Explorez tous les épisodes du podcast GeriPal - A Geriatrics and Palliative Medicine Podcast

When you think of palliative care pharmacotherapy, you probably think about the tried-and-true mainstays of our field like morphine, haloperidol, and senna. But the landscape of palliative symptom management is rapidly evolving, with hot new drug classes and rediscovered old-school opioids (and not just buprenorphine!)

On today's episode of the GeriPal Podcast, we sit down with three expert palliative care clinical pharmacists, Max Stevenson, Alex McPherson, and Nisha Iyer, to talk about 5 hot new drugs (or rediscovered):

1. Suzetrigine: It works for bunions (at least as well as opioids, maybe?), but can it work in palliative care?  My take-home point here is that its not ready for prime time, but you may have a different take after listening.

2. Levorphanol: The forgotten opioid that looks a lot like methadone but more NMDA.  Should we bring it back to the living?  Maybe if it were cheaper (why does an old drug cost this much?)

3. Tapentadol: Basically a better version of tramadol (aka Tamadont) that combines mu-opioid agonism with norepinephrine reuptake inhibition. Expensive but our guests varied in the potential benefit here.

4. Dual Orexin Receptor Antagonists (DORAs): Rerouting sleep management away from sedating Z-drugs and benzodiazepines to these new agents seems reasonable (again if cost was no concern) given that they appear safer (check out this JAGS article on DORAs and the risk of falls)

5. GLP-1 Receptor Agonists: Wait, GLP1's in palliative care (not just stopping it when we get consults for weight loss)? There may be a couple reasons to consider…

Also check out some of these podcasts that we talked about in this episode:

• Gabapentinoids – Gabapentin and Pregabalin: Tasce Bongiovanni, Donovan Maust and Nisha Iyer

• Tramadon't: a podcast with David Juurlink about the dangers of Tramadol

• Buprenorphine Use in Serious Illness: A Podcast with Katie Fitzgerald Jones, Zachary Sager and Janet Ho

• All the Questions You Had About Opioids But Were Afraid To Ask: A Podcast with Mary Lynn McPherson

Love the story Judy Solerno tells at the start of this podcast. The story is about how John Snow, the father of modern epidemiology, mapped out cases of Cholera in London in the year 1854.  He was able to identify a concentration of cases near a neighborhood water pump.  Simply removing the handle from the pump halted the outbreak.  This is one of the earliest recorded uses of maps for public health purposes.

Our guests today, Judy Salerno (President Emeritus of the New York Academy of Medicine) and Lindsay Goldman (CEO of Grantmakers in Aging) have done some wonderful work creating detailed, in-depth, interactive maps of aging in New York City. Go to IMAGENNYC and try it yourself.

Today we talk about:

• How the whole country became familiar with these sort of maps during Covid

• The case for using these maps for health needs of older adults, outside of the use cases in infections like Cholera and Covid

• Our "favorite" density maps of resources, services, and amenities, including: benches, crosswalks, tree canopy, heat vulnerability, among others.

• Use cases for these maps in public health and planning, grantmaking/philanthropy, and politics/policy advocacy.

• Judy's work creating similar maps for Sao Paulo Brazil (will add link here when website is up).

• How others can replicate this process in their home cities or counties

And I get to sing Tapestry, by Carol King, which Judy chose in honor of two recently deceased giants of feminism, Dolly Parton and Gloria Steinem.  My wife Cindy plays piano on the audio only podcast.

-Alex Smith

Just in time for respiratory virus season, this episode of the podcast breaks down essential vaccine guidance for older adults. From flu, COVID-19, and RSV to an added bonus deep dive into shingles, we cover everything you need to know to protect older adults this season.

Our expert guests include:

• Kenneth Schmader, MD: A geriatrician and vaccine researcher who helped develop the zoster vaccine. Ken serves on the Working Groups for the Herpes Zoster, Influenza, COVID-19, RSV and General Adult Immunization Guidelines for the US Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP).

• Sharon Brangman, MD: a geriatrician extraordinaire whom we've had in the past for her work in Alzheimer's, and whom we've now asked to talk about her work with the AGS Older Adults Vaccine Initiative.

We covered a lot of topics, including:

• Who needs which vaccine at what age: Clear guidelines for COVID-19, RSV, flu, and shingles vaccines.

• Optimal seasonal timing: What the optimal timing during the year to receive the schedule their shots?

