Figures
- FIGURE 1
Symptoms of complicated grief and post-traumatic stress disorder (PTSD) at 6 months in 282 bereaved relatives. Relatives completed the Inventory of Complicated Grief and the Revised Impact of Event Scale questionnaires 6 months after the patient's death. Assessments were performed in 59.4% of the 475 relatives included in the study. Among the 193 relatives who were not assessed for complicated grief and PTSD, 146 never responded to the telephone calls or the letters, 45 refused to respond (after initially agreeing to participate to the study) and two relatives died.
- FIGURE 2
Flow chart of patients and relatives. ICU: intensive care unit. #: patients either died before ICU day 3 or did not have a relative visiting them before the time of death.
- FIGURE 3
Plot distribution of independent determinants of complicated grief and post-traumatic stress disorder (PTSD) symptoms identified by multivariate analysis. Data are presented as odds ratios. Whiskers represent 95% confidence intervals.
- FIGURE 4
Focused principal-component analysis of determinants of post-traumatic stress disorder (PTSD) symptoms and symptoms of complicated grief (CG) at 6 months. This graphical display is focused on CG and its correlation with other variables. This representation allows both the pattern of relationships between CG and the dependencies between the responses to be seen. The relative positions of the predictors may distinguish some clusters of explanatory variables. CG is at the center of the diagram and the distance of this point to another variable may be translated into correlation. When two points are close to one another, then the two underlying variables are positively correlated. When two points form a right angle with the origin, the two underlying variables are uncorrelated. When two points are diametrically opposed, then the two underlying variables are negatively correlated. The variables inside the red circle are significantly correlated with the dependent variable at the 5% level. Three clusters of explanatory variables are depicted in this figure: first, the year of intensivist's board certification and the fact that patients died while intubated are positively correlated; a second cluster (patient's refusal of treatment, female relative, relative living alone following the loss and patient who could not breathe peacefully) is diametrically opposite and therefore negatively correlated to the first one; the third cluster includes the fact that relatives witnessed the death and did not say goodbye to the dying patient.
Tables
- TABLE 1
Circumstances of death in 475 patients who died in 41 intensive care units (ICUs)
Circumstances of death Subjects Death following decision to withhold or withdraw treatments No 91 (19.2) Decision to withhold treatment 152 (32) Decision to withdraw treatment 232 (48.8) Decision-making process No decision 91 (19.2) Relatives only informed of the decision 160/384 (42) Relatives involved in the decision making process 224/384 (58) Family agreement with EOL decision 373 (78.5) Disclosure of death Family was present at patient's bedside 266 (56) Family was informed over the phone 152 (32) Family was informed upon arrival to the ICU 57 (12) Death and ventilation Patient died while intubated 318 (67) Patient died after recent extubation 69 (14.5) Patient was never ventilated 88 (18.5) Who was present in patient's room at the time of death?# Relatives 266 (56) Physician at bedside 165 (34.7) Nurse at bedside 304 (64) Compliance with quality indicators for EOL care [47] Family-centred decision-making/involvement 224 (47.1) 24-h family presence 166 (34.7) Spiritual support 62 (13) Emotional support available in ICU 176 (37.1) Intervention of external palliative care consultant 12 (2.5) Data are presented as n (%) or n/N (%). EOL: end of life. #: the sum exceeds 475 as more than one person could be present at the time of death for the same patient.
- TABLE 2
Complicated grief and other markers of post-intensive care unit burden over the year following the death in 475 bereaved relatives
Complicated grief as assessed by the ICG 6 months 282/475 (60) ICG score 27 (16–40) Presence of complicated grief# 147 (52.1) 12 months 215/475 (45.3) ICG score 26 (14–40) Presence of complicated grief# 113 (53) PTSD-related symptoms as assessed by the IES-R 3 months 386/475 (81.3) IES-R score 29 (13–45) Presence of significant PTSD-related symptoms 173 (44.8) 6 months 282/475 (60) IES-R score 29 (16–44) Presence of significant PTSD-related symptoms 123 (43.6) 12 months 215/475 (45.3) IES-R score 26 (13–42.5)** Presence of significant PTSD-related symptoms 78 (36.2)** Symptoms of anxiety and depression as assessed by the HADS 3 months 386/475 (81.3) Global HADS scale 13.5 (7–22) Global HADS score >18 127 (32.9) Anxiety subscale score 8 (4–12) Anxiety subscale score≥8 199 (51.6) Depression subscale 5 (2–10) Depression subscale score≥8 139 (36) Data are presented as n/N (%), median (interquartile range) or n (%). ICG: Inventory of Complicated Grief; PTSD: post-traumatic stress disorder; IES-R: Revised Inventory of Event Scale; HADS: Hospital Anxiety and Depression Scale. #: ICG score >25. **: p<0.01 between ICG scores at 6 and 12 months.
- TABLE 3
Determinants of complicated grief at 6 months
Variables Univariate analysis Multivariate analysis OR (95% CI) p-value OR (95% CI) p-value ICU characteristics Nurse involvement in clinical research 1.57 (0.84–2.92) 0.155 1.75 (0.84–3.66) 0.135 Physician and nurse characteristics Intensivist board certification before 2009 3.02 (1.38–6.60) 0.006 3.82 (1.57–9.34) 0.003 Nurses >2 years of ICU experience 0.71 (0.41–1.23) 0.221 Patient characteristics Age 0.98 (0.96–0.99) 0.017 Length of ICU stay 1.01 (1.00–1.02) 0.101 1.01 (1.00–1.02) 0.155 Need for vasopressors 2.10 (1.20–3.68) 0.009 Patient died while intubated 2.54 (1.53–4.22) <0.001 2.12 (1.16–3.89) 0.015 Family involvement in EOL decision 0.57 (0.35–0.92) 0.022 Family disagreement with EOL decision 3.92 (1.79–8.60) 0.001 Relative characteristics Female sex 2.87 (1.67–4.94) <0.001 3.07 (1.62–5.80) 0.001 Being the spouse 1.96 (1.19–3.23) 0.008 Living alone 1.64 (1.01–2.70) 0.044 1.97 (1.10–3.51) 0.022 Relative reports that Patient's dignity was not respected 3.18 (1.13–8.92) 0.028 Death was not anticipated 2.33 (1.18–4.6) 0.015 Communication with physician was unsatisfactory 3.64 (1.92–6.91) <0.001 3.27 (1.42–7.50) 0.005 Communication with nurses was unsatisfactory 3.21 (1.5–6.85) 0.003 2.26 (0.84–6.10) 0.106 Patient refused treatments# 0.38 (0.17–0.86) 0.021 0.24 (0.08–0.69) 0.008 They did not say good bye to loved one 2.28 (1.35–3.85) 0.002 2.47 (1.30–4.68) 0.006 They were present at the time of death 1.89 (1.18–3.03) 0.009 2.91 (1.62–5.21) <0.001 Uni- and multivariate analyses are shown. Univariate logistic regression was performed to estimate odds ratios; p-values were calculated using the Wald test. Mixed multivariate logistic regression with intensive care unit (ICU) as a random effect was performed to estimate adjusted odds ratios and p-values. Hosmer–Lemeshow goodness of fit test: p=0.764. EOL: end of life. #: patient decision to withhold or withdraw treatment for themselves.
