Caring Beyond the Bedside: Family Bereavement Support in Critical Care

More than 5 million individuals are admitted to intensive care units (ICUs) in the United States each year. Whereas pediatric ICU mortality is estimated at 2%, adult mortality ranges from 10% to 29% depending on age, disease severity, and comorbidities.1 These deaths follow illness trajectories that may be sudden and unexpected or protracted and expected (Figure 1). In rapid unexpected deaths, patients often have not made end-of-life (EOL) decisions. In contrast, expected deaths usually follow a chronic illness with recognizable decline, allowing clinicians to communicate to families that death is imminent.Bereavement is the biopsychosocial state associated with loss. This lived experience challenges individuals to process the past—the story of their loved one’s death alongside the backstory of their lives together—while looking ahead to a future without them.3 Grief usually dissipates over many months for most,4 but ICU family members are at higher risk for continued anxiety, depression, posttraumatic stress disorder (PTSD) or prolonged grief disorder (PGD) than the general population.5–12 Although the 4 illness trajectories can influence how families understand and cope with loss,2 bereavement may also be shaped by the quality of ICU care2—timeliness of transition to palliative or EOL care, effectiveness of symptom management, communication, continuity of care, family support, ability for unrestricted family presence, and opportunity for follow-up meetings.2,10,13–15 These issues can influence how families judge the quality of death and dying (QODD)—a factor that can mitigate depression and PTSD.10 Other buffering influences include do-not-resuscitate orders before death, social work involvement and individual factors (eg, anticipatory grieving, mental health/well-being, family dynamics, lack of financial hardship).2,9,16,17Nurses are in a unique position to facilitate adaptive grieving among families who experience the death of a loved one in the ICU. As clinicians most consistently present at the bedside, critical care nurses often serve as witnesses to family distress, as well as compassionate guides addressing families’ complex informational and psychosocial needs that accompany EOL experiences. Yet estimates suggest only a limited proportion of pediatric and adult ICUs offer formalized bereavement programs or follow-up interventions, highlighting a critical gap in post–ICU care.18,19 Given the significant emotional and psychological impacts of bereavement, there is an urgent need for evidence-based strategies that promote healthy adaptation to loss.3 Therefore, the focused question guiding this evidence synthesis was, What effect do bereavement support interventions for relatives of patients who died in the ICU have on anxiety, depression, PTSD, and other grief-related outcomes?The strategy included searching CINAHL and MEDLINE. Keywords included grief, bereavement, intensive or critical care, family, interventions, anxiety, depression, PTSD or post–intensive care syndrome–family (PICS-F). The search was limited to original research in the past 7 years.Ten studies were retrieved. Of these, 4 were systematic reviews/meta-analyses, 2 were randomized controlled trials, and 4 were qualitative studies. An array of single or bundled bereavement interventions outlined in Figure 2 were studied during the first year of bereavement. The quantitative studies evaluated interventions using psychological and acceptability outcomes (Table 1), whereas qualitative studies described themes about the impact of ICU diaries.27–29Outcomes for all bereavement interventions were mixed. Some interventions had positive effects as follows: Family members also perceived some interventions as follows: Although most interventions were benign or beneficial, a few—particularly bereavement brochures and condolence cards or letters—were associated with increased anxiety, depression, or PTSD in some family members.23–25Most bereavement support evidence represents level A or B evidence (Table 2). Research on a whole array of bereavement interventions is emerging. Across studies, findings on grief symptoms, family experience, and acceptability are mixed, with interventions yielding positive, negative, or null effects. More high-quality research is needed to evaluate the effectiveness, acceptability, and feasibility of single-component and multicomponent interventions.Surveys show that nurses and physicians frequently provide bereavement support at the time of death (64%-88%) but rarely follow up with families afterward (6%-16%).31,32 Most believe families should be offered a brochure (94.3%), condolence card (79.7%), memory keepsake (75.6%), and counseling services (69.1%).31 Although bereavement support was viewed as an important part of practice, many clinicians felt uncomfortable and desired formal training.31Additional barriers included limited time and resources; in pediatric ICUs, similar challenges emerged, along with unit culture, diverse cultural perceptions of child death, lack of financial support, and availability of palliative care consultation.18 In an observational study, Santiago et al33 found that sending condolence cards and memorial service invitations was feasible, whereas contacting family members for follow-up phone calls was not.In their guidelines on family-centered care in adult ICUs, the Society for Critical Care Medicine recommends providing bereavement support.34 While the Society does not endorse specific interventions due to insufficient evidence, it advocates for family bereavement support due to its potential for benefit and little evidence of harm. Indeed, more research is needed to understand the negative effects observed with bereavement brochures and condolence cards in some family members. Many supports—such as condolence cards—are designed to offer comfort rather than reduce normal grief responses during early bereavement.25 Thus, the intent of interventions warrants consideration. Other explanatory factors may relate to intervention timing or the potential for unexpected contact to reactivate traumatic memories in the absence of supportive follow-up. In a qualitative study,35 the suddenness of death influenced families’ bereavement experiences, potentially affecting when and how they would be receptive to such support. As Santiago et al33 reported, not all interventions were desired by family, indicating that a nonstandardized approach should be considered. Involving bereaved ICU family members in designing bereavement interventions through venues such as family advisory committees is ideal.36–38 Such collaboration helps ensure that supportive interventions are perceived as helpful, comforting, and acceptable and that they facilitate individualized bereavement pathways.Bereavement is an inescapable dimension of critical care practice—one that requires evidence and empathy. Although research on ICU bereavement interventions remains early with mixed findings, emerging evidence shows that even small thoughtful gestures can ease suffering and support healing. Nurses, who accompany families through their most difficult moments, are uniquely positioned to lead these efforts. By advancing evidence-informed bereavement support, cultivating staff education and resources, and collaborating with families to codesign meaningful interventions, the critical care community can reimagine the ICU as a setting not only of crisis, but also of compassion, connection, and healing.