Christine DeForge, CCRN, MSN, RN, MPhil
Columbia University School of Nursing
Disclosure information not submitted.
Maureen George, PhD, RN, AE-C, FAAN
Professor of Nursing
Columbia University Irving Medical Center, United States
Disclosure information not submitted.
Katherine South, BSN, RN
PhD Student
Columbia University School of Nursing, United States
Disclosure information not submitted.
Marlene McHugh, DNP, DCC, FNP-BC, ACHPN, FPCN
Associate Professor of Nursing
Columbia University Irving Medical Center, United States
Disclosure information not submitted.
Arlene Smaldone, PhD, CPNP-PC, CDE, FAAN
Professor of Nursing and Dental Behavioral Sciences; Assistant Dean, Scholarship and Research
Columbia University Irving Medical Center, United States
Disclosure information not submitted.
Title: A Systematic Review & Meta-Analysis of Interventions for ICU Surrogates Making End-of-Life Decisions
Introduction: ICU surrogates experience symptoms of psychological distress which can persist for months. Symptoms are more prevalent among those faced with end-of-life (EoL) decisions and among those who become bereaved. Interventions have been developed to support these surrogates but results have varied. It is unclear if interventions overall are associated with improvements in symptoms.
Methods: Following an a priori protocol and PRISMA guidelines, we conducted a systematic review of randomized controlled trials of interventions delivered to ICU surrogates facing EoL decisions. Five databases were searched on 2/19/21 including a grey literature search of ClinicalTrials.gov. Studies were eligible if the intervention (1) targeted adult surrogates of adult ICU patients who died or had high likelihood of mortality and (2) measured surrogate symptoms. Two independent reviewers performed data extraction and assessed risk of bias (RoB) using the Cochrane RoB 2 tool. Studies measuring symptoms similarly at the same time point were eligible for meta-analysis. Pooled effects were estimated using a random effects model (Comprehensive Meta-Analysis [Bio-stat, Inc., Englewood, NJ]). Heterogeneity (Q and I2 statistics) and publication bias (funnel plot) were assessed.
Results: Of 1,443 records after removing duplicates, 9 studies were included; 7 were eligible for meta-analysis. Only 2 were deemed low RoB. Sample sizes ranged from 29 to 1,106 and were majority female. Most (n=6) interventions focused on improving communication and enhancing psychological support. All measured anxiety, depression, and post-traumatic stress (PTS). There was no pooled symptom improvement at either 3 or 6 months. Heterogeneity of effect (3-month anxiety and PTS; 6-month depression and PTS) was present. No evidence of publication bias was found.
Conclusions: Interventions delivered to ICU surrogates facing EoL decisions have not demonstrated overall improvement in psychological symptoms at either 3- or 6-months. Clinical significance of differences in symptom scores must be considered. Surrogates may simply experience symptoms regardless of intervention in the context of bereavement. Prioritizing outcome measures other than symptoms (e.g., quality of communication, decisional conflict, satisfaction with patient care) warrants future research.