Risk Factors For Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of Patients With Chronic Critical Illness PDF

ANNALSATS Articles in Press. Published on 10-September-2018 as 10.1513/AnnalsATS.
201806-420OC
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Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of

Patients with Chronic Critical Illness
Blair Wendlandt1, MD; Agathe Ceppe1, MS; Summer Choudhury1, MPH; Judith E. Nelson5, MD,
JD; Christopher E. Cox2, MD, MPH; Laura C. Hanson1, MD, MPH; Marion Danis3, MD; James A.
Tulsky4, MD; Shannon S. Carson1, MD
1
University of North Carolina School of Medicine, Chapel Hill, North Carolina; 2Duke University
Medical Center, Durham, North Carolina; 3National Institutes of Health, Bethesda, Maryland;
4
Dana Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School,
Boston, Massachusetts; 5Memorial Sloan Kettering Cancer Center and Weill-Cornell Medical
College, New York, New York
Corresponding Author:
Blair Wendlandt, MD
130 Mason Farm Road CB#7020
Chapel Hill, NC 27599
Phone: 919-966-2531 Fax: 919-966-7013
Email: blair.wendlandt@unchealth.unc.edu
Author Contributions: BW, AC, and SCa had full access to all data and are responsible for the
integrity and the accuracy of the data analysis. BW, JN, CC, LH, MD, JT, and SCa were
responsible for study design. BW, AC, SCh, JN, CC, LH, MD, JT, and SCa were responsible for
acquisition, analysis, or interpretation of the data. BW, AC, SCh, JN, CC, LH, MD, JT, and SCa
critically revised the manuscript.
Word Count: 2732
Funding: This project was supported by institutional training grant 2Y32HL007106-41 and R01-
NR012413
Declaration of Interests: The authors declare no competing interests.
Running Title: Risk Factors for Post-Traumatic Stress in CCI Surrogates
Key Words: Critical Care, Emotional Stress, Surrogate decision-maker, Mechanical ventilation
Copyright © 2018 by the American Thoracic Society

ANNALSATS Articles in Press. Published on 10-September-2018 as 10.1513/AnnalsATS.201806-420OC
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Abstract
Rationale: Chronically critically ill patients are often dependent on family members for
surrogate decision-making, and these surrogates are at high risk for emotional distress. We
hypothesized that patient- and surrogate-specific risk factors for surrogate post-traumatic
stress disorder (PTSD) symptoms can be identified early in the course of chronic critical illness.
Objectives: To identify risk factors for (PTSD) symptoms in surrogate decision-makers of
chronically critically ill patients.
Methods: We performed a secondary analysis of the database from a multicenter randomized
trial of a communication intervention for CCI patients and surrogates. Variables pre-selected for
plausible mechanism for increasing PTSD symptoms and identifiable by day 10 of mechanical
ventilation were included in the analysis for association with surrogate PTSD symptoms at 90
days as measured by the Impact of Events Score-Revised (IES-R). Patient factors included
demographics, insurance status, baseline functional status, chronic co-morbidities, illness
severity, and presence of advance directive. Surrogate variables included demographics,
education level and employment, religion, relationship to patient, and Hospital Anxiety and
Depression score (HADS) measured at enrollment. Multivariable linear regression models were
then constructed for 26 potential risk factors, including biologically or mechanistically plausible
confounders for each, with IES-R score as the outcome. All models were adjusted for multiple
respondents, using a mixed model, considering the patients as a random factor.
Results: Our analysis included 306 surrogates for 224 patients. Forty-nine percent of patients
were female, and mean age was 59 years (95% CI 56.4 to 60.7). Seventy-one percent of
surrogates were female, and mean age was 51 years (95% CI 49.3 to 52.4). After examining

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each potential risk factor in a separate multivariable model, only day 10 surrogate HADS score
(coefficient 1.02, 95% CI 0.73 to 1.30) and patient unresponsiveness (coefficient 8.39, 95% CI
0.83 to 15.95) were associated with higher IES-R scores.
Conclusions: Among surrogate decision-makers for chronically critically ill patients, high anxiety
and depression scores and patient unresponsiveness on or near day 10 of mechanical
ventilation are risk factors for PTSD symptoms at 90 days.
Abstract Word Count: 331

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Chronic critical illness (CCI) is a syndrome characterized by prolonged dependence on life-
sustaining therapies following resolution of the acute phase of organ failure (1). Estimates of
one-year mortality range between 50% and 60%, and of those patients who require prolonged
mechanical ventilation (PMV) and are alive at the end of one year, only 10% will be living at
home with functional independence (2). Critical illness represents a major life-altering event,
and is often fraught with a series of decisions that must be made regarding invasive life-
sustaining therapies. However, because of ongoing cognitive dysfunction (3), chronically
critically ill patients are rarely capable of communication and decision-making in the intensive
care unit (ICU). As such, many patients with CCI become depend upon family members to assist
with decision-making about life-sustaining care.
Acting as a family surrogate decision-maker is associated with a number of negative
consequences, including a subjective sense of overload and burden, emotional distress, and
poor health-related quality of life (4, 5). Specific stressors that surrogate decision-makers
frequently identify include uncertainty regarding the patient’s prognosis, perception of conflict
with the provider team, and a sense of guilt surrounding medical decisions (6). Perhaps as a
result, anxiety, depression, and post-traumatic stress disorder (PTSD) have all been described in
family decision makers of patients with critical illness (4, 7). One longitudinal cohort study
found that 35% of family surrogates experienced symptoms of post-traumatic stress 6 months
following a loved one’s admission to the ICU as compared to 15% who experienced anxiety and
6% who experienced depression (8). When comparing patient-caregiver dyads, symptoms of
PTSD are higher and persist for longer in the caregivers (9). Identifying potential risk factors for
surrogate PTSD symptoms early in the course of a loved one’s chronic critical illness could

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enable physicians, nurses, and social workers to more effectively target support services
towards those at highest risk.
Given that PTSD symptoms are common and persistent amongst surrogates for CCI
patients, we sought to identify potential risk factors present early in the course of CCI that can
help identify family members who might benefit from early intervention. We hypothesized that
both patient-specific and surrogate decision-maker-specific risk factors for surrogate PTSD
symptoms at 90 days can be identified on day 10 of patient mechanical ventilation.
Methods
We performed a secondary analysis of the data from the Supportive Information Team (SIT)
study, a multicenter, randomized controlled trial to determine whether family informational
and support meetings would improve emotional outcomes for family surrogates of CCI patients
when compared with routine care (10). We enrolled patients from two tertiary care centers and
a community hospital in the Southeastern United States and an urban tertiary care center in the
Northeastern United States between October 2010 and November 2014. Participation was
offered to patients in four medical ICUs who were ≥21 years of age with at least seven days of
mechanical ventilation, and to two categories of surrogate decision-makers: The primary
surrogate with responsibility for health care decision-making if the patient lacked capacity, and
additional family decision-makers if they also participated in health-care decision-making.
Among the exclusions were patients who were ventilated for >7 days at an outside hospital, or
had chronic neuromuscular disease, trauma, or burns. We assessed patient and family

