Overview

• The VHA aims to improve care for patients with advanced illness and at heightened risk of a life-threatening event by promoting high-quality Goals of Care Conversations (GoCCs) earlier in treatment through a coordinated set of evidence-based strategies including practice standards, staff training, a standardized progress note template and order set, information technology tools, and a two-year multi-facility demonstration project.

Organization Name

Veterans Health Administration (VHA), US Department of Veteran Affairs (VA)

Organization Type

• Integrated healthcare system/network

National/Policy Context

There is an emerging consensus that clinicians should initiate a proactive goals of care conversation (GoCC) with patients whose serious illness is likely to involve decisions about life-sustaining treatments (LSTs) such as artificial nutrition, ventilator support, or cardiopulmonary resuscitation. The purpose of this conversation is to elicit the patient’s values, goals, and preferences as a basis for shared decisions about treatment planning while the patient has decision-making capacity and prior to a health care crisis.

Local/Organizational Context

• VHA currently has 1,234 outpatient points of care and 143 hospitals located throughout the United States (Data current as of 6/30/2018).

Patient Population Served and Payor Information

• VHA provides a continuum of health care services for our nation’s Veterans with over 9 million total enrollees. VHA appropriations are from Congress.
• Patients who receive care within VHA and who have advanced illness and are at a heightened risk of a life-threatening event within one to two years.

Leadership

• VA’s National Center for Ethics in Health Care (NCEHC)

Funding

• No external funding source

Research + Planning

• NCEHC engaged stakeholders and subject matter experts through multidisciplinary work groups including VA and academic affiliate members to review literature on the state of the science in advance care planning and on improving communication with patients and families near the end of life.
• In February 2013, NCEHC convened a VHA advisory board meeting to promote successful implementation of the policy initiative. The meeting’s purpose was to educate staff/veterans about required practice changes and engage providers in LST education.
• After a multiyear drafting and review process, a draft policy was submitted in May 2015 for formal review and approval by all VHA clinical and administrative program offices.
• Handbook 1004.03 was published in January 2017 to define VHA practice standards for GoCCs:
  • Practitioners are required to initiate proactive GoCC with seriously ill patients or their surrogates prior to writing LST orders.
  • Practitioners are required to document these conversations using the national standardized VHA LST progress note template and order set.
• A four facility, two-year demonstration project was commenced to test and refine all aspects of LSTDI prior to national rollout.

Tools or Products Developed

• Progress note template and order set: a standardized, durable LST progress note template and order set for documenting goals of care and LST decisions was created (see Progress Note under Daily Work Flow below for more detail).
• Care Assessment Need (CAN) score: a predictive analytic risk assessment tool based on Veteran data was used to identify patients at high risk of hospitalization or death. Practitioners and other clinical staff are trained to use the CAN score to identify patients who would benefit from a proactive goals of care conversation.
• The Patient Care Assessment System (PCAS): this was adopted to help teams identify, manage, and track GoCC completion with high-risk patients via several mechanisms:
  • It automatically generates a list of veterans at highest risk (based on CAN score) for whom GoCCs should be prioritized.
  • Other veterans can be added manually to the list.
  • GoCC tasks can be assigned, scheduled, and managed across the patient’s health care team.
• Cognitive aids: these aids, such as pocket cards, were developed for healthcare providers to help them initiate GoCC conversations in the clinical environment.
• Educational materials: these were created for health providers to understand ethical bases for LSTDI, proactively identify high-risk patients, and document their goals.
  • Tools include videos, online modules, podcasts, and avatar-based simulations for distinct learning styles for individuals/teams scalable to clinician time constraints.
• Monitoring reports: these reports were developed to assist facilities in assessing adoption of new practices and to identify improvement opportunities.

Training

• Trainers (physicians and other experienced clinical staff) are selected to attend a ‘train the trainer’ course and then deliver training in their home facilities using nationally standardized curricula through two programs.
  • The first program targets physicians, advance practice nurses and physician assistants authorized to make decisions with patients about LST plans and write LST orders.
    • It includes 5 interactive modules delivered in one block or a series of one-hour sessions across several weeks. Topics include:
      • Delivering serious news
      • Assessing patient understanding
      • Eliciting patient goals
      • Communicating treatment recommendations  
  • The second program is for nurses, social workers, psychologists, and chaplains who care for high-risk patients and help prepare them for GoCC with practitioners who complete the LST plan and write LST orders. This training includes:
    • Face-to-face, day-long training with short didactic segments, video demos, communication exercises, and a module to help teams identify team members’ different roles.
    • Teaching communication skills for engaging patients/families while ensuring handoff to practitioners for LST decision-making.
• Monthly teleconferences for VA trainers provided a forum for problem-solving and sharing best practices in teaching communication skills to clinicians.

