Clinical question: Does a proactive, three-step, support strategy decrease prolonged grief in relatives of patients who die in the intensive care unit (ICU)?
Dr. Wood
Background: Prolonged grief and symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD) are common among families of patients who die in the ICU. Poor communication and perceived lack of support from the ICU team are known risk factors. Prior studies have shown modest improvement with interventions such as family meetings or bereavement pamphlets prior to death.
Study design: Prospective, multi-center, cluster-randomized controlled trial
Setting: 34 ICUs in France prior to the COVID-19 pandemic
Synopsis: 875 relatives of adult ICU patients for whom the decision to withdraw or withhold life-sustaining treatment had already been made were randomized to receive standard end-of-life care or a three-step support strategy. This entailed three in-person family visits with the ICU physician and nurse: first in preparation for the dying process, second in the patients’ rooms when death was imminent, and third after death had occurred. The intervention clinicians received structured training in verbal and non-verbal communication followed by one month of practice. At six months, the median score on the PG-13 (a validated diagnostic scale for prolonged grief disorder) was lower in the intervention arm (19 versus 21) with fewer relatives meeting the criteria for the disorder (15% versus 21%). Symptoms of PTSD (at three months) and anxiety (at six months) were also lower. These benefits were statistically significant.
A strength of this intervention is its simplicity and low cost. However, the magnitude of the benefits was generally modest across the range of measured psychiatric outcomes. Though conducted in an ICU setting, the strategy is easily applicable to hospital medicine and addresses an important but often overlooked clinical responsibility: ongoing support of a patient’s family after the decision to withdraw care has been made.
Bottom line: Proactive structured communication directly between the ICU team and patients’ families after a decision to withhold/withdraw care has been made improves families’ symptoms of prolonged grief, anxiety, and PTSD.
Citation: Kentish-Barnes N, et al. A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomized trial. Lancet. 2022;399(10325):656-664.
Dr. Wood is a hospital medicine physician at Maine Medical Center, Portland, Maine.