Surrogate resilience and clinical titration of presence in the open intensive care unit: a systematic narrative synthesis.

Background: Open-access intensive care unit policies prioritize family integration. However, these guidelines may not fully account for the physical and psychological demands placed on surrogate decision-makers. Continuous, unregulated family presence is associated with physical exhaustion and cognitive fatigue. This burden may negatively affect the decisional capacity these policies intend to support. Objectives: This study aimed to evaluate the evidence regarding the psychological burden on intensive care unit surrogates and to construct a resilience framework based on the Conservation of Resources theory. Design and methods: This systematic narrative synthesis (Resilience Ecosystem for Surrogate Titration, Overload Recovery, and Engagement) combined the methodological rigor of systematic identification, utilizing structured database searches, dual screening, and standardized quality appraisal, with narrative thematic analysis. A multi-database search (PubMed, Scopus, Web of Science) identified relevant literature published through February 2026. After quality appraisal, data from 35 articles were analyzed using thematic synthesis and mapped onto the Conservation of Resources framework. Results: Findings suggest that current evaluation metrics often equate visitation duration with quality of care, which may not account for the physiological limits of surrogates. The synthesis identifies "Compulsive Hyper-engagement," a state of cognitive fatigue associated with continuous, unstructured visitation. To address this, the framework proposes the Clinical Titration of Family Presence, which uses structured rest periods ("Restorative Dosing") to regulate the intensity of family engagement. Furthermore, a Pan-Dimensional Matrix for Surrogate Resilience is introduced. This matrix categorizes protective interventions across five dimensions: physiological infrastructure, cognitive support, psycho-spiritual frameworks, social architecture, and technological connectivity. Conclusions: The synthesized evidence identifies a plausible risk that unrestricted intensive care unit visitation without structural support may contribute to surrogate exhaustion. To preserve decisional capacity, clinical practice may benefit from shifting toward actively structuring family resilience. Implementing the Clinical Titration of Presence suggests providing scheduled rest intervals. This approach aims to reduce surrogate guilt and support their role as capable partners in shared decision-making. Registration: Not applicable. (As a narrative synthesis, prospective registration is not required; however, an internal methodological protocol was followed).