By Kathryn Radigan, MD, MSc

Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago

Dr. Radigan reports no financial relationships relevant to this field of study.

SYNOPSIS: Interventions that teach resilience may improve family members’ experiences in the ICU.

SOURCE: Sottile PD, et al. Association between resilience and family member psychologic symptoms in critical illness. Crit Care Med 2016;44:e721-7.

Family members of critically ill patients suffer from increased rates of depression, anxiety, and stress disorders. Interventions to help family members diminish this burden have not been studied. Resilience, or the ability to adapt to a stressful or traumatic situation, is a teachable skill that may assist family members in mitigating adverse psychological outcomes. To investigate the relationship between resilience and symptoms of depression, anxiety, and acute stress in family members, Sottile et al conducted a cross-sectional study in three ICUs in Colorado.

Between June 2013 and March 2015, all family members of critically ill patients admitted for more than 48 hours were approached for enrollment. Inclusion criteria included age > 18 years, English speaking, and a family member present in the ICU with an expressed interest in the patient’s care. Patients were excluded from enrollment if they were < 18 years of age, pregnant, in custody, actively dying, or per attending physician request. The Connor-Davidson Resilience Scale was used to differentiate family members as resilient or nonresilient. To further quantify satisfaction with care along with symptoms of depression, anxiety, and acute stress, family members filled out questionnaires, including the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and Family Satisfaction in the ICU, prior to their family member’s discharge.

Out of the 608 patients screened, 227 patients did not meet exclusion criteria and were approached to be in the study. In all, 170 family members were enrolled in the study. Among those who did not consent, 56 family members declined, 35 families failed to complete the survey, and six patients refused to consent. Out of 170 family members enrolled, 78 family members were resilient. Resilient family members experienced fewer symptoms of anxiety (14.2% vs. 43.6%; P < 0.001), depression (14.1% vs. 44.9%; P < 0.001), and acute stress (12.7% vs. 36.3%; P = 0.001), and were more satisfied with care in the ICU (76.7 vs. 70.8; P = 0.008). Interventions that teach resilience may improve family members’ experiences in the ICU.

COMMENTARY

Although it is well described that there are increased rates of depression, anxiety, and stress disorders in families of critically ill patients, there are few interventions directed toward family members to mitigate this stress. Resilience, a teachable psychological construct, may be helpful in diminishing adverse psychological outcomes. To further investigate the relationship between resilience and symptoms of depression, anxiety, and acute stress, Sottile et al conducted a multicenter, cross-sectional survey with the family members of critically ill patients. Results revealed that resilient family members experienced fewer symptoms of depression, anxiety, and acute stress and were better satisfied with care delivered.

After further investigation of potential contributing factors, there was no association between family member age or sex with resilience status. Furthermore, the patient’s relationship (spouse/partner vs. other relationship) with the family member was not associated with rates of resilience (49% vs. 50%; P = 0.99). There also was no significant change in resilience between family members with prior ICU experience vs. those without prior ICU experience (49% vs. 51%; P = 0.65) or time of survey completion since admission and resilience status (4 [IQR, 3-7] vs. 4 [IQR, 2-7] days; P = 0.91).

Despite this study revealing that resilient family members experience fewer psychologic sequelae of critical illness, many questions remain. It is unclear whether there is a causal relationship between resilience and fewer symptoms of depression, anxiety, and acute stress disorder in the families of critically ill patients. This study simply highlighted an association. Furthermore, the questionnaires used are not reflective of disease states but only describe symptoms of patients’ families. Also, this study only included patients’ families who were present in the ICU. Out of the 608 patients who were screened, 343 patients had no family present. Only 38 patients met exclusion criteria. Out of the 227 patients who were approached, 56 families declined, 35 families did not complete the survey, and six patients refused consent. There were 170 family members, representing 135 patients, enrolled. Again, this study represents only 22% of patients’ families within the ICU. It is also unclear whether this proportion are representative of ICU patients’ families as a whole. The data gathered, more likely than not, are representative of family members who evade the ICU entirely or declined to participate.

These results must be followed by future studies that focus on the implementation of interventions to foster resilience, either through interventions directed at doctors and how they interact with family or directly with the family. For example, Lautrette et al were successful in reducing the stress on the family members of critically ill patients when providers met five objectives in end-of-life meetings and gave family members a brochure on bereavement. The five objectives incorporated were to value and appreciate what the family members said, to acknowledge the family members’ emotions, to listen, to ask questions that would allow the caregiver to understand who the patient was as a person, and to elicit questions from the family members.1 As for interventions for family members, it is interesting to note that resilience may be learned through cognitive behavioral methods, mindfulness-based stress reduction, expressive writing, and relaxation techniques.2 All these interventions may be possible in our patient populations but do mandate extra manpower to execute appropriately. Regardless, it would be of interest to see if future studies show there is benefit for family members.

REFERENCES

  1. Lautrette A, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478.
  2. Milne D. People Can Learn Markers on Road to Resilience. Psychiatric News, Jan. 19, 2007. Available at: http://bit.ly/2t9gVTs. Accessed July 11, 2017.