The ICU as more than a medical arena

A growing body of literature has begun to reframe the ICU as more than a medical arena. The Society of Critical Care Medicine’s recent family-centered care guidelines view families as partners in the care of the critically ill (Hwang et al. Reference Hwang, Oczkowski and Lewis2025). Likewise, several international initiatives to “humanize” intensive care have gained momentum; most recently, Azoulay and colleagues have characterized the ICU as a relational, dynamic ecosystem shaped by the “shared injury” of critical illness among patients, families, and staff (Azoulay et al. Reference Azoulay, Pochard and Kentish-barnes2026). These converging frameworks name the psychological toll of the ICU with increasing clarity: post-intensive care syndrome among survivors, post-traumatic stress disorder, anxiety, and depression among family members, and burnout and moral distress among clinicians. Yet across all of them, one dimension of shared vulnerability remains largely unnamed: the domain of meaning-making.

Naming the domain of meaning-making

Meaning-making is the process by which patients, families, and clinicians reconstruct coherence, purpose, and connection in the face of life-threatening illness. Critical illness disrupts this process at precisely the moment it is most needed. Spiritual and existential distress encompasses loss of meaning and purpose, disrupted identity, religious struggle, fear of death, and the profound difficulty of integrating a catastrophic illness experience into one’s life narrative (Fitchett et al. Reference Fitchett, Campbell and Chang2026). Importantly, these concerns are not confined to the religious. As such, spirituality is indeed best understood as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred” (Puchalski et al. Reference Puchalski, Vitillo and Hull2014). A substantial and growing evidence base now links spiritual well-being, and its neglect, to health outcomes, quality of life, patient satisfaction, and the quality of end-of-life care across serious illness (Balboni et al. Reference Balboni, VanderWeele and Doan-soares2022). In the ICU, where questions of what makes a life worth living are not theoretical but daily determinants of treatment decisions, the spiritual and existential dimensions of human experience move from the periphery of care to the center.

How common is spiritual and existential distress?

The distress that arises at this level of personhood is neither rare nor incidental. Across 5 studies summarized by Fitchett and colleagues, between 43% and 66% of patients with serious illness reported some degree of religious/spiritual distress, whether low, moderate, or high (Fitchett et al. Reference Fitchett, Campbell and Chang2026); within that range, 10–25% reported moderate to high levels of distress specifically, a level associated with poorer coping and diminished quality of life (Fitchett et al. Reference Fitchett, Campbell and Chang2026). In another recent multisite study using a validated spiritual assessment with palliative care patients across care settings, moderate to severe spiritual concerns were identified among 50% of patients near the end of life (Byrne-Martelli et al. Reference Byrne-Martelli, Palmer and Cole2026). Among ICU survivors specifically, approximately half of 196 respondents attending a post-ICU follow-up clinic reported unmet spiritual and social support needs, and these unmet needs were significantly associated with anxiety, depression, and cognitive dysfunction, which are core features of post-intensive care syndrome (Eaton et al. Reference Eaton, Scheunemann and Butcher2022). Similar patterns extend to family members, whose spiritual and existential struggles frequently overlap with – and may in turn amplify – the post-traumatic symptoms consistently documented after an ICU admission (Smith et al. Reference Smith, Ferguson and Russell2025). For clinicians, the moral distress of being unable to act in accordance with one’s ethical commitments is itself an existential challenge, and this distress is implicated in burnout, attrition, and depersonalized care (Dodek et al. Reference Dodek, Cheung and Burns2021). In each group, in other words, the psychological morbidity that critical care already measures is often accompanied by spiritual and existential burdens.

