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

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

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

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

• Our podcast with Tony Back as well as Wendy Anderson on “Communication Skills in a Time of Crises”

• Our podcast with James Tulsky on “The Messiness of Medical Decision-Making in Advanced Illness.”

• Any one of our podcasts with Bob Arnold, including this one on the language of serious illness or this one on books, to become a better mentor.

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

By: Eric Widera

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

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

• The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI.  (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a  re-evaluation of what it means to be human, or deserving of moral standing).

• The moral questions at stake vs the biologic questions (and links between them)

• The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story)

• What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others.

• Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions.

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

Eventually, of course, everything must cease.  

-@AlexSmithMD

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

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

Today we talk with George Kuchel and Alison Huang about:

• Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline

• Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes)

• How the assessment leads naturally to therapeutic approaches

• Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy

• “Last ditch” pharmacologic treatments. 

• Landmark studies by Neil Resnick and Joe Ouslander.  

Enjoy!

-@AlexSmithMD 

 

You have a patient with dementia severe enough that she cannot recognize relatives.  She falls and breaks her hip.  Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation?  Should she be treated non-operatively, with aggressive symptom management?  A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia.

In today’s podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia.  Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what’s to be done about the pressure and incentives our health system exerts to operate, operate, operate.  

-@AlexSmithMD

Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm.  The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is: 

In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer.

Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis.  In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here.

Mara keeps working at it, and the more she works, the closer we are to fine.

-@AlexSmithMD

There are a lot of old myths out there about managing urinary tract symptoms and UTI’s in older adults.  For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.

 

On today’s podcast, we are gonna bust some of those myths.  We’ve invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.  

First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.  We discuss with her how we should work-up and manage “urinary tract infections” (I’ve added air quotes to “UTI” in honor of Tom Finucane’s JAGS article titled “Urinary Tract Infection”—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.)

Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men.  We also discuss Scott’s recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.  

 

In the US, geriatrics “grew up” as an academic profession with a heavy research base.  This was in part due to the tremendous support of the National Institute on Aging.  Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population. 

Palliative care, in contrast, saw explosive growth in US hospitals.  In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized “home” at the National Institutes of Health.  The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need.

Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care.  Kate’s journey is in a way emblematic of the lack of centralized funding for palliative care: she’s received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC.

We talk with Kate about how despite how far we’ve come in palliative care research, we still don’t have answers to some fundamental questions, such as:

• Who should get specialized palliative care?  Should eligibility and access be determined by clinician referral? By diagnosis?  By prognosis?  By need?
• If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged?  Can nudges help?  (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern)
• When should people get palliative care?  What does “early” really mean?  We can’t possibly meet the needs of all people with newly diagnosed serious illness
• How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings?  What’s the role of implementation science? What is a pragmatic trial?
• What outcomes should we measure?

We cover a lot of ground!  Working on a mystery.  Going wherever it leads.  Runnin down a dream…

-@AlexSmithMD

We are two and a half years into the COVID pandemic.  We’ve lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU’s overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the “zoom meeting.” 

But what have we really learned over this seemingly endless pandemic other than how to make a quarantini?  Well, on today’s podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease.

Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital.  In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post.  Some call her an optimist or maybe a pragmatist, but I’d call her someone who inherently understands the value in harm reduction when it’s clear harm elimination just ain’t gonna happen.

So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list:

• Medscape article on how “COVID-19 Vaccines Work Better and for Longer Than Expected Across Populations, Including Immunocompromised Individuals”
• Stat news article about variants/COVID becoming more predictable
• A good twitter criticism of the CDC 1 in 5 COVID survivors have long COVID study
• NIH study about long COVID published the day before in Annals of Internal Medicine
• Evusheld and how it works against BA4 and BA5
• Our World in Data COVID graphs

It’s been a while since we’ve done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here).  But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations.  

This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity.  They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities.  The basis of their argument is the ethical notion of “reciprocity” - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action.  Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion.

To be sure, Paxlovid is no longer as scarce as it was a few months back.  But the argument is important because, as we’ve seen, new treatments are almost always scarce at the start.  Evusheld is the latest case in point. 

Sometimes, you can’t always get what you want…

-@AlexSmithMD

A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid).   How do you do that?  Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to? 

Well on today’s podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead.

But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table! 

Oh boy, what should we do?  Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data?   Listen to this spicy podcast with these wonderful guests to make up your own minds (I’m sticking with the equianalgesic table for now).

