GeriPal: Recent Episodes

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Up until just a couple years ago, an 85-year-old patient presenting with gradual, amnestic memory loss was almost automatically presumed to have Alzheimer's disease. However, new biomakers and the recognition of conditions like Limbic-predominant age-related TDP-43 encephalopathy (LATE) are reshaping our understanding of cognitive decline in older adults. It's looking more clear that pure Alzheimers dementia is rare in older adults, and co-occurring pathologies that may include Alzheimer's, LATE, Lewy Body, and vascular neuropatholigies, are the rule rather than the exception.

In this episode of the GeriPal Podcast, we sit down with Sterling Johnson and Nate Chin from the University of Wisconsin. Sterling is a clinical neuropsychologist and researcher who leads the CLARiTI study, which is attempting to uncover the intersecting causes of dementia. Nate is the medical director and Clinical Core Co-Leader for the Wisconsin Alzheimer's Disease Research Center (ADRC), the host of the Dementia Matters podcast, and author of a new book When Memory Fades.

We tackle the real-world complexity of mixed dementia and its major diagnostic and clinical treatment dilemmas. We also go in deep to discuss LATE, from what it is, to how it presents, to whether it should change how we think about using newly approved disease-modifying therapies when a patient has confirmed amyloid positivity alongside suspected LATE.

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Can simple, evidence-based video decision aids—paired with structured clinician training—improve Advance Care Planning (ACP) documentation and goal-concordant care? That's the question we pose in this week's podcast with Dr. Joshua Lakin and Dr. Kei Ouchi. We break down the methodologies behind two major clinical trials in which they were involved that implemented this video-enhanced approach.

The first study, published in JGIM, was a multicenter, parallel randomized trial of 598 seriously ill older adults in emergency departments (EDs). It tested whether watching a 5-minute video and having a short, 10-minute structured clinical conversation during acute ED visits could establish longitudinal care preferences. The researchers found that this intervention not only increased ACP documentation at 3 months (45.6% vs. 31.3%), but also significantly increased goal-concordant care in a subset of study participants who died in the hospital.

The second study, published in JAMA Network Open, was a multicenter, stepped-wedge trial involving 13,800 older adults with advanced cancer across 29 outpatient oncology clinics. Practices in the trial received patient video tools and VitalTalk clinician training. The bundled intervention led to a statistically significant increase in electronic health record (EHR) ACP documentation (25.3% vs. 20.8% with usual care).

Both studies provide strong evidence that combining video-enhanced ACP with clinician training improves documentation of these discussions. What I loved most, though, is that the JGIM paper offers some of the first evidence that combining these approaches directly helps patients receive care aligned with their true values.

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The longevity industry is booming. Influencers are promoting this and that as promoting healthy aging, longevity, and healthspan, and it's hard for us, much less our patients, to make sense of it. To be sure, we should always start by recommending exercise, nutritious foods, good sleep habits, and meaningful social interaction. We wanted to go beyond that to talk about the promise and potential and risks/harms of "biohacks."

Today we talk with Mahtab Jafari, PharmD, and John Newman, MD, PhD, and to discuss:

• How we clinicians should think about this movement, knowing many of our patients (and ourselves) also prize living as long as we can as healthy as we can, and at the same time acknowledge that a high quality of life, growth, and a meaningful life are possible with support in states of disability or dementia.
• How animal models can leading to promising therapeutics but must be tested in humans
• What it takes for a drug to obtain approval for longevity or healthspan indications when we cannot realistically wait around 40 years for a result
• We ask them to rate the evidence for many treatment on the scale of very promising, meh, or snake oil/avoid, including creatine, metformin, GLP1, SGLT2i, NAD+, testosterone/estrogen, red light therapy, rapamycin, and rodeola rosea.

And I get to sing Wake Me Up by Avicii - an uplifting song with lyrics that could have multiple meanings - makes you think!

-Alex Smith

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Who's better at delivering palliative care to patients with liver disease: palliative care specialists, or hepatologists who have received liver disease-specific palliative care training?

That's the question we take a deep dive into on this week's podcast by breaking down the PAL-LIVER trial, published this year in JAMA Internal Medicine. We've invited three of the trial's authors, Manisha Verma, Chris Woodrell, and Marie Bakitas, to discuss this cluster-randomized clinical trial spanning 19 U.S. medical centers.

We'll discuss:

• Why was this trial done?
• Do we really need to run a separate palliative care trial for every single organ disease?
• What kind of specialized palliative care training did the hepatologists receive?
• What exactly is meant by the finding that hepatologists were not statistically superior, but were shown to be statistically non-inferior?

Lastly, we discuss whether these results change anyone's practice, and whether healthcare systems should decide which type of palliative care model to fund (primary vs. specialty.)

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References we discussed

• Developing palliative care interventions in liver disease using formative and summative qualitative evaluation. Hepatology 2026
• Palliative Care for Advanced Liver Disease: Hepatology and Palliative Care Specialists Experiences. J Pain Symptom Manage 2026

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Emergency Podcast! Our guests Sean Morrison, Ken Covinsky, and Stacy Fischer believe that you should care deeply about the proposed shakeup at the National Institutes of Health. Major proposed rules changes at the Office of Management and Budget, would affect a huge range of government grants, from Headstart to Transportation to the National Science Foundation, as well as the National Institutes of Health (NIH), the subject of today's podcast.

You dear listeners should all care. You should care because you care for older adults, or you're a researcher who studies palliative care, or you're a chaplain who visited with the family of a patient who died today. You should care because these rule changes are so sweeping that they would remove standard components of the scientific review process and instead put them in the hands of political appointees.

You should care because if rules like this were in place in the 1980s, we might not have developed treatments to stop the HIV/AIDS epidemic. You should care because if these rules go into effect we will not be able to work with researchers in other countries studying outbreaks of Ebola or Hauntavirus. You should care because these rules silence federal research into groups of people we care for daily.

And if you're not a researcher, your voice is even more important here. As Sean says, researchers who protest these proposed rule changes might come across as self-serving. Clinicians who are not researchers - who can say that these rules will negatively impact the science that improves care of older adults living with chronic conditions and their families - your voices may resonate even more.

What can you do? Most of these rule changes are open for public comment here until July 13, 2026. Every comment will be read and requires a response. It's ok to respond anonymously. Personalized stories matter more than form responses. Tips:

1. 1: Say (or just describe to keep anonymous) who you are and why you are qualified to comment. Telling the story of how patients and families you care for or study is enough. Get your partner and parents to respond too. Simply being a concerned citizen is perfectly fine.

2. 2: List the exact provision #s that concern you, and explain what they would do. You do not need to quote the rule directly. Just explain what you understand it to mean in plain terms.

   1. Political Appointees Take Control of Grant Awards (§200.205);
   2. Peer Review Is No Longer Binding (§200.205(d));
   3. Active Grants Can Be Terminated at Any Time, for Any Reason (§200.340);
   4. DEI, Gender Research, and Related Topics Banned as Grant Conditions (§200.300);
   5. Prohibition on International Scientific Collaboration (§200.220);
   6. Conference Attendance Now Requires Express Agency Pre-Approval (§200.432);
   7. Publication Costs and Open Access Fees Presumptively Unallowable (§200.461)
   8. 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect?
   9. 4: Closing: State clearly what you want OMB to do. This can be as simple as: "I urge OMB to withdraw these specific provisions: §200.340, §200.202, §200.205." or "I urge OMB not to finalize this rule."

Submit your comment in opposition here: The deadline is July 13, 2026. You can also email your congressperson or senator.

Times they are a changin'.

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Today's podcast is a natural follow up to our podcasts on Slow Codes and Unilateral DNR orders.Today we talk about a new study about how clinicians talk about potentially non-beneficial life-prolonging treatments, published in JAMA Network Open. Do they adhere to society guidelines, which allow as permissible approaches only shared decision-making and following institutional policy. Or do they take alternative approaches, like not offering interventions, not mentioning interventions, or simply stating a plan to limit interventions? Turns out doctors are using these alternative approaches frequently.

Our guests are Jason Batten, Liz Dzeng, and Teva Brender, all clinicians, all of whom have been thinking about and wrestling with the ethical reasoning behind these approaches. We all admit to using these approaches. Are the alternative approaches wicked games (song hint), and our response should be to stop these behaviors, beginning with ourselves? After all, if you ask patients or surrogates, they're likely to say they want all the options and may not universally welcome recommendations. Or, as with slow codes, does the fact that these alternative approaches are in common use suggest that the guidelines should be revised? You listen and decide!

-Alex Smith

Additional links:

Dzeng 2023 JAMA IM: The larger ethnographic study from which data was drawn with data drawn from high- medium- and low-intensity hospitals. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806959

Brender 2025 JAMA NO: Factors that exacerbate or mitigate moral distress related to potentially non-beneficial treatments.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835316

Dzeng 2015 JAMA IM: Study illustrating that more senior physicians feel more comfortable not offering or recommending against futile CPR. Relevant quote: "Experienced physicians at all sites generally were comfortable engaging in best interest decision making and, when clinically appropriate, not offering or making explicit recommendations against offering resuscitation." https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265

Weiss Goitiandia AJOB 2025: Reasons why some clinicians would hesitate to go to the ethics committee / futility process for these discussions: https://www.tandfonline.com/doi/10.1080/15265161.2025.2457734?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%20%200pubmed

Axelrod AJOB 2025: Discusses some of the systemic consequences of using physiologic futility as a standard and how it might contribute to a healthcare system that imposes aggressive treatments on vulnerable patients. https://www.tandfonline.com/doi/full/10.1080/15265161.2025.2530715#d1e152

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Today we revisit a topic we last discussed in a 2020 podcast with Laura Mosqueda: elder mistreatment. Our guests today are geriatricians Carrie Rubenstein and Julia Hiner, and Tony Rosen, an emergency medicine doctor. They talk about where we are now, in 2026, with elder mistreatment, including:

• Terminology: elder mistreatment vs. abuse and neglect
• The need to incorporate prevention and solutions into how we talk about mistreatment
• This is not rocket science. Studying elder mistreatment is much harder than rocket science.
• Highlighting the reasons they focus on elder mistreatment, including inspiring words for why this led them to geriatrics and aging research
• Should we screen for elder mistreatment? The US Preventive Services Task Force doesn't see enough evidence to recommend screening. Our guests may differ…
• Which clinicians should assess for elder mistreatment? Hospitalists? ED docs? Primary care providers? Tony published a study in JAGS showing older adults who experienced elder mistreatment were as likely to visit primary care as those who did not, also great accompanying editorial by Mara Rosenberg and Lena Makaroun gets a shout out.
• Early evidence that supporting caregivers can reduce elder mistreatment (in one small study of the COACH intervention, rates of mistreatment were reduced to zero)
• Borrowing from pediatrics: many/most hospitals and emergency departments can call a Child Protective Services Team. Tony is piloting a parallel team for older adults - the Vulnerable Elders Protection Team (see JAGS paper).
• We talk about key members of interdisciplinary teams across sites, systems, and counties. Social workers get a big shout out.
• A one year fellowship in capacity assessment and elder mistreatment at UT Houston, directed by Julia.
• An Elder Abuse Curriculum for Medical Residents and Geriatric Medicine Fellows
• https://pmc.ncbi.nlm.nih.gov/articles/PMC10842324/

Kudos to my son Renn for recording 5 overlapping cello parts on Eleanor Rigby!

-Alex Smith

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Two retired luminaries in geriatrics join us today to share their personal experiences. First, John Burton, a geriatrician and Director of the Division of Geriatric Medicine at Johns Hopkins for some 35 years, shares his journey moving into a Continuing Care Retirement Community (CCRC) during Covid. You can read about John's early experiences in his JAGS commentary titled, "Waiting for the Other Shoe to Drop." The tone is bleak. John's experience since Covid, as you'll hear, is very positive. Many of the concerns he raised about isolation have been addressed.

Second, we hear from Bill Applegate, Geriatrician, retired faculty at Wake Forest, and former Editor in Chief of JAGS (Bill recruited Eric and me to join JAGS as editors about 10 years ago). Bill had a distinctly negative experience in two assisted living facilities (ALFs), which you can read about in his JAGS essay, titled, "My Journey Through Assisted Living Facilities." Bill is seriously concerned about the lack of national oversight, poor staffing, and financial motivations behind for-profit and private-equity owned ALFs.

Finally, we hear from Melissa Aldridge, a former banker turned health services researcher, about the rise of private equity purchases of Assisted Living Facilities nationally. This is a follow up to our prior podcast on private equity gobbling up hospices with Melissa, Lauren Hunt, and Krista Harrison. Melissa is concerned that private equity has a very short time frame to turn acquisitions profitable, and cutting staff is often their first move. Further, private equity is financing these acquisitions with debt that is increasingly hard to trace and regulate. We talk about how private equity moving from purchasing fast food chains, toy stores, and hotels into CCRC, ALF, nursing home, and hospice ownership is a major concern. This is not the same as Blackstone buying the Hilton and turning a profit. These institutions provide healthcare, daily care needs, and community for a huge swath of older adults. These concerns should trigger a higher level of scrutiny, oversight, and regulation than other industries.

What can you do about this, dear listeners? Listen to the end to find out!

Thanks to Jerry Gurwitz for suggesting this podcast. We appreciate your suggestions. Keep 'em coming.

-Alex Smith

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Our focus today is on the search for the geriatrician identity, a continuation of the conversation we started with Jerry Gurtwitz on the Future of Geriatrics. Today's conversation is prompted by multiple articles in JAGS: (1) an article by Jerry Gurwitz with a title the same as this podcast; (2) an article by Helen Fernandez on "Med-Geri", a new combined 4 year internal medicine residency and geriatrics fellowship track; and (3) an article by Mary Tinetti titled, "Mainstream or Extinction: Can Defining Who We Are Save Geriatrics?" Of note, Mary's article is a follow up to her 2017 article in JAGS in which she wrote:

Those outside the field have difficulty understanding what geriatrics is and what geriatricians do. We contribute to this lack of clarity. We are experts in complexity but are often bad at communicating simply. Our well-intentioned efforts to be inclusive and comprehensive lead to the creation of long, complex descriptions of what we do that further compromises understanding while eroding interest in, and support of, our field.

Today we tackle this problem, discussing:

• A "funny if it wasn't so painful" video and JAGS article in which geriatricians from Johns Hopkins roamed the streets of Baltimore asking lay people "What is a geriatrician?" The responses (something to do with Ben and Jerry's ice cream? Jury-atrician?) will make you laugh and cry at the same time.
• 4 different types of geriatricians as described by Jerry in his JAGS paper: the complexivist, the healthful longevitist, the syndromist, and the contextualist.
• As with the 4Ms, Ken couldn't help but add a 5th, the "identityist", arguing that maybe Geriatricians worry too much in public about their identity, and should instead focus in public on what unites them: shared sense of purpose and mission to focus on whole person care and what matters most to older adults. Ken gave a rousing talk on being a Geriatrician at the Society of General Internal Medicine that received a lengthy standing-ovation (and a Cubs Jersey with his name on it).
• Innovative new programs such as Med-Geri and GeriPal fellowship as ways to bring more people into the profession.
• How to balance our effort between recruiting specialist geriatricians to the profession and teaching all clinicians geriatrics principles and skills.
• A paper in JAGS by Richard G. Stefanacci and Ankur Patel in JAGS making the argument that a geriatrician "yields per-patient annual net cost savings of approximately $3495 (specialist consultation avoidance +$1500; ED reduction +$45; hospitalization reduction +$1950)..." and "The reason fee-for-service fails geriatricians is not that their skills are wrong for primary care—it is that the payment model is wrong for their skills. Payvider programs operating under capitation invert every structural disadvantage of fee-for-service. Under capitation, there are no RVUs. There is no penalty for spending 40 min with a complex patient. There is no revenue loss when the patient is dual-eligible rather than commercially insured—the capitated payment is the same regardless of original coverage source. And every unnecessary specialist referral, every avoidable hospitalization, every ED visit that could have been managed in-house represents a cost to the organization rather than a revenue stream."

Stay until the end when Mary has one of the best answers yet (in over 400 podcasts!) to Eric's "if you had a magic wand" question.

Enjoy!

-Alex Smith

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I had the privilege of learning from fellow Greenwall Faculty Scholar Lisa Harris about a term she termed, "dangertalk." As an ob/gyn and abortion provider, Lisa found the debate around the legality of abortion so polarizing that it created a false dichotomy: you're either for or against. Any talk about misgivings, uncertainty, ambiguity, or ambivalence was silenced. Talking about these issues in the face of polarization was deemed dangerous and undermining to one side or another. "How could you?" For Lisa's work in finding common ground and embracing nuance she was awarded the 2023 Bernard Lo Award for forging connections across divisions.

In today's podcast we focus on the equivalent experience of moral uncertainty, distress, and residue among prescribers of medical aid in dying. We are joined by Carly Zapata and Dani Chammas, prescribers of medical aid in dying in California. We discuss:

• Their journey prescribing medical aid in dying, and reasons for choosing to prescribe
• The legality of prescribing in California. We compare California to Canada, as we have previously on this podcast. We discuss new limited survey data suggesting that legal barriers may not explain the remarkable 20 fold differences in use of medical aid in dying between California and Canada; rather, Canada has 6x the number of providers per capita as California, and much greater awareness of the legality of medical aid in dying. We talk about cases that are not as clear - e.g. people who have voluntarily stopped eating and drinking.
• Moral issues, including ambiguity and ambivalence, distress and residue. For example the moral distress created when a patient requests medical aid in dying due to what is clearly a systems failure (see this Atlantic article for clear examples from Canada). We ask if they sometimes feel frustrated that more people who are in favor of medical aid in dying are not prescribing, instead leaving prescribing responsibility to a relatively small group of clinicians.
• How core ethical ideas might lead to very different conclusions about medical aid in dying, and ways Dani teaches ethics to trainees.
• Psychological models that can help navigate this complex terrain with patients and families, including formulations and countertransference.

And I can't believe I haven't played, "I will follow you into the dark" previously - but google couldn't find it - really? In 400+ GeriPal podcasts? Great song. So fitting. My son Renn plays guitar on the audio only version.

-Alex Smith

Additionally, some take home points, sent by Dani after recording:

(1) Holding the dialectic: On one hand, people deserve the highest level of attention to their personhood and their suffering—an effort that, at times, can soften or even resolve a desire for hastened death. And on the other hand, some people will authentically experience this as the most values-aligned way of dying, given their circumstances.

(2) Learning to accept that while laws create the safety rails, within those boundaries, morality is pluralistic. Both patients and clinicians bring deeply held moral frameworks to these decisions—and those frameworks deserve to be acknowledged and respected.

(3) We have to be willing to ask the hard questions—and to show up for one another as we do. Because this work, more than almost any other, has taught us the profound impact of not feeling alone when navigating grey terrain.

I view the discussion as an invitation for our field to not necessarily to become more certain, but to be willing to wrestle with the hard questions—while still showing up with rigor and compassion.

And to remember that our patients are people before they are cases. If we can stay close enough to truly know them, we're much more likely to respond in ways that honor both their suffering and their dignity—whatever path that ultimately leads to.

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While we have previously discussed brain death criteria on the GeriPal Podcast, we have yet to explore the complex landscape families face regarding organ donation. In this episode, we dive into the nuances of Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), and clarify the essential role of healthcare providers who are not part of an organ procurement organization.

In this episode of the GeriPal Podcast, we step into a space in serious illness care that is often misunderstood, overlooked, or reduced to a simple "call the organ donation network" checklist item.

Joining us are three experts to help us understand the process and our role in it:

• Samantha (Sam) Taylor, a Donation Support Specialist and expert trainer on the donation request conversation
• Dr. Nikole Neidlinger, an abdominal transplant surgeon and medical director for the organ and tissue donation program at the University of Washington
• Dr. Toby Campbell, palliative care physician and host of the Extraordinary Conversations podcast, which is focused on organ donation for its first season.

We'd also like to send a big thank you to Toby as he was the one who recommended doing this podcast, and we'd encourage all of our listeners to check out Extraordinary Conversations. I personally love episodes like this as it opens up a black box that I otherwise dont think about (similar to our Undertaker podcast with Thomas Lynch where we talk about what happens after someone dies).

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In this episode of the GeriPal podcast, we dive into the fascinating world of geriatric dermatology, or "GeriDerm," with two exceptional guests: Dr. Daniel Butler from the University of Arizona and Dr. Eleni Linos from Stanford University.

First, we tackle the big question: how do we keep our skin healthy as we age? I see this on a daily basis with my own skin, but I'm unsure what to do about it, including whether we all need to use sun protection and moisturizers, and if so, which ones?

Then we explore the lag time to benefit in dermatology by examining whether we need to treat every actinic keratosis and basal cell carcinoma aggressively, or whether there are cases where we can opt for watchful waiting.

We also explore chronic itch with Daniel, covering the three main sources of itch and how our management should change accordingly. Importantly, antihistamines were not a prominent part!

We finally asked Eleni whether artificial intelligence (AI) and digital tools can revolutionize the way we diagnose and manage skin conditions, especially in older adults.

For a deeper dive into the topic, check out these two papers that we talk about on the podcast

• Daniel's JAMA paper on Chronic Pruritus
• Elani's JAMA IM paper on Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma

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Eric and I were delighted to be invited to Brazil to give a series of presentations in Sao Paulo at their annual geriatrics meeting. We met people doing important, interesting, and innovative work in Brazil and throughout Latin America. We got the audience to sing along, including (in another talk) the magnificent Brazilian song Sozinho by Caetano Veloso in Portuguese, with my son Renn playing guitar.

For our final talk, a podcast in front of a live conference audience, we asked our 3 guests, Eduardo Ferriolli, Marlon Aliberti, & Edison Iglesias to select a recent article to discuss. We talked about:

1. Intrinsic capacity (selected by Eduardo). What is it? What is it used for? How do you measure it? (hint ICOPE). Eduardo emphasized that intrinsic capacity is a positive aspect of aging, focused on potential rather than deficit. We asked him to work intrinsic capacity into George Kushel's famous analogy using the golden gate bridge to describe phenotypic frailty (pillars), deficit accumulation frailty (cable supports), and resilience (withstand stress of wind and cars). Eduardo says intrinsic capacity would be the car, and would vary by type of car and intended purpose. I loved Eduardo's selected article, which percentiles intrinsic capacity, in order to use within individuals to assess how they're tracking over time, and at a public health level, to identify regions or groups of people with lower intrinsic capacity. He draws the analogy to growth curves in pediatrics - if you're consistently at 80% - then drop off - your primary care provider should take notice and investigate/intervene.
2. Geriatric syndromes in hospitalized older adults (selected by Marlon). If intrinsic capacity is for primary care, our guests argue that the comprehensive geriatric assessment, which takes a long time to administer, should be reserved for specialist geriatrics. And yet, this paper finds that a limited shorter version of the comprehensive geriatrics assessment can document geriatric syndromes in hospitalized older adults. Accumulation of multiple geriatric syndromes is associated with increased mortality, and presents an opportunity for risk stratification, goals of care discussions, and intervention.
3. Advance care planning across Latin America (selected by Edison). Back around 2005, when Edison first heard about advance care planning, he says, "it sounded like science fiction." In Brazil, as with Latin America, medicine was highly hierarchical and patriarchal. Doctors knew best. The doctor decided. If there was no patient choice, why would there be a system to protect the decisions of patients made in advance? In the intervening years, Edison and others have worked to incorporate and adapt advance care planning to the Latin American context, which is much more focused on family-centered relational autonomy than individual, and incorporates spirituality to a much greater extent. Edison has been mindful too of not repeating the mis-steps of the advance care planning and advance directive movements in the US.

We took questions from our audience and sang "Imagine" in Portuguese together. Enjoy!

-Alex Smith

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Lynn Flint and Anne Kelly join as hosts in a reprise of last year's ask us anything format. Thank you for sending in your terrific questions! Lynn and Anne condensed them to about 20, and we ran through them rather rapid fire. Also on fire? Our mouths. As with our 300th episode, we did this Hot Ones-style. Every few questions, we had to eat a chicken wing slathered in hot sauce. The hot sauces got progressively hotter, though as we discovered, the ordering may have been a littttttle bit off. Still, by the time we hit the really hot ones, our mouths were on fire, we were blowing our noses, gulping down milk, and terrified of what the next hot wing would bring…

We covered so much in this podcast, including:

• Coffee or tea? What jokes do you make with patients?
• Where do we see ageism?
• Why are we still advocating for advance care planning?
• Concerns about expansion of medical aid in dying
• Should doctors reveal that they're using AI in clinical care (thanks for the question mom!)
• The future of geriatrics and palliative care
• What we'd do differently about the podcast if we could start over, or what we could do that is new going forward. Surprises in terms of who is listening, our audience.
• Ideas for others to build community as we do at GeriPal
• Influence of our own spirituality and religion on our clinical practice
• Lasting practice changes from prior podcasts, or from Covid experience
• Why PC in the ED hasn't taken off
• And more!

Looking back on 10 years and 400 podcasts, Eric and I are filled with gratitude for you, dear listeners. You sustain us. You keep us going. Please stay involved, send us messages about show ideas, and introduce yourself to us at national meetings.

Thank you!

-Alex Smith

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Rural populations in the United States face unique healthcare challenges. These communities tend to be older, have higher mortality rates, and experience higher rates of chronic conditions and physical disabilities compared to urban populations. Despite the increased need for palliative care in rural areas, access remains alarmingly limited. Even in hospital settings, where palliative care programs are more common in urban areas, only 35% of rural hospitals report having such programs, compared to 81% of urban hospitals.

In this week's podcast, we explore the challenges and opportunities of delivering palliative care in rural communities with our esteemed guests Karl Bezak, Jeanie Youngwerth, Adie Goldberg, and Gregg Vandekieft. We begin by discussing what inspired each of them to focus on rural palliative care. From there, we dive into what rural palliative care looks like and examine how it differs from care provided in urban settings. Our guests also share insights into the challenges of delivering this care in resource-limited rural environments and explore innovative strategies to ensure patients and families receive the support they need (like providing remote fellowship training for docs living in rural areas!).

We also tackle the role of telemedicine in rural palliative care, both the good part, connecting patients in remote areas with specialists who might otherwise be unavailable, and the bad part, the huge digital divide seen in rural areas.

Join us for what I thought were some valuable insights our guests brought on how we can better serve rural populations and create a more equitable system for palliative care delivery. And if you want to learn more, check out some of these resources:

• University of Colorado's Community Hospice and Palliative Medicine (CHPM) Fellowship, which allows mid-career providers to obtain training while continuing to live and work in their community supported through online and distance learning technology
• Master of Science in Palliative Care Program: Master of Science Degree
• The Rural Health Information Hub's Rural Hospice and Palliative Care Overview
• Stratis Health's Rural Community-based Palliative Care resource center
• The Washington Rural Palliative Care Initiative website
• CAPC's Safety-Net and Rural Care website
• The paper validating the AI Algorithm used to identify patient in rural ED for the TeleGOC Pause Model at UPMC (SafeNET)
• A Google Site where Karl is hosting their most recent data related to the TeleGOC Pause Model

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Today we're delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine. Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing).

This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit.

In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms. Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives.

I'm going to cut to the pushback to this article right up front:

• The study's primary outcomes were advanced directives or completion of POLST forms - haven't we moved beyond thinking completion of forms should be the primary outcome of advance care planning research?
• There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention. People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention?
• Observed documentation - 13-20% - was low. Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms?

Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself. Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade.

And a fun fact about All You Need is Love - the verses are in 7/4 time!

-Alex Smith

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In 2025, the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals participating in the Hospital Inpatient Quality Reporting (IQR) program to report on a new "Age-Friendly Hospital Measure." The hope is that, by attesting to this measure, hospitals will develop evidence-based processes to improve care for older adults in hospital settings.

On this week's podcast, we explore this new measure with Sheri Ling, CMS's Deputy Chief Medical Officer serving in the Center for Clinical Standards and Quality (CCSQ). We've also invited some returning guests from our past Age Friendly Health Systems podcast, Julia Adler-Milstein and Stephanie Rogers, to discuss how they are thinking about this new measure and how we should operationalize it.

We go over everything you will want to know about the new measure, including:

• How does this CMS measure differ from both Age-Friendly Health Systems and the 4Ms movement we've been hearing about for years (and that we did the podcast on in 2020 here)
• Why is CMS finally making "Age-Friendly" a formal, structural requirement for hospitals now?
• What is an attestation measure vs outcome measure, and why is this one an attestation measure?
• A deeper dive into the 5 domains to the measure (Eliciting Patient Goals, Medication Management, Frailty Screening, Social Determinants of Health, and Leadership/Governance.

Lastly, here are some great resources if you want to help get this started at your hospital:

• A report by JAHF, Julia and others on how to think about different dimensions of measure performance
• Health Affairs Scholar paper on related the 4Ms to the 5 domains

• Two CMS resources with detailed information on how to meet and report on the five domains of this measure:

• • Age-Friendly Hospital Specifications (July 2025)
  • Age-Friendly Hospital Measure Attestation Guide

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A few weeks ago, I was skimming this NEJM paper for UCSF's Division of Geriatrics Journal club on de-prescribing anti-hypertensive medications for older adults in nursing homes. Seemed to make a world of sense. The study found no difference between the deprescribing arm and the usual care arm in mortality, the primary study outcome. I thought, great! So we can deprescribe anti-hypertensives without changing mortality, that must be what the authors concluded.

I was shocked, therefore, to read in the first paragraph of the discussion that the deprescribing arm did not achieve the hypothesized 25% reduction in mortality. What?!? Why would deprescribing be associated with reduced mortality? That's not the main reason or even the first reason I think of for deprescribing. Reducing side effects that impair quality of life, sure. Less pill burden, of course. But prolonged life? Seemed a stretch.

Today we hear from the first author of this study, Athanase Benetos, an esteemed geriatrician-researcher from France. For context, we also interviewed Mike Steinman, co-chair of the Beers criteria and co-lead of the US Deprescribing Research Network.

We learned about:

• Why the hypothesis of reduced mortality in deprescribing was justified, based on natural decreases in blood pressure with aging, and the Partridge study, an observational study that found higher risks of mortality associated with using multiple anti-hypertensive and low blood pressure.
• Why mortality was chosen as the primary outcome.
• Is a negative superiority study the same as what they might have found in a non-inferiority study? (stay with us)
• Variation in outcome by frailty status
• How to place this study in context with other research, such as the Danton study mentioned on a recent podcast about deprescribing near the end of life. Dantos was a study of deprescribing for nursing home residents with dementia that was stopped early due to safety concerns. Other studies for context include Sprint, Optimize, and an observational study by Bocheng Jing (UCSF statistician in our group).

At the end, we ask our guests to put it together. With all that we know at this point, what's a clinician to do? To deprescribe or not to deprescribe?

And, zoot alors! I get to sing Hymne A L'amour in French! Athanase recounts the moving story of how Edith Piaf sang this song the night she learned the man she loved, Marcel Cerdan, died in a plane crash.

-Alex Smith

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It's an era of breakthroughs in Alzheimer's research, yet for many clinicians, it's also a time of profound uncertainty. We are currently navigating competing definitions of the disease, multiple new biomarkers coming on market seemingly every week, and the clinical rollout of new amyloid antibodies.

How do we translate this rapid-fire science into daily practice? On this week's GeriPal podcast, we sit down with dementia experts Halima Amjad, Barak Gaster, and Heather Whitson. We dive deep into:

• The evolving definitions of Alzheimer's disease. Does someone have Alzheimer's disease if you have only an abnormal biomarker as defined by the Alzheimer's Association, or is amyloid pathology necessary but not sufficient to define Alzheimer's as per the International Working Group (IWG) recommendations?
• Where do blood-based biomarkers for Alzheimer's fit into the diagnostic workup, and should they be used at all in primary care? FYI - here is my take on that question in a recent JAMA IM article titled "The Limited Role of Alzheimer's Disease Blood-Based Biomarkers in Primary Care."
• What's the role of amyloid antibodies in the care of individuals with Alzheimer's disease, including who to use them on?

We covered a lot and discussed some of these resources that you can do a deeper dive on:

• Blood-based biomarker resources
• JAMA article on Blood-Based Biomarkers for Alzheimer's Disease: Preventing Unintended Consequences
• Alzheimer's Dementia article on Blood-based biomarkers for detecting Alzheimer's disease pathology in cognitively impaired individuals within specialized care settings: A systematic review and meta-analysis

• JAMA IM article on The Limited Role of Alzheimer Disease Blood-Based Biomarkers in Primary Care

• Appropriate use recommendations for amyloid antibodies

• Donanemab: Appropriate use recommendations

• Lecanemab: Appropriate Use Recommendations

• Primary Care Resources

• Cognition in Primary Care program

• A JAGS article on "Large Health System Quality Improvement Intervention Providing Training and Tools to Improve Detection of Cognitive Impairment in Primary Care"

• Other resources

• AGS's new online curriculum for Alzheimer's Disease

By Eric Widera

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Today we're doing something different. Today, dear listeners, you get two podcasts for the price of one! (OK, our podcasts are both free, but you get the idea).

We're joined today by Chris Comeaux, host of TCN Talks, a podcast about leadership, strategy, innovation, and the future of serious illness care, and author of The Anatomy of Leadership. We are also joined by TCN Talks' frequent guest host Cordt Kassner, CEO of Hospice Analytics, which provides in depth data on hospice quality, utilization, and access, and publisher of Hospice and Palliative Care Today, a daily email about the hottest stories and news in the field.

This is an "ask us anything" style podcast in which we get to ask each other questions. Our discussions focus on concerning trends in hospice, Ira Byock's white paper, concerning trends in hospice, certificate of need, danger of losing a generation of junior researchers and hope in the form of ASCENT, various measures of hospice quality including Cordt's National Hospice Locator, which ranks all area hospice by quality, unlike CMS's Hospice Care Compare, which only has star ratings for about 30% of hospices.

Hospice and palliative care are going through a tough growth period, and sometimes being real with your friends and colleagues in your field means tough love. Love hurts. And no, I'm not attempting the Nazareth version!

-Alex Smith

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Philippe Pinel remarked in 1800 that "It is an art of no little importance to administer medicines properly, but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them." This insight remains profoundly relevant today, especially in hospice care, where inappropriate prescribing is a common issue. Studies show that 20%–70% of hospice patients receive at least one unnecessary medication near the end of life, including drugs like antihypertensives, statins, and vitamins.

In this episode of the GeriPal Podcast, we tackle the pressing topic of deprescribing at the end of life with expert guests Jennifer Tjia, Jon Furuno, and Simon Mooijaart. The conversation focuses on identifying medications that should almost always be discontinued—such as statins, osteoporosis meds, finasteride, and vitamins, which offer minimal benefit for patients with limited life expectancy. We also delve into more nuanced cases, such as antithrombotics, which present complex decisions that challenge clinicians, particularly when prognosis spans the many weeks to months range.

Finally, we explore practical strategies for engaging patients and families in deprescribing conversations. Our guests highlight tools such as the FRAME mnemonic (Focus on the goals of care, Review current medications, Assess each medication's risk/benefit, Minimize the medication burden, and Evaluate regularly) and the Goal Concurrent Prescribing tool, which helps ensure medication decisions align with patients' values and end-of-life priorities.

By: Eric Widera

Other resources discussed in the podcast

• Prevalence and Factors Associated With Receiving a Prescription for Antithrombotic Therapy on Hospice Admission," JAGS. 2025
• Discontinuation of Anticoagulants and Occurrence of Bleeding and Thromboembolic Events in Vitamin K Antagonist Users with a Life-limiting Disease. 2025
• Effects of the discontinuation of antihypertensive treatment on neuropsychiatric symptoms and quality of life in nursing home residents with dementia (DANTON): a multicentre, open-label, blinded-outcome, randomised controlled trial. 2024
• Perspectives on deprescribing in palliative care. Expert Review of Clinical Pharmacology. 2023
• Developing a decision support tool for the continuation or deprescribing of antithrombotic therapy in patients receiving end-of-life care: Results of a European Delphi study. Thrombosis Research. 2025
• Human-Centered Design Development and Acceptability Testing of a Goal Concordant Prescribing Program in Hospice. JPM 2025
• Reduction of Antihypertensive Treatment in Nursing Home Residents. NEJM 2025

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Do you think your hospital should allow unilateral DNR orders? Under what circumstances? Through what process? Do you think that when you obtain the assent of a family to not code their loved one, that assent DNR should be counted as a unilateral DNR order? Should we document unilateral DNR and the rationale? Why for DNR, when we don't document unilateral dialysis not offered, or unilateral no ECMO offered? Is the assent of a family member to a statement that we will not code their loved one a nudge, and is the assent approach ethical? Reasonable people will disagree, as we do on this podcast.

Our guests today are Gina Piscitello, Erin DeMartino, and Will Parker, authors of a terrific viewpoint in JAMA about the need to address inadequate documentation of unilateral DNR orders. You might recall Gina was a guest on our lively podcast about slow codes, and we pick up where that podcast left off.

We highlight the many clinical, practical, and ethical issues at stake, including Gina's finding that during Covid, 3% of critically ill patients receiving pressors had a unilateral DNR order. Black patients and those who spoke Spanish had higher rates of unilateral DNR. That variation should trouble those in favor of unilateral DNR orders. We talk about variation Gina found at the state and health system level, and what exactly is concerning, the variation itself, or the lack of thought and care that went into some of these policies.

Are you a heartbreaker? Dream Maker? Love taker? Don't you mess around with me. (song hint)

-Alex

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The idea of embedding various forms of non-emergency care in the emergency department makes a WORLD of sense. If an older adult comes into the ED with a fall, the minimum the ED has to do is address the fall injury and send them out. But many emergency providers realize this is often a band aid. They see that patient again the next time they fall. And again. And again. The same could be said for the patient who is malnourished and dehydrated and admitted for "failure to thrive," again. And again.

Our two guests today, Liz Goldberg and Lauren Southerland, both emergency medicine physician-researchers, have had enough. On our podcast today they discuss how these sorts of experiences led them to argue that other services that can address the underlying causes that lead to ED visits. Liz Goldberg developed the GAPcare model to address falls, which includes a physical therapist and pharmacist seeing patients on the spot in the ED. Lauren Southerland got Columbus Ohio Office of Aging staff to re-locate from their desks to the emergency department, where they could sign patients up for home delivered meals, medical transportation, adult day services, home modification such as grab bars, and utility assistance for electricity, gas, and water bills.

With GAPcare, Liz saw a 66% drop in ED visits for fall over 6 months from her pilot (subsequent fall outcomes of the GAPcare II study will be linked here when published). Remarkable, particularly in the context of the primary care STRIDE intervention, which did not reduce injurious falls (e.g. the type that would result in an ED visit). Maybe the ED is just a better place to intervene? Patients are motivated to change. Get the physical therapist and pharmacist in there!

In a study published in JAGS, Lauren found 50% of participants were linked to a new Office of Aging service initiated during the ED visit, with no increase in ED length of stay or hospital admission rate. See also this terrific JAGS editorial on Lauren's paper by Liz. Putting on my JAGS editor hat - both the study and editorial have terrific color figures. A great way to increase your odds of review and acceptance at JAGS is to include one or more high-impact color figures that convey the main findings or points of your manuscript.

We talk about the potential downsides, real and perceived in embedding care in the ED. Should everything be embedded? We talk about how these interventions relate to geriatric ED certification. Lauren talks about a remarkable model in Australia that includes a geriatric RN embedded in the ED.

Most encouraging is that Liz and Lauren are finding other adopting these interventions. Word is spreading. Other emergency providers have had enough of the endless cycle. Enough.

And I got to belt out Gravity, by John Mayer!

-Alex

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Today we interviewed Bob Wachter about his book, "A Giant Leap: How AI Is Transforming Healthcare and What That Means for Our Future." You may recall we interviewed Bob in April 2024 about AI, and at that time he was on the fence about AI - more promise or more peril for healthcare? As his book's title suggests, he's come down firmly on the promise side of the equation. On our podcast we discuss:

• Why Bob wrote this book, at this time, and concerns about writing a static book about AI and Healthcare, a field that is dynamic and shifting rapidly. He's right though - we've not had a "ChatGPT"-launch type moment recently.
• Top 5 or so ways in which Bob uses AI for work, from clinical care to book writing
• Concerns about job losses in healthcare, and will we still need doctors?
• AI for diagnosis, and the recent NEJM Clinical Case in which recent GeriPal guest and superstar clinician-educator Gurpreet Dhaliwal beats an AI.
• UpToDate vs OpenEvidence
• Trust issues - should we trust AI after being let down before? Clinicians felt burned by their experience with the hype and promise of EHRs - but they've been much less a game changer and much more a soul sucking chore designed to maximize billing rather than improve patient care. Yet early returns on AI have largely been positive. Time saved from writing notes, prior authorizations, and summarizing charts…all to the good!

Sadly, we didn't have Bob on piano singing the song for this one. He was in the office, not home. So I made do with ChatGPT's choice, Handle With Care, which has some surprisingly pertinent lyrics about AI in healthcare, including:

"Been beat up and battered aroundBeen sent up, and I've been shot downYou're the best thing that I've ever foundHandle me with care"

Enjoy!

-Alex Smith

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Recent randomized controlled trials have shown that routine perioperative palliative care does not improve outcomes for patients undergoing curative-intent cancer surgery. No, that wasn't a typo. Regardless of how the data were analyzed, the findings remained consistent: perioperative palliative care DID NOT improve outcomes in the only two randomized controlled trials conducted in this area—the SCOPE and PERIOP-PC trials.

Null trials like these often receive less attention in academic and clinical settings, but they can be profoundly practice-changing. Consider the Shannon Carson study on palliative care for chronically critically ill patients. While some have argued it "wasn't a palliative care study," I've always regarded it as one of the most significant studies for understanding not what works—but what doesn't—for palliative care in specific patient populations.

The same holds true for the SCOPE and PERIOP-PC trials. Both were null, but their findings are deeply relevant to clinical practice. That's why we invited the lead authors, Rebecca Aslakson (PERIOP-PC) and Myrick "Ricky" Shinall (SCOPE), to share insights into what they did in their studies and why they think they got the results that they did.

One key takeaway for me from this discussion was the idea that patients undergoing curative-intent surgery might simply be too early in their cancer trajectory to derive meaningful benefits from palliative care, and maybe the focus should be more on geriatrics. I especially appreciated the closing discussion about the future of research in this area: if routine perioperative palliative care doesn't improve outcomes, what should the next generation of studies focus on?

Eric Widera

Studies we talk about during the podcast

• Aslakson et al. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open. 2023
• Shinall et al. Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer: A Randomized Clinical Trial. JAMA Surg. 2023
• Carson et al. Effect of Palliative Care–Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA. 2016
• Holdsworth et al. Patient Experiences of Specialty Palliative Care in the Perioperative Period for Cancer Surgery. JPSM. 2024
• Williams et al. Patient Perceptions of Specialist Palliative Care Intervention in Surgical Oncology Care. Am J Hosp Palliat Care. 2025
• Yefimova et al. Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surg. 2020

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"I just want to say one word to you. One word. Plastics… There's a great future in plastics."

This iconic line from the movie The Graduate is at the top of my mind when I think about where we are heading in healthcare. I've interpreted "plastics" as symbolizing a dystopian, mass-produced future of medicine—where artificiality and inauthenticity dominate in the pursuit of efficiency and profit margins. After listening to today's podcast on the growth of community-based palliative care, I find my perspective shifting on this quote. Perhaps the advice given for a future in plastics reflects the past generation's established worldview, failing to recognize a countercultural revolution seeking transformation and meaningful change, even if it may come across as a little brash.

In this thought-provoking episode of the GeriPal podcast, we are joined by Alan Chiu (Chief of Palliative Care at Monogram Health), Mindy Stewart-Coffee (National Vice President of Palliative Care at Optum Home and Community), and Ben Thompson (National Medical Director for Hospice and Palliative Care at Gentiva) to discuss this revolution happening in palliative care. The conversation centers around the rapid growth and investment in community-based palliative care, which has emerged as a key area of innovation and opportunity to meet the largely unmet needs of patients living with serious illnesses. With a focus on expanding access, improving outcomes, and addressing workforce shortages, the guests explore how value-based care models are reshaping palliative care delivery.

The discussion highlights the differences between traditional fee-for-service models and newer value-based care approaches, including how they incentivize care. We take a deep dive into the risks and benefits of these models, emphasizing the importance of maintaining high standards of care while fostering innovation. We also delve into the role of for-profit organizations and private equity in driving change, acknowledging concerns about motivations while recognizing that these entities can help spur innovation and improve access when led by clinicians committed to patient-centered care.

Ultimately, this podcast serves as a call to action for the palliative care community to help shape not just the "Wild West" of community-based care, but palliative care 3.0 as a whole. Do we sit back and wait for a future dominated by a plastic version of palliative care, or do we help lead this revolution to ensure it maintains the authentic heart of what brought us to this field? As Diane Meier aptly warns, "if you are not at the table, you're on the menu."

Eric Widera

Of Note: the views expressed in this podcast are our guests' own opinions and not representative of their organizations.

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The only certainty in medicine is uncertainty. It touches every aspect of clinical practice, from diagnosis to treatment to prognosis. Despite this, many clinicians view uncertainty as something to tolerate at best or eliminate at worst. But what if we need to rethink and reframe our relationship with uncertainty in medicine?

In this episode, we sit down with Jonathan Ilgen and Gurpreet Dhaliwal, co-authors of the New England Journal of Medicine article, "Educational Strategies to Prepare Trainees for Clinical Uncertainty." Together, we explore the nature of uncertainty in clinical practice, its effects on trainees and seasoned clinicians, and strategies to embrace it as a fundamental part of medical reasoning rather than a regrettable byproduct.

Jonathan and Gurpreet share insights from research and clinical experience, offering practical methods to help trainees and clinicians recognize, manage, and even embrace uncertainty. Key topics we discuss include:

• The paradoxical nature of uncertainty: When perceived as a threat, it can provoke anxiety or fear; yet when framed as an opportunity, it can inspire hope and optimism.
• Why uncertainty is inevitable in medical practice and its impact on clinicians.
• Is uncertainty a state or a trait?
• The distinction between epistemic uncertainty (knowledge gaps) and aleatoric uncertainty (randomness in outcomes).
• How experienced clinicians utilize strategies such as forward planning and monitoring to navigate uncertainty.
• Communicating uncertainty with patients: how to do it effectively without eroding trust.
• How to integrate uncertainty into medical education.

During the conversation, we explore the emotional responses to uncertainty and how these reactions can influence clinical practice and decision-making.

Importantly, Jonathan and Gurpreet emphasize the importance of openly communicating uncertainty with colleagues, supervisors, and patients—a practice that, contrary to common belief, actually strengthens trust, fosters transparency, and encourages collaboration. By normalizing and embracing uncertainty, clinicians can better manage the complexities of medicine and build confidence in their ability to care for patients in the face of the unknown.

👉 We're thrilled that Meg Wallhagen, Professor of Nursing at UCSF, has recorded an intro to this week's podcast. Any listener who contributes $1000+ is invited to record an intro to a GeriPal podcast! You can donate here, any amount is appreciated. Also, Meg is looking for practicing or student clinicians (physicians and nurses) who are willing to participate in a study on how a simulation of hearing loss promotes a greater appreciation of the experience of hearing loss. Participation should take no more than one to one and one half hour and you will receive a gift card in acknowledgement of your time. If interested, please contact her directly at meg.wallhagen@ucsf.edu.

For more info, click the following link to open the flyer (PDF format): Information_Flyer_Practitioneer

NOTE: To claim CME credit for this episode, click here

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In a recent episode of the GeriPal podcast, we explored whether the field of palliative care is in need of saving—and, if so, how to save it—with guests Ira Byock, Kristi Newport, and Brynn Bowman. Today, we shift focus to one actionable way to improve palliative care: through quality improvement (QI) collaboratives, registries, and benchmarking.

To guide this discussion, we've invited three leading experts in the field—Drs. Steve Pantilat, David Currow, and Arif Kamal—who bring invaluable experience as pioneers in developing QI collaboratives and registries. Together, they authored a recent paper in JPSM titled "The Case for Collaboration to Optimize Quality," which underscores the importance of these efforts.

In this episode, Dr. David Currow shares lessons from Australia's Palliative Care Outcomes Collaborative (PCOC), a national model for standardized data collection and benchmarking that has driven measurable improvements in palliative care. Meanwhile, Drs. Steve Pantilat and Arif Kamal reflect on the history of the Palliative Care Quality Collaborative (PCQC), a U.S.-based initiative formed in 2019 by merging the National Palliative Care Registry (NPCR), the Palliative Care Quality Network (PCQN), and the Global Palliative Care Quality Alliance (GPCQA). Although the PCQC had ambitious goals, it ultimately closed earlier this year. Together, the panelists unpack the reasons behind its closure and discuss the lessons future registries can take away from its challenges.

Throughout the conversation, we tackle some of the field's biggest questions about registries and QI collaboratives: What data should be collected to create meaningful quality indicators? How can we minimize the administrative burden of data collection on clinicians? And how do we balance the risk of becoming narrowly focused "symptomatologists" with the need to maintain holistic, person-centered care? By addressing these questions, the panel highlights the immense potential of QI initiatives to enhance palliative care while remaining true to the field's core mission: ensuring that patients and their families feel deeply cared for during life's most vulnerable moments.

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Have you had one of those consults in which you're thinking, huh, sounds like the patient's goals are clear, it's really that the clinician consulting us disagrees with those goals? To what extent is it our job as consultants to navigate, manage, or attend to clinician distress? What happens when that clinician distress leads eventually to conflict between the consulting clinician and the palliative care team?

Today our guests Sara Johnson, Yael Schenker, & Anne Kelly discuss these issues, including:

• A recent paper first authored by Yael asking if attending to clinician distress is our job, published in JPSM. See also the wonderful conversation in the response letters from multidisciplinary providers (e.g. of course that's our job! And physicians may not be trained in therapy, but many social workers and chaplains are, and certainly psychologists).
• A SPACE pneumonic for addressing clinician conflict developed by Sara Johnson, Anne Kelly and others. They presented this at a recent AAHPM/HPNA meeting. See below for what SPACE stands for.
• We referenced a prior episode on therapeutic presence and creating a holding space with Kerri Brenner and Dani Chammas, and this article by Kerri.
• We talked about the role of the consultant, including this classic paper on consultation etiquette by Diane Meier and Larry Beresford.

Enjoy!

-Alex Smith

SPACE: Navigating Conflict with Colleagues

"Between stimulus and response there is a space. In that space is our power to choose our response." -Viktor E. Frankl

SPACE: Conflict Navigation Toolkit

• Self-awareness: Pause & Notice Before Responding
• What am I feeling? Take own temperature.
• Where am I coming from? What do I need?
• Perspective-Taking: Ask-Tell-Ask
• Where are they coming from? Check your understanding with them.
• "Tell me how you're thinking about this?"
• "I hear you are concerned about…is that right?"
• Agenda: Yours and theirs, then focus on common ground
• Where are we going together?
• "It seems like we both want…"
• Curiosity: Reframe and explore to understand
• Am I missing anything?
• Why is this kind, smart & hard-working colleague thinking differently than I am?
• "To help me better understand, what is your biggest concern about…?"
• Empathy:
• For others: Empathic statements around the situation & silence
• For self: Your feelings are valid, reflect on it later.
• You will misstep in tense moments: apologize, learn from it. Eating helps.

Authors:

Ethan Silverman MD University of Pittsburgh

Anne Kelly LCSW San Francisco VA Health Care System

Jasmine Hudnall DO Gundersen Health System

Cassie Shumway MS, RN, OCN, CHPN UW Health Hospitals & Clinics

Andrew O'Donnell RN University of Wisconsin

Sara K. Johnson MD University of Wisconsin

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In this week's podcast, we sit down with Drs. Sarguni Singh, Christian Furman, and Lynn Flint, three authors of the recent Journal of the American Geriatrics Society article, "Rehab and Death: Improving End-of-Life Care for Medicare Skilled Nursing Facility Beneficiaries."

The authors dive into the challenges facing seriously ill older adults discharged to Skilled Nursing Facilities (SNFs), where fragmented care transitions, misaligned Medicare policies, and inadequate access to palliative care often result in burdensome hospitalizations and goal-discordant care.

The discussion highlights key barriers in Medicare's SNF and hospice benefits, including the inability to access concurrent hospice and SNF care, and explores solutions to improve care. Among the recommendations is leveraging Medicare's Patient Driven Payment Model (PDPM) to reimburse SNFs for providing palliative care, commissioning a Government Accountability Office (GAO) report on SNF utilization at the end of life, and piloting a model that allows time-limited concurrent hospice and rehabilitation care.

Also, check out these two resources if you want a deeper dive:

• Our past podcast we did, now nearly 6 years ago, on the original NEJM paper, Rehabbed to Death.
• Joan Carpenter's article titled "Forced to Choose: When Medicare Policy Disrupts End-of-Life Care" in the Journal of Aging & Social Policy

👉 This episode of the GeriPal Podcast is sponsored by IU Health's Geriatrics Department, in partnership with Indiana University's School of Medicine, an amazing group, rich in innovative Geriatric Medicine. They are looking for physician faculty to join them in the inpatient and outpatient settings. To learn more about job opportunities, please click the following links:

• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at Eskenazi Hospital
• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at IU Health Fishers Hospital

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Six years ago we had John Newman on GeriPal to talk about Geroscience (Song choice Who Wants to Live Forever by Queen, perfect selection). John explained the basics of geroscience, what is it, what are the key theories in geroscience, what is senescence, why people who provide clinical care for older adults should care about geroscience, and potential therapeutics like metformin and rapamycin.

Today we bring on three rising stars in Geroscience, Brian Andonian, Sara LaHue, Joe Hippensteel, to talk about one of the key pillars of Geroscience: inflammaging. We use this terrific paper they published in Geroscience as a springboard. We discuss:

• What is inflammaging? Chronic progressive low grade inflammation with aging.
• I try to get one of them to stake a claim that inflammaging should be the organizing principle of geroscience
• How does inflammaging operate in rheumatologic conditions like rheumatoid arthritis (Brian), neurologic conditions like traumatic brain injury (Sara), and critical illness (Joe). We talk about Post-ICU Syndrome (PICS) and relate inflammaging to our prior podcast with Wes Ely about his book Every Deep Drawn Breath. We also talk about how inflammaging is not just a factor in chronic conditions like diabetes or inflammatory bowel disease, which make intuitive sense, but also in acute conditions, like sepsis or traumatic brain injury in older adults.
• The state of the science on clinical and research tests for inflammaging - ready for prime time? What is the state of the science for therapeutics? Why should some anti-inflammatory therapeutics make us nervous in frail older adults? Inflammation developed evolutionarily for a reason. E.g. tthink of drugs that wipe out the immune system.
• The outsized discrepancy between non-FDA products marketed to consumers as anti-inflammaging and the state of academic Geroscience. We announce GeriPal's new lineup of skin care anti-inflammaging products!
• We discuss lifestyle interventions such as exercise, meditation, caloric restriction and intermittent fasting, and strength/resistance training.
• \We recognize the efforts of Clin-STAR in bringing together multidisciplinary aging researchers to advance aging research, including our guests.

And what a joy to sing Billy Joel! Here's a link to the documentary I mentioned, which is on my list to see.

-Alex Smith

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In this week's episode, we delve into the powerful documentary The Chaplain and The Doctor with two extraordinary guests: Betty Clark, the chaplain at the heart of the film, and Dr. Jessica Zitter, the physician and filmmaker who brought this story to the screen.

The film provides a deeply moving look into the ways personal stories and biases shape our interactions in healthcare. Through our conversation with Betty and Jessica, I gained a valuable insight: the narratives we carry within ourselves—whether conscious or unconscious—act as invisible forces that influence how we engage with patients and colleagues. I also learned that recognizing these stories and the biases they may produce, rather than avoiding them, can foster more genuine and empathetic care. They also may lead to deep friendships, as is clearly shown between Betty and Jessica.

I love both this podcast episode and the film itself, as they shine a light on the deeply human—and oftentimes flawed—experience of working in healthcare. They remind us of the vital role of storytelling in shaping how we care for patients, and the often-overlooked yet essential contributions of chaplains in healthcare settings. Betty and Jessica's reflections underscore how chaplains bring compassion and humanity to the medical team, offering emotional and spiritual support to patients and providers alike.

If you're interested in watching The Chaplain and The Doctor during its festival tour, or would like to host a screening at your own institution, I encourage you to visit the film's website at TheChaplainandTheDoctor.com.

This episode of the GeriPal Podcast is sponsored by UCSF's Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://aprecruit.ucsf.edu/apply/JPF05811

NOTE: To claim CME credit for this episode, click here

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In June of 2025, hospice and palliative care pioneer Ira Byock published a white paper outlining the urgent challenges facing the field today. In a nutshell, he expressed concerns that the quality of hospice care in the United States has become highly variable, with disturbing frequency of unethical practices and avaricious owners. He also raised concern that the rapid increase in palliative care program growth during the first two decades of this century has stalled, leaving us with understaffed programs that are often inadequately trained.

Along with Ira, we've invited Kristi Newport, a palliative care doctor and Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, and Brynn Bowman, Chief Executive Officer of the Center to Advance Palliative Care, to discuss these issues and outline a strategic path forward for the field.

In particular we talk about Ira's four-part solution to transform the field and restore its integrity: (1) publishing clear clinical and programmatic standards, (2) making meaningful data publicly available to ensure transparency and accountability, (3) fostering quality-based competition among providers, and (4) embracing the authentic brand of hospice and palliative care—expert care that alleviates suffering and fosters well-being.