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characteristics measured on or near day 10 of mechanical ventilation for association with
surrogate PTSD symptoms measured 90 days after enrollment in the clinical trial. The protocol
for this secondary analysis of existing data was reviewed and approved by the University of
North Carolina Institutional Review Board.
Potential Risk Factors
We selected 26 potential patient and surrogate decision-maker-specific risk factors for
surrogate PTSD symptoms from the larger database a priori based on prior literature and a
plausible mechanistic role in the development of PTSD symptoms. Potential patient factors
included race, functional status, severity of acute illness, selected co-morbid diagnoses, and
level of alertness. Surrogate factors were age, demographics, religious beliefs, relationship to
patient, and symptoms of anxiety and depression. Surrogate race was self-reported using fixed
categories during the interviews with family members and was included because of its
association with higher symptoms of depression (11). Functional status prior to admission was
scored as a summary of the total number of activities of daily living (ADLs) and instrumental
activities of daily living (IADLs) that the patient was able to perform as reported by their
primary surrogate (12, 13). Severity of illness was defined by generating an estimate of one-
year mortality using the ProVent 14 score (14). Select chronic co-morbidities used in the
analysis included chronic cerebrovascular disease or hemiplegia, liver disease, history of end-
stage renal disease, or cancer. The Richmond Agitation Sedation Scale (RASS) score (15) was
measured for each patient by a trained research assistant to assess the patient’s level of
alertness at the time of enrollment in the clinical trial. For analyses the RASS score was

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categorized as RASS -5 or -4 (unresponsive), RASS -3 to -1 (arousable), and RASS ≥0 (awake).
Surrogate symptoms of anxiety and depression were assessed at the time of enrollment
using the Hospital Anxiety and Depression Scale (HADS) (16, 17). The HADS is a validated
instrument designed to measure symptoms of anxiety and depression in hospitalized patients,
and has been utilized for family subjects in the ICU setting (7). The HADS consists of two
subscales (anxiety and depression), each containing seven items with a score ranging from 0
(lowest level of symptoms) to 3 (highest level of symptoms). A score ≥11 on either subscale
suggests the presence of anxiety and/or depression disorder(s); scores from 8 to 10 may
represent “borderline” symptom levels. Additional information on available variables can be
found in descriptions of the SIT clinical trial (10).
Primary Outcome Measure
The presence and severity of surrogate PTSD symptoms were defined using the Impact of
Events Scale-Revised (IES-R), a validated instrument that has been used to evaluate the
experience of families of ICU survivors and non-survivors (18, 19). The IES-R includes 22 items in
3 subscales, thought intrusion, avoidance, and hyperarousal, rated for “how distressing each
difficulty has been” over the past seven days from 0 (not at all) to 4 (extremely). Subscales are
scored individually (mean of item scores) and then summed. Total scores for IES-R range from 0
to 88; a score ≥33 is a cut-off used to suggest PTSD-related symptoms at a level consistent with
a probable diagnosis of PTSD. The IES-R was administered to all available enrolled surrogate
decision-makers beginning 90 days following study enrollment.

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Analyses
Descriptive statistics were analyzed using mean and standard deviation for continuous variables
with normal distribution or median and interquartile range for variables with non-normal
distribution. Categorical variables were reported as proportions. To examine the association
between each preselected potential risk factor and heightened surrogate PTSD symptoms at 90
days, we constructed individual multiple linear regression models with each potential risk factor
as the exposure and the IES-R score as the outcome. Potential confounders were selected for
each model by investigators (BW, SCa) based on biologic or mechanistic plausibility. All models
were adjusted for multiple respondents, using a mixed model, considering the patients as a
random factor. All tests were 2-sided, with a significance level of 0.05. Analysis was performed
using SAS 9.4 (SAS Institute Inc).
Results
The original database contained information for 365 surrogate decision makers and 256
associated CCI patients. Potential risk factor variables were measured on day 10 ± 3.4 of
mechanical ventilation. Ninety-day follow-up was complete for 306 (84%) of enrolled
surrogates, corresponding to 224 patients. Seventy-one percent of surrogates were female, and
mean age was 51 years old. The majority of surrogates were either the spouse/partner or adult
child of the patient. Mean HADS score was 16 (95% CI 15.1-16.9). Ninety-one of 306 family
surrogates (30%) had an IES-R score ≥33, consistent with a probable diagnosis of PTSD, at the
90-day follow-up interview. Complete surrogate characteristics are shown in Table 1.

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About half of the patients (49%) were female and were slightly older than surrogates
with a mean age of 59 years. Mean ADL score in the two weeks prior to hospital admission was
5 (95% CI 4.6-5.2), indicating relatively high functionality. Liver disease (24%) and cancer (13%)
were the most common co-morbid conditions, and one-year mortality risk as estimated by the
ProVent14 score was 62% (95% CI 58.6-64.8). Complete patient characteristics are shown in
Table 2.
Preselected patient- and surrogate-related characteristics were then assessed for
association with 90-day surrogate IES-R score. A complete list of variables included in the
analysis are shown in Tables 3 (surrogate characteristics) and 4 (patient characteristics), along
with the associated mean change in IES-R score as represented by a beta coefficient. Covariates
included in the individual models are listed in Tables 3 and 4; the associated beta coefficient
and 95% confidence interval for each covariate is available in the supplement. Starting with 26
pre-selected potential risk factors, only two – day 10 surrogate HADS score and patient
unresponsiveness as indicated by a RASS score of -5 or -4 – were significantly associated with
caregiver PTSD symptoms at 90 days. Patient RASS score was negatively associated with
surrogate IES-R score, with more surrogate PTSD symptoms for patients with a RASS of -5 or -4
(unresponsive) as compared to surrogates of patients with a RASS of 0 or above (awake)
(coefficient 8.39, 95% CI 0.83 to 15.95). HADS (measured on day 10 ± 3.4 of mechanical
ventilation) and 90-day PTSD symptoms were positively associated so that each one-point
increase in HADS, indicating worse anxiety and depression, was associated with a nearly one-
point increase in IES-R (coefficient 1.02, 95% CI 0.73 to 1.30). Predicted surrogate IES-R score by
day 10 HADS score from the linear regression model is shown in Figure 1.

