Recent studies confirm what many have observed about intensive care: it can be traumatic for patients and their loved ones. In a 2008 systematic review by Davydow and colleagues, for instance, 22% of ICU survivors reported clinically significant symptoms of posttraumatic stress disorder (PTSD).

Dying in the hospital, rather than at home, stresses patients and caregivers alike, according to one recent prospective longitudinal study. Wright and colleagues recruited 666 subjects (333 dyads, each comprising a patient with advanced cancer and her or his informal caregiver) between 2002 and 2008, and assessed the quality of the patients' lives and the mental health of the caregivers. Two-thirds of the patients died at home; the rest died in the hospital (8% in an ICU). Compared with patients dying at home, those dying in an ICU had far lower scores on measures of quality of life, physical comfort, and well-being, and their caregivers had both "a heightened risk of developing PTSD" (21% versus 4% of those whose loved one died at home) and debilitating grief (22% versus 5%).

The researchers hypothesize that "the often frightening nature of aggressive, life-prolonging care" in ICUs may traumatize caregivers and that further research will specify "which experiences lead to caregiver PTSD and interventions to mitigate these traumatic exposures."

ICU diaries. In an attempt to mitigate the trauma experienced by patients in the ICU, British researchers had ICU staff chronicle patients' ICU stays in diaries to be given to the patients. Between 2006 and 2008 at six European hospitals, Jones and colleagues recruited subjects who had been in the ICU at least 72 hours; had been intubated at least 24 hours; and had no previous psychiatric illness, including PTSD. Staff compiled the written and photographic record of each subject's time in the ICU with family members' help. Patients were assessed shortly after discharge and one and three months after discharge. At one month, 352 were randomized to either the intervention group, in which they received a diary as soon as they wished to, or the control group, in which they received it three months after discharge. Each diary was presented by a nurse or physician.

At three months, of the 333 patients still enrolled, 5% of intervention subjects and 13% of controls showed new symptoms linked to PTSD-even though 43% and 47%, respectively, said their experience in the ICU was traumatic.

The researchers acknowledge the costs of preparing and presenting such diaries but suggest that they're small compared with the costs of treating PTSD. Patient diary guidelines used in this study are available at http://bit.ly/bX2bPN.-Joy Jacobson