Emotional disorders in pairs of patients and their family members during and after ICU stay

Family engagement in the care of infectious patients in intensive care units: A hybrid concept analysis

AIM

This study aims to define and investigate characteristics, antecedents, and consequences of the concept of family engagement in caring for patients with infectious diseases hospitalised in intensive care units.

DESIGN

This is a three-phase hybrid model study (theoretical, fieldwork, and analytical phase).

METHODS

The York University Guidelines were used in the theoretical phase, and ultimately, 16 pieces of literature related to the subject under study from 2011 to 2021 were reviewed. The content analysis was used for fieldwork phases; eight participants were interviewed. Then, the theoretical and fieldwork findings were compared, integrated, and analysed.

RESULTS

This concept has characteristics such as; awareness, belief, perception, and willingness of the nurse to engage the family; a sense of responsibility, willingness, and sacrifice of the family; the physical or virtual presence of the family; triangular interaction between the nurse, patient, and family; perception and identifying the goals; education and information transfer; team collaboration; delegation of responsibility to the family; decision making; and protection of the family. Antecedents include the availability of infrastructure; patient, family, and nurse conditions; and the quality implementation of engagement. The consequences include positive consequences related to the patient, family, nursing, and society, as well as some negative consequences. This study provided a comprehensive perception of family engagement in the care of patients with infectious diseases in intensive care units and defined it more clearly, showing its characteristics, antecedents, and consequences.

PATIENT OR PUBLIC CONTRIBUTION

Eight participants were interviewed, including five nurses, two family caregivers, and one patient.

Depressive symptoms over time among survivors after critical illness: A systematic review and meta-analysis

OBJECTIVE

Critical illness survivors frequently experience various degrees of depressive symptoms, which hinder their recovery and return to daily life. However, substantial variability in the prevalence of depressive symptoms has been reported among critical illness survivors. The exact prevalence remains uncertain.

METHODS

A systematic search was performed in PubMed, Embase, CINAHL, and PsycINFO from inception to August 2023 for observational studies that reported depressive symptoms in adult critical illness survivors. The random-effects model was used to estimate the prevalence of depressive symptoms. Subgroup analysis and meta-regression were conducted to explore potential moderators of heterogeneity. Study quality was evaluated using the Joanna Briggs Institute's tool and the GRADE approach.

RESULTS

Fifty-two studies with 24,849 participants met the inclusion criteria. Overall prevalence estimate of depressive symptoms was 21.1% (95% CI, 18.3-24.1%). The prevalence of depressive symptoms remains stable over time. Point prevalence estimates were 21.3% (95% CI, 9.9-35.4%), 19.9% (95% CI, 14.6-25.9%), 18.5% (95% CI, 9.6-29.2%), 21.0% (95% CI, 16.8-25.5%), and 22.6% (95% CI, 14.4-31.8%) at <3, 3, 6, 12, and > 12 months after discharge from intensive care unit (ICU), respectively.

CONCLUSIONS

Depressive symptoms may impact 1 in 5 adult critically ill patients within 1 year or more following ICU discharge. An influx of rehabilitation service demand is expected, and risk stratification to make optimal clinical decisions is essential. More importantly, to propose measures for the prevention and improvement of depressive symptoms in patients after critical care, given the continuous, dynamic management of ICU patients, including ICU stay, transition to general wards, and post-hospital.

The spectrum of psychological disorders in family members of patients suffering from delirium associated with critical illness: a prospective, observational study

During intensive care unit admission, relatives of critically ill patients can experience emotional distress. The authors hypothesized that families of patients who are diagnosed with intensive care unit (ICU) delirium experience more profound depression and anxiety disorders related to stress than do families of patients without delirium. We performed a prospective observational single-center study including families of adult patients (age above 18 years) hospitalized in a 17-bed ICU of a university hospital for at least 48 h who completed research questionnaires at day 2 after admission and day 30 after initial evaluation using dedicated questionnaires (HADS, CECS, IES, PTSD-C). A total of 98 family members of patients hospitalized in the ICU were included in the final analysis (50 family members whose relatives were CAM-ICU positive (DEL+), and 48 family members of patients without delirium (DEL-)). No statistically significant differences in demographics and psychosocial data were found between the groups. In the follow-up 30 days after the first conversation with a family member, the mean PTSD score for the relatives of patients with delirium was 11.02 (Me = 13.0; SD = 5.74), and the mean score for nondelirious patients' family members was 6.42 (Me = 5.5; SD = 5.50; p < 0.001). A statistically significant increase in IES scores for family members of patients with delirium was observed for total PTSD (p = 0.001), IES-intrusion (p < 0.001), and IES-hyperarousal (p = 0.002). The prevalence of anxiety symptoms, depression, and posttraumatic stress disorder (PTSD) was higher in families of patients diagnosed with ICU delirium within 48 h of admission to the ICU. No factors increasing the depth of these disorders in family members of patients with ICU delirium were identified. Taking appropriate actions and thus providing families with appropriate support will contribute to the understanding of unfavorable emotional states, including anxiety, stress, depression, anger, agitation, or avoidance.

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.

Physical, social, mental and spiritual functioning of COVID-19 intensive care unit-survivors and their family members one year after intensive care unit-discharge: A prospective cohort study

OBJECTIVE

To describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain.

DESIGN

A single-centre, prospective cohort study with a mixed-methods design.

SETTING

The intensive care unit of the University Medical Center Groningen in the Netherlands.

MAIN OUTCOME MEASURES

To study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members.

RESULTS

A total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0-68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43-66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was 'returning to normal' in the interviews with survivors and 'if the patient is well, I am well' in the interviews with family members.

CONCLUSIONS

One year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members' well-being is strongly impacted by the health of the survivor.

Effects of participation in interdisciplinary rounds in the intensive care unit on family satisfaction: A cross-sectional study

OBJECTIVE

To investigate whether family participation in intensive care unit interdisciplinary bedside rounds affects family satisfaction.

METHODS

A cross-sectional study was conducted at a 56-bed, adult, mixed intensive care unit of a tertiary hospital in Southern Brazil. From May to June 2019, family members of patients who stayed in the intensive care unit for at least 48 hours were invited to participate in the study at the time of patient discharge. The main exposure variable was participation in intensive care unit bedside rounds during the intensive care unit stay. Family satisfaction was assessed by using the Brazilian version of the Family Satisfaction in the Intensive Care Unit questionnaire.

RESULTS

Of the 234 screened individuals, 118 were included. Eleven participants withdrew consent. A total of 107 individuals were assessed; 58 (54%) reported being present during bedside rounds, and 49 (46%) reported never being present. General satisfaction and satisfaction with the decision-making process were higher among families who were present during rounds than among families who were not (p = 0.01 and p = 0.007, respectively).

CONCLUSION

The presence during interdisciplinary rounds was associated with improved general satisfaction and satisfaction with the decision-making aspect. This outcome indicates that efforts must be directed to conduct studies with more robust methodologies to confirm this association.

