National Center for Ethics in Health Care
The Life-Sustaining Treatment Decisions Initiative
The Life-Sustaining Treatment Decisions Initiative (LSTDI) is a national VHA quality improvement project led by the National Center for Ethics in Health Care (NCEHC). The aim of the initiative is to promote personalized, proactive, patient-driven care for Veterans with serious illness by eliciting, documenting, and honoring their values, goals, and preferences. The initiative involves a new national policy to standardize practices related to discussing and documenting goals of care and life-sustaining treatment decisions, and the tools, resources, education, and monitoring to support clinicians and facilities in making practice changes.
NOTE: See the Additional Resources links at the bottom of the page to find materials for clinical staff, Clinical Applications Coordinators, and those who are implementing this initiative in their facilities.
While the practices promulgated through the Life-Sustaining Treatment Decisions initiative have been widely endorsed by experts as the standard for high quality care (such as the National Academy of Medicine, the National Quality Forum, the American College of Physicians, and the Hastings Center), VA is the first health care system in the world to develop and implement practices and related tools across the health care system, setting a new standard for discussing and documenting treatment decisions with high risk patients. The new practices and tools now released for use in all VA health care systems were extensively tested in four VA sites: Salt Lake City, Black Hills, Madison, and Lovell Federal Health Care Center in North Chicago. These demonstration sites have played a crucial role in shaping the VHA policy and improving the resources to support it. One of the key lessons learned from the demonstration sites is that leadership direction and support is essential in ensuring staff education and successful adoption of new practices.
Please view the video, “Leading the Way on the Life-Sustaining Treatment Decisions Initiative,” to learn about the demonstration site experience.
For more information on specific elements of the LSTDI and supporting materials, please see below.
- VHA Handbook 1004.03, Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences, was published on January 11, 2017. It reflects the input of many clinical stakeholders to ensure that new practices support patient-centered care and can be accomplished efficiently by clinical staff. Facilities have 18 months from the date of publication to implement the policy.
- VHA Handbook 1004.03 replaces VHA Handbook 1004.3, Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs (VA).
- For policy resources related to VHA Handbook 1004.03, including a Medical Center Memorandum template, FAQs, and a crosswalk between VHA Handbook 1004.3 and VHA Handbook 1004.03 template, go to the NCEHC Policy webpage.
National Standardized Life-Sustaining Treatment Progress Note Template and Order Set
- As part of the LSTDI, a national progress note template and order set have been developed to document patients’ values, goals and preferences regarding life-sustaining treatments in the electronic health record. Use of the national progress note and order set is required by VHA Handbook 1004.03. Therefore, VA facilities should not develop a local progress note or order set to document this information. For resources related to the national standardized progress note template and order set, including a step-by-step installation guide and a schedule of installation support calls, see Additional Resources for Clinical Application Coordinators/Health Informatics Specialists Installing LST Tools in CPRS (only accessible behind VA firewall).
Frequently Asked Questions (FAQs)
The National Center for Ethics in Health Care has developed Frequently Asked Questions (FAQs) to support VA health care facilities and clinical staff with local development, deployment and implementation of the Life-Sustaining Treatment Decisions Initiative.
For Health Care Facilities Implementing the Life-Sustaining Treatment Decisions Initiative – Includes a step-by-step Implementation Guide, a monitoring tool, a schedule of implementation support teleconferences, and other resources to support implementation of new practices outlined in VHA Handbook 1004.03.
For Clinical Staff Caring for High-Risk Patients – Includes a wide range of tools and educational resources to support clinical staff in conducting goals of care conversations and documenting these discussions in the electronic health record.
For Clinical Application Coordinators/Health Informatics Specialists Installing LST Tools in CPRS (only accessible behind VA firewall) – Includes a step-by-step Installation Guide for the national standardized Life-Sustaining Treatment progress note template and order set, and a schedule of installation support teleconferences.
For questions regarding the LSTDI, please review VHA Handbook 1004.03, FAQs, and related materials on this site. If these don’t answer your question, please contact firstname.lastname@example.org.