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Bio

Bio

CONTACT:

Email: periyakoil@stanford.edu

Twitter: @palliator


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 is the Chair of the Ethnogeriatrics Committee of the American Geriatrics Society, was the founding 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 Aging, Geriatrics and Ethnogeriatrics transdisciplinary collaborative center (SAGE Center), the Ethno-geriatrics & the Successful Aging Project (http://geriatrics.stanford.edu ), and the Palliative Care portal (http://palliative.stanford.edu) and the Letter Project (http://med.stanford.edu/letter.html).

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 (periyakoil@stanford.edu) or through twitter : @palliator

Academic Appointments

Administrative Appointments

  • 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)
  • Director, Stanford Aging, Geriatrics and Ethnogeriatrics Center, National Institute of Aging (granting agency) (2018 - 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)

Professional Education

  • Board Certification, American Board of Internal Medicine, Geriatric Medicine (2010)

Community and International Work

  • Member, Board of Directors, Ravenswood Community Clinic, East Palo A;lto

    Topic

    Clinical care

    Location

    Bay Area

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Member, Board of Directors, East Palo Alti

    Partnering Organization(s)

    Ravenswood Family Center (FQHC)

    Location

    Bay Area

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Member, Board of Directors, American Cancer Society Santa Clara County Unit, Campbell, CA, Campbell, California

    Topic

    Advocacy through ACS community-based cancer outreach, advocacy, and volunteer efforts.

    Partnering Organization(s)

    American Cancer Society

    Populations Served

    Cancer patients in Santa Clara County

    Location

    Bay Area

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

Contact

Links

Research & Scholarship

Current Research and Scholarly Interests

Present research funding:

2011-2018Funder: Ludwig Gift Fund
Title: Cancer Stem Cell Patient Reported Outcomes (CanSR-PRO)
Role: PI

2011-2018Funder: NIH/NIMHD
Title: In-reach for Successful Aging through Education (iSAGE)
Role: PI

2014-2018Funder: NIH/NHLBI
Title: Technology innovations for supporting health in Alaska Native people
Role: co-I

2015-2020Funder: VA HSR&D QUE 15-288
Title: Implementing Goals of Care Conversations with Veterans in VA LTC Settings
Role: Co-PI (project 1), co-I overall project and Palo Alto VA Site PI

2016-2121 Funder: NIMHD/NIH, U54MD010724
Title: Trial of strategies to communicate genetic information to different ethnic and racial subpopulations
Role: PI
Note: This is one of three RO1 projects in the ?Stanford Precision Health for Ethnic and Racial Equity (SPHERE) Transdisciplinary Collaborative Center? grant.

2017-2020 Funder NIA/NIH
Outreach, Recruitment and Education Core, Alzheimer?s Disease Research Center
Role: Core PI

2018-2019 Funder: NIMHD/NIH as an Dementia Administrative Supplement of U54MD010724
Title: Precision Aging and Dementia care for all Races and Ethnicities (PADRE)
Role: Project Lead.

2018-2023 Funder NIA/NIH: P30AG059307 9/30/2018-8/31/2023
Stanford Aging Geriatrics and Ethnogeriatrics Transdisciplinary Collaborative Center (SAGE Center)
Role: Contact PI Periyakoil.


2018-2023 Funder NIA/NIH: RO1AG062239 9/30/2018-8/31/2023
Role: PI
Palliative care needs and outcomes for dementia patients

Clinical Trials

  • Comparing the Stanford Letter Project Form to Traditional Advance Directives Recruiting

    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.

    View full details

  • Trial of Strategies to Communicate Genetic Information to Different Ethnic Subpopulations Recruiting

    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.

    View full details

  • Stanford Letter or Traditional Advance Directive in Advance Care Planning in Patients Undergoing Bone Marrow Transplant Not Recruiting

    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.

    Stanford is currently not accepting patients for this trial. For more information, please contact VJ PERIYAKOIL, MD, 650-493-5000 Ext. 61925.

    View full details

  • Supportive Care for Cognitively Impaired Patients and Families Not Recruiting

    Currently almost 5 million Americans suffer from the distressing symptoms related to dementia and this number that will triple by 2050. The overall goals of the proposed project are to evaluate, in community dwelling Alzheimer's Disease Research Center participants the benefits of a 12-month nurse-led early palliative intervention on symptoms, quality of life, health care resource use. The relevance of this research to public health is that there is an urgent need to improve the palliative care of persons with dementia living in the community. This study will contribute substantially to that effort.

    Stanford is currently not accepting patients for this trial. For more information, please contact VJ Periyakoil, MD, (650) 723 - 4000.

    View full details

Projects

  • 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

    Location

    Palo Alto

Teaching

2018-19 Courses

Graduate and Fellowship Programs

Publications

All Publications

  • Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Periyakoil, V. S. 2019; 67: S423?S432

    Abstract

    The population of minority older adults is going to explode over the next four decades. Older adults from racial and ethnic minorities face persistent and pervasive health disparities. Health disparities exert a huge fiscal burden on the nation. The national financial cost of health disparities for the years 2002 to 2006 was an estimated 1.23 trillion dollars. As the aging population becomes more diverse, these disparity-related costs are expected to increase. Older adults from racial and ethnic minorities face multiple barriers to accessing health and support services that will help them to age and die in place in the community. Patient-related barriers include limited English proficiency, low health literacy, varying levels of acculturation, biases about Western healthcare and medications, mistrust of clinicians, inability to navigate the complex healthcare system, and cultural beliefs and taboos. Clinician-related barriers include ageism (ie, discrimination against older people due to negative and inaccurate stereotypes), conscious and unconscious bias, being deeply entrenched in the culture of biomedicine, and the lack of training in the principles and practice of providing culturally respectful care. Health system-related barriers include lack of culturally tailored services, including access to medical interpreters. We conclude by identifying three specific strategies to facilitate culturally humble and respectful care for diverse patients. J Am Geriatr Soc 67:S423-S432, 2019.

