Barriers Identified for Veterans in Nursing Homes Planning Goals of Care

Nursing home (NH) residents, including veterans receiving care in Veterans Affairs (VA)-paid community nursing homes, have low rates of completion for structured goals of care conversations and documenting life-sustaining treatment preferences despite evidence that these steps can improve the delivery of goal-concordant care. 

Researchers conducted semi-structured qualitative interviews with stakeholders involved with the Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program to understand the unique barriers and facilitators of completing and documenting goals of care conversations. 

Between July 2021 and July 2022, key stakeholders across 6 VA Medical Center community NH programs were interviewed. Transcripts were subsequently converted into memo templates using the Tailored Implementation for Chronic Disease Checklist and analyzed with qualitative data analysis software. 

Though the majority of 40 participants consisting of nurses (n = 13), social workers (n = 25), and VA physicians (n = 2) felt confident conducting goals of care conversations, several barriers were recognized. 

Results of the analysis indicated staff inconsistently completed goals of care conversations and documentation due to a lack of training, experienced confusion over roles and responsibilities, and felt challenged communicating within the VA as well as with community NHs. At the organizational level, a need to standardize life-sustaining treatment preference documentation across sites was identified. 

The key barriers identified for patients were related to the readiness of patients and family members and issues finding surrogate decision makers. COVID-19 lockdowns were also noted to hinder communication about the goals of care.

“Findings from this pre-implementation evaluation revealed multilevel barriers in conducting and documenting goals of care conversations with veterans receiving VA-paid CNH care, as well as several facilitators that can be used to inform strategies for improvement,” concluded researchers. 

Reference: 
Keddem, S, Ayele, R, Ersek, M, et al. Barriers and facilitators to goals of care conversations with Veteran residents of community nursing homes. J Am Geriatr Soc. Published online April 10, 2023. doi:10.1111/jgs.18365