If you want to take a deeper dive into some of the references, here you go:

• Pallmed Post on why “Opioid Equianalgesic Tables are Broken”
• Pallimed post on “Simplifying Opioid Conversions”
• Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone.
• Our previous podcast with Mary Lynn titled “All the Questions You Had About Opioids But Were Afraid To Ask”

 

In today’s podcast we talk with Dr. Rajagopal (goes by “Raj”), one of the pioneers of palliative care in India.  Raj is an anesthesiologist turned palliative care doctor.  He is also author of the book, “Walk with the Weary: Lessons in Humanity in Health Care,” and was featured in this Atlantic article.  Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India.  We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF.

In this podcast, we cover a great deal of ground, including:

• Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn’t see addressing suffering as a priority
• Prognosis communication and the subtle ways we may communicate it without intention
• Social pain and loneliness
• Community-based palliative care networks 
• Raj’s reflections on the state of palliative care in the US
• How definitions bind us, for example the division between chronic pain and palliative pain in much of the US
• Ways listeners can learn more and contribute (see this link in the US)

Because the song request was the short theme-song for Pallium, I recorded it two ways.  The intro is the upbeat guitar driven version.  The outro is the synthesizer (new toy!) slowed down version.

Enjoy!

-@AlexSmithMD 

Think about the last time you attended a talk on communication skills or goals of care discussions.  Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice?  I’m guessing not.  Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life.  

Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored.  On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care.  Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF.

We talk with Nick and Meg about:

• Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals
• How to screen for hearing loss
• Communication techniques we can use when talking to individuals with hearing loss
• The use of assistive listening devices like pocket talkers and hearing aids
• Their thoughts on the approval and use of over the counter hearing aids

If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following:

• Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners
• COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers
• Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults
• Over-the-counter hearing aids: What will it mean for older Americans?
• Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic

 

Comics. Cartoons. Graphic Novels. Graphic Medicine.  I’m not sure what to title this podcast but I’ve been looking forward to it for some time.  Heck, I’m not even sure to call it a podcast, as I think to get the most out of it you should watch it on YouTube.

Why, because today we have Nathan Gray joining us.  Nathan is a Palliative Care doctor and an assistant professor of Medicine at Johns Hopkins. He uses comics and other artwork to share his experiences in palliative care and educate others about topics like empathy and communication skills.  His work has been published in places like the L.A. Times, The BMJ, and Annals of Internal Medicine.  

We go through a lot of his work, including some of the comics you can see on our blog post. However if you want to take a deeper dive, check out his website “The Ink Vessel” or his amazing twitter feed which has a lot of his work in it.

 

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

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

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

In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine.  In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging.

In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry.  

As with aging, poetry operates on multiple levels within the palliative care space.  

Poetry puts us in our patient’s shoes. As Redwing’s poem says, “why not live as long as possible?”  

Poetry holds us in that liminal space so many of our patients are in. Paradox.  The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I’m paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go.  

Or as in Mark Nepo’s poem Adrift, I am so sad and everything is beautiful.

Poetry helps us grapple with our own experiences of illness.  Redwing, who is a cancer survivor, shares poems about her experiences with cancer.  Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis.  

We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality.

And along the way, we really felt like we got to the heart of things.  To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide.

-@AlexSmithMD 

Links to Redwing’s poetry workshops:

Food for Thought Poetry for Resiliency 

Loss, Losing  and Loosening, poetry for grief and loss  

Wounded Healer poetry sessions 

Advance Care Planning

Links to Redwing Keyssar’s poetry collections 

Redwing’s website: www.redwingkeyssar.com

Institute for Poetic Medicine

Mike Rabow’s Comprehensive Care Team randomized trial of outpatient palliative care

Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out).

In addition to Redwing’s own songs and poems, other poems read by Mike and Redwing during the podcast:

In Blackwater Woods by Mary Oliver

Therapy by John Wright

Adrift by Mark Nepo

Talk Before Sleep by Elizabeth Berg

Late Fragment by Raymond Carver

 

Buprenorphine.  It’s been around for a long time but is acting like the hot new kid in town.  Just look at this year’s AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now.  But does this drug really live up to the hype?

On today’s podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care).

We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes). 

And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles:

Learn more about caring for those with substance use disorder: 

• Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness 

Learn about using the low dose buprenorphine patch: 

• Low-Dose Buprenorphine Patch for Pain - Fast Fact

Learn about how to initiate buprenorphine: 

• Sublingual Buprenorphine Initiation: The Traditional Method  - Palliative Care Network of Wisconsin
• Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach

Good review on buprenorphine for pain

• Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

 

In her essay “Why Read a Poem in a Time Like This?”, Marilyn McEntyre writes:

All of us need it. We need it because good poems do something prose can’t do. They invite and enable us to notice the precarious fissures in what we think is solid ground. They direct us toward the light at the edge of things — the horizon, the fragment of dream before dawn, the feeling that’s hard to name, and can only be accurately captured by metaphor. They take us to the edge of “what can’t be said,” and ambush us into feeling before we think, so that we can’t simply and complacently “believe everything we think.” Poetry deals in surprise and subversion and turns old words to new purposes.