    View details for DOI 10.1111/jgs.15939

    View details for Web of Science ID 000467584600008

    View details for PubMedID 31074850

  • A Practical Approach to Assessing and Mitigating Loneliness and Isolation in Older Adults. Journal of the American Geriatrics Society Perissinotto, C., Holt-Lunstad, J., Periyakoil, V. S., Covinsky, K. 2019

    Abstract

    Loneliness and social isolation are strongly associated with several adverse health outcomes in older persons including death and functional impairments. The strength of these associations has been compared with smoking. Accordingly, loneliness and isolation have significant public health implications. Despite the adverse impacts of loneliness and social isolation on quality of life, and their strong association with health outcomes, the evaluation of loneliness and isolation have not been integrated into medical care. The risks for loneliness may be of particular concern to persons with serious illness as patients and caregivers cope with the experience of loss, loss of independence, and increasing care needs. To date, there has been no uniform way of evaluating and documenting loneliness and social isolation as a part of a review of a patient's social determinants of health. This article provides a framework for healthcare systems, providers, and community members working with older adults to (1) understand loneliness, isolation, and its counterpart social connection; (2) describe the different ways loneliness affects health; and (3) create a framework for asking about and documenting these experiences. Finally, because the lack of studies assessing whether targeting loneliness can improve health outcomes is a major gap, we provide guidance on the future of interventions.

    View details for DOI 10.1111/jgs.15746

    View details for PubMedID 30762228

  • Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings. Journal of gerontological nursing Carpenter, J., Miller, S. C., Kolanowski, A. M., Karel, M. J., Periyakoil, V. S., Lowery, J., Levy, C., Sales, A. E., Ersek, M. 2019; 45 (3): 21?30

    Abstract

    The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

    View details for DOI 10.3928/00989134-20190211-03

    View details for PubMedID 30789986

  • A Three-Step Letter Advance Directive Procedure to Facilitate Patient-Proxy Alignment in Advance Care Planning JOURNAL OF PALLIATIVE MEDICINE Alagappan, M., Richardson, M. T., Schoen, M. K., Muffly, L., Tierney, K., Jenkins, P., Neri, E., Kraemer, H. C., Periyakoil, V. S. 2018

    Abstract

    Little is known about the extent of alignment between hematopoietic stem cell transplant (HSCT) patients and their healthcare proxies with respect to advance care planning (ACP).To determine if a structured three-step process using the letter advance directive (LAD) could (1) allow for the differences in opinion between patient-proxy dyads to surface and (2) help bridge preexisting discordance about specific treatment choices.Blinded to each other, the HSCT patient (LAD-1) and proxy (LAD-2) each completed the LAD (step 1). They unmasked, compared LAD-1 and LAD-2, and discussed their choices (step 2). They completed a final letter directive (LAD-3) by consensus (step 3). Settings/Participants: Convenience sample of eighty dyads (patient and proxy) at a regional HSCT referral center.The mean patient-proxy concordance was 72.9% for the 12 questions in the LAD. Wanting to be pain free at the end of life was the statement with the most amount of agreement (88.75% in LAD-1, 91.25% in LAD-2, and 90% in LAD-3). Patient-proxy dyads had notable discordance related to specific treatments. The highest discordance was related to ventilator support (46.3% of patients refused it, while 58.8% of proxies refused on behalf of the patient). Overall, proxies were more likely than patients to opt in for dialyses and hospice care but more likely to opt out for cardiac resuscitation and sedation to palliate refractory symptoms. On open discussion, patient-proxy discordance mostly resolved in favor of the patient.The ACP process should allow for patient-proxy differences to surface, facilitate a discussion about the granular details with the goal of reaching consensus. Our three-step approach using the LAD is an effective way to identify areas of patient-proxy concordance and discordance about specific treatment preferences. A structured patient-proxy discussion using the LAD helped reconcile discordance and most often in favor of a patient's original wishes.

    View details for PubMedID 30247088

  • 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 oncology Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. S., Kahn, J. S., Bhattacharya, J., Asch, S. M., Milstein, A., Bundorf, M. K. 2018

    Abstract

    Importance: Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited.Objective: To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis.Design, Setting, and Participants: Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017.Interventions: Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care.Main Outcomes and Measures: The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs.Results: Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P<.001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P<.001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P=.68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P=.002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P<.001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P<.001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23?482 [$9708-$55?648]; P<.001) than patients in the control group.Conclusions and Relevance: Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life.Trial Registration: ClinicalTrials.gov Identifier: NCT02966509.

    View details for PubMedID 30054634

  • End-of-Life Care for Unauthorized Immigrants in the U.S. Journal of pain and symptom management Metchnikoff, C., Naughton, G., Periyakoil, V. S. 2018; 55 (5): 1400?1407

    Abstract

    The Universal Declaration of Human Rights recognizes the inherent dignity, the equal and unalienable rights to be universally protected for all humans irrespective of race, color, gender, language, religion, political or other opinion, national or social origin, property, birth or other status. Though this includes the right to dignity-conserving care for terminally ill unauthorized immigrants, access to quality end-of-life care eludes them. Most of the estimated 11.3 million unauthorized immigrants either entered the country without the knowledge of the U.S. Immigration and Customs Enforcement, or were admitted on a temporary visa and stayed past its expiration date. Unsafe living conditions, occupational hazards, lack of access to routine healthcare, scarceness of a social and financial support system, fear of deportation, discrimination and incarceration limit healthcare access of unauthorized immigrants. Lack of access to preventative primary care encounters often results in this population's dependence on acute emergency services for treatment. Lack of opportunity for advance care planning discussions and lack of eligibility to hospice services commonly contributes to poor end of life care. As unauthorized immigrants approach the last days of life, they may often die alone, away from their loved ones, with little-to-no psychosocial support in their final moments. This article provides an overview on end-of-life care for unauthorized immigrants and makes recommendations for potential strategies to providing humane care and support to this vulnerable population.

