A randomised controlled trial of a nurse facilitator to promote communication for family members of critically ill patients.

PURPOSE: Suboptimal communication with clinicians, fragmented care and failure to align with patients' preferences are determinants of post intensive care unit (ICU) burden in family members. Our aim was to evaluate the impact of a nurse facilitator on family psychological burden. METHODS: We carried out a randomised controlled trial in five ICUs in France comparing standard communication by ICU clinicians to additional communication and support by nurse facilitators. We included patients > 18 years, with expected ICU length of stay > 2 days, chronic life-limiting illness, and their family members. Facilitators were trained to help families to secure care in line with patient's goals, beginning in ICU and continuing for 3 months. Assessments were made at baseline and 1, 3 and 6 months post-randomisation. Primary outcome was the evolution of family symptoms of depression over 6 months using a linear mixed effects model on the depression subscale of the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included HADS-Anxiety, Impact of Event Scale-6, goal-concordant care and experience of serious illness (QUAL-E). RESULTS: 385 patients and family members were enrolled. Follow-up at 1-, 3- and 6-month was completed by 284 (74%), 264 (68.6%) and 260 (67.5%) family members respectively. The intervention was associated with significantly more formal meetings between the ICU team and the family (1 [1-3] vs 2 [1-4]; p < 0.001). There was no significant difference between the intervention and control groups in evolution of symptoms of depression over 6 months (p = 0.91), nor in symptoms of depression at 6 months [0.53 95% CI (- 0.48; 1.55)]. There were no significant differences in secondary outcomes. CONCLUSION: This study does not support the use of facilitators for family members of ICU patients.

Resilience and Mental-Health Symptoms in ICU Healthcare Professionals Facing Repeated COVID-19 Waves.

Rationale: Psychological resilience (the ability to thrive in adversity) may protect against mental-health symptoms in healthcare professionals during coronavirus disease (COVID-19) waves. Objectives: To identify determinants of resilience in ICU staff members. Methods: In this cross-sectional survey in 21 French ICUs, staff members completed the 10-item Connor-Davidson Resilience Scale, Hospital Anxiety and Depression Scale, and Impact of Event Scale-Revised (for post-traumatic stress disorder [PTSD]). Factors independently associated with resilience were identified. Measurements and Main Results: The response rate was 73.1% (950 of 1,300). The median 10-item Connor-Davidson Resilience Scale score was 29 (interquartile range, 25-32). Symptoms of anxiety, depression, and PTSD were present in 61%, 39%, and 36% of staff members, respectively. Distress associated with the COVID-19 infodemic was correlated with symptoms of depression and PTSD. More resilient respondents less often had symptoms of anxiety, depression, and PTSD. Greater resilience was independently associated with male sex, having provided intensive care during the early waves, having managed more than 50 patients with COVID-19, and, compared with earlier waves, working longer hours, having greater motivation, and more often involving families in end-of-life decisions. Independent risk factors for lower resilience were having managed more than 10 patients who died of COVID-19, having felt frightened or isolated, and greater distress from the COVID-19 infodemic. Conclusions: This study identifies modifiable determinants of resilience among ICU staff members. Longitudinal studies are needed to determine whether prior resilience decreases the risk of mental ill health during subsequent challenges. Hospital and ICU managers, for whom preserving mental well-being among staff members is a key duty, should pay careful attention to resilience.

Prediction of post-traumatic stress disorder in family members of ICU patients: a machine learning approach.

PURPOSE: Post-traumatic stress disorder (PTSD) can affect family members of patients admitted to the intensive care unit (ICU). Easily accessible patient's and relative's information may help develop accurate risk stratification tools to direct relatives at higher risk of PTSD toward appropriate management. METHODS: PTSD was measured 90 days after ICU discharge using validated instruments (Impact of Event Scale and Impact of Event Scale-Revised) in 2374 family members. Various supervised machine learning approaches were used to predict PTSD in family members and evaluated on an independent held-out test dataset. To better understand variables' contributions to PTSD predicted probability, we used machine learning interpretability methods on the best predictive algorithm. RESULTS: Non-linear ensemble learning tree-based methods showed better predictive performances (Random Forest-area under curve, AUC = 0.73 [0.68-0.77] and XGBoost-AUC = 0.73 [0.69-0.78]) than regularized linear models, kernel-based models, or deep learning models. In the best performing algorithm, most important features that positively contributed to PTSD's predicted probability were all non-modifiable factors, namely, lower patient's age, longer duration of ICU stay, relative's female sex, lower relative's age, relative being a spouse/child, and patient's death in ICU. A sensitivity analysis in bereaved relatives did not alter the algorithm's predictive performance. CONCLUSION: We propose a machine learning-based approach to predict PTSD in relatives of ICU patients at an individual level. In this model, PTSD is mostly influenced by non-modifiable factors.

