Table 3.

Characteristics of TLTs mentioned by ICU physicians

Characteristic	Description	Representative quotes
Who	Patient factors: TLTs tend to be used for older patients with reversible disease processes whose clinical trajectories are unknown, who tend to have serious underlying conditions and/or ‘want everything’.	‘It should be a bridge to something. And if we're coming in with things that aren't potentially bridgeable, then it doesn't make really sense, what we're doing.’ ‘I remember one lady she knew her oncologist like 10 or 15 years and when he came in [to the ICU] and was like, ‘Hey, listen, I really recommend you do that.’ I mean, you can't replace a 15-year relationship.’
	Family factors: TLTs help provide families time to make decisions and come to an agreement about the care of their loved ones.
	Clinician factors: TLTs should be able to be initiated by anyone on the care team, which sometimes might be consultants who have an established relationship with the patient.
	Unit factors: ICU physicians felt that patient and family preferences are best elicited elsewhere, prior to a critical event.
What	TLTs give ICU clinicians the ability to try out life-sustaining therapies over a defined period of time and watch for defined clinical endpoints. No change in a patient’s status by the end of the agreed on time period is often viewed as a poor outcome.	‘Rarely do I hear people talk about it formally, and I think that a very, very small amount has ever heard of a time-limited trial, they probably have experienced it and just not known that’s what it was called. So, I think the majority probably know what these things are in practice, but don't think about them formally.’ ‘Usually, you think about these for your patients that are coming in with severe medical comorbidities that may or may not benefit from ICU-level care. And so in those settings, I generally use it when I expect that things are going to go poorly, to define an endpoint essentially ahead of time.’
	Despite the lack of formal guidelines, ICU physicians are generally familiar with TLTs. However, they do not necessarily call them TLTs.
	TLTs tend to be personalised based on patients’ comorbidities and severity of illness.
When	Some ICU physicians might consider a TLT immediately after a patient is admitted to the ICU, whereas others prefer to provide 48 hours of aggressive care first.	‘My thought is that the time-limited trial has be within the timeframe of what I think is a natural course of the disease process. So I can't offer a time-limited trial for three days if the natural course of something is going to be more on the order of weeks.’ ‘If I establish rapport and we're initiating some sort of time-limited trial with a family and then I’m coming off service and handing it off, I think is always hard. It’s always hard to not see something through. But at the same time, I realize that’s the nature of our practice.’
	TLTs can last anywhere from 48 hours to 2 weeks.
	There might be multiple TLTs across the ICU admission; one TLT can sometimes lead to another.
	ICU physicians prefer that the same team that initiates a TLT complete it, but recognise that the academic staffing model makes this challenging.
Where	TLTs are often planned and/or discussed by clinicians with the healthcare team during ICU rounds.	‘I can see how it’s challenging during rounds to have a discussion like this, but I also think that if it’s the right thing to do for patients and family, then it should be done at the bedside. I guess the answer to [when a TLT should be initiated] for me would be wherever and whenever is the right moment and time that this needs to happen… Getting people and family all in the same room, it’s more ideal. But if that’s going to take three hours from now, four hours from now, then we should just do it right then and there.’ ‘Probably a mix of both. So we might have that discussion on rounds, with the team, to decide how we want to approach this. And then certainly in family discussions, when we're talking about prognosis and next steps in management or goals of care or anything like that. So definitely there (in family meetings), but I think (during) rounds, we talked about that too.’
	TLTs are often formalised and/or agreed on with surrogate decision makers during family meetings.
	Patient values, even if elicited and documented outside of the ICU, will be taken into consideration when creating a TLT.
Why	Patients: TLTs help ensure that care addresses the patients’ immediate needs while being concordant with values and preferences.	‘If we're talking about a CRRT patient who has multiorgan failure from septic shock or something like that, and in my discussions with the family it was clear that this patient is in the dying process. Escalating care, more lifesaving therapies was not what they would want, then I wouldn't even consider a time-limited trial then.’ ‘It also allows a little bit of time, if things are truly going poorly, to declare themselves. You can then make a firmer recommendation and essentially remove some of that decision-making burden from that patient, from the patient’s family. … I think it’s helpful from a stewardship standpoint.’
	Families: TLTs help convey the seriousness of the situation while alleviating some of the decision-making burden.
	Clinicians: TLTs should not be used to delay death. It is important to balance the need to buy time in the face of uncertainty while not placing patients in ‘ICU purgatory’.
	Unit: TLTs help physicians be effective stewards of ICU resources by ensuring that the provision of life support is in concordance with the patients’ current health status, and the patient and families’ preferences and values.

ICU, intensive care unit; TLTs, time-limited trials.