Associate Chief of Staff for Extended Care, VA Palo Alto Health Care System (2004 - Present)
Honors & Awards
2002 Henry J Kaiser Award for Outstanding and Innovative Contributions to Medical Education, Stanford School of Medicine (2002)
David M. Worthen Award for Academic Excellence, Department of Veterans Affairs (2002)
Pioneer in Palliative Care, Journal of Palliative Medicine (2009)
Chief Resident, Stanford, Internal Medicine (1987)
Residency, UCSF, Internal Medicine (1986)
MD, Emory University, Medicine (1983)
Current Research and Scholarly Interests
Research in hospice and palliative care with emphases on physician education, cultural aspects of end-of-life care, and healthcare system issues.
- Pain management in American nursing homes – a long way to go. Journal of the American Geriatrics Society 2015; 63 (4): 642-643
- Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death? JOURNAL OF PALLIATIVE MEDICINE 2012; 15 (8): 848-853
- Narrative Empathy and How Dealing with Stories Helps: Creating a Space for Empathy in Culturally Diverse Care Settings JOURNAL OF PAIN AND SYMPTOM MANAGEMENT 2010; 40 (3): 471-476
- Cutting Through Yesterday's Understanding JOURNAL OF PALLIATIVE MEDICINE 2009; 12 (8): 683-685
Access to end-of-life care venues
AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE
2008; 25 (3): 245-249
Quality of care at the end of life is strongly correlated with where patients die. This review discusses the influence of patient and health system variables affecting access to common venues of death--the acute care hospital, the nursing home, and home--with or without hospice. Access to care is considered in terms of a flow model, wherein pressure gradients push patients toward care in certain venues and away from alternatives. Dynamic interactions between patient-specific variables and health care system variables influence the nature of patient flow, moving patients toward certain terminal venues of care and away from others. Efforts to improve quality of care at the end of life must be cognizant of these effects and should work to adjust patterns of flow in more favorable directions.
View details for DOI 10.1177/1049909108315519
View details for Web of Science ID 000258664200012
View details for PubMedID 18480016
- Evidence-based medicine and palliative care JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (1): 2-4
- A request for nondisclosure: Don't tell mother JOURNAL OF CLINICAL ONCOLOGY 2007; 25 (31): 5030-5034
Outcomes from a national multispecialty palliative care curriculum development project
JOURNAL OF PALLIATIVE MEDICINE
2007; 10 (2): 408-419
In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery.To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project.Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports.Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs. Conclusions: Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.
View details for DOI 10.1089/jpm.2006.0183
View details for Web of Science ID 000246275900025
View details for PubMedID 17472513
Quality of care in a veterans affairs' nursing home-based hospice unit
JOURNAL OF PALLIATIVE MEDICINE
2007; 10 (1): 127-135
To report on quality of care in a Veterans Affairs (VA) dedicated hospice unit.Mortality follow-back survey of bereaved family members, using a quality of care instrument.A VA inpatient hospice unit.Bereaved family members.Satisfaction with care as perceived by family members using a telephone survey.159 family members were contacted with 102 completing full and 37 completing abbreviated surveys. (Overall response rate: 87.4%, complete responses: 64.2%) 98% of all respondents reported overall quality of care as Excellent or Very Good.High levels of satisfaction were reported by family members. Implications of this initiative for the provision of hospice care in nursing homes are discussed, including replication of the model in both VA and non-VA nursing home settings.
View details for DOI 10.1089/jpm.2006.0141
View details for Web of Science ID 000244135100021
View details for PubMedID 17298261
Faculty development in end-of-life care: Evaluation of a national train-the-trainer program
2006; 81 (11): 1000-1007
To address serious deficiencies in physician training in end-of-life care, the authors developed and disseminated a faculty development curriculum. The overall goals of this curriculum were to enhance physician competence in end-of-life care, foster a commitment to improving care for the dying, and improve teaching related to end-of-life care. The authors provide descriptions of the curriculum and the train-the-trainer programs (2000-2002) that successfully prepared 17 medical faculty as in-house end-of-life care faculty developers at institutions nationwide. They also report on a study of the effects of the 16-hour, end-of-life care curriculum delivered by trained facilitators to 62 faculty and residents at their home sites. Program evaluation showed that the home-site seminars enhanced the knowledge, skills, and attitudes of participating faculty and residents. When project evaluation concluded in 2003, trained facilitators had disseminated the 16-hour curriculum as well as modified versions of the curriculum to approximately 3,400 medical teachers. An adapted version of the curriculum is available on the Internet for use in health professions education. The importance of this type of faculty development effort was confirmed by the positive impact of the 16-hour curriculum on participants' knowledge, skills, and attitudes related to end-of-life care, the high ratings of the program's educational and clinical relevance, and the finding that, on average, more than 50% of the material was new to them.
