Increasing Goals of Care Discussions Among Veterans with Cirrhosis: A Veterans Health Administration Quality Improvement Initiative

BACKGROUND AND AIMS: Goals of care discussions (GCDs) are recommended for patients with cirrhosis but rarely conducted. Since 2017, the Veterans Health Administration (VA) has provided a standardized note template that clinicians can use to document GCDs for Veterans with serious illness. We aimed to quantify the frequency and timing of GCDs in this population, along with the factors associated with GCDs and their content. METHODS: This retrospective cohort study identified Veterans with cirrhosis from January 2017 to July 2022 and captured GCDs until July 2023. We assessed the association between demographics, clinical factors, use of health services, and GCD documentation. We also examined contents of completed GCDs, time from GCD completion to death, and changes in GCD documentation rates following targeted quality improvement (QI) initiatives from May 2020 to May 2023. RESULTS: By July 2023, 29.8% of 167,727 Veterans with cirrhosis had a completed GCD. GCD completion was significantly associated with palliative care consultation (OR=3.86 95% CI: 3.69-4.03), liver-related hospitalization (OR=3.27, 95% CI: 3.08-3.46), decompensated disease (OR=2.27, 95% CI: 2.20-2.33), and higher Charlton Comorbidity Index (OR=1.22, 95% CI: 1.17-1.26). GCD completion improved from 0.4% to 21.2% from May 2020 to May 2023 following targeted QI initiatives. Among those with completed GCDs, median time between first GCD and death was 37 days. Surrogate decision making (71.8%) and goals of care (64.9%) were common elements, but only half of Veterans were considered to have sufficient illness understanding (52.5%). CONCLUSION: GCD documentation increased over time in the context of targeted QI initiatives. Future interventions should be conducted earlier and address illness understanding.