Marilyn is joined by Guy Micco to talk about why poetry is important in general, why it’s important in medical or nursing education, and why it’s important for people who care for older adults.

Along the way, they read poems, talk about poems, and sing a song by John Prine.  We talk about how poetry can surprise, how poems can be playful, how they unlock dimensions and emotions that are otherwise locked away.  How sometimes good poetry can be like a needed punch.

And maybe, just maybe, we convince that poetry skeptic Eric Widera that there is a place for poetry in medicine after all.

Enjoy!

-@AlexSmithMD

 

Links to essays and books by Marilyn McEntyre

• Why A Poem in a Place Like This?
• Why Read a Poem in a Time Like This?
• Patient Poets: Illness from the Inside Out
• Caring for Words in a Culture of Lies

Links to Songs/Poems from the Podcast:

• Hello in There by John Prine
• After Apple Picking by Robert Frost
• Sonnet 73: That Time of Year Thou Mayest in me Behold by Shakespear
• Jane by George Bilgere
• Long Life by Elaine Feinstein
• Sonnet 60 by Pat Schneider (not online)

 

One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, “Can We Agree to Disagree?” 

And today our guests agree to disagree.  

And yet, and yet…

They also agree across a whole range of issues, some of which surprised us.

This is the latest in our series of podcasts on concerns about, and potential of advance care planning.  If you’re new to this discussion, don’t start with this podcast!  Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki.  

On today’s podcast we ask our guests about areas in which there might be agreement or disagreement, including:

• The Best New York style bagels are made in California.
• Assigning a surrogate decision maker is important for everyone, including those who don’t have serious illness.
• Where does POLST fit in with this debate?
• All decisions are made in advance, the question that we are debating is how far in advance and what to call it
• Completion of advance directives and billing codes for advance care planning as quality metrics

Among other topics.  I’m heartened that we could have this discussion as a field, as it shows that we’ve grown to the point where we can agree to disagree respectfully with each other.  

We can work it out!

Links to a few couple items mentioned on the podcast:

• Objectives for Advance Care Planning
• 2018 Systematic Review of Systematic Reviews on ACP

-@AlexSmithMD

If you develop dementia, odds are you will spend the last months to years of your life in a nursing home or assisted living facility.   While we like to think about how our goals and preferences will influence what that life looks like, including whether you will get potentially burdensome interventions, your fate is probably influenced more by factors like where you live and what nursing home you happen to end up in. 

On today’s podcast we dive into drivers of invasive procedures and hospitalizations in advanced dementia by talking to some pretty brilliant nursing and nurse practitioner researchers focused on dementia, geriatrics, and palliative care in nursing homes: Ruth Palan Lopez, Caroline Stephens, Joan Carpenter, and Lauren Hunt.

We start off discussing the findings of Ruth Palan Lopez's publication in JAMA IM on the ADVANCE study.  This study explored nursing home organizational factors and staff perceptions that are associated with the variation in care for residents with advanced dementia.  Now when I say variation, I’m not talking about small little clinically questionable variations.  I’m talking about some nursing homes with no residents with advanced dementia being tube fed, and some with nearly half of their residents with advanced dementia being tube fed.  

We go on to talk about other findings of this study including that staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in ACP and preferred more aggressive care, issues with the skilled nursing facility benefit (“rehabbing to death”), the palliative care needs of nursing home residents, and so much more.

For a deeper dive, check out some of these other studies and resources we talked about in the podcast:

• The Influence of Nursing Home Culture on the Use of Feeding Tubes.  Archives of Internal Medicine 2010
• The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia
• Rehabbed to Death. NEJM
• Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block
• A Podcast with Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion

 

A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken’s post is still one of the most searched and viewed posts on GeriPal.

This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today.  Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade - what happens over the next 10, 20, 30 years?  

And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation.  In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission.  Lauren uses her magic wand to address the measurement issue: we’re not measuring function, frailty, and cognition routinely in hospitalized older adults.  We wouldn’t dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure.

Additional links:

• GeriPal podcast with Lauren Ferrante and Nathan Brummel on geriatricizing the ICU
• GeriPal podcast with Tom Gill on the Precipitating Events Study, distressing symptoms, disability, and hospice
• GeriPal podcast with Linda Fried on frailty
• Shunichi Nakagawa’s Tweet that went viral on responding a patient request to drink ice water before death.

And a note- on the podcast you’ll hear a drum track on the song (!).  I’m taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills.  Bear with me!  I’m having fun working on these songs from home during COVID.

