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Critical Care Medicine www.ccmjournal.org 1
DOI: 10.1097/CCM.0000000000006416
Copyright © 2024 The Author(s).
Published by Wolters Kluwer Health,
Inc. on behalf of the Society of Critical
Care Medicine and Wolters Kluwer
Health, Inc. This is an open-access
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License 4.0 (CCBY-NC-ND), where
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without permission from the journal.
Fur-Hsing Wen, PhD1
Holly G. Prigerson, MD, PhD2
Li-Pang Chuang, MD3
Wen-Chi Chou, MD4,5
Chung-Chi Huang, MD3,6
Tsung-Hui Hu, MD7
Siew Tzuh Tang , DNSc4,8,9,10
CLINICAL INVESTIGATION
Predictors of ICU Surrogates’ States of
Concurrent Prolonged Grief, Post-Traumatic
Stress, and Depression Symptoms
OBJECTIVES: Scarce research explores factors of concurrent psychologic dis-
tress (prolonged grief disorder [PGD], post-traumatic 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 pre-
viously 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 refer-
ence). Intrapersonal: Prior use of mood medications correlated with the subthresh-
old 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 subthresh-
old 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.
KEYWORDS: depression; intensive care unit care; post-traumatic stress
disorder; prolonged grief disorder; quality of dying and death; surrogate decision
makers
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2 www.ccmjournal.org XXX 2024 • Volume 52 • Number 12
Death in an ICU is common (1), increasing (2),
and costly (3), especially since COVID-19 (4).
Meanwhile, quality of end-of-life (EOL) care
in ICUs is improving but still poor (5, 6). Improving
EOL ICU care is a priority (7), particularly for family
surrogates (8, 9). ICU loss is traumatic and painful (10,
11). Although most adjust over time (12), bereaved
surrogates may suer prolonged grief disorder (PGD)
(13), post-traumatic stress disorder (PTSD) (14), and
depression (15). PGD, PTSD, and depression are dis-
tinguishable (16, 17) and co-occur more oen than not
(18), synergistically worsening physical/mental health
and social functioning (19–22). We previously identi-
ed among ICU family surrogates four PGD-PTSD-
depressive-symptom states: resilient, subthreshold
depression-dominant, PGD-dominant, and PGD-
PTSD-depression concurrent states (23).
Co-occurrence of PGD, PTSD, and depres-
sion symptoms manifests as distinct latent patterns
among bereaved adults (19–27). In prior studies,
bereaved adults survived anthropogenic, traumatic,
violent, or suicidal losses (19, 20, 22, 27) or lost their
loved one predominantly (80–91.3%) from illness
not specically in ICUs (21, 24–26), although ICU
literature suggests investigating factors of psycho-
logic distress from a broader stress-response perspec-
tive (11). Furthermore, most prior studies (19–22,
24–27) identied psychologic-distress patterns and
predictors cross-sectionally, which cannot deter-
mine directional relationships between factors and
psychologic-distress states nor consistency of factor
associations over time.
Predictors of psychologic-distress classes have
rarely been comprehensively explored. e integra-
tive framework of predictors for bereavement out-
comes (28) includes: 1) intrapersonal risk factors, 2)
interpersonal risk factors, 3) appraisal and coping, 4)
bereavement-related stressors and 5) death circum-
stances. All existing studies explored intrapersonal
risk factors including demographics (gender [19, 21,
22, 24, 25], preexisting mental health conditions [20],
age [22, 24–26], education [20, 24, 26, 27], and nan-
cial adequacy [20]) and bereavement-related factors
(kinship [20–22, 24–27], time since loss [19, 21, 22,
24–26], and cause of loss [natural vs. unnatural] [21,
24–26]). Four studies explored appraisal and coping
factors (e.g., sense of unrealness, meaning-making,
and anxious or depressive avoidance) (19, 21, 25, 26).
Only one examined interpersonal risk factors like so-
cial support (20).
Lastly, modiable clinical predictors of concur-
rent symptoms of PGD, PTSD, and depression have
never been studied among bereaved ICU surrogates.
