scholarly journals Changing Culture Around Serious Illness: The VA Life-Sustaining Treatment Decisions Initiative

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 751-752
Author(s):  
Joan Carpenter ◽  
Robert Burke
Keyword(s):  
Treatment Decisions ◽  
Treatment Preferences ◽  
Veterans Health ◽  
Health Administration ◽  
Comfort Care ◽  
Goals Of Care ◽  
Serious Illness ◽  
Wide Range ◽  
Life Sustaining Treatment ◽  
Seriously Ill

Abstract Discussing and documenting goals of care and life-sustaining treatment decisions with seriously ill patients is a widely endorsed practice by healthcare and professional organizations. In 2018, The Veterans Health Administration (VA) initiated a new national policy to standardize such practices, the Life Sustaining Treatment Decisions Initiative (LSTDI), which included a coordinated set of evidence-based strategies and practice standards for conducting, documenting, and supporting high-quality goals of care conversations (GoCCs); staff training to enhance skills in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting patients’ goals and preferences; and monitoring and information technology tools to support implementation and improvement. In this symposium, we will describe the first 20 months of implementing the LSTDI across the VA, the largest integrated healthcare system in the US. The first paper will focus on the factors associated with documentation of a GoCC and treatment preferences. The second paper will present findings describing facilitators and barriers to implementing the LSTDI and identifying factors that promote high rates of LSTDI documentation. The third paper examines patient level outcomes associated with a documented goal of comfort care, specifically the odds of receipt of hospice/palliative care, hospitalization, or ICU admission. This symposium will provide attendees with important information regarding a wide range of individual and system strategies to enhance the care of seriously ill older adults by engaging patients with serious illness in GoCCs and documenting their preferences for treatment in durable, easily accessible notes and orders.

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

2020 ◽  
Vol 38 (1) ◽  
pp. 68-76
Author(s):  
Karleen F. Giannitrapani ◽  
Anne M. Walling ◽  
Ariadna Garcia ◽  
MaryBeth Foglia ◽  
Jill S. Lowery ◽  
...  
Keyword(s):  
Treatment Decisions ◽  
Department Of Veterans Affairs ◽  
Do Not Resuscitate ◽  
Policy And Practice ◽  
Goals Of Care ◽  
Chart Abstraction ◽  
Integrated Health Care System ◽  
Life Sustaining Treatment ◽  
Seriously Ill Patients ◽  
Seriously Ill

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.

scholarly journals Patient–physician conversations about life-sustaining treatment: Treatment preferences and participant assessments

2021 ◽  
pp. 1-7
Author(s):  
Lone Doris Tuesen ◽  
Hans-Henrik Bülow ◽  
Anne Sophie Ågård ◽  
Sverre Maintz Strøm ◽  
Erik Fromme ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiopulmonary Resuscitation ◽  
Nursing Home Residents ◽  
Treatment Preferences ◽  
Comfort Care ◽  
Life Sustaining Treatment ◽  
Seriously Ill Patients ◽  
High Degree ◽  
Seriously Ill ◽  
Very High

Abstract Objective In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients’ treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form. Methods The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making. Results A total of 95 patients (aged 41–95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree. Significance of results The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Serious illness communication among patients with head and neck cancer.

2019 ◽  
Vol 37 (31_suppl) ◽  
pp. 2-2
Author(s):  
Floyd Buen ◽  
Emily J Martin ◽  
Neil Wenger ◽  
Kirsten Buen ◽  
Anne M. Walling
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Retrospective Analysis ◽  
Neck Cancer ◽  
Medical Records ◽  
Primary Care Providers ◽  
Treatment Preferences ◽  
Care Providers ◽  
Goals Of Care ◽  
Serious Illness

