Intensive care unit diaries to help bereaved family members in their grieving process: a systematic review

[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.

Family's preferences for and experiences of writing practices in adult intensive care and its use in early bereavement: A descriptive qualitative study

BACKGROUND

Family partaking in writing practices, such as writing intensive care unit (ICU) patient diaries, personal diaries/journaling, social media, or instant messaging services, during ICU admission may allow the family to unintentionally participate in a form of expressive writing. These writing practices could provide structure for the family authors to explore emotions and manage significant life events, including death of a loved one. Limited studies have explored the family's postmortem experiences and perceived value of writing practices maintained during an ICU admission.

OBJECTIVES

The objective of this study was to explore the family member's preferences for and experiences of writing practices in the adult ICU and its use in early bereavement.

METHODS

descriptive qualitative design using inductive reflexive thematic analysis from a purposeful, convenience sample of 16 bereaved participants from a tertiary referral, adult ICU in Australia who discussed their experiences of and preferences in writing practices. Reporting adheres to the consolidated criteria for reporting qualitative research checklist.

FINDINGS

Six participants maintained writing practices during the ICU admission and 10 did not. Three themes were generated from the data: the decision to maintain writing practices was shaped by past behaviours and perceived utility; moments captured were influenced by the loved ones' clinical status and their ability to access the writing medium; and writing practices have limited utility as a memory making object in early bereavement.

CONCLUSIONS

Based on the generated findings, participants who did not maintain writing practices did not later regret this decision during early bereavement. Participants who did maintain writing practices predominately used a personal diary/journal that they carried with them. As the loved one approached death, the written entries became shorter, then ceased. Most of the written entries were not read during early bereavement, suggesting the writing practices' psychological value might have been predominately gained at the time of writing, rather than during early bereavement.

The role of intensive care unit diaries in the grieving process: A monocentric qualitative study

BACKGROUND

The growing importance of psychological recovery for patients and their families following intensive care unit (ICU) experiences in recent years cannot be overemphasized. The ICU diary is used to aid patients in reducing the prevalence of post-traumatic stress disorder, anxiety, and depression. The usefulness of maintaining a diary during the grieving process has not yet been thoroughly investigated.

AIM

To investigate the role of ICU diaries in the grief process experienced by family members of a person who died in the intensive care unit.

STUDY DESIGN

Nine family members of seven deceased ICU patients with an ICU diary were contacted and interviewed by phone using a semi-structured interview. A qualitative data analysis was performed using thematic synthesis.

SETTING

Italian general intensive care unit.

FINDINGS

Interviewed family members felt that the diary helped them during the grieving process. The return of diaries was desired by family members for support and to remember one's loved one. The diary helped them process their losses in various ways, including signs of evidence of care, emotional involvement, consideration, and coping with grief. Four main themes emerged from the analysis: writing the diary, reading the diary, talking about the diary, and the diary during the grieving process.

CONCLUSIONS

The overall perception of the ICU diary was positive. The diary mostly helped relatives to "give back something of what we lost". This study also affirms the positive link between ICU diaries and bereavement in Italian ICU. Further studies are required to confirm the usefulness of this tool in the grieving process.

RELEVANCE TO CLINICAL PRACTICE

The ICU diary can help patients' family members understand what happened to their loved one and play an important role in the grieving process. The diary served as a valuable source of information that aided in providing bereavement support to the family by helping them to gain a rational and emotional understanding of the patient's death.

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.

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

BACKGROUND

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

AIM

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CLINICAL PRACTICE

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

Thematic analysis of intensive care unit diaries kept by staff: insights for caring

OBJECTIVE

To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Qualitative study.

SETTING

Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021.

METHODS

ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed.

FINDINGS

Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations).

CONCLUSION

The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

Factors affecting the emotional reactions of patient relatives who receive news of death: a prospective observational study

Background

Reporting the death of relatives to a family member is a very stressful task for physicians. Grief reactions differ from person to person.

Methods

Demographic data of 100 patients who died after staying in ICU for more than three days were recorded. For each patient, one of the family members filled a form which contained their own age, gender, education level, marital status, number of children, degree of relationship, psychiatric treatment status, living in the same house as the patient, and whether they had ever visited the ICU before. Grief reactions were evaluated in five different categories: normal grief response, initial shock reaction, denial, feeling guilty and anger.

Results

When the death was reported, 55.0% of the relatives accepted this situation as normal, 19.0% felt guilty and 14.0% showed an initial shock reaction. The results showed that for a one-unit increase in the patient's age, the probability of the denial reaction among relatives was reduced by 746 times and the probability of feeling guilty was reduced by 698 times.

Conclusion

The rate of denial and guilt in the grief reactions among patient relatives when given news of death in the intensive care unit increases with the decrease in patient age.