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

Published online by Cambridge University Press:  08 July 2021

Wendy G. Lichtenthal*
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Martin Viola
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Madeline Rogers
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Kailey E. Roberts
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
Lindsay Lief
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY
Christopher E. Cox
Department of Medicine, Division of Pulmonary & Critical Care Medicine, Duke University School of Medicine, Durham, NC
Chris R. Brewin
Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
Jiehui Cici Xu
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Paul K. Maciejewski
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Cynthia X. Pan
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY Division of Geriatrics & Palliative Care Medicine, NewYork-Presbyterian Queens, Flushing, NY
Taylor Coats
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
Daniel J. Ouyang
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Shayna Rabin
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
Susan C. Vaughan
Department of Psychiatry, Columbia University Irving Medical Center, New York, NY
William Breitbart
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
Marjorie E. Marenberg
Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA
Holly G. Prigerson
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY
Author for correspondence: Wendy G. Lichtenthal, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, New York, NY 10065, USA. E-mail:



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.


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.


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 Article
Copyright © The Author(s), 2021. Published by Cambridge University Press

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