Adaptation of the Quality of Communication Questionnaire for Family Members and Its Validity Evidence for Use in Brazil

Assessment of communication between physicians and patients' family members is essential to improving healthcare quality. To adapt the Quality of Communication Questionnaire (QoC) for family members and to analyze its validity evidence for use in Brazil. Data were collected between 2017 and 2019, with family members of patients in intensive care (IC) and palliative care (PC) from five public hospitals in the South Brazil. The QoC was adapted for family members for use in Brazil, and its cross-cultural adaptation was carried out. The clarity and cultural appropriateness of the pre-final version were evaluated by 30 family members of patients in IC. The final version was responded by 198 family members of patients. All items were considered clear, and appropriate to Brazilian culture. The goodness of fit index for proposed model had CFI 0.96 (CI95%: 0.94 - 0.98), TLI 0.95 (CI95%: 0.92 - 0.97), RMSEA 0.07 (CI90%: 0.06 - 0.08), and χ²/df 2.18. Cronbach's alpha coefficient (α) among family members of patients in PC was 0.88 for the general communication (first subscale) and 0.80 for the end-of-life communication (second subscale). However, among family members of patients in IC, α was 0.86 for the first subscale and only 0.53 for the second subscale. The QoC for family members and its cross-cultural adaptation were carried out successfully. It has strong validity evidence among those with loved ones in PC, but only the QoC general communication subscale has strong validity evidence among those with loved ones in IC.

High-value care for critically ill oncohematological patients: what do we know thus far?

The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors Affecting Psychological Distress in Family Caregivers of Critically Ill Patients: A Qualitative Study

BACKGROUND

Family caregivers often experience psychological distress during a critical care hospitalization, potentially compromising their ability to function effectively in a supportive role. A better understanding of the sources of family caregiver distress is needed to inform strategies to mitigate its development and impact.

OBJECTIVE

To explore sources of family caregiver psychological distress during a critical care hospitalization and how caregivers' experiences may differ by their anxiety level.

METHODS

Forty adult family members of patients receiving mechanical ventilation for more than 72 hours in 2 intensive care units at an academic medical center were interviewed. A qualitative directed content analysis was done. Experiences were compared by anxiety level group, defined using the Hospital Anxiety and Depression Scale: anxiety (n = 15), borderline anxiety (n = 11), and low anxiety (n=14).

RESULTS

Most family members (32%) were adult children; no major demographic differences were noted across anxiety groups. Among caregivers in the anxiety group, salient factors included early unknowns around critical illness, health care team processes, care decisions made, financial and housing concerns, family dysfunction, and new responsibilities. In general, low-anxiety family caregivers did not express their concerns using language of distress but rather expressed emotion and disappointment and often took action to process their concerns.

CONCLUSIONS

Factors influencing family caregiver distress during the critical care stay were wide-ranging and varied by level of anxiety. The findings highlight several key areas and potential interventions to reduce psychological distress, especially among caregivers with anxiety.

Stress and mental health of COVID-19 survivors and their families after hospital discharge: relationship with perceived healthcare staff empathy

Several studies attest to the long-term consequences of COVID-19 infection on survivors' mental illness, especially in terms of high prevalence of post-traumatic stress disorder (PTSD) 1-3 months after hospitalization. Aims of the present study were (1) to jointly evaluate PTSD and positive mental health among COVID-19 survivors and family members after hospital discharge, and (2) to investigate the relationship between perceived healthcare staff's relational empathy during hospitalization and survivors' post-traumatic stress levels. In this cross-sectional study, 60 survivors (M_age = 60.45; 63.3% men) and 40 family members (M_age = 52.33; 60% women) participated in an online survey 3-7 months after hospital discharge. In addition to providing socio-demographic data, they completed PTSD Checklist for DSM-5 and Mental Health Continuum Short Form. Survivors also completed the Consultation and Relational Empathy measure. Percentages of participants meeting a provisional PTSD and mental health diagnosis (flourishing, moderate, languishing) were calculated. A hierarchical regression analysis was performed on survivors' data, with perceived staff's empathy as predictor and post-traumatic stress symptoms (PTSS) as outcome. One-fifth of the participants received a provisional PTSD diagnosis, about half were diagnosed with flourishing or moderate mental health, and only 5% were languishing, with no significant between-group differences. Among survivors, a negative association was detected between perceived healthcare staff's empathy and PTSS, explaining 10.5% of the model variance over and above demographic and clinical variables. Findings highlighted the coexistence of PTSD and positive mental health among survivors and family members, suggesting the usefulness of assessing both negative and positive dimensions of mental health, in order to promote psycho-social adaptation once returning to everyday life. In addition, the role of compassionate care in clinical practice emerged as a potential means to mitigate severe traumatic reactions among survivors.

Validation of an Instrument to Measure Family Engagement in Acute Cardiac Care

Background

Engaging families in care leads to improved patient- and family-centreed outcomes and is recommended by cardiovascular societies. However, no validated tools are currently available to measure family engagement in acute cardiac care. We previously described the development of the FAMily Engagement (FAME) instrument. The purpose of this study is to validate the FAME instrument in acute cardiac care.

Methods

The FAME questionnaire was administered to family members of patients in a cardiovascular intensive care unit and ward at an academic tertiary care hospital in Montreal, Canada. After hospital discharge, we assessed family satisfaction in the intensive care unit (FS-ICU) and mental health (using the Hospital Anxiety and Depression Scale [HADS]). Higher FAME scores indicate increased care engagement. Reliability was assessed using internal consistency testing. Predictive validity was evaluated by assessing the relationship between the FAME score and the FS-ICU score and whether the FAME score was correlated with the HADS score. Convergent validity was assessed by comparing the FAME score with engagement elements of the FS-ICU score.

Results

A total of 160 family participants were included (age 54.8 ± 14.8 years; 66% women; 36% non-White). The most common relationships to the patient were spouse/partner and adult child (both n = 62; 39%). The mean FAME score was 70.8 ± 16.0. The FAME instrument had high internal consistency (Cronbach's a = 0.86). The FAME score was associated with family satisfaction in the multivariable analysis (P < 0.001). No correlation occurred between FAME and HADS anxiety or depression scores.

Conclusions

The FAME tool demonstrated reliability and convergent and predictive validity in the acute care cardiac population. Further research is needed to explore whether selected engagement interventions can impact the FAME score favourably.

Prevalence and factors associated with symptoms of depression in family members of people hospitalized in the intensive care unit

OBJECTIVE

To evaluate the prevalence and factors associated with depression in family members of people hospitalized in intensive care units.

METHODS

A cross-sectional study was conducted with 980 family members of patients admitted to the intensive care units of a large public hospital in the interior of Bahia. Depression was measured using the Patient Health Questionnaire-8. The multivariate model consisted of the following variables: sex and age of the patient, sex and age of the family member, education level, religion, living with the family member, previous mental illness and anxiety.

RESULTS

Depression had a prevalence of 43.5%. In the multivariate analysis, the model with the best representativeness indicated that factors associated with a higher prevalence of depression were being female (39%), age younger than 40 years (26%) and previous mental illness (38%). A higher education level was associated with a 19% lower prevalence of depression in family members.

CONCLUSION

The increase in the prevalence of depression was associated with female sex, age younger than 40 years and previous psychological problems. Such elements should be valued in actions aimed at family members of people hospitalized in intensive care.

Provider’s Perception of Parental Anxiety in the Pediatric Intensive Unit

Parents of critically ill children in the Pediatric Intensive Care Unit (PICU) commonly experience new or worsening anxiety, which can lead to long-term sequelae in the form of post-traumatic stress disorder (PTSD). To investigate how well the PICU providers recognize and assess parental anxiety, we assessed the acute and baseline anxiety level of 30 parents in the PICU with the State-Trait Anxiety Inventory (STAI) and compared the results with the PICU physician's and nurses' assessments. All but four parents experienced higher acute anxiety scores compared to baseline, with a 34% increase in the number of parents with moderate and high anxiety scores. All PICU providers performed poorly in recognizing and assessing parental anxiety, with a tendency to underestimate the level of anxiety. Proper screening tools and strategies are essential to recognize and help parents in distress and potentially prevent long-term psychological sequelae.

Factors associated with limitation of care after fatal injury

BACKGROUND

There is variability in end-of-life care of trauma patients. Many survive resuscitation but die after limitation of care (LoC). This study investigated LoC at a level I center.

