title: Barriers and Facilitators to Initiating and Completing Time-Limited Trials in Critical Care.
abstract: OBJECTIVE
  A time-limited trial is an agreement between clinicians and patients or surrogate decision makers to use medical therapies over a defined period of time to see if the patient improves or deteriorates according to agreed-upon clinical milestones. Although time-limited trials are broadly advocated, there is little empirical evidence of the benefits and risks of time-limited trials, when they are initiated, when and why they succeed or fail, and what facilitates completion of them. Our study objectives were to 1) identify the purposes for which clinicians use time-limited trials and 2) identify barriers and facilitators to initiating and completing time-limited trials.
  
  
  METHODS
  Semistructured interviews: We analyzed interviews using qualitative description with constant comparative techniques.
  
  
  METHODS
  Nine hundred-bed, academic, tertiary hospital in Houston, Texas. Interviewees were from open medical, surgical, neurosurgical, and cardiovascular ICUs.
  
  
  METHODS
  Thirty healthcare professionals were interviewed (nine surgeons, 16 intensivists, three nurse practitioners, and two "other" clinicians).
  
  
  METHODS
  None.
  
  
  RESULTS
  Interviewees reported initiating time-limited trials for three different purposes: to prepare surrogates and clinicians for discussion and possible shifts toward comfort-care only therapies, build consensus, and refine prognostic information. The main barriers to initiating time-limited trials involve clinicians' or surrogate decision makers' disagreement on setting a time limit. Barriers to completing time-limited trials include 1) requesting more time; 2) communication breakdowns because of rotating call schedules; and 3) changes in clinical course. Finally, facilitators to completing time-limited trials include 1) having defined goals about what could be achieved during an ICU stay, either framed in narrow, numeric terms or broad goals focusing on achievable activities of daily living; 2) applying time-limited trials in certain types of cases; and 3) taking ownership to ensure completion of the trial.
  
  
  CONCLUSIONS
  An understanding of barriers and facilitators to initiating and completing time-limited trials is an essential first step toward appropriate utilization of time-limited trials in the ICUs, as well as developing educational or communication interventions with clinicians to facilitate time-limited trial use. We provide practical suggestions on patient populations in whom time-limited trials may be successful, the setting, and clinicians likely to benefit from educational interventions, allowing clinicians to have a fuller sense of when and how to use time-limited trials.
authors.affiliation: 1Department of Medicine, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. 2Department of Medicine, Houston Methodist Hospital System, Houston Methodist Hospital System Biomedical Ethics Program, Houston, TX. 3Weill Cornell Medical College, New York, NY. 4Division of Critical Care, Department of Medicine, Houston Methodist Hospital, Houston, TX. 5Division of Palliative Care, Department of Nursing, Houston Methodist Hospital, Houston, TX. 6Division of Social Work, Department of Social Work and Case Management, Houston Methodist Hospital, Houston, TX. 7Department of Critical Care Medicine, Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh Medical Center, Pittsburg, PA.
authors.forename: Courtenay R
authors.initials: CR
authors.lastname: Bruce
authors.forename: Cecilia
authors.initials: C
authors.lastname: Liang
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Blumenthal-Barby
authors.forename: Janice
authors.initials: J
authors.lastname: Zimmerman
authors.forename: Andrea
authors.initials: A
authors.lastname: Downey
authors.forename: Linda
authors.initials: L
authors.lastname: Pham
authors.forename: Lisette
authors.initials: L
authors.lastname: Theriot
authors.forename: Estevan D
authors.initials: ED
authors.lastname: Delgado
authors.forename: Douglas
authors.initials: D
authors.lastname: White
mesh_terms: D000046:Academic Medical Centers; D003142:Communication; D032921:Consensus; D003422:Critical Care / Q000458:organization & administration* / Q000592:standards; D003657:Decision Making; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000592:standards; D007407:Interviews as Topic; D007600:Judgment; D008297:Male; D010347:Patient Care Planning / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D057240:Patient Preference; D010564:Personnel, Hospital; D010818:Practice Patterns, Physicians' / Q000458:organization & administration* / Q000592:standards; D013727:Terminal Care / Q000458:organization & administration; D013997:Time Factors