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In a post hoc sensitivity analysis, day 10 HADS score remained a risk factor for surrogate
PTSD symptoms even after adjusting for events that occurred later the ICU stay or after hospital
discharge including death by the time of 90-day family interview and study group from the
clinical trial (coefficient 1.08, 95% CI 0.81 to 1.35).
Discussion
In this analysis of potential risk factors for PTSD symptoms in surrogate decision-makers of
patients with chronic critical illness, surrogate anxiety and depression (HADS score) and patient
unresponsiveness on or near day 10 of mechanical ventilation were risk factors for increased
surrogate PTSD symptoms at 90 days. No variables pertaining to surrogate or patient
demographics, premorbid patient health status, or events of the hospitalization prior to ICU
admission were found to be significant. HADS is a simple scale that can be administered to
family members in a few minutes, and level of arousal and responsiveness is routinely assessed
in all patients.
Family surrogate decision-makers with higher HADS scores near day 10 of mechanical
ventilation, especially when their loved one is unresponsive while they are at the bedside, can
be targeted for early interventions to help them cope with severe illness and decision-making.
Interventions to reduce long-term emotional distress in surrogate decision-makers have met
with limited success in rigorous clinical trials to date (10, 19-22). Targeting those individuals
who are at highest risk and implementing interventions early in the course of CCI could enhance
the success of such interventions, and this could be facilitated by using the risk factors

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identified in this study. A simple means to identify higher risk family decision-makers could also
help to deploy intervention resources in a more focused and efficient manner.
The finding that unresponsiveness remained a risk factor even after adjusting for HADS
is an interesting one for which there are several possible explanations. A RASS score of -4 or -5
at day 10 of mechanical ventilation could reflect deep sedation due to severe hypoxemia or
ventilator dyssynchrony or due to advanced encephalopathies related to underlying acute
diseases. Trauma patients were excluded from the SIT study, and acute cerebral vascular events
were unusual in this medical ICU population. One explanation for this finding is that
unresponsiveness is a surrogate for advanced illness and poor prognosis. However, other illness
severity measures were not significantly associated. Another explanation is that a patient’s
unresponsiveness over days is an extremely distressing experience for the family, secondary to
either the fact that it is an overt and constant reminder of the critical nature of their loved
one’s illness and/or the fact that it places a heavier burden on the surrogate decision-maker
without guidance from the patient (23).
Our findings provide novel insight into the identification of surrogates at highest risk for
emotional distress following a loved one’s discharge from the ICU. A 2005 study of caregivers in
the general ICU population in France measured a limited number of variables and found that
female sex, cancer in the ICU patient, and being a child of the ICU patient were independently
associated with increased risk for post-traumatic stress symptoms, but as chronic critical illness
represents a distinct syndrome with a potentially separate profile for long-term surrogate
distress, these findings may not be generalizable to the CCI population. Reliance on these
demographic factors alone to identify surrogates at risk for heightened PTSD symptoms could

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result in omission of high-risk surrogates in other categories, such as high-risk male surrogates.
Furthermore, some of the factors identified in that study, such as surrogate perception that
information was incomplete or patient death in the ICU, occur later in the course of critical
illness and thus represent less useful targets for screening and intervention during the patient’s
ICU course. Another study of a Greek cohort of family caregivers for patients admitted to the
ICU found that female sex and baseline anxiety were significant joint predictors of the
development of PTSD symptoms prior to hospital discharge, although this study was limited by
small sample size with just 32 caregivers (24). Investigation of a German cohort found that
higher relationship satisfaction between the patient and the surrogate was protective against
post-traumatic stress in the CCI population, but this study was limited by low follow up rate
with only 12% of enrolled patient-surrogate dyads available for 6 month follow up (25). A
recent study by Torke and colleagues demonstrated that baseline distress as measured by the
Kessler six-item Psychological Distress Scale was positively associated with post-traumatic stress
at 6-8 weeks following hospitalization for family surrogate decision-makers of older adults
admitted to either the ICU or the general wards (26). As compared to the population in this
study, our patients had a much higher severity of illness and worse long-term outcomes, and
family members had a more significant degree of PTSD symptoms. The SIT study is the largest
completed randomized controlled trial of CCI patients and surrogates to date, thus providing a
rich dataset and a unique opportunity to explore potential risk factors for surrogate PTSD in this
population.
Our study has several limitations. The observational nature of the analysis limits our
ability to fully elucidate the cause-and-effect nature of the observed risk factors and the

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outcome of interest. Additionally, because we are unable to measure PTSD symptoms prior to
patients’ hospital admission, we do not know whether surrogates experienced significant PTSD
symptoms at baseline due to other life events. However, inclusion of anxiety and depression as
a variable in our analysis at least partially accounts for this possibility as there is some overlap
between anxiety symptoms and PTSD symptoms. We chose to evaluate 26 variables selected
from an existing database based on clinical intuition and previously published literature, and it
is possible that there are additional risk factors that were not measured or analyzed. Finally,
our database consists of family members who consented to participation in a clinical trial and
patients who were admitted to medical ICUs at mostly large academic medical centers.
Therefore results may not be generalizable to all chronically critically ill patients and surrogates.
In conclusion, among surrogate decision-makers of patients with chronic critical illness,
high surrogate anxiety and depression scores and patient unresponsiveness on or near day 10
of mechanical ventilation are risk factors for PTSD symptoms that are identifiable early in the
course of CCI. Identifying risk factors for surrogate PTSD symptoms early in the course of a
loved one’s chronic critical illness could ultimately enable physicians, nurses, and social workers
to more effectively target support services towards those at highest risk. Further work is
needed to determine whether there are elements of clinician support and communication that
mitigate PTSD risk in surrogates and to use this knowledge to develop targeted interventions.

