Training in time-limited trials associated with less use of nonbeneficial ICU treatments

In a pre- and postintervention quality improvement study, physicians at three academic hospitals in California were trained to use time-limited trials of interventions in communication and care planning with families and surrogate decision makers of critically ill ICU patients.

Using time-limited trials as the default approach for planning care in critically ill patients may decrease the duration and intensity of nonbeneficial ICU care, a study found.

Researchers in California performed a prospective quality improvement study from June 1, 2017, to Dec. 31, 2019, in medical ICUs at three academic public hospitals to determine whether time-limited trials of ICU treatments reduced nonbeneficial care. With time-limited trials, physicians have detailed discussions about patients' care preferences and prognoses and agree with patients or their surrogate decision makers to use certain interventions for defined periods. Follow-up meetings address whether patients have improved or worsened based on predetermined clinical parameters, and next steps are evaluated based on the results, the authors said.

Patients in the current study were identified as being at risk for nonbeneficial ICU treatments according to admission and triage categories defined by the Society of Critical Care Medicine. Hospital physicians were trained to use time-limited trials as the default for communication and care planning with families and surrogate decision makers. Over four to six weeks, physicians participated in focus groups to identify barriers to time-limited trials, didactic sessions to define time-limited trials and review protocols for their use, and simulations of family meetings (with actors) using a time-limited trial protocol. Physicians also received a conversation guide to assist them during family meetings, including a checklist of key components to be discussed and sample phrases to use. The main outcome measures were the quality of family meetings and the length of ICU stay. Results were published April 12 by JAMA Internal Medicine.

Two hundred nine patients were included in the study. The mean age was 63.6 years, 60.8% were men, and 48.3% were Hispanic. One hundred thirteen patients (54.1%) were seen in the preintervention period, and 96 patients (45.9%) were seen in the postintervention period. Formal family meetings were held for 68 of 113 patients (60.2%) in the preintervention period versus 92 of 96 patients (95.8%) in the postintervention period (P<0.01). Risks and benefits of ICU treatments (34.9% vs. 94.9%), values and preferences of patients (46.5% vs. 98.4%), and clinical markers of improvement (20.9% vs. 88.1%) were discussed more frequently after the intervention (P<0.01 for all comparisons). Median length of ICU stay decreased significantly between the pre- and postintervention periods (8.7 days [interquartile range, 5.7 to 18.3 days] vs. 7.4 days [interquartile range, 5.2 to 11.5 days]; P=0.02) and use of invasive ICU procedures was less frequent, while hospital mortality rates were similar (58.4% vs. 58.3%; P=0.99).

The researchers noted that their intervention was multifaceted and that they could not determine which components had an impact, among other limitations. They concluded that the quality improvement intervention in their study, which trained physicians to communicate and plan ICU care with family members of critically ill patients using time-limited trials, was associated with improved quality of family meetings and reduced intensity and duration of ICU treatments. Of note, they said, hospital mortality rates did not change and family satisfaction did not decrease. “Our study highlights an approach that prioritizes patients' values and preferences and may reduce disproportionate use of nonbeneficial ICU treatments,” the researchers wrote.

An accompanying commentary acknowledged the study's limitations but said that the results were promising and that time-limited trials allow physicians to acknowledge uncertainty in discussions with patients and families. Sequential conversations offer the opportunity to narrow the range of options and increase families' acceptance of bad news by breaking it over time, the commentary authors wrote. “When caring for patients with poor prognoses, critical care clinicians face a series of seemingly opposing tasks: doing all they can to save a life, while also ensuring a good death and genuinely supporting a family's hope and simultaneously offering honest and realistic information,” they wrote. “By giving clinicians the space to acknowledge and communicate their uncertainty, [time-limited trials] provide them with a path forward.”