EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

Wendy G Lichtenthal; Lindsay Lief; Madeline Rogers; David Russell; Martin Viola; Hillary Winoker; Sophia Kakarala; Chani Traube; Taylor Coats; Carol Fadalla; Kailey E Roberts; Madison Pavao; Francesco Osso; Chris R Brewin; Cynthia X Pan; Paul K Maciejewski; David Berlin; Stephen Pastores; Neil Halpern; Susan C Vaughan; Christopher E Cox; Holly G Prigerson

doi:10.1016/j.jpainsymman.2024.03.002

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

J Pain Symptom Manage. 2024 Mar 11:S0885-3924(24)00658-4. doi: 10.1016/j.jpainsymman.2024.03.002. Online ahead of print.

Authors

Wendy G Lichtenthal¹, Lindsay Lief², Madeline Rogers², David Russell³, Martin Viola⁴, Hillary Winoker², Sophia Kakarala², Chani Traube², Taylor Coats⁵, Carol Fadalla⁶, Kailey E Roberts⁷, Madison Pavao², Francesco Osso², Chris R Brewin⁸, Cynthia X Pan⁹, Paul K Maciejewski², David Berlin², Stephen Pastores¹⁰, Neil Halpern¹⁰, Susan C Vaughan², Christopher E Cox¹¹, Holly G Prigerson²

Affiliations

¹ University of Miami Miller School of Medicine (W.G.L.), Miami, Florida, USA; Memorial Sloan Kettering Cancer Center (W.G.L., K.E.R., S.P., N.H.), New York, New York, USA. Electronic address: wendy.lichtenthal@miami.edu.
² Weill Cornell Medicine (L.L., M.R., H.W., S.K., C.T., M.P., F.O., P.K.M., D.B., S.C.V., H.G.P.), New York, New York, USA.
³ Appalachian State University (D.R.), Boone, North Carolina, USA.
⁴ Harvard Medical School (M.V.), Boston, Massachusetts, USA.
⁵ Pacific University (T.C.), Forest Grove, Oregon, USA.
⁶ Texas Tech University (C.F.), Lubbock, Texas, USA.
⁷ Memorial Sloan Kettering Cancer Center (W.G.L., K.E.R., S.P., N.H.), New York, New York, USA; Yeshiva University (K.E.R.), Bronx, New York, USA.
⁸ University College London (C.R.B.), London, England.
⁹ New York-Presbyterian Queens (C.X.P.), Flushing, New York, USA.
¹⁰ Memorial Sloan Kettering Cancer Center (W.G.L., K.E.R., S.P., N.H.), New York, New York, USA.
¹¹ Duke University School of Medicine (C.E.C.), Durham, North Carolin, USA.

PMID: 38479536
DOI: 10.1016/j.jpainsymman.2024.03.002

Abstract

Context: Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

Objectives: The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

Methods: Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

Results: Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

Conclusions: EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Keywords: Critical care; grief; psychological intervention; surrogate decision-making; trauma.