Improving Inpatient Life Sustaining Treatment Documentation at the Orlando VA

From the 2022 HVPA National Conference

Michael Stewart DO (University of Central Florida HCA Healthcare GME, Greater Orlando, Florida), Jomaris Centeno Girona MD, Lahari Tumuluri MD, Patrick Abou Jaoude MD, Muhaimeen Hossain DO, George Alvarez DO, Ashwini Komarla MD, Joshua Shultz MD


As the United States population ages, early identification and proper documentation of goals of care (GOC) is of utmost importance. Early GOC discussion can improve patient’s quality of life, while respecting patient’s wishes, decreasing patient suffering, avoiding ethical dilemmas, and reducing healthcare expenditure. Part of the challenge is the inability to identify high risk populations that would benefit from early GOC conversations including code status, transfusion, dialysis, intubation, and then documentation of these wishes via Life Sustaining Treatment (LST) note. The surprise question has been proposed as a useful high risk identification tool by answering “would I be surprised if my patient died within the next 12 months?”. It has been proposed to aid in identifying those patients that would benefit from palliative care.


Our objective is to increase resident physician’s ability to identify high risk patients and increase GOC documentation using the inpatient LST note by 50% by July of 2022.


Deidentified patient data was collected from Orlando VA Medical Center Admission Tracker during February 2021 to April 2022. This was reviewed monthly to gather data for the studied population that included all patients admitted during this time to resident teams. Exclusion criteria were all patients from non-resident teams and those that passed away.

Data collected from patients’ charts included LST notes during prior 12 months, LST done during current admission, presence of high-risk conditions or end stage chronic diseases, Age>80, and author evaluation of the patient via the medical record to determine a “yes” or “no” response to the surprise question.

A survey was created to assess the residents’ knowledge regarding GOC conversation, LST note documentation, and ability to identify high risk patients. Based on the survey results, interventions targeting resident physicians were implemented to improve outcomes. Interventions included education on identification of high-risk patients, proper completion of an LST note though senior resident lead teaching, palliative care attending-led lectures, fliers, and QR code placed on a lanyard that provides a link to LST note required documentation and identification of high risk patients.

Data was analyzed using run charts with rate of LST notes completed over time and LST notes completed on high-risk patients over time.


Pre-intervention survey results of postgraduate year 1-3 showed that greater than 50% of residents did not feel comfortable completing LST notes, and 15% did not know what these notes were. Pre-intervention data showed LST notes were done in 35% of total patients and 54% of those deemed high risk. After interventions were implemented, LST note completion rates peaked at 76.5% with 52% completed in high-risk patients.


Proper documentation and completion of GOC discussion using LST notes were deficient in pre-intervention data. Through education, time management strategies, and team-based multidisciplinary teaching, LST note completion rates doubled. With proper education and increased team motivation, there is the ability to improve proper documentation of a patient’s wishes. There is an opportunity for further growth by identifying high-risk patients and working to increase the rate of adequate LST note completion in these at-risk patients.

Clinical Implications

Increasing rates of GOC discussion has the prospect to decrease patient suffering and align more closely with their values. Improving resident physician comfort with these conversations and learning proper documentation has the potential to enhance patient care and resident education.

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