Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians

Abstract

Rationale: Therapeutic alliance is a novel measure of the multifaceted caregiver-clinician relationship and a promising intervention target for improving patient-centered outcomes. However, therapeutic alliance has not been studied in an intensive care unit (ICU) setting.

Objectives: To explore the relationships among caregiver-reported therapeutic alliance and psychological distress as well as patient, caregiver, and ICU clinician factors.

Methods: In this cross-sectional study, we enrolled consecutive patient caregivers of mechanically ventilated patients discharged from all ICUs at Duke University and the Medical University of South Carolina Hospitals between December 2013 and August 2014.

Measurements and main results: Caregivers completed an in-person, hospital-based interview that included measures of therapeutic alliance with the ICU physicians (Human Connection Scale) as well as patient centeredness of care; symptoms of depression, anxiety, and post-traumatic stress; decisional conflict; and quality of communication. We performed a multivariate regression to characterize associations between Human Connection Scale scores and key variables. A total of 56 caregivers were included in these exploratory analyses. Patients were largely disabled (47%) and Medicare insured (53%). Caregivers were highly educated and generally had high therapeutic alliance (median, 55; interquartile range, 48-58) with the ICU clinicians. Therapeutic alliance was strongly correlated with patient centeredness (r = 0.78) and poorly correlated with psychological distress (r < 0.2). Stepwise multivariate modeling revealed that higher therapeutic alliance was associated with fewer baseline patient comorbidities as well as caregiver report of greater trust in the ICU team, better quality of communication, and less decisional conflict (all P < 0.012).

Conclusions: Therapeutic alliance encompasses measures of trust, communication, and cooperation, which are intuitive to forming a good working relationship. Therapeutic alliance among ICU caregivers is strongly associated with both modifiable and nonmodifiable factors. Our exploratory study highlights new intervention targets that may inform strategies for improving the quality of the caregiver-clinician interaction.

Keywords: critical illness; psychological distress; quality of life; surrogate decision maker; therapeutic alliance.

Figure 1.

Study participant flow.

Figure 2.

Study outcomes. Scores for each questionnaire are displayed as indicated in the figure legend above, with extremes displayed as more negative (i.e., more distress) to the left and more positive (i.e., less distress) to the right. Medians are represented by the dark vertical lines and corresponding numerical values in bold above the lines. Interquartile ranges are represented by darker color shades, with numerical values of their boundaries shown above. Lighter shaded sections represent the entire range of all participant responses. The scale of each questionnaire's values has been adjusted to fit a 100-point standard distance.

Figure 3.

Therapeutic alliance and its relationship to key stakeholder characteristics and outcomes in our conceptual model. Correlations are shown between key variables in the figure. Asterisks represent correlations with P < 0.05. APACHE = Acute Physiology and Chronic Health Evaluation; PTSD = post-traumatic stress disorder.