METHODS

Adult trauma deaths between January 2016 and June 2020 were reviewed. Patients were stratified into "full code" versus any LoC (i.e., do not resuscitate, no escalation, or withdrawal of care) and by timing to LoC. Emergency department and "brain" deaths were excluded. Unadjusted logistic regression and Cox proportional hazards were used for analyses. Results include n (%) and odds ratios (ORs) with 95% confidence intervals (CIs), with α = 0.05.

RESULTS

A total of 173 patients were included; 15 patients (8%) died full code and 158 (91%) died after LoC. Seventy-seven patients (48%) underwent incremental LoC. Age (OR, 1.05; 95% CI, 1.02-1.08; p = 0.0010) and female sex (OR, 3.71; 95% CI, 1.01-13.64; p = 0.0487) increased the odds of LoC; number of anatomic injuries (OR, 0.91; 95% CI, 0.85-0.98; p = 0.0146), chest injuries (Abbreviated Injury Scale [AIS] score chest, >3) (OR, 0.02; 95% CI, 0.01-0.26; p = 0.0021), extremity injury (AIS score, >3) (OR, 0.08; 95% CI, 0.01-0.64; p = 0.0170), and hospital complications equal to 1 (OR, 0.21; 95% CI, 0.06-0.78; p = 0.0201) or ≥2 (OR, 0.19; 95% CI, 0.04-0.87; p = 0.0319) decreased the odds of LoC. For those having LoC, final limitations were implemented in <14 days for 83% of patients; markers of injury severity (e.g., Injury Severity Score, Glasgow Coma Scale score, and AIS score) increased the odds of early LoC implementation.

CONCLUSION

Most patients died after LoC was implemented in a timely fashion. Significant head injury increased the odds of LoC. The number of injuries, severe chest and extremity injuries, and increasing number of complications decreased the odds of LoC, presumably because patients died before LoCs were initiated. Understanding factors contributing to end-of-life care could help guide discussions regarding LoCs.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Internet-based cognitive-behavioural writing therapy for reducing post-traumatic stress after severe sepsis in patients and their spouses (REPAIR): results of a randomised-controlled trial

OBJECTIVES

To investigate the efficacy, safety and applicability of internet-based, therapist-led partner-assisted cognitive-behavioural writing therapy (iCBT) for post-traumatic stress disorder (PTSD) symptoms after intensive care for sepsis in patients and their spouses compared with a waitlist (WL) control group.

DESIGN

Randomised-controlled, parallel group, open-label, superiority trial with concealed allocation.

SETTING

Internet-based intervention in Germany; location-independent via web-portal.

PARTICIPANTS

Patients after intensive care for sepsis and their spouses of whom at least one had a presumptive PTSD diagnosis (PTSD-Checklist (PCL-5)≥33). Initially planned sample size: 98 dyads.

INTERVENTIONS

ICBT group: 10 writing assignments over a 5-week period; WL control group: 5-week waiting period.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: pre-post change in PTSD symptom severity (PCL-5).

SECONDARY OUTCOMES

remission of PTSD, depression, anxiety and somatisation, relationship satisfaction, health-related quality of life, premature termination of treatment. Outcomes measures were applied pre and post treatment and at 3, 6 and 12 months follow-up.

RESULTS

Twenty-five dyads representing 34 participants with a presumptive PTSD diagnosis were randomised and analysed (ITT principle). There was no evidence for a difference in PCL-5 pre-post change for iCBT compared with WL (mean difference -0.96, 95% CI (-5.88 to 3.97), p=0.703). No adverse events were reported. Participants confirmed the applicability of iCBT.

CONCLUSIONS

ICBT was applied to reduce PTSD symptoms after intensive care for sepsis, for the first time addressing both patients and their spouses. It was applicable and safe in the given population. There was no evidence for the efficacy of iCBT on PTSD symptom severity. Due to the small sample size our findings remain preliminary but can guide further research, which is needed to determine if modified approaches to post-intensive care PTSD may be more effective.

TRIAL REGISTRATION NUMBER

DRKS00010676.

The Psychological Impact on Relatives of Critically Ill Patients: The Influence of Visiting Hours

OBJECTIVES:

To identify the psychologic impact of admission to the ICU on the relatives of critically ill patients, the influence of coping, and the factors involved.

DESIGN:

We performed a cohort study with repeated measures evaluation using descriptive and comparative bivariate and multivariate analyses.

SETTINGS:

An adult ICU of a third-level complexity hospital.

PATIENTS:

The family members of patients (maximum of three per patient) staying longer than 3 days.

INTERVENTIONS:

Not applicable.

MEASUREMENTS AND MAIN RESULTS:

Psychologic impact was assessed using two subgroups of psychologic distress: anxiety (by the State-Trait Anxiety Inventory) and depression (by the Beck Depression Inventory). Satisfaction and coping were assessed by the Critical Care Family Needs Inventory and the Brief Coping Orientations to Problems Experienced Inventory, respectively. We included 104 family members; psychologic distress was high at admission (72% had anxiety, 45% had depression, and 42% had both) but decreased at discharge (34% had anxiety, 23% had depression, and 21% had both). The risk factors related to psychologic impact were severity (anxiety: Acute Physiology and Chronic Health Evaluation score ≥ 18 points: relative risk [RR], 2; 95% CI, 1–4; p = 0.03), invasive mechanical ventilation (anxiety: RR, 1.9; 95% CI, 1–3.6; p = 0.04), recent psychotropic medication use by relatives (depression: RR, 1.6; 95% CI, 1–2.9; p = 0.05), a restrictive visiting policy (anxiety: RR, 5.7; 95% CI, 2–10.4; p = 0.002), no emotion-focused coping strategy (anxiety: strategy < 11 points, RR, 6.1; 95% CI, 1.2–52; p = 0.01), and functional impairment (depression: Barthel index ≤ 60 points, RR, 7.4; 95% CI, 1.7–26.3; p = 0.01).

CONCLUSIONS:

The psychologic impact from admission to the ICU on family members is high. Visiting hours is the main modifiable factor to reduce the impact.

Caregiver burden and emotional wellbeing in informal caregivers to ICU survivors-A prospective cohort study

BACKGROUND

Informal caregivers to intensive care unit (ICU) survivors may develop post-intensive care syndrome family (PICS-F), including depression, anxiety and post-traumatic stress (PTS). Our primary aim was to investigate associations between caregiver burden in informal caregivers cohabiting with ICU survivors and patients' physical and psychological outcomes.

METHODS

A prospective, multicentre cohort study in four ICUs in Sweden. Adults cohabiting with ICU patients included in a previous study were eligible for inclusion. Three months post-ICU, informal caregivers received questionnaires assessing caregiver burden, health-related quality of life (HRQL) and symptoms of depression, anxiety and PTS. In parallel, patients reported their three-month physical and psychological status via validated questionnaires. The primary outcome of this study was to compare caregiver burden in informal caregivers to patients with and without adverse physical and psychological outcomes 3 months post-ICU. Secondary outcomes were correlations between caregiver burden and informal caregivers' mental HRQL.

RESULTS

Among 62 included informal caregivers, 55 (89%) responded to the follow-up questionnaires. Caregiver burden was higher among informal caregivers to patients with an adverse outcome, compared to informal caregivers to patients without an adverse outcome, caregiver burden scale score mean (±standard deviation) 52 (11) and 41 (13) respectively (p = 0.003). There was strong negative correlation between caregiver burden and informal caregivers' mental HRQL (r_s -0.74, p < 0.001).

