Time-limited ICU trial — FFICM MCQ

Correct answer: D — Offer a time-limited trial with agreed goals and review points if consistent with his values

The correct answer is D, offer a time-limited trial with agreed goals and review points if consistent with his values. When reversibility is uncertain, best interests decisions under the Mental Capacity Act 2005 require balancing potential benefit against burden, guided by the patient's known wishes and values rather than diagnosis alone. A time-limited trial of organ support with pre-agreed goals and a fixed review date allows objective reassessment of trajectory, avoiding both premature withdrawal and prolonged non-beneficial treatment, and directly respects his fear of prolonged machine dependence. GMC end of life guidance requires decisions for patients lacking capacity to rest on an assessment of overall benefit incorporating their wishes, not on prognosis category alone. Why the other options are wrong: A. Refuse ICU because metastatic cancer excludes benefit: metastatic cancer is not synonymous with futility; reversibility of the acute septic episode determines short term ICU benefit, and blanket exclusion by diagnosis is discriminatory. B. Admit indefinitely until every therapy has failed: open-ended escalation without review points risks prolonged burdensome treatment contrary to his expressed wish to avoid extended dependence, and lacks structured reassessment. C. Ask the family to choose the ventilator settings: families inform best interests decisions about the patient's values, not technical clinical parameters; that responsibility remains with the treating team. E. Use APACHE II alone to decide admission: severity scores are population level prognostic tools, not validated for individual admission or withdrawal decisions, and cannot replace individualised best interests assessment. Key point: In prognostic uncertainty, a time-limited trial with explicit goals and review dates operationalises best interests decision making by testing reversibility while honouring the patient's previously expressed values.

Reference: GMC, Treatment and care towards the end of life: good practice in decision making (updated 2022), gmc-uk.org/professional-standards/the-professional-standards/treatment-and-care-towards-the-end-of-life/guidance