Risk Factors for PTSD in Surrogate Decision Makers of Critically Ill Patients

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Acting in the capacity of a surrogate decision maker can lead to emotional distress and poor health-related quality of life.

Risk factors for posttraumatic stress disorder (PTSD) among family members and other surrogates who care for and must make decisions on behalf of chronically critically ill patients include high anxiety and depression scores and patient unresponsiveness at or near day 10 of mechanical ventilation, according to the results of a study published in the Annals of the American Thoracic Society.

Critical illness often involves decisions regarding invasive life-sustaining therapies, and because many chronically critically ill people have cognitive impairment, family members are often called on to make these decisions. Acting in the capacity of a surrogate decision maker can lead to emotional distress and poor health-related quality of life. One study showed that as many as 35% of family surrogates experience symptoms of PTSD 6 months after a loved one is admitted to the intensive care unit, compared with 15% who experience anxiety and 6% who experience depression.

Blair Wendlandt, MD, of the University of North Carolina School of Medicine, Chapel Hill, and colleagues performed a secondary analysis of the data from a multicenter randomized trial that included people with chronic critical illness and their surrogates to identify risk factors for symptoms of PTSD among the surrogates. The researchers included markers identified by day 10 of mechanical ventilation in the analysis to determine any association with surrogate PTSD symptoms at day 90 as measured by the Impact of Events Score-Revised (IES-R). The investigators constructed multivariable linear regression models for 26 potential risk factors.

The analysis included 306 surrogates for 224 patients. Of the surrogates, 91 (30%) had an IES-R score ≥33, which is consistent with a diagnosis of PTSD. Of the 26 potential risk factors, only day 10 surrogate Hospital Anxiety and Depression score and patient unresponsiveness, as indicated by a Richmond Agitation Sedation Scale score of -5 or -4, showed a significant association with surrogate IES-R score.

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The study is limited by its observational nature, which hinders the ability to establish causality. Furthermore, the investigators were unable to measure PTSD symptoms in surrogates prior to patient admission to the intensive care unit to eliminate PTSD that may have been caused by other life events.

The authors suggest that targeting individuals who are at highest risk for PTSD with support services early in the course of chronic critical illness could improve the success of such interventions.


Wendlandt B, Ceppe A, Choudhury S, et al. Risk factors for post-traumatic stress disorder symptoms in surrogate decision-makers of patients with chronic critical illness [published online September 10, 2018]. Ann Am Thorac Soc. doi:10.1513/AnnalsATS.201806-420OC