CONCLUSION

Informal caregivers to ICU survivors with adverse physical or psychological outcome experience a higher caregiver burden. A higher caregiver burden correlates with worse caregiver mental HRQL. ICU follow-up programs should consider screening and follow-up of informal caregivers for mental health problems.

Nurse perceptions of a nurse family liaison implemented during the COVID-19 pandemic: A qualitative thematic analysis

Objective

Stress among family members of hospitalised intensive care unit patients may be amplified in the context of a global pandemic and strict visitor restrictions. A nurse family liaison role in the COVID-19 units was implemented to serve as a connection between the care team and a designated family member. Our objective was to describe the experience of a nurse family liaison role implemented during the COVID-19 pandemic from the perspective of nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons.

Research method/design

This was a qualitative study using thematic analysis involving a one-time semi-structured interview. A convenience sample of nurses were invited to participate. The analytic approach involved (1) becoming familiar with the data; (2) finding meaning in the data; (3) organising meaningful statements into patterns to generate themes.

Setting/participants

Nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons in an adult academic health center in the Midwest United States.

Main outcome measure

To describe the psychosocial experience of nurse family liaison role implementation.

Findings

The sample (n = 11) mean age was 36 years (range 26–49) and the majority were female (n = 10; 90%), White/non-Hispanic (n = 11; 100%), Bachelor prepared (n = 10; 90%), and had an average of 10 years of experience as a nurse (range 4–25). The major themes identified by participants were living in a pandemic, establishing the role and workflow and experiencing human connection.

Conclusion

Hospital organisations should consider how they can provide family-centred care, specifically within the context of a global crisis such as a pandemic. Participant descriptions of the role indicate that liaison implementation alleviated nurse moral distress and fostered development of close family connections. Findings can help inform implementation of similar roles in hospital settings.

Palliative Care and Shared Decision Making in the Neurocritical Care Unit

PURPOSE OF REVIEW

This article reviews the evidence on integrating palliative care into the care of patients with various types of serious neurologic illness, emphasizes the importance of palliative care in the neurocritical care unit, and suggests tools for clinicians to improve their communication skills and decision making.

RECENT FINDINGS

Palliative care is a holistic approach to medical care that aims to relieve physical, psychological, social, and spiritual suffering. It is both a medical specialty as young as neurocritical care itself and an approach to patient care by all clinicians who manage patients with serious illness. Patients presenting to the neurocritical care unit and their families have unique palliative care needs that challenge communication and shared decision making.

SUMMARY

Palliative care, effective communication, and shared decision making require a set of core skills that all neurology clinicians should master.

Family Satisfaction in the Adult Intensive Care Unit: A Concept Analysis

Admission of patients to an intensive care unit is often a stressful event for family members. In the context of patient- and family-centered care, family satisfaction is recognized as a quality indicator of intensive care unit care. However, family satisfaction has not been consistently used or conceptualized in the literature. A modified version of Walker and Avant's method for concept analysis was utilized to examine the concept of family satisfaction in the adult intensive care unit. Antecedents, attributes, consequences, and empirical referents of family satisfaction are presented and implications for practice, research, and policy.

The family intensive care unit syndrome: A qualitative content analysis

BACKGROUND

Hospitalization of patients in an intensive care unit (ICU) is associated with a series of psychological problems for their family members called family intensive care unit syndrome (FICUS). Nonetheless, family members of patients in ICU often receive little attention from health care providers. Exploring family members' experiences of their patients' hospitalization in ICU helps health care providers focus more clearly on their problems.

AIMS AND OBJECTIVES

This study aimed to explore FICUS-related experiences among the family members of patients in ICU.

DESIGN

This was a qualitative content analysis study.

METHODS

This qualitative study was conducted in 2019. Participants were 14 family members of patients in ICU who were purposively selected from three hospitals in Tehran, Iran. Data were collected using semi-structured interviews and were analyzed using qualitative content analysis.

RESULTS

Participants' experiences of FICUS fell into four categories, that is, threat to psychological well-being (with four subcategories), threat to physical health (with three subcategories), threat to social health (with three subcategories), and change in spiritual orientation (with two subcategories). The 12 subcategories of these categories were emotional disturbances, hopelessness, changes in sleep pattern, mood changes, physical symptoms, aggravation of the existing illnesses, negligence towards personal health, alteration in social interactions, alteration in the burden of responsibility, alternation in the life process, resort to spiritual beliefs, and spiritual conflict, respectively.

CONCLUSION

FICUS symptoms are not limited to psychological problems, rather they include a wide range of psychological, physical, social, and spiritual problems, which can affect the different aspects of family members' lives. Along with care delivery to patients in ICU, health care providers should provide care and support to patients' family members.

RELEVANCE TO CLINICAL PRACTICE

FICUS is a major threat to health among the family members of patients in ICU. Careful assessment of these family members helps identify family members who are at risk for FICUS and identify FICUS effects on their decisions and health status.

Psychological distress among the family members of Intensive Care Unit (ICU) patients: A scoping review

AIMS AND OBJECTIVES

To map research-based psychological distress among the family members with patients in the intensive care unit (ICU).

BACKGROUND

Having a loved one in the ICU is a stressful experience, which may cause psychological distress for family members. Depression, anxiety and stress are the common forms of psychological distress associated with ICU patient's family members. Directly or indirectly, psychological distress may have behavioural or physiological impacts on the family members and ICU patient's recovery.

DESIGN

The study was based on the five-stage methodological framework by Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19) and were guided by the PRISMA-ScR Checklist.

METHODS

A comprehensive and systematic search was performed in five electronic databases, namely the Scopus, Web of Sciences, CINAHL^® Complete @EBSCOhost, ScienceDirect and MEDLINE. Reference lists from the screened full-text articles were reviewed.

RESULTS

From a total of 1252 literature screened, 22 studies published between 2010-2019 were included in the review. From those articles, four key themes were identified: (a) Prevalence of psychological distress; (b) Factors affecting family members; (c) Symptoms of psychological distress; and (d) Impact of psychological distress.

CONCLUSIONS

Family members with a critically ill patient in ICU show high levels of anxiety, depression and stress. They had moderate to major symptoms of psychological distress that negatively impacted both the patient and family members.

RELEVANCE TO CLINICAL PRACTICE

The review contributed further insights on psychological distress among ICU patient's family members and proposed psychological interventions that could positively impact the family well-being and improve the patients' recovery.

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient.

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.

Mechanism of a Flexible ICU Visiting Policy for Anxiety Symptoms Among Family Members in Brazil: A Path Mediation Analysis in a Cluster-Randomized Clinical Trial

OBJECTIVES

To investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care.

DESIGN

We embedded a multivariable path mediation analysis within a cluster-randomized crossover trial as a secondary analysis of The ICU Visits Study (ClinicalTrials.gov number: NCT02932358).

SETTING

Thirty-six medical-surgical ICUs in Brazil.

PATIENTS

Closest relatives of adult ICU patients.

INTERVENTIONS

Flexible visitation (12 hr/d) supported by family education or usual restricted visitation (median, 1.5 hr/d).

MEASUREMENTS AND MAIN RESULTS

Overall, 863 family members were assessed (mean age, 44.7 yr; women, 70.1%). Compared with the restricted visitation (n = 436), flexible visitation (n = 427) resulted in better mean anxiety scores (6.1 vs 7.8; mean difference, -1.78 [95% CI, -2.31 to -1.22]), as well as higher standardized scores of satisfaction (67% [95% CI, 55-79]) and involvement in patient care (77% [95% CI, 64-89]). The mediated effect of flexible visitation on mean anxiety scores through each incremental SD of satisfaction and involvement in patient care were -0.47 (95% CI, -0.68 to -0.24) and 0.29 (95% CI, 0.04-0.54), respectively. Upon exploratory analyses, emotional support, helping the ICU staff to understand patient needs, helping the patient to interpret ICU staff instructions, and patient reorientation were the domains of involvement in patient care associated with increased anxiety.

