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

Introduction: Traumatic stress is common for critically ill patients and their surrogate decision-makers. Traumatic stress symptoms in the ICU have been linked to surrogate-clinician conflict. We hypothesize that conflict may arise from clinicians misinterpreting traumatic stress symptoms as “difficult” behaviors. To explore this hypothesis, we described how ICU clinicians document their perceptions of surrogates experiencing substantial traumatic stress.


Methods: We conducted a qualitative study of electronic health record notes referencing family members of critically ill, mechanically ventilated patients. We analyzed notes from 25 ICU cases where surrogates reported traumatic stress symptoms consistent with post-traumatic stress disorder (PTSS-10 score >35). Using inductive and deductive methods, we developed a codebook focused on descriptions of surrogate behaviors, interpersonal relationships, and supportive resources. Two coders double-coded 20% of cases; then, after achieving 96% agreement, they separately coded the remaining cases. The team identified themes through iterative discussion until consensus was reached. Artificial intelligence was used to improve the grammar and readability of this abstract.


Results: The 25 included surrogates had a median age of 48, were mostly female (22/25, 88%), and were often the spouse (11/25, 44%) or child (10/25, 40%) of the patient. We identified three themes related to how clinicians described surrogate traumatic stress. First, clinician documentation uncommonly reflected the high level of surrogate stress unless it impacted workflow, suggesting that distress goes unrecognized. When mentioned, surrogate emotions were framed as a hindrance to medical decision-making. Second, surrogate stress was exacerbated by surrogate-medical team goal misalignment and perceived pressure from the ICU team to pursue comfort-oriented care. Third, multidisciplinary team members emerged as key supports for families under stress, serving as bridges to improve communication and shared decision-making.


Conclusions: These findings highlight the need for standardized approaches to identifying and addressing surrogate traumatic stress in the ICU. Investment in multidisciplinary teams is also essential to ease surrogate distress and facilitate trust and collaborative decision-making.