You are not alone when you have become critically ill. That is when you are not in the midst of a raging pandemic. Homo sapiens is a deeply connected social being, and social stems from the Latin noun “socius” meaning fellow, companion, partner. So, your beloved ones—family and friends—are there for you, but they are worried and mourn and struggle as well. Three behavioral principles guide us, members of the multidisciplinary team: the awareness that 1) excellent and satisfactory tertiary care consists of one part: excellent doctors and nurses and their idem functioning multidisciplinary teams, one part of excellent technical facilities and one part of great psychosocial care. 2) The final level of quality of life and satisfaction after discharge from hospital start already on day 1 of admission—and so depends on it. After all, there exists only one chance for an excellent first impression. 3) The subject matter of successful and highly satisfactory medical care depends not only from the answer on the question: “How do I successfully treat this pneumonia, or this broken leg, or this critical illness?” But even more so from the extended and fundamentally different question: “How do we treat this human being with this social context with this pneumonia, or broken leg, or critical illness?” (1,2).
So the article published in this issue of Critical Care Medicine from Cherak et al (3) is very welcome as these authors set the focus on the informal caregivers of the critically ill patient. The strengths are as follows: an exclusive focus on these informal caregivers of the critically ill, by means of a systematic review that follows up closely the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines, the big numbers, and clarity of style and text. Their main finding—after including and studying 102 intervention trials and 56 randomized controlled trials—is that psychologic interventions are successful regarding anxiety and depression, but only on the short term. And that these even may increase the burden of the informal caregivers as an involuntary side effect. Important limitations are as follows: a lack of presenting explanations for this main finding on the short term, and/or a guideline how to distinguish between those who can and those who cannot tolerate these psychologic interventions. And as an observation, we beg to differ partially with their conclusion: “There is no magic bullet to improve informal caregiver mental health.” And, a last point of concern is the lack of stratification regarding the different target groups. After all, all these caregivers suffer, but nothing compares with the anxiety and despair of the parents/and other caregivers of a critically ill child at the P(ICU). To see your child suffer and struggle to survive and the always present fear of losing your child by dying, compare to nothing.
So here, we present some additional thoughts and address seven issues. First of all, we fully acknowledge that “Nobody asked for this” and/or “Nobody wants to swap positions/or to be in our position”—so we have many reasons to be compassionate, patient, and humble toward these heavenly challenged caregivers. Besides, we also cannot prevent misery, anxiety, misfortune, exhaustion of the caregivers, and the death of their beloved one. We can only try to partially prevent and or ameliorate these outcomes, also perhaps by anticipating these onsets and their multitude of negative side effects. Important other negative side effects are stress, sleeping problems, nightmares, posttraumatic stress disorder (PTSD), addiction, relationship problems and divorce, financial problems, and the risk of “losing my job.”
So, our seven issues are as follows: 1) personal skills can be divided into specific and aspecific. The specific skills are the technical learned ones for performing a specific job like the typical skills for being a doctor or a nurse. The aspecific ones are at least as important but often considered in a lesser extent. These are the social skills, which can be taught and learned and improved upon as well, for example, empathy, sensitivity, compassion, humor, being courteous and honest, making true promises and being able to acknowledge a mistake AND making up. These common human skills are especially challenged and dearly needed in the context of the P(ICU) and in the encounters with patients, caregivers, and colleagues. So, being aware of these aspects and participating in team intervision/encounters can be very helpful. 2) Medical social work and case management right from the start can be very helpful for: 2.1) making short, focused psychosocial assessments of the caregivers personal histories, as well as in 2.2) supporting them with the conversations/negotiations with external organizations and bosses/supervisors of their jobs, and 3) in combination with the daily/weekly grand rounds, one then can assess properly, which are also the needs of these informal caregivers. 4) A close collaboration with a psychiatry and psychology consultation-liaison service may be extra helpful for making even better indications for mental health interventions (4,5). And, in this way also a 7 × 24 hours service can be organized. 5) Empowering Families and Family members—the F from the Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment (ABCDEF) bundle—may increase strength and mental health (2). 6) And, the possibilities of an information leaflet regarding mental health aspects (like how to prevent and or deal with anxiety, depressed mood, PTSD, sleeping problems, stress, addiction, and exhaustion) at the P(ICU) and the possibility to connect with mental health organizations and or patient organizations/platforms may also be of a huge relief for them. 7) And finally, an excellent timely communication between the medical specialists of the tertiary hospital on the one hand and primary care: the specific general physician of the caregiver on the other hand is mandatory. The psychosocial/mental health aftercare by their own family physician can be of great importance. Life also goes on after a hospital dismissal of a beloved one with a critical illness. Special attention must then be paid toward further stress reduction, PTSD like symptoms like flashbacks and lost final opportunities, sleeping problems, pathologic mourning, addiction tendencies, and partner relationship problems. Time and time again, all the sequalae of such severe traumatic life events, which also for the informal caregivers proved to be severe struggles for survival and living on the automatic pilot, only emergence then. So weeks or months after the outcome—good or bad—of this critical illness of the beloved one. And then, it may be a huge relief as also the familiar home physician/the primary care team is also ready for this next episode, and they are prepared to help.
1. The Oxford Dictionary of Medical QuotationsPeter McDonald; Index/Person: Page: 76 (Caleb Parry); Page 94 (Francis Scott Smyth). 2004Oxford, Oxford University Press,
2. Pun BT, Balas MC, Barnes-Daly MA, et al.: Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in over 15,000 adultsCrit Care Med 2019; 47:3–14
3. Cherak SJ, Rosgen BK, Amarbayan M, et al.: Mental Health
Interventions to Improve Psychologic Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-AnalysisCrit Care Med 2021; 49:1414–1426
4. Kaupp JW, Rapoport-Hubschman N, Spiegel D: Levenson JL (Ed). Psychosocial treatments. In: Textbook of Psychosomatic Medicine. 2005, Arlington, VA, American Psychiatric Publishing, Inc., 923–956
5. Sargent J: Shaw RJ, DeMaso DRFamily interventions.Textbook of Pediatric Psychosomatic Medicine. 2010, Arlington, VA, American Psychiatric Publishing, Inc., pp 439–448In