The VA Life‐Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease

BACKGROUND: Documentation of patients' goals of care is integral to promoting goal‐concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system‐wide initiative to standardize documentation of patients' preferences for life‐sustaining treatments (LST) and related goals‐of‐care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care. METHODS: We performed a qualitative analysis of documentation in the VA electronic medical record for a national random sample of 500 adults with advanced kidney disease for whom at least one LST note was completed between July 2018 and March 2019 to identify prominent themes pertaining to the content and context of LST notes. RESULTS: During the observation period, a total of 723 (mean 1.5, range 1–6) LST notes were completed for this cohort. Two themes emerged from the analysis: (1) Reactive approach: LST notes were largely completed in response to medical crises, in which they focused on short‐term goals and preferences rather than patients' broader health and goals, or certain clinical encounters designated by the initiative as “triggering events” for LST note completion; (2) Practitioner‐driven: Documentation suggested that practitioners would attempt to engage patients/surrogates in GoCC to lay out treatment options in order to move care forward, but patients/surrogates sometimes appeared reluctant to engage in GoCC and had difficulty communicating in ways that practitioners could understand. CONCLUSIONS: Standardized documentation of patients' treatment preferences and related GoCC was used to inform in‐the‐moment decision‐making during acute illness and certain junctures in care. There is opportunity to expand standardized documentation practices and related GoCC to address patients'/surrogates' broader health concerns and goals and to enhance their engagement in these processes.