    View details for PubMedID 29496325

  • Should We Bury "The Good Death"? JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Smith, A. K., Periyakoil, V. S. 2018; 66 (5): 856?58

    View details for DOI 10.1111/jgs.15321

    View details for Web of Science ID 000433585500004

    View details for PubMedID 29508391

    View details for PubMedCentralID PMC5992042

  • Our Differences Make Us Stronger. Journal of pain and symptom management Periyakoil, V. S., O'Mahony, S., Elk, R., Quill, T. 2018; 55 (5): 1398?99

    View details for DOI 10.1016/j.jpainsymman.2018.02.008

    View details for PubMedID 29481962

  • Reversals and limitations on high-intensity, life-sustaining treatments PLOS ONE Chavez, G., Richman, I. B., Kaimal, R., Bentley, J., Yasukawa, L., Altman, R. B., Periyakoil, V. S., Chen, J. H. 2018; 13 (2): e0190569

    Abstract

    Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs.This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders.10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28-1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69-2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49-2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27-2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38-1.48] per decade), female (HR 1.30 [95% CI 1.17-1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25-1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48-2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42-1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33-1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15-1.72]).Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.

    View details for PubMedID 29489814

  • Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol (vol 11, 132, 2016) IMPLEMENTATION SCIENCE Sales, A. E., Ersek, M., Intrator, O. K., Levy, C., Carpenter, J. G., Hogikyan, R., Kales, H. C., Landis-Lewis, Z., Olsan, T., Miller, S. C., Montagnini, M., Periyakoil, V. S., Reder, S. 2018; 13: 29

    Abstract

    The authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 "Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals, and Preferences".

    View details for DOI 10.1186/s13012-018-0724-y

    View details for Web of Science ID 000425143900003

    View details for PubMedID 29426346

    View details for PubMedCentralID PMC5809112

  • Why Do You Want to Know and Why Should I Trust You? Implicit Messaging in Cross-Cultural (Mis)Understandings Singer, M., Periyakoil, V., Elk, R. ELSEVIER SCIENCE INC. 2018: 583

    View details for Web of Science ID 000425399300117

  • Advance Care Planning in Cognitively Impaired Older Adults. Journal of the American Geriatrics Society deLima Thomas, J., Sanchez-Reilly, S., Bernacki, R., O'Neill, L., Morrison, L. J., Kapo, J., Periyakoil, V. S., Carey, E. C. 2018; 66 (8): 1469?74

    Abstract

    Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision-making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision-makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual-, clinician-, and system-related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision-makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision-making capacity, identifying surrogate decision-makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care.

    View details for PubMedID 30277566

  • Square Pegs; Round Holes: Our Healthcare System Is Failing Seriously Ill Older Americans in Their Last Years. Journal of the American Geriatrics Society Periyakoil, V. J. 2018; 66 (1): 15?17

    View details for PubMedID 29165786

    View details for PubMedCentralID PMC5777873

  • 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 Cappell, K., Sundaram, V., Park, A., Shiraz, P., Gupta, R., Jenkins, P., Periyakoil, V. S., Muffly, L. 2018

    Abstract

    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 PubMedID 29371107

  • Common Items on a Bucket List. Journal of palliative medicine Periyakoil, V. S., Neri, E., Kraemer, H. 2018

    Abstract

    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%), ?2?=?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 PubMedID 29415602

  • A Randomized Controlled Trial Comparing the Letter Project Advance Directive to Traditional Advance Directive. Journal of palliative medicine Periyakoil, V. S., Neri, E., Kraemer, H. 2017

    Abstract

    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?

    View details for DOI 10.1089/jpm.2017.0066

    View details for PubMedID 28471713

  • A Randomized Clinical Trial Comparing the Letter Advance Directive to Traditional Advance Directives Periyakoil, V. WILEY. 2017: S113

    View details for Web of Science ID 000402876300322

  • Redesigning Cancer Care Delivery: Views From Patients and Caregivers. Journal of oncology practice Patel, M. I., Periyakoil, V. S., Blayney, D. W., Moore, D., Nevedal, A., Asch, S., Milstein, A., Coker, T. R. 2017; 13 (4): e291-e302

    Abstract

    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

  • "I Understand There's A New Law ...": Responding to Patient Inquiries About Physician-Assisted Dying VandeKieft, G., Widera, E., Periyakoil, V., Hess, D. ELSEVIER SCIENCE INC. 2017: 332

    View details for DOI 10.1016/j.jpainsymman.2016.12.060

    View details for Web of Science ID 000397118300089

  • A Randomized Clinical Feasibility Trial Comparing the Letter Project Advance Directive to Traditional Advance Directive Periyakoil, V. J. ELSEVIER SCIENCE INC. 2017: 419

    View details for DOI 10.1016/j.jpainsymman.2016.12.228

    View details for Web of Science ID 000397118300250

  • 2017 AAHPM Fellowship Directors Program: Building a Community of Educators Thomas, J., Back, A. L., Gustin, J., Jackson, V. A., Jacobsen, J., Landzaat, L. H., Levine, S. K., Neri, V., Periyakoil, V., Smith, C. ELSEVIER SCIENCE INC. 2017: 305?6

