Time-Limited Trials in Intensive Care Medicine: A Tool for Avoiding Inappropriate Treatment.

IF 6.5 2区医学 Q1 MEDICINE, GENERAL & INTERNAL

Deutsches Arzteblatt international Pub Date : 2025-04-04 DOI:10.3238/arztebl.m2025.0016

Martin Russwurm

{"title":"Time-Limited Trials in Intensive Care Medicine: A Tool for Avoiding Inappropriate Treatment.","authors":"Martin Russwurm","doi":"10.3238/arztebl.m2025.0016","DOIUrl":null,"url":null,"abstract":"Background: Approximately 16% of patients treated in intensive care units do not outlive the treatment. Among patients in intensive care units who undergo mechanical ventilation or dialysis, only half survive longer than six months. Prognostication is unreliable in the individual case. Time-limited trials (TLT) may help prevent inappropriate treatment, particularly for older and chronically ill patients.Methods: This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Scopus databases and the Google Scholar searching service.Results: 19 empirical studies and 15 medical-ethical analyses on time-limited trials were identified, as well as expert opinions, guidelines, and review articles. If the prognosis of a patient in intensive care is poor or unclear, the patient or representative can agree with the treating team on a trial of predefined treatment, for a limited period of time, to attain objectifiable, individual therapeutic goals. These goals are set and assessed with the aid of scores used in intensive care medicine, along with the patient's individual values and resources. TLTs enable more accurate prognostication based on the observed effect of treatment in the individual patient, so that a joint decision can be taken on whether to provide further treatment with curative intent or to switch to palliative care. In this way, inappropriate treatment can be avoided-both over- and undertreatment. Initial findings suggest that TLT can identify patients who will not benefit from continued intensive treatment.Conclusion: TLTs are well founded in medical ethics and address a central problem in intensive care medicine, namely, the question of individual benefit. Only sparse empirical data on TLTs are available to date. TLTs should be standardized and evaluated in prospective studies to determine whether their expected benefit can truly be achieved in the complex real world of intensive care medicine.","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":" Forthcoming","pages":"180-185"},"PeriodicalIF":6.5000,"publicationDate":"2025-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Deutsches Arzteblatt international","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.3238/arztebl.m2025.0016","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"MEDICINE, GENERAL & INTERNAL","Score":null,"Total":0}

引用次数: 0

Abstract

Background: Approximately 16% of patients treated in intensive care units do not outlive the treatment. Among patients in intensive care units who undergo mechanical ventilation or dialysis, only half survive longer than six months. Prognostication is unreliable in the individual case. Time-limited trials (TLT) may help prevent inappropriate treatment, particularly for older and chronically ill patients.

Methods: This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Scopus databases and the Google Scholar searching service.

Results: 19 empirical studies and 15 medical-ethical analyses on time-limited trials were identified, as well as expert opinions, guidelines, and review articles. If the prognosis of a patient in intensive care is poor or unclear, the patient or representative can agree with the treating team on a trial of predefined treatment, for a limited period of time, to attain objectifiable, individual therapeutic goals. These goals are set and assessed with the aid of scores used in intensive care medicine, along with the patient's individual values and resources. TLTs enable more accurate prognostication based on the observed effect of treatment in the individual patient, so that a joint decision can be taken on whether to provide further treatment with curative intent or to switch to palliative care. In this way, inappropriate treatment can be avoided-both over- and undertreatment. Initial findings suggest that TLT can identify patients who will not benefit from continued intensive treatment.

Conclusion: TLTs are well founded in medical ethics and address a central problem in intensive care medicine, namely, the question of individual benefit. Only sparse empirical data on TLTs are available to date. TLTs should be standardized and evaluated in prospective studies to determine whether their expected benefit can truly be achieved in the complex real world of intensive care medicine.

查看原文本刊更多论文

重症监护医学的限时试验：避免不当治疗的工具。

背景：大约16%在重症监护病房接受治疗的患者不能活过治疗期。在重症监护病房接受机械通气或透析的患者中，只有一半的患者存活时间超过6个月。个别情况下的预测是不可靠的。限时试验（TLT）可能有助于防止不适当的治疗，特别是对老年人和慢性病患者。方法：本综述基于在PubMed和Scopus数据库以及b谷歌Scholar检索服务中选择性检索到的相关出版物。结果：确定了19项实证研究和15项有时限试验的医学伦理分析，以及专家意见、指南和综述文章。如果重症监护患者的预后较差或不明确，患者或其代表可以同意治疗团队在有限的时间内进行预先确定的治疗试验，以达到可实现的个性化治疗目标。这些目标是根据重症监护医学中使用的分数以及患者的个人价值和资源来设定和评估的。tlt可以根据观察到的治疗效果对患者进行更准确的预测，从而可以共同决定是提供进一步的治疗还是转向姑息治疗。通过这种方式，可以避免不适当的治疗——过度治疗和治疗不足。初步研究结果表明，TLT可以识别出无法从持续强化治疗中获益的患者。结论：tlt有良好的医学伦理基础，解决了重症监护医学的核心问题，即个人利益问题。迄今为止，只有稀疏的tlt经验数据可用。应在前瞻性研究中对tlt进行标准化和评估，以确定其预期效益是否能在复杂的重症医学现实世界中真正实现。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

Deutsches Arzteblatt international 医学-医学：内科

CiteScore

4.10

自引率

5.20%

发文量

306

审稿时长

4-8 weeks

期刊介绍： Deutsches Ärzteblatt International is a bilingual (German and English) weekly online journal that focuses on clinical medicine and public health. It serves as the official publication for both the German Medical Association and the National Association of Statutory Health Insurance Physicians. The journal is dedicated to publishing independent, peer-reviewed articles that cover a wide range of clinical medicine disciplines. It also features editorials and a dedicated section for scientific discussion, known as correspondence. The journal aims to provide valuable medical information to its international readership and offers insights into the German medical landscape. Since its launch in January 2008, Deutsches Ärzteblatt International has been recognized and included in several prestigious databases, which helps to ensure its content is accessible and credible to the global medical community. These databases include: Carelit CINAHL (Cumulative Index to Nursing and Allied Health Literature) Compendex DOAJ (Directory of Open Access Journals) EMBASE (Excerpta Medica database) EMNursing GEOBASE (Geoscience & Environmental Data) HINARI (Health InterNetwork Access to Research Initiative) Index Copernicus Medline (MEDLARS Online) Medpilot PsycINFO (Psychological Information Database) Science Citation Index Expanded Scopus By being indexed in these databases, Deutsches Ärzteblatt International's articles are made available to researchers, clinicians, and healthcare professionals worldwide, contributing to the global exchange of medical knowledge and research.