(365) Clinician Perspectives on Use of Time-Limited Trials in Out-of-Hospital Cardiac Arrest Patients

Introduction: Out-of-hospital cardiac arrests (OHCA) have high mortality and morbidity following return of spontaneous circulation. Targeted temperature management (TTM) is a promising treatment to optimize neurological recovery, however, it is limited by prognostic uncertainty. Conceptualizing TTM as a time-limited trial (TLT)—a collaborative plan between clinicians and a patient/surrogate to use life-sustaining therapies for a defined duration—may allow for TTM to be implemented more successfully. We sought to understand how clinicians who provided care to OHCA patients considered TLTs in their practice.

Methods: Between 2021-2024, clinicians engaged in the Influence of Cooling duration on Efficacy in Cardiac Arrest Patients trial who provided TTM to OCHA patients were invited to participate in an embedded qualitative study. Semi-structured interviews were conducted, recorded, and transcribed with clinicians during which the definition of TLT was given. Clinicians were asked to reflect on their awareness and application of TLTs for OHCA patients. Inductive thematic content analysis was employed to determine the context in which TLTs are implemented for OCHA patients.

Results: Of the 20 clinicians, 13 were from academic medical centers, 12 were men, and 14 were attendings. This included emergency, Neuro, palliative care, and pulmonary-critical care specialists. The majority (N=16) reported an awareness of TLTs that aligns with the given definition. TLTs were considered appropriate in two main contexts—when there is clinical uncertainty surrounding prognosis and to achieve goal concordant care. The most common perceived barrier to applying TLTs was the ethical challenge of balancing the ability to continue life sustaining therapies with unclear benefits given the high mortality and morbidity associated with OHCA survivorship.

Conclusions: TLTs are a useful strategy to align life-sustaining care with patients’ goals. They are deemed appropriate when the clinical trajectory or patient’s goals are uncertain. Considering TTM as a form of TLT highlights ethical dilemmas clinicians face with caring for OCHA patients. Further research should explore how TLTs are implemented and perceived across multi-disciplinary teams when there is a high level of prognostic uncertainty.