Dr. Harman graduated from Case Western Reserve University School of Medicine. She then completed a residency in Internal Medicine at Stanford and a Palliative Care fellowship at the Palo Alto VA/Stanford program before joining the faculty at Stanford. She is the founding medical director of Palliative Care Services for Stanford Health Care and a 2017 Cambia Sojourns Scholar Leader Awardee. She is a Clinical Associate Professor in the Department of Medicine and a faculty member in the Stanford Center for Biomedical Ethics. She serves as the clinical section chief of Palliative Care in the Division of Primary Care and Population Health and co-chairs the Stanford Health Care Ethics Committee. Her research and educational interests include communication training in healthcare, bioethics in end-of-life care, and the application of machine learning to improve access to palliative care.
- Palliative Care
- Internal Medicine
- Biomedical Ethics
Clinical Associate Professor, Medicine - Primary Care and Population Health
Ethics Committee, Co-Chair (2013), Stanford University Medical Center (2007 - Present)
Professional Practice and Evaluation Committee, Stanford Department of Medicine (2009 - 2017)
Associate Residency Program Director, Department of Medicine (2011 - 2017)
Chairperson, Jonathan King Lectureship Committee, Stanford Center for Biomedical Ethics (2011 - Present)
Stanford Senior Physicians Disaster Management Committee, Stanford University Medical Center (2011 - Present)
Stanford Commitee on Professional Satisfaction and Support, Stanford University Medical Center (2012 - Present)
Leadership Council on Clinical Excellence, Stanford Department of Medicine (2014 - Present)
Honors & Awards
Cambia Sojourns Scholar Leadership Award, Cambia Health Foundation (October 1, 2017)
Fellow, Stanford Faculty Fellows Program, Stanford University School of Medicine (2013-2014)
Arnold P. Gold Professorship, Arnold P. Gold Foundation (2011-2014)
Isaac Stein Award for Compassionate Care, Stanford Hospital and Clinics Board of Directors (September 23, 2009)
Boards, Advisory Committees, Professional Organizations
Member, American Academy of Hospice and Palliative Medicine (2007 - Present)
Member, Faculty (2017), Academy on Communication in Healthcare (2011 - Present)
Associate Editor, PC-FACS (publication of the AAHPM) (2013 - 2017)
Leader, Palliative Medicine Interest Group, Society of General Internal Medicine (2013 - 2017)
Ethics Committee Member, Society of General Internal Medicine (2015 - Present)
Medical Education:Case Western Reserve School of Medicine (2003) OH
Residency:Stanford University Hospital -Clinical Excellence Research Center (2006) CA
Board Certification: Internal Medicine, American Board of Internal Medicine (2006)
Board Certification: Hospice and Palliative Medicine, American Board of Internal Medicine (2008)
Fellowship:Palo Alto VA Healthcare System (2007) CA
A ProspectiveTrial Using Video Images in Advance Care Planning in Hospitalized Seriously Ill Patients With Advanced Cancer
The purpose of this study is to compare the decision making of hospitalized subjects with advanced cancer having a verbal discussion about CPR compared to subjects using a video.
Stanford is currently not accepting patients for this trial. For more information, please contact Ryan Oden, (650) 725 - 5417.
- Independent Studies (5)
Prior Year Courses
- Medical Ethics II
PEDS 251B (Aut)
- Medical Ethics II
Graduate and Fellowship Programs
Hospice & Palliative Medicine (Fellowship Program)
Improving palliative care with deep learning.
