VJ Periyakoil, MD , Associate Professor of Medicine at Stanford University School of Medicine; Director, Stanford Palliative Care Education & Training Program & the Stanford Hospice & Palliative Medicine Fellowship Program.
Dr. Periyakoil is a member of the study section for the National Institute of Aging, National Institutes of Health, the Senior Associate Editor of the Journal of Palliative Medicine and Associate Editor, the Journal of the American Geriatrics Society. She serves as the Chair of the Ethnogeriatrics Committee of the American Geriatrics Society, the Chair of the American Board of Internal Medicine’s Hospice & Palliative Medicine SEP Committee, Board member of the Council of faculty and Societies, founding Chair , Diversity Committee of the American Association of Medical Colleges. Her work has been and is funded by grants from NIH, HRSA, foundations as well as the Department of Veterans Affairs.
A nationally recognized leader in geriatrics and palliative care, Periyakoil founded and directs Stanford eCampus (http://ecampus.stanford.edu), the Ethno-geriatrics & the Successful Aging Project (http://geriatrics.stanford.edu ), and Stanford Palliative Care (http://palliative.stanford.edu).
She has won many research awards including an young investigator award by the American Association of Hospice and Palliative Medicine, a plenary research paper award by the American Geriatrics Society (2014), Ethnogeriatrics Research poster award (2015) and a research award by the American Association of Hospice and Palliative Medicine (2015) and an Innovator award from the American Medical Association (2015)
In the clinical realm, she serves as the Associate Director of Palliative Care Services at the VA Palo Alto Health Care Center. Her research focuses on wellbeing of multi-cultural persons in the context of geriatrics, ethno-geriatrics and hospice, palliative care & end-of-life care. She has presented in numerous national meetings including the plenary of the American Geriatrics Society and the National Hospice & Palliative Care Organization annual meetings as well as the recent End-of-Life meeting of the Institute of Medicine.
She can be contacted by email (email@example.com) or through twitter : @palliator
- Hospice and Palliative Medicine
- Cross Cultural Medicine
Associate Director, Palliative Care Services, VA Palo Alto Health Care System System (2003 - Present)
Director, VA Interprofessional Fellowship in Palliative Care, VA Palo Alto Health Care System System (2005 - Present)
Director, Stanford e-Campus, Stanford University (2008 - Present)
Director, Stanford University Hospice and Palliative Medicine Fellowship Program, Stanford University (2008 - Present)
Director of Palliative Care Education and Training, Stanford University (2008 - Present)
Honors & Awards
Member, Nominating Committee, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2017)
Founding Chair, Diversity Committee, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2016)
Associate Editor, Journal of the American Geriatrics Society (JAGS), Wiley Publishers (2016-)
Doctors and End-of-Life Discussions: : http://to.pbs.org/1QbE3JK, Public Broadcasting Service (January 2016)
American Medical Association and Medical Group Management Association Practice Innovation Award, American Medical Association (October 2015)
Pitfalls for Proxies: Op-ed http://opinionator.blogs.nytimes.com/author/vj-periyakoil/?_r=0, New York Times (November 2015)
Doctor-reported barriers to conducting EOL conversations with diverse patients. (Mixed methods), American Geriatrics Society; Presidential Best Poster Award for Health and Healthcare Disparities (May 2015)
Best Paper Award for Outstanding Excellence in Geriatrics Research in All Categories, American Geriatrics Society (May 2014)
We Need a Role Reversal in the Conversation on Dying, New York Times http://opinionator.blogs.nytimes.com/author/vj-periyakoil/?_r=0 (April 2015)
Board Member, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2015)
Member, Communications Committee, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2015)
Research award: Doctor reported barriers to end-of-life conversations with diverse patients., American Association of Hospice and Palliative Medicine (2015)
Member,Review Committee, Dying in America: Improving Quality and Honoring Individual Preferences, Institute of Medicine (2014)
Member, Council of Faculty and Academic Societies (CFAS)., Association of American Medical Colleges (2013-)
Member, Public Health: Care, Prevention, and Disparities Committee,, Interagency Pain Research Coordinating Committee (IPRCC) Department of Health and Human Services (2013-)
Member, Scientific Review Panel, National Institutes of Health (NIH), National Institute of Aging (NIA) (2013-)
Vice Chair, Ethno Geriatrics Committee, American Geriatrics Society (2013-)
Clinical Teaching Award, Department of Medicine (2013)
Member, Publications Committee, American Academy of Hospice and Palliative Medicine (2012-)
Chair, Self Evaluation Process for Hospice and Palliative Medicine, American Board of Internal Medicine (2012)
Editor-in-Chief, AAHPM Quarterly, American Academy of Hospice and Palliative Medicine (2012)
Member of the Program Planning Committee, American Geriatrics Society (2012)
Member of the National Planning Committee on end of life care, Institute of Medicine (2011)
Member, Primary Palliative Care Committee, American Board of Internal Medicine (2011)
Senior Associate Editor for Social Media, Journal of Palliative Medicine (2011)
Certificate of Merit for service, American Cancer Society Santa Clara Chapter (2010)
Clinical Teaching Award, Division of General Internal Medicine (2010)
Member, National Priorities Partnership (NPP) Palliative and end-of-life Convening Workshop, National Quality Forum (2010)
Award for Outstanding Service to Palliative Care, Department of Veterans Affairs (2008)
Outstanding service award:, American Geriatrics Society: Ethnogeriatrics committee (2008)
Young investigator award, American Association of Hospice and Palliative Medicine (2007)
Boards, Advisory Committees, Professional Organizations
Founding Chair, Diversity Committee,, CFAS, AAMC (2016 - Present)
Chair, Ethnogeriatrics Committee, American Geriatrics Society (2015 - Present)
Board Member, Council of Faculty and Societies, American Association of Medical Colleges (2015 - Present)
National Pain Strategy Committee Member: http://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf, Interagency Pain Research Coordinating Committee & Department of Health and Human Services (2014 - 2016)
Member, Council of Faculty and Academic Societies, American Association of Medical Colleges (2014 - Present)
Vice Chair, Ethnogeriatrics Committee, American Geriatrics Society (2012 - 2015)
Publication committee member, American Academy of Hospice and Palliative Medicine (2010 - 2015)
Fellowship:Stanford University - CAPS (2000) CA
Residency:San Joaquin General Hospital - GME OFFICE (1997) CA
Internship:San Joaquin General Hospital - GME OFFICE (1995) CA
Medical Education:University of Madras (1991)
Board Certification, American Board of Internal Medicine, Geriatric Medicine (2010)
Board Certification: Hospice and Palliative Medicine, American Board of Internal Medicine (2008)
Board Certification: Geriatric Medicine, American Board of Internal Medicine (2000)
Community and International Work
Member, Board of Directors, American Cancer Society Santa Clara County Unit, Campbell, CA, Campbell, California
Advocacy through ACS community-based cancer outreach, advocacy, and volunteer efforts.
