Search Results (114)

Background: Population aging has led to an increasing proportion of older adults (aged 65 and older) acting as informal caregivers. These caregivers face risks of burden, stress, and depression. While research frequently documents negative psychological outcomes, resilience represents a crucial protective process. This systematic review synthesizes and maps the empirical evidence regarding the association between the socio-ecological resilience process and the well-being of older informal caregivers. Methods: Following Joanna Briggs Institute (JBI) mixed-methods guidelines, a convergent segregated mixed studies systematic review was conducted. A systematic search of Medline (PubMed), CINAHL, PsycINFO, and Scopus identified primary articles (2014–2025) in English and Spanish. Methodological quality was appraised using JBI critical appraisal checklists and the Mixed Methods Appraisal Tool. PROSPERO registration number: CRD420251142190. Results: Thirty-one studies were included. Elevated caregiver resilience was associated with lower reported symptoms of depression and anxiety, higher self-rated health, and positive psychological adaptation. Framed within a social ecological model, personal resources such as spirituality, hope, and self care, alongside relational assets like dyadic relationship quality and mutual coping, demonstrated a positive association with resilience and a reduction in subjective burden. Within the community context, informal peer networks and Online Health Communities functioned as essential supportive resources. On a structural level, both household wealth and the regional availability of long-term care beds acted as moderators for spousal well-being, whereas exceeding 30 weekly caregiving hours acted as a temporal threshold for positive adaptation. Conclusions: These findings suggest that resilience in older caregivers may be best conceptualized not as a static individual trait, but as a multi-level, dynamic socio-ecological process. Rather than relying on individual coping alone, public policies and clinical practice should prioritize systemic, relational, and structural environmental support, including formal respite services and long-term care infrastructure, to preserve the well-being of older spousal caregivers. Full article

Context: Previous studies and reviews in adult patients have shown that hope is an important coping mechanism in patients with serious health problems. Although there are individual studies in pediatric patients, there is a lack of a systematic review of how hope manifests and how it can be supported in children with life-threatening illnesses and their families. Objectives: This systematic review aims to identify the key factors that are associated with the experience of hope in pediatric palliative care. It examines how hope is fostered or diminished in children with life-limiting illnesses, their parents, and other family members. Methods: A systematic search was conducted across major medical databases for studies published between 1990 and 2024. Thematic analysis was used to identify factors associated with hope. The quality of the included studies was critically appraised. Results: Out of 1373 identified records, 105 studies met the inclusion criteria. Most studies were qualitative in design and met a high proportion of the applicable criteria in their respective design-specific appraisal tools. Factors associated with increased hope included open and empathetic communication, trusting relationships with healthcare providers, strong social and family support, spiritual and religious faith, effective symptom management, involvement in care decisions, and access to practical resources. Conversely, reduced hope was associated with poor communication, social isolation, uncontrolled symptoms, uncertainty, caregiver distress, financial strain, and negative healthcare experiences. These factors were consistent across cultural and diagnostic contexts, with some variation in emphasis. Conclusions: Hope in pediatric palliative care is associated with relational, psychological, spiritual, and systemic factors. Many of these are modifiable. A family-centered and multidisciplinary approach is essential to sustaining hope in pediatric palliative contexts. Full article

Background/Objectives: End-of-life (EOL) preparedness remains critically understudied among Hispanic patients with advanced breast cancer and their patient–caregiver dyads, despite evidence that preparedness significantly influences quality of life, care decisions, and caregiver well-being. This study aimed to explore how Hispanic patient–caregiver dyads conceptualize and experience EOL preparedness. Methods: A qualitative descriptive design was employed, guided by the Dyadic Cancer Outcomes Framework, which highlights patient and caregiver characteristics, relationship processes, individual and relational outcomes, the cancer care trajectory, and the broader social context as interrelated influences on dyadic experience. Semi-structured individual interviews were conducted in Spanish with 11 metastatic patient–caregiver dyads (n = 22 participants) recruited through Ponce Health Sciences University and the Ponce Research Institute in Puerto Rico. Data were analyzed using codebook thematic analysis in NVivo 15, with themes interpreted through the framework’s components. Results: Six interdependent themes of EOL preparedness were identified: psychological and emotional, spiritual, informational, practical, physical, and caregiver role preparedness. Spiritual preparedness, grounded in faith, prayer, and surrender to divine will, functioned as the foundational axis organizing all other themes. Preparedness was dynamic and turning-point-driven, challenged anew at each stage of disease progression. Financial vulnerability, caregiver invisibility within formal care systems, and insufficient anticipatory information were identified as primary barriers. Family support and faith communities were the most consistently cited facilitators. Conclusions: The findings yield the first grounded, dyadic conceptualization of EOL preparedness with Hispanic advanced breast cancer patient–caregiver dyads. We propose a formal definition positioning preparedness as a dynamic, multidimensional, relationally embedded, and spiritually anchored process that is fundamentally interdependent between patient and caregiver. These results directly inform the development of a culturally tailored, dyadic EOL preparedness intervention for this underserved population. Full article

