Purpose
Family members of patients who die in the intensive care unit (ICU) may experience symptoms of stress, anxiety, depression, posttraumatic stress disorder (PTSD), and/or prolonged grief. We ...evaluated whether grief symptoms were alleviated if the physician and the nurse in charge at the time of death sent the closest relative a handwritten condolence letter.
Methods
Multicenter randomized trial conducted among 242 relatives of patients who died at 22 ICUs in France between December 2014 and October 2015. Relatives were randomly assigned to receiving (
n
= 123) or not receiving (
n
= 119) a condolence letter. The primary endpoint was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary endpoints included HADS, complicated grief (ICG), and PTSD-related symptoms (IES-R) at 6 months. Observers were blinded to group allocation.
Results
At 1 month, 208 (85.9%) relatives completed the HADS; median score was 16 IQR, 10–22 with and 14 8–21.5 without the letter (
P
= 0.36). Although scores were higher in the intervention group, there were no significant differences regarding the HADS-depression subscale (8 4–12 vs. 6 2–12, mean difference 1.1 −0.5 to 2.6;
P
= 0.09) and prevalence of depression symptoms (56.0 vs. 42.4%, RR 0.76 0.57–1.00;
P
= 0.05). At 6 months, 190 (78.5%) relatives were interviewed. The intervention significantly increased the HADS (13 7–19 vs. 10 4–17.5,
P
= 0.04), HADS-depression subscale (6 2–10 vs. 3 1–9,
P
= 0.02), prevalence of depression symptoms (36.6 vs. 24.7%,
P
= 0.05) and PTSD-related symptoms (52.4 vs. 37.1%,
P
= 0.03).
Conclusions
In relatives of patients who died in the ICU, a condolence letter failed to alleviate grief symptoms and may have worsened depression and PTSD-related symptoms.
Trial registration
Clinicaltrials.gov Identifier: NCT02325297.
Intensive care unit (ICU) admission of a relative is a stressful event that may cause symptoms of post-traumatic stress disorder (PTSD).
Factors associated with these symptoms need to be identified.
...For patients admitted to 21 ICUs between March and November 2003, we studied the family member with the main potential decision-making role.
Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey during a telephone interview. Linear regression was used to identify factors associated with the risk of post-traumatic stress symptoms.
Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Post-traumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe post-traumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life.
Post-traumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.
There is a need for close communication with relatives of patients dying in the intensive care unit (ICU). We evaluated a format that included a proactive end-of-life conference and a brochure to see ...whether it could lessen the effects of bereavement.
Family members of 126 patients dying in 22 ICUs in France were randomly assigned to the intervention format or to the customary end-of-life conference. Participants were interviewed by telephone 90 days after the death with the use of the Impact of Event Scale (IES; scores range from 0, indicating no symptoms, to 75, indicating severe symptoms related to post-traumatic stress disorder PTSD) and the Hospital Anxiety and Depression Scale (HADS; subscale scores range from 0, indicating no distress, to 21, indicating maximum distress).
Participants in the intervention group had longer conferences than those in the control group (median, 30 minutes interquartile range, 19 to 45 vs. 20 minutes interquartile range, 15 to 30; P<0.001) and spent more of the time talking (median, 14 minutes interquartile range, 8 to 20 vs. 5 minutes interquartile range, 5 to 10). On day 90, the 56 participants in the intervention group who responded to the telephone interview had a significantly lower median IES score than the 52 participants in the control group (27 vs. 39, P=0.02) and a lower prevalence of PTSD-related symptoms (45% vs. 69%, P=0.01). The median HADS score was also lower in the intervention group (11, vs. 17 in the control group; P=0.004), and symptoms of both anxiety and depression were less prevalent (anxiety, 45% vs. 67%; P=0.02; depression, 29% vs. 56%; P=0.003).
Providing relatives of patients who are dying in the ICU with a brochure on bereavement and using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement. (ClinicalTrials.gov number, NCT00331877.)
ICU clinicians are primarily involved in organ donation after brain death of ICU patients. Their perceptions of organ donation may affect outcomes. Our objective was to describe ICU clinician's ...perceptions and experience of organ donation.
Cross-sectional study among physicians and nurses (90 ICUs in France). We used factorial correspondence analysis to describe categories of clinicians regarding their perceptions and experience of organ donation. Factors associated with a positive (motivating) or negative (stressful) experiences were studied using multivariate logistic regression.
Physicians and nurses.
