Teachable Moment 

February 13, 2023

Time-Limited Trials of Intensive Care Unit Care

John J. Popovich, Isadore Budnick, Thanh H. Neville

JAMA Intern Med. 2023;183(4):360-361. doi:10.1001/jamainternmed.2022.6792

Story From the Front Lines

Apatient in their 70s with pancreatic adenocarcinoma with known hepatic metastases and peritoneal carcinomatosis was admitted from the emergency department due to gastric outlet obstruction. Prior to admission, the patient had few functional limitations from their cancer or treatment. Esophagogastroduodenoscopy revealed extrinsic duodenal compression and a nonbleeding duodenal ulcer. Several days later, the patient developed large-volume hematemesis accompanied by hypotension, tachycardia, and acute encephalopathy. Prompt goals-of-care conversations were had with the family. It was decided that, given the potential reversibility of this acute decompensation, it would be within the patient’s goals of care to proceed with intensive care unit (ICU) admission and interventions with the ultimate goal of discharging to home with hospice. A plan was made to reassess the patient’s clinical status and the utility of ICU care after 48 hours (or sooner, especially if they had ongoing bleeding or hemodynamic instability). The patient was aggressively resuscitated with intravenous fluids and blood products. The patient underwent mesenteric arteriography followed by prophylactic coiling of their gastroduodenal artery. The patient was discharged to the acute care floor and eventually to home with hospice.

Teachable Moment

There is increasing evidence of overuse of ICU care, particularly for patients with end-stage disease and unfavorable prognoses.¹ Efforts to better understand potentially inappropriate treatment at the end of life have identified early goals-of-care meetings that focus on patients’ goals and preferences as a potential mitigating factor.²

Medical decision-making for patients with substantial comorbidities who experience an acute decompensation is uniquely challenging; such situations create urgency in identifying patients’ goals of care yet can be fraught with prognostic uncertainty. In such circumstances, a time-limited trial (TLT) of ICU care may be helpful.

A TLT is “an agreement between clinicians and a patient/family to use certain medical therapies over a defined period to see if the patient improves or deteriorates according to agreed-on clinical outcomes.”³ The idea of TLTs arose from a desire to offer patients potentially helpful treatments without committing them indefinitely to burdensome therapies. There are 5 components to the TLT framework (Table).³ After the predetermined time frame, the patient either meets the predetermined goals, and disease-directed therapies continue, or, if they do not, goals of treatment are transitioned to focus on comfort. If their trajectory remains unclear, another TLT can be planned.

Patients who might benefit most from TLTs are ones for whom ICU interventions cannot be clearly determined as beneficial or nonbeneficial by the physician, family, or both. One approach suggests that appropriate candidates may be those who fit the FRAIL mnemonic (falls/functional decline, reactions, altered mental status, illnesses, and living situation), which captures patients with substantial functional impairment, recurrent hospitalizations, advanced or end-stage chronic disease, irreversible organ failure, and those with long hospital stays with minimal improvement or substantial complications.⁴ Quill and Holloway³ also offer TLT examples that involve the use of continuous invasive therapies, which can be more challenging to de-escalate than a specific procedure. In one such example, a TLT of mechanical ventilation for a patient with end-stage heart failure was offered with the understanding that the patient would be liberated from the ventilator in 3 to 7 days with diuresis or transitioned to comfort care.

Clinical judgment remains paramount (ie, not all who meet FRAIL criteria should have a TLT). For patients who clearly can benefit from ICU care (eg, a patient with severe diabetic ketoacidosis), TLTs are inappropriate.¹ Similarly, a TLT is not advisable in situations where it is clear that the ICU intervention is nonbeneficial and will only be burdensome to the patient and their family. For such situations, a transition to comfort-focused care would be more appropriate.

Barriers to successful implementation and possible strategies to overcome these barriers have been previously explored.⁵ Frequent barriers are disagreement about clinical trajectory between surrogates and/or clinicians and a time frame that is unclear or repeatedly adjusted. These barriers may be overcome if specific goals are set and open communication about the patient’s prognosis is maintained, so that a transition to comfort-focused care (if that is more appropriate) is not delayed by iterative TLTs.

There is emerging evidence supporting TLTs. One recent study trained clinicians to use TLTs as the default approach to care planning for patients who were at risk for nonbeneficial ICU treatment.¹ In this pre-post study, implementation of TLTs was associated with decreased ICU length of stay, decreased receipt of procedures, and improvements in measures of family meeting quality, without a change in in-hospital mortality or family satisfaction with ICU care.

Decision-making in the ICU is complex, the evidence base for TLTs is still developing, and more research is needed to best identify the patients and situations that will most benefit from the TLT framework. Nonetheless, when used appropriately, TLTs can provide a patient-centered, goal-oriented framework for care planning when caring for patients in the ICU with substantial comorbidities and/or uncertain benefit from ICU care.