On behalf of the Canadian Association of Psychosocial Oncology, we are pleased to present the abstracts from the 2026 Annual Conference, titled “A New Horizon: Expanding the Access and Impact of Psychosocial Oncology”. The 41st Annual CAPO Conference was held in St. John’s, Newfoundland from 8 June 2026 to 9 June 2026. As we stand at a new horizon in psychosocial oncology, we recognize the unprecedented opportunities to expand both the access to and the impact of comprehensive cancer care. This conference will explore innovative strategies for breaking down traditional barriers that have historically limited access to psychosocial support, including geographic isolation, resource constraints, cultural disparities, and systemic inequities in healthcare delivery. This expansion of reach and influence represents not merely growth in service numbers, but a fundamental transformation in how we conceptualize, design, and implement patient-centered psychosocial care across diverse communities and care settings. We will explore scalable solutions that amplify impact while maintaining the deeply personal, human-centered approach that defines excellence in psychosocial oncology. From telehealth innovations and peer support networks to community-based interventions and integrated care models, this conference will showcase evidence-based strategies that expand our collective ability to support individuals and families navigating the cancer journey, wherever they may be. This conference brought together key stakeholders including multidisciplinary professionals from nursing, psychology, psychiatry, social work, spiritual care, nutrition, medicine, rehabilitation medicine, occupational health and radiation therapy for both adult and pediatric populations. Participants included clinicians, researchers, educators in cancer care, community-based organizations and patient representatives. Patients, caregivers and family members presented abstracts that speak to their role in managing cancer experiences and care. Over one-hundred and fifty (150) abstracts were submitted for presentation as symposia, 20 min oral presentations, 10 min oral presentations, 90 min workshops and poster presentations. We congratulate all the presenters on their research work and contributions. Full article

Background: Cervical cancer remains a significant health issue in Indonesia, where structural barriers, fragmented information, and sociocultural norms continue to hinder timely diagnosis and treatment. Families play a central role throughout the illness journey, yet their perspectives are often overlooked in the development of digital patient navigation systems. This study explored family experiences, caregiving challenges, and expectations for a family-centered digital navigation model, DIVA.ID, by integrating Digital Health frameworks and Family Systems Theory. Methods: A qualitative descriptive approach was employed through semi-structured, in-depth interviews with 18 purposively selected family caregivers of women with cervical cancer at a major referral hospital in West Java. Participants were selected because they were directly involved in daily care, treatment decisions, logistical support, or emotional assistance. Interviews were conducted between August and October 2025 and continued until thematic saturation was reached, as indicated by repetition of categories and the absence of new major codes in the final interviews. Data were analyzed using inductive–deductive content analysis guided by Elo and Kyngäs, with five researchers conducting independent coding, iterative code comparison, consensus meetings, and theoretical mapping. Results: Four main themes emerged: (1) family involvement in decision-making, including collective discussion, shifting authority roles, and patient autonomy; (2) caregiver burden, involving physical exhaustion, psychological distress, social restriction, stigma, financial pressure, and employment disruption; (3) psycho-spiritual coping mechanisms, including emotional sharing, prayer, crying, patience, and surrender to God; and (4) digital healthcare needs, covering BPJS guidance, treatment information, scheduling, communication pathways, shelter support, and mental–spiritual support. Mapping these themes to Digital Health frameworks and Family Systems Theory clarified how DIVA.ID could translate family experiences into practical navigation functions. Conclusions: This study provides empirical foundations for a culturally sensitive, family-centered digital navigation model in Indonesia. Rather than demonstrating effectiveness, the findings identify design requirements for DIVA.ID that should be tested in subsequent feasibility, usability, and intervention studies. Full article