• Vaccine selection: How to choose between options, including standard-dose, high-dose, and new mRNA flu vaccines?

• Does the shingles vaccine really prevent dementia?

Listen now and explore the links below for more resources.

Eric

Resources:

• AGS Vaccine Initiative Website.  They have a variety of resources including:

• Get the Basics: Essential Vaccines for Older Adults

• Learn More: What You Need to Know About COVID-19 Vaccines for Older Adults (Age 65+)

• Ask The Expert: The Flu Vaccine

• Learn More: What You Need to Know About the Shingles Vaccine

• Get the Basics: RSV Vaccines for Older Adults (60+)

• CDC Adult Immunization Schedule

• The Nature study we discussed on the effect of herpes zoster vaccination on dementia

Difficulty managing money is often one of the earliest signs of Alzheimer's disease and related dementias, frequently appearing years before an official diagnosis. This loss of financial capacity leaves individuals vulnerable to costly mistakes and exploitation, threatening the financial security and quality of life of entire families.

In this episode, we sit down with Dr. Lauren Hersch Nicholas, Dr. Duke Han, and Dr. Jason Karlawish to examine the intersection of cognitive decline, financial decision-making, and patient protection. We covered a lot of topics, including these key ones:

• The Financial Prodrome: Dr. Nicholas shares her health economics research showing that missed payments and credit score drops can appear up to six years before a dementia diagnosis—causing major wealth loss long before healthcare providers catch the issue, especially in lower-income communities.

• Brain Function & Social Buffers: Dr. Han discusses new neuroimaging research on how cognitive decline impairs financial judgment and explains how strong social connections can serve as a critical protective buffer.

• Clinical & Policy Solutions: Dr. Karlawish outlines the medical, policy, and financial-sector interventions needed to safeguard vulnerable patients.

For a deeper dive on some of the articles we discussed, check out these references:

• My first JAMA paper on Finances in the Older Patient With Cognitive Impairment 

• Lauren's plant money podcast on how your bank account might predict dementia 

• Lauren's article on Management of Financial Assets by Older Adults With and Without Dementia or Other Cognitive Impairments 

• Jason's editorial on the Importance of Asking Older Adults Whether They Are Having Difficulty Managing Finances. 

• Jason's article on Desktop Medicine and the Practice of Wealth Care

• Duke's article on Financial exploitation vulnerability and social connectedness in middle-aged and older adults without dementia https://www.tandfonline.com/doi/full/10.1080/13607863.2025.2475331

GLP-1 receptor agonists (the "Ozempics of the world") have been a truly revolutionary pharmacological advance in modern medicine. In randomized controlled trials (RCTs), these agents have been shown to do much more than just reduce weight, including significantly reducing cardiovascular events, lowering all-cause mortality in patients with type 2 diabetes, and even slowing the progression of chronic kidney disease.

But as we see their use rapidly expand among older adults, we have to ask: at what cost?

In geriatrics, weight loss is rarely simple. In older bodies, GLP1s carry increased risks, including accelerated muscle loss, functional decline, and possibly decreased bone density. So are we just trading weight loss for frailty?

To help us untangle this complex web, we sit down with three expert geriatricians in obesity: Dr. John Batsis, Dr. Shen Dewar, and Dr. Aruna Josyula.

What We Discuss in This Episode:

• How age-related changes alter the distribution of fat and muscle, even when body weight stays exactly the same.

• What are sarcopenia (muscle loss) and sarcopenic obesity, and why are they so dangerous for independence?

• A discussion on what happens to fat, muscle, and bone during standard weight loss versus weight loss accelerated by GLP-1s.

• Whether GLP-1-induced muscle loss a direct biological side effect from suppressed muscle protein synthesis, or is it simply the indirect result of a massive caloric deficit and dropping protein intake?

• A broad, geriatric-focused approach to weight, including a vital review of common medications that might actually be causing weight gain in the first place.

• Practical, actionable strategies to protect muscle mass and function when prescribing GLP1s

• A discussion of red flags in older adults, where we should have major hesitation before ever writing a prescription for a GLP-1

We cover this and more in the podcast. There is a forthcoming article in JAGS that addresses this topic, and we will add the link here once published.  If you want to take a deeper dive, take a look at some of the following references we discuss:

1. Aruna's article in JAGS titled "One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults"

2. John's Annal's article on the "Effect of Incretin-Based and Nonpharmacologic Weight Loss on Body Composition: A Systematic Review"

3. John's article on the "Unintended risks of sarcopenic obesity during weight-loss interventions in older people" in Nature Med.  