American Cancer Society
Cancer patients in Santa Clara County
Opportunities for Student Involvement
Current Research and Scholarly Interests
My work is in two areas
1. I study research problems where biological, psychosocial and cultural aspects meet in the care of persons with chronic and serious illnesses.
2. I study the pedagogy of health e-learning using multi-media and Web 2.0 techniques with a special interest in the science of Social Media ( blogs, micro-blogs, etc) and videos to foster learning behaviors and change
Comparing the Stanford Letter Project Form to Traditional Advance Directives
Our goal is to compare two types of advance directives forms available in English and Spanish to determine which is more easy to use for patients.
Stanford Letter or Traditional Advance Directive in Advance Care Planning in Patients Undergoing Bone Marrow Transplant
The purpose of the proposed research study is to evaluate whether bone marrow transplant patients prefer the Stanford letter advance care planning tool to the standard Advance directive. Completion of advance care planning prior to BMT is very important, but not often done. The investigators believe that the Stanford Letter will be preferred by patients and will allow them to feel more comfortable and share more of their wishes with family members and the medical team.
Trial of Strategies to Communicate Genetic Information to Different Ethnic Subpopulations
The goal of this study is to better understand how clinicians give genetic risk information to patients from multi-ethnic groups and how patients understand this information and remember it and act upon it. In addition investigators want to know how to better communicate with patients about complex health issues across the health literacy divide and communication gap that exists between doctors and their patients.
Stanford Letter Project, Stanford University
The goal of this project is to empower diverse Americans to complete advance care planning using the Letter Project tool, available in eight different languages. The tool has been proven to be effective based on a recently published randomized clinical trial: https://www.ncbi.nlm.nih.gov/pubmed/28471713
- Compassionate presence at the bedside: A palliative practicum
MED 51Q (Aut)
- Independent Studies (5)
Prior Year Courses
- Compassionate Presence at the Bedside: The Healer's Art
MED 51B (Win)
- Palliative Medicine, Hospice and End of Life Care for Diverse Americans
MED 51Q (Aut)
- Compassionate Presence at the Bedside: The Healer's Art
Graduate and Fellowship Programs
Common Items on a Bucket List.
Journal of palliative medicine
To provide preference-sensitive care, we propose that clinicians might routinely inquire about their patients' bucket-lists and discuss the impact (if any) of their medical treatments on their life goals.This cross-sectional, mixed methods online study explores the concept of the bucket list and seeks to identify common bucket list themes. Data were collected in 2015-2016 through an online survey, which was completed by a total of 3056 participants across the United States. Forty participants who had a bucket list were identified randomly and used as the development cohort: their responses were analyzed qualitatively using grounded theory methods to identify the six key bucket list themes. The responses of the remaining 3016 participants were used for the validation study. The codes identified from the development cohort were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 3016 validation cohort transcripts were coded for presence or absence of each of the six bucket list themes.Around 91.2% participants had a bucket list. Age and spirituality influence the patient's bucket-list. Participants who reported that faith/religion/spirituality was important to them were most likely (95%) to have a bucket list compared with those who reported it to be unimportant (68.2%), χ2 = 37.67. Six primary themes identified were the desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve financial stability (24.3%), and desire to do a daring activity (15%).The bucket list is a simple framework that can be used to engage patients about their healthcare decision making. Knowing a patient's bucket list can aid clinicians in relating each treatment option to its potential impact (if any) on the patient's life and life goals to promote informed decision making.
View details for DOI 10.1089/jpm.2017.0512
View details for PubMedID 29415602
- Square Pegs; Round Holes: Our Healthcare System Is Failing Seriously Ill Older Americans in Their Last Years. Journal of the American Geriatrics Society 2018; 66 (1): 15–17
Advance Directive Utilization is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation.
