Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments

Abstract

IMPORTANCEFor critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit.OBJECTIVE To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care. DESIGN, SETTING, AND PARTICIPANTSThis prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage. INTERVENTIONS Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers. MAIN OUTCOMES AND MEASURES Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure). RESULTS A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02). CONCLUSIONS AND RELEVANCEIn this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care.

Goal-Concordant Care After Severe Acute Brain Injury

“…One in four patients in our study may have been receiving unwanted aggressive care in the acute setting. It is possible that LST was provided with the mutual understanding of a timelimited trial, whereby family and clinicians have agreed on a period of aggressive interventions to see if the patient improves according to outcomes consistent with the patient's presumed goals-of-care (10,20). In that case, this relatively high prevalence of aggressive care may be ethically justified as long as the prognostic uncertainty persists and as long as the time-limited trial is brought to a conclusion.…”

Palliative Withdrawal of Mechanical Ventilation and Other Life Supports

“…The physician should then schedule a date to discuss progress, or lack of improvement, and further options with the patient or surrogate, unless new findings or changes require significant discussions sooner. This constitutes a time-limited trial, which is a useful framework for acknowledging the uncertainty of outcomes of critical illness [2].…”

Appropriate care for the elderly in the ICU

“…The chances that antibiotic therapy and mechanical ventilation will be successful are small but an ICU test will give the patient and their family the reassurance that everything possible has been done. In a multicentre, quality improvement study in critically ill patients with advanced medical illnesses who were at risk of receiving non‐beneficial ICU treatments, introduction of time‐limited trials as the default approach to such patients was associated with improved communication with relatives and reduced intensity and duration of ICU treatments [33]. Importantly, the patient (where possible) and the family must be fully aware and agreed that this is just a trial for a limited period of time and that if no benefit is seen within the specified timeframe, the treatment will be withdrawn [31].…”