Editorials 7. Aslakson R, Cheng J, Vollenweider D, et al: Evidence-based palliative care in the intensive care unit: A systematic review of interventions. J Palliat Med 2014; 17:219–235 8. Khandelwal N, Curtis JR: Economic implications of end-of-life care in the ICU. Curr Opin Crit Care 2014; 20:656–661 9. Morrison RS, Dietrich J, Ladwig S, et al: Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood) 2011; 30:454–463 10. Shaw DJ, Davidson JE, Smilde RI, et al: Multidisciplinary team training to enhance family communication in the ICU. Crit Care Med 2014; 42:265–271 11. Lautrette A, Darmon M, Megarbane B, et al: A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356:469–478
12. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363:733–742 13. Khandelwal N, Kross EK, Engelberg RA, et al: Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review. Crit Care Med 2015; 43:1102–1111 14. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013; 310:2271–2281 15. Howell AA, Nielsen EL, Turner AM, et al: Clinicians’ perceptions of the usefulness of a communication facilitator in the intensive care unit. Am J Crit Care 2014; 23:380–386
The Importance of Caregiver Outcomes After Critical Illness* Erin K. Kross, MD Division of Pulmonary and Critical Care Medicine Department of Medicine University of Washington Harborview Medical Center Seattle, WA
F
amily members of critically ill patients are at risk for a number of adverse psychologic outcomes, including posttraumatic stress disorder, depression, anxiety, and complicated grief. In 2010, a task force of the Society of Critical Care Medicine proposed a new term for this cluster of complications—post–intensive care syndrome-family (1). Family caregivers are integral to the care of patients who survive critical illness. Providing this care can be detrimental to the caregiver, and caregiving has been shown to increase stress and even mortality (2–4). Recently, there has been increasing awareness of the importance of improving outcomes for caregivers, the value that family-centered care may add to improving patient outcomes, and the responsibility clinicians have to recognize caregiver burden (5, 6). Recognition of the importance of caregiver outcomes after critical illness is growing. Although some of the initial descriptions focused on bereaved family members (7–9), more recent studies have explored the burden of symptoms for family members who survive critical illness. Our understanding of the emotional toll of critical illness on caregivers of patients who survive critical illness is essential. These family members are often called *See also p. 1112. Key Words: caregivers; critical illness; depression; posttraumatic stress; psychologic outcomes Dr. Kross’s institution received grant support from a National Heart, Lung and Blood Institute K23 award and an American Lung Association award. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000910
Critical Care Medicine
upon to provide post-ICU care and support for the surviving patient, a role that may be compromised if the burden is too great. In this issue of Critical Care Medicine, Haines et al (10) add to the growing body of literature with an informative systematic review of the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. The authors identified 14 articles that met their criteria for inclusion. They conclude that adverse psychological symptoms are experienced by a substantial portion of ICU caregivers and that these symptoms persist for some time after discharge. Depression was both the most commonly reported symptom in these articles and also the most prevalent adverse psychological symptom among caregivers. Depressive symptoms were highest during the acute phase of the patient’s illness and demonstrated some improvement over time. However, significant depressive symptoms were still present in approximately 25% of caregivers at 1 year, which is higher than what is seen in the general population (11). The authors provide a thorough exploration of risk factors for adverse psychologic outcomes, providing insights to nonmodifiable characteristics that may identify individuals at risk including sex, age, and patient characteristics, as well as modifiable characteristics that may be amenable to intervention, including social support, fatigue, burden, and health risk behaviors. Other important adverse psychologic symptoms that were less often reported include caregiver burden, activity restriction, health-related quality of life, and posttraumatic stress disorder. The authors provide a concise summary of the prevalence, time course, and risk factors for each, as best they are able from the current literature. Although the authors initially sought to include anxiety and stress, none of the studies included in the review reported on these outcomes. The authors acknowledge a number of weaknesses of their review, including the limited number of studies meeting criteria for inclusion, the generally low methodologic quality of the studies which are mostly observational in nature, and a lack of www.ccmjournal.org
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premorbid assessments of psychologic symptoms in most studies. Overall, they found significant heterogeneity in the included studies, both in terms of time of assessment and outcome measures, and for this reason were unable to conduct a metaanalysis. Although this review provides us with a great deal of information about the adverse consequences of critical illness for caregivers, Haines et al (10) astutely note that this review only captures the negative symptom burden experienced by caregivers and therefore does not describe the full potential spectrum of outcomes. In addition to the more commonly reported negative symptoms, there can also be positive personal changes that occur in conjunction with or after a traumatic event such as critical illness (12, 13). The full spectrum of psychological responses to the trauma of critical illness (14) has not been well-described. A better understanding of both the positive and negative consequences of critical illness may provide additional targets for intervention with the goal to improve outcomes for both patients and their caregivers. Although this important review highlights the sizeable burden of psychological symptoms for caregivers of patients who survive critical illness and provides the critical care community insight into the risk factors and trajectory of these adverse symptoms as experienced by caregivers, questions remain. What can we learn from the majority of caregivers who do not develop adverse psychologic symptoms after critical illness? Are there protective psychosocial characteristics or modifiable components of the ICU experience (such as high-quality communication with providers) that may prevent or attenuate these negative outcomes? What role might different types of coping skills play? Given the influence that these adverse symptoms can have on the health of both caregivers and patients after critical illness, further high-quality research is needed to better inform timely and relevant
1150
www.ccmjournal.org
interventions with the goal to improve outcomes for both caregivers and patients alike.