So take a listen and dive a little deeper with these resources, and dont forget, you too can get involved in AAHPM (click here for opportunities):

• Ira's paper titled "A Strategic Path Forward for Hospice and Palliative Care: A White Paper on the Potential Future of the Field"
• Our previous podcast on "Is Hospice Losing Its Way"
• Our previous podcast on Private Equity Gobbling Up Hospices plus Hospice and Dementia with Melissa Aldridge, Krista Harrison, & Lauren Hunt
• CAPC's Serious Ilness Scorecard - a state-by-state look at palliative care capacity
• CAPC's second annual Palliative Pulse survey offers insight into how palliative care professionals across the country are feeling this year and what they're focused on
• National Hospice Locator and TCMTalks Podcast by Chris Comeaux and Cordt Kassner

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Today's topic on palliative care for sickle cell disease may raise eyebrows with some of you. You might think, wait, now we're doing sickle cell? On top of liquid cancer and transplant, kidney disease, liver disease, and survivorship? Where does it end? Do we have staff for all of this?

Well I implore you, dear listeners, to keep an open mind and listen to this podcast. Our guests do a fabulous job of stating the case for palliative care in sickle cell disease, to the point that we ask: why haven't we been doing this all along?

Our guests today are Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa, three palliative care docs who have been advancing the practice in palliative care for sickle cell for a long time. Our discussion ranges from what is sickle cell; to outcomes; to social determinants and discrimination; to PCAs, ketorolac, and bupenorphine; and to the importance of the interdisciplinary team.

I would also encourage you to check out Eberechi's NEJM Perspective on Involving Palliative Care to Improve Outcomes in Sickle Cell, which includes a table of the challenges and action items needed to move the field forward. I'd also encourage you to sample this AAHPM Flight on the same topic (we learned that a flight is similar to a flight of drinks - a quick sampling).

As Eberechi notes at the start, we should be grateful for the community of people who are advancing palliative care in sickle cell. Thank you for being a friend (song hint!).

-Alex Smith

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Last month, the "Billing Boys"—Chris Jones and Phil Rodgers—joined the GeriPal podcast to demystify medical billing and coding in palliative care. This month, we're back with part two, shifting the focus to geriatrics. While billing and coding may not be the most exciting topic, they're essential for ensuring fair reimbursement for the complex care we provide and for supporting the work of our interprofessional teams, many of whom can't bill directly for their services. When we underbill or leave money on the table, we not only shortchange ourselves but also devalue the critical role of geriatrics in the healthcare system.

This time, we're joined by experts Peter Hollmann, Ken Koncilja, and Audrey Chun to dive into key questions: Why does billing matter, and who does it benefit? What's the difference between CPT, E&M, and ICD-10 codes (if you need a refresher, check out our chat with the Billing Boys here)? We explore how to think about billing for complexity versus time, and unpack new and impactful codes like the Cognitive Assessment and Care Plan Services code (99483), advance care planning (ACP) billing codes, and G2211, which acknowledges the added work of managing patients with chronic conditions. We also highlight the new APCM G-codes for 2025, a set of HCPCS codes that could provide substantial financial support for interdisciplinary teams in geriatrics.

Finally, we discuss the advocacy behind these codes. The American Geriatrics Society (AGS) plays a vital role on the AMA's RUC committee, helping to improve reimbursement for the complex care of older adults. Tune in to this week's GeriPal podcast for expert advice, practical strategies, and insights that will help you optimize your billing practices and sustain the future of geriatrics!

Here are some of the resources we also talked about:

• The physician fee schedule look up tool Wwere you can find out CMS expected charge based off where you practice
• AGS's annual coding update
• Geriatrics at Your Fingertips, which has a one-pager on billing
• Medicare Claims Processing Manual

👉 NOTE: Eric and Alex are giving UCSF Geriatrics Grand Rounds on Wednesday November 5, 4-5pm Pacific Time. The topic is, "What we've learned from nearly 400 GeriPal podcasts." Join us! This will be highly interactive. If you'd like to join via Zoom, you can use this link: https://ucsf.zoom.us/webinar/register/WN_qLJSlL0wSlq3SwASXw_S4w. Or join in person, grand rounds are open to all! We will be speaking at the main UCSF Campus, 500 Parnassus Ave, in the Health Sciences West Building, 3rd floor, room 303. You can ask for directions when you arrive at UCSF, or email Alex to arrange for someone to meet you at the front (https://profiles.ucsf.edu/alexander.smith).

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I'm going to begin with a wonderful quote from a recent editorial in Bioethics by our guests Parker Crutchfield & Jason Wasserman. This quote illustrates the tension between the widely held view in bioethics that slow codes are unethical, and the complexity of real world hospital practice: "Decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas."

Gina Piscitello, our third guest, recently surveyed doctors, nurses and others at 2 academic medical centers about slow codes. In a paper published in JPSM, she found that two thirds had cared for a patient where a slow code was performed. Over half believed that a slow code is ethical if they believed the code is futile.

Slow codes are happening. The accepted academic bioethics stance that slow codes are unethical is not making it through to practicing clinicians. Our 3 guests were panelists at a session of the American Society of Bioethics and the Humanities annual meeting last year, and their panel discussion was apparently the talk of the meeting.

Today we talk about what constitutes a slow code, short code, show code, and "Hollywood code." We talk about walk don't run, shallow compressions, and…injecting the epi into the mattress! We explore the arguments for and against slow codes: harm to families, harm to patients, moral distress for doctors and nurses; deceit, trust, and communication; do outcomes (e.g. family feels code was attempted) matter more than values (e.g. never lie or withhold information from family)? We talk about the classic bioethics "trolley problem" and how it might apply to slow codes (for a longer discussion see this paper by Parker Crutchfield). We talk about the role of the law, fear of litigation, and legislative overreach (for more see this paper by Jason Wasserman). We disagree if slow codes are ever ethical. I argue that Eric's way out of this is a slow code in disguise.

One thing we can all agree about: the ethics of slow codes need a rethink.

Stop! In the name of love. Before you break my heart. Think it over…

-Alex Smith

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This is the second GeriPal podcast we've recorded live using this format, see this link to our prior podcast at the Center to Advance Palliative Care (CAPC) meeting in Philadelphia. Also look for our upcoming podcast recorded live from the São Paulo Geriatrics & Gerontology Congress, click here to register.

Today we join you from beautiful Banff, Alberta, Canada at the National Palliative Care Research Center (NPCRC) annual Kathleen Foley retreat. This meeting was bittersweet. I've been fortunate to attend every meeting in one capacity or another since 2006. The NPCRC made an enormous impact on the growth and capacity for palliative care research nationally. Personally, NPCRC funding was essential support as I was a new faculty member and had not yet secured longer term career development funding.

More than anything, though, I will miss the NPCRC community. I treasure those meals, hikes, sing-alongs with others dedicated to improving care of people with serious illness through research.

On today's podcast, we invited Dio Kavalieratos, Prasanna Ananth, and Alexi Wright to join us to talk about three articles that spoke to them. For each I leave you with a teaser of a hard question that was raised that we couldn't really answer.

1. Prasanna chose an article by Abby Rosenberg about being fired in palliative care. We talked about why palliative care clinicians get fired, with Prasanna, a pediatric oncologist, raising the issue that it's more problematic when you're the oncologist providing primary palliative care and you get fired than if the consultant specialty palliative care provider is fired.
2. Dio chose an article about the economic benefits of palliative care internationally, a call to action. We talked about the needs of palliative care internationally, and Alexi raised the question: should the highest standard of palliative care (e.g. in the US) apply to palliative care in every country, a la the Partners in Health model pioneered by the late Paul Farmer? Or should we "settle" for access to affordable opioids?
3. Alexi chose an article about cancer care in prison. Alexi used it as a springboard to talk about other populations at compounded risk for poorer care in the current political environment.

We hope you enjoy this one as much as we did, dear listeners. We're always trying to improve, and welcome your suggestions for how to improve upon this new "live" format. So far we've heard we need to be better at summarizing the articles for the audience/listeners, and finding ways to involve our live audience to a greater extent than the occasional question. Please let us know if you have other suggestions!

Final note - check out the wonderful video NPCRC created about their impact on the field of palliative care (Eric and I were filmed recording GeriPal).

-Alex Smith

This episode of the GeriPal Podcast is sponsored by UCSF's Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://aprecruit.ucsf.edu/apply/JPF05811

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Eric and I had the pleasure of doing a GeriPal Live! Podcast as the closing keynote for the recent Center to Advance Palliative Care (CAPC) National Assembly in Philadelphia PA.

For this podcast, we invited 3 guests to each select an article of interest to them, and engage in a discussion about the article, including questions from the CAPC attendees in the audience.

Our guests chose the following articles (in the order discussed)

• Matt Gonzales used AI to select an article by Ravi Parikh on algorithm based nudges to default patients with advanced cancer into a palliative care consult, published in JAMA Network Open, finding 44% in the intervention arm received palliative care consults, vs 8% in the control arm. We discussed use of AI to select the article, nudges, sludge, and the impressive though still less than 50% rate of PC consults.
• Kim Curseen selected an article by Harry Han in JPSM that surveyed palliative care fellowships, finding that clinical fellows spent 5 weeks in outpatient care and 24 weeks in inpatient care, on average. We discussed the mismatch between outpatient training, and the needs of people with serious illness who spend most of their lives outside the hospital, and training in inpatient care, where most hospitals have robust services and needs. Training in non-onc palliative care was particularly low.
• Karen Bullock selected a letter she first authored in response to Ira Byock’s white paper on a path forward in hospice and palliative care. We discussed the need to view all issues in geriatrics, hospice, and palliative care through an equity lens, particularly in view of the disparate impact on historically marginalized communities of concerning practices and trends in hospice and palliative care (e.g. private equity gobbling up hospices).

And at the end, we sang a tribute to the Lady Gaga of Palliative Care, with the whole Assembly singing along!

Stay tuned for future GeriPal Live! Podcasts, including recordings at the NPCRC Foley Retreat in Banff, and the São Paulo Geriatrics & Gerontology Congress, click here to register.

-Alex Smith

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We love getting requests from listeners for podcast topics. This request came from geriatricians we met at the annual American Geriatrics Society meeting in Chicago. They wanted to know more about what a geriatrician should do in a pre-operative risk assessment. So we invited Vicky Tang and Houman Javedan, two geriatricians and leaders in the pre-operative assessment and prehab space, to talk with us.

As is our style, we backed up to some bigger questions, including:

-Why do patients need a geriatric assessment pre-operatively?-Why are our surgical colleagues asking us? Is it due to liability concerns? -Why do we do them? Recognizing we may have different motivations than our consultants (hint: stealth geriatrics) -How does the comprehensive geriatric assessment fit int? Do the 4Ms fit into pre-operative assessment if at all? (an entertaining disagreement ensued) -Must a geriatrician do this? -What is the Geriatric Surgery Verification Program? -What’s the most important part of

Many links from our guests below.

And please forgive my Spanish on the song, I tried! Thanks to sons Kai and Renn on Ukulele and Bass for making it sound better.

-Alex

From Vicky:

1. Systematic review of Prehab https://pubmed.ncbi.nlm.nih.gov/39655991/
2. Geriatric Surgery Verification Program https://www.facs.org/quality-programs/accreditation-and-verification/geriatric-surgery-verification/
3. shared decision making in surgical patients https://pubmed.ncbi.nlm.nih.gov/40551447/

From Houman:

Geriatric Surgical Co-management Evidence

1. Trauma survival with geriatric assessment 2022- https://pubmed.ncbi.nlm.nih.gov/36102764/ 2. Hip fracture survival benefit meta-analysis 2014- https://pubmed.ncbi.nlm.nih.gov/23912859/ 3. Elective abdominal surgery benefits POSH program 2018- https://pubmed.ncbi.nlm.nih.gov/29299599/ 4. POSH Program for Spine 2021- https://pubmed.ncbi.nlm.nih.gov/33382460/ 5. Elective orthopedic joints ED readmission decreases 2024 - https://pubmed.ncbi.nlm.nih.gov/39715294/ 6. The need for geriatricians, tools and education models (aka Ms) are not enough - https://pubmed.ncbi.nlm.nih.gov/30916758/

Sub Topics

1. Utility of minicog and where our improved local mortality of 18% and delirium of 11% reported - https://pubmed.ncbi.nlm.nih.gov/27147687/

2. Geriatrician performed CGA-FI best at predicting mortality in rib fractures 2025 - https://pubmed.ncbi.nlm.nih.gov/39800638/

3. Geriatrician performed CGA-FI predicting mortality better than age in hip fractures 2024- https://pubmed.ncbi.nlm.nih.gov/39007664/

4. Multidomain frailty assessment and surgery showing severely frail patients at risk of mortality even with low risk procedures (eg. Cystoscopy) - https://pubmed.ncbi.nlm.nih.gov/31721994/

5. Different outcomes for hip fracture surgery in the severely frail - https://pubmed.ncbi.nlm.nih.gov/38892908/

6. Complexity of aging physiology- example of prostaglandin based free water excretion in collecting duct of aging kidney first paragraph on page 360- https://pubmed.ncbi.nlm.nih.gov/36948780/

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What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful?

Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers.

In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We are also joined by Rasa Mikelyte and Edison Vidal, co-authors of a recent study comparing the perspectives of people with dementia in the UK and Brazil on what constitutes a good death.

In addition to exploring the nature of a good death and their individual studies, we will discuss:

• Whether an external criterion for a good death exists, or if it is entirely dependent on the perspective of the dying individual.
• The role of culture and spirituality in defining a good death.
• The role of healthcare providers in the discussion about the nature of a good death.

Key references we discuss include:

• Our previous GeriPal podcast, “Should the Concept of ‘The Good Death’ Be Buried?” with VJ Periyakoil.
• Karen’s 2000 JAMA article, “Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers.”
• Rasa and Edison’s article, “Comparing the Views of People with Dementia in the UK and Brazil about a Good Death.”
• A short video from the EPEC project that Edison mentioned during the recording of an interview with Cicely Saunders, where she shares her advice for anyone going into medicine or palliative care and her views about the principles of palliative care.

Lastly, if you would like to join Eric, Edison, and I in Brazil on April 6, 2026, for the São Paulo Geriatrics & Gerontology Congress, click here to register.

-Alex Smith

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A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following:

1. Billing is complicated, but it isn’t hard.
2. Effectively billing helps pay for the interprofessional team members who often can't bill
3. We should know our worth and bill for it. Just because a visit didn’t feel HARD to a well-trained provider doesn’t mean it wasn’t complex or valuable. Many of us have long suffered from low professional self-esteem when it comes to money, and it’s high time we stop that.
4. While exclusively billing on time may have been right 20 years ago, we must now understand complexity and advance care planning (ACP).

We can't cover everything in the 45 minutes we are together, so here are some of the resources we reference in the podcast:

• Chris’s and Phil’s consulting contact info via Lightning Bolt Partners
• CAPC resources:
• CAPC’s Billing and Coding Toolkit
• CAPC’s Monthly office hours in Inpatient and Community-Based PC Billing and Coding run by Andy Esch, Phil Santa Emma, and Chris Jones

• CAPC’s 2025 Annual Billing and Coding Update done by Phil and Chris each year

• Advance Care Planning resource from the Medicare Learning Network

• Top Ten Tips for Using Advance Care Planning Codes
• CPT 2025 Professional Edition. This is the book that has the Complexity Grid in it. The answers are all here! And your coders will likely share.

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On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program. It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population.

We unpack the intriguing findings of a recent JAMA Network Open study authored by one of our guests, Susan “Nicki” Hastings, looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT). While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn't translate into expected improvements like more time at home or better self-rated health.

We discuss the potential reasons behind this with our other two guests, one a geriatrics fellow, Kristie Hsu, and the other a recurring guest and host of the podcast, Ken Covinsky. Was it just that it didn’t work, or were there other things going on, from the intensity of "usual care" to the challenges of measuring complex health outcomes and the possibility that 18 months simply wasn't long enough to see the full benefits?

Despite what was ostensibly a negative trial, we highlight some reassuring aspects and future hopes for GeriPACT and how we can all incorporate some of these components into the care of our patients. We'll also pose critical questions for future research, emphasizing why continued development and evaluation of new care models are essential for the health of our older population.

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With all the attention focused on Alzheimer's biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA.

We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — D-CARE and IN-PEACE — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the comparative effectiveness of health system-based dementia care, a community-based program, and usual care, while IN-PEACE assessed the addition of palliative care to dementia care programs for individuals with moderate to severe dementia.

Despite their pragmatic trial designs and high expectations, both studies' primary outcomes were negative, although there were some intriguing positive secondary outcomes. We discuss how some critical questions about the integration of these findings into practice, and how they fit in with previous research that did show benefits (see this past podcast on using health navigators to improve dementia care).

If you want to learn more about comprehensive dementia care, check out these past podcasts:

• Our previous podcast on comprehensive dementia care with Lee Jennings and Chris Callahan
• Our podcast on the GUIDE Model with Malaz Boustani and Diane Ty
• Our podcast on Transforming the Culture of Dementia Care with Anne Basting, Ab Desai, Susan McFadden, and Judy Long

Lastly, here is the link to Greg Sachs' NEJM article that describes his maternal grandmother decline from Alzheimer's disease.

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In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:

• What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment?
• Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it?
• Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle.
• Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions)
• How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)?
• How long does it take to conduct a comprehensive geriatrics assessment?
• What’s the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment?
• What are the outcomes we hope for from the comprehensive geriatrics assessment?

That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).

As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means).

We published this article because its bottom line is of great interest to geriatricians. In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.

And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system).

I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial:

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab.

Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.

-Alex Smith

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On a prior podcast we talked with Todd Semla and Mike Steinman about the update to the AGS Beers Criteria of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel). One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead?

Today we talk with Todd and Mike about their new recommendations of alternative treatments to the AGS Beers Criteria, published recently in JAGS, and also presented at the 2025 AGS conference in Chicago (and available on demand online).

We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria. In our last podcast, the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed. You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list.

Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved. Really upping the anti!!!

The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts):

• Insomnia (Doxepin is an alternative, trazodone and melatonin are not?!?)
• Diabetes management
• PPI for GERD
• Treatments for pain, including NSAIDS, COX2, and gabapentinoids
• Cannabis
• Deprescribing,org - terrific Canadian website (no tariff to use)

And I hope that the prescribing landscape is indeed getting better (thanks to Kai on guitar)!

-Alex Smith

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Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum.

In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, Amy Klein, Laura Morrison, and Gordon Wood, share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired to do the same.

You'll also hear how engaging with museum-based medical education can help health care professionals deepen empathy and emotional awareness, practice the skill of multiple perspective-taking, and grow more comfortable with ambiguity and uncertainty.

Resources mentioned in the podcast include:

• A story about one medical student's experience with a day in the museum using multiple museum-based education exercices
• A Journal Article published in the Journal of Palliative Medicine titled “Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs”
• A journal article on “Twelve Tips for Starting a Collaboration with an Art Museum.”
• A handout from the 2025 AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training.
• Alex’s summary of some prompts we discussed for the “Personal Responses Tour”, which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include:
• Find a work of art that reminds you of a patient
• Find a work of art that reflects a challenging clinical situation
• Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism
• Find a work that connects to the path you took into palliative care or geriatrics
• Find a piece that makes you think about community
• Find a piece that reflects your idea of what a “good death” is

Lastly, stay on the “look out for” the 2026 Art Museum-Based Education preconferences session at the AAHPM/HPNA annual meeting on March 4, 2026 in San Diego!

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In his book, “Why We Revolt,” Victor Montori decries the industrialization of healthcare. We’ve become a healthcare factory, beholden to health systems motivated by profit. In particular, he laments the loss of the “care” aspect of healthcare.

Clinicians are under the clock to churn through patients. Patients are tasked with doing work outside of the clinic. Patients are tasked with hours and hours of work to self manage, obtain and manage medications, track weights and fingersticks, not to mention scheduling visits and waiting around for the visit to start.

Now we have an app for that. For what, you ask? Well, for everything! Digital burden is real. Think about what we ask patients to do: charge your device, remember your password, 2 factor authentication, each interface is different, wait…where do you enter your fingersticks again?

Victor is an endocrinologist who often provides care for older patients with multiple chronic conditions, polypharmacy, and complex social situations. He’s “one of us.”

Some might argue that these circumstances call for incremental change. Not Victor. He argues that we need a revolution. In particular, he argues that the revolution must come from patients to be successful.

On this podcast we discuss:

• Why do we need a revolution? What made him get to this point of arguing for a revolt?
• Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play?
• What is minimally disruptive medicine (a term Victor coined with Carl May and Francis Mair in 2009)?
• How does shared decision making fit into the revolution?
• What’s the matter with guidelines? What’s the role of standardization?
• We suspect that most geriatrics and palliative care providers feel like they’ve escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being. Are we deluding ourselves?

If you’d like to join the revolution, please check out Victor’s website, patientrevolution.org

And I believe this is the first Peter Gabriel song request! I think Peter Gabriel’s album So was the first cassette tape I purchased. About time, 350+ podcasts in. My son Kai turns this very non-guitar friendly song into an acoustic jam for the audio-only podcast version; you get my weaker attempt on YouTube :)

Finally, a quick plug for the Sommer Lecture series in Portland OR. Victor and I had a terrific time bonding at this year’s lecture series. While not strictly geriatrics and palliative care focused, the lectures seem targeted at a broad audience, with something for everyone. And yes, I made them sing parody songs :)

-Alex Smith

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Most health care providers understand the importance of goals-of-care conversations in aligning treatment plans with patients’ goals, especially for those with serious medical problems. And yet, these discussions often either don't happen or at least don't get documented. How can we do better?

In today’s podcast, we sit down with Ira Byock, Chris Dale, and Matthew Gonzales to discuss a multi-year healthcare system-wide goals of care implementation project within the Providence Health Care System. Spanning 51 hospitals, this initiative was recently described in NEJM Catalyst, showing truly impressive results, including an increase from 7% to 85% in goals of care conversation documentation for patients who were in an ICU for 5 or more days.

How did they achieve this? Our guests will share insights into the project’s inception and the strategies that drove its success, including:

1. Organizational Alignment: Integrating GOC documentation into the health system’s mission, vision, and strategic objectives.
2. Clinical Leadership Partnership: Collaborating with clinical leaders to establish robust quality standards and metrics.
3. Ease of Documentation: Upgrading the electronic health record (EHR) system to streamline the documentation and retrieval of GOC conversations.
4. Communication Training: Conducting workshops based on the Serious Illness Conversation Guide to equip clinicians with the skills needed for impactful GOC conversations.

Join us as we explore how these strategies were implemented and learn how you can apply similar approaches in your own healthcare setting.

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What is death anxiety? We spend the first 15 minutes of the podcast addressing this question. And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on therapeutic presence and the angry patient). After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss!

Several key points stood out to me from this podcast, your key points may differ:

• The “anxiety” in “death anxiety” is not a pathological phenomenon or a DSM diagnosis; it references an existential concern that is fundamental to the human experience . To me,” awareness of mortality” might be a better term, but in fairness, the idea of “death anxiety” was coined well before the formal establishment of “anxiety disorders.”
• The ways in which death anxiety manifests in our patient’s choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no “one size fits all” approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient in remission from cancer any pain might signal return of cancer.
• Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience.
• Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can’t define (sorry Dani and Keri!), but also through our own unexamined fears about death.
• As clinicians who regularly care for people who are dying, we might find ourselves becoming “used to” death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients.

I mean, don’t fear the reaper, right? Sorry, no cowbell in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version.

Here are some resources for listeners wanting to learn more about this topic:

Books:

• Yalom ID. Existential Psychotherapy. New York, NY: Basic Books; 1980.
• Yalom ID. Staring at the Sun: Overcoming the Terror of Death. San Francisco, CA: Jossey-Bass; 2008.
• Solomon S, Greenberg J, Pyszczynski T. The Worm at the Core: On the Role of Death in Life. New York, NY: Random House; 2015.
• Becker E. The Denial of Death. Free Press; 1973.

Articles:

• Emanuel LL, Solomon S, Chochinov HM, et al. Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care. J Palliat Med. 2023;26(2):235-243.
• Chochinov HM, McClement SE, Hack TF, et al. Death anxiety and correlates in cancer patients receiving outpatient palliative care. J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052.
• Clark D. Between hope and acceptance: the medicalisation of dying. BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905.
• Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. The terror management of medical decisions: The effect of mortality salience and religious fundamentalism on support for faith-based medical intervention. J Pers Soc Psychol. 2009;97(2):334–350.
• Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomized controlled trials. J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00
• Brown TL, Chown P, Solomon S, Gore G, De Groot JM. Psychosocial correlates of death anxiety in advanced cancer: A scoping review. Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068.
• Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. Top Ten Tips Palliative Care Clinicians Should Know About Attending to the Existential Experience. J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453.

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What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the SPRINT trial? Or should we be more flexible—especially for those who are frail or among the oldest old?

This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher.

Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled How Low Should We Go with Blood Pressure in Older Adults?” Yes, we sure did, but we decided to revisit this topic as Mitra Jamshidian and Simon Ascher published a new JAGS research study focused on developing a framework to individualize the net benefit of intensive blood pressure control based on the results of the SPRINT trial. Their key finding: most community-dwelling older adults in the SPRINT trial experienced greater benefits than harms from more aggressive blood pressure targets—even those who were older, frail, or on multiple medications.

Join us for an in-depth discussion on balancing risks, benefits, and patient preferences in hypertension management for older adults. Plus, we might just sneak in a little Frank Sinatra for good measure.

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In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems.

We’ve invited two palliative care doctors to talk about survivorship with us: Laura Petrillo, a physician-researcher at Mass General Hospital and Harvard Medical School, and Laura Shoemaker, an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we support people who are living with it.

If you want some further reading on survivorship, check out some of these articles:

• A NEJM article titled “Time to Study Metastatic-Cancer Survivorship”
• A ASCO publication that includes a section on survivorship - Patient-Centered Palliative Care for Patients With Advanced Lung Cancer
• A webinar on survivorship - Blending Survivorship and Palliative Care (NCI)

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June Lunney famously characterized the end of life functional course of people with dementia as a slow dwindle over time. Tom Gill later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives.

But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia. Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover. And they’re often a sign of (or cause of?) worsening prognosis.

Today we talk about disruptive events, or health and wealth shocks. We start with Lauren Hunt, who described the incidence and outcomes of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia. We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in JAMA Network Open. Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries. Tsai-Chin’s article, published in Lancet Healthy Longevity, found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function.

Wait, so one key message is that social health is linked to physical and cognitive health?!? And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners.

And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics!

-Alex Smith

Additional links mentioned by Tsai-Chin Cho:

-Wealth shocks and mortality in the US

-Change in marital status as a risk for wealth shock

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Happy Pride Month GeriPal listeners!

Transgender issues are in the news. Just today (June 17th) as we record this podcast:

• Ezra Klein released a wonderful interview with Sarah McBride, the first openly transgender member of congress
• A judge ruled that cuts to NIH grants focused on minority groups, including transgender people, were illegal and ordered the government to restore funding.
• It’s Pride month, and our guests remind us of the leadership of two trans women in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation.

Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having multiple federal grants cancelled because they included transgender participants. We cover many topics, including:

• Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+
• Gender affirming care
• Major health and medical issues associated with aging as a transgender person
• Allostatic load
• Accelerated aging
• What can clinicians do - pointers, pearls, and attitudes
• Dementia risk
• Caregiver issues
• Hormone replacement therapy at the end of life
• Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely
• Mentioned: Harvey Chochinov’s Dignity Therapy question, and our prior podcast on LGBT Care for older adults and serious illness with Carey Candrian and Angela Primbas

So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast.

-Alex Smith

Many links!

-Rainbows of Aging: Jace Flatt’s research site.

-LGBTQcaregivers

-Callen-Lorde gender affirming trans health services

-GLMA: organization for health professional advancing LGBTQ+ equality

-Center of Excellence for Transgender Health at UCSF

-World Professional Association for Transgender Health

-Sage advocacy services for LGBTQ+ Elders: focus on impact of Medicaid cuts

-Trans bodies, Trans selves: resource guide

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If you’re anything like me, you might find the process of what happens to patients when they visit a radiation oncologist somewhat mysterious. During my training, I didn’t receive much education about radiation oncology, and I’m not entirely sure what some of the terms mean (hypofractionated means fewer sessions, right?). Well, today’s podcast aims to clear up all these uncertainties.

We’ve invited Anish Butala, the Chief of the Palliative Radiotherapy Service at Penn Medicine, and Emily Martin, a palliative care doctor and past president of the Society for Palliative Radiation Oncology (SPRO), to explain everything we should know about radiation oncology. Additionally, Evie Kalmar, who suggested today’s topic, will join us as one of our guest hosts.

Tune in and we will walk you through the patient’s journey from the initial planning visit to the final treatment, discuss common indications like bone and brain metastases, hear about when to consider steroid therapy, and highlight radiation therapy emergencies.

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The need for better palliative care in nursing homes is significant. Consider this: the majority of the 1.4 million adults residing in U.S. nursing homes grapple with serious illnesses, and roughly half experience dementia. Many also suffer from distressing symptoms like pain. In addition, about 25% of all deaths in the United States occur within these facilities.

Despite these substantial needs, specialized palliative care beyond hospice is rare in nursing homes. Furthermore, only about half of nursing home residents nearing the end of life receive hospice care.

So, how can we improve palliative care for individuals in nursing homes? Today's podcast explores this crucial question with three leading experts: Connie Cole, Kathleen Unroe, and Cari Levy.

Our discussion delves into:

• The specific palliative care needs of nursing home residents.
• How to think about primary and specialized palliative care in this setting.
• The obstacles hindering referrals to palliative care services.
• Practical strategies to overcome these barriers and enhance care.

We also take a dive into these 2 articles that Connie first authored:

• Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. JAGS 2024
• Nursing Home Palliative Care Referral Process, Barriers, and Proposed Solutions: A Qualitative Study. 2024

If you are interested in learning more, check out some of our other palliative care in nursing home podcasts including:

• Discussion of a primary palliative care multinational trial with Lieve Van den Block
• Understanding the variability in nursing home care
• A podcast on Palliative Rehab?!? with Ann Henshaw, Tamra Keeney, and Sarguni Singh

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Have any of you watched the movie “The Notebook”? At the end, one of the characters, who has dementia, experiences an episode of lucidity. When I watched it, between tears (I’m a complete softie) I remember thinking, “Oh no! This will give people false hope! That their loved one is ‘in there.’ If only they could find the right key to unlock the lock and let them out.”

Today we talk about lucid episodes and what they might mean to the person with dementia, their family and loved ones, to philosophers, to clinicians, to neuroscientists. Our guests are Andrea Gilmore-Bykovskyi, a nurse researcher, and Andrew Peterson, a philosopher.

We had a wide ranging discussion that touched on (among many things):

• A consensus definition developed at an NIH conference, organized by the recently retired NIA program officer Basil Eldadah (we will miss you Basil!).
• Andrew complicates this definition, stating is raises more questions than answers.
• Hospice nurses know that terminal lucidity “is a thing” and have pretty much all seen it
• Family and caregiver stories of lucid episodes and what they meant to them, including early glimpses into a study Andrea is doing using video to capture episodes and show them to family.
• Potential for experiences to elicit “false hope”, misunderstanding/misinterpreting, and changing say code status from DNR to full code (rare but happens).
• Sam Parnia’s work on brain activity during CPR and near death episodes
• Ethical issues these lucid episodes raise
• Should clinicians treat people with dementia as always lucid? Having some level of awareness?
• Parallels between how we treat people with advanced dementia, who may or may not be lucid, and how we treat AI, who may or may not be conscious, or experiencing paradoxical lucidity on their way to full consciousness. I try to say please and thank you to the AI I interact with other than Alexa, who is obviously way behind.
• The Age of Aging podcast episode on lucidity, featuring Anne Bastings, Jason Karlawish, Elizabeth Donnarumma, and Justin Clapp
• Was Andrew’s song choice, “I can see clearly now” better than Eric’s suggestion “Silent Lucidity” by Queensryche?

Enjoy!

-Alex Smith

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As you know, dear listeners, I love music. We start each podcast with a song in part to shift the frame, taking people out of their academic selves and into a more informal conversation.

Well, today’s guests love music at least as much if not more than me, and they each make a strong case for music as medicine. Jenny Chen is a palliative care fellow at Yale who regularly sings for her seriously ill patients. Look for Jenny to potentially appear on the show America’s Got Talent (no lie).

Tyler Jorgensen not only plays music for his patients, starting out with just pulling up a tune on his iPhone, he and others at UT Austin and Dell med now wheel a record player into patients rooms and play vinyl, taking patients back to the sounds and routines - think taking the record out of the sleeve, placing the needle in the groove - of younger days. You can here Tyler and I having a great time singing together and sharing stories around his podcast My Medical Mixtape.

And Theresa Allison is a geriatrician and ethnomusicologist who studies the role of music for people with dementia. The ability to appreciate, recognize, and engage with music is preserved even until late stages of dementia, and Theresa is examining how music can be useful from the time of diagnosis, not only for the person with dementia, but their caregivers.

Many links today, including:

-Alive Inside Movie and Music and Memory movement

-Music and Creativity in Healthcare Settings - book by Hilary Moss

-Tyler Jorgensen’s article on Bringing Music to patients at the Bedside in JGIM

-Tyler’s reflection/story comparing palliative medicine to jazz - something I arrived at independently and tell all new trainees! This is not highly scripted orchestral music, people, it’s Jazz.

-Systematic review of music (and prognosis) in palliative care

-Review of music and dementia interventions (Theresa Allison author)

-Theresa Allison’s paper on Music Engagement in Dementia Caregiver Relationships in Gerontologist

-Jenny Chen’s YouTube channel.

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Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine.

To start. we review:

• What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.
• Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.
• What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge.
• Examples of nudges, some based in health care, others in coffee.

This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups:

1. Usual care
2. Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect
3. Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies.
4. Both the prognosis and comfort care nudge.

A few key points of discussion:

• Is an EHR prompt a nudge or sludge?
• The intervention was a negative study for the primary outcome, hospital length of stay. Why?
• The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?
• The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? Imagine!

-Alex Smith

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We’ve covered psychedelics on the podcast before—first in 2019 with Ira Byock, where we explored their potential role in medicine, and then again in 2023 with Stacy Fischer, Brian Anderson, and Theora Cimino, focusing on the reasons to approach psychedelic use in patients with caution.

In today’s episode, we’re taking a closer look at the current state of the science around one specific psychedelic: psilocybin. We'll discuss three recent clinical trials involving patients with serious illness, joined by our guests James Downar, Ali John Zarrabi, and Margaret Ross.

We begin with a refresher on psilocybin—what it is, how it might work, what conditions it may help treat (including demoralization), and how it’s typically administered. What makes this episode especially compelling is our deep dive into the three studies, which highlight two different approaches to using psilocybin: daily microdosing, similar to traditional antidepressants, and a more intensive model known as psilocybin-assisted therapy. This latter approach involves three structured phases—preparation, the dosing session, and post-session integration with trained therapists.

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Peter Selwyn, one of today’s guests, has been caring for people living with HIV for over 40 years. In that time, care of people with HIV has changed dramatically. Initially, there was no treatment, then treatments with marginal efficacy, complex schedules, and a tremendous burden of side effects and drug-drug interactions. The average age at death was in the 30s.

Now, more people in the US die with HIV rather than from HIV. Treatment regimens are simplified, and the anti-viral drugs are well tolerated. People are living with HIV into advanced ages. The average age at death is likely in the 60s. Nearly half of people living with HIV are over age 55. One in 10 people with newly diagnosed HIV is an older adult. Our second guest, Meredith Greene, is a geriatrician and researcher who focuses on care of older adults living with HIV, in the US and Africa.

On today’s podcast we discuss:

• Implications of aging with HIV for clinical care
• Loneliness and social isolation among older adults living with HIV
• Persistence of stigma
• Need to consider HIV in the differential diagnosis for older adults
• Screening for HIV
• Screening for osteoporosis in people living with HIV
• Dementia and cognitive impairment risk in people living with HIV
• When to stop anti-virals near the end of life

Toward the end we speak to the moment. More older adults live with HIV in SubSaharan Africa and the global South than anywhere else in the world. Funding for research and clinical care is at risk, as USAID and PEPFAR (which is under USAID), are shuttered. Millions of lives are at stake. Meredith wore a shirt that said Silence=death.

Eric gave me the hook during my live cover of One, by U2, a song released in 1992 whose proceeds went entirely to AIDS research. I couldn’t help it, forgive me dear listeners, I had to do a longer than usual cut at the start!

-Alex Smith

Useful links:

Peter's article on the evolution of HIV: https://link.springer.com/article/10.1007/s11524-011-9552-y

Peter’s book Surviving the Fall: Personal Journey of an AIDS Doctor

PEPFAR: Global Health Policy | KFF

Articles:

Geriatric Syndromes in Older HIV-Infected Adults - PMC

Loneliness in Older Adults Living with HIV

Management of Human Immunodeficiency Virus Infection in Advanced Age https://pmc.ncbi.nlm.nih.gov/articles/PMC3684249/

About Act-up for those who might know the Silence=Death t-shirt reference: https://www.npr.org/2021/06/16/1007361916/act-up-a-history-of-aids-hiv-activism

https://www.newyorker.com/magazine/2021/06/14/how-act-up-changed-america

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More and more people are, “doing their own research.” Self-identified experts and influencers on podcasts (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals. An increasing number of federal leaders have a track record of endorsing such products.

We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently. Ivermectin to treat cancer. Stem cell treatments. Chelation therapy. Daneila Lamas wrote about this issue in the New York Times this week -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube.

Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken). We discuss an article they wrote about PULET for the American Journal of Hospice and Palliative Medicine, including:

• What makes a PULET a PULET? Key ingredients are both potentially unsafe and low evidence. If it’s low evidence but not unsafe, not generally an issue. Think vitamins. If it’s potentially unsafe, but has robust evidence, well that’s most of the treatments we offer seriously ill patients! Think chemo.
• What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity.
• What counts as low-evidence? Animal studies? Theoretical only?
• Does PULET account for avoiding known effective treatments?
• Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR.
• How does integrative medicine fit in with this? Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this.
• How ought clinicians respond? Hint: If you’re arguing over the scientific merits of a research study, you’re probably not doing it right. Instead, think VitalTalk, REMAP, and uncover and align with the emotion behind the request.
• Does the approach shift when it’s a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child?

For more, Laura suggests a book titled, How to Talk to a Science Denier.

And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give Grand Rounds, and the conversations I had with Adam and Laura during the visit. We love it when listeners engage with us to suggest topics that practicing clinicians find challenging.

And I get to sing Bon Jovi’s Bad Medicine, which is such a fun song!

-Alex Smith

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I read Farah Stockman’s article in the NYT on why attacks on DEI will cost us all, and thought, “Yes, and ‘everyone’ includes harm to our healthcare workforce, our patients, and their families.”

So we’re delighted that Farah Stockman, pulitzer prize winning journalist, author of American Made: What Happens to People When Work Disappears, and editorial board member at the New York TImes joins us to set the bigger picture for this discussion. Farah provides clear examples from the Biden administration, in which having the most diverse cabinet in history was critical to building bridges, empathy, and inspiring others to feel included.

We are also pleased to welcome Ali Thomas, a hospitalist, member of the Baha'i Faith, leader of anti-racism efforts in the Pacific Northwest, and founder of the BIPOC Health Careers Ecosystem. Ali talks about the history of affirmative action, which started as a program for Whites, the importance of diversity in the healthcare workforce, the history of allyship and cross cultural collaboration, and his own efforts to provide opportunity and support for historically oppressed groups in his own community to obtain healthcare careers.

And Ken Covinsky, avid baseball fanatic, joins us and notes that the day we record (April 15) is Jackie Robinson day. Many may be familiar with the story of Jackie Robinson breaking the color barrier in major league baseball in 1947, but may not be aware of the tremendous adversity Jackie Robinson faced, and persistence he displayed, off the field.

We address many things, including:

• The movement in Corporate America and institutes of higher education to implement DEI programming in the wake of George Floyd
• The general agreement in America of the value of diversity, and disagreement, unpopularity, and backlash about DEI as it was implemented
• How the pursuit of diversity and excellence are not in tension, they are aligned and necessary for each other
• What we can do to build bridges across differences

There was so much we hoped to talk about and didn’t get to, but I will link to now, including: Ali’s mom’s personal history with and study of school desegregation in South Carolina, Farah’s mom’s pioneering work as a speech language pathologist, and Ken’s perspectives on the importance of studying ageism and racism in research.

What a Wonderful World could be sung in irony at this moment. I hope we all take it literally, with the hope this podcast ends with. The podcast follows the arc towards hope of this video on Race Amity from the National Center for Race Amity, courtesy of Ali Thomas (his dad is featured).

-Alex Smith

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Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department. I asked emergency medicine clinicians what they thought when a patient who is seriously ill and DNR comes to the ED, and some responded, (paraphrasing), what are they doing here? This is not why I went into emergency medicine. I went into emergency medicine to act. I can’t do the primary thing I’ve been trained to do: ABC, ABC, ABCs. Most emergency providers wanted to do the right thing for seriously ill patients, but they didn’t have the knowledge, skills, or experience to do it.

Today we focus on an intervention, published in JAMA, that gave emergency clinicians basic palliative care knowledge, training, and skills. We talk with Corita Grudzen and Fernanda Bellolio about their cluster stepped wedge randomized trial of a palliative care intervention directed at emergency clinicians. They got training in Vital Talk and ELNEC. They got a decision support tool that identified hospice patients or those who might benefit from a goals of care discussion. They got feedback.

So did it matter? Hmmm….it depends. We are fortunate to have Tammie Quest, emergency and palliative trained and long a leader in this space, to help us unpack and contextualize these findings. Today we discuss:

• Why the study was negative for the primary (hospitalization) and all secondary outcome (e.g. hospice use).
• Why to emergency clinicians, this study was a wild success because they had the skills they wanted/needed to feel like they could do the right thing (during the onset of Covid no less).
• Why this study was a success due to the sheer size (nearly 100,000 patients in about 30 EDs) of the study, and the fact that, as far as the investigators know, all study sites continue to employ the clinical decision support tool.
• What is a cluster stepped wedge randomized trial?
• Were they surprised by the negative findings?
• How do we situate this study in the context of other negative primary palliative care interventions, outside the ED? E.g. Yael Shenker’s negative study of primary palliative care for cancer, Randy Curtis’s negative study of a Vital Talk-ish intervention, Lieve Van den Block’s negative study of primary PC in nursing homes. Why do so many (most, all??) primary palliative care interventions seem to fail, whereas specialized palliative care interventions have a relatively robust track record of success. Should we give up on primary palliative care? What’s next for primary palliative care interventions in the ED?

And if your Basic Life Support training certification is due, you can practice the correct chest compression rate of 110 beats per minute to Another One Bites the Dust.

-Alex Smith

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Whelp, goodbye folks! Eric and I have been DOGE’d.

In a somewhat delayed April Fools, Nancy Lundebjerg and Annie Medina-Walpole have taken over podcast host duties this week.

Their purpose is to interview me, Eric, and Ken Covinsky about your final AGS literature review plenary session taking place at the Annual Meeting in Chicago this May (for those attending, our session is the plenary the morning of May 10). We discuss our favorite articles, parody songs, and memories from AGS meetings past, with a little preview of a song for this year’s meeting.

We covered:

• The first parody song I wrote, for AGS 2018 in Orlando, about this article by Nancy Schoenborn on how to discuss stopping cancer screening.
• Ken’s favorite articles, including
• The Impact of Rudeness on Medical Team Performance: A Randomized Trial

• Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization

• Eric’s favorite article on the effect of chair placement on physicians’ behavior and patients’ satisfaction

• Tim Anderson’s study on the intensification of older adults’ outpatient blood pressure treatment at hospital discharge
• Nancy’s favorite topic and parody song, Aducanumab, which won Drug of the Year in 2021.

Enjoy! And maybe, just maybe, Eric and I will be reinstated and return as hosts next week…

-Alex Smith

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A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice. Outcomes are typically assessed from available records. Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations.

Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine.

We spend the last portion of the podcast discussing the surprising finding of the study. In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group. What?!? Not a typo.

We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including:

• Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control). Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions?
• Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care.
• Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings. My goals will differ if I think I probably have 2 years to live vs 10 years.
• Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed).
• Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning. As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful.

And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French!

-Alex Smith

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Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (VSED), and multiple episodes about the ethical issues surrounding medical aid in dying (MAID). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life?

To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of Minimal Comfort Feeding (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit.

We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medical aid in dying medications and their respective articles on the topic. We discussed what makes an illness “terminal”, what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers.

-Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host)

Articles referenced in this discussion:

• “Mr. Smith Has No Mealtimes”: Minimal Comfort Feeding for Patients with Advanced Dementia by Hope Wechkin et al in JPSM
• Medical Aid in Dying to Avoid Late-Stage Dementia by Thaddeus Pope and Lisa Brodoff in JAGS
• Law not loopholes: Medical aid in dying for those with dementia also in JAGS by Joshua Briscoe and Eric Widera

Past GeriPal Podcast Episodes on MAID:

MAID podcasts

https://geripal.org/what-is-going-on-with-maid-in-canada-bill-gardner-leonie-herx-sonu-gaind/

https://geripal.org/conscientous-provision-of-maid-and-abortion-robert-brody-lori-freedman-mara-buchbinder/

https://geripal.org/assisted-dying-podcast-with-lewis-cohen/

https://geripal.org/dilemmas-in-aid-in-dying-podcast-with/

Past GeriPal Podcast Episode about VSED:

https://geripal.org/tim-quill-vsed/

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As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way?

In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care. Sue Britton was the first nurse hired on that palliative care unit. Michael Kearney on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry. Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including:

• Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more…
• Whole-person-care
• Total pain
• Healing as a process distinct from the deterioration of the body
• Sympomatologists
• The patient and family as the unit of care

Our guests referenced many articles on this podcast, linked above and below. If you read just one, read Palliative Medicine - Just Another Specialty? by Kearney. I promise it’s short. 2 pages. Here’s a taste:

…While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty.

And love that Jim Croce choice. What’s in a name? I’ve got a name.

Enjoy!

-Alex Smith

Links

• Link to the McGill National Grand Rounds Series on Palliative Care, Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming.
• Palliative Medicine - Just Another Specialty? In Palliative Medicine By Kearney
• Joe Wood’s book on Total Pain
• Balfour Mount’s memoir Ten Thousand Crossroads paper on Healing Connections in JPSM and Healing and Palliative Care in Palliative Medicine
• Cicely Saunders: A Life and Legacy, by David Clark
• Self-Care of Physicians Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series
• Twycross on Readdressing Balance in Hospice

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I was very proud to use the word “apotheosis” on today’s podcast. See if you can pick out the moment. I say something like, “Palliative care for people experiencing homelessness is, in many ways, the apotheosis of great palliative care.” And I believe that to be true. When you think about the early concepts that shaped the field, you can see how palliative care for persons experiencing homelessness fits like a hand in a glove: total pain envisioned by Cicely Saunders, which even its earliest sketches included social suffering like loneliness; or Balfour Mount, who coined the term “palliative care,” lamenting the cruel irony of our care for the dying, and the desperate need to create programs to reach more people experiencing suffering.

Today we talk with Naheed Dosani, a palliative care physician at St. Michael’s Hospital in Toronto, and health justice activist. His story, which he shares on today’s podcast, is remarkable. Just out of fellowship, Naheed built a palliative care program for homeless persons called the Palliative Education and Care for the Homeless (PEACH) Program. This podcast is a complement to our prior podcast on aging and homelessness with Margot Kushel. Today we discuss:

• What is the best terminology? Homeless? Homelessness? Houseless? Marginally housed?
• What makes palliative care for people experiencing homelessness challenging? What makes it rewarding?
• What is unique about the practice of palliative care for people experiencing homelessness? We discuss the principles of harm reduction, social determinants of health, and trauma informed care. Major overlap with substance use disorder issues, which we have covered recently (and frequently) on this podcast.
• How are the health systems designed or not designed to meet the needs of people experiencing homelessness?
• What are the equity issues at stake, and at risk of being cut, both in Canada and the US?

Many more links below. And I had a blast playing Blinding Lights by that Toronto band The Weekend.

Enjoy!

-Alex

End Well Talk

https://www.youtube.com/watch?v=eG4QE-hfPQU

Resources on the PEACH Program

• Program Review Paper – A recent publication in Longwoods Healthcare Quarterly reviewing the PEACH model. https://pubmed.ncbi.nlm.nih.gov/37144698/
• Promising Practice Recognition – PEACH was named a Promising Practice in equity-oriented palliative care as part of a national initiative funded by Health Canada, operated by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. https://www.healthcareexcellence.ca/media/z3jifqqd/pp-peach-en-2024-v2.pdf
• Toronto Star Feature https://www.thestar.com/life/together/people/dr-naheed-dosani-started-peach-to-provide-palliative-care-for-homeless-and-vulnerably-housed-populations/article_c56d8f45-cbe9-522e-9554-46778bf50407.html
• CityNews Toronto Feature https://toronto.citynews.ca/2022/08/08/peach-team-palliative-health-care-homelessness/

Psychosocial Interventions at PEACH

In addition to medical care, PEACH also runs two key psychosocial interventions for our clients:

• PEACH Grief Circles – Structured spaces for workers in the homelessness sector to process grief. CBC covered this a few years ago, including a radio segment feature on CBC White Coat, Black Art (which you can access at the below link). https://www.cbc.ca/radio/whitecoat/palliative-care-team-helps-the-homeless-die-with-dignity-a-healing-circle-helps-them-grieve-1.5048409
• PEACH Good Wishes Program – A program that provides meaningful gifts for unhoused individuals who are terminally ill. https://www.cbc.ca/news/canada/toronto/toronto-homeless-palliative-holidays-1.5407360

Kensington Hospice & 'Radical Love' Equity-Oriented Hospice Palliative Care

Naheed Dosani also serves as the Medical Director of Kensington Hospice, Toronto’s largest hospice. There, he helps run an innovative program called 'Radical Love' Equity-Oriented Hospice Palliative Care, which provides low-threshold, low-barrier access to hospice care for structurally vulnerable individuals (e.g., those experiencing homelessness). The program also operates via a partnership with the PEACH Program.

• As a result of the 'Radical Love' program at Kensington Hospice: At any given time, Kensington Hospice has evolved from caring for structurally vulnerable individuals

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Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.

Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:

• Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?”
• Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in JPSM.
• What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).
• When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?
• Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?
• And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…

Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!

Sometimes the drugs don’t work.

-Alex: @alexsmithmd.bsky.social

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Trauma is a universal experience, and our approach as health care providers to trauma should be universal as well. That’s my main take-home point after learning from our three guests today when talking about trauma-informed care, an approach that highlights key principles including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity.

With that said, there is so much more that I learned from our guests for this trauma-informed care podcast. Our guests include Mariah Robertson, Kate Duchowny, and Ashwin Kotwal. Mariah discussed her JAGS paper on applying a trauma-informed approach to home visits. Kate and Ashwin talked about their research on the prevalence of lifetime trauma and its association with physical and psychosocial health among adults at the end of life. We also explored several questions with them, including how to define trauma, its prevalence in older adults, the impact of past traumatic experiences, the potential triggers of trauma screening, and the application of trauma-informed principles in clinical practice.

If you want a deeper dive, check out the following resources:

• Our “Nature of Suffering” podcast with BJ Miller and Naomi Saks
• Dani Chammas’ Annals paper on countertransference and why we shouldn’t say “that the patient was difficult rather than that I felt frustrated.”
• A great Curbsiders podcast episode on Trauma-informed care with Megan Gerber
• CAPC’s Trauma-informed care toolkit
• Mariah’s article on Home-Based Care for LGBTQ or another diverse gender identity Older Adults

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In today’s podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Medicine Nurses Association (HPNA). Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully). On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of moderator.

Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed Prepare-for-your-care vs. facilitated Respecting Choices style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer. From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including:

• Marie’s tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served? Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served?
• Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let’s assume that there are clear important benefits. Based on the results of Yael’s study, should resources be allocated to resource intensive nurse facilitated sessions (Respecting Choices), which had significantly better engagement, or to low resource intensive patient-facing materials (Prepare), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)?
• One interpretation of Na’s study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis. Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality. Which is it?
• Bonus: Simon says he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?). Garfunkel says Simon was writing about Garfunklel’s friend and college roomate Sandy, who was blind. Who’s got the right of it?

Enjoy!

-Alex Smith

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Things are changing quickly in the Alzheimer’s space. We now have biomarkers that can reasonably approximate the degree of amyloid build-up in the brain with a simple blood test. We have two new FDA-approved medications that reduce that amyloid buildup and modestly slow down the progression of the disease. So, the question becomes, what, if anything, should we do differently in the primary care setting to diagnose the disease?

On today’s podcast, we’ve invited Nathaniel Chin back to the GeriPal podcast to talk about what primary care needs to manage this new world of Alzheimer’s disease effectively. Nate is a geriatrician and clinician-scientist at the University of Wisconsin, as well as the host of the Wisconsin ADRC's podcast, "Dementia Matters." In each bi-weekly episode, he interviews Alzheimer's disease experts about research advances and caregiver strategies. Nate also wrote a NEJM piece last year on “Alzheimer’s Disease, Biomarkers, and mAbs — What Does Primary Care Need?”

We address the following questions with Nate:

• Has anything changed for the primary care doctor when diagnosing Alzheimer’s? How should we screen for cognitive impairment?
• Does a good history matter anymore?
• What’s the role of assessing function?
• What do we do with those who have only subjective cognitive complaints?
• Can’t we skip all this and just send some blood-based biomarkers?
• What is the role of the amyloid antibody treatments?

Lastly, take a look at the following if you want to take a deeper dive into some of the other articles and podcasts we discuss:

• First, two competing definitions of what is Alzheimer’s:
• Alzheimer Disease as a Clinical-Biological Construct—An International Working Group (IWG) Recommendation

• Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup

• Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): Executive summary of recommendations for primary care

• Podcasts we mentioned
• Prevention of Dementia: A Podcast with Kristine Yaffe
• Screening for Dementia: A Podcast with Anna Chodos, Joseph Gaugler and Soo Borson

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It is a battle royale on this week’s GeriPal podcast. In one corner, weighing in at decades of experience, well known for heavy hits of bedside assessments, strong patient-family relationships, and a knockout punch of interdisciplinary collaboration, we have in-person palliative care consults. But watch out! Travel time can leave this champ vulnerable to fatigue and no-shows. In the other corner, we have the young upstart, able to reach patients across vast distances when delivering palliative care, all in the comfort of wearing pajamas, we have telehealth delivered palliative care. However, lack of physical presence may make this contender struggle to land the emotional support punch that is at the very heart of palliative care.

Who will emerge victorious? Will in-person palliative care use its experience and bedside manner to overwhelm telehealth palliative care, or will telehealth deliver the knockout blow of efficiency and accessibility?

Find out on this week’s podcast where we invite Joseph Greer, Simone Rinaldi, and Vicki Jackson to talk about their recent JAMA article on “Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer - A Multisite Randomized Clinical Trial.”

Additionally, here are some of the resources we talked about during the podcast:

• Eduardo Bruera’s editorial that accompanies the JAMA paper titled “Improving Palliative Care Access for Patients With Cancer”
• Our podcast on Stepped Palliative Care with Jennifer Temel, Chris Jones, and Pallavi Kumar
• The book “What's in the Syringe? Principles of Early Integrated Palliative Care” by Juliet Jacobsen, Vicki Jackson, Joseph Greer, and Jennifer Temel

Lastly, don’t forget about attending some of the sessions Vicki mentioned at the end of the podcast during the HPNA/AAHPM annual meeting in Denver, as well as the GeriPal #HPMParty Pub Crawl!

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It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes.

In our first segment, we discuss a study led by Constance Fung and her team, which investigated the use of a masked tapering method combined with augmented cognitive behavioral therapy for insomnia (CBTI) to help patients discontinue benzodiazepines. The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts.

Next, we turn to Emily McDonald, the director of the Canadian Medication Appropriateness and Deprescribing Network, to discuss her study on the impact of direct-to-consumer educational brochures on gabapentin deprescribing. Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see here for the brochure). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use.

In our third segment, we explore Amy Linsky’s study that examined the effect of patient-directed educational materials on clinician deprescribing of potentially low-benefit or high-risk medications, such as proton pump inhibitors, high-dose gabapentin, or risky diabetes medications. The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click here for the brochure). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety.

Finally, we discuss Michelle Odden’s study, which used a target trial emulation approach to investigate the effects of deprescribing antihypertensive medications on cognitive function in nursing home residents. The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast (DANTE and OPTIMIZE) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the DANTON study adds more questions to that conclusion.

Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research!

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Many older adults lose decision-making capacity during serious illnesses, and a significant percentage lack family or friends to assist with decisions. These individuals may become “unrepresented,” meaning they lack the capacity to make a specific medical decision, do not have an advance directive for that decision, and do not have a surrogate to help.

In today’s podcast, we talk with Joe Dixon, Timothy Farrell, and Yael Zweig, authors of the AGS position statement on making medical treatment decisions for unrepresented older adults. We define “unrepresented” and address the following questions:

• What is the scope of the unrepresented problem?
• Why not use the older term “unbefriended”?
• How should we care for unrepresented individuals in inpatient and outpatient settings?
• What can we do to prevent someone from becoming unrepresented?

Find answers to these questions and more in this week’s podcast. Listen in, and if you’re interested, explore the topic further with the following resources:

• AGS Position statement on making medical treatment decisions for unrepresented older adults
• VA Policy on Advance Care Planning and on Informed Consent

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We’ve talked a lot before about integrating psychiatry into palliative care (see here and here for two examples). Still, we haven’t talked about integrating palliative care into psychiatry or in the care of those with severe mental illness.

