The Time-Limited Trial

Bottom line: The well-known tool in the palliative care bag o' tricks, the Family Meeting, was severely injured during the COVID pandemic -- a lack of visitors led to lonely patient rooms and a loss of the developed relationships that were formed during a patient's hospitalization. All too often, a family would be allowed to see a patient or step foot in the hospital only in the most intense crises, and in these moments it isn't hard to understand why an advocate would push for us to "do everything" despite a relatively "hopeless" situation. And while it is not a new concept, the thought of a time-limited trial (TLT) gained some resurgent momentum. Links are provided to both an early commentary and a very recent, media-acclaimed RCT that highlight some of the strengths of a TLT. I highly recommend incorporating language surrounding TLTs into any care involving ICU-level care or potential slow terminal declines.

Personal use: I often use TLTs in ICU settings, and I consistently recommend a TLT if we are starting to come to worries about medical futility. I have also found benefit of at least starting conversations about TLTs if we are approaching a new treatment line for anti-neoplastic cares or artificial nutrition in progressive neurologic conditions (I know this is a faux pas in the strictly clinical sense, but often times it is needed to let a patient and family see their narrative through). I attempt to incorporate prognostic information from any specialist willing to yield it, and set criteria for a family and team that serve as a marker of success or failure if a TLT. I am very lenient in saying we need to adhere to any particular component of a TLT, such that time can be stretched to meet the clinical need. As these demands to "do everything" are usually part of an early grief period, often by the time a TLT has concluded a family has started to process their grief and next steps can be taken to care for the patient in the way that makes the most sense regarding elicited goals of care and appropriate medical interventions.

References:

• Quill, Timothy E., and Robert Holloway. "Time-limited trials near the end of life." Jama 306.13 (2011): 1483-1484.

• Chang, Dong W., et al. "Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments." JAMA Internal Medicine 181.6 (2021): 786-794.