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Meta-Analysis
. 2022 Nov 1;50(11):e779-e790.
doi: 10.1097/CCM.0000000000005642. Epub 2022 Aug 23.

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

Christine E DeForge  1 , Maureen George  1 , Matthew R Baldwin  2 , Katherine South  1 , Melissa Beauchemin  1 , Marlene E McHugh  1   3 , Arlene Smaldone  1   4
Affiliations
Meta-Analysis

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

Christine E DeForge et al. Crit Care Med. .

Abstract

Objectives: Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions.

Data sources: MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022.

Study selection: Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified.

Data extraction: Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation).

Data synthesis: Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose.

Conclusions: Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

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Conflict of interest statement

Ms. DeForge’s institution received funding from the National Center for Advancing Translational Sciences; she received funding from Society of Critical Care Medicine (2022 Critical Care Congress Scholarship Grant). Ms. DeForge and Dr. Baldwin received support for article research from the National Institutes of Health. Dr. George received funding from AstraZeneca, Genetech, Sanofi Regeneron, and Teva. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.
Figure 2.
Figure 2.
Results of meta-analysis (3 mo).
Figure 3.
Figure 3.
Results of meta-analysis (6 mo).
See this image and copyright information in PMC

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