A structured approach helps ICU clinicians align treatment with family goals and values.
Time-limited trials (TLTs)—an approach to planning and prioritizing ICU efforts for critically ill patients—clarified goals and values of family members and reduced potentially non-beneficial treatment, a prospective study suggested. In addition, the intervention was associated with significant reductions in ICU length of stay and use of invasive procedures, without changes in hospital mortality, reported Dong Chang, MD, MS, and colleagues. “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,” they wrote in JAMA Internal Medicine.
In structured meetings, family members, surrogate decision-makers, the clinical team, and the patient (if able) regularly updated a mutually agreed-on care plan with time limits and criteria for continuing or discontinuing specific treatments. Examples included mechanical ventilation, dialysis, or central venous catheterization. The study team instituted the TLT intervention as the default care planning process in three public academic hospital medical ICUs. The ICU care team, rather than ancillary clinical or other personnel, met with family and surrogates.
Promoting Structured Dialogue & Setting Rational Boundaries
Comparisons of data from pre- and post intervention periods showed:
Formal family meetings increased from 60.2% pre-intervention to 95.8% at post intervention in admitted patients, with increases in talks of risks and benefits of ICU treatments (34.9% vs 94.9%, respectively), elicited values and preferences of patients (46.5% vs 98.3%), and identified clinical markers of improvement (20.9% vs 88.1%).
Median ICU length of stay was significantly reduced, from 8.7 to 7.4 days.
Invasive ICU procedures were used less frequently in the post-intervention period; for example, mechanical ventilation use dropped from 85.8% to 72.9%.
Hospital mortality rates were similar in the pre- and post-intervention periods (58.4% vs 58.3%). “Time-limited trials promote regular structured dialogue between clinicians, patients, and families, and consensus in decision making,” Dr. Chang and colleagues noted. “They also set rational boundaries to treatments based on patients’ goals of care while reassuring families that all indicated interventions have been pursued. For patients with advanced illnesses who prefer aggressive care, TLTs may prioritize patients’ values and preferences and may reduce ICU treatments that prolong suffering without benefit.”
Building Trust & Mitigating Inconsistent Messaging
“This study builds on previous work examining structured communication approaches in critical care, which treat these conversations—and family meetings, in particular—as medical procedures based on skills that can be taught, learned, and deliberately practiced,” noted Richard Leiter, MD, MA, and James Tulsky, MD, both of the Dana-Farber Cancer Institute in Boston, in an accompanying editorial. “In contrast to previous interventions that have been delivered by additional staff, the intervention by Chang et al involves the primary clinical team caring for the patient, which may build trust and mitigate the risk of inconsistent messaging.”
Extant programs have tied prognostic information to discussions of goals and values, but time-limited trials “take an important next step by integrating an acknowledgment of uncertainty into the conversation,” Drs. Leiter and Tulsky noted. “Although managing uncertainty is one of the key elements of medical practice, communication of that uncertainty is rarely emphasized in medical training.”
A Closer Look at the Study
A 2019 study suggested that as many as 20% of patients receiving invasive treatments in medical ICUs were unlikely to have meaningful recovery. A 2014 meta-analysis concluded that pro-active palliative care in the ICU decreased hospital and ICU length of stay, did not affect satisfaction, and either decreased or did not affect mortality. “Unfortunately, structured care planning and communication between clinicians, critically ill patients, and families are inconsistent,” Dr. Chang and colleagues observed.
As interest in the appropriateness and efficacy of ICU interventions has grown, TLT has been proposed as a way to reduce non-beneficial care. In this study, the researchers included 209 patients with a mean age of approximately 64 years from the medical ICUs of three academic public hospitals in the Los Angeles County from June 2017 to December 2019; about 61% were men. They excluded patients managed with comfort care after initial discussions and those without surrogate decision-makers. The most common ICU diagnoses were acute respiratory failure, cardiopulmonary arrest, and shock. The pre intervention median ICU days to first family meeting were 5.5 and 1.0 post-intervention. Data were available from two of the three centers for family satisfaction. Analysis showed no change versus pre-intervention for satisfaction with care overall, medical care specifically, or decision making.
“It is important to clarify the goal of TLTs in our study,” the researchers noted. “Time-limited trials were not intended to limit care or pressure families into uncomfortable decisions. Instead, the goal was to create opportunities for clinicians to understand the values and preferences of patients and families, discuss risks and benefits of ICU treatments, and align ICU care with these preferences. Through this process of sharing information and examining the effects of ICU treatments together, it may have been easier to recognize when invasive treatments were not achieving their intended aims and place rational limits to minimize unnecessary suffering.”
