A Unified Vision for Palliative Care

Just as Stephanie Harman, MD (clinical associate professor, General Medical Disciplines), began medical school, her father-in-law was diagnosed with metastatic lung cancer, unexpectedly sparking her interest in palliative care. As his illness progressed, she accompanied him to his appointments; reviewing his treatment options, discussing how he wanted to spend his remaining time, and eventually witnessing his transition to hospice care. “I had this internal realization that this process was so important,” she recalls. This realization stuck with Harman as she progressed through medical school and residency, where she continued to seek out hospice and palliative care training.

In 2007, Harman and a handful of multidisciplinary experts established Stanford Health Care’s first-ever inpatient consultative palliative care service. As palliative care gained momentum and recognition in hospitals and health care system nationwide, the program experienced tremendous growth. “We’ve grown from three team members to over 25,” Harman says, “and the number of patients we’re seeing has more than quadrupled.” 

Stephanie Harman, MD, and Karl Lorenz, MD, MSHS

Today, Harman and her colleagues are working to scale up Stanford’s infrastructure to address this growing demand. “We’re in the process of building and designing a new inpatient hospice unit,” she explains, “and we’re partnering with a community hospice agency, Pathways, to create a program to help patients transition from the hospital to hospice.” She continues: “We now have outpatient teams in three different sites, including clinics in our two Cancer Centers, led by Kavitha Ramchandran, MD (clinical assistant professor, Oncology), and our newest clinic at Hoover Pavilion led by Joshua Fronk, MD (clinical instructor, General Medical Disciplines). All of our teams reflect a multidisciplinary model to address the complex needs of patients and families, including physicians, nurses, social workers, and chaplains.”

Across town, Karl Lorenz, MD, MSHS (professor, General Medical Disciplines), who is based at the Veterans Affairs Palo Alto Health Care System (VA), is waging his own campaign to change the culture of palliative care.

Lorenz’s passion for these issues began in 1998, when he heard his mentor Joanne Lynn speak at UCLA about the failure of the SUPPORT study – an ambitious, $29 million effort sponsored by the Robert Wood Johnson Foundation to improve end-of-life care. Like Harman, he had a significant realization: “I realized for the first time that I was a bad provider of end-of-life care. But part of the reason was that I’d never received any training, and that I had never thought about it as an aspect of practice that I should be good at. I suddenly realized that I was going to have one crack at making a difference, and I wanted to be doing something that no one else was paying attention to, because I realized what a cost it had been in the past for my patients and me. And I didn’t think that was right.”

Lorenz committed himself to the field of palliative care, and began to work closely with leadership from the VA. “One of my earliest experiences was meeting James Hallenbeck, the associate chief of staff for Palo Alto VA, and sharing in some of the early meetings that established palliative care training programs through the VA’s Office of Academic Affiliations,” he recalls. Along with Randall Gale, PhD, an investigator at the Palo Alto VA, Lorenz now directs a national resource center that develops provider-facing informatics tools for the electronic health record to improve palliative care.

The Stanford Letter Project helps patients communicate their end-of-life wishes to doctors and loved ones. http://stanford.io/1OIhjvU

Posted by Stanford Department of Medicine on Thursday, April 23, 2015

The VA and Stanford Health Care palliative care programs each bring great strengths to the table. “Traditionally the two programs have operated fairly independently,” says Harman. “Collaboration will be a great opportunity to share best practices and resources, to learn from each other, and also to build up a much more robust academic section with research, education, and clinical programs.” The teams are evaluating the current palliative care landscape to develop a core set of program priorities and goals. As Lorenz explains, “We’re currently in the middle of an assessment process. One of our goals is to think through the advantages of our existing programs and resources and identify where the gaps are to prioritize some direction for us as a group.”

They also have plans to expand education and training efforts and leverage new technologies to support palliative care. “This is a great opportunity to innovate and to think more broadly about using technology in palliative care training, education, and delivery,” says Harman. Lorenz agrees, adding: “We’ll get to test and identify the technologies and models of care that will best serve the needs of patients and their families.”

Research is another key component of the combined VA-Stanford palliative care program. Several projects are already in the pipeline, including an examination of ways to spread palliative care within cancer practice by Manali Patel, MD (instructor, Oncology) and Risha Gidwani, DrPH (consulting assistant professor, General Medical Disciplines); and innovative research on end-of-life communication modes by VJ Periyakoil, MD (clinical associate professor, General Medical Disciplines). “We want to be doing cutting-edge research that is not only cited elsewhere but is adopted,” notes Lorenz.

A robust and effective academic partnership will be a reflection of Stanford’s commitment to palliative care, says Lorenz. “This will be an opportunity to think about what palliative care can really mean within the Stanford Health Care system. Veterans, patients, and their families all have much to gain from a growing program aspiring to excellence in palliative and end-of-life care.”

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