View details for Web of Science ID 000241569300014
View details for PubMedID 17065869
High context illness and dying in a low context medical world.
The American journal of hospice & palliative care
2006; 23 (2): 113-118
This article provides an introduction to the field of intercultural communication. Miscommunication among patients, families, and clinicians often results when participants are contextually "out-of-synch. " High context communication embeds more information in the contexts within which people communicate and is less dependent on language. Very sick and dying patients often use high context communication strategies. Low context communication stresses explicit verbal communication and is commonly used by clinicians. When clinicians use low context forms of communication with patients using high context styles, misunderstandings frequently arise. Suggestions are given for avoiding miscommunication and enhancing mutual understanding.
View details for PubMedID 16572749
- Lipid Lowering Agents: the authors' response J Palliative Medicine 2006; 9 (3): 621
- Palliative care training for the generalist - a luxury or a necessity J Gen Int Med 2006; 21 (9): 1005-6
- Reevaluating PEG tube placement in advanced illness GASTROINTESTINAL ENDOSCOPY 2005; 62 (6): 960-962
Palliative care in the final days of life - "They were expecting it at any time"
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2005; 293 (18): 2265-2271
Providing care to actively dying patients presents unique challenges for the clinician. Patients in their final days require careful symptom management. Families need support and coaching as death approaches. Care does not end with the death of the patient but continues through death pronouncement, family notification of the death, discussion of autopsy, and immediate bereavement support. Skills in these and related areas are discussed in the context of one man's death, as illuminated by comments made after death by his daughter and his physician. This case also highlights the often differing perspectives of families and clinicians as they work to deal with a patient's death. A goal of mastering the palliative skills necessary to competently care for an actively dying patient is to enable a patient to die peacefully and relatively free of discomfort. Achieving such competency should also help to relieve clinician stress attendant to caring for dying patients.
View details for Web of Science ID 000228981100028
View details for PubMedID 15886382
The development and initial validation of the Terminally Ill Grief or Depression Scale (TIGDS)
INTERNATIONAL JOURNAL OF METHODS IN PSYCHIATRIC RESEARCH
2005; 14 (4): 202-212
Patients often experience 'preparatory-grief' as they cope with the dying process. Some may be depressed. The Terminally Ill Grief or Depression Scale (TIGDS), comprising grief and depression sub-scales, is a new self-report measure designed to differentiate between preparatory-grief and depression in adult inpatients. The initial 100-item inventory was assembled based on literature review, interviews with clinicians and dying patients and then shortened to 42 items based on consensus expert opinion. Validity and reliability were tested in a sample of 55 terminally ill adults. The consensus clinical opinion was used as the gold standard to differentiate between preparatory grief and depression. The intra-class correlation coefficient was high (it was calculated to estimate the test-retest reliability for the 47 patients who had completed the TIGDS twice--retest was administered 2 to 7 days after the initial test), ranging from 0.86 (grief) to 0.97 (depression). The validity of TIGDS was assessed using a receiver operating characteristic curve analysis, comparing the first test with the clinical criterion. The first and only variable and cut-point was the depression score (chi-square = 18.4, p < 0.001, cut point = 3). The sensitivity of the TIGDS was 0.727 and specificity was 0.886 for the depression = 3 cutoff score. The construct validity of the TIGDS was tested by comparing with the Hospital Anxiety and Depression Scale (HADS). The TIGDS depression subscale showed strong convergent validity and the TIGDS grief subscale showed strong discriminant validity with the HADS total score.
View details for DOI 10.1002/mpr.8
View details for Web of Science ID 000234094000003
View details for PubMedID 16395873
- Doctor and friend. The virtual mentor : VM 2005; 7 (6)
- Discontinuing cardiovascular medications at the end of life: lipid-lowering agents J. Palliative Medicine 2005; 8 (4): 876-81
Communication across cultures.
