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7. Aslakson R, Cheng J, Vollenweider D, et al: Evidence-based palliative

care in the intensive care unit: A systematic review of interventions.
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Med 2007; 356:469478

12. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for
patients with metastatic non-small-cell lung cancer. N Engl J Med
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of Palliative Care Interventions and Advance Care Planning on ICU
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14. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills
training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013;
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Am J Crit Care 2014; 23:380386

The Importance of Caregiver Outcomes After

Critical Illness*
Erin K. Kross, MD
Division of Pulmonary and Critical Care Medicine
Department of Medicine
University of Washington
Harborview Medical Center
Seattle, WA

amily members of critically ill patients are at risk for

a number of adverse psychologic outcomes, including posttraumatic stress disorder, depression, anxiety,
and complicated grief. In 2010, a task force of the Society of
Critical Care Medicine proposed a new term for this cluster
of complicationspostintensive care syndrome-family (1).
Family caregivers are integral to the care of patients who survive critical illness. Providing this care can be detrimental to
the caregiver, and caregiving has been shown to increase stress
and even mortality (24). Recently, there has been increasing
awareness of the importance of improving outcomes for caregivers, the value that family-centered care may add to improving patient outcomes, and the responsibility clinicians have to
recognize caregiver burden (5, 6).
Recognition of the importance of caregiver outcomes after
critical illness is growing. Although some of the initial descriptions focused on bereaved family members (79), more recent
studies have explored the burden of symptoms for family members who survive critical illness. Our understanding of the emotional toll of critical illness on caregivers of patients who survive
critical illness is essential. These family members are often called
*See also p. 1112.
Key Words: caregivers; critical illness; depression; posttraumatic stress;
psychologic outcomes
Dr. Krosss institution received grant support from a National Heart, Lung
and Blood Institute K23 award and an American Lung Association award.
Copyright 2015 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000000910

Critical Care Medicine

upon to provide post-ICU care and support for the surviving

patient, a role that may be compromised if the burden is too great.
In this issue of Critical Care Medicine, Haines et al (10) add
to the growing body of literature with an informative systematic review of the prevalence, risk factors, and trajectory of
psychosocial morbidity in informal caregivers of critical care
survivors. The authors identified 14 articles that met their criteria for inclusion. They conclude that adverse psychological
symptoms are experienced by a substantial portion of ICU
caregivers and that these symptoms persist for some time after
discharge. Depression was both the most commonly reported
symptom in these articles and also the most prevalent adverse
psychological symptom among caregivers. Depressive symptoms were highest during the acute phase of the patients illness
and demonstrated some improvement over time. However,
significant depressive symptoms were still present in approximately 25% of caregivers at 1 year, which is higher than what
is seen in the general population (11). The authors provide a
thorough exploration of risk factors for adverse psychologic
outcomes, providing insights to nonmodifiable characteristics
that may identify individuals at risk including sex, age, and
patient characteristics, as well as modifiable characteristics
that may be amenable to intervention, including social support, fatigue, burden, and health risk behaviors.
Other important adverse psychologic symptoms that were
less often reported include caregiver burden, activity restriction, health-related quality of life, and posttraumatic stress
disorder. The authors provide a concise summary of the prevalence, time course, and risk factors for each, as best they are
able from the current literature. Although the authors initially sought to include anxiety and stress, none of the studies
included in the review reported on these outcomes.
The authors acknowledge a number of weaknesses of their
review, including the limited number of studies meeting criteria for inclusion, the generally low methodologic quality of the
studies which are mostly observational in nature, and a lack of



premorbid assessments of psychologic symptoms in most studies. Overall, they found significant heterogeneity in the included
studies, both in terms of time of assessment and outcome measures, and for this reason were unable to conduct a metaanalysis.
Although this review provides us with a great deal of information about the adverse consequences of critical illness for
caregivers, Haines et al (10) astutely note that this review only
captures the negative symptom burden experienced by caregivers and therefore does not describe the full potential spectrum of outcomes. In addition to the more commonly reported
negative symptoms, there can also be positive personal changes
that occur in conjunction with or after a traumatic event such
as critical illness (12, 13). The full spectrum of psychological
responses to the trauma of critical illness (14) has not been
well-described. A better understanding of both the positive
and negative consequences of critical illness may provide additional targets for intervention with the goal to improve outcomes for both patients and their caregivers.
Although this important review highlights the sizeable
burden of psychological symptoms for caregivers of patients
who survive critical illness and provides the critical care community insight into the risk factors and trajectory of these
adverse symptoms as experienced by caregivers, questions
remain. What can we learn from the majority of caregivers
who do not develop adverse psychologic symptoms after critical illness? Are there protective psychosocial characteristics
or modifiable components of the ICU experience (such as
high-quality communication with providers) that may prevent or attenuate these negative outcomes? What role might
different types of coping skills play? Given the influence that
these adverse symptoms can have on the health of both caregivers and patients after critical illness, further high-quality research is needed to better inform timely and relevant


interventions with the goal to improve outcomes for both

caregivers and patients alike.


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and immunity in family caregivers of Alzheimers disease victims.
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4. Schulz R, Beach SR: Caregiving as a risk factor for mortality: The
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5. Adelman RD, Tmanova LL, Delgado D, et al: Caregiver burden: A
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7. Gries CJ, Engelberg RA, Kross EK, et al: Predictors of symptoms of
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8. Kross EK, Engelberg RA, Gries CJ, et al: ICU care associated
with symptoms of depression and posttraumatic stress disorder
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associated with a relatives serious illness. Fam Syst Health 2011;
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