1Department of Medicine, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. 2Department of Medicine, Houston Methodist Hospital System, Houston Methodist Hospital System Biomedical Ethics Program, Houston, TX. 3Weill Cornell Medical College, New York, NY. 4Division of Critical Care, Department of Medicine, Houston Methodist Hospital, Houston, TX. 5Division of Palliative Care, Department of Nursing, Houston Methodist Hospital, Houston, TX. 6Division of Social Work, Department of Social Work and Case Management, Houston Methodist Hospital, Houston, TX. 7Department of Critical Care Medicine, Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh Medical Center, Pittsburg, PA.
Crit Care Med. 2015 Dec;43(12):2535-43. doi: 10.1097/CCM.0000000000001307.
A time-limited trial is an agreement between clinicians and patients or surrogate decision makers to use medical therapies over a defined period of time to see if the patient improves or deteriorates according to agreed-upon clinical milestones. Although time-limited trials are broadly advocated, there is little empirical evidence of the benefits and risks of time-limited trials, when they are initiated, when and why they succeed or fail, and what facilitates completion of them. Our study objectives were to 1) identify the purposes for which clinicians use time-limited trials and 2) identify barriers and facilitators to initiating and completing time-limited trials.
Semistructured interviews: We analyzed interviews using qualitative description with constant comparative techniques.
Nine hundred-bed, academic, tertiary hospital in Houston, Texas. Interviewees were from open medical, surgical, neurosurgical, and cardiovascular ICUs.
Thirty healthcare professionals were interviewed (nine surgeons, 16 intensivists, three nurse practitioners, and two "other" clinicians).
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Interviewees reported initiating time-limited trials for three different purposes: to prepare surrogates and clinicians for discussion and possible shifts toward comfort-care only therapies, build consensus, and refine prognostic information. The main barriers to initiating time-limited trials involve clinicians' or surrogate decision makers' disagreement on setting a time limit. Barriers to completing time-limited trials include 1) requesting more time; 2) communication breakdowns because of rotating call schedules; and 3) changes in clinical course. Finally, facilitators to completing time-limited trials include 1) having defined goals about what could be achieved during an ICU stay, either framed in narrow, numeric terms or broad goals focusing on achievable activities of daily living; 2) applying time-limited trials in certain types of cases; and 3) taking ownership to ensure completion of the trial.
An understanding of barriers and facilitators to initiating and completing time-limited trials is an essential first step toward appropriate utilization of time-limited trials in the ICUs, as well as developing educational or communication interventions with clinicians to facilitate time-limited trial use. We provide practical suggestions on patient populations in whom time-limited trials may be successful, the setting, and clinicians likely to benefit from educational interventions, allowing clinicians to have a fuller sense of when and how to use time-limited trials.
限时试验是临床医生和患者或替代决策人之间的一项协议，即在规定的时间内使用医疗疗法，以观察患者是否根据商定的临床里程碑改善或恶化。尽管广泛提倡限时试验，但关于何时启动限时试验、何时以及为何成功或失败以及什么有助于完成限时试验，其益处和风险的经验证据很少。我们的研究目的是：1）确定临床医生使用限时试验的目的；2）确定启动和完成限时试验的障碍和促进因素。
半结构化访谈：我们使用定性描述和恒定性比较技术分析访谈。
德克萨斯州休斯顿的一家拥有 900 张床位的学术性三级医院。受访者来自开放式医疗、外科、神经外科和心血管 ICU。
共采访了 30 名医疗保健专业人员（9 名外科医生、16 名重症监护医生、3 名执业护士和 2 名“其他”临床医生）。
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受访者报告了启动限时试验的三个不同目的：为讨论和可能转向仅提供舒适护理的治疗方法、建立共识和完善预后信息做准备；为临床医生或替代决策人设定时间限制方面存在分歧是启动限时试验的主要障碍。完成限时试验的障碍包括：1）要求更多时间；2）由于轮班时间表导致沟通中断；3）临床过程的变化。最后，完成限时试验的促进因素包括：1）在 ICU 期间，对可以实现的目标有明确的定义，要么以狭窄的数字术语定义，要么以关注可实现的日常生活活动的广泛目标来定义；2）将限时试验应用于某些类型的病例；3）拥有所有权以确保试验完成。
了解启动和完成限时试验的障碍和促进因素是在 ICU 中适当利用限时试验的必要的第一步，也是与临床医生一起开展教育或沟通干预以促进限时试验使用的第一步。我们就可能成功的患者人群、设置和可能从教育干预中受益的临床医生提供了实际建议，使临床医生更全面地了解何时以及如何使用限时试验。
