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

Abstract

BACKGROUND: 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. OBJECTIVE: Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion. DESIGN: 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.

End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever

“…We measured medical comorbidities using the Elixhauser method with a one-year look back period. ( 21 , 22 ) We also collected data on site of death and four care process indicators that are associated with high-quality EOL care: 1) receipt of a comprehensive palliative care consult in the last 90 days of life;( 23 ) 2) completion of a life-sustaining treatment note and orders;( 24 , 25 ) 3) Veteran/family contact with a chaplain in the last month of life; and 4) presence of a “Do Not Resuscitate” order. ( 26 , 27 ) All indicators were coded as dichotomous variables (yes/no).…”

“…Veterans in selected "Covid-19 hotspot" facilities (n=1,073)Excluded from Bereaved Family Survey (BFS) sample (n=189):• Death within 24 hours of admission without a previous admission greater than24 hours in the last month of life (n=25) • Missing or inaccurate contact information (n=135) • No NOK listed in EMR (n=29) Sample contacted by phone to complete the BFS (n=884) BFS nonrespondents (n=556): Unable to contact by telephone (n=386) • Declined to participate (n=107) • Did not have adequate knowledge to evaluate Veteran's care (n=57) • Did not complete the entire BFS (n=6) BFS respondents (n=328)J o u r n a l P r e -p r o o f…”

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

“…A recent large national study confirmed that nonwhites in general were less likely to receive GoCC in VA; this preliminary information is confirmed by broader national data and indicates a disparity requiring attention. 24…”

Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life

“…[9][10][11][12] As patients approach end of life, many choose to limit life-sustaining treatments and other therapies, and focus on comfort. [13][14][15] Continuing statins is not well aligned with these goals, especially in light of the lack of survival benefits 16 and heightened potential for adverse effects 17,18 (eg, muscle pain) in this population. Although little research has examined outcomes of statin discontinuation in adults with LLE/AD, one trial found that patients with less than 1 year life expectancy randomized to discontinue statins reported higher quality of life with no increased risk of mortality, 16 lending support to discontinuation.…”

“…However, several geriatric groups explicitly recommend against using statins in older adults with LLE (<2 years) and/or AD 9‐12 . As patients approach end of life, many choose to limit life‐sustaining treatments and other therapies, and focus on comfort 13‐15 . Continuing statins is not well aligned with these goals, especially in light of the lack of survival benefits 16 and heightened potential for adverse effects 17,18 (eg, muscle pain) in this population.…”