Surrogates’ Long-Term Distress Is Ethical Concern
April 1, 2025
By Stacey Kusterbeck
Communication breakdowns between clinicians and surrogates in intensive care units (ICUs) may contribute to surrogates’ long-term psychological distress. However, there is no consensus on how to address this concern. “Prior interventions that have focused on improving information sharing between clinicians and surrogates have largely been unsuccessful in improving patient and family outcomes,” says Rachel A. Butler, MHA, MPH, program manager for the Center for Research, Investigating and Systems Modeling of Acute Illness (CRISMA) Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh School of Medicine.
Butler and colleagues evaluated an intervention that provides surrogates with multiple types of support during a family member’s ICU stay: emotional; communication; decisional; and, if indicated, anticipatory grief. The intervention did not affect surrogates’ ratings of quality of communication, patient and family-centeredness of care, or surrogates’ anxiety and depression symptoms. These are some possible reasons the intervention was ineffective, suggest the study authors:
- The individual who provided the education was not a usual part of the ICU team.
- The intervention was only delivered in the ICU setting. Therefore, the intervention could not mitigate effects of events surrogates experienced after the ICU stay that may have contributed to long-term psychological distress (such as caregiver burden or bereavement).
- Surrogates may need more psychologically robust support to develop appropriate coping strategies. For instance, surrogates can benefit from early involvement of specialty palliative care consultants.
“Ethicists should work behind the scenes with leadership to make sure care processes are in place to deliver good family support,” says Butler.
It is not feasible for ethicists to consult on all critically ill patients. “Instead, it may be worth screening in ICUs to identify nascent conflict or ethical dilemmas and intervene early on such cases,” says Butler.
Reference
1. Butler RA, Seaman JB, Felman K, et al. Randomized clinical trial of the four supports intervention for surrogate decision-makers in intensive care units. Am J Respir Crit Care Med. 2025;211(3):370-380.
Communication breakdowns between clinicians and surrogates in intensive care units may contribute to surrogates’ long-term psychological distress. However, there is no consensus on how to address this concern.
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