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Resources for Clinical Staff Caring for High-Risk Patients



This page contains information and resources to support VA clinical staff who are involved in caring for high-risk patients, conducting goals of care conversations, and honoring patients’ life-sustaining treatment decisions.

The Life-Sustaining Treatment Decisions Initiative

LSTDI Video  – Featuring staff from VA LSTDI Demonstration Sites in Madison, Salt Lake City, Black Hills, and North Chicago (Lovell), this short video highlights new practices and how they enhance patient-centered care for patients with serious illness.  (13:33)

LSTDI Online Module - Provides an overview of the initiative, including new practices for conducting proactive goals of care conversations with high-risk patients and documenting those discussions in a new progress note template and order set.  Addresses questions frequently asked by clinical staff about how new processes will impact their practice.  NOTE: This program will be offered through TMS and is accredited for physicians, APRNs, PAs, nurses, social workers, and psychologists. 

LSTDI Overview PowerPoint – Provides basic information about the initiative.  For more complete information, see the online module above.

Podcast: Differences Between Life-Sustaining Treatment Orders and Advance Directives – Provides information for clinical staff about the ways in which Life-Sustaining Treatment Orders, which are completed by practitioners, are different than advance directives, which are completed by patients. Features staff at VA LSTDI Demonstration Sites (08:37).

Proactively Identifying High-Risk Patients

Identifying High-Risk Patients PowerPoint – Provides information about a tool that helps identify high-risk patients who may be candidates for goals of care conversations, available through a panel management software program for VA Primary Care Teams (Patient Care Assessment System (PCAS)].  This tool can be used to proactively identify high-risk patients, assign tasks to team members, and monitor completion of goals of care conversations in primary care.

Preparing High-Risk Patients (or Their Surrogates) for Goals of Care Conversations

Setting Health Care Goals: A Guide for People with Health Problems – Handout for patients and surrogates that explains the nature and purpose of goals of care conversations, helping prepare them for a discussion about the patient’s goals and life-sustaining treatment decisions. 8.5"x11”, large font, six pages.  Podcast version is also available.

Information about Life-Sustaining Treatments – Handouts for patients and surrogates about common life-sustaining treatments.  8.5”x11”, large font.

Feeding Tubes – four pages
Dialysis – six pages
CPR – four pages

An Informational Booklet that includes both Setting Health Care Goals and Information about Life-Sustaining Treatments can be ordered by VA staff free of charge in multiples of 25. Instructions are found here. This booklet is also available for direct download – 26 pages, 8.5” x 11”, large font.

Conducting Goals of Care Conversations

Goals of Care Conversations Pocket Card for Physicians, APRNs, and PAs – Outlines the steps for conducting a conversation with patients (or surrogates) about the patient’s values, goals, and life-sustaining treatment decisions.  Four pocket cards per 8.5” x 11” page; can be printed, laminated and then cut into individual pocket cards.

Goals of Care Conversations Worksheet for Physicians, APRNs, and PAs – Outlines the steps for conducting a conversation with a patient (or surrogate) about the patient’s values, goals, and life-sustaining treatment decisions, and includes space for taking notes during the conversation.  Two pages, 8.5” x 11”.

Introduction to Eliciting Values, Goals, and Preferences when Patients Have a Serious Illness – Online presentation designed for social workers, nurses, psychologists, and chaplains who care for patients with serious illness.  Addresses issues related to conducting goals of care conversations (GOCCs), including  proactive identification  high risk patients, the steps involved in conducting a GOCC, and documenting these conversations in the electronic health record.  NOTE:  This program is offered through TMS and is accredited for physicians, APRNs, PAs, nurses, social workers, and psychologists. The PowerPoint associated with this program is available for review here without continuing education credit.

Team-Based Approaches to Eliciting Values, Goals, and Preferences when Patients Have a Serious Illness – Online presentation that addresses steps health care teams should take to successfully implement goals of care conversations in their clinics.  Features innovative team-based models used in Madison, Salt Lake City, and Brooklyn VA facilities.  NOTE:  This program is offered through TMS and is accredited for physicians, APRNs, PAs, nurses, social workers, and psychologists. The PowerPoint associated with this program is available for review here without continuing education credit.

