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Abstract

Introduction

Personality traits, specifically neuroticism, are related to stress in surrogate decision-makers (SDMs) in outpatient settings. We hypothesized that intrinsic traits are related to SDM stress in the intensive care unit (ICU) to determine if personality considerations should be included in interventions to support SDMs.

Methods

Eligible participants (adult SDMs of non-capacitated ICU patients) completed validated questionnaires including stress (Impact of Events Scale-Revised, IES-R) and personality (Big Five Inventory, BFI) within 72 hours of ICU admission and again at 3 months post-ICU discharge (in addition to a qualitative interview). Bivariate Pearson correlations explored the relationship between BFI and IES-R at each time point (95% CI) and t-tests explored the relationship between stress and COVID-19. Mixed-methods analysis integrated qualitative and quantitative data.

Results

Of 32 SDMs, 71.9% were female, 93.8% white, and 97.0% were family members. Neuroticism was not significantly correlated to IES-R at 72 hours (r = 0.09; p = 0.64), but r increased 3 months post-discharge (r = 0.32; p = 0.07). Other BFI traits did not show similar patterns. Total stress was greater in surrogates of COVID-19-positive patients (COVID-19-positive: 60.6; COVID-19-negative: 49.8; p = 0.025). Mixed-methods analysis demonstrated that participants with high neuroticism scores had poorer emotional regulation than those with low neuroticism scores.

Conclusions

This study supports that personality, particularly neuroticism, influences the stress of SDMs in the ICU. Further study of personality traits may identify surrogates who are at higher risk of stress-related disorders, which can guide future interventions.

Keywords

personality traits stress neuroticism surrogates decision-making advance care planning critical care mixed methods

Introduction

The experience of having a family member in the intensive care unit (ICU) can be very stressful for surrogate decision-makers (SDMs). Previous studies have shown that surrogate decision-makers for ICU patients experienced high levels of psychological and physical symptoms such as fatigue and poor appetite after their loved one was admitted to the ICU.¹ Simply receiving care in an ICU may lead to a series of complications that has been labeled post-intensive care syndrome-family, which includes post-traumatic stress disorder.² To address this problem, many interventions related to decision-making and decisional support have been designed and implemented. However, few have demonstrated success in reducing stress for these decision-makers.³ This may be, in part, because the interventions used cognitive-focused approaches such as an online decisions aid and knowledge tools^4,5 or are broadly targeted to any and all surrogate decision-makers in the ICU.⁶ In the absence of success in interventional research, recent work has begun to focus on gaining a better understanding of how intrinsic traits such as personality traits and decision-making style impacts the way family members experience the stress of having a chronically ill loved one.^4,7 Work in this area has shown that numerous factors such as finances, grief, and caregiving demands contribute to stress, which may help explain failures in current interventional approaches.^6,8 To date, we have only a rudimentary understanding of how intrinsic traits (such as personality) play a role in the way families experience stress and thus, their outcomes.

It is well established, however, that personality traits, particularly neuroticism, are associated with anxiety, depression, and other conditions, such as substance abuse.^9-11 Although to our knowledge there is no research on the role of personality traits in surrogate decision-making in the ICU, there has been some work in other populations. For example, a study found that caregivers of elderly, chronically ill relatives who scored higher on neuroticism were found to have higher scores of depression, anxiety, and loneliness, and lower scores of well-being when compared to other personality traits.¹² Another study found that caregivers of patients with schizophrenia experienced high levels of burden and concluded that personality traits like psychoticism (using the Eysenck’s Personality Questionnaire)¹³ increase risk of caregiver burden.¹⁴ Additionally, personality traits in parents of children with spina bifida were found to be stronger determinants of stress than the severity of the child’s disease.¹⁵ We also recently demonstrated an association between Big Five Inventory (BFI) personality types (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and psychological health in surrogate decision-makers of chronically ill patients in that the neuroticism trait was strongly correlated to stress.⁷ Therefore, in light of these relationships in other caregiver populations, it is possible that personality plays a role in other contexts, such as the ICU. To our knowledge there is no literature that examines how the personality traits of decision-makers of patients in an ICU setting may relate to outcomes.

