Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Family Care Rituals in the ICU to Reduce Symptoms of Post-Traumatic Stress Disorder in Family Members—A Multicenter, Multinational, Before-and-After Intervention Trial

Amass, Timothy H. MD, ScM1; Villa, Gianluca MD2; OMahony, Sean MB BCh, BAO, MS3; Badger, James M. RN, PhD4; McFadden, Rory RN, MSN3; Walsh, Thomas BS5; Caine, Tanis JD5; McGuirl, Don MBS5; Palmisciano, Amy RN, BSN5; Yeow, Mei-Ean BMBCh6; De Gaudio, Raffaele MD2; Curtis, J. Randall MD, MPH7; Levy, Mitchell M. MD1

doi: 10.1097/CCM.0000000000004113
Clinical Investigation: PDF Only

Objectives: To assess the feasibility and efficacy of implementing “Family Care Rituals” as a means of engaging family members in the care of patients admitted to the ICU with a high risk of ICU mortality on outcomes including stress-related symptoms in family members.

Design: Prospective, before-and-after intervention evaluation.

Setting: Two U.S. academic medical ICU’s, and one Italian academic medical/surgical ICU.

Subjects: Family members of patients who had an attending predicted ICU mortality of greater than 30% within the first 24 hours of admission.

Interventions: A novel intervention titled “Family Care Rituals” during which, following a baseline observation period, family members enrolled in the intervention phase were given an informational booklet outlining opportunities for engagement in care of the patient during their ICU stay.

Measurements and Main Results: Primary outcome was symptoms of post-traumatic stress disorder in family members 90 days after patient death or ICU discharge. Secondary outcomes included symptoms of depression, anxiety, and family satisfaction. At 90-day follow-up, 131 of 226 family members (58.0%) responded preintervention and 129 of 226 family members (57.1%) responded postintervention. Symptoms of post-traumatic stress disorder were significantly higher preintervention than postintervention (39.2% vs 27.1%; unadjusted odds ratio, 0.58; p = 0.046). There was no significant difference in symptoms of depression (26.5% vs 25.2%; unadjusted odds ratio, 0.93; p = 0.818), anxiety (41.0% vs 45.5%; unadjusted odds ratio, 1.20; p = 0.234), or mean satisfaction scores (85.1 vs 89.0; unadjusted odds ratio, 3.85; p = 0.052) preintervention versus postintervention 90 days after patient death or ICU discharge.

Conclusions: Offering opportunities such as family care rituals for family members to be involved with providing care for family members in the ICU was associated with reduced symptoms of post-traumatic stress disorder. This intervention may lessen the burden of stress-related symptoms in family members of ICU patients.

1Department of Medicine, Division of Pulmonary, Critical Care & Sleep, Brown University, Providence, RI.

2Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.

3Department of Internal Medicine, Palliative Medicine Section, Rush University Medical Center, Chicago, IL.

4Department of Psychiatry, Brown University, Providence, RI.

5Rhode Island Hospital, Research Division of Pulmonary, Critical Care & Sleep, Providence, RI.

6Center for Palliative Care, Mayo Clinic, Rochester, NY.

7Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA.

This research was completed at following institutions: Rhode Island Hospital, Rush Medical Center, Azienda Ospedaliero-Universitaria Careggi.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

The James M Cox Foundation provide support for this trial in the form of grant funding for study coordination, travel, supplies, and statistical analysis.

Dr. Amass’s institution received funding from the National Heart, Lung, and Blood Institute (grant T32 HL134625), and he received support for article research from the National Institutes of Health. Drs. Amass’s, OMahoney’s, Caine’s, and Palmisciano’s institutions received funding from the James M. Cox Foundation. Dr. Villa received funding from Baxter and Pall. Dr. OMahoney received support for article research from the Family Foundation Grant. Ms. McFadden, Mr. Walsh, Ms. Caine, and Ms. Palmisciano received support for article research from James M. Cox Foundation. Dr. De Gaudio’s institution received funding from MSD Italia and Pall, and he received funding from Baxter. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Timothy H. Amass, MD, ScM, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine. Department of Veterans Affairs, Eastern Colorado Health System. 1700 N. Wheeling Street, Office F2-266, Denver, CO 80045 E-mail:

Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.