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation
Background Allogeneic hematopoietic cell transplantation (HCT) is associated with significant morbidity and mortality, making advance care planning (ACP) and management especially important in this patient population. A paucity of data exists on the utilization of ACP amongst allogeneic HCT recipients, and the relationship between ACP and intensity of health care utilization in these patients. Methods We performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died following HCT. Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record. Outcomes of interest included (a) utilization of intensive care unit level of care (ICU) at (i) any time point following HCT, (ii) within 30 days of death, (iii) within 14 days of death, (b) use of mechanical ventilation at any time point following HCT, and (c) location of death. Univariate logistic regression was performed to explore associations between AD completion and each outcome. Results Of the 1031 patients who received allogeneic HCT during the study period, there were 422 (41%) decedents who are included in the analysis. Forty-four percent had AD documentation prior to death. A majority of patients (69%) indicated that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with Non-Hispanic White patients documenting ADs more frequently (51%) compared to Hispanic (22%) or Asian patients (35%); p= 0.0007. Patients with AD were less likely to utilize the ICU during the transplant course (41% for patients with AD versus 52% of patients without AD; p= 0.03) and also were less likely to receive mechanical ventilation at any point following transplantation (21% versus 37%; p<0.001). AD documentation was also associated with decreased ICU utilization at the end-of-life; relative to patients without AD, patients with AD were more likely to die at home or in hospital as opposed to in the ICU (OR 0.44, 95% CI 0.27-0.72).ACP remains underutilized in allogeneic HCT. Adoption of a systematic practice to standardize AD documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU utilization and mechanical ventilation while improving quality of care at end-of-life in HCT recipients.
View details for DOI 10.1016/j.bbmt.2018.01.014
View details for PubMedID 29371107
- Talk to Your Doctor About Your Bucket List New York Times. 2018 ; Well|Live
A Randomized Controlled Trial Comparing the Letter Project Advance Directive to Traditional Advance Directive.
Journal of palliative medicine
Simpler alternatives to traditional advance directives that are easy to understand and available in multiple formats and can be initiated by patients and families will help facilitate advance care planning. The goal of this study was to compare the acceptability of the letter advance directive (LAD) to the traditional advance directive (TAD) of the state of California.A web-based, randomized controlled trial was conducted, in which the participants were randomized to one of two types of advance directives (ADs): the LAD (intervention) or the TAD (control). Primary outcomes were participant ratings of the ease, value, and their level of comfort in the AD document they completed.A total of 400 participants completed the study, with 216 randomized to the LAD and 184 to the TAD by a computerized algorithm. Overall, participants preferred the LAD to the TAD (success rate difference [SRD] = 0.46, 95th percentile confidence interval [CI]: 0.36-0.56, p < 0.001). The participants felt that, compared to the TAD, the LAD was easier to read and understand (SRD = 0.56, CI: 0.47-0.65, p < 0.001); better reflected what matters most to them (SRD = 0.39, CI: 0.29-0.48, p < 0.001); helped stimulate their thinking about the types of treatments they wanted at the end of life (SRD = 0.32, CI: 0.23-0.42, p < 0.001); allowed them to describe how they made medical decisions in their family (SRD = 0.31, CI: 0.21-0.40, p < 0.001); and could help their doctor(s) (SRD = 0.24, CI: 0.13-0.34, p < 0.001) and their families (SRD = 0.19, CI: 0.08-0.28, p < 0.001) understand their end-of-life treatment preferences.Patients reported the letter advance directive to be a better alternative to the traditional advance directive form.
View details for DOI 10.1089/jpm.2017.0066
View details for PubMedID 28471713
Redesigning Cancer Care Delivery: Views From Patients and Caregivers.
Journal of oncology practice
2017; 13 (4): e291-e302
Cancer is a leading cause of death in the United States. Although treatments have improved, patients and caregivers continue to report significant gaps in their care. The objective of this study was to examine the views of patients and caregivers on their experiences with current cancer care delivery and identify key strategies to improve the delivery of care.Semistructured interviews were conducted with 75 patients and 45 caregivers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Participants reported multiple gaps in care delivery, including barriers in health communication with health care providers, lack of elucidation of care goals, lack of care coordination, and challenges in accessing care. Participants identified that greater use of nonphysician providers and alternative formats, such as telephone-based care and home and community-based care, would narrow these gaps.Understanding patients' and caregivers' experiences with gaps in cancer care delivery can inform cancer care delivery redesign efforts and lead to targeted interventions that result in patient-centered and family-oriented care.
View details for DOI 10.1200/JOP.2016.017327
View details for PubMedID 28399387
Delivering End-of-Life Cancer Care: Perspectives of Providers.
The American journal of hospice & palliative care
Persistent gaps in end-of-life cancer care delivery and growing associated expenditures remain imminent US public health issues. The objective of this study was to understand clinical providers' experiences delivering cancer care for patients at the end of life and their perspectives on potential solutions to improve quality of care.Semistructured interviews were conducted with 75 cancer care providers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Providers identified 3 major cancer care delivery challenges including lack of time to educate patients and caregivers due to clinical volume and administrative burdens, ambiguity in determining both prognosis and timing of palliative care at the end-of-life, and lack of adequate systems to support non-face-to-face communication with patients. To address these challenges, providers endorsed several options for clinical practice redesign in their settings. These include use of a lay health worker to assist in addressing early advance care planning, proactive non-face-to-face communication with patients specifically regarding symptom management, and community and in-home delivery of cancer care services.Specific strategies for cancer care redesign endorsed by health-care providers may be used to create interventions that can more efficiently and effectively address gaps in end-of-life cancer care.
