By Elaine Chen, MD
Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago
SYNOPSIS: When physicians and nurses offer collaborative and repeated support to families of patients dying in the intensive care unit, it may decrease prolonged grief, depression, and anxiety symptoms.
SOURCE: Kentish-Barnes N, Chevret S, Valade S, et al. A three-step support strategy for relatives of patients dying in the intensive care unit: A cluster randomised trial. Lancet 2022;399:656-664.
Families of patients who die in an intensive care unit (ICU) are at risk for anxiety, depression, post-traumatic stress disorder (PTSD), and prolonged grief. This study was a prospective, multicenter, cluster randomized controlled trial designed to compare standard care with a three-step support strategy during the dying process for families of patients with a decision to withdraw or withhold life support. The authors hypothesized that this proactive support strategy would decrease the post-ICU burden and presence of prolonged grief disorder six months after death.
The three-step, physician-driven, nurse-aided support strategy is loosely summarized here, with more specific details for each step detailed in the manuscript. First, during the preparation process, the physician and nurse together attend the meeting about deciding to withdraw or withhold life support, encourage discussion of emotions, and offer spiritual support. Second, during the dying process, both the physician and nurse individually enter the patient room to check on the family, answer questions, and ensure non-abandonment. Third, after death, both the physician and nurse meet with or call the family to express condolences, answer questions, and acknowledge emotions. Clinicians randomized to the intervention group underwent a comprehensive training process about the strategy as well as general communication skills. The control group provided best standard of care, noting that nurses and chaplains were not regularly involved in end-of-life (EOL) conversations as part of standard care in France, where this study took place.
During the study period from February 2017 to October 2019, 4,334 patients died in 34 participating ICUs, 1,135 patients met inclusion criteria, and 875 family members enrolled. In 17 control ICUs, 391 family members were enrolled, and in 17 intervention ICUs, 484 family members agreed to participate. A total of 309 (79%) control family members and 379 (78%) intervention family members completed the full series of questionnaires in six-month follow-up.
The intervention was effectively applied in 452 (93%) relatives in step 1, 446 (92%) in step 2, and 410 (85%) in step 3. The primary outcome was the Prolonged Grief Disorder-13 (PG-13) questionnaire score. Secondary outcomes included one-month reports of quality of death and dying, relatives’ experiences, and satisfaction with EOL communication, as well as serial assessments of symptoms of anxiety, depression, and PTSD. The median PG-13 score was significantly lower in the intervention group compared with the control group (19, interquartile range [IQR, 14-26] vs. 21 [IQR, 15-29]; mean difference 2.5; 95% confidence interval, 1.04-3.95), with fewer relatives with scores of 80 or higher (57% vs. 66%; P = 0.035). Nearly all of the secondary outcomes at all time points were significantly improved in the intervention group compared with the control group.
This study found that a proactive, physician-driven, nurse-aided, stepwise support strategy for family members of patients dying in the ICU after a decision to withhold or withdraw life support significantly decreased the prevalence of prolonged grief, PTSD-related symptoms, and anxiety symptoms.
COMMENTARY
The steps listed in this support strategy are relatively simple to perform, and all intensivists and ICU nurses regularly complete some of the evidence-based steps with patients’ families. Each individual step has been shown previously, often by the authors’ research team, to benefit bereaved relatives of patients dying in the ICU.1,2 The innovation of this study is to systematically aim to complete all three steps (physician and nurse together at the family conference, physician and nurse visiting the family separately during the dying process, and physician and nurse offering condolences after death) and to ensure a multidisciplinary team presence. Because of the nature of this study, it is impossible to study the granularity of which part of the process decreases prolonged grief and anxiety; thus, the pieces can only be assessed comprehensively.
The authors noted that ICU practices and policies may differ between cultural settings. ICU beds per capita are much higher in the United States compared to Europe;3 thus, bed availability or rationing may play a part in communication and decision-making strategies. Additionally, while experts advocate and endorse shared decision-making as optimal in complex ICU decisions, the culture in the United States tends toward a more autonomous style, whereas decision-making in Europe tends toward a more paternalistic/parentalistic style.4 One may wonder whether family members’ sense of control or helplessness may contribute to their prolonged symptoms.
In considering the presence of the multidisciplinary team, the authors reported that chaplains and nurses rarely are present during EOL conferences. In my practice, we have a strong nursing presence, and I believe that nurses attend a majority of key family conferences. Chaplain support is nearly ubiquitous following a decision to withdraw life support, at the time of withdrawal, and at the time of death; families also may invite their own clergy to the hospital. Additionally, the palliative care, social work, and psychosocial support teams often are available for families. The presence of these multidisciplinary levels of support also may contribute to improving families’ support. Evaluation of a similar protocol in a U.S. health system may yield different results.
There are challenges to implementation and maintenance of this type of support program. The intervention arm clinicians received comprehensive education from a panel of communication experts, and it is difficult to find educators as well as time to provide such education. To maintain such a program, clinicians must be mindful and proactive; it would be easy to forget one part or another. Because of clinician schedules, it is difficult for the same physician and nurse to be present for each portion of the protocol.
Regardless, it is not difficult to try to have a nurse and a doctor present at the family meeting, check in during the death process, and follow up and offer support after death. The multidisciplinary model provides a unified front and may offer an additional level of support to families. This is a relatively low-stakes, low-cost, but potentially high-yield intervention, and consideration could be made for a more formal process of implementation.
REFERENCES
- Kentish-Barnes N, Chaize M, Seegers V, et al. Complicated grief after death of a relative in the intensive care unit. Eur Respir J 2015;45:1341-1352.
- Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-128.
- Prin M, Wunsch H. International comparisons of intensive care: Informing outcomes and improving standards. Curr Opin Crit Care 2012;18:700-706.
- Kon AA. The shared decision-making continuum. JAMA 2010;304:903-904.
When physicians and nurses offer collaborative and repeated support to families of patients dying in the intensive care unit, it may decrease prolonged grief, depression, and anxiety symptoms.
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