Predictors of ICU Surrogates’ States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms

OBJECTIVES: Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder PGD, posttraumatic stress disorder PTSD, and depression). This study models surrogates’ longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability. DESIGN: Prospective cohort study. SETTING: Medical ICUs of two Taiwanese medical centers. SUBJECTS: Two hundred eighty-eight family surrogates. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio 95% CI = 1.781 1.562–2.031 to 2.768 2.288–3.347). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 1.603–47.768) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 1.531–10.784) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 1.231–133.775), and worst (12.820 1.806–91.013) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 0.001–0.097) and a do-not-resuscitate order issued before death (0.177 0.032–0.978) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates’ higher educational attainment, married status, and longer time since loss. CONCLUSIONS: Surrogates’ concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care—commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.