The objective of this mixed methods study is to begin to explore potential relationships between personality traits and psychological outcomes of surrogate decision-makers of ICU patients. We hypothesize that personality traits, specifically neuroticism, are associated with stress-related outcomes. Since the study was conducted in the height of the pandemic, we also explored whether stress-related outcomes were related to a diagnosis of COVID-19.

Methods

Overview of Study Design

This explanatory, sequential mixed methods¹⁶ study was performed at a single, academic tertiary care center in Hershey, PA, from August 2021 to 2022 (during the COVID-19 pandemic). Data was collected at 2 timepoints (at 72 hours post-ICU admission, Phase 1; and at 3 months post-ICU discharge, Phase 2). Quantitative questionnaires assessed participants’ symptoms of PTSD (as measured by the validated Impact of Event Score-Revised; IES-R)^17,18 and personality traits (as measured by the BFI.)^19,20 Qualitative interviews were conducted to explain how participants perceived that their personality may have played a role in their stress. Surrogates were included in phase 2 regardless of patient disposition from the ICU (including death).

Recruitment

The study was approved by the Institutional Review Board (STUDY00017884). Participants were identified by first screening ICU censuses for patients meeting inclusion criteria receiving care in the medical intensive care unit (MICU), neurological critical care unit (NCCU), Heart and Vascular Institute critical care unit (HVICCU), and surgical intensive care unit (SICU). Inclusion criteria for patients were age greater than 18 years, had a projected ICU stay of greater than 72 hours, and determined to be medically non-capacitated by the healthcare team. Upon identification of patients, the care team identified the surrogate decision-makers of the selected patients. Inclusion criteria for surrogate decision-makers were age greater than 18 years and able to read and write in English. Eligible participants were approached by a research assistant either in person or by phone, depending on availability of the surrogate. Surrogates provided verbal informed consent and could withdraw at any time.

Measures

Demographics and Chart Review

An 18-item questionnaire was completed at baseline to determine the surrogate’s age, gender, race and ethnicity, education level, and relationship to the patient. Surrogates answered a similar set of questions for their loved one.

Personality: Big Five Inventory

Surrogates’ personality traits were measured using the BFI,^19,20 a well validated and reliable questionnaire of the five main domains that correspond to thoughts, feelings, and behaviors. Each of the 44 items has a stem beginning with “I see myself as someone who…[e.g., is talkative.]” Participants choose from a 5-point Likert scare as to their level of agreement (1 = disagree strongly; 5 = agree strongly) with each subsequent characteristic. The BFI measures five domains: extraversion, neuroticism, openness to experience, agreeableness, and conscientiousness. Scores are calculated as averages of the scale-specific item responses (ranging from 1-5).^19,20 Higher scores correspond to greater levels of that specific personality trait. Surrogates completed this survey once at 72 hours of their loved one’s ICU admission.

Subjective Stress (Symptoms of PTSD): Impact of Events Scare-Revised

The Impact of Events Scale-Revised (IES-R) is a validated 22-item questionnaire that screens for stress-related symptoms including post-traumatic stress disorder (PTSD).^17,18 The IES-R was administered at 72 hours of SDMs’ loved one’s ICU admission and at 3 months post-ICU discharge or death. Each item is scored on a 0-4 scale; total scores range 0-88. Total scores of 24-33 indicate subthreshold symptoms of PTSD and scores above 33 are suggestive of PTSD.^17,18 The measure contains three subscales that distinguish different stress responses: intrusion (intrusive thoughts, nightmares, intrusive feelings and images, dissociative-like re-experiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, or a heightened startle response).^17,18

Qualitative Interviews

Surrogates also participated in semi-structured interviews 3 months after ICU discharge (see Qualitative Interview Guide in supplemental materials). The interview assessed three constructs: their self-described personality, how their personality related to their stress and coping, and their perceptions of how their personality affected their decision-making. Interviews lasted an average of 22.2 minutes (SD 6.1) and were audio-recorded and transcribed verbatim.

Chart Review for Patient Hospitalization and Outcomes

A chart review was completed on each patient to record age, sex, diagnosis for admission, COVID-19 status, sequential organ failure assessment (SOFA) score and code status on admission, and hospital and ICU length of stay. We also recorded patient ICU discharge disposition or death.