 

There is a lively debate going on in academic circles about the value of Advance Care Planning (ACP).  It’s not a new debate but has gathered steam at least in palliative care circles since Sean Morrisons published a JPM article titled “Advance Directives/Care Planning: Clear, Simple, and Wrong.”  Since then there has been a lot of back and forth, with even a couple of podcasts from us, several JAMA viewpoints, and most recently a series of published replies from leaders in the field on why ACP is still valuable (see below for references).   Despite all of these publications, I’m still left at a loss of what to think about it all.  Most of the debate seems rather wonky, as honestly it feels like we are getting stuck in the weeds of semantics and definitions, like what counts as ACP versus in the moment decisions.  But the consequences are real, from research funding dollars to health systems investment.  

So in today's podcast, we have invited Juliet Jacobsen and Rachelle Bernacki to talk about what all the fuss is about.  Juliet and Rachelle are two of the authors of a recent JAMA viewpoint titled “Shifting to Serious Illness Communication.”  

We discuss the debate, how to think about definitions of ACP vs serious illness communication, what should go into high quality conversations, the evidence for and against any of this, and ultimately where we go from here.   

Also see the image from Alex’s forthcoming editorial in JAGS, a Venn diagram of advance care planning and serious illness communication (please go to GeriPal.org to view the image).

So check out the podcast and if you are interested in diving into this debate, here are some great links to learn more:

• What’s Wrong With Advance Care Planning? JAMA 2021

• Controversies About Advance Care Planning. JAMA 2022 (a reply to the above)

• Shifting to Serious Illness Communication. JAMA 2022

• Our podcast with Sean Morrison titled “Advance Care Planning is Wrong”

• Our podcast with Rebecca Sudore and Ryan McMahan titled “Advance Care Planning is So Right”

• Our podcast with Rachelle Bernacki and Jo Paladino on the Serious Illness Conversation Guide

 

 

My mom is an Asian woman in her 70s with osteoporosis.  She tried an oral bisphosphonate and had horrible esophagitis.  She said never again, though she eventually tried an IV bisphosphonate.  She had terrible flu-like symptoms.  She said never again.  But based on reports that symptoms are worse the first time, she tried the IV again the next year and fortunately experienced no symptoms.  (Story used with permission, thanks mom!).  

I tell this story because these issues don’t typically register as more than a nuisance for clinicians, who frequently don’t understand why their older patient with osteoporosis is not taking a bisphosphonate.  But our patients are walking with their feet, and adherence to bisphosphonates for osteoporosis is poor and decreases with time.

When we have a medication with up front harms and downstream benefits, it’s critical that we consider the time to benefit, or how long it will take an individual to benefit from a test or treatment.  Think of the 10 years it takes to benefit from colon or breast cancer screening, which is designed to detect slow growing cancers.  For individuals with a life expectancy less than the time to benefit, the up front harms outweigh the downstream benefits.  

In this context, we talked this week with James Deardorff and Sei Lee about their study of time to benefit of bisphosphonates for osteoporosis, published in JAMA IM. What they found somewhat surprised us: it’s pretty short, about 1 year!  

Which makes me feel better about urging my mom to get treatment.  Bisphosphonates are pretty darn effective, and act quickly.

We also discuss discontinuing bispohsophantes, and if we can use the same logic we consider when starting them.  

Toward the end we talk about the launch of ePrognosis’ new Time to Benefit tool.  This tool provides a clinical recommendation for starting/stopping medications and cancer screening based on the prognosis of the patient in front of you.  See screenshot below.  You can either access it directly here.  I you use the Lee Schonberg prognostic index for community dwelling older adults you will be directed to the tool, and it will automatically place the life expectancy at the calculated prognostic estimate.  

James and Sei requested a terrific song - Bad to the Bone - much better than the Hannah Montana Bone Dance song they threatened me with (maybe next time).

Enjoy!

-@alexSmithMD

This week many of our listeners will gather for the annual American Academy of Hospice and Palliative Medicine (AAHPM) & Hospice and Palliative Nursing Association (HPNA) annual meeting.  While the majority of this meeting is focused on subspecialty care in the US, the majority of individuals who are in need of palliative care live in low and middle-income countries without even basic access to palliative care.  

On this week's podcast, we talk with three leaders in helping improve palliative care worldwide: Kathy Foley, Stephen Connor, and Eric Krakauer.  I don't think I can really sum up these three guests in a sentence each, but I’ll give you how we introduced them in our podcast. Kathy Foley is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative (IPCI). Stephen Connor is a licensed clinical psychologist  and executive director of the Worldwide Hospice and Palliative Care Alliance.  Eric Krakauer is an Associate Professor of Medicine and of Global Health & Social Medicine at Harvard Medical School, an attending physician in the Division of Palliative Care & Geriatrics at Massachusetts General Hospital, and a former medical officer for palliative care at the World Health Organization. 

