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Objectives: Hospitalized patients may require goals of care (GOC) or Advance Health Care Planning (ACP), which can be time-consuming and emotionally tolling for providers. A nursing team specializing in code status (CODE), GOC, and ACP was developed to provide meaningful support for patients and families and decrease provider burden. Interest in CODE, GOC, ACP, and effectiveness of a nursing team to lead these conversations prompted this study. Methods: A collaborative nursing team was trained to address CODE, GOC, and ACP with patients demonstrating illness or geriatric syndrome. This team conducted 3 visits per patient on average during hospitalization using structured CODE templates to establish longer term goals and document what matters in the healthcare journey. Comprehensive narratives for ACP and GOC were included in charting, syncing the medical team, nursing, patient, and family. Consults were tracked over nine months with data reviewed retrospectively from medical charts. Descriptive analyses of cohort demographics, CODE and outcomes were completed. Results: The study group comprised 3342 patients between October 2022 and June 2023. Patients ranged in age from 18-106 years, with majority (88%) age 65 years and older. Mean length of stay (LOS) was 6.8 days with CODE documented for 91% upon admission. Of the 3166 older adults with known CODE on admission, 946 (30%) changed CODE by discharge, of which 95% were de-escalated. 83% of older patients arriving with limited CODE maintained limitations at discharge, with a small portion converting to comfort (16%). Conclusion: Employing a focused nursing team to conduct CODE, GOC, and ACP conversations may be an effective use of time and resources and result in de-escalation of resuscitation orders for patients demonstrating illness or geriatric syndrome.

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BACKGROUND: Advance care planning initiatives are becoming more widespread, increasing expectations for providers to engage in goals of care conversations. However, less is known about how providers communicate advance care planning within and throughout a health care system. AIM: To explore perspectives of communication processes in the rollout of an advance care planning initiative. DESIGN: Theoretically informed secondary analysis of 31 semi-structured interviews. SETTING/PARTICIPANTS: Key partners in a Veterans Health Administration goals of care initiative. RESULTS: Using the constant comparative approach followed by qualitative mapping of themes to the layers of the Socio-Ecological Model, four themes and corresponding Socio-Ecological layers were identified: Goals of Care Communication Training (Policy, Community, and Institutional) requires more resources across sites and better messaging to reduce provider misconceptions and promote an institutional culture invested in advance care planning; Interprofessional Communication (Interpersonal) suggests care team coordination is needed to facilitate continuity in goals of care messaging; Communication in Documentation (Institutional, Interpersonal, and Intrapersonal) highlights the need for capturing the context for goals of care preferences; and Patient/Family Communication (Interpersonal and Intrapersonal) encourages offering materials and informational resources early to facilitate rapport building and readiness to determine goals of care. CONCLUSIONS: Findings support the need for initiatives to incorporate an evaluation of how goals of care are discussed beyond the interpersonal exchange between patient and provider and signal opportunities for applying the Socio-Ecological Model to better understand goals of care communication processes, including opportunities to improve initiation and documentation of goals of care.

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BACKGROUND: Some have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients' families. METHODS: We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012-2017 to look at how the term "suffering" and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached. RESULTS: Of 146 available transcripts, 34 (23%) contained the word "suffer" or "suffering" at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious. CONCLUSIONS: Our results did not support the claim that the term "suffering" and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion.

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BACKGROUND: This study assessed neurological outcomes and variables associated with favorable outcomes in aSAH patients with low functional status (Glasgow Coma Scale [GCS] score ≤8) on postbleed day 7 (PBD7). METHODS: A retrospective analysis was conducted of all patients in the Barrow Ruptured Aneurysm Trial (January 1, 2014-July 31, 2019) treated for a ruptured aneurysm and who had a GCS score ≤8 on PBD7. The primary outcome was a favorable neurological outcome (modified Rankin Scale score ≤2) at last follow-up. RESULTS: Of 312 patients, 63 had low GCS scores at PBD7. These patients had a significantly greater proportion of poor Hunt and Hess scale grades (≥4) (44/63 [70%] vs 49/249 [19.7%], P < 0.001) and poor Fisher grades (grade=4) (58/63 [92%] vs 174/249 [69.9%], P < 0.001) compared to patients who did not have low GCS scores on PBD7, but no differences were found in age, sex, anterior location, aneurysm size, or type of treatment. Of the 63 patients, 7 (11%) experienced a favorable neurological outcome. On univariate analysis, none of the physical examination reflexes predicted a favorable neurological outcome. The middle cerebral artery aneurysm territory was the only significant predictor of a favorable neurological outcome by multivariate analysis (odds ratio, 10.8; 95% confidence interval, 1.16-100], P = 0.04). CONCLUSIONS: This study yielded no significant physical examination findings that predict a favorable outcome in patients with GCS score ≤8 on PBD7. This finding may inform the decision of whether to prolong hospital management or arrange for end-of-life care.