On this week’s podcast, we talk with two experts about palliative psychiatry. We invited Dani Chammas, a palliative care physician and psychiatrist at UCSF (and a frequent guest to the GeriPal podcast), as well as Brent Kious, a psychiatrist at the Huntsman Mental Health Institute, focusing on the management of severe persistent mental illnesses.

We discuss the following:

• What is Palliative Psychiatry (and how is it different from Palliative Care Psychiatry)?
• What does it look like to take a palliative approach to severe mental illness?
• Is "terminal" mental illness a thing?
• Is hospice appropriate for people with serious mental illness (and does hospice have the skills to meet their needs?)
• Controversy over Medical Aid in Dying for primary psychiatric illness (and for those with serious medical illness who have a comorbid psychiatric illness)
• The level of provider moral distress that can be created in a system not designed to meet the needs of specific populations... and when we are asked to meet a need we don't feel equipped to meet.

Here are a couple of articles if you want to do a deeper dive:

• Dani and colleagues article on “Psychiatry and Palliative Care: Growing the Interface Through Education.”
• Dani and colleagues article on “Palliative Care Psychiatry: Building Synergy Across the Spectrum.”
• Brent’s article on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?”
• A NY Times article titled “Should Patients Be Allowed to Die From Anorexia?”

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Surrogate decision making has some issues. Surrogates often either don’t know what patients would want, or think they know but are wrong, or make choices that align with their own preferences rather than the patients. After making decisions, many surrogates experience regret, PTSD, and depressive symptoms. Can we do better?

Or, to phrase the question for 2024, “Can AI do better?” Follow that path and you arrive at a potentially terrifying scenario: using AI for surrogate decision making. What?!? When Teva Brender and Brian Block first approached me about writing a thought piece about this idea, my initial response was, “Hell no.” You may be thinking the same. But…stay with us here…might AI help to address some of the major issues present in surrogate decision making? Or does it raise more issues than it solves?

Today we talk with Teva, Dave Wendler, and Jenny Blumenthal-Barby about:

• Current clinical and ethical issues with surrogate decision making
• The Patient Preferences Predictor (developed by Dave Wendler) or Personalized Patient Preferences Predictor (updated idea by Brian Earp) and commentary by Jenny
• Using AI to comb through prior recorded clinical conversations with patients to play back pertinent discussions; to predict functional outcomes; and to predict patient preferences based on prior spending patterns, emails, and social media posts (Teva’s thought piece)
• A whole host of ethical issues raised by these ideas including the black box nature, the motivations of private AI algorithms run by for profit healthcare systems, turning an “is” into an “ought”, defaults and nudges, and privacy.

I’ll end this intro with a quote from Deb Grady in an editor’s commentary to our thought piece in JAMA Internal Medicine about this topic: “Voice technology that creates a searchable database of patients’ every encounter with a health care professional? Using data from wearable devices, internet searches, and purchasing history? Algorithms using millions of direct observations of a person’s behavior to provide an authentic portrait of the way a person lived? Yikes! The authors discuss the practical, ethical, and accuracy issues related to this scenario. We published this Viewpoint because it is very interesting, somewhat scary, and probably inevitable.”

-@alexsmithmd.bsky.social

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We’ve covered stories before. With Liz Salmi, Anne Kelly, and Preeti Malani we talked about stories written up in the academic literature, such as the JAMA Piece of My Mind series. We talked with Thor Ringler, who helped found the My Life My Story Project at the VA and beyond, and Heather Coats about the evidence base for capturing patient stories.

Today’s podcast is both similar and different. Similar in that the underlying theme of the power of stories. Different in that these storytelling initiatives, the Nocturnists and the Palliative Story Exchange, are focused on clinicians sharing stories with each other in small groups to heal. There’s something magical that happens in small group storytelling. It’s that mixture of intimacy and vulnerability, of shared clinical experiences, that fosters a sense of belonging. We model that small group storytelling experience today.

We discuss:

• The “origin stories” of the Nocturnists Live Show and Podcast and the Palliative Story Exchange
• The process for story creation and development, written in advance or not, feedback or not after the story, and the aims and goals of each initiative
• And we each tell a short story, modeling the process for The Nocturnists and the Palliative Story Exchange for our listeners

These initiatives arose organically from clinicians as part of a journey away from burnout, moral distress, shame, and loneliness toward healing, wholeness, gratitude, and belonging. A journey taken one story at a time.

One final note on the song request: About 20 years ago I took an epidemiology course as part of a Masters program. The instructor, Fran Cook, gave all the students a survey without explanation. We answered the survey and handed it in. One of the questions was, “Can you name a song by the Tragically Hip?” It later turned out the survey was a prognostic index designed to determine if the respondent was Canadian.

-@AlexSmithMD

Here’s a link to an article about the Palliative Story Exchange.

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Denial. Substance use. Venting. Positive reframing. Humor. Acceptance. All of these are ways we cope with stressful situations. Some we may consider healthy or unhealthy coping strategies, but are they really that easy to categorize? Isn’t it more important to ask whether a particular coping behavior is adaptive or not for a particular person,in a particular time or situation?

We are going to tackle this question and so many more about coping on this week's podcast with Dani Chammas, a recurring GeriPal guest, psychiatrist, and palliative care doc at UCSF, and Amanda Moment, a Palliative Care Social Worker at Brigham and Women's Cancer Center. There are so many take-home points for me on this podcast, including this one on a framework for assessing coping in serious illness:

1. nonjudgmentally observe their coping
2. wonder about the impacts of their coping
3. prioritize helping patients maintain their psychological integrity
4. mindfully think through how we can serve their coping in ways that they can tolerate, always calibrating based on the person, the moment, and the setting in front of us.

Here are some more resources we’ve discussed in the podcast

• Dani’s NEJM article on coping: “Should I Laugh at That? Coping in the Setting of Serious Illness”
• Dani’s GeriPal podcast with us on “Improving Serious Illness Communication By Developing Formulations”
• A great journal article on “Formulation in Palliative Care: Elevating Our Potential for Therapeutic Communication”
• A study on how palliative care may work by enhancing patients’ ability to access adaptive coping - “Role of Patient Coping Strategies in Understanding the Effects of Early Palliative Care on Quality of Life and Mood

NOTE: To claim CME credit for this episode, click here

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Falls are very common among older adults but often go unreported or untreated by healthcare providers. There may be lots of reasons behind this. Patients may feel like falls are just part of normal aging. Providers may feel a sense of nihilism, that there just isn't anything they can do to decrease the risk of falling. On this week's podcast, we try to blow up this nihilism with our guest Sarah Berry.

Sarah is a geriatrician at Hebrew SeniorLife in Boston where she does research on falls, fractures, and osteoporosis in older adults. We pepper Sarah with questions ranging from:

• Why should we care about falls?
• What are ways we should screen for falls?
• What are evidence based interventions to decrease the risk of falls?
• What about Vitamin D and falls???
• How should we assess for fracture risk?
• What are some evidence-based ways to decrease fracture risk?
• When should we prescribe vs deprescribe bisphosphonate therapy? How does life expectancy fit in with all of this?

If you want to do a deeper dive into some of the articles we discuss, take a look at the following:

• An awesome JAMA review by Sarah on fall risk assessment and prevention in community-dwelling adults.
• The Fracture Risk Assessment in Long term care (FRAiL) website
• James Deardorff’s JAMA IM article on “Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis
• Sarah’s article on “Controversies in Osteoporosis Treatment of Nursing Home Residents”, which includes this helpful flow chart on starting/stopping osteoporosis drugs in nursing homes

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We recently published a podcast on palliative care for kidney failure, focusing on conservative kidney management. Today we’re going to focus upstream on the decision to initiate dialysis vs conservative kidney management.

As background, we discuss Manju Kurella Tamura’s landmark NEJM paper that found, contrary to expectations, that function declines precipitously for nursing home residents who initiate dialysis. If the purpose of initiating dialysis is improving function - our complex, frail, older patients are likely to be disappointed.

We also briefly mention Susan Wong’s terrific studies that found a disconnect between older adults with renal failure’s expressed values, focused on comfort, and their advance care planning and end-of-life care received, which focused on life extension; and another study that found quality of life was sustained until late in the illness course.

One final briefly mentioned piece of background: John Oliver’s hilarious and disturbing takedown of the for profit dialysis industry, focused on DaVita.

And the main topic of today is a paper in Annals of Internal Medicine, Maria first author, that addressed the tradeoffs between initiating dialysis vs continued medical/supportive management. Turns out, in summary people who initiate dialysis have mildly longer lives, but spend more time in facilities, away from home. We also discuss (without trying to get too wonky!) immortal time bias and target emulation trials. Do target trials differ from randomized trials and “ordinary” observational studies, or do they differ?!? Eric is skeptical.

Bottom line: if faced with the decision to initiate dialysis, waiting is generally better. Let it be (hint hint).

-Additional link to study with heatmaps of specific locations (hospital, nursing home, home) after initiating dialysis.

-@AlexSmithMD

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In March 2020, we launched our first podcast on COVID-19. Over the past four years, we’ve seen many changes—some positive, some negative. While many of us are eager to move past COVID (myself included), it’s clear that COVID is here to stay.

This week, we sit down with infectious disease experts Peter Chin-Hong and Lona Mody to discuss living with COVID-19. Our conversation covers:

• The current state of COVID
• Evidence for COVID boosters, who should get them, and preferences between Novavax and mRNA vaccines
• COVID treatments like Molnupiravir and Paxlovid
• Differences in COVID impact on nursing home residents and those with serious illnesses

We wrap up with a “magic wand” question. My wish was for better randomized evidence for vaccines and treatments, though I worry this might not be feasible. In the meantime, there’s significant room to improve vaccine uptake among high-risk groups, particularly nursing home residents. Currently, only 1 in 5 nursing home residents in the US have received the COVID booster, compared to over 50% in the UK.

By: Eric Widera

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Cannabis is complicated. It can mean many things, including a specific type of plant, the chemicals in the plant, synthetic analogs, or products that have these components. The doses of the most widely discussed pharmacologically active ingredients, THC and CBD, vary by product, and the onset and bioavailability vary by how it is delivered. If you believe the evidence for efficacy to manage symptoms like neuropathic pain, how do you even start to think about recommending these products to patients?

On today’s podcast, we answer that question with our guests, David Casarett and Eloise Theisen. David is a physician who wrote the book “Stoned: A Doctor's Case for Medical Marijuana” and gave a TED talk on “A Doctor's Case for Medical Marijuana” that was watched over 3 million times. Eloise is a palliative care NP at Stanford and co-founder of The Radicle Health Clinician Network.

So, take a listen and check out the following resources to learn more about medical cannabis:

• Radicle Health’s curriculum and modules for healthcare professionals on cannabis
• NEJM Catalyst article on integrating medical cannabis into clinical care
• David’s TED talk on “A Doctor's Case for Medical Marijuana”
• A JPSM systematic review of current evidence for cannabis in palliative care
• Our past GeriPal episode with Bree Johnston and Ben Han on cannabis in older adults

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When treating heart failure, how do we distinguish between the expanding list of medications recommended for “Guideline Directed Medical Therapy” (GDMT) and what might be considered runaway polypharmacy? In this week’s podcast, we’ll tackle this crucial question, thanks to a fantastic suggestion from GeriPal listener Matthew Shuster, who will join us as a guest host.

We’ve also invited two amazing cardiologists, Parag Goyal and Nicole Superville, to join us about GDMT in heart failure with reduced ejection fraction (HFrEF) and in Heart Failure with preserved EF (HFpEF). We talk about what is heart failure, particularly HFpEF, how we treat it (including the use of sodium–glucose cotransporter-2 inhibitors (SGLT2’s), and how we should apply guidelines to individual patients, especially those with multimorbidity who are taking a lot of other medications.

I’d also like to give a shout out to a recent ACP article on HFpEF with an outstanding contribution from Ariela Orkaby, geriatrician extraordinaire (we also just did a podcast with her on frailty).

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In fellowship, one of the leaders at MGH used to quote Balfour Mount as saying, “You say you’ve worked on teams? Show me your scars.” Scars, really? Yes. I’ve been there. You probably have too. On the one hand, I don’t think interprofessional teamwork needs to be scarring. On the other hand, though it goes against my middle-child “can’t we all get along” nature, disagreement is a key aspect of high functioning teams. The key is to foster an environment of curiosity and humility that welcomes and even encourages a diversity of perspectives, including direct disagreement.

Today we talk with DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace about the notion that we should revolutionize our education programs, training programs, teams, incentive structures, and practice to be intentionally interprofessional in all phases. The many arguments, theories, & approaches across settings and conditions are explored in detail in the book they edited, “Intentionally Interprofessional Palliative Care” (discount code AMPROMD9). Of note: these lessons apply to geriatrics, primary care, hospital medicine, critical care, cancer care, etc, etc.

And they begin on today’s podcast with one clinical ask: everyone should be a generalist and a specialist. In other words, in addition to being a specialist (e.g. social worker, chaplain), everyone should be able to ask a question or two about spiritual concerns, social concerns, or physical concerns.

Many more approaches to being interprofessional on today’s podcast. But how about you! What will you commit to in order to be more intentionally interprofessional?

If we build this dream together, standing strong forever, nothing’s gonna stop us now…

-@AlexSmithMD

Interprofessional organizations that are not specific to palliative care are doing excellent work

• National Center for Interprofessional Practice and Education: https://nexusipe.org/
• National Collaborative for Improving the Clinical Learning Environment https://ncicle.org/
• Interprofessional Education Collaborative (home of the IPEC Competencies) https://www.ipecollaborative.org/
• American Interprofessional Health Collaborative (sponsor of the biennial meeting "Collaborating Across Borders") https://aihc-us.org/index.php/
• Health Professions Accreditors Collaborative https://healthprofessionsaccreditors.org/

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world-class palliative care. They are looking to build on both their research and clinical programs and are interviewing candidates for the Associate Chief of Research and for full-time physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

NOTE: To claim CME credit for this episode, click here

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Can death be portrayed as beautiful?

In this episode, we share the joy of talking with Wendy MacNaughton (artist, author, graphic journalist) and Frank Ostaseski (Buddhist teacher, author, founder of the Metta Institute and Zen Hospice Project) about using drawings and images as tools for creating human connections and processing death and dying.

You may know Wendy as the talented artist behind Meanwhile in San Francisco or Salt Fat Acid Heat. Our focus today, however, was on her most recently published book titled How to Say Goodbye. This beautiful book began as a very personal project for Wendy while she was the artist-in-residence at Zen Hospice. As BJ MIller writes in the foreword, “May this book be a portal -- a way for us to move beyond the unwise territory of trying to ‘do it right’ and into the transcendent terrain of noticing what we can notice, loving who we love, and letting death -- like life --surprise us with its ineffable beauty.”

Some highlights from our conversation:

• The role of art in humanizing the dying process.

• How the act of drawing can help us sloooow down, pay attention to the people and world around us, and ultimately let go…

• The possibility of incorporating drawings in research and even clinical care.
• The wisdom and experiences of hospice caregivers (who are often underpaid and undervalued).
• How to use the “Five Things” as a framework for a “conversation of love, respect, and closure” with someone who is dying.

And finally, Wendy offers a drawing lesson and ONE-MINUTE drawing assignment to help us (and our listeners) be more present and connect with one another. You can read more about this blind contour exercise from Wendy’s DrawTogether Strangers project. The rules are really quite simple:

• Find another person.
• Sit down and draw each other for only one minute.
• NEVER lift up your pen/pencil (draw with a continuous line)
• NEVER look down at your paper

That’s it! While the creative process is what truly matters, we think that the outcome is guaranteed to be awesome and definitely worth sharing. We invite you to post your drawings on twitter and tag us @GeriPalBlog!

Happy listening and drawing,

Lingsheng @lingshengli

Additional info:

• For weekly lessons on drawing and the art of paying attention from Wendy, you can subscribe to her Substack DrawTogether with WendyMac and join the Grown-Ups Table (GUT)!
• To learn more about Frank’s teaching and philosophy on end-of-life care, read his book The Five Invitations

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If palliative care was a drug, one question we would want to know before prescribing it is what dose we should give. Give too little - it may not work. Give too much, it may cause harm (even if the higher dose had no significant side effects, it would require patients to take a lot of unnecessary additional pills as well as increase the cost.)

So, what is the effective dose of palliative care? On today’s podcast, we talk about finding an evidence-based answer to this dosing question with three leaders in palliative care: Jennifer Temel, Chris Jones, and Pallavi Kumar. All three of our guests were co-authors of a randomized control trial on “Stepped Palliative Care” published in JAMA this year.

We talk about what stepped palliative care is, how it is different from usual care or intensive palliative care, why these palliative care dosing questions are important, and dive deep into the results of their trial. We also discuss some of the other important trials in palliative care, including Jennifer Temel’s landmark NEJM study on outpatient palliative care and another study that gave an intervention we dubbed “fast-food palliative care” in an older GeriPal blog post.

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Well-being and resilience are so hot right now. We have an endless supply of CME courses on decreasing burnout through self-care strategies. Well-being committees are popping up at every level of an organization. And C-suites now have chief wellness officers sitting at the table. I must admit, though, sometimes it just feels off… inauthentic, as if it's not a genuine desire to improve our lives as health care providers, but rather a metric to check off or a desire to improve productivity and billing by making the plight of workers a little less miserable.

On today’s podcast, we talk with Jane Thomas, Naomi Saks, and Ishwaria Subbiah about the concepts of wellness, well-being, resilience, and burnout, as well as what can be done to truly improve the lives of healthcare providers and bring, I dare say it, joy into our work.

For more on resources for well-being, check out the following:

1. Cynda Rushton, PHD, MSN, RN — Transforming Moral Distress into Moral Resilience https://www.youtube.com/watch?v=L1gE5G8WnTU

2. Tricia Hersey: Rest & Collective Care as Tools for Liberation https://www.youtube.com/watch?v=7OuXnLrKyi0

3. Beyond resiliency: shifting the narrative of medical student wellness https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/

4. Fostering resilience in healthcare professionals during and in the aftermath of the COVID-19 pandemic https://www.cambridge.org/core/journals/bjpsych-advances/article/fostering-resilience-in-healthcare-professionals-during-and-in-the-aftermath-of-the-covid19-pandemic/0ADCA3737D12CAF308567A7F59EFC267

5. The Greater Good Science Center studies the psychology, sociology, and neuroscience of well-being and teaches skills that foster a thriving, resilient, and compassionate society. https://ggsc.berkeley.edu/?_ga=2.230263642.712840261.1724681290-1268886183.1680535323

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In today’s podcast we set the stage with the story of Dax Cowart, who in 1973 was a 25 year old man horribly burned in a freak accident. Two thirds of his body was burned, most of his fingers were amputated, and he lost vision in both eyes. During his 14 month recovery Dax repeatedly demanded that he be allowed to die. The requests were ignored. After, he said he was both glad to be alive, and that the doctors should have respected his wish to be allowed to die.

But that was 1973, you might say. We don’t have such issues today, do we?

Louise Aronson’s recent perspective about her mother in the NEJM, titled, “Beyond Code Status” suggests no, we still struggle with this issue. And Bill Andereck is still haunted by the decision he made to have the police break down the door to rescue his patient who attempted suicide in the 1980s, as detailed in this essay in the Cambridge Quarterly of HealthCare Ethics. The issues that are raised by these situations are really hard, as they involve complex and sometimes competing ethical values, including:

• The duty to rescue, to save life, to be a “lifeguard”
• Judgements about quality of life, made on the part of patients about their future selves, and by clinicians (and surrogate decision makers) about patients
• Age realism vs agism
• The ethics of rationale suicide, subject of a prior GeriPal episode
• Changes in medical practice and training, a disconnect between longitudinal care and acute care, and frequent handoffs
• The limitations of advance directives, POLST, and code status orders in the electronic health record
• The complexities of patient preferences, which extend far beyond code status
• The tension between list vs goals based approaches to documentation in the EHR

And a great song request, “The Cape” by Guy Clark to start and end.

Enjoy!

-@AlexSmithMD

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Serious illness communication is hard. We must often deliver complex medical information that carries heavy emotional weight in pressured settings to individuals with varying cultural backgrounds, values, and beliefs. That’s a hard enough task, given that most of us have never had any communication skills training. It feels nearly impossible if you add another degree of difficulty, whether it be a crying interpreter or a grandchild from another state who shows up at the end of a family meeting yelling how you are killing grandma.

On today’s podcast, we try to stump three VitalTalk expert faculty, Gordon Wood, Holly Yang, Elise Carey, with some of the most challenging communication scenarios that we (and some of our listeners) could think up.

During the podcast, we reference a newly released second-edition book that our guests published titled “Navigating Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope.” I’d add this to your “must read” list of books, as it takes readers through the VitalTalk method that our guests use so effectively when addressing these challenging scenarios.

If you are interested in learning more about VitalTalk, check out their and some of these other podcasts we’ve done with three of the other authors of this book (and VitalTalk co-founders):

• Our podcast with Tony Back as well as Wendy Anderson on “Communication Skills in a Time of Crises”
• Our podcast with James Tulsky on “The Messiness of Medical Decision-Making in Advanced Illness.”
• Any one of our podcasts with Bob Arnold, including this one on the language of serious illness or this one on books, to become a better mentor.

Lastly, I reference Alex’s Take Out the Trash video, where he uses communication skills learned in his palliative care training at home with his wife. The results are… well… let’s just say less than perfect.

By: Eric Widera

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We’ve talked about Brain Death before with Robert (Bob) Troug and guest-host Liz Dzeng, and in many ways today’s podcast is a follow up to that episode (apologies Bob for mispronouncing your last name on today’s podcast!).

Why does this issue keep coming up? Why is it unresolved? Today we put these questions to Winston Chiong, a neurologist and bioethicist, and Sean Aas, a philosopher and bioethicist. We talk about many reasons and ways forward on this podcast, including:

• The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI. (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a re-evaluation of what it means to be human, or deserving of moral standing).
• The moral questions at stake vs the biologic questions (and links between them)
• The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story)
• What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others.
• Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions.

As we joke about at the start - talking with philosophers and bioethicists, you almost always get a response along the lines of, “well that’s a good question, but let’s examine a deeper more fundamental question.” Today is no different. And the process of identifying the right questions to ask is absolutely the best place to start.

Eventually, of course, everything must cease.

-@AlexSmithMD

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Anti-Asian hate incidents rose dramatically during COVID, likely fueled by prominent statements about the “Chinese virus.” VIewed through the wider lens of history, this was just the latest in a long experience of Anti-Asian hate, including the murder of Vincent Chin, the Chinese Exclusion Act, and the internment of Japanese Americans during WWII. For those who think that anti-Asian hate has receded as the COVID has “ended,” just two days prior to recording this episode a Filipino woman was pushed to her death on BART in San Francisco. These incidents are broadcast widely, particularly in Asian News outlets.

Today we talk about the impact of anti-Asian hate on the health and well being of older adults with Russell Jeung, sociologist, Professor of Asian Studies at San Francisco State, and co-founder of Stop AAPI-Hate, LInghseng Li, geriatrician/palliative care doc and T32 fellow at UCSF, and Jessica Eng, medical director of On Lok, a PACE, and Associate Professor in the UCSF Division of Geriatrics.

We discuss:

• What is considered a hate incident, how is it tracked, what do we know about changes over time
• The wider impact of Anti-Asian hate on older Asians, who are afraid to go out, leading to anxiety, social isolation, loneliness, decreased exercise, missed appointments and medications. Lingsheng (and I) recently published studies on this in JAMA Internal Medicine, and JAGS.
• Ongoing reports from patients about anti-Asian hate experiences
• Should clinicians screen for Anti-Asian hate? Why? Why not?
• Proposing the clinicians ask a simple follow up question to the usual “do you feel safe at home?” question used to screen for domestic violence. Add to this, “do you feel safe outside the home?” This question, while providing an opportunity to talk about direct and indirect experiences, can be asked of all patients, and opens the door to conversations about anti-semitism, islamophobia, or anti-Black racism.

See also guides for how to confront and discuss anti-Asian hate in these articles in the NEJM and JGIM.

And to balance the somber subject, Lingsheng requested the BTS song Dynamite, which was the group’s first English language song, and was released at the height of the COVID pandemic. I had fun trying to make a danceable version with electronic drums for the audio-only podcast. Maybe we’ll get some BTS followers to subscribe to GeriPal?!?

-@AlexSmithMD

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(We couldn’t resist when Miguel Paniagua proposed this podcast idea and title. And no, you’ll be relieved to hear Eric and I did not imitate the interview style of Zach Galifiniakis).

We’ve talked a good deal on this podcast about what happens before death, today we talk about what happens after. Our guest today is Thomas Lynch, a poet and undertaker who practiced for years in a small town in Michigan. I first met Thomas when he visited UC Berkeley in the late 90’s after publishing his book, “The Undertaking: Stories from the Dismal Trade.”

We cover a wide range on this topic, weaving in our own stories of loss with Thomas’s experiences, stories, and poems from years of caring for families after their loved one’s have died.

We cover:

• The cultural shift from grieving to celebration, the “disappearance” of the body and death from funerals
• The power of viewing the body and participating in preparing the body, including cremation
• The costs of funerals
• The story of why Thomas became an undertaker
• A strong response to Jessica Mitford’s scathing critique of the American Funeral Industry published in “The American Way of Death”
• Our own experiences with funerals and burial arrangements for our loved ones
• Shifting practices, with a majority of people being cremated after death, a dramatic increase

This podcast was like therapy for us. And I got to sing Tom Waits’ Time, one of my favorites.

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What is a healthy diet and how much does it really matter that we try to eat one as we age? That’s the topic of this week's podcast with three amazing guests: Anna Pleet, Elizabeth Eckstrom, and Emily Johnston.

Emily Johnston is a registered dietitian, nutrition researcher, and Assistant professor at NYU. Anna Pleet is an internal medicine resident at Allegheny Health Network who has a collection of amazing YouTube videos on aging and the Mediterranean diet. Elizabeth Eckstrom is a geriatrician, professor of medicine at OHSU, and author of a new book, the Gift of Aging.

I love this podcast as while we talk about the usual topics in a medical podcast, like the role of screening, energy balance, and evidence-based for specific diets, we also talk about what a Mediterranean diet actually looks like on a plate and pepper our guests with questions about their favorite meals to convince Alex and me to eat more like a Sardinian.

Eric

PS. NEJM just published a great summary of diets summing up adherence to the Mediterranean diet and the following improved health outcomes: death from any cause, cardiovascular diseases, coronary heart disease, myocardial infarction, cancer, neurodegenerative diseases, and diabetes

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We are dusting off our crystal balls today with three amazing guests who have all recently published an article on prognosis over the last couple months: Kara Bischoff, James Deardorff, and Elizabeth Lilley.

To start us off we talk with Kara Bischoff about the article she just published in JAMA Network on a re-validation of the Palliative Performance Scale (PPS) in a modern day palliative care setting. Why do this? The PPS is one of the most widely used prognostic tools for seriously ill patients, but the prognostic estimates given by the PPS are based on data that is well over a decade old.

Next, we talk with James Deardorff about whether we can accurately predict nursing home level of care in community-dwelling older adults with dementia. Spoiler alert, he published a study in JAMA IM on a prognostic index that does exactly that (which is also on eprognosis.org).

Lastly, we invite Liz Lilley to talk about her paper in Annals of Surgery about prognostic allignment, including why as palliative care and geriatrics teams we need to take time to ensure that all disciplines and specialities are prognostically aligned before a family meeting.

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The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies? Should it? If so, how do we screen and who do we screen?

On this week’s podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist. Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia.

In addition to the questions asked above, we also cover the following topics with our guests:

• What is dementia screening?
• Who should get it if anyone?
• What should we use to screen individuals?
• What happens after they test positive?

And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.

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Emergency podcast! We’ve been asked by many people, mostly junior/mid career faculty, to quickly record a podcast on ageism and the elections. People are feeling conflicted. On the one hand, they have concerns about cognitive fitness of candidates for office. On the other hand, they worry about ageism. There’s something happening here, and what it is ain’t exactly clear. We need clear eyed thinking about this issue.

In today’s podcast, Louise Aronson, author of Elderhood, validates that this conflict between being concerned about both fitness for the job and alarmed about ageism is exactly the right place to be. We both cannot ignore that with advancing age the prevalence of cognitive impairment, frailty, and disability increase. At the same time, we can and should be alarmed at the rise in ageist language that equates aging with infirmity, and images of politicians racing walkers or a walker with the presidential seal. Ken Covinsky reminds us that we should not be making a diagnosis based on what we see on TV, and that if a patient’s daughter expressed a concern that their parent “wasn’t right,” we would conduct an in depth evaluation that might last an hour. Eric Widera reminds us of the history of the Goldwater Act created by the American Psychological Association in the 1960s which states that psychiatrists should refrain from diagnosing public figures, and the American Medical Association code of ethics which likewise discourages armchair diagnosis (rule established in 2017).

We frame today’s discussion around questions our listeners proposed in response to our Tweets, and are grateful for questions from Anand Iyer, Sandra Shi, Mike Wasserman, Ariela Orkaby, Karen Knops, Jeanette Leardi, Sarah McKiddy, Cecilia Poon, Colleen Christmas, and Kai Smith. We talk about positive aspects of aging, cognitive screening, the line between legitimate concerns and ageism, ableism, advice for a geriatrician asked to comment on TV, frailty and physical disability, images in the press, historical situations including , and an upper age limit for the Presidency, among other issues.

Of note, we talk about candidates from all parties today. We acknowledge concerns and speculation that others have raised about candidates across the political spectrum, current and former. We do not endorse or disclose our personal attitudes toward any particular candidate. Fitness for public office is a non-partisan issue that applies to all candidates for office, regardless of political party.

There’s something happening here, and what it is ain’t exactly clear.

Strong recommendation to also listen to this terrific podcast with another geriatrician all star, Jim Pacala, on MPR!

-@AlexSmithMD

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In May we did a podcast on KidneyPal (the integration of palliative care in renal disease), which made us think, hmmm… one organ right next door is the liver. Maybe we should do a podcast on LiverPal? (or should we call it HepatoPal?)

On today’s podcast, we do that by inviting four palliative care leaders who are integrating palliative care into the care of those with liver disease: Kirsten Engel, Sarah Gillespie-Heyman, Brittany Waterman, and Amy Johnson.

It’s a jampacked 50 minutes, filled with pearls on taking care of patients with liver disease. We cover:

• How each of their LiverPal teams are structured
• Why and how LiverPal differ from general palliative care or other palliative care specialty areas (KidneyPal, PalliPulm, etc)
• How to prognosticate in liver disease and how they communicate this with patients
• How to think about expectations of transplants and limitations of it
• How to manage complications and symptoms ranging from ascites, hepatic encephalopathy, pain, itching, cramps, and depression

Also, if you want to take an ever deeper dive, check out our 2022 podcast on End Stage Liver Disease with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel

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“Anxiety is a lot like a toddler. It never stops talking, tells you you’re wrong about everything, and wakes you up at 3 a.m.” I’m not sure who wrote this quote, but it feels right to me. We’ve all had anxiety, and probably all recognize that anxiety can be a force of action or growth but can also spiral to quickly take over our lives and our sleep. How, though, do we navigate anxiety and help our patients who may end up in the anxiety spiral that becomes so hard to get out of?

On today’s podcast, we’ve invited Alex Gamble and Brianna Williamson to talk to us about anxiety. Alex is a triple-boarded (palliative care, internal medicine, and psychiatry) assistant professor of medicine at Stanford. Brianna is one of UCSF’s palliative care fellows who just completed her psychiatry residency.

We start by defining anxiety (harder said than done), move on to talking about when it becomes maladaptive or pathologic, and how DSM5 fits into all of this. We then walk through how we should screen for anxiety and how we should think about a differential. Lastly, we talk about both non-pharmacologic and pharmacologic treatments.

It’s a lot to cover in 45 minutes, so for those who like to take a deeper dive, here are some of the references we talked about:

• Alex Sable-Smith’s great BATHE video on YouTube:
• Two books that Alex Gamble often recommends to patients can help build up your capacities to sit with anxiety (per Alex, both are from an Acceptance and Commitment Therapy framework)
• Things Might Go Terribly, Horribly Wrong: A Guide to Life Liberated from Anxiety
• The Reality Slap

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I have to start with the song. On our last podcast about urinary incontinence the song request was, “Let it go.” This time around several suggestions were raised. Eric suggested, “Even Flow,” by Pearl Jam. Someone else suggested, “Under Pressure,” but we’ve done it already. We settled on, “Oops…I did it again,” by Britney Spears.

In some ways the song title captures part of the issue with urinary incontinence. If only we lived in a world in which much of urinary incontinence was viewed as a natural part of aging, the normal response wasn’t embarrassment and shame, but rather an ordinary, “Oops…I did it again.” And if only we lived in a world in which this issue, which affects half of older women and a third of older men, received the research and attention it deserves. We shouldn’t have therapeutic nihilism about those who seek treatment, yet urinary incontinence is woefully understudied relative to its frequency and impact, and as we talk about on the podcast, basic questions about urinary incontinence have yet to be addressed. I don’t see those perspectives as incompatible.

Today we talk with George Kuchel and Alison Huang about:

• Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline
• Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes)
• How the assessment leads naturally to therapeutic approaches
• Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy
• “Last ditch” pharmacologic treatments.
• Landmark studies by Neil Resnick and Joe Ouslander.

Enjoy!

-@AlexSmithMD

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I always find cachexia in serious illness puzzling. I feel like I recognize it when I see it, but I struggle to give a clear definition or provide effective ways to address it.

In today's podcast, we had the opportunity to learn from a renowned expert in palliative care, Eduardo Bruera, about cachexia and anorexia in serious illness. Eduardo established one of the first palliative care programs in 1984, created the Edmonton Symptom Assessment Scale (ESAS), and significantly contributed to the evidence base for palliative care symptoms that many of us rely on daily.

During our discussion with Eduardo, we delved into how we can define cachexia and anorexia, why they occur in conditions like cancer, how to assess for them, and explored the interventions that are helpful and those that are not in the treatment of these conditions.

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As Eric notes at the end of today’s podcast, we talk about many difficult issues with our patients. How long they might have to live. Their declining cognitive abilities. What makes their lives meaningful, brings them joy, a sense of purpose. But one issue we’re not as good at discussing with our patients is sexual health.

On today’s podcast Areej El-Jawahri, oncologist specializing in blood cancers at MGH, says that sexual health is one of the top if not the top issue among cancer survivors. Clearly this issue is important to patients. Sharon Bober, clinical psychologist at DFCI, notes that clinicians can get caught in an anxiety cycle, in which they are afraid to ask, don’t ask, then have increased anxiety about not asking. Like any other conversation, you have to start, and through experience learn what language is comfortable for you. Don Dizon, oncologist specializing in pelvic malignancies at Brown, suggests speaking in plain language, starting by normalizing sexual health issues, to paraphrase, “Many of my patients experience issues with intimacy and sexual health. Is that an issue for you? I’m happy to talk about it at any time.” All guests agree that clinicians feel they need to have something they can do if they open Pandora's box. To that end, we talk about practical advice, including:

• The importance of intimacy over and above physical sexual function for many patients
• Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors
• Treatments for erectile dysfunction - first time the words “cock ring” have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn
• The importance of a pelvic exam for women experiencing pain
• What is “pelvic physical therapy?”
• Treatments for vaginal dryness and atrophy
• ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created

And I get to sing Lady Gaga, also a first for GeriPal! And let me tell you, there’s nothing like the first time (sorry, I couldn’t help it!).

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The landscape of options for treating people with kidney failure is shifting. It used to be that the “only” robust option in the US was dialysis. You can listen to our prior podcast with Keren Ladin talking about patients who viewed dialysis as their only option, and structural issues that led to this point (including this takedown of for profit dialysis companies by John Oliver). One of the problems was a lack of an alternative robust option to offer patients. As one of our guests says, you have to offer them something viable as an alternative to dialysis.

Today we interviewed Sam Gelfand, dually trained in nephrology and palliative care, Kate Sciacca, a nurse practitioner (fellowship trained in palliative care), and Josh Lakin, palliative care doc, who together with a social worker and other team members started KidneyPal at DFCI/BWH, a palliative care consult service for people with advanced kidney disease. As a team, they provide a robust alternative to dialysis for patients with kidney failure: conservative kidney management.

And “conservative,” as they note, can mean not only a “conservative approach,” as in non-invasive/less aggressive, but also an effort to “conserve” what kidney function remains.

We get right down to the nitty gritty of kidney supportive care techniques they incorporate in clinic, including:

• Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs? Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those “additional” days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management..
• Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis.
• Approaches to treating fatigue
• Approaches to treating pain - the second most common symptom (!) - and the answer isn’t tramadol (or tramadon’t) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don’t count out the NSAIDS!
• Approaches to treating itching/pruritus
• Approaches to treating nausea

Our guests were deeply grateful to their colleagues Dr. Frank Brennan, Dr. Mark Brown, and clinical nurse consultant Elizabeth Josland of the renal supportive care team at St. George Hospital in Sydney, Australia (down under) for teaching them the ropes of palliative care in kidney failure. And we got to learn some new vocabulary, including the meaning of “chunder.”

Enjoy!

-@AlexSmithMD

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Who gets to decide on what it means to have a disease? I posed this question a while back in reference to Alzheimer's disease. I’ll save you from reading the article, but the main headline is that corporations are very much the “who” in who gets to define the nature of disease. They do this either through the invention of disease states or, more often, by redrawing the boundaries of what is considered a disease (think pre-diabetes).

On today's podcast, we invite Adriane Fugh-Berman to discuss the influence of industry, whether it be pharma or device manufacturers, on healthcare. Adriane founded PharmedOut, a Georgetown University Medical Center project that “advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices.”

I’ve listened to a lot of Adriane’s talks. It is clear to me that she is not anti-medicine or even anti-pharma but is very much against both the visible and hidden influences that pharma and device manufacturers use to sell their products. This could be through overt marketing like advertisements or drug rep visits, or more covert measures like unrestricted grants to advocacy organizations, funding of CME, paying “key opinion leaders,” or the development of “disease awareness campaigns.”

So take a listen and dont worry, while GeriPal podcasts offer CME, we never take money from industry.

By: Eric Widera

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On today’s podcast, we’ve invited four hospice and palliative care social media influencers (yes, that’s a thing!), all of whom focus their efforts on educating the general public about living and dying with a serious illness. Their work is pretty impressive in both reach (some of their posts are seen by millions of viewers) and breadth of work. We’ve invited:

• Julie McFadden (aka Hospice Nurse Julie): Julie is a social media superstar, with 1.5 million subscribers on TikTok, another 400,000 subscribers on her YouTube channel, and another 350k followers on Instagram. She covers topics on death, dying, and hospice from a hospice nurse perspective, and she also has a book coming out called “Nothing to Fear: Demystifying Death to Live More Fully,” which is now available for pre-order.
• Matt Tyler (aka Pallidad for those on Twitter): Matt is the Hospice and Palliative care doctor who created How To Train Your Doctor, which helps patients living with serious illness find tips on “owning” their healthcare plan on his Instagram and YouTube pages. He was also the one who we have to thank for suggesting this podcast!
• Hsien Seow & Samantha (“Sammy”) Winemaker: Hsein and Sammy's goal was to start a revolution with their podcast “The Waiting Room Revolution,” which is now in its 7th season! The hope was by going directly to those living with a life-changing illness, we could directly tackle the question that comes up so many times - “Why didn’t anyone tell me that sooner…” They also just published a book,” Hope for the Best, Plan for the Rest,” and Sammy is a TikTok star in her own right, with some posts having over a million views.

We covered a lot of topics in the podcast from::

• What motivated them to create public-facing social media channels?
• Why focus on the public rather than other health care providers?
• How do they deal with professional barriers and the barrage of comments?
• Advice for others who might want to dabble in social media outreach

So, take a listen and check out their social media sites to get inspired. Just don't let Alex make me do another TikTok dance…

Eric Widera

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As Betty Ferrell says on our podcast today, nurses play an essential role in care of people with serious illness. Who spends the most time with the patient in the infusion center? Doing home care? Hospice visits? In the ICU at the bedside? Nurses.

ELNEC (End-of-Life Nursing Education Consortium) celebrates it’s 25th anniversary in 2025. We talk today with Betty Ferrell, who has been a nurse for 47 years, and is the founder and PI of ELNEC.

As I argue on the podcast, ELNEC has likely done more to lift the primary palliative care skills of clinicians than any other initiative. Full stop. Some numbers to back it up:

1. ELNEC has trained more than 48,000 providers in a train the trainer model
2. Over 1.5 million clinicians have been educated in ELNEC
3. ELNEC curricula are integrated int 1180 undergraduate and 394 graduate Schools of Nursing
4. ELNEC has been taught in over 100 countries

Today we talk about the origin story of ELNEC, the special role of nurses in palliative care, empowering as well as educating nurses, interprofessional ELNEC training, and opportunities and challenges ELNEC faces over the next 25 years.

Enjoy!

-@AlexSmithMD

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Eric asks the question that is on many of our minds - is the future of AI more Skynet from Terminator, in which AI takes over the world and drives humanity to the brink of extinction, or Wall-E, in which a benevolent and empathetic AI restores our humanity?

Our guest today is Bob Wachter, Chair of Medicine at UCSF and author of the Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. Bob recently wrote an essay in JAMA on AI and delivered a UCSF Grand Rounds on the same topic. We discuss, among other things:

• Findings that in several studies AI was rated by patients as more empathetic than human clinicians (not less, that isn’t a typo). Turns my concern about lack of empathy from AI on its head - the AI may be more empathetic than clinicians, not less.
• Skepticism on the ability of predictive models to transform healthcare
• Consolidation of EHR’s into the hands of a very few companies, and potential for the drug and device industry to influence care delivery by tweaking AI in ways that are not transparent and already a sort of magical black box.
• AI may de-skill clinicians in the same way that autopilot deskilled pilots, who no longer new how to fly the plane without autopilot
• A live demonstration of AI breaking a cancer diagnosis to a young adult with kids (VITAL Talk watch out)
• Use cases in healthcare: Bob predicts everyone will use digital scribes to chart within two years
• Concerns about bias and other anticipated and unanticipated issues

And a real treat- Bob plays the song for this one! Terrific rendition of Tomorrow from the musical Annie on piano (a strong hint there about Bob’s answer to Eric’s first question). Enjoy!

-@AlexSmithMD

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Ambivalence is a tough concept when it comes to decision-making. On the one hand, when people have ambivalence but haven't explored why they are ambivalent, they are prone to bad, value-incongruent decisions. On the other hand, acknowledging and exploring ambivalence may lead to better, more ethical, and less biased decisions.

On today's podcast, Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby, and Olubukunola Dwyer discuss the challenges of ambivalence and ways to address them. This podcast was initially sparked by Josh’s “Note From a Family Meeting” Substack post titled “Ambivalence in Clinical Decision-Making,” which discussed Bryanna’s and Jenny’s 2022 article titled “Two Minds, One Patient: Clearing up Confusion About Ambivalence."

Bryanna’s and Jenny’s article is particularly unique as it discusses these “ambivalent-related phenomena” and that these different kinds of “ambivalence” may call for different approaches with patients, surrogates (and health care providers):

In addition to defining these “ambivalent related phenomena” we ask our guests to cover some of these topics:

• Is ambivalence good, bad, or just a normal part of decision-making?
• Does being ambivalent mean you don’t care about the decision?
• What should we be more worried about in decision-making, ambivalence or the lack thereof?
• The concern about resolving ambivalence too quickly, as it might rush past important work that needs to be done to make a good decision.
• What about ambivalence on the part of the provider? How should we think about that?
• How do you resolve ambivalence?

Lastly, the one takeaway point from this podcast is that the next time I see ambiguity (or have it myself), I should ask the following question: “I see you are struggling with this decision. Tell me how you are feeling about it.”

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In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative state. In 1988, Cruzan’s parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan’s was Ken Starr, who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc).

In 1990 the Supreme Court ruled…for the state of Missouri. On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions. Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan’s eventually cleared. Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients.

Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan. We use Bernie’s NEJM Perspective as a springboard for discussion. We discuss, among other things:

• How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions
• And validating the importance of the advance directive forms in some circumstances, and in starting conversations
• The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use?
• Is the POLST useful? How? Under what circumstances?
• Should we abandon the term, “comfort measures?”

In case you miss the introductions at the start of the podcast, Bernie and Laurie are married, and offer wonderful reminiscence of their clinical practice over the last several decades. So when Bernie says, “I’ve heard you take these phone calls in the middle of the night, Laurie…” Now you know why!

And great song choice: Both Sides Now by Joni Mitchell. Joni suffered a stroke and had to completely re-learn how to play guitar. Her comeback performances are inspirational, such as this one at the Newport Folk Festival, attended by another influential GeriPal couple, Sean Morrison and Diane Meier. You get to hear my stripped down Hawaiian slack key style version of Both Sides Now (easy to play with 2 fingers, still in rehab for broken hand, hoping to have full use again soon). Enjoy!

-@AlexSmithMD

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One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans. Well, as a kick off to this year’s first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented.

Today we interview the authors of these 3 abstracts about their findings:

• Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety)
• Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support)
• Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization)

Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” - more to say that we’ve reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data.

We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties. I believe these issues were more than made up for by our guests' forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one).

Enjoy! -@AlexSmithMD

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What is frailty? Kate Callahan relates a clear metaphor on today’s podcast. A frail person is like an origami boat: fine in still water, but can’t withstand a breeze, or waves. Fundamentally, frailty is about vulnerability to stress.

In 2021 we talked with Linda Fried about phenotypic frailty. Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty. What is the difference, you ask? George Kushel probably explained it best in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers. Damage to those critical functions and the bridge can collapse. Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK. But miss a bunch and things fall apart. Resilience is the ability of the bridge to withstand stress, like bridge traffic, wind, waves, and the occasional earthquake (hey it’s California!).

Frailty research has come a long way. We’re now at a point where frailty can be measured automatically, or electronically, as we put in the title. Kate created an eFrailty tool that measures frailty based on the electronic health record (EHR) data. Ariela created a VA frailty index based on the EHR of veterans. And Dae created an index using Medicare Claims. Today we’re beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients.

We should not get too hung up on battles over frailty. As Kate writes in her JAGS editorial, “If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed.”

To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings. It’s called eFrailty, check it out now!

Did I cheat and play the guitar part for Sting’s Fragile at ⅔ speed then speed it up? Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break!

-@AlexSmithMD

Additional Links:

eFrailty website is: efrailty.hsl.harvard.edu (efrailty.org is fine).

Dae’s Frailty indexesCGA-based frailty index web calculator for clinical use: https://www.bidmc.org/research/research-by-department/medicine/gerontology/calculator

The Medicare claims-based frailty index program for research: https://dataverse.harvard.edu/dataverse/cfi/

Ariela’s VA-FI:Original VA frailty index: https://academic.oup.com/biomedgerontology/article/74/8/1257/5126804

ICD-10 version https://academic.oup.com/biomedgerontology/article/76/7/1318/6164923

Link to the code for investigators (included in the appendix): https://github.com/bostoninformatics/va_frailty_index

As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource (CIPHER)

Recent validation against clinical measures of frailty: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18540

Kate’s eFrailty Index https://doi.org/10.1093/gerona/glz017 our original eFI paper

https://doi.org/10.1111/jgs.17027 & https://doi.org/10.1001/jamanetworkopen.2023.41915 on eFI and surgery

https://doi.org/10.1111/jgs.17510 editorial in JAGS

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Almost a decade ago, our hospice and palliative care team decided to do a “Thickened Liquid Challenge.” This simple challenge was focused on putting ourselves in the shoes of our patients with dysphagia who are prescribed thickened liquids. The rules of the challenge were simple: fluids must be thickened to “honey consistency” using a beverage thickener for a 12-hour contiguous period.

All of us failed the challenge. We then decided to challenge others and asked them to post their videos online using the hashtag #thickenedliquidchallenge. Here are some of the results of those videos: https://geripal.org/the-thickened-liquid-challenge/

On today’s podcast, we revisit dysphagia and thickened liquids with two researchers and speech-language pathologists, Raele Donetha Robison and Nicole Rogus-Pulia. We talk with them about the epidemiology, assessment, and management of dysphagia, including the role of modifying the consistency of food and liquids, feeding tubes, and the role of dysphagia rehabilitation like tongue and cough strengthening. We also talk about the importance of a proactive approach to involving speech-language pathologists in the care of individuals early on with neurodegenerative diseases like dementia and ALS.

If you want to take a deeper dive, take a look at these articles:

• A nice overview of swallowing disorders in the older adults published in JAGS
• A study in JAGS showing that 89% of feeding tubes inserted during hospitalization were in patients with no preexisting dysphagia
• Nicole’s article on shifting to a proactive approach of dysphagia management in neurodegenerative disease

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In the last several years, I’ve seen more and more articles about end-of-life doulas (like this NY Times article from 2021). Despite this, in my 20-year career as a palliative care physician, I have yet to see a death doula in the wild. I’m unsure what they do, how often they’re used, and who pays for their work. So, on today’s podcast, we try to get to the bottom of what exactly is an end-of-life doula.

We’ve invited two death doulas, Jane Euler and John Loughnane (who is also a family doc and palliative care physician), to talk about the role of a doula at the end of life. We also invited Beth Klint to speak about the doula's role within a traditional hospice organization. Why Beth? In addition to being a palliative and hospice RN, she is the Executive Director for Goodwin Hospice, a large non-profit hospice that added end-of-life doula care to their services in collaboration with Jane and John’s doula organization, Present for You.

If you are interested in learning more about death doulas, check out the following links

• Goodwin Hospice’s article on the collaboration with Present for You
• A HospiceNews article talking about the value proposition of death doulas for hospices
• NHPCO’s End-of-Life Doula Council page that includes a lot of great links

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Today we celebrate eight years, around 2 million listens, and 300 podcasts!

Eric and I take questions from you, our listeners, about: why we podcast, our most controversial podcast, which podcast changed our practice, favorite song request, should all nursing home residents complete the POLST, expanding access to durable medical equipment, palliative care in rural regions, do we have an advance directive, what we’d do to improve healthcare with 7 trillion dollars, treatment for poor appetite, and Eric on how to make a latte. Thank you to Lynn Flint and Anne Kelly who serve as hosts for this episode, asking us the tough questions.

We answer your questions hot ones style. I borrowed some screaming hot sauces from my friends Jerome Kim and Tony Le, and added them to my small collection of extra mild sauces. Every two questions we ate a chicken wing covered in hot sauce. The hot sauces progressed from mild to extreme (and I mean extreme) heat.

Can I just say…it works? Being asked a question with your mouth on fire, sweat streaming down your face, feeling the most awake and terrified you have ever been in your life, forces you to give an unadorned answer, straight from the heart.

Don’t take my word for it, listen for yourself! Or better yet, watch the video of this one on YouTube. Some of the funniest parts are caught on video, in the background. We will be re-watching this one for years to come.

Thank you, dear listeners, for sending us your questions, for your enthusiasm, and for your support. Enjoy!

-@AlexSmithMD

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In our podcast with palliative care pioneer Susan Block, she identified the psychological/psychiatric aspects of palliative care as the biggest are of need for improvement. As she said, when you think about the hardest patients you’ve cared for, in nearly all cases there was some aspect of psychological illness involved. That rings true to me.

Today we talk with two psychologists who are deeply invested in addressing psychological aspects of care for people living with serious illness. Elissa Kozlov, a geropsychologist and director of a new population aging MPH at Rutgers, surveyed AAHPM members, and found that doctors reported major shortcomings in level of comfort and knowledge caring for patients with psychological illness. She conducted a systematic review and meta-analysis of 38 palliative care trials, finding that many excluded people with serious illness, and a lack of impact on psychological outcomes. Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here).

Des Azizoddin is a psychologist at the University of Oklahoma primarily focused on pain for people with cancer. Des delivered a plenary at this year’s National Palliative Care Research Center’s Foley retreat. She began by asking, “Raise your hand if you think there is a psychological component to cancer pain.” All hands go up. Then, “Keep your hand up if you frequently refer patients with cancer pain to a psychologist?” All hands go down. Unfortunately, we lack the financial structures to reimburse psychologists that would incentivize widespread inclusion on palliative care teams. Because we live in the world as it is, not as it should be, Des has helped develop an app (link to pilot trial hot off the press!) to help people with cancer pain engage in cognitive behavioral therapy in bite sized 3-4 minute sessions (there are other apps available now developed in the VA, who have been leaders in the psychology/palliative care space). Des additionally studied stigma associated with opioid use among patients with cancer in the context of the opioid epidemic; depression, pain catastrophizing, recent surgery and opioid use among people with cancer.

And, we talk about these issues and more (with far more nuance than I can include in this post).

Kudos and credit to my son Renn, age 15, for the guitar on Heartbeats (hand still broken at time of recording).

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We've talked about Falls a couple of times on this podcast, most recently with Tom Gill about the STRIDE study and before that with Sarah Szanton about the CAPABLE study. A takeaway from those podcasts is that fresh innovative thinking in the falls prevention space is welcome.

Today we talk with the twin sister power duo of Carmen Quatman and Katie Quatman-Yates about an intervention that is both brilliant and (in retrospect) should have been obvious. The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient’s homes. They were stunned by the number of calls for lift assistance for older adults who had fallen. Going into patient's homes was eye opening. There were trip hazards, loose carpets, some people were hoarders. And yet, after assisting the older adult to their feet, the EMS providers would leave. Their job was done. It's not surprising that the number of repeat calls for falls is alarmingly high. Addressing the root environmental causes of falls was not part of EMS providers' job description. In addition to stigma, practical barriers to older adults addressing environmental issues themselves abound. For example, Carmen and Katie found thousands of grab bars on Amazon (overwhelming), and when they called installation companies (handypersons), received different quotes if the person calling was a man or a woman.

So Carmen and Katie developed an EMS Community Partnership program. EMS providers were trained to provide practical home modifications: installation of grab bars, removal of carpets, removal of other obstacles. They created a seamless link between this Community Partnership program and 911 calls for falls. People who had grab bars installed through the program called their neighbors and say, hey you should get this too. Word of mouth spread rapidly. And the number of calls for falls dropped.

Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community.

In addition to the podcast, you can see more about this in Carmen's TEDx talk.

Thanks to my wife Cindy Hsu for piano on Eye of the Tiger. Enjoy!

-@alexsmithMD

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In 1982 Eric Cassell published his landmark essay: On the Nature of Suffering and the Goals of Medicine. Though his narrow definition of suffering as injured or threatened personhood has been critiqued, the central concept was a motivating force for many of us to enter the fields of geriatrics and palliative care, Eric and I included.

Today we talk about suffering in the many forms we encounter in palliative care. Our guests are BJ Miller, palliative care physician and c-founder of Mettle Health, and Naomi Saks, chaplain at UCSF.

We discuss:

• How to respond when a nurse or trainee says, “I think this patient is suffering,” but the family does not share that perception
• The trap in comparing one person’s suffering to another person’s suffering
• How to respond to suffering, from naming to rebirth
• Ways in which suffering can bring meaning and purpose, or at the very least co-exist alongside growth and transformation
• The extent to which elimination of suffering ought to be a goal of palliative medicine (with a nod to Tolstoy)
• A simple 2 sentence spiritual assessment

Credit to my son Kai Smith on guitar on Everybody Hurts for those listening to audio only (hand still splinted at time of this recording)

-@AlexSmithMD

Additional links:

Screening for suffering: https://pubmed.ncbi.nlm.nih.gov/27714532/ and https://pubmed.ncbi.nlm.nih.gov/35195465/ and https://pubmed.ncbi.nlm.nih.gov/31387655/

Evans CB, Larimore LR, Grasmick VE. Hospital Chaplains, Spirituality, and Pain Management: A Qualitative Study. Pain Manag Nurs. 2023 Dec 20:S1524-9042(23)00202-3. doi: 10.1016/j.pmn.2023.11.004. Epub ahead of print. PMID: 38129210.

Kleinman, A. (2020). The illness narratives suffering, healing, and the human condition.

Accepting This Poem by Mark Nepo https://marknepo.com/poems_accepting.php

Saks, N., Wallace, C.L., Donesky, D., & Millic, M. (in preparation). “Profession-specific Roles in Palliative Care.” In Donesky, D., Wallace, C.L., Saks, N., Milic, M. & Head, B. (eds.), Textbook on Interprofessional Palliative Care. Oxford University Press.

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Last week we talked about a trial of a nurse and social worker outpatient palliative care intervention published in JAMA. This week, we talk about the other major palliative care trial of default palliative care consults for hospitalized older adults with COPD, kidney disease, or dementia, published in the same issue of JAMA. (See also our accompanying editorial, first author Ashwin Kotwal who joins today as a co-host, and a podcast I recorded with JAMA editor Preeti Malani). For context, listen to the prior podcast with Scott on “nudges” and prior podcast with Kate on who should get palliative care.

Three things I love about this podcast, and why you should listen. First, in our editorial, we expressed concern about the length of stay metric not being patient centric, though important for health systems focused on cost savings. It was refreshing to hear Scott and Kate express similar sentiments. Second, we wanted to know how the palliative care clinicians felt about the increased workload - and we had some glimpses into those experiences (and hope for a future publication that fleshes it out further). Finally, we heard about next steps and lessons learned, as though this was the largest pragmatic trial of palliative care to date, it isn’t their last. Much more to come. And next time maybe we really will play the game where every time the word pragmatic is mentioned you have to drink 🙂

And I get to play Phish, who Scott has seen about 100 times in concert. I saw them only twice. Once as an undergraduate at Michigan, in 1994. They played Hill auditorium and I signed up to be an usher. Can you imagine trying to usher Phish Heads to stay in their assigned seats? Yeah, no. Gave up at some point and joined them. Full electric experience. Second time was with Neil Young at the Bridge School Benefit at the Shoreline Amphitheater, California in 1998. That concert, entirely acoustic, was impressive in its sheer musical virtuosity. You're kind of naked playing acoustic like that. On today’s podcast you get me, not naked, though still only with 2 left fingers (hand still broken) on the guitar, playing “Miss You.”