View details for DOI 10.1177/1049909117719879
View details for PubMedID 28691498
- Supporting patients who are bereaved. BMJ (Clinical research ed.) 2017; 358: j2854
Multi-Ethnic Attitudes Toward Physician-Assisted Death in California and Hawaii
JOURNAL OF PALLIATIVE MEDICINE
2016; 19 (10): 1060-1065
As aid-in-dying laws are gaining more public acceptance and support, it is important to understand diverse perceptions toward physician-assisted death (PAD). We compare attitudes of residents from California and Hawaii to identify variables that may predict attitudes toward PAD.A cross-sectional online survey of 1095 participants (a 75.8% survey completion rate) from California and 819 from Hawaii (a 78.4% survey completion rate). Data were collected between July through October 2015.Majority of study participants in California (72.5%) and Hawaii (76.5%) were supportive of PAD. Only 36.8% of participants in Hawaii and 34.8% of participants in California reported completing advance directives. To better understand which subgroups were most in favor of PAD, data were analyzed using both recursive partitioning and stepwise logistic regression. Older participants were more supportive of PAD in both states. Also, all ethnic groups were equally supportive of PAD. Completion of advance directives was not a significant predictor of attitudes toward PAD. Persons who reported that faith/religion/spirituality was less important to them were more likely to support PAD in both states. Thus, the major influences on the attitudes to PAD were religious/spiritual views and age, not ethnicity and gender. Even in the subgroups least supportive of PAD, the majority supported PAD.This study shows that in the ethnically diverse states of California and Hawaii, faith/religion/spirituality and age are major influencers of attitudes toward PAD and not ethnicity and gender. Even in the subgroups least supportive of PAD, the majority supports PAD.
View details for DOI 10.1089/jpm.2016.0160
View details for Web of Science ID 000385376500010
View details for PubMedID 27276445
Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol
The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance.We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.
View details for DOI 10.1186/s13012-016-0497-0
View details for Web of Science ID 000384773200001
View details for PubMedID 27682236
View details for PubMedCentralID PMC5041212
Patient-Reported Barriers to High-Quality, End-of-Life Care: A Multiethnic, Multilingual, Mixed-Methods Study.
Journal of palliative medicine
2016; 19 (4): 373-379
The study objective was to empirically identify barriers reported by multiethnic patients and families in receiving high-quality end-of-life care (EOLC).This cross-sectional, mixed-methods study in Burmese, English, Hindi, Mandarin, Tagalog, Spanish, and Vietnamese was held in multiethnic community centers in five California cities. Data were collected in 2013-2014. A snowball sampling technique was used to accrue 387 participants-261 women, 126 men, 133 Caucasian, 204 Asian Americans, 44 African Americans, and 6 Hispanic Americans. Measured were multiethnic patient-reported barriers to high-quality EOLC. A development cohort (72 participants) of responses was analyzed qualitatively using grounded theory to identify the six key barriers to high-quality EOLC. A new validation cohort (315 participants) of responses was transcribed, translated, and back-translated for verification. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 315 validation cohort transcripts were coded for presence or absence of the six barriers.In the validation cohort, 60.6% reported barriers to receiving high-quality EOLC for persons in their culture/ethnicity. Primary patient-reported barriers were (1) finance/health insurance barriers, (2) doctor behaviors, (3) communication chasm between doctors and patients, (4) family beliefs/behaviors, (5) health system barriers, and (6) cultural/religious barriers. Age (χ(2) = 9.15, DF = 1, p = 0.003); gender (χ(2) = 6.605, DF = 1, p = 0.01); and marital status (χ(2) = 16.11 DF = 3, p = 0.001) were associated with reporting barriers; and women <80 years were most likely to report barriers to receiving high-quality EOLC. Individual responses of reported barriers were analyzed and only the participant's level of education (Friedman statistic = 2.16, DF = 10, p = 0.02) significantly influenced choices.Multiethnic patients report that high-quality EOLC is important to them; but unfortunately, a majority state that they have encountered barriers to receiving such care. Efforts must be made to rapidly improve access to culturally competent EOLC for diverse populations.
View details for DOI 10.1089/jpm.2015.0403
View details for PubMedID 26575114
- Patient-Reported Barriers to High-Quality, End-of-Life Care: A Multiethnic, Multilingual, Mixed-Methods Study JOURNAL OF PALLIATIVE MEDICINE 2016; 19 (4): 373-379
Women in Academic Medicine: Measuring Stereotype Threat Among Junior Faculty
JOURNAL OF WOMENS HEALTH
2016; 25 (3): 292-298
Gender stereotypes in science impede supportive environments for women. Research suggests that women's perceptions of these environments are influenced by stereotype threat (ST): anxiety faced in situations where one may be evaluated using negative stereotypes. This study developed and tested ST metrics for first time use with junior faculty in academic medicine.Under a 2012 National Institutes of Health Pathfinder Award, Stanford School of Medicine's Office of Diversity and Leadership, working with experienced clinicians, social scientists, and epidemiologists, developed and administered ST measures to a representative group of junior faculty.174 School of Medicine junior faculty were recruited (62% women, 38% men; 75% assistant professors, 25% instructors; 50% white, 40% Asian, 10% underrepresented minority). Women reported greater susceptibility to ST than did men across all items including ST vulnerability (p < 0.001); rejection sensitivity (p = 0.001); gender identification (p < 0.001); perceptions of relative potential (p = 0.048); and, sense of belonging (p = 0.049). Results of career-related consequences of ST were more nuanced. Compared with men, women reported lower beliefs in advancement (p = 0.021); however, they had similar career interest and identification, felt just as connected to colleagues, and were equally likely to pursue careers outside academia (all p > 0.42).Innovative ST metrics can provide a more complete picture of academic medical center environments. While junior women faculty are susceptible to ST, they may not yet experience all of its consequences in their early careers. As such, ST metrics offer a tool for evaluating institutional initiatives to increase supportive environments for women in academic medicine.
