A National Pilot of Goals of Care Conversations for Seriously Ill Veterans: Patient and Site Variation and Associations with Bereaved Family Survey Outcomes (TH323D)

Abstract

•Describe patient characteristics from four VA pilot sites that are associated with having a Goals of Care Conversation (GoCC) documented on the standardized Life Sustaining Treatment (LST) Progress Note template.•Determine whether the occurrence of a documented GoCC predicts higher Bereaved Family Survey (BFS) perceptions of a positive patient care experience. Prior to national implementation, VA piloted the Life Sustaining Treatment Decision Initiative (LSTDI), including practice standards requiring Goals of Care Conversations (GoCC) for seriously ill Veterans, at four geographically diverse sites. We examined patient characteristics associated with GoCC and the association of GoCC with Bereaved Family Survey (BFS) data on end-of-life quality. To assess a pilot of an initiative to ensure GoCC for high risk patients, including to: 1) describe characteristics of patients with GoCC; association with the BFS; and how implementation and quality varied across diverse sites. We examined Veteran characteristics in association with documentation of a GoCC. We evaluated the first occurrence of GoCC (n=6,664) among Veterans who received care at the sites (N=221,383). Among decedents (n=15,177), we examined whether GoCC was associated with higher BFS outcomes versus propensity-score matched controls by site. Veteran's with widower [OR=1.68(1.53,1.86), p<0.001] and urban status [OR=1.79(1.43,2.24), p <0.001] were more likely to have a GoCC. Patients >=65 years were twice as likely to have a GoCC [OR=2.65(2.46,2.86), p<0.001], and patients with more serious health conditions were more likely to receive a GoCC compared to frail patients. Findings were similar among Veterans with a higher risk index. Of Veterans with BFS data, we identified 353 GoCC and non-GoCC patient pairs. Comparing across sites, a GoCC was not significantly associated with a higher BFS Overall Score [OR=1.29(0.84,1.99), p=0.24], Communication Score [OR=1.32(0.81,2.16), p=0.27], or Support Score [OR=1.54(0.97,2.47), p=0.07]. Individually analyzed, GoCC was associated with a higher Support Score [OR=1.31(1.09,1.57), p=0.003] at one site. Despite site differences, recipients of GoCC generally had higher illnesses burden and prognostic risk. Site-level heterogeneity in outcomes suggest the need for deeper understanding of implementation and communication fidelity. These issues are critical to achieve expected benefits from widespread efforts to implement GoCC.