To the Editor:
Death in intensive care units (ICUs) is common (1, 2) and increasing (2, 3). Still, end-of-life (EOL) care quality remains poor despite improvements (4), prompting global calls for reform (5). Uncertain recovery, complex decisions, and aggressive life-sustaining treatments (LSTs) often traumatize bereaved ICU families, leading to symptoms of post-traumatic stress disorder (PTSD) (6–9). PTSD symptoms contribute to somatic/physiological disorders (10), mental distress (10, 11), risks of self-harm (11), functional impairment (12), and increased healthcare use/costs (13), posing a significant public mental health priority (10).
Adults exhibit heterogeneous PTSD symptom patterns (14) that evolve along distinct trajectories (14–23). Resilient (15–23), recovery (14–19, 21–23), and chronic (15–23) trajectories are most common, whereas delayed onset is less frequently observed (15–19). Membership in more severe and prolonged trajectories is linked to poorer physical health (16), diminished self-perceived health and social functioning (18), reduced quality of life, and lower work productivity (21).
The whole ICU team can help reduce PTSD symptoms among bereaved families by identifying vulnerable individuals and delivering high-quality, family-centered EOL care (5). Achieving this goal requires a clearer understanding of risk factors associated with PTSD-symptom trajectories. However, research on such trajectories among ICU family members—particularly the bereaved—is limited (18, 21–23). Existing studies focus primarily on nonmodifiable predictors, including sociodemographics (e.g., sex, age) (21–23), patient clinical characteristics (e.g., ICU length of stay, disease severity) (21–23), and caregivers’ preexisting emotional distress (e.g., anxiety, depression, trauma, or resilience) (21, 23). Although quality of dying is increasingly recognized as just as important as survival, modifiable ICU-based EOL care factors remain unexamined—limiting targeted intervention development for better bereavement outcomes. Addressing this need, the present study comprehensively investigated risk factors for PTSD symptom trajectories among bereaved ICU family members.
Methods
We prospectively followed 291 family members from two level III Taiwanese ICUs (January 2018–March 2020) while their loved ones were dying through December 2022. The 22-item Impact of Event Scale–Revised (24) assessed PTSD symptoms at 1, 3, 6, 13, 18, and 24 months after loss. We previously identified three trajectories: resilient, recovery, and delayed onset by a latent growth mixture model (18). The resilient group had persistently low symptoms. The recovery group showed steep early improvement. The delayed-onset group worsened by 13 months, then plateaued and declined, but remained the most symptomatic at 24 months (18).
Guided by the integrative framework of bereavement outcome predictors (25), multinomial logistic regression examined associations between distinct PTSD symptom trajectories and intrapersonal, interpersonal, and contextual risk factors (resilient as reference). Intrapersonal factors included sociodemographic variables and susceptibilities, including economic strain, prior health conditions, and anxiety via the Hospital Anxiety and Depression Scale anxiety subscale; interpersonal factors were measured by perceived social support using the Medical Outcomes Study Social Support Survey. Bereavement-related stressors encompassed type of loss (kinship), demographic variables, and clinical characteristics of the deceased. Death circumstances were specified by family-assessed quality of dying and death in ICUs measured using the Quality of Dying and Death (QODD) questionnaire. We conducted latent class analysis on the QODD frequency component, identifying four classes: high (40.9%), moderate (20.3%), poor to uncertain (22.3%), and worst (16.5%)—distinguished by symptom control, emotional preparedness for death, and intensity of LSTs (26). Independent variable effects were reported as adjusted odds ratios with 95% confidence intervals. Notably, parts of the Methods and Results sections were previously presented as a conference poster (27).
Results
Participants were predominantly in the resilient trajectory (82.8%), followed by recovery (13.1%) and delayed-onset (4.1%) trajectories. Most participants were female (59.1%); married (74.6%); the patient’s adult child (54.0%) or spouse (29.2%); and, on average (SD), 49.63 (12.53) years old (Table 1).
Table 1.
