Life-Sustaining Treatment Decisions Initiative Research Articles

Evaluating feedback reports to support documentation of veterans’ care preferences in home based primary care

BackgroundTo evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.MethodsWe distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.ResultsLST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.ConclusionsFeedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

Randomized controlled trial of tailored audit with feedback in VHA long-term care settings

BackgroundThe Long-Term Care QUERI program supported implementation of the Life-Sustaining Treatment Decisions Initiative in US Veterans Health Administration long-term care settings. The program worked with eleven Community Living Centers (CLCs) and twelve Home-Based Primary Care (HBPC) programs to increase rates of completed templates, using audit with feedback. We distributed monthly feedback reports to site champions showing the number of Veterans with appropriate documentation. Although feedback reports are a common implementation tool, little is known about the most effective ways to design, distribute, and support them. We sought to test tailoring reports with tips using site-specific data, as well as national comparator data.MethodsWe conducted a cluster randomized controlled trial of monthly feedback reports utilizing site-tailored tips and national comparator data compared to our original feedback reports that included only graphical and numerical data. CLC and HBPC team members were invited to participate in brief surveys each quarter to determine if they had received and used the feedback reports. The outcome for CLC residents was the percent with a completed LST template any time prior to the 14th day of their stay. The outcome for HBPC residents was the percent of Veterans with a completed LST template by their second HBPC visit.ResultsThe response rate to the survey ranged between 6.8 and 19.3% of staff members across the CLC and HBPC sites with 12.8–25.5% of survey respondents reporting that they had seen the feedback reports. The linear regression models showed no significant association between receiving the enhanced feedback reports and having a higher documentation completion rate.ConclusionsReceiving feedback reports tailored to sites by including tips based on baseline context assessments and qualitative findings, and reports showing national comparator data, did not have an impact on the number of Veterans with a completed LST template. Having a higher proportion of CLC or HBPC team members view the reports was not associated with an increase in LST template completion. These findings suggest that tailored audit with feedback may not have been effective at the program level, although the proportion of respondents who reported seeing the reports was small.

The Geriatrics Surgery Verification Program and the Life-Sustaining Treatment Decisions Initiative: Coupling Two Programs to Improve Advanced Care Planning for Older Veterans Undergoing Surgery (TH121A)

The Geriatrics Surgery Verification Program and the Life-Sustaining Treatment Decisions Initiative: Coupling Two Programs to Improve Advanced Care Planning for Older Veterans Undergoing Surgery (TH121A)

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Evaluating implementation strategies to support documentation of veterans' care preferences.

To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.

Associations between the Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative and Quality of Care at the End of Life.

Background: In 2017, Veterans Health Administration (VHA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) to promote goals-of-care conversations (GoCC) between seriously ill patients and their practitioners, to document patient preferences in the electronic health record, and to provide care consistent with patients' goals. Objectives: We evaluated the associations between this initiative and quality of care in the last month of life (i.e., emergency department/intensive care unit [ED/ICU] visits and hospice consultations). Design: We conducted patient-level propensity score analyses to evaluate the associations between LSTDI and care utilization in the last 30 days of life. The primary exposure was a three-level factor: no GoCC (reference group), GoCC with Full Code, and GoCC with do not resuscitate (DNR). The outcomes were ED/ICU visits and hospice consultations within 30 days of death. Setting/Subjects: A total of 44,320 patients receiving care in Veterans (VA), who were older than 18, and who died and had a completed encounter within 24 months of death in a VA primary care, mental health, or medical specialty between January 2017 and December 2019. Results: Patients with a documented GoCC and DNR code status had decreased risk of ED visits (odds ratio [OR] = 0.6, 89% credible intervals [CI] = [0.57-0.64]) and ICU visits (OR = 0.49, 89% CI = [0.45-0.53]), and increased rates of hospice visits (β = 2.18, 89% CI = [2.11-2.26]) compared with patients with no GoCC. Conclusion: The LSTDI had a positive impact by eliciting and documenting patient preferences for care at the end of life and quality of care in the last month of life. We observed associations between care preferences and ED/ICU visits and hospice consultations within 30 days of death. Further research should address the associations between LSTDI and use of palliative care, and outcomes associated with limits to specific life-sustaining treatments such as mechanical ventilation, artificial nutrition, and hydration.

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

Background: The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient’s treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. Aim: Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. Design: A qualitative thematic analysis of semi-structured interviews. Setting/participants: Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. Results: Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can “overwhelm” providers. Conclusions: Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.

Playing Nice in the Sandbox: Lessons on Roles, Interdisciplinary Collaboration, and Leadership from a VA National Improvement Intervention (F405D)