-@AlexSmithMD

Additional links:

Trey Anasatsio playing Miss You alone and acoustic, start around 21 minutes for the lead in

Original article describing the potential for default options to improve health care delivery: https://www.nejm.org/doi/full/10.1056/NEJMsb071595

Scott on goals of care as the elusive holy grail outcome of palliative care trials (we discussed toward the end): https://www.nejm.org/doi/full/10.1056/NEJMp1908153

The protocol paper for REDAPS: https://www.atsjournals.org/doi/10.1513/AnnalsATS.201604-308OT

Big recently funded PCORI trial comparing specialist PC delivered by default vs. generalist PC following CAPC training + a different EHR nudge: https://www.pcori.org/research-results/2023/comparative-effectiveness-generalist-versus-specialist-palliative-care-inpatients

Kate’s “Palliative Connect” RCT: https://clinicaltrials.gov/study/NCT05502861?term=katherine%20courtright&rank=1

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In a JAMA 2020 systematic review of palliative care for non-cancer serious illness, Kieran Quinn found many positives, as we discussed on our podcast and in our editorial. He also found gaps, including very few studies of patients with lung disease, and little impact of trials on quality of life. The article we discuss today, also published in JAMA, addresses these two gaps.

David Bekelman conducted a RCT of a nurse and social worker telephone intervention (ADAPT intervention) for people with heart failure and lung disease (COPD or ILD). David has been conducting outpatient trials in this space for some time, such as the CASA study he mentions today, learning important lessons along the way. This is the first study that is unequivocally positive, improving overall quality of life and depression. Today we unpack this study, with the help of Lyndsay Degroot, a postdoc and nurse researcher focused on identifying the core aspects of the study and eventually testing the study in more diverse populations. In the accompanying editorial written by Ashwin Kotwal, Lauren Hunt, and the guy singing on today’s podcast, we talk about the strengths and limitations of this study, something we “get into” with the authors toward the end of today’s podcast. We are also joined by Diah Martina, a palliative care doctor trying to grow palliative care in Indonesia, in part by starting a palliative care podcast in Indonesian (she was observing today).

You can also listen to an audio interview with Alex and JAMA Deputy Editor Preeti Malani about this study and the other RCT of default palliative care for hospitalized older adults with noncancer serious illness published in the same issue. Stay tuned for a GeriPal podcast with the authors of the other study next week.

Credit to my wife Cindy for piano on the audio-only version of Ben Rector’s The Best is Yet to Come. Enjoy!

-@AlexSmithMD

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The CDC’s Guideline for Prescribing Opioids for Chronic Pain excludes those undergoing cancer treatment, palliative care, and end-of-life care. In doing so, it seems to give the impression that pain seen in cancer is inherently different than pain seen in other conditions and that those with cancer may not have the same risk for opioid use disorder as compared to other conditions.

Today's podcast tackles these issues and more with three amazing guests: Katie Jones, Jessica Merlin, and Devon Check. We start off the conversation by talking about whether patients with cancer and cancer pain are really that different, and their paper that was just published on January 11th in JAMA Oncology showing that substance use disorder is not uncommon in individuals with cancer.

After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise. In particular, we talk about Katie’s and Jesica’s paper in NEJM titled “Juggling Two Full-Time Jobs — Methadone Clinic Engagement and Cancer Care,” which described the difficulty in managing cancer pain and methadone for opioid use disorder.

Lastly, we discuss Katie’s paper on substance use disorder in an aging population and how one can incorporate the 5 Ms (ie, matters most, medications, mind, mobility, and multicomplexity) into a framework for age-friendly care for older adults with substance use disorder.

If you want to do a deeper dive, here are some other references we talk about in the podcast:

Previous podcasts on substance use disorder

• Buprenorphine Use in Serious Illness: A Podcast with Katie Fitzgerald Jones, Zachary Sager and Janet Ho
• Substance Use in Older Adults: A Podcast with Ben Han
• Palliative Care, Chronic Pain, and the Opioid Epidemic: GeriPal Podcast with Jessie Merlin

Expert consensus-based guidance

• Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use
• Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder
• Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder

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Four percent of deaths in Canada are due to Medical Assistance in Dying (MAID). Four percent.

The number of people who have used MAID in Canada since it was legalized in 2016 has increased year on year from about 1,000 people in the first year to over 13,000 people in 2022. California, which has a similar population size as Canada and legalized MAID around the same time, has fewer than 1000 deaths per year from MAID.

In further contrast to the United States, MAID in Canada is almost entirely administered by a clinician, whereas in the United States patients must self administer. To be eligible in Canada patients must have a “grievous and irremediable” condition, including disability; they do not have to have a terminal illness with a prognosis of less than 6 months. They could have a prognosis of years, or decades.

A planned expansion of MAID to include people with mental illness was placed on hold until March 2024. The Canadian parliament will soon hear a report on potentially expanding MAID to “mature minors.” A recent Human Rights podcast discussed the story of a Canadian seeking MAID because he could not afford to stay housed.

Today we talk about these issues with Bill Gardner, a psychologist at the University of Ottawa who is living with cancer, Leonie Herx, a palliative care physician at the University of Calgary, and Sonu Gand, a psychiatrist at the University of Toronto and former president of the Canadian Psychiatric Association. We talk about how Canada got to this point, including the degree to which offering MAID to anyone who is eligible has become standard practice in many places. We hear Bill Gardner's experience being told that his cancer could not be treated and immediately offered two options: palliative care or MAID. We talk about the role of palliative care and lack of access for many people living with serious illness in Canada. We go in depth about ethical issues raised by the planned expansion of MAID to people with mental illness.

Much of the criticism of the explosion of MAID in Canada is coming from people like, our guests, who feel that MAID should be an option for a select few, rather than coming from under-no-circumstance opponents.

To many this rapid expansion will represent autonomy run amok. It is the slippery slope made real. To others MAID represents a seemingly easy and inexpensive mechanism to address failures of the system to address potentially reversible sources of suffering on a systemic level, from difficult conversations at the bedside, to meeting basic needs like housing.

For those listening to the podcast, credit to Kai for guitar on Neil Young’s Cortez the Killer (my left hand is still broken at the time of this recording). You get me with one-finger-chords on the guitar if you're watching on YouTube (best I could manage).

-@AlexSmithMD

Overview of MAID in Canada

Bill Gardner’s article about MAID in Comment Magazine https://comment.org/death-by-referral/

Bill Gardner’s articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/ https://mbird.com/religion/testimony/in-the-electors-school/

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We’ve talked a lot about comprehensive dementia care on the GeriPal podcast but while the evidence is clear that these programs work, the uptake has been limited largely because there hasn't been a strong financial case for it. Don’t get me wrong, the evidence points to cost savings, but as Chris Callahan and Kathleen Unroe pointed out in a JAGS editorial in 2020 “in comprehensive dementia care models, savings may accrue to Medicare, but the expenses accrue to a fluid and unstable network of local service providers, patients, and their families.”

The good news is that the financial case for comprehensive dementia care is changing thanks to a new Center for Medicare and Medicaid Innovation (CMMI) alternative payment model (APM) called Guiding an Improved Dementia Experience (GUIDE) Model. This model will give participating programs a per-member-per-month payment to offer care management, care coordination, and other services such as caregiver training, disease education, and respite.

On today's podcast we talk with Malaz Boustani of Indiana University, as well as Diane Ty, the senior director of the Milken Institute Center for the Future of Aging, about the GUIDE model. We’ll cover why the GUIDE model is important (hint - it all comes down to funding), how it was developed, what components will it include, and how it will be evaluated.

To read more about the GUIDE model, check out the following links:

• Diane’s article in Health Affairs titled “A Promising Turning Point For Dementia Care: The GUIDE Model”
• Another Health Affairs article titled “Applying An Evidence-Based Approach To Comprehensive Dementia Care Under The New GUIDE Model”
• The CMS site if you are interested in learning more or applying to be a site (the application period will close on January 30, 2024)

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One of the things I love about Liz Dzeng’s work is the way in which it draws upon, echoes, and advances our understanding of the influence of culture on the end of life experience. This field is not new. In his book The Hour of our Death Philip Aries described a long evolution in western civilization of cultural attitudes towards dying. More recently Sharon Kaufman 's book And a Time to Die described the ways in which physicians, nurses, hospital systems, and payment mechanisms influenced the hour and manner of patient's deaths. Similarly Jessica Zitter, an intensivist and palliative care doctor analogized the inevitable clinical momentum toward highly aggressive intensive care in US hospitals as a conveyor belt.

Today Liz Dzeng discusses her journey towards studying this issue in detail. Having trained in different institutions within the United States and in the United Kingdom, and as both a sociologist and a hospitalist physician, Liz brings a unique perspective and set of skills to this issue. On this podcast we talk about her paper in JAMA Internal Medicine which studied three hospitals that varied in the intensity of care they provided to seriously ill patients. We discuss the moral distress that clinicians felt including, as one physician put it, a sense of your soul being ripped out. At the end we also pay tribute to Randy Curtis, senior author on this paper and mentor to Liz. Eric and I are joined today on this podcast by Anne Kelly palliative care social worker to discuss these issues with Liz.

-@alexsmithMD

Additional links:

From Liz: “policies that are too restrictive can actually have an opposite of hindering ethically and clinically appropriate practices whereas policies that allow for flexibility and transparency to act ethically can promote high quality end-of-life care” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/

Other papers that are relevant:

JAMA IM 2015: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265

JPSM LAT France paper: https://www.jpsmjournal.com/article/S0885-3924(21)00399-7/pdf

ICM paper policies: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/

JPSM aggressive care: https://www.jpsmjournal.com/article/S0885-3924(17)30425-6/fulltext

BMJ QS moral distress ethical climate: https://qualitysafety.bmj.com/content/27/10/766.long

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To my teenagers, climate change is an existential crisis. It’s the end of the world as we know it. They decry the lack of serious attention and prioritization this issue has in the US. My kids ask - why don’t adults care about this issue the same way that they and their friends care about it? My kids have taught me that the emphasis on personal responsibility (reduce your carbon footprint!) was supported by the fossil fuel industry, because it shifted responsibility for change from industry to individuals. Voting and emailing congress to advocate for systemic change (e.g. less reliance on fossil fuels) likely has a greater impact than recycling your newspaper.

Today we find inspiration for my kids: there are adults who care deeply about this issue, particularly for older adults who are much more vulnerable to health effects of climate change. Karl Pillemer is a sociologist and gerontologist who studies this issue and has created a platform called, “Aging and Climate Change Clearinghouse,” that is a wide tent with room for older adults, researchers, and organizations. As a researcher, I found the bibliography fascinating, including this gem by the gerontologist Rick Moody on the moral obligation of older adults to address climate change.

Leslie Wharton is a leader in the 26,000 member grassroots organization Elders Climate Action, which organizes older adults to create communities engaged in making a difference at local, state, and national levels. As she notes, these volunteer activities can bring meaning and purpose, in the face of a seemingly insurmountable problem, to the elders in her organization.

And we talk with Ruth McDermott-Levy, who wrote a practical guide for discharge planning in the era of climate change (example - a generator safety checklist). Ruth advocates for and teaches about aging and climate change at Villanova, and calls on nurse scientists and other health researchers to study climate change.

-@AlexSmithMD

Additional links:

JAMA paper on clinical research risks, climate change, and health

Geriatric medicine in the era of climate change

Health Care Without Harm: https://noharm.org/

Practice Green Health: https://practicegreenhealth.org/

Global Consortium for Climate and Health Education: https://www.publichealth.columbia.edu/research/programs/global-consortium-climate-health-education

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There is a growing push to change how we define Alzheimer's disease from what was historically a clinically defined syndrome to a newer biological definition based on the presence of positive amyloid biomarkers. This proposed new definition, championed by the Alzheimer's Association (AA) and the National Institute on Aging (NIA), proposes that the disease exists when the earliest manifestation of Alzheimer’s pathophysiology can be detected (amyloid), even though onset of symptoms may be years in the future.

On today's podcast we talk about the benefits and drawbacks of redefining Alzheimers to a biological definition with three experts in the disease: Heather Whitson, Jason Karlawish, and Lon Schneider. In particular we spend a good deal of time talking about what this means for asymptomatic patients who may have an abnormal biomarker, which by the proposed new definition would mean they would now have Alzheimer's disease.

If you are interested in learning more about the draft guidelines and the response from AGS to these guidelines, check out the following links:

• Revised Criteria for Diagnosis and Staging of Alzheimer's Disease: Alzheimer’s Association Workgroup
• AGS’s response to the revised criteria

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Coaching is in. During the later stages of the pandemic, it seemed every other person, and particularly the junior faculty in our Division, were either being coached, in training to coach, or coaching others. When I was a junior faculty, coaching wasn’t a thing. Sure, Atul Gawande wrote about coaching in surgery - having someone observe you and coach you on your technical skills- but that’s a far cry from the coaching programs focused on empowerment that are exploding around the country today.

Today we learn more about coaching from 3 coaches: Greg Pawlson, coach and former president of the American Geriatrics Society, Vicky Tang, geriatrician-researcher at UCSF and coach, and Beth Griffiths, primary care internist at UCSF and coach. We address:

• What is coaching? How does it differ from therapy? How does it differ from mentoring
• What is typically covered in coaching sessions?
• What is the evidence (see many links below, sent by Beth)
• What are the standards for becoming a coach?
• Who is coaching for?

My take: coaching has tremendous potential. There seems to be a gender story here as well - coaching may be of particular benefit to women who are at higher risk for burnout. Note, for example, the hot off the press JAMA Network Open trial which demonstrated modest benefits across a range of outcomes was conducted exclusively in female resident physicians. Kemi Doll, a physician-researcher and coach, has a terrific podcast I highly recommend everyone listen to, though it is targeted at women of color in academic medicine. On the other hand, there is a concerning side, described in this Guardian article titled, I’m a life coach, you’re a life coach: rise of an unregulated industry. See also the long list of disclosures in the JAMA Network Open study. Our guests note, rightly, that the same profit motive and concerns are true about colleges. Still, I remain concerned when I see that the Life Coach School costs $21K; when the founder of the Life Coach School’s goal is to grow a $100 million/year business; and when my spidey sense tells me there’s something cultish about the empowerment industry. So, I see the potential of coaching, particularly for groups that face challenges in academic medicine; and I worry about the injection of profit-motives and the goals of industry leaders pushing the meteoric rise of the life coach industry.

-@AlexSmithMD

1. Hot off the presses RCT in JAMA October 2023: Study that looks at 1000 female resident physicians at 26 sites that showed that coaching improved each outcome assessed (burnout, moral injury, imposter syndrome, self-compassion, and flourishing).

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810135 2. An RCT for female residents published in JAMA May 2022: This was the initial pilot single institution study by the same team as above. Their findings concluded that it was feasible to implement an online coaching program for female residents and that coaching improved emotional exhaustion, imposter syndrome and self-compassion. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791968?fbclid=IwAR0taY5CGpUa5eyfleNIl7RfXLT7qVt0GakKPGlT9ESIPLn0yCKWG9obrZo 3. A March 2022 study of Stanford offering coaching as a benefit to their physicians and finding improved self-compassion and burnout. https://www.mayoclinicproceedings.org/article/S0025-6196(22)00038-6/fulltext 4. The initial RCT published on physician coaching in JAMA in 2019 showing that coaching improves quality of life. This is the first RCT that was available for coaching in physicians. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740206

1. A 2020 RCT of coaching for primary care physicians shows that coaching improves burnout well-being during the intervention and has a sustained duration at 6 months of follow up. From Beth Israel and UNC. https://pubmed.ncbi.nlm.nih.gov/32297776/ 6. The Business Case for Investing in Physician Wellness, again in JAMA. This paper includes coaching as a sign of a more mature physician wellness program and states it has a positive return on investment. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2653912

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What does the future hold for geriatrics? I’ve seen this question come up a lot since finishing fellowship nearly two decades ago. Historically, answers generally lamented the ever increasing need for geriatrics without a corresponding growth in the number of specialists in the field. But, it's also hard not to be bullish on the future of the field to see the consistent strides geriatrics has made in the last two decades in improving care for older adults. For example, I never would have imagined two decades ago the push for age-friendly health care systems and the growth of non-geriatricians, like surgeons and oncologists, adopting geriatric principles into their training and research.

On today’s podcast, we are going to do a deep dive on the future of geriatrics with three amazing guests. First, we’ve invited Jerry Gurwitz to talk about his recently published article in JAMA titled The Paradoxical Decline of Geriatric Medicine as a Profession (while it’s not the most upbeat title for the future of geriatrics, Jerry sees it as a call to action). We’ve also invited Mike Harper, the Chair of the Board of Directors of the American Geriatrics Society (AGS) as well as past-president for the society (and my previous program director).

Lastly, we’ve asked one of the brightest rising stars of geriatrics, Ryan Chippendale, to join us as well. I’m a huge fan of Ryan’s, in part for her work in co-creating the GERI-A-FLOAT (GERIAtrics Fellows Learning Online And Together). This is a great virtual curriculum designed to convene geriatric fellows nationwide for learning and peer support (and if you are interested in having your own fellows join, click here).

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Often podcasts meet clinical reality. That’s why we do this podcast- to address real world issues in palliative care, geriatrics, and bioethics. But rarely does the podcast and clinical reality meet in the same day.

Within hours of recording this podcast, I joined a family meeting of an older patient who had multiple medical problems including cancer, and a slow but inexorable decline in function, weight, and cognition. Physical therapy had walked with him that day and noted improvement compared to previous walks, suggesting that he should be discharged to a skilled nursing facility for rehabilitation on discharge. The patient's capacity to make decisions was marginal, and his sons were shouldering much of the responsibility. The sons were very focused on rehabilitation, and the patient gave his assent. In the meeting, I used the language suggested by Sarguni Singh, “I worry that going to SNF for rehab may not result in your being independent.” We additionally discussed hospice care as an option for care that might follow the trial of rehabilitation.

Today we talk with Sarguni Singh, hospitalist-researcher at the University of Colorado, Ann Henshaw, Occupational Therapist who teaches at George Washington and works clinically at Georgetown, and Tamra Keeney, Physical Therapist-researcher at Mass General Hospital and Harvard Medical School. Lynn Flint, author of the NEJM perspective titled, “Rehabbed to Death,” joins Eric and I as co-host.

We cover a lot of ground in this podcast, including an evidence based toolkit to promote collaboration between therapy fields and palliative care, outcomes of rehabilitation for people with advanced cancer (hint: not much hospice, lots of re-hospitalization), and a JAGS study on use of post-acute care among patients with heart failure. We also heard from Tamra about her opinion piece in which she laments, “The role of rehabilitation is often myopically constrained to facilitation of efficient discharge planning.” Therapists are so much more.

At the end of the day, I lamented that physical, occupational, and speech therapists aren’t more tightly integrated with palliative care teams. As Lynn says at the end of the podcast, to paraphrase, “Physical therapy, occupational therapy, speech therapy - all this therapy for older frail patients is a core part of good palliative care.”

And our guests sing along with “Sweet Caroline” - so good, so good, so good!

-@AlexSmithMD

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

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What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric? The answers to these questions will vary. Reasonable people will disagree. And today, on our podcast, our guests disagree. Firmly. AND we are delighted that our guests modeled respectful disagreement. With no hard feelings. Respectful disagreement is in short supply these days.

Our guests today are Kelly Vranas, pulm crit care doc who published a systematic review in JAGS of the evidence for POLST (as well as other articles here, here,and here); Abby Dotson, who is Executive Director for National POLST and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of National POLST; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a Viewpoint in JAMA that was critical of the concept and evidence base for POLST (and argues little has changed).

We had a full podcast, and I wasn’t able to give my take on the existing evidence for POLST, so I’ll write it here. I’m in the middle between Scott and Karl, where I suspect Kelly is, though we didn’t ask her explicitly. On the one hand, I agree with Scott that observational studies finding those who complete a POLST stating a preference for comfort oriented care and DNR are not go to the ICU says little about the effectiveness of POLST. Far more likely that those underlying preferences and values are what drove the findings than completion of the POLST form that codified the preferences into orders.

On the other hand, I agree with Karl that the POLST has face validity, and anecdotal evidence is overwhelming. Certainly SOME of those avoided hospitalizations, CPR, and ICU stays were due to documentation of those orders in the POLST. The unanswered question is: HOW MUCH of the differences are due to the POLST? It’s not zero, as many of us have had cases in which we said, “Thank god we completed that POLST, it clearly stopped X from happening.” But is it a tiny, meaningless, fraction? Or a substantial proportion? My guess is a small but meaningful fraction of differences in observational studies is due to completion of the POLST, though the majority of differences are due to underlying preferences and values. Is that fraction due to POLST large enough that we should design quality metrics around completion of POLST? Absolutely not. Do we need better evidence, preferably from an RCT of POLST vs no POLST? Yes. Caveat as well that RCTs should not be placed on pedestal as the only answer- often patients enrolled in RCTs do not represent real world patients - observational studies do. For a trial to have value, it should not exclude patients over age 80, or those with dementia, or patients residing in nursing homes. And it must be powered to detect a small but meaningful difference, not the same level of effect seen in observational studies. OK, I’ll step off my soap box.

Additional links mentioned in the podcast:

Recent JGIM article on POLST in California nursing homes, hospitalization, and nursing home care

Karl’s GeriPal post on appropriate use of POLST

Enjoy!

-@AlexSmithMD

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For surgeons and patients, deciding if and when to operate can be challenging. Often, the way surgeons communicate about these decisions doesn’t make things any easier for themselves or their patients. And, surgeons often spend the majority of their conversations with patients describing anatomical details and exactly how they plan to ‘fix it’, with little discussion of what that ‘fix’ will do for a patient’s overall goals.

Instead, what if your surgeon told you that the operation she was discussing could help with only 4 things: live longer, feel better, prevent disability, or obtain a diagnosis? And, what if your surgeon openly discussed the expected ‘bad stuff’ of post-operative recovery, instead of rotely reciting a list of possible complications?

We invited Gretchen Schwarze and Justin Clapp to discuss with us these communication strategies, which are the focus of a series of 4 Viewpoints recently published in JAMA Surgery. I love this series of articles because each presents a component of a practical, patient-centered approach to patient-surgeon communication and decision making, and language surgeons (and surgical trainees) can start using in their next patient visit.

We hope you enjoy this episode. Take a look at some of these links to learn more:

• Innovations in Surgical Communication series:
• Provide Your Opinion, Don’t Hide It
• Focus on the Goals of Surgery
• Promote Deliberation, Not Technical Education

• Present the Downsides of Surgery, Not Just Risks

• Dr. Schwarze’s article, “Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention'' in which surgeons used “fix-it” language in 92% of conversations and did not establish an overall goal of treatment 80% of the time.

• South Park “Underpants Gnomes”
• Orthopaedics vs Anesthesia

By: Alexis Colley

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Communicating about a serious illness is hard. Last week’s podcast we talked about the challenge around miscommunication in serious illness. This week we dive into the challenges with communication when it comes to life sustaining treatments and CPR. Take for example the simple question:

“If her breathing gets any worse, she will need to be intubated.”

This seems like an innocuous statement of fact, but does she really “need” to be intubated if, for example, her primary goals are to be comfortable and die at home? Of course not.

We’ve invited Jacqueline Kruser and Bob Arnold on this week's podcast to talk about their recently published JAMA Viewpoint article titled “Reconsidering the Language of Serious Illness.” I love this article as it specifically discusses what’s wrong with “need” statements and how we can shift our communication and thinking to create space for deliberation about patients’ priorities and the best course of action.

We’ve also invited Sunita Puri to talk about the language of life sustaining treatments, in particular CPR. Sunita recently published a wonderful New Yorker article titled The Hidden Harms of CPR arguing among other things that these conversations “are procedures, demanding the same precision of everything else in medicine.”

So take a listen and check out some of these other links to dive deeper:

• Our first podcast in the series of 3 podcasts “Miscommunication”
• A great article on why you shouldn't ask what patients “want”
• Sunita’s book That Good Night: Life and Medicine in the Eleventh Hour
• The paper Jacky talked about regarding the ingrained pattern of focusing on the “need” for specific life-sustaining interventions, typically as the reason to admit a patient to the ICU
• Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016
• Cardiopulmonary Resuscitation on Television — Miracles and Misinformation
• Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

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Medical communication is tough, although fundamentally at its most basic unit of delivery, it includes really only three steps. First, a clinician’s thoughts must be encoded into words, then transmitted often via sounds, and finally decoded back to thoughts by a patient or family member. Simple, right? Not so much, as each one of these steps is fraught with miscommunication.

For example, a surgeon may want to convey that all visible tumors were removed during surgery, but transmits that message to the patient by saying “we got it all” only to have the patient hear an entirely different message that the cancer is gone and they are now cancer free.

On today’s podcast we talk with three communication experts, Abby Rosenberg, Don Sullivan, and Shunichi Nakagawa about the concept of miscommunication, including examples of it and ways we can mitigate this issue.

This podcast was inspired by Abby and Don’s recent JAMA Oncology paper titled Miscommunication in Cancer Care—Do You Hear What I Hear? We also ask Shunichi Nakagawa about some of the amazing communication pearls he posts on his Twitter account (don’t tell me to call it X).

Lastly, we also plan to have two more podcasts coming up on communication, one on the language of life sustaining treatments and one on surgical communication, so stay tuned!

Eric

Note: For more reading on this subject, check out these links:

• Shunichi Nakagawa’s Twitter account
• Miscommunication in Cancer Care—Do You Hear What I Hear?
• Patient Values: Three Important Questions-Tell me more? Why? What else?
• A "Three-Stage Protocol" for Serious Illness Conversations: Reframing Communication in Real Time

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The proportion of people living with dementia who identify as Black/African Americans is on the rise, and so too are the proportion of caregivers who identify as Black/African American. As our guests talk about today, caregiving for people living with dementia takes a tremendous toll, and when this toll is set atop the challenges of racism in all its forms, the reality of caregiving while Black can be overwhelming.

Today we talk with Fayron Epps and Karen Moss, two nurse researchers who are focused on improving the experience of Black/African American caregivers of persons living with dementia. We talk in particular about:

• Terminology. Acknowledging that the most sensitive terms shift over time, what terms are they using today and why? Black? African American? Black/African American? We also learn that the term stakeholder, so common in research, should be avoided for its early usage as White colonialists staked out land taken from Native American peoples.
• Why a focus on Black/African American caregivers and people with dementia? Why should interventions be culturally tailored for this group?
• Feyron has centered her work in Black/African American faith communities and churches - a program she titled Alter. Why this focus?
• Karen has a Cambia Sojourns award to pilot an intervention in which Black/African American former caregivers are trained to provide peer support to current caregivers (Peer2Care). This seems like a triple win - the bereaved former caregiver has the opportunity to be generative, share their story, and give back; the current caregiver connects with someone similar who listens when so many people are tuning them out; the person with dementia benefits from the caregiver’s improved sense of self-efficacy, decreased loneliness/social isolation, and better coping overall.
• Why are nurse researchers in particular critical to the study of these issues?

And Karen brings a tambourine in the studio for I’ll Fly Away (see YouTube version)!

-@AlexSmithMD

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Hospitals are hazardous places for older adults. These hazards include delirium, malnutrition, falls, infections, and hospital associated disability (which about ⅓ of older adults get during a hospital stay). What if, for at least some older adults who need acute-level care, instead of treating them in the hospital, we treat them at home? That’s the focus of the hospital-at-home movement, and the subject we talk about in this week’s podcast.

We talk with Bruce Leff and Tacara Soones about the hospital-at-home movement, which has been shown to reduce costs, improve outcomes and improve the patient experience. In addition to discussing these outcomes, we also discuss:

• The history of the hospital-at-home movement.
• The practicalities of how it works including who are good candidates, where does it start (the ED?), what happens at home, do you need a caregiver, what happens if they need something like imaging?
• How is it financed and what comes next?

If you are interested in learning more and meeting a community of folks interested in hospital-at-home, check out the hospital-at-home user group at hahusersgroup.org or some of these publications:

• Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Int Med. 2020
• Hospital at Home-Plus: A Platform of Facility-Based Care. JAGS
• Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Network Open

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The comprehensive geriatric assessment is one of the cornerstones of geriatrics. But does the geriatric assessment do anything? Does it improve outcomes that patients, caregivers, and clinicians care about?

Evidence has been mounting about the importance of the geriatric assessment for older adults with cancer, the subject of today’s podcast. The geriatric assessment has been shown in two landmark studies (Lancet and JAMA Oncology) to reduce high grade toxicity, improve patient and caregiver satisfaction, and improve completion of advance directives (can listen to our prior podcast on this issue here).

Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care.

We talk about these new guidelines today with William Dale, a geriatrician at City of Hope and lead author of the guideline update in the Journal of Clinical Oncology, Mazie Tsang, palliative care/heme/onc physician-researcher at Mayo Clinic Arizona who authored a study of geriatric and palliative conditions in older adults with poor prognosis cancers published in JAGS, and John Simmons, a retired heme/onc doctor, cancer survivor, and patient advocate. We talk about:

• What is a practical geriatric assessment and how can busy oncologists actually do one? (hint: 80% can be done in advance by patients or caregivers)
• Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars?
• What can you do with the results of a geriatric assessment?
• How does the geriatric assessment lead to improved completion of advance directives, when the assessment doesn’t address advance care planning/directives at all?
• How does palliative care fit into all this? Precision medicine?
• What groups are being left out of trials?
• What are the incentives to get oncologists and health systems to adopt the geriatric assessment?

And Mazie, who is from Hawaii, requested the song Hawaii Aloha in honor of the victims of the wildfire disaster on Maui. You can donate to the Hawaii Red Cross here.

Aloha, -@AlexSmithMD

Additional Links:

Brief ASCO Video of how to conduct a practical geriatrics assessment Brief ASCO Video of how to use the results of a practical geriatrics assessment Time to stop saying the geriatric assessment is too time consuming

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How do people react when they hear they have a serious illness? Shock, “like a car is rushing straight at me” (says Bill Gardner on our podcast). After the shock? Many people strive, struggle, crawl even back toward a “normal” life. And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness.

Today we talk with deep thinkers about this issue. Bill Gardner is a psychologist living with advanced cancer who blogs “I have serious news,” Brad Stuart is an internist and former hospice director whose book is titled, “Facing Death: Spirituality, Science, and Surrender at the End of Life,” and Juliet Jacobson is a palliative care doc who wrote a paper finding that geriatricians do NOT consider aging a serious illness. We have a wide ranging conversation that touches on how to place aging, disability, and multimorbidity in the context of serious illness conversations, “striving toward normal,” stoicism, existentialism, psychedelics, the goals of medicine, medical aid in dying and more. We could have talked for hours! And I get to play a Bob Dylan song that’s been on my bucket list to learn.

Enjoy!

-@AlexSmithMD

Additional links:

Bill Gardner’s article about MAID in Comment Magazine
https://comment.org/death-by-referral/

Bill Gardner’s articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/
https://mbird.com/religion/testimony/in-the-electors-school/

Brad Stuat’s website:
https://bradstuartmd.com

Juliet mentioned:
On existential threat and terror management:
The Worm at the Core: On the role of death in life by Soloman, Greenberg, and Pyszczynski

On how existential threat is stored in the brain.
https://pubmed.ncbi.nlm.nih.gov/31401240/

Papers on “striving toward normalcy” in the setting of serious illness
https://pubmed.ncbi.nlm.nih.gov/36893571/
https://pubmed.ncbi.nlm.nih.gov/35729779/

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I hear the word dignity used a lot in the medical setting, but I’m never sure what people mean when they use it. You’d imagine that as a seasoned palliative care doc, I’d have a pretty good definition by now of what “maintaining dignity” or “loss of dignity” means, but you’d be sadly wrong.

Well that all changes today as we’ve invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast. Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches.

We talk with Harvey about how he defines “dignity” and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks “what do I need to know about you as a person to give you the best care possible.” In addition, we talk with Harvey about some other recent publications he has written, including one on “Intensive Caring” and one on the “Platinum Rule” (do unto others as they would want done unto themselves).

So take a listen and if you are interested in learning more, check out these wonderful links:

• Harvey’s latest book is called, Dignity in Care: The Human Side of Medicine
• Intensive Caring: Reminding Patients They Matter

• Michael J. Fox gives patients hope there may be a place that illness doesn’t touch

• Depression is a Liar

• Why is Being a Patient Such a Difficult Pill to Swallow
• Better Patient Care Calls for a ‘Platinum Rule’ to Replace the Golden One. Scientific American
• Letter to the Editor: Response to Downar et al. Medical Assistance in Dying and Palliative Care: Shared Trajectories

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It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab). Praised by the FDA, Alzheimer’s Association (AA), and Pharma as a “game changer”, but derided by others for the drug’s lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words “rife with irregularities”. Instead of Biogen’s expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco).

The outlook on amyloid antibodies are looking brighter though in 2023. Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer. However, they are none of these.

So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them? We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation).

Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease. There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one. One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp

By: Eric Widera

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Insomnia. We’ve all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you’re not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more.

For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia.

We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

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There’s a saying, “never let a crisis go to waste.” The pandemic was horrific in many ways. One positive change that came about was the lifting of restrictions around the use of telemedicine. Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic. Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others. So now that the emergency response has ended, what’s to be done?

In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brooke Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness. This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world. Now is the time to act, dear listeners! You can:

• Write an Op-Ed to your local paper as Carly Zapata and colleagues did. Start with a story as Carly did in her Op Ed. Stories trump data.
• Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home
• Write to the DEA, with guidance from AAHPM’s comments to the DEA March 2023.
• Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf

Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth. Enjoy!

-@AlexSmithMD

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Today’s podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention. On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations. Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+. They found a difference of 4% in documented goals of care discussions. Is 4% meaningful? You’ll have to decide for yourself, though it likely is meaningful on a population basis. Intriguingly, in a sub-analysis, they found a much higher rate of difference among minoritized older adults - more like 10%. In a compelling editorial, Doug White and Sarah Anderson argue that even a 4% difference is important on a population basis, and that higher rates of difference among minoritized older adults demonstrate the potential of the intervention to address long-standing disparities in goals of care.

Randy Curtis was first author of the JAMA paper. Randy died February 26, 2023. We begin today’s podcast asking his co-authors Erin Kross, Bob Lee, and Ruth Engelberg, all from the University of Washington and the Cambia Palliative Care Center of Excellence, to reflect on Randy and his dedication to seeing this work completed while living with ALS. Eric and I also reflect on the podcast Randy generously did with us on his experience living with and studying serious illness. We have lost a giant. He is sorely missed, and celebrated.

And…the guests torture me about songs I can’t play with the word Jump.

-@AlexSmithMD

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You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it? What about State Departments of Aging or state master plans for aging? Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions? No? Ok, what about Aging and Disability Resource Connection (ADRC) services?

Well, if you are like me, you’ve probably heard of these programs but are at a loss to know exactly what they do. On today's podcast we dive deep into how state and local governments are addressing the needs of older adults, answering all of these questions and more thanks to our three amazing guests: Susan DeMarois (the Director of California Department of Aging), Greg Olsen (the Director of the New York State Office for the Aging), and Lindsey Yourman (the Chief Geriatric Officer for the County of San Diego).

It’s a fun podcast with our guest bringing in a ton of knowledge and passion for the work that they do. If there is one take-away from the podcast, it is something Dr. Yourman emailed me after we met:

“My hope is that every geriatrics clinician/Geriatrics Department/Division that listens to our podcast will be motivated to reach out to their Area Agency on Aging (if they haven't done so previously) to ask for a meet and greet and to learn about their resources, services, and recommended community-based organizations for older people.”

To learn more about what we talked about, check out the following links:

• Eldercare Locator, a public service of the U.S. Administration on Aging connecting you to services for older adults and their families
• California’s Master Plan for Aging
• New York’s Master Plan for Aging

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I don't know 'bout religion
I only know what I see
And in the end when I hold their hand
It's both of us set free

These are the ending lyrics to Bonnie Raitt’s song “Down the Hall”, an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week’s podcast we interviewed the medical director and the chaplain of the prison’s hospice unit (Hospice in Prison Part 1). This week we turn our attention to the inmates.

Pastoral Care Workers are inmates who volunteer time to care for the dying who come from all around California to spend their last days, weeks or months in the prison’s hospice unit, fulfilling a mission that “no prisoner dies alone.”

On today's podcast we talk with three of these Pastoral Care Workers, Jerry Judson, Jeffrey Maria, and Allan Krenitzky. We discuss with them why they decided to volunteer for the hospice unit, what a day in the life of a Pastoral Care Worker looks like, and among other things their thoughts on forgiveness, redemption, rehabilitation, and compassionate release.

We also had the pleasure to take a walk through the hospice unit garden with Mr. Gerald Hite. He taught us a little about the different flowers and plants, and along the way a little about why he does what he does.

While this is a podcast about volunteers in a prison hospice, I think it also serves as a lesson for us all about how we make meaning to our own lives and define ourselves by not only what we have done in the past, but what we do now. One story that Allen told perfectly sums this up. He said one day his son asked his wife what he does for a living, and his wife said “Papa helps sick people.”

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In the early 1990’s, California Medical Facility (CMF) created one of the nation’s first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release. Many are there until they die.

Today’s podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls.

We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services. We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population. We also talk about the eligibility for the unit, what makes it run including the interdisciplinary team and the inmate peer workers, and the topic of compassionate release.

Afterwards, we chat with the prison’s chaplain, Keith Knauf. Keith per many reports, is the heart and sole of the hospice unit and oversees the Pastoral Care Workers. These are inmates that volunteer to work in the hospice unit, serving a mission that “no prisoner dies alone.” We chat with Keith about how hospice in prison is different and similar to community hospice work, the selection process and role of the peer support workers, the role of forgiveness and spirituality in the care of dying inmates, and what makes this work both rewarding and hard.

Part two of the podcast, which comes next week, is solely focused on the Pastoral Care Workers. We interview three of them in the hospice unit and take a little tour of the hospice gardens.

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Artificial Intelligence, or AI, has tremendous potential. We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF.

• Social companions to address the epidemic of loneliness among older adults
• Augmenting ability of clinicians by taking notes
• Searching the electronic health record for data
• Predicting mortality and other outcomes

We talk also about the pitfalls of AI, including:

• Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities
• Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?
• Hallucinations, or when the AI lies or bullshits, then denies it
• When the AI approaches sentience, is it ethical to unplug it?

I’m sure this is a subject we will return to, given the rapid progress on AI.

Enjoy!

-@AlexSmithMD

Links:

Papers on AI and palliative care and concerns about bias:
https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/
https://academic.oup.com/jamia/article/27/12/2020/5859726

Comparison of machine learning vs traditional prognostic methods based on regression:
https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011

Other links on the issue of AI and racial or ethnic bias:

Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare
https://www.nber.org/papers/w30700
https://www.science.org/doi/10.1126/sciadv.add2704
https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168

MD Calc approach to inclusion of race https://www.mdcalc.com/race

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Diabetes is common. When I’m on nursing home call, the most common page I receive is for a blood sugar value. When I’m on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications.

Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue. Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone). And yet we’re also in a different place in diabetes monitoring and management.

To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home.

And we invited Tamryn Gray from the Dana Farber joins us to ask insightful questions, including:

What blood sugar range should we target for patients in the nursing home or hospice? How high is too high? Should considerations differ for people with dementia? What are the risks and rewards of new classes of medications? How do caregivers fit into this? Continuous glucose monitoring (CGM) is commonplace in Type 1 and gaining traction in Type 2. We debate the merits of use of CGM in the nursing home and other late life settings (Eric and I argue against CGM and lose). Ozempic is a new fancy med that, by the way, leads to weight loss among celebrities, resulting in shortages of the drug from people using it off-label for that purpose. Should we use Ozempic (if we can find it) in patients with serious illness, which often results in undesirable and profound weight loss?

Listen in to learn more!

-@AlexSmithMD

Additional Links:

-Fingerstick monitoring in VA nursing homes (too common!)

-Improving diabetes management in hospice

-Continuous Glucose Monitoring complicating end of life care

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Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP). Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP. Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes. Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting). It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing.

We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried’s commentary in JAGS that caregiver outcomes matter more than goal concordant care (the “holy grail”), completion of advance directives, or changes in health care services use. Did the caregiver feel heard and understood? Did they have PTSD? Complicated grief? Depression?

Group visits are one way of reaching diverse communities to which advance care planning has not traditionally been targeted. In a group visit there is a social norming effect - “if my neighbor is doing it, perhaps I should be doing it to?”

Please tune in to hear more, and listen to the whistle of the “Friendship train!”

-@AlexSmithMD

Links:

Community Based Participatory Research and ACP in Latinx communities: https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18236

Community based ACP in the Black Community: https://link.springer.com/article/10.1007/s11606-023-08134-2

ACP in the Chinese American Community: https://www.sciencedirect.com/science/article/pii/S0885392423000982

Group ACP in primary care: https://www.annfammed.org/content/14/2/125.short and https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16694

Project Talk Website: www.ProjectTalkTrial.org

Project Talk Trial Protocol Paper: https://journals.sagepub.com/doi/pdf/10.1177/1049909116656353

Hello Article (including Black churches): https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2765685

Communication Quality Analysis: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819

Conceptualizing Surrogate Decision Making: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819

What counts as a surrogate decision: https://journals.sagepub.com/doi/abs/10.1177/10499091231168976

For e-training modules on ACP group visits: https://cuelearning.org

Click on the Register link (upper right corner). A pop-up box will appear and enter your email address and set up your password. For Registration Code, enter: ENACT (not case sensitive).

The ACP Group visit implementation guide is available here: www.coloradocareplanning.org. Scroll down to “Innovations in ACP page”

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Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people.

We’ve invited two members who helped update the criteria including Todd Semla and Mike Steinman. We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades. We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications.

And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the:

• 2023 AGS Beers Criteria App
• Beers pocket card

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We’ve had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here). As today’s guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention. Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors. If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment.

Today we talk about steps we can and should take to reduce the risk of dementia, including:

• Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word)
• Physical activity
• Sleep
• Depression
• Smoking
• Social isolation
• Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson)

We also delve into an exciting new trial Kristine led with others on the impact of risk factor reduction on cognition - here’s a link to press about the trial from a fall meeting presentation - article forthcoming.

And because we can’t resist, we dip into aducanumab and lecanemab at the end.

-@AlexSmithMD

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I haven’t worked with many adolescents and young adults (AYA, roughly teens to twenties). But when I have, I find that they’re often some of the hardest patients to care for. Why? We talk about why it’s so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal). We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host. Here are just a few of the explanations for why it’s so hard:

• They are closer in age to some of us (younger clinicians). Countertransference hits hard.
• There’s an in-between space between adolescence and adulthood - and there’s something that we identify with in that in-between space, tugging at our heart strings
• Everyone has been a teenager. Everyone has lived through their early 20s. Every member of the interdisciplinary team. Adolescence and young adulthood is a romanticized time of life in our culture. We remember bucking the rules, figuring out who you are, hair on fire, feeling invulnerable, trying to figure out who you are - and now those adolescents are stuck in the hospital, with doctors and parents telling them what to do, having their autonomy crushed by the medical institution, realizing they’re not invulnerable.

We talk about these issues and more - what resources to leverage, how to cope as a team. We in geriatrics and adult palliative care clinicians have so much to learn from our colleagues in pediatrics - and though many of these lessons are specific to adolescents and young adults - many of the lessons are valuable for the care of patients in older life stages.

Links to resources for working with AYA, from Nick Purol):

The Courageous Parents Network has a wealth of information/resources/videos/articles on many overlapping issues and topics related to caring for children/adolescents/young adults with serious illness (from both the provider and clinician perspective): https://courageousparentsnetwork.org

Courageous Parents Network

Empowering parents caring for children with serious illness through video, shared community, professional guidance, and palliative care. You are Not Alone.

courageousparentsnetwork.org

Voicing My Choices is a wonderful tool for discussing goals/wishes and introducing advance directives in the context of serious illness. It's based off 5 Wishes and validated for AYA through direct feedback from the population: https://store.fivewishes.org/ShopLocal/en/p/VC-MASTER-000/voicing-my-choices

The Oxford Textbook of Palliative Social Work has several chapters relating to working with AYA (either due to family illness or their own), with many psychosocial clinicians in our field contributing: https://www.amazon.com/Oxford-Textbook-Palliative-Social-Work/dp/0197537855

Same is true for the Interdisciplinary Pediatric Palliative Care Textbook: https://www.amazon.com/Interdisciplinary-Pediatric-Palliative-Joanne-Wolfe/dp/0190090014/ref=sr_1_1?crid=33YG2UAKDZ8DO&keywords=interdisciplinary+pediatric+palliative+care&qid=1682288312&s=books&sprefix=interdisciplinary+pediatric+palliative+car%2Cstripbooks%2C101&sr=1-1&asin=0190090014&revisionId=&format=4&depth=1

-@AlexSmithMD

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We have a special extra podcast this week. During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field.

We couldn’t fit everyone’s responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video.

Eric and Alex

DISCLAIMER

While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly. Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.

Palliative Care the Next Generation: How the Service May Grow and Evolve https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/

AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers.

“We’ve got a very large palliative care practice,” Rodgers told PCN. “What we’ve seen to make it really work is you either have to be in the hospital, where we’ve taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective].”

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In 1990 11% of homeless persons were older than 50. Today half are over age 50. Today we talk with Margot Kushel about how we got here, including:

• That sense of powerlessness as a clinician when you “fix up” a patient in the hospital, only to discharge them to the street knowing things will fall apart.
• Chronic vs acute homelessness
• What is the major driver of homelessness in general?
• What is the major driver of the increase in older homeless persons?
• Why do we say “over 50” is “older” for homeless persons, why not 65?
• To what extent is the rise of tech in San Francisco to blame for our local rise in homelessness?
• What are the structural factors and individual factors that contribute to homelessness?
• How has the history of redlining and the federal tax subsidy of wealthy (mostly white) people in the form of a mortgage interest deduction contributed to racial inequalities in homelessness?
• What can we do about it? What are the highest yield interventions and policy changes?
• What should we call it - homeless or unhoused?

We were fortunate to make it to the end of this podcast before Margot lost power. It’s storming again in the Bay Area at the time we record this. So much harder than for the older homeless people on the streets with no power to lose. A mad world out there (song hint).

Key references:

-Margot Kushel’s UCSF Grand Rounds

-JAMA IM paper on mortality among older homeless persons

-NEJM perspective arguing that interventions to address homelessness shouldn’t be evaluated on cost savings.

-@AlexSmithMD

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Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing social isolation, the objective lack of contact with friends, family, or the community, or loneliness, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down?

On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and Neuroscience at Brigham Young University, an international expert on loneliness, social isolation, and social interventions, who has served on the National Academy of Sciences committee on social isolation and loneliness and advised the UK Loneliness Campaign, 2) Dr. Thomas Cudjoe, Assistant Professor of Medicine at Johns Hopkins University, who has conducted groundbreaking work on the measurement of social isolation and mechanisms of impact on health, and 3) Dr. Carla Perissinotto, Professor of Medicine at UCSF, who has pioneered the clinical and policy approach to addressing loneliness and social isolation.

We talk about:

• Their personal and clinical inspiration for studying loneliness and social isolation, and hurdles encountered in bringing these needs to the clinical world.
• The Listening "EAR" approach that simplifies assessment of loneliness and social isolation in clinical settings, and other practical pointers.

Check out some of their recent work, including:

• Dr. Holt-Lunstad’s and Dr. Perissinotto’s powerful perspective piece in the New England Journal of Medicine which provides a clinical framework for addressing loneliness and social isolation.
• Dr. Cudjoe’s recent work demonstrating the impact of social isolation on dementia risk, populations at risk, and how our social lives "getting under our skin."
• Dr. Kotwal's work showing how social isolation impacts end-of-life health care use, including hospice and acute care.

We touch briefly on (and build on) topics discussed in prior podcasts such as loneliness during the pandemic. Tune in to hear Alex’s acoustic rendition of Outkast’s Hey Y’All!

-Ashwin Kotwal

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Do we need an RCT to establish the worth of chaplaincy?

Einstein once said, “Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.”

A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: “It’s like being told to measure the taste of orange juice with a ruler.”

On the other hand, all of our guests agree that chaplains are often the most vulnerable to being cut from hospital and health system budgets. These studies are important.

Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU, published in JPSM and plenary presentation at AAHPM/HPNA. To provide context, we are joined by Karen Steinhauser, a social scientist at Duke who has been studying spirituality for years (and published one of the most cited papers in palliative care on factors considered important at the end of life, as well as one of my favorite qualitative papers to give to research trainees). We are also joined by LaVera Crawly, a physician turned chaplain, now VP of Spiritual Care at Common Spirit Health (and author of another of my favorite and most cited papers on palliative care in the African American Community).

We dive into the issues of measuring spirituality, chaplaincy, the need for an expanded vocabulary around spirituality, spiritual assessments, spiritual history, LaVera’s journey from physician to chaplain (listen to her compelling answer to the magic wand question at the end).

For further context, please check out our prior podcast on spirituality, and this discussion of the RCT by Lexy that I helped moderate for Transforming Chaplaincy.

Thanks to my son Kai for playing the guitar part in 5/4 with strange chords on Riverman by Nick Drake!

-Alex

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Two weeks ago on the GeriPal podcast we talked about why and how to write for the general public. This week we’ve invited three guests to share their stories about storytelling that’s written for healthcare providers.

The first guest is Liz Salmi. Liz wrote a fabulous perspectives piece in the NEJM titled “Deciding on My Dimples” which talks about her experience as a patient doing shared decision making during neurosurgery for resection of an astrocytoma. In addition to this being a fascinating story, Liz brings in a great perspective as a patient, advocate, researcher, and a punk rocker.

Our second guest is a recurring star of GeriPal, Anne Kelly. She just published an essay for JAMA Piece of My Mind titled “The Last Visit”. In this piece Anne describes her experience with the expressions of love she and her mother shared in the last days of her mothers life.

Lastly, but certainly not least, we’ve invited Preeti Malani. Preeti is the editor for JAMA’s Piece of My Mind section. We’ve asked Preeti to come on to describe what happens behind the curtain when evaluating these stories, including what makes those few that get accepted stand out.

We’ve also love to hear from you on twitter and facebook your own experiences writing for the medical world (and please include links!)

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In November of 2022, Ava Kofman published a piece in the New Yorker titled “How Hospice Became a For-Profit Hustle.” Some viewed this piece as an affront to the amazing work hospice does for those approaching the end of their lives by cherry picking stories of a few bad actors to paint hospice is a bad light. For others, this piece, while painful to read, gave voice to what they have been feeling over the last decade - hospice has in some ways lost its way in a quest of promoting profit over care.

On today’s podcast, live from the American Academy of Hospice and Palliative Medicine Annual Meeting, we invite two thought leaders in the field, Ira Byock and Joseph Shega, to discuss among other things:

• Is hospice losing its way?
• Is there a difference between for-profit and not-for-profit when it comes to quality of care?
• What is our role as hospice and palliative care providers in advocating for high-quality hospice care?

If you are interested in signing the position statement “Core Roles and Responsibilities of Physicians in Hospice Care”, click here. For a deeper diver into these issues, check out some of the following links:

• Ira’s Stat new article “Hospice care needs saving”
• GeriPal’s episode on the growing role of private equity in hospice care
• Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA IM 2021
• Hospice Acquisitions by Profit-Driven Private Equity Firms. JAMA Health Forum. 2021
• Association of Hospice Profit Status With Family Caregivers’ Reported Care Experiences. JAMA IM 2023
• A shout-out to my NPR episode on 1A titled the “State of Hospice Care”

DISCLAIMER

While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly. Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly.

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So you want to write a book.

So you want to write a book!

So…you want to write a book?!?

Today we talk with two geriatricians: Rosanne Leipzig, author of Honest Aging: An Insider's Guide to the Second Half of Life; and Louise Aronson, author of Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. (You can hear our prior podcast on Louise’s book here). We talk with them about writing for the lay public, including:

• Why write a book for the lay public?
• Why write about aging? Was there pushback from publishers (hint: hell yes)
• What terms to use to describe the “old age” time period?
• How did they start writing a book?
• How do you find time to write and also be doctors and academic professors?
• Revisions and working with editors
• Writing an Op Ed - how to start, what to write, where to send it
• TheOpEdProject as a resource for learning more

We look forward to the books and op-eds our listeners will write!

In all seriousness, you don’t actually have to want to write a book to be interested in this podcast. You don’t have to want to play professional basketball to appreciate The Last Dance, which documents the final season of Michael Jordan with the Chicago Bulls. These are inherently interesting interviews because the motivations, process, and struggle of monumental undertakings are interesting in and of themselves.

Enjoy!

-@AlexSmithMD

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Psychedelics are having a moment. Enthusiasm is brimming. Legalization is moving forward in several states, following the lead of Oregon and Colorado. FDA is considering approval, shifting away from Schedule I restrictions, paving the way for use in clinical practice. Potential use in palliative care, chronic pain, and for mood disorders is tantalizing. Early data on efficacy in patients with anxiety and demoralization are promising. Research is exploding. Two of our guests today, Stacy Fischer and Brian Anderson, are involved in large multicenter trials of psychedelics for patients with advanced cancer (Fischer) or life-limiting illness (Anderson). Theora Cimino conducted an observational study (publication in the works) of marginally housed/homeless persons many of whom had experience with psychedelics.

And yet there are reasons for caution. In our prior podcast with Ira Byock on psychedelics in 2019 we talked primarily about the potential of psychedelics. Today we largely focus on reasons for caution, including:

• We know almost nothing about psychedelics in older adults - only about 1% of patients in published trials were older adults, much less older adults with multiple chronic conditions, multiple medications, and frailty. Bree Johnston and Brian Anderson wrote a terrific summary of the evidence (or lack thereof) in older adults.
• There is a marked lack of diversity in published trials. Most participants are White and well-resourced.
• Psilocybin, the most commonly used psychedelic, increases heart rate and blood pressure, which may potentially lead to cardiovascular events.
• The efficacy of psychedelics without therapy, and the impact of variations in therapy type, training, duration, is unknown.
• Ethical issues, including colonization of psychedelics by big pharma. Psychedelics have been used by communities around the globe for hundreds of years (or more).

We cover these issues and more in today’s podcast.

Note, I butchered the chorus on the YouTube version - please listen to the podcast for my souped up version with drums and bass!

-@AlexSmithMD

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Gabapentin is the 10th most prescribed drug in the United States and use is increasing. In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin). By 2015 that number increased to 4% of US adults.

There are a lot of reasons that may explain the massive increase in use of these drugs. One thing is clear, it is not because people are using it for FDA approved indications. The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications.

On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer. It’s a big episode covering a lot of topics.

First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug).

Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later).

Donovan discusses the growth of “mood stabilizers/antiepileptics” (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin).

Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug. This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial.

I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies:

• Gabapentin in the Perioperative setting:
• Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022
• Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022

• Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort. JAMA Surgery 2018

• Gabapentin and mood stabilizers in the Nursing Home Setting:

• Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022

• Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020

• Efficacy of Gabapentinoids:

• Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019

• Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017

• The Illegal Marketing Practices by Pharma promoting ineffective:

• The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009
• Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006

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You know when you walk out of a patient's room and have that sense, “This isn’t going to go well.” The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle. Should you stop at “no?”

Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn’t stop at “no.” We owe it to the patient to explore the reasons behind the “no,” commonly not wanting to be a burden to their family. In such cases, we owe it to the patient to use persuasion, for example, “I hear that you don’t want to be a burden. And I’m worried that there may come a time when you have trouble making decisions for yourself. We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you’re sick, that you’re hospitalized, that you’re in the ICU, and that you can’t make your own decisions? That’s a huge amount of news all at once. It would help her to prepare if we could start talking with her now.”

We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent. Consent is often viewed as “all or nothing” for any specific decision. Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision. I’d hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone. Emily’s expanded notion of consent is grounded in the concept of “relational autonomy.” Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another. Emily’s notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent. Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making.

My favorite line from Emily’s paper: “Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care.”

Enjoy!

-@AlexSmithMD

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Think about the last time a patient yelled at you in anger. How did you react? The last time this happened to me I immediately went on the defensive despite years of training in serious illness communication skills. Afterwards, I thought there must be a better way.

Well on today’s podcast we invite two of our favorite palliative care psychiatrists, Dani Chammas and Keri Brenner, to teach us about going beyond simple communication skills like naming the emotion when interacting with the angry patient (see our podcast on avoiding the uncanny valley for a deeper dive into the dangers of becoming too rote and scripted). As Keri put it in the podcast, we must go beyond “a hammer and a nail” philosophy to approaching anger by developing a toolkit for anger that is vast and varied.

