Inclusion Criteria:  CLINICIANS VA primary care advance practice clinicians (MDs, APRNs) at one of the three study sites able to complete LST notes and orders. Advance practice clinicians will be eligible for randomization if they have at least 15 eligible patients without LST notes at the start of stage 1 (to allow participating clinicians ample opportunities to write notes) and have written fewer than 4 LST notes in the previous year (to select clinicians who need improvement), and can potentially receive the planned implementation strategies, i.e., clinicians who regularly attend the Patient Aligned Care Team (PACT) team meetings.  PATIENTS  Veteran enrolled in VHA health care in one of the three study sites who is a current patient of one of the eligible primary care clinicians Diagnosis of cancer, heart failure, interstitial lung disease, chronic obstructive pulmonary disease, end-stage renal disease, end-stage liver disease, and dementia Care Assessment Needs score of > or equal to 90 using the one-year combined hospitalization/mortality variable  Exclusion Criteria:  PATIENTS  Prisoner Pregnant under 18 years of age.