Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates

Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates' PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care.

Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors.

Most surrogates were female (59.1%), the patient's adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult-child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class.

Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support.