Modiable factors present the greatest potential for
improving clinical EOL care practice. Indeed, co-
occurrence of complicated grief and PTSD-related
symptoms were associated with whether the patient
died while intubated, family had said goodbye to
the patient, and family was present at time of death
(13). erefore, we drew from the integrative frame-
work of predictors for bereavement outcomes (28),
emphasizing modiable factors of PGD-PTSD-
depressive-symptom states among bereaved ICU
family surrogates. is study augments previous anal-
yses of the same dataset: examinations of associations
of severe anxiety and depressive symptoms (29) and
clinically signicant PTSD symptoms (30) in the rst
bereavement year with objective process-based indi-
cators of high-quality EOL ICU care and subjective
family-assessed satisfaction with ICU care, as well as
the reexive, intertwined nature of psychologic be-
reavement outcomes (31, 32).
KEY POINTS
Question: What are the factors associated with
ICU bereaved family surrogates’ membership in
the prolonged grief disorder (PGD)-post-traumatic
stress disorder (PTSD)-depressive-symptom
states?
Findings: 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 tra-
jectory, whereas social-worker involvement and a
do-not-resuscitate order mitigated this risk.
Meaning: By improving quality of dying and
death, providing early palliative care, facilitat-
ing social-worker involvement and a do-not-
resuscitate order, and alleviating surrogates’
anxiety symptoms during bereavement, healthcare
professionals may prevent concurrent symptoms
of PGD, PTSD, and depression among bereaved
surrogates of ICU decedents.
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MATERIALS AND METHODS
Study Design, Setting, and Study Participants
is study extends our previous identication of four
PGD-PTSD-depressive-symptom states for bereaved
ICU surrogates (23) using data from our longitudinal,
observational study on eects of quality of EOL ICU
care on family surrogates’ bereavement adjustment
(29–32). Briey, we consecutively recruited the pri-
mary family-surrogate decision maker of critically
ill patients (Acute Physiology and Chronic Health
Evaluation II scores > 20) from level III medical ICUs
at two academically aliated Taiwanese hospitals
from January 2018 to March 2020 and followed them
through July 2022. Each enrolled surrogate signed
informed consent for participation. is study was
approved by the Chang Gung Medical Foundation
Institutional Review Board (201700343B0; March 20,
2017; Impact of end-of-life care quality in intensive
care units on adjustment of bereaved family mem-
bers). Study procedures followed ethical standards of
the responsible committee on human experimentation
(institutional) and of the Helsinki Declaration of 1975.
Measures
Outcome Variable: PGD-PTSD-Depressive Symptoms
States. Symptoms of PGD, PTSD, and depression
were measured by the Prolonged Grief (PG)-13 scale
(33), Impact of Event Scale-Revised (IES-R) (34), and
Hospital Anxiety and Depression Scale (HADS) (35),
respectively. Instrument scoring details are in Online
Data Supplement 1 (http://links.lww.com/CCM/
H585). Identication and description of symptom
states (resilient, subthreshold depression-dominant,
PGD-dominant, and PGD-PTSD-depression concur-
rent states) (23), 6–24 months post-loss are detailed
in Online Data Supplement 2 (http://links.lww.com/
CCM/H585), and signicant dierences in symptoms
across the four states were reported (23) (Fig. E1,
http://links.lww.com/CCM/H585).
Independent Variables. Factors associated with
symptom states were examined based on the integrative
framework of predictors for bereavement outcomes
(28), except for appraisal and coping. Measurement
details are in Online Data Supplement 1 (http://links.
lww.com/CCM/H585).
Intrapersonal risk factors included surrogates’
sociodemographics and personal vulnerabilities, for
example, nancial hardship, preexisting physical-
mental health problems (36), and anxiety symptoms.
Interpersonal risk factors were indicated by perceived
social support measured by the Medical Outcomes Study
Social Support Survey (MOS-SSS) (37).
Bereavement-related stressors included type of loss,
patient demographics and clinical characteristics, and
time since loss.
