Cited by 524Family and Patient Care in Intensive Care UnitsPalliative Care and End-of-Life IssuesEthics in medical practice

A randomized trial of a family-support intervention in intensive care units

Open access
White, Douglas B., Angus, Derek C., Shields, Anne-Marie, Buddadhumaruk, Praewpannarai, Pidro, Caroline, Paner, Cynthia, Chaitin, Elizabeth, Chang, Chung-Chou H. +7 more·2018·New England Journal of Medicine

Abstract

BACKGROUND: Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences. METHODS: We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay. RESULTS: A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001). CONCLUSIONS: Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1056/nejmoa1802637

Cites

49 of 49 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Family support interventions may help reduce psychological impacts on family members, as suggested by four systematic reviews and two recent studies.

    “Family support interventions may help to reduce these psychological impacts, as suggested by four systematic reviews, 37,71,72,83 and two recent studies. 84,85”

    From European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions (2021) · cites this paper as [84]

    The Discussion states that this family-support intervention did not significantly affect surrogates’ psychological symptoms at six months. The Abstract reports no significant difference from usual care in either HADS or IES scores, contrary to citing this trial as evidence that the intervention may reduce those impacts. (LLM, conf=0.90)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured
  • Elevated decisional conflict has been linked to delayed choices, post-decision regret, and strained clinician-family relationships, all of which can compromise care quality.

    “Elevated decisional conflict has been linked to delayed choices, post-decision regret, and strained clinician–family relationships, all of which can compromise care quality3.”

    From Decisional conflict among Chinese family caregivers prior to ECMO initiation: a cross-sectional study (2025) · cites this paper as [3]

    The Background (page unavailable) says ICU surrogates struggle with decisions and that these decisions can cause distress and care that does not align with patients’ preferences. It also links communication breakdowns to burdensome, potentially misaligned treatment. The paper does not link elevated decisional conflict to delayed choices, post-decision regret, or strained clinician–family relationships; searches for those terms found no supporting passage. (LLM, conf=0.82)

    Experimental — accuracy not yet measured
  • Previous trials led by ICU and palliative care clinicians have proven inefficacious in improving mental health outcomes in informal caregivers.

    “Previous trials led by ICU and palliative care clinicians have proven inefficacious in improving mental health outcomes in informal caregivers [5–11].”

    From Enhancing &amp; Mobilizing the POtential for Wellness &amp; Emotional Resilience (EMPOWER) among Surrogate Decision-Makers of ICU Patients: study protocol for a randomized controlled trial (2019) · cites this paper as [11]

    The Primary and Secondary Outcomes section reports no significant improvement in surrogates’ anxiety, depression, or post-traumatic stress symptoms after an intervention delivered by the ICU team. The Discussion also says two other recent ICU communication trials did not improve most measures of long-term psychological distress. These findings support a lack of demonstrated benefit, but do not prove that the interventions are inefficacious. (LLM, conf=0.88)

    Experimental — accuracy not yet measured
  • Prior interventions to address family surrogates' distress have had limited success, and some may even exacerbate surrogates' traumatic stress responses.

    “However, prior research has shown these interventions not only have limited success but that some may even exacerbate surrogates' traumatic stress responses (14-20).”

    From EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU (2024) · cites this paper as [19]

    The Discussion (page unavailable) says numerous previous interventions were largely unsuccessful and that two recent ICU communication trials did not improve most measures of surrogates’ long-term distress. It does not report that an intervention exacerbated traumatic stress; this trial found no significant difference in post-traumatic stress symptoms between groups (Primary and Secondary Outcomes, page unavailable). (LLM, conf=0.87)

    Experimental — accuracy not yet measured
  • A recent pragmatic trial of a nurse-led intervention in the ICU that provided intensive emotional support to families and frequent family meetings improved patient-centeredness of care and reduced length of stay, although it did not improve surrogates' psychological distress.

    “a recent pragmatic trial of a nurse-led intervention in the ICU that provided intensive emotional support to families and frequent family meetings improved patient-centeredness of care and reduced length of stay, although it did not improve surrogates’ psychological distress (44).”

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. [8]8. Selph RB, Shiang J, Engelberg R, Cur- tween physicians and surrogate decision makers of critically ill patients. JAMA 2016; 315: 2086-94.
  2. [21]21. Kahneman D. A perspective on judg- ment and choice: mapping bounded ratio- nality. Am Psychol 2003; 58: 697-720.
  3. [46]46. Committee on the Robert Wood John- son Foundation Initiative on the Future of Nursing at the Institute of Medicine. The future of nursing: leading change, ad- vancing health. Washington, DC: Nation- al Academies Press, 2011.

Cited by

Sorted by citations

Authors
White, D. B., Angus, D. C., Shields, A.-M., Buddadhumaruk, P., Pidro, C., Paner, C., Chaitin, E., Chang, C.-C. H., Pike, F., Weissfeld, L., Kahn, J. M., Darby, J. M., Kowinsky, A., Martin, S., & Arnold, R. M.
Affiliations
  • From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of...
  • University of Pittsburgh (US)
  • Eli Lilly (United States) (US)
  • Statistics Collaborative (US)
Venue
New England Journal of Medicine
Published
2018-06-21
Volume
378
Issue
25
Pages
2365-2375
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
OpenAlex
W2804920713
Cited by
524
References
49
Citations by year
2026: 63 · 2025: 55 · 2024: 59 · 2023: 67 · 2022: 65 · 2021: 82 · 2020: 66 · 2019: 53 · 2018: 13
FWCI
70.49
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • The Greenwall Foundation (n/a)
  • UPMC Innovation Fund (n/a)
Topics
  • Health Sciences › Health Professions › Radiological and Ultrasound Technology › Family and Patient Care in Intensive Care Units
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
Keywords
family support interventions, surrogate decision makers, intensive care unit, goals of care, clinician-family communication, patient-centered care, anxiety and depression, psychological distress, multidisciplinary team, family-centered care, ICU length of stay, end-of-life decisions, Hospital Anxiety and Depression Scale
MeSH terms
Aged, Anxiety, Communication, Critical Care, Decision Making, Depression, Family, Female, Humans, Intensive Care Units, Length of Stay, Male, Middle Aged, Professional-Family Relations, Stress, Psychological, Critical Illness, Caregivers, Hospital Mortality, Third-Party Consent, Critical Care Nursing

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review