Our Research

The Stanford Letter Project is based on years of clinical experiences caring for thousands of seriously ill patients and their families. We have empirically created a three-pronged approach to help all patients and families document their life goals, specific wishes, and preferences for care.

There are three letters for you to complete. This can be done at any point in your life and ideally while you are young and healthy.

  1. Letter 1 is to your doctor and documents “What Matters Most”: The “What Matters Most” Letter is a form intended to help people write a simple letter to their doctor expressing their goals, values, and preferences for care. The “What Matters Most” Letter Advance Directive is a legally valid advance directive that is available to you free of cost.
  2. Letter 2 is to your family and documents “Who Matters Most”: The “Who Matters Most” Letter template will help you complete the seven vital tasks of life review and share your insights and wisdom with your loved ones.
  3. Letter 3 is the “I Matter Too” letter to yourself and documents your life goals: Charting your life goal list has been shown to help patients identify specific life goals and timelines to accomplish them.

Recent Randomized Controlled Trial Research

Virtual, Nurse-Led Early Primary Palliative Care Intervention (ELICIT) for Community-Dwelling Older Adults With Cognitive Impairment: Protocol for a Randomized Controlled Trial

While dementia and cognitive decline unfold over many years, the supportive and palliative care needs of individuals living at home remain poorly understood. We will recruit and randomize 200 chronically-ill community dwelling patients who are at risk of or have cognitive impairment to either usual care or usual care plus a virtual, nurse-Led Early Primary Palliative Care Intervention, with outcomes focused on identification of supportive care needs, completion of goals-of-care conversations and advance care planning, symptom burden, patient activation, quality of life, and end-of-life care patterns. The study hypothesizes that the ELICIT intervention will lead to greater expression of supportive care needs, increased advance care planning, higher rates of goal-concordant care, and lower end-of-life resource use compared with usual care. Findings will help us enable trained nurses to provide primary palliative care to patients who are in the early stages of cognitive impairment.

 

Click here to view the full text protocol here

SELECTED RESEARCH PAPERS ON THE STANFORD LETTER PROJECT:  Dr. Periyakoil's research work has been funded by the National Institutes of Health, the Department of Veterans Affairs, and private foundations. We are currently conducting a large randomized clinical trial to study the impact of the "What Matters Most" and the "I Matter Too" letter templates on patients' goals of care and documentation of their advance care planning documents.

Periyakoil VS, Neri E, Kraemer H. A Randomized Controlled Trial Comparing the Letter Project Advance Directive to Traditional Advance Directive. J Palliat Med. 2017 Sep;20(9):954-965. doi: 10.1089/jpm.2017.0066. Epub 2017 May 4. PMID: 28471713.

Rodriguez DK, Periyakoil VS. Can virtual reality travel help nursing home patients fulfill their bucket list? J Am Geriatr Soc. 2023 Sep;71(9):2976-2978. doi: 10.1111/jgs.18392. Epub 2023 May 12. PMID: 37171553.

Periyakoil VJ. The Need of the Hour: Culturally Competent Care for Seriously Ill Patients. J Palliat Med. 2020 Apr;23(4):440-441. doi: 10.1089/jpm.2020.0087. PMID: 32216689; PMCID: PMC7364299.

Periyakoil VS, Neri E, Kraemer H. Common Items on a Bucket List. J Palliat Med. 2018 May;21(5):652-658. doi: 10.1089/jpm.2017.0512. Epub 2018 Feb 8. PMID: 29415602; PMCID: PMC5946728.

Rodriguez DK, Hewage SA, Periyakoil VS. Factors affecting the recruitment of Hispanic/Latinx American older adults in clinical trials in the United States: A scoping review. J Am Geriatr Soc. 2023 Jun;71(6):1974-1991. doi: 10.1111/jgs.18264. Epub 2023 Apr 3. PMID: 37013348; PMCID: PMC10258132.

