Time-limited trials for patients with critical illness: a review of the literature.

Dec 18, 2023

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

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.
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 intensive care units (ICU) in the United States, but their use varies according to unit and clinician factors. Some ICU clinicians 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 such as 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.
Time-limited trials are endorsed by clinicians, 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.

Copyright © 2023. Published by Elsevier Inc.

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ABOUT THE EXPERTS

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

Jacqueline M Kruser

Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. Electronic address: jkruser@wisc.edu.

Nandita R Nadig

Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Elizabeth M Viglianti

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

Justin T Clapp

Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA, USA.

Katharine E Secunda

Department of Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.

Scott D Halpern

Department of Medicine, Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA, USA.