Typology of ICU-Healthcare Providers Who Delayed or Declined COVID-19 Vaccination.

OBJECTIVES: To assess COVID-19 vaccination rates in ICU-healthcare providers (HCPs) in France and to identify the typology of those who delayed or declined vaccination. DESIGN: Cross-sectional study. SETTING: Twenty-one ICUs in France. SUBJECTS: Members of the nursing and medical staff and other allied professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six hundred ninety-six of the 950 respondents (73.3%) had undergone a full vaccination schedule. Other HCPs either declined vaccination ( n = 112) or delayed vaccination until it became mandatory ( n = 142). Factors independently associated with full vaccination were age older than 50 years (odds ratio, 0.25 [95% CI, 0.12-0.51]), more than 5 years of ICU experience (0.66 [0.47-0.93]), increasing working time during the surge (0.94 [0.88-1.00]), and spending time with the family (0.92 [0.85-0.99]). Conversely, being a nurse (1.94 [1.25-2.99]) or a nurse assistant (2.77 [1.62-4.73]), and feeling not supported by hospital and ICU directors (1.49 [1.01-2.20]) was independently associated with not being vaccinated. CONCLUSIONS: These results are important to take into account to better implement vaccination strategies in HCPs for existing or future pandemics.

PTSD Symptoms Among Family Members of Patients With ARDS Caused by COVID-19 After 12 Months.

This study compares data on the symptoms of posttraumatic stress disorder (PTSD) among family members of patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 vs non­COVID-19 ARDS.

Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach.

PURPOSE: Data are scarce regarding the experience of critically ill patients at high risk of death. Identifying their concerns could allow clinicians to better meet their needs and align their end-of-life trajectory with their preferences and values. We aimed to identify concerns expressed by conscious patients at high risk of dying in the intensive care unit (ICU). METHODS: Multiple source multicentre study. Concerns expressed by patients were collected from five different sources (literature review, panel of 50 ICU experts, prospective study in 11 ICUs, in-depth interviews with 17 families and 15 patients). All qualitative data collected were analyzed using thematic content analysis. RESULTS: The five sources produced 1307 concerns that were divided into 7 domains and 41 sub-domains. After removing redundant items and duplicates, and combining and reformulating similar items, 28 concerns were extracted from the analysis of the data. To increase accuracy, they were merged and consolidated, and resulted in a final list of 15 concerns pertaining to seven domains: concerns about loved-ones; symptom management and care (including team competence, goals of care discussions); spiritual, religious, and existential preoccupations (including regrets, meaning, hope and trust); being oneself (including fear of isolation and of being a burden, absence of hope, and personhood); the need for comforting experiences and pleasure; dying and death (covering emotional and practical concerns); and after death preoccupations. CONCLUSION: This list of 15 concerns may prove valuable for clinicians as a tool for improving communication and support to better meet the needs of patients at high risk of dying.

Association of COVID-19 Acute Respiratory Distress Syndrome With Symptoms of Posttraumatic Stress Disorder in Family Members After ICU Discharge.