View details for DOI 10.1089/jwh.2015.5380
View details for Web of Science ID 000372173200014
Achieving High-Quality Multicultural Geriatric Care.
Journal of the American Geriatrics Society
As the ethnic diversity of the U.S. population increases, there is a growing awareness of healthcare disparities and the need to address them. This position statement that the American Geriatrics Society (AGS) Ethnogeriatrics Committee developed outlines healthcare disparities in the United States and the minimum quality indicators that healthcare organizations and healthcare providers should adopt to ensure that all older adults receive care that is culturally appropriate and takes into account level of health literacy.
View details for DOI 10.1111/jgs.13924
View details for PubMedID 26804356
A Never-Ending Battle.
New England journal of medicine
2015; 373 (25): 2399-2401
"Were you in the Army, Navy, Air Force, Marine Corps, or the `Guard'?" I asked as I admitted my patient, a 78-year-old veteran. Mr. M. had florid heart failure, the result of multiple myocardial infarctions over years, each one taking a big bite out of his heart's pumping abilities and leaving his lungs and body waterlogged. His aging kidneys had slacked off, too, and despite maximal medical therapy he was now looking at a remaining lifespan of weeks. He was wheelchair-bound and tethered to his oxygen cylinder owing to profound air hunger. He sketched me a mocking salute. "U.S. Army . . .
View details for DOI 10.1056/NEJMp1505976
View details for PubMedID 26536398
- No Easy Talk: A Mixed Methods Study of Doctor Reported Barriers to Conducting Effective End-of-Life Conversations with Diverse Patients PLOS ONE 2015; 10 (4)
Understanding frailty in cancer patients.
2014; 20 (5): 358-366
As population ages, the number of older adults with cancer is increasing rapidly. Chronological age per se is a poor guide for an oncologist to determine tolerance to cancer treatment. Older adults have been underrepresented in cancer clinical trials, leading to paucity of guidelines to meet the treatment challenges in this population. To evaluate an older adult with cancer, oncologists must understand age-related changes and identify the subset of population who is vulnerable and at risk of cancer treatment toxicity. Comprehensive geriatric assessments focusing on functional status, multimorbidity, nutritional status, cognitive impairment, and psychosocial support help recognize heterogeneity among older adults, leading to individualized approaches toward cancer treatment. The treatment decisions need to be made in collaboration with the patient's values and preferences.
View details for DOI 10.1097/PPO.0000000000000068
View details for PubMedID 25299146
Prognostic stratification in older adults commencing dialysis.
journals of gerontology. Series A, Biological sciences and medical sciences
2014; 69 (8): 1033-1039
Accurate prognostic models could inform treatment decisions for older adults with end-stage renal disease who are considering dialysis and might identify patients more appropriate for conservative care or hospice.In a cohort of patients aged ≥67 years commencing dialysis in the United States between January 1, 2008 and June 30, 2009, we compared the discrimination of three existing instruments (the Liu index; the French Renal Epidemiology and Information Network score; and hospice eligibility criteria) for the prediction of 6-month mortality. We estimated the odds of death associated with each prognostic index using logistic regression with and without adjustment for age. Predictive indices were compared using the concordance ("c")-statistic.Of 44,109 eligible patients, 10,289 (23.3%) died within 6 months of dialysis initiation. The c-statistic for the Liu, Renal Epidemiology and Information Network, hospice eligibility criteria, and combined Liu/hospice eligibility criteria scores without and with age were 0.62/0.65, 0.63/0.66, 0.65/0.68, and 0.68/0.70, respectively. Discrimination was poorer at older ages, especially for the Liu and Renal Epidemiology and Information Network scores. Although sensitivity was poor, a Renal Epidemiology and Information Network score ≥9 or an hospice eligibility criteria ≥3 had relatively high specificity.Existing prognostic indices based on administrative data perform poorly with respect to prediction of 6-month mortality in older patients with end-stage renal disease commencing dialysis.
View details for DOI 10.1093/gerona/glt289
View details for PubMedID 24482541
- Raising the Bar for the Care of Seriously Ill Patients: Results of a National Survey to Define Essential Palliative Care Competencies for Medical Students and Residents ACADEMIC MEDICINE 2014; 89 (7): 1024-1031
Position statement on interdisciplinary team training in geriatrics: an essential component of quality health care for older adults.
Journal of the American Geriatrics Society
2014; 62 (5): 961-965
Interdisciplinary team training (IDT) is an important component of ensuring quality geriatric care delivery, which can be complex and time intensive, requiring coordination of many medical, psychosocial, and therapeutic interventions and professionals. The Partnership for Health in Aging (PHA), a loose coalition of more than 30 organizations representing healthcare professionals who care for older adults supported by the American Geriatrics Society, identified IDT training in geriatrics as a priority area in addressing the geriatrics workforce shortage described in the 2008 Institute of Medicine report, Retooling for An Aging America: Building the Health Care Workforce. A PHA Workgroup on Interdisciplinary Team Training in Geriatrics was convened to review the literature focused on geriatrics IDT training and to develop a position statement that would inform and influence groups involved in the development and expansion of academic and continuing education programs in IDT training, including professional associations, credentialing and licensing bodies, accreditation organizations, and university administrators. There are significant challenges to expanding the development and implementation of geriatrics IDT training for health professionals, and such training will be successful only with substantial and sustained advocacy from the above professional groups.
View details for DOI 10.1111/jgs.12822
View details for PubMedID 24738753
Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives.
