A Concurrent, Mixed-Methods Evaluation of the Four Supports Intervention in ICUs

<h3>Background</h3> Surrogate decision-makers in ICUs frequently struggle in this role and experience lasting psychological distress. A recent multicenter trial of the Four Supports Intervention, a multicomponent family support intervention delivered by an external interventionist, revealed that the intervention did not improve patient- or family-centered outcomes, but the main trial results do not provide insights into why the intervention was ineffective. <h3>Research Question</h3> How was the Four Supports Intervention experienced by families and clinicians and how can the intervention be improved? <h3>Study Design and Methods</h3> We conducted a concurrent mixed-methods evaluation of the Four Supports Intervention among 45 participants in the intervention arm of the trial (30 surrogates and 15 clinicians). The research team and participants were masked to trial results during data collection and analysis. Participants completed a quantitative survey and a semistructured interview focusing on their perceptions of whether the intervention provided emotional support to surrogates, facilitated effective clinician-family communication, and fostered patient-centered decision-making. Coders used a thematic analysis approach to identify key themes from the interviews. <h3>Results</h3> Ninety percent of surrogates perceived that the intervention improved the degree to which their needs and concerns were addressed, 93% of surrogates and 100% of clinicians perceived that the intervention improved clinician-family communication, and 87% of surrogates and 87% of clinicians reported that the intervention improved the patient-centeredness of care. Key themes from the interviews with surrogates included that the interventionist provided comfort, was present and listened during a difficult time, and ensured that needed clinician-family conversations happened. Interviews with clinicians revealed that the intervention prepared family members for the role of surrogate decision-maker, helped in recognizing and addressing nascent misunderstandings, and aided creation of positive clinician-family relationships. Surrogates and clinicians suggested potential improvements, including extending the intervention into the period after discharge, better integrating the interventionists' role with the ICU team, and prioritizing families most in need. <h3>Interpretation</h3> Surrogate decision-makers and clinicians reported that the Four Supports Intervention improved emotional support for surrogates and communication about goals of care. In light of the negative trial results, these findings have important implications for the field.