Three thousand three hundred twenty-five clinicians working in 77 ICUs returned questionnaires. Professionals who experienced organ donation as motivating were younger (odds ratio, 0.41; 95% CI, 0.32-0.53; p < 0.001), more often potential organ donors (odds ratio, 1.92; 95% CI, 1.56-2.35; p < 0.001), less likely to describe inconsistency (odds ratio, 0.43; 95% CI, 0.23-0.8) or complexity (odds ratio, 0.55; 95% CI, 0.45-0.67) of their feelings versus their professional activity, less likely to report that organ donation was not a priority in their ICU (odds ratio, 0.68; 95% CI, 0.55-0.84), and more likely to have participated in meetings of transplant coordinators with relatives (odds ratio, 1.71; 95% CI, 1.37-2.14; p < 0.001). Professionals who felt organ donation was stressful were older (odds ratio, 1.84; 95% CI, 1.34-2.54; p < 0.001), less often physicians (odds ratio, 0.58; 95% CI, 0.44-0.77; p < 0.001), more likely to describe shift from curative care to organ donation as emotionally complex (odds ratio, 1.83; 95% CI, 1.52-2.21; p < 0.001), care of relatives of brain-dead patients as complex (odds ratio, 1.59; 95% CI, 1.32-1.93; p < 0.001), and inconsistency and complexity of personal feelings about organ donation versus professional activity (odds ratio, 3.25; 95% CI, 1.92-5.53; p < 0.001), and more likely to have little experience with caring for potential organ donors (odds ratio, 1.49; 95% CI, 1.09-2.04).
Significant differences exist among ICU clinician's perceptions of organ donation. Whether these differences affect family experience and consent rates deserves investigation.
Purpose
To develop an instrument designed specifically to assess the experience of relatives of patients who die in the intensive care unit (ICU).
Methods
The instrument was developed using a mixed ...methodology and validated in a prospective multicentre study. Relatives of patients who died in 41 ICUs completed the questionnaire by telephone 21 days after the death, then completed the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief after 3, 6, and 12 months.
Results
A total of 600 relatives were included, 475 in the main cohort and 125 in the reliability cohort. The 15-item questionnaire, named CAESAR, covered the patient’s preferences and values, interactions with/around the patient and family satisfaction. We defined three groups based on CAESAR score tertiles: lowest (≤59,
n
= 107, 25.9 %), middle (
n
= 185, 44.8 %) and highest (≥69,
n
= 121, 29.3 %). Factorial analysis showed a single dimension. Cronbach’s alpha in the main and reliability cohorts was 0.88 (0.85–0.90) and 0.85 (0.79–0.89), respectively. Compared to a high CAESAR score, a low CAESAR score was associated with greater risks of anxiety and depression at 3 months 1.29 (1.13–1.46),
p
= 0.001, post-traumatic stress-related symptoms at 3 1.34 (1.17–1.53),
p
< 0.001, 6 OR = 1.24 (1.06–1.44),
p
= 0.008 and 12 OR = 1.26 (1.06–1.50),
p
= 0.01 months and complicated grief at 6 OR = 1.40 (1.20–1.63),
p
< 0.001 and 12 months OR = 1.27 (1.06–1.52),
p
= 0.01.
Conclusions
The CAESAR score 21 days after death in the ICU is strongly associated with post-ICU burden in the bereaved relatives. The CAESAR score should prove a useful primary endpoint in trials of interventions to improve relatives’ well-being.
Background Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may ...contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists’ perceptions of triage and of the quality of the dying process before and after formal academic training. Methods Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods. Results More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician’s age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members’ reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process. Conclusions Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.
Working in the ICU during the first COVID-19 wave was associated with high levels of mental health disorders.
What are the mental health symptoms in health care providers (HCPs) facing the second ...wave?
A cross-sectional study (October 30-December 1, 2020) was conducted in 16 ICUs during the second wave in France. HCPs completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised (for post-traumatic stress disorder), and the Maslach Burnout Inventory.
Of 1,203 HCPs, 845 responded (70%) (66% nursing staff, 32% medical staff, 2% other professionals); 487 (57.6%) had treated more than 10 new patients with COVID-19 in the previous week. Insomnia affected 320 (37.9%), and 7.7% were taking a psychotropic drug daily. Symptoms of anxiety, depression, post-traumatic stress disorder, and burnout were reported in 60.0% (95% CI, 56.6%-63.3%), 36.1% (95% CI, 32.9%-39.5%), 28.4% (95% CI, 25.4%-31.6%), and 45.1% (95% CI, 41.7%-48.5%) of respondents, respectively. Independent predictors of such symptoms included respondent characteristics (sex, profession, experience, personality traits), work organization (ability to rest and to care for family), and self-perceptions (fear of becoming infected or of infecting family and friends, feeling pressure related to the surge, intention to leave the ICU, lassitude, working conditions, feeling they had a high-risk profession, and “missing the clapping”). The number of patients with COVID-19 treated in the first wave or over the last week was not associated with symptoms of mental health disorders.
The prevalence of symptoms of mental health disorders is high in ICU HCPs managing the second COVID-19 surge. The highest tiers of hospital management urgently need to provide psychological support, peer-support groups, and a communication structure that ensure the well-being of HCPs.
As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered ...on the patient's and/or the relatives' experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study.
Physicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort.
Among the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses 62/75 (59; 66) and physicians 64/75 (61; 68). Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002). Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside.
We described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.
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