CONCLUSIONS

A flexible ICU visiting policy reduces anxiety symptoms among family members and appears to work by increasing satisfaction. However, increased participation in some activities of patient care as a result of flexible visitation was associated with higher severity of anxiety symptoms.

Theorising survivorship after intensive care: A systematic review of patient and family experiences

AIMS AND OBJECTIVE

This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined.

BACKGROUND

Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research.

DESIGN

Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed.

RESULTS

The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship.

CONCLUSION

We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

In sechs Wochen hat sich die Welt verändert: COVID-19

In six weeks the world has changed: COVID-19 - Family-centered care in the intensive care unit Abstract. Background and problem definition: The admission of patients to an intensive care unit is extremely stressful for relatives during the COVID-19 pandemic, as they are not allowed to visit their family members due to a visitation restriction.

OBJECTIVES

To describe the experience of relatives during the COVID-19 pandemic and to derive support information for health professionals.

METHODS

Qualitative analysis of three written testimonies of relatives whose family members were hospitalized with COVID-19 or other disease at intensive care unit.

RESULTS

Relatives report the sudden, unexpected occurrence of the disease. "It was there, out of nowhere, hits the heart of life, doesn't just go away, does what it wants. It is an unknown virus that we have to get to know very closely." The ban on visiting was harsh, it made her faint. The first visit was an indescribable joy. Knowing how the family member was and that the health care professionals were taking professional and empathetic care of the sick person were the only things the relatives could hold on to.

DISCUSSION

Relatives were reassured when they experienced a high level of commitment on the part of health professionals and received repeated comprehensible information by phone. Limitations and transfer: Restrictions on visits depend on national legislation. Measures such as video calls can also be useful outside of a pandemic to build relationships with relatives.

Feasibility and Efficacy of a Resiliency Intervention for the Prevention of Chronic Emotional Distress Among Survivor-Caregiver Dyads Admitted to the Neuroscience Intensive Care Unit: A Randomized Clinical Trial

IMPORTANCE

To our knowledge, there are no evidence-based interventions to prevent chronic emotional distress (ie, depression, anxiety, and posttraumatic stress [PTS]) in critical care survivors and their informal caregivers.

OBJECTIVE

To determine the feasibility and preliminary effect of the novel dyadic resiliency intervention Recovering Together (RT) on reducing symptoms of depression, anxiety, and PTS among hospitalized patients and their informal caregivers.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind, pilot randomized clinical trial of RT vs an educational control was conducted among 58 dyads in which either the survivor or caregiver endorsed clinically significant symptoms of depression, anxiety, or PTS. The study was conducted in the neuroscience intensive care unit at Massachusetts General Hospital. Data were collected from September 2019 to March 2020.

INTERVENTIONS

Both RT and control programs had 6 sessions (2 at bedside and 4 via live video after discharge), and both survivor and caregiver participated together.

MAIN OUTCOMES AND MEASURES

The primary outcomes were feasibility of recruitment and intervention delivery, credibility, and satisfaction. The secondary outcomes included depression and anxiety (measured by the Hospital Depression and Anxiety Scale), PTS (measured by the PTSD Checklist-Civilian Version), and intervention targets (ie, mindfulness, measured by the Cognitive and Affective Mindfulness Scale-Revised; coping, measured by the Measure of Current Status-Part A; and dyadic interpersonal interactions, measured by the Dyadic Relationship Scale). Main outcomes and targets were assessed at baseline, 6 weeks, and 12 weeks.

RESULTS

The 58 dyads were randomized to RT (29 dyads [50.0%]; survivors: mean [SD] age, 49.3 [16.7] years; 9 [31.0%] women; caregivers: mean [SD] age, 52.4 [14.3] years; 22 [75.9%] women) or control (29 dyads [50.0%]; survivors: mean [SD] age, 50.3 [16.4] years; 12 [41.3%] women; caregivers, mean [SD] age, 52.1 [14.9], 17 [58.6%] women). Feasibility (recruitment [76%], randomization [100%], and data collection [83%-100%]), adherence (86%), fidelity (100%; κ = 0.98), satisfaction (RT: 57 of 58 [98%] with scores >6; control: 58 of 58 [100%] with scores >6), credibility (RT: 47 of 58 [81%] with scores >6; control: 46 of 58 [80%] with scores >6), and expectancy (RT: 49 of 58 [85%] with scores >13.5; 51 of 58 [87%] with scores >13.5) exceeded benchmarks set a priori. Participation in RT was associated with statistically and clinically significant improvement between baseline and postintervention in symptoms of depression (among survivors: -4.0 vs -0.6; difference, -3.4; 95% CI, -5.6 to -1.3; P = .002; among caregivers: -3.8 vs 0.6; difference, -4.5; 95% CI, -6.7 to -2.3; P < .001), anxiety (among survivors: -6.0 vs 0.3; difference, -6.3; 95% CI, -8.8 to -3.8; P < .001; among caregivers: -5.0 vs -0.9; difference, -4.1; 95% CI, -6.7 to -1.5, P = .002), and PTS (among survivors: -11.3 vs 1.0; difference, -12.3; 95% CI, -18.1 to -6.5, P < .001; among caregivers, -11.4 vs 5.0; difference, -16.4, 95% CI, -21.8 to -10.9; P < .001). Improvements sustained through the 12-week follow-up visit. We also observed RT-dependent improvement in dyadic interpersonal interactions for survivors (0.2 vs -0.2; difference, 0.4; 95% CI, 0.0 to 0.8; P = .04).

CONCLUSIONS AND RELEVANCE

In this pilot randomized clinical trial, RT was feasible and potentially efficacious in preventing chronic emotional distress in dyads of survivors of the neuroscience intensive care unit and their informal caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03694678.

Positive Appraisal of Caregiving for Intensive Care Unit Survivors: A Qualitative Secondary Analysis

BACKGROUND

More than half of intensive care unit survivors require assistance from family caregivers after discharge. Caregiving is associated with negative consequences including poor health-related quality of life, psychosocial distress, and burden. Little is known about how family caregivers find satisfaction and meaning in their experience.

OBJECTIVES

To explore positive descriptions of the experiences of family caregivers of critically ill patients and to describe factors that family caregivers view as important to a positive caregiving experience from hospitalization to 4 months after discharge.

METHODS

Qualitative secondary analysis was performed on data from semistructured interviews conducted as part of a longitudinal study that examined physical and psychological responses to stress in a convenience sample of family caregivers of adult intensive care unit patients who underwent prolonged mechanical ventilation (≥ 4 days). Interviews were conducted at 4 time points: during the hospitalization and within 2 weeks, 2 months, and 4 months after discharge.

RESULTS

Participants (n = 41) reported factors that helped them positively appraise their caregiving experience in 113 interviews conducted face to face or via telephone. During patients' hospitalization, caregivers described changes in their role, with their primary responsibility being to advocate for the patient. They described how this experience fulfilled their identity and strengthened their relationship with the patient. Most family caregivers mentioned the importance of social support and prayer.

CONCLUSIONS

Family caregivers of intensive care unit patients can identify positive aspects of caregiving during the experience. Interventions to reframe the caregiving experience in a positive light are warranted.

Anxiety and Depression among Patients Admitted to Intensive Care

BACKGROUND

Critically ill patients in intensive care units frequently experience high levels of anxiety and depression. These symptoms affect the patient's treatment plan and response to treatment.

