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Editorial
Cristobal Padilla-Fortunatti 1
1 Escuela de Enfermería, Pontificia Universidad Católica de Chile, Chile.
0000-0001-5452-8415
cfpadill@uc.cl
Para citar este editorial / To reference this editorial / Para citar este editorial Padilla-Fortunatti C. Families in Critical Condition: Between the Uncertainty of the Evidence and the Duty of Care. Aquichan. 2026;26(1):e2549. DOI: https://doi.org/10.5294/aqui.2025.25.4.9
Keywords (Source: DeCS): Intensive care; family; practice guidelines as topic; humanization of care; research
Palabras clave (Fuente: DeCS): Cuidados intensivos; familia; guías clínicas; humanización de la atención; investigación
Palavras-chave (Fonte: DeCS): Cuidados intensivos; família; guias de prática clínica como assunto; humanização da atenção; pesquisa
Introduction
Admission to an Intensive Care Unit (ICU) is a significant event that affects not only the patient's health but also that of their family, who experience high levels of stress related to the patient's illness severity, sudden hospitalization, and uncertainty about prognosis (1). Additionally, family members must face this crisis in a physical environment that is not designed to accommodate them and establish communication with the healthcare team that does not always meet their expectations and needs (2). Over the past 25 years, evidence has consistently documented the profound and frequent impact that ICU hospitalization has on the well-being of family members in both the short and long term (3). During ICU admission and stay, up to 81% of family members report significant symptoms of anxiety and up to 36% report symptoms of depression (4). Likewise, the literature shows that 57% of family members report symptoms of post-traumatic stress disorder (PTSD) six months after the patient's discharge (5).
In this context, ICU nursing professionals can play a central role by promoting clear and empathetic communication, facilitating the understanding of technical information, educating family members, and providing support in complex decision-making processes (6). In any healthcare setting, but particularly in the ICU, evidence-based clinical guidelines are fundamental tools for reducing variability in care, ensuring safe practices, and achieving optimal patient management (7). Therefore, the care of the family of the critically ill patient should not be an exception, as it is essential that nursing professionals are familiar with and apply the scientific evidence supporting these interventions.
In 2017, the Society of Critical Care Medicine (SCCM) published the Clinical Practice Guidelines for Family-Centered Care in neonatal, pediatric, and adult ICUs (8). An international panel of experts reviewed more than 450 scientific articles and formulated 23 evidence-based recommendations, addressing interventions to improve communication, family presence, support strategies, and operational and environmental aspects of ICUs. However, all of these recommendations were classified, according to the GRADE method, as weak in favor, since the quality of the evidence ranged from very low to moderate, highlighting the need to generate more and better evidence to support family care in ICUs (9).
Despite these efforts, in 2020 the COVID-19 pandemic triggered a global health crisis that imposed unprecedented prevention and control measures, including partial or total restrictions on family visits in ICUs. Likewise, communication between family members and healthcare professionals in the ICU was affected, reducing its frequency and prioritizing remote methods such as telephone and video calls (9). These measures directly impacted fundamental
family needs, such as access to information and physical proximity (10), which exacerbated the emotional distress associated with the pandemic and the hospitalization of patients in the ICU due to COVID-19. As a result, a significant increase in symptoms of anxiety, depression, and PTSD was observed among family members (9,11).
In February 2025, the SCCM published an update of the Family-Centered Care Guidelines in Adult ICUs, which included 17 statements: one strong recommendation in favor, 14 conditional recommendations in favor, and two best practice statements. Regarding the certainty of the evidence, 82.4% of the statements were assessed as having low or very low certainty (12). Considering the profound impact of the COVID-19 pandemic on family presence in ICUs, and that a significant proportion of ICUs maintained restrictive visiting policies (13), the implementation of liberalized visit policies as standard practice was the only intervention to receive a strong recommendation in favor, although it was supported by low-certainty evidence. In particular, key aspects for implementing flexible visit policies include the perceptions and attitudes of the healthcare team, logistical challenges, and the lack of clarity regarding what constitutes an 'open' or 'flexible' visit in the scientific literature (14). Similarly, the only intervention with moderate certainty of evidence was the implementation of educational programs that provide context for family members regarding ICU physical spaces, the healthcare team and their roles, and basic clinical concepts and terminology. To deliver this content, the use of informational brochures, online materials, question guides, or individualized orientation is proposed. The need for studies on their cost-effectiveness and feasibility is emphasized (12).
Among the new recommendations of the 2025 guidelines, the implementation of ICU diaries is highlighted. Although their effectiveness in reducing anxiety, depression, or PTSD in family members is uncertain (15), the recommendation is based on evidence regarding PTSD symptoms in patients. Their application should consider costs and the time required for staff training (12). Likewise, the guidelines recommend family participation in basic patient care, as it has shown benefits for family members' mental health and limited adverse effects (16). Nevertheless, its implementation requires assessing the willingness of both the family member and the patient, as well as the resources needed for training and supervision (12).
Although most of the SCCM guidelines recommendations are conditional and supported by low-certainty evidence, they reflect a professional consensus on the urgent need to humanize ICU care and to consolidate family care as an ethical and clinical standard. The current state of the evidence on interventions for families of critically ill patients calls for action by healthcare professionals, researchers, and scientific and academic societies. These stakeholders must work together to promote the development, publication, and dissemination of initiatives, ideally through research projects that generate evidence on their impact on clinical outcomes, cost-effectiveness, and added value for patients, families, and ICU teams (17).
To address this challenge, the nursing discipline offers conceptual frameworks that help understand family members' experiences in ICUs. One example is Mishel's Uncertainty in Illness Theory (18), which provides a framework to analyze how families interpret and cope with the ambiguity inherent in the clinical course of critically ill patients, the fragmentation of information, and the unpredictability of prognosis. Incorporating this theoretical-disciplinary perspective deepens the understanding of the mechanisms through which family-centered interventions regulate uncertainty and, consequently, influence emotional well-being (19).
In a complementary manner, Davidson's middle-range Theory of Facilitated Sensemaking (20) proposes an active role for nurses in optimizing communication between the family and the healthcare team, identifying unmet needs, and promoting family participation in basic care activities. These actions help family members understand what occurs during ICU admission and stay, as well as adopt a role in the patient's recovery, thereby reducing feelings of helplessness, fear, and horror-factors associated with the development of PTSD symptoms. Both nursing theories applied to family care in the critical care context, and most of the interventions suggested by the SCCM guidelines require additional empirical studies to strengthen their validity and guide clinical practice.
Conclusion
Clinical practice guidelines for family-centered care in ICUs offer an evidence-based framework for action and an urgent research agenda. Without a solid scientific foundation, there is a risk of implementing well-intentioned interventions that do not generate real benefits or may even produce adverse effects for families in ICUs (21). In this context, every experience of liberalizing visitation, every educational program, every initiative of family participation or emotional support that is implemented can become an opportunity to generate evidence, if it is planned, implemented, and evaluated rigorously. In this way, care for the family of the critically ill patient becomes a source of evidence, and humanization ceases to be a distant ideal and becomes a measurable and sustainable reality in ICUs, where every action promotes the dignity and value of families in crisis.
References
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