Death circumstances were indicated by process-based
indicators of high-quality EOL care in ICUs (38) (here-
aer as care-quality indicators; Online Data Supplement
1, http://links.lww.com/CCM/H585) and surrogates’
perceived quality of the patient’s dying and death in
ICUs by the quality of dying and death (QODD) ques-
tionnaire in ICU (39). Latent class analysis was used
to identify QODD latent classes (40): high, moderate,
poor to uncertain, and worst QODD class (Online Data
Supplement 3, http://links.lww.com/CCM/H585).
QODD classes dier by physical symptom control,
emotional preparedness for death, and amount of life-
sustaining treatments (LSTs) received (40) (Table E1,
http://links.lww.com/CCM/H585).
Data Collection
Time-invariant intrapersonal risk factors and
bereavement-related stressors were collected at en-
rollment. Patient clinical characteristics and care-
quality indicators were abstracted from medical records
throughout admission. QODD was assessed at 1 month
post-loss. Surrogates’ grief-related psychologic distress
(including anxiety symptoms) and perceived social sup-
port were assessed by phone interviews at 1, 3, 6, 13, 18,
and 24 months post-loss to comply with the greater than
or equal to 1 month duration criterion for PTSD (33)
and to avoid measuring the anniversary eect.
Data Analysis
Factors associated with PGD-PTSD-depression-
symptom states were identied by a multinomial lo-
gistic regression model in Latent GOLD 5.1 (Statistical
Innovations Inc. Belmont, MA) using resilient state
as reference. Lagged time-varying variables of anxiety
symptoms and perceived social support were meas-
ured in the prior wave of assessment to establish tem-
poral precedent to the outcome variable. e eect of
each independent variable was represented as adjusted
odds ratio (AOR) with 95% CI.
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RESULTS
Participant Characteristics
A total of 288 bereaved family surrogates provided
sucient data on independent and outcome variables
to constitute the sample. Detailed characteristics of
the whole sample and across the four PGD-PTSD-
depression-symptom states are in Table E2 (http://
links.lww.com/CCM/H585). Most surrogates were
female (58.0%), married (74.0%), the patient’s adult
child (53.5%), and on average () 49.6 years old (12.5
yr old). Few had preexisting physical-mental prob-
lems that required emergency department (ED) vis-
its (6.6%) or hospitalization (4.5%). Overall anxiety
symptoms were low (3.9 [3.7]/21) over the rst two
bereavement years.
Factors Associated With Membership in PGD-
PTSD-Depression-Symptom States
Surrogate demographics were generally not associated
with membership in PGD-PTSD-depression-symptom
states (Table E3, http://links.lww.com/CCM/H585).
Educational attainment greater than or equal to senior
high school and married status decreased surrogates’
membership in the PGD-PTSD-depression concur-
rent (AOR [95% CI] = 0.114 [0.016–0.803]) and PGD-
dominant (0.113 [0.035–0.365]) state, respectively.
In contrast, personal vulnerability was signicantly
associated with PGD-PTSD-depression-symptom
state membership. Financial hardship (4.983 [1.332–
18.632]) and ED visits in the year before the patient’s
critical illness (98.790 [6.607–1477.047]) increased
membership in the PGD-PTSD-depression concur-
rent state. Prior use of mood medications increased
membership in the subthreshold depression-dominant
state (6.234 [1.162–33.439]). Higher anxiety symptoms
increased subsequent membership in the three more
profound psychologic-distress states (ranged 1.781
[1.562–2.031] to 2.768 [2.288–3.347]).
Surrogates in the PGD-dominant and the PGD-
PTSD-depression concurrent states perceived substan-
tially lower social support than those in the resilient
state (mean [] = 67.9 [20.2] and 57.2 [15.0] vs.
73.7 [12.2]) (Table E2, http://links.lww.com/CCM/
H585), but dierences were not statistically signif-
icant primarily due to small states (i.e., small num-
bers of participants in the PGD-dominant and the
PGD-PTSD-depression concurrent states [Table E3,
http://links.lww.com/CCM/H585]). However, better
perceived social support increased surrogates’ mem-
bership in the subthreshold depression-dominant state
(1.053 [1.019–1.089] per unit increase in MOS-SSS
score).