AIMS AND OBJECTIVES

To identify the prevalence of anxiety and depression among patients admitted to intensive care units in Jordan and their correlation with quality of life.

DESIGN

A descriptive cross-sectional survey design was used.

METHODS

The sample for this study consisted of 108 patients admitted to intensive care units in seven governmental hospitals in Jordan. Three instruments were used to collect the data: the demographic data sheet, Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life tool.

RESULTS

More than half of the participants were female (56.5%), and the mean age was 44.6 years (SD 18.2); 84.3% had anxiety with a mean total score of 12.1 (SD 4.3), and 79.6% of the patients had depression with a mean total score of 11.5 (SD 4.5). A significant negative correlation was found between the mean total anxiety score (r = -0.541, P < .001), depression (r = -0.616, P < .001), and the mean total quality of life score.

CONCLUSIONS

Management programmes for anxiety and depression are highly recommended for intensive care units patients. Such programmes should focus on teaching health care providers correct assessment and management techniques. In addition, developing and implementing a psychiatric consultation support system for these patients might contribute to better management of anxiety and depression.

RELEVANCE TO CLINICAL PRACTICE

This study reveals high prevalence of anxiety and depression among critically ill patient in ICUs. So, regular assessment of anxiety and depression should be conducted by healthcare provider. This requires using a valid and reliable assessment tool. Early correct assessment would result in optimal management for anxiety and depression through patient referral to psychiatric care and the use of pharmacological and non-pharmacological interventions. Guidelines to assess and manage anxiety and depression should be adapted and implemented into clinical practice within the intensive care units. Regular psychiatric consultation for patients admitted to ICU might be helpful in detecting and managing anxiety and depression symptoms.

Psychological Sequelae in Family Caregivers of Critically III Intensive Care Unit Patients. A Systematic Review

Rationale: Family members of critically ill patients hospitalized in the intensive care unit (ICU) often become caregivers, and they are at risk to develop adverse psychological outcomes. There is a need to understand the psychological impact of critical illness on family caregivers. Objectives: The aim of this systematic review is to document the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) in family caregivers of critically ill patients and identify potential risk factors for psychological outcomes to inform clinical and future research recommendations. Methods: A literature search for psychological outcomes for family caregivers of critically ill patients was conducted. A total of 1,148 studies from PsycINFO, CINAHL, Web of Science, SCOPUS, and Medline were identified. Results: Forty studies met inclusion criteria and were included in the review. The prevalence of psychological outcomes in family caregivers ranged from 4% to 94% for depression, 2% to 80% for anxiety, and 3% to 62% for PTSD. Caregiver depression, anxiety, and PTSD decreased in most studies that assessed longitudinal outcomes. Common risk factors identified for adverse psychological outcomes included younger caregiver age, caregiver relationship to the patient, lower socioeconomic status, and female sex. Conclusions: The prevalence of depression, anxiety, and PTSD varies greatly across studies of family caregivers of critically ill patients. This finding highlights the need for more systematic investigations of psychological outcomes and the implementation of clinical interventions to prevent or reduce depression, anxiety, and PTSD in family caregivers of critically ill patients.

Spirituality alleviates the burden on family members caring for patients receiving palliative care exclusively

Background

Spirituality can give meaning to life, providing support and guidance in complex situations. Despite its importance in palliative care, the role of spirituality for family caregivers of patients under exclusive palliative care has not received enough attention in the literature. We aimed to address the correlation between spirituality and the emotional burden of family members of patients under exclusive palliative care.

Methods

This transversal study was conducted in a tertiary private teaching hospital, in São Paulo, Brazil. The study comprised family members of patients receiving palliative care exclusively. Only one caregiver who cared for the patient for at least 2 months was invited to participate. Family members answered the following questionnaires: WHOQOL spirituality, religiousness and personal beliefs (SRPB), Zarit Burden Interview (ZBI) and Self-Reporting Questionnaire (SRQ-20). They were excluded if patients were residing in a Long Stay Institution. Continuous variables were expressed by median and quartiles and analyzed with the Kruskal-Wallis test with Muller-Dunn post-test adjusted by Bonferroni or with the Mann-Whitney test for two groups. We used multivariable linear regression to identify independent predictors of caregiver burden.

Results

A total of 178 family members were interviewed in a median of 8 [4–13.25] days after patient admission. Almost 40% of families presented high score of burden. Faith and Meaning in Life were the facets that scored the highest, with a median of 4.50 [4.00–5.00] for both facets. There was an inverse correlation between Zarit score and all of the WHOQOL-SRPB facets, indicating that the lower the spirituality, the greater the emotional burden. Inner peace was the strongest protective factor associated with burden.

Conclusions

Psycho-socio-spiritual interaction can improve the coping ability of family caregivers of patients under exclusive palliative care, addressing a critical gap in the provision of holistic palliative care services.

Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of Patients with Chronic Critical Illness

RATIONALE

Chronically critically ill patients are often dependent on family members for surrogate decision-making, and these surrogates are at high risk for emotional distress. We hypothesized that patient- and surrogate-specific risk factors for surrogate post-traumatic stress disorder (PTSD) symptoms can be identified early in the course of chronic critical illness.

OBJECTIVES

To identify risk factors for PTSD symptoms in surrogate decision-makers of chronically critically ill patients.

METHODS

We performed a secondary analysis of the database from a multicenter randomized trial of a communication intervention for chronic critical illness patients and surrogates. Variables preselected for plausible mechanism for increasing PTSD symptoms and identifiable by Day 10 of mechanical ventilation were included in the analysis for association with surrogate PTSD symptoms at 90 days, as measured by the Impact of Events Score-Revised (IES-R). Patient factors included demographics, insurance status, baseline functional status, chronic comorbidities, illness severity, and presence of advance directive. Surrogate variables included demographics, education level and employment, religion, relationship to patient, and Hospital Anxiety and Depression Scale score measured at enrollment. Multivariable linear regression models were then constructed for 26 potential risk factors, including biologically or mechanistically plausible confounders for each, with IES-R score as the outcome. All models were adjusted for multiple respondents, using a mixed model, considering the patients as a random factor.

RESULTS

Our analysis included 306 surrogates for 224 patients. A total of 49% of patients were female, and mean age was 59 years (95% confidence interval [CI], 56.4-60.7). A total of 71% of surrogates were female, and mean age was 51 years (95% CI, 49.3-52.4). After examining each potential risk factor in a separate multivariable model, only Day-10 surrogate Hospital Anxiety and Depression Scale score (β coefficient = 1.02; 95% CI, 0.73-1.30) and patient unresponsiveness (β coefficient = 8.39; 95% CI, 0.83-15.95) were associated with higher IES-R scores.

CONCLUSIONS

Among surrogate decision-makers for chronically critically ill patients, high anxiety and depression scores and patient unresponsiveness on or near Day 10 of mechanical ventilation are risk factors for PTSD symptoms at 90 days.

Stress Management Intervention to Prevent Post-Intensive Care Syndrome-Family in Patients' Spouses

BACKGROUND

Post-intensive care syndrome-family (PICS-F) refers to acute and chronic psychological effects of critical care on family members of patients in intensive care units (ICUs). Evidence suggests that increased distress during the ICU stay increases risk of PICS-F. Sensation Awareness Focused Training (SĀF-T) is a new, promising stress management intervention, but the feasibility of such training during the ICU stay for family caregivers who are acting as the surrogate decision-maker for patients who are undergoing mechanical ventilation is unknown.

OBJECTIVES

To assess feasibility and acceptability of SĀF-T to inform a future larger randomized controlled trial.

