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Observational Study
. 2024 Sep 16;6(9):e1148.
doi: 10.1097/CCE.0000000000001148. eCollection 2024 Sep 1.

Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study

Affiliations
Observational Study

Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study

Joy X Moy et al. Crit Care Explor. .

Abstract

Importance: A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.

Objectives: To characterize TLT use in patients with acute respiratory failure (ARF).

Design, setting, and participants: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.

Main outcomes and measures: Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.

Results: Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).

Conclusions and relevance: In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

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Conflict of interest statement

Dr. Kruser was supported, in part, by National Institutes of Health/National Heart, Lung, and Blood Institute grant K23HL146890 and R01HL168474. Dr. Kruser’s spouse receives honoraria for lectures and speakers bureaus from Astra Zeneca. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
The frequency and outcomes of time-limited trials among patients with acute respiratory failure receiving invasive mechanical ventilation.
Figure 2.
Figure 2.
Number of time-limited trials (TLTs) conducted per attending ICU physician in relationship to their total number of cohort patients cared for. Individual ICU physicians are ordered along the X-axis from the highest to lowest number of TLTs conducted.
Figure 3.
Figure 3.
The distribution of ICU length of stay for patients who participated in a time-limited trial (TLT) compared with those who did not. A, The distribution for the full cohort. B, The distribution for the restricted cohort of decedents.

References

    1. Meadow W, Pohlman A, Frain L, et al. : Power and limitations of daily prognostications of death in the medical intensive care unit. Crit Care Med 2011; 39:474–479 - PubMed
    1. Meadow W, Pohlman A, Reynolds D, et al. : Power and limitations of daily prognostications of death in the medical ICU for outcomes in the following 6 months. Crit Care Med 2014; 42:2387–2392 - PubMed
    1. Detsky ME, Harhay MO, Bayard DF, et al. : Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA 2017; 317:2187–2195 - PMC - PubMed
    1. Quill TE, Holloway R: Time-limited trials near the end of life. JAMA 2011; 306:1483–1484 - PubMed
    1. Vink EE, Azoulay E, Caplan A, et al. : Time-limited trial of intensive care treatment: An overview of current literature. Intensive Care Med 2018; 44:1369–1377 - PubMed

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