Associations Between Family-Assessed Quality-of-Dying-and-Death Latent Classes and Bereavement Outcomes for Family Surrogates of ICU Decedents

Abstract

Objectives: To examine associations between family surrogates’ bereavement outcomes and four previously determined quality of dying and death (QODD) latent classes (high, moderate, poor-to-uncertain, and worst). Design: Prospective, longitudinal, observational study. Setting: Medical ICUs at two academically affiliated medical centers in Taiwan. Patients/Participants: Three hundred nine family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Health Evaluation II scores > 20) from a disease. Interventions: None. Measurements and Main Results: Participants were assessed by the depression and anxiety subscales of the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, 11 items of the Prolonged Grief Disorder (PGD) scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey at 1, 3, 6, 13, 18, and 24 months post-loss. We simultaneously examined associations of four QODD latent classes with physical and mental health-related quality of life (HRQOL) and symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and PGD assessed over 24 bereavement months using multivariate hierarchical linear modeling. Surrogates’ distinct QODD latent classes assessed at 1-month post-loss were significantly associated with bereavement outcomes, except for physical HRQOL and PGD symptoms. Significantly more depressive symptoms and worse mental HRQOL (β [95% CI]) were reported by bereaved surrogates in the moderate (1.958 [1.144–2.772], –2.245 [–3.961 to –0.529]), poor-to-uncertain (2.224 [1.438–3.010], –7.026 [–8.683 to –5.369]), and worst (2.081 [1.215–2.964], –4.268 [–6.096 to –2.440]) QODD classes than those in the high QODD class. Bereaved surrogates in the moderate (2.095 [1.392–2.798]) and poor-to-uncertain (0.801 [0.123–1.480]) QODD classes reported more anxiety symptoms, whereas those in the poor-to-uncertain QODD class suffered more PTSD symptoms (2.889 [1.005–4.774]) than those in the high QODD class. Conclusions: The four distinct QODD latent classes were significantly associated with ICU family surrogates’ bereavement outcomes, suggesting targets to improve end-of-life care quality in ICUs.