1.Apply organizational role theory in examining health care system initiative for goals of care conversations.2.Identify strategies that can increase health care system adoption of goals of care initiatives. The Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) nationally in 2017. This policy encourages universal goals of care conversations (GoCCs) regarding life-sustaining treatments among veterans with serious illnesses. A key component is expanding clinician roles, including nurses and social workers, in GoCCs. To evaluate the impact of organizational structure on clinician role expansion in the LSTDI. We undertook secondary analyses of LSTDI implementation evaluation interviews to understand site experiences with expanded clinician roles. Interviews purposively sampled interdisciplinary providers from 12 diverse national VA sites. Organizational role theory informed our coding framework. Using an iterative, constant comparative, dual coding process, we summarize major themes. 1) Organizational culture change is needed to expand clinician roles in GoCCs. Most sites described the acceptance of expanded roles required a “culture shift” within the organization. Sites that defined GoCCs as “everyone’s job” increased adoption of the LSTDI. 2) Supportive executive leadership and diverse middle management are key in clinician role expansion. A diverse advisory council, including front-line staff, helped clinicians take GOCCs as a “role-specific versus person-specific” task. 3) Diverse education champions, trainers, and materials increased clinician readiness for role expansion, by enhancing a “provider’s initiative and comfort in having that kind of a conversation”. 4) Clarity in roles across disciplines improved acceptance of role expansion. Leadership support for interdisciplinary team structure increased uptake of the initiative. 5) Role expansion increased clinician task burden. Clinicians felt “overwhelmed, it was just one more thing on their plate”. Leadership acknowledgment alleviated this burden through dedicated clinician time to the initiative. Organizational role theory provided insights on LSTDI implementation and informs specific preparatory strategies to foster expanded clinician roles and improve system-wide adoption of GoCCs.

Management of Do Not Resuscitate Orders Before Invasive Procedures.

In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures. To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments. Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists' documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model. The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% (P = .01). Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.

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

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.

Best Practices in Implementing the VA’s Life-Sustaining Treatment Decisions Initiative

To study use and completion of Life Sustaining Treatment (LST) templates across the Department of Veterans Affairs (VA) healthcare system, we designed a qualitative study to interview VA sites we identified who had high rates of LST template completion between July 1, 2018 (the official implementation start date) and March 2019. We then conducted site visits with two VA sites and phone interviews with nine other VA site to better describe facilitators and barriers to implementation of this new practice and identified factors influencing high rates of LST documentation completion. Researchers who conducted the interviews analyzed interview data through applying the Consolidated Framework for Implementation Research. From these efforts, we identified best practices used, including the importance of a formally appointed implementation leader, gaining leadership support, and engaging staff through education. We will share these recommendations with VA sites across the healthcare system to improve LST documentation.

VA’s Life-Sustaining Treatment Decisions Initiative: First 20 Months of National Implementation

This retrospective observational study describes the first 20 months of implementing the Life-Sustaining Treatment Decisions Initiative. We examined patient and facility characteristics associated with life sustaining treatment (LST) orders template completion, including the association between template completion and the Care Assessment Need (CAN) score, which quantifies Veterans’ risk of hospitalization and mortality. As of February 29, 2020, over 274,200 Veterans received at least one goal of care conversation and LST preferences documented on a template. Eighty-two percent of deceased Veterans with the highest risk of hospitalization or mortality had an LST note and order documented prior to their death. Factors that predicted a greater likelihood of LST template completion included higher CAN score, older age, nursing home stay, and being white non-Hispanic. Findings suggest that clinicians are engaging older, sicker veterans in goals of care conversations. Research is needed to understand potential disparities in LST template completion.

Implementation of VA's Life-Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers

ContextIn 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs). ObjectivesThe aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network. MethodsFrom September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook. ResultsWe divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate. ConclusionAlthough self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.

Honoring Veterans' Preferences: The Association Between Comfort Care Goals and Care Received at the End of Life

ContextAs part of its Life-Sustaining Treatment (LST) Decisions Initiative, the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events. ObjectivesTo evaluate whether goals of “to be comfortable” were associated with greater palliative care (PC) use and lesser acute care use. MethodsWe identified Veterans with VA inpatient or nursing home stays overlapping July 2018–January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a “to be comfortable” goal. Using VA and Medicare data, we determined PC use (consultations and hospice) and hospital, intensive care unit, and emergency department use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest. ResultsSixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort care goals received hospice and 57% PC consultations (versus 57% and 46%, respectively, for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, intensive care unit, and emergency department use near the end of life. In the last 30 days of life, Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized. ConclusionFindings support the VA's commitment to honoring of Veterans' preferences post introduction of its Life Sustaining Treatment Decisions Initiative.

Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative

ContextThe Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017. ObjectivesOur goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls. MethodsWe conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation. ResultsThree primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships. ConclusionLearning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.

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

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. To describe a 2-year pilot of the LSTDI at 4 demonstration sites. Prospective observational study. A total of 6664 patients who had at least one GoCC. 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. 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.

Improving End-of-Life Care using the Life Sustaining Treatment Decision Initiative in a Veterans Affairs Community Living Center

In 2018, the Department of Veterans Affairs (VA) implemented the Life Sustaining Treatment Decisions Initiative (LSTDI), a national, multi-pronged program to support clinicians in conducting Goals of Care Conversations (GoCC) with seriously ill Veterans and documenting them using a standardized note and orders template. Addressing GoCC is a crucial part of comprehensive care in LTC facilities and thus Veterans residing in VA nursing homes (Community Living Centers, CLCs) are appropriate recipients of this initiative. However, due to the challenges of addressing the many complex medical and psychosocial needs of veterans in CLCs, even the minimum task of completing the LSTDI note can be challenging.

Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences.

On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. Evaluate the first 7months of LSTDI implementation and identify predictors of LST template completion. Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. All veterans with VA utilization between July 1, 2018, and January 31, 2019. Completed LST templates, goals and LST preferences, and predictors of documentation. LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

A Rapid Qualitative Synthesis of Insights from the Veterans Administration Life-Sustaining Treatment Decisions Initiative (LSTDI) National Implementation (QI703)

A Rapid Qualitative Synthesis of Insights from the Veterans Administration Life-Sustaining Treatment Decisions Initiative (LSTDI) National Implementation (QI703)