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VA Maryland Health Care System


LSTDI: Launching Tough Conversations

Training for the LSTDI initiative.

Social worker Jean McHale and nurse Helen Hart are training social workers, psychologists, nurses, and chaplains, to ask patients about their preferences and goals for future medical care in the event they lose capacity to decide for themselves.

Friday, August 10, 2018

Have you had that difficult conversation with your loved ones about what you would want to happen if you were to lose capacity to make your own health care decisions? If you have, did you document your decision and has it been updated? Without these decisions documented in Advance Directives, your fate is in the hands of others.  Because having Advance Directives is not yet the norm, many decisions for patients who have lost capacity to decide for themselves are routinely made during a health care crisis. The VA Maryland Health Care System wants to change that. Armed with the Life Sustaining Treatment Decisions Initiative (LSTDI) the VA Maryland Health Care System is educating clinicians, Veterans, and their families about Advance Directives and end-of-life decisions, encouraging them to make actionable plans before the onset of serious or life-threating illness.

“If you are over 18 years old, you should have Advance Directives in place,” said Dr. Debra S. Wertheimer, director of Hospice and Palliative Care at the VA Maryland Health Care System who is leading the initiative across the VA Capitol Health Care Network (VISN 5) facilities, including Maryland’s and the VA health care systems in Washington DC, Martinsburg, Clarksburg, and Beckley W.Va. “Without Advance Directives in place, your surrogates may not always know what you want for yourself.”

Dr. Preeti John, director of Surgical Palliative Care Services, is leading the LSTD Initiative at the VA Maryland Health Care System. She and Wertheimer are working to increase awareness about this initiative and train clinicians (physicians, NPs and PAs) on how to begin these tough conversations with their patients. Social worker Jean McHale and nurse Helen Hart are training social workers, psychologists, nurses, and chaplains, to ask patients about their preferences and goals for future medical care in the event they lose capacity to decide for themselves. The focus is ensuring that Veterans participate in these discussions and understand the importance of having three documents at the ready:

  • First, the Advance Directives document, which travels with the patient and outlines preferences and goals in regard to future medical treatment options and also names a surrogate decision- maker in the event of lost decision-making capacity;
  • Second, Life Sustaining Treatment Decision orders that allow this difficult conversation between clinicians and practitioners and patients to become part of the patients’ notes in the VA electronic health records where it’s easily accessible when needed, and it will be followed;
  • Third, the Maryland Orders for Life-Sustaining Treatment form, or MOLST. “None of these expire and all have to be actively changed when goals and preferences change.  The LSTD note does not travel outside of the VA system,” Wertheimer said.

“This new LSTD initiative also empowers the Veteran to make their own decisions, based on their personal beliefs and values about life,” said Helen Hart, a nurse educator.

“Without documentation, family members might insist on measures that are not clinically sound, or they want to keep their loved one alive no matter what for as long as possible for reasons that have nothing to do with the patient’s medical condition,” said Christopher Buser, chief of Social Work at the VA Maryland Health Care System.  “For those individuals who have no relatives, no close friends, who are alone, documentation gives clinicians a clear idea of what this person would want for him or herself,” Buser added, noting that that health care systems must petition the courts to appoint a surrogate decision-maker for the patient without Advance Directives and relatives or even close friends. “There’s a hierarchy of who can be appointed, and for those without living relatives or close friends, the court often appoints a third party to serve as a surrogate decision-maker.”

Promoting personalized, proactive, patient-drive care by helping Veterans document their wishes long before a medical crisis is the aim of the LSTD Initiative. The process allows patients to reflect about their experiences, values, desires, goals and preferences and to talk to their family members or friends whom they want as their surrogate decision-makers. Once those conversations are completed, patients will then be equipped to take action by sharing those preferences and goals with their health care providers. The LSTDI team stresses that the discussion of values and goals of care, of wishes, preferences, and desires is an ongoing process, and that the documents ought to be revisited each time a life-changing milestone-- such as marriage, divorce, and births-- takes place. The documentation simply provides patients, family members, and health care providers with the needed communications about wishes, preferences, goals, and desires when one is no longer able to speak for oneself.

This is not a conversation only for elderly people or only for those with chronic illness because health can decline at any time and in any number of unexpected ways from car crashes to sporting accidents and other activities that cause unintentional injuries. Advance Directives, the LSTD notes, and the MOLST communicate preferences, goals, desires, and wishes when one can’t. Yet, despite the availability of Advance Directive and MOLST forms, John said only about 38 percent of adults and only 38.2 percent of people with chronic illnesses in the U.S. have completed any of the documentation, and thus, many families find themselves having intense emotional discussions after loved ones have lost capacity to make their own decisions.

Have you had that difficult conversation with your loved ones and health care providers about what your health goals would be if you lose the capacity to make your own decisions? If not, veterans are urged to bring it up next time you they see their health care providers at the VA.


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