Bereavement-related stressors were not associ-
ated with surrogates’ membership in PGD-PTSD-
depression-symptom states, except for type of loss
and time since loss (Table E3, http://links.lww.com/
CCM/H585). Spousal surrogates were more likely than
other relationships (e.g., surrogates other than spouse
or adult child) to be in the PGD-dominant (11.235
[1.833–68.855]) state. Membership decreased in the
three more profound psychologic-distress states over
time, reaching statistical signicance for the PGD-
dominant (0.328 [0.131–0.820]) state between 6 and
18 months post-loss.
Death-circumstances evident as care-quality indica-
tors were primarily not associated with membership in
PGD-PTSD-depression-symptom states (Table E3, http://
links.lww.com/CCM/H585). However, social-worker in-
volvement (0.004 [0.001–0.097]) and a do-not-resuscitate
(DNR) order issued before death (0.177 [0.032–0.978])
decreased membership in the PGD-PTSD-depression
concurrent and subthreshold depression-dominant state,
respectively. In contrast, palliative care increased mem-
bership in the PGD-PTSD-depression concurrent state
(8.750 [1.603–47.768]).
QODD classes were signicantly associated with
PGD-PTSD-depression-symptom states (Table
E3, http://links.lww.com/CCM/H585). Poor-to-
uncertain or worst QODD classes generally led to
the three more profound psychologic-distress states
than did the high QODD class. Surrogates whose
loved one was evaluated as in the poor-to-uncertain
QODD class were signicantly more likely than those
of the high QODD class to be in the subthreshold
depression-dominant (4.063 [1.531–10.784]) and the
PGD-PTSD-depression concurrent (12.833 [1.231–
133.775]) states. Furthermore, the worst QODD class
increased surrogate membership in the PGD-PTSD-
depression concurrent state (12.820 [1.806–91.013]).
DISCUSSION
We conrmed the utility of the integrative frame-
work of predictors for bereavement outcomes (28) in
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determining bereaved ICU surrogate membership in
PGD-PTSD-depression-symptom states. Factors of the
three more profound psychologic-distress states in-
cluded surrogate nancial hardship, ED visits and use
of mood medications in the year before the patient’s
critical illness, higher anxiety symptoms and better
perceived social support in the prior wave of assess-
ment, spousal loss, provision of palliative care, and
poor-to-uncertain or worst QODD class (Table E3,
http://links.lww.com/CCM/H585). Buering factors
included surrogates’ higher educational attainment,
married status, time since loss, social-worker involve-
ment in EOL care, and a DNR order issued before the
patient’s death.
From the intrapersonal risk-factor domain, we con-
rmed vulnerability of those with lower education
(20, 24, 26) and nancial inadequacy (20) for more
profound/persistent psychologic distress as shown by
increased membership in the PGD-PTSD-depression
concurrent state in our study. Lower educational
attainment is closely associated with nancial hardship
(41). Financial toxicity/distress from critical illness is
common for family surrogates (42) and increases un-
certainty while making LST decisions (42). Echoing
a recent report of increased suicidal ideation among
bereaved cancer caregivers with nancial hardship
(43), our nding highlights the negative eect of -
nancial hardship on suering PGD-PTSD-depression
concurrent state during bereavement.
We also conrmed preexisting mental health prob-
lems pose vulnerability by increased membership in
the three more profound psychologic-distress states.
Specically, use of mood medications in the year be-
fore the patient’s critical illness and higher anxiety
symptoms in the prior wave of assessment increased
membership in the subthreshold depression-
dominant state and the three more profound
psychologic-distress states, respectively. Our ndings
contrast with no observed relationship between preex-
isting mental-health status and group membership for
bereaved 9/11 family members (20) and an association
between use of mood medication and higher PTSD
symptoms for bereaved ICU family members (13).