    View details for Web of Science ID 000397118300035

  • Delivering End-of-Life Cancer Care: Perspectives of Providers. The American journal of hospice & palliative care Patel, M. I., Periyakoil, V. S., Moore, D., Nevedal, A., Coker, T. R. 2017: 1049909117719879

    Abstract

    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 PubMedID 28691498

  • Supporting patients who are bereaved. BMJ (Clinical research ed.) Shear, M. K., Muldberg, S., Periyakoil, V. 2017; 358: j2854

    View details for DOI 10.1136/bmj.j2854

    View details for PubMedID 28684392

  • Multi-Ethnic Attitudes Toward Physician-Assisted Death in California and Hawaii JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S., Kraemer, H., Neri, E. 2016; 19 (10): 1060-1065

    Abstract

    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 PubMedID 27276445

  • Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol IMPLEMENTATION SCIENCE Sales, A. E., Ersek, M., Intrator, O. K., Levy, C., Carpenter, J. G., Hogikyan, R., Kales, H. C., Landis-Lewis, Z., Olsan, T., Miller, S. C., Montagnini, M., Periyakoil, V. S., Reder, S. 2016; 11

    Abstract

    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

  • Renal Palliative Care Studies: Coming of Age JOURNAL OF PALLIATIVE MEDICINE Cheung, K. L., Periyakoil, V. S. 2016; 19 (6): 582?83

    View details for DOI 10.1089/jpm.2016.0175

    View details for Web of Science ID 000378044100001

  • Physician Assisted Death in California and Hawaii: Multi-ethnic Perspectives Periyakoil, V., Kraemer, H., Neri, E. WILEY-BLACKWELL. 2016: S99

    View details for Web of Science ID 000374763800275

  • Patient-Reported Barriers to High-Quality, End-of-Life Care: A Multiethnic, Multilingual, Mixed-Methods Study JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S., Neri, E., Kraemer, H. 2016; 19 (4): 373-379

    Abstract

    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 (?(2)?=?9.15, DF?=?1, p?=?0.003); gender (?(2)?=?6.605, DF?=?1, p?=?0.01); and marital status (?(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 Web of Science ID 000373237500009

  • Patient-Reported Barriers to High-Quality, End-of-Life Care: A Multiethnic, Multilingual, Mixed-Methods Study. Journal of palliative medicine Periyakoil, V. S., Neri, E., Kraemer, H. 2016; 19 (4): 373-379

    Abstract

    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 (?(2)?=?9.15, DF?=?1, p?=?0.003); gender (?(2)?=?6.605, DF?=?1, p?=?0.01); and marital status (?(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

  • Women in Academic Medicine: Measuring Stereotype Threat Among Junior Faculty JOURNAL OF WOMENS HEALTH Fassiotto, M., Hamel, E. O., Ku, M., Correll, S., Grewal, D., Lavori, P., Periyakoil, V. J., Reiss, A., Sandborg, C., Walton, G., Winkleby, M., Valantine, H. 2016; 25 (3): 292-298

    Abstract

    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??0.42).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

  • When Faith Hurts: Redemptive Suffering and Refusal of Symptomatic Treatment Macauley, R., Periyakoil, V. ELSEVIER SCIENCE INC. 2016: 315?16

    View details for DOI 10.1016/j.jpainsymman.2015.12.127

    View details for Web of Science ID 000373472900053

  • A Mixed-Methods Study of Multi-Ethnic, Multi-Lingual Patient-Reported Barriers to Receiving Quality Care at the End of Life Periyakoil, V. ELSEVIER SCIENCE INC. 2016: 371?72

    View details for DOI 10.1016/j.jpainsymman.2015.12.236

    View details for Web of Science ID 000373472900159

  • From Surviving to Thriving: A Self-Care Path to Resilience Sanchez-Reilly, S., Periyakoil, V., Kapo, J., Thomas, J., O'Neill, L. ELSEVIER SCIENCE INC. 2016: 312

    View details for DOI 10.1016/j.jpainsymman.2015.12.118

    View details for Web of Science ID 000373472900045

  • Achieving High-Quality Multicultural Geriatric Care. Journal of the American Geriatrics Society 2016

    Abstract

    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 Periyakoil, V. S. 2015; 373 (25): 2399-2401

    Abstract

    "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 Periyakoil, V. S., Neri, E., Kraemer, H. 2015; 10 (4)

    Abstract

    Though most patients wish to discuss end-of-life (EOL) issues, doctors are reluctant to conduct end-of-life conversations. Little is known about the barriers doctors face in conducting effective EOL conversations with diverse patients. This mixed methods study was undertaken to empirically identify barriers faced by doctors (if any) in conducting effective EOL conversations with diverse patients and to determine if the doctors' age, gender, ethnicity and medical sub-specialty influenced the barriers reported.Mixed-methods study of multi-specialty doctors caring for diverse, seriously ill patients in two large academic medical centers at the end of the training; data were collected from 2010 to 2012.Doctor-reported barriers to EOL conversations with diverse patients.1040 of 1234 potential subjects (84.3%) participated. 29 participants were designated as the development cohort for coding and grounded theory analyses to identify primary barriers. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort (n= 996 doctors). Qualitative responses from the validation cohort were coded and analyzed using quantitative methods. Only 0.01 % doctors reported no barriers to conducting EOL conversations with patients. 99.99% doctors reported barriers with 85.7% finding it very challenging to conduct EOL conversations with all patients and especially so with patients whose ethnicity was different than their own. Asian-American doctors reported the most struggles (91.3%), followed by African Americans (85.3%), Caucasians (83.5%) and Hispanic Americans (79.3%) in conducting EOL conversations with their patients. The biggest doctor-reported barriers to effective EOL conversations are (i) language and medical interpretation issues, (ii) patient/family religio-spiritual beliefs about death and dying, (iii) doctors' ignorance of patients' cultural beliefs, values and practices, (iv) patient/family's cultural differences in truth handling and decision making, (v) patients' limited health literacy and (vi) patients' mistrust of doctors and the health care system. The doctors' ethnicity (Chi-Square = 12.77, DF = 4, p = 0.0125) and medical subspecialty (Chi-Square = 19.33, DF = 10, p =0.036) influenced their reported barriers. Friedman's test used to examine participants relative ranking of the barriers across sub-groups identified significant differences by age group (F statistic = 303.5, DF = 5, p < 0.0001) and medical sub-specialty (F statistic =163.7, DF = 5, p < 0.0001).Doctors report struggles with conducting effective EOL conversations with all patients and especially with those whose ethnicity is different from their own. It is vital to identify strategies to mitigate barriers doctors encounter in conducting effective EOL conversations with seriously ill patients and their families.