The podcast tries to cover a lot of topics including:

• Why is addressing worldwide needs of palliative care important?
• What are the needs of palliative care worldwide?
• How do you quantify worldwide suffering and what is the serious health related suffering index?
• What are some of the main barriers to palliative care?
• What are the models of palliative care worldwide?
• What are some of the resources to improve palliative care?

I encourage you to take a listen, and if you want to learn more check out some of these resources:

• Worldwide Hospice Palliative Care Alliance (WHPCA)
• Open Society Foundation’s International Palliative Care Initiative 
• Global Atlas of Palliative Care
• International Association for Hospice and Palliative Care
• JPSM’s issue on the The International Palliative Care Initiative
• eHospice - a globally run news and information resource

 

 

 

In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness.  

We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University.  We discuss:

• What are the differences between structural, institutional, and interpersonal racism?
• Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest’s personal experiences.
• The importance of attention to religion and spirituality 
• Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities
• How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making.
• Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference).
• Co-opting of disparities issues by the Alzheimer’s Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here).  Action Item: Please submit a comment to CMS about aducanumab coverage today.  Feel free to express your outrage at the lack of diversity in the trials.

We could have continued talking with our guests for hours.  We will continue to address the issue of racism in future podcasts.

-@AlexSmithMD

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

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

• The importance of intimacy over and above physical sexual function for many patients

• Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors

• Treatments for erectile dysfunction - first time the words “cock ring” have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn

• The importance of a pelvic exam for women experiencing pain

• What is “pelvic physical therapy?”

• Treatments for vaginal dryness and atrophy

• ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created

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

Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant.  Outcomes are worse among those who are frail.  Symptoms are common, including pain, ascites, encephalopathy, and pruritus.  Patients with end stage liver disease are often some of the most disadvantaged patients we care for.  Caregiver burden is immense; divorce is common.  Some will go on to receive a transplant, but many will not.  Many are confused about the diagnosis and feel poorly supported.  Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list.  Advance care planning is rare (or serious illness communication for those of you who don’t consider this advance care planning).  Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain.  

In this week’s podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective.  We talk about the tension patients face between putting on the “best face” to be listed for transplant (e.g. full code, goals focused on extending life).  We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease.  We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance.

And…Radiohead! Great request…thank you Nneka!

-@AlexSmithMD

More Health Policy this week! Today, we discuss “SNPs” but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life. 

We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society). 

We discuss: 

• Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients
• What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new “Hospice Carve-In”

This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick’s and Dr. Rick Gilfillan’s critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients. 

Alex plays The Purchaser’s Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl’s dog. 

Investor money and venture capital funding is pouring into Medicare Advantage (MA) plans. Enrollment in MA plans has more than doubled from 12 million members in 2011 to 26 million in 2021. What does this mean for us and our patients? Do these plans deliver better care for vulnerable older adults? Or are they a money making machine driving up healthcare costs in the name of profit? 

On today’s podcast, we are joined by UCSF geriatrics fellow Alex Kazberouk to talk with Dr. Don Berwick (founder of the Institute for Healthcare Improvement, former administrator of Center for Medicare and Medicaid Services) and Dr. Richard Gilfillan (former CEO of Geisinger Health Plan and Director of the Center for Medicare and Medicaid Innovation). Their recent two part post on the Health Affairs Blog about the Medicare “Money Machine” has stirred up a debate about challenges and misaligned incentives within Medicare Advantage.

We talk about:

1. What Medicare Advantage is all about - its history, operations, potential benefits, and what it means for us and our patients
2. Rick and Don’s Health Affairs post on the downsides of MA plans and the Medicare “Money Machine”
3. Policy solutions to improve the system without throwing the baby out with the bathwater

We also touch upon prior podcast topics such as the area deprivation index and population health. As a special, Alex plays a superb rendition of this song which is definitely not a Rickroll.

This is part one of a two part series on Medicare Advantage and healthcare financing. We have a follow-up with Claire Ankuda and Cheryl Philips on Special Needs Plans and the Medicare Advantage Hospice Carve-In coming soon.

Three months ago we did a podcast with Randy Curits about his recent diagnosis of ALS in March and what it was like for someone who studies and cares for people living with serious illness, to now be someone who is living with serious illness.  It was one of our favorite podcasts we’ve done, but also got us to think “wait, how come we’ve never done a podcast on ALS?”

We fix that on today’s podcast.  We’ve invited Elizabeth Lindenberger and Kara Bischoff to talk about what every geriatrician and palliative care clinician should know about ALS.   

Topics include: prognosis in ALS, disease modifying therapies (and when/if to discontinue, advance care planning in ALS, the role of embedding geriatrics/palliative care in ALS clinics, interventions in ALS (noninvasive ventilation, PEG tubes, and trachs), and symptom management as the disease progress. 