Background: Understanding the psychological and spiritual needs of family caregivers, including their experiences of death anxiety and levels of death literacy, is essential for delivering holistic palliative care. This study aimed to examine the relationships between death anxiety, spiritual well-being, and death literacy among relatives of patients receiving palliative care in Türkiye. Methods: A cross-sectional correlational study was conducted with 160 relatives of patients receiving treatment in a palliative care unit in Türkiye. The participants had a mean age of 47.56 ± 12.33 years, and 62.5% were male. Data were obtained using the Abdel-Khalek Death Anxiety Scale (ASDA), the Three-Factor Spiritual Well-Being Scale (SWBS), and the Death Literacy Index (DLI). Results: The mean scores were 61.34 ± 17.45 for ASDA, 122.94 ± 15.84 for SWBS, and 96.13 ± 16.36 for DLI. Participants exhibited relatively elevated death anxiety scores, comparatively higher spiritual well-being scores, and moderate death literacy scores within the study sample. Correlation analyses showed that death anxiety was positively associated with spiritual well-being and negatively associated with death literacy, whereas death literacy was positively associated with spiritual well-being. Regression analyses further indicated that spiritual well-being was independently and positively associated with both death anxiety and death literacy, whereas death literacy was independently and negatively associated with death anxiety. Conclusions: The findings suggest that psychosocial, spiritual, and informational dimensions should be considered together in holistic palliative care. Supporting death literacy and spiritual well-being may contribute to better coping with death-related concerns among relatives of patients receiving palliative care. Full article

Background/Objectives: To identify and evaluate contemporary clinical practice guidelines for the care of adult patients in their last days of life, their families and caregivers. Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement (PROSPERO: CRD42021258311). PubMed, TRIP Database, Cochrane Library, ProQuest, and CINAHL were searched for CPGs published between January 2016 and December 2025 in English or Spanish, supplemented by searches of seven palliative care organisation websites. Two independent reviewers screened records; the AGREE II instrument was applied by four evaluators to assess methodological quality. Recommendations from included guidelines were categorised into 12 inductively derived decision areas encompassing recognition of the dying phase, communication and decision-making, multidisciplinary care, symptom management, and grief and bereavement. A narrative synthesis was adopted due to heterogeneity in guideline structure and recommendation grading systems. Results: Of 1118 records identified, 20 were retrieved for full-text assessment. Sixteen met CPG criteria and were appraised with AGREE II, of which eight were finally included. Included guidelines originated from five countries (UK, Spain, USA, Canada, and Europe) and were published between 2018 and 2021. Overall AGREE II scores ranged from 71% to 100%, with the lowest domain scores consistently found in Applicability. Strong recommendations were identified across most guidelines for recognition of the LDS, communication, and interdisciplinary coordination; recommendations on symptom management were mixed. Conclusions: Findings may inform professionals and health system managers in identifying key LDS care recommendations. Gaps in social, cultural, and spiritual dimensions should guide future guideline development. Key limitations include heterogeneity in guideline methods and restriction to English and Spanish publications. No external funding was received. Full article

Background/Objectives: Spirituality is increasingly recognised as a core dimension of holistic and palliative care. Neurodegenerative diseases such as dementia, amyotrophic lateral sclerosis and Parkinson’s disease involve prolonged trajectories of loss, uncertainty and relational change, which may heighten spiritual and existential needs for patients, particularly among those involved in caregiving, such as family caregivers and, to a lesser extent, healthcare professionals. However, evidence on how spirituality is understood, experienced and addressed within neurodegenerative palliative care remains fragmented and conceptually heterogeneous. This scoping review aimed to map the literature on caregivers’ spiritual needs and challenges. Methods: A scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews (PRISMA ScR). Searches were conducted across PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycINFO, and Scopus, with no date or geographical restrictions. Grey literature was searched through Google Scholar and relevant organisational and policy sources in the field of palliative care and spirituality. Reference list screening of included studies and relevant reviews was also conducted. Quantitative, qualitative, and mixed methods studies published in English or Italian were included. Results: Twenty-four studies published between 2007 and 2025 were included. Findings were organised into three interconnected domains: spiritual needs, spiritual processes and spiritual care. Spirituality emerged as a dynamic, relational and context-dependent dimension of caregiving, encompassing meaning, identity, connection and coping with vulnerability and loss. Spiritual needs and processes were widely described, while spiritual care was inconsistently recognised within healthcare systems. Conceptual ambiguity, under-representation of end-of-life dementia and cultural imbalances were evident. The evidence predominantly focused on family caregivers, with limited representation of healthcare professionals. Conclusions: This scoping review highlights a persistent gap between caregivers’ lived spiritual experiences and system-level responses in neurodegenerative palliative care in caregiving contexts globally. The findings support integrated, caregiver-inclusive and culturally responsive approaches to spiritual care. Full article

