Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms

Fur-Hsing Wen; Holly G Prigerson; Li-Pang Chuang; Wen-Chi Chou; Chung-Chi Huang; Tsung-Hui Hu; Siew Tzuh Tang

doi:10.1097/CCM.0000000000006416

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms

Crit Care Med. 2024 Sep 11;52(12):1885-1893. doi: 10.1097/CCM.0000000000006416. Online ahead of print.

Authors

Fur-Hsing Wen¹, Holly G Prigerson², Li-Pang Chuang³, Wen-Chi Chou^{4

5}, Chung-Chi Huang^{3

6}, Tsung-Hui Hu⁷, Siew Tzuh Tang^{4

8

9

10}

Affiliations

¹ Department of International Business, Soochow University, Taiwan, ROC.
² Department of Medicine, Weill Cornell Medicine, New York City, NY.
³ Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
⁴ Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
⁵ College of Medicine, School of Medicine, Chang Gung University, Tao-Yuan, Taiwan, ROC.
⁶ Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, ROC.
⁷ Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC.
⁸ School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, ROC.
⁹ Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC.
¹⁰ Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan, ROC.

Abstract

Objectives: Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability.

Design: Prospective cohort study.

Setting: Medical ICUs of two Taiwanese medical centers.

Subjects: Two hundred eighty-eight family surrogates.

Interventions: None.

Measurements and main results: Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss.

Conclusions: Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.