Caregiver engagement and ICU satisfaction: insights into language based disparities. From Observers to Participants: Families in ICU Care.

Delirium, characterised by acute disturbances in cognition and attention, is associated with poor short and long-term outcomes in critically ill patients. These include prolonged ventilation, increased length of stay, cognitive and functional decline and higher mortality, making delirium a major burden for patients, their families and the healthcare system. (1)

Exposure to delirium symptoms such as altered consciousness, agitation, and behavioural disturbances is associated with significant psychological distress among family members. These experiences may contribute to anxiety, depressive symptoms and post-traumatic stress. A lack of understanding of delirium can further exacerbate this burden, leading to misinterpretation, feelings of helplessness and reduced trust in the healthcare team, ultimately affecting communication and satisfaction with ICU care. (2)

In this context, Ellberg et al. evaluated whether structured caregiver engagement using the Family Confusion Assessment Method (FAM-CAM) could improve satisfaction with ICU care. In this prospective cohort study conducted across two academic ICUs, 120 patient–caregiver dyads were included with balanced representation of English and Spanish speaking caregivers. Caregivers were assigned to either an intervention group that performed daily FAM-CAM assessments or a control group that received usual care. Satisfaction was assessed 3 days later using the validated FS-ICU-24 questionnaire. (3)
Three main observations emerge. First, Spanish-speaking caregivers reported lower satisfaction compared with English speaking caregivers with a significant difference in the decision making domain, highlighting persistent communication and inclusion gaps. Second, caregiver participation through FAM-CAM was associated with higher satisfaction across all domains with differences of approximately 7–9 points, within a clinically meaningful range. Third, although delirium was associated with lower satisfaction, engagement with FAM-CAM appeared to attenuate this effect, particularly among caregivers of patients with delirium.
The differential impact across domains is noteworthy. Improvements in decision making were more pronounced among English speaking caregivers, whereas Spanish speaking caregivers experienced greater gains in care, suggesting greater trust and perceived support. This pattern underscores both the potential and the limitations of such interventions: while structured engagement may foster inclusion and understanding, it does not fully overcome systemic communication barriers, particularly in shared decision making.

These findings should be interpreted in the context of prior studies, where interventions targeting caregiver experience have generally yielded modest benefits. In contrast, FAM-CAM represents a pragmatic, low-resource approach that actively involves caregivers in clinical processes. Its impact likely derives less from the tool itself than from the repeated engagement it facilitates, shifting caregivers from passive observers to active participants. Such involvement may enhance understanding, promote “sense making” and strengthen the caregiver–clinician relationship.

Several limitations warrant consideration. The non-randomised design, with allocation based on day of enrolment, introduces potential bias related to ICU workflow and staffing patterns. The study was not powered for satisfaction outcomes and the relatively small sample size, together with imbalance between groups, limits the robustness of the findings. Satisfaction was assessed early during the ICU stay, precluding evaluation of longer-term outcomes such as PICS-F. In addition, high baseline satisfaction may limit generalisability to other settings.

STUDY STRENGTHS & LIMITATIONS

This study addresses an important gap by including a linguistically diverse caregiver population, a group often underrepresented in ICU research. The use of a validated outcome measure (FS-ICU-24) and the evaluation of a simple, low-resource and scalable intervention enhance both the methodological rigour and clinical applicability of the findings. The observed effect sizes, which fall within a clinically meaningful range, further support the potential relevance of caregiver engagement strategies in ICU practice.

However, several limitations merit consideration. The non-randomised design, with allocation based on enrolment date, introduces potential selection bias and confounding related to ICU workflow. The study was not powered for satisfaction outcomes and the relatively small sample size, together with the imbalance between groups, limits the strength of inference. Satisfaction was assessed early during the ICU stay, precluding evaluation of longer-term outcomes such as PICS-F. A potential Hawthorne effect should also be considered, whereby caregivers exposed to the intervention may have experienced higher satisfaction due to increased attention and perceived involvement inherent to study participation, rather than the specific effect of FAM-CAM. In addition, high baseline satisfaction may limit generalisability and excluding more distressed caregivers who declined to participate may have led to an overestimation of satisfaction.

TAKE-HOME MESSAGES

Caregiver satisfaction in the ICU remains influenced by language proficiency and communication barriers, with caregivers with limited English proficiency at higher risk of poorer experience, particularly in decision making. Structured engagement through tools such as FAM-CAM may improve satisfaction by enhancing understanding, inclusion, and trust, while partially mitigating the negative impact of delirium on families. These findings highlight the potential of simple, scalable interventions to improve both quality and equity of care. However, confirmation in larger, adequately powered randomised studies, including assessment of long-term outcomes is required before widespread implementation.

This article review was prepared and submitted by Dr Nikita Singh for the ESICM Journal Review Club.