Independent variables across three distinct post-traumatic stress disorder symptom states (N = 291)
| PTSD Symptom Trajectories | Resilient (n = 241) | Recovery (n = 38) | Delayed onset (n = 12) | Total |
|---|---|---|---|---|
| Variables | (N = 291) | |||
| Family demographics and predisposing vulnerabilities | ||||
| Age, yr, mean [SD] | 49.40 [11.88] | 50.95 [16.93] | 50.08 [9.31] | 49.63 [12.53] |
| Sex, n [%] | ||||
| Male | 106 [44.0] | 12 [31.6] | 1 [8.3] | 119 [40.9] |
| Female | 135 [56.0] | 26 [68.4] | 11 [91.7] | 172 [59.1] |
| Educational attainment, n [%] | ||||
| >Senior high school | 204 [84.6] | 26 [68.4] | 9 [75.0] | 239 [82.1] |
| ≤Senior high school | 37 [15.4] | 12 [31.6] | 3 [25.0] | 52 [17.9] |
| Marital status, n [%] | ||||
| Married | 180 [74.7] | 28 [73.7] | 9 [75.0] | 217 [74.6] |
| Unmarried | 61 [25.3] | 10 [26.3] | 3 [25.0] | 74 [25.4] |
| Financial insufficiency to make ends meet, n [%] | ||||
| Yes | 26 [10.8] | 10 [26.3] | 5 [41.7] | 41 [14.1] |
| No | 215 [89.2] | 28 [73.7] | 7 [58.3] | 250 [85.9] |
| Hospitalizations, n [%] | ||||
| Yes | 14 [5.8] | 0 [0.0] | 0 [0.0] | 14 [4.8] |
| No | 227 [94.2] | 38 [100.0] | 12 [100.0] | 277 [95.2] |
| Emergency room visits, n [%] | ||||
| Yes | 18 [7.5] | 2 [5.3] | 0 [0.0] | 2 0[6.9] |
| No | 223 [92.5] | 36 [94.7] | 12 [100.0] | 271 [93.1] |
| Use of pain medications, n [%] | ||||
| Yes | 31 [12.9] | 2 [5.3] | 2 [16.7] | 35 [12.0] |
| No | 210 [87.1] | 36 [94.7] | 10 [83.3] | 256 [88.0] |
| Anxiety symptoms, mean [SD] | 2.98 [2.40] | 8.11 [4.52] | 9.67 [6.53] | 3.92 [3.66] |
| Interpersonal risk factors | ||||
| Perceived social support, mean [SD] | 74.61 [12.53] | 64.40 [18.78] | 61.61 [19.70] | 72.74 [14.38] |
| Bereavement-related stressors | ||||
| Type of loss: relationship with patient, n [%] | ||||
| Spouse | 57 [23.7] | 20 [52.6] | 8 [66.7] | 85 [29.2] |
| Child | 142 [58.9] | 13 [34.2] | 2 [16.7] | 157 [54.0] |
| Others | 42 [17.4] | 5 [13.4] | 2 [16.7] | 49 [16.8] |
| Patient demographics and disease characteristics | ||||
| Age, yr, mean [SD] | 67.63 [13.56] | 63.76 [16.47] | 50.92 [11.52] | 66.43 [14.28] |
| Sex, n [%] | ||||
| Male | 154 [63.9] | 21 [55.3] | 8 [66.7] | 183 [62.9] |
| Female | 87 [36.1] | 17 [44.7] | 4 [33.3] | 108 [37.1] |
| Diagnosis, n [%] | ||||
| Cancer | 117 [48.5] | 19 [50.0] | 9 [75.0] | 145 [49.8] |
| Noncancer | 124 [51.5] | 19 [50.0] | 3 [75.0] | 146 [50.2] |
| APACHE II score, mean [SD] | 32.69 [5.82] | 32.68 [6.28] | 28.58 [4.70] | 32.52 [5.88] |
| Length of ICU stay, mean [SD] | 14.32 [12.94] | 14.32 [11.66] | 15.67 [16.92] | 14.37 [12.91] |
| Death circumstances | ||||
| Classes of family perceived quality of dying and death for ICU patients, n [%] | ||||
| High quality of dying and death | 108 [44.8] | 8 [21.1] | 3 [25.0] | 119 [40.9] |
| Moderate quality of dying and death | 47 [19.5] | 9 [23.7] | 3 [25.0] | 59 [20.3] |
| Poor to uncertain quality of dying and death | 49 [20.3] | 15 [39.5] | 1 [8.3] | 65 [22.3] |
| Worst quality of dying and death | 37 [15.4] | 6 [15.8] | 5 [41.7] | 48 [16.5] |
Definition of abbreviations: APACHE II = Acute Physiology and Chronic Health Evaluation II; ICU = intensive care unit; PTSD = post-traumatic stress disorder; SD = standard deviation.
