Date of Award

Spring 5-25-2024

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Katie Lais, DNP, PMHNP-BC

Second Advisor

Joseph Burkard, DNSc, CRNA, AACN

Third Advisor

DNP, APRN, PMHNP-BC

Abstract

Abstract

Introduction: This Doctor of Nursing Practice project aimed to enhance the knowledge and confidence of the San Diego Veterans Health Administration’s (VASD) Intensive Care Unit (ICU) medical providers in goals-of-care discussions (GOCD). Additionally, this project aimed to improve the documentation of these discussions.

Background: Delays in GOCD can lead to futile medical and surgical interventions, inappropriate antibiotic use, and higher rates of mental health conditions in patients and their loved ones. Earlier GOCD are associated with lower ventilation and resuscitation rates, earlier hospice enrollment, reduced ICU admissions, lower financial costs, and better patient and caregiver quality of life. However, medical providers caring for patients in VASD and other hospital settings are often underprepared or hesitant to facilitate GOCD. As a result, these discussions are frequently delayed and documented inconsistently.

Methods: This project implemented three education sessions on an evidence-based standardized tool for facilitating GOCD to 14 physicians within their first five postgraduate years. Participants were then instructed to use the tool with every admitted patient and document GOCD in a life-sustaining treatment (LST) note. Pre- and post-implementation surveys containing the Advanced Care Planning Self-Efficacy scale (ACP-SE) were administered. The frequency of LST was recorded for the three months before and during training.

Results: Pre-survey data showed an average ACP-SE score of 3.23 out of 5, with 5 indicating the highest provider GOCD self-efficacy rating. Half of those surveyed reported having received no prior training in GOCD. The post-survey ACP-SE average was 4.54; however, four out of the 14 participants completed the post-survey. LST note documentation in the ICU began at 16.9% of total admissions and increased by 1% during the project.

Evaluation: New medical providers at the VASD ICU may benefit from additional education and practice in GOCD. Moreover, on-site peer champions, financial incentives, and supervisory involvement may optimize post-survey data collection and LST documentation. Provider self-efficacy with and documentation of GOCD at the VASD ICU may benefit from further quality improvement projects, documentation policy updates, and evidence-based education interventions.

Keywords: advance care planning, education, goals of care, self-efficacy, life-sustaining treatment, intensive care unit

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