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Table 1: Characteristics of Surrogate Decision-Makers at Enrollment
Characteristic Surrogates
(n=306)
Age, mean (95% CI), y 51 (49.3-52.4)
Female sex, No. (%) 218 (71)
Race, No. (%)
Black 72 (24)
Caucasian 193 (63)
Other 41 (13)
Ethnicity, No. (%)
Hispanic or Latino) 38 (12)
Not Hispanic or Latino) 267 (88)
Marital Status, No. (%)
Married / Live with partner 207 (68)
Separated / Divorced 38 (12)
Single / Widowed 61 (20)
Education, No. (%)
Advanced Degree 53 (17)
College Graduate 82 (27)
Some College 84 (28)
High School or less 86 (28)
Employment, No. (%)
Disabled from employment 30 (10)
Employed / Student 168 (55)
Homemaker 22 (7)
Retired 58 (19)
Primary Surrogate Income, No. (%)
< $15,000 31 (14)
$15,000 - $39,999 41 (19)
$40,000 - $100,000 71 (33)
> $100,000 25 (12)
Prefer not to answer 49 (23)
Religion, No. (%)
Catholic 56 (18)
Jewish 17 (6)
Protestant 200 (66)
Other 16 (5)
None 16 (5)
Relationship, No. (%)
Child 109 (36)
Parent 41 (13)

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Sibling 37 (12)
Spouse/Partner 100 (33)
Other 19 (6)
Number of decision makers per patient, No. (%)
1 152 (50)
2 or more 154 (50)
Designated as Legal Healthcare Power of Attorney, No. (%) 186 (61)
Hospital Anxiety and Depression Scale score at day 10 of
mechanical ventilation, mean (95% CI)
Total 16 (15.1-16.9)
Anxiety Subscale 10 (9-10.1)
Depression Subscale 7 (6-7)

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Table 2: Characteristics of Patients at Enrollment
Characteristic Patients
(n=224)
Age, mean (95% CI), y 59 (56.4-60.7)
Female sex, No. (%) 109 (49)
Race, No. (%)
Black 53 (24)
Caucasian 138 (63)
Unavailable 17 (8)
Other 10 (5)
Insurance, No. (%)
Medicare 107 (48)
Medicaid 20 (9)
Commercial 76 (34)
None 21 (9)
Language
English 197 (90)
Spanish 12 (6)
Other 9 (4)
History of liver disease, No. (%) 29 (13)
History of cancer, No. (%) 53 (24)
History of stroke, No. (%) 20 (9)
History of end stage renal disease, No. (%) 9 (4)
Presence of advance directive at enrollment, No. (%) 31 (14)
Activities of daily living score, mean (95% CI)a 5 (4.6-5.2)
Instrumental activities of daily living score, mean (95% CI)b 16 (14.8-16.9)
Hospital length of stay prior to trial enrollment, mean (95% 13 (11.8-13.5)
CI), d
Cardiac arrest prior to enrollment, No. (%) 8 (4)
1-yr mortality as predicted by ProVent score, mean % (95% 62 (58.6-64.8)
CI)
Richmond Agitation Sedation Scale at enrollment, No. (%)
-5 or -4 (unresponsive) 95 (44)
-3 to -1 (arousable) 81 (38)
0 and above (awake) 38 (18)
a
The range is 0 (dependent) to 6 (independent) in 6 activities.
b
The range is 8 (dependent) to 31 (independent) in 8 activities.

Page 20 of 35
Table 3: Results of Multivariable Analysis, Surrogate Decision-Maker-related variables€

Exposure Variable Coefficient (95%CI)^ Potential Confounders
Surrogate religion
Surrogate employment
Surrogate Age -0.08 (-0.25 to 0.08)
Surrogate education
Surrogate HADS*
Surrogate Race Surrogate religion
Black 1.86 (-3.44 to 7.15) Surrogate employment
Surrogate education
Other 3.96 (-2.32 to 10.25) Surrogate marital status
White --- Surrogate HADS*
Surrogate religion
Surrogate female sex 2.47 (-1.82 to 6.75)
Surrogate education
Surrogate HADS*
Surrogate religion
Surrogate Hispanic or Surrogate employment
-1.68 (-8.49 to 5.12)
Latino Surrogate education
Surrogate HADS*
Surrogate Marital Status
Married/Live with
-2.34 (-7.38 to 2.71) Surrogate race
partner
Surrogate religion
Separated/Divorced -0.86 (-7.78 to 6.07) Surrogate HADS*
Single /Widowed ---
Surrogate Level of Surrogate race
Education Surrogate ethnicity
Advanced Degree -1.16 (-7.45 to 5.14) Surrogate sex
College Graduate -1.05 (-6.59 to 4.49) Surrogate religion
Some College 1.24 (-4.2 to 6.69)
Surrogate HADS*
Surrogate marital status
High School or less ---
Patient insurance
Surrogate Employment Surrogate race
Disabled 5.79 (-3.22 to 14.8) Surrogate ethnicity
Surrogate sex
Employed/Student 3.45 ( -3.4 to 10.31) Surrogate age
Homemaker -1.48 (-11.09 to 8.12) Surrogate education
Retired 2.95 (-5.63 to 11.53) Surrogate HADS*

Page 21 of 35

Unemployed --- Patient insurance
Level of income of Surrogate race
Primary Surrogate** Surrogate ethnicity
Surrogate sex
Prefer not to answer -6.3 (-15.16 to 2.57)
Surrogate age
> $100,000 -3.4 (-14.24 to 7.43) Surrogate education
$40,000-$100,000 -5.44 ( -14.18 to 3.3)
$15,000 - $39,999 -7.57 ( -16.43 to 1.29) Patient insurance
< $15,000 --- Surrogate HADS*
Surrogate Religious
Beliefs
Catholic 6.54 (-4.24 to 17.32) Surrogate race
Surrogate ethnicity
Jewish 6.97 (-5.75 to 19.7)
Surrogate sex*
Protestant 6.05 (-3.54 to 15.63) Surrogate age
Other 13.13 (0.64 to 25.62)
None ---
Surrogate Relationship
to Patient
Child -0.65 (-8.79 to 7.5)
Surrogate HADS*
Parent 2.44 (-6.58 to 11.47)
Patient age
Sibling 2.6 (-6.36 to 11.57)
Spouse/Partner 1.89 (-6.12 to 9.9)
Other ---
Two or more surrogate
decision makers per -3.63 (-7.74 to 0.48) Surrogate HADS*
patient
Patient Cancer
Surrogate Designation
Patient ADLs
as Legal Healthcare -2.22 (-6.45 to 2.0)
Patient iADLs
Power of Attorney
Patient HADS*

