Abstract & Commentary
By David J. Pierson, MD, Professor of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington. Dr. Pierson reports no financial relationship to this field of study.
Synopsis: When closest family members of critically ill patients were interviewed 90 days later, significant post-traumatic stress symptoms were present in one-third of them. Risks for PTSD were more prevalent if the patient had died in the ICU, especially after end-of-life decision-making in which the family member participated.
Source: Azoulay E, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987-994.
During an 8-month period, Azoulay and colleagues investigated the prevalence and correlates of post-traumatic stress in family members of critically ill patients in 21 French medical and surgical ICUs. They identified the closest family member for surrogate decision-making purposes, and obtained informed consent from that person at the time of the patient’s death or discharge from the ICU. Ninety days later, one of the investigators, a medical sociologist, interviewed that family member by telephone. Instruments used were the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), the Hospital Anxiety and Depression Scale, and the 36-item Short Form General Health Survey (SF-36).
Of 459 patients screened for the study, family members of 284 (62%) agreed to participate, were reached at 90-days follow-up, and completed the telephone interview. These 284 family members corresponded to 228 patients who survived and 56 who died. Of the latter group, 50 had end-of-life decisions made, and in these instances, the family member was involved in the decision 22 times and informed of the decision by the patients’ caregivers 28 times. There were no significant differences in patient characteristics between the 284 study patients and the 175 patients whose family members were not available or declined to participate.
While in the ICU, 65% of the study patients underwent invasive mechanical ventilation; 22% had noninvasive ventilation, 48% received vasopressors, and 13% underwent hemodialysis or other renal replacement therapy. Mortality was 20% in the ICU and 31% at 90 days. Family members were involved in the care of the patients in 25% of cases, and participated in decision making in approximately the same proportion. Overall, most family members were satisfied with the information they received from the ICU staff, although 15% felt that insufficient time had been spent giving them information, 16% considered the information insufficiently clear, and 33% felt that the information they received was incomplete.
Of the family members who were interviewed after 90 days, 33% scored more than 30 on the Impact of Event Scale, indicating post-traumatic stress reactions with a significant risk for post-traumatic stress disorder (PTSD). This degree of PTSD risk was found in about half of those who considered the information they received from the ICU staff to have been insufficient, and in more than 80% of those who shared in end-of-life decision-making. Family members of patients who died in the ICU were more likely to have severe post-traumatic stress. Severe post-traumatic stress reaction consistent with a high risk for PTSD in family members was associated with increased rates of anxiety and depression, and also with decreased quality of life.
Commentary
Several follow-up studies have shown that just surviving a critical illness is not the end of the story. Quality of life in survivors of the acute respiratory distress syndrome and other critical illnesses is impaired in a high proportion of cases when patients are interviewed after 6 or 12 months. With increasing focus on PTSD in the survivors of war, torture, and other traumatic experiences, attention has also been directed to the occurrence of this syndrome in individuals who have been critically ill and spent time in an ICU. PTSD is a specific psychiatric disorder.1 The present study did not attempt to diagnose PTSD in the family members of critically ill patients. However, it showed that accepted risk factors for PTSD were present to an alarming degree in close family members whose loved ones had been cared for in an ICU. It also showed that the more intimately those family members had been involved in end-of-life decision-making, especially for loved ones who died in the ICU, the more likely they were to have post-traumatic stress.
This study was carried out in France, where the involvement of next of kin in patient management and the participation of family members in end-of-life decision making differ substantially from what happens in most American ICUs. In more than half the cases, a decision to discontinue curative care was made by the patients’ physicians and other caregivers, and the family was simply informed that this was to be done. However, in those instances in which family members participated in end-of-life decision-making, the prevalence of post-traumatic stress was especially high. Particularly in those cases, the findings of this study may be applicable to family members of patients cared for in ICUs in this country. However, it remains to be established whether or how more direct family involvement in end-of-life decisions affects the likelihood of post-traumatic stress. Despite the differences in critical care as practiced in France vs the United States, this study demonstrates that PTSD is a threat for those whose loved ones experience critical illness, and not only for the patients themselves.
Reference
1. Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346:108-114.
When closest family members of critically ill patients were interviewed 90 days later, significant post-traumatic stress symptoms were present in one-third of them. Risks for PTSD were more prevalent if the patient had died in the ICU, especially after end-of-life decision-making in which the family member participated.
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