Stephanie Harman

All Publications

• Education About Specialty Palliative Care Among Non-Healthcare Workers: A Systematic Review. Journal of pain and symptom management Smith, G. M., Singh, N., Hui, F., Sossenheimer, P. H., Hannah, J. M., Romano, P., Wong, H. C., Heidari, S. N., Harman, S. M. 2023

  Abstract

  Despite the expansion of palliative care (PC) services, the public has little knowledge and holds misperceptions about PC, creating barriers to accessing timely specialty PC.To systematically review the evidence regarding the efficacy of educational interventions to improve knowledge and attitudes about PC among non-healthcare workers.We searched five databases (PubMed/MEDLINE, Embase, CIANHL, Web of Science, and Scopus) for studies investigating educational interventions about specialty PC in adults who identified as patients, caregivers, or members of the public. We included studies that were available in English and had a comparator group. We excluded studies that only sampled health professionals or children. We used the Mixed Methods Appraisal Tool to assess quality and risk of bias.Of 12,420 records identified, we screened 5,948 abstracts and assessed 526 full texts for eligibility. 21 articles were extracted for analysis, representing 20 unique educational interventions. Common methodologies included quasi-experimental (9, 45%), randomized controlled trial (4, 20%), and non-randomized trial (2, 10%). Common components of the educational interventions included video presentations (9, 45%), written materials (8, 40%), and lectures (4, 20%). Content included definition (14, 70%) and philosophy (14, 70%) of PC, distinctions between PC and hospice (11, 55%), and eligibility for PC (11, 55%). Fourteen (70%) interventions showed statistically significant positive differences in either knowledge or attitudes about PC.While educational interventions can positively impact knowledge and attitudes about PC among non-healthcare workers, more research is needed to inform the design, delivery, and evaluation of interventions to increase knowledge and attitudes about PC.

  View details for DOI 10.1016/j.jpainsymman.2023.09.023

  View details for PubMedID 37797678

• Designing Code Status Orders that Convey Patient Preferences for Emergency Intubation: A Qualitative Assessment Batten, J., Blythe, J., Shearer, E., Dzeng, E., Cotler, M., Porter-Williamson, K., Kayser, J., Harman, S., Magnus, D., Wieten, S. LIPPINCOTT WILLIAMS & WILKINS. 2023: 170

  View details for Web of Science ID 001058985600062

• "No Escalation of Treatment" Designations: A Multi-Institutional Exploratory Qualitative Study. Chest Batten, J. N., Blythe, J. A., Wieten, S. E., Dzeng, E., Kruse, K. E., Cotler, M. P., Porter-Williamson, K., Kayser, J. B., Harman, S. M., Magnus, D. 2022

  Abstract

  BACKGROUND: No Escalation of Treatment (NoET) designations are used in intensive care units internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied.QUESTION: How do physicians understand and perceive NoET designations, especially with regards to their utility and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations?STUDY DESIGN AND METHODS: Qualitative study at seven United States hospitals, employing semi-structured interviews with thirty physicians and review of relevant institutional records (e.g., hospital policies, screenshots of ordering menus in the electronic health record).RESULTS: At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (e.g., a DNR/Do-Not-Escalate code status order); at the remaining hospitals, a variety of informal methods (e.g., verbal handoffs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) Helping physicians navigate pre-arrest clinical decompensations, (3) Helping surrogate decision makers transition toward comfort care, (4) Preventing patient harm from invasive measures, and (5) Conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations.INTERPRETATION: Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.