    View details for DOI 10.1371/journal.pone.0122321

    View details for Web of Science ID 000353331500019

    View details for PubMedID 25902309

    View details for PubMedCentralID PMC4406531

  • No Easy Task: A Mixed Methods Study of Barriers to Conducting Effective End-Of-Life Conversations Reported by Multi-Specialty Doctors Periyakoil, V., Neri, E., Kraemer, H. ELSEVIER SCIENCE INC. 2015: 446?47

    View details for DOI 10.1016/j.jpainsymman.2014.11.255

    View details for Web of Science ID 000348478200234

  • Training Fellows to Be Leaders: Ensuring the Future of Palliative Care Kapo, J., Carey, E., Periyakoil, V., Thomas, J., Morrison, L. ELSEVIER SCIENCE INC. 2015: 354

    View details for DOI 10.1016/j.jpainsymman.2014.11.078

    View details for Web of Science ID 000348478200057

  • Women in Academic Medicine: Measuring Stereotype Threat Among Junior Faculty. Journal of women's health (2002) Fassiotto, M., Hamel, E. O., Ku, M., Correll, S., Grewal, D., Lavori, P., Periyakoil, V. J., Reiss, A., Sandborg, C., Walton, G., Winkleby, M., Valantine, H. 2015

    Abstract

    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??0.42).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 PubMedID 26555562

  • Understanding frailty in cancer patients. Cancer journal Baijal, P., Periyakoil, V. 2014; 20 (5): 358-366

    Abstract

    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 Cheung, K. L., Montez-Rath, M. E., Chertow, G. M., Winkelmayer, W. C., Periyakoil, V. S., Kurella Tamura, M. 2014; 69 (8): 1033-1039

    Abstract

    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 Schaefer, K. G., Chittenden, E. H., Sullivan, A. M., Periyakoil, V. S., Morrison, L. J., Carey, E. C., Sanchez-Reilly, S., Block, S. D. 2014; 89 (7): 1024-1031

    Abstract

    Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts.Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains.The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains.This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

    View details for DOI 10.1097/ACM.0000000000000271

    View details for Web of Science ID 000338210000023

    View details for PubMedCentralID PMC4077186

  • 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

    Abstract

    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 Towards Advance Directives Periyakoil, V., Kraemer, H. C., Neri, E. WILEY-BLACKWELL. 2014: S1?S2

    View details for Web of Science ID 000333405500004

  • Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA-the journal of the American Medical Association Porsteinsson, A. P., Drye, L. T., Pollock, B. G., Devanand, D. P., Frangakis, C., Ismail, Z., Marano, C., Meinert, C. L., Mintzer, J. E., Munro, C. A., Pelton, G., Rabins, P. V., Rosenberg, P. B., Schneider, L. S., Shade, D. M., Weintraub, D., Yesavage, J., Lyketsos, C. G. 2014; 311 (7): 682-691

    Abstract

    Agitation is common, persistent, and associated with adverse consequences for patients with Alzheimer disease. Pharmacological treatment options, including antipsychotics are not satisfactory.The primary objective was to evaluate the efficacy of citalopram for agitation in patients with Alzheimer disease. Key secondary objectives examined effects of citalopram on function, caregiver distress, safety, cognitive safety, and tolerability.The Citalopram for Agitation in Alzheimer Disease Study (CitAD) was a randomized, placebo-controlled, double-blind, parallel group trial that enrolled 186 patients with probable Alzheimer disease and clinically significant agitation from 8 academic centers in the United States and Canada from August 2009 to January 2013.Participants (n?=?186) were randomized to receive a psychosocial intervention plus either citalopram (n?=?94) or placebo (n?=?92) for 9 weeks. Dosage began at 10 mg per day with planned titration to 30 mg per day over 3 weeks based on response and tolerability.Primary outcome measures were based on scores from the 18-point Neurobehavioral Rating Scale agitation subscale (NBRS-A) and the modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC). Other outcomes were based on scores from the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI), ability to complete activities of daily living (ADLs), caregiver distress, cognitive safety (based on scores from the 30-point Mini Mental State Examination [MMSE]), and adverse events.Participants who received citalopram showed significant improvement compared with those who received placebo on both primary outcome measures. The NBRS-A estimated treatment difference at week 9 (citalopram minus placebo) was -0.93 (95% CI, -1.80 to -0.06), P?=?.04. Results from the mADCS-CGIC showed 40% of citalopram participants having moderate or marked improvement from baseline compared with 26% of placebo recipients, with estimated treatment effect (odds ratio [OR] of being at or better than a given CGIC category) of 2.13 (95% CI, 1.23-3.69), P?=?.01. Participants who received citalopram showed significant improvement on the CMAI, total NPI, and caregiver distress scores but not on the NPI agitation subscale, ADLs, or in less use of rescue lorazepam. Worsening of cognition (-1.05 points; 95% CI, -1.97 to -0.13; P?=?.03) and QT interval prolongation (18.1 ms; 95% CI, 6.1-30.1; P?=?.01) were seen in the citalopram group.Among patients with probable Alzheimer disease and agitation who were receiving psychosocial intervention, the addition of citalopram compared with placebo significantly reduced agitation and caregiver distress; however, cognitive and cardiac adverse effects of citalopram may limit its practical application at the dosage of 30 mg per day.clinicaltrials.gov Identifier: NCT00898807.