Journal of palliative medicine
2004; 7 (3): 477-480
View details for PubMedID 15265361
The explanatory model #26.
Journal of palliative medicine
2003; 6 (6): 931-?
View details for PubMedID 14733686
- When do we stop, and how do we do it? Medical futility and withdrawal of care JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2003; 196 (4): 621-654
- When do we stop, and how do we do it? Medical futility and withdrawal of care J Am College of Surgeons 2003; 196 (4): 621-51
Identifying and managing preparatory grief and depression at the end of life
AMERICAN FAMILY PHYSICIAN
2002; 65 (5): 883-890
Grief and depression present similarly in patients who are dying. Conventional symptoms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depression in these patients may be imprecise because these symptoms are also present in preparatory grief and as a part of the normal dying process. Preparatory grief is experienced by virtually all patients who are dying and can be facilitated with psychosocial support and counseling. Ongoing pharmacotherapy is generally not beneficial and may even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hopelessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low threshold for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life.
View details for Web of Science ID 000174255800009
View details for PubMedID 11898960
- Tube feed or not tube feed J Palliative Medicine 2002; 5 (6): 909-10
- Differentiating between depression and preparatory grief at the end-of-life Am Fam Phys 2002; 65 (5): 883-90
- What's the story - how patients make medical decisions Am J Med 2002; 113: 73-4
Stenting the sigmoid colon in a terminally ill patient with prostate cancer.
Journal of palliative medicine
2001; 4 (2): 153-156
Large bowel obstruction in the terminally ill patient can be difficult to manage. We describe a patient with sigmoid colon obstruction caused by metastatic prostate cancer in the pelvis who required hospitalization because of severe pain and obstructive symptoms. Treatment with an endoscopically placed self-expandable metal stent allowed the patient to have immediate resolution of symptoms and to receive hospice care at home.
View details for PubMedID 11441623
Intercultural differences and communication at the end of life
2001; 28 (2): 401-?
Cross-cultural encounters at the end of life are common and can result in misunderstandings and conflicts. The primary care physician is ideally suited to facilitate communication that can promote understanding and conflict resolution.
View details for Web of Science ID 000169854900012
View details for PubMedID 11406443
- Nutrition and hydration in end-of-life care and non-pain symptom management V.H.S.J 2001; 5 (11 (Supp)): 31-32
- Ask the right question V.H.S.J 2001; 6 (5): 60-61
- Preparing for close encounters; practicing communication skills through impromptu role plays V.H.S.J 2001; 6 (8): 69-70
- Palo Alto Hospice: Unique relationships with community hospices V.H.S.J 2001; 5 (11(Supp)): 23-24
- Knowledge, Attitudes, and Skills V.H.S.J 2001; 6 (6): 65-66
Terminal sedation: ethical implications in different situations.
Journal of palliative medicine
2000; 3 (3): 313-320
Terminal sedation (TS) is a recently coined term that may apply to a variety of practices with differing ethical implications. Two hypothetical cases are presented and contrasted. The first presents the more common scenario in which sedation is used for severe distress in a patient very close to death, who has stopped eating and drinking. The second case is more problematic: a nonterminally ill spinal cord injury patient requests sedation because of psychic distress. Sedation is supported in the former, but not the latter case. Suggested principles guiding the ethical use of sedation are: (1) While respect for autonomy is important, we are not obliged under all circumstances to provide sedation. (2) Physician intent matters. In providing sedation the physician's primary intent should be to alleviate suffering. (3) Reasonable inferences of intent can be made from physician actions, providing safeguards to ensure proper care. Sedatives should be titrated to observable signs of distress. (4) Proximity to death is a more useful concept than terminality in weighing benefits and burdens of sedation. (5) The nature of physician action should depend upon the nature of the suffering. Not all suffering is appropriately treated with sedation. (6) In patients close to death who have already stopped eating and drinking, sedation cannot be said to hasten death through dehydration or starvation. (7) Where TS is otherwise appropriate and where dehydration may in fact hasten death, ethical concerns may be addressed through informed consent. If hydration is refused, TS cannot be considered synonymous with euthanasia.
