• Karleen F Giannitrapani, Anne M Walling, Ariadna Garcia, MaryBeth Foglia, Jill S Lowery, Natalie Lo, David Bekelman, Cati Brown-Johnson, Marie Haverfield, Natalia Festa, Scott T Shreve, Randall C Gale, Lisa Soleymani Lehmann, and Karl A Lorenz.
• Center for Innovation to Implementation, 19977VA Palo Alto Health Care System, Menlo Park, CA, USA.
• Am J Hosp Palliat Care. 2021 Jan 1; 38 (1): 68-76.

BackgroundPrior 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.AimTo describe a 2-year pilot of the LSTDI at 4 demonstration sites.DesignProspective observational study.Setting/ParticipantsA total of 6664 patients who had at least one GoCC.ResultsDescriptive 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.ConclusionThe 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.

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