Fargo Veterans Administration Medical Center Description

The Veterans Administration is an academic, non-profit, federal agency, with hospital, clinic and community living center beds within the facility. There are approximately 59 acute care beds and 50 community center living beds.

Program Description

The Advanced Care Planning (ACP), under the umbrella of Palliative Care, consists of a multi-disciplinary team that works with the veteran and his/her family to address physical, social, emotional and spiritual issues that arise during the end of life period. Each discipline of the ACP team serves as a support resource to the veteran and their family. A preset minimum number of visits from each discipline are scheduled with the veteran in addition to existing clinical appointments. A minimum of seven ACP visits are scheduled per veteran with individuals from the specific disciplines, including nurses, physicians, physician assistants, occupational therapists, chaplains, social workers and dietitians.

These interactions enable the ACP team to assist the veteran from the point of diagnosis with a life-threatening illness to the end of life. A variety of quality indicators are measured and assessed on a continuous basis throughout the duration of each patient's involvement in the program.

The indicators selected were common treatment choices and interventions addressed when caring for someone in an end of life situation.

Description of Topic

As a pilot project, we limited our ACP services to veterans with stage IV cancer. After 6 months of implementing the program, the ACP program was further examined to determine whether ACP services translated to improve quality of care at end of life for any veteran. Twelve specific indicators were used to compare treatment choices and medical outcomes of veterans with stage IV cancer who were enrolled in ACP services and veterans with stage IV cancer who died prior to the program's inception.

The selected indicators represented common end of life care choices and interventions. Indicators included: DNR, scheduled narcotic and laxative for pain and symptom management, pain score, advanced directives, hospice referral, ICU utilization, interdisciplinary visits, feeding tube, IV hydration, and acute care admissions. Six of these items were found to be significantly different between the two groups.

Impact on Program

Our results indicate that end of life care for veterans was significantly improved by implementing the Advanced Care Planning program. Study findings underscore the importance of providing specialized, patient centered care to veteran's facing end of life issues. Following completion of this study, additional multi-disciplinary team members have been hired.

Lessons Learned/ Results

1. In our chart review, the highest pain scores were found with veterans in the ICU.
2. All veterans both in usual care and in ACP were given chaplain and social work visits, demonstrating the comprehensive care given to the veteran.
3. DNR orders were clarified earlier for veterans with ACP, inferring that the ACP veteran may have been better prepared for the inevitable event of death.
4. ACP veterans were referred to hospice more often than veterans who did not have Advanced Care Planning (ACP.)
5. Those with ACP had more advanced directive completion than the "usual care" veteran facing end of life.
6. The ACP veteran had routine, round the clock scheduled pain and laxative medication; this method is preferred for the chronic pain and constipation associated with advanced cancer.