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

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 an assessment of EMPOWER's acceptability, 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=0.90). 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.