GME Patient Safety Quality and Innovation Symposium

Background: Advance care planning is essential to providing medical care that is aligned with patients’ goals and values. However, conversations regarding goals of care and life-sustaining interventions are often initiated late in the course of illness, such as during hospitalization for critical illness or after loss of decision-making capacity. For high-risk patients in particular, proactive initiation of these discussions in the primary care setting is important to ensure patients’ preferences are known and respected throughout their medical care.

As part of a nationwide quality improvement initiative at the VA, the Life Sustaining Treatment (LST) note was implemented to document patients’ preferences regarding resuscitation and other life-sustaining interventions. LST documentation is especially important for high-risk patients who are at an increased risk for hospitalization and mortality—defined as having a Care Assessment Needs (CAN) score of ≥ 95. The rate of LST note completion for high-risk patients at the San Diego VA is 27%, compared to the national VA average of 49%. To address this need, we conducted a quality improvement initiative to increase advance care planning discussions and LST documentation for high-risk patients in the VA primary care setting.

Methods: Patients with a CAN score of ≥ 96 and no prior LST documentation were identified across eight VA primary care resident clinic panels. Dedicated appointments for up to 30 minutes (in-person, video, or phone) were scheduled for each patient. Family members were encouraged to join if the patient preferred. Educational materials with detailed information regarding advance care planning and life-sustaining treatments were mailed to each patient for review 1-2 weeks prior to the appointment. One medical provider conducted all appointments. Patients' health care goals and life-sustaining treatment preferences were discussed, and an LST note was completed along with an advance directive (if not previously completed) and POLST form (if applicable). Resuscitation status orders were updated in the VA Computerized Patient Record System (CPRS).

Results: Of the 10 patients identified as high-risk, 8 patients agreed to participate in this intervention. 5 patients (63%) had not previously discussed advance care planning with a medical provider. 2 patients (25%) had not previously completed an advance directive. 4 of 5 patients (80%) with a do-not-resuscitate status did not have a previously completed POLST form. During the 4-week intervention period, there was a 100% rate of LST note, advance directive, and POLST form completion.

Conclusions: We have demonstrated an effective approach to integrating advance care planning and LST documentation for high-risk patients in the primary care setting. An important next step involves developing a team-based workflow to routinely access the CAN score database, identify patients with high CAN scores, and notify providers. In addition, surveying patients about their experience participating in this intervention can help assess the impact and benefit of these discussions and identify areas for improvement. Future efforts will also focus on increasing provider education and engagement in this initiative across other VA primary care clinics.