  View details for DOI 10.1016/j.chest.2022.08.2211

  View details for PubMedID 36007596

• Top Ten Tips Palliative Care Clinicians Should Know About Their Work's Intersection with Clinical Ethics. Journal of palliative medicine Weaver, M. S., Boss, R. D., Christopher, M. J., Gray, T. F., Harman, S., Madrigal, V. N., Michelson, K. N., Paquette, E. T., Pentz, R. D., Scarlet, S., Ulrich, C. M., Walter, J. K. 2021

  Abstract

  Palliative care (PC) subspecialists and clinical ethics consultants often engage in parallel work, as both function primarily as interprofessional consultancy services called upon in complex clinical scenarios and challenging circumstances. Both practices utilize active listening, goals-based communication, conflict mediation or mitigation, and values explorations as care modalities. In this set of tips created by an interprofessional team of ethicists, intensivists, a surgeon, an attorney, and pediatric and adult PC nurses and physicians, we aim to describe some paradigmatic clinical challenges for which partnership may improve collaborative, comprehensive care.

  View details for DOI 10.1089/jpm.2021.0521

  View details for PubMedID 34807737

• "Relax City Homecare team; protocols are ready for you" - A Quality Improvement Project Conducted on Behalf of the City Homecare Unit Team at the Trivandrum Institute of Palliative Sciences. Indian journal of palliative care Sunilkumar, M. M., Thampi, A., Lekshmi, S., Harman, S. M., Vallath, N. 2021; 27 (2): 204-210

  Abstract

  The city homecare unit (CHU) of the Trivandrum Institute of Palliative Sciences was dissatisfied with the quality of care provided to their patient population.This study aims to improve the average satisfaction score of CHU during their daily homecare services.The improvement project for the CHU activities was conducted with a prospective plan-do-study-act design, with stepwise application of improvement tools.The A3 quality improvement (QI) methodology, which uses tools for (i) analysing contributors (process mapping, cause-effect diagram); (ii) to derive key drivers (Pareto chart) and (iii) for measuring impact of interventions and sustainability (annotated run chart) was applied. The project was conducted as a mentored activity of the PC-PAICE program. The team's weekly average satisfaction score was recorded prospectively as the outcome parameter, with 0 representing total dissatisfaction and 10 representing total satisfaction. Accuracy of triaging and appropriateness of registration process were the process parameters selected. These were recorded as run charts across the project period of 9 months.The cause-effect tool and the impact effort tool were used to analyse the mapped CHU processes. Even though we identified 22 contributors to the problem, eight of them were found to be significant. Key drivers were determined based on these eight and applied to the CHU processes. Over the project period, the satisfaction scores of the CHU improved significantly from 5.82 to 7.6 that is, satisfaction levels were high on most days. The triaging and registration goals were achieved. The team also built its own capacity for QI.The application of the A3 methodology simplified and streamlined efforts and achieved the quality goal for the CHU team.

  View details for DOI 10.25259/IJPC_408_20

  View details for PubMedID 34511785

  View details for PubMedCentralID PMC8428877

• "Relax City Homecare team; protocols are ready for you" - A Quality Improvement Project Conducted on Behalf of the City Homecare Unit Team at the Trivandrum Institute of Palliative Sciences INDIAN JOURNAL OF PALLIATIVE CARE Sunilkumar, M. M., Thampi, A., Lekshmi, S., Harman, S. M., Vallath, N. 2021; 27 (2): 204-210

  View details for DOI 10.25259/IJPC_408_20

  View details for Web of Science ID 000685478800003

• Palliative Care to the People: Partnering with a Patient Experience Department to Raise Awareness of Palliative Care in the Community Smith, G. M., Bragg, A., Bleymaier, C. R., Mirkin, R. A., Harman, S. M. ELSEVIER SCIENCE INC. 2021: 647

  View details for Web of Science ID 000621206400037

• A framework for making predictive models useful in practice. Journal of the American Medical Informatics Association : JAMIA Jung, K., Kashyap, S., Avati, A., Harman, S., Shaw, H., Li, R., Smith, M., Shum, K., Javitz, J., Vetteth, Y., Seto, T., Bagley, S. C., Shah, N. H. 2020