REFERENCES
1. Davidson JE, Jones C, Bienvenu OJ: Family response to critical illness: Postintensive care syndrome-family. Crit Care Med 2012; 40:618–624 2. Kiecolt-Glaser JK, Glaser R, Shuttleworth EC, et al: Chronic stress and immunity in family caregivers of Alzheimer’s disease victims. Psychosom Med 1987; 49:523–535 3. Christakis NA, Allison PD: Mortality after the hospitalization of a spouse. N Engl J Med 2006; 354:719–730 4. Schulz R, Beach SR: Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. JAMA 1999; 282:2215–2219 5. Adelman RD, Tmanova LL, Delgado D, et al: Caregiver burden: A clinical review. JAMA 2014; 311:1052–1060 6. Lynn J: Strategies to ease the burden of family caregivers. JAMA 2014; 311:1021–1022 7. Gries CJ, Engelberg RA, Kross EK, et al: Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2010; 137:280–287 8. Kross EK, Engelberg RA, Gries CJ, et al: ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU. Chest 2011; 139:795–801 9. Siegel MD, Hayes E, Vanderwerker LC, et al: Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008; 36:1722–1728 10. Haines KJ, Denehy L, Skinner EH, et al: Psychosocial Outcomes in Informal Caregivers of the Critically Ill: A Systematic Review. Crit Care Med 2015; 43:1112–1120 11. Richards D: Prevalence and clinical course of depression: A review. Clin Psychol Rev 2011; 31:1117–1125 12. Tedeschi RG, Calhoun LG: Post-traumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry 2004;15:1–18 13. Loiselle KA, Devine KA, Reed-Knight B, et al: Posttraumatic growth associated with a relative’s serious illness. Fam Syst Health 2011; 29:64–72 14. Carver CS: Resilience and thriving: Issues, models and linkages. J Soc Issues 1998; 54:245–266
May 2015 • Volume 43 • Number 5
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
12. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363:733–742 13. Khandelwal N, Kross EK, Engelberg RA, et al: Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review. Crit Care Med 2015; 43:1102–1111 14. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013; 310:2271–2281 15. Howell AA, Nielsen EL, Turner AM, et al: Clinicians’ perceptions of the usefulness of a communication facilitator in the intensive care unit. Am J Crit Care 2014; 23:380–386
The Importance of Caregiver Outcomes After Critical Illness* Erin K. Kross, MD Division of Pulmonary and Critical Care Medicine Department of Medicine University of Washington Harborview Medical Center Seattle, WA
F
amily members of critically ill patients are at risk for a number of adverse psychologic outcomes, including posttraumatic stress disorder, depression, anxiety, and complicated grief. In 2010, a task force of the Society of Critical Care Medicine proposed a new term for this cluster of complications—post–intensive care syndrome-family (1). Family caregivers are integral to the care of patients who survive critical illness. Providing this care can be detrimental to the caregiver, and caregiving has been shown to increase stress and even mortality (2–4). Recently, there has been increasing awareness of the importance of improving outcomes for caregivers, the value that family-centered care may add to improving patient outcomes, and the responsibility clinicians have to recognize caregiver burden (5, 6). Recognition of the importance of caregiver outcomes after critical illness is growing. Although some of the initial descriptions focused on bereaved family members (7–9), more recent studies have explored the burden of symptoms for family members who survive critical illness. Our understanding of the emotional toll of critical illness on caregivers of patients who survive critical illness is essential. These family members are often called *See also p. 1112. Key Words: caregivers; critical illness; depression; posttraumatic stress; psychologic outcomes Dr. Kross’s institution received grant support from a National Heart, Lung and Blood Institute K23 award and an American Lung Association award. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000910
Critical Care Medicine
upon to provide post-ICU care and support for the surviving patient, a role that may be compromised if the burden is too great. In this issue of Critical Care Medicine, Haines et al (10) add to the growing body of literature with an informative systematic review of the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. The authors identified 14 articles that met their criteria for inclusion. They conclude that adverse psychological symptoms are experienced by a substantial portion of ICU caregivers and that these symptoms persist for some time after discharge. Depression was both the most commonly reported symptom in these articles and also the most prevalent adverse psychological symptom among caregivers. Depressive symptoms were highest during the acute phase of the patient’s illness and demonstrated some improvement over time. However, significant depressive symptoms were still present in approximately 25% of caregivers at 1 year, which is higher than what is seen in