2 Background: Head and neck cancer is associated with significant morbidity and mortality, yet little is known about the frequency and content of discussions addressing patients’ values, goals of care, and treatment preferences. Methods: Using an institutional cancer registry, we conducted a retrospective analysis of 70 decedents who underwent surgical treatment for squamous cell carcinoma of the head and neck. We abstracted patients’ medical records using a standardized template. An independent reviewer re-abstracted 20% of the records. For abstracted data pertaining to documented values, goals of care, and/or treatment preferences our inter-rater reliability was greater than 93%. Results: The mean age at diagnosis was 66 years and 69% were male. An enduring advance directive, a completed Physician Order for Life Sustaining Treatment form, and a serious illness conversation documented in the medical record were noted in 27%, 4%, and 49% of the medical records, respectively. Half of the documented goals of care discussions were held in the inpatient setting, over 50% were held in the last month of life, and 25% were held in the last week of life. These conversations involved specialist palliative care providers (47%), hematologist/oncologists (41%), hospitalists (32%), head and neck surgeons (21%), radiation oncologists (19%), and intensivists (18%). None of these discussions involved patients’ primary care providers. Of those with a known location of death, 58% died in the hospital and 4 out of 5 of these patients died during attempted cardiopulmonary resuscitation. Conclusions: In this retrospective analysis, serious illness communication was documented in the minority of patients who died of head and neck cancer. These discussions occurred late in the trajectory of illness. The continuity relationships of teams treating head and neck cancer patients (e.g., head and neck surgeon, radiation/oncologist and hematologist/oncologist) situate these clinicians in the best position to enact serious illness conversations. These data suggest that opportunities to have these discussions upstream are often missed.

scholarly journals Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

2021 ◽  
Author(s):  
Lucinda B. Leung ◽  
Hannah N. Ziobrowski ◽  
Victor Puac-Polanco ◽  
Robert M. Bossarte ◽  
Corey Bryant ◽  
...  
Keyword(s):  
Treatment Adherence ◽  
Patient Preferences ◽  
Veterans Health Administration ◽  
Self Report ◽  
Treatment Preferences ◽  
Depression Treatment ◽  
Veterans Health ◽  
Health Administration ◽  
Treatment Type ◽  
To Receive

Abstract Background Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes. Objective To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment. Design Patient self-report surveys at treatment initiation linked to medical records. Setting Veterans Health Administration (VA) clinics nationally, 2018–2020. Participants A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) Main Measures Patient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables. Key Results More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence. Conclusions Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

scholarly journals The "State of Implementation" Progress Report (SIPREP): A Pilot Demonstration of a Navigation System for Implementation

2020 ◽  
Author(s):  
Edward J Miech ◽  
Angela Larkin ◽  
Julie C Lowery ◽  
Andrew J Butler ◽  
Kristin M Pettey ◽  
...  
Keyword(s):  
Navigation System ◽  
Organizational Context ◽  
Medical Center ◽  
Veterans Health ◽  
Health Administration ◽  
Novel Approach ◽  
Wide Range ◽  
The Individual ◽  
Implementation Progress ◽  
Specific Implementation

Abstract Background: Implementation of new clinical programs across diverse facilities in national healthcare systems like the Veterans Health Administration (VHA) can be extraordinarily complex. Implementation is a dynamic process, influenced heavily by local organizational context and the individual staff at each medical center. It is not always clear in the midst of implementation what issues are most important to whom or how to address them. In recognition of these challenges, implementation researchers within VHA developed a new systemic approach to map the implementation work required at different stages and provide ongoing, detailed and nuanced feedback about implementation progress.Methods: This observational pilot demonstration project details how a novel approach to monitoring implementation progress was applied across two different national VHA initiatives. Stage-specific grids organized the implementation work into columns, rows and cells, identifying specific implementation activities at the site level to be completed along with who was responsible for completing each implementation activity. As implementation advanced, item-level checkboxes were crossed off and cells changed colors, offering a visual representation of implementation progress within and across sites across the various stages of implementation. Results: Applied across two different national initiatives, the SIPREP provided a novel navigation system to guide and inform ongoing implementation within and across facilities. The SIPREP addressed different needs of different audiences, both described and explained how to implement the program, made ample use of visualizations, and revealed both what was happening and not happening within and across sites. The final SIPREP product spanned distinct stages of implementation. Conclusions: The SIPREP made the work of implementation explicit at the facility level (i.e., who does what, and when) and provided a new common way for all stakeholders to monitor implementation progress and to help keep implementation moving forward. This approach could be adapted to a wide range of settings and interventions, and is planned to be integrated into the national deployment of two additional VHA initiatives within the next 12 months.