  Abstract

  OBJECTIVE: To analyze the impact of factors in healthcare delivery on the net benefit of triggering an Advanced Care Planning (ACP) workflow based on predictions of 12-month mortality.MATERIALS AND METHODS: We built a predictive model of 12-month mortality using electronic health record data and evaluated the impact of healthcare delivery factors on the net benefit of triggering an ACP workflow based on the models' predictions. Factors included nonclinical reasons that make ACP inappropriate: limited capacity for ACP, inability to follow up due to patient discharge, and availability of an outpatient workflow to follow up on missed cases. We also quantified the relative benefits of increasing capacity for inpatient ACP versus outpatient ACP.RESULTS: Work capacity constraints and discharge timing can significantly reduce the net benefit of triggering the ACP workflow based on a model's predictions. However, the reduction can be mitigated by creating an outpatient ACP workflow. Given limited resources to either add capacity for inpatient ACP versus developing outpatient ACP capability, the latter is likely to provide more benefit to patient care.DISCUSSION: The benefit of using a predictive model for identifying patients for interventions is highly dependent on the capacity to execute the workflow triggered by the model. We provide a framework for quantifying the impact of healthcare delivery factors and work capacity constraints on achieved benefit.CONCLUSION: An analysis of the sensitivity of the net benefit realized by a predictive model triggered clinical workflow to various healthcare delivery factors is necessary for making predictive models useful in practice.

  View details for DOI 10.1093/jamia/ocaa318

  View details for PubMedID 33355350

• Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study. BMJ quality & safety Batten, J. N., Blythe, J. A., Wieten, S., Cotler, M. P., Kayser, J. B., Porter-Williamson, K., Harman, S., Dzeng, E., Magnus, D. 2020

  Abstract

  BACKGROUND: US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.DESIGN AND METHODS: Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.RESULTS: The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.CONCLUSIONS: There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.

  View details for DOI 10.1136/bmjqs-2020-011222

  View details for PubMedID 33082165

• What If I Get Seriously Ill? A Virtual Workshop for Advance Care Planning During COVID-19. Journal of pain and symptom management Smith, G. M., Hui, F. A., Bleymaier, C. R., Bragg, A. R., Harman, S. M. 2020

  Abstract

  The coronavirus disease 2019 (COVID-19) has brought public attention to questions regarding the type of care individuals would want to receive in the event of becoming suddenly critically ill. Advance care planning (ACP) is one way to help individuals and families address these questions. However, social distancing, stay-at-home orders, and hospital visitor restrictions have raised new barriers to facilitating these conversations. Here, we describe the implementation and evaluation of a novel, public-facing, 2-part virtual ACP workshop. Participants were recruited through electronic communication, and evaluations were collected through surveys administered after each part of the workshop. We found that utilizing a virtual format allowed us to reach a large, geographically diverse audience. Participants were likely to recommend the workshop to friends and family. There was no change in advance care planning engagement between the post-session surveys between the first and second parts of the workshop.

  View details for DOI 10.1016/j.jpainsymman.2020.08.022

  View details for PubMedID 32835831

• Power and perils of prediction in palliative care LANCET Porter, A. S., Harman, S., Lakin, J. R. 2020; 395 (10225): 680–81

  View details for Web of Science ID 000516755200017

• Power and perils of prediction in palliative care. Lancet (London, England) Porter, A. S., Harman, S., Lakin, J. R. 2020; 395 (10225): 680–81

  View details for DOI 10.1016/S0140-6736(20)30318-4

  View details for PubMedID 32113499

• The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative. Journal of pain and symptom management Lorenz, K. A., Mickelsen, J. n., Vallath, N. n., Bhatnagar, S. n., Spruyt, O. n., Rabow, M. n., Agar, M. n., Dy, S. M., Anderson, K. n., Deodhar, J. n., Digamurti, L. n., Palat, G. n., Rayala, S. n., Sunilkumar, M. M., Viswanath, V. n., Warrier, J. J., Gosh-Laskar, S. n., Harman, S. M., Giannitrapani, K. F., Satija, A. n., Pramesh, C. S., DeNatale, M. n. 2020

