Improving Life-Sustaining Treatment Discussions and Order Quality in a Primary Care Clinic
Background
Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”1 Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.2 Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).
Aim
The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.
Methods
The Model for Improvement was used for this quality improvement project.3 One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.
Results
Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.
Conclusions
We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.