So take a listen and if you want to take a deeper dive, take a look at these articles:

• Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned
• Top Ten Tips Palliative Care Clinicians Should Know About Amyotrophic Lateral Sclerosis

 

It’s GeriPal’s 200th episode.  Yup, we started the podcast in 2016 and over the years we have grown from basically podcasting for Alex’s mom to now getting over 25,000 plays per month.   

So to celebrate our 200th, and given that the last two years kinda sucked in a lot of ways, we are going to pivot to appreciative inquiry.  We have invited leaders in geriatrics and palliative care to quickly share:

1. One thing that you are grateful for in Geriatrics and Palliative Care (other than GeriPal!)
2. One thing you are hopeful for in 2022

The guests we had were an awesome group that included Rachelle Bernacki (@rbernack), Kim Curseen (@Curseen), William Dale (@WilliamDale_MD), Helen Fernandez (@hfernandez01), Lynn Flint (@lynnmomdoc), Anne Kelly, Allison Kestenbaum (@ARKestenbaum), Christopher Langston (@calangst), Nancy Lundebjerg (@nlundebjerg), Mary Lynn McPherson (@mlmcpherson), Sean Morrison, Christine Ritchie (@RitchieCS), Christian Sinclair (@ctsinclair), Wendy-Jo Toyama(@WJSvetanoff), James Tulsky (@jatulsky), and Haider Warraich (@haiderwarraich).

We also invite you to join us in this discussion.  Go to either our Twitter account or youtube channel and share your answers to these two questions.  

Eric

Geriatric Oncology has arrived.  Yes, Louise Walter has been leading the fight to improve cancer screening in older adults for years.  But when it came to geriatricizing the way we assess and treat older adults with cancer, the evidence was thin. In our prior podcast with Supriya Mohile and William Dale on geriatric assessment in oncology, we couldn’t say for certain if a geriatric assessment was helpful for patients with cancer.  Well now we can.  

We are joined by Melisa Wong, a geriatric oncologist, and Louise Walter, a geriatrician and leader in cancer screening for older adults, to talk about the shifting landscape of geriatric oncology, including:

• How to think about cancer screening in older adults, moving beyond a one-size-fits all age-based approach to individualize cancer screening decisions.  We also talk about the importance of thought pieces in driving a field forward.
• 2 landmark trials of the geriatric assessment in oncology, one in JAMA Oncology (first author Daneng Li) and the other in the Lancet (first author Supriya Mohile) (William Dale senior author for both studies).  In both studies, grade 3+ toxicity was reduced in the geriatric assessment arm.
• Melisa Wong’s study in JAGS finding a constriction of life space for older adults with cancer, and discussion of patient centered outcomes beyond traditional outcomes such as grade 3+ chemotherapy toxicity.

Links of Interest:

• Association of Community Cancer Center site on Geriatric Oncology
• Cancer and Aging Research Group

And as a bonus, you get to hear Louise on piano and vocals and I cover Wouldn’t It be Loverly, from My Fair Lady.  

-Enjoy!

Geriatric anesthesia is a thing.  The average age of people getting surgery is increasing.  Anesthesiologists and surgeons feel that with new techniques and approaches they can perform surgery on patients at ever older ages, patients who they previously would have excluded from surgery.  

One of the key advances in geriatric anesthesia is the use of spinal anesthesia, a form of regional anesthesia that also includes epidurals and peripheral nerve blocks.  When older adults experience a hip fracture, there’s a growing consensus that spinal anesthesia offers superior outcomes compared to general anesthesia.  

It’s surprising therefore, to talk with Mark Neuman about the results of his randomized trial in NEJM, which finds essentially no difference between general anesthesia and spinal. Importantly, as a primary outcome Mark selected walking ability based on feedback from older adults - this is the outcome our patients care about most.  But he finds no difference in primary outcome or secondary outcomes, including (surprisingly) delirium.  

We break down potential reasons, with thoughtful commentary from Liz Whitlock and Cindy Hsu, two anesthesiologists with experience caring for older adults with hip fracture.  Liz is a friend of the pod and researcher who we interviewed previously about “pumphead.”  Cindy is...my wife.  She also helps me out with the accompaniment on piano as it’s tough for me to play guitar with a broken clavicle.  Thank you dear wife!  We had fun learning to play/sing Drivers License by Olivia Rodrigo.  Ah...teen angst...the angst!!!

-@AlexSmithMD

The great resignation is upon us.  One in five health-care workers has left their job since the pandemic started.  Geriatrics and palliative care are not immune to this, nor are we immune to the burnout that is associated with providers leaving their jobs. 