  Abstract

  Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

  View details for DOI 10.1016/j.jpainsymman.2020.08.025

  View details for PubMedID 32858163

  View details for PubMedCentralID PMC7445485

• Protecting the Sanctity of the Patient-Physician Relationship JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Harman, S., Verghese, A. 2019; 322 (20): 1957–58

  View details for DOI 10.1001/jama.201917965

  View details for Web of Science ID 000502573000009

• Protecting the Sanctity of the Patient-Physician Relationship. JAMA Harman, S., Verghese, A. 2019

  View details for DOI 10.1001/jama.2019.17965

  View details for PubMedID 31661114

• Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention ACADEMIC MEDICINE Harman, S. M., Blankenburg, R., Satterfield, J. M., Monash, B., Rennke, S., Yuan, P., Sakai, D. S., Huynh, E., Chua, I., Hilton, J. F., Patient Engagement Project 2019; 94 (7): 1010–18

  View details for DOI 10.1097/ACM.0000000000002715

  View details for Web of Science ID 000474593100021

• Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention. Academic medicine : journal of the Association of American Medical Colleges Harman, S. M., Blankenburg, R., Satterfield, J. M., Monash, B., Rennke, S., Yuan, P., Sakai, D. S., Huynh, E., Chua, I., Hilton, J. F., Patient Engagement Project 2019

  Abstract

  PURPOSE: To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco.METHOD: The 8-week Patient Engagement Project Study intervention, delivered at 4 services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the 9-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least 1 trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on 9 SDM behaviors per patient encounter.RESULTS: In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all 9 SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33 to 2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team.CONCLUSIONS: The intervention increased behaviors supporting SDM during ward rounds on 4 independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.

  View details for PubMedID 30893066

• Implementing a Bereaved Family Survey to Improve Palliative and End of Life Care at Academic Medical Centers Kaltman, J., Walling, A., Lorenz, K., Casarett, D., Harman, S. ELSEVIER SCIENCE INC. 2019: 402

  View details for DOI 10.1016/j.jpainsymman.2018.12.106

  View details for Web of Science ID 000456406900115

• Women in Leadership: Pathways for Empowerment, Leadership, Action and Culture Change (CAMBIA) Bernacki, R., Davidson, P., Harman, S., Kutner, J. S., Lafond, D., Maguire, P., Ritchie, C. ELSEVIER SCIENCE INC. 2019: 440

  View details for DOI 10.1016/j.jpainsymman.2018.12.178

  View details for Web of Science ID 000456406900185

• Thrombophilia testing in the inpatient setting: impact of an educational intervention. BMC medical informatics and decision making Kwang, H. n., Mou, E. n., Richman, I. n., Kumar, A. n., Berube, C. n., Kaimal, R. n., Ahuja, N. n., Harman, S. n., Johnson, T. n., Shah, N. n., Witteles, R. n., Harrington, R. n., Shieh, L. n., Hom, J. n. 2019; 19 (1): 167

  Abstract

  Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients.During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention.Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls.A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.

  View details for DOI 10.1186/s12911-019-0889-6

  View details for PubMedID 31429747

• THE RELATIONSHIP BETWEEN DO-NOT-RESUSCITATE AND NO ESCALATION OF TREATMENT Batten, J., Taylor, G., Blythe, J., Porter-Williamson, K., Dzeng, E., Cotler, M., Kayser, J., Harman, S., Magnus, D. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000498593400363

• Improving palliative care with deep learning. BMC medical informatics and decision making Avati, A., Jung, K., Harman, S., Downing, L., Ng, A., Shah, N. H. 2018; 18 (Suppl 4): 122

  Abstract

  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 PubMedID 30537977

• Update in Hospital Palliative Care: Symptom Management, Communication, Caregiver Outcomes, and Moral Distress JOURNAL OF HOSPITAL MEDICINE Havyer, R. D., Pomerantz, D. H., Jayes, R. L., Harris, P. F., Harman, S. M., Ansari, A. A. 2018; 13 (6): 419–23

