Pilot of the Life-Sustaining Treatment Decisions Initiative Among Veterans With Serious Illness

Abstract

Background: Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support. Aim: To describe a 2-year pilot of the LSTDI at 4 demonstration sites. Design: Prospective observational study. Setting/Participants: A total of 6664 patients who had at least one GoCC. Results: Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation. Conclusion: The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.

Goals of Care Documentation: Insights from A Pilot Implementation Study

“…Both the patient and site affect the occurrence of a documented goals of care conversation (e.g., readiness to discuss) and known differences seen also in non-VA settings (e.g., fewer documented goals of care among nonwhite race) are reflected both in our pilot and national data on LSTDI use. 11,25 Components of LSTDI rollout such as the quality of trainings, engagement of leadership, organizational levels and disciplines involved in the initiative were particular to each site and had potential to affect the experience and outcomes of efforts across entire facilities, as has been noted in other implementation contexts. 29,30 The influence of site-level effects are crucial to acknowledge in research on goals of care conversations and future communication research.…”

“…Each pilot site provides inpatient, outpatient, and home care services, with outpatient primary care clinics at locations separate from the primary medical center(s). 11 On-site extended care facilities and hospice beds are available at three of the four sites.…”

“…Veterans with documentation of these four required fields were included in the goals of care documentation group and those who may have been eligible for a documented goals of care conversation but whose records did not show documentation comprised the non-goals of care group. Although a minority of the documented group had two or more goals of care conversations documented, 11 we used data recorded during the initial goals of care conversation for this analysis and we used data from the first qualifying encounter for comparison in the non-goals of care group. We summarized demographic characteristics using means/frequencies and standardized mean differences.…”

Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach

“…35 Sampling CBJ and NL purposively approached local medical center champions and used snowball sampling to identify additional participants. We interviewed key stakeholders at four demonstration medical centers (Centers A-D) 36 and eight subsequent spread centers (Centers E-L). These centers varied by timing of implementation, location, size, and implementation uptake.…”

Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations

“…The LSTDI encompasses intervention elements including point-of-care triggering events for high-risk patients, clinical training, and a national electronic documentation template. 8,9 The LSTDI can be completed in any Veterans Affairs VA care setting, and invasive procedures are designated as one of the triggering events prompting the LSTDI. 10 We aimed to provide an overview of the use and timing of perioperative LST note completion and assess the association between patient risk of hospitalization or death and LST note completion among surgical patients.…”