Page 22 of 35
Surrogate Race
Surrogate Ethnicity
Surrogate Sex
Surrogate Age
Surrogate Employment
Surrogate Hospital Status
Anxiety and Depression 1.02 (0.73 to 1.3)* 2+ Surrogates Per Patient
Scale Relationship to patient
Patient age
Patient Advance directive
Patient ADLs
Patient Liver disease
Patient Cancer
^
For continuous variables, the coefficient represents mean change in IES-R score per one unit
increase. For categorical variables, the coefficient represents mean difference in IES-R score as
compared to the reference group. €All models were adjusted for multiple respondents
*p<0.05
**Model includes primary surrogate decision-makers only
--- Indicates reference group

Page 23 of 35
Table 4: Results of Multivariable Analysis, Patient-related variables€

Exposure Variable Coefficient (95%CI)^ Potential Confounders
Patient ADLs
Patient iADLs
Patient cancer
Patient age -0.05 (-0.18 to 0.08) Patient liver disease
Patient stroke
Patient ESRD
Patient advance directive
Surrogate HADS*
Patient female sex -2.01 (-6.59 to 2.58)
Patient Insurance Patient stroke
Commercial 2.2 (-5.3 to 9.69) Patient ESRD
Medicaid 1.81 (-7.73 to 11.35) Patient cancer
Medicare 0.22 (-7.07 to 7.51) Patient liver disease
None --- Patient advance directive
Surrogate
Patient HADS*
age
Patient insurance
Patient History of Liver
2.48 (-4.29 to 9.25) Patient ADLs
Disease
Patient iADLs
Surrogate HADS*
Patient
PatientRASS*
age
Patient race
Patient ethnicity
Patient History of Patient insurance
-4.45 (-9.53 to 0.62)
Cancer Patient advance directive
Patient ADLs
Patient iADLs
Surrogate HADS*
Patient age
Patient race
Patient insurance
Patient History of Stroke
-1.4 (-9.26 to 6.45) Patient advance directive
Patient ADLs
Patient iADLs
Surrogate HADS *

Page 24 of 35
Patient age
Patient race
Patient insurance
Patient History of End-
Patient advance directive
Stage Renal Disease -8.58 (-20.94 to 3.79)
Patient ADLs
Patient iADLs
Surrogate HADS*
Patient RASS*
Patient age
Patient race
Patient ethnicity
Patient insurance
Presence of Advance Patient cancer
-4.74 (-9.82 to 0.34)
Directive Patient ESRD
Patient stroke
Patient ADLs
Patient iADLs
Surrogate HADS*
Patient Age
Patient insurance
Patient cancer
Activities of Daily Living Patient ESRD
0.14 (-1.32 to 1.6)
(ADLs) Patient liver disease
Patient stroke
Patient iADLs
Surrogate HADS*
Patient liver disease
Pre-ICU Hospital Length
0.01 (-0.22 to 0.25) Surrogate HADS*
of Stay
Patient age
Patient Pre-ICU LOS

One-Year Mortality as
Surrogate HADS*
Estimated by ProVent14 -0.04 (-0.15 to 0.08)
Patient RASS*
Score
Patient ADLs
Richmond Agitation
Sedation Scale at Patient liver disease
enrollment Patient ESRD
-5 or -4 8.39 (0.83 to 15.95) Patient ProVent
(unresponsive)
-3 to -1 (arousable) 2.48 (-5.18 to 10.15) Surrogate HADS*
0 and above (awake) ---

Page 25 of 35
^
For continuous variables, the coefficient represents mean change in IES-R score per one unit
increase. For categorical variables, the coefficient represents mean difference in IES-R score as
compared to the reference group.
€
All models were adjusted for multiple respondents
*p<0.05
**Model includes primary surrogate decision-makers only

Page 26 of 35
Figure 1
Figure 1: Predicted IES-R Score from logistic regression by HADS score, adjusted for multiple
respondents.

Page 27 of 35
Online Data Supplement
Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of

Patients with Chronic Critical Illness
Blair Wendlandt, MD; Agathe Ceppe, MS; Summer Choudhury, MPH; Judith E. Nelson, MD, JD;
Christopher E. Cox, MD, MPH; Laura C. Hanson, MD, MPH; Marion Danis, MD; James A. Tulsky,
MD; Shannon S. Carson, MD

Page 28 of 35
Supplementary Table E1: Results of Multivariable Analysis of association of IES-R score with Surrogate
Decision-Maker-related variables, with coefficients and 95% confidence intervals for confounders€
Potential Risk Factor Beta coefficient

Covariate Covariate Category P value
Adjusted Beta coefficient (95% CI) ^ (95% CI) ^
Advanced Degree -1.82 (-7.89 to 4.26) 0.68

Surrogate Education College Graduate -1.23 (-6.5 to 4.04) 0.68
Some College 1.42 (-3.82 to 6.66) 0.68
High School or Less ---
Disabled 5.87 (-3.01 to 14.75) 0.38
Employed/Student 4.15 (-2.76 to 11.06) 0.38
Surrogate Employment Homemaker -1.51 (-11.03 to 8.01) 0.38
Surrogate Age Retired 3.33 (-5.13 to 11.78) 0.38
-0.08 (-0.25 to 0.08) Unemployed ---
Catholic 5.54 (-4.08 to 15.15) 0.47
Jewish 6.09 (-5.58 to 17.75) 0.47
Surrogate Religion Other 11.14 (-0.65 to 22.93) 0.47
Protestant 6.06 (-2.69 to 14.8) 0.47
None ---
Surrogate Age -0.08 (-0.25 to 0.08) 0.32
Surrogate HADS 0.96 (0.72 to 1.19) <.0001
College Graduate -0.77 (-6.02 to 4.47) 0.76
Surrogate Education
Some College 1.59 (-3.67 to 6.85) 0.76
Employment 5.41 (-3.4 to 14.23) 0.30
Surrogate Female Sex Surrogate Employment Homemaker -2.57 (-12.07 to 6.93) 0.30
Retired 1.68 (-6.01 to 9.36) 0.30
2.47 (-1.82 to 6.75) Unemployed ---
Catholic 3.37 (-6.13 to 12.86) 0.61
Jewish 4.22 (-7.25 to 15.69) 0.61
Protestant 3.87 (-4.75 to 12.49) 0.61
None ---
Surrogate Education
Some College 1.61 (-3.7 to 6.91) 0.82
Disabled 5.33 (-3.56 to 14.22) 0.44
Surrogate Employment Employed/Student 4.07 (-2.91 to 11.06) 0.44
Homemaker -1.31 (-10.97 to 8.36) 0.44
Retired 2.23 (-5.56 to 10.01) 0.44
Surrogate Race
Unemployed ---
Black 1.86 (-3.44 to 7.15) Married/Live with partner -2.2 (-7.33 to 2.93) 0.68
Surrogate Marital
Separated/Divorced -0.91 (-7.96 to 6.13) 0.68
Other 3.96 (3.96 to 10.25) Status
Single/Widowed ---
White --- Catholic 3.86 (-5.63 to 13.35) 0.62
Surrogate Religion
Jewish 5.07 (-6.66 to 16.8) 0.62