Advance Care Planning and Advance Directives, Goals of Care Conversations and Life-Sustaining Treatment Decisions, State-Authorized Portable Orders: How Do These Pieces Fit Together to Elicit and Document Patient Treatment Preferences? – Online presentation designed for social workers who care for patients with serious illness (also appropriate for other clinicians who care for patients with serious illness). This addresses VA policies on eliciting and documenting patient treatment preferences, the difference between advance directives, life-sustaining treatment orders, and state-authorized portable orders. It also addresses key progress note titles for documenting patient treatment preferences, and activities that are within scope and out-of-scope for VA social workers in advance care planning and goals of care conversations with Veterans. NOTE: This program is an Adobe Connect recording of the July 25, 2017 VA Care Management and Social Work training call and is not accredited. The PowerPoint associated with this program is available for review here.

Video: Conducting a Goals of Care Conversation with a Patient – Video of a practitioner conducting a goals of care conversation with a patient who has a serious life-limiting illness. (20:20)

Goals of Care Conversations Sim LEARN Module – Avatar-based communication skills training for practitioners who conduct goals of care conversations with patients with serious illness.  NOTE:  Use of this module is currently only available on the VA network and requires downloading Unity Web Player software. VA staff can download the software with the help of IT staff in just a few minutes.  A preview of the module is available for both VA and non-VA viewers (0:41).

Goals of Care Conversations Skills Training for Physicians, Advance Practice Nurses, and Physician Assistants – This face-to-face training program builds communication skills of practitioners who care for patients with serious illness.  Includes training in delivering serious news, conducting goals of care conversations, and making shared decisions with patients and surrogates about life-sustaining treatment. You can find course materials here.

Goals of Care Conversations Training for Nurses, Social Workers, Psychologists, and Chaplains - This face-to-face training for clinicians who care for patients with serious illness builds communication skills around discussing the patient’s goals, values, surrogate, and preferred treatments and services.  Includes training in team-based strategies for routinely identifying high-risk patients and completing goals of care conversations. You can find course materials here.

Reviewing Existing Life-Sustaining Treatment Orders

Pocket Card: Reviewing Life-Sustaining Treatments Orders (Including DNR) Prior to Procedures – Outlines the steps for reviewing and changing existing life-sustaining treatment orders with patients (or surrogates) prior to procedures involving general anesthesia, initiation of hemodialysis, cardiac catheterization, electrophysiology studies or any procedure that poses a high risk of serious arrhythmia or cardiopulmonary arrest.  Four pocket cards per 8.5” x 11” page; can be printed, laminated and then cut into individual pocket cards.

Multidisciplinary Committee Review Process: Life-Sustaining Treatment (LST) Plans for Patients Who Lack Decision-Making Capacity and Have No Surrogate

Flowchart: Establishing Life-Sustaining Treatment (LST) Plans for Patients Who Lack Decision-Making Capacity, Have No Surrogate, and Have No Active LST Orders – This flowchart maps out the decision-making process to establish LST plans for patients who lack decision-making capacity, have no surrogate, and have no active VA LST orders.

Monitoring Completion of Goals of Care Conversations

The LST Facility Report, available through the VHA Support Services Center (VSSC) website, allows VA facilities to track the number and location of goals of care conversations conducted with high risk patients across all clinical settings, based on completion of the Life-Sustaining Treatment Progress Note.  This report helps facilities monitor implementation of VHA Handbook 1004.03 and conduct quality improvement projects.  Information about the report can be found in the Data Definitions document. The link to view all reports is available here. NOTE:  General data in the LST report is accessible to all VA staff.  Approval is required to view data in the report that includes PHI.

National VA Policy

VHA Handbook 1004.03, Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences - Standardizes practices in VA with respect to conducting and documenting goals of care conversations with high-risk patients.  Includes policy for determining life-sustaining treatment plans for patients without decision-making capacity who have no surrogate, resolving conflicts related to life-sustaining treatment, conscientious objection, naturally administered nutrition/hydration, and VA’s prohibition against assisted suicide and euthanasia.  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 [January 11, 2017] to implement the policy.

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.

Additional Resources

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 Application Coordinators/Health Informatics Specialists Installing LST Tools in CPRS (only available 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 vhaethics@va.gov.