Critical Care/Respiratory Care

Time-limited Trials in the Intensive Care Unit to Promote Goal-Concordant Patient Care

VanKerkhoff, Todd D. MD^*; Viglianti, Elizabeth M. MD, MPH, MSc^†; Detsky, Michael E. MD, MSHP^‡,§; Kruser, Jacqueline M. MD, MS^∥,¶

Author Information

Departments of ^*Medicine

^∥Medicine, Division of Pulmonary and Critical Care Medicine

^¶Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL

^†Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI

^‡Division of Critical Care Medicine, University Health Network/Sinai Health System

^§Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Disclosure: J.M.K.: supported, in part, through NIH/NHLBI K23 HL146890. E.M.V.: supported through NIH T32 HL7749-25. The remaining authors declare that they have no conflicts of interest.

Address correspondence to: Jacqueline M. Kruser, MD, MS, 240 E Huron Street, McGaw M-335, Chicago, IL 60611. E-mail: [email protected].

Clinical Pulmonary Medicine 26(5):p 141-145, September 2019. | DOI: 10.1097/CPM.0000000000000323

Abstract

Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxemic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty and uncertainty with regard to patients’ goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to use a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient’s progress according to previously established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently, and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal time frames for TLTs, and interventional trials to determine whether TLTs ultimately improve the delivery of goal-concordant care in the ICU.