In Wisconsin, one in three older adults is admitted to an intensive care unit (ICU) near the end of their life despite the vast majority expressing preferences to avoid such care. This can be distressing for their surrogate decision makers and families and demoralizing for clinicians.
A time-limited trial is an agreement between clinicians and a patient or their surrogate to apply certain medical treatments for a predefined period before evaluating whether the treatment is helping the patient. This project translated the model into a tangible, clinical tool to support navigating challenging decisions about the use of life-sustaining treatments in the ICU. Focus groups revealed that older adults and their families broadly endorse this patient care model, view it as better than their prior healthcare experiences and believe it will improve outcomes for critically ill patients and their families.
The Challenge
In Wisconsin, one in three older adults is admitted to an ICU near the end of their life. Older adults’ prevailing preferences are to avoid invasive and prolonged life-sustaining treatments in near death, yet a substantial number receive such care. Failure to uphold these preferences compromises dignity and value at the end of life. Previous efforts to improve end-of-life care in the ICU for older adults have successfully improved communication between clinicians, patients and their surrogates, yet did not change treatment decision-making or improve surrogates’ distress.
Project Goals
The goal of this project is to optimize the time-limited trial model to meet the needs of older adults admitted to the ICU and their surrogate decision makers.
Results
The research team designed a graphic aid to support ICU clinicians and surrogates of critically older adults when planning a time-limited trial. The “ICU Care Plan” tool was created through partnership with older adults and their caregivers living in Wisconsin and ICU physicians who practice across the state. To broaden accessibility of the tool, they developed a Spanish-language version of the graphic aid and a set of procedures to help guide clinicians when using the graphic aid with an interpreter. The next steps will be clinical pilot testing this tool in preparation for a large, randomized clinical trial.
The researchers used focus groups to evaluate perspectives on this approach to ICU care. Older adults with serious illness and adults with surrogate decision-making experience viewed and reacted to a video depicting a hypothetical time-limited trail planning conversation between ICU clinicians and a patient’s family. Analysis revealed that older adults and experienced decision makers broadly endorse the time-limited trail approach to patient care. They found the model’s structured plan distinct from the open-ended unknowns of usual care. Participants also described potential hazards, such as determining the duration of the time-limited trial, that are critical to ensure the successful support of patients and their families and to avoid unintended harm.