IMPORTANCE: Persistent physical and mental disorders are frequent in survivors of COVID-19-related acute respiratory distress syndrome (ARDS). However, data on these disorders among family members are scarce. OBJECTIVE: To determine the association between patient hospitalization for COVID-19 ARDS vs ARDS from other causes and the risk of posttraumatic stress disorder (PTSD)-related symptoms in family members. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study in 23 intensive care units (ICUs) in France (January 2020 to June 2020 with final follow-up ending in October 2020). ARDS survivors and family members (1 family member per patient) were enrolled. EXPOSURES: Family members of patients hospitalized for ARDS due to COVID-19 vs ARDS due to other causes. MAIN OUTCOMES AND MEASURES: The primary outcome was family member symptoms of PTSD at 90 days after ICU discharge, measured by the Impact of Events Scale-Revised (score range, 0 [best] to 88 [worst]; presence of PTSD symptoms defined by score >22). Secondary outcomes were family member symptoms of anxiety and depression at 90 days assessed by the Hospital Anxiety and Depression Scale (score range, 0 [best] to 42 [worst]; presence of anxiety or depression symptoms defined by subscale scores ≥7). Multivariable logistic regression models were used to determine the association between COVID-19 status and outcomes. RESULTS: Among 602 family members and 307 patients prospectively enrolled, 517 (86%) family members (median [IQR] age, 51 [40-63] years; 72% women; 48% spouses; 26% bereaved because of the study patient's death; 303 [50%] family members of COVID-19 patients) and 273 (89%) patients (median [IQR] age, 61 [50-69] years; 34% women; 181 [59%] with COVID-19) completed the day-90 assessment. Compared with non-COVID-19 ARDS, family members of patients with COVID-19 ARDS had a significantly higher prevalence of symptoms of PTSD (35% [103/293] vs 19% [40/211]; difference, 16% [95% CI, 8%-24%]; P < .001), symptoms of anxiety (41% [121/294] vs 34% [70/207]; difference, 8% [95% CI, 0%-16%]; P= .05), and symptoms of depression (31% [91/291] vs 18% [37/209]; difference, 13% [95% CI, 6%-21%]; P< .001). In multivariable models adjusting for age, sex, and level of social support, COVID-19 ARDS was significantly associated with increased risk of PTSD-related symptoms in family members (odds ratio, 2.05 [95% CI, 1.30 to 3.23]). CONCLUSIONS AND RELEVANCE: Among family members of patients hospitalized in the ICU with ARDS, COVID-19 disease, as compared with other causes of ARDS, was significantly associated with increased risk of symptoms of PTSD at 90 days after ICU discharge. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04341519.

A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trial.

BACKGROUND: In relatives of patients dying in intensive care units (ICUs), inadequate team support can increase the prevalence of prolonged grief and other psychological harm. We aimed to evaluate whether a proactive communication and support intervention would improve relatives' outcomes. METHODS: We undertook a prospective, multicentre, cluster randomised controlled trial in 34 ICUs in France, to compare standard care with a physician-driven, nurse-aided, three-step support strategy for families throughout the dying process, following a decision to withdraw or withhold life support. Inclusion criteria were relatives of patients older than 18 years with an ICU length of stay 2 days or longer. Participating ICUs were randomly assigned (1:1 ratio) into an intervention cluster and a control cluster. The randomisation scheme was generated centrally by a statistician not otherwise involved in the study, using permutation blocks of non-released size. In the intervention group, three meetings were held with relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after the patient's death to offer condolences and closure. ICUs randomly assigned to the control group applied their best standard of care in terms of support and communication with relatives of dying patients. The primary endpoint was the proportion of relatives with prolonged grief (measured with PG-13, score ≥30) 6 months after the death. Analysis was by intention to treat, with the bereaved relatives as the unit of observation. The study is registered with ClinicalTrials.gov, NCT02955992. FINDINGS: Between Feb 23, 2017, and Oct 8, 2019, we enrolled 484 relatives of ICU patients to the intervention group and 391 to the control group. 379 (78%) relatives in the intervention group and 309 (79%) in the control group completed the 6-month interview to measure the primary endpoint. The intervention significantly reduced the number of relatives with prolonged grief symptoms (66 [21%] vs 57 [15%]; p=0·035) and the median PG-13 score was significantly lower in the intervention group than in the control group (19 [IQR 14-26] vs 21 [15-29], mean difference 2·5, 95% CI 1·04-3·95). INTERPRETATION: Among relatives of patients dying in the ICU, a physician-driven, nurse-aided, three-step support strategy significantly reduced prolonged grief symptoms. FUNDING: French Ministry of Health.

Lived Experiences of Family Members of Patients With Severe COVID-19 Who Died in Intensive Care Units in France.