Carpenter JG, Scott WJ, Kononowech J, Foglia MB, Haverhals LM, Hogikyan R, Kolanowski A, Landis-Lewis Z, Levy C, Miller SC, Periyakoil VJ, Phibbs CS, Potter L, Sales A, Ersek M. Evaluating implementation strategies to support documentation of veterans' care preferences. Health Serv Res. 2022 Aug;57(4):734-743. doi: 10.1111/1475-6773.13958. Epub 2022 Mar 8. PMID: 35261022; PMCID: PMC9264454.

Miller SC, Scott WJ, Ersek M, Levy C, Hogikyan R, Periyakoil VS, Carpenter JG, Cohen J, Foglia MB. Honoring Veterans' Preferences: The Association Between Comfort Care Goals and Care Received at the End of Life. J Pain Symptom Manage. 2021 Apr;61(4):743-754.e1. doi: 10.1016/j.jpainsymman.2020.08.039. Epub 2020 Sep 7. PMID: 32911038.

Alagappan M, Richardson MT, Schoen MK, Muffly L, Tierney K, Jenkins P, Neri E, Kraemer HC, Periyakoil VS. A Three-Step Letter Advance Directive Procedure to Facilitate Patient-Proxy Alignment in Advance Care Planning. J Palliat Med. 2018 Dec;21(12):1749-1754. doi: 10.1089/jpm.2018.0150. Epub 2018 Sep 19. PMID: 30247088; PMCID: PMC6308271.

Patel MI, Sundaram V, Desai M, Periyakoil VS, Kahn JS, Bhattacharya J, Asch SM, Milstein A, Bundorf MK. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol. 2018 Oct 1;4(10):1359-1366. doi: 10.1001/jamaoncol.2018.2446. PMID: 30054634; PMCID: PMC6233780.

Cappell K, Sundaram V, Park A, Shiraz P, Gupta R, Jenkins P, Periyakoil VSJ, Muffly L. Advance Directive Utilization Is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant. 2018 May;24(5):1035-1040. doi: 10.1016/j.bbmt.2018.01.014. Epub 2018 Jan 31. PMID: 29371107; PMCID: PMC6364975.

Periyakoil VJ. Square Pegs; Round Holes: Our Healthcare System Is Failing Seriously Ill Older Americans in Their Last Years. J Am Geriatr Soc. 2018 Jan;66(1):15-17. doi: 10.1111/jgs.15161. Epub 2017 Nov 22. PMID: 29165786; PMCID: PMC5777873.

American Medical Association Practice Improvement Module using the Stanford Letter Project.

 

 

 

Ongoing research using the Stanford Letter Project:

Large observational study using the Stanford Letter Project

We are building a national Letter Library of letters written by people who have utilized the Stanford Letter project template and shared it with us for research. Our goal is to build a large online searchable library of letters that any patient can use to complete their advance care planning.

Feasibility trial using the Stanford Letter Project

We have completed a large feasibility trial and the manuscript is currently under review by a prominent peer reviewed medical journal.

Bone Marrow Transplant (BMT) population

  • Patient-Proxy Alignment Study: We are conducting a study to better understand the differences (if any) between patients receiving Bone Marrow Transplant and their proxy decision makers as determined by the  Stanford Letter Project directive
  • BMT patient randomized clinical trial: We have recently received funding from the Palliative Care Research Cooperative to complete a randomized clinical trial comparing the Stanford Letter project directive to traditional directive in the bone marrow transplant population.their advance care planning.

Quality Improvement Project at Stanford Hospital using the Stanford Letter Project

We have conducted a quality improvement project comparing the Stanford Letter Project Directive to traditional advance directive. Key findings were as follows:

  • The Stanford  Project Letter Directive improved general understanding of patients’ goals and values compared to the traditional advance directives.
  • The Stanford  Project Letter Directive improved provider understanding of where patients would like to spend their last days (home vs hospital).
  • The Stanford  Project Letter Directive may increase provider understanding of their patients’ values and Goals of Care.
  • Doctors overwhelmingly felt the Letter was helpful and would be useful in guiding Goals of Care discussions with their patients.