Analysis

Sample Size Determination

Sample size was calculated in terms of precision for estimating a correlation coefficient with an expected correlation coefficient of .5, based on correlation coefficients from prior work.⁷ A sample size of 29 participants (assuming two completed timepoints) provides a 95% confidence interval that has width ±.4. In addition, for a two-sided, .05 significance level, paired t-test, the sample size of 29 yields 80% statistical power for detecting an effect size of .54 standard deviation units. Forty-three participants completed questionnaires at 72 hours (Phase 1). Given that 11 participants were lost to follow-up, 32 participants completed Phases 1 and 2 and were included in the final analysis (Figure 1).

Figure 1.

Consort diagram demonstrating recruitment and retention.

Quantitative Analysis

All quantitative analyses were performed using SPSS Statistics software, version 29.0.0.0 (241). Descriptive statistics were assembled using mean and standard deviation. BFI and IES-R scores were calculated as described in the measures section; means and standard deviations are reported for all BFI traits, total IES-R, and all IES-R subdomains. Bivariate Pearson correlations were performed using a 95% confidence interval to explore the relationship between surrogates’ personality and stress. We performed independent t-tests to determine the relationship between COVID-19 status and total stress. Our analyses excluded participants that did not complete all questionnaires or were lost at 3-month follow-up.

Qualitative Analysis

We applied a phenomenological approach^16,21 to conventional content analysis. To do so, analysts independently reviewed transcripts and inductively created preliminary categories and codes. The two analysts then merged codes together to refine the codebook and jointly wrote definitions for each code. Both analysts then used the final codebook by each independently coding the entire dataset using MAXQDA software (Version 2022). Inter-rater reliability was assessed using Cohen’s Kappa reports to guide calibration and resolution of coding discrepancies between coders to maintain kappa >.70 for each code. Final coding reports and patterns were used to generate the final themes. Only themes and subthemes related to this study’s research question are presented. Additional themes (for example, ways surrogates make decisions unrelated to personality, factors that influence decisions, and perceptions about communication) will be reported separately.

Mixed Methods Analysis

In this explanatory, sequential mixed methods study, quantitative findings were analyzed and interpreted first.²¹ Then, qualitative themes were integrated by connecting the quantitative data to the qualitative themes by stratifying the themes based on relevant personality traits as measured by the BFI.²²

Results

Participant and Patient Demographics

Participants in this sample included those who completed all questionnaires at 72 hours and 3 months (n = 32; Figure 1). Family member participants had a mean age of 50.5 years; 71.9% were female and 93.8% were white. Most (97.0%) were family members of the patient; 40.7% were the patient’s child and 37.5% were the patient’s spouse (Table 1). Patient characteristics are shown in Table 2. Most patients were treated in the medical ICU (71.9%) and remained in the ICU for an average of 23.6 days. Half the patients (n = 16) were treated for COVID-19; 14 patients (43.8%) deceased prior to discharge, 10 of which had COVID-19 (Table 2).

Table 1.

Demographics of Surrogate Decision-Makers (SDMs).

Characteristics	SDMs (n = 32)
Age in years, mean (SD)^a	50.5	(15.4)
Gender, female, n (%)	23	(71.9)
Race/ethnicity, n (%)
Asian	0	(.0)
Black	2	(6.3)
White	30	(93.8)
Hispanic or Latino	1	(3.1)
Education, n (%)
Did not finish high school	2	(6.3)
High school graduate or GED	12	(37.5)
Some college	3	(9.4)
Associate degree	5	(15.6)
Bachelor's degree	7	(21.9)
Graduate or professional school	3	(9.4)
Relationship to patient, n (%)
Spouse	12	(37.5)
Parent	4	(12.5)
Child	13	(40.7)
Sibling	2	(6.3)
Friend/other	1	(3.1)

^aat time of recruitment.

Table 2.

Patient Characteristics.