  Abstract

  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 PubMedID 29261818

• Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication. Journal of hospital medicine Blankenburg, R., Hilton, J. F., Yuan, P., Rennke, S., Monash, B., Harman, S. M., Sakai, D. S., Hosamani, P., Khan, A., Chua, I., Huynh, E., Shieh, L., Xie, L. 2018

  Abstract

  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 PubMedID 29401211

• "Don't Limit Me'': Discussing Serious News with Intellectually Disabled Adults Vega, C., Hui, F., Harman, S., Mildred, L., Schroeder, K. ELSEVIER SCIENCE INC. 2018: 622

  View details for Web of Science ID 000425399300190

• A Qualitative Study on Inappropriate ICU Admissions: One Step Closer to Preventing Inappropriate ICU Care Harman, S., Marks, N., Kruse, K., Bruce, J., Magnus, D. ELSEVIER SCIENCE INC. 2018: 686

  View details for Web of Science ID 000425399300304

• INAPPROPRIATE ICU ADMISSIONS: ONE STEP CLOSER TO ADDRESSING INAPPROPRIATE ICU CARE FOR PATIENTS Marks, R., Kruse, K., Magnus, D., Bruce, J., Harman, S. LIPPINCOTT WILLIAMS & WILKINS. 2018: 229

  View details for DOI 10.1097/01.ccm.0000528506.64775.d8

  View details for Web of Science ID 000436794300452

• Psychiatric and Palliative Care in the Intensive Care Unit CRITICAL CARE CLINICS Harman, S. M. 2017; 33 (3): 735-+

  Abstract

  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 PubMedID 28601143

• Early Experience With the California End of Life Option Act: Balancing Institutional Participation and Physician Conscientious Objection. JAMA internal medicine Harman, S. M., Magnus, D. 2017

  View details for DOI 10.1001/jamainternmed.2017.1485

  View details for PubMedID 28531248

• 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 Mirarchi, F. L., Cooney, T. E., Venkat, A., Wang, D., Pope, T. M., Fant, A. L., Terman, S. A., Klauer, K. M., Williams-Murphy, M., Gisondi, M. A., Clemency, B., Doshi, A. A., Siegel, M., Kraemer, M. S., Aberger, K., Harman, S., Ahuja, N., Carlson, J. N., Milliron, M. L., Hart, K. K., Gilbertson, C. D., Wilson, J. W., Mueller, L., Brown, L., Gordon, B. D. 2017

  Abstract

  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

• The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital. Journal of hospital medicine Rennke, S. n., Yuan, P. n., Monash, B. n., Blankenburg, R. n., Chua, I. n., Harman, S. n., Sakai, D. S., Khan, A. n., Hilton, J. F., Shieh, L. n., Satterfield, J. n. 2017; 12 (12): 1001–8

  Abstract

  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 PubMedID 29073314

• Improving Palliative Care with Deep Learning Avati, A., Jung, K., Harman, S., Downing, L., Ng, A., Shah, N. H., Hu, X. H., Shyu, C. R., Bromberg, Y., Gao, J., Gong, Y., Korkin, D., Yoo, Zheng, J. H. IEEE. 2017: 311–16

  View details for Web of Science ID 000426504100061

• A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgraduate medical journal Hom, J. n., Kumar, A. n., Evans, K. H., Svec, D. n., Richman, I. n., Fang, D. n., Smeraglio, A. n., Holubar, M. n., Johnson, T. n., Shah, N. n., Renault, C. n., Ahuja, N. n., Witteles, R. n., Harman, S. n., Shieh, L. n. 2017