Men were less likely than women to be in the delayed-onset trajectory (adjusted odds ratio [95% confidence interval], 0.003 [0.000, 0.206]) (Table 2). Older age and higher education reduced membership in the recovery trajectory. Membership in the recovery (1.540 [1.304, 1.840]) and delayed-onset (1.589 [1.270, 1.990]) trajectories was increased by higher anxiety symptoms measured in the first month of bereavement. Spouses were more likely, and adult children were less likely, than other family members to be in the two more profound PTSD symptom trajectories, respectively. The likelihood of the delayed-onset trajectory decreased with patient age (0.793 [0.645, 0.976]) and increased with a cancer diagnosis (14.759 [1.273, 171.149]). Membership in the recovery trajectory was increased by family perception of QODD in ICUs classified as poor to uncertain (5.253 [1.109, 24.885]) compared with the high QODD class.
Table 2.
Factors associated with post-traumatic stress disorder symptom trajectories for bereaved family members of intensive care unit decedents (N = 291)
| PTSD symptom trajectories | Recovery |
Delayed Onset |
||||||
|---|---|---|---|---|---|---|---|---|
| Independent Variables | AOR | 95% CI | P Value | AOR | 95% CI | P Value | ||
| Intrapersonal risk factors | ||||||||
| Family demographics and preexisting mental health or medical conditions in year before patient’s critical illness | ||||||||
| Sex (male vs. female) | 1.133 | 0.424 | 3.023 | 0.804 | 0.003 | 0.000 | 0.206 | 0.007 |
| Age | 0.933 | 0.875 | 0.994 | 0.031 | 1.207 | 0.988 | 1.473 | 0.065 |
| Educational attainment (> vs. ≤ senior high school) | 0.322 | 0.104 | 0.989 | 0.048 | 0.800 | 0.181 | 3.545 | 0.769 |
| Marital status (married vs. unmarried) | 0.443 | 0.115 | 1.703 | 0.236 | 0.025 | 0.000 | 2.059 | 0.101 |
| Financial insufficiency to make ends meet (yes vs. no) | 0.870 | 0.315 | 2.400 | 0.788 | 0.525 | 0.110 | 2.509 | 0.420 |
| Emergency room visits (yes vs. no) | 1.006 | 0.153 | 6.616 | 0.995 | 0.000 | 0.000 | 0.000 | — |
| Use of pain medications (yes vs. no) | 0.272 | 0.059 | 1.255 | 0.095 | 1.313 | 0.212 | 8.130 | 0.770 |
| Anxiety symptoms | 1.540 | 1.304 | 1.840 | <0.001 | 1.589 | 1.270 | 1.990 | <0.001 |
| Interpersonal risk factors | ||||||||
| Perceived social support | 0.983 | 0.939 | 1.030 | 0.478 | 0.980 | 0.917 | 1.048 | 0.558 |
| Bereavement-related stressors | ||||||||
| Type of loss: relationship with the patient (vs. others) | ||||||||
| Spouse | 3.316 | 0.680 | 16.181 | 0.138 | 461.940 | 4.281 | 49851.1 | 0.010 |
| Child | 0.163 | 0.029 | 0.906 | 0.038 | 152.1403 | 0.367 | 63046.4 | 0.109 |
| Patient demographics and disease characteristics | ||||||||
| Age | 1.019 | 0.981 | 1.058 | 0.340 | 0.793 | 0.645 | 0.976 | 0.028 |
| Sex (male vs. female) | 0.613 | 0.174 | 2.163 | 0.447 | 0.055 | 0.002 | 1.601 | 0.092 |
| Diagnosis (cancer vs. noncancer) | 1.161 | 0.466 | 2.893 | 0.749 | 14.759 | 1.273 | 171.149 | 0.031 |
| APACHE II score | 1.047 | 0.971 | 1.128 | 0.232 | 0.906 | 0.803 | 1.022 | 0.108 |
| Length of ICU stay | 1.022 | 0.990 | 1.055 | 0.186 | 1.032 | 0.959 | 1.110 | 0.399 |
| Death circumstances | ||||||||
| Classes of family perceived quality of dying and death for ICU patients (vs. high quality of dying and death) | ||||||||
| Moderate | 0.536 | 0.099 | 2.906 | 0.470 | 0.327 | 0.047 | 2.270 | 0.258 |
| Poor to uncertain | 5.253 | 1.109 | 24.885 | 0.037 | 1.396 | 0.038 | 50.968 | 0.856 |
| Worse | 2.427 | 0.573 | 10.286 | 0.229 | 5.526 | 0.419 | 72.857 | 0.194 |
Definition of abbreviations: AOR = adjusted odds ratio; APACHE II = Acute Physiology and Chronic Health Evaluation II; CI = confidence interval; ICU = intensive care unit; PTSD = post-traumatic stress disorder.
