• Cari Levy, Mary Ersek, Winifred Scott, Joan G Carpenter, Jennifer Kononowech, Ciaran Phibbs, Jill Lowry, Jennifer Cohen, and Marybeth Foglia.
• Department of Veterans Affairs, Rocky Mountain VA Medical Center, Aurora, CO, USA. Cari.Levy@va.gov.
• J Gen Intern Med. 2020 Jun 1; 35 (6): 180318121803-1812.

BackgroundOn 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.ObjectiveEvaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion.DesignRetrospective 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.SubjectsAll veterans with VA utilization between July 1, 2018, and January 31, 2019.Main MeasuresCompleted LST templates, goals and LST preferences, and predictors of documentation.ResultsLST 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.ConclusionsLST 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.

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