Time-Limited Trials for Patients With Critical Illness: A Review of the Literature

Abstract

Topic importance: Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps.

Review findings: We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies.

Summary: Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.

Keywords: communication; critical care; end-of-life care; medical decision-making; palliative care; time-limited trials.

Figure 1

Literature search results.

Figure 2

The 16 essential elements for conducting a time-limited trial in critical care, according to a modified Delphi process sponsored by the American Thoracic Society. (Reprinted with permission of the American Thoracic Society. Copyright © 2024 American Thoracic Society. All rights reserved. Kruser JM, Ashana DC, Courtright KR, et al. Defining the time-limited trial for patients with critical illness: an official American Thoracic Society Workshop Report, Ann Am Thorac Soc.2024;21(2):187-199. Annals of the American Thoracic Society is an official journal of the American Thoracic Society.)