In today’s podcast, we talk with Janet Bull and Arif Kamal about what we can do to address burnout and increase resiliency, both from an institutional and individual perspective.   Janet Bull is the Chief Medical Officer and Chief Innovations officer at Four Seasons Hospice and Arif Kamal is an oncologist, palliative care doctor and researcher at Duke.

We discuss Arif’s and Janet’s article published in JPSM on the prevalence and predictors of burnout among hospice and palliative care clinicians, as well as Arif’s Health Affairs article on the policy changes that are key to promoting sustainability and growth of specialty palliative care workforce.  In that later article, Arif found that among many things:

• Burnout was reported by approximately one-third of physicians, nurses, social workers, and other respondents in the specialty of hospice and palliative care
• The presence of burnout was associated with increased odds of intending to leave early

If you want to learn more about what you can do to promote wellness on your team, check out this article Arif published with other colleagues in JPSM titled the “Top Ten Tips Palliative Care Clinicians Should Know about Implementing a Team Wellness Program.”

Eric

I don’t consider myself spiritual.  For some in palliative care, this would be considered heresy as we are told “everyone is spiritual.”  But, hey, I’m not.  So there.  However, despite not being spiritual, I do believe that spiritual care is fundamental to the care I give patients and families.  I also recognize it is the one palliative care domain I am most uncomfortable with and the one that as a field, we actually don’t support very well (odds are, if your palliative care team doesn’t have a full interdisciplinary team, the discipline you are likely missing is chaplaincy).

So, on today’s podcast, we break down spiritual care in palliative care with three leaders in the field: Allison Kestenbaum, Katy Hyman, and Paul Galchutt.   We ask these experts a veritable smorgasbord of questions on spiritual care that includes:

1. What the heck is spirituality and is the term itself inherently religious?
2. What is the difference between a “spiritual care history” vs “spiritual screening” vs a “spiritual assessment” and why does it matter
3. What do you do if your spiritual screen or assessment uncovers something?
4. How do we ask our patients if they would like to see a chaplain?  Should we ask or just like any of our other team members just have them stop by?
5. What does spiritual care for the non-religious look like?
6. What are some specific communication tips to take a deeper dive into patient/family/caregiver suffering. 
7. Can you research spirituality?

Also, for all you palliative practitioners and researchers, here is a link to freely join the Hospice-Palliative Spiritual Care Research Network (HPSCRN) with Transforming Chaplaincy The HPSCRN is a space to connect, inform, explore, and coordinate for all interprofessionals.

 

Though “breath” is in the title of Wes Ely’s book (and his song choice by the Police), relationships are its beating heart.

The book operates on two levels.

On one level, Wes Ely’s book is an autobiography of a critical care doctor’s horror and shame at discovering that his ICU practice of heavily sedating patients for days on end was leading to lifelong physical, cognitive, and psychological harm; and the arc of his redemptive journey to find a better way to care for patients in the ICU.  

But this book also operates on a second, much deeper level.  On this deeper level the book is a story of Wes Ely’s journey toward rediscovering the humanity in medicine by forging deep, lasting connections with his patients.  We begin and end today’s podcast at this deeper level, talking about the spiritual connections, that doctors can forge caring for critically ill patients. (quick plug: next week’s podcast is with Chaplains on Spirituality and Palliative Care).

We are joined today by Lekshmi Santhosh, head of UCSF’s post-COVID and post-ICU clinic, to interview Wes about these themes that animate his book, and more, including how we lost our way in treating ICU patients during COVID, returning to the practice of heavily sedating patients for days on end.

Of note, Wes is donating proceeds from his book to the CIBS center, to benefit research and patient care to improve care for people with critical illness, during and after the ICU stay.  

-@AlexSmithMD

 

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

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

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

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

• Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs?  Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those “additional” days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management..

• Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis.

• Approaches to treating fatigue

• Approaches to treating pain - the second most common symptom (!) - and the answer isn’t tramadol (or tramadon’t) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don’t count out the NSAIDS!

• Approaches to treating itching/pruritus

• Approaches to treating nausea

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

Enjoy!

-@AlexSmithMD

 

Anyone who cares for individuals with serious illness must live in a messy space where tough conversations about treatment decisions are common and complicated.  

On today’s podcast we talk with James Tulsky about living in this messy space of medical decision making and the challenges that come with communication around advanced treatment decisions. 

We talked about James’ path to the work that he has done, including early studies he did that included audio recording DNR discussions between physicians and patients, to his most recent study looking at the “Triadic agreement about advanced cancer treatment decisions.”   

 

In this last study, James’ group surveyed 70 triads of patients, caregivers, and their oncologists shortly after making a cancer treatment decision and found that only 40% of triads completely agreed on the goal of treatment. In all of the remaining cases, at least one member of the triad disagreed about the goal of treatment. 