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BACKGROUND: In the United States, disparities persist in end-of-life care outcomes between Black and White nursing home (NH) residents, particularly concerning infection-related management. Timely goals of care (TGOC) discussions are crucial for improving end-of-life outcomes but exhibit racial variations within NHs that are not well understood. OBJECTIVES: Examine the association between the proportion of Black residents within NHs and TGOC discussion related to infection management. DESIGN: A national analysis of palliative care survey data from NHs with the Minimum Dataset 3.0 and administrative data. SETTING/SUBJECTS: 892 NHs representing a weighted sample of 14,981 facilities. MEASURMENTS: TGOC discussions related to infection management were quantified using an index score from the palliative care survey (range: 0-18). Multivariable analyses assessed the association between the proportion of Black residents (≤2%, 2.1%-15%, >15%) and TGOC index scores. RESULTS: The majority of NHs were for-profit, chain-affiliated, urban facilities with fewer than 100 beds, serving both Medicare and Medicaid beneficiaries. In stratified analyses, NHs with 2.1%-15% (-0.97 score; 95%CI -1.86, -0.07; P < .05) and 15% or more Black residents (-3.86 score; 95%CI -6.62, -1.10; P < .01) showed lower TGOC index scores compared to NHs with 2% or fewer Black residents in the West. NHs with 2.1%-15% Black residents had 1.29 lower TGOC index scores compared to NHs with 2% or fewer Black residents (95%CI -2.51, -0.07; P < .05) in the Northeast. CONCLUSIONS: TGOC discussions in US NHs are influenced by the proportion of Black residents, highlighting the need for targeted interventions to address regional disparities and improve end-of-life care equity.

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When the goal is to help patients improve their quality of life, it makes sense to focus directly on the activities and relationships that are most important to each patient. This can be accomplished most effectively by following a three-step process that includes 1) connecting with the patient around what matters to them, 2) co-creating a goal-oriented plan, and 3) collaborating with patient, family, team members, and consultants to increase the probability of success. Once this approach has been mastered and the necessary systems, processes, and relationships are in place, this should not take more time than a problem-oriented approach, and it will almost certainly be more satisfying for both physician and patient. The impact on population-based quality metrics is uncertain. Though fewer patients may choose to follow standard recommendations, those who do may be more likely to adhere to them.

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Objective: The American College of Surgeons recommends structured family meetings (FM) for high-risk surgical patients. We hypothesized that goals of care discussions (GOCD) in the form of an FM, multidisciplinary family meeting (MDFM), or palliative care consult (PCC) would be underutilized in imminently dying thoracic surgery patients. Methods: A retrospective chart review at a tertiary academic medical center was performed on all inpatient mortalities and discharges to hospice after any thoracic surgery operation. The utilization of GOCDs was compared between the 2 groups. Secondary outcomes were length-of-stay, comatose status and ventilator dependence during initial GOCD, and timing of code status change. Results: In total, 56 patients met inclusion criteria: 44 of 56 (78.6%) died and 12 of 56 (21.4%) were discharged to hospice. Most patients had a FM (79.5% mortality vs 100% hospice, P = .29) and few had an MDFM (25.0% mortality vs 25.0% hospice, P = 1.00). Patients discharged to hospice were more likely to have a PCC (66.7% vs 31.2%, P = .03) and less likely to be comatose (16.7% vs 59.1%, P = .009) or ventilator dependent during initial GOCD (16.7% vs 70.5%, P = .001). Among patients who died and were DNR-CC (do not resuscitate-comfort care; 37 of 44), 75.7% died the same day of code status change and 67.6% died within 48 h of initial GOCD. Discussion: Although FMs were common, MDFMs were infrequent. Patients discharged to hospice were more likely to have a PCC. Most deaths occurred shortly after initial GOCD and most code status changes occurred on day-of-death. This data suggest an opportunity to improve GOCDs in critically ill thoracic surgery patients.

