title: Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians.
abstract: BACKGROUND
  Therapeutic alliance is a novel measure of the multifaceted caregiver-clinician relationship and a promising intervention target for improving patient-centered outcomes. However, therapeutic alliance has not been studied in an intensive care unit (ICU) setting.
  
  
  OBJECTIVE
  To explore the relationships among caregiver-reported therapeutic alliance and psychological distress as well as patient, caregiver, and ICU clinician factors.
  
  
  METHODS
  In this cross-sectional study, we enrolled consecutive patient caregivers of mechanically ventilated patients discharged from all ICUs at Duke University and the Medical University of South Carolina Hospitals between December 2013 and August 2014.
  
  
  RESULTS
  Caregivers completed an in-person, hospital-based interview that included measures of therapeutic alliance with the ICU physicians (Human Connection Scale) as well as patient centeredness of care; symptoms of depression, anxiety, and post-traumatic stress; decisional conflict; and quality of communication. We performed a multivariate regression to characterize associations between Human Connection Scale scores and key variables. A total of 56 caregivers were included in these exploratory analyses. Patients were largely disabled (47%) and Medicare insured (53%). Caregivers were highly educated and generally had high therapeutic alliance (median, 55; interquartile range, 48-58) with the ICU clinicians. Therapeutic alliance was strongly correlated with patient centeredness (r = 0.78) and poorly correlated with psychological distress (r < 0.2). Stepwise multivariate modeling revealed that higher therapeutic alliance was associated with fewer baseline patient comorbidities as well as caregiver report of greater trust in the ICU team, better quality of communication, and less decisional conflict (all P < 0.012).
  
  
  CONCLUSIONS
  Therapeutic alliance encompasses measures of trust, communication, and cooperation, which are intuitive to forming a good working relationship. Therapeutic alliance among ICU caregivers is strongly associated with both modifiable and nonmodifiable factors. Our exploratory study highlights new intervention targets that may inform strategies for improving the quality of the caregiver-clinician interaction.
authors.affiliation: 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and.
authors.forename: Nidhi G
authors.initials: NG
authors.lastname: Huff
authors.affiliation: 2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Nandita
authors.initials: N
authors.lastname: Nadig
authors.affiliation: 2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Dee W
authors.initials: DW
authors.lastname: Ford
authors.affiliation: 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and.|3 Duke Program to Support People and Enhance Recovery, Duke University, Durham, North Carolina; and.
authors.forename: Christopher E
authors.identifier: 0000-0002-4486-0681
authors.initials: CE
authors.lastname: Cox
mesh_terms: D000328:Adult; D000368:Aged; D001007:Anxiety / Q000523:psychology; D017028:Caregivers / Q000523:psychology*; D003142:Communication; D003422:Critical Care / Q000592:standards*; D016638:Critical Illness / Q000628:therapy*; D003430:Cross-Sectional Studies; D003863:Depression / Q000523:psychology; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018802:Patient-Centered Care; D010820:Physicians; D011369:Professional-Patient Relations; D011569:Psychiatric Status Rating Scales; D011788:Quality of Life; D012044:Regression Analysis; D012720:Severity of Illness Index; D017741:Survivors / Q000523:psychology*; D055815:Young Adult
keywords: critical illness; psychological distress; quality of life; surrogate decision maker; therapeutic alliance