So take a listen and also check out this wonderful ACP article that James did with Joshua Lakin and Rachelle Bernacki titled “Time Out Before Talking: Communication as a Medical Procedure” which we also discuss on the podcast. 

“The secret sauce of the Transitions, Referral and Coordination (TRAC) team was including a  lawyer.”  This is brilliant and will ring true to those of us who care for complex older adults who end up in the hospital for long, long, long admissions.

On today’s podcast we talk with Kenny Lam, Jessica Eng, Sarah Hooper, and Anne Fabiny about their successful interdisciplinary intervention to reduce prolonged admissions, published in NEJM Catalyst.  Many of the problems that older adults face are not medical.  How to find housing.  How to stay in their homes.  How to get a paid caregiver to help them stay at home.  How to get someone to pay bills.  How to assign a surrogate health care decision maker.  The legal obstacles to accomplishing these tasks for complex older adults, particularly those who may have marginal decision making capacity, can seem insurmountable.  Having a lawyer on the team is brilliant - in much the same way that having a handyperson on the team for project CAPABLE to keep people at home was brilliant.  For more, listen also to our prior podcast with Sarah Hooper on medical-legal partnerships.

Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure.  Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain.  But these outcomes represent a thin view of the human experience.  What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose.  Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales.

In this week’s podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities.  Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression’s ability to participate in meaningful activities.  Most people think that a good quality of life isn’t possible for people with these conditions. Anna’s study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities.

Theresa’s qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same.  Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities.  Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care.

-@AlexSmithMD

 

The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD).  Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE?  Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials?

In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab:

Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions. 

Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab.

For more podcasts on aducanumab, check out these two:

• All things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici
• Aducanumab (Aduhelm) for the Treatment of Alzheimers: A Podcast with Aaron Kesselheim and Jason Karlawish

“The take home message of this study is NOT that primary palliative care does not work.”  So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer.

And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts)  - is it time to start to question the effectiveness of primary palliative care? 

We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness.  But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is “good enough” to impact outcomes.

That’s one interpretation.  Another is that we need a “stronger dose” of primary palliative care.  In Yael and Bob’s study nurses averaged 2.2 visits, hardly robust longitudinal palliative care.  Patients who had 3 visits had better outcomes.

Unpacking negative studies is just as interesting as unpacking positive studies.  Knowing what doesn’t work is just as important as knowing what does.

Links:

• Negative multi-national study of primary palliative care in nursing homes
• Negative ICU primary palliative care intervention
• Project ENABLE
• Podcast on palliative care’s diversity problem
• Systematic review of palliative care

 

Time-limited trials. We’ve all probably used them before. We meet with patients and families.  We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments.  If not, we stop them.  At least that is how it’s supposed to go. 

On today’s podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter.  Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units.   Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire.   

We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive.  The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention).  We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast). 

If you want to read more about time-limited trials, check out these articles as well: 

• Paula Spans NY Times article on Time limited trials titled “I need to know I tried” 
• The JAMA IM study and editorial on time-limited trials
• Tim Quill and Robert Holloways article in JAMA on Time-Limited Trials from 2011
• And lastly our nudging podcast that we brought up several times

 

I’m going to start this introduction the way Eric ended our podcast.

You are a GeriPal listener.  Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness.  This is hard, complex, and deeply important work we’re engaged in.  Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice?  We will assume that you are doing the same right now if you haven’t done so already, though we suppose you are free to choose not to if you don’t believe in the mission of helping seriously ill older adults.

Ha! Gotcha.

Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of “nudging,” or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice.  Jenny just published a terrific book on the topic, “Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.”  Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. “In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?”).

Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I’m a believer in the GeriPal mission too, we’re on the same side), appealing to ego (you’re a good person because you believe in an important cause), and changing the defaults (you’re giving us a five star rating right now unless we hear otherwise).  

We distinguish between nudges and coercion, mandates, and incentives.  We talk about how clinicians are constantly, inescapably nudging patients.  We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.  

Nudges are powerful.  At best, nudges can be used to promote care that aligns with a patient’s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote “doctor knows best” paternalism, and to “strongarm” patients into care that doesn’t align with their deeply held wishes.  

What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don’t have deeply held preferences, goals and values? Hmmm.... 

Hey, have you completed your five star rating of GeriPal yet?

-@AlexSmithMD

Other citations:

-Randy Curtis and Robert Burt on unilateral DNR and informed assent

-GeriPal podcast with Angelo Volandes about using video to improve choices

Randy Curtis, a paragon of palliative care research, was diagnosed with ALS in March.  

Randy is in a unique position as someone who studies and cares for people living with serious illness, who now shares his