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Original Investigation
Less Is More
April 12, 2021

Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments

Author Affiliations
  • 1Division of Pulmonary and Critical Care Medicine, Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
  • 2Los Angeles County Department of Health Services, Los Angeles, California
  • 3Division of Pulmonary and Critical Care Medicine, Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
  • 4Division of Pulmonary and Critical Care Medicine, Olive View Medical Center, David Geffen School of Medicine at UCLA, Sylmar, California
  • 5Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
  • 6Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
  • 7Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
JAMA Intern Med. 2021;181(6):786-794. doi:10.1001/jamainternmed.2021.1000
Key Points

Question  Is there an intensive care unit (ICU) communication and care-planning approach that might be used to reduce nonbeneficial treatments?

Findings  In this quality improvement study of 209 patients, the use of protocoled time-limited trials (TLTs) as the default communication and care-planning approach for critically ill patients with advanced medical illnesses was associated with significant reductions in ICU length of stay and use of invasive procedures without changes in hospital mortality or family satisfaction.

Meaning  For patients with advanced illnesses who prefer aggressive care, TLTs may prioritize patients’ values and preferences and may reduce ICU treatments that prolong suffering without benefit.

Abstract

Importance  For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit.

Objective  To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care.

Design, Setting, and Participants  This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage.

Interventions  Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers.

Main Outcomes and Measures  Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure).

Results  A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02).

Conclusions and Relevance  In this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care.

Trial Registration  ClinicalTrials.gov Identifier: NCT04181294

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