Background: Families caring for children with medical complexity (CMC) face sustained psychosocial demands that may impair health-related quality of life (HRQoL) and mental health. A clear map of how these outcomes are assessed and which factors shape them is needed to guide family-centered care. Methods: We conducted a scoping review following the Joanna Briggs Institute guidelines, and reports were prepared according to the PRISMA guidelines. Searches were conducted in PubMed, CINAHL, and EMBASE (January 2011 to December 2023) to find studies reporting on health-related quality of life (HRQoL) and/or mental health outcomes (anxiety, depression, burden) of family members and/or caregivers of CMC, including operationalization based on complex chronic condition (CCC) classifications, technology dependency, or the Pediatric Medical Complexity Algorithm (PMCA). Two reviewers independently screened records and recorded data, and the findings were synthesized narratively and thematically. Results: Sixty-seven studies met the inclusion criteria and spanned cross-sectional, cohort, case–control, pre–post and qualitative designs across conditions such as epilepsy, congenital heart disease, cerebral palsy, technology dependence and cancer. Common measures were PedsQL™ Family Impact Module, SF-36/12, HADS, Beck inventories and Zarit burden scales. Across the included studies, caregivers, predominantly mothers, frequently reported poorer HRQoL and higher levels of anxiety, depressive symptoms, or burden than comparison groups when these were available. Six recurrent themes emerged: (1) gendered caregiving with disproportionate maternal burden; (2) socio-economic gradients and financing models shaping outcomes; (3) culture, religion and spirituality as coping resources; (4) family and social support buffering distress; (5) school participation and coordinated services potentially reducing burden; and (6) interdependence between caregiver and child outcomes. Conclusions: Heterogeneous CMC definitions, outcome measures, and study designs limited comparability across studies. The mapped evidence suggests that family HRQoL and mental health outcomes are shaped by interacting clinical, social, and contextual factors. These findings may inform more family-centered and equity-oriented approaches to care. Future research should harmonize CMC definitions, standardize outcome measures, and prospectively evaluate multicomponent interventions. Full article

Cancer caregiving is increasingly recognized as a major psychosocial challenge, yet the mental health needs of caregivers remain insufficiently addressed in oncology research and practice. This narrative review examines the experiences of cancer caregivers within the context of rising cancer incidence and prolonged survival, conditions frequently accompanied by sustained psychological burden and anticipatory grief, with particular attention to depressive symptoms. Relevant qualitative and quantitative studies were identified through targeted searches of major databases (PubMed, Scopus, PsycINFO, and Google Scholar), including studies published up to January 2026. Study selection was guided by conceptual relevance and applied significance to the intersection between religiosity, spirituality, caregiving, and mental health outcomes. The reviewed literature highlights substantial psychological burden among caregivers, with depression affecting approximately 20–40% of cancer caregivers and identifies religiosity and spirituality as potentially supportive resources. Across studies, recurrent themes include meaning-making, hope maintenance, emotional regulation, moral orientation, and perceived social support as mechanisms through which these dimensions are associated with lower levels of depression and improved psychological adjustment. Evidence suggests that both religiosity, understood as the lived engagement with religious values, and spirituality, defined as a broader existential orientation toward meaning and purpose, contribute to coping in caregiving contexts; however, findings remain heterogeneous and largely based on cross-sectional analyses. Notable gaps persist, including limited caregiver-specific research, conceptual imprecision, and a lack of longitudinal designs. By integrating conceptual clarification with empirical synthesis, this review outlines potential psychological pathways linking religiosity and spirituality to caregiver mental health outcomes. In summary, religiosity and spirituality are considered adjunctive, non-exclusive resources that complement conventional psychological and psychiatric care within comprehensive models of caregiver support. Full article

