Project Summary
Intensive Care Units (ICUs) are stressful places fraught with grief and potentially traumatic exposures for those
witnessing a critically ill family member in pain, struggling to breathe, maintain consciousness, and stay alive.
Compounding their distress, family caregivers are often thrust into the position of patient “surrogate,” needing
to make life-and-death decisions on the patient's behalf. We have shown that end-of-life (EoL) decision-making
is compromised by elevated symptoms of distressing and disabling grief, resulting in family surrogates making
suboptimal EoL choices that often prolong patient suffering, further exacerbating surrogates' grief, trauma, and
regrets. The coronavirus (COVID-19) pandemic has made this bad situation worse, particularly among Black,
Indigenous, and People of Color (BIPOC). Prior efforts to address the plight of these family surrogates have
proved disappointing, with some significantly worsening surrogates' psychological trauma. Yet these were not
psychological interventions, much less ones using psychological techniques with proven efficacy. To address
these shortcomings, we developed a brief, flexibly administered intervention applying empirically supported
cognitive-behavioral and acceptance-based techniques. In an R21 pilot, this intervention, EMPOWER
(Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience), dramatically reduced experiential
avoidance, grief, and traumatic stress, and was associated with higher rates of advance care planning,
including among BIPOC. The proposed multisite, mixed-methods trial will randomize 172 family surrogates to
receive EMPOWER (N=86) or a standardized supportive conversation (SC; N=86) delivered via
videoconferencing. Surrogate symptoms will be assessed pre-intervention, immediately post-intervention, and
3- and 12-months post-intervention. The primary aim of this study is to compare the efficacy of EMPOWER to
SC. We hypothesize that, compared to SC, EMPOWER will yield significantly greater declines in H1a.
surrogate grief and posttraumatic stress (primary outcomes) and H1b. experiential avoidance, depression,
regrets, and increase patients' receipt of value concordant care (secondary outcomes). The secondary aim of
this study is to contextualize quantitative RCT results. H2. Qualitative interviews will provide complementary
data on perceived barriers to and facilitators of symptom improvement, dissemination, and implementation, as
well as insights into the impact of medical mistrust, perceived discrimination and COVID-19 on outcomes. The
third aim will explore experiential avoidance as a mediator of intervention effects: H3. Reductions in experien-
tial avoidance will mediate reductions in grief and posttraumatic stress. This study is expected to confirm
EMPOWER's efficacy and enhance understanding of ways to improve telehealth delivery to psychologically
vulnerable and historically underserved surrogates. If successful, EMPOWER will address the urgent need for
effective, culturally competent interventions for distressed surrogates, which may improve critically ill patients'
EoL experience in the context of extreme challenges that have been exacerbated by the COVID-19 pandemic.