Our inability to nd associations between use of mood
medications and membership in the PGD-dominant
state may be attributable to insucient power, despite
higher use among surrogates in this more profound
psychologic-distress state than in the resilient state
(5.6% vs. 2.2%) (Table E2, http://links.lww.com/CCM/
H585). However, we conrmed the important role
of preexisting anxiety symptoms in positive associa-
tions with depression (44), PTSD symptoms (14), and
prolonged-grief symptoms (18) using a lagged
approach to establish temporal precedence, acknowl-
edging that temporal associations of anxiety symptoms
with subsequent depression and PTSD symptoms are
complex (31). Finally, we observed that ED visits in the
year before the patient’s critical illness increased mem-
bership in the PGD-PTSD-depression concurrent
state. Whether ED visits indicate preexisting mental
vulnerability or whether loss in an ICU reactivates
feelings of fear and powerlessness from prior ED vis-
its to produce profound PGD, PTSD, and depressive
symptoms during bereavement warrants further inves-
tigation preferably by qualitative research.
Better perceived social support increased surrogate
membership in the subthreshold depression-dominant
state, which seems counterintuitive and contrasts with
the nding that greater satisfaction with social support
predicted lower likelihood in the comorbid anxiety/
depression/PTSD with grief-related functional impair-
ment group among bereaved individuals who survived
the September 11, 2001, terrorist attacks in New York
City (20). We speculate that social support facilitates
natural grieving (elevated depression symptoms below
the clinical threshold) (Fig. E1C, http://links.lww.com/
CCM/H585) to prevent severe PGD or PTSD symp-
toms and acknowledge potentially insucient power
to detect lower membership in the two more profound
psychologic-distress states than in the resilient state.
Regarding bereavement-related stressors, we con-
rmed kinship and time since loss were associated with
surrogates’ membership in PGD-PTSD-depressive-
symptom states. Spousal loss was associated with
increased membership in the PGD-dominant state,
consistent with the observation that losing a partner
was associated with increased membership in the PGD
class (24–27) or the high-PGD moderate-depression/
PTSD class (21), although no association (22) and
decreased membership in comorbid anxiety/depres-
sion/PTSD with grief-related functional impairment
(20) were also reported in prior studies for bereaved
individuals. Loss of the long-lasting, more intimate
spousal relationship than other relationships may bring
family surrogates painful grief reactions of yearning,
longing for and/or a persistent preoccupation with
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thoughts and memories of the deceased; marked sense
of disbelief; diculties with acceptance; and anger-
characterized as PG symptoms (33).
In addition, we found PGD-dominant state mem-
bership declined over time consistent with reports that
less time since loss brought increased membership in
the PGD class (22, 25, 26) or the high-PGD moderate-
depression/PTSD class (21), despite no signicant dif-
ference in time since loss across classes reported in
prior studies (19, 24). Our nding supports gradual
adjustment to bereavement (12).
Regarding death circumstances, palliative care,
a DNR order, social-worker involvement, and
QODD classes were associated with PGD-PTSD-
depressive-symptom states. A DNR order decreased
surrogates’ membership in the subthreshold depression-
dominant state partially consistent with a report that
a DNR order predicts improved mental health aer
loss (45). A DNR order may indicate surrogates’ pre-
paredness for loss and prevent unnecessary patient
suering from potentially ineective but frightening
cardiopulmonary resuscitation, thereby facilitating
bereavement adjustment to decrease membership in
the subthreshold depression-dominant state. Social-
worker involvement decreased membership in the
PGD-PTSD-depression concurrent state. Social work-
ers in Taiwan, beyond providing psychologic support,
primarily seek nancial resources for patients who
need a subsidy, thereby mitigating nancial hardship
in providing EOL care, which in turn decreased sur-
rogates’ membership in the PGD-PTSD-depression
concurrent state.
