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.

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.

BACKGROUND: 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. This conversation is intended to elicit the patient's values, goals, and preferences as a basis for shared decisions about treatment planning. LST decisions are often postponed until the patient is within days or even hours of death and no longer able to make his or her goals and preferences known. Decisions then fall to surrogates who may be uncertain about what the patient would have wanted. LIFE-SUSTAINING TREATMENT DECISIONS INITIATIVE (LSTDI): The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative (LSTDI) was designed to ensure that patients' goals, values, and preferences for LSTs are elicited, documented, and honored across the continuum of care. The LSTDI includes a coordinated set of evidence-based strategies that consists of enterprisewide practice standards for conducting, documenting, and supporting high-quality GoCCs; staff training to enhance proficiency in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting GoCCs; monitoring and information technology tools to support implementation and improvement; a two-year multifacility demonstration project conducted to test and refine strategies and tools and to identify strong practices; and a program of study to evaluate the LSTDI and identify strategies critical to improving care for patients with serious illness. CONCLUSION: The LSTDI moves beyond traditional advance care planning by addressing well-documented barriers to goal-concordant care for seriously ill patients.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings.

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

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

CONTEXT: The 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. OBJECTIVES: Our 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. METHODS: We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation. RESULTS: Three 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. CONCLUSION: Learning 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.

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.

A Health Care Systems Approach to Improving Care for Seriously Ill Patients.

Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment. We offer a stepwise framework for communication with seriously ill patients and describe a systems approach to transforming the process of eliciting, documenting, and honoring patients' life-sustaining treatment preferences in the U. S. Veterans Health Administration.

Impact of bereavement on progression of AIDS and HIV infection: a review.

BACKGROUND: Human immunodeficiency virus (HIV) disease is associated with bereavement and grief reactions brought about by the disease process itself and by the losses of loved ones. OBJECTIVE: The goal of this review is to assess the current literature regarding grief, HIV, and immunity. METHOD: The authors reviewed applicable articles retrieved from a MEDLINE literature search with the search terms "bereavement/HIV," "grief/HIV," and "immunity/grief/HIV." RESULTS: Data continue to emerge that suggest a profound role for bereavement in mediating HIV illness and the need to effectively deal with bereavement issues. CONCLUSIONS: Patients who experience maladaptive grief show more rapid losses of CD4 T-cells over time, even when controlling for age, health status, use of antiretrovirals, and illicit drug abuse. This immune dysfunction may be managed by a variety of psychotherapeutic techniques.