An unmet need hiding in plain sight

Despite this burden, addressing spiritual and existential concerns remains strikingly invisible in routine ICU practice. In a multicenter study of recorded goals-of-care conferences involving surrogate decision-makers with a comparatively high degree of religiosity, religious or spiritual considerations were discussed in fewer than 20% of conferences, and when surrogates themselves raised such concerns, clinicians rarely explored them further (Ernecoff et al. Reference Ernecoff, Curlin and Buddadhumaruk2015). Potential reasons for avoiding spiritual and existential topics in ICU settings are familiar: time pressure, discomfort, uncertainty about role boundaries, and variation in spiritual care staffing and referral practices. Notably, professional healthcare chaplains function as specialists in meaning-making, values clarification, and emotional support, and their work with patients, families, and staff extends beyond religious ritual (Torke et al. Reference Torke, Varner-Perez and Burke2025; Fitchett et al. Reference Fitchett, Campbell and Chang2026). Properly characterizing chaplaincy in these terms (i.e., as specialist, meaning-oriented care rather than a religious service) is a prerequisite for reaching the patients, families, and clinicians who suffer existentially but would never think to ask for a chaplain.

Evidence that meaning-centered care helps

Moreover, spiritual and existential distress is not merely describable; it is responsive to targeted intervention. In a randomized controlled trial of 192 patient-surrogate dyads across 5 ICUs, proactive chaplain-delivered spiritual care was associated with significantly lower surrogate anxiety at follow-up, with intervention participants showing roughly 3-fold higher adjusted odds of achieving a clinically meaningful reduction, alongside higher spiritual well-being and greater satisfaction with spiritual care (Torke et al. Reference Torke, Varner-Perez and Burke2023). Chaplain-provided spiritual care may also help family members process difficult medical information and cope with its existential weight, potentially reducing the distress that can otherwise cloud high-stakes decision-making on a patient’s behalf (Torke et al. Reference Torke, Varner-Perez and Burke2025).

Beyond the ICU, a systematic review and meta-analysis of dignity therapy demonstrated meaningful improvements in dignity-related distress, hope, and quality of life among patients receiving palliative care (Wulandari and Rochmawati Reference Wulandari and Rochmawati2024), and meaning-centered group psychotherapy has been shown in another randomized trial to improve spiritual well-being and quality of life while reducing depression and hopelessness in advanced cancer (Breitbart et al. Reference Breitbart, Rosenfeld and Pessin2015). These interventions differ in format and setting, but they share a common premise: that meaning-making is more than a private matter left to chance. The evidence from ICU family surrogates is especially salient here, because surrogates carry both the decisional burden of critical illness and much of its long-term psychological morbidity (Wendlandt et al. Reference Wendlandt, Ceppe and Choudhury2019).

Two steps toward whole-person critical care

Treating meaning-making as a clinical responsibility, however, requires deliberate structure. We therefore propose 2 practical steps toward whole-person critical care. A feasible first step is including brief, periodic spiritual screening. Validated tools, such as the single-item screening question “Does your religion or spirituality provide you all the strength and comfort you need from it right now?” and the spiritual pain item adapted from the Edmonton Symptom Assessment Scale, are acceptable in acute care settings and implementable within existing workflows (Torke et al. Reference Torke, Varner-Perez and Burke2025; Fitchett et al. Reference Fitchett, Campbell and Chang2026). This type of screening with timely chaplaincy referral requires no major structural expansion and should not be understood as an optional aspect of clinical care. When prognosis is poor, or when survival may come at the cost of outcomes a patient would find unacceptable, care decisions cannot be made without knowing what patients value, which often goes beyond mere survival. Eliciting spiritual and existential concerns is, in this sense, part of the values elicitation on which goal-concordant care depends. Like pain scores or mood scores, screening results should be documented, revisited, and acted upon, and members of the interprofessional team such as clinical social workers and chaplains should be intentionally consulted when appropriate.