the general population (11). The authors provide a thorough exploration of risk factors for adverse psychologic outcomes, providing insights to nonmodifiable characteristics that may identify individuals at risk including sex, age, and patient characteristics, as well as modifiable characteristics that may be amenable to intervention, including social support, fatigue, burden, and health risk behaviors. Other important adverse psychologic symptoms that were less often reported include caregiver burden, activity restriction, health-related quality of life, and posttraumatic stress disorder. The authors provide a concise summary of the prevalence, time course, and risk factors for each, as best they are able from the current literature. Although the authors initially sought to include anxiety and stress, none of the studies included in the review reported on these outcomes. The authors acknowledge a number of weaknesses of their review, including the limited number of studies meeting criteria for inclusion, the generally low methodologic quality of the studies which are mostly observational in nature, and a lack of www.ccmjournal.org
1149
Editorials
premorbid assessments of psychologic symptoms in most studies. Overall, they found significant heterogeneity in the included studies, both in terms of time of assessment and outcome measures, and for this reason were unable to conduct a metaanalysis. Although this review provides us with a great deal of information about the adverse consequences of critical illness for caregivers, Haines et al (10) astutely note that this review only captures the negative symptom burden experienced by caregivers and therefore does not describe the full potential spectrum of outcomes. In addition to the more commonly reported negative symptoms, there can also be positive personal changes that occur in conjunction with or after a traumatic event such as critical illness (12, 13). The full spectrum of psychological responses to the trauma of critical illness (14) has not been well-described. A better understanding of both the positive and negative consequences of critical illness may provide additional targets for intervention with the goal to improve outcomes for both patients and their caregivers. Although this important review highlights the sizeable burden of psychological symptoms for caregivers of patients who survive critical illness and provides the critical care community insight into the risk factors and trajectory of these adverse symptoms as experienced by caregivers, questions remain. What can we learn from the majority of caregivers who do not develop adverse psychologic symptoms after critical illness? Are there protective psychosocial characteristics or modifiable components of the ICU experience (such as high-quality communication with providers) that may prevent or attenuate these negative outcomes? What role might different types of coping skills play? Given the influence that these adverse symptoms can have on the health of both caregivers and patients after critical illness, further high-quality research is needed to better inform timely and relevant
1150
www.ccmjournal.org
interventions with the goal to improve outcomes for both caregivers and patients alike.
REFERENCES
1. Davidson JE, Jones C, Bienvenu OJ: Family response to critical illness: Postintensive care syndrome-family. Crit Care Med 2012; 40:618–624 2. Kiecolt-Glaser JK, Glaser R, Shuttleworth EC, et al: Chronic stress and immunity in family caregivers of Alzheimer’s disease victims. Psychosom Med 1987; 49:523–535 3. Christakis NA, Allison PD: Mortality after the hospitalization of a spouse. N Engl J Med 2006; 354:719–730 4. Schulz R, Beach SR: Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. JAMA 1999; 282:2215–2219 5. Adelman RD, Tmanova LL, Delgado D, et al: Caregiver burden: A clinical review. JAMA 2014; 311:1052–1060 6. Lynn J: Strategies to ease the burden of family caregivers. JAMA 2014; 311:1021–1022 7. Gries CJ, Engelberg RA, Kross EK, et al: Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2010; 137:280–287 8. Kross EK, Engelberg RA, Gries CJ, et al: ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU. Chest 2011; 139:795–801 9. Siegel MD, Hayes E, Vanderwerker LC, et al: Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008; 36:1722–1728 10. Haines KJ, Denehy L, Skinner EH, et al: Psychosocial Outcomes in Informal Caregivers of the Critically Ill: A Systematic Review. Crit Care Med 2015; 43:1112–1120 11. Richards D: Prevalence and clinical course of depression: A review. Clin Psychol Rev 2011; 31:1117–1125 12. Tedeschi RG, Calhoun LG: Post-traumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry 2004;15:1–18 13. Loiselle KA, Devine KA, Reed-Knight B, et al: Posttraumatic growth associated with a relative’s serious illness. Fam Syst Health 2011; 29:64–72 14. Carver CS: Resilience and thriving: Issues, models and linkages. J Soc Issues 1998; 54:245–266
May 2015 • Volume 43 • Number 5
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
