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Content provided by GeriPal, Alex Smith, and Eric Widera. All podcast content including episodes, graphics, and podcast descriptions are uploaded and provided directly by GeriPal, Alex Smith, and Eric Widera or their podcast platform partner. If you believe someone is using your copyrighted work without your permission, you can follow the process outlined here https://player.fm/legal.
A geriatrics and palliative care podcast for every health care professional. We invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn and maybe sing along. Hosted by Eric Widera and Alex Smith. CME available!
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A geriatrics and palliative care podcast for every health care professional. We invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn and maybe sing along. Hosted by Eric Widera and Alex Smith. CME available!
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1 Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson 48:55
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Play Later Play Later Lists Like LikedHave 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…
1 Music as Medicine: Jenny Chen, Tyler Jorgensen, & Theresa Allison 42:03
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Play Later Play Later Lists Like LikedAs 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. -S ystematic 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.…
1 Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh 48:27
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Play Later Play Later Lists Like LikedOur 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: Usual care Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect 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. 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…
1 Psilocybin in Serious Illness: A Podcast with James Downar, Ali John Zarrabi and Margaret Ross 46:57
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Play Later Play Later Lists Like LikedWe’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.…
1 HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene 48:59
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Play Later Play Later Lists Like LikedPeter 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…
1 Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan 45:26
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Play Later Play Later Lists Like LikedMore 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…
1 Loss of DEI Hurts Everyone: Farah Stockman, Ali Thomas, Ken Covinsky 47:18
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Play Later Play Later Lists Like LikedI 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…
1 RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest 50:34
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Play Later Play Later Lists Like LikedEarly 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…
1 GeriPal Takeover! Nancy Lundebjerg and Annie Medina-Walpole 51:34
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Play Later Play Later Lists Like LikedWhelp, 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…
1 Pragmatic Trial of ACP: Jennifer Wolff, Sydney Dy, Danny Scerpella, and Jasmine Santoyo-Olsson 47:04
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Play Later Play Later Lists Like LikedA 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…
1 Hastening Death by Stopping Eating and Drinking: Hope Wechkin, Thaddeus Pope, & Josh Briscoe 51:26
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Play Later Play Later Lists Like LikedEric 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/…
1 The Roots of Palliative Care: Michael Kearney, Sue Britton, and Justin Sanders 48:50
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Play Later Play Later Lists Like LikedAs 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…
1 PC for People Experiencing Homelessness: Naheed Dosani 46:46
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Play Later Play Later Lists Like LikedI 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 sketche s 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…
1 PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers 51:26
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Play Later Play Later Lists Like LikedMuch 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…
1 Trauma-Informed Care: A Podcast with Mariah Robertson, Kate Duchowny, and Ashwin Kotwal 47:07
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Play Later Play Later Lists Like LikedTrauma 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Plenary Abstracts at AAHPM/HPNA: Yael Schenker, Na Ouyang, Marie Bakitas 47:19
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Play Later Play Later Lists Like LikedIn 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 How to Make an Alzheimer's Diagnosis in Primary Care: A Podcast with Nathaniel Chin 47:52
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Play Later Play Later Lists Like LikedThings 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 car e 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Telehealth vs In-Person Palliative Care: Guests Joseph Greer, Lynn Flint, Simone Rinaldi, and Vicki Jackson 51:14
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Play Later Play Later Lists Like LikedIt 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Deprescribing Super Special III: Constance Fung, Emily McDonald, Amy Linsky, and Michelle Odden 49:49
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Play Later Play Later Lists Like LikedIt’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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Caring for the Unrepresented: A Podcast with Joe Dixon, Timothy Farrell, Yael Zweig 47:27
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Play Later Play Later Lists Like LikedMany 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Palliative Care for Mental Illness: A Podcast with Dani Chammas and Brent Kious 49:44
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Play Later Play Later Lists Like LikedWe’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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GeriPal - A Geriatrics and Palliative Care Podcast
1 AI for Surrogate Decision Making?!? Dave Wendler, Jenny Blumenthal-Barby, Teva Brender 47:52
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Play Later Play Later Lists Like LikedSurrogate 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 issue s 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Stories We Tell Each Other to Heal: Ricky Leiter, Alexis Drutchas, & Emily Silverman 48:34
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Play Later Play Later Lists Like LikedWe’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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Coping with Serious Illness: Danielle Chammas and Amanda Moment 50:24
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Play Later Play Later Lists Like LikedDenial. 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: nonjudgmentally observe their coping wonder about the impacts of their coping prioritize helping patients maintain their psychological integrity 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Falls and Fractures: A Podcast with Sarah Berry 46:46
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Play Later Play Later Lists Like LikedFalls 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Dialysis vs Conservative Management for Older Adults: Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath 47:07
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Play Later Play Later Lists Like LikedWe 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 COVID Updates: A Podcast with Peter Chin-Hong and Lona Mody 43:56
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Play Later Play Later Lists Like LikedIn 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Medical Cannabis Revisited: A Podcast with David Casarett and Eloise Theisen 52:07
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Play Later Play Later Lists Like LikedCannabis 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Guidelines or Goals in Heart Failure: Parag Goyal, Nicole Superville, and Matthew Shuster 48:28
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Play Later Play Later Lists Like LikedWhen 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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GeriPal - A Geriatrics and Palliative Care Podcast
1 Intentionally Interprofessional Care: DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace 47:56
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Play Later Play Later Lists Like LikedIn 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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