  Abstract

  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 PubMedID 28663352

• Improving palliative care with deep learning. IEEE International Conference on Bioinformatics and Biomedicine Avati, A., Jung, K., Stephanie, H., Lance, D., Ng, A., Shah, N. 2017
• Prevalence and Financial Impact of Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting: A Retrospective Analysis Mou, E., Kwang, H., Hom, J., Shieh, L., Ahuja, N., Harman, S., Johnson, T., Kumar, A., Shah, N., Witteles, R., Berube, C. AMER SOC HEMATOLOGY. 2016

  View details for Web of Science ID 000394452508066

• The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation? Academic medicine Hom, J., Richman, I., Hall, P., Ahuja, N., Harman, S., Harrington, R., Witteles, R. 2016; 91 (11): 1534-1539

  Abstract

  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

• The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation? ACADEMIC MEDICINE Hom, J., Richman, I., Hall, P., Ahuja, N., Harman, S., Harrington, R., Witteles, R. 2016; 91 (11): 1534–39

  View details for DOI 10.1097/ACM.0000000000001034

  View details for Web of Science ID 000387208300024

• A resident-created hospitalist curriculum for internal medicine housestaff. Journal of hospital medicine Kumar, A., Smeraglio, A., Witteles, R., Harman, S., Nallamshetty, S., Rogers, A., Harrington, R., Ahuja, N. 2016; 11 (9): 646-649

  Abstract

  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

• GOT SDM?: A MULTIMODAL INTERVENTION TO IMPROVE SHARED DECISION-MAKING DURING INPATIENT ROUNDS ON MEDICINE AND PEDIATRIC SERVICES Blankenburg, R., Rennke, S., Sakai, D. S., Harman, S. M., Yuan, P., Hosamani, P., Xie, L., Shieh, L., Chua, I., Khan, A., Huynh, E., Satterfield, J., Monash, B. SPRINGER. 2016: S233–S234

  View details for Web of Science ID 000392201600260

• When Worlds Collide: Decision Making and Palliative Care for Patients with Mental Illness Harman, S., Hsin, G., Kilbane, E. ELSEVIER SCIENCE INC. 2016: 378

  View details for DOI 10.1016/j.jpainsymman.2015.12.248

  View details for Web of Science ID 000373472900171

• SHARED DECISION-MAKING DURING INPATIENT ROUNDS: DISSIMILAR YET CORRELATED PERSPECTIVES OF PATIENTS/GUARDIANS AND PHYSICIAN OBSERVERS Rennke, S., Monash, B., Blankenburg, R., Yuan, P., Harman, S. M., Hilton, J. F., Sakai, D. S., Chua, I., Huynh, E., Hosamani, P., Khan, A., Shieh, L., Xie, L., Satterfield, J. SPRINGER. 2015: S252

  View details for Web of Science ID 000358386901079

• Curricular Innovations for Medical Students in Palliative and End-of-Life Care: A Systematic Review and Assessment of Study Quality JOURNAL OF PALLIATIVE MEDICINE DeCoste-Lopez, J., Madhok, J., Harman, S. 2015; 18 (4): 338-349

  Abstract

  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 Web of Science ID 000351274500008

  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 Decoste-Lopez, J., Madhok, J., Harman, S. 2015; 18 (4): 338-349

  Abstract

  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

• SHARED DECISION MAKING DURING INPATIENT ROUNDS: OPPORTUNITIES FOR IMPROVEMENT IN PATIENT ENGAGEMENT AND COMMUNICATION Harman, S. M., Hosamani, P., Shieh, L., Huynh, E., Rennke, S., Monash, B., Yuan, P., Hilton, J. F., Blankenburg, R., Sakai, D. S., Chua, I., Khan, A., Xie, L., Satterfield, J. SPRINGER. 2015: S251

  View details for Web of Science ID 000358386901078

• Lights! Camera! Feedback! Video-Based Coaching to Improve Teaching and Communication Skills Harman, S., Arnold, R., Carey, E. ELSEVIER SCIENCE INC. 2015: 348–49

