Department of Veterans Affairs, Rocky Mountain VA Medical Center, Aurora, CO, USA.
Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA.
J Gen Intern Med. 2020 Jun;35(6):1803-1812. doi: 10.1007/s11606-020-05697-2. Epub 2020 Feb 24.
On 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.
Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion.
Retrospective 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.
All veterans with VA utilization between July 1, 2018, and January 31, 2019.
Completed LST templates, goals and LST preferences, and predictors of documentation.
LST 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.
LST 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.
2018 年 7 月 1 日，退伍军人健康管理局（VA）国家医疗保健伦理中心实施了维持生命治疗决策倡议（LSTDI）。其目标是识别、记录和尊重重病退伍军人的 LST 决定。提供者使用标准化的 LST 模板和医嘱集来记录退伍军人的目标和决定。
评估 LSTDI 实施的头 7 个月，并确定 LST 模板完成情况的预测因素。
回顾性观察性研究临床和行政数据。我们确定了所有已完成的 LST 模板，定义为完成四个必需模板字段。模板还包括四个非必需字段。结果按由 Care Assessment Need（CAN）评分估计的住院或死亡风险分层。
2018 年 7 月 1 日至 2019 年 1 月 31 日期间在退伍军人事务部有就诊记录的所有退伍军人。
已完成的 LST 模板、目标和 LST 偏好，以及记录的预测因素。
共记录了 108145 名退伍军人的 LST 模板，85%的退伍军人除了必填字段外，还完成了一个或多个非必填字段。大约一半的人记录了对心肺复苏术的偏好。在记录具体目标的退伍军人中，一半希望改善或维持功能、独立性和生活质量，而 28%的目标是延长生命，无论是否有住院/死亡风险，45%的目标是舒适。只有 7%的人表示希望治愈。记录的预测因素包括退伍军人事务部疗养院居住、年龄较大、脆弱和合并症，而非白种人、农村居住和在医疗中心接受较低复杂性护理与不记录相关。
记录了有高住院或死亡风险的退伍军人的 LST 决策。虽然很少有人表示希望治愈，但有一半人希望接受心肺复苏术。记录的预测因素通常与现有文献一致。通过利用现有的退伍军人事务部资源和计划，可以减少观察到的差异。
