Advertisement

Surrogates of Patients With Severe Acute Brain Injury Experience Persistent Anxiety and Depression Over the 6 Months After ICU Admission

      Abstract

      Context

      Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty.

      Objectives

      To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV).

      Methods

      We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons.

      Results

      Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2–6.0).

      Conclusion

      Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pain and Symptom Management
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cox CE
        • Carson SS.
        Medical and economic implications of prolonged mechanical ventilation and expedited post-acute care.
        Semin Respir Crit Care Med. 2012; 33: 357-361https://doi.org/10.1055/s-0032-1321985
        • Unroe M
        • Kahn JM
        • Carson SS
        • et al.
        One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.
        Ann Intern Med. 2010; 153: 167-175https://doi.org/10.7326/0003-4819-153-3-201008030-00007
        • Han JH
        • Vasilevskis EE
        • Shintani A
        • et al.
        Impaired arousal at initial presentation predicts 6-month mortality: an analysis of 1,084 acutely Ill older patients.
        Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2014; 9: 772-778https://doi.org/10.1002/jhm.2276
        • Herridge MS
        • Chu LM
        • Matte A
        • et al.
        The Recover program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation.
        Am J Respir Crit Care Med. 2016; 194: 831-844https://doi.org/10.1164/rccm.201512-2343OC
        • Cameron JI
        • Chu LM
        • Matte A
        • et al.
        One-year outcomes in caregivers of critically Ill patients.
        N Engl J Med. 2016; 374: 1831-1841https://doi.org/10.1056/NEJMoa1511160
        • Carson SS
        • Cox CE
        • Wallenstein S
        • et al.
        Effect of palliative care-led meetings for families of patients with chronic critical illness: a randomized clinical trial.
        JAMA. 2016; 316: 51-62https://doi.org/10.1001/jama.2016.8474
        • Cox CE
        • White DB
        • Hough CL
        • et al.
        Effects of a personalized web-based decision aid for surrogate decision makers of patients with prolonged mechanical ventilation: a randomized clinical trial.
        Ann Intern Med. 2019; https://doi.org/10.7326/m18-2335
        • Long AC
        • Kross EK
        • Curtis JR.
        Family-centered outcomes during and after critical illness: current outcomes and opportunities for future investigation.
        Curr Opin Crit Care. 2016; 22: 613-620https://doi.org/10.1097/MCC.0000000000000360
        • Te Ao B
        • Brown P
        • Tobias M
        • et al.
        Cost of traumatic brain injury in New Zealand: evidence from a population-based study.
        Neurology. 2014; 83: 1645-1652https://doi.org/10.1212/wnl.0000000000000933
        • de Roulet A
        • Inaba K
        • Strumwasser A
        • et al.
        Severe injuries associated with skiing and snowboarding: a national trauma data bank study.
        J Trauma Acute Care Surg. 2017; 82: 781-786https://doi.org/10.1097/ta.0000000000001358
        • Lorenz L
        • Katz G.
        Severe brain injury in nassachusetts: assessing the continuum of care.
        Issue Brief (Mass Health Policy Forum). 2015; : 1-62
        • Creutzfeldt CJ
        • Longstreth WT
        • Holloway RG.
        Predicting decline and survival in severe acute brain injury: the fourth trajectory.
        BMJ. 2015; 351: h3904https://doi.org/10.1136/bmj.h3904
        • Cox CE
        • Carson SS
        • Lindquist JH
        • et al.
        Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study.
        Crit Care. 2007; 11: R9https://doi.org/10.1186/cc5667
        • Azoulay E
        • Pochard F
        • Kentish-Barnes N
        • et al.
        Risk of post-traumatic stress symptoms in family members of intensive care unit patients.
        Am J Respir Crit Care Med. 2005; 171: 987-994https://doi.org/10.1164/rccm.200409-1295OC
        • Chan KS
        • Aronson Friedman L
        • Bienvenu OJ
        • et al.
        Distribution-based estimates of minimal important difference for hospital anxiety and depression scale and impact of event scale-revised in survivors of acute respiratory failure.
        Gen Hosp Psychiatry. 2016; 42: 32-35https://doi.org/10.1016/j.genhosppsych.2016.07.004
        • Suttorp MM
        • Siegerink B
        • Jager KJ
        • Zoccali C
        • Dekker FW.
        Graphical presentation of confounding in directed acyclic graphs.
        Nephrol Dial Transplant. 2015; 30: 1418-1423https://doi.org/10.1093/ndt/gfu325
        • Textor J