Characteristics	Patients (n = 32)
Age in years^a, mean (SD)	60.5	(15.0)
Gender, female, n (%)	11	(34.4)
ICU unit, n (%)
Medical intensive care unit	23	(71.9)
Neurological critical care unit	3	(9.4)
Heart and Vascular Institute critical care unit	4	(12.5)
Surgical intensive care unit	2	(6.3)
SOFA score at time of ICU admission, mean (SD)	7.8	(3.1)
COVID-19 positive, n (%)	16	(50.0)
Hospital length of stay in days, mean (SD)	33.5	(23.1)
ICU Length of stay in days, mean (SD)	23.6	(15.6)
Disposition from ICU, n (%)
Home	0	(.0)
Rehabilitation facility	1	(3.1)
Long term acute care facility	2	(6.3)
Deceased	14	(43.8)
Deceased, COVID-19 positive patients	10	(31.3)
Downgrade to ward	15	(46.9)

^aat time of admission.

Personality Traits and Stress

Table 3 shows mean scores for each of the BFI traits and mean summative scores from the IES-R. Agreeableness had the highest mean of all BFI traits (4.27, SD 0.45). Neuroticism scores had a mean of 3.00 (SD .89). The mean total IES-R score was 54.78 (SD 16.62) at 72 hours and 57.72 (SD 20.05) at 3 months. The highest subscale scores were for the Intrusion domain at both time points (72 hours: mean 23.03, SD 7.43; 3 months: mean 23.37, SD 8.94).

Table 3.

Descriptive Statistics Reporting Responses on Intrinsic Traits of Stress of Participants.^a

Measure	Mean	SD
BFI (1 = low trait levels; 5 = high trait levels)^b
Agreeableness	4.27	.45
Conscientiousness	3.92	.78
Extraversion	3.49	.74
Neuroticism	3.00	.89
Openness	3.74	.54
IES-R at 72 hours
Total stress	54.78	16.62
Intrusion	23.03	7.43
Avoidance	17.41	6.60
Hyperarousal	14.34	5.36
IES-R at 3 months
Total stress	57.72	20.05
Intrusion	23.37	8.94
Avoidance	19.22	7.26
Hyperarousal	15.13	6.56

^an = 32.

^bSince traits typically follow a normal distribution, a mean score of 2.5 suggests a moderate “level” for each trait.

Correlations Analysis: Relationships Between Stress and Personality Traits

Tables 4 and 5 show correlations between personality and stress at 72 hours and 3 months post-discharge, respectively. At 72 hours, no significant relationships existed between any of the Big Five domains and stress. Neuroticism was not correlated to IES-R at 72 hours (r = .09; P = .64), but the correlation coefficient increased at 3 months post-discharge, albeit not reaching statistical significance (r = .32; P = .07). The correlation coefficients between neuroticism and all IES-R subdomains increased at the 3-month timepoint (Table 5) but did not reach significance. Neuroticism was significantly correlated to hyperarousal at 3 months but not at 72 hours (3 months: r = .36, P = .046; 72 hours: r = .23, P = .20). The other four Big Five traits did not show similar patterns.

Table 4.

Correlations Among Personality Traits With Stress Scores at 72 Hours.

	IES-total r (p)	IES-intrusion r (p)	IES-avoidance r (p)	IES-hyperarousal r (p)
Personality traits
Agreeableness	.12 (.53)	.06 (.74)	.14 (.46)	.11 (.55)
Conscientiousness	-.09 (.61)	-.08 (.66)	-.15 (.43)	.00 (.99)
Extraversion	-.08 (.67)	-.09 (.65)	.02 (.91)	-.16 (.39)
Neuroticism	.09 (.64)	.06 (.74)	-.04 (.83)	.23 (.20)
Openness	-.03 (.88)	.06 (.74)	-.17 (.37)	.03 (.85)

95% confidence interval.

Table 5.

Correlations Among Personality Traits With Stress Scores at 3 Months.