METHODS

This randomized controlled trial of SĀF-T (n = 5) versus a control (n = 5) group was conducted at a level 1 trauma center. Participants assigned to SĀF-T completed 1 session daily for 3 days. Measures included enrollment rate, data completion rate, acceptability of SĀF-T, and symptoms of PICS-F. Scales used included Perceived Stress, Hospital Anxiety and Depression, Impact of Event, and National Institutes of Health Toolbox Emotion Battery.

RESULTS

Mean age was 58 (SD, 12) years; 70% of participants were female. Predetermined feasibility criteria were met in enrollment rate (67%), outcome measures completion rate (> 90%), and SĀF-T acceptability (100% of doses completed during the ICU stay) without adverse events. Stress scores after SĀF-T were significantly lower than scores before SĀF-T (z = -3.5, P = .01).

CONCLUSIONS

SĀF-T intervention during the ICU stay is feasible, acceptable, and may improve family caregivers' post-ICU outcomes. Larger clinical trial to assess the effectiveness of SĀF-T in preventing PICS-F seem warranted.

Improving communication toward ICU families to facilitate understanding and reduce stress. Protocol for a multicenter randomized and controlled Italian study

OBJECTIVE

Families of ICU patients have a pressing need for information: they find themselves suddenly in a complex technical environment often because of a life-threatening illness of a loved one. Some evidence suggests that specific communication tools (like websites or brochures) could improve the experience of ICU families.

DESIGN

Randomized, multicenter, stepped wedge trial for large-scale assessment of the effectiveness of a multitasking intervention to improve communication with families of critically ill patients.

MAIN OUTCOME

correct understanding of the prognosis.

SECONDARY OUTCOMES

correct understanding of medical treatments, prevalence of anxiety, depression and post-traumatic stress symptoms in the first ICU week. Prevalence of PTSD 6 months from ICU discharge. Empathy and burnout among ICU staff. Prevalence of refusals for tissues/organ donation, and medical claims.

SUBJECTS

2100 ICU relatives of critically ill patients.

INTERVENTIONS

The intervention employs specific tools especially designed to raise the correctness of information and to improve the quality of communication: a website presenting the ICU world and justifying the relatives' emotions, with a webpage specifically dedicated to each participating ICU; a standard brochure; eight posters for the families' waiting room and a signboard for the ICU door.

MEASUREMENTS AND MAIN RESULTS

The study plans to assess these materials in up to 300 Italian ICUs that will participate, according to a five waves program, each one with randomized starting order. This way the effect of the intervention will be evaluated simultaneously.

CONCLUSION

This is an educational study, aiming to spread good medical practices, while also verifying their real effectiveness in a large number of ICUs.

TRIAL REGISTRATION NUMBER

NCT03438175.

Psychological Issues of Patient Transition from Intensive Care to Palliative Care

End-of-life care in the intensive care unit is fraught with complicated psychological responses by patients, families, and staff. Empathic and mindful communication, inclusion of all integral staff in decision-making meetings, and multidimensional support of patients and families can ease the transition away from aggressive life-prolonging to comfort-oriented end of life care. Primary palliative care communication strategies can help clarify goals of care and facilitate transitions. Early integration of specialist palliative care is recommended.

Early Risk and Resiliency Factors Predict Chronic Posttraumatic Stress Disorder in Caregivers of Patients Admitted to a Neuroscience ICU

OBJECTIVES

Informal caregivers-that is, close family and friends providing unpaid emotional or instrumental care-of patients admitted to ICUs are at risk for posttraumatic stress disorder. As a first step toward developing interventions to prevent posttraumatic stress disorder in ICU caregivers, we examined the predictive validity of psychosocial risk screening during admission for caregiver posttraumatic stress disorder at 3 and 6 months post hospitalization.

DESIGN

An observational, prospective study.

PARTICIPANTS

Ninety-nine caregivers were recruited as part of a longitudinal research program of patient-caregiver dyads in a neuroscience ICU.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Caregiver posttraumatic stress disorder symptoms were assessed during admission (baseline), 3 months, and 6 months post hospitalization. We 1) characterized prevalence of clinically significant symptoms at each time point 2); calculated sensitivity and specificity of baseline posttraumatic stress disorder screening in predicting posttraumatic stress disorder at 3 and 6 months; and 3) used recursive partitioning to select potential baseline factors and examine the extent to which they helped predict clinically significant posttraumatic stress disorder symptoms at each time point. Rates of caregiver posttraumatic stress disorder remained relatively stable over time (16-22%). Screening for posttraumatic stress disorder at baseline predicted posttraumatic stress disorder at 3 and 6 months with moderate sensitivity (75-80%) and high specificity (92-95%). Screening for posttraumatic stress disorder at baseline was associated with caregiver anxiety, mindfulness (i.e., ability to be aware of one's thoughts and feelings in the moment), and bond with patient. Furthermore, baseline posttraumatic stress disorder screening was the single most relevant predictor of posttraumatic stress disorder at 3 and 6 months, such that other baseline factors did not significantly improve predictive ability.

CONCLUSIONS

Screening neuroscience ICU caregivers for clinically significant posttraumatic stress disorder symptoms during admission is the single most important way to identify the majority of those likely to suffer from chronic posttraumatic stress disorder following discharge. Addressing early posttraumatic stress disorder symptoms and their psychosocial correlates during admission may help prevent chronic posttraumatic stress disorder in these at-risk caregivers.

Mental health and quality of life outcomes in family members of patients with chronic critical illness admitted to the intensive care units of two Brazilian hospitals serving the extremes of the socioeconomic spectrum

Chronic critical illness (CCI) is a relevant clinical, social and financial health issue. The aim of this study was to compare the mental outcomes (symptoms of anxiety and depression) and quality of life outcomes of the family members of patients with CCI from different socioeconomic backgrounds who were admitted to one of the intensive care units (ICUs) in two Brazilian hospitals, one private and one public. It is a prospective study involving a public hospital that serves a low-income population and a tertiary private hospital that serves a high-income population. Family members of patients with CCI answered the Hospital Anxiety and Depression Scale (HADS) and The World Health Organization Quality of Life–WHOQOL-bref questionnaires. They responded to the European Quality of life Five Dimension three Level (EuroQol-5D-3L) and the Activities of Daily Living (ADL) questionnaires on behalf of the patients at three time points: during the ICU stay, 30 and 90 days after the patient was discharged. We used logistic regression models to evaluate the main predictors of a binary outcome regarding symptoms of anxiety and depression. We enrolled 186 patients with CCI. Many patients from public hospitals who were independent became dependent for their ADLs at 90 days (41.7% versus 14.3%, p = 0.03). At 30 days, family members from public hospital had worse impact on all domains of WHOQOL-bref compared with families from private hospital. At 90-days, the difference persists in the physical domain, worse for families from public hospital (p = 0.006). The symptoms of depression at 30-days (p = 0.008) and at 90-days (p = 0.013) were worse in the public hospital. CCIs affected quality of life and the emotional condition of family members, especially in families with fewer resources when the patients became more dependent. Family members with higher education were more likely to experience depression, while depression was associated with cohabiting with the patient in low-income families.

Satisfaction of family members of critically ill patients admitted to a public hospital intensive care unit and correlated factors

Objective

To analyze the satisfaction, medical situation understanding and symptoms of anxiety and depression in family members of patients admitted to the intensive care unit.

Methods

The family members of patients who were hospitalized for ≥ 72 hours were invited to participate in the study, which was performed in a public hospital. Questionnaires were answered to assess the understanding of the diagnosis, treatment and prognosis, and the support received in the intensive care unit. The family needs were also evaluated using a modified version of the Critical Care Family Needs Inventory (CCFNI). The Hospital Anxiety and Depression Scale (HADS) was used to assess the symptoms of anxiety and depression.

