Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness
Open accessAbstract
BACKGROUND: Problems persist with surrogate decision making in intensive care units, leading to distress for surrogates and treatment that may not reflect patients' values. OBJECTIVES: To assess the feasibility, acceptability, and perceived effectiveness of a multifaceted, nurse-led intervention to improve surrogate decision making in intensive care units. STUDY DESIGN: A single-center, single-arm, interventional study in which 35 surrogates and 15 physicians received the Four Supports Intervention, which involved incorporating a family support specialist into the intensive care team. That specialist maintained a longitudinal relationship with surrogates and provided emotional support, communication support, decision support, and anticipatory grief support. A mixed-methods approach was used to evaluate the intervention. RESULTS: The intervention was implemented successfully in all 15 patients, with a high level of completion of each component of the intervention. The family support specialist devoted a mean of 48 (SD 36) minutes per day to each clinician-patient-family triad. All participants reported that they would recommend the intervention to others. At least 90% of physicians and surrogates reported that the intervention (1) improved the quality and timeliness of communication, (2) facilitated discussion of the patient's values and treatment preferences, and (3) improved the patient-centeredness of care. CONCLUSIONS: The Four Supports Intervention is feasible, acceptable, and was perceived by physicians and surrogates to improve the quality of decision making and the patient-centeredness of care. A randomized trial is warranted to determine whether the intervention improves patient, family, and health system outcomes.
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A multicomponent, nurse-led intervention designed to reduce depression, anxiety, and PTSD focused on emotional, communication, decisional, and anticipatory grief support for ICU family caregivers but did not utilize targeted strategies to reduce clinical symptoms.
“Finally, a multicomponent, nurse-led intervention designed to reduce depression, anxiety, and PTSD focused on the provision of emotional, communication, decisional, and anticipatory grief support for ICU family caregivers, but did not utilize targeted strategies to reduce clinical symptoms [9, 10].”
From Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience (EMPOWER) among Surrogate Decision-Makers of ICU Patients: study protocol for a randomized controlled trial (2019) · cites this paper as [10]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredPrevious 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 & Mobilizing the POtential for Wellness & Emotional Resilience (EMPOWER) among Surrogate Decision-Makers of ICU Patients: study protocol for a randomized controlled trial (2019) · cites this paper as [10]
The paper’s background discussion (indexed as Abstract > Conclusions; page unavailable) says several prior ICU interventions did not improve patient or surrogate outcomes and describes null findings from clinician-led trials. The outcomes it specifies are treatment intensity, palliative-care measures, length of stay, decisions, and family ratings of communication—not informal caregivers’ mental health. Its Discussion also says some palliative-care or ethics consultations may improve outcomes for families, so the blanket claim that such trials were proven ineffective overstates the source. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPrior 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 [18]
The paper’s Conclusions section (page unavailable) reports that several earlier interventions failed to improve patient or surrogate outcomes, supporting the claim of limited success. It does not report that any intervention exacerbated surrogates’ traumatic stress responses; its discussion of adverse psychological outcomes concerns problems with ICU communication, not harms caused by an intervention. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe majority of prior trials of surrogate interventions did not target surrogates who are anxious and/or emotionally dependent on the patient.
“which the majority of prior trials of surrogate interventions did not do (14-20)”
From EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU (2024) · cites this paper as [18]
The Conclusions say prior interventions focused largely, though not exclusively, on communication and information rather than surrogates’ emotional and interpersonal considerations. That supports the broad contrast, but the paper does not say that most prior trials failed to target surrogates selected for anxiety or emotional dependence on the patient. (LLM, conf=0.82)
Experimental — accuracy not yet measuredSeveral interventions have not observed strong effects on psychological outcomes.
“distinguishing it from several interventions that have not observed strong effects on psychological outcomes (14-20)”
From EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU (2024) · cites this paper as [18]
The passage labeled Abstract > Conclusions (page unavailable) reports that several interventions did not improve patient or surrogate outcomes. Its examples concern treatment intensity, palliative-care measures, family ratings of communication, and length of stay—not specifically psychological outcomes. The source supports the claim of limited effects from several interventions, but not its psychological-outcomes qualification. (LLM, conf=0.82)
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“However, prior intervention trials have produced mixed results (Lautrette et al., 2007; White et al., 2012, 2018; Curtis et al., 2013; Carson et al., 2016; Cox et al., 2019; Dionne-Odom et al., 2020).”
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Self-citationEMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU
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- Authors
- White, D. B., Cua, S. M., Walk, R., Pollice, L., Weissfeld, L., Hong, S., Landefeld, C. S., & Arnold, R. M.
- Affiliations
- University of Pittsburgh (US)
- Venue
- American Journal of Critical Care
- Publisher
- AACN Publishing
- Published
- 2012-10-31
- Volume
- 21
- Issue
- 6
- Pages
- 396-409
- ISSN
- 1062-3264 (ISSN-L)
- 1937-710X
- PMC
- PMC3547494
- OpenAlex
- W2131800241
- Semantic Scholar
- c37228870f4e9dc0b95b963c2af3231f50b9b8dc
- Cited by
- 120
- References
- 59
- Citations by year
- 2026: 3 · 2025: 20 · 2024: 8 · 2023: 3 · 2022: 4 · 2021: 14 · 2020: 13 · 2019: 4 · 2018: 8 · 2017: 7 · 2016: 17 · 2015: 6 · 2014: 11 · 2013: 2
- FWCI
- 13.37
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Critical Care (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (K23AG032875)
- 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
- surrogate decision-making, nurse-led intervention, intensive care unit, end-of-life care, clinician-family communication, anticipatory grief, patient-centered care
- MeSH terms
- Aged, Communication, Decision Making, Family, Feasibility Studies, Female, Humans, Intensive Care Units, Male, Middle Aged, Nursing Staff, Hospital, Patient Care Team, Pennsylvania, Professional-Family Relations, Social Support, Critical Illness, Proxy, Third-Party Consent
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