Time-limited trials (TLTs) —an approach to planning and prioritizing intensive care unit (ICU) efforts for critically ill patients—clarified goals and values of family members and reduced potentially nonbeneficial 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 coauthors. “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.
Dr. Chang and colleagues 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.
Time-Limited Trial Use Vs Standard Care
Comparisons of data from pre-and postintervention periods showed:
❯ Formal family meetings increased from 60.2% preintervention to 95.8% at postintervention in admitted patients (P<0.01), with increases in discussions of risks and benefits of ICU treatments (34.9% vs 94.9%, respectively; P<0.01), elicited values and preferences of patients (46.5% vs 98.3%, P<0.01), and identified clinical markers of improvement (20.9% vs 88.1%, P<0.01).
❯ Median ICU length of stay was significantly reduced from 8.7 to 7.4 days (P=0.02).
❯ Invasive ICU procedures were used less frequently in the post-intervention period; for example, mechanical ventilation dropped from 85.8% to 72.9% (P=0.02).
❯ Hospital mortality was similar in the pre-intervention and post-intervention periods (58.4% vs 58.3%, P=0.99).
“Time-limited trials promote regular structured dialogue between clinicians, patients, and families, and consensus in decisionmaking,” 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 & Limiting 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, 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,” they wrote.
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 added. “Although managing uncertainty is one of the key elements of medical practice, communication of that uncertainty is rarely emphasized in medical training.”
Understanding Patient & Family Values & Preferences
“It is important to clarify the goal of TLTs in our study,” Dr. Chang and colleagues 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.”