Background: VA implemented the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document, and honor the values, goals, and preferences of Veterans with serious illness. The National Academy of Medicine recommends, and patients and families prefer goals of care conversations (the foundation of the LSTDI) occur when they are not acutely ill in the outpatient setting. However, across VA nationally, most goals of care conversations occur in the inpatient setting close to death; only 39% occur in the outpatient setting. Significance/Impact: This study will identify strategies to improve LSTDI implementation in the outpatient setting. This is significant to Veterans because it ensures they can express their goals and preferences for life sustaining treatments and have them honored. Two VA Secretary priorities are addressed: (1) the goal to provide “clear information to make informed decisions” about life-sustaining treatments, and (2) the goal for Veterans to receive “care and support… that emphasizes their well-being and independence throughout their life journey.” This proposal addresses the R&D goal to increase real-world impact of VA research by understanding how to improve implementation of a national VA policy. Alignment with HSR&D priorities is described in the proposal. Innovation: The proposal uses an innovative study design, a sequential multiple assignment randomized trial (SMART). The combination of patient-facing and provider-facing implementation strategies, deemed important in our preliminary studies, is also innovative. Finally, we take a population-based approach to understand the implementation of goals of care conversations in seriously ill Veterans with serious non-cancer illnesses including heart failure and chronic pulmonary, renal, and kidney diseases. Specific Aims. Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers. Methodology: Study sites include the VA Eastern Colorado, Greater Los Angeles, and Palo Alto Health Care Systems. We will target clinicians with low rates of goals of care conversations among Veterans with medical illness in the top 10th percentile of risk of hospitalization or death. We will first test less resource intensive strategies, and subsequently randomize PACT teams with continued low rates of conversations to either an increased intensity of the current strategy or more time with the current strategy. Data will be collected from the VA Corporate Data Warehouse (Aims 1 and 2) and patient, caregiver, and clinician interviews or surveys (Aims 2 and 3). Data will be analyzed using qualitative and quantitative methods. Next Steps/Implementation: Study findings will be disseminated in collaboration with our operations partners (National Center for Ethics in Health Care, Primary Care, Palliative Care). Our partners can implement policies based on study findings to increase early, outpatient implementation of the LSTDI.

VA developed the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document, and honor the values, goals, and preferences of Veterans with serious illness. The LSTDI is important to Veterans because it ensures they can express their preferences for life sustaining treatments (e.g., cardiopulmonary resuscitation, breathing machine, artificial nutrition) and have them honored. However, across VA nationally, only 39% of LSTDI conversations occur in the outpatient setting; the majority occur in the inpatient setting often close to death. At this late stage, Veterans are often not able to make their preferences known because they are so ill. Decisions fall to surrogates who may be uncertain about what the Veteran would have wanted. This study will examine ways to increase LSTDI conversations among Veterans and their health care providers earlier in illness in the outpatient setting.