A second step is structural: embedding board-certified chaplains within the ICU team as a standard of practice – rather than relying on intermittent referral triggered by crisis – such as imminent death or explicit religious request. Team-embedded chaplains can proactively identify distress in patients who may not self-refer because they do not identify as religious. Chaplains may contribute to the care of families by helping them examine the moral questions which are often inseparable from frameworks of belief and meaning. And finally, chaplains are formally trained to accompany clinicians navigating grief, moral distress, and the cumulative burden of witnessing suffering (Tartaglia et al. Reference Tartaglia, White and Corson2024) – precisely the injuries that contemporary frameworks identify among ICU staff (Azoulay et al. Reference Azoulay, Pochard and Kentish-barnes2026). This positions chaplaincy integration as a component of burnout prevention. Team-embedded chaplaincy also normalizes conversations about meaning within the culture of the unit, signaling to trainees and fellow intensivists that attending to existential distress is part of excellent critical care. Interprofessional training programs that pair clinicians and chaplains as co-learners, such as the Interprofessional Spiritual Care Education Curriculum (ISPEC^©,TM), developed at the George Washington University Institute for Spirituality and Health, have demonstrated that this model builds mutual competence and equips clinician-chaplain teams to implement collaborative spiritual care as partners within their home institutions (Puchalski et al. Reference Puchalski, Jafari and Buller2020, Reference Puchalski, Ferrell and Borneman2022). ISPEC^©,TM is based on the generalist-specialist model of spiritual care, with all clinicians being generalist spiritual care providers and board-certified chaplains functioning as specialist spiritual care professionals (Puchalski et al. Reference Puchalski, Ferrell and Virani2009).

Acknowledging the challenges

Nonetheless, we recognize important challenges. Chaplaincy workforce capacity varies widely across institutions and countries, and in many health systems spiritual care remains unfunded or informal. The evidence base, while growing, still relies on heterogeneous outcome measures, and interventions validated in oncology and palliative care require adaptation and testing in critical care populations, including among patients who cannot communicate. Cultural and secular contexts differ, and screening must be implemented with sensitivity rather than as a checkbox.

From ABCDE to ABCDE(F)

These elements can be brought together within the frameworks already reshaping critical care. The “ABCDE” model recently proposed by Azoulay and colleagues – acceptance of the importance of families, burnout prevention, an ethical ICU climate, dedicated time for relational care, and encouragement of healthcare professionals – offers a useful scaffold (Azoulay et al. Reference Azoulay, Pochard and Kentish-barnes2026). We propose that it, and other family-centered frameworks like it, be expanded to include “F”: “Finding meaning” – defined broadly enough to encompass religious, non-religious, spiritual, and existential dimensions, and operationalized through routine spiritual screening and integrated chaplaincy care for patients, families, and staff alike (Figure 1).

Figure 1.

The ABCDE(F) model for the synthesis of whole-person and family-centered support within the intensive care unit (ICU). This conceptual framework broadens the initial ABCDE paradigm articulated by Azoulay et al. (Reference Azoulay, Pochard and Kentish-barnes2026) through the integration of “F”: “Finding meaning.” This addition recognizes the vital role of existential, spiritual, religious, and secular avenues for purpose among patients, their loved ones, and the clinical team. Collectively, these 6 domains advocate for a comprehensive critical care philosophy that harmonizes relational engagement, clinician resilience, and ethical integrity with a structured focus on meaning-making. By doing so, the framework seeks to mitigate the collective vulnerability and psychological morbidity inherent in the ICU ecosystem.

Figure 1 Long description

Finding Meaning in the Shared Journey of Critical Illness presents the ABCDEF model for whole-person care. It includes six components: A) Accepting the importance of families: Proactive chaplain-delivered care significantly reduces symptoms of anxiety and improves spiritual well-being. B) Burnout prevention: Chaplains are trained to prevent, recognize and address burnout, integrating this into the team at a clinical necessity. C) Ethical ICU climate: The moral questions families face are often inescapable from the religious and spiritual frameworks that shape their social worlds. D) Dedicated time for relational care: Timely care requires the right team, including the relational skills of chaplains and social workers. E) Encouragement of healthcare professionals: Family-centered care involves equipping clinicians with a spiritual, psychosocial and cultural understanding as part of institutional practice. F) Finding meaning: Spiritual, religious and existential distress is clinically prevalent and responsive to intervention. The footer reads, ′Whole-person care for patients, families and staff addressing the full depth of human vulnerability.′.

Taken together, these steps point toward a broader conclusion. If the ICU is a site of shared injury, it is also a site of profound possibility, where patients, families, and clinicians confront together what matters most. Reimagining critical care as a fully relational effort, and recognizing the expertise, care, and leadership available from interprofessional colleagues, requires attending not only to the vulnerabilities of critical illness but also to the opportunities for meaning-making it reveals. Naming the value of meaning-making, screening for associated distress, and formally prioritizing this care are essential steps toward true whole-person care.