Discussion
PTSD symptom trajectories were associated with both nonmodifiable (e.g., family/patient demographics, clinical characteristics) and modifiable factors (e.g., early bereavement anxiety, perceived ICU quality of dying). We highlight the elevated risk of more severe PTSD symptom trajectories among family members of younger patients with cancer. In Taiwanese culture, death at a young age is perceived as unnatural and traumatic, disrupting filial expectations and life milestones. As a result, bereaved families of younger ICU decedents may experience more profound and prolonged PTSD symptoms. Cancer-related deaths in ICUs may heighten family members’ PTSD symptoms (6), particularly because of the emotional toll of surrogate decision making. Although ICU patients with cancer receive fewer LSTs than noncancer patients (28), families may still pursue aggressive ICU care after repeated treatment failures, driven by a desperate hope to save the patient. However, witnessing the patient’s suffering from such interventions can lead to decisional regret (29) and traumatized grief, as bereaved family members gradually internalize their loss—raising the risk of delayed-onset grief trajectories.
A key finding was the association between family-perceived QODD classes and PTSD symptom trajectories. Families in the poor to uncertain and worst QODD classes reported patient suffering more from inadequate control of pain and dyspnea, less emotional preparedness for death, and greater use of LSTs than those in the high QODD class. These distressing memories may traumatize grief and contribute to PTSD symptoms in recovery or delayed-onset trajectories. Because of the small delayed-onset group, only the link between poor to uncertain QODD and the recovery trajectory was significant. In addition, associations between the delayed-onset group and key predictors (sex, spousal relationship, cancer diagnosis) were imprecise.
Clinical implications
ICU clinical teams should identify at-risk family members, particularly those of younger patients with cancer, and ensure high-quality EOL care during the dying process. This includes adequate symptom management to address persistent gaps in pain and dyspnea control (30), facilitating emotional preparedness for death, avoiding potentially inappropriate LSTs, and ensuring timely psychological support for bereaved families showing early anxiety or prolonged PTSD symptoms.
Footnotes
Supported by the National Health Research Institutes (NHRI-EX111-10704PI) with partial support from the Ministry of Science and Technology (MOST 111-2314-B-182-009-MY3) and Chang Gung Memorial Hospital (BMRP888). No funding sources had any role in designing and conducting the study; collecting, managing, analyzing, and interpreting the data; preparing, reviewing, or approving the article; and in the decision to submit the report for publication.
This study was conducted with the approval for human subject research of the central institutional review board of the study sites (Chang Gung Medical Foundation Institutional Review Board approval number 201700343B0; approval date, March 20, 2017; study title, Impact of end-of-life care quality in intensive care units on adjustment of bereaved family members). Study procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional) and with the Helsinki declaration of 1975. Each family surrogate signed informed consent for participation. The views expressed in this article do not communicate an official position of the funding sources.
The sharing of anonymized data from this study is restricted because of ethical and legal constrictions. Data contain sensitive personal health information, which is protected under the Personal Data Protection Act in Taiwan, thus making all data requests subject to institutional review board (IRB) approval. Per the study hospital IRB, the data that support the findings of this study are restricted for transmission to those in the primary investigative team. Data sharing with investigators outside the team requires IRB approval. All requests for anonymized data will be reviewed by the research team and then submitted to the study hospital IRB for approval. Upon approval from the IRB, the data supporting the findings of this study are available from the corresponding author upon reasonable request.
Author Contributions: F.-H.W., L.-P.C., T.-H.H., C.-C.H., W.-C.C., and S.T.T. contributed substantially to the study conception and design. L.-P.C., T.-H.H., C.-C.H., and W.-C.C. contributed by providing study patients. L.-P.C., T.-H.H., C.-C.H., W.-C.C., and S.T.T. contributed to collection and/or assembly of data. F.-H.W., L.-P.C., T.-H.H., C.-C.H., W.-C.C., and S.T.T. contributed to data analysis and interpretation. F.-H.W., L.-P.C., T.-H.H., C.-C.H., W.-C.C., and S.T.T. contributed to the writing and final approval of the manuscript. The corresponding author (S.T.T.) takes responsibility for the content of the manuscript; has full access to all of the data in the study; and is responsible for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects.
Specifications for MPlus codes for statistical analyses are available from the first and corresponding authors upon reasonable request.
Artificial Intelligence Disclaimer: No artificial intelligence tools were used in writing this manuscript.
Author disclosures are available with the text of this letter at www.atsjournals.org.
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