Dani and Kery present three steps for interacting with an angry patient:

1. Look within: What is this anger bringing up in me? How is this anger making me feel, think, and react?
2. Ask why: What is underneath the anger for this particular patient? Creating a “formulation” for the patient
3. Act mindfully: Decide what can we do, and how we can respond therapeutically (and no there is no mnemonic for this step)

Here are some other great references we discussed in the podcast:

• Shalev D, Rosenberg LB, Brenner KO, Seaton M, Jacobsen JC, Jackson VA. Foundations for Psychological Thinking in Palliative Care: Frame and Formulation. J Palliat Med. 2021;24(10):1430-1435. doi:10.1089/jpm.2021.0256
• Rosenberg LB, Brenner KO, Jackson VA, et al. The Meaning of Together: Exploring Transference and Countertransference in Palliative Care Settings. J Palliat Med. 2021;24(11):1598-1602. doi:10.1089/jpm.2021.0240
• Brenner KO, Rosenberg LB, Cramer MA, et al. Exploring the Psychological Aspects of Palliative Care: Lessons Learned from an Interdisciplinary Seminar of Experts. J Palliat Med. 2021;24(9):1274-1279. doi:10.1089/jpm.2021.0224
• Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887. doi:10.1056/NEJM197804202981605
• What's in the Syringe?: Principles of Early Integrated Palliative Care

And for those interested in other podcast we did with Dani and Keri, check out the following:

• Therapeutic Presence in the Time of COVID
• Improving Serious Illness Communication by Developing Formulation
• What is Emotional PPE?

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Amber Barnato is an expert in simulation studies. A health services researcher and palliative care physician, Amber lauds the ability of simulation studies to isolate one variable in a study. For example, we spend the first half talking about a RCT simulation study of clinician verbal and non-verbal communication with a seriously ill patient with cancer. In one room the physician under study interacts with a white patient-actor, and in another room interacts with a Black patient-actor. They found no differences in verbal communication, but clear differences in non-verbal rapport building communication: physicians stood farther away, crossed their arms, didn’t touch the Black patient as frequently. Amber tells the moving story of how these findings led a clinical colleague, her chief, to question and change his behavior. Of note, we talked about implicit bias in depth in this podcast with Kimberely Courseen.

As we’ve written about on GeriPal when we were a blog (a decade ago!) these simulation studies can be used to study language, such as patient or surrogate choices when we use the terms “allow natural death” vs “do-not-resuscitate.” This change in framing is a nudge, more evidence that the choices we make to use one phrase or another, or the order in which we present options, are all nudges that influence patient choice - listen to our podcast on the ethics of nudging with Jenny Blumenthal-Barby and Scott Halpern for more.

Additional links to simulation studies:

https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-495OC

https://journals.lww.com/ccmjournal/Abstract/2011/07000/A_randomized_trial_of_the_effect_of_patient_race.9.aspx

https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0089

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687021/

https://journals.sagepub.com/doi/pdf/10.1177/0272989X14522099

Theoretical underpinnings: https://home.csulb.edu/~cwallis/382/readings/482/nisbett%20saying%20more.pdf

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Sometimes you read a book and get a flash of insight - that “ah ha!” moment - about yourself and the ways you interact with others. That happened to me when reading “Range: Why Generalists Triumph in a Specialized World.” It helped me to understand and justify my interest in (this won’t surprise you) EVERYTHING related to geriatrics or palliative care. Also hat tip to Matthew Growdon for recommending the book.

Today we talk with Bob Arnold, who has a long list of recommendations for books that have the potential to generate an “ah ha!” moment. The podcast is ostensibly focused on becoming a better mentor, but as you’ll hear, we discuss techniques that can help you cope with anxiety, stress, your spouse…the list goes on. In reality, insights from these books can help you be a better teacher, a more curious person, as well as a better mentor or mentee.

Bob urges you to buy these books from your local bookstore. To that end, we’re not including links with the titles below. Please shop locally.

As a bonus, Lauren Hunt, frequent guest on GeriPal, heard we recorded this podcast and wanted to add a couple books to Bob’s list (she saw Bob give a talk about these books at the NPCRC Foley retreat). Her list will strongly resonate with women in academics. See below for Lauren’s two additions to Bob’s list, with her personal commentary.

Enjoy!

-@AlexSmithMD

Bob’s booklist:

• Lori Gottlieb, Maybe You Should Talk to Somebody: A Therapist, Her Therapist, and Our Lives Revealed
• Ethan Kross, Chatter: The Voice Inside Our Head, Why It Matters, and How to Harness It
• Eric Barker, Plays Well With Others: The Surprising Science Behind Why Everything You Know About Relationships Is (Mostly) Wrong
• Stephanie Foo, What My Bones Know: A Memoir of Healing From Complex Trauma
• Jennifer L. Eberhardt, Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do
• Claude M. Steele, Whistling Vivaldi: How Stereotypes Affect Us and What We Can Do
• Marcus Buckingham, Nine Lies About Work: A Freethinking Leader's Guide to the Real World
• Marshall Goldsmith, What Got You Here Won't Get You There
• Adam Grant, Give and Take: Why Helping Others Drives Our Success
• David Epstein, Range: How Generalists Triumph in a Specialized World
• Douglas Stone, Thanks for the Feedback: The Science and Art of Receiving Feedback Well
• Douglas Stone, Difficult Conversations: How to Discuss What Matters Most
• Kerry Patterson, Crucial Conversations: Tools for Talking When Stakes Are High
• Kerry Patterson, Crucial Accountability: Tools for Resolving Violated Expectations, Broken Commitments, and Bad Behavior
• Anne Lamott, Bird by Bird: Some Instructions on Writing and Life
• James Clear, Tiny Changes, Remarkable Results, Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones
• Michael Bungay Stanier, The Coaching Habit: Say Less, Ask More & Change the Way You Lead Forever
• Peter Bergman, You Can Change Other People: The Four Steps to Help Your Colleagues, Employees--Even Family--Up Their Game
• Doug Lemov, The Coach's Guide to Teaching
• Doug Lemov, Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to College
• Doug Lemov, Practice Perfect: 42 Rules for Getting Better at Getting Better

​​From Lauren:

The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It by Valerie Young

I was inspired to read this book after reading a post on the 80,000 hours blog. I had heard of course heard of imposter syndrome in the past but I didn’t make the connection to myself until I read this article and saw my thoughts printed on the page. You would think that after several years of a number of career successes, the imposter syndrome would have abated for me, but rather I found it getting worse! I thought that I should know more of what I was doing by this point in my career, but instead I often felt like I had no idea what I was doing!

So I came across this book and found it very helpful. Young defines people who have imposter syndrome as those who have a “persistent belief in their lack of intelligence, skills, or competence. They are convinced that other people’s praise and recognition of their accomplishments is undeserved, chalking up their achievements to chance, charm, connections, and external factors. Unable to internalize or feel deserving of their success, they continually doubt their ability to repeat past successes.”

I certainly related to the point that instead of successes alleviating feelings of fraudulence, the opposite happens, because it increases pressures to uphold one’s reputation. The pressures can be intense, leaving one wondering if it’s all worth it, and prompting fantasies of leaving the charade behind.

One thing I really liked about this book is that it places the imposter syndrome into the context of a patriarchal, misogynistic, racist society and organizations that create cultures that cultivate self-doubt (ahem academia). Imposter syndrome is a rationale response to a crazy world. We exist in a society and culture that actually judges women to be less competent at work (the studies she details are SUPER disturbing). It is not surprising we would internalize these norms. Also that being underrepresented in a field creates pressures not only to represent just oneself, but an entire gender. She focuses on women, but these concepts obviously apply to people of color and other disadvantaged social groups. And of course men can have imposter syndrome too.

Another part I liked about the book is digging into the notion that one’s success is due to luck, or being in the right place at the right time. She dispels these notions by pointing out that, first of all, luck is always present, even for people who are enormously talented and second, being the right place at the right time, having the right connections, and having a winning personality can sometimes actually be the result of skills or abilities, often the result of hard-work, hustling, and efforts to develop one’s socioemotional capacity.

This is a self-help book, so throughout she offers some useful rules and self-talk for responding to imposter syndrome thoughts. She details different ways to respond to thoughts based on your competence type. For example, if you are a perfectionist, she recommends reframing to a “good enough” quality standard—a mantra I adopted from colleague during the pandemic and has been incredibly helpful for me over the past few years. For the rugged individualist who equate true competence equals solo, unaided achievement, the reframe is “competence means knowing how to identify the resources needed to get the job done.”

Another really important idea she raises is that women often have difficult choices to make about their career and its impact on other parts of their families and their other social networks that aren’t as pronounced for men in our society. Sometimes it is difficult to disentangle these questions from feelings of imposter syndrome. For example, is reluctance to take on more responsibility at work or relocate because you feel inadequate or is it because of genuine concern about the impact on your family? Moreover, women (generalizing here) tend to place lower value on traditional measures of work success (e.g. money, power, influence) and greater value on connection and meaning. It can require a lot of soul searching to figure out whether one is avoiding career “success” out of fear or that certain paths are just truly not aligned with our values.

Finally, towards the end of the book, she introduces the idea of “faking it till you make it” and having chutzpah—i.e going for it. Of course, she’s not advocating for a George Santos approach (no lying) but just having a little bit more of a mindset that you’ll figure it out once you’re on the job.

I’d definitely recommend this book if you’ve ever struggled with similar feelings or mentor people who might. She’s got a breezy and relatable writing style that’s easy to read, lots of great real-world stories, and piquant quotes.

The No Club: Putting a Stop to Women’s Dead-End Work by Linda Babcock, Brenda Peyser, Lise Vesterlund, and Laurie Weingart

Summary of the book’s premise:

• Work activities fall on a spectrum from promotable and non-promotable (NPT).

• Promotable activities are those that advance one’s career. They use the word “advance” quite broadly to encompass various outcomes, like earning a promotion, getting plum assignments, increasing compensation, and enhancing marketability for other jobs. Promotable tasks are visible to others and increase the organization’s currency. Some tasks may be indirectly promotable—they help you develop skills that have the potential to enhance your future success or access to future promotable work.

• NPT’s are important to your organization but will not help to advance your career. These tasks have low visibility (think committees and other service).

• Too many NPT’s can lead to work/work imbalance where promotable tasks get pushed to the side and advancement slows, or work-life imbalance, where advancement continues but at the expense of time in one’s personal life (or both).

• Although not exclusively a problem for women, women are more likely to take on NPT’s at work. This is because they are both asked more often and are more likely to say yes when asked.

• They propose both bottom-up (women saying no to more things) and top-down solutions (organizations making efforts to divide up NPT’s more fairly and ensuring everyone is pitching in).

Before I read this book, I didn’t fully grasp the idea that an activity would be helpful to the organization but not to my own career. Sometimes requests for participation in these activities come with a veneer or prestige and lots of feel-good gratitude. I personally feel a lot of guilt and worry about disappointing people when I say no to things. Even declining to review an article for a journal is accompanied by some stomach knots (it’s so hard to find reviewers!) I also place a lot of value in collaboration and working in teams, and the idea of working in a culture where everyone is only looking out for themselves is not appealing to me. But I’m also worried at the level of overwhelm I experience at times and perhaps some of you have experienced as well. How do we ensure that we are on sustainable path where we can stay in and build the world we want to live and work in?

The book also got me thinking about what is promotable or not in academia, i.e. what is the currency. I think we all know that grants and publications are promotable activities, but even within that there are hierarchies. Some of these hierarchies I think I understand: a data-based paper in a high-impact journal has higher promotability than an editorial in a lower-impact journal. Some of them I’m not sure about: is an NIH project grant more promotable than a foundation grant and if so why (bc higher indirects?) Also, things like mentorship seem gray to me: senior-authored articles are evidence of independence and potential track to mentoring awards, but people often seem to place mentorship in the NPT category. I think having more transparency and discussion about what is promotable or not would be very useful.

Highly recommend this book for women, men, people in leadership, and employees. It’s extremely well-written, nuanced, and eye-opening.

SPONSOR:

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

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The Covid epidemic laid bare two major structural issues. First, Black and Latinx persons experienced much higher rates of mortality than other groups. Second, as we discussed in last week’s podcast, older adults, particularly those in nursing homes, were far more likely to die than younger individuals. These are structural issues because the fundamental causes of these issues were not biological issues, they were social. These worse outcomes were not due to differences in genes, they are due to structural racism and ageism.

In today’s podcast we talk about the intersection of racism and ageism. We use the Covid pandemic and lack of diversity in trials for recently approved Alzheimer’s drugs aducanumab and (to a lesser extent) lecanemab as springboards for discussion. Our guests Tim Farrell, Ramona Rhodes, and Nancy Lunderbjerg wrote an article in JAGS on this issue, and Sharon Brangman wrote a separate JAGS article on the need to achieve diversity in study populations. In a third piece, Ramona Rhodes wrote about efforts to improve diversity, equity, and inclusion at JAGS (in the journal itself, including content and editorial leadership). The article was titled, “Change is coming” - which also gives you a hint as to today’s song request.

One final note: at the start of today’s podcast we thank one of our generous donors, Meg Wallhagen, and ask her why she donated to GeriPal. A prior guest on GeriPal, Meg is a tireless advocate and researcher for hearing impairment issues affecting older adults. She has a study that is open to recruitment for any adult - hearing impaired or not - please see the blurb below to learn more and participate.

Enjoy!

-@Alex Smith

From Meg Wallhagen: The Federal Drug Administration (FDA) now allows hearing aids to be sold Over-the-Counter (OTC-HAs) to adults with mild to moderate hearing loss. We – Meg Wallhagen from UCSF and Nick Reed from John Hopkins University - are interested to learn what people like you know about OTC-HAs and if you would consider buying them. The survey should only take about 10-20 minutes to complete. If you are willing to consider taking the survey, please click on the following link to learn more. https://ucsf.co1.qualtrics.com/jfe/form/SV_9ZbReHYH72m82gK

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In April 2022, the National Academies of Sciences, Engineering and Medicine (NASEM) issued a report on how the United States delivers, regulates, finances, and measures the quality of nursing home care. It’s massive with over 600 pages detailing everything from the history of nursing home care in the United States to the latest issues that nursing homes have had to face with COVID-19.

On today's podcast we invited Jasmine Travers, Alice Bonner, Isaac Longobardi, and Mike Wasserman to talk about the report. Jasmine was one of the committee members for the NASEM report, and Alica and Issac are chairing and directing a coalition called Moving Forward tasked with taking the goals identified in the NASEM report and identifying specific and practical initiatives, test concepts, and promote their adoption for lasting improvements.

We could have gone on for a couple hours for this podcast, but alas time ran out. But if you want to learn more, check out these links:

1. The report by NASEM titled “The National Imperative to Improve Nursing Home Quality”
2. The website for the Moving Forward

We will also link to the JAGS articles co-authored by seven committee members that focus on specific recommendations of the NASEM report when they get published (stay tuned).

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Acute Care for Elders (ACE Units) have been around for over a quarter of a century. Randomized trials of ACE units date back to 1996 when Seth Landefeld and colleagues published a study in NEJM showing that they improve basic activities of daily living at discharge and can reduce the frequency of discharge to long-term care institutions. But if ACE units are so great, why do so few hospitals have them?

On today's podcast we talk about ACE units with geriatricians Kellie Flood and Stephanie Rogers. They recently published a paper in JAGS looking at the current landscape of ACE units in the US. In the podcast we go over these issues and more:

• What are ACE units and what structural elements go into them (see the picture below for a nice summary)?
• Which patients are eligible to go to an ACE unit?
• What are the benefits of an ACE unit?
• If ACE units are so great, why are they not so common?
• What does the future look like for ACE units and how does it differ (if at all) from Age Friendly Health Systems?

If you want to do a deeper dive in ACE units, check out some of the following articles:

• The original NEJM paper on ACE units from 1996
• Kellie Flood’s paper in JAMA IM showing that not only ACE units deliver better care, but also help with the hospitals bottom line

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Today’s podcast may be a stretch for our listeners. Please stick with us. No matter what your position on medical aid in dying (I’m ambivalent) or abortion (I’m pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think. All three of today’s guests are well established bioethicists.

Let me start by quote/paraphrasing one of today’s guests, Mara Buchbinder, who puts her finger on the issue we talk about today:

“Typically when we think about conscience in medical ethics we think about it in terms of a negative claim of conscience, where a clinician refuses (or objects) to provide care. But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it’s abortion provision or medical aid in dying - because of a deeply held conviction that this is the right thing to do.”

I’ll continue by quoting Lisa Harris, who wrote in the NEJM:

Bioethicists have focused on defining conditions under which conscientious refusals are acceptable but, with rare exceptions, have neglected to make the moral case for protecting the conscientious provision of care. Indeed, there is a real asymmetry between negative duties (to not do something) and positive duties (to do something) and, accordingly, between negative and positive claims of conscience. Violations of negative claims are considered morally worse than violations of positive ones.However, as bioethicist Mark Wicclair argues, the moral-asymmetry thesis does not provide adequate ethical justification for current conscience law, which protects only conscience-based refusals. Moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs.

Lisa was writing about providing abortion care, but she just as easily could have been writing about providing medical aid in dying in states where it is illegal.

Today we wrestle with this issue of conscientious provision. We start by talking with Robert Brody, an internist who recalls physicians helping patients die during the height of the AIDS epidemic in San Francisco. Robert was first asked by one of his own patients for assistance in dying in 1991, far before aid in dying was legalized in California in 2016. Robert went on to be the founding chair of the board of Compassion and Choices, the major national advocacy organization for medical aid in dying. Today, medical aid in dying is legal in some 10 states, and illegal in others.

Also today, in the wake of the Supreme Court’s recent Dobbs decision, some 13 states ban abortion. To examine how clinicians might act in the face of such bans, we turn to Lori Freedman, who wrote a book about clinicians (primarily Ob-Gyn’s) who work in Catholic Hospitals. She describes the “workarounds” these clinicians used to skirt the rules in order to provide reproductive care for women.

We talk about the parallels between these issues at the beginning and end of life, and areas in which these parallels fall apart. For example, Jack Kevorkian excepted, clinicians have not been prosecuted for providing aid in dying in states where it is illegal. In contrast, there is a justified fear of prosecution of providing abortion care in states where it is illegal.

It took contemplation on a bike ride to put my finger on why I “wrestle” with the notion of conscientious provision. On the one hand, when I hear of Ob-Gyn’s in Catholic Healthcare systems using “workarounds” to provide reproductive care, I’m standing up and cheering on the inside. On the other hand, when I hear of workarounds to assist patients to die, or even euthanize them, I worry that we’ve gone back to a time when the doctor or nurse knows best - and should be morally permitted to do whatever they think is right, according to their conscience. Do we really trust all doctors and nurses so far? Would you, with your parents, trust any doctor or nurse to make such life or death decisions, regardless of the law? There have to be limits to conscientious provision, just as there are limits placed on conscientious objection. In conscientious objection, there are general rules, such as: the patient must be given time to seek a clinician who is willing to provide the treatment; and clinicians can only object to specific treatments under specific circumstances. And yet, I worry about explicitly creating ethical rules for conscientious provision. Ought we, in bioethics, create ethical rules for providing care that is illegal? Who will follow them, and what would be their incentive for doing so? Would such ethical guidelines foster or feed suspicion of the motivations of bioethics?

We could have talked for hours. We may reconvene for another podcast as we see how these issues continue to unfold.

Oh life. It’s bigger. It’s bigger than you and you are not me.

-@AlexSmithMD

Many links:

Mara Buchbinder’s book - Scripting Death: Stories of Assisted Dying in Americahttps://www.ucpress.edu/book/9780520380202/scripting-death

Lori Freedman’s book (forthcoming) - Bishops and Bodies: Reproductive Care in American Catholic Hospitalshttps://www.rutgersuniversitypress.org/bishops-and-bodies/9781978828865

Lisa Harris piece mentioned on podcasthttps://www.nejm.org/doi/full/10.1056/NEJMp1206253

Alta Charo piece mentioned on podccasthttps://www.nejm.org/doi/full/10.1056/nejmp058112

Yvonne Lindgren article mentioned on podcasthttps://dc.law.utah.edu/cgi/viewcontent.cgi?article=1002&context=ulr

Art Caplan piece mentioned on podcasthttps://www.thehastingscenter.org/abortion-law-lessons-from-medical-aid-in-dying/

George Annas piece mentioned on podcasthttps://dsc.duq.edu/cgi/viewcontent.cgi?article=3090&context=dlr

https://muse.jhu.edu/pub/1/article/722811

https://journalofethics.ama-assn.org/article/why-post-roe-era-requires-protecting-conscientious-provision-we-protect-conscientious-refusal-health/2022-09

https://www.amazon.com/Doctors-Conscience-Struggle-Provide-Abortion/dp/0807021016/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1670624994&sr=1-1

SPONSOR:

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

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From discussing “taking away the keys to the car” for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine. How well though are we taught to handle conflict and disagreement? I’d say not well as I don’t think I’ve ever received a formal talk on the issue.

On today’s podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski. We’ve had Lee on before to talk about her Plan your Lifespan project. We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers.

For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge training, feel free email the NegotiAge Research Team at negotiage@northwestern.edu):

• Getting to Yes: Negotiating Agreement without Giving In by Roger Fisher, William Ury, and Bruce Patton
• Getting Past No: Negotiating in Difficult Situations by William Ury
• Negotiation Training for Case Managers to Improve Older Adult Acceptance of Services. Prof Case Manag. 2021
• Training Hospitalists in Negotiations to Address Conflicts with Older Adults around Their Social Needs. Geriatrics. 2020
• Conflicts Experienced by Caregivers of Older Adults With the Health-Care System. Journal of Patient Experience. December 2020
• Dealing with conflict in caring for the seriously ill: "it was just out of the question". JAMA 2005

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We’ve talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA’s decision to approve it.

But wait, there’s a shiny new anti-amyloid drug, lecanemab! (No it’s not just the French version of Aducanumab).

In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo. Wow! Wow? Wait, what?

On today’s podcast we talk with Jason Karlawish, who we’ve had on previously talking about his book The Problem of Alzheimer’s and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky.

They debate today’s central question: is it time for geriatricians to get on board with lecanemab? Along the way we address:

• Is this degree of slowed cognitive decline meaningful to patients or care partners?
• What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for brain swelling and bleeding, case report level risk of death?
• Did the study do enough to address issues of inclusion and diversity by age, race and ethnicity, and multimorbidity?
• What does this study say about the amyloid hypothesis?
• Should the FDA approve, and under what conditions?

Their answers may surprise you.

As a preview of final thoughts at the end of the episode, Ken and Jason agree that the FDA should approve lecanemab conditional on a post-approval monitoring system and public access to study data, geriatricians should be prepared to have thoughtful conversations with patients about the risks and benefits of lecanemab in view of their values and priorities, and ultimately, that geriatricians should be open to prescribing it.

Wow!

The times, they are a changin.

-@AlexSmithMD

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Eric and I weren’t sure what to call this podcast - storytelling and medicine? Narrative medicine? We discussed it with today’s guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet. It wasn’t until the end that the best term emerged - storycatching. Because that really is what this is about. Clinicians “catching” patient life stories.

What’s in a story? Well, as we learned, everything. Our patients aren’t “the 76 year old with heart failure in room 202,” as Heather Coats astutely noted. They’re people, and what makes us people if not our life’s stories? Our loves, our triumphs, our failures, our work, our families.

Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin. It’s since spread to over 70 VAs. VA “gets” the importance of storytelling in medicine, without the need for reams of research to back it up. As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them documented, and for the clinicians who get to truely and deeply know their patients in far greater depth than “what brought you to the hospital?” Heather Coats is hard at work establishing the evidence base for the power of capturing patient stories in healthcare settings, for those health systems that need a little more convincing.

Wonderful work. Enjoy!

Many links:

VA Presents: My Life, My Story: George: A Voice To Be Heard on Apple Podcastshttps://podcasts.apple.com/us/podcast/id1529359511?i=1000489683280

Every Veteran has a story. Our mission is to help them tell it.https://www.va.gov/wholehealth/mylifemystory/

My Life, My Story: VA’s healthcare improvements through deliberate storytelling - YouTubehttps://www.youtube.com/watch?v=fpzgVlExS20&ab_channel=VeteransHealthAdministration

Storytelling Helps Hospital Staff Discover The Person Within The Patienthttps://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient

A few data based publication links from Person-Centered Narrative Intervention Program of Research:

Unpacking characteristics of spirituality through the lens of persons of colour living with serious illness: The need for nurse-based education to increase understanding of the spiritual dimension in healthcarehttps://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16055

Integration of Person-Centered Narratives Into the Electronic Health Record: Study Protocolhttps://pubmed.ncbi.nlm.nih.gov/32740306/

Bennett, C.R., Shive, N., Coats, H. (2020). What Mattered Then, Now, and Always: Illness Narratives From Persons of Color. Journal of Hospice and Palliative Nursing, 22 (5):392-400/ PMID: 32740304https://pubmed.ncbi.nlm.nih.gov/32740304/

Coats, H., Meek, P., Schilling, L., Akard, T., Doorenbos, A. (2020). Connection -- The Integration of a Person-Centered Narrative Intervention into the Electronic Health Record: An implementation study. Journal of Palliative Medicine, 23 (6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249456/

Coats, H., Crist, J., Berger, A., Sternberg, E., & Rosenfeld, A. (2015). African American elders’ serious illness experiences: Narratives of “God did,” “God will,” and “Life is better.” Qualitative Health Research. doi:10.1177/1049732315620153. PMID: 26701962https://journals.sagepub.com/doi/abs/10.1177/1049732315620153.

Narrative Methods Textbook referenced in podcastNarrative Methods for the Human Sciences

A few Dignity Therapy- Harvey Max Chochinov links https://dignityincare.ca/en/about-us.html

About us - Dignity in Carehttps://dignityincare.ca/en/about-us.html

Research Team - Dignity in Carehttps://dignityincare.ca/en/research-team.html

Other links:

Curiosity by Faith Fitgeraldhttps://www.acpjournals.org/doi/full/10.7326/0003-4819-130-1-199901050-00015

Eric’s blog post on Dignity Therapy from 2011https://geripal.org/study-of-dignity-therapy-on-distress/

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What would it take to transform dementia care? While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer’s disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast).

In order to truly transform dementia care we need to think much broader than the amyloid hypothesis. So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include:

• Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need them and how we can create them
• Anne Basting, PhD, a MacArthur Genius Grant awardee and professor (English/Theatre), University of Wisconsin, Milwaukee. She created TimeSlips which we talk about in our podcast. Her most recent book is Creative Care: a revolutionary approach to dementia and elder care
• Abhilash Desai, MD, geriatric psychiatrist, adjunct associate professor in the department of psychiatry at University of Washington School of Medicine, and poet! He wrote a book titled “Psychiatric consultation in long term care” that has a strengths based approach to staging dementia (how cool is that)
• Judy Long, MDiv, BCC, palliative care chaplain and educator at UCSF and caregiver. She directs UCSF MERI’s patient, family, and clinician support with classes and consultation on resiliency, well-being, and grief.

We discuss the importance of viewing individuals with dementia from a lens of resilience, the importance of creative engagement (as noted in Anne and Susan’s wonderful article on this subject), the role of collaborative care, and what we can do to improve inclusivity for individuals with dementia in our community and health care systems.

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Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly? That’s the central question on today’s podcast. The problem is the tremendous heterogeneity in services offered and quality of care. If you’ve seen one Assisted Living Community you’ve seen one Assisted Living Community.

To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents. The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care). The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of the corporations that own most Assisted Living Facilities (profit) and the ideal services offered in Assisted Living Facilities.

We additionally firmly establish that the song How to Save a Life by the Fray was a product of the aughts (2005, to be exact), not the 90’s ):

Enjoy!

-@AlexSmithMD (still on Twitter at present)

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Health care professionals are human, and as humans we experience loss both in and out of work. You’d imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses. Turns out, it’s maybe not.

That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called “Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals”. It’s a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss.

On today’s podcast, we’ve invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.

We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings. These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work. Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings.

So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness:

• Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals
• Dates & registration info about debriefings offered by CAPC
• The CAPC Debrief Facilitator Training Manual we developed: PDF Download.
• Jared Rubensteins' "Token of Appreciation" video
• A great website for dealing with loss and grief: refugeingrief.com

SPONSOR:

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

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Health care professionals are human, and as humans we experience loss both in and out of work. You’d imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses. Turns out, it’s maybe not.

That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called “Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals”. It’s a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss.

On today’s podcast, we’ve invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.

We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings. These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work. Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings.

So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness:

• Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals
• Dates & registration info about debriefings offered by CAPC
• The CAPC Debrief Facilitator Training Manual we developed: PDF Download.
• Jared Rubensteins' "Token of Appreciation" video
• A great website for dealing with loss and grief: refugeingrief.com

SPONSOR:

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

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Dr. Faith Fitzgerald once quipped that prognostic modeling is the “punctilious quantification of the amorphous.” She has a point. Prognosis is inherently uncertain. As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful. As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making. What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury? James Deardorff replies that there is something inherently different about predicting mortality. Death is different. For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue). And yet, the only thing that may be worse than a prognostic calculator is a clinician relying solely on their clinical intuition.

Today our guests Alex Lee, James Deardorff, and Sei Lee, talk to us about the uses, limitations, and clinical use cases for prognostic models. As a springboard for this conversation we discuss new prognostic models developed to predict (simultaneously) mortality, disability, and mobility impairment (Alex Lee first author, JAGS) and mortality for people with dementia residing in the community (James Deardorff first author, JAMA IM).

Both new models are now available and free to use on ePrognosis.

And Sei and Eric reminisce about slow dancing to “Forever Young” by Alphaville in their teenage years.

Enjoy!

-AlexSmithMD

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The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians? On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the National Alzheimer’s Project Act. Dr. Sherry shares her expertise in aging health policy and helps us make sense of the role of her Office and how she coordinates with the multitude of federal agencies aligned around the goal of advancing aging research, policy, and health. For the policy buffs and policy newbies out there, we hope this podcast is an essential primer to government in action. We talk about: * The structure of federal agencies and how they coordinate * Priorities of the National Alzheimer’s Project Act, and the unique role of ASPE and BHDAP in guiding the agenda and long-term goals * The recent focus on nursing facilities and long term supportive services during the pandemic, along with key gaps * How HHS and ASPE solicit input from clinicians, community leaders, and older adults and how much it impacts policy decisions (spoiler alert: this involvement is CRUCIAL) * How to make your voice heard and get involved

We also touch briefly on topics discussed in prior podcasts such as loneliness and federal responses to the pandemic in relation to long-term care. Tune to hear Alex’s rendition of 'With a Little Help from My Friends'! - Ashwin Kotwal, MD, MS

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When I’m on service these days there is inevitably a moment when a resident says “Patient so-and-so is on X” - and I have absolutely no idea what X is. Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up.

In this context, we’re excited to hear from infectious disease experts and nephrologists about updates in the care of older adults. Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I’ve never finished a course of antibiotics, and maybe your patients don’t need that full course either). Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race. We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I’m not 100% sold that race should always be removed - if removal is likely to worsen disparities for example - at least until a superior race-blind calculator can be developed).

These articles are part of a new series called Clin-Star Corner, a new series in JAGS that reviews practice changing articles in the care of older adults.

And yeah, they made me sing a Miley Cyrus song…(but not this hilarious parody about UTIs).

Enjoy!

-@AlexSmithMD

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Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy:

From a Latin word for “to cloak”, it’s the type of care given to seriously ill patients to provide comfort without curing

What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn’t provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round! The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field.

So what do we do about it? Well, on today’s podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning. The result is a new toolkit to help us fix our messaging & engage the public: seriousillnessmessaging.org

Questions we talk about include:

• What do we know about the public’s perception of palliative care, hospice, and advance care planning?

• What’s wrong with the “pictures of hands clasping each other” as our palliative care meme?

• How can we bring in marketing strategies into our public messaging?

• Don't palliative care clinicians already know how to explain things with empathy? Why is this different from clinical communication skills?
• If we avoid talking about death, is it just contributing to the public death denial that is rampant in American culture?

Related Links

Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review
https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0111

Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust
https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0719

Effective Messaging Strategies: A Review of the Evidence. Communicating to Advance the Public's Health: Workshop Summary
https://www.ncbi.nlm.nih.gov/books/NBK338333/

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Have you had difficulty managing a particular type of cancer pain? For me it’s radiation induced mucositis/esophagitis. Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things):

• Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects
• Lidocaine: worth the hype?
• Strengths and weaknesses of buprenorphine for cancer pain
• Fentanyl patch: often missed issues
• Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis

Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.

And yes, this would be a great one for CME. Eric and I are working on it…maybe by 2023?

Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!?

Enjoy!

-@AlexSmithMD

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Have you had difficulty managing a particular type of cancer pain? For me it’s radiation induced mucositis/esophagitis. Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things):

• Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects
• Lidocaine: worth the hype?
• Strengths and weaknesses of buprenorphine for cancer pain
• Fentanyl patch: often missed issues
• Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis

Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.

And yes, this would be a great one for CME. Eric and I are working on it…maybe by 2023?

Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!?

Enjoy!

-@AlexSmithMD

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Have you had difficulty managing a particular type of cancer pain? For me it’s radiation induced mucositis/esophagitis. Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things):

• Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects
• Lidocaine: worth the hype?
• Strengths and weaknesses of buprenorphine for cancer pain
• Fentanyl patch: often missed issues
• Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis

Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.

And yes, this would be a great one for CME. Eric and I are working on it…maybe by 2023?

Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!?

Enjoy!

-@AlexSmithMD

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Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you’ve uttered a hundred times before, came out rote and scripted? Maybe some phrase you learned from a prominent podcast or VitalTalk? And in response, the family or patient looked at you like you were from another planet? Yeah, I’ve been there too.

Josh Briscoe, our guests on today’s podcast, argues that you’ve entered the Uncanny Valley. In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still “off” appearance. Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families. Today we talk with Josh about how to anticipate and avoid the uncanny valley. And talk about times when we’ve fallen into it.

Key message: Listen to the music. All the time. ;)

Links:

-Uncanny Valley post on Josh’s fantastic substack Notes from a Family Meeting

-Anticipatory corpse book mentioned several times on the podcast

-GeriPal post about teaching using YouTube (some links are old and don’t work, but you get the idea, I recently gave a spontaneous talk to the palliative care fellows and was able to find the video snippets)

-Ira Byock’s 4 things that matter most

-@AlexSmithMD

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Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you’ve uttered a hundred times before, came out rote and scripted? Maybe some phrase you learned from a prominent podcast or VitalTalk? And in response, the family or patient looked at you like you were from another planet? Yeah, I’ve been there too.

Josh Briscoe, our guests on today’s podcast, argues that you’ve entered the Uncanny Valley. In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still “off” appearance. Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families. Today we talk with Josh about how to anticipate and avoid the uncanny valley. And talk about times when we’ve fallen into it.

Key message: Listen to the music. All the time. ;)

Links:

-Uncanny Valley post on Josh’s fantastic substack Notes from a Family Meeting

-Anticipatory corpse book mentioned several times on the podcast

-GeriPal post about teaching using YouTube (some links are old and don’t work, but you get the idea, I recently gave a spontaneous talk to the palliative care fellows and was able to find the video snippets)

-Ira Byock’s 4 things that matter most

-@AlexSmithMD

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Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you’ve uttered a hundred times before, came out rote and scripted? Maybe some phrase you learned from a prominent podcast or VitalTalk? And in response, the family or patient looked at you like you were from another planet? Yeah, I’ve been there too.

Josh Briscoe, our guests on today’s podcast, argues that you’ve entered the Uncanny Valley. In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still “off” appearance. Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families. Today we talk with Josh about how to anticipate and avoid the uncanny valley. And talk about times when we’ve fallen into it.

Key message: Listen to the music. All the time. ;)

Links:

-Uncanny Valley post on Josh’s fantastic substack Notes from a Family Meeting

-Anticipatory corpse book mentioned several times on the podcast

-GeriPal post about teaching using YouTube (some links are old and don’t work, but you get the idea, I recently gave a spontaneous talk to the palliative care fellows and was able to find the video snippets)

-Ira Byock’s 4 things that matter most

-@AlexSmithMD

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Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80. The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.

On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.

We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes. What they found was fascinating:

• Most programs require that DNR status be temporarily rescinded for the procedure.
• The time required before DNR was reinstated varied substantially among programs (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge).

Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them. They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!)

Here are more resources if you want to take a deeper dive into the subject:

• Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022
• The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017
• Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021

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Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80. The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.

On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.

We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes. What they found was fascinating:

• Most programs require that DNR status be temporarily rescinded for the procedure.
• The time required before DNR was reinstated varied substantially among programs (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge).

Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them. They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!)

Here are more resources if you want to take a deeper dive into the subject:

• Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022
• The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017
• Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021

View Details

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80. The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.

On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.

We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes. What they found was fascinating:

• Most programs require that DNR status be temporarily rescinded for the procedure.
• The time required before DNR was reinstated varied substantially among programs (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge).

Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them. They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!)

Here are more resources if you want to take a deeper dive into the subject:

• Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022
• The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017
• Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021

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Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder. She recalls being “a social scientist [Holly] in room a full of psychiatrists,” who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one. This led her on a remarkable journey. Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death. Prolonged grief is associated with increased risk of suicide and other negative health outcomes. This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V.

And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work. “Everyone has experienced grief, which makes everyone the expert.” Today we offer Holly a chance to answer her critics, including assertions that:

• Grief is love; how can love be wrong?
• Pathologizing grief leads to overmedicalization of a natural condition
• Prolonged grief disorder is a tool made for the pharmaceutical industry
• Prolonged grief disorder does not account for cultural variation in mourning practices

Along the way we talk about other related studies Holly has conducted, including a validation of DABDA - Elizabeth Kubler Ross’s famous stages of grief.

And a song choice from the great lyricist Tom Waits.

Enjoy!

-@AlexSmithMD

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Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder. She recalls being “a social scientist [Holly] in room a full of psychiatrists,” who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one. This led her on a remarkable journey. Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death. Prolonged grief is associated with increased risk of suicide and other negative health outcomes. This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V.

And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work. “Everyone has experienced grief, which makes everyone the expert.” Today we offer Holly a chance to answer her critics, including assertions that:

• Grief is love; how can love be wrong?
• Pathologizing grief leads to overmedicalization of a natural condition
• Prolonged grief disorder is a tool made for the pharmaceutical industry
• Prolonged grief disorder does not account for cultural variation in mourning practices

Along the way we talk about other related studies Holly has conducted, including a validation of DABDA - Elizabeth Kubler Ross’s famous stages of grief.

And a song choice from the great lyricist Tom Waits.

Enjoy!

-@AlexSmithMD

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Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder. She recalls being “a social scientist [Holly] in room a full of psychiatrists,” who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one. This led her on a remarkable journey. Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death. Prolonged grief is associated with increased risk of suicide and other negative health outcomes. This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V.

And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work. “Everyone has experienced grief, which makes everyone the expert.” Today we offer Holly a chance to answer her critics, including assertions that:

• Grief is love; how can love be wrong?
• Pathologizing grief leads to overmedicalization of a natural condition
• Prolonged grief disorder is a tool made for the pharmaceutical industry
• Prolonged grief disorder does not account for cultural variation in mourning practices

Along the way we talk about other related studies Holly has conducted, including a validation of DABDA - Elizabeth Kubler Ross’s famous stages of grief.

And a song choice from the great lyricist Tom Waits.

Enjoy!

-@AlexSmithMD

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In day-to-day practice, It’s hard to imagine providing excellent hospice or palliative care services without access to a team social worker.  Social workers augment a team’s ability to provide whole-person care, often aiding to identify and meaningfully address the wide variety of challenges and unmet needs faced by individuals and families facing serious illness. But are we really taking full advantage of ALL social workers have to offer our field?

On today’s podcast, we are talking with Barbara Jones – a national hospice and palliative care social work leader whose many accolades include being a founding member of the Social Work in Hospice and Palliative Care Network (SWHPN), a Professor of Direct Social Work Practice and Associate Dean for Health Affairs at the Steve Hicks School of Social Work at UT Austin.

Barbara highlights social workers’ inherent leadership qualities and tasks us to consider whether our own team and organizational structures are allowing for optimal social work engagement and influence. Whether in direct practice or in research and academia, we should work together to help Hospice and Palliative Care Social Work meet its full potential. 

by: Anne Kelly, LCSW, APHSW-C

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Two major shifts are transforming the landscape of hospice.

First, private equity firms are gobbling up hospices. As Melissa Aldridge, a health services researcher and former banker explains, we should be very concerned. Private equity firms try to turn companies as profitable as possible within 3-5 years. Thus, they have little in the way of long term vision for hospices, instead focused on cutting costs and maximizing profits.

Second, Hospice was originally designed for patients with advanced cancer, but the fastest growing admitting diagnosis is dementia. People with dementia make up about half of hospice admissions. And yet, we know little about the clinical experience of people with dementia in hospice. Krista Harrison found, to her surprise, that caregivers of people with dementia who died rated hospice as well as similar patients without dementia who died on hospice. And yet, disenrollment from hospice, either due to patient/family revoking the benefit or stabilization of illness (extended prognosis) is remarkably high for people with dementia among some hospices. In fact, as Lauren Hunt found, the average likelihood that a person will be disenrolled from one hospice vs. another is two. In other words, which hospice you enroll in has a tremendous influence on whether you’re going to be disenrolled from hospice, which often feels to patients and families like being expelled.

And I had a blast playing Take the Money and Run!

-@AlexSmithMD

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Two major shifts are transforming the landscape of hospice.

First, private equity firms are gobbling up hospices. As Melissa Aldridge, a health services researcher and former banker explains, we should be very concerned. Private equity firms try to turn companies as profitable as possible within 3-5 years. Thus, they have little in the way of long term vision for hospices, instead focused on cutting costs and maximizing profits.

Second, Hospice was originally designed for patients with advanced cancer, but the fastest growing admitting diagnosis is dementia. People with dementia make up about half of hospice admissions. And yet, we know little about the clinical experience of people with dementia in hospice. Krista Harrison found, to her surprise, that caregivers of people with dementia who died rated hospice as well as similar patients without dementia who died on hospice. And yet, disenrollment from hospice, either due to patient/family revoking the benefit or stabilization of illness (extended prognosis) is remarkably high for people with dementia among some hospices. In fact, as Lauren Hunt found, the average likelihood that a person will be disenrolled from one hospice vs. another is two. In other words, which hospice you enroll in has a tremendous influence on whether you’re going to be disenrolled from hospice, which often feels to patients and families like being expelled.

And I had a blast playing Take the Money and Run!

-@AlexSmithMD

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Today we have the honor of interviewing Susan Block, MD, one of the pioneering leaders in the fields of palliative care, particularly psychosocial aspects of palliative care. Susan led the Project on Death in America’s Faculty Scholars program, used her dual training in internal medicine and psychiatry to shine a light on psychosocial aspects of palliative care, and founded the Department of Psychosocial Care at the Dana Farber Cancer Institute and Brigham and Women’s Hospital.

We talk with Susan about how far the field has come, from early days when the attending physician would decide which patients were DNR and place a black “no code” dot in the chart. We talk about challenges facing the field today. In particular, she reminds us that when we think about the most challenging of our patient encounters, they almost always involve a complex psychosocial dynamic, and this has received far less attention than communication and symptom management issues.

We delighted to be joined by Brian Block, pulmonary/critical care faculty at UCSF and frequent guest host on GeriPal…and also nephew to Susan.

-@AlexSmithMD

Links:

-PDIA Faculty Scholars Program

-Serious Illness Conversation Guide podcast

-Therapeutic presence in the time of covid podcast

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A year ago we did our first “Deprescribing Super Special”. Today we are coming back for more (or less given the content), talking about the following articles with their lead authors:

First up, we talk with Ariel Green about her article in JAMA Network on preferred phrases a clinician may use to explain why they should reduce or stop the medication. My take home from this is that while the most preferred explanation for deprescribing statins and sedative-hypnotics is one focused on the risk of side effects, we also need to individualize it to the patient and the medication that they are taking.

Next up, we chat with Liz Bayliss about her JAMA IM article that studied whether increasing awareness about deprescribing prior to primary care visits can reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment. While the study was largely negative, it does bring up important implications about how we should think about deprescribing in older adults (added bonus too - all of the resources used in the study can be found on the US Deprescribing Research Network website).

Lastly, we talk with Kevin McConeghy about one deprescribing intervention that was hugely successful, although somewhat atypical. Kevin’s study looks at a period of time in the COVID pandemic when a large multistate nursing home provider created a “nonessential medication on hold” (NEMOH) policy in order to conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact. Although the policy was not originally envisioned as a deprescribing intervention, 54% of held medications were discontinued. That’s huge! While it’s unlikely this will be repeated, we talk about lessons we can learn from this natural experiment.

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We are fortunate today to interview two oncologists whose research has catapulted palliative care forward: Jennifer Temel, author of the landmark NEJM study on early outpatient palliative care for patients with advanced lung cancer; and Areej El-Jawahri, author of the landmark JAMA article on inpatient palliative care for patients with blood cancers undergoing stem cell transplant.

Jennifer’s study is most widely known for the “kicker” - not only did it improve quality of life, palliative care was associated with a couple months longer survival.

Areej’s study is remarkably novel in that it is, to our knowledge, the first study of palliative care during curative treatment.

We cover a huge amount of ground today, including:

• Jennifer’s reaction when she unblinded the study and found that palliative care was associated with prolonged life
• Differences between inpatient and outpatient palliative care for cancer
• What’s in the secret sauce of palliative care? (hint: coping)
• What’s the right dose of palliative care?
• Do we need separate palliative care models for each cancer?
• What is next for these two?
• Celine Dion

Additional links:

• Editorial on Areej’s study
• Palliative care in lung and GI cancers
• GeriPal post on qualitative study of the Temel RCT
• GeriPal post on “fast food” style palliative care in chronic critical illness
• JAMA paper on remote symptom monitoring in cancer

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The science of balancing safety and independence of older drivers has come a long way. Some key points from our podcast today with Emmy Betz (emergency physician-researcher) and Terri Cassidy (occupational therapist and certified driving rehab specialist) include:

• It’s no longer gouache to say “taking away the keys” - which sound punitive and risks infantilizing
• Instead the new lingo is “driving retirement”
• Driving retirement can be a process, similar to a harm reduction model, in which the activity is not eliminated all together but restricted to minimize harm: e.g. driving only during the day, or avoiding freeways.
• A JAGS randomized trial demonstrated that a free online tool that assess readiness to stop driving helped older drivers with the difficult decision about driving cessation.
• Often the work of the certified driving rehab specialist is to assess the older drivers goals, assess prognosis for driving, and help the family navigate discussions around driving cessation (hmmm…sounds like an approach to family meetings).
• There is a dearth of Certified Driving Rehab Specialists: 12 for the entire state of Colorado!

We learned this and much more, and I had a great time making engine noises singing the Woody Guthrie song “driving in my car.”

Additional Links:

(A to Z – under driving)
https://decisionaid.ohri.ca/cochsystem.html

(OT programs)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347878/

An Advance Directive for When Driving Becomes Unsafe
https://geripal.org/an-advance-directive-for-when-driving/

ADED (Association for Driver Rehabilitation Specialists)
https://www.aded.net/search/custom.asp?id=2046

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“Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You’re short on gowns and facemasks. You’re short on nurses and nurse aids so now you have to help deliver meals.”

This was the opening paragraph that I wrote in March of 2020 when introducing a podcast we did with Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond. That was his literally his life during those spring months of 2020 and it scared the hell out of me.

Lucky, Jim and many others like him were willing to come on to our podcast those first several months of the pandemic and share their experiences and lessons learned caring for COVID positive patients and their family members.

On today’s podcast, we look back to those early months of the pandemic and look forward to the future. We invited Jim back with us along with Darrell Owens, DNP, MSN, who is the head of palliative care for the University of Washington’s Northwest campus.

For those who didn't listen to our podcast with Darrell, when most of us were still trying to figure out what COVID was, he created an on call 24/7 palliative care service to have goals of care conversations with elderly patients in the emergency department under investigation for COVID, and also established an admitting inpatient palliative care service at his hospital for patients on exclusively comfort measures. What I loved about this March 2020 podcast was that Darrell pushed us to think differently:

“Expect that it’s not business as usual. Very first thing, you’re going to have to do things differently, so be open to that. Be totally open-minded. Now the old, “We’re not an admitting service or we don’t do that and we don’t do this,” don’t start with what you don’t do. Start with what you can do, what’s your capacity.

So take a walk down memory lane with us and hear from both Darrell and Jim where they think we are going.

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On today’s podcast we welcome back Haider Warraich to talk about pain. Now this may surprise our frequent listeners as we have had Haider on before to talk about heart failure as well as palliative inotropes, so why are we having him come on to talk about pain? .

Well, Haider has an intimate relationship with pain, having experienced chronic pain himself and now having dove deep into the latest research on pain for his new book The Song of Our Scars: The Untold Story of Pain.

We discussed the nature of pain, what makes chronic pain different from acute pain, what’s the difference between proprioception, pain, and suffering, and so much more. So take a listen and if you are up for it, check out some of Haider’s other books including Modern Death: How Medicine Changed the End of Life and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.

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You have a patient with dementia severe enough that she cannot recognize relatives.  She falls and breaks her hip.  Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation?  Should she be treated non-operatively, with aggressive symptom management?  A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia.

In today’s podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia.  Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what’s to be done about the pressure and incentives our health system exerts to operate, operate, operate.  

-@AlexSmithMD

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Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm. The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is:

In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer.

Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis. In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here.

Mara keeps working at it, and the more she works, the closer we are to fine.

-@AlexSmithMD

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There are a lot of old myths out there about managing urinary tract symptoms and UTI’s in older adults. For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.

On today’s podcast, we are gonna bust some of those myths. We’ve invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.

First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. We discuss with her how we should work-up and manage “urinary tract infections” (I’ve added air quotes to “UTI” in honor of Tom Finucane’s JAGS article titled “Urinary Tract Infection”—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.)

Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men. We also discuss Scott’s recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.

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In the US, geriatrics “grew up” as an academic profession with a heavy research base. This was in part due to the tremendous support of the National Institute on Aging. Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population. Palliative care, in contrast, saw explosive growth in US hospitals. In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized “home” at the National Institutes of Health. The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need.

Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care. Kate’s journey is in a way emblematic of the lack of centralized funding for palliative care: she’s received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC.

We talk with Kate about how despite how far we’ve come in palliative care research, we still don’t have answers to some fundamental questions, such as:

• Who should get specialized palliative care? Should eligibility and access be determined by clinician referral? By diagnosis? By prognosis? By need?
• If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged? Can nudges help? (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern)
• When should people get palliative care? What does “early” really mean? We can’t possibly meet the needs of all people with newly diagnosed serious illness
• How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings? What’s the role of implementation science? What is a pragmatic trial?
• What outcomes should we measure?

We cover a lot of ground! Working on a mystery. Going wherever it leads. Runnin down a dream…

-@AlexSmithMD

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We are two and a half years into the COVID pandemic. We’ve lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU’s overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the “zoom meeting.”

But what have we really learned over this seemingly endless pandemic other than how to make a quarantini? Well, on today’s podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease.

Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital. In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post. Some call her an optimist or maybe a pragmatist, but I’d call her someone who inherently understands the value in harm reduction when it’s clear harm elimination just ain’t gonna happen.

So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list:

• Medscape article on how “COVID-19 Vaccines Work Better and for Longer Than Expected Across Populations, Including Immunocompromised Individuals”
• Stat news article about variants/COVID becoming more predictable
• A good twitter criticism of the CDC 1 in 5 COVID survivors have long COVID study
• NIH study about long COVID published the day before in Annals of Internal Medicine
• Evusheld and how it works against BA4 and BA5
• Our World in Data COVID graphs

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It’s been a while since we’ve done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here). But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations. This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity. They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities. The basis of their argument is the ethical notion of “reciprocity” - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action. Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion.

To be sure, Paxlovid is no longer as scarce as it was a few months back. But the argument is important because, as we’ve seen, new treatments are almost always scarce at the start. Evusheld is the latest case in point.

Sometimes, you can’t always get what you want…

-@AlexSmithMD

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A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid). How do you do that? Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to?

Well on today’s podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead.

But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table!

Oh boy, what should we do? Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data? Listen to this spicy podcast with these wonderful guests to make up your own minds (I’m sticking with the equianalgesic table for now).

If you want to take a deeper dive into some of the references, here you go:

• Pallmed Post on why “Opioid Equianalgesic Tables are Broken”
• Pallimed post on “Simplifying Opioid Conversions”
• Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone.
• Our previous podcast with Mary Lynn titled “All the Questions You Had About Opioids But Were Afraid To Ask”

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In today’s podcast we talk with Dr. Rajagopal (goes by “Raj”), one of the pioneers of palliative care in India. Raj is an anesthesiologist turned palliative care doctor. He is also author of the book, “Walk with the Weary: Lessons in Humanity in Health Care,” and was featured in this Atlantic article. Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India. We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF. In this podcast, we cover a great deal of ground, including:

• Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn’t see addressing suffering as a priority
• Prognosis communication and the subtle ways we may communicate it without intention
• Social pain and loneliness
• Community-based palliative care networks
• Raj’s reflections on the state of palliative care in the US
• How definitions bind us, for example the division between chronic pain and palliative pain in much of the US
• Ways listeners can learn more and contribute (see this link in the US)

Because the song request was the short theme-song for Pallium, I recorded it two ways. The intro is the upbeat guitar driven version. The outro is the synthesizer (new toy!) slowed down version.

Enjoy!

-@AlexSmithMD

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Think about the last time you attended a talk on communication skills or goals of care discussions. Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice? I’m guessing not. Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life. Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored. On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care. Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF.

We talk with Nick and Meg about:

• Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals
• How to screen for hearing loss
• Communication techniques we can use when talking to individuals with hearing loss
• The use of assistive listening devices like pocket talkers and hearing aids
• Their thoughts on the approval and use of over the counter hearing aids

If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following:

• Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners
• COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers
• Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults
• Over-the-counter hearing aids: What will it mean for older Americans?
• Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic

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Comics. Cartoons. Graphic Novels. Graphic Medicine. I’m not sure what to title this podcast but I’ve been looking forward to it for some time. Heck, I’m not even sure to call it a podcast, as I think to get the most out of it you should watch it on YouTube.

Why, because today we have Nathan Gray joining us. Nathan is a Palliative Care doctor and an assistant professor of Medicine at Johns Hopkins. He uses comics and other artwork to share his experiences in palliative care and educate others about topics like empathy and communication skills. His work has been published in places like the L.A. Times, The BMJ, and Annals of Internal Medicine.

We go through a lot of his work, including some of the comics you can see on our blog post. However if you want to take a deeper dive, check out his website “The Ink Vessel” or his amazing twitter feed which has a lot of his work in it.

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In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine. In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging.

In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry.

As with aging, poetry operates on multiple levels within the palliative care space.

Poetry puts us in our patient’s shoes. As Redwing’s poem says, “why not live as long as possible?”

Poetry holds us in that liminal space so many of our patients are in. Paradox. The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I’m paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go.

Or as in Mark Nepo’s poem Adrift, I am so sad and everything is beautiful.

Poetry helps us grapple with our own experiences of illness. Redwing, who is a cancer survivor, shares poems about her experiences with cancer. Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis.

We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality.

And along the way, we really felt like we got to the heart of things. To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide.

-@AlexSmithMD

Links to Redwing’s poetry workshops:

Food for Thought Poetry for Resiliency

Loss, Losing and Loosening, poetry for grief and loss

Wounded Healer poetry sessions

Advance Care Planning

Links to Redwing Keyssar’s poetry collections

Redwing’s website: www.redwingkeyssar.com

Institute for Poetic Medicine

Mike Rabow’s Comprehensive Care Team randomized trial of outpatient palliative care

Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out).

In addition to Redwing’s own songs and poems, other poems read by Mike and Redwing during the podcast:

In Blackwater Woods by Mary Oliver

Therapy by John Wright

Adrift by Mark Nepo

Talk Before Sleep by Elizabeth Berg

Late Fragment by Raymond Carver

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Buprenorphine. It’s been around for a long time but is acting like the hot new kid in town. Just look at this year’s AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now. But does this drug really live up to the hype? On today’s podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care).

We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes).

And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles:

Learn more about caring for those with substance use disorder:

• Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness

Learn about using the low dose buprenorphine patch:

• Low-Dose Buprenorphine Patch for Pain - Fast Fact

Learn about how to initiate buprenorphine:

• Sublingual Buprenorphine Initiation: The Traditional Method - Palliative Care Network of Wisconsin
• Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach

Good review on buprenorphine for pain

• Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

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In her essay “Why Read a Poem in a Time Like This?”, Marilyn McEntyre writes:

All of us need it. We need it because good poems do something prose can’t do. They invite and enable us to notice the precarious fissures in what we think is solid ground. They direct us toward the light at the edge of things — the horizon, the fragment of dream before dawn, the feeling that’s hard to name, and can only be accurately captured by metaphor. They take us to the edge of “what can’t be said,” and ambush us into feeling before we think, so that we can’t simply and complacently “believe everything we think.” Poetry deals in surprise and subversion and turns old words to new purposes.

Marilyn is joined by Guy Micco to talk about why poetry is important in general, why it’s important in medical or nursing education, and why it’s important for people who care for older adults.

Along the way, they read poems, talk about poems, and sing a song by John Prine. We talk about how poetry can surprise, how poems can be playful, how they unlock dimensions and emotions that are otherwise locked away. How sometimes good poetry can be like a needed punch.

And maybe, just maybe, we convince that poetry skeptic Eric Widera that there is a place for poetry in medicine after all.

Enjoy!

-@AlexSmithMD

Links to essays and books by Marilyn McEntyre

• Why A Poem in a Place Like This?
• Why Read a Poem in a Time Like This?
• Patient Poets: Illness from the Inside Out
• Caring for Words in a Culture of Lies

Links to Songs/Poems from the Podcast:

• Hello in There by John Prine
• After Apple Picking by Robert Frost
• Sonnet 73: That Time of Year Thou Mayest in me Behold by Shakespear
• Jane by George Bilgere
• Long Life by Elaine Feinstein
• Sonnet 60 by Pat Schneider (not online)

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One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, “Can We Agree to Disagree?” And today our guests agree to disagree.