2014; 9 (5)
High-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.Doctors in two academic medical centers participated in an AD simulation and attitudes survey in 2013 and their responses were compared to a cohort of doctors in 1989.Resuscitation and organ donation preferences (2013 cohort) and attitudes toward AD (1989 and 2013 cohorts).In 2013, 1081 (94.2%) doctors of the 1147 approached participated. Compared to 1989, 2013 cohort did not feel that widespread acceptance of AD would result in less aggressive treatment even of patients who do not have an AD (p<0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p<.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p<.001, AUC = 0.57). The gender (p = 0.00172), ethnicity (χ2 14.68, DF = 3,p = .0021) and sub-specialty (χ2 28.92, p = .004, DF = 12) influenced their attitudes towards AD. 88.3% doctors chose do-not-resuscitate status and wanted to become organ donors. Those less supportive of AD were more likely to opt for "full code" even if terminally ill and were less supportive of organ donation.Doctors' attitudes towards AD has not changed significantly in the past 23 years. Doctors' gender, ethnicity and sub-specialty influence their attitudes towards AD. Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients but personally forego such care for themselves at the end of life.
View details for DOI 10.1371/journal.pone.0098246
View details for PubMedID 24869673
- Do Unto Others: Doctors' Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives. PloS one 2014; 9 (5)
Changes in QTc Interval in the Citalopram for Agitation in Alzheimer's Disease (CitAD) Randomized Trial.
2014; 9 (6)
A Food and Drug Administration (FDA) safety communication in August 2011 warned that citalopram was associated with a dose dependent risk of QT prolongation and recommended dose restriction in patients over the age of 60 but did not provide data for this age group.CitAD was a randomized, double-masked, placebo-controlled, multicenter clinical trial for agitation in Alzheimer's disease (AD). Participants were assigned to citalopram (target dose of 30 mg/day) or placebo in a 1∶1 ratio. 186 people, 181 of whom were over the age of 60, having probable AD with clinically significant agitation were recruited from September 2009 to January 2013. After the FDA safety communication about citalopram, ECG was added to the required study procedures before enrollment and repeated at week 3 to monitor change in QTc interval. Forty-eight participants were enrolled after enhanced monitoring began.Citalopram treatment was associated with a larger increase in QTc interval than placebo (difference in week 3 QTc adjusting for baseline QTc: 18.1 ms [95% CI: 6.1, 30.1]; p = 0.004). More participants in the citalopram group had an increase ≥30 ms from baseline to week 3 (7 in citalopram versus 1 in placebo; Fisher's exact p = 0.046), but only slightly more in the citalopram group met a gender-specific threshold for prolonged QTc (450 ms for males; 470 ms for females) at any point during follow-up (3 in citalopram versus 1 in placebo, Fisher's exact p = 0.611). One of the citalopram participants who developed prolonged QTc also displayed ventricular bigeminy. No participants in either group had a cardiovascular-related death.Citalopram at 30 mg/day was associated with improvement in agitation in patients with AD but was also associated with QT prolongation.ClinicalTrials.gov NCT00898807.
View details for DOI 10.1371/journal.pone.0098426
View details for PubMedID 24914549
View details for PubMedCentralID PMC4051660
- Asian Indian American Older Adults Doorway Thoughts: Cross-Cultural Health Care for Older Adults American Geriatrics Society. 2014
- Hinduism Doorway Thoughts: Cross-Cultural Health Care for Older Adults American Geriatrics Society. 2014; 2
- Pakistani American Older Adults Doorway Thoughts: Cross-Cultural Health Care for Older Adults American Geriatrics Society. 2014; 2
Filipino American Older Adults
Doorway Thoughts: Cross-Cultural Health Care for Older Adults
American Geriatrics Society. 2014; 2
View details for DOI 1-886775-33-8
- Successful Aging of Multi-cultural American Older Adults edited by Periyakoil, V. S. Stanford University. 2014
- Doorway Thoughts: Cross-Cultural Health Care for Older Adults edited by Brangman, S., Periyakoil, V. S. American Geriatrics Society. 2014
- The flipped classroom paradigm for teaching palliative care skills. The virtual mentor : VM 2013; 15 (12): 1034-1037
- The patient perspective and physician's role in making decisions on instituting dialysis. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2013; 28 (11): 2663-2666
Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life.
Journal of palliative medicine
2013; 16 (10): 1285-1289
The majority of U.S. cancer patients express the desire to die at home, though most do not, and are often subjected to ineffective therapies near the end of life (EOL). In 2008 the U.K. Department of Health and National Health Care Service implemented a set of 10 quality markers to improve EOL care (EOLC) for seriously ill persons. Data show that this intervention has had a positive impact on patients' EOLC.The study assessed the quality of EOLC received by terminally ill cancer patients admitted to the intensive care unit (ICU) in the last two weeks of life.A retrospective chart review was done of the electronic medical record (EMR) of 2498 patients admitted to the ICU from January to August 2011. The six U.K. quality indicators pertaining to patients were used to assess quality of EOLC.The setting was a tertiary academic medical center with 663 beds and 66 adult ICU beds in northern California.EMR analysis identified 2498 patients admitted to the ICU during the study period--232 died within two weeks of admission. Sixty-nine decedents had metastatic cancer. Of the patients, 58% were male, average age 59.8 years (range 25-91).Quality indicators were met in a relatively small percentage of patients admitted to the ICU in the last two weeks of life: prognostication 67%, advance care planning 32%, goals of care 42%, caregiver needs 0%, coordination of care across organizational boundaries 7%, and standardized care pathway implementation 58%. Palliative care consultations occurred in 28 patients.Quality indicators for EOLC were unmet in cancer patients admitted to the ICU in the last two weeks of life. Hospital-wide provider education about the need for early advance care planning with all seriously ill patients has been implemented in an effort to improve quality of care at EOL.