Page 29 of 35
Other 9.38 (-2.44 to 21.19) 0.62

Protestant 5.04 (-3.73 to 13.81) 0.62
None ---
Surrogate Education
Some College 1.34 (-3.92 to 6.61) 0.77
Disabled 5.22 (-3.61 to 14.05) 0.34
Employed / Student 3.87 (-3.06 to 10.8) 0.34
Surrogate Hispanic or Latino Surrogate Employment Homemaker -2.19 (-11.69 to 7.3) 0.34
Ethnicity
Retired 1.62 (-6.1 to 9.34) 0.34
-1.68 (-8.49 to 5.12) Unemployed ---
Catholic 4.52 (-5.15 to 14.18) 0.63
Jewish 3.87 (-7.62 to 15.37) 0.63
Protestant 4.34 (-4.24 to 12.93) 0.63
None ---
Disabled 5.68 (-2.91 to 14.27) 0.44
Retired 2.7 (-4.87 to 10.27) 0.44
Unemployed ---
Black 1.93 (-3.37 to 7.22) 0.37
Surrogate Race Other 4.2 (-2.02 to 10.42) 0.37
White ---
Catholic 4.45 (-4.97 to 13.87) 0.56
Jewish 5.48 (-6.1 to 17.06) 0.56
Protestant 5.63 (-3.04 to 14.3) 0.56
Surrogate Marital Status None ---
Married/Live with partner Disabled 5.25 (-3.72 to 14.22) 0.45
-2.34 (-7.38 to 6.07)
Separated/Divorced Homemaker -1.6 (-11.29 to 8.08) 0.45
-0.86 (-7.78 to 6.07) Retired 2.12 (-5.71 to 9.96) 0.45
Unemployed ---
Single/Widowed Married/Live with partner -2.74 (-7.96 to 2.48) 0.57
--- Surrogate Marital
Status
Single/Widowed ---
Black 1.92 (-3.48 to 7.33) 0.27
White ---
Catholic 4.65 (-5.27 to 14.58) 0.68
Jewish 5.89 (-5.91 to 17.68) 0.68
Protestant 4.61 (-4.31 to 13.52) 0.68
None ---
Surrogate Sex Female 2.1 (-2.25 to 6.46) 0.34
Patient Insurance Commercial 1.56 (-6.34 to 9.46) 0.89

Page 30 of 35
Medicaid -0.16 (-10.04 to 9.72) 0.89

Patient Insurance Medicare -0.37 (-7.93 to 7.19) 0.89
None ---
Surrogate ethnicity Hispanic or Latino -4.52 (-12.16 to 3.11) 0.24
Disabled 5.25 (-3.72 to 14.22) 0.4475
Retired 2.12 (-5.71 to 9.96) 0.4475
Unemployed ---
Surrogate Education Married/Live with partner -2.74 (-7.96 to 2.48) 0.5688
Surrogate Marital
Status
Advanced Degree Single/Widowed ---
-1.16 (-7.45 to 5.14) Black 1.92 (-3.48 to 7.33) 0.2685
College Graduate
-1.05 (-6.59 to 4.49) White ---
Catholic 4.65 (-5.27 to 14.58) 0.6754
Some College Jewish 5.89 (-5.91 to 17.68) 0.6754
1.24 (-4.2 to 6.69)
High School or Less Protestant 4.61 (-4.31 to 13.52) 0.6754
--- None ---
Commercial 1.56 (-6.34 to 9.46) 0.8931
Medicaid -0.16 (-10.04 to 9.72) 0.8931
Patient Insurance
Medicare -0.37 (-7.93 to 7.19) 0.8931
None ---
Surrogate Education
Some College 1.59 (-3.8 to 6.98) 0.71
Disabled Married/Live with partner -2.44 (-7.78 to 2.9) 0.60
5.79 (-3.22 to 14.8) Surrogate Marital
Status
Single/Widowed ---
Employed/Student
3.45 (-3.4 to 10.31) Black 2.32 (-2.91 to 7.56) 0.26
Homemaker White ---
-1.48 (-11.09 to 8.12) Surrogate Sex Female 1.86 (-2.37 to 6.1) 0.38
Commercial 1.55 (-6.18 to 9.29) 0.90
Retired
2.95 (-5.63 to 11.53) Medicaid -0.04 (-9.77 to 9.7) 0.90
Patient Insurance
Medicare -0.33 (-7.74 to 7.07) 0.90
Unemployed None ---
---
Surrogate Age -0.06 (-0.23 to 0.11) 0.51
Primary Surrogate Income* Advanced Degree -3.23 (-11.07 to 4.6) 0.73
$15,000 - $39,999
-7.57 (-16.43 to 1.29) Surrogate Education Some College 1.05 (-5.67 to 7.77) 0.73

Page 31 of 35
$40,000 - $100,000 Disabled 12.02 (-0.25 to 24.29) 0.13

-5.44 (-14.18 to 3.3)
Income > $100,000 Surrogate Employment Homemaker -1.48 (-14.81 to 11.84) 0.13
-3.4 (-14.24 to 7.43) Retired 3.1 (-8.81 to 15) 0.13
Unemployed ---
Prefer not to answer
Married/Live with partner -0.15 (-7.01 to 6.71) 0.39
-6.3 (-15.16 to 2.57) Surrogate Marital
Status Separated/Divorced 5.35 (-3.92 to 14.62) 0.39
<$15,000 Single/Widowed ---
--- Black 1.87 (-4.25 to 8) 0.51
White ---
Patient Insurance Commercial 4.69 (-4.87 to 14.25) 0.42
Medicaid -2.81 (-14.22 to 8.6) 0.42
Patient Insurance Medicare 2.12 (-7.21 to 11.46) 0.42
None ---
Surrogate Age Surrogate Age -0.02 (-0.24 to 0.2) 0.87
HADS 1.01 (0.7 to 1.31) <.0001
Surrogate Religion Married/Live with partner -1.9 (-7.52 to 3.72) 0.67
Surrogate Marital Separated/Divorced 0.46 (-7.18 to 8.1) 0.67
Catholic 6.54 (-4.24 to 17.32) Status
Single/Widowed ---
Jewish 6.97 (-5.75 to 19.7) Black -0.07 (-5.82 to 5.68) 0.33
Other 13.13 (0.64 to 25.62) White ---
Surrogate Sex Female 5.12 (0.67 to 9.57) 0.03
Protestant 6.05 (-3.54 to 15.63)
Surrogate Age -0.14 (-0.29 to 0.01) 0.07
None --- Surrogate ethnicity Hispanic or Latino -4.81 (-12.81 to 3.18) 0.23
Relationship to Patient
Child 0.65 (-8.79 to 7.5) Surrogate Age -0.12 (-0.29 to 0.04) 0.14
Parent 2.44 (-6.58 to 11.47)
Sibling 2.6 (-6.36 to 11.57)
Spouse/Partner 1.89 (-6.12 to 9.0) Surrogate HADS 0.93 (0.7 to 1.17) <.0001
Other ---
≥2 Surrogates Per Patient
-3.63 (-7.74 to 0.48)
Patient Cancer Yes -3.94 (-8.72 to 0.83) 0.10

