Optimizing Advance Care Planning: The Veterans Health Administration's “Life-Sustaining Treatment Decisions Initiative”

Dear Editor:

“Advance Care Planning” (ACP) aims to optimize care provided to patients toward the end of life. It rests on the bioethical principle of respect for patient autonomy. Patient wishes regarding life-sustaining treatments (LSTs), including, but not limited to, cardiopulmonary resuscitation, are elicited by having goals of care conversations (GoCC). The aim is to provide goal concordant care in the event of loss of capacity or the ability to communicate. This specialized form of communication should be considered a vital component of patient care, especially for those patients considered to be at high risk for clinical deterioration. Ideally, GoCC should occur (and be documented) when the individual is well enough to think and communicate clearly about treatment preferences.

Traditional ACP involves completion of a legal document: Advance Directive. A health care surrogate is named (“designated power of attorney”) and end-of-life treatment preferences are conveyed in the living will section. Unfortunately, studies indicate that <20% of Americans formalize their preferences in a living will. ¹ Moreover, it can be interpreted in various ways and when nuanced treatment decisions are required, cannot easily be translated into a set of medical orders. State-authorized portable orders, also a form of ACP documentation, are signed by clinicians and used by emergency medical personnel during transport. However, they are not regularly uploaded into medical records or used within facilities.

Clear documentation of patients' preferences for LSTs is of paramount importance. It minimizes confusion among staff, miscommunication with families, and errors in code situations. ² The National Quality Forum's (NQF) 2010 “Safe Practices for Better Health Care” recommend that written documentation of the patient's preferences for LSTs is prominently displayed in the chart and that organizational policies should be in place that address and prioritize end-of-life treatment practices. ³

The Veterans Health Administration (VHA) is the largest health care organization in the United States, with >9 million enrolled veterans. Historically, the VHA has led in many aspects of health care delivery. It pioneered the use of electronic health records and filmless radiology. In January 2017, it introduced an initiative called the “Life-Sustaining Treatment Decisions Initiative” (LSTDI). The LSTDI aims to optimize practices related to ACP and improve the quality of care provided toward the end of life. It encourages early GoCC and standardizes the location of documentation reflecting these conversations in the electronic health record—thereby making the VHA the largest health care organization in the United States to implement the NQF's recommendations within its entire system of hospitals and outpatient facilities. ⁴

Until the development of more advanced methods of ACP using web-based technologies that patients can use to document their own wishes, eliciting and appropriately documenting patient wishes remain within the context of physician–patient relationships; and the responsibility of providing goal concordant end-of-life care rests with health care providers and organizations. With the implementation of the LSTDI, the VHA is leading the way in prioritizing and optimizing ACP.