BMC medical informatics and decision making
2018; 18 (Suppl 4): 122
BACKGROUND: Access to palliative care is a key quality metric which most healthcare organizations strive to improve. The primary challenges to increasing palliative care access are a combination of physicians over-estimating patient prognoses, and a shortage of palliative staff in general. This, in combination with treatment inertia can result in a mismatch between patient wishes, and their actual care towards the end of life.METHODS: In this work, we address this problem, with Institutional Review Board approval, using machine learning and Electronic Health Record (EHR) data of patients. We train a Deep Neural Network model on the EHR data of patients from previous years, to predict mortality of patients within the next 3-12 month period. This prediction is used as a proxy decision for identifying patients who could benefit from palliative care.RESULTS: The EHR data of all admitted patients are evaluated every night by this algorithm, and the palliative care team is automatically notified of the list of patients with a positive prediction. In addition, we present a novel technique for decision interpretation, using which we provide explanations for the model's predictions.CONCLUSION: The automatic screening and notification saves the palliative care team the burden of time consuming chart reviews of all patients, and allows them to take a proactive approach in reaching out to such patients rather then relying on referrals from the treating physicians.
View details for DOI 10.1186/s12911-018-0677-8
View details for PubMedID 30537977
Update in Hospital Palliative Care: Symptom Management, Communication, Caregiver Outcomes, and Moral Distress
JOURNAL OF HOSPITAL MEDICINE
2018; 13 (6): 419–23
Updated knowledge of the palliative care (PC) literature is needed to maintain competency and best address the PC needs of hospitalized patients. We critiqued the recent PC literature with the highest potential to impact hospital practice.We reviewed articles published between January 2016 and December 2016, which were identified through a handsearch of leading journals and a MEDLINE search. The final 9 articles selected were determined by consensus based on scientific rigor, relevance to hospital medicine, and impact on practice.Key findings include the following: scheduled antipsychotics were inferior to a placebo for nonterminal delirium; a low-dose morphine was superior to a weak opioid for moderate cancer pain; methadone as a coanalgesic improved high-intensity cancer pain; many hospitalized patients on comfort care still receive antimicrobials; video decision aids improved the rates of advance care planning (ACP) and hospice use and decreased costs; standardized, PC-led intervention did not improve psychological outcomes in families of patients with a chronic critical illness; caregivers of patients surviving a prolonged critical illness experienced high and persistent rates of depression; people with non-normative sexuality or gender faced additional stressors with partner loss; and physician trainees experienced significant moral distress with futile treatments.Recent research provides important guidance for clinicians caring for hospitalized patients with serious illnesses, including symptom management, ACP, moral distress, and outcomes of critical illness.
View details for DOI 10.12788/jhm.2895
View details for Web of Science ID 000433302000011
View details for PubMedID 29261818
Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication.
Journal of hospital medicine
BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM.OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services.DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews.SETTING: Two large quaternary care academic medical centers.PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics).INTERVENTION: Observational study.MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM.RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9).CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.
View details for DOI 10.12788/jhm.2909
View details for PubMedID 29401211
A Qualitative Study on Inappropriate ICU Admissions: One Step Closer to Preventing Inappropriate ICU Care
ELSEVIER SCIENCE INC. 2018: 686
View details for Web of Science ID 000425399300304
"Don't Limit Me'': Discussing Serious News with Intellectually Disabled Adults
ELSEVIER SCIENCE INC. 2018: 622
View details for Web of Science ID 000425399300190
- INAPPROPRIATE ICU ADMISSIONS: ONE STEP CLOSER TO ADDRESSING INAPPROPRIATE ICU CARE FOR PATIENTS LIPPINCOTT WILLIAMS & WILKINS. 2018: 229
Psychiatric and Palliative Care in the Intensive Care Unit
CRITICAL CARE CLINICS
2017; 33 (3): 735-+
Palliative care is specialized medical care focused on patients with serious illness and their families. In the intensive care unit (ICU), palliative care encompasses core skills to support patients and their families throughout their ICU course and post-ICU stays. Psychiatric symptoms are common among patients approaching the end of life and require particular attention in the setting of sedating medications, typically used when patients require ventilators and other life-sustaining treatments. For patients with preexisting severe mental illness who have a concurrent serious medical illness, a palliative psychiatric approach can address complex symptom management and support ethical and value-based shared decision making.
View details for DOI 10.1016/j.ccc.2017.03.010
View details for Web of Science ID 000404499400015
View details for PubMedID 28601143
- Early Experience With the California End of Life Option Act: Balancing Institutional Participation and Physician Conscientious Objection. JAMA internal medicine 2017
TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care.
