Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

Wendy G. Lichtenthal, Martin Viola, Madeline Rogers, Kailey E. Roberts, Lindsay Lief, Christopher E. Cox, Chris R. Brewin, Jiehui Cici Xu, Paul K. Maciejewski, Cynthia X. Pan, Taylor Coats, Daniel J. Ouyang, Shayna Rabin, Susan C. Vaughan, William Breitbart, Marjorie E. Marenberg, Holly G. Prigerson

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Objective The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes. Method Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. Results Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30). Significance of results Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Original languageEnglish
Pages (from-to)167-177
Number of pages11
JournalPalliative and Supportive Care
Issue number2
StatePublished - 29 Apr 2022
Externally publishedYes


  • Critical care
  • Grief
  • Intensive care unit
  • Intervention
  • Surrogate decision-making


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