	IES-total r (p)	IES-intrusion r (p)	IES-avoidance r (p)	IES-hyperarousal r (p)
Personality traits
Agreeableness	.14 (.46)	.08 (.66)	.09 (.64)	.21 (.25)
Conscientiousness	-.25 (.17)	-.27 (.13)	-.21 (.26)	-.16 (.37)
Extraversion	-.21 (.25)	-.23 (.21)	-.12 (.51)	-.20 (.28)
Neuroticism	.32 (.07)	.30 (.10)	.20 (.27)	.36 (.046)
Openness	-.32 (.07)	-.25 (.17)	-.26 (.15)	-.35 (.048)

Relationship Between IES-R and COVID-19 Status

Sixteen patients (50.0%) were positive for COVID-19 (Table 2). In response to this observation, we conducted a sub-analysis to determine the role of this diagnosis. At 72 hours and 3 months, total IES-R was not significantly different in surrogate decision-makers of patients with COVID-19 compared to those without COVID-19 (72 hours: P = .10; 3 months: P = .46) (eTables 1 and 2 in supplement). When including all participants who completed Phase 1 (n = 43), total IES-R was higher in decision-makers of patients with COVID-19 than those without COVID-19 (COVID-19-positive: 60.6; COVID-19-negative: 49.8; P = .03) (eTable 3 in supplement).

Qualitative Interviews

Two themes related to personality traits and stress emerged from the interviews. Themes, subthemes and exemplar quotes are presented in Table 6.

Table 6.

Themes, Subthemes, and Exemplar Quotes From Qualitative Interviews With Surrogate Decision-Makers (SDMs).^a,b

Theme 1: Personality influenced the SDM experience of stress in a variety of ways.
1A. Optimism alleviated stress	“I think because I’m always looking to the bright side of things. I’m always looking for the positive. And that’s just always been my personality. I think that helped me.” (26) “…I think that makes a substantial difference in strengths if you practice positive thinking and practice, you know, focusing on the positive versus the negative things you can’t change.” (45)
1B. SDMs who described themselves as determined or persistent tended to benefit from those traits	“I don’t know what else it would be. I mean, my whole life, I’ve pushed. I put myself through college. I raised kids on my own. I worked. I traveled. I mean, when my ex left, I had never even been on a plane. And the job that I got, I had to go all over the United States to Navy shipyards. I mean, that makes you strong. I guess I’d have to say that strength is what I leaned on.” (09) “Well, I think because I can try to be the teacher in me and the one to take charge—that came out of me—more than normal. Like, normally I can lay back and let other things happen. But I think because I can do that, I was able to kind of separate maybe the emotions that were there. I think that’s maybe what I did.” (30)
1C. Participants who were inquisitive by nature tended to experience less stress because they were better informed and felt like it was easier to make decisions	“I think it played a big role in it because I could ask my more technical questions, and they could answer them. And plus, thinking more logically, it was like, OK, they’ve already tried this. They’ve tried that. And what to expect next and what the quality of life would be, moving forward, and everything.” (13) “I used to be afraid to ask questions. I wasn’t afraid to ask questions. I had my questions written down. I was organized. That’s part of my personality. I had everything there written out so I was prepared to ask the questions. And I wrote down anything that they told me so I could make sure I was giving the best care.” (30)
1D. Reserved and calm personality traits benefitted some SDMs and worsened the stress of others	“So while we were going through everything, I kind of became the go-to person because I stayed calm and mellow and was able to think in a more rational, peaceful way, to where, I think if I wouldn’t have had that type of personality, it would’ve been a lot harder to do that.” (25) “I think it played a big part because I’m also kind of laid back. I don’t get real excited things. And I don’t blow up very easily. I’m pretty much calm, so, by doing that, you’re keeping things inside. So I just didn’t get over it.” (44)
Theme 2: Factors beyond the patient’s health status increased the amount of stress perceived by the SDM.
2A. COVID-19 restrictions, specifically the inability to visit loved ones, increased the amount of stress experienced by SDMs	“I kind of felt it because I could not be in there to see him, or to hold his hand, or to talk to him, or anything like that, I felt like I was having to protect him from home, and that was stress.” (17) “I mean, my mother was on the ICU before, but I got to go in to see her. And I understand COVID was different, and there was precautions, but not being able to see him was what hurt me the worst.” (28)
2B. Poor communication between providers and family members made the ICU experience more stressful for SDMs	“One day, it would be, I want him off the Precedex and on Versed. And then they’d get him off of that. And then the next doctor that comes in at night, no, I want him off the Versed and not the Precedex. And it’s like, just get on the same page. We need to get on the same page and stop doing this stuff. I think that if the doctors would communicate more with each other and have a game plan together instead of one doctor wants to do something and then the next doctor that comes on wants to do something differently.” (08) “The only thing I’d say is more like information from the ICU over the phone, like more calls, like saying how she was doing, keeping us informed that she was alright, especially if we couldn’t make it over.” (11)

^aParticipant number in parentheses.