Importance: During the initial surge of the COVID-19 pandemic, family members were often separated from their loved ones admitted to intensive care units (ICUs), with a potential for negative experiences and psychological burden. Objective: To better understand the experiences of bereaved family members of patients who died in an ICU during the COVID-19 pandemic, from the time of hospital admission until after the patient's death. Design, Setting, and Participants: This qualitative study used semistructured, in-depth interviews to collect experiences from bereaved family members of patients who died from severe COVID-19 in 12 ICUs during the first wave of the pandemic in France. Purposeful sampling was used to ensure the diversity of study participants with respect to sex, age, relationship with the patient, and geographic location. All data were collected between June and September 2020, and data analysis was performed from August to November 2020. Main Outcomes and Measures: Interviews were conducted 3 to 4 months after the patient's death and were audio-recorded and analyzed using thematic analysis. Results: Among 19 family members interviewed (median [range] age, 46 [23-75] years; 14 [74%] women), 3 major themes emerged from qualitative analysis. The first was the difficulty in building a relationship with the ICU clinicians and dealing with the experience of solitude: family members experienced difficulties in establishing rapport and bonding with the ICU team as well as understanding the medical information. Distance communication was not sufficient, and participants felt it increased the feeling of solitude. The second involved the patient in the ICU and the risks of separation: because of restricted access to the ICU, family members experienced discontinuity and interruptions in the relationship with their loved one, which were associated with feelings of powerlessness, abandonment, and unreality. The third was regarding disruptions in end-of-life rituals: family members described "stolen moments" after the patient's death, generating strong feelings of disbelief that may lead to complicated grief. Conclusions and Relevance: This qualitative study found that during the initial wave of the COVID-19 pandemic in France, bereaved family members described a disturbed experience, both during the ICU stay and after the patient's death. Specific family-centered crisis guidelines are needed to improve experiences for patients, families, and clinicians experiences.

Symptoms of Mental Health Disorders in Critical Care Physicians Facing the Second COVID-19 Wave: A Cross-Sectional Study.

BACKGROUND: Working in the ICU during the first COVID-19 wave was associated with high levels of mental health disorders. RESEARCH QUESTION: What are the mental health symptoms in health care providers (HCPs) facing the second wave? STUDY DESIGN AND METHODS: A cross-sectional study (October 30-December 1, 2020) was conducted in 16 ICUs during the second wave in France. HCPs completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised (for post-traumatic stress disorder), and the Maslach Burnout Inventory. RESULTS: Of 1,203 HCPs, 845 responded (70%) (66% nursing staff, 32% medical staff, 2% other professionals); 487 (57.6%) had treated more than 10 new patients with COVID-19 in the previous week. Insomnia affected 320 (37.9%), and 7.7% were taking a psychotropic drug daily. Symptoms of anxiety, depression, post-traumatic stress disorder, and burnout were reported in 60.0% (95% CI, 56.6%-63.3%), 36.1% (95% CI, 32.9%-39.5%), 28.4% (95% CI, 25.4%-31.6%), and 45.1% (95% CI, 41.7%-48.5%) of respondents, respectively. Independent predictors of such symptoms included respondent characteristics (sex, profession, experience, personality traits), work organization (ability to rest and to care for family), and self-perceptions (fear of becoming infected or of infecting family and friends, feeling pressure related to the surge, intention to leave the ICU, lassitude, working conditions, feeling they had a high-risk profession, and "missing the clapping"). The number of patients with COVID-19 treated in the first wave or over the last week was not associated with symptoms of mental health disorders. INTERPRETATION: The prevalence of symptoms of mental health disorders is high in ICU HCPs managing the second COVID-19 surge. The highest tiers of hospital management urgently need to provide psychological support, peer-support groups, and a communication structure that ensure the well-being of HCPs.

Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study.

Rationale: Frontline healthcare providers (HCPs) during the coronavirus disease (COVID-19) pandemic are at high risk of mental morbidity.Objectives: To assess the prevalence of symptoms of anxiety, depression, and peritraumatic dissociation in HCPs.Methods: This was a cross-sectional study in 21 ICUs in France between April 20, 2020, and May 21, 2020. The Hospital Anxiety and Depression Scale and the Peritraumatic Dissociative Experience Questionnaire were used. Factors independently associated with reported symptoms of mental health disorders were identified.Measurements and Main Results: The response rate was 67%, with 1,058 respondents (median age 33 yr; 71% women; 68% nursing staff). The prevalence of symptoms of anxiety, depression, and peritraumatic dissociation was 50.4%, 30.4%, and 32%, respectively, with the highest rates in nurses. By multivariable analysis, male sex was independently associated with lower prevalence of symptoms of anxiety, depression, and peritraumatic dissociation (odds ratio of 0.58 [95% confidence interval, 0.42-0.79], 0.57 [95% confidence interval, 0.39-0.82], and 0.49 [95% confidence interval, 0.34-0.72], respectively). HCPs working in non-university-affiliated hospitals and nursing assistants were at high risk of symptoms of anxiety and peritraumatic dissociation. Importantly, we identified the following six modifiable determinants of symptoms of mental health disorders: fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, and witnessing hasty end-of-life decisions.Conclusions: HCPs experience high levels of psychological burden during the COVID-19 pandemic. Hospitals, ICU directors, and ICU staff must devise strategies to overcome the modifiable determinants of adverse mental illness symptoms.

