Impact of COVID-19 on implementation and outcomes of VA's Life-Sustaining TreatmentDecisions Initiative

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Proactive goals of care conversations (GoCCs) conducted in advance of clinical deterioration are a hallmark of high-quality, patient-centered care. When done well, GoCCs allow healthcare providers to tailor end-of-life care to patient values and improve key outcomes for patients, caregivers, providers, and the healthcare system. Given the need for structures and processes to promote GoCCs, the VA National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) at all VA facilities in 2018 to promote standardized documentation of GoCCs for Veterans at high risk of clinical deterioration. As of early 2020, proactive GoCCs remained vastly underutilized. The onset of the COVID pandemic reinforced the need for and importance of GoCCs to guide end-of-life care, acting as a catalyst for innovations to LSTDI implementation. In response to the pandemic, guidelines and lay media instilled a new urgency among patients and providers to proactively discuss and document GoCCs. Many sites both within and outside of VA developed innovations to facilitate proactive GoCCs, including outreach to high-risk patients (e.g., those with dementia), holding GoCCs by telehealth (a new modality for these sensitive discussions), and tasking and training outpatient providers previously unreached by the LSTDI with conducting GoCCs. [At least 40 VA facilities have increased outpatient GoCCs in 2021 compared with pre-pandemic rates.] [Yet it remains unknown how these sites increased and maintained GoCC rates, or whether COVID-catalyzed LSTDI implementation innovations improved GoCC rates at the expense of GoCC quality or equity. Our hypothesis is that some facilities prioritized outpatient LSTDI implementation during the pandemic, achieving sustainable increases in both reach and quality of GoCCs without exacerbating disparities in GoCCs among Black Veterans. From close evaluations of LSTDI implementation at selected sites, we will identify sustainable innovations catalyzed by the pandemic that can be spread across VA to improve LSTDI implementation and delivery of high-quality, equitable, patient-centered end-of-life care, even after the pandemic recedes.] Our sequential explanatory mixed methods study is designed to [comprehensively assess the long-term impact] of the COVID pandemic on LSTDI implementation and the frequency, quality, and equity of GoCCs. We begin with time series analyses to examine how COVID affected LSTDI implementation across VA facilities, with attention to [sustained] changes in reach to Veterans and adoption by providers (Aim 1). We will then leverage time series and proportional hazard analyses to assess quality and equity of outpatient GoCCs, as determined by documentation of National Quality Forum preferred practices in LSTDI notes (Aim 2a), and length of time from GoCC to death, a marker of proactive advance care planning (Aim 2b). Finally, in Aim 3, we will interview Veterans, providers, and leaders from [10] sites purposively selected based on Aims 1 and 2 findings to identify best practices to improve [and maintain frequency, quality, and equity of GoCCs, with special attention to approaches to engage Black Veterans and patients with dementia]. Findings will inform a playbook to improve quality, equity, and sustainability of LSTDI implementation. The changes wrought by the pandemic to VA healthcare delivery created an unprecedented opportunity to identify innovations, challenges, and unintended consequences in implementing the LSTDI, as well as outcomes of GoCCs on quality and equity of end-of-life care delivered before, during, and after COVID. This study is designed to leverage the unique circumstance and sense of urgency created by the pandemic and will produce a usable deliverable: an implementation playbook capturing best practices and innovations catalyzed by the pandemic. This work is strongly supported by our partners in the National Center for Ethics in Health Care and the Office of Primary Care to help spread the LSTDI, and it is of central importance to achieving the VA mandate to conduct GoCCs to improve the quality, equity, and patient-centeredness of end-of-life care.