BEREAVEMENT support services available to families in critical care are "informal, sporadic and rudimentary" despite the units accounting for a similar proportion of deaths in Scotland each year as hospices.
Researchers, who have compiled figures for the first time comparing deaths in critical care units and hospices, also warned that the "paucity" of support would hit people from poorer areas hardest as a much higher proportion of those dying in intensive care or high dependency wards were from the most deprived neighbourhoods.
A sudden or traumatic loss of a loved one has known physiological impacts, increasing the risk of mental health and cardiovascular problems, with those bereaved by a critical care death more often experiencing prolonged and "complicated" grief which can be harmful to their own health.
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There are fears this discrepancy has been exacerbated by Covid, with those living in Scotland's least affluent areas much more likely to end up in ICU and to die as a result of the disease.
"With Covid you do have more of a run up, compared to someone in a road traffic accident," said lead researcher, Dr Nazir Lone, an ICU consultant at the Royal Infirmary of Edinburgh.
"But it is still unexpected - people expect to survive Covid."
The study, published in the BMJ journal Supportive and Palliative Care, covered a 12 year period in Scotland from 2005 to 2017.
It found that the number of people dying annually had increased steadily over that time, rising by 23 per cent in critical care and 22% in hospices.
In total, over the 12 years, 5.1% (36,316) of all recorded deaths occurred in critical care units compared to 6.1% (42,988) in hospices.
However, the researchers stressed that "given the younger age profile, greater social deprivation and unexpected nature of deaths in critical care units, there is a pressing need for a specific focus on end-of-life care that includes bereavement support services".
They found that three times as many people aged 16 to 40 had died in critical care units as hospices (2326 deaths versus 769), and that 29% of those who had died in critical care were from the most deprived areas compared to 12% from the least deprived.
By contrast, a higher share of those who died in hospices - 19% compared to 12% - were from the most affluent postcodes.
The researchers argue that the differing socioeconomic status of people dying in critical care compared to hospices "highlights potential inequities in access to palliative care and bereavement support" and demonstrates "the need for national initiatives to address this imbalance".
Causes of death were also markedly different.
In critical care, comparatively few deaths were caused by cancer - just 11% compared to more 90% of those in hospices.
Heart attacks, strokes, accidents, respiratory disease and liver disease were vastly more common among critical care patients, with 2,760 liver disease deaths in critical care units over the 12 years compared to just 96 in hospices.
It comes after figures last week revealed that the number of alcohol-specific deaths in Scotland reached a 12 year high in 2020, with two thirds caused by liver disease.
The authors note that while "sudden or violent death and a lack of time to prepare increase the risk of complicated grief" for those bereaved, with potential health harms as a result, at least 32% of those occurring in critical care units were considered "unexpected" compared to around 5% of those in hospices where bereavement services are "well-organised".
They add: "In contrast, bereavement support in critical care units is informal, sporadic and rudimentary."
Dr Lone, who is also chair of the Scottish Intensive Care Society Audit Group (SICSAG), said: "We see it on the shop floor everyday but I think others outside don't appreciate how different the deaths are.
"Everyone associates hospices with end of life care, even though that's not all they do, and really it was just important to get the message out that there's a lot of death in critical care as well, and it's often unexpected for families and it's skewed to younger people.
"There are obviously older people dying in ICU too but it's the suicides and accidents that we see not infrequently.
"It's very sad and tragic when that happens, but it's the ongoing care for families that we are most worried about."
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Dr Lone said work is already underway in Edinburgh and Glasgow, spurred by the pandemic, to ensure that people who have lost a loved one in critical care are better signposted to bereavement organisations as well as making relevant charities more aware of the ways in which a critical care experience can complicate the grief process.
He said: "We have these very intense periods of time with families - it's often two or three days and then they die.
"They take a death certificate from us and that's often it.
"We need to find ways of making sure they are aware that there might be problems for them down the line, and making sure that when they are ready they know what support services are there.
"That's our plan - that's what we'd like to make sure is happening.
"The purpose of this research is to give us the numbers."
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