Team Members Involved

• PAs
• Physicians
• Psychologist
• Social Worker

Workflow Steps

• Progress notes capture vital information about patient goals and LST decisions through a mix of checkboxes and text fields.
  • Four sections must be filled in to complete the template:
    • Patient’s decision-making capacity
    • Goals of care
    • Treatment preferences in the event of cardiac arrest
    • Informed consent
  • Currently optional sections include:
    • Authorized surrogate
    • Review of related documents such as advance directives
    • Patient/surrogate understanding of the patient’s condition/prognosis
    • Plan for LST in circumstances other than cardiac arrest
• This set of recorded decisions in progress notes allows clinicians to launch orders automatically from documented decisions (e.g. a decision not to attempt CPR in the event of cardiac arrest launches a DNR order). This reduces the risk of transcribing errors and speeds up the documentation process.
• The LST order set may be written in any VHA care setting (e.g. outpatient, inpatient, nursing home), is durable across VHA settings, and remains in effect until it is modified based on changes in the patient’s goals or decisions.
  • Clinicians are trained to revisit LST decisions when clinically appropriate (e.g. when the patient’s health declines, when there is a medical crisis, or when there are indications that the patient’s preferences may have changed).
• Each facility must develop a progress note for nurses, social workers, and health providers to document discussions with patients or surrogates about his/her values, goals, and preferences when shared decisions about LSTs have not yet been made.
• Facility leaders and LSTDI facility based advisory boards were responsible for LSTDI implementation with ongoing support from the NCEHC implementation team.

Budget Details

• Time spent by healthcare providers training, attending advisory board meetings, and discussing GoCCs with patients during their clinical time.
• Time/money spent employing engineers to create new documentation systems and improve existing ones required for the intervention.

Where We Are

• • The project is currently ongoing.
  • Early evaluation of the 6,300 GoCCs conducted during the four-site demonstration project is ongoing. This analysis aims to describe patient/provider/facility characteristics associated with GoCCs, assess variability in LST decisions based on the patient’s diagnosis, and assess the utility of LSTDIs.
  • The VA’s Quality Enhancement Research Initiative has funded a four-year study to examine practices promoting GoCCs in home-based primary care and nursing homes.

Outcomes

• Goal concordant care: percentage of patients who received care that is consistent with the patients documented goals and preferences for life-sustaining treatments
• Clinical capacity: change in clinic’s capacity to engage in high quality GoCC
• Early consultation with palliative care
• Patient centered utilization of health care resources
• Surrogate satisfaction with end-of-life decision making

Above is a logic model which summarizes LSTDI’s policy goals, implementation strategies, core activities and anticipated short and long-term outcomes.

Future Outcomes

• With more than 9 million enrolled Veterans, VHA represents the largest health care organization in the United States and is well-positioned to evaluate population-based outcomes related to this initiative.
• Comparative effectiveness and randomized control studies are currently being developed with other research collaborators.

Benefits

• The quality of care received by veterans with serious illness will be enhanced as facilities ensure patients’ goals and values for LSTs are elicited, documented, and honored across the continuum of care.
• Clinicians will have the communication skills needed to engage in high quality goals of care conversations
• The intervention enables patients to make their preferences for life-sustaining treatments known while they have decision-making capacity and prior to a health care crisis.
• LSTDI moves beyond traditional advanced care planning by addressing barriers to goal-concordant care. It establishes accurate standards and more robust support for VHA patients whose condition places them at risk of a life-threatening event requiring decisions about life-sustaining treatments to be made.
• LSTDI is adaptable to other health care systems that care for patients with advanced illness.

Unique Challenges

• It is a challenge to integrate new practices into ongoing operations to create a high reliability system. Leadership support is critical.
• Conducting and documenting GoCC earlier in the course of serious illness in the primary care setting requires clear roles and responsibilities across the multidisciplinary team.
• The intervention requires that new residents are trained to the new practices. This process must be systematic and sustainable.
• These new practices require culture change throughout the VA, the largest integrated health care system in the US, which is a significant undertaking.

Glossary

• Life-Sustaining Treatment (LST): a medical treatment intended to prolong the life of a patient who would be expected to die soon without it (e.g. artificial nutrition, ventilation).
• LST Progress Note: a health record documenting a GoCC and the resulting LST plan using a nationally standardized Computerized Patient Record System (CPRS) template.
• Goals of Care Conversation (GoCC): a conversation between a healthcare practitioner and a patient/surrogate with the intent of determining patient values, goals, and preferences for care in order to inform decision-making about whether to initiate, limit, or discontinue life-sustaining treatments (LSTs).
• High-Risk Patient: a patient considered at high risk for a life-threatening clinical event within the next one-two years because he/she has a serious life-limiting medical condition associated with a significantly shortened lifespan.

Sources

• Significant input from Mary Beth Foglia,
• Mary Beth Foglia, Jill Lowery, Virginia Ashby Sharpe, Paul Tompkins, Ellen Fox. “A Comprehensive Approach to Eliciting, Documenting, and Honoring Patient Wishes for Care Near the End of Life: The Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative.” The Joint Commission Journal on Quality and Patient Safety, vol. 45, no. 1, 2019, p.p. 47-56, doi: 10.1016/j.jcjq.2018.04.007.
• https://www.ethics.va.gov/LST.asp LSTDI materials are publicly available at this website.