^bQuotes have been minimally edited for clarity.

Theme 1: Surrogates described their personality traits as both a benefit and detriment to their experience of stress

Participants described that the optimistic, determined, and inquisitive components of their personalities improved the ICU experience (Subthemes 1A-1C). Some surrogates who described themselves as reserved found this trait to be helpful, while others found it to be a mechanism of concealment of their emotions (Subtheme 1D).

Theme 2. Factors beyond the patient’s health status increased the amount of stress perceived by the SDM

A substantial proportion of participants cited visitation restrictions as a major stressor during their loved one’s admission (Subtheme 2A). Insufficient communication, both between healthcare teams and between families and providers, also contributed to surrogates’ stress (Theme 2B).

Mixed Methods Integration

The qualitative and quantitative findings were integrated by stratifying qualitative findings by scores on the neuroticism trait of the BFI since the neuroticism trait had the strongest relationship to stress in correlations. Patterns emerged in qualitative data showing that those with high neuroticism scores (>2.5) described themselves as being highly emotional, while those with lower neuroticism scores (<2.5) exerted better emotional regulation (Table 7). Participants with high neuroticism scores commonly described substantial anxiety, panic, and depression, such as Participants 44 (neuroticism score 3.8) and 9 (neuroticism score 4.9). On the other hand, surrogates with low neuroticism scores tended to exert a greater control over their emotions while remaining calm and optimistic. For example, Participant 11 (neuroticism score 1.4) noted how their personality impacted the way they coped with the stress. Several participants with low neuroticism score explicitly noted how personality traits related to excitability and rationale may be somewhat protective during decision-making, such as participants 29 (neuroticism score 1.9) and 45 (neuroticism score 1.6) (Table 7).

Table 7.

Mixed Methods Integration: Quotes Stratified by Neuroticism Score.

Participant 44 (neuroticism score 3.8)	“…I had to make a lot of phone calls to family and friends and let them know what was going on almost every day. I would break down when those phone calls were done…I didn’t cry and breakdown in front of people. I just kept it to myself…behind closed doors was when the tears came and the breakdowns.”
Participant 9 (neuroticism score 4.9)	“I’m a worrier…that’s why I need to go-between between me and the doctors because when they use all those little terms, it just, like, panics me. And I don’t understand what they’re saying, and it just—the words just scare me…”
Participant 11 (neuroticism score 1.4)	“I feel like with how my personality was, I kind of was able to rein myself in so I could be strong enough and take a part of her, and be strong for her, and then also try to keep things flowing normal, as in the home life, since she was kind of like the one that kept things going in the home. I picked right up after that and kept things going so that when she would come home, it would be just like nothing changed. So that way, she would feel good about coming home. But I’d definitely say with the stress slice of things, I kind of kept myself, like, right in neutral factor where I didn’t overstress myself out or under stress myself… …So, I mean, I kind of was more calm, calmer, because something like this can have stress, but I kind of can control my stress on this point.”
Participant 29 (neuroticism score 1.9)	“So, if you don’t get too excited, and you think about them in a more rational [way], then you should be able to cope with what’s being thrown at you easier, right? If you have a personality that’s not too excitable, it’s probably going to be better in the long run with making decisions that are important, right?”
Participant 45 (neuroticism score 1.6)	“I’m like OK, we just have to see and hope for the best and take it a day at a time. Like, 20%, to 30% of my personality is…that I am fairly optimistic. I’m thinking about the positive, And then, also for the future. Those combination of things, I think, help…”

