Time-limited trials for acute dialysis decision-making for critically ill older patients: rationale, communication strategies, and future research

Purpose of review Provide an overview of the rationale for implementing time-limited dialysis trials (TLT-Ds) in critically ill older adults with acute kidney injury treated with dialysis, the communication strategies required for proper implementation, and future research directions. Recent findings AKI-D is linked to high mortality, reduced renal recovery, and a substantial chance of discharge to nursing homes in older adults. Many older people value independence and quality of life over longevity. Yet acute dialysis often remains the reflexive treatment option, while patients and families face prognostic uncertainty in the face of mortality. A TLT-D is an ethically sound, person-centered approach that aligns with many patients’ preferences. Its benefits include providing a structured opportunity for clinicians, families, and patients to assess the biomedical efficacy of dialysis while allowing time for deliberation, prognostic clarity, and emotional processing. This can inform whether to continue acute dialysis or transition to comfort care or chronic dialysis within prespecified or evolving goals. Summary Acute dialysis decision-making for critically ill older adults needs improvement. Reflexive initiation followed by automatic transition to chronic dialysis may not align with many patients’ goals. TLT-Ds can promote goal-concordant care. Further research is needed to guide their implementation and evaluate person-centered outcomes.