Designation as HCPOA Patient Baseline ADLs 0.21 (-1.23 to 1.66) 0.77
-2.22 (-6.45 to 2) Surrogate HADS 0.95 (0.72 to 1.18) <.0001

Patient Baseline iADLs 0.23 (-0.14 to 0.59) 0.22
Patient Cancer Yes -4.15 (-10.15 to 1.85) 0.17
Patient Chronic Liver
Surrogate HADS Yes 1.38 (-6.22 to 8.99) 0.72
Disease
Patient End-Stage
1.02 (0.73 to 1.3) Yes -7.64 (-22.88 to 7.59) 0.32
Renal Disease
Surrogate Employment Disabled 7.05 (-2.79 to 16.9) 0.32

Page 32 of 35

Homemaker -3.26 (-14.86 to 8.35) 0.32
Retired 5.71 (-3.99 to 15.4) 0.32
Unemployed ---
Black 4.99 (-1.69 to 11.67) 0.27
White ---
1 6.82 (-1 to 14.64) 0.11
Patient RASS Score
2 1.94 (-6.03 to 9.9) 0.11
Child -2.14 (-16.15 to 11.86) 0.97
Parent -4.03 (-18.58 to 10.53) 0.97
Relationship to Patient Sibling -2.9 (-14.99 to 9.19) 0.97
Spouse/Partner -1.6 (-12.22 to 9.01) 0.97
Other ---
≥2 Surrogates Per
-3.64 (-9.03 to 1.76) 0.18
Patient
Patient Baseline ADLs -0.89 (-2.25 to 0.48) 0.20
Patient Advance
Yes -1.86 (-9.27 to 5.54) 0.61
Directive
Surrogate Age -0.12 (-0.47 to 0.24) 0.52
Patient Age -0.12 (-0.49 to 0.25) 0.51
ProVent14 Score 0.05 (-0.11 to 0.2) 0.56
^
For continuous variables, the coefficient represents mean change in IES-R score per one unit increase. For categorical variables, the
coefficient represents mean difference in IES-R score as compared to the reference group.
€
*Model includes primary surrogate decision-makers only

Page 33 of 35
Supplementary Table E2: Results Multivariable Analysis with coefficients and 95% Confidence intervals for
confounders, Patient-related variables€
Potential Risk Factor

Beta coefficient
Adjusted Beta Covariate Covariate Category P value
(95% CI) ^
coefficient (95% CI) ^
Patient Female Sex None None -2.01 (-6.59 to 2.58) 0.39
Patient Cancer -4.39 (-9.24 to 0.46) 0.083
Patient History of Stroke -1.11 (-8.73 to 6.52) 0.77
Patient Chronic Liver Disease 1.96 (-4.76 to 8.67) 0.56
Patient End-Stage Renal
-9.01 (-21.23 to 3.21) 0.15
Disease
Patient Age
Patient Baseline ADLs 0.08 (-1.37 to 1.53) 0.91
Patient Advance Directive -4.56 (-10.38 to 1.25) 0.12
Patient Insurance Patient Cancer -4.41 (-9.37 to 0.54) 0.08
Commercial Patient History of Stroke -0.91 (-8.55 to 6.73) 0.81

2.2 (-5.3 to 9.69)
Medicaid
1.81 (-7.73 to 11.35 Patient End-Stage Renal
-9.49 (-21.17 to 2.18) 0.11
Disease
Medicare
0.22 (-7.07 to 7.51) Patient Advance Directive -3.44 (-9.21 to 2.33) 0.24
None
--- Surrogate HADS 0.96 (0.73 to 1.19) <.0001
-5 to -4 (unresponsive) 9.52 (3.45 to 15.59) 0.004

Patient RASS Score -3 to -1 (arousable) 3.49 (-2.67 to 9.65) 0.004
0 or above (awake) ---
Commercial -0.12 (-7.87 to 7.64) 0.99
Patient Chronic Liver Medicaid -1.49 (-11.34 to 8.36) 0.99
Disease Patient Insurance
Medicare -0.26 (-8.42 to 7.9) 0.99
2.48 (-4.29 to 9.25) None ---
Patient Age -0.11 (-0.26 to 0.04) 0.16
Commercial 3.19 (-4.6 to 10.98) 0.70
Medicaid 0.06 (-9.77 to 9.89) 0.70
Patient Insurance
Medicare 0.74 (-7.38 to 8.86) 0.70
Patient Cancer None ---

4.45 (-9.53 to 0.62) Patient Advance Directive -4.46 (-10.54 to 1.62) 0.15
Patient Age -0.04 (-0.19 to 0.11) 0.58

Page 34 of 35
Patient Ethnicity Hispanic or Latino -1.6 (-9.7 to 6.5) 0.70

Black 2.83 (-2.37 to 8.04) 0.47
Patient Race Other -1.22 (-8.9 to 6.46) 0.47
White ---
Commercial 2.61 (-5.19 to 10.42) 0.83
Medicaid 0.05 (-9.84 to 9.94) 0.83

Patient Insurance
Medicare 0.83 (-7.33 to 8.99) 0.83
None ---
Patient History of Patient Baseline ADLs 0.22 (-1.25 to 1.69) 0.77
Stroke
-1.4 (-9.26 to 6.45) Surrogate HADS 0.96 (0.72 to 1.19) <.0001
Patient Age -0.04 (-0.2 to 0.11) 0.59
Black 3.97 (-1.24 to 9.17) 0.27