  View details for DOI 10.1016/j.jpainsymman.2014.11.067

  View details for Web of Science ID 000348478200046

• Patients Who Lack Capacity and Lack Surrogates: Can They Enroll in Hospice? JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Effiong, A., Harman, S. 2014; 48 (4): 745-U277

  Abstract

  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 Web of Science ID 000343856500026

• Patients who lack capacity and lack surrogates: can they enroll in hospice? Journal of pain and symptom management Effiong, A., Harman, S. 2014; 48 (4): 745-50 e1

  Abstract

  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 Humphreys, J., Harman, S. 2014; 12 (4): 129-136

  Abstract

  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

• HOW PATIENT-CENTERED ARE YOU? THE IMPLEMENTATION AND ASSESSMENT OF A TRAIN-THE-TRAINER SHARED DECISION MAKING CURRICULUM FOR HOSPITAL BEDSIDE ROUNDS Rennke, S., Monash, B., Blankenburg, R., Sakai, D., Harman, S. M., Khan, A., Braddock, C. H., Yuan, P., Satterfield, J. SPRINGER. 2014: S520

  View details for Web of Science ID 000340996203118

• PALLIATIVE CARE AND ANTI-CANCER CARE INTEGRATION: DESCRIPTION OF THREE MODELS OF CARE DELIVERY AT A TERTIARY MEDICAL CENTER Ramchandran, K. J., Fronk, J., Trieu, S., Wakelee, H. A., Das, M., Neal, J. W., Harman, S., Dwyer, P., Bosch, J., Shaw, H., Safari, S., Oden, R., Morrison, T., Blayney, D. LIPPINCOTT WILLIAMS & WILKINS. 2013: S1324

  View details for Web of Science ID 000339624906208

• Outpatient palliative care at a tertiary cancer center: Perceptions, pathways, and pitfalls Ramchandran, K., Trieu, S., Harman, S., Passaglia, J., Rodriguez, J., Dwyer, P., Oden, R. AMER SOC CLINICAL ONCOLOGY. 2012

  View details for DOI 10.1200/jco.2012.30.34_suppl.28

  View details for Web of Science ID 000208943900029

• EARLY VS. LATE ACCESS TO PALLIATIVE CARE CONSULTATION: DOES IT MAKE A DIFFERENCE? Humphreys, J., Harman, S. SPRINGER. 2012: S174

  View details for Web of Science ID 000209142900180

• Update in Palliative Care-2011 National Meeting of the Society-of-General-Internal-Medicine (SGIM) Harris, P. F., Arnold, R. M., Braun, U. K., Fromme, E., Ghermay, R., Harman, S., Jayes, R. L., Walling, A. M. SPRINGER. 2012: 582–87

  Abstract

  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

  View details for PubMedCentralID PMC3326102

• Palliative Care Rounds: Toward Evidence-Based Practice JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Dy, S. M., Harman, S. M., Braun, U. K., Howie, L. J., Harris, P. F., Jayes, R. L. 2012; 43 (4): 795-801

  Abstract

  Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence to inform the decision, focusing on the specific question of whether the benefits of palliative biliary stents in patients with advanced cancer outweigh the risks. We then apply the evidence to the issue of how the primary and/or palliative care team and the interventionist communicate with patients and their families about the risks and benefits of palliative procedures. Review of the evidence found several prospective case series without control groups that measured patient-centered outcomes. Studies had high attrition rates, results for improvements in symptoms and quality of life were mixed, and rates of complications and short-term mortality were high. In conclusion, the limited evidence does not support that the benefits of palliative biliary stents in this population outweigh the risks. We propose that primary care teams consider and discuss the larger picture of the goals of care with patients and families when considering offering these procedures, as well as benefits and potential harms, and consider involving palliative care services early, before consultation with an interventionist.

  View details for DOI 10.1016/j.jpainsymman.2011.12.269

  View details for Web of Science ID 000303194400018

  View details for PubMedCentralID PMC4696003