Accepted for/Published in: JMIR Research Protocols
Date Submitted: Sep 17, 2019
Open Peer Review Period: Sep 17, 2019 - Sep 24, 2019
Date Accepted: Oct 22, 2019
(closed for review but you can still tweet)
Time Limited Trials in Critically-ill Patients with Advanced Medical Illnesses: Protocol to Reduce Non-beneficial Intensive Care Unit Treatments
ABSTRACT
Background:
Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically-ill patients/families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time limited trials (TLTs) are agreements between the clinicians and patients/decision-makers to use certain medical therapies over defined periods of time and evaluate whether patients improve or worsen according to pre-determined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision-making, and set rational boundaries to treatments based on patients’ goals of care.
Objective:
To examine whether a multi-component quality improvement strategy that uses protocoled time limited trials as the default ICU care planning approach for critically-ill patients with advanced medical illnesses will decrease duration and intensity of non-beneficial ICU care without changing hospital mortality
Methods:
This study will be conducted in medical ICUs of 3 public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semi-structured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those considered by treating ICU physicians to be at high risk for non-beneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be schedule by trained care managers. The improvement strategy will be implemented sequentially in the 3 participating hospitals, and outcomes will be evaluated using a before-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.
Results:
As of September 2019, the interventions and data collection were completed in 2 out of the 3 hospitals, and ongoing at the third hospital. The results of the study are expected to be available in the first quarter of 2020.
Conclusions:
The successful completion of the aims in this proposal may identify a systematic approach to improve communication/shared decision-making and reduce non-beneficial invasive treatments for ICU patients with advanced medical illnesses.
Citation
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Copyright
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