        • van der Zander B
        • Gilthorpe MS
        • Liskiewicz M
        • Ellison GT.
        Robust causal inference using directed acyclic graphs: the R package ‘dagitty’.
        Int J Epidemiol. 2016; 45: 1887-1894https://doi.org/10.1093/ije/dyw341
        • Lederer DJ
        • Bell SC
        • Branson RD
        • et al.
        Control of confounding and reporting of results in causal inference studies. Guidance for authors from editors of respiratory, sleep, and critical care journals.
        Ann Am Thorac Soc. 2019; 16: 22-28https://doi.org/10.1513/AnnalsATS.201808-564PS
        • Wendlandt B
        • Ceppe A
        • Cox CE
        • et al.
        The association between patient health status and surrogate decision maker PTSD symptoms in chronic critical illness.
        Ann Am Thorac Soc. 2021; https://doi.org/10.1513/AnnalsATS.202010-1300OC
        • Hough CL
        • Caldwell ES
        • Cox CE
        • et al.
        Development and validation of a mortality prediction model for patients receiving 14 days of mechanical ventilation.
        Crit Care Med. 2015; 43: 2339-2345https://doi.org/10.1097/CCM.0000000000001205
        • Teasdale G
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale.
        Lancet (London, England). 1974; 2: 81-84https://doi.org/10.1016/s0140-6736(74)91639-0
        • Johnson CC
        • Suchyta MR
        • Darowski ES
        • et al.
        Psychological sequelae in family caregivers of critically-Ill intensive care unit patients: a systematic review.
        Ann Am Thorac Soc. 2019; https://doi.org/10.1513/AnnalsATS.201808-540SR
        • Kiker WA
        • Rutz Voumard R
        • Andrews LIB
        • et al.
        Assessment of discordance between physicians and family members regarding prognosis in patients with severe acute brain injury.
        JAMA Netw Open. 2021; 4e2128991https://doi.org/10.1001/jamanetworkopen.2021.28991
        • Boyd RW LE
        • Weeks LD
        • McLemore MR
        On racism: a new standard for publishing on racial health inequities.
        Health Affairs Blog. 2020; (Available at:) (. Accessed December 15, 2021)
        • Ioannidis JPA
        • Powe NR
        • Yancy C
        Recalibrating the use of race in medical research.
        JAMA. 2021; 325: 623-624https://doi.org/10.1001/jama.2021.0003
        • Rutz Voumard R
        • Kiker WA
        • Dugger KM
        • et al.
        Adapting to a new normal after severe acute brain injury: an observational cohort using a sequential explanatory design.
        Crit Care Med. 2021; https://doi.org/10.1097/ccm.0000000000004947
        • Schutz RE
        • Coats HL
        • Engelberg RA
        • Curtis JR
        • Creutzfeldt CJ.
        Is there hope? Is she there? How families and clinicians experience severe acute brain injury.
        J Palliat Med. 2017; 20: 170-176https://doi.org/10.1089/jpm.2016.0286
        • Lee JD
        • Jennerich AL
        • Engelberg RA
        • et al.
        Type of intensive care unit matters: variations in palliative care for critically Ill patients with chronic, life-limiting illness.
        J Palliat Med. 2021; 24: 857-864https://doi.org/10.1089/jpm.2020.0412
        • Wendlandt B
        • Ceppe A
        • Choudhury S
        • et al.
        Modifiable elements of ICU supportive care and communication are associated with surrogates' PTSD symptoms.
        Intensive Care Med. 2019; https://doi.org/10.1007/s00134-019-05550-z
        • Kross EK
        • Engelberg RA
        • Downey L
        • et al.
        Differences in end-of-life care in the ICU across patients cared for by medicine, surgery, neurology, and neurosurgery physicians.
        Chest. 2014; 145: 313-321https://doi.org/10.1378/chest.13-1351
        • Bar B
        • Creutzfeldt CJ
        • Rubin MA.
        Palliative care in the Neuro-ICU: perceptions, practice patterns, and preferences of neurointensivists.
        Neurocrit Care. 2020; 32: 302-305https://doi.org/10.1007/s12028-019-00838-w
        • 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: 280-287https://doi.org/10.1378/chest.09-1291
        • 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: 469-478https://doi.org/10.1056/NEJMoa063446
        • Creutzfeldt CJ
        • Hanna MG
        • Cheever CS
        • et al.
        Palliative care needs assessment in the Neuro-ICU: effect on family.
        Neurocrit Care. 2017; https://doi.org/10.1007/s12028-017-0426-3
        • Vranceanu AM
        • Bannon S
        • Mace R
        • et al.
        Feasibility and efficacy of a resiliency intervention for the prevention of chronic emotional distress among survivor-caregiver dyads admitted to the neuroscience intensive care unit: a randomized clinical trial.
        JAMA Netw Open. 2020; 3e2020807https://doi.org/10.1001/jamanetworkopen.2020.20807