View details for DOI 10.1089/jpm.2013.0257
View details for PubMedID 24020919
- Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life. Journal of palliative medicine 2013; 16 (10): 1285-1289
Frailty as a terminal illness.
American family physician
2013; 88 (6): 363-368
View details for PubMedID 24134043
Caring for oneself to care for others: physicians and their self-care.
The journal of supportive oncology
2013; 11 (2): 75-81
It is well known that clinicians experience distress and grief in response to their patients' suffering. Oncologists and palliative care specialists are no exception since they commonly experience patient loss and are often affected by unprocessed grief. These emotions can compromise clinicians' personal well-being, since unexamined emotions may lead to burnout, moral distress, compassion fatigue, and poor clinical decisions which adversely affect patient care. One approach to mitigate this harm is self-care, defined as a cadre of activities performed independently by an individual to promote and maintain personal well-being throughout life. This article emphasizes the importance of having a self-care and self-awareness plan when caring for patients with life-limiting cancer and discusses validated methods to increase self-care, enhance self-awareness and improve patient care.
View details for PubMedID 23967495
Multicultural Long-Term Care Nurses' Perceptions of Factors Influencing Patient Dignity at the End of Life
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2013; 61 (3): 440-446
The goal of this mixed-methods study was to characterize the perceptions of multicultural long-term care nurses about patient dignity at the end-of-life (EOL). The study was conducted in a large, urban, long-term care (LTC) facility. Participants were 45 long-term care nurses and 26 terminally ill nursing home residents. Nurses completed an openended interview about their perceptions of the concept of dying with dignity, and the data were analyzed using grounded theory methods. Main themes identified as promoting resident dignity at the EOL included treating them with respect, helping them prepare for the EOL, promoting shared decision-making, and providing high-quality care. The nurses’ cultural and religious backgrounds influenced their perceptions of what constitutes dignity-conserving care. Foreign-born nurses stressed the need for EOL rituals, but this was strikingly absent in the statements of U.S.-born nurses. Foreign-born Catholic nurses stated that the dying experience should not be altered using analgesics to relieve suffering or by attempts to hasten death by forgoing curative therapy or by other means. Nurses and terminally ill individuals completed the Dignity Card-sort Tool (DCT). A comparison of the DCT responses of the LTC nurses cohort with those of the terminally ill participants revealed that the nurses felt patient dignity was eroded when patient wishes were not followed and when they were treated without respect. In contrast, dying LTC residents felt that poor medical care and loss of ability to choose care options were the most important factors leading to erosion of dignity.
View details for DOI 10.1111/jgs.12145
View details for Web of Science ID 000316334900019
View details for PubMedID 23496266
- What Would Osler Do? : Editorial Journal of Palliative Medicine 2013; 16 (2): 118-119
- Measuring Grief and Depression in Seriously III Outpatients Using the Palliative Grief Depression Scale JOURNAL OF PALLIATIVE MEDICINE 2012; 15 (12): 1350-1355
- Differentiating Grief and Depression in Patients Who Are Seriously Ill AMERICAN FAMILY PHYSICIAN 2012; 86 (3): 232-?
Citalopram for agitation in Alzheimer's disease: Design and methods
ALZHEIMERS & DEMENTIA
2012; 8 (2): 121-130
Agitation is one of the most common neuropsychiatric symptoms of Alzheimer's disease (AD), and is associated with serious adverse consequences for patients and caregivers. Evidence-supported treatment options for agitation are limited. The citalopram for agitation in Alzheimer's disease (CitAD) study was designed to evaluate the potential of citalopram to ameliorate these symptoms.CitAD is a randomized, double-masked, placebo-controlled multicenter clinical trial, with two parallel treatment groups assigned in a 1:1 ratio and randomization stratified by clinical center. The study included eight recruiting clinical centers, a chair's office, and a coordinating center located in university settings in the United States and Canada. A total of 200 individuals having probable AD with clinically significant agitation and without major depression were recruited for this study. Patients were randomized to receive citalopram (target dose of 30 mg/d) or matching placebo. Caregivers of patients in both treatment groups received a structured psychosocial therapy. Agitation was compared between treatment groups using the NeuroBehavioral Rating Scale and the AD Cooperative Study- Clinical Global Impression of Change, which are the primary outcomes. Functional performance, cognition, caregiver distress, and rates of adverse and serious adverse events were also measured.The authors believe the design elements in CitAD are important features to be included in trials assessing the safety and efficacy of psychotropic medications for clinically significant agitation in AD.