Patients with end-stage liver disease (ESLD) and their caregivers experience extensive physical, psychological, and social burdens and needs for resources. However, empirical evidence on patients’ and caregivers’ specific reported use of resources to help manage ESLD is lacking. Understanding the type and helpfulness of resources used could strengthen clinical care to address individual needs for resources. Aim: To examine and compare resources patients and caregivers identified as being most helpful in managing ESLD in relation to resources they felt would be helpful. Methods: Patients with ESLD and their caregivers responded in writing to two open-ended questions as part of a survey: (1) What resources have you found most helpful in dealing with patient’s liver disease? and (2) What resources would be helpful in dealing with patient’s liver disease? Conventional content analysis was used to identify resource categories. Results: A total of 192 patients and 198 caregivers completed surveys. We identified two major resource domains—medical and non-medical—and five categories within each. Analysis revealed participant group- and disease severity-based differences in helpful resources. Conclusions: Proactively engaging patients and caregivers early in the course of illness to identify relevant resources that might facilitate ability to manage ESLD. An interprofessional care approach would facilitate efforts supporting financial, social, spiritual, emotional, and mental health needs. Future longitudinal research of unique resource needs along the disease trajectory may help to develop effective interventions. Full article

Lung cancer is one of the leading causes of mortality in the United States. Despite overall declines in incidence and mortality nationwide, rural communities continue to experience higher rates of lung cancer incidence and mortality than their urban counterparts, a disparity that has persisted over recent decades. This review synthesizes evidence from epidemiologic and clinical studies evaluating rural–urban differences in lung cancer incidence, mortality, diagnostic stage, access to screening, and treatment outcomes. Factors influencing these differences—tobacco use and environmental exposures, socioeconomic inequities, access to healthcare, and psychosocial and spiritual support—are examined as well. The review highlights the importance of increasing access to lung cancer screening and suggests interventions to improve early detection, access to treatment, and enhance psychosocial and spiritual support for patients and caregivers residing in rural areas. In this review, we have followed the urban–rural classification designated by the United States Census Bureau as a rural area consisting of populations, housing, and territory not included within an urban-classified area. Full article

Background: Family and friend caregivers provide essential support across health and social care systems but remain inconsistently identified, assessed, and supported in routine practice. Although numerous caregiver needs’ assessment instruments exist, many focus on burden, distress, or preparedness rather than explicitly eliciting caregiver-defined support needs, limiting their utility for care planning, care transitions, and system integration. Methods: We conducted a rapid scoping review to identify and characterize caregiver needs’ assessment tools developed for family and friend caregivers. Searches were conducted in MEDLINE, PsycINFO, CINAHL, Web of Science, Health and Psychosocial Instruments, and the Cochrane Library. Eligible studies described the development, validation, or implementation of instruments designed to assess caregiver needs. Data were extracted on tool characteristics, domains assessed, administration methods, and implementation-relevant features. Item-level content analysis distinguished caregiver-defined support needs from related constructs, including burden, strain, preparedness, and care-recipient monitoring. Results: Forty-three studies describing caregiver needs’ assessment instruments were included (19 instruments; 17 instrument families). Tools varied widely in length, administration, and conceptual framing. Seven domains of caregiver-defined support needs were identified: caregiver health and self-care; emotional and psychological support; information, communication, and navigation; practical and instrumental support; social and relational support; autonomy and life participation; and spiritual, cultural, and existential support. Information and navigation needs were most frequently assessed, while autonomy and spiritual domains were least consistently represented. Many instruments demonstrated construct drift, assessing stressors or impacts rather than explicitly eliciting caregiver-defined support needs. Few tools were designed for longitudinal reassessment, workflow integration, or documentation within electronic medical records. Conclusions: Existing caregiver needs’ assessment tools inadequately support routine, system-integrated caregiver-centered care. Advancing caregiver-centered practice requires tools that explicitly elicit caregiver-defined support needs and are designed for workflow integration, longitudinal use, and interdisciplinary care pathways. Full article

