Validating Feelings of Grieving Families Eases the Pain of Loss

PARIS, Jan. 31 -- Treating the families of dying patients with compassion, keeping them informed, and establishing good communications with ICU staffers in a formal process can ease the pain of bereavement.

That's the conclusion of Alexandre Laurette, M.D., of Saint-Louis Hospital here and colleagues, who conducted a randomized study comparing a formalized family intervention with conventional ICU family conferences.

Dr. Laurette and colleagues found that three months after the death of a loved one, those family members who were went through the formalized process had lower levels of post-traumatic stress disorder (PTSD) symptoms, anxiety, and depression and were better able to cope with their loss.

"A proactive strategy for routine end-of-life family conferences that included provision of a brochure on bereavement, as compared with customary practice, resulted in longer meetings in which families had more opportunities to speak and to express emotions, felt more supported in making difficult decisions, experienced more relief from guilt, and were more likely to accept realistic goals of care," the investigators wrote in the Feb. 1 issue of the New England Journal of Medicine.

In an accompanying editorial, Craig M. Lilly, M.D., of the University of Massachusetts Medical School in Worcester, and Barbara J. Daly, Ph.D, R.N., of Case Western University in Cleveland, applauded the authors for taking a scientific approach to a hard-to-quantify subject.

"This study is groundbreaking in its demonstration of a statistically and clinically significant improvement in symptoms of anxiety, depression, and PTSD among family members, and it shows that expanding the focus of critical care to include family-centered outcomes is appropriate and desirable," they wrote. "In reporting these advances in the peer-reviewed literature, it is often difficult for authors to fully explain the core of their interventions, in part because of the complex, diverse, and emotion-laden nature of these multidimensional conversations."

Dr. Laurette and colleagues ramdomly assigned family members of 126 patients dying in 22 ICUs in to receive either the intervention format or to the institution's customary end-of-life conference.

Families assigned to the intervention group attended the end-of-life family conference that was held in according to detailed guidelines developed by study's co-author, J. Randall Curtis, M.D., M.P.H., of the University of Washington in Seattle.

The families were given a brochure on bereavement, and the conference focused of five objectives, represented by the acronym VALUE. Caregivers were expected to:

• Value and appreciate what the family members said.
• Acknowledge the emotions of family members.
• Listen.
• Understand, by asking questions "who the patient was as a person."
• Elicit questions from family members.

One investigator at each ICU was responsible for the study, which included six consecutive patients and their surrogates.

Three months after the death of the patient, one member of each family -- either the patient's designated surrogate or the chief decision maker in the group -- was interviewed by telephone. Each interviewer rated how the family member was coping via the Impact of Event Scale, with scores ranging from 0, indicating no symptoms, to 75, indicating severe symptoms related to post-traumatic stress disorder, and with the Hospital Anxiety and Depression Scale with subscale scores ranging from 0, indicating no distress, to 21, indicating maximum distress.

The investigators found that those family members who took part in the formal intervention had had significantly longer end-of-life conferences than controls, at a median of 30 minutes (interquartile range, 19 to 45 minutes), compared with 20 minutes (IR, 15 to 30 minutes, P

"Recommendations to improve care for patients dying in ICUs are rooted in both observational and interventional studies," Dr. Lilly and Dr. Daly wrote in their editorial. "Observational studies confirm our own practical experience that nearly every American family will be affected by the loss of a loved one in an ICU and that the effect of this loss can be mitigated by high-quality care."

The editorialists estimated the time required for this type of internvention. They wrote that "on the basis of our research, we propose that the time clinicians working in adult ICUs spend supporting family members in shared decision making should roughly correspond to the mortality rate of the ICU patient population. For example, a full-time clinician serving a surgical ICU with a mortality rate of 2% would spend about two hours a week supporting patients and families. The same clinician would spend about two hours per day supporting families when serving a medical ICU with a mortality rate of 20%."