View details for DOI 10.1016/j.jalz.2011.01.007
View details for Web of Science ID 000301991600005
View details for PubMedID 22301195
View details for PubMedCentralID PMC3333484
Assessment of Factors Influencing Preservation of Dignity at Life's End: Creation and the Cross-Cultural Validation of the Preservation of Dignity Card-Sort Tool
JOURNAL OF PALLIATIVE MEDICINE
2010; 13 (5): 495-500
Preserving patient dignity is a sentinel premise of palliative care. This study was conducted to gain a better understanding of factors influencing preservation of dignity in the last chapter of life.We conducted an open-ended written survey of 100 multidisciplinary providers (69% response rate) and responses were categorized to identify 2 main themes, 5 subthemes, and 10 individual factors that were used to create the preservation of dignity card-sort tool (p-DCT). The 10-item rank order tool was administered to a cohort of community dwelling Filipino Americans (n = 140, age mean = 61.3, 45% male and 55% female). A Spearman correlation matrix was constructed for all the 10 individual factors as well as the themes and subthemes based on the data generated by the subjects.The individual factors were minimally correlated with each other indicating that each factor was an independent stand-alone factor. The median, 25th and 75th percentile ranks were calculated and "s/he has self-respect" (intrinsic theme, self-esteem subtheme) emerged as the most important factor (mean rank 3.0 and median rank 2.0) followed by "others treat her/him with respect" (extrinsic theme, respect subtheme) with a mean rank = 3.6 and median = 3.0.The p-DCT is a simple, rank order card-sort tool that may help clinicians identify patients' perceptions of key factors influencing the preservation of their dignity in the last chapter of life.
View details for DOI 10.1089/jpm.2009.0279
View details for Web of Science ID 000277973800004
View details for PubMedID 20420549
Creation and the Empirical Validation of the Dignity Card-Sort Tool To Assess Factors Influencing Erosion of Dignity at Life's End
JOURNAL OF PALLIATIVE MEDICINE
2009; 12 (12): 1125-1130
Patients often experience erosion of dignity as they cope with the dying process. Preserving patient dignity is a sentinel premise of palliative care. This study was conducted to gain a better understanding of factors influencing erosion of dignity at the end of life. We conducted an open-ended written survey of 100 multidisciplinary providers (69% response rate) and responses were categorized to identify 18 themes that were used to create a card-sort tool. The initial 18-item tool was administered to nurses (n = 83), nonhospice community-dwelling subjects (n = 190) and hospice patients (n = 26) and a principal component analysis (PCA) was used to identify the 6 primary factors. The key item in each factor as identified by the PCA was used to create the final 6-item dignity card-sort tool (DCT). The DCT was also administered to physicians caring for palliative care patients (n = 21). For each of the final 6 items, the correlation between the respondents (nurses, physicians, nonterminally ill subjects, and subjects receiving hospice care) was calculated using the Spearman's correlation coefficient. The nurses were very highly positively correlated with the physicians (correlation coefficient = 0.94) and the community-dwelling nonterminally ill subjects were highly positively correlated with the subjects receiving hospice care (correlation coefficient = 0.67). More importantly, both the nurses and physicians were negatively correlated with both community dwelling nonterminally ill subjects and the subjects receiving hospice care. The health professionals in the study felt that treating a patient with disrespect and not carrying out their wishes resulted in erosion of dignity. In contrast patients thought that poor medical care and untreated pain were the most important factors leading to erosion of dignity at life's end. The DCT is a promising tool that may help clinicians identify key factors resulting in perceptions of erosion of dignity in adult palliative care patients.
View details for DOI 10.1089/jpm.2009.0123
View details for Web of Science ID 000272525200017
View details for PubMedID 19708793
- Change Management: The Secret Sauce of Successful Program Building JOURNAL OF PALLIATIVE MEDICINE 2009; 12 (4): 329-330
- Education techniques in palliative care Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/EducationTechniquesinPalliativeCare 2009
- Consultation etiquette: Marketing and patient referrals Center for Advancement of Palliative Care Campus Online: http://campus.capc.org/PalliativeCareCourses/ConsultationEtiquette 2009
- Marketing for palliative care programs Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/MarketingforPalliativeCarePrograms 2009
- Organizational change Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/OrganizationalChange 2009
- Using metaphors in medicine JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (6): 842-844
- Geography decides destiny JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (5): 694-695
- The role of international medical graduates in the future of palliative care JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (4): 563-564
- On the endangered species list: Palliative care junior faculty JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (3): 431-433
- Growing pains: Health care enters "team"-age JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (2): 171-175
- Borders without doctors JOURNAL OF PALLIATIVE MEDICINE 2008; 11 (1): 31-32
- Wrap your worthy cause in a corporate image JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (6): 1256-1257
- Declaration of interdependence: The need for mosaic mentoring in palliative care JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (5): 1048-1049
- First, do not abandon JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (4): 865-866
- Taming wicked problems in modern health care systems JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (3): 658-659
- Panic disorder at the end of life # 145 JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (2): 483-484
"Be nice-until it is time not to be nice".
Journal of palliative medicine
2007; 10 (2): 308-?
View details for PubMedID 17472500
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
- Mainstreaming palliative care JOURNAL OF PALLIATIVE MEDICINE 2007; 10 (1): 40-42
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
Kappa coefficients in medical research
STATISTICS IN MEDICINE
2002; 21 (14): 2109-2129
Kappa coefficients are measures of correlation between categorical variables often used as reliability or validity coefficients. We recapitulate development and definitions of the K (categories) by M (ratings) kappas (K x M), discuss what they are well- or ill-designed to do, and summarize where kappas now stand with regard to their application in medical research. The 2 x M(M>/=2) intraclass kappa seems the ideal measure of binary reliability; a 2 x 2 weighted kappa is an excellent choice, though not a unique one, as a validity measure. For both the intraclass and weighted kappas, we address continuing problems with kappas. There are serious problems with using the K x M intraclass (K>2) or the various K x M weighted kappas for K>2 or M>2 in any context, either because they convey incomplete and possibly misleading information, or because other approaches are preferable to their use. We illustrate the use of the recommended kappas with applications in medical research.
View details for DOI 10.1002/sim.1180
View details for Web of Science ID 000176726900009
View details for PubMedID 12111890
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