scholarly journals The “State of Implementation” Progress Report (SIPREP):A Pilot Demonstration of a Navigation System for Implementation

2020 ◽  
Author(s):  
Edward J Miech ◽  
Angela Larkin ◽  
Julie C Lowery ◽  
Andrew J Butler ◽  
Kristin M Pettey ◽  
...  
Keyword(s):  
Navigation System ◽  
Organizational Context ◽  
Medical Center ◽  
Veterans Health ◽  
Health Administration ◽  
Novel Approach ◽  
Wide Range ◽  
The Individual ◽  
Implementation Progress ◽  
Specific Implementation

Abstract Background: Implementation of new clinical programs across diverse facilities in national healthcare systems like the Veterans Health Administration (VHA) can be extraordinarily complex. Implementation is a dynamic process, influenced heavily by local organizational context and the individual staff at each medical center. It is not always clear in the midst of implementation what issues are most important to whom or how to address them. In recognition of these challenges, implementation researchers within VHA developed a new systemic approach to map the implementation work required at different stages and provide ongoing, detailed and nuanced feedback about implementation progress.Methods: This observational pilot demonstration project details how a novel approach to monitoring implementation progress was applied across two different national VHA initiatives. Stage-specific grids organized the implementation work into columns, rows and cells, identifying specific implementation activities at the site level to be completed along with who was responsible for completing each implementation activity. As implementation advanced, item-level checkboxes were crossed off and cells changed colors, offering a visual representation of implementation progress within and across sites across the various stages of implementation. Results: Applied across two different national initiatives, the SIPREP provided a novel navigation system to guide and inform ongoing implementation within and across facilities. The SIPREP addressed different needs of different audiences, both described and explained how to implement the program, made ample use of visualizations, and revealed both what was happening and not happening within and across sites. The final SIPREP product spanned distinct stages of implementation. Conclusions: The SIPREP made the work of implementation explicit at the facility level (i.e., who does what, and when) and provided a new common way for all stakeholders to monitor implementation progress and to help keep implementation moving forward. This approach could be adapted to a wide range of settings and interventions, and is planned to be integrated into the national deployment of two additional VHA initiatives within the next 12 months.

Serious Illness Conversations in advanced kidney disease: a mixed-methods implementation study

2021 ◽  
pp. bmjspcare-2020-002830
Author(s):  
Natanong Thamcharoen ◽  
Pitchaphon Nissaisorakarn ◽  
Robert A Cohen ◽  
Mara A Schonberg
Keyword(s):  
Mixed Methods ◽  
Pilot Study ◽  
Kidney Disease ◽  
Advance Care Planning ◽  
Disease Stage ◽  
Treatment Preferences ◽  
Care Planning ◽  
Goals Of Care ◽  
Serious Illness ◽  
Advance Care

ObjectiveAdvanced kidney disease is associated with a high risk of morbidity and mortality. Consequently, invasive treatments such as dialysis may not yield survival benefits. Advance care planning has been encouraged. However, whether such discussions are acceptable when done earlier, before end-stage kidney treatment decision-making occurs, is unclear. This pilot study aimed to explore whether use of the Serious Illness Conversation Guide to aid early advance care planning is acceptable, and to evaluate the information gained from these conversations.MethodsPatients with advanced kidney disease (stage 3B and above) and high mortality risk at 2 years were enrolled in this mixed-methods study from an academic nephrology clinic. Semi-structured interviews were conducted using the adapted Serious Illness Conversation Guide. Thematic analysis was used to assess patients’ perceptions of the conversation. Participants completed a questionnaire assessing conversation acceptability.ResultsTwenty-six patients participated, 50% were female. Participants felt that the conversation guide helped them reflect on their prognosis, goals of care and treatment preferences. Most did not feel that the conversation provoked anxiety (23/26, 88%) nor that it decreased hopefulness (24/26, 92%). Some challenges were elicited; patients expressed cognitive dissonance with the kidney disease severity due to lack of symptoms; had difficulty conceptualising their goals of care; and vocalised fear of personal failure without attempting dialysis.ConclusionsPatients in this pilot study found the adapted Serious Illness Conversation Guide acceptable. This guide may be used with patients early in the course of advanced kidney disease to gather information for future advanced care planning.

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