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Abstract
BackgroundInvasive 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 and their 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 the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined 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.ObjectiveThe aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality.MethodsThis study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured 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 who the treating ICU physicians consider to be at high risk for nonbeneficial 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 scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-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 (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.ResultsThe study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020.ConclusionsThe successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses.International Registered Report Identifier (IRRID)DERR1-10.2196/16301
Highlights
BackgroundClinical Significance of Intensive Care Unit Overutilization Among Patients With Advanced Medical IllnessesIn the United States, 1 in 5 people die using intensive care unit (ICU) services, frequently receiving invasive treatments despite minimal anticipated benefit [1,2]
Investigators in our research group found that 20% of ICU patients in the University of California Los Angeles (UCLA) health care system were perceived by physicians to be receiving futile care [3]
This trend represents an important health care problem; a multicenter controlled study estimated that patients with advanced medical illnesses who died in ICUs spent an average of 8 days in undesirable states, such as being comatose or receiving mechanical ventilation [14]
Summary
BackgroundClinical Significance of Intensive Care Unit Overutilization Among Patients With Advanced Medical IllnessesIn the United States, 1 in 5 people die using intensive care unit (ICU) services, frequently receiving invasive treatments despite minimal anticipated benefit [1,2]. Most patients with advanced medical illnesses prefer not to receive such aggressive care at the end of life [1,8,9,10,11,12] but ICU care in this population is increasing [2,13]. Terminal hospitalizations account for 7.5% of total inpatient costs in the United States, with ICU care accounting for nearly 80% of these costs [1,15] Overall, these findings show that optimizing ICU utilization among patients with advanced medical illnesses is an opportunity to improve the quality and efficiency of care in this high-risk, high-cost population. Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. 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
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