    View details for DOI 10.1001/jama.2014.93

    View details for PubMedID 24549548

  • Hear Today, Gone Tomorrow: Working Effectively With Seriously Ill Patients with Limited Health Literacy and Numeracy Periyakoil, V. ELSEVIER SCIENCE INC. 2014: 388?89

    View details for DOI 10.1016/j.jpainsymman.2013.12.031

    View details for Web of Science ID 000331150000050

  • Special Issues in Effectively Palliating Head and Neck Cancer Periyakoil, V., Sirjani, D. ELSEVIER SCIENCE INC. 2014: 435

    View details for DOI 10.1016/j.jpainsymman.2013.12.103

    View details for Web of Science ID 000331150000121

  • Changes in QTc Interval in the Citalopram for Agitation in Alzheimer's Disease (CitAD) Randomized Trial. PloS one Drye, L. T., Spragg, D., Devanand, D. P., Frangakis, C., Marano, C., Meinert, C. L., Mintzer, J. E., Munro, C. A., Pelton, G., Pollock, B. G., Porsteinsson, A. P., Rabins, P. V., Rosenberg, P. B., Schneider, L. S., Shade, D. M., Weintraub, D., Yesavage, J., Lyketsos, C. G. 2014; 9 (6)

    Abstract

    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

  • Do Unto Others: Doctors' Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives. PloS one Periyakoil, V. S., Neri, E., Fong, A., Kraemer, H. 2014; 9 (5): e98246

    Abstract

    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 (?2 14.68, DF?=?3,p?=?.0021) and sub-specialty (?2 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

    View details for PubMedCentralID PMC4037207

  • Asian Indian American Older Adults Doorway Thoughts: Cross-Cultural Health Care for Older Adults Periyakoil, V. S. American Geriatrics Society. 2014
  • Hinduism Doorway Thoughts: Cross-Cultural Health Care for Older Adults Periyakoil, V. S., Rao, A., Sharma, P. American Geriatrics Society. 2014; 2
  • Pakistani American Older Adults Doorway Thoughts: Cross-Cultural Health Care for Older Adults Buttar, A., Periyakoil, V. S. American Geriatrics Society. 2014; 2
  • Filipino American Older Adults Doorway Thoughts: Cross-Cultural Health Care for Older Adults McBride, M., Nora, R., Periyakoil, V. American Geriatrics Society. 2014; 2

    View details for DOI 1-886775-33-8

  • Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives. PloS one Periyakoil, V. S., Neri, E., Fong, A., Kraemer, H. 2014; 9 (5)

    Abstract

    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 (?2 14.68, DF?=?3,p?=?.0021) and sub-specialty (?2 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

    View details for PubMedCentralID PMC4037207

  • The flipped classroom paradigm for teaching palliative care skills. The virtual mentor : VM Periyakoil, V. S., Basaviah, P. 2013; 15 (12): 1034-1037

    View details for DOI 10.1001/virtualmentor.2013.15.12.medu1-1312

    View details for PubMedID 24331444

  • 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 Kurella Tamura, M., Periyakoil, V. S. 2013; 28 (11): 2663-2666

    View details for DOI 10.1093/ndt/gft379

    View details for PubMedID 24009286

    View details for PubMedCentralID PMC3811061

  • Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life. Journal of palliative medicine Blechman, J. A., Rizk, N., Stevens, M. M., Periyakoil, V. S. 2013; 16 (10): 1285-1289

    Abstract

    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 Blechman, J. A., Rizk, N., Stevens, M. M., Periyakoil, V. S. 2013; 16 (10): 1285-1289

    View details for DOI 10.1089/jpm.2013.0257

    View details for PubMedID 24020919

  • Frailty as a terminal illness. American family physician Periyakoil, V. S. 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 Sanchez-Reilly, S., Morrison, L. J., Carey, E., Bernacki, R., O'Neill, L., Kapo, J., Periyakoil, V. S., Thomas, J. d. 2013; 11 (2): 75-81

    Abstract

    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 Periyakoil, V. S., Stevens, M., Kraemer, H. 2013; 61 (3): 440-446

    Abstract

    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

    View details for PubMedCentralID PMC3636182

  • Doctoring in the 21st Century: Improve Patient Safety and Enhance Quality of Patient Care Using the ACGME's Competency-Based Training Model Periyakoil, V., Dohn, A. ELSEVIER SCIENCE INC. 2013: 347?48

    View details for DOI 10.1016/j.jpainsymman.2012.10.056

    View details for Web of Science ID 000315684600066

  • Fellowship Directors-Looking 10 Years into the Future Levine, S., Reilly, S., Periyakoil, V., Ross, J., Rosielle, D., Gustin, J. ELSEVIER SCIENCE INC. 2013: 319?20

    View details for DOI 10.1016/j.jpainsymman.2012.10.010

    View details for Web of Science ID 000315684600020

  • Last Among Equals? Identifying and Managing Pain Disparities in Multicultural Populations Periyakoil, V. ELSEVIER SCIENCE INC. 2013: 335

