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

Jacqueline M Kruser; Nandita R Nadig; Elizabeth M Viglianti; Justin T Clapp; Katharine E Secunda; Scott D Halpern

doi:10.1016/j.chest.2023.12.014

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

Chest. 2024 Apr;165(4):881-891. doi: 10.1016/j.chest.2023.12.014. Epub 2023 Dec 13.

Authors

Jacqueline M Kruser¹, Nandita R Nadig², Elizabeth M Viglianti³, Justin T Clapp⁴, Katharine E Secunda⁵, Scott D Halpern⁶

Affiliations

¹ Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI. Electronic address: jkruser@wisc.edu.
² Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
³ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
⁴ Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA.
⁵ Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA.
⁶ Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA.

PMID: 38101511
DOI: 10.1016/j.chest.2023.12.014

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.

Publication types

Review

MeSH terms

Aged
Critical Care / methods
Critical Illness* / therapy
Humans
Intensive Care Units
Physicians*
Uncertainty
United States

Grants and funding

R01 HL168474/HL/NHLBI NIH HHS/United States