Results

A total of 35 family members were interviewed within the patients' first week of stay in the intensive care unit. Most patients (57.1%) were male, aged 54 ± 19 years. Sepsis was the main reason for admission to the intensive care unit (40%); the median of the Simplified Acute Physiology Score (SAPS) 3 was 68 (48 - 77), and 51.4% of the patients died in the intensive care unit. The majority of the family members were female (74.3%) and were sons or daughters of patients (54.3%), with a mean age of 43.2 ± 14 years. Overall, 77.1% of the family members were satisfied with the intensive care unit. A total of 37.1% of the family members did not understand the prognosis. Receiving clear and complete information in the intensive care unit and the doctor being accessible were factors that were significantly correlated with the overall family satisfaction. The prevalence of symptoms of anxiety (60%) and depression (54.3%) in the family members was high.

Conclusion

The emotional distress of family members is high during a patient's hospitalization in the intensive care unit, although satisfaction is also high. Clear and complete information provided by the intensivist and the support received in the intensive care unit are significantly correlated with the satisfaction of family members in a public hospital.

Critically ill patients' experiences of nursing care in the intensive care unit

BACKGROUND

Understanding critically ill patients' experiences of nursing care is an important aspect that can improve quality of care in the intensive care unit.

AIM

To elicit critically ill patients' experiences of nursing care in the adult intensive care units.

DESIGN

A qualitative descriptive design was utilized.

METHODS

Sixteen patients who had a predicted mortality risk of above 50% within the first 24 h of admission to the intensive care unit and had been discharged to the ward were purposively selected. The study was conducted at three academic affiliated, tertiary/quaternary specialist hospitals in South Africa. Individual semi-structured interviews were conducted with the selected participants until a point of data saturation was reached. Data were analysed using a conventional content analysis technique (Hsieh and Shannon, 2005). Lincoln and Guba's criteria for ensuring the trustworthiness of qualitative research were applied.

FINDINGS

Four major themes emerged: 'being in someone's shoes', 'communication', 'presence' and 'religion and spirituality'.

CONCLUSIONS

Even though some participants' responses reflected 'good' nursing care, the majority of the participants had negative experiences in relation to the nursing care they received while admitted in the selected intensive care units.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates critically ill patients' voices and preferences of intensive nursing care and describes some issues that require not only nurses' but also managerial improvements and interventions in order to ensure quality care and, eventually, patients' satisfaction with intensive nursing care.

Depression and anxiety in relatives of out-of-hospital cardiac arrest patients: Results of a prospective observational study

PURPOSE

Relatives of patients admitted to the intensive care unit (ICU) with out-of-hospital cardiac arrest (OHCA) may suffer from adverse psychological outcomes. We assessed prevalence and risk factors for depression and anxiety in such relatives 90 days after ICU admission.

MATERIALS AND METHODS

This study included consecutive relatives of OHCA patients admitted to the ICU of University Hospital in Basel, Switzerland. Relatives were interviewed upon admission regarding psychosocial risk factors and satisfaction with communication. Symptoms of depression and anxiety were assessed by Hospital Anxiety and Depression Scale (HADS) 90 days after inclusion.

RESULTS

Of 101 included relatives, 17% and 13% of relatives reported symptoms of depression and anxiety, respectively. Witnessing cardiopulmonary resuscitation was associated with depression (gender- and age-adjusted odds ratio [OR] 6.71; 95%CI 1.27 to 35.34; p = .025). Satisfaction with information and decision-making was associated with lower risk of depression (adjusted OR 0.95; 95%CI 0.91 to 0.99; p = .013). Unemployment (adjusted OR 10.42; 95%CI 1.18 to 92.35; p = .035) and lower perceived health status were associated with anxiety (adjusted OR 0.93; 95%CI 0.87 to 0.99; p = .025).

CONCLUSIONS

Many relatives of OHCA patients report symptoms of depression and anxiety after 90 days. Improving initial care and communication may help to reduce these risks.

Psychological distress in relatives of critically ill patients: Risk and protective factors

The admission to an intensive care unit can result in a significant burden of emotional distress in the family. This study analyzes the psychological distress of 89 relatives of intensive care unit patients and the potential risk/protective factors for such distress. Families show high levels of anxiety, depression, and stress. Regarding risk factors, having steady partner, being a woman, and being a mother are associated with increased risk of anxiety, depression, and stress. Contrarily, being younger and having higher educational level are associated with reduced anxiety and stress. Influencing these trends could change positively the suffering course experienced by relatives and intensive care unit patients indirectly.

Outcomes and experiences of relatives of patients discharged home after critical illness: a systematic integrative review

BACKGROUND

Patients discharged from intensive care may experience psychological and physical deficits resulting in a long and complex rehabilitation upon discharge. Relatives are also vulnerable to psychological pathologies and diminished health-related quality of life following the patients' critical illness. Relatives often provide care during the patients' rehabilitation, which may influence their health.

AIM

To report the outcomes and experiences of relatives of patients discharged home after critical illness.

DESIGN

Systematic integrative review.

METHODS

Electronic databases Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase®, and PsychINFO® were searched using keywords, synonyms, and medical subject headings. Reference lists of articles and critical care journals were manually searched. Studies eligible for inclusion reported primary research and were published in English between 2007 and 2017. Studies were appraised using the Critical Appraisal Skills Programme checklists. Data were extracted and then analysed according to framework.

FINDINGS

Twenty-five studies were included: 19 quantitative, 4 qualitative, and 1 mixed method study. Three themes were identified: health and well-being, employment and lifestyle, and caregiving role. Health and well-being reports the incidence and significance of psychological morbidity such as post-traumatic stress disorder, anxiety, and depression. Employment and lifestyle describes the impact of caregiving on the relative's ability to work and engage in usual social activities. The final theme describes and discusses the caregiving role in terms of activities of daily living, knowledge and skills, and adaption to the role.

CONCLUSIONS

There is a significant and meaningful impact on outcomes and experiences of relatives of patients discharged home after critical illness. Relatives' caregiving is embedded within the context of their psychological morbidity and social adjustment.

RELEVANCE TO PRACTICE

If informal care giving is to be sustainable, there is a need to design effective strategies of supporting families through all stages of the critical illness trajectory.

Reprint of Recovery programme for ICU survivors has no effect on relatives' quality of life: Secondary analysis of the RAPIT-study

BACKGROUND

Relatives of intensive care patients are at risk of developing symptoms of anxiety, depression and posttraumatic stress resulting in reduced health-related quality of life. Recovery programmes for patients have been implemented, but their effect on relatives is uncertain.

AIM

To determine whether relatives benefit from a recovery programme intended for intensive care survivors.

RESEARCH DESIGN

A randomised controlled trial of 181 adult relatives: intervention group (n = 87), control group (n = 94).

SETTING

Ten intensive care units in Denmark.

MAIN OUTCOME MEASURES

Primary outcome: health-related quality of life (HRQOL).

SECONDARY OUTCOMES

Sense of coherence (SOC), and symptoms of anxiety, depression and posttraumatic stress, compared to standard care at 12 months after intensive care discharge.

RESULTS

No difference in HRQOL between groups was observed at 12 months (mean difference in mental component summary score, 1.35 [CI 95%: -3.13; 5.82], p = 0.55; and physical component summery score, 1.86 [CI 95%: -1.88; 5.59], p = 0.33). No differences were found in secondary outcomes.

CONCLUSION

The recovery programme intended for intensive care survivors did not have an effect on the relatives. Future recovery programmes should be targeted to help both patient and family, and future research should be conducted on a larger scale to make conclusions with higher probability.