Documentation of Family Surrogate Traumatic Stress in the Intensive Care Unit: A Qualitative Analysis

Abstract

Objective

Traumatic stress among families of critically ill patients is common and associated with interpersonal conflict between families and intensive care unit (ICU) clinicians. This qualitative study aimed to characterize clinician documentation of family members with high levels of traumatic stress in the electronic health record (EHR).

Methods

Mechanically ventilated patients with surrogate decision makers reporting a Post-Traumatic Stress Symptoms Scale score >35 (consistent with post-traumatic stress disorder) were included. All electronic notes from patients’ ICU stays were included. Thematic analysis used a structured codebook focused on surrogate behaviors, relationships, and coping strategies; resources provided to surrogates; and medical decision making.

Results

Twenty-five surrogates were largely female (n = 22, 88.0%) and had a median age of 48 years (interquartile range [IQR] 41-55 years) and median PTSS-10 score of 46 (IQR 38-53). Most of their critically ill loved ones (n = 17, 68%) survived the hospitalization. Three major themes emerged: (1) documentation of surrogate traumatic stress was inconsistent unless it disrupted clinical care; (2) surrogate-clinician conflict and goal misalignment intensified surrogate distress; and (3) multidisciplinary team members were crucial for providing emotional support and bridging communication.

Conclusion

These findings suggest the need for standardized approaches to identify and address surrogate traumatic stress in the ICU. Investment in multidisciplinary teams is also essential—not only to ease surrogate distress but also to facilitate trust, communication, and collaborative decision-making. Investing in these resources and bringing awareness to how our documentation can perpetuate stigma are key steps toward reducing re-traumatization and advancing person-centered care in the ICU.