Formal Academic Training on Ethics May Address Junior Physicians' Needs.

BACKGROUND: Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training. METHODS: Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods. RESULTS: More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process. CONCLUSIONS: Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.

Symptoms of depression in ICU physicians.

BACKGROUND: Work and family are the two domains from which most adults develop satisfaction in life. They also are responsible for stressful experiences. There is a perception in the community that work is increasingly the source of much of our stress and distress. Depressive symptoms may be related to repeated stressful experiences. Intensive care unit (ICU) physicians are exposed to major stressors. However, the existence of depressive symptoms in these doctors has been poorly studied. This study was designed to evaluate the prevalence and associated risk factors of depressive symptoms in junior and senior ICU physicians. METHOD: A one-day national survey was conducted in adult intensive care units (ICU) in French public hospitals. Symptoms of depression were assessed using the Centers of Epidemiologic Studies Depression Scale (CES-D). RESULTS: A total of 189 ICUs participated, and 901 surveys were returned (75.8% response rate). Symptoms of depression were found in 23.8% of the respondents using the CES-D scale. Fifty-eight percent of these intensivists presenting symptoms of depression wished to leave their job compared with only 33% of those who did not exhibit signs of depression as assessed by the CES-D scale (p < 0.0001). Multiple logistic regression showed that organizational factors were associated with the presence of depressive symptoms. Workload (long interval since the last nonworking weekend, absence of relief of service until the next working day after a night shift) and impaired relationships with other intensivists were independently associated with the presence of depressive symptoms. A high level of burnout also was related to the presence of depressive symptoms. In contrast, no demographic factors regarding ICU physicians and no factor related to the severity of illness of patients were retained by the model. The quality of relationships with other physicians (from other departments) was associated with the absence of depressive symptoms (protective effect). CONCLUSIONS: Approximately one of four intensivists presented symptoms of depression. The next step could be to test whether organization modification is associated with less depressive symptoms and less desire to leave the job.

Impact of an intensive care unit diary on psychological distress in patients and relatives*.

OBJECTIVE: To assess the impact of an intensive care unit diary on the psychological well-being of patients and relatives 3 and 12 months after intensive care unit discharge. DESIGN: Prospective single-center study with an intervention period between two control periods. SETTING: Medical-surgical intensive care unit in a 460-bed tertiary hospital. PATIENTS: Consecutive patients from May 2008 to November 2009 and their relatives. Study inclusion occurred after the fourth day in the intensive care unit. INTERVENTIONS: A diary written by both the patient's relatives and the intensive care unit staff. MEASUREMENTS AND MAIN RESULTS: Patients and relatives completed the Hospital Anxiety and Depression Scale and Peritraumatic Dissociative Experiences Questionnaire 3 months after intensive care unit discharge, and completed the Impact of Events Scale assessing posttraumatic stress-related symptoms 12 months after intensive care unit discharge. Of the 378 patients admitted during the study period, 143 were included (48 in the prediary period, 49 in the diary period, and 46 in the postdiary period). In relatives, severe posttraumatic stress-related symptoms after 12 months varied significantly across periods (prediary 80%, diary 31.7%, postdiary 67.6%; p<.0001). Similar results were obtained in the posttraumatic stress-related symptom score after 12 months in the surviving patients (prediary 34.6 ± 15.9, diary 21 ± 12.2, and postdiary 29.8 ± 15.9; p = .02). CONCLUSIONS: The intensive care unit diary significantly affected posttraumatic stress-related symptoms in relatives and surviving patients 12 months after intensive care unit discharge.

[Meeting the needs of families of patients in intensive care units]. / Communiquer avec les families des patients en réanimation.

As patients in intensive care units (ICUs) are not always able to decide for themselves, their family must receive thorough information on the diagnosis, prognosis and available treatments (unless the patient has expressed his/her opposition). It is crucial to provide this information before requesting the family's involvement. Together, the family and ICU physicians can ensure that the patient receives the most appropriate care. Next-of-kin may either be called on to make decisions (as surrogates) or simply to offer their considered opinion. Good communication and information are a source of comfort and empowerment for the family, especially in end-of-life settings. Finally, we examine areas warrantingfurther research on the family-physician relationship in ICUs.