White ---
Patient RASS Score -3 to -1 (arousable) 9.13 (3.02 to 15.24) 0.007
0 or above (awake) ---
Commercial 0.93 (-6.86 to 8.71) 0.98
Medicaid -0.7 (-10.52 to 9.12) 0.98
Patient Insurance
Medicare 0.67 (-7.52 to 8.86) 0.98
Patient End-Stage None ---
Renal Disease Patient Baseline ADLs 0.28 (-1.23 to 1.78) 0.71
-8.58 (-20.94 to 3.79)

Patient Age -0.1 (-0.25 to 0.06) 0.21
Black 3.33 (-1.93 to 8.59) 0.28
White ---
-10.35 (-22.88 to 2.17) 0.10
Disease
Commercial 3.54 (-4.24 to 11.32) 0.74
Patient Advance Medicaid 0.86 (-9.02 to 10.73) 0.74
Directive
Patient Insurance
Medicare 1.49 (-6.65 to 9.64) 0.74
-4.74 (-9.82 to 0.34)
None ---
Patient Age -0.04 (-0.19 to 0.11) 0.62

Page 35 of 35
Patient Ethnicity Hispanic or Latino -1.76 (-9.84 to 6.33) 0.67

Black 3.72 (-1.63 to 9.06) 0.33
White ---
-7.95 (-20.38 to 4.49) 0.21
Disease
Patient Activities of Commercial 2.34 (-5.49 to 10.16) 0.84

Daily Living
Patient Insurance Medicaid 0.07 (-9.89 to 10.04) 0.84
0.14 (-1.32 to 1.6)
Medicare 0.3 (-7.87 to 8.47) 0.84
None ---
Patient Age -0.06 (-0.21 to 0.09) 0.44
Pre-ICU Hospital Patient Chronic Liver Disease 3.39 (-3.07 to 9.85) 0.301
Length of Stay Surrogate HADS 0.94 (0.71 to 1.17) <.0001
0.01 (-0.22 to 0.25) Patient Age -0.05 (-0.18 to 0.08) 0.43
Patient RASS Score -3 to -1 (arousable) 3.75 (-4.02 to 11.52) 0.02
ProVent14 Score 0 or above (awake) ---
-0.04 (-0.15 to 0.08) Patient Baseline ADLs -0.92 (-2.19 to 0.35) 0.15
Pre-ICU Hospital LOS 0.15 (-0.13 to 0.43) 0.30
Patient RASS Score
-5 to -4 (unresponsive)
8.39 (0.83 to 15.95)
-4.45 (-19.24 to 10.33) 0.55
-3 to -1 (arousable) Disease
2.48 (-5.18 to 10.15)
0 or above (awake)
--- ProVent14 Score -0.02 (-0.14 to 0.09) 0.71
^
For continuous variables, the coefficient represents mean change in IES-R score per one unit increase. For categorical variables, the
coefficient represents mean difference in IES-R score as compared to the reference group.
€

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ANNALSATS Articles in Press. Published on 10-September-2018 as 10.1513/AnnalsATS.

Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of

Word Count: 2732

Declaration of Interests: The authors declare no competing interests.

Running Title: Risk Factors for Post-Traumatic Stress in CCI Surrogates

Copyright © 2018 by the American Thoracic Society

Objectives: To identify risk factors for (PTSD) symptoms in surrogate decision-makers of

chronically critically ill patients.

Methods: We performed a secondary analysis of the database from a multicenter randomized

demographics, insurance status, baseline functional status, chronic co-morbidities, illness

severity, and presence of advance directive. Surrogate variables included demographics,

respondents, using a mixed model, considering the patients as a random factor.

Copyright © 2018 by the American Thoracic Society

0.83 to 15.95) were associated with higher IES-R scores.

and depression scores and patient unresponsiveness on or near day 10 of mechanical

ventilation are risk factors for PTSD symptoms at 90 days.

Abstract Word Count: 331

Copyright © 2018 by the American Thoracic Society

Chronic critical illness (CCI) is a syndrome characterized by prolonged dependence on life-

sustaining therapies. However, because of ongoing cognitive dysfunction (3), chronically

with decision-making about life-sustaining care.

Acting as a family surrogate decision-maker is associated with a number of negative

6% who experienced depression (8). When comparing patient-caregiver dyads, symptoms of

Copyright © 2018 by the American Thoracic Society

towards those at highest risk.

symptoms at 90 days can be identified on day 10 of patient mechanical ventilation.

study, a multicenter, randomized controlled trial to determine whether family informational

mechanical ventilation, and to two categories of surrogate decision-makers: The primary

additional family decision-makers if they also participated in health-care decision-making.

Copyright © 2018 by the American Thoracic Society

characteristics measured on or near day 10 of mechanical ventilation for association with

North Carolina Institutional Review Board.

Potential Risk Factors

We selected 26 potential patient and surrogate decision-maker-specific risk factors for

Copyright © 2018 by the American Thoracic Society

categorized as RASS -5 or -4 (unresponsive), RASS -3 to -1 (arousable), and RASS ≥0 (awake).

instrument designed to measure symptoms of anxiety and depression in hospitalized patients,

represent “borderline” symptom levels. Additional information on available variables can be

found in descriptions of the SIT clinical trial (10).

Primary Outcome Measure

decision-makers beginning 90 days following study enrollment.

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distribution. Categorical variables were reported as proportions. To examine the association

using SAS 9.4 (SAS Institute Inc).

90-day follow-up interview. Complete surrogate characteristics are shown in Table 1.

Copyright © 2018 by the American Thoracic Society

Preselected patient- and surrogate-related characteristics were then assessed for

unresponsiveness as indicated by a RASS score of -5 or -4 – were significantly associated with

(unresponsive) as compared to surrogates of patients with a RASS of 0 or above (awake)

Copyright © 2018 by the American Thoracic Society

clinical trial (coefficient 1.08, 95% CI 0.81 to 1.35).

surrogate PTSD symptoms at 90 days. No variables pertaining to surrogate or patient

Interventions to reduce long-term emotional distress in surrogate decision-makers have met

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help to deploy intervention resources in a more focused and efficient manner.

ventilator dyssynchrony or due to advanced encephalopathies related to underlying acute

without guidance from the patient (23).

Copyright © 2018 by the American Thoracic Society

Copyright © 2018 by the American Thoracic Society

In conclusion, among surrogate decision-makers of patients with chronic critical illness,

Copyright © 2018 by the American Thoracic Society

Copyright © 2018 by the American Thoracic Society

Copyright © 2018 by the American Thoracic Society