Background/Objectives: Dementia represents a complex syndrome in which biological, psychological, social, and cultural dimensions intersect. While its clinical features are well documented, less is known about how lived experiences, caregiving contexts, and cultural beliefs shape the trajectory of illness. This study explored clinical, behavioral, and socio-cultural dimensions related to the quality of life of people living with dementia from an anthropological perspective, focusing on the interaction between comorbidities, cognition, lifestyle, and caregiving environments as reported by their informal caregivers. Methods: We conducted a single-center, observational cross-sectional study including 73 family caregivers of patients with clinically diagnosed dementia who accessed care at the Neurology–Psychiatry Department of the C.F.2 Clinical Hospital (Bucharest, Romania) between November 2023 and April 2024. Caregivers provided socio-demographic, behavioral, lifestyle, and cultural information using a newly developed anthropological questionnaire. Descriptive and exploratory inferential analyses were performed to examine relationships between cognitive performance, comorbidities, lifestyle factors, and socio-cultural variables. Results: People with dementia had a mean age of 79.2 ± 7.5 years (range 66–95) and were predominantly female (71.2%). Multimorbidity was common, averaging 2.22 ± 1.03 chronic conditions, mainly neurological (84.9%) and cardiovascular (68.5%). The mean BMI was 26.1 ± 3.8 kg/m². Cognitive impairment was substantial (MMSE mean 11.47 ± 7), with descriptively lower scores among older individuals and those with lower education or income, although inferential tests were underpowered. Appetite and sleep disturbances were frequent and tended to co-occur with lower activity levels. Disclosure of diagnosis occurred in 74% of cases; reactions varied widely, ranging from acceptance to denial, confusion, anxiety, and sadness. Family responses likewise reflected a heterogeneous and often ambivalent adjustment process. Cultural beliefs and spirituality played a salient role in shaping explanatory models and coping strategies, with many caregivers attributing importance to religious practices and, to a lesser extent, alternative treatments. Conclusions: In this Romanian cohort, dementia was shaped not only by age-related multimorbidity and cognitive decline but also by caregiving practices, socioeconomic constraints and culturally grounded interpretations of illness. These findings highlight the relevance of integrative approaches to dementia care that consider medical, behavioral, and socio-cultural dimensions and that incorporate caregiver perspectives to improve the quality of life of both patients and families. Full article

Background: Family caregivers of intensive care unit (ICU) patients face a double burden: the psychological toll of critical illness and the economic and occupational disruptions that often accompany prolonged caregiving. While prior research has examined caregiver distress, few studies have systematically integrated economic, psychological and spiritual domains over long-term follow-up. Methods: This study presents a cross-sectional analysis conducted at long-term follow-up examining economic, occupational, psychological, and spiritual correlates among family caregivers of former ICU patients. From an initial cohort of 189 caregivers, 92 participated in a five-year follow-up, completing validated psychometric instruments (SCL-90-R, SpREUK, CD-RISC-10, Heartland Forgiveness, F-COPES). Multivariate regression models were used to identify predictors of psychological and spiritual outcomes, while cluster analysis explored heterogeneity in caregiver profiles. Results: Job loss emerged as a strong predictor of anxiety and hostility, while reduced working hours showed a protective association against depression and anxiety. Financial burden was less consistently associated with psychopathology. Spirituality demonstrated an ambivalent pattern of correlational associations: while dimensions such as trust and reflection were linked to adaptive coping, higher levels of spiritual engagement were also associated with elevated depressive symptoms, suggesting a reactive rather than purely protective role. Resilience and coping resources (e.g., reframing, forgiveness, personal competence) mitigated distress, whereas neuroticism amplified vulnerability. Cluster analysis revealed three distinct caregiver subgroups: a high-burden cluster (severe psychopathology and economic strain), a moderate cluster with mixed spiritual and psychological engagement and a resilient cluster with minimal burden. Conclusions: This study highlights that economic stressors are not peripheral but central drivers of caregiver distress and that spirituality, although valued, may operate in both adaptive and maladaptive ways. Tailored interventions must integrate financial protection, psychological support and sensitive spiritual care to address the multidimensional reality of ICU caregiving. Full article