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Jöbges S, Seidlein AH, Knochel K, Michalsen A, Duttge G, Supady A, Dutzmann J, Meier S, Barndt I, Neitzke G, Nauck F, Rogge A, Janssens U. [Time-limited trials (TLT) in the intensive care unit : Recommendations from the ethics section of the DIVI and the ethics section of the DGIIN]. Med Klin Intensivmed Notfmed 2024; 119:291-295. [PMID: 38345649 PMCID: PMC11059002 DOI: 10.1007/s00063-024-01112-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 04/30/2024]
Abstract
The rise in intensive care treatment procedures is accompanied by an increase in the complexity of decisions regarding the selection, administration and duration of treatment measures. Whether a treatment goal is desirable in an individual case and the treatment plan required to achieve it is acceptable for the patient depends on the patient's preferences, values and life plans. There is often uncertainty as to whether a patient-centered treatment goal can be achieved. The use of a time-limited treatment trial (TLT) as a binding agreement between the intensive care unit (ICU) team and the patient or their legal representative on a treatment concept over a defined period of time in the ICU can be helpful to reduce uncertainties and to ensure the continuation of intensive care measures in the patients' best interest.
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Affiliation(s)
- Susanne Jöbges
- Klinik für Anästhesiologie und Intensivmedizin, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - Anna-Henrikje Seidlein
- Institut für Ethik und Geschichte der Medizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Kathrin Knochel
- Institut für Geschichte und Ethik der Medizin, Technische Universität München, München, Deutschland
| | - Andrej Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
| | - Gunnar Duttge
- Institut für Kriminalwissenschaften, Abteilung für strafrechtliches Medizin- und Biorecht, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | - Alexander Supady
- Interdisziplinäre Medizinische Intensivtherapie, Universitätsklinikum Freiburg, Freiburg i.Br, Deutschland
| | - Jochen Dutzmann
- Klinik für Innere Medizin III, Universitätsmedizin Halle (Saale), Halle (Saale), Deutschland
| | - Stefan Meier
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Iris Barndt
- Klinik für Kardiologie und internistische Intensivmedizin, Universitätsklinikum Johannes Wesling, Minden, Deutschland
| | - Gerald Neitzke
- Institut für Ethik, Geschichte und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Friedemann Nauck
- Klinik für Palliativmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Annette Rogge
- Fachbereich Neurologie, Paracelsus Nordseeklinik Helgoland, Helgoland, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital, Eschweiler, Deutschland
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Kruser JM, Nadig NR, Viglianti EM, Clapp JT, Secunda KE, Halpern SD. Time-Limited Trials for Patients With Critical Illness: A Review of the Literature. Chest 2024; 165:881-891. [PMID: 38101511 DOI: 10.1016/j.chest.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/08/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023] Open
Abstract
TOPIC IMPORTANCE Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps. REVIEW FINDINGS We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies. SUMMARY Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.
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Affiliation(s)
- Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Nandita R Nadig
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Katharine E Secunda
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research (PAIR) Center, Philadelphia, PA
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Batten JN, Blythe JA, Wieten SE, Dzeng E, Kruse KE, Cotler MP, Porter-Williamson K, Kayser JB, Harman SM, Magnus D. "No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study. Chest 2023; 163:192-201. [PMID: 36007596 PMCID: PMC9993335 DOI: 10.1016/j.chest.2022.08.2211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND No Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND METHODS Qualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record). RESULTS At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations. INTERPRETATION Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.
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Affiliation(s)
- Jason N Batten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA.
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah E Wieten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Philosophy, Durham University, Durham, England
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Katherine E Kruse
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Critical Care, Children's Minnesota, Minneapolis, MN
| | - Miriam P Cotler
- Department of Health Sciences, California State University Northridge, Northridge, CA
| | | | - Joshua B Kayser
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | | | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA
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Lin M, Deming R, Wolfe J, Cummings C. Infant mode of death in the neonatal intensive care unit: A systematic scoping review. J Perinatol 2022; 42:551-568. [PMID: 35058594 DOI: 10.1038/s41372-022-01319-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To characterize literature that describes infant mode of death and to clarify how limitation of life-sustaining treatment (LST) is defined and rationalized. STUDY DESIGN Eligible studies were peer-reviewed, English-language, and included number of infant deaths by mode out of all infant deaths in the NICU and/or delivery room. RESULT 58 included studies were primarily published in the last two decades from North American and European centers. There was variation in rates of infant mode of death by study, with some showing an increase in deaths following limitation of LST over time. Limitation of LST was defined by the intervention withheld/withdrawn, the relationship between the two practices, and prior frameworks. Themes for limiting LST included diagnoses, low predicted survival and/or quality of life, futility, and suffering. CONCLUSION Limitation of LST is a common infant mode of death, although rates, study definitions, and clinical rationale for this practice are variable.
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Affiliation(s)
- Matthew Lin
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA.
| | - Rachel Deming
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Christy Cummings
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA
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Abstract
This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.
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Affiliation(s)
- Matthew Lin
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | | | - Christy L Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Bioethics, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Cheung JCH, Yip YY, Lam KN. Rethinking ICU readmission and time-limited trial in the contingency capacity. J Crit Care 2020; 62:183-184. [PMID: 33412480 DOI: 10.1016/j.jcrc.2020.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/24/2020] [Indexed: 11/25/2022]
Affiliation(s)
| | - Yu-Yeung Yip
- Intensive Care Unit, North District Hospital, Hong Kong, China
| | - Koon Ngai Lam
- Intensive Care Unit, North District Hospital, Hong Kong, China
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