequelae that worsen after death. We synthesized outcomes reported from ICU bereavement interventions intended to improve informal caregivers’ ability to cope with grief.

Data sources

MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2020.

Study selection

Randomized controlled trials (RCTs) of bereavement interventions to support informal caregivers of adult patients who died in ICU.

Data extraction

Two reviewers independently extracted data in duplicate. Narrative synthesis was conducted.

Data synthesis

Bereavement interventions were categorized according to the UK National Institute for Health and Clinical Excellence three-tiered model of bereavement support according to the level of need: (1) Universal information provided to all those bereaved; (2) Selected or targeted non-specialist support provided to those who are at-risk of developing complex needs; and/or (3) Professional specialist interventions provided to those with a high level of complex needs. Outcome measures were synthesized according to core outcomes established for evaluating bereavement support for adults who have lost other adults to illness.

Results

Three studies of ICU bereavement interventions from 31 ICUs across 26 hospitals were included. One trial examining the effect of family presence at brain death assessment integrated all three categories of support but did not report significant improvement in emotional or psychological distress. Two other trials assessed a condolence letter intervention, which did not decrease grief symptoms and may have increased symptoms of depression and post-traumatic stress disorder, and a storytelling intervention that found no significant improvements in anxiety, depression, post-traumatic stress, or complicated grief. Four of nine core bereavement outcomes were not assessed anytime in follow-up.

Conclusions

Currently available trial evidence is sparse and does not support the use of bereavement interventions for informal caregivers of critically ill patients who die in the ICU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00763-w.

Mental Health Interventions to Improve Psychological Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-Analysis

Supplemental Digital Content is available in the text.

Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients.

Psychological effects of remote-only communication among reference persons of ICU patients during COVID-19 pandemic

Background

During COVID-19 pandemic, visits have been prohibited in most French ICUs. Psychological effects, for reference persons (RPs), of remote-only communication have been assessed.

Methods

All RPs of patients referred to ICU for COVID-19 were included. HADS, IES-R, and satisfaction were evaluated at admission, discharge/death, and 3 months. At 3 months, a psychologist provided a qualitative description of RPs’ psychological distress.

Results

Eighty-eight RPs were included. Prevalence of anxiety and depression was 83% and 73% respectively. At 3 months, lower HADS decrease was associated with patient death/continued hospitalization, and/or sleeping disorders in RPs (p < 0.01). Ninety-nine percent RPs felt the patient was safe (9 [7; 10]/10 points, Likert-type scale), confident with caregivers (10 [9; 10]/10 points), and satisfied with information provided (10 [9; 10]/10 points). All RPs stressed the specific-type of “responsibility” associated with being an RP in a remote-only context, leading RPs to develop narrow diffusion strategies (67%) and restrict the array of contacted relatives to a very few and/or only contacting them rarely. 10 RPs (30%) related the situation to a prior traumatic experience.

Conclusion

RPs experienced psychological distress and reported that being an RP in a remote-only communication context was a specific responsibility and qualified it as an overall negative experience.

Trial registration

NCT04385121. Registered 12 May 2020. https://clinicaltrials.gov/.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00520-w.

Experiences of Bereaved Family Members Receiving Commemorative Paintings: A Qualitative Study

IMPORTANCE

Although family members of patients who die in the intensive care unit commonly experience long-term psychological distress, end-of-life bereavement support programs for such relatives are uncommon. Whether art influences the grief experience of families is largely unexplored.

OBJECTIVE

To explore the influence of personalized paintings created to honor deceased critically ill patients on family members' bereavement experience.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative descriptive analysis was conducted of semistructured interviews of grieving relatives who received a painting after the death of their loved one. The deceased patients were from a 21-bed medical-surgical intensive care unit. Eleven families were invited to receive a painting, of whom 1 family declined. A total of 22 family members of 10 patients who died in the intensive care unit were interviewed in the study between July 11, 2017, and May 19, 2019.

INTERVENTIONS

Patients were enrolled in an end-of-life care program that elicits and implements wishes of patients and their families to bring peace during the dying process. Selected families of 10 decedents were invited to receive a painting to honor their loved one 1 to 10 months after the patient's death. Using details about the patient's life story, the artist created individualized paintings to commemorate each patient.

MAIN OUTCOMES AND MEASURES

The experiences of family members receiving a personalized painting and its reported influence on their grieving experience.

RESULTS

The family members of 10 decedents (mean [SD] age, 60 [14] years; 5 women [50%]; 8 White patients [80%]) were interviewed. The central theme of art to facilitate healing was illustrated through the following domains: the cocreation process, painting narratives, postmortem connections, and legacy. The process of cocreating the paintings with the artist and family members involved reminiscing, storytelling, and creativity. Family members emphasized the role of art to facilitate healing, exemplified through connections with images portrayed that deeply resonated with memories of their loved one. Participants indicated that the paintings validated that the patient was remembered, helped families feel less alone during a time of grief, honored the loved one's life, and enhanced connections between family members and clinicians.

CONCLUSIONS AND RELEVANCE

This qualitative study's findings suggest that the creation of personalized paintings commemorating the lives of patients may help foster legacy and postmortem connections with clinicians and may help family members in their healing process.

Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study

Rationale: Frontline healthcare providers (HCPs) during the coronavirus disease (COVID-19) pandemic are at high risk of mental morbidity.

Objectives: To assess the prevalence of symptoms of anxiety, depression, and peritraumatic dissociation in HCPs.

Methods: This was a cross-sectional study in 21 ICUs in France between April 20, 2020, and May 21, 2020. The Hospital Anxiety and Depression Scale and the Peritraumatic Dissociative Experience Questionnaire were used. Factors independently associated with reported symptoms of mental health disorders were identified.

Measurements and Main Results: The response rate was 67%, with 1,058 respondents (median age 33 yr; 71% women; 68% nursing staff). The prevalence of symptoms of anxiety, depression, and peritraumatic dissociation was 50.4%, 30.4%, and 32%, respectively, with the highest rates in nurses. By multivariable analysis, male sex was independently associated with lower prevalence of symptoms of anxiety, depression, and peritraumatic dissociation (odds ratio of 0.58 [95% confidence interval, 0.42–0.79], 0.57 [95% confidence interval, 0.39–0.82], and 0.49 [95% confidence interval, 0.34–0.72], respectively). HCPs working in non–university-affiliated hospitals and nursing assistants were at high risk of symptoms of anxiety and peritraumatic dissociation. Importantly, we identified the following six modifiable determinants of symptoms of mental health disorders: fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, and witnessing hasty end-of-life decisions.

Conclusions: HCPs experience high levels of psychological burden during the COVID-19 pandemic. Hospitals, ICU directors, and ICU staff must devise strategies to overcome the modifiable determinants of adverse mental illness symptoms.

Family and Clinician Experiences of Sympathy Cards in the 3 Wishes Project

BACKGROUND

A recent randomized trial of bereaved family members of patients who died in an intensive care unit identified symptoms of depression and posttraumatic stress in recipients of semistructured condolence letters.

OBJECTIVES

To explore family member and clinician experiences with receiving or sending handwritten sympathy cards upon the death of patients involved in a personalized end-of-life intervention, the 3 Wishes Project.

METHODS

Interviews and focus groups were held with 171 family members and 222 clinicians at 4 centers to discuss their experiences with the 3 Wishes Project. Interview transcripts were searched to identify participants who discussed sympathy cards. Data related to sympathy cards were independently coded by 2 investigators through conventional content analysis.

RESULTS

Sympathy cards were discussed during 32 interviews (by 25 family members of 21 patients and by 11 clinicians) and 2 focus groups (8 other clinicians). Family members reported that personalized sympathy cards were a welcome surprise; they experienced them as a heartfelt act of compassion. Clinicians viewed cards as an opportunity to express shared humanity with families, reminding them that they and their loved one were not forgotten. Signing cards allowed clinicians to reminisce individually and collectively with colleagues. Family members and clinicians experienced sympathy cards as a meaningful continuation of care after a patient's death.

CONCLUSIONS

Inviting clinicians who cared for deceased patients to offer personalized, handwritten condolences to bereaved family members may cultivate sincere and individualized expressions of sympathy that bereaved families appreciate after the death of patients involved in the 3 Wishes Project.

Developing and testing a nurse-led intervention to support bereavement in relatives in the intensive care (BRIC study): a protocol of a pre-post intervention study

BACKGROUND

When a patient is approaching death in the intensive care unit (ICU), patients' relatives must make a rapid transition from focusing on their beloved one's recovery to preparation for their unavoidable death. Bereaved relatives may develop complicated grief as a consequence of this burdensome situation; however, little is known about appropriate options in quality care supporting bereaved relatives and the prevalence and predictors of complicated grief in bereaved relatives of deceased ICU patients in the Netherlands. The aim of this study is to develop and implement a multicomponent bereavement support intervention for relatives of deceased ICU patients and to evaluate the effectiveness of this intervention on complicated grief, anxiety, depression and posttraumatic stress in bereaved relatives.

METHODS

The study will use a cross-sectional pre-post design in a 38-bed ICU in a university hospital in the Netherlands. Cohort 1 includes all reported first and second contact persons of patients who died in the ICU in 2018, which will serve as a pre-intervention baseline measurement. Based on existing policies, facilities and evidence-based practices, a nurse-led intervention will be developed and implemented during the study period. This intervention is expected to use 1) communication strategies, 2) materials to make a keepsake, and 3) a nurse-led follow-up service. Cohort 2, including all bereaved relatives in the ICU from October 2019 until March 2020, will serve as a post-intervention follow-up measurement. Both cohorts will be performed in study samples of 200 relatives per group, all participants will be invited to complete questionnaires measuring complicated grief, anxiety, depression and posttraumatic stress. Differences between the baseline and follow-up measurements will be calculated and adjusted using regression analyses. Exploratory subgroup analyses (e.g., gender, ethnicity, risk profiles, relationship with patient, length of stay) and exploratory dose response analyses will be conducted.

DISCUSSION

The newly developed intervention has the potential to improve the bereavement process of the relatives of deceased ICU patients. Therefore, symptoms of grief and mental health problems such as depression, anxiety and posttraumatic stress, might decrease.

TRIAL REGISTRATION

Netherlands Trial Register Registered on 27/07/2019 as NL 7875, www.trialregister.nl.