Advertisement

Critical Care

, 17:1003 | Cite as

Sleepless nights in the ICU: the awaken family

  • Matthieu Schmidt
  • Elie Azoulay
Commentary

Abstract

Having a loved-one in the ICU is a traumatic experience for family members that can lead to a cluster of psychological complications, recently defined as post-intensive care family syndrome. In a previous issue of Critical Care, Day and colleagues stressed the severe sleep disturbance and fatigue experienced by a majority of ICU patient family members. However, despite this burden being well characterised, the best preventive coping strategy remains undetermined.

Keywords

Sleep Deprivation Panic Disorder Family Burden Complicated Grief Surrogate Decision Maker 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

In a previous issue of Critical Care, Day and colleagues [1] investigated sleep, anxiety and fatigue in family members of patients admitted to the ICU. Using validated self-report tools, the majority of family members of ICU patients reported moderate to severe sleep disturbance and fatigue. This newly recognized family burden may have dramatic consequences as sleep deprivation may interfere with their decision-making and care-taking abilities. These findings emphasize the immense turmoil experienced by family members and suggest that surrogate decision makers could be temporarily incompetent, raising issues about the shared decision-making model [2].

Perhaps, more so in intensive care than in other medical disciplines, relatives of critically ill patients playa key role during the long ICU course. They frequently play both caregiver and surrogate decision maker roles. Thus, the patient-physician relationship moves to a family-patient-physician-nurse relationship, making the ICU environment quite unique. Among stakeholders, each party may suffer from stress. Neglected for too long, the damaging psychological consequences of an ICU stay on physicians [3] and on relatives are now better characterized [4]. As underlined by Day and colleagues [1], family members of ICU patients have frequent intense sleep deprivation and are exposed to symptoms of anxiety and depression that could lead to psychiatric diseases such as panic disorder, post-traumatic stress disorder [5], or complicated grief [6].

As the aging population requires more critical care and ICU mortality decreases, family members will increasingly have opportunities to share in the care of their loved one [7]. Managing a relative's burden remains the main issue. We advocate that our ICUs have enough resources to prevent post-ICU burden. This requires communication strategies and improved behaviours. For instance, seeing family members sleeping in the waiting room is, unfortunately, a frequent occurrence for night shift clinicians [8]. We have to admit that most of our ICUs do not offer accommodation for family members, and a change in ICU design that integrates night accommodation for family members is warranted and unrealistic at the same time. Instead, several simple measures, mostly based on improving communication strategies and on family-centred ICU organization, have shown an ability to improve family burden. To be effective, interventions must be feasible, easy to reproduce, accessible, resource minimising, and easily integrated at the bedside. Informative hand-outs for educating families about critical illness and intensive therapies, as well as proactive and effective communication strategies fulfil these requirements [9]. As suggested by 25% of the respondents in the study of Day and colleagues [1], improving the frequency and the quality of the information related to their loved ones could allow them to leave the hospital during the night and improve the quality of their sleep. Simple changes in ICU structure, including but not limited to open visitation policies for families and rooms dedicated to family conferences, could also possibly have a beneficial impact on family anxiety and satisfaction. Additionally, flexible visitation in the ICU setting provides the family with opportunities to maintain social links (child care, professional activities, social commitments, and soon). These changes could enable them to manage daily life while allowing them breathing space. Free visitation policies are also an opportunity to alleviate their guilt. This is particularly true for families with ICU patients with lengthy ICU stays.

Multiple risk factors of family burden have been identified, and preventative strategies rest on multifaceted programs. Thus, rather than a single intervention, we believe implementing multiple simple and accessible interventions (that is, family information leaflets, routine family conferences, daily family rounds, structured information, unrestricted visiting hours, regular nurse-family-physician meetings, family care specialist nurses, and so on) may prove effective in preventing post-intensive care family syndrome. We are at a time where a qualitative 'care bundle' for family members has to be implemented in our daily practice. In addition to reducing sedation intensity in critically ill patients, we should find ways to provide healing information to family members and encourage them to safeguard their sleeping time. Studies to improve sleep quality in family members are warranted.

Notes

References

  1. 1.
    Day A, Haj-Bakri S, Lubch ansky S, Mehta S: Sleep, anxiety, and fatigue in family members of patients admitted to the intensive care unit: a questionnaire study. Crit Care 2013, 17: R91. 10.1186/cc12736PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Garrouste-Orgeas M, Timsit J F, Montuclard L, Colvez A, Gattolliat O, Philippart F, Rigal G, Misset B, Carlet J: Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission. Intensive Care Med 2006, 32: 1045-1051. 10.1007/s00134-006-0169-7CrossRefPubMedGoogle Scholar
  3. 3.
    Embriaco N, Azoulay E, Ba rrau K, Kentish N, Pochard F, Loundou A, Papazian L: High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007, 175: 686-692. 10.1164/rccm.200608-1184OCCrossRefPubMedGoogle Scholar
  4. 4.
    Jones C, Skirrow P, Griffiths RD, Humphris G, Ingleby S, Eddleston J, Waldmann C, Gager M: Post-traumatic stress disorder-related symptoms in relatives of patients following intensive care. Intensive Care Med 2004, 30: 456-460. 10.1007/s00134-003-2149-5CrossRefPubMedGoogle Scholar
  5. 5.
    Azoulay E, Pochard F, Ken tish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larché J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B, FAMIREA Study Group: Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005, 171: 987-994. 10.1164/rccm.200409-1295OCCrossRefPubMedGoogle Scholar
  6. 6.
    Casarett D, Kutner JS, Abra hm J: Life after death: a practical approach to grief and bereavement. Ann Intern Med 2001, 134: 208-215. 10.7326/0003-4819-134-3-200102060-00012CrossRefPubMedGoogle Scholar
  7. 7.
    Jabre P, Belpomme V, Azoulay E, Jacob L, Bertrand L, Lapostolle F, Tazarourte K, Bouilleau G, Pinaud V, Broche C, Normand D, Baubet T, Ricard-Hibon A, Istria J, Beltramini A, Alheritiere A, Assez N, Nace L, Vivien B, Turi L, Launay S, Desmaizieres M, Borron SW, Vicaut E, Adnet F: Family presence during cardiopulmonary resuscitation. N Engl J Med 2013, 368: 1008-1018. 10.1056/NEJMoa1203366CrossRefPubMedGoogle Scholar
  8. 8.
    Van Horn E, Tesh A: The effect of critical care hospitalization on family members: stress and responses. Dimensions Crit Care Nursing 2000, 19: 40-49.CrossRefGoogle Scholar
  9. 9.
    Lautrette A, Darmon M, Mega rbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, Curtis JR, Fieux F, Galliot R, Garrouste-Orgeas M, Georges H, Goldgran-Toledano D, Jourdain M, Loubert G, Reignier J, Saidi F, Souweine B, Vincent F, Barnes NK, Pochard F, Schlemmer B, Azoulay E: A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007, 356: 469-478. 10.1056/NEJMoa063446CrossRefPubMedGoogle Scholar

Copyright information

© BioMed Central Ltd 2013

Authors and Affiliations

  1. 1.Université Paris 6 - Pierre et Marie CurieParisFrance
  2. 2.Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles FoixService de Pneumologie et Réanimation médicaleParisFrance
  3. 3.AAP-HP, Hôpital Saint-Louis, Medical ICUUniversity Paris-7 Paris-Diderot,UFR de MédecineParisFrance

Personalised recommendations