4. An article titled "The Effects of Incretin Mimetic Therapies on Muscle and Bone Health in Older Adults"

5. A systematic review of the effect of weight loss on muscle-based indices

6. An article on "Treating Sarcopenic Obesity in the Era of Incretin Therapies: Perspectives and Challenges"

7. Shen's article describing "The Optimal Health Weight and Lifestyle (OHWL) Clinic"

8. Shen's article titled "A Geriatrician's Approach to Managing the Complex Older Adult with Obesity"

9. Another JAGs article on "Older Adults with Obesity: The Need for a 4Ms Age-Friendly Approach to Care"

10. Lastly, CMS's information on the GLP1 bridge program

As Diane Meier remarks to start today's podcast, palliative care has come a long way from the days when we were the "brink of death" consult. We're seeing patients earlier and earlier in the course of illness.  In fact, the evidence base for specialist palliative care is arguably stronger in the outpatient setting than the inpatient setting.

In some ways, as Eric remarked, we are a victim of our own success. We've pushed on the boundaries of seeing patients earlier in the course of illness, we've demonstrated remarkable value to our colleagues and health systems: now they want us to see more and more patients, with conditions we would not have previously considered core to palliative care practice.

Our guests modeled respectful disagreement, and we were somewhat surprised that there was more agreement than we expected.  I'm sure you will all have strong feelings about the opinions expressed, please let us know!

In addition to Diane Meier, we welcome back Bob Arnold and Justin Sanders to talk through these issues, including:

• We agree specialist palliative care is for people with "serious illness" - but what constitutes "serious illness"

• Is a limited prognosis part of the definition of serious illness?  We discuss the Center to Advance Palliative Care definition of palliative care and Amy Kelley's oft-cited definition of serious illness.  

• Many patients with conditions that overlap with palliative care would benefit from our help, e.g. chronic pain, opioid use disorder, mental illness. Our health system is not meeting their needs.  Should palliative care see them, in the absence of a clear life-limiting illness?

• How limited a prognosis should we consider here - months, years…decades?

• We have a tremendous workforce shortage.  There are not enough specialist palliative care providers to see all patients with advanced cancer, much less the many other conditions whose guidelines now say should include palliative care.  The reality does not match the mission.  Does that change our mission? 

• Should local workforce issues dictate who should see palliative care? See this article by Pelleg in which clinicians at Mt Sinai agreed that patients with serious illness and high risk of mortality should be prioritized, explicitly excluding patients with chronic pain or psychosocial distress in the absence of serious illness.

• What is the role for Patient Reported Outcomes (PROs)? e.g. patients regularly reporting pain or other symptoms and an escalation in symptoms triggering a palliative care intervention. 

• How is the definition of who should see palliative care expanding in Canada, and is there a linkage to who is eligible for medical aid in dying in Canada.  Justin makes a good plug for the McGill National Palliative Care Grand Rounds Programme

• What is our vision for where palliative care should be 10 years from now? Population health specialists, or healing patients one visit at a time? To be sure, these are not mutually exclusive.

• How long should palliative care fellowship be - should we expand it to 3 years so palliative care specialists can care for people with a wider range of conditions?  

• What is Precision Palliative Care? Diane mentions this article by Ramy Sedhom on a couple of occasions.  

• Should palliative care see patients with sickle cell disease? How about survivorship clinics? How about very elderly patients with multiple mild chronic conditions (e.g. mild heart failure, mild COPD, mild cognitive impairment, arthritis, diabetes, hypertension)?

• And much more!

Please listen to the audio only version of Stand by Me - my son Renn added an upright base, snap, and triangle parts - it's much better than the live version for YouTube that I accidentally started in a much too high key!

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.

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.

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

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.)

—-

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 

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)

3. 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect?

4. 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'.

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=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_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

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

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 

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

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.

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).

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

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

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

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 

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

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

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

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

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

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

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

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

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 around
Been sent up, and I've been shot down
You're the best thing that I've ever found
Handle me with care"

Enjoy!

-Alex Smith

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 

"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.

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 **

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.

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

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

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

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 **

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

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

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).  

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

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

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

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

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

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

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

10.  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/

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

12.  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/ 

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

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. 

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.

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.

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