And yet, and yet…

They also agree across a whole range of issues, some of which surprised us.

This is the latest in our series of podcasts on concerns about, and potential of advance care planning. If you’re new to this discussion, don’t start with this podcast! Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki.

On today’s podcast we ask our guests about areas in which there might be agreement or disagreement, including:

• The Best New York style bagels are made in California.
• Assigning a surrogate decision maker is important for everyone, including those who don’t have serious illness.
• Where does POLST fit in with this debate?
• All decisions are made in advance, the question that we are debating is how far in advance and what to call it
• Completion of advance directives and billing codes for advance care planning as quality metrics

Among other topics. I’m heartened that we could have this discussion as a field, as it shows that we’ve grown to the point where we can agree to disagree respectfully with each other.

We can work it out!

Links to a few couple items mentioned on the podcast:

• Objectives for Advance Care Planning
• 2018 Systematic Review of Systematic Reviews on ACP

-@AlexSmithMD

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If you develop dementia, odds are you will spend the last months to years of your life in a nursing home or assisted living facility. While we like to think about how our goals and preferences will influence what that life looks like, including whether you will get potentially burdensome interventions, your fate is probably influenced more by factors like where you live and what nursing home you happen to end up in. On today’s podcast we dive into drivers of invasive procedures and hospitalizations in advanced dementia by talking to some pretty brilliant nursing and nurse practitioner researchers focused on dementia, geriatrics, and palliative care in nursing homes: Ruth Palan Lopez, Caroline Stephens, Joan Carpenter, and Lauren Hunt.

We start off discussing the findings of Ruth Palan Lopez's publication in JAMA IM on the ADVANCE study. This study explored nursing home organizational factors and staff perceptions that are associated with the variation in care for residents with advanced dementia. Now when I say variation, I’m not talking about small little clinically questionable variations. I’m talking about some nursing homes with no residents with advanced dementia being tube fed, and some with nearly half of their residents with advanced dementia being tube fed.

We go on to talk about other findings of this study including that staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in ACP and preferred more aggressive care, issues with the skilled nursing facility benefit (“rehabbing to death”), the palliative care needs of nursing home residents, and so much more.

For a deeper dive, check out some of these other studies and resources we talked about in the podcast:

• The Influence of Nursing Home Culture on the Use of Feeding Tubes. Archives of Internal Medicine 2010
• The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia
• Rehabbed to Death. NEJM
• Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block
• A Podcast with Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion

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A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken’s post is still one of the most searched and viewed posts on GeriPal.

This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today. Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade - what happens over the next 10, 20, 30 years?

And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation. In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission. Lauren uses her magic wand to address the measurement issue: we’re not measuring function, frailty, and cognition routinely in hospitalized older adults. We wouldn’t dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure.

Additional links:

• GeriPal podcast with Lauren Ferrante and Nathan Brummel on geriatricizing the ICU
• GeriPal podcast with Tom Gill on the Precipitating Events Study, distressing symptoms, disability, and hospice
• GeriPal podcast with Linda Fried on frailty
• Shunichi Nakagawa’s Tweet that went viral on responding a patient request to drink ice water before death.

And a note- on the podcast you’ll hear a drum track on the song (!). I’m taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills. Bear with me! I’m having fun working on these songs from home during COVID.

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There is a lively debate going on in academic circles about the value of Advance Care Planning (ACP). It’s not a new debate but has gathered steam at least in palliative care circles since Sean Morrisons published a JPM article titled “Advance Directives/Care Planning: Clear, Simple, and Wrong.” Since then there has been a lot of back and forth, with even a couple of podcasts from us, several JAMA viewpoints, and most recently a series of published replies from leaders in the field on why ACP is still valuable (see below for references). Despite all of these publications, I’m still left at a loss of what to think about it all. Most of the debate seems rather wonky, as honestly it feels like we are getting stuck in the weeds of semantics and definitions, like what counts as ACP versus in the moment decisions. But the consequences are real, from research funding dollars to health systems investment.

So in today's podcast, we have invited Juliet Jacobsen and Rachelle Bernacki to talk about what all the fuss is about. Juliet and Rachelle are two of the authors of a recent JAMA viewpoint titled “Shifting to Serious Illness Communication.”

We discuss the debate, how to think about definitions of ACP vs serious illness communication, what should go into high quality conversations, the evidence for and against any of this, and ultimately where we go from here.

Also see the image from Alex’s forthcoming editorial in JAGS, a Venn diagram of advance care planning and serious illness communication (please go to GeriPal.org to view the image).

So check out the podcast and if you are interested in diving into this debate, here are some great links to learn more:

• What’s Wrong With Advance Care Planning? JAMA 2021
• Controversies About Advance Care Planning. JAMA 2022 (a reply to the above)
• Shifting to Serious Illness Communication. JAMA 2022
• Our podcast with Sean Morrison titled “Advance Care Planning is Wrong”
• Our podcast with Rebecca Sudore and Ryan McMahan titled “Advance Care Planning is So Right”
• Our podcast with Rachelle Bernacki and Jo Paladino on the Serious Illness Conversation Guide

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My mom is an Asian woman in her 70s with osteoporosis. She tried an oral bisphosphonate and had horrible esophagitis. She said never again, though she eventually tried an IV bisphosphonate. She had terrible flu-like symptoms. She said never again. But based on reports that symptoms are worse the first time, she tried the IV again the next year and fortunately experienced no symptoms. (Story used with permission, thanks mom!). I tell this story because these issues don’t typically register as more than a nuisance for clinicians, who frequently don’t understand why their older patient with osteoporosis is not taking a bisphosphonate. But our patients are walking with their feet, and adherence to bisphosphonates for osteoporosis is poor and decreases with time.

When we have a medication with up front harms and downstream benefits, it’s critical that we consider the time to benefit, or how long it will take an individual to benefit from a test or treatment. Think of the 10 years it takes to benefit from colon or breast cancer screening, which is designed to detect slow growing cancers. For individuals with a life expectancy less than the time to benefit, the up front harms outweigh the downstream benefits.

In this context, we talked this week with James Deardorff and Sei Lee about their study of time to benefit of bisphosphonates for osteoporosis, published in JAMA IM. What they found somewhat surprised us: it’s pretty short, about 1 year!

Which makes me feel better about urging my mom to get treatment. Bisphosphonates are pretty darn effective, and act quickly.

We also discuss discontinuing bispohsophantes, and if we can use the same logic we consider when starting them.

Toward the end we talk about the launch of ePrognosis’ new Time to Benefit tool. This tool provides a clinical recommendation for starting/stopping medications and cancer screening based on the prognosis of the patient in front of you. See screenshot below. You can either access it directly here. I you use the Lee Schonberg prognostic index for community dwelling older adults you will be directed to the tool, and it will automatically place the life expectancy at the calculated prognostic estimate.

James and Sei requested a terrific song - Bad to the Bone - much better than the Hannah Montana Bone Dance song they threatened me with (maybe next time).

Enjoy!

-@alexSmithMD

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This week many of our listeners will gather for the annual American Academy of Hospice and Palliative Medicine (AAHPM) & Hospice and Palliative Nursing Association (HPNA) annual meeting. While the majority of this meeting is focused on subspecialty care in the US, the majority of individuals who are in need of palliative care live in low and middle-income countries without even basic access to palliative care. On this week's podcast, we talk with three leaders in helping improve palliative care worldwide: Kathy Foley, Stephen Connor, and Eric Krakauer. I don't think I can really sum up these three guests in a sentence each, but I’ll give you how we introduced them in our podcast. Kathy Foley is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative (IPCI). Stephen Connor is a licensed clinical psychologist and executive director of the Worldwide Hospice and Palliative Care Alliance. Eric Krakauer is an Associate Professor of Medicine and of Global Health & Social Medicine at Harvard Medical School, an attending physician in the Division of Palliative Care & Geriatrics at Massachusetts General Hospital, and a former medical officer for palliative care at the World Health Organization.

The podcast tries to cover a lot of topics including:

• Why is addressing worldwide needs of palliative care important?
• What are the needs of palliative care worldwide?
• How do you quantify worldwide suffering and what is the serious health related suffering index?
• What are some of the main barriers to palliative care?
• What are the models of palliative care worldwide?
• What are some of the resources to improve palliative care?

I encourage you to take a listen, and if you want to learn more check out some of these resources:

• Worldwide Hospice Palliative Care Alliance (WHPCA)
• Open Society Foundation’s International Palliative Care Initiative
• Global Atlas of Palliative Care
• International Association for Hospice and Palliative Care
• JPSM’s issue on the The International Palliative Care Initiative
• eHospice - a globally run news and information resource

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In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness. We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University. We discuss:

• What are the differences between structural, institutional, and interpersonal racism?
• Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest’s personal experiences.
• The importance of attention to religion and spirituality
• Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities
• How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making.
• Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference).
• Co-opting of disparities issues by the Alzheimer’s Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here). Action Item: Please submit a comment to CMS about aducanumab coverage today. Feel free to express your outrage at the lack of diversity in the trials.

We could have continued talking with our guests for hours. We will continue to address the issue of racism in future podcasts.

-@AlexSmithMD

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Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant. Outcomes are worse among those who are frail. Symptoms are common, including pain, ascites, encephalopathy, and pruritus. Patients with end stage liver disease are often some of the most disadvantaged patients we care for. Caregiver burden is immense; divorce is common. Some will go on to receive a transplant, but many will not. Many are confused about the diagnosis and feel poorly supported. Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list. Advance care planning is rare (or serious illness communication for those of you who don’t consider this advance care planning). Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain. In this week’s podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective. We talk about the tension patients face between putting on the “best face” to be listed for transplant (e.g. full code, goals focused on extending life). We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease. We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance.

And…Radiohead! Great request…thank you Nneka!

-@AlexSmithMD

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More Health Policy this week! Today, we discuss “SNPs” but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life.

We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society).

We discuss:

• Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients
• What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new “Hospice Carve-In”

This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick’s and Dr. Rick Gilfillan’s critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients.

Alex plays The Purchaser’s Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl’s dog.

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Investor money and venture capital funding is pouring into Medicare Advantage (MA) plans. Enrollment in MA plans has more than doubled from 12 million members in 2011 to 26 million in 2021. What does this mean for us and our patients? Do these plans deliver better care for vulnerable older adults? Or are they a money making machine driving up healthcare costs in the name of profit?

On today’s podcast, we are joined by UCSF geriatrics fellow Alex Kazberouk to talk with Dr. Don Berwick (founder of the Institute for Healthcare Improvement, former administrator of Center for Medicare and Medicaid Services) and Dr. Richard Gilfillan (former CEO of Geisinger Health Plan and Director of the Center for Medicare and Medicaid Innovation). Their recent two part post on the Health Affairs Blog about the Medicare “Money Machine” has stirred up a debate about challenges and misaligned incentives within Medicare Advantage.

We talk about:

1. What Medicare Advantage is all about - its history, operations, potential benefits, and what it means for us and our patients
2. Rick and Don’s Health Affairs post on the downsides of MA plans and the Medicare “Money Machine”
3. Policy solutions to improve the system without throwing the baby out with the bathwater

We also touch upon prior podcast topics such as the area deprivation index and population health. As a special, Alex plays a superb rendition of this song which is definitely not a Rickroll.

This is part one of a two part series on Medicare Advantage and healthcare financing. We have a follow-up with Claire Ankuda and Cheryl Philips on Special Needs Plans and the Medicare Advantage Hospice Carve-In coming soon.

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Three months ago we did a podcast with Randy Curits about his recent diagnosis of ALS in March and what it was like for someone who studies and cares for people living with serious illness, to now be someone who is living with serious illness. It was one of our favorite podcasts we’ve done, but also got us to think “wait, how come we’ve never done a podcast on ALS?”

We fix that on today’s podcast. We’ve invited Elizabeth Lindenberger and Kara Bischoff to talk about what every geriatrician and palliative care clinician should know about ALS.

Topics include: prognosis in ALS, disease modifying therapies (and when/if to discontinue, advance care planning in ALS, the role of embedding geriatrics/palliative care in ALS clinics, interventions in ALS (noninvasive ventilation, PEG tubes, and trachs), and symptom management as the disease progress.

So take a listen and if you want to take a deeper dive, take a look at these articles:

• Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned
• Top Ten Tips Palliative Care Clinicians Should Know About Amyotrophic Lateral Sclerosis

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It’s GeriPal’s 200th episode. Yup, we started the podcast in 2016 and over the years we have grown from basically podcasting for Alex’s mom to now getting over 25,000 plays per month.

So to celebrate our 200th, and given that the last two years kinda sucked in a lot of ways, we are going to pivot to appreciative inquiry. We have invited leaders in geriatrics and palliative care to quickly share:

1. One thing that you are grateful for in Geriatrics and Palliative Care (other than GeriPal!)
2. One thing you are hopeful for in 2022

The guests we had were an awesome group that included Rachelle Bernacki (@rbernack), Kim Curseen (@Curseen), William Dale (@WilliamDale_MD), Helen Fernandez (@hfernandez01), Lynn Flint (@lynnmomdoc), Anne Kelly, Allison Kestenbaum (@ARKestenbaum), Christopher Langston (@calangst), Nancy Lundebjerg (@nlundebjerg), Mary Lynn McPherson (@mlmcpherson), Sean Morrison, Christine Ritchie (@RitchieCS), Christian Sinclair (@ctsinclair), Wendy-Jo Toyama(@WJSvetanoff), James Tulsky (@jatulsky), and Haider Warraich (@haiderwarraich).

We also invite you to join us in this discussion. Go to either our Twitter account or youtube channel and share your answers to these two questions.

Eric

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Geriatric Oncology has arrived. Yes, Louise Walter has been leading the fight to improve cancer screening in older adults for years. But when it came to geriatricizing the way we assess and treat older adults with cancer, the evidence was thin. In our prior podcast with Supriya Mohile and William Dale on geriatric assessment in oncology, we couldn’t say for certain if a geriatric assessment was helpful for patients with cancer. Well now we can.

We are joined by Melisa Wong, a geriatric oncologist, and Louise Walter, a geriatrician and leader in cancer screening for older adults, to talk about the shifting landscape of geriatric oncology, including:

• How to think about cancer screening in older adults, moving beyond a one-size-fits all age-based approach to individualize cancer screening decisions. We also talk about the importance of thought pieces in driving a field forward.
• 2 landmark trials of the geriatric assessment in oncology, one in JAMA Oncology (first author Daneng Li) and the other in the Lancet (first author Supriya Mohile) (William Dale senior author for both studies). In both studies, grade 3+ toxicity was reduced in the geriatric assessment arm.
• Melisa Wong’s study in JAGS finding a constriction of life space for older adults with cancer, and discussion of patient centered outcomes beyond traditional outcomes such as grade 3+ chemotherapy toxicity.

Links of Interest:

• Association of Community Cancer Center site on Geriatric Oncology
• Cancer and Aging Research Group

And as a bonus, you get to hear Louise on piano and vocals and I cover Wouldn’t It be Loverly, from My Fair Lady.

-Enjoy!

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Geriatric anesthesia is a thing. The average age of people getting surgery is increasing. Anesthesiologists and surgeons feel that with new techniques and approaches they can perform surgery on patients at ever older ages, patients who they previously would have excluded from surgery.

One of the key advances in geriatric anesthesia is the use of spinal anesthesia, a form of regional anesthesia that also includes epidurals and peripheral nerve blocks. When older adults experience a hip fracture, there’s a growing consensus that spinal anesthesia offers superior outcomes compared to general anesthesia.

It’s surprising therefore, to talk with Mark Neuman about the results of his randomized trial in NEJM, which finds essentially no difference between general anesthesia and spinal. Importantly, as a primary outcome Mark selected walking ability based on feedback from older adults - this is the outcome our patients care about most. But he finds no difference in primary outcome or secondary outcomes, including (surprisingly) delirium.

We break down potential reasons, with thoughtful commentary from Liz Whitlock and Cindy Hsu, two anesthesiologists with experience caring for older adults with hip fracture. Liz is a friend of the pod and researcher who we interviewed previously about “pumphead.” Cindy is...my wife. She also helps me out with the accompaniment on piano as it’s tough for me to play guitar with a broken clavicle. Thank you dear wife! We had fun learning to play/sing Drivers License by Olivia Rodrigo. Ah...teen angst...the angst!!!

-@AlexSmithMD

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The great resignation is upon us. One in five health-care workers has left their job since the pandemic started. Geriatrics and palliative care are not immune to this, nor are we immune to the burnout that is associated with providers leaving their jobs.

In today’s podcast, we talk with Janet Bull and Arif Kamal about what we can do to address burnout and increase resiliency, both from an institutional and individual perspective. Janet Bull is the Chief Medical Officer and Chief Innovations officer at Four Seasons Hospice and Arif Kamal is an oncologist, palliative care doctor and researcher at Duke.

We discuss Arif’s and Janet’s article published in JPSM on the prevalence and predictors of burnout among hospice and palliative care clinicians, as well as Arif’s Health Affairs article on the policy changes that are key to promoting sustainability and growth of specialty palliative care workforce. In that later article, Arif found that among many things:

• Burnout was reported by approximately one-third of physicians, nurses, social workers, and other respondents in the specialty of hospice and palliative care
• The presence of burnout was associated with increased odds of intending to leave early

If you want to learn more about what you can do to promote wellness on your team, check out this article Arif published with other colleagues in JPSM titled the “Top Ten Tips Palliative Care Clinicians Should Know about Implementing a Team Wellness Program.”

Eric

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I don’t consider myself spiritual. For some in palliative care, this would be considered heresy as we are told “everyone is spiritual.” But, hey, I’m not. So there. However, despite not being spiritual, I do believe that spiritual care is fundamental to the care I give patients and families. I also recognize it is the one palliative care domain I am most uncomfortable with and the one that as a field, we actually don’t support very well (odds are, if your palliative care team doesn’t have a full interdisciplinary team, the discipline you are likely missing is chaplaincy).

So, on today’s podcast, we break down spiritual care in palliative care with three leaders in the field: Allison Kestenbaum, Katy Hyman, and Paul Galchutt. We ask these experts a veritable smorgasbord of questions on spiritual care that includes:

1. What the heck is spirituality and is the term itself inherently religious?
2. What is the difference between a “spiritual care history” vs “spiritual screening” vs a “spiritual assessment” and why does it matter
3. What do you do if your spiritual screen or assessment uncovers something?
4. How do we ask our patients if they would like to see a chaplain? Should we ask or just like any of our other team members just have them stop by?
5. What does spiritual care for the non-religious look like?
6. What are some specific communication tips to take a deeper dive into patient/family/caregiver suffering.
7. Can you research spirituality?

Also, for all you palliative practitioners and researchers, here is a link to freely join the Hospice-Palliative Spiritual Care Research Network (HPSCRN) with Transforming Chaplaincy The HPSCRN is a space to connect, inform, explore, and coordinate for all interprofessionals.

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Though “breath” is in the title of Wes Ely’s book (and his song choice by the Police), relationships are its beating heart.

The book operates on two levels.

On one level, Wes Ely’s book is an autobiography of a critical care doctor’s horror and shame at discovering that his ICU practice of heavily sedating patients for days on end was leading to lifelong physical, cognitive, and psychological harm; and the arc of his redemptive journey to find a better way to care for patients in the ICU.

But this book also operates on a second, much deeper level. On this deeper level the book is a story of Wes Ely’s journey toward rediscovering the humanity in medicine by forging deep, lasting connections with his patients. We begin and end today’s podcast at this deeper level, talking about the spiritual connections, that doctors can forge caring for critically ill patients. (quick plug: next week’s podcast is with Chaplains on Spirituality and Palliative Care).

We are joined today by Lekshmi Santhosh, head of UCSF’s post-COVID and post-ICU clinic, to interview Wes about these themes that animate his book, and more, including how we lost our way in treating ICU patients during COVID, returning to the practice of heavily sedating patients for days on end.

Of note, Wes is donating proceeds from his book to the CIBS center, to benefit research and patient care to improve care for people with critical illness, during and after the ICU stay.

-@AlexSmithMD

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Anyone who cares for individuals with serious illness must live in a messy space where tough conversations about treatment decisions are common and complicated.

On today’s podcast we talk with James Tulsky about living in this messy space of medical decision making and the challenges that come with communication around advanced treatment decisions.

We talked about James’ path to the work that he has done, including early studies he did that included audio recording DNR discussions between physicians and patients, to his most recent study looking at the “Triadic agreement about advanced cancer treatment decisions.”

In this last study, James’ group surveyed 70 triads of patients, caregivers, and their oncologists shortly after making a cancer treatment decision and found that only 40% of triads completely agreed on the goal of treatment. In all of the remaining cases, at least one member of the triad disagreed about the goal of treatment.

So take a listen and also check out this wonderful ACP article that James did with Joshua Lakin and Rachelle Bernacki titled “Time Out Before Talking: Communication as a Medical Procedure” which we also discuss on the podcast.

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“The secret sauce of the Transitions, Referral and Coordination (TRAC) team was including a lawyer.” This is brilliant and will ring true to those of us who care for complex older adults who end up in the hospital for long, long, long admissions.

On today’s podcast we talk with Kenny Lam, Jessica Eng, Sarah Hooper, and Anne Fabiny about their successful interdisciplinary intervention to reduce prolonged admissions, published in NEJM Catalyst. Many of the problems that older adults face are not medical. How to find housing. How to stay in their homes. How to get a paid caregiver to help them stay at home. How to get someone to pay bills. How to assign a surrogate health care decision maker. The legal obstacles to accomplishing these tasks for complex older adults, particularly those who may have marginal decision making capacity, can seem insurmountable. Having a lawyer on the team is brilliant - in much the same way that having a handyperson on the team for project CAPABLE to keep people at home was brilliant. For more, listen also to our prior podcast with Sarah Hooper on medical-legal partnerships.

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Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure. Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain. But these outcomes represent a thin view of the human experience. What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose. Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales.

In this week’s podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities. Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression’s ability to participate in meaningful activities. Most people think that a good quality of life isn’t possible for people with these conditions. Anna’s study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities.

Theresa’s qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same. Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities. Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care.

-@AlexSmithMD

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The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD). Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE? Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials?

In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab:

Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions.

Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab.

For more podcasts on aducanumab, check out these two:

• All things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici
• Aducanumab (Aduhelm) for the Treatment of Alzheimers: A Podcast with Aaron Kesselheim and Jason Karlawish

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“The take home message of this study is NOT that primary palliative care does not work.” So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer.

And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts) - is it time to start to question the effectiveness of primary palliative care?

We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness. But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is “good enough” to impact outcomes.

That’s one interpretation. Another is that we need a “stronger dose” of primary palliative care. In Yael and Bob’s study nurses averaged 2.2 visits, hardly robust longitudinal palliative care. Patients who had 3 visits had better outcomes.

Unpacking negative studies is just as interesting as unpacking positive studies. Knowing what doesn’t work is just as important as knowing what does.

Links:

• Negative multi-national study of primary palliative care in nursing homes
• Negative ICU primary palliative care intervention
• Project ENABLE
• Podcast on palliative care’s diversity problem
• Systematic review of palliative care

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Time-limited trials. We’ve all probably used them before. We meet with patients and families. We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments. If not, we stop them. At least that is how it’s supposed to go.

On today’s podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter. Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units. Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire.

We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive. The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention). We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast).

If you want to read more about time-limited trials, check out these articles as well:

• Paula Spans NY Times article on Time limited trials titled “I need to know I tried”
• The JAMA IM study and editorial on time-limited trials
• Tim Quill and Robert Holloways article in JAMA on Time-Limited Trials from 2011
• And lastly our nudging podcast that we brought up several times

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I’m going to start this introduction the way Eric ended our podcast.

You are a GeriPal listener. Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness. This is hard, complex, and deeply important work we’re engaged in. Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice? We will assume that you are doing the same right now if you haven’t done so already, though we suppose you are free to choose not to if you don’t believe in the mission of helping seriously ill older adults.

Ha! Gotcha.

Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of “nudging,” or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice. Jenny just published a terrific book on the topic, “Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.” Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. “In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?”).

Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I’m a believer in the GeriPal mission too, we’re on the same side), appealing to ego (you’re a good person because you believe in an important cause), and changing the defaults (you’re giving us a five star rating right now unless we hear otherwise).

We distinguish between nudges and coercion, mandates, and incentives. We talk about how clinicians are constantly, inescapably nudging patients. We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.

Nudges are powerful. At best, nudges can be used to promote care that aligns with a patient’s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote “doctor knows best” paternalism, and to “strongarm” patients into care that doesn’t align with their deeply held wishes.

What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don’t have deeply held preferences, goals and values? Hmmm....

Hey, have you completed your five star rating of GeriPal yet?

-@AlexSmithMD

Other citations:

-Randy Curtis and Robert Burt on unilateral DNR and informed assent

-GeriPal podcast with Angelo Volandes about using video to improve choices

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Randy Curtis, a paragon of palliative care research, was diagnosed with ALS in March.

Randy is in a unique position as someone who studies and cares for people living with serious illness, who now shares his reflections on being on the other side, to reflect on the process of living with serious illness. His reflections are illuminating and inspiring.

We talk with Randy about his experience being in the patient role, rather than the physician or researcher role. We ask if knowing the prognosis for his subtype of ALS is helpful to him, and if he’s seeing a palliative care clinician. We talk with Randy about his legacy, principally his focus on mentoring. We talk about how his approach to his life, his clinical work, and research has shifted in the face of living with serious illness. We end by talking about our favorite “Randy Curtis” studies.

Thank you Randy for modeling vulnerability and willingness to talk about ALS. Thank you for your mentoring which has nurtured a veritable forest of trainees, and for your research which has improved care for people living with serious illness and their families.

And here’s to your song choice: a “good life” indeed, by any measure.

Links:

-Prior GeriPal podcast with Randy Curtis on an earlier study of the JumpStart patient-priming intervention for goals of care discussion

-ICU family meetings: Increased proportion of family speech is associated with increased satisfaction

-Alterations in translated ICU family meetings

-A communication strategy and brochure for ICU family meetings

-Practical guidance for ICU family meetings

-Empathy in life support decisions

-Cambia Center of Excellence for Palliative Care Research

-Cambia Sojourns Scholars Leadership Program

-@AlexSmithMD

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alliative care has a diversity problem. The workforce of palliative care looks nothing like the patient population that we care for in the hospital and in our clinics. For example, in 2019-2020 academic year only 4% of Hospice and Palliative Care fellows identified as black, compared to 12% of the overall US population using the most recent census information. These issues are similar for hospice and geriatrics.

On today’s podcast we talk about this diversity problem with Lindsay Bell, Tessie October, and Riba Kelsey. Lindsay, Riba, and Tessie recently published an article in JPSM that found that trainees at historically black colleges and universities and residents at institutions with the highest percentage of black medical students lack access to palliative care training.

Riba Kelsey is the Family Medicine residency director at Morehouse School of Medicine, and we talk with her about the implications of these findings at historically black colleges and universities (HBCUs), as well as what we can do in the field of palliative care in general to improve our workforce issues.

One shining example we discuss in depth is the ongoing collaboration between the University of Pittsburgh Palliative care group and Morehouse School of Medicine. We hope that collaborations like these will lead to a wider pipeline of palliative care informed trainees from diverse backgrounds, and someday soon, greater diversity in the palliative care workforce.

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Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients. Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different. She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other.

There are many reasons this essay likely touched so many people (it seemed to be all over Twitter). One is that there’s a silence around this experience of death. Krista’s essay opens up a space to talk about it. Another is that the experience of grief is in fact universal, whether it’s the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of “a return to normal” following COVID.

Krista wanted to add a couple of things not mentioned in the podcast that she found helpful. First, she treasures videos she has of her loved ones recorded before death. Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck.

We talk with Krista about these and many other things on this week’s podcast. Let’s keep the conversation going.

Links:

• Making Space for Grief in Academia, JAMA
• The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs
• Live Discharge from Hospice Isn’t Graduating - It’s Getting Expelled, JAGS
• Griefcast podcast
• RadioLab: The Queen of Dying Podcast
• The Dougy Center Grief Out Loud Podcast
• On Being Podcast
• The Five Invitations by Frank Ostaseski
• Resilient Grieving by Lucy Hone
• The Art of Losing (poems)
• When Things Fall Apart by Pema Chodron

-@AlexSmithMD

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Today’s podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings.

Why are we doing a podcast on #academiclifehacks? You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation. As part of this award he presented a talk titled "Confessions of an Unfocused Researcher." We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex’s award and talk about some of the topics he brought up in his talk, as well as other tips and tricks.

So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine. In particular we focused on several key issues that new faculty need to address as they start their careers including:

• Academic focus and goals
• Mentorship (and mentoring up)
• Academic scholarship & writing
• Collaboration & Networking
• Work / Life Balance

We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet.

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“Loneliness is different than isolation and solitude. Loneliness is a subjective feeling where the connections we need are greater than the connections we have. In the gap, we experience loneliness. It’s distinct from the objective state of isolation, which is determined by the number of people around you.” - Vivek Murthy, two time (and current) Surgeon General.

We have heard a lot about loneliness and social isolation, particularly during the pandemic with enforced social distancing and near imprisonment of older adults in nursing homes. In this context, we bring in two experts on these topics, Carla Perissinotto and Ashwin Kotwal, to explain:

• How loneliness and social isolation overlap and are distinct
• How common these measures of social well being are in geriatrics and palliative care
• Why we should care as clinicians
• How we can ask about them
• How we should respond to care for patients who are lonely or isolated

Some key references from among the many we discuss on the podcast:

• Loneliness in older adults predicts functional decline and death (JAMA IM 2012)
• The epidemiology of loneliness and social isolation during the last years of life (JAGS 2021)
• Use of high risk medications among lonely older adults (JAMA IM 2021)
• Integrating social care into healthcare: GeriPal podcast with Kirsten Bibbens-Domingo
• Coalition to end social isolation and loneliness

-@AlexSmithMD

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On June 7th, 2021 FDA approved the amyloid beta-directed antibody aducanumab (Aduhelm) for the Treatment of Alzheimers. This approval of aducanumab was not without controversy. Actually, let me restate that. The approval of aducanumab was a hot mess, inside a dumpster fire, inside a train wreck.

After the approval, three members of the FDA advisory panel, which unanimously was not in favor of the approval of aduhelm, quit. One of them, Aaron Kesselheim (who we have on our podcast today) described it as “the worst drug approval decision in recent U.S. history" in his resignation letter. Then the FDA had to revise the label one month after publishing it because the original didn't even come close to looking like the population in which treatment was initiated in clinical trials. Then, wait for it, after a firestorm of criticism the FDA’s commissioner had to ask for an independent investigation to look into the interactions between Biogen representatives and FDA members. And now CMS is deciding if and how to cover Aduhelm, a drug that will cost at least $56,000 a year per patient not incluiding the doctor’s visits, amyloid PET scans, and frequent MRIs that will be necessary to monitor for side effects.

On today's podcast we talk all about aducanumab with Aaron Kesselheim, Professor of Medicine at Harvard Medical School and previous member of that now famous FDA advisory committee, as well as Jason Karlawish, Professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine.

I’d love to point you to the journal articles for the two phase III trials on aducanumab, but as of yet, they are unpublished (this should tell you a little about the faith Biogen has on its drug data), so I’ll leave you with these resources instead:

• Our podcast with Gil Rabinovici on “All things Amyloid, including Aducanumab and Amyloid PET scans”
• AGS’s preliminary advice on prescribing Aducanumab -
• Jason Karlawish’s book, The Problem of Alzheimer's, and the previous podcast that we did on it
• FDA’s document dump on Aduhelm
• Biogen’s open letter to the Alzheimer’s disease community complaining about the
  “turn outside the boundaries of legitimate scientific deliberation” that has occurred with aduhelm (while ignoring the fact that the trials have not been published yet).
• CMS’s request for public comment for their National Coverage Determination analysis to determine whether Medicare should cover the drug and any other monoclonal antibodies directed at amyloid

The last one is particularly important as whether you are for or against the coverage of aducanumab, your voice matters. There is a letter being circulated by physicians who care for people with Alzheimer's Disease urging CMS not to cover aducanumab given the limited clinical evidence for benefit, known harms, and exorbitant cost. You can find the letter here. If you would like to sign the letter, you can add your name by clicking this link.

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Cannabis use by older adults has increased substantially over the last decade, a trend that has paralleled the legalization of its use for medical and recreational purposes. In that same time, there has been a decreased perceived risk associated with cannabis use in older adults as noted in a recent study published in JAGS.

On today’s podcast we talk with Drs. Bree Johnston and Ben Han about what the health care providers role is in cannabinoid prescribing and advising when caring for older adults.

We try to cover a lot in this podcast, including some of these topics:

• Epidemiology of cannabis used by older adults (including aspects of the JAGS study)
• The basic pharmacology and dosing of cannabinoids
• The latest evidence for the efficacy of cannabis
• Specific risks and side effects that providers should be aware about, and how we should monitor patients using cannabinoid products
• Drug interactions we should be aware about

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In a new study in JAGS, Matthew Growdon found that the average number of medications people with dementia took in the outpatient setting was eight, compared to 3 for people without dementia.

In another study in JAGS, Anna Parks found that among older adults with atrial fibrillation, less than 10% of disability could be explained by stroke over an almost 8 year time period. She also talked about the need for a new framework for anti-coagulation decisions for patients in the last 6 months of life, based on an article she authored in JAMA Internal Medicine with Ken Covinsky.

In today’s podcast we talk with Matthew and Anna, joined by co-author Mike Steinman, to talk about polypharmacy, deprescribing, where we are and what we need to do to stop this freight train of ever more medications for older adults and those living with serious illness.

We start by addressing the root cause of the problem. Clinicians want to “do something” to help their patients. And one thing we know how to do is prescribe. It’s much harder psychologically for clinicians to view deprescribing a medication as “doing something.” This attitude needs to change. It will take teamwork to get there, with robust involvement of pharmacists, and likely activating patients to advocate for themselves.

And Eric might have mentioned aducanumab a time or two…

-AlexSmithMD

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Older adults often turn to institutional settings like nursing homes when they need more help than they can get at home. However, since the 1970s, there has been a program that allows older adults to receive nursing home-level care outside of nursing homes. That model of care is known as the Program of All-inclusive Care for the Elderly, or PACE.

On today’s podcast, we discuss PACE with two leaders in the PACE community, Dan Drake and Jay Luxenberg. Dan is the President and CEO of Trinity Health PACE, the second largest provider of PACE in the country, and Jay is the Chief Medical Officer of On Lok, the very first PACE demonstration site in the nation.

We talk with Dan and Jay about all things PACE, including:

• What is PACE and what is included in it that makes it able to care for nursing home level care in peoples homes?
• How is PACE paid for, what does it need to cover, and who is eligible?
• How did PACE start and what’s the evidence that it works?
• What are the challenges to PACE implementation and what do they think the future has in store for PACE?
• Why should you work at a PACE program?

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We have made remarkable progress in reducing the use of feeding tubes for patients with advanced dementia. This has been due to the leadership of people like Susan Mitchell and Joan Teno, among others. One might hope that this reduction in use of feeding tubes has been in part due to advance care planning discussions that helped align care and treatment with patients goals.

How then, do we explain the concerning findings in a pair of recent papers demonstrating high rates of mechanical ventilation among patients with dementia? In today’s podcast, we talk with Rashmi Sharma, who in JAGS found that rates of mechanical ventilation rose from 4% to 12% among whites with advanced dementia and 9% to 22% among blacks between 2001 and 2014. One in five blacks with advanced dementia admitted from a nursing home received mechanical ventilation. That’s startling.

And Zhi Jia found in a Medicare sample that Asians were more likely to receive mechanical ventilation than whites, and disparities were higher for older Asians with dementia compared to cancer.

We have made progress, due to the leadership of GeriPal superstars. But even as we make progress in feeding tubes, it doesn’t seem to have translated across the board to mechanical ventilation, a burdensome and potentially non-beneficial treatment for patients with dementia. The fact that rates are highest among older blacks and Asians is particularly concerning. Though the reasons behind this are complex, it’s likely that structural racism plays a major role in these growing inequalities.

We have more work to do.

-@AlexSmithMD

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While palliative care most traditionally grew up with a strong association with cancer care and end-of-life care, more and more evidence is coming out about how to integrate palliative care into a variety of serious illnesses from heart failure to chronic lung conditions. Another emerging field is the integration of neurology and palliative care, something that has been coined as “neuropalliative care.”

We had Benzi on a previous GeriPal podcast to talk about palliative care in Parkinson's disease. On this week’s podcast we go much deeper into the field of neuropalliative care by inviting leaders of the new field and in the International Neuropalliative Care Society (INPCS), Benzi Kluger, Edward Richfield, and Christine Ritchie. INPCS connects clinicians, researchers, interdisciplinary team members, people living with neurological illness, family members, and advocates at the intersection of neurology and palliative care.

In addition to talking about why INPCS was developed, we talk with these leaders about:

• What are the unique palliative care needs of patients with neurological conditions and their family members?
• Do we really need a society focused on a subspecialty in palliative care and do we need it for every subspecialty in palliative care?
• How can palliative care be integrated into neurology practice?
• What are the gaps in the field of palliative care when addressing the needs of patients with neurological diseases?
• What are some key lessons learned doing neuropalliative care on how to care for patients with neurological diseases?

One other big shout out too for INPCS is for their inaugural Annual Meeting on November 4-6, 2021. The online conference will offer attendees the opportunity to learn from experts, hear updates in practice patterns, review the state of the science in neuropalliative care, and network with others interested in this growing field. Best part, it’s free! So sign up.

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What if there was a tool that could break down a neighborhood’s socioeconomic measures, like income, education, employment and housing quality, to give us a sense of how those factors influence overall health, and maybe even inform where to target health resources and social interventions.

On today’s podcast we talk with Dr. Amy Kind from the University of Wisconsin School of Medicine and Public Health, who developed that tool, the Neighborhood Atlas. The Neighborhood Atlas uses the “Area Deprivation Index,” which includes 17 measures of education, housing quality and poverty, and can be used free by anyone by going to the Neighborhood Atlas website (https://www.neighborhoodatlas.medicine.wisc.edu/).

In addition to talking with Amy about the Atlas, we discuss some of the following questions:

• What is neighborhood disadvantage and what health outcomes is it linked to?
• How should providers use neighborhood disadvantage when caring for patients?
• How should health care systems use neighborhood disadvantage?
• How does the Atlas also identify areas of resilience in communities?

So take a listen and if you want to read more about it, check out Amy’s NEJM article on the topic - https://www.nejm.org/doi/full/10.1056/NEJMp1802313

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Harm reduction, as so clearly described by our guest Monica Gandhi on this podcast, began as a public health approach that guided management of HIV. Harm reduction represented an alternative to an abstinence-only approach, which clearly did not work. In the harm reduction model, you acknowledge that people will take some risks, and that the goal is to decrease risk, not eliminate it.

And yet, here we are with a fear-not-facts approach to the COVID-19 pandemic. Some are advocating for the use of masks in schools, hospitals, and nursing homes in perpetuity. As in, forever. Sounds eerily like an abstinence-only approach, right? Science would dictate that now that we have vaccines, which Monica describes as “the solution,” we don’t need to engage in masking (with a few exceptions).

Monica Gandhi, an infectious disease doctor at UCSF, has advocated strongly for a fact-based approach to school opening, early masking and now dropping masking, and global access to vaccinations (and temporarily dropping vaccine patents), among other things. You can and should follow her: @MonicaGandhi9

And from Ashwin Kotwal, geriatrician and palliative care doc-researcher, we hear about experiences caring for patients who are afraid to return to normal after a year of masking and forced isolation, despite the toll these experiences have taken on them (documented in his recent paper in the Journal of the American Geriatrics Society).

It’s time to get back where we once belonged. (song choice hint)

-@AlexSmithMD

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In your clinical experience, you may have cared for patients receiving palliative chemotherapy and wondered, hmmm, why is that called “palliative” chemotherapy? We’ve written about this issue previously here at GeriPal (“a term that should be laid to rest”) as has Pallimed (“an oxymoron”).

Well, now we have “palliative” inotropes for people with heart failure. And we have to ask, is this a fitting term? And the answer is...complex...more so than you might think. Recall that in one of our earliest podcasts, we talked with Nate Goldstein who memorably proclaimed “the best palliative care for heart failure is treatment for heart failure.”

To unpack the issue of palliative inotropes, we welcome back Haider Warraich, a cardiologist with a strong interest in palliative care. We are joined again by Anne Rohlfing, palliative care fellow at UCSF who spent last year as a hospitalist on the heart failure service.

Please tune in to hear more about the role of palliative care in inotrope therapy, inotropes in hospice, Haider’s study on palliative needs of patients with heart failure, and a bit about Left Ventricular Assist Devices (including a shout out to Dan Matlock’s decision aids) and Haider’s Journal of Palliative Medicine paper on top 10 tips for palliative care clinicians on caring for patients with LVADs.

-@AlexSmithMD

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What is a care manager? In this week’s podcast we talk with Chanee Fabius, who after a personal experience caring for a family member with dementia, became a care manager. Chanee explains in clear terms what a care manager is, what training is required, and what training is required. In essence, a care manager is a “glue person” who hold things together.

After observing major race/ethnic disparities in caregiving, Chanee was inspired to obtain a doctoral degree in gerontology, and her research is now directed toward reducing disparities in caregiving, particularly for patients with dementia. See for example, her recent paper in the Gerontologist describing Black and White differences in caregiving.

We are also joined by Halima Amjad, a geriatrician-researcher, who, like Halima, is at Hopkins. Halima is very interested in improving care for people with dementia. As she notes, when we talk about outcomes for older adults, we often talk about the characteristics of the patient as predictors, but rarely do we consider how caregiver factors might influence important outcomes for older adults. In a paper published in JAGS, Halima found that caregiver factors predict hospitalization. For example, caregivers who are new to the caregiving role are more likely to care for someone who is subsequently hospitalized than someone who has been caregiving for longer.

We talk about all things caregivers, including research issues around the need to assess the needs of caregivers, health policy issues such as how to provide more support for caregivers, and clinical issues, such as the fact that the identity and contact information for caregivers are not routinely captured in the EHR.

-@AlexSmithMD

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A September 2000 New York Times article titled, “Sometimes Saving the Heart Can Mean Losing the Memory” describes a relatively newly described phenomena of difficulty with memory and other cognitive tasks six months after cardiac bypass graft surgery, or CABG. The syndrome was termed “pump head.” A doctor is quoted in the article as stating that older patients he might have previously considered CABG for he would try to manage medically, with a stent. Data on the impact of CABG on cognitive function over the subsequent 20 years has been mixed. The problem with these prior studies is they enrolled patients at the time of the CABG. They didn’t have a sense of what the cognitive trajectory was before the procedure.

In this context, enter Liz Whitlock’s study published this week in JAMA comparing cognitive trajectories before and after CABG versus stenting procedures. Liz finds no difference in the decline in memory before or after CABG vs PCI - in other words - their memory continued to decline at the same rate after each procedure as before. Furthermore, a newer procedure intended to spare patients the risks of bypass, called “off pump” CABG, was found in this study to be associated with greater memory decline than on pump CABG.

Pump head, it seems, is not a thing. Those who get CABGs likely also had vascular disease in the brian that was leading to a steady cognitive decline before the procedure.

To contextualize these findings for practicing geriatricians and other PCPs, we are joined by Mike Rich, one of the early movers and shakers in the field of geriatric cardiology. We are doing these cardiac procedures on ever older and older patients. What should we be concerned about? How should we counsel our patients? Listen to find out!

-@AlexSmithMD

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Frailty.  What the heck is it?  Why does it matter? How do we recognize it and if we do recognize it, is there anything we can do about it?   On today’s podcast we talk to Linda Fried, Dean of Columbia University's Mailman School of Public Health and world renown frailty researcher about all things frailty.  

We talk to Dr. Fried about how she first got interested in frailty, how we define it including the difference between phenotypic frailty and a “deficit accumulation model’ frailty index”, and how we should think about assessing frailty and managing it.

We also talk with Dr. Fried about how she thinks about resiliency and the analogy put forth by George A. Kuchel in a wonderful article published in the Journal of American Geriatrics Society (JAGS) that uses the Golden Gate Bridge to explain different definitions of frailty.

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Though origins of the term “moral injury” can be traced back to religious bioethics, most modern usage comes from a recognition of a syndrome of guilt, shame, and sense of betrayal experienced by soldiers returning from war. One feels like they crossed a line with respect to their moral beliefs. The spectrum of acts that can lead to moral injury is broad, ranging from killing of an enemy combatant who is shooting at the soldier (seemingly acceptable under wartime ethics), to killing of civilians or children (unacceptable). One need to witness the killing - dropping bombs or napalm can result in moral injury as well - nor need it be killing; harassment, hazing, and assault can result in moral injury, as can bearing witness to an event. While there is often overlap between moral injury and post-traumatic stress disorder (PTSD), they are not synonymous.

Today we talk with Shira Maguen, psychologist and Professor at UCSF and the San Francisco VA. One of the many fascinating parts of our discussion is when we talk about the moral injury faced by healthcare workers during COVID. I encourage you to listen to the last podcast to hear what moral injury can sound like - being asked to care for patients under far less than ideal circumstances, care that is the best under the circumstances but is not standard of care, wondering if as a result patients may have been harmed or died.

One common feature of moral injury in combat is a feeling of betrayal by superior officers who order soldiers to act in a way that contravenes their self-conception of right and wrong. One might say we in healthcare experienced a similar betrayal of leadership that flouted the science of mask wearing, stated that doctors were billing for COVID excessively to turn a profit, and touted unproven and potentially harmful medications as miracle cures.

We also talk about treatment (and it’s more than “I wanna hold your hand,” song choice hint)

Links:

• Moral Injury Fact Sheet:
• Moral Injury in Health Care Workers:
• Health and Human Services: Moral Injury for Healthcare Workers:
• Gender differences in Moral Injury
• Moral Injury in the Wake of Coronavirus: Attending to the Psychological
• Impact of the Pandemic on Healthcare Workers: Moral Injury

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During the winter peak in coronavirus cases, things got busy in my hospital, but nothing close to what happened in places like New York City last spring or Los Angeles this winter. Hospitals in these places went way past their capacity, but did this strain on the system lead to worse outcomes? Absolutely.

On today’s podcast, we talk with Brian Block, lead author of a Journal of Hospital Medicine study that showed that patients with COVID-19 admitted to hospitals with larger COVID-19 patient surges had an increased odds of death. We talk about the findings in his study, which also included some variation in the surge hospitals as well as potential reasons behind these outcomes.

We’ve also invited two other guests, Denise Barchas and Sunita Puri, to describe their hospital experiences in a COVID surge. Denise is a ICU nurse at UCSF who volunteered in New York during the spring surge of COVID cases. Sunita is the Medical Director of Palliative Medicine at USC’s Keck Hospital & Norris Cancer Center in Los Angeles. She is also the author of numerous books and essays, including “That Good Night: Life and Medicine in the Eleventh Hour” (if you haven't read it yet you should!)

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We know from study after study that most older adults would prefer to age in place, in their homes, with their families and embedded in their communities. But our health system is in many ways not particularly well set up to help people age in place. Medicare does not routinely require measurement or tracking of disability that leads many people to move out of their homes, and many interventions that support people to age in place are unfunded, underfunded, or funded by philanthropy rather than the government.

Today we talk with Sarah Szanton, who created the CAPABLE multi-disciplinary model to help older adults stay at home, and Kenny Lam, who used a national study to examine the need for home-modification devices. And we preview another of the AGS songs for the literature update - this one to the tune of “My Get up and Go” by Pete Seeger.

Enjoy!

-@AlexSmithMD

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There are no currently approved disease modifying drugs for Alzheimer's disease, but in a couple months that may change. In July of 2021, the FDA will consider approval of a human monoclonal antibody called Aducanumab for the treatment of Alzheimer's disease. If approved, it will not only make this drug the defacto standard of care for Alzheimer's disease, but will create a monumental shift in the usage of other currently limited diagnostic tests, including Amyloid PET scans and other biomarkers.

On today's podcast, we talk about all things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici. Dr. Rabinovici is the Edward Fein and Pearl Landrith Endowed Professor in Memory & Aging at UCSF.

I could talk to Gil all day long, but we try to fit all of these topics in this jam-packed podcast:

• The heterogeneity of dementia and potentially Alzheimer's disease
• Where are we now with disease modifying treatments for Alzheimer’s disease
• The Role of Amyloid PET scans and other biomarkers both now and in the future
• The wild story Aducanumab and the controversy surrounding its pending FDA approval

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One of our earliest COVID podcasts with Jim Wright and David Grabowski a year ago addressed the early devastating impact of COVID on nursing homes.

One year ago Mike Wasserman, geriatrician and immediate past president of the California Long Term Care Association, said we’d have a quarter million deaths in long term care. A quarter of a million deaths. No one would publish that quote - it seemed inconceivable to many at the time. And now, here we are, and the numbers are going to be close.

In this podcast we look back on where we’ve been over the last year, where we are now, and what’s ahead.

One theme that runs through the podcast is that if this level of death, confinement, and fear occured to any other population, change would have been swift. But nursing home residents, for the most part, don’t have a voice, they’re not able to speak up, they lack power to move politicians and policy.

Mike Wasserman is a provocateur. He is a needed voice for the nursing home residents and the nursing home staff who often are not able to speak for themselves. He is regularly quoted in major news outlets, and was in the Washington Post about opening up nursing homes to visitation the day of our podcast. If you don’t follow him on Twitter @Wassdoc you should!

-Link to Wassmerm and Grabowski’s article in the Health Affairs blog on the need for financial transparency in nursing homes.

-Link to webinar about what to do about COVID in long term care from April 2020

-@AlexSmithMD

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COVID has taken a devastated toll in nursing homes. Despite representing fewer than 5% of the total US events, at least 40% of COVID‐19–related deaths occurred in older individuals living in nursing homes. The good news is that with the introduction of COVID vaccines in nursing homes, numbers of infections and outbreaks have plummeted. However, only about 2/3rds of nursing home patients and only about ½ of nursing home staff have been vaccinated, largely due to hesitancy about taking the vaccine.

On today's podcast we talk about vaccine hesitancy with Sarah Berry, Kimberly Johnson, and David Gifford and the lessons learned from their “town hall” intervention they did that was just published in the Journal of the American Geriatrics Society.

A couple of take-home messages for me in this study was that vaccine misinformation was rampant, many nursing staff had lingering questions they wanted answered before getting the shot, and that sharing stories and personal experiences is an important way to overcome hesitancy.

In addition to listening to the podcast, we really encourage everyone to take a look at the JAGS article as it has two great tables for anyone willing to do similar town halls. The first is a summary of the concerns of healthcare staff. The second is sample responses to address some of these concerns.

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Hospice may not be a great match for all of the care needs of people with dementia, but it sure does help. And, as often happens, when patients with dementia do not decline as expected, they are too frequently discharged from hospice, an experience that Lauren Hunt and Krista Harrison refer to in an editorial in the Journal of the American Geriatrics Society (JAGS) as feeling like being “expelled.”

We talk on this week’s podcast with Elizabeth Luth, author of a study in JAGS about her study of patients in a large New York Hospice with dementia who either are discharged from hospice or live longer than 6 months. Turns out this happens - brace yourselves - nearly 40% of the time!

And we talk with Elizabeth and Lauren Hunt, who helps us contextualize these findings in the setting of larger issues around the fit of hospice for persons with dementia and hospice Medicare policy.

(We will add the link to the editorial when it’s uploaded to the JAGS website).

-@AlexSmithMD

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The COVID pandemic brought to light many things, including how society views older adults. Louise Aronson wrote a piece in the NY Times titled “‘Covid-19 Kills Only Old People.’ Only? Why are we OK with old people dying?”. The ageist viewpoint she was rallying against was also brought to light in a study of ageism in social media. When looking at those tweets that were related to older adults and covid, more than 1 in 10 tweets implied that either the life of older adults was less valuable or that it downplayed the pandemic because it mostly harms older adults.

So on today's podcast we are going to talk about the initiative to “Reframe Aging” with Patricia D'Antonio. Patricia is a geriatric pharmacist, and the Vice President of Professional Affairs at the Gerontological Society of America (GSA).

The Reframing Aging initiative is a national effort, led by GSA and supported by Archstone Foundation, uses an evidence-based approach to communicating more effectively about older adults. There are a variety of resources available, including research reports, an online toolkit, and free instructional videos, to help us talk about our work in geriatrics and aging.

For information about the Reframing Aging Initiative, please check out their webpage www.reframingaging.org. In particular, check out these two helpful resources on their website:

• Finding the Frame: An Empirical Approach to Reframing Aging and Ageism (2017):
• • This report explains the process and research behind the development of the evidence-based reframing aging narratives shown to improve attitudes toward aging and to boost understanding of the structural and systemic changes needed to capture the longevity dividend.
• Reframing Aging: Effect of a Short-Term Framing Intervention on Implicit Measures of Age Bias (2019)
• • This article appearing in The Journals of Gerontology: Series B describes the effect of a reframing aging intervention on implicit age bias.

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So what exactly does a hospice medical director do?  Why do some choose to become hospice physicians?  What additional training is needed, if any, beyond Hospice and Palliative Medicine fellowship and boards?  Who should take the new Hospice Medical Director Certification Board Examination?  A recent study in JAGS found high rates of hospice disenrollment (“live discharge”) for people with dementia - is that a good thing or a bad thing?  Hmmm…

We address these and other questions in this week’s podcast with Tommie Farrell, hospice physician in West Texas and Chair of the Hospice Medical Director Certification Board, and Kai Romero, Chief Medical Officer for Hospice By the Bay (that’s San Francisco Bay).

And I get a re-do attempt at REM’s “Everybody Hurts!”. Apologies for the first attempt!  

-@AlexSmithMD

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Where are we with Alzheimers?  Are we about to see a revolution in how we diagnose and treat it with Amyloid PET scans and the amyloid antibody aducanumab (which is currently on FDA’s desk for approval)?  Or are we still in the same place where there is no meaningfully effective treatment?  Or is it somewhere in between, given the data that we have on comprehensive dementia care?

We talk today with Jason Karlawish, a professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. In addition to being a geriatrician extraordinaire, he is the author of the new book “The Problem of Alzheimer’s: How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It.”

In addition to talking about PET scans and new drugs like aducanumab, we discuss with Jason about the history of Alzheimers, the history of how we care for a fund caregivers, and where we go from here.

So take a listen and check out Jason’s book!

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Nursing home residents have been devastated by COVID. Somewhere around 40% of deaths from COVID have been among nursing home residents, though they make up just a sliver of the US population.

Prognostication among nursing home residents who have COVID is important for a host of reasons - for counseling patients and families about what to expect, for making clinical decisions, and potentially for allocation of scarce resources such as treatments.

In today’s podcast, we talk with Orestis Panagiotou and Elizabeth White, the authors of a JAMA IM study that finds that physical and cognitive function are key predictors of mortality prediction for nursing home residents with COVID. We also talk with Marlon Aliberti, who authored a commentary.

Physical and cognitive function are easy to assess measures that should be routinely captured for older adults, in nursing homes and elsewhere. Study after study document the importance of function to risk prediction.

We also have a brief debate about how vaccinations should be allocated - according to a “one size fits all” age criteria, or a prognostic model that individualizes risk. Though I’m an advocate for prognostic models (see eprognosis.org) I’m actually on the age criteria alone side of the debate, with generous distribution among hardest hit minority communities.

And sing along to This Little Light of Mine!

-@AlexSmithMD

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Lesbian, gay, bisexual and transgender (LGBT) older adults have lived through a lifetime of discrimination, social stigma, prejudice, and marginalization. Is the care that we are giving them in later life changing any of that or are we pushing them back into the closet?

This is what we talk about in this week's podcast with Carey Candrian from the University of Colorado School of Medicine, and Angela Primbas from Stanford University (and future geriatrics fellow at UCSF!).

Carey has published a wonderful article in the Gerontologist titled “She’s Dying and I Can’t Say We’re Married?”: End-of-Life Care for LGBT Older Adults, in which she describes how older LGBT adults may be at higher risk for having their health care wishes ignored or disregarded, their families of choice are less likely to be included in their decision making, and they may experience increased isolation, bullying, mistreatment, or abuse, which ultimately contribute to receipt of poor-quality health care.

We talk about the scripts that we use in medicine that may hamper open discussions about sexual orientation and gender identity (SOGI) including the term “family meeting”, the need to revise our intake forms to incorporate SOGI questions, and the need for education. We also get a chance to hear Alex Sing “The Story” whose lyrics very much speak to the subject at hand:

“All of these lines across my face
Tell you the story of who I am
So many stories of where I've been
And how I got to where I am
But these stories don't mean anything
When you've got no one to tell them to…”

If you want to learn more, please check out these wonderful resources:

• LGBT Resource Center https://www.lgbtagingcenter.org
• LGBTQ Resource List from GLAAD: https://www.glaad.org/resourcelist
• National Resource Center on LGBT Aging: https://www.lgbtagingcenter.org/
• Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE): https://www.sageusa.org/

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On the one hand, every year we are fortunate to have new medications that help older adults and people living with serious illness. New treatments for lung cancer with remarkable survival outcomes come to mind, for example.

On the other hand, the tremendous growth in medications has led to an explosion of prescribing, polypharmacy, with attendant side effects and harms.