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OBJECTIVES: Clinicians in the emergency department (ED) frequently encounter seriously ill patients at a time when advance directives may be pivotal in improved clinician decision-making. The objectives of this study were to identify the prevalence of advanced directives in ED patients, as well as patterns of advance care discussions between patients and providers. This study describes patients' perceptions and expectations of such serious illness discussions in an emergency care setting with the expectation of including patients as strategic members of the care team. METHODS: Trained research assistants in two emergency departments surveyed patients over age 65, or their caregivers, from July 2016 to August 2018. Patients were verbally administered a standard survey tool related to advance directives and advance care planning. RESULTS: 497 out of 877 patients completed surveys (59.4%). 50% of patients reported having an advance care planning document. The large majority (92%) of patients with an advance directive had not been asked about it during their ED visit. When questioned about their personal preferences, 79% of patients thought emergency physicians should be aware of their wishes regarding life-sustaining treatments and end-of-life care. Paradoxically, only 38% expressed a desire to discuss advance care plans with an ED clinician. CONCLUSIONS: Older patients expect emergency clinicians to be aware of their care preferences, yet most are not asked about these care preferences in the ED. The large gap between patient preference and reality suggests the need for more targeted discussion by ED clinicians and translation of patient perspectives into system healthcare improvements. Future studies should explore barriers to advance care planning in the ED as well as patient preferences for these conversations to support a true healthcare learning system.

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BACKGROUND: Timely goals-of-care (GOC) discussions are essential for end-of-life planning, particularly during acute hospital admissions, where ambiguity often persists. Frailty, prevalent in the ageing population and linked to adverse outcomes, underscores the need to align treatment strategies with quality of life. Recognising frailty as a trigger for GOC discussions during rapid response calls (RRCs) is critical for efficient resource management and improving patient outcomes. METHODS: This single-centre retrospective cohort study included all hospitalised patients aged ≥65 years admitted between September 2021 and June 2023 who experienced an RRC. Frailty was assessed using the Clinical Frailty Scale (CFS) during the RRC. The primary outcome was to investigate whether frailty, specifically assessed by the CFS as screened during an RRC, could be a suitable clinical trigger for initiating GOC discussions. We also aimed to identify the proportion of patients with frailty (CFS score: ≥5) and predictors at the time of RRC, resulting in recommendations for GOC discussions. RESULTS: Among 4954 patients, 1685 (34.0%) were classified as frail (CFS score: ≥5). Recommendations increased with frailty levels (nonfrail [CFS score: 1-4]: 6.6%, mildly frail [CFS score: 5]: 19.3%, moderate-to-severely frail [CFS score: 6-9]: 32.2%; p < 0.001). Frailty independently increased the probability of GOC recommendations during an RRC (area under the receiver operating characteristic curve = 0.71). The CFS cut-off point for GOC recommendations was ≥5. The presence of frailty was associated with higher odds of receiving GOC recommendations for mildly frail (CFS score: 5; odds ratio [OR] = 2.53; 95% confidence interval: 1.96-3.27) and moderate-to-severely frail (CFS score: 6-9; OR = 4.69; 95% confidence interval: 3.81-5.78) compared to nonfrail patients. CONCLUSION: Frailty, identified during an RRC, served as a robust trigger for GOC recommendations, highlighting the importance of tailored proactive discussions before episodes of deterioration. Higher levels of frailty (CFS score: ≥5) demonstrate practical markers for aiding clinicians with proactive GOC discussions.

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Cardiopulmonary resuscitation (CPR) outcomes vary for patients with cancer. Here, we characterized cancer patients who underwent CPR in the emergency department (ED), their outcomes, and the effects of advanced care planning (ACP). The hospital databases and electronic medical records of cancer patients at a comprehensive cancer center who underwent CPR in the ED from 6 March 2016 to 31 December 2022 were reviewed for patient characteristics, return of spontaneous circulation (ROSC), conversion to do-not-resuscitate (DNR) status afterward, hospital and intensive care unit (ICU) length of stay, mortality, cost of hospitalization, and prior GOC discussions. CPR occurred in 0.05% of all ED visits. Of the 100 included patients, 67 patients achieved ROSC, with 15% surviving to hospital discharge. The median survival was 26 h, and the 30-day mortality rate was 89%. Patients with and without prior ACP had no significant differences in demographics, metastatic involvement, achievement of ROSC, or in-hospital mortality, but patients with ACP were more likely to change their code status to DNR and had shorter stays in the ICU or hospital. In conclusion, few cancer patients undergo CPR in the ED. Whether this results from an increase in terminally ill patients choosing DNR status requires further study. ACP was associated with increased conversion to DNR after resuscitation and decreased hospital or ICU stays without an increase in overall mortality.

