BACKGROUND:Family members of patients in intensive care units (ICUs) are at risk for mental health morbidity both during and after a patient's ICU stay. OBJECTIVES:To determine prevalences of and factors associated with anxiety, depression, posttraumatic stress and complicated grief in family members of ICU patients.DESIGN: Prospective, longitudinal cohort study. PARTICIPANTS: Fifty family members of patients inICUs at a large university hospital participated. MEASUREMENTS: We used the Control PreferencesScale to determine participants' role preferences for surrogate decision-making. We used the Hospital Anxiety and Depression Scale, Impact of Event Scale, and Inventory of Complicated Grief to measure anxiety and depression (at enrollment, 1 month, 6 months), posttraumatic stress (6 months), and complicated grief (6 months). RESULTS:We interviewed all 50 participants at enrollment, 39 (78%) at 1 month, and 34 (68%) at 6 months. At the three time points, anxiety was present in 42% (95% CI, 29-56%), 21% (95% CI, 10-35%), and 15% (95% CI, 6-29%) of participants. Depression was present in 16% (95% CI, 8-28%), 8% (95% CI, 2-19%), and 6% (95% CI, 1-18%). At 6 months, 35% (95% CI, 21-52%) of participants had posttraumatic stress. Of the 38% who were bereaved, 46% (95% CI, 22-71%) had complicated grief. Posttraumatic stress was not more common in bereaved than nonbereaved participants, and neither posttraumatic stress nor complicated grief was associated with decision-making role preference or with anxiety or depression during the patient's ICU stay.CONCLUSIONS: Symptoms of anxiety and depression diminished over time, but both bereaved and nonbereaved participants had high rates of posttraumatic stress and complicated grief. Family members should be assessed for posttraumatic stress and complicated grief.

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The University of Pittsburgh Medical Center (UPMC) has implemented a personal health record grounded in the Chronic Care Model, UPMC HealthTrak, to assist patients with diabetes self-management. UPMC HealthTrak is based in the physician office and connects the patient, physician, and electronic medical record (EMR). Its functionalities include secure, electronic communication with the physician's office, along with preventive healthcare reminders, and disease-specific tools and information. In this paper, we describe challenges to office-based implementation of and initial patient reaction to the technology in the context of diabetes care. UPMC has deployed a secure Web-based patient portal, UPMC HealthTrak. We implemented UPMC HealthTrak in the ambulatory setting and assessed its impact on patient-practice communication. We conducted 10 90-minute focus groups (five pre- and five postimplementation) to assess patient reaction to UPMC HealthTrak. Focus groups were analyzed using grounded theory techniques. During the period September 2004-January 2007, there was no significant change in number of patient encounters or telephone calls received in our office, but the number of HealthTrak messages increased. Our 39 pre- and postimplementation focus group participants felt that the system would enhance communication with the office, and that the reminder system would be helpful. They also liked having access to laboratory tests remotely. They were frustrated when tests were not released and messages not answered. A Web-based patient portal can be integrated into a clinical office, although patients may not quickly change communication patterns. Patients are responsive to technology. Future work should focus on diabetes-related outcomes assessment and intensifying interventions.

Although decisions regarding end-of-life care are personal and important, they may be influenced by the ways in which options are presented. To test this hypothesis, we randomly assigned 132 seriously ill patients to complete one of three types of advance directives. Two types had end-of-life care options already checked—a default choice—but one of these favored comfort-oriented care, and the other, life-extending care. The third type was a standard advance directive with no options checked. We found that most patients preferred comfort-oriented care, but the defaults influenced those choices. For example, 77 percent of patients in the comfort-oriented group retained that choice, while 43 percent of those in the life-extending group rejected the default choice and selected comfort-oriented care instead. Among the standard advance directive group, 61 percent of patients selected comfort-oriented care. Our findings suggest that patients may not hold deep-seated preferences regarding end-of-life care. The findings provide motivation for future research examining whether using default options in advance directives may improve important outcomes, including patients’ receipt of wanted and unwanted services, resource use, survival, and quality of life.