In this week's podcast, we talk with Nagham Ailabouni, a pharmacist and researcher joining us from Australia (song choice: Down Under!) about her review of major articles on medication safety and quality for older adults. Dr. Ailabouni summarized the top four hardest hitting in a recent publication in the Journal of the American Geriatrics Society, or JAGS. The four articles are:

1. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission
2. Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation
3. Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial
4. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

Dr. Ailabouni’s pet peeve medication she sees prescribed to hospice patients? High dose metformin. Listen to the podcast for more!

-@AlexSmithMD

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Most of us know we are going to die. How often though do we actually let ourselves really internalize that understanding? To imagine it? To feel it? To try to accept it?

On today’s podcast we invited BJ Miller back on our podcast to talk about death using as our guide his recent NY Times editorial What Is Death? How the pandemic is changing our understanding of mortality. In addition to being the author of this NY Times article, BJ is a Hospice and Palliative Care doc, and the founder of Mettle Health which aims to provide personalized, holistic consultations for any patient, caregiver or clinician who need help navigating the practical, emotional and existential issues that come with serious illness and disability.

We start off with BJ appropriately picking the song "Ebony Eyes" as our intro song, which is a good analogy to talking about death, as it was initially banned by the BBC from airplay as its lyrics were considered too upsetting to play on the radio. We then go into his thoughts on how we picture our deaths and dealing with those emotions we feel when we do, how we “live with death”, and...

Also check out BJ’s article that is geared towards kids/students - https://www.nytimes.com/2021/01/06/learning/how-do-you-view-death.html. As BJ put it in an email to us: “It’s fascinating to me how they’re taking care to reach out to younger minds, further proof that the idea that no one wants to think or talk about death - especially youngsters - is bunk.

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Many of us in geriatrics and palliative care assume that we are the experts in health care when it comes to understanding the caregiver experience. Every once in a while, we are humbled and reminded of what we don’t know.

Jessica Zitter had such an experience. Jessica, as many of you know, is an award winning author (link to our podcast about her book Extreme Measures) and was featured in an Academy Award winning film titled Extremis. She sought out to make another movie about the story of one of her patients who enrolled in hospice. The idea was it would be a film about all of the support that hospice provides and how it’s a transformative experience. What she realized, however, is that the real story in this film is about the caregiver in the film, who is overworked, overburdened, and has few options for supportive to care for his wife’s daily needs.

The film is titled Caregiver: A Love Story. See links below about how to view it. It’s not yet widely available via a major distributor, so your best bet is to view a screening locally or arrange for a showing to your hospital/hospice/palliative care team/social work group combined with a discussion with Jessica Zitter. The movie is less than 30 minutes, so leaves plenty of time in an hour for discussion.

-@AlexSmithMD

Link to Trailer
Link to Caregiver: A Love Story website

If you want info on the film or any stills to use for promotion, you can take a look at our PR folder.

Available virtual screenings:
Dec 18-Jan 28th at the Roxie Theater (link)
Jan 1-Feb 4th at the Laemmle Theater (link)

Education:
CME program using the film plus education module, provides credits for physicians, social workers, and nurses (link)

Jessica can also offer the CME program live.

We also have a live educational program for family caregivers.

To arrange any live event, you can reach out to caregiver@jessicazitter.com

Info on Jessica Zitter:
Website
Book: Extreme Measures: Finding a Better Path to the End of Life
Social media: Facebook Twitter

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Surrogate decision‐making around life-sustaining treatments in the hospital even in the best of circumstances is hard. It’s maybe even harder when caring for those who are conserved or have a professional guardian. The conservator may not have known the patient prior to them losing capacity, they may not know their values or goals that can help guide decisions, and they may be restricted by state statutes on what decisions they can make without getting a judge's approval.

The prevailing wisdom is all of the barriers to decision making while under guardianship likely leads to delays in decision making or one that errs on choosing high‐intensity treatment even if it is unlikely to benefit the patient. But is that really the case?

On today's podcast, we talk with Andy Cohn, lead author of a recent Journal of the American Geriatrics Society (JAGS) paper titled “Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes” and Liz Dzeng, the lead author of the accompanying editorial to the paper.

The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians. We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results. We also talk to Liz about whether substituted judgement is really all that it’s cracked up to be.

So take a listen and also check out these articles to read more about it:

• Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes.
• We Need a Paradigm Shift Around End‐of‐Life Decision Making.
• Guardianship and End-of-Life Decision Making

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“Diagnose and adios.” That’s the sad phrase that I’ve heard quoted more than once, representing caregivers' sentiment of what it’s like to be told by a clinician that your loved one has dementia.

This week we talked with Zaldy Tan, Geriatrician and Director of the Memory and Aging program at Cedars Sinai in Los Angeles. With David Reuben at UCLA and others working LA realized that current caregiver training programs were lacking. Caregivers for people with dementia are stressed, short on time, and thirsty for high impact information and skills training that can be delivered efficiently. To meet this need they launched a new caregiver “bootcamp” 1-day training (with the help of Archstone Foundation which also funds GeriPal). We cover many topics, including dissemination of the bootcamp to Spanish-speaking caregivers, converting to video boot camp during COVID, and ways you can partner with them to create your own boot camp.

Listen to the podcast to learn more!

(And “Remember Me” from Coco - great song choice)

JAGS article on caregiver boot camp

Dementia caregiver IcareD website (including upcoming bootcamp calendar)

CAPC website on caregiver support

-@AlexSmithMD

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What does it mean to create a cultural shift to the end of life experience? Is it even possible? How do you even start something like that?

On today's podcast, we talk to Shoshana Ungerleider about her experience making that change. Shoshana is one of those amazing advocates for palliative and end of life care. She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care education. She is Executive Producer of the Academy Award-nominated end of life documentaries, Extremis and Netflix’s End Game. Oh yah. She also started End Well back in 2017 which brought together people from all different backgrounds and professions with a goal to talk about end of life care.

This year she is taking the conference virtual with "Take 10" on December 10th. Take 10 brings names like Maria Shriver, Taraji P. Henson, Andy Cohen, Justin Baldoni, and Atul Gawande to speak about issues within palliative care, caregiving, geriatric medicine, and end-of-life care, all in light of what we can learn from the COVID crisis. And best of all it's free. So take a listen to the podcast and sign up for Take 10 here:

• Date: December 10, 2020 Time: 10:00am PST - 2:00pm PST
• Location: https://endwellproject.org/
• Register for free here thru 12.10.2020: https://endwellproject.org/take-10-end-well-2020/#register

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How long does it take to see a benefit of statin therapy for primary prevention of cardiovascular events in adults aged 50 to 75 years? That's the question we try to answer with our two guests today, Drs Lindsey Yourman and Sei Lee, the lead and senior author of a JAMA IM study that tried to answer this question.

In this podcast Drs. Yourman and Lee define what time to benefit is, why it is important in regards to decision making for older adults, and common lag time to benefits for common preventative interventions. We then take a deep dive into the JAMA IM meta-analysis of 8 trials, which showed 2.5 years were needed to avoid 1 cardiovascular event for 100 patients aged 50 to 75 years of age treated with a statin.

So give it a listen and tell us what you think on either our Twitter or Facebook posts about this podcast.

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An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults.  These needs are categorized around the 4 M’s - Medication, Mentation, Mobility, and What Matters Most.  

But we cannot achieve the ideal of an age friendly health system without, well, changing systems.  In this week’s podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M’s.  We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF.

Enjoy!

-@AlexSmithMD

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The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient. Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so. There often is limited information about the patient, their functional status, or their prognosis. These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!)

So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals? We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question.

Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled "Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure." We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on "Work Grief: A Practical Primer for Emergency Medicine Providers".

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In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness, published in JAMA. We also talk with Krista Harrison, first author of an accompanying editorial.

JAMA editors cut out some of my favorite parts of Krista's editorial, possibly because they were more like a blog post than a JAMA editorial. (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited:

"As with many people’s best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders’ English hospice programs. Dr. Mount coined the term “palliative care” to connote the core goals of the service: to improve quality of life and to mitigate sources of distress. The field of palliative care was born. The year was 1975. Forty-five years later, palliative care retains its central focus on improving quality of life for people living with serious, life-limiting illnesses and their families by addressing physical and psychological symptoms, social and spiritual needs, and aligning patient and family values with available care options."

In our podcast, we talk about the surprising finding in Keiran's study that palliative care for noncancer illness was associated with a modest improvement in symptoms, reduced hospitalization and emergency department use, increased advance care planning but not improved quality of life. How can palliative care, since inception designed to improve quality of life, not improve quality of life?

Listen to the podcast to find out!

-@AlexSmithMD

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There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and <10% of patients with heart failure receive a palliative care consult. So what can we do to bridge the gap between heart failure and palliative care?

As a current palliative care fellow and former hospitalist on UCSF's Advanced Heart Failure service, I have a strong interest in this question. This week I was lucky to have Alex and Eric let me join in interviewing Haider Warraich, Associate Director of Heart Failure at the Boston Veterans Affairs Hospital and Associate Professor at Brigham and Women's Hospital, a cardiologist trained in advanced heart failure and with a strong interest in palliative care who has written multiple books (Modern Death: How Medicine Changed the End of Life, State of the Heart: Exploring the History, Science, and Future of Cardiac Disease), op eds, and research articles on the subject.

In the podcast we talk about all things heart failure - from the culture of cardiology, how to impart palliative care on trainees, and practical tips on helping predict prognosis and symptom management. For more reading be sure to check out Haider's article in JPM on Top 10 Tips for Palliative Care Clinicians Caring for Heart Failure Patients and his article with Diane Meier in NEJM on Serious Illness 2.0 - Meeting the Needs of Patients with Heart Failure.

• Anne Rohlfing

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On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine.  

Now with COVID among us, Lauren talks to us about her recently published JAGS article titled Home Video Visits: 2‐D View of the Geriatric 5‐Ms.   In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework: mind, mobility, medications, multicomplexity, and what matters most. 

Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine.  One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article:

"I recommend that you discourage patients and families from using the backgrounds of outer space, peaceful woods and lakes, or other fancy pictures that are available on Zoom, Webex, and other virtual meetings. Doing so will hide what could be extremely valuable information when assessing the M’s of geriatrics."

So take a listen and maybe even sing along to Alex's version of "Video Killed the Radio Star."

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Last month we published a podcast with Sean Morrison that garnered a great deal of attention, in which Sean Morrison argued that Advance Care Planning is an idea that is “clear, simple, and wrong.” This week, we have a fresh updated counterpoint from Rebecca Sudore and Ryan McMahan. These two published a paper this week in the Journal of the American Geriatrics Society, or JAGS, that argues that the field of advance care planning has come a long way. Early studies of advance care planning evaluated it with advance directives, and studies of advance directives showed little to no difference. However, In their review they find recent (since 2010) high quality trials demonstrate the potential of advance care planning by using modern conceptions of advance care planning as a longitudinal conversation to help surrogates prepare for in the moment decision making. These studies evaluated a broader (and more fitting) range of outcomes than prior work, including surrogate preparedness. My take away is that if we’re looking for advance care planning to result in “goal concordant care” - we’re asking too much of it. That doesn’t mean it’s not useful. It’s primary use is helping surrogates feel like they are prepared and satisfied with the difficult choices they have to make for seriously patients. Doesn’t that matter too, and, some would argue, just as much? The surrogates live with these decisions the rest of their lives. So the issue is nuanced. One of my favorite parts of the podcast is when Rebecca Sudore returns to Sean Morrison’s Ford Pinto analogy and really uncover the real world complexities of how it should be applied to advance care planning. That Ford Pinto analogy just keeps on giving! Enjoy! -@AlexSmithMD

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In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria. Over the next 50 years, the debate over the concept of brain death has never really gone away. Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria. On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Troug. Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School. He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA: - The 50-Year Legacy of the Harvard Report on Brain Death - Understanding Brain Death - Brain Death—Moving Beyond Consistency in the Diagnostic Criteria In addition to talking about how Robert got interested in the topic of brain death, we discuss the history of the concept of brain death, how we diagnose it and the variability we see around this, the recent JAMA publication from the World Brain Death Project, why brain death is not biologic death (and what is it then) and what the future is for the concept of brain death.

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Chris Callahan (of Indiana University) and Lee Jennings (University of Oklahoma) have some righteous anger. Why do we have comprehensive cancer care centers and not comprehensive dementia care centers? We have a body of evidence dating back 30 years to support people with dementia and their caregivers with Comprehensive Dementia Care. Lee Jennings added to this robust body of work with a study published in the Journal of the American Geriatrics Society demonstrating that a comprehensive dementia care program based out of UCLA reduced ED visits, hospital length of stay, increased hospice enrollment, and delayed time to admission to long term care. As Chris Callahan notes in his accompanying editorial in JAGS, a fundamental problem with our healthcare system is that savings from Comprehensive Dementia Care accrues not to the dementia care program, but to the hospital and Medicare (ED visits, hospital length of stay) or Medicaid (long term care admission). Our fragmented healthcare system lacks the coordinated big picture financial incentives to make this happen for our patients. One more major point - Chris Callahan emphasizes in the podcast that we as clinicians need to stop saying, "there's nothing that we can do for dementia; nothing works." That's simply not true. While we lack Comprehensive Dementia Care programs in nearly every region of the US, we have tremendous community resources for people with dementia and their caregivers. The Alzheimer's Association is a great place to start. The song request was This Land is Your Land, classic Woodie Guthrie as Lee Jennings works at the University of Oklahoma. Chris Callahan rewrote the lyrics to address the topic, and if you listen to the very end of the podcast, you'll get this version: This land needs dementia care Comprehensive dementia care From California to Indiana From Oklahoma to the New York Island We need dementia care for our families As I sought clearly, the research to frame I saw clear data of the triple aim I saw the workforce, we need to train We need dementia care for our families -@AlexSmithMD

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Every year, about a third of older adults fall. About one in five of those falls result in moderate to severe injury. What can we do to help not only prevent those falls but also the complications of them? On todays podcast, we talk to Tom Gill, one of the authors of the recent Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study published in the NEJM. The STRIDE study was huge, 5,451 patients in 86 primary care clinics from 10 different health care systems. Individuals assigned to the interventions worked with a “falls care manager” whose goal was to help identify and make plans about risk factors for falls and fall-related injuries. What did it show? Well, the conclusion of the NEJM abstract states that this multifactorial intervention "did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care." We talk to Tom about whether that is the right take home from this pragmatic study and how should we think about fall prevention in our own clinical practices.

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No dear listeners and readers, that is not a typo. Eric Widera is indeed our guest today to discuss his first author publication in the New England Journal of Medicine, Family Meetings on Behalf of Patients with Serious Illness. Our other guests include other authors James Frank, Wendy Anderson, Lekshmi Santhosh, me and actress and frequent GeriPal guest-host Anne Kelly. There's a story behind this one folks. One day, Ken Covinsky walked into our office and said, "You know how the NEJM has this Videos in Clinical Medicine series? With videos like, 'How to insert a central venous catheter?' You should send them a video of your palliative care 'intervention' - how to conduct a family meeting." Brilliant idea. Well...that was 2014...a funny thing happened on the way to the theater. After several iterations, videos, reviews, a rejection, and lessons in persistence, we finally published. We were helped by an outstanding cast who role played the family meeting in the video (including Wendy as the physician and Anne as the social worker). The video introduces clinicians to core family meeting skills such as the importance of the pre-meeting, a structured approach to the meeting, and pointers on how to respond to emotion. On the podcast, we go around the "zoom room" and discuss our favorite teaching points on how to conduct family meetings. And a bonus feature! Eric requested any song from the Movie "The Descendants," and I was fortunate to be joined by my kids Kai and Renn on guitar and ukulele on the traditional Hawaiian song "Hi'ilawe." Grateful also to Jeff Peterson for pointers on the Hawaiian pronunciation. You may notice when you listen that I purchased some recording equipment for my home study, as this COVID thing doesn't seem to have an end in sight...I may have gone overboard with the production, forgive me listeners! Enjoy! -Alex

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COVID-19 has created a perfect storm in nursing homes. As noted in a recent Journal of the American Geriatrics Society (JAGS) article by Joe Ouslander and David Grabowski, the storm is created by the confluence risks, including a vulnerable population that develop atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources including testing and personal protective equipment (PPE), and lack of effective treatments. The result? Nearly half of COVID-19-related deaths in the US occur in people cared for in nursing homes and assisted living facilities, and about a quarter of all facilities have had at least one COVID case. On this weeks podcast, we talk to Dr. Ouslander about his JAGS article on this perfect storm, as well as strategies that one can take from a clinical, public health, and policy interventions to help calm the storm. In particular Joe summarizes a lot of research published in JAGS lately on COVID-19 (visit GeriPal.org for links to these research articles).

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Sean Morrison dropped a bomb. It's a perspective I've heard before from outside of palliative care, most clearly by bioethicists Angie Fagerlin and Carl Schnieder in their landmark article Enough: The Failure of the Living Will. But Sean Morrison, Director of the National Palliative Care Research Center and Chair of the Department of Geriatrics and Palliative Medicine at Mt. Sinai, former President of the American Academy of Hospice and Palliative Medicine, is about as inside palliative care as one can get. Sean argues in his Journal of Palliative Medicine piece that we should stop putting resources into making advance care planning and advance directives work. For decades, we have tried and tried, pouring $300 million dollars into research, untold intellectual capitol, at the expense of those resources going toward other areas of need such as disparities in access and outcomes for people with serious illness. And what do we have to show for it? 1660 studies and 80 systematic reviews providing weak low quality evidence that advance care planning and advance directives impact outcomes. Sean likens this to his family's efforts to fix their fundamentally flawed Ford Pinto, an analogy we take to new heights in this week's podcast. We challenge Sean about his perspective in the podcast, as I'm sure many of you are eager to do. We love it when people write perspectives or do research that challenges accepted geriatrics or palliative care practice/dogma. This article should force us to think deeply and do some serious reflection about our clinical and research priorities, and the extent to which advance care planning and advance directives should be ranked highly among them. And, of course, great song choice: Won't be Fooled Again by the WHO. If you watch the Youtube video to the end, you get to see me do my best Pete Townshend impression. Enjoy! -Alex Smith

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In this week's GeriPal podcast we talk with Louise Aronson, author of the Pulitzer prize finalist Elderhood (https://www.amazon.com/Elderhood-Redefining-Transforming-Medicine-Reimagining/dp/1620405466). Louise has been one of the (sadly) few voices beating a loud and urgent drum in the medical and lay press about the insidious ageism taking place in the time of COVID. In a prior podcast we discussed the ways in which structural racism contributed to vast disparities in COVID, and similarly in this podcast we talk about the ways in which COVID exposes existing ageist assumptions, attitudes, and systematic forms of discrimination. To give a sense about how prolific Louise Aronson has been writing about ageism, here are links to just a sampling of her articles in the NEJM, New York Times 1 and 2, VOX, Forbes, and the Atlantic. She also mentions this terrific piece by Nathan Stall and Samir Sinha during the podcast. And wow - love the song choice - It's the End of the World As We Know It by REM. Sure seems like it these days. -Alex Smith

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Despite being in the field over 15 years, I've never felt so far outside my comfort zone as as palliative care provider as I have felt in the last four months. A worldwide pandemic of a novel virus had me questioning how I communicate prognostic information when uncertainty was one of the few things I was certain about. It also pushed me to have these conversations via telemedicine, something I was previously more than happy to leave as a tool for only outpatient providers. The pandemic and the murder of George Floyd brought to the forefront the systemic racism that permeates our society and my own inadequacies in discussing the trauma that these killings and mistreatment have on black Americans. We grow though when we are pushed outside of our comfort zones. I'm pretty sure Tony Back, the co-founder of VitalTalk, would probably say that I have found my "learning edge". Lucky for me, we have Tony, along with another VitalTalk guru, Wendy Anderson, on today's GeriPal Podcast, to give some tips on how to approach communication skills in a time of crises. I'd like to highlight some of the exceptional Vitaltalk resources that we talked about on the podcast that can help to improve our communication skills, including (note: links to the following resources can be found on GeriPal.org). - Vital Talk COVID resources - A graphical version of the VitalTalk COVID playbook by Tony and Nathan Gray published in BMJ - Communication Skills in the Age of COVID-19 paper in Annals of Internal Medicine and the video commentary - Vital Talk's Communication skills for bridging inequity - Decompress, the podcast (Apple podcast link here) I'd also like to mention one other great resource that I came across by Drs. Marva Robinson and - Keisha Ross from the St. Louis VA, and Dr. Maurice Endsley from the Hines VA: - Discussing Community Trauma in Response to Killings and Mistreatment ofBlack and Brown Americans by: Eric Widera

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If you looked at the academic literature, you would think that elder abuse and neglect, collectively called elder mistreatment, did not exist before the 1990s. Of course that's not true at all, it was hidden, covered, and not a major subject of research. Several pioneers have placed elder mistreatment firmly on the map, including XinQi Dong, Mark Lachs, and today's GeriPal podcast guest, Dean Laura Mosqueda (@MosquedaMD) of the Keck School of Medicine at the University of Southern California and Director of the National Center of Elder Abuse. Archstone Foundation, who funds our podcast, was a critical early investor in efforts to raise awareness, study, and intervene to prevent elder mistreatment. Today we learn about what a long term care Ombudsman is, about the impact of Covid19 on elder mistreatment, and ethical issues at the core of elder mistreatment (autonomy vs. safety and public health). One major take home point that I'd like to emphasize here are three questions that Dean Mosqueda asks of all of her patients by way of screening: 1. Is anybody hurting you? 2. Are you afraid of anybody? 3. Is anybody using your money without your permission? Finally, June 15th is Elder Abuse Awareness Day, and here's a link to find out more about how you can get involved. And great song choice - Veronica by Elvis Costello - check out this YouTube video of Elvis talking about his grandmother who had Alzheimer's dementia and how talking with her he would "bounce around the years." Enjoy! - Alex Smith

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This was a remarkable podcast. Eric and I were blown away by the eloquence of our guests, who were able to speak to this moment in which our country is hurting in so many ways. Today's topic is the impact of COVID19 on minority communities, but we start with a check in about George Floyd's murder and subsequent protests across the country. Our guest Monica Peek, Associate Professor of Medicine and Director of Research at the MacLean Center of Clinical Medical Ethics at the University of Chicago, notes right off the bat: COVID19 and the reaction to Floyd are related. The covid epidemic has created an economic crisis, a heightened level of worry, and a disproportionate number of deaths among the African American community. When we add COVID on top of the long history of police brutality that has been heightened over the last several years that has been ignored by the federal government - in that context, it's not surprising that we're seeing protesters put their lives on the line to stand up for what they believe in. These protesters are putting their lives on the line due to the twin risks of reprisals from police or national guard, as well as the risk of acquiring COVID during a protest. As we turn later to the topic of COVID19 and impact on minority communities, Alicia Fernandez, Professor of Medicine at UCSF and Director of the UCSF Latinx Center of Excellence, notes that so many people reach for a biologic rationale for the excess exposure and mortality among minority communities - it's a genetic factor, it's racial/ethnic differences in ACE receptors, or it's the higher rates of diabetes and kidney disease among minority communities. How is it then that Latinos, and immigrants in particular, who tend to be younger and healthier, have higher mortality rates? What COVID19 is exposing are the underlying disparities in social determinants of health. For example, Africans Americans and Latinos represent a disproportionate share of essential workers, are more likely to live together in multigenerational households, and may reside in areas with less access to testing and high quality hospital care. We turn finally, to what we can do. As Monica says, "This is the fight of our lives. And this may be our last fight." Alicia notes that we need better reporting about detailed race, ethnicity, and language of people impacted by COVID for public health reasons. We talk about the need for professional interpreters for all goals of care conversations with patients (and Yael Shenker and Alicia's must read article for all clinicians on this topic). And we return to Doug White's framework that persons who reside in areas with a high Area of Deprivation Index score get a boost in their chances of obtaining scarce treatments for COVID. Finally, I encourage you all to watch this YouTube video of the song Seriously (song choice for the Podcast), sung by Leslie Odom Junior (Aaron Burr in the original Hamilton), about how Barak Obama might have reacted aloud to the 2016 election. It's speaks to this moment as well. The link is https://www.youtube.com/watch?v=hI8TCA3fJcs - Alex Smith

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The question of who should get limited supplies of drugs that treat COVID-19 is not a theoretical question, like what seems to have happened with ventilators in the US. This is happening now. Hospitals right now have limited courses of remdesivir. For example the University of Pittsburgh hospital system has about 50 courses of remdsivir. They expect it to last to mid-June, enough for about 30% of patients who will present in the next 3 weeks. Who do you give it to? The first that present to the hospital (give it all away in the first week)? Random lottery? Or something else that is also accounts for the greater impact of COVID-19 has on disadvantaged communities ? On today's Podcast we talk with Colette DeJong, 3rd year medicine resident at UCSF, and Alice Hm Chen, Deputy Secretary for Policy and Planning at the California Health and Human Services Agency, who were two of the authors of a recently published JAMA article titled "An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US". We also bring on our repeat guest, Doug White, who authored the University of Pittsburgh model hospital policy for fair allocation of scarce COVID-19 medications, which can be found here. The University of Pittsburgh allocation strategy doesn't use a first-come, first-served or random allocation, but rather a waited lottery that is aimed at reducing the impact of social inequities on COVID-19 outcomes in disadvantaged communities. In particular, the following groups receive heightened priority in this framework: Individuals from disadvantaged areas, defined as residing at an address with an Area Deprivation Index score of 8 to 10 (range 1-10; with higher numbers meaning worse deprivation) Essential workers, defined by the state’s list of essential businesses that are required to continue physical operations during the pandemic, which include lower-paid workers who may be socially and economically vulnerable, such as grocery store clerks, bus drivers, agricultural workers, and custodial workers. Of note, the Area Deprivation Index was developed in large part by Amy Kind, Geriatrician at the University of Wisconsin, and recipient of the 2019 American Geriatrics Society Thomas and Catherine Yoshikawa Award for Excellence in Scientific Achievement. by: Eric Widera NOTE: Links to the papers discussed above can be found on our blog site at GeriPal.org

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Immune Checkpoint Inhibitors. They are revolutionary and transforming cancer care. They shrink tumors and extend lives. Plus they have a better side effect profile than traditional therapies for conditions like metastatic lung cancer, so when those with really poor performance status can't tolerate traditional chemotherapy, immune checkpoint inhibitors are an attractive option. We talk on today's podcast with Laura Petrillo, a palliative medicine clinician and investigator at Massachusetts General Hospital and Harvard Medical School. Laura was the first author of a paper published in Cancer titled "Performance Status and End-Of-Life Care Among Adults With Non-Small Cell Lung Cancer Receiving Immune Checkpoint Inhibitors." (https://acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/cncr.32782) In this study, Laura looked at 237 patients with advanced non-small cell lung cancer who initiated immune checkpoint inhibitors from 2015 to 2017. She found that those with impaired performance status had significantly shorter survival after treatment with these medications that those with a bettter performance status. They also receive immune checkpoint inhibitors near death more often than those with better performance status, and they found that those recieving immune checkpoint inhibitors near the end of life had lower hospice use and an increased risk of death in the hospital. Along with how we should think about the findings of this study, we talk about common side effects of immune checkpoint inhitors that geriatricians and palliative care clinicians should know about, the cost of theses medications, and the differences with different types of cancer treatments like "targeted therapies". by: Eric Widera

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As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay (https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim), one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU. And look at where we are today. Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal. What a difference a year makes. This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care. Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service. Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults (https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204). Their service peaked at 50 consults per day, and as they note, that is likely an undercount. About half of the consults were in the ED. Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay. Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper. And (bonus!) you get to sing along to "Call Me Maybe." - Alex Smith

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Parkinson disease affects 1% to 2% of people older than 65 years. Most known for its distinctive motor symptoms, other distressing symptoms are pain, fatigue, depression, and cognitive impairment. About 2/3rds of individuals with Parkinson's will die from disease-related complications, making it the 14th leading cause of death in the United States. While there are great palliative care needs for this population, little has been published on how best to meet these needs. On today's podcast we talk with Benzi Kluger from the University of Rochester Medical Center and the lead author of a JAMA Neurology paper that compares outpatient integrated palliative care with standard care alone in 210 patients and 175 caregivers. Every 3 months for a year, participants received palliative care visits either in person or via telemedicine from a neurologist, social worker, chaplain, and nurse with guidance from a palliative medicine specialist. Benzi's study demonstrated the palliative care group had better quality of life, symptoms burden, and advance directive completion. In addition to talking about the study, we get tips on how best to care for Parkinson's patients, both in palliative care and geriatrics. We also discuss some of these other helpful articles (visit our blog post at https://bit.ly/3c1EkwE for the links): - Implementation issues relevant to outpatient neurology palliative care. Ann Palliat Med. 2018 - Top Ten Tips Palliative Care Clinicians Should Know About Parkinson's Disease and Related Disorders. J Palliat Med. 2018 - Palliative care and Parkinson's disease: outpatient needs and models of care over the disease trajectory. Ann Palliat Med. 2020 - Palliative Care and Parkinson's Disease: Caregiver Perspectives. J Palliat Med. 2017 - Parkinson disease patients' perspectives on palliative care needs: What are they telling us?

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Eight of the 10 largest outbreaks in the US have been in correctional facilities. Physical distancing is impossible in prisons and jails - they're not built for it. Walkways 3 feet wide. Bunk beds where you can feel your neighbor's breath. To compound the issue, prisoners are afraid that if they admit they're sick they will be "put in the hole" (solitary confinement). So they don't admit when they're sick. Many people think of prisons as disconnected from society. Like a cruise ship. "It's happening between those walls, behind the barbed wire, not out here." But for every two people in a correctional facility there's about 1 person who works in the correctional facility and lives in the community. The workers are bringing whatever they've been exposed to in prison out into the community, and bringing whatever they've been exposed to in the community into the prisons. This is a national problem, not a prison or a jail problem. We learned about these critical issues in our podcast with Brie Williams, Professor of Medicine in the UCSF Division of Geriatrics and Director of Amend (https://amend.us/), a program to change correctional culture; Adnan Khan, Executive Director of Re:store Justice (https://restorecal.org/), a justice advocacy organization; and Eric Maserati-E Abercrombie, a singer/songwriter and filmmaker through First Watch (https://restorecal.org/firstwatch/), a media project of currently and formerly incarcerated filmmakers. Adnan and Eric Maserati-E are former inmates of San Quentin prison. What can we do about this? The major response should be decarceration. Reduce the crowding in our overcrowded correctional facilities. If prisoners have less than a year left, let them out. If they have a long sentence and are low risk to society, and a place to go, let them go home with an ankle bracelet and return later to complete their sentence. Brie reminds us that people in prison can make an advance care plan, they can sign an advance directive, they have the right to engage in goals of care decisions, and a right to elect someone to be their health care proxy. And everybody, including prisoners, has a right to say goodbye to their loved one, though it may be by phone or video. We learn about these and other critical steps we need to take as a society and as hospice and palliative care clinicians. Eric Maserati-E does the music for this one. He needs to be discovered! If you know someone in the music industry, make them listen to him. Check out and subscribe to Eric's YouTube channel (https://www.youtube.com/channel/UCZN4YxjDR41RL_xIlDysU8Q). Also, listen to this terrific podcast, Ear Hustle (https://www.earhustlesq.com/), produced from inside San Quentin, the latest episode featuring Eric's music. - Alex Smith

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One million inpatient falls occur annually in U.S. acute care hospitals. Sitters, also referred to as Continuous Patient Aids (CPA's) or safety attendants, are frequently used to prevent falls in high-risk patients. While it may make intuitive sense to use sitters to prevent falls, it does beg the question, what's the evidence that they work? We discussed with Drs. Adela Greeley and Paul Shekelle from the West Los Angeles Veterans Affairs Medical Center their recent systematic review published in Annals of Internal Medicine. Their review identified 20 studies looking at this issue (none of which are randomized trials). To sum up their findings, there were only two studies comparing sitters to usual care and they came up with conflicting conclusions (in one, the fall rate was lowered; in the other, it was not). In the other 18 studies, alternatives to sitter use were evaluated. The only thing that seems to have some evidence for was video monitoring (fall rates either stayed the same or improved, with a decrease in sitter usage). We also talk about multi-component interventions and how we should think about them. One intervention that is sometimes included in multicomponent interventions are bed alarms, which we discussed in our very first GeriPal podcast. It's also the podcast where we dreamed up the "anti-bed alarm" that would alert patients who haven't gotten out of bed yet. Now that's a fall intervention that that I can get behind. by: Eric Widera / Twitter @ewidera

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We are rationing in the US. We may not be explicitly rationing, as we're going to discuss on this podcast, but we are rationing - in the way we allocate fewer tests and less PPE to nursing homes compared to hospitals, in the way we allow hospitals and states to "fend for themselves" resulting in those hospitals/states with better connections and more resources having more PPE and testing availability. And in some parts of the world, ICU and ventilator resources are scare, and they are rationing by age. We talked on our last podcast about decisions Italy made to ration by age, and on this podcast we talk about two countries in South America we have heard are using age as a criteria for rationing ventilators. In this context, we are fortunate to welcome Tim Farrell, Associate Professor of Geriatrics at the University of Utah and Vice Chair of the American Geriatrics Society (AGS) Ethics Committee, and returning guest Doug White, Vice Chair and Professor at the University of Pittsburgh School of Medicine. In our prior podcast with Doug we talked about his University of Pittsburgh (and colleagues) policy for allocation of scarce resources that has been adopted by over a hundred hospitals. Today's podcast is focused on the release of the AGS guidelines for allocation of scarce resources and the accompanying paper that explains the ethical rationale behind the AGS ethics committee's decisions. Both papers are available now on the Journal of the American Geriatrics Society (JAGS) COVID19 webpage. We talk about how the AGS and Pittsburgh guidelines are far more similar than different, and the ethical principles that led them to make the choices they made, and how these choices have evolved over time. The two issues we cover in depth are: (1) Should age be used to ration scarce resources? How should age be used, if at all, as an "up front" consideration, or a "tiebreak?" And (2) How should we account for socioeconomic determinants of health in resource allocation decision making? Stay healthy and safe, and keep doing the good work that you're doing, GeriPal listeners. -@AlexSmithMD

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The cross-over episode is an American tradition that is near and dear to my heart. My childhood is filled with special moments that brought some of my very favorite characters together. Alf crossed over with Gilligan's Island. The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time. To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast! The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman. Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina. She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Zara Cooper, and Diane Meier. That's an amazing lineup. We also welcome Joe Lin as a co-host for this topic. Joe is a surgery resident and palliative care fellow at UCSF. We talk to both Joe and Red about - How they got interested in the intersection of surgery and palliative care - How the culture of surgery and palliative care differ (and the misconceptions that both fields have of each other) - What the day in the life of a surgical palliative care physician looks like - A recent article in JAMA Surgery titled "Palliative Care and End-of-Life Outcomes following High-Risk Surgery" - What palliative care skills all surgeons should have (primary palliative care) - And lots of other topics! So take a listen and check out Red's Surgical Palliative Care Podcast (https://thesurgicalpalliativecarepodcast.buzzsprout.com/)

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We are delighted to have Dani Chammas, psychiatrist and palliative care physician, back on the GeriPal podcast to talk about emotional PPE. None of us can recall who originated the term, but we've all heard it bandied about much needed for front line providers treating patients with coronavirus. Headlines about the New York emergency room doctor committing suicide are likely only the tip of the iceberg in terms of the trauma, distress, and moral injury taking place. We talk with Dani about key issues and questions, including: - What is trauma? What is moral injury? - Is this a big deal? What evidence do we have? - What can we do about it? Dani goes over 3 broad buckets of responses, organized with the letter C: Connection, Culture, and Coping. - Normalizing rather than stigmatizing clinicians seeking mental health support We also decided to add a page to GeriPal titled "emotional PPE" with a list of resources for providers caring for patients with COVID, and we will link to that page once it's up. Please visit GeriPal.org for the following important mental health resources for providers: - The NYC COVID Worker Care Network - Pro-Bono Counseling for Frontline Physicians and APCs - Physician Support Line. - Disaster Distress Help Line - How to be a Catalyst of Calm in COVID19 -@AlexSmithMD

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What's the role of geriatrics and palliative care in the care of individuals with COPD? We talk this week with Anand Iyer, the lead author of this weeks JAMA IM article on this subject. It's a little off from our ongoing COVID topics, but given that his along with his co-authors (Randy Curtis and Diane Meier) JAMA IM piece just got published, we figured now is the right time to highlight #PalliPulm. What is #PallPulm? #PalliPulm is something that Anand Iyer founded, and is an online community of clinicians, investigators, patients, and others interested in the intersection of palliative care and geriatrics. Anand is also an Assistant Professor in Division of Pulmonary, Allergy, and Critical Care Medicine at the University of Alabama at Birmingham (UAB) and faculty at the Center for Palliative and Supportive Care at UAB. Anands research on this subject has shown a lot of things, including that COPD patients are often referred too late to palliative care and hospice, pulmonologists often equate hospice with palliative care, there is high symptom and emotional needs in COPD patients, and that patients and family members feel palliative care should be integrated early on in the care of COPD. Links to the following articles can be found on this blog post at https://www.geripal.org/2020/04/integration-of-geriatrics-and-palliaitve-care-in-COPD.html: - A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease - A Formative Evaluation of Patient and Family Caregiver Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease across Disease Severity - End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease We also talk about this podcast with David Currow on the use of opioids in dypsnea: -Opioids for Breathlessness: A Podcast with David Currow So take a listen and join the conversation at #PalliPulm! by: @ewidera

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Many of you listened to our prior podcast with Jim Wright and David Grabowski about COVID in long term and post acute care settings. In this follow up podcast, we talk about the situation in long term and post acute care in Indiana with Kathleen Unroe, Associate Professor at Indiana University, a scientist at the Regenstief Institute, and a PI of Optimistic and founder of Probari, and Ellen Kaehr, Assistant Professor of Clinical Medicine at Indiana University and geriatrician and medical director of a nursing home. A few highlights to wet your appetite: - About 2/3 of the Ellen's nursing home is COVID positive. This has led to so many challenges - how did this happen? (asymptomatic staff). How to cohort? Issues with PPE, with transitions to the hospital, with visitors. - We talked about the unique impact of COVID on people with dementia. For example, mobile persons with dementia wander, which has negative aspects, but does keep them functional/mobile. Now they're confined to their rooms and at much higher risk for debility/decline. They're also noticing a loss of orientation due to lack of structured activities. - We talk about the impact on Assisted Living Facilities, something that Kathleen has been thinking about increasingly from a policy perspective. There are twice as many people living in assisted living facilities as nursing homes. And yet assisted living facilities have received scant attention in this epidemic. - Impact on providers. This has been so hard. And clinicians and staff are working so hard to meet this challenge. How can we support each other during this difficult time? And they chose an AWESOME song, Paradise by the late great singer songwriter John Prine, who sadly died of COVID related illness. I couldn't help but overlay a few harmonies on the vocal track. Sing along! -@AlexSmithMD

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We were asked by Sean Morrison, Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, to compose a brief GeriPal video of thanks, support, and gratitude for all of the hard work they are doing in New York. These videos are played every Friday during the Mt. Sinai's Town Hall. Prior guests include Tom Brokaw, Mandy Patinkin, Martha Stewart, and Liz Gilbert. August company indeed! Here is our video link: https://youtu.be/xQT6xK4QjRw - This one is probably better watched as a video than as a podcast, though either will work. At GeriPal, we are happy to do what we can to support, inform, and entertain those working hard on the front lines, whether it be in New York, Detroit, Seattle, New Orleans, Indiana, Chicago, or wherever you may be. Special guests from UCSF include: Rebecca Sudore, Steve Pantilat, Pei Chen, Natalie Young, Louise Walter, Brie Williams, Anne Fabiny, Ken Covinsky, and Sandra Moody. -@AlexSmithMD

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The peak hospitalizations and deaths in New York City hit around April 7th. Life though in hospitals in New York though have not returned to normal. What were previously operating rooms, post-hip fracture units, or cardiac cath labs, are now units dedicated to the care of individuals hospitalized with COVID. We talk with two NYU clinicians, Ab Brody and Audrey Tan about what life is like right now in this new state of limbo as both palliative care clinicians and as their role as either a NP hospitlist or Emergency department physician. Ab Brody is the Associate Director of the Hartford Institute for Geriatrics Nursing at NYU. Audrey is the Director of Emergency of Medicine and Palliative Care in the Department of Emergency Medicine at NYU. We are also welcoming back our guest host Nauzley Abedini from UCSF. A couple of topics that we talk about include: - What's life like right now at NYU post-surge? - What's it like to look at the COVID crises in the lens of a palliative care consultant and their role as a primary provider in the ED or the hospital? - Geriatric issues that they are seeing in the ED or the wards. - How they are recognizing and dealing with morel distress? - The worry about PTSD and the worry for our workforce post this pandemic. - The stress that not only comes with work but also what it's like to go home by: Eric Widera (@ewidera)

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In today's podcast we talk with Zara Cooper, Rachelle Bernacki, and Ricky Leiter about the state of COVID at the Brigham and Women's hospital and Dana Farber Cancer Center in Boston. While they have flattened the curve somewhat in Boston, they're still seeing huge numbers of seriously ill Covid patients in Massachusetts. They have 143 out of their ~1000 bed hospital filled with COVID19 patients, including 78 Covid patients in ICU, many of which are followed by palliative care. This has resulted in the need to drastically restructure the palliative care team, including: - Embedding palliative care in the ED. They quickly found that if they waited for consults, they got not calls, and had to proactively go out and find consults in the ED. By demonstrating their usefulness, acceptance has increased. - Embedding palliative care in the ICU. These experiences are hard. Zara Cooper, who works as an intensivist in the ICU (as well as surgeon, as well as palliative care doc, as well as researcher, as well as superwoman) relates the ethical dilemmas and moral distress associated with providing care in the ICU. Ricky Leiter talks about how hard it is emotionally for the palliative care teams, how the cadence of our usually palliative care consult becomes compressed in these cases, and how their teams are dealing with the challenges of prognostic uncertainty, video meetings, and not being able to see patients in person. - Their first instinct was to protect the fellows from COVID19 patients. The fellows rebelled. They wanted to be involved, and now they are, and are functioning as an integral part of the response. All of this and more, including forgiving yourself if due to these extreme circumstances you can't give "gold star" palliative care, but maybe "bronze star" is enough? For links to the Pallicovid.app, Covid Protocols, and the Ariadne Labs COVID Response Toolkit, please visit our Covid page at https://www.geripal.org/p/covid.html or our website at GeriPal.org. -@AlexSmithMD

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"It's not about perfection...it's about connection." - Keri Brenner This week's podcast features a dynamic duo of palliative care psychiatrists, Dr. Keri Brenner from Stanford, and Dr. Dani Chammas from UCSF. Dani was a huge hit as a guest on one of our earliest podcasts talking about "Formulations in Palliative Care." This week, Keri and Dani talk about "Therapeutic Presence," an important concept in both psychiatry and palliative care (links to articles about this concept and application at https://bit.ly/2VpXxS7. They describe 3 key ingredients of therapeutic presence, including being deeply attentive, naming (I'd call it complex naming), and creating a safe "holding space" for patients' emotions. But come on, you might say, we're in the midst of a pandemic. How can we maintain a therapeutic presence in a zoom meeting with family members you've never met, or with a patient who has a disease that could spread to you and infect not only you but your family. Keri and Dani speak to the challenge of taking on the strong emotions we're all feeling during this pandemic - anxiety, fear, and the unique vulnerability this disease places on us as health care providers. They note high rates of depression, anxiety, and other adverse mental health outcomes for healthcare workers in China who dealt with COVID. This was an awesome podcast. It was like a therapy session for our collective GeriPal souls. I hope you enjoy it as much as we did. To stay up to date on relevant links, check out our new COVID page at https://www.geripal.org/p/covid.html -@AlexSmithMD

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The vast majority of hospice services are delivered in patient's homes or other places of residence like nursing homes. This makes the traditional model of hospice care vulnerable in this coronavirus pandemic, especially in the era of social distancing and limited personal protective equipment (PPE). So how are hospice's responding to the COVID-19 pandemic? On this weeks podcast, we talk to two leaders of two large hospice agencies, Drs. Kai Romero and Todd Cote, to get their views on this question. Kai is the Chief Medical Office of Hospice by the Bay in California. Todd is the Chief Medical Officer at Bluegrass Care Navigators in Kentucky. It's inspiring to hear how these hospices and others are stepping up to the challenge of caring for both COVID positive and non-COVID positive patients during this time. Among subjects we talk about include: - The variability how this pandemic is affecting hospices in how they are responding to COVID (even if they take COVID positive patients) - Supply limitations (PPE, medications, etc) - The role of telemedicine in hospice visits and the challenges with trying to do some hospice visits virtually - How COVID influences prognostic eligibility to hospice - Special issues in vulnerable populations like homeless and rural populations Check out our new COVID page at https://www.geripal.org/p/covid.html for important links we talk about in this podcast as well as previous COVID podcasts.

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Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You're short on gowns and facemasks. You're short on nurses and nurse aids so now you have to help deliver meals. This is what Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond is living through right now. I felt overwhelmed just listening to Jim talk about his experience since mid-March, and am so grateful that he joined to talk about COVID in the long term care setting, along with David Grabowski, author of the JAMA piece titled "Postacute Care Preparedness for COVID-19 - Thinking Ahead." A couple key points that I learned from Jim's experience. The first point is that half of patients who tested positive were asymptomatic, so you really don't know who has it or who doesn't unless you test everyone. The only thing you really know is that if you have 5 symptomatic patients who test positive for COVID, assume there are at least 5 asymptomic patients. The second point is that there seems to be different clinical courses for those who are symptomatic that David summarized as the following: - Indolent course, deadly: Initial 24-28 hours of fever and severe respiratory symptoms. Then Stabilization for 3-5 days. Then decompensation on days 5-7 with death within 24 hours - Indolent course, convalescence 1. Fortunately, the majority of our patients. Same course as indolent to death although continued improvement over 7-10 days. - Acute respiratory failure: Symptoms begin with fever and acute respiratory failure with death within 6-12 hours. - Sepsis-like picture: Sudden onset of AMS, hypoxia and hypotension without fever. A small subset of patients in our experience. All have tested positive for COVID (may simply have been asymptomatic carriers who developed sepsis independently In the second half of the podcast David Grabowski walks us through the challenges facing nursing facilities and potential solutions to the looming crisis in long term care, including - creating COVID only specialized post acute care settings - increasing the level of home health care and hospital-at-home model - whether nursing homes that don't yet have COVID should be forced to take COVID+ patients form hospitals. So listen up and comment below. Also, check out some of our past COVID podcasts and new resources on our new COVID page at https://www.geripal.org/p/covid.html.

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In today's podcast we talk with Audrey Chun, Professor in the Department of Geriatrics and Palliative Medicine at Mount Sinai, and Sheila Barton, a social worker in the Geriatrics practice at Mt. Sinai. Mt. Sinai has a HUGE outpatient geriatrics service, with a mean age of 85. We talk with Audrey and Sheila about the challenges they face in overcoming obstacles. Everything is harder now, such as how to get basic needs met for older adults isolating in the community, such as food and assistance with basic activities with daily living. Higher order concerns are challenging as well, including conducting advance care planning conversations with patients and family members over the phone, and finding a home hospice agency willing to care for a COVID positive patient. We talked as well about this article by Jason Karlawish arguing that caregivers are essential health workers who should be allowed into hospitals to care for their older at-risk-of-delirium relatives. Oy. Tough times. One thing Audrey and Sheila emphasize repeatedly is how supported they feel by their health system, by volunteers, and even from their own patients who message them with words of encouragement and kindness. New Yorkers are tough, but they also have big hearts and rally around one another time and time again when faced with challenges. On additional note, if you'd like to sign up for palliative care COVID discussions, here's a link to sign up to participate in weekly chats, thanks to Zachary Sager and Leslie Blackhall. -@AlexSmithMD

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In the latest in our series of talking with front line providers in the midst of the COVID pandemic, we talk with Drs. Craig Blinderman, Shunichi Nakagawa, and Ana Berlin of the palliative care service at Columbia University Irving Medical Center. We cover a host of topics, including the urgent need to conduct advance care planning with our outpatients (including Craig's new Epic dotphrase below, and guide to COVID advance care planning); the need to be flexible to suit shifting demands; to stock up on iPads to engage patients/family members in goals of care discussions from outside the room. We mention the new JAMA papers on "informed assent" to DNR/I orders by Randy Curtis and colleagues (and Craig's prior JAMA paper), and on rationing scarce resources by Doug White and Bernie Lo (see also our prior podcast on rationing with Doug with links to the practical framework). I cried after this one. Maybe it was Ana talking about how hard it was have an agenda when discussing goals of care with the family of a 90 year old woman with dementia. We're taught in palliative care to match patient/family goals, and to not bring an agenda. But we do have an agenda now, as Ana says. The patient will not survive a code or prolonged intubation. Coding her would expose Ana's colleagues to COVID, and use scarce PPE and ICU resources, including a ventilator. We can't check that agenda at the door anymore. This is hard. You can hear their moral distress as they talk through these experiences. Maybe it was the three of them talking about the pace of change. Last week they felt "impotent" as they awaited the coming storm. Then the ICU called; they want palliative care. Then the ED called; they want palliative care. Today Shunichi spent the entire day having goals of care conversations with likely COVID patients and their families in the crowded ED. Today they say they want a new inpatient palliative care service, ASAP, maybe even tomorrow. They thought they would have until next week. The tsunami hit Wednesday. Maybe it was Ana saying her daughter had a fever and might have COVID, and that one thing she is thankful for is that kids are spared serious illness. Maybe it was the song choice, the Ghost of Tom Joad by Bruce Springsteen, with its inspirational and haunting message. Craig says he chose this song because the lyrics are about standing up to meet the challenges faced by the most vulnerable. As he notes, COVID is the AIDS crisis of our day. We're all in this together. -@AlexSmithMD FYI - for links to referenced material, please visit our website at GeriPal.org

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New York is the current epicenter of the COVID-19 outbreak in the US, with over 30,000 confirmed cases as of March 25th. Hospitals and ED's are seeing a surge of patients, and geriatrics and palliative care providers, like Cynthia Pan, are doing their best to meet the needs of these patients and their family members. Today, we talk with Dr. Pan, the Chief of the Division of Geriatrics and Palliative Care Medicine, and the current attending on the palliative care service at New York-Presbyterian Queens, located in Flushing, New York. In our discussion we talk about what it is like to be on the front lines right now, lessons learned during this surge, and how she is managing the distress in caring for these patients.

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Many of us with clinical roles are waiting for the other shoe to drop. Today we hear from Dr. Darrell Owens, DNP, MSN, head of palliative care for the University of Washington's Northwest campus, a community hospital in Seattle. The UW Northwest hospital has born the brunt of the COVID epidemic in one of our nation's hardest hit areas. Darrell has stepped up the the plate in remarkable, aspirational ways. First, he is on call 24/7 to have goals of care conversations with elderly patients in the emergency department under investigation for COVID who do not have an established a code status. On the podcast Darrell walks us through the language he uses to speak with these patients about the poor outcomes of CPR and ventilation among older adults with COVID. We note on the podcast that the Center to Advance Palliative Care recently put together Toolkit for COVID including a thoughtful communication guide spearheaded by Tony Back and our friends at VitalTalk. Second, Darrell has established an inpatient palliative care service at his hospital for patients on exclusively comfort measures. Darrell and his team admit and are first call for these patients. This service off-loads the hospitalists so they can care for other patients. Darrell talks with us about the challenges of titrating medications for symptomatic patients when you're trying to minimize using protective equipment going in and out of the room, and the challenges of returning home from work to his family after treating patients with COVID all day. By closing let me repeat two things from the podcast. First, we too can and should step up to the plate. By engaging patients in goals of care discussion at the time of admission we are likely to help patients reach different decisions than they otherwise might have made had discussions occurred with rushed and less skilled clinicians (i.e. the usual code status discussion). Before we get to rationing, we can and should engage patients in the highest quality informed goals of care discussions. The results of these informed discussions are likely to decrease the need for scarce ICU beds and ventilators. That is why Darrell is specifically on call for these conversations. Simply put, we do it better. We have the best skill. Further, like Darrell, we too can create or expand inpatient palliative care services to provide the best possible care for these patients and free up hospitalists and others to meet the growing clinical needs due to the pandemic. Second, Eric and I have never been prouder of our fields. Every day we hear stories of geriatricians, palliative care clinicians, and bioethicists rising to the occasion to meet needs of this moment. As Eric notes, we will found out a great deal about ourselves and what we stand for these next few weeks and months. Thank you for all that you do. -@AlexSmithMD

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You are caring for two adults with COVID-19. One who is a previously healthy 70 year old. One is 55 with multiple medical comorbidities. Both are now requiring mechanical ventilation, but there is only one ventilator left in the hospital and all attempts to transfer the patients to another hospital for care have failed. Which patient would you give the life saving treatment to and why? On today's podcast with talk with Doug White, Professor of Critical Care Medicine at the University of Pittsburgh, and James Frank, Professor of Medicine and fellowship director for the UCSF Pulmonary and Critical Care Medicine Fellowship, about this type of tragic choice that we may soon be making if we do not flatten the curse on the COVID-19 pandemic (for more on that, check out our last podcast with Lona Mody). If you don't think that would be even remotely possible, just read this quote from a NEJM article that came out yesterday: Quote: "Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence — or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. 'This is not a nice thing to say,' he told me. 'You will just scare a lot of people.'" In our podcast we reference a fair amount of articles and resources. Links to the following articles and resources can be found on our website at GeriPal.org : - Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions. Annals of Internal Medicine - Principles for allocation of scarce medical interventions. Lancet 2009 Definitive Care for the Critically Ill During a Disaster: A Framework forAllocation of Scarce Resources in Mass Critical Care. Chest 2008 - Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest 2019 - Meeting the challenge of pandemic influenze: ethics guidance for leaders and health care professionals in the Veterans Health Administration - Ventilator Allocation Guidelines:New York State Task Force on Life and the LawNew York State Department of Health - NYT interview with Italian ICU director in Bergamo, Italy. Truly sobering and it’s clear that many patients are dying after being triaged to no ICU/ventilation. - Flattening the curve infographic - Excellent illustration of how surge capacity will be increased as it relates to ICU staffing

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Covid19 is changing the way we interact with each other (from 6 feet away or via Zoom) the way we care for out patients (increasingly by video or telephone) and for some unfortunate few, the way we die (alone, in a hospital for days, isolated from family and friends). This is the first podcast in a series of podcasts about Covid 19. In this first podcast we talk with Lona Mody, Professor of Medicine at Michigan Medicine and John Mills, Associate Epidemiologist with Michigan Medicine. We cover terminology, epidemiology of the disease, and what we can do to protect our older and vulnerable patients. We also provide a new suggestion for a 22 second song you can sing while washing your hands in lieu of happy birthday (some of us are sick of singing happy birthday so many times a day). Our next podcast, to be released tomorrow, will be with Doug White and James Frank on the ethics of rationing ventilators. In both podcasts, we refer to this New York Times Daily podcast with Dr. Marco in Milan Italy titled, “It’s Like a War.” Every day they admit 50-70 patients with severe pneumonia due to Coronavirus infection to their 1000 bed hospital. More than half of the hospital is filled with Coronavirus infections. 460 nurses are home sick or in home quarantine due to contact with infected patients. They’re admitting their colleagues. 20 patients died from Coronavirus in one day. He talks about rationing ICU beds by age. He says, “My colleagues, both physicians and nurses, they cry everyday.” Important take away from both podcasts: Flatten. The. Curve. Now. -@AlexSmithMD

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Project ENABLE is a landmark palliative care intervention. And yet, I will admit (Eric did too) we didn’t really understand what it was. So we interviewed ENABLE founder Dr. Marie Bakitas and ENABLE distinguished protégée Dr. Nick Dionne-Odom to learn more about ENABLE. During the interview, we learned a great deal about ENABLE, how it has evolved, iterated, and shifted over time to include persons with diseases other than cancer, minorities with serious illness, and caregivers. We break the results of ENABLE CHF-PC, a planned plenary abstract presentation for the State of the Science meeting that was supposed to happen next week (here’s a link to the published abstract https://www.jpsmjournal.com/article/S0885-3924(19)30854-1/fulltext). About that State of the Science. Yeah. Well, as you probably know the State of the Science, the AAHPM/HPNA/SWHPN meeting, and the GeriPal/Pallimed pub crawl have been cancelled, for all the right reasons. Er, reason. Covid19. So sadly, this will not be an oral presentation next week, but you can still hear all about it here on this podcast! We’d like to express our gratitude to the organizers of AAHPM/HPNA/SWHPN and the SOS meeting, including the staff of these organizations, planning chairs, and committees. They put in countless hours preparing for what would have been the largest palliative care meeting of all time. Thank you for all you’ve done! And yes, Marie and Nick forced me to sing Taylor Swift. Sorry! -@AlexSmithMD

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"Tell me about the problems you have with your medications." A simple open-ended question that is probably rarely asked, but goes beyond the traditional problems that clinicians worry about, like non-adherence, inappropriate prescribing, and adverse reactions. What do you find when you go deeper? Well we talk with Francesca Nicosia and Mike Steinman about the work they have done around deprescribing and medication related problems, including a recent JGIM study that attempts to better understand patient perspectives on medication-related problems. This study also gives a pretty fascinating picture of where the overlap and divergence is between what patients and physician see as medication related problems as shown in this figure from the article: In addition to medication related problems, we talk about some other important updates in deprescribing, including their work in the newly formed US Deprescribing Research Network and new pilot awards of up to $60,000 in funds to catalyze investigator initiated research projects around deprescribing. by: Eric Widera (@ewidera)

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Home-based palliative care is booming. And with the growth of home-based palliative care come unique struggles and challenges: how can it be financed, what does the ideal team look like (or do you need a team?), retaining clinicians who may feel isolated doing this work, identifying patients who are most likely to benefit. In this week's podcast we talk about these and other issues with Brook Calton, home-based palliative care physician in the Division of Palliative Medicine at UCSF and Grant Smith, a recent graduate of UCSF's palliative medicine fellowship now faculty at Stanford. To supplement our podcast, Grant has written a series of thought pieces that flesh out and complement our discussion. His first reflection was published in the Journal of Palliative Medicine last month. We will post one additional reflection per day for the next three days. Hope you enjoy my attempt at a Southern drawl while singing! -@AlexSmithMD

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On this week's podcast we have the honor of talking with David Reuben about health care for older adults and how it's time to think different. It really is a smörgåsbord of topics, ranging from how to think about population health for older adults (and how we as individuals providers can provide at least some level of population health), the UCLA Alzheimer's and Dementia Care Program and its outcomes, Medicare Advantage for All, working with community partners through voucher systems, and tips for leading change. Dr. Reuben is Director of the Multicampus Program in Geriatrics Medicine and Gerontology and Chief of the Division of Geriatrics at the University of California, Los Angeles (UCLA). He is also the Archstone Foundation Chair and Director of the UCLA Claude D. Pepper Older Americans Independence Center and the UCLA Alzheimer's and Dementia Care program. If you want to read more about some of the topics, check out these links on our website at geripal.org: - Patient and Caregiver Benefit From a Comprehensive Dementia Care Program: 1‐Year Results From the UCLA Alzheimer's and Dementia Care Program - The Effect of a Comprehensive Dementia Care Management Program on End‐of‐Life Care - UCLA Alzheimer’s and Dementia Care Program Website

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We had fun on this in-studio podcast with Dan Matlock, geriatrician and palliative care clinician researcher at the University of Colorado, and frequent guest and host on GeriPal. We most recently talked with Dan about Left Ventricular Assist Devices and Destination Therapy. Today we talked with Dan about Implantable Cardiac Defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT) - everything a geriatrician or palliative care clinician should know. Dan and his team have developed a number of terrific decision aids around ICD implantation (see patientdecisionaid.org), and have seen uptake and use of these decision aids skyrocket following CMS's mandate requiring an shared decision making interaction prior to ICD implantation. Enjoy! -@AlexSmithMD

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In this week’s podcast we talk about food insecurity in older adults with UCSF’s Hilary Seligman, MD. Hilary has done pioneering work in this area. Some of this work was funded by Archstone Foundation (full disclosure: Archstone is a GeriPal funder). Hilary's expertise runs the gamut from federal nutrition programs (including SNAP), food banking and the charitable feeding network, hunger policy, food affordability and access, and income-related drivers of food choice. I have a confession. I knew almost nothing about food insecurity before this podcast. Is it hunger? Why should we think about food insecurity and health in the same sentence? Why is this an issue for older adults in particular? I was absolutely blown away by what I learned in this podcast. I have since quoted Hilary Seligman 4 or 5 times in other meetings. Food insecurity is one of those topics that people don’t talk about but is likely far more critical to the health and well-being of the people we care about than other topics we spends gobs of time and money on (e.g. cholinesterase inhibitors for dementia). So take a listen and if you want to take a deeper dive in some of the topics we talked about, check out the links for this blog post at http://bit.ly/2vbEEZE or geripal.org. Enjoy! -@AlexSmithMD

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Should Geriatric Assessments be part of the routine ontological care for older adults with cancer? On this weeks podcast we attempt to answer this question with national experts in Geriatric Oncology: Dr. Supriya Mohile from the University of Rochester and William Dale from City of Hope, as well as UCSF's Melissa Wong. Lucky for us, they also have a little evidence on their side thanks to a recently published JAMA Oncology article that they authored titled "Communication With Older Patients With Cancer Using Geriatric Assessment - A Cluster-Randomized Clinical Trial". We discuss not only the trial results, but also: - reasons why geriatric principles is important in oncology - what a geriatric assessment includes - who should do a geriatric assessment (including does it need a geriatrician?) We also talk about these resources if you want to take a deeper dive in geriatric oncology: - ASCO's Geriatric Oncology page - ASCO's guideline for geriatric oncology by: Eric Widera (@ewidera) P.S. Please visit our blog page at geripal.org for links to the referenced material above.