Journal of patient safety
End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.
View details for DOI 10.1097/PTS.0000000000000357
View details for PubMedID 28198722
A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.
Postgraduate medical journal
Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
View details for DOI 10.1136/postgradmedj-2016-134617
View details for PubMedID 28663352
Improving Palliative Care with Deep Learning
IEEE. 2017: 311–16
View details for Web of Science ID 000426504100061
The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital.
Journal of hospital medicine
2017; 12 (12): 1001–8
Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.
View details for DOI 10.12788/jhm.2865
View details for PubMedID 29073314
View details for PubMedCentralID PMC5709161
- Improving palliative care with deep learning. IEEE International Conference on Bioinformatics and Biomedicine 2017
The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation?
2016; 91 (11): 1534-1539
The medical student performance evaluation (MSPE), a letter summarizing academic performance, is included in each medical student's residency application. The extent to which medical schools follow Association of American Medical Colleges (AAMC) recommendations for comparative and transparent data is not known. This study's purpose was to describe the content, interpretability, and transparency of MSPEs.This cross-sectional study examined one randomly selected MSPE from every Liaison Committee on Medical Education-accredited U.S. medical school from which at least one student applied to the Stanford University internal medical residency program during the 2013-2014 application cycle. The authors described the number, distribution, and range of key words and clerkship grades used in the MSPEs and the proportions of schools with missing or incomplete data.The sample included MSPEs from 117 (89%) of 131 medical schools. Sixty schools (51%) provided complete information about clerkship grade and key word distributions. Ninety-six (82%) provided comparative data for clerkship grades, and 71 (61%) provided complete key word data. Key words describing overall performance were extremely heterogeneous, with a total of 72 used and great variation in the assignment of the top designation (median: 24% of students; range: 1%-60%). There was also great variation in the proportion of students awarded the top internal medicine clerkship grade (median: 29%; range: 2%-90%).The MSPE is a critical component of residency applications, yet data contained within MSPEs are incomplete and variable. Approximately half of U.S. medical schools do not follow AAMC guidelines for MSPEs.
View details for PubMedID 26703411
A resident-created hospitalist curriculum for internal medicine housestaff.
Journal of hospital medicine
2016; 11 (9): 646-649
The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2590
View details for PubMedID 27079160
Curricular innovations for medical students in palliative and end-of-life care: a systematic review and assessment of study quality.
Journal of palliative medicine
2015; 18 (4): 338-349
Recent focus on palliative and end-of-life care has led medical schools worldwide to enhance their palliative care curricula.The objective of the study was to describe recent curricular innovations in palliative care for medical students, evaluate the quality of studies in the field, and inform future research and curricular design.The authors searched Medline, Scopus, and Educational Resource Information Center (ERIC) for English-language articles published between 2007 and 2013 describing a palliative care curriculum for medical students. Characteristics of the curricula were extracted, and methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).The sample described 48 curricula in 12 countries. Faculty were usually interdisciplinary. Palliative care topics included patient assessment, communication, pain and symptom management, psychosocial and spiritual needs, bioethics and the law, role in the health care system, interdisciplinary teamwork, and self-care. Thirty-nine articles included quantitative evaluation, with a mean MERSQI score of 9.9 (on a scale of 5 to 18). The domain most likely to receive a high score was data analysis (mean 2.51 out of 3), while the domains most likely to receive low scores were validity of instrument (mean 1.05) and outcomes (mean 1.31).Recent innovations in palliative care education for medical students represent varied settings, learner levels, instructors, educational modalities, and palliative care topics. Future curricula should continue to incorporate interdisciplinary faculty. Studies could be improved by integrating longitudinal curricula and longer-term outcomes; collaborating across institutions; using validated measures; and assessing higher-level outcomes including skills, behaviors, and impact on patient care.