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Rationale: Outpatients with interstitial lung disease often experience serious symptoms, yet infrequently receive palliative care. Objective: To determine the feasibility and clinical impact of a mobile application (PCplanner) in an outpatient setting. Methods: We conducted a pilot randomized controlled trial among adults with interstitial lung disease in a single-center academic clinic. Clinical outcomes included change in Needs at the End-of-Life Screening Tool (NEST) scale between baseline and 3 months as well as frequency of advance care planning discussions and referrals to palliative care services. Results: Observed feasibility outcomes were similar to targeted benchmarks including randomization rates (82.1% vs 80%) and retention (84.8% vs 80%). Mean NEST scores between the intervention and control group were 38.9 (SD, 18.9) vs 41.5 (SD, 20.5) at baseline, 34.6 (SD, 18.9) vs 33.6 (SD, 19.4) at 1 month after clinic visit, 40.5 (SD, 21.6) vs 35.3 (SD, 25.0) at 3 months after clinic visit. Changes in NEST scores between baseline and 3 months showed no difference in the primary outcome (P = 0.481, 95% CI [-8.45, 17.62]). Conclusion: Among patients with interstitial lung disease, a mobile app designed to focus patients and clinicians on palliative care principles demonstrated evidence of feasibility. Although changes in self-reported needs were similar between intervention and control groups, more patients in the intervention group updated their advance directives and code status compared to the control group. Clinical Trial Registration: Palliative Care Planner (PCplanner) NCT05095363. https://www.clinicaltrials.gov/study/NCT05095363.

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BACKGROUND: Cultural competence is important in approaching serious illness communication with diverse patients about goals of care. Culture colors patients' perspectives on many healthcare issues, including end-of-life care, and impacts how clinicians make decisions with patients. Communication about serious neurological illnesses can be additionally challenging due to disease impact on patients' cognition and decision-making abilities. We aim to understand provider experiences regarding cross-cultural serious neurological illness communication with diverse patients and families. METHODS: Using non-stratified purposive and snowball sampling, we conducted semi-structured interviews with 17 multidisciplinary participants, including neurosurgeons, neurologists, and social workers, who provide care for patients diagnosed with serious neurological disorders, at three hospital settings between 2021 and 2022. We used standard qualitative content analysis methods with dual review. RESULTS: Five themes reflected provider perspectives about serious neurological illness communication with diverse patients and families. Theme 1: providers recognize that patients' personal biases and lived experiences impact attitudes about healthcare and communication. Theme 2: challenges in communication can arise when providers miss chances to identify important cultural values. Theme 3: understanding how to engage with family members is important for effective communication about serious neurological illness. Theme 4: providers want to accommodate patients. Theme 5: cultivating trust builds a strong patientprovider partnership, even when racial or cultural discordance is present. CONCLUSIONS: Our study highlights elements of cross-cultural communication and opportunities for providers to approach diverse patients and families within a racial or culturally discordant context. Effective communication, fostered through respecting individual experiences and variation, eliciting cultural perspectives, engaging family, and cultivating trust reflects processes and learned skills required of highquality teams caring for patients with serious neurological conditions.