View details for PubMedID 15859672
- A dying patient, like me? AMERICAN FAMILY PHYSICIAN 2000; 62 (4): 888-890
- A dying patient, like me? Am Fam Physician 2000; 62: 888-90
- Best practices in the care of the dying Ann Long-term Care 2000; 8: 38-44
A medical resident inpatient hospice rotation: experiences with dying and subsequent changes in attitudes and knowledge.
Journal of palliative medicine
1999; 2 (2): 197-208
To evaluate intern experience in end-of-life care and self-assessed changes in attitude and knowledge, following a mandatory rotation on an inpatient hospice and in a nursing home.Twenty-seven interns enrolled in an internal medicine residency program completed a questionnaire examining experiences with dying patients, prior training in end-of-life care, and self-ratings of pertinent attitudes and knowledge. The questionnaire used a retrospective before and after design. Comparisons were evaluated using dependent two-tailed r-tests.Prior training was largely limited to undergraduate didactic courses. Few interns had received formal training in symptom management. Most felt poorly prepared to care for terminally ill patients. Eighty-two percent of interns had previously cared for a dying patient only in acute care. Fifty-nine percent had never cared for a dying patient without intravenous fluids. Prior modeling of end-of-life care communication by attending physicians was uncommon. On a 5-point scale (strongly disagree-strongly agree) mean responses increased from 2.1 before-rotation to 3.0 after-rotation (p < 0.001) for the statement, "I feel as comfortable with a dying patient as I do with any other patient." Pain management knowledge increased from 2.0 before-rotation to 3.8 after-rotation (p < 0.001). Seventy-seven percent strongly agreed with the statement, "some training in care of terminally ill patients should be mandatory for all internists."Prior experiences did not adequately prepare interns to deliver competent care. Significant improvements in attitude and knowledge were noted following the intervention. More hands-on clinical experiences in end-of-life care for residents are needed. Occasional didactic sessions will be inadequate.
View details for PubMedID 15859816
- Terminal sedation for intractable distress: not slow euthanasia but a prompt response to suffering Western J Med 1999; 171 (4): 222-3
Cultural considerations of death and dying in the United States
CLINICS IN GERIATRIC MEDICINE
1996; 12 (2): 393-?
Culture is not something apart from us. It is always here, and we, like fish in an ocean, may be blind to the water in which we swim. We recommend that, in addition to learning as much as possible about people from cultures other than our own, we consider carefully the cultural roots of our own thoughts and actions. A combination of respectful behavior and a conscientious effort to understand individuals from another culture will go far in enabling us to work well with dying patients from many backgrounds.
View details for Web of Science ID A1996UL98800013
View details for PubMedID 8799356
PROGNOSIS OF MECHANICALLY VENTILATED PATIENTS
WESTERN JOURNAL OF MEDICINE
1993; 159 (6): 659-664
In this Department of Veterans Affairs cooperative study, we examined predictors of in-hospital and 1-year mortality of 612 mechanically ventilated patients from 6 medical intensive care units in a retrospective cohort design. The outcome variable was vital status at hospital discharge and after 1 year. The results showed that 97% of patients were men, the mean age was 63 +/- 11 years (SD), and hospital mortality was 64% (95% confidence interval, 60% to 68%). Within the next year, an additional 38% of hospital survivors died, for a total 1-year mortality of 77% (95% confidence interval, 73% to 80%). Hospital and 1-year mortality, respectively, for patients older than 70 years was 76% and 94%, for those with serum albumin levels below 20 grams per liter it was 92% and 96%, for those with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score greater than 35 it was 91% and 98%, and for patients who were being mechanically ventilated after cardiopulmonary resuscitation it was 86% and 90%. The mortality ratio (actual mortality versus APACHE II-predicted mortality) was 1.15. Conclusions are that patient age, APACHE II score, serum albumin levels, or the use of cardiopulmonary resuscitation may identify a subset of mechanically ventilated veterans for whom mechanical ventilation provides little or no benefit.
View details for Web of Science ID A1993ML92900001
View details for PubMedID 8128673
- Prognosis of mechanically ventilated medical patients: results of a Veterans Affairs Cooperative Study Western J. Med 1993; 159 (6): 659-64
- Nutrient bioavailability from nasojejunally adminstered enteral formulas: comparison to solid food Am J Clin Nutrition 1984; 39: 242-50