View details for DOI 10.1089/jpm.2014.0270
View details for PubMedID 25549065
- Curricular Innovations for Medical Students in Palliative and End-of-Life Care: A Systematic Review and Assessment of Study Quality JOURNAL OF PALLIATIVE MEDICINE 2015; 18 (4): 338-349
- Patients Who Lack Capacity and Lack Surrogates: Can They Enroll in Hospice? JOURNAL OF PAIN AND SYMPTOM MANAGEMENT 2014; 48 (4): 745-U277
Patients who lack capacity and lack surrogates: can they enroll in hospice?
Journal of pain and symptom management
2014; 48 (4): 745-50 e1
Patients who lack capacity and lack surrogates are among the most vulnerable patients we care for in palliative care. In the case we present here, we have considered how to make end-of-life decisions for a patient who lacks both capacity and surrogates, who has a terminal illness, and who is not a candidate for disease-modifying treatments. We first define and characterize this population of patients through a review of the literature and then explore some decision-making quandaries that are encountered at the end of life. Finally, we make recommendations on how best to proceed with decision making for this vulnerable population.
View details for DOI 10.1016/j.jpainsymman.2013.12.244
View details for PubMedID 24709366
Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes.
The Journal of community and supportive oncology
2014; 12 (4): 129-136
Palliative care services in the United States are increasing in their prevalence but continue to vary in their implementation, with different referral policies and timing of patient access to services.To better define a late referral and to understand the association of late referrals to palliative care with patient health outcomes, including postreferral length of hospital stay and in-hospital mortality.We performed a retrospective study using multiple linear and logistic regressions on 1,225 patients with pre-existing oncologic diagnoses who received a referral to Stanford Hospital's palliative care service.Those oncologic patients who were referred to palliative care in the first week following admission had significantly shorter lengths of stay after referral, as well as lower in-hospital mortality, compared with patients who were referred later than 1 week following admission. Regression analyses, adjusted for demographic variables, DNR status, and sickness, revealed that waiting 1 week or longer to refer a patient was associated with an overall increased length of stay of 2.70 days (P < .001). This increased to 3.40 days (P < .001) when patients who died in the hospital were removed from the data, suggesting that in-hospital mortality was not solely responsible for the trend. Waiting 1 week to refer was associated with increased odds of a patient's dying in the hospital vs being discharged alive by a factor of 3.04 (P < .001).This study was limited to analyzing inpatient palliative care consultation services with a emphasis on patients with metastatic solid tumors. We used a proxy for patient sickness burden but did not analyze outcomes specific to cancer stage or individual oncologic diagnosis separately.Our study suggests that late referrals may have a marked negative impact on health outcomes, which argues for the design and implementation of hospital policies that encourage early referral to palliative care for advanced cancer patients.
View details for PubMedID 24971422
Update in Palliative Care-2011
National Meeting of the Society-of-General-Internal-Medicine (SGIM)
SPRINGER. 2012: 582–87
The aim of this update is to summarize scientifically rigorous articles published in 2010 that serve to advance the field of palliative medicine and have an impact on clinical practice.We conducted two separate literature searches for articles published between January 1, 2010 and December 31, 2010. We reviewed title pages from the Annals of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, JAMA, Journal of Clinical Oncology, JGIM, Journal of Pain and Symptom Management, Journal of Palliative Medicine, Lancet, New England Journal of Medicine, PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care). We also conducted a Medline search with the key words "palliative," "hospice," and "terminal" care. Each author presented approximately 20 abstracts to the group. All authors reviewed these abstracts, and when needed, full text publications. We focused on articles relevant to general internists. We rated the articles individually, eliminating by consensus those that were not deemed of highest priority, and discussed the final choices as a group.We first identified 126 articles with potential relevance. We presented 20 at the annual SGIM update session, and discuss 11 in this paper.
View details for DOI 10.1007/s11606-011-1929-9
View details for Web of Science ID 000302869300019
View details for PubMedID 22127796
- Palliative Care Rounds: Toward Evidence-Based Practice JOURNAL OF PAIN AND SYMPTOM MANAGEMENT 2012; 43 (4): 795-801