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RATIONALE: The prognosis of patients with lung cancer admitted to the intensive care unit (ICU) is often perceived as poor. We described the characteristics, management, and outcomes of critically ill patients with lung cancer and determined the predictors of mortality. METHODS: We retrospectively studied patients with lung cancer who were admitted to the ICU of a tertiary care hospital between 1999 and 2021 for the reasons other than routine postoperative care. We noted their characteristics, ICU management, and outcomes. We performed the multivariable logistic regression analysis to determine the predictors of hospital mortality. RESULTS: In the 23-year period, 306 patients with lung cancer were admitted to the ICU (median age = 63.0 years, 68.3% males, 45.6% with moderate/severe functional disability, most had advanced lung cancer, and median Acute Physiology and Chronic Health Evaluation II score = 24.0). Life support measures included invasive mechanical ventilation (47.1%), vasopressors (34.0%), and new renal replacement therapy (8.8%). Do-Not-Resuscitate orders were implemented during ICU stay in 30.1%. The hospital mortality was 43.8% with a significantly lower rate in patients admitted after 2015 (28.0%). The predictors of mortality were moderate/severe baseline disability (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.22, 5.78), advanced lung cancer (OR 8.36, 95% CI 1.81, 38.58), lactate level (OR 1.45, 95% CI 1.12, 1.88, invasive mechanical ventilation (OR 10.92, 95% CI 4.98, 23.95), and admission period after 2015 (OR 0.37, 95% CI 0.16, 0.85). CONCLUSIONS: The mortality rates in patients with lung cancer admitted to the ICU during a 23-year period decreased after 2015. Functional disability, advanced lung cancer stage, vasopressor use, and invasive mechanical ventilation predicted mortality.

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Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making. Herein, we review the role of the ethics consultation in anesthesia practice and special ethic issues encountered by the anesthesiologist.

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Background: Prior studies reveal a lack of illness understanding and prognostic awareness among patients with hematological malignancies. We evaluated prognostic awareness and illness understanding among patients with acute leukemia and multiple myeloma (MM) and measured patient-hematologist discordance. Methods: We prospectively enrolled patients with acute leukemia and MM at Mount Sinai Hospital or Yale New Haven Hospital between August 2015 and February 2020. Patients were administered a survey assessing prognostic awareness, goals of care (GOC), and quality of life. Hematologists completed a similar survey for each patient. We assessed discordance across the cohort of patients and hematologists using the likelihood-ratio chi-square test and within patient-hematologist pairs using the kappa (κ) statistic. Results: We enrolled 185 patients (137 with leukemia and 48 with MM) and 29 hematologists. Among patients, 137 (74%) self-identified as White, 27 (15%) as Black, and 21 (11%) as Hispanic. Across the entire cohort, patients were significantly more optimistic about treatment goals compared with hematologists (p = 0.027). Within patient-hematologist pairs, hematologists were significantly more optimistic than patients with respect to line of treatment (κ = 0.03). For both leukemia and MM cohorts, patients were significantly more likely to respond "don't know" or deferring to a faith-based response with 88 (64%) and 34 (71%), respectively, compared with only 28 (20%) and 11 (23%) of hematologists, respectively. Conclusions: We observed significant discordance regarding prognosis and GOC among patients with hematological malignancies and their hematologists. These data support future interventions to improve prognostic understanding among this patient population to facilitate informed treatment choices.

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BACKGROUND: Do Not Attempt Resuscitation (DNAR) orders allow patients with life-threatening conditions to decline resuscitation efforts should the need arise. The American Society of Anesthesiologists (ASA) recommends discussions with patients on their code status to clarify and honor their goals of care perioperatively. This project sought to determine the prevalence of DNAR orders and to identify the demographics and potential clinical predictors of DNAR status at the beginning and end of admission, which would help anesthesiologists at our center facilitate these discussions. METHODS: Factors associated with DNAR status at beginning and at end of hospital stay were determined through univariate logistic regressions. For DNAR status at beginning and end of hospital admission, variables assessed were age at arrival, race, sex, palliative consult, use of palliative care service, length of stay in days, presence of surgery, presence of emergent surgery, care level, and medical service. RESULTS: Approximately 2.4 percent of the sample had an active DNAR order at the beginning of their hospital admission compared to 7.4 percent at the end of hospital admission. Factors significantly associated with DNAR status at the beginning of the hospital stay were consistent with prior literature (age, palliative care consult or service). However, factors significantly associated with DNAR status at the end of hospital stay that were notable included length of stay, undergoing emergent surgery, higher level of care, and being on the oncology service and medical respiratory intensive care unit. CONCLUSIONS: This retrospective study allows anesthesiologists at our institution to identify patients who may benefit from a more comprehensive perioperative discussion about code status based on certain clinical characteristics, which may improve quality of care by preventing unwanted resuscitative measures that do not align with a patient's goals of care.

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Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups.

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BACKGROUND: Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. METHODS: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. CONCLUSION: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

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BACKGROUND: Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. METHODS: Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. RESULTS: LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. CONCLUSIONS: Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.

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