    View details for DOI 10.1016/j.jpainsymman.2012.10.037

    View details for Web of Science ID 000315684600047

  • Dying After Discontinuing Dialysis: Two Patients' Stories and Lessons Learned Periyakoil, V., Cheung, K. ELSEVIER SCIENCE INC. 2013: 409

    View details for DOI 10.1016/j.jpainsymman.2012.10.269

    View details for Web of Science ID 000315684600160

  • Unmet Quality Indicators of Care for Metastatic Cancer Patients Admitted to ICU in Last 2 Weeks of Life Blechman, J., Periyakoil, V. J. ELSEVIER SCIENCE INC. 2013: 422

    View details for DOI 10.1016/j.jpainsymman.2012.10.127

    View details for Web of Science ID 000315684600180

  • Mentoring Academy: An Immersive Learning Workshop for Interdisciplinary Professionals Periyakoil, V., O'Neill, L., Bernacki, R., Reilly, S., Thomas, J., Kapo, J., Block, S., Ferrell, B., Weissman, D., von Gunten, C. ELSEVIER SCIENCE INC. 2013: 324?25

    View details for DOI 10.1016/j.jpainsymman.2012.10.019

    View details for Web of Science ID 000315684600029

  • What Would Osler Do? : Editorial Journal of Palliative Medicine Periyakoil, V. 2013; 16 (2): 118-119
  • Measuring Grief and Depression in Seriously III Outpatients Using the Palliative Grief Depression Scale JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S., Kraemer, H. C., Noda, A. 2012; 15 (12): 1350-1355

    View details for DOI 10.1089/jpm.2012.0280

    View details for Web of Science ID 000311937500011

    View details for PubMedID 23066859

    View details for PubMedCentralID PMC3509503

  • Differentiating Grief and Depression in Patients Who Are Seriously Ill AMERICAN FAMILY PHYSICIAN Periyakoil, V. S. 2012; 86 (3): 232-?

    View details for Web of Science ID 000307152500004

    View details for PubMedID 22962985

  • "SERIOUSLY ILL OCTOGENARIANS & NONAGENARIANS"-ROLE OF PALLIATIVE CARE CONSULTS IN INITIATING "DO NOT ESCALATE CARE" PATHWAY AND DISCHARGE TO HOSPICE IN SERIOUSLY ILL OLDEST OLD PATIENTS ADMITTED TO A TERTIARY ACADEMIC MEDICAL CENTER. Kawai, F., Periyakoil, V. WILEY-BLACKWELL. 2012: S123?S124

    View details for Web of Science ID 000302464800358

  • Citalopram for agitation in Alzheimer's disease: Design and methods ALZHEIMERS & DEMENTIA Drye, L. T., Ismail, Z., Porsteinsson, A. P., Rosenberg, P. B., Weintraub, D., Marano, C., Pelton, G., Frangakis, C., Rabins, P. V., Munro, C. A., Meinert, C. L., Devanand, D. P., Yesavage, J., Mintzer, J. E., Schneider, L. S., Pollock, B. G., Lyketsos, C. G. 2012; 8 (2): 121-130

    Abstract

    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

  • Defining and Validating Palliative Care Competencies for Medical Students and Residents: A National Consensus Project Schaefer, K., Chittenden, E., Periyakoil, V., Carey, E., Morrison, L., Reilly, S., Block, S. ELSEVIER SCIENCE INC. 2012: 363

    View details for DOI 10.1016/j.jpainsymman.2011.12.083

    View details for Web of Science ID 000300054900067

  • Giving Feedback to Palliative Care Learners Morrison, L., Thomas, J., O'Neill, L., Carey, E., Jacobsen, J., Reilly, S., Kapo, J., Bernacki, R., Periyakoil, V. ELSEVIER SCIENCE INC. 2012: 414

    View details for DOI 10.1016/j.jpainsymman.2011.12.166

    View details for Web of Science ID 000300054900150

  • Latest Updates in Geriatrics and Palliative Medicine: A Skill-Based Immersive Learning Workshop Periyakoil, V. S. ELSEVIER SCIENCE INC. 2011: 167

    View details for DOI 10.1016/j.jpainsymman.2010.10.007

    View details for Web of Science ID 000286053400020

  • 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 Periyakoil, V. S., Noda, A. M., Kraemer, H. C. 2010; 13 (5): 495-500

    Abstract

    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

    View details for PubMedCentralID PMC2938912

  • Blue's Clues: Differentiating between Grief and Depression in Patients with Serious Life Limiting Illnesses (422) Periyakoil, V. J. ELSEVIER SCIENCE INC. 2010: 399

    View details for DOI 10.1016/j.jpainsymman.2009.11.299

    View details for Web of Science ID 000279280400148

  • Hidden in Plain Sight: Master the Secrets of Non-Verbal Communication (400) Periyakoil, V. J. ELSEVIER SCIENCE INC. 2010: 370?71

    View details for DOI 10.1016/j.jpainsymman.2009.11.285

    View details for Web of Science ID 000279280400104

  • Peer Mentoring: An Innovative Model for Professional Advancement in Hospice and Palliative Medicine (320) Bernacki, R., Sanchez-Reilly, S., Carey, E., Thomas, J., Kapo, J., Morrison, L., Periyakoil, V. J., O'Neill, L. ELSEVIER SCIENCE INC. 2010: 357

    View details for DOI 10.1016/j.jpainsymman.2009.11.068

    View details for Web of Science ID 000279280400080

  • 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 Periyakoil, V. S., Kraemer, H. C., Noda, A. 2009; 12 (12): 1125-1130

    Abstract

    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

    View details for PubMedCentralID PMC2939852

  • Change Management: The Secret Sauce of Successful Program Building JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2009; 12 (4): 329-330

