Healthy Sleep for Family Members of Intensive Care Unit Patients

We read the Ask the Experts article by Dr Kidd regarding sleep in the critical care setting (Critical Care Nurse. 2023;43[5]:63-66) with great interest,1 and we would like to echo and amplify her important message by discussing healthy sleep for intensive care unit (ICU) family members. Aspects of the sleep environment within households such as neighborhood noise levels, safety, and variation in daily schedules may affect all family members. Consequently, exploring ways to support healthy sleep habits for ICU family members should be a strategy to support post-discharge patient adjustment.Many ICU family members worry about the patient. Choices faced by decision-making surrogates are often novel and tax their cognitive and emotional resources, especially when the patient's wishes and goals of care are not well documented or when the critical illness is sudden. Although the role of sleep in supporting decision-making is unclear, because new information about the patient is more difficult to assimilate when one is sleep-deprived. Experimental research links sleep disruption to poorer decision-making, particularly in situations that are unanticipated and emotional and require creative thinking and complex communication.2,3 More research is needed to determine whether efforts to support the sleep of families during the ICU stay could benefit problem-solving and shared decision-making.Family members of ICU patients are also vulnerable to symptoms consistent with posttraumatic stress disorder (PTSD).4 Although reactions to severe stress are varying, distress often involves sleep disruptions. Furthermore, as Kidd notes, sleep disturbances convey risks for later distress, including PTSD symptoms.5 More research is needed to determine if sleep disturbances have a longer-term impact on family well-being, but family members' altered sleep habits during the patient's stay in the ICU could serve as an early warning signal for family difficulties adjusting to new routines following the patient's ICU discharge.On the one hand, the ICU is a busy environment that presents challenges for in-depth caregiver assessment and interventions. On the other hand, nurses often have repeated contact with family members, affording opportunities for bonding, social support, and education. Intensive care unit providers may have some familiarity with certain conditions such as sleep apnea. Anecdotally, our work in medical centers suggests that many caregivers are receptive to brief psychoeducation. In some cases, the family will be so focused on the patient that they need reminders or "permission" to engage in basic self-care. Encouragement to "go home and get some rest" can be complemented with gentle advice and basic sleep education such as, "Some sleep disruption is natural right now. Try to avoid alcohol and caffeine before bed and stick to a regular sleep schedule as much as possible. If you go to bed with questions in your mind about the patient, get out of bed and write those concerns down. Bring your list and we can talk about them tomorrow after you've rested."At present, we are unaware of specific models for supporting sleep among ICU families. Dr Kidd highlighted several assessment tools that could be useful for identifying sleep-related difficulties. Subjective self-report tools (eg, the Pittsburgh Sleep Quality Index) applicable to the needs of ICU patients can also be used with family members.6 These tools could be useful for identifying common preexisting conditions such as primary insomnia or for tracking declines in sleep quality as ICU stress and decision-making demands strain sleep routines. These tools could be provided as part of caregiver resource packets with earplugs and sleep masks. Referrals for evidence-based treatments such as cognitive behavioral therapy for insomnia,7 which is accessible online, can be provided when persistent sleep disruptions are evident at follow-up appointments.In conclusion, we hope these ideas inspire further dialogue about the important role of sleep among ICU patients and their families.