Division 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.
Los Angeles County Department of Health Services, Los Angeles, California.
JAMA Intern Med. 2021 Jun 1;181(6):786-794. doi: 10.1001/jamainternmed.2021.1000.
For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit.
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.
Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers.
Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure).
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).
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.
ClinicalTrials.gov Identifier: NCT04181294.
对于患有晚期疾病和预后不良的危重患者，过度使用侵入性重症监护病房（ICU）治疗可能会延长痛苦而没有获益。
研究在患有晚期疾病的危重患者中，采用限时试验（TLT）作为默认的护理计划方法，是否与非有益 ICU 护理的持续时间和强度降低有关。
设计、地点和参与者：这是一项从 2017 年 6 月 1 日至 2019 年 12 月 31 日在加利福尼亚州的 3 所学术性公立医院的医疗 ICU 进行的前瞻性质量改进研究。使用重症监护医学会指南中用于入院和分诊的类别，确定由于晚期疾病而有非有益 ICU 治疗风险的患者。
培训临床医生在与家属和替代决策人进行的会议中使用 TLT 作为默认的沟通和护理计划方法。
家庭会议的质量（过程测量）和 ICU 住院时间（临床结果测量）。
共纳入 209 名患者（平均[标准差]年龄，63.6[16.3]岁；127 名男性[60.8%]；101 名西班牙裔患者[48.3%]），其中 113 名患者（54.1%）在干预前，96 名患者（45.9%）在干预后。正式的家庭会议从干预前的 113 名患者中的 68 名（60.2%）增加到干预后的 96 名患者中的 92 名（95.8%）（P<.01）。家庭会议的关键内容，如 ICU 治疗风险和获益的讨论（干预前，15 [34.9%] vs 干预后，56 [94.9%]；P<.01）、患者价值观和偏好的引出（干预前，20 [46.5%] vs 干预后，58 [98.3%]；P<.01）以及识别临床改善的标志物（干预前，9 [20.9%] vs 干预后，52 [88.1%]；P<.01），在干预后讨论得更频繁。干预前后 ICU 住院时间明显缩短（8.7 [四分位间距（IQR），5.7-18.3]天 vs 7.4 [IQR，5.2-11.5]天；P=.02）。干预前后的医院死亡率相似（分别为 66 名患者[58.4%] vs 56 名患者[58.3%]；P=.99）。在干预后期间，侵入性 ICU 程序的使用频率降低（例如，机械通气干预前，97 [85.8%] vs 干预后，70 [72.9%]；P=.02）。
在这项研究中，一项质量改进干预措施培训医生在 ICU 中与危重患者的家属使用 TLT 进行沟通和规划 ICU 护理，与家庭会议质量的提高以及 ICU 治疗的强度和持续时间的降低有关。这项研究强调了一种以患者为中心的治疗危重患者的方法，可能会减少非有益的 ICU 护理。
ClinicalTrials.gov 标识符：NCT04181294。