    View details for DOI 10.1089/jpm.2009.9645

    View details for Web of Science ID 000264626700015

    View details for PubMedID 19327068

  • Organizational change Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/OrganizationalChange Periyakoil V.S., Weissman D 2009
  • Consultation etiquette: Marketing and patient referrals Center for Advancement of Palliative Care Campus Online: http://campus.capc.org/PalliativeCareCourses/ConsultationEtiquette Periyakoil VS, Weissman D 2009
  • Marketing for palliative care programs Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/MarketingforPalliativeCarePrograms Periyakoil V.S., Weissman D 2009
  • Education techniques in palliative care Center for advancement of palliative care: http://campus.capc.org/PalliativeCareCourses/EducationTechniquesinPalliativeCare V.S. Periyakoil, MD, Weissman.D 2009
  • Using metaphors in medicine JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (6): 842-844

    View details for DOI 10.1089/jpm.2008.9885

    View details for Web of Science ID 000258896100011

    View details for PubMedID 18715175

  • Geography decides destiny JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (5): 694-695

    View details for DOI 10.1089/jpm.2008.9905

    View details for Web of Science ID 000257535100009

    View details for PubMedID 18588399

  • The role of international medical graduates in the future of palliative care JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (4): 563-564

    View details for DOI 10.1089/jpm.2008.9925

    View details for Web of Science ID 000256241300007

    View details for PubMedID 18454607

  • On the endangered species list: Palliative care junior faculty JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (3): 431-433

    View details for DOI 10.1089/jpm.2008.9955

    View details for Web of Science ID 000254651800009

    View details for PubMedID 18363484

  • Growing pains: Health care enters "team"-age JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (2): 171-175

    View details for DOI 10.1089/jpm.2008.9975

    View details for Web of Science ID 000254651600011

    View details for PubMedID 18333730

  • Borders without doctors JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2008; 11 (1): 31-32

    View details for DOI 10.1089/jpm.2008.9995

    View details for Web of Science ID 000252559900008

    View details for PubMedID 18370889

  • Wrap your worthy cause in a corporate image JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2007; 10 (6): 1256-1257

    View details for DOI 10.1089/jpm.2007.9845

    View details for Web of Science ID 000252157200011

    View details for PubMedID 18095802

  • Declaration of interdependence: The need for mosaic mentoring in palliative care JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2007; 10 (5): 1048-1049

    View details for DOI 10.1089/jpm.2006.9911

    View details for Web of Science ID 000251086100012

    View details for PubMedID 17985959

  • First, do not abandon JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2007; 10 (4): 865-866

    View details for DOI 10.1089/jpm.2007.9932

    View details for Web of Science ID 000249251700014

    View details for PubMedID 17803405

  • Taming wicked problems in modern health care systems JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2007; 10 (3): 658-659

    View details for DOI 10.1089/jpm.2007.9955

    View details for Web of Science ID 000247498900013

    View details for PubMedID 17592976

  • Panic disorder at the end of life # 145 JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S. 2007; 10 (2): 483-484

    View details for DOI 10.1089/jpm.2006.9977

    View details for Web of Science ID 000246275900032

    View details for PubMedID 17472520

  • "Be nice-until it is time not to be nice". Journal of palliative medicine Periyakoil, V. S. 2007; 10 (2): 308-?

    View details for PubMedID 17472500

  • Mainstreaming palliative care JOURNAL OF PALLIATIVE MEDICINE Periyakoil, V. S., von Gunten, C. F. 2007; 10 (1): 40-42

    View details for DOI 10.1089/jpm.2006.9993

    View details for Web of Science ID 000244135100011

    View details for PubMedID 17298251

  • Quality of care in a veterans affairs' nursing home-based hospice unit JOURNAL OF PALLIATIVE MEDICINE Hallenbeck, J., Hickey, E., Czarnowski, E., Lehner, L., Periyakoil, V. S. 2007; 10 (1): 127-135

    Abstract

    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

  • Prazosin helpful in pacing for patients with dementia. Kim, S. J., Fayad, W., Wexler, B., Periyakoil BLACKWELL PUBLISHING. 2006: S161

    View details for Web of Science ID 000237069300472

  • Perceptions of loss of dignity at the end-of-life: Providers are from abstractville; Patients are from concretecity Periyakoil, V. S., Kraemer, H., Noda, A. BLACKWELL PUBLISHING. 2006: S78

    View details for Web of Science ID 000237069300227

  • Differentiating grief from depression in patients at the end-of-life Periyakoil GERONTOLOGICAL SOCIETY AMER. 2005: 527?28

    View details for Web of Science ID 000233615001511

  • Patient and provider perspectives on factors influencing loss of dignity at the end of life Periyakoil GERONTOLOGICAL SOCIETY AMER. 2005: 226?27

    View details for Web of Science ID 000233615000588

  • The development and initial validation of the Terminally Ill Grief or Depression Scale (TIGDS) INTERNATIONAL JOURNAL OF METHODS IN PSYCHIATRIC RESEARCH Periyakoil, V. S., Kraemer, H. C., Noda, A., Moos, R., Hallenbeck, J., Webster, M., Yesavage, J. A. 2005; 14 (4): 202-212

    Abstract

    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 Kraemer, H. C., Periyakoil, V. S., Noda, A. 2002; 21 (14): 2109-2129

    Abstract

    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 Periyakoil, V. S., Hallenbeck, J. 2002; 65 (5): 883-890

    Abstract

    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

  • Differentiating between preparatory-grief and depression at the end of life Periyakoil, V. S., Kraemer, H., Hallenbeck, J. LIPPINCOTT WILLIAMS & WILKINS. 2000: S13

    View details for Web of Science ID 000088887000076

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