Discussion

To our knowledge, this is the first study to examine potential relationships between personality traits and stress in the context of ICU surrogate decision-making. Understanding the stress experience is important because poor psychological outcomes (such as anxiety, depression, and PTSD) are known to be prevalent in surrogate decision-makers of ICU patients.¹ Prior research seeking to support family members and improve these psychological outcomes after decision-making has had mixed results.^4-6 Given that the association of personality traits of surrogate decision-makers and stress have been demonstrated in other settings,^7,11,23 we investigated the relationship between personality and stress in the ICU setting. This study did not demonstrate a quantitative relationship between personality and stress, although qualitative findings provided some insights into how participants view the way their personality played a role in their ICU experience, suggesting that a relationship may be present. Thus, although the study was underpowered to detect quantitative associations, the qualitative data helped elucidate a potential relationship. When we integrated our mixed methods data, we found that participants with low scores on the neuroticism scale seemed to describe better emotional regulation (using layman’s terminology) than those with high neuroticism scores. This is notable because the relationship between poor emotional regulation and neuroticism is well-established.¹⁰

In addition to being underpowered, it is possible that our quantitative data did not yield significant relationships as a result of the high-stress, life-or-death nature of the ICU experience. The high-stress experience of the ICU may have simply overrode any relationship between personality and stress in this context. Further, the COVID-19 pandemic, which introduced additional stresses and potentially confounding issues related to visitation restrictions may have impacted our findings.^24,25 Our sub-analysis exploring the role of COVID-19 found that decision-makers for patients with COVID-19 did indeed have higher stress scores than those without COVID-19. Thus, the impact of the COVID-19 pandemic may have ‘washed out’ the relationship between personality and stress.

Strengths and Limitations

Strengths of this study include the use of a well validated personality index and a mixed methods approach that provided insight not yielded from the quantitative findings alone. This study was limited by small sample size, lack of power, and a non-diverse, largely white, female population. Further, our power calculations did not include considerations for multiplicity corrections, and COVID-related analyses were post-hoc; thus findings should be interpreted with caution. Last, additional confounders that may have contributed to participants’ perception of stress, including death or final disposition, social support systems, family dynamics, and illness narrative and disease type, among other variables, were unmeasured.

Implications for Clinical Practice

Our findings suggest that it might be beneficial to consider personality traits when designing interventions intended to support surrogate decision-makers in the ICU. Surrogates may respond well to interventions tailored to their personality trait profiles since personality is linked to coping and emotional regulation.^26-28 Further, using a personality assessment (such as the Big Five Inventory) may help to quickly identify individuals with personality profiles at highest risk for poor psychological outcomes using this brief and simple screening tool. Such screening would permit a tailored approach to surrogate support that attends to personality traits and may help address poor psychological outcomes associated with ICU surrogate decision-making. More research in this area is warranted to further elucidate if and how personality traits play a role in the ICU experience. Thus, attending to the wide range of needs of surrogate decision makers, rather than a ‘one-size fits all’ approach, may help to improve interventional efficacy.

Conclusion

Personality traits, particularly neuroticism, may influence the stress experience in surrogate decision-makers of ICU patients. Research to understand if and how personality traits relate to psychological outcomes and decision-making may help improve efficacy of interventions intended to support surrogates of ICU patients.

Supplemental Material

Supplemental Material - Relationships Between Personality Traits and Perceived Stress in Surrogate Decision-Makers of Intensive Care Unit Patients

Supplemental Material for Relationships Between Personality Traits and Perceived Stress in Surrogate Decision Makers of Intensive Care Unit Patients by Brody Greenleaf, Andrew Foy and Lauren Van Scoy in American Journal of Hospice and Palliative Medicine®

Footnotes

Acknowledgments

We thank the following people for their assistance in this study: Maria Katsaros, Morgan Loeffler, Pamela Witt, and the Penn State College of Medicine Qualitative and Mixed Methods Core. We also would like to thank Drs. Vernon Chinchilli and Chloe Bliton for their expertise on biostatistics and personality traits, respectively.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Center for Advancing Translational Sciences (UL1 TR002014).

ORCID iDs

Brody Greenleaf

Lauren Van Scoy

Supplemental Material

Supplemental material for this article is available online.

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