Ronald L. Hickman

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

BACKGROUND Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. RESULTS Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. CONCLUSIONS The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Decisional conflict and regret: Consequences of surrogate decision making for the chronically critically ill

Decisional conflict may predispose surrogate decision makers (SDMs) of the chronically critically ill (CCI) to making health care decisions that are not aligned with the patients health care preferences and increase the SDMs likelihood of experiencing decision regret. This study establishes the relationship between decisional conflict and decision regret and offers insight on tailoring decision support interventions to the preferences of SDMs of CCI patients.

Avatar-based depression self-management technology: promising approach to improve depressive symptoms among young adults.

Major depressive disorder is prevalent among American young adults and predisposes young adults to serious impairments in psychosocial functioning. Without intervention, young adults with depressive symptoms are at high risk for worsening of depressive symptoms and developing major depressive disorder. Young adults are not routinely taught effective depression self management skills to reduce depressive symptoms and preempt future illness. This study reports initial results of a randomized controlled trial among young adults (18-25 years of age) with depressive symptoms who were exposed to an avatar-based depression self-management intervention, eSMART-MH. Participants completed self-report measures of depressive symptoms at baseline and at 4, 8, and 12 weeks follow-up. Participants who received eSMART-MH had a significant reduction in depressive symptoms over 3 months, while individuals in the attention-control condition had no change in symptoms. In this study, eSMART-MH demonstrated initial efficacy and is a promising developmentally appropriate depression self-management intervention for young adults.

Psychometric evaluation of the revised attribution questionnaire (r-AQ) to measure mental illness stigma in adolescents

The Revised Attribution Questionnaire (r-AQ) measures mental illness stigma. This study’s purpose is to evaluate the factor structure of the (r-AQ) and examine the validity of the factor structure in adolescents. A convenience sample (n = 210) of adolescents completed the r-AQ and these data were used in exploratory (EFA) and confirmatory factor analyses (CFA). The EFA established a five item single factor structure, which we called the modified r-AQ and captures the negative emotional reactions to people with mental illness, a domain of mental illness stigma. The CFA established the validity of the factor structure (χ2 = 2.4, df = 4, p = .659, TLI = 1.042, CFI = 1.00, RMSEA = .000). Internal consistency reliability for the scale was acceptable (α = .70). The modified r-AQ is a reliable and valid measure of the emotional reaction to people with mental illness.

Depression among white and nonwhite caregivers of the chronically critically ill

PURPOSE The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms. MATERIALS AND METHODS This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge. RESULTS Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race. CONCLUSIONS Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.

Hair Cortisol Analysis: A Promising Biomarker of HPA Activation in Older Adults

Prolonged stress is a potentially harmful and often undetected risk factor for chronic illness in older adults. Cortisol, one indicator of the bodys hormonal responses to stress, is regulated by the hypothalamic-pituitary-adrenal (HPA) axis and is commonly measured in saliva, urine, or blood samples. Cortisol possesses a diurnal pattern and thus collection timing is critical. Hair cortisol is a proxy measure to the total retrospective activity of the HPA axis over the preceding months, much like hemoglobin A1c is a proxy measure of glucose control over the past 3 months. The aim of this review is to examine a novel biomarker, hair cortisol, as a practical measure of long-term retrospective cortisol activity associated with chronic stress in older adults. Hair cortisol analysis advances the science of aging by better characterizing chronic stress as a risk factor for chronic illness progression and as a biomarker of the effectiveness of stress reduction interventions.

Evaluating the critical care family satisfaction survey for chronic critical illness.

Recognition of the family as a component of patient-centered critical care has shifted our attention to the assessment of family satisfaction in the intensive care unit (ICU). To date, there are no established measures of satisfaction with ICU care for family members of the chronically critically ill (CCI). This study evaluated psychometric properties of the Critical Care Family Satisfaction Survey (CCFSS) in 326 family members of the CCI using exploratory and confirmatory factor analysis (CFA). From the exploratory factor analysis, two unique structural models emerged, each with alpha coefficients of .72 to .91 and discriminant validity among factors (r < .70). The CFA confirmed the best-fitting structural model was a 14-item, three-factor solution (χ2 = 354, df = 148, p < .001, Tucker Lewis Index = .88, Comparative Fit Index = .90, root mean square error of approximation = .06). Thus, the modified 14-item version of the CCFSS is reliable and valid in family members of CCI patients.

