Abstract Rationale A time-limited trial (TLT) is a collaborative plan among clinicians, a patient, and family to use life-sustaining therapy (LST) for a defined duration, after which patient response informs whether to continue recovery-directed care or pursue comfort-focused care. TLTs have disseminated into clinical practice because of their promise to help navigate challenging decisions about LST, but their real-world use and impact remain unclear. We sought to characterize scenarios in which TLTs are currently used. Methods We conducted a 15-month focused ethnography of TLTs in 6 medical ICUs within 5 hospitals. We included patients with acute respiratory failure receiving invasive mechanical ventilation and a TLT, as identified by their ICU physician. We observed care delivery (e.g., rounds), audio-recorded family meetings, interviewed families and clinicians, and abstracted health records. We qualitatively analyzed these data using constructivist grounded theory. Results We reached theoretical saturation after enrolling 52 cases (4—15 per ICU). Of 52 patients (mean age 64 SD: ± 13.3 years), 61.5% were male. The cohort was 57.7% White, 21.2% Black/African American, 5.8% Asian, and 5.8% Hispanic. We identified three scenarios in which TLTs were most commonly used (Table). In the first, a patient with longstanding, life-limiting illness experiences acute decompensation. Clinicians, the patient (when able), and the family discuss a TLT to help determine whether this event represents the end of life or a temporary setback. In the second, clinicians and families acknowledge the patient will not survive the acute episode. A TLT signals upcoming end of life and/or provides time before LST is stopped. In the third, a TLT arises by default because of a clinical protocol (e.g., neuroprognostication after cardiac arrest) that aligns with the definition of a TLT. Across scenarios, we found TLTs were typically initiated in response to a patient’s desire to limit LST and sometimes used to override preexisting limits (e.g., do not resuscitate/intubate orders). Conclusions In this multi-center ethnography, we found TLTs were predominantly used in end-of-life scenarios—either to address short-term uncertainty for patients with longstanding, life-limiting illness or as a decisional buffer at end of life. They were driven by and sometimes used to override patient-expressed LST limits. These findings suggest real-world TLT use differs from the ethical and clinical rationales established in the literature. To achieve the promise of TLTs, there is a need to reconcile these differences and clarify how TLTs should be used. This abstract is funded by: National Heart, Lung, and Blood Institute
Campbell et al. (Fri,) studied this question.