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National Center for Ethics in Health Care


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Implementing New Practices: Resources for Health Care Facilities

This page contains information and resources to support facilities in implementing the new practices outlined in VHA Handbook 1004.03, Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences, published on January 11, 2017.  VA facilities have 18 months from the date of publication to implement new practices.

LSTDI Implementation Guide for Facilities

This step-by-step guide contains information and resources necessary to successfully implement the Life-Sustaining Treatment Decisions Initiative (LSTDI), including new practices required by Handbook 1004.03.


  • Strategies for successfully gaining leadership and key stakeholder support
  • Educational resources to prepare staff for practice changes
  • Tools for tracking implementation of goals of care conversations with high-risk patients
  • Videos, checklists, timelines, and many other helpful resources

Communications Tools for Facilities

Leading the Way on the Life-Sustaining Treatment Decisions Initiative - short video featuring staff from VA LSTDI demonstration sites, highlighting new practices and how they enhance patient-centered care for patients with serious illness. This video is a useful tool for introducing key stakeholders to the initiative. (13:33) 

Facility Director Letter - template text from facility director describing how the facility is implementing LSTDI and what it means for Veterans. For use in newsletters, email blasts, and other communications.

Nursing Director Letter - template text from facility director of nursing describing the role of the nursing staff in implementing LSTDI and what it means for Veterans. For use in newsletters, email blasts, and other communications to nursing staff.

Implementation Support Teleconferences

Monthly teleconferences are offered to support VA facilities in implementing the Life-Sustaining Treatment Decisions Initiative.  The teleconferences are designed to walk through the implementation process step-by-step, and provide opportunities for facilities to share successful strategies with one another.

Policy Development Tools

NEW! The Model LST MCM was created to help VA medical facility personnel develop local facility policy that is consistent with VHA Handbook 1004.03.

The Crosswalk of Policy Changes describes the major differences between old and new requirements. 

Monitoring Implementation

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.

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.

Facility LSTDI Implementation Coordinators

LSTDI Implementation Coordinators are responsible for managing processes related to implementation of VHA Handbook 1004.03, with the assistance of facility leadership and other key stakeholders.   Implementation Coordinators will be supported by staff at the National Center for Ethics in Health Care through monthly teleconferences and ad hoc consultation.

Additional Resources

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 (accessible only 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