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You’ve probably heard patients say, “Of course I’m depressed, I’m dying. Wouldn’t you be?” This is a fundamental question - to what extent are depressive symptoms “normal” at the end of life? To what extent are they maladaptive, a fancy word for psychological conditions that have a negative impact on your life. In this week’s GeriPal podcast we talked with Elissa Kozlov, a psychologist-researcher at Rutgers, and Claire Ankuda, a palliative care physician-researcher at Mt. Sinai about their JAGS paper describing the epidemiology of depressive symptoms in the last year of life. This was an interesting conversation, as Drs. Kozlov and Ankuda are pushing the boundaries of how we conceptualize depressive symptoms near the end of life. Their work suggests that depression is far more common than we suspect clinically. And they chose a great song - Hurt as arranged by Johnny Cash (not the Nine Inch Nails original). Enjoy! -@AlexSmithMD

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Do opioids improve breathlessness? A simple question that unfortunately doesn't seem to have a simple answer. We get into the nitty-gritty of potential answers to this question with a preeminent researcher in this field, David Currow. David is a Professor of Palliative Medicine at University of Technology Sydney. His research has challenged common practices in Hospice and Palliative Care, including randomized control trials on oxygen for breathlessness, octreotide for malignant bowel obstruction, and antipsychotics for delirium in palliative care patients. His most recent study was published in Thorax titled "Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial." It showed no differences between those that got sustained-release morphine and those that got placebo in regards to breathlessness, but the intervention arm did use less rescue immediate-release morphine. We talk to David about how to interpret these results, as well as what to make out of the broadened inclusion criteria and whether there was an issue with the primary outcome. Other articles we reference in the podcast include: * The safety study: No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness * And the oxycodone SA study: Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. by Eric Widera, @ewidera

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In this weeks podcast we talk with Kirsten Bibbins-Domingo, general internist, Professor of Medicine and Epi/Biostats at UCSF, and chair of a National Academies of Sciences task force on Integrating Social Care into the Delivery of Health Care. See Kirsten's JAMA paper summary here (https://jamanetwork.com/journals/jama/article-abstract/2752359), and the full report here (http://nationalacademies.org/hmd/Reports/2019/integrating-social-care-into-the-delivery-of-health-care). This podcast spans the gamut from the individual clinician's responsibility to be aware of the social needs of their patients and impacts on health (think homeless person with no place to store their insulin), and adjustment to meet these needs (such as keeping on oral medications), to larger health policy issues including the need to integrate health and social policy. This was a fun podcast, as you'll hear. This is a topic that lends itself well to discussion. Eric really pushes this issue: to what extent are meeting the our patient's needs for housing, transportation, and food a health issue? Are these issues that a doctor should care about, and why? And our rendition of "Waiting on the World to Change" was perfect in every possible way!!! Enjoy! by: Alex Smith, @AlexSmithMD GeriPal is funded by Archstone Foundation (https://archstone.org/). Archstone Foundation is a private grantmaking foundation whose mission is to prepare society in meeting the needs of an aging population

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On this weeks podcast we talk to Julie Bynum on the question "Do Nurses Die Differently?" based on her recent publication in JAGS titled "Serious Illness and End-of-Life Treatments for Nurses Compared with the General Population." Julie is a Professor of Geriatric and Palliative Medicine at the University of Michigan, and Geriatric Center Research Scientist at the Institute of Gerontology, as well as a deputy editor at the Journal of the American Geriatrics Society. Overall, Julie's study found small differences in end of life care for both dementia and CHF as seen in the chart on our blog post at https://www.geripal.org/2019/12/do-nurses-die-differently-podcast-with.html One can think of these numbers as so small of a difference that there really isn't a difference. With that said, my favorite part of this interview is Julie's take on this difference, which is that while the difference is small, there is a difference ("There is a signal!"). This means "I know it can be different, because it is different." by: Eric Widera

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We have had some amazing guests on our Podcast. True luminaries in geriatrics and palliative care. This week we are fortunate to be joined by none other than Mary Tinetti, MD, to talk about her recent JAMA Internal Medicine trial of Patient Priorities Care (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2752365). In this study of older adults with multiple chronic conditions, patients are guided through a process of identifying their health priorities and objectives, and this information is communicated to their primary care physicians. The trail resulted in more medications discontinued, fewer self-managment and diagnostic tests, and less report of treatment burden. This podcast builds on our prior podcast on this topic with Aanand Naik (awesome song choice, Lumineers' Gun Song). We talk with Mary Tinetti about what exactly Patient Priorities Care is, how it differs from geriatrics and palliative care (or does it?), and how to disseminate this program widely (hint: start by going to their amazing website at patientprioritiescare.org). And...ah...Mary made me sing Joni Mitchell's Ladies of the Canyon. My deepest apologies to fans of Joni Mitchell... by: @AlexSmithMD

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On today's podcast we take a moment to celebrate 100 episodes of the GeriPal podcast. Yes, 100 episodes that have covered everything from cranberry juice for UTIs to medical aid in dying. In this episode, Anne Kelly, Lynn Flint and Ken Convinsky lead us down memory lane, asking Alex and me hard hitting questions about the birth of the podcast, our favorite episodes, and our most memorable moments. We also take time to listen to the feedback that we received from our call in listener line (929-GeriPal) and maybe, just maybe, a song is sung to celebrate the occasion. Lastly, we also have two very special thank you's. First is to Archstone foundation, who just became GeriPal's first sponsor! It's really is an honor to be backed by such a wonderful organization with a mission so aligned with our podcast. We also want to thank all of our listeners for your support and encouragement. It is really touching every time we hear some feedback about our shows and we love it when we hear that you are sharing our show with others. So join us for this episode (warning - there is audience participation in a song at the end) by: Eric Widera (@ewidera)

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Nursing homes are a tough place to do palliative care. There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice. So what can we do to improve the palliative care outlook in nursing homes? On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week. Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries. Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes. I struggle with just trying to improve palliative care in one site! We discuss with Lieve the results of the study, her take on why they got the outcomes that they did, and her view on a path forward to improving palliative care in these settings. We also have the authors of the accompanying JAMA IM editorial with us too (that was easy, it was Alex and our recurring guest host Lauren Hunt.) So take a listen and tell us what you think in the comments below, on social media, or on our GeriPal phone # (929-GeriPal).

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A recent study by Vince Mor published in JAMA Oncology found that veterans with advanced lung cancer treated in Veterans Affairs (VA) Medical Centers with high hospice use were more likely to receive concurrent cancer care and also less likely to receive aggressive care. On top of that, veterans treated at facilities with high levels of hospice use also incurred lower costs of care. This is a strong case for the concept of concurrent care in which individuals can avoid the "terrible choice" between hospice and life prolonging therapies. On this weeks podcast, we interview the lead author, Vince Mor, about this study and whether concurrent care is ready for prime time outside of a integrated health care system like the VA. We also put a plug in the end for the NIA Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory that Vince is helping to lead. If you want to learn more about the collaborators, please check out our GeriPal website at https://geripal.org for links to this and other info. by: Eric Widera

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Do you remember the scene from the movie The Graduate where Ben's dad says, "One word: Plastics"? Well, I write this blog post from the National Palliative Care Research Center's annual Foley retreat, a who's who of palliative care researchers. The words on everyone's lips: "Lay Health Navigators." This is not to draw equivalency between environmentally destructive materials and people who help those with serious illness and caregivers navigate our complex health care system. Rather, it's to point out that revolutions occur in palliative care research just as they do in business. In this week's podcast, we talk with Kate Possin, PhD and Sarah Dulaney, RN CNS of UCSF about the Care Ecosystem project. In this remarkable study, published in JAMA Internal Medicine, lay health workers helped caregivers of persons with dementia navigate the health care system by providing support, education, and care coordination with dementia specialists. The intervention was mainly by telephone, with about 1 phone call per month. Results were remarkable, including improved quality of life for persons with dementia, reduced emergency department visits, and reduced caregiver depression and burden. As Nick Dionne-Odom pointed out yesterday, "Caregiving in dementia is a monumental task. There is tremendous room for improvement." Listen or read on for more! Also - be sure to check out the outstanding Care Ecosystem website: https://memory.ucsf.edu/research-trials/professional/care-ecosystem. The training materials are all FREE to use! by: @AlexSmithMD

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Before we get into this week's topic, would you please take 1 MINUTE to complete this GeriPal survey! It will really help us out. We swear, only 1 minute! Click the link below to access the survey (or copy and paste in your browser). Thank you! GERIPAL SURVEY https://ucsf.co1.qualtrics.com/jfe/form/SV_esS7pUAOgSIbNGZ Now on to this week's topic... Alex: What do you get when you mix a doctor and an architect? Eric: An Archidoc? Alex: No a Dochitect. What do you get when you mix a gerontologist with an architect? Eric: A gerontolitect? Alex: No an environmental gerontologist. OK, so we didn't have that EXACT conversation on this podcast, but something close to it. There is a growing recognition that many of the settings where older adults receive healthcare are not designed to meet the needs of older adults. The early part of this movement resulted in the Americans with Disabilities Act, which mandated such things as accessibility for persons with wheelchairs. But it so much more than that. The architecture of health care buildings can actually impair the health of older adults or people living with serious illness - think lack of windows, rooms designed around beds, and placement close to noisy workspaces. Can you say delirium??? Re-designed spaces also have the potential to improve outcomes for older adults and people with serious illness. Further, redesigned spaces can improve quality of life for healthcare providers, and those benefits may be passed on to our patients. To discuss these fascinating issues we talked with Dochitect Diana Anderson, MD, M. Arch (UCSF geriatrics fellow) and Emi Kiyota, PhD, environmental gerontologist. Click here (http://www.dochitect.com/) to learn more about Diana and links to her publications, and here (https://ibasho.org/) to learn more about Emi and her website Ibasho, Japanese for "a place where one can feel at home and be oneself." Enjoy! by: @AlexSmithMD

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What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)? I've never been in one. I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support. For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home. And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF. In his JAGS study of about 14,000 patients admitted to LTACs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities). One third died in an LTAC, never returning home. So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs? Right? Wrong. 3% were seen by a geriatrician during their LTAC stay, and 1% by a palliative care clinician. Ouch. Plenty of room for more research and improvement. Read or listen for more! See also this nice write up by Paula Span in the New York Times, and this prior study on geographic variation in LTAC also by Anil. Please also note that our 100th podcast approaches! Please call 929-GERI-PAL to let us know what is working and what can be better about GeriPal. You might make it on the air! by: Alex Smith @AlexSmithMD

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Ok, I'll admit it. When I hear the phrase "the biology of aging" I'm mentally preparing myself to only understand about 5% of what the presenter is going to talk about (that's on a good day). While I have words like telomeres, sirtuins, or senolytics memorized for the boards, I've never been able to see how this applies to my clinical practice as it always feels so theoretical. Well, today that changed for me thanks to our podcast interview with John Newman, a "geroscientist" and geriatrician here at UCSF and at the Buck Institute for Research on Aging. In this podcast, John breaks down what geroscience is and how it impacts how we think about many age-related conditions and diseases. For example, rather than thinking about multimorbidity as the random collection of multiple different clinical problems, we can see it as an expression of the fundamental mechanisms of aging. This means, that rather than treating individuals diseases, targeting aging pathways may be a better way to prevent or ameliorate multimorbidity. We talk with John about this, and current trials underway to test this hypothesis, along with so much more! If you're interested in taking a deeper dive in the subject, take a look at these papers that John co-authored: - From discoveries in ageing research to therapeutics for healthy ageing. Nature 2019 - Creating the Next Generation of Translational Geroscientists. JAGS 2019 by: Eric Widera (@ewidera) Note: To view the YouTube version, links to the research papers, and/or the transcript for this episode, please visit our GeriPal website at: https://www.geripal.org/2019/10/geroscience-and-its-impact-on-human.html

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Joanne Lynn, a geriatrician and palliative care physician who leads Altarum’s work on eldercare, wrote a recent JAGS editorial titled The “Fierce Urgency of Now”: Geriatrics Professionals Speaking up for Older Adult Care in the United States” which is very much a call to action for those who care for older adults. We talk with Joanne about this article and some meaningful things clinicians in both geriatrics and palliative care can do to be advocates for a growing population of older adults. One way I would like to plug to better advocate for our patients is through our national societies. To learn more what both AAHPM and AGS are doing to improve care for older adults and those with serious illness, and to learn how you can help lead change, check out the following links: - AAHPM’s advocacy page - http://aahpm.org/advocacy/overview - AGS’s Health in Aging Advocacy Center - http://cqrcengage.com/geriatrics/ So check out the podcast and pick one thing that you can do to better advocate for older adults or those living with serious illness. Eric (@ewidera)

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You're the attending physician on a teaching service. Your resident says we shouldn't order a CT because CT's are over-used for this condition, and represent overuse, waste, and low-value care. In this case, however, you suspect that's not the resident's real reason. The real reason behind the resident's decision is that they are serial minimizers - residents who make little of potentially important findings. You feel they might be hiding their minimizing behind the sexy, trendy notion of providing "high value care." Does this sound familiar to you? It did to me. I've been in the awkward situation of being the consulting palliative care physician saying to the primary team, I know they have cancer and that's the most likely explanation for this abdominal pain. I also worry that this pain is out of proportion and different from other pain I've seen, and I think it should be evaluated with further testing. Kind of strange to say that as the palliative care doctor. Kind of strange as well to hear that perspective exposed by Chris Moriates and Vinny Arora, who spend most of their academic careers fighting against wasteful low-value tests and treatments (they run a non-profit called Costs of Care). To be sure, they note this problem is not as great as overuse of consultants, tests, and treatment. The challenge, as Stephanie Rogers our guest host (and guest fiddle player!) points out, is coming up with the right words to teach "right sizing" care to the patient in front of us. And what are the root causes of minimizing? Blame the house staff would be the easy way out, but Chris and Vinny don't take that road. Read more about their thoughts in this article in the Journal of Hospital Medicine and listen to or read our podcast! -Alex @AlexSmithMD Note: For links to referenced articles as well as a transcript of this episode, please visit our blog page at geripal.org/2019/09/hiding-behind-high-value-care-podcast.html

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On this weeks podcast, we talk with Krista Harrison about the life of individuals living with moderate dementia, as well as what we know about their caregivers. Krista is is an Assistant Professor in the Division of Geriatrics at UCSF, a social scientist, and something that we learned in this podcast, someone who knows a thing or two about singing opera. Krista recently published a JAGS paper titled "Care Settings and Clinical Characteristics of Older Adults with Moderately Severe Dementia." In this paper, which we discuss in the podcast, she gives us a snapshot of older adults in the United States who have experienced the onset of moderately severe dementia within the past year. We learn that 2/3'rds of these individuals are living in the community. Interestingly, older adults living at home were 2 to 5 times more likely to be members of disadvantaged populations and had more medical needs. In the podcast we discuss some potential reasons why this may be the case, along with what role geriatricians and palliative care doctors can play in the care of these individuals. So take a listen and let us know what you think. Also, take a peek at Joanne Lynn's editorial on Krista's paper, which includes a suggestion to create a default path similar to how obstetrics works. Eric (@ewidera)

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In this week's podcast we talk with Lew Cohen, MD, about his new book "A Dignified Ending: Taking Control Over How We Die." Eric and I approached reading this book with trepidation. We feared it would be a polemic defending physician aid in dying. It is not. Dr. Cohen does not hide his beliefs and opinions. He also does not shy away from the complexity of the issue - he interviews leading disability rights activists and challenges leaders of the aid in dying movement. His book is filled with stories of the people and family, doctors and activist who have defined this movement. As Eric says, he takes the controversy meter up to 11 with notions of approving aid in dying and euthanasia for progressive neurological conditions such as dementia (with thoughtful safeguards). We challenge Lew, somewhat forcefully at times. Personally, I disagree with many of his stances (as you will hear/read), but I can respect how thoughtfully he's gone about putting together his study of the issue. As Dr. Cohen notes, no issue seems to activate the strong emotion centers of our brain like aid in dying. In this time of extreme polarization, it's critical that we engage in thoughtful and respectful communication about aid in dying. - Alex Smith, MD

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In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer. The issue of lay health navigators raises several issues that we discuss, including: - What is a lay health navigator? - What do they do? How are they trained? - What do lay health navigators offer that specialized palliative care doesn't? Are they replacing us? - What makes the health navigator intervention particularly appropriate for Latinos and rural individuals? For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why). Enjoy! Alex Smith, MD

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This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End." As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care. His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times. As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement. The book he and Berger wrote is filled to the brim with practical advice. I mean, nuts and bolts practical advice. Things like: - How to clean out not only your emotional house but your physical house (turns out there are services for that!) - Posting about your illness on social media (should you post to Facebook) - What is the difference between a funeral home and mortuary - Can I afford to die? How much will it cost? We focus our discussion with BJ on his reasons for writing the book, sexuality and serious illness, and priming people to check the instincts of a medical system that favors aggressive/intensive/invasive care and crappy deaths. And BJ came up with some nice harmonies to "Tonight, You Belong to Me." Enjoy! AlexSmithMD

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This weeks podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang. Vicky is an assistant professor and researcher here at UCSF. We talk about her local and national efforts focused on this intersection, including: * Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. * Prehab clinics and how ACP fits into these clinics * The Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgery * How frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and enjoy this informative podcast. You can also check out associated links that can be found in this podcast on our website at: https://www.geripal.org/2019/06/advance-care-planning-before-major-surgery.html

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There are few names more closely associated with palliative care than Diane Meier. She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC). We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including: * What keeps her up at night? * Does palliative care need a national strategy and if so why and what would it look like? * The history of CAPC and the leadership centers * Advice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careers * What she imagines palliative care will look like in 10 or 15 years? * What is the biggest threat facing palliative care? We hope you join us for this great podcast!

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In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life. Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously." In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness. Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

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In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th. We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody). This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey in medicine and as a geriatrician facing burnout, aging and death of family members, filled with stories of patients, etc. We focus therefore on the main things we think our listeners and readers will be interested in. First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"? Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking? We focus on Louise's delectable takedown of Ezekiel Emanuel's Atlantic Article "Why I hope to Die at 75" Third- Louise's throws down the guantlet to the field of geriatrics. She argues that we have held too narrow a view of ourselves as clinicians for the oldest old and frailest frail. Instead, we should expand our vision of the field to include all older adults - including healthy 60/70 year olds & healthy aging - and become the default clinicians for all people entering life's last stage. Elderhood is a terrific read, and you are listeners/readers will all be inspired by the ideas, moved by the stories (you will identify with them), and challenged to re-imagine our clinical practice. (apologies - I had a cold so sort of struggle through the singing, far different from my usual perfect rendition!) Enjoy!

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In this week's GeriPal podcast we discuss the research into delirium with a focus on prevention. We are joined by internationally acclaimed delirium researcher Sharon Inouye, MD, MPH. Dr Inouye is Professor of Medicine at Harvard Medical School and Director of the Aging Brain Center in the Institute for Aging Research at Hebrew SeniorLife.

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Estimating prognosis is hard and clinicians get very little training on how to do it. Maybe that is one of the reasons that clinicians are more likely to be optimistic and tend to overestimate patient survival by a factor of between 3 and 5. The question is, aren't we better as palliative care clinicians than others in estimating prognosis? This is part of our training and we do it daily. We got to be better, right?

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On today's podcast we talk with one of the national experts on multimorbidity, Melissa Wei. Dr. Wei is an Assistant Professor and physician researcher at the University of Michigan. In addition to destroying the lyrics to Bohemian rhapsody, we talk to Dr. Wei about how we should conceptualize multi morbidity, it's impact on older adults, and about her recent JAGS publication titled "Multimorbidity and Mental Health-Related Quality of Life and Risk of Completed Suicide."

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In this weeks GeriPal podcast we take a deeper dive into this issue of language and medicine. We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.

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Our first live podcast at the annual meeting for the American Academy of Hospice and Palliative Medicine! We invited Rachelle Bernacki and Jo Paladino to discuss their two papers published today on the the Serious Illness Care Program.

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As Eric notes in the introduction, this recent study in JAMA by Jeff Williamson and colleagues led to some very contradictory headlines. Some headlines proclaimed that lowering blood pressure prevents dementia, and others stated the opposite, that lowering blood pressure does not prevent dementia. So what exactly did the study show? Do these results apply to patients we commonly see in Geriatrics? What should we make of the fact that after the trial was stopped early the blood pressures in the lower blood pressure target group rose - does this mean you can't achieve intensive blood pressure lowering "in the real world"?

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In the 1990s, Susan Tolle helped create the POLST. Now she and Elizabeth Eckstrom want to change it. And personally, I think they're right.

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On this week's podcast we have Bridget Sumser, a clinical palliative care social worker, board member for the Advanced Palliative Hospice Social Worker certification exam, and now co-author of a new book "Palliative Care: A Guide for Health Social Workers".

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Three reasons you should listen to this podcast: The issue of patients cycling back and forth between the hospital and skilled nursing facilities near the end of life is common, will ring true to those of you who are clinicians, and has largely been ignored in the literature. It's about a hot off the press article published today in the NEJM. Lynn Flint, Palliative care doc at UCSF in the Division of Geriatrics, first author, and our guest, makes me sing "Hit Me Baby One More Time" by Brittany Spears. This moment is either a new high or a new low for the GeripPal podcast, I can't tell which. You really need to listen to the final seconds when Eric joins in singing, "still believe" in high falsetto.

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Geriatrics teaches us that older adults with infections often present with non-specific symptoms rather than typical localizing symptoms of infection present in younger adults. Sometimes they present with fever, delirium, malaise, or fatigue. In today's GeriPal/JAGS joint podcast, Jeff Caterino challenges this common teaching by examining the extent to which non-specific symptoms are predictive of infection for older adults presenting to the emergency department. Turns out - they're not so predictive as you might think!

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May Hua's study addresses the still unanswered question - do specialized palliative care consults in the ICU do anything? She looked a number of outcomes comparing ICU patients in hospitals with and without palliative care consults. While most outcomes were similar, rates of hospice use were higher in hospitals with palliative care teams.

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On todays Podcast we talk with Marian (Emmy) Betz about firearm safety, including how to counsel individuals with dementia about guns. Emmy is an Associate Professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, and has written some pretty amazing papers on the subject of firearm safety.

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In this week's GeriPal podcast we talk with Tim Girard, Plumonary Critical Care physician-researcher at the University of Pittsburgh about his study NEJM study of Haloperidol vs. Ziprasidone vs. Placebo for ICU delirium in critically ill patients.

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On this weeks podcast we are talking with Aanand Naik about his recent JAGS article titled "Development of a Clinically Feasible Process for Identifying Individual Health Priorities".

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We thought it would be an excellent time to talk about substance use in older adults as many of us gather around the Thanksgiving dinner table with our extended families. We invited Ben Han, a geriatrician and Assistant Professor of Medicine in Geriatrics at NYU, to talk about the research that he has done in this area. In particular, we talked with Ben about the recent increase in substance use in older adults with the rising baby boomer generation, including use of alcohol, marijuana, heroin and prescription opiate misuse, and other drugs.

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In this week's GeriPal podcast we interview Randy Curtis, Professor of Medicine and Pulmonary Critical Care and Director of the Palliative Care Center of Excellence at the University of Washington. We address the question: how do we get more patients with chronic and serious illness to engage in goals of care conversations with their doctors.

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On this weeks podcast, we invited Rebecca Sudore to talk about the results of her PREPARE randomized trial that was published in JAMA Internal Medicine this week. The trial enrolled nearly 1,000 English and Spanish speaking older adults being cared for in a public hospital. The headline results showed that after reviewing the PREPARE For Your Care online program and the easy-to-read advance directive, 98% of older adults reported increased engagement in advance care planning (ACP) and 43% had new ACP documentation in their medical record. Even more good news, PREPARE worked equally well among English and Spanish-speakers and across health literacy levels.

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In this week's GeriPal podcast we talk with Guy Micco, MD, a longtime bioethicists, internist, hospice physician, teacher in the UC Berkeley and UCSF Joint Medical Program, mentor, and friend. Guy and I wrote an article recently for the journal Perspectives in Biology and Medicine about the intersection and issues between the fields of geriatrics, palliative care, and bioethics. The main thrust of the paper is that we need a workforce that is trained in the principles of all three fields to take the best care of the very sick, the very frail, and the very old. And for those of you who listen, Guy sings a great rendition of Hello in There, by John Prine: sweet, sad, and sentimental. Chorus: You know that old trees just grow stronger And old rivers grow wilder every day Old people just grow lonesome Waiting for someone to say, "Hello in there, Hello." Enjoy!

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All the Questions You Had About Opioids But Were Afraid To Ask: A Podcast with Mary Lynn McPherson by Alex Smith and Eric Widera

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How do you teach communication in serious illness? Can you? Do you teach it the same way to doctors and nurses in training? What level trainee do you target - medical students, interns, residents? How do we know our teaching is working? We discuss these and other bread and butter communication issues with Dr. Wendy Anderson, a palliative care physician at UCSF, director of the Bay Area Hub for Vitaltalk, and leader of IMPACT-ICU, a project to train ICU nurses in communication. Enjoy! -@AlexSmithMD

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In this week's podcast we talk with Helen Kales, Professor of Psychiatry at the University of Michigan the VA Center for Clinical Management and Research. We've spent a great deal of effort in Geriatrics describing what we shouldn't do to address behavioral symptoms in dementia: physical restraints, antipsychotics, sedating antidepressants. Helen Kales was lecturing around the country about all of these things we shouldn't do a few years back, and people would raise their hands and ask, "Well, what should we do?" She realized she needed to give caregivers tools to help. Dr. Kales went on to develop the DICE approach to managing behavioral and psychiatric symptoms in dementia. Listen or read the full podcast to learn more! You'd be "crazy" not to! (hint: song choice).

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On this weeks podcast, we interview Dr. Joan Teno about her recently published study in JAMA titled "Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015." In 2013, Dr. Teno published a study that showed how good our health care system in the US promotes patient churn. Despite positive signs of more hospice use and decreased deaths in the hospital, Dr. Teno found the from 2000 to 2009 we "churned" patients through more ICU visits, more hospitalizations, and more late transitions that are burdensome to dying persons in their family. Dr. Teno's latest study shows us how we are doing now, extending that work to 2015 and now including Medicare Advantage (MA) plans. So what did she find? Well here is a summary quote from Dr. Teno of the good news: "So, we see a continued decline in people dying in acute care hospital. Increase gross of hospice to nearly half the decedents. And what got me excited about these findings was we saw burdensome patterns of care decreasing. So, people who spent less than three days of hospice decreased from 14.2% in 2009 to 10.8%. People having three or more hospitalizations the last 90 days in life decreased from 11.5 to 7.1. The other thing is transitions between a nursing home and hospital and hospital nursing home nearly had a 50% reduction." And here is the bad news (depending on how you look at it): "So if you just take a look at that, it looks like we're heading in the right direction. One thing that we didn't see a budge in was, the use of ICU in the last 30 days of life. Now, is the glass half empty or is the glass half full? I have to admit I was pretty excited that ICUs wasn't going up." But there is so much more to summarize, including the difference between traditional Medicare fee-for-service and Medicare Advantage plans that you should just listen to the whole podcast as Dr. Teno is always someone I learn a ton from. Also, for more on this subject, check out our past podcast with Shi-Yi Wang, Assistant Professor in the School of Public Health at Yale, on her JAGS paper: "End-of-Life Transition Patterns of Medicare Beneficiaries."

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This week we talk with Charlie Wray, MD, Assistant Professor of Medicine at UCSF, about why clinicians should use social media in their professional lives. Charlie is a hospitalist and the Associate Social Media Editor for the Journal of Hospital Medicine. His arguments for using social media are germane to all clinicians, however. "Number Needed to Tweet" is the title of his recent grand rounds on this subject.

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In this week's GeriPal podcast we talked with Dr. John Nelson, who has been Medical Director of Hospice of Humboldt for 17 years.

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In this week's podcast we talked with Dr. Bernard Lo (Bernie as he is known). Dr. Lo is President of the Greenwall Foundation, a foundation dedicated to improving Bioethics research nationally. Prior to Greenwall, Dr. Lo was Professor of Medicine at UCSF and head of the Bioethics Program. He still maintains a primary care practice at UCSF. We talked with Bernie about several dilemmas in the area of physician aid in dying, with conversation jump started by his recent NEJM perspective on this topic

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For today's GeriPal Podcast we talk with Drs. Nathan Brummel and Lauren Ferrante, both critical care physician-researchers, about integrating geriatrics principles in intensive care units.

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Tramadol. Is it just a misunderstood opioid that is finally seeing its well deserved day in the sun, or is it as our podcast guest David Jurrlink would say, what would happen if "codeine and Prozac had a baby, and that baby grew into a sullen, unpredictable teenager who wore only black and sometimes kicked puppies and set fires."

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On today's episode we talk to Larry Allen and Dan Matlock about decision making around destination therapy. No this has nothing to do with your summer vacation plans. Rather, we talk about how individuals with heart failure decide about whether or not to pursue "destination therapy" with an Left Ventricular Device, or LVAD.

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In this weeks GeriPal podcast, we interview Dr. Barak Gaster, Professor of Medicine and General Internist at the University of Washington in Seattle. Dr. Gaster felt like there was hole in the advance directives landscape around future planning for people with dementia. People with dementia experience a fairly common set of complications and decisions around feeding, loss of independence, and loss of ability to make complex decisions. His dementia specific advance directive has specific sections for care preferences for persons who progress through stages of dementia, including descriptions of mild, moderate, or severe dementia.

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Can routine initiation of goals of care discussions by a palliative care social worker improve prognostic understanding, elicit advanced care preferences, and influence care plans for high-risk patients discharged after a heart failure hospitalization? That is the question we attempt to answer with this weeks podcast guest, Arden E. O’Donnell. kbez8pby

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This week's guest is Doug White, Professor of Critical Care Medicine at the University of Pittsburgh and lead author of a randomized controlled study of a nurse-led intervention to provide emotional support to families of seriously ill patients in the ICU and improve the quality of communication, published in the NEJM.

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How do patients come to the decision regarding whether or not to initiate dialysis? Well, that is the question that we talk about with Keren Ladin on this week's podcast. Keren is a social science researcher, bioethicist, and assistant professor in the department of Occupational Therapy at Tufts. What becomes clear when you look at Keren's research is the for many patients, there isn't a decision that is made.

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This week, Eric and I talked with Melissa Wachterman, a physician researcher from the Dana Farber Cancer Institute and Harvard Medical School. Melissa used a national dataset of people receiving hemodialysis linked to Medicare claims for older adults who died.

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In this week's GeriPal podcast we talk with Cynthia Boyd, Professor of Medicine and Geriatrician at Johns Hopkins University School of Medicine about how physicians communicate with home health agencies. Home health plays a critical role in caring for persons residing at home, and in the best of circumstances extend a seamless network of care from the primary care physician's office to the home. Sadly, reality is not so rosy. The major form of communication between physicians and home health nurses is, well, a form. CMS Form 485 to be specific. In a recent study published in Annals of Internal Medicine, Dr. Boyd revealed that most primary clinicians barely read what the home health nurses write on the form, don't find the form useful, and rarely does it change management. It's the 21st century people. Can we move beyond lame forms and communicate with each other, perhaps using some modern technology? Or even 20th century technology, such as phones, if not 21st Century technology, such as video chats? Listen or read more to learn more. Enjoy!

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There is a lot of discussion about the right to die. Although most of these have to do with Physician Assisted Death (PAD). What about in those who are not dying but express a dire to end their lives in the absence of a diagnosable mental illness? Do they have the same right? Well, on today's podcast we are going to step into this tricky topic with our guest, Dr. Meera Balasubramaniam, a Geriatric Psychiatrist from NYU. Meera wrote a paper for JAGS titled "Rational Suicide in Elderly Adults: A Clinician's Perspective". We talk with Meera about her article, including how she would define rational suicide, how can we help best explore these thoughts that patients consider rational, and how society and baby boomers are changing the way we think about this. We also dive into some other interesting topics include agism. I really love this quote from Meera, so I'll post it here, but for the full transcript read below or listen to the podcast: Ageism is a very interesting and distinct concept. It's fear of growing old or fear of being in that state. It's so distinct from something like racism or sexism. If a person is racist about a certain other race, it's less likely that they are going to be part of the other race that they are having negative connotations about. Similarly, if you are sexist, it's less likely less likely that you are going to belong to the other gender. When it comes to age, it's quite fascinating that most of us are actually going to get to that stage that we're being ageist about. What it is about growing old and about being down in the future that scares most of us has been sort of the crux of part of my work from a society perspective.

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In this weeks podcast we talked with David Wang about how palliative care can join forces with the emergency department to improve care for the serious ill. This conversation was motivated in part by a recent expert consensus statement on key knowledge and skills standards about hospice and palliative medicine for emergency medicine providers. What should the core training be? How do emergency providers feel about palliative care? How can palliative care services that are typically available bankers hours work with the emergency department, open 24-7?

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On todays podcast, we will be talking with Brooke Namboodri and we have Tim Platts-Mills from the University of North Carolina at Chapel Hill about their new article in the Journal of American Geriatric Society (JAGS) on "Elder abuse identification in the prehospital setting, an examination of state EMS protocols." We talk with Brooke and Tim about the state of EMS protocols in the US and how often the mention elder abuse in them (spoiler alert: not very often), how this compares to mentions of child abuse, the role EMS should play in elder abuse identification and management, and the role of potential screening tools for elder abuse.

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In this weeks GeriPal/JAGS Podcast we talked witk Kei Ouchi, an emergency medicine physician, internist, and researcher at the Brigham and Women's Hospital and Harvard Medical School in Boston. We recorded this podcast in the hallways of the annual meeting. We talked about outcomes following intubation in the emergency department. Kei published a paper in JAGS that is notable for several things, but perhaps most of all for the innovative use of color imagery to convey a message. The image in the @AGSJournal tweet above is from Dr. Ouchi's article - this tweet went viral by the way - and notice what it does: (1) convey the main message that outcomes are worse with advancing age, and are not good in general overall; (2) grab your attention and make you want to learn more. Kei is very thoughtful about how these data should be used - not on the spot in the ED, when a patient is gasping for air, and you pull up the color figure on your iphone Twitter app - no, not then. Better to use this information in advance, when things are calm, outside the ED, for people at risk of going to the ED in extremis. This is the first in a series of GeriPal podcasts on the GeriPal - ED interface. ED stands for Emergency Department by the way. Enjoy! -By @AlexSmithMD

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On this week's podcast, we talk with the authors of a Journal of the American Geriatrics Society (JAGS) article titled Should We Bury “The Good Death"? As luck may have it, one of the authors is co-host Alex Smith, and the other is a leader in geriatrics and palliative care, VJ Periyakoil. Alex and VJ's critique of the ‘good death’ was published alongside a paired commentary from Age and Ageing from the British Geriatrics Society.

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For this week's GeriPal podcast we are honored to be joined by Tim Quill, palliative care physician and bioethicist from the University of Rochester, New York. Dr. Quill has pushed our nation to seriously grapple with the issue of physician aid in dying with a remarkably thoughtful and measured approach. We talk with Dr. Quill on this podcast about voluntary stopping eating and drinking, and a paper on this topic he recently published in JAMA Internal Medicine. As noted in the podcast, I am deeply ambivalent about physician aid in dying. I find voluntary stopping eating and drinking (VSED) to be far more acceptable. Some of this has to do with the acceptability of positive and negative acts (positive act - giving a patient a prescription for lethal medication; negative act - not inserting a feeding tube in a patient who refuses to eat and drink). Some of this just has to do with the time course: patients who stop eating and drinking must have the resolve and dedication over time. And they can change their minds. We address many aspects of this issue on the podcast, including: Who is VSED appropriate for? What can patients expect? How does VSED compare to other "options of last resort?" What is the role of palliative care? Should hospice's deem a patient eligible if they would not have a less than six month prognosis if they continued to eat and drink? When should a psychiatrist be involved? What if the suffering is not physician, but social or psychological? Is VSED legal? Should clinicians routinely offer VSED to all patients with serious illness as an option? How do you feel about this topic? Feel free to respond in the comments, or on Twitter!

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For this weeks podcast, we talk with Laura Petrillo, lead author of a recent paper published in JAMA IM titled “Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes”. Laura is a palliative care physician and researcher at Massachusetts General Hospital and Harvard Medical School. Laura's finding should serve as a wakeup call for anyone caring for individuals on hospice living in nursing homes. They found that 1 in 9 nursing home patients with type 2 diabetes experienced hypoglycemia. So take a listen an tell us what you think in the comment section on this GeriPal post.

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Many in palliative care (including us) have argued that the default care model in nursing homes should be a palliative approach. Revealing indeed, therefore, to talk with nurse researcher Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion for nearly 200 residents of 3 San Francisco area nursing homes, finding: 70% of nursing home residents were palliative care-eligible, but other than 2 patients on hospice, none were receiving consultative palliative care 99% of residents had completed a POLST, but almost no one remembered filling it out Listen to the podcast for more, including answer to questions: What does palliative-care eligible mean? How could they fill out a POLST but not remember it, did they all have dementia? What is Campbell's law, and does it have anything to do with his soup? We're joined on this podcast by Sei Lee, MD, regular guest host and as it happens senior author on the nursing home study, and Lynn Flint, MD, palliative care physician with extensive experience working in nursing home settings. Enjoy!

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Proton pump inhibitors are one of the most widely used medications. As I note in the podcast below, I was in my local drug store the other day, and an entire shelf segment, top to bottom, was filled with medications for "heartburn," and most of them were proton pump inhibitors. And those are just the over the counter variety. So wouldn't it be a public health disaster if proton pump inhibitors, or PPIs, increased a persons risk for dementia? Even if the increase in dementia risk is only slight, on a population level, given the vast number of people using PPIs, the consequences would be disastrous. A major study in JAMA showed just such a linkage, raising serious alarm about this issue. So with this urgent question in mind, we talk with two authors about their more recent studies in JAGS suggesting that there is no such linkage. We talked with Shelly Gray, from the School of Pharmacy and the University of Washington, and Felicia Goldstein from Emory University, about their studies, the current evidence as a whole, and what an individual on PPI's should think at this time about his or her risk of dementia. Here is the bottom line, for those who can't wait. In response to Eric asking what advice they would give their 75 year old neighbor who is taking PPI's, Dr. Gray said: I would tell her that the information is conflicting, but some really high quality studies have been done and have not found an association, and if this medication is necessary to manage her condition, that she should continue taking it. However, I will say that we do know that these medications are overused, and so I still believe in the tenet of geriatric medicine that we try to deprescribe when possible, so I would try to reassure her and let her know that it's not a done deal and that the high quality studies do indicate that there doesn't seem to be an association.

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Today we have Lee Lindquist with us on the GeriPal podcast to talk about planning for the "4th quarter" of life. Dr. Lindquist is a geriatrician and chief of geriatrics at Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine in Chicago. Dr. Lindquist developed a website called PlanYourLifespan.org to help older adults create strategies for dealing with health crises, such as hospitalization, a serious fall, and dementia. Using the website, older adults can think about what services they may need in the last 10 or 15 years of their lives, what choices they can make now, and how to access these services when needed. Her work was also recently published in a a Journal of Hospital Medicine paper showing that the website helped older adults plan for posthospital discharge needs before a hospitalization occurs. So give it a listen and comment below on what you think should be address in the last quarter of life.

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We have a great podcast this week exploring the advance care planning needs for hospitalized adults and what palliative care teams are doing (and not doing) to meet these needs. We've invited Kara Bischoff, a palliative care doctor and Assistant Professor at UCSF in the Department of Hospital Medicine, who published a paper in JAMA Internal Medicine on this very topic. Why was this JAMA IM paper so important for those who work in our field? This was a real world study, looking at over 73,000 consultations from the Palliative Care Quality Network (PCQN). They found palliative care teams consistently identified surrogates for patients, often addressed their preferences regarding life sustaining treatments, including code status, and frequently found a preference regarding life sustaining treatments that was different than what was previously documented before the consult. But rarely completed advance directives (only 3.2% of patients seen by palliative care teams) or Physicians Orders for Life-Sustaining Treatment (POLST) forms (12.3% of patients seen by palliative care teams).

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Our guests this week are Lena Makaroun, MD, a research fellow at the VA Pudget Sound, and Sei Lee, MD, Associate Professor of Medicine at UCSF and frequent co-host on this podcast. They recently wrote a paper in JAMA Internal Medicine on wealth disparities in the US and England, and implications for mortality and disability. Major take home points: “It’s not that great to be rich, but it really sucks to be poor.” Those in the bottom quintile of wealth had the greatest difference in disability and mortality (ie worse). Differences between those in the highest quintile of wealth and the next highest were relatively minor in comparison. “Rather than saying universal healthcare doesn't help, I would just say it's not enough.” Worse disability and mortality with lower wealth were observed in the US and England, both before and after age 65. Does this mean National Health Service isn’t working? The authors expected to find less difference in England where universal coverage is, well universal, and not just after age 65 in the US (Medicare). The authors give thoughtful responses.

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For this weeks podcast, we talk all about prognostication with Christian Sinclair. Christian is a palliative care physician at University of Kansas Medical Center, past president of AAHPM, recent AAHPM "Visionary" awardee, and Pallimed social media guru. We go over a lot of topics at the heart of prognostication in hospice and palliative care including: - The importance that prognostication plays in daily practice, especially in goals of care discussions - Helpful tools and skills to estimate prognosis - How prognosis changes the way we think about prescribing opioids - How to think about prognosis when it comes to hospice eligibility and why it may be that one of the most important tools used for prognostication in the hospice setting, the hospice eligibility guidelines, were last updated over two decades ago. So we have a ton to talk about and we would love for you to continue this discussion in the comment section of this blog, on Facebook or on twitter.

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In this week's GeriPal podcast, we talk with Jessie Merlin, Palliative Care Faculty at the University of Pittsburgh, who is addressing another important aspect of this issue: the role of palliative care in chronic pain. We disucss issues such as: - Do outpatient palliative care providers see patients with chronic pain currently? (please take this survey to help Jessie figure this out!) - Should palliative care fellowship training include management of chronic pain? - Is there really a distinction between "cancer pain" and "non-cancer pain?" - To what extent is or should prognosis be a factor in determining treatment of pain? - Everybody Hurts by REM (and a hack rendition)

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In this week's GeriPal Podcast, sponsored also by the Journal of the American Geriatrics Society, we talk with Tom Gill, MD, Professor of Medicine at Yale. With guest co-host Dan Matlock, MD, from the University of Colorado, we talk with Tom about his recent JAGS publication on the relationship between distressing symptoms, disability, and hospice enrollment. Tom conducted this study in a long running cohort of older adults that has made a number of outstanding contributions to the GeriPal literature (see links on the GeriPal website). Tom's song request? Stairway to Heaven. This podcast was recorded at the recent Beeson meeting, an aging research meeting, near Albuquerque, New Mexico. At the end, you hear about 30-40 of us singing the end of Stairway around a campfire. As in singing, "And as we wind on down the road...:" Nailed it!

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On this week's podcast, we have invited Dr. Kimberly Curseen to talk about how implicit bias influences us as providers in geriatrics, hospice, and palliative care, as well as the role of that cultural competence and cultural humility should play in our practice. Kimberly Curseen, M.D. is an Associate Professor of Internal Medicine at Emory School of Medicine and Director of Outpatient Supportive/Palliative Care, Emory Healthcare.

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On this GeriPal podcast we discuss the value of "scenario planning" in informed decision making with Gretchen Schwarze, Associate Professor in the Division of Vascular Surgery at the University of Wisconsin. Dr. Schwarze is a board-certified vascular surgeon and medical ethicist who recently wrote an article on this subject in the New England Journal of Medicine (NEJM). Scenario planning comes from the economics literature, but Dr. Schwarze advocates for its use in medicine, giving healthcare providers the tools to say “I cannot predict the future, but if all goes well, this is what is likely to follow, and if things go poorly, this is what we can expect.” The aim is not to develop the “correct” scenario, but to describe a range of stories illustrating how the future might unfold.

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Back in 2009, Pallimed created one of my favorite posts titled "Top 10 Contemporary Palliative Care Songs". In it, they made a list of "contemporary" songs from many different genres that have palliative themes. For todays podcast, we aim to update this list with songs that inspire, move, or make us think about geriatrics or palliative care. As with the Pallimed post, this is all personal preference. So we would love to hear from you. What one song would you have included in this podcast if you were sitting in the studio? Put it in the comments section on www.geripal.org

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On this weeks podcast, we have Sarah Hooper, J.D., the Executive Director of the UCSF/UC Hastings Consortium on Law, Science and Health Policy, an interprofessional partnerships in education, research, and clinical training and service. We talk with Sarah about her work creating the Medical-Legal Partnership for Seniors Clinic (MLPS) in which law students and faculty provide free legal assistance to low-income older patients at the UCSF Medical Center and at the San Francisco VA.

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Zara Cooper the Need to Integrate Geriatrics and Palliative Care into Trauma Surgery by Alex Smith and Eric Widera

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How to have a code status conversation with Laura Petrillo and a live studio audience by Alex Smith and Eric Widera

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Vicki Jackson and David Ryan: Living with Cancer by Alex Smith and Eric Widera

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The Veterans Healthcare System is the largest integrated healthcare system in the United States and one that trains the majority of physicians who practice in the US. We interview journalist and author Suzanne Gordon about the battle that is going on for the $70 billion spent on Veterans health every year.

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We interview Anna Chodos, Assistant Professor in the Department of Medicine and Division of Geriatrics at UCSF, about her work in creating the Optimizing Aging Collaborative. The collaborative's goal is to enhance and unify care of older adults in the community by creating a unique partnerships between public, human service, and academic organizations. The Optimizing Aging Collaborative at UCSF, which was founded in July 2015 as a Geriatric Workforce Enhancement Program (GWEP) by the U.S. Health Resources and Services Administration (HRSA). The collaborative includes a broad array of experts to provide education and innovative services that address older adults’ health, social, and legal needs, that hopefully other cities can replicate.

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On today's podcast, we interview Steve Pantilat about his new book "Life After the Diagnosis: Expert Advice on Living Well with Serious Illness for Patients and Caregivers." Steve is a Professor of Medicine, the Department of Medicine at UC San Francisco, Kates-Burnard and Hellman Distinguished Professor in Palliative Care, and Founding Director, the UCSF Palliative Care Program. In his book, Steve writes to patients and family members coping with serious illnesses about the difficult decisions they face in a convoluted medical system, giving them practical advice on a wide range of common concerns. We talk with Steve about how he came up with the idea of the book, his views on living well and what a "good death is", the role that hope plays in decision making, and the language that we use in medicine that can easily be misunderstood.

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This week's GeriPal Podcast features NY Times journalist Paula Span about what we can do as educators, as researchers, and as clinicians, to collaborate with the media. During Paula's extensive career as a reporter, she has written for the Washington Post, Philadelphia Inquirer, the Boston Globe, the Wall Street Journal, Newsweek, New York Magazine, Esquire, Parenting, Glamour, Ms and several city magazines. Paula currently writes at The New York Times for The New Old Age, and trains the next generation of journalists at the Columbia University Graduate School of Journalism.

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What should you say to your older patient when it's time to stop cancer screening? This week's GeriPal Podcast features Nancy Shoenborn, Assistant Professor of Medicine at Johns Hopkins. Dr. Shoenborn published a paper in JAMA Internal Medicine this week on older adults perspectives on cancer screening cessation, and using life expectancy to justify stopping screening.

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Today's GeriPal Podcast features Vanessa Grubbs, a nephrologist and Associate Professor of Medicine at UCSF. Vanessa talks with us about her forthcoming book titled, "Hundreds of Interlaced Fingers," to be released June 13, but available for pre-order now. Dr. Grubbs' book tells the story of her journey from primary care to nephrology to palliative care, of falling in love with a man to donating a kidney to him to marriage, and of the journeys of the diverse, older, complex patients she's cared for with chronic kidney disease, who sometimes choose not to start dialysis.

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For this week's GeriPal podcast we talk with Sandra Moody, MD, about her experiences in geriatrics and palliative care in Kamogawa City, Japan. Sandra helped to start the hospice and palliative care service at the San Francisco Veterans Affairs Medical Center prior to moving to Japan. We spoke with Sandra about differences between geriatrics and palliative care as practiced in the US vs. Japan.

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We talked with Rebecca about the results of The Prepare Trail, a randomized controlled trial of an easy-to-read advance directive PLUS a web-based decision aid vs the easy-to-read advance directive alone in 414 older veterans with chronic disease

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A study published in JAGS reported approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. We discuss with the studies author about how he became interested in transitions and why this is important.

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On todays podcast, we interview Dr. Samir K. Sinha, MD on how he has influenced local and national policy to redesign the care we give to older adults. Dr. Sinha is the Director of Geriatrics at the Sinai Health System, an Associate Professor of Medicine at the University of Toronto, and Assistant Professor of Medicine Johns Hopkins University School of Medicine. Among his many accomplishments is that he lead Ontario's “seniors care strategy" and is now involved in the development of a National Seniors Strategy.

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On this weeks podcast, we interview Michael D. Fratkin, a palliative care clinician and founder of ResolutionCare, a palliative care service for rural and resource poor areas in Northern California. We discuss the barriers and benefits of providing specialty level palliative care for areas that generally have no access to these services. We also discuss novel approaches, including in-home video conferencing.

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Today's GeriPal podcast features Sean Morrison, Geriatrician and Palliative Medicine physician, director of the National Palliative Care Research Center and the Hertzberg Palliative Care Institute at Mount Sinai in New York. We talk with Sean about a new report titled, "How We Work: Trends and Insights in Hospital Palliative Care." This report was co-produced by the National Palliative Care Research Center and the Center to Advance Palliative Care. The report summarizes the current state of palliative care practice in the US.

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Today's GeriPal podcast features Laura Hanson, Geriatrician and Palliative Medicine physician at the University of North Carolina, Chapel Hill. Laura discusses her recent JAMA RCT of a goals of care intervention for nursing home residents with advanced dementia.

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We discuss with geriatrician, palliative care clinician, professor of medicine at Harvard Medical School, and author Muriel Gillick about the state of our current health care system for older adults as they journey through our health care system.

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In this GeriPal Podcast we talk with Dr. Mark A. Supiano about a blood pressure management in older adults in the light of new evidence from the Systolic Blood Pressure Intervention Trial (SPRINT). In particular, we talk about a recent paper he co-author with Jeff Williamson in the Journal of the American Geriatrics Society (JAGS) titled "Applying the Systolic Blood Pressure Intervention Trial Results to Older Adults."

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We talk with Dr. Jessica Zitter, a pulmonary critical care and palliative medicine physician, and author of Extreme Measures: Finding a Better Path to the End of Life. We talk with Jessica about her experience transitioning from being an ICU doctor to an ICU/Palliative doctor, how she is treated differently when she sees patients as an ICU attending vs a palliative care attending, the Big 3 (CPR, mechanical ventilation, and feeding tubes), and most importantly WHO she is wearing to the Oscars!

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On todays podcast we interview Nathan Goldstein, MD, Chief of the Division of Palliative Care for Mount Sinai Beth Israel. We discuss his experiences and research focused on improving communication and the delivery of palliative care to patients with advanced heart failure.

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On todays podcast, we talk with Vicki Jackson, Chief of the Palliative Care Division at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, about her work in building the evidence base for palliative care.

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Nursing home residents are often sent to the hospital for care that often offers little hope of improving quality of life or changing the course of illness. Some facilities though seem to do much better in preventing these "potentially burdensome hospitalizations". We discuss with Andrew Cohen, the lead author of a recent JAMA IM paper on this subject, to learn a little about what is in the secret sauce of these exceptional nursing homes.

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Clinical formulations, something that few of us outside of mental health providers know about, but are critical in improving communication skills, especially around serious illness. Learn about them from our special guest, Dani Chammas, who makes the case that the single most valuable thing clinicians can do to improve communication is to get into the practice of developing a formulation.

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On todays podcast, we talk with Angelo Volandes about the use of video to improve advance care planning.

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Just in time for Thanksgiving, we are having an episode dedicated to the humble cranberry. We discuss the use of cranberries to preventing urinary tract infections with Dr. Manisha Juthani-Mehta. In addition to hearing about something called proanthocyanidin, we discuss her recent publication in JAMA on whether cranberry capsules decrease the presence of bacteriuria plus pyuria in older women living in nursing homes.

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There are a lot of ways one can imagine on how to integrate palliative care into the intensive care unit (ICU). Today, we talk with ICU doctor and researcher, Bill Ehlenback, about his recent study of a proactive palliative care rounding intervention.

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Truth telling is an ethical pillar of medicine. But, are there instances when it is ever ok to lie? In this episode of the GeriPal podcast we explore the use of deception and lies in modern healthcare, including those sweet little “therapeutic lies” commonly used in dementia care. For more about this topic, and some good articles about it, visit GeriPal.org.

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This week’s GeriPal podcast is all about mechanical ventilation in nursing home residents with advanced dementia. In particular, we discuss a new finding that use of mechanical ventilation doubled for these individuals from 2000 to 2013 without a substantial improvement in survival.

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The second GeriPal podcast is a book review of "When Breath Becomes Air."

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This is the first of the GeriPal podcasts focused on all things geriatrics, hospice, and palliative care.