Advance directives lessen the decisional burden of surrogate decision‐making for the chronically critically ill

AIMS AND OBJECTIVES To identify the relationships between advance directive status, demographic characteristics and decisional burden (role stress and depressive symptoms) of surrogate decision-makers (SDMs) of patients with chronic critical illness. BACKGROUND Although the prevalence of advance directives among Americans has increased, SDMs are ultimately responsible for complex medical decisions of the chronically critically ill patient. Decisional burden has lasting psychological effects on SDMs. There is insufficient evidence on the influence of advance directives on the decisional burden of surrogate decision-makers of patients with chronic critical illness. DESIGN The study was a secondary data analysis of cross-sectional data. Data were obtained from 489 surrogate decision-makers of chronically critically ill patients at two academic medical centres in Northeast Ohio, United States, between September 2005-May 2008. METHODS Data were collected using demographic forms and questionnaires. A single-item measure of role stress and the Center for Epidemiological Studies Depression (CESD) scale were used to capture the SDMs decisional burden. Descriptive statistics, t-tests, chi-square and path analyses were performed. RESULTS Surrogate decision-makers who were nonwhite, with low socioeconomic status and low education level were less likely to have advance directive documentation for their chronically critically ill patient. The presence of an advance directive mitigates the decisional burden by directly reducing the SDMs role stress and indirectly lessening the severity of depressive symptoms. CONCLUSIONS Most SDMs of chronically critically ill patients will not have the benefit of knowing the patients preferences for life-sustaining therapies and consequently be at risk of increased decisional burden. RELEVANCE TO CLINICAL PRACTICE Study results are clinically useful for patient education on the influence of advance directives. Patients may be informed that SDMs without advance directives are at risk of increased decisional burden and will require decisional support to facilitate patient-centred decision-making.

Stigma Scale for Receiving Psychological Help (SSRPH) An Examination Among Adolescent Girls

Stigma is one of the greatest obstacles to care and impedes recovery. The Stigma Scale for Receiving Professional Psychological Help (SSRPH), a measure of public stigma, has been used in young adults and has limited psychometric data in adolescents. This article reports the reliability and validity of the SSRPH in adolescent girls (N = 156, age = 13-17). Discriminant validity was supported, but concurrent validity was not. The confirmatory factor analysis revealed excellent model fit and serves as beginning evidence for construct validity. Cronbach’s alpha for the SSRPH was .65. The SSRPH was stable over 8 weeks. Findings suggest that the SSRPH can serve as a foundation for further instrument development. Future studies may explore enhancing the reliability and validity of the SSRPH and use advanced analytic techniques to examine the overall global construct of stigma, the latent constructs of public and private stigma, and associations of individual items to these constructs.

Multimedia decision support intervention: A promising approach to enhance the intention to complete an advance directive among hospitalized adults

Purpose: We examined the acceptability and initial efficacy of a multimedia decision support (MDS) intervention to improve intention to complete an advanced directive (AD) among hospitalized adults following an episode of critical illness. Data sources: We used comparative quasi‐experimental posttest only design. Forty‐nine hospitalized adults, recovering from a critical illness, received either MDS or AD educational brochure. Demographic characteristics and self‐report measures of AD knowledge were captured at baseline and used as covariates. Helpfulness of the intervention (acceptability) and the outcome variable, intention to complete an AD decision, were assessed after exposure to the MDS intervention or educational brochure (information‐only control condition). Conclusions: The MDS was a more acceptable form of education compared to a brochure. After adjusting for covariates, participants exposed to the MDS intervention were 24.7 times more likely to intend to complete an AD compared to those who were assigned to the information‐only control condition. Implications for practice: This pilot study establishes the acceptability and initial efficacy of the MDS intervention among individuals with critical illness, who are at high risk for hospital readmission life‐sustaining treatment. This study illuminates a teachable moment in which patients are more receptive to interventions to complete an AD.