Counter to our expectation, palliative care increased
membership in the PGD-PTSD-depression concurrent
state. We speculated that the failure of palliative care to
relieve surrogates’ psychologic distress may be related to
late referral, limiting realization of the full benets of pal-
liative care for which an optimal duration of at least 3–4
months was suggested (46). However, in international
routine practice, the median duration from initiation
of palliative care to death was 18.9 days (interquartile
range [IQR], 0.09 d), substantially shorter for noncancer
diseases (6 vs. 15 d for cancer) (47). Indeed, in our study,
palliative care was provided a median of 7.0 days (IQR,
4–16 d) before death commonly in response to high
physical- and psychologic-symptom distress, primarily
among patients and sometimes among family members,
as well as heavy caregiving burden while the patient
was still in ICU. Furthermore, bereavement care (e.g.,
sending a sympathy card, calling families, providing a
support group) is rarely provided in Taiwan to support
bereaved surrogates’ psychologic needs under hospice
care relative to worldwide practices, but bereavement
care is still globally recognized as limited and poorly
resourced. Given that surrogates with potentially higher
psychologic distress and heavier caregiving burden were
referred late to palliative care without adequate bereave-
ment care to meet their post-loss psychologic needs,
their likelihood of being in the PGD-PTSD-depression
concurrent state might increase. Our nding warrants
cross-national validation.
Poor-to-uncertain or worst QODD classes gener-
ally increased membership in the three more profound
psychologic-distress states, reaching a statistically
signicant level for the subthreshold depression-
dominant and the PGD-PTSD-depression concur-
rent states. ICU patients in the poor-to-uncertain and
worst QODD latent classes were perceived to suer
pain and dyspnea most frequently, had moderate/in-
sucient/uncertain emotional preparedness for death,
less religious and family support, and received more
LSTs than those in the high QODD latent class (Table
E1, http://links.lww.com/CCM/H585). Painful memo-
ries of unrelieved pain/dyspnea, uncertain or insu-
cient patient emotional preparedness for their own
death, and patient suering from frightening LSTs may
preclude bereaved surrogate acceptance and sense-
making of the patient’s death, leading to PGD symp-
toms like yearning, longing for, and/or a persistent
preoccupation with thoughts and memories of the de-
ceased. ese memories of the death circumstances
can also be distressing, intrusive, and challenging to
manage, thereby subsequently eliciting excessive cog-
nitive or behavioral avoidance of loss reminders to
increase surrogates’ vulnerability to PTSD symptoms
(48). ose who feel excessive guilt and self-blame (es-
pecially aer EOL care decisions like initiating LSTs)
may progress to endorse negative beliefs about them-
selves, the world, and the future, leading to profound
depressive symptoms (48).
Several limitations should be acknowledged. Our
study should be replicated with other bereaved family
samples internationally to support generalizability
given the worldwide cultural dierences in manifesta-
tion of emotional symptoms during bereavement (12,
30). Our results cannot be generalized to unnatural
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Clinical Investigation
Critical Care Medicine www.ccmjournal.org 7
causes of loss. We used symptom severity scales (PG-
11, IES-R, and HADS), not structured diagnostic
interviews, to assess symptom severity of PGD, PTSD,
depression, and anxiety. In this observational study,
a causal relationship cannot be inferred between fac-
tors and PGD-PTSD-depressive-symptom states nor
can we exclude the potential impact of unmeasured
covariates, especially considering that predictors from
the appraisal and coping domain were excluded in this
study. Future research should explore the role of surro-
gates’ appraisal of the loss (19, 21, 25) and their coping
strategies (25, 26).
CONCLUSIONS AND CLINICAL
IMPLICATIONS
Membership in more profound PGD-PTSD-
depressive-symptom states for bereaved surrogates
of ICU decedents was associated with both unmodi-
able pre-traumatic intrapersonal risk factors and
bereavement-related stressors as well as more pow-
erful (49) but modiable peri-/post-traumatic inter-
personal risk factors and death circumstances. Special
eorts should target vulnerable family surrogates who
report nancial hardship or have low educational
attainment, preexisting mental illness requiring mood
medications or ED visits, or high anxiety symptoms
during bereavement. Focused EOL ICU care tailored
to modiable factors is urgently warranted to prevent
subclinical depression, PGD, and concurrent PGD-
PTSD-depressive symptoms among bereaved ICU
family surrogates. Specically, healthcare professionals
should provide high-quality EOL ICU care by improv-
ing symptom management, facilitating patients’ emo-
tional preparedness for their death, leveraging family
support for the dying patient and their surrogate,
avoiding potentially inappropriate LSTs, and facilitat-
ing a DNR order, social worker involvement in EOL
care, and early referral to palliative care to actualize
full benets. Doing so may facilitate a good QODD
and minimal concurrent PGD, PTSD, and depressive
symptoms during bereavement.
ACKNOWLEDGMENTS
We thank Erica Light (Language Editor).
1 Department of International Business, Soochow University,
Taiwan, ROC.
2 Department of Medicine, Weill Cornell Medicine, New York
City, NY.
3 Department of Internal Medicine, Division of Pulmonary and
Critical Care Medicine, Chang Gung Memorial Hospital at
Linkou, Tao-Yuan, Taiwan, ROC.
4 Division of Hematology-Oncology, Chang Gung Memorial
Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
5 College of Medicine, School of Medicine, Chang Gung
University, Tao-Yuan, Taiwan, ROC.
6 Department of Respiratory Therapy, Chang Gung University,
Tao-Yuan, Taiwan, ROC.
7 Department of Internal Medicine, Division of Hepato-
Gastroenterology, Chang Gung Memorial Hospital at
Kaohsiung, Kaohsiung, Taiwan, ROC.
8 School of Nursing, Medical College, Chang Gung University,
Tao-Yuan, Taiwan, ROC.
9 Department of Nursing, Chang Gung Memorial Hospital at
Kaohsiung, Kaohsiung, Taiwan, ROC.
10 Department of Nursing, Chang Gung University of Science
and Technology, Tao-Yuan, Taiwan, ROC.
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
(http://journals.lww.com/ccmjournal).
The corresponding author (to Dr. Tang) takes responsibility for
the content of the article, has full access to all of the data in the
study, and is responsible for the integrity of the data, the accuracy
of the data analysis, including and especially any adverse effects.
All authors contributed substantially to the study conception and
design. Drs. Chuang, Chou, Huang, and Hu contributed by pro-
viding study patients. Drs. Chuang, Chou, Huang, Hu, and Tang
contributed to collection and/or assembly of data. All authors
contributed to data analysis and interpretation. All authors con-
tributed to the writing and final approval of the article.
Supported, in part, by grant from the National Health Research
Institutes (NHRI-EX111-10704PI) with partial support from
Ministry of Science and Technology (MOST-110-2314-B-182-
009-MY3) and Chang Gung Memorial Hospital (BMRP888).
The authors have disclosed that they do not have any potential
conflicts of interest.
For information regarding this article, E-mail: sttang@mail.cgu.
edu.tw
The views expressed in this article do not communicate an offi-
cial position of the funding sources.
Each patient’s legal family surrogate signed informed consent for
reviewing the patient’s medical record and their own participa-
tion. All authors have read the article and consented for this ar-
ticle to be published by Critical Care Medicine.
The sharing of anonymized data from this study is restricted due
to ethical and legal constrictions. Data contains sensitive per-
sonal health information, which is protected under The Personal
Data Protection Act in Taiwan, thus making all data requests sub-
ject to Institutional Review Board (IRB) approval. Per Chang
Gung Memorial Hospital (CGMH) IRB, the data that support
the findings of this study are restricted for transmission to those
in the primary investigative team. Data sharing with investiga-
tors outside the team requires IRB approval. All requests for
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Wen et al
8 www.ccmjournal.org XXX 2024 • Volume 52 • Number 12
anonymized data will be reviewed by the research team and then
submitted to the CGMH IRB for approval. Upon approval from
the Chang Gung Medical Foundation IRB, the data supporting
the findings of this study are available from the corresponding au-
thor (Dr. Tang) upon reasonable request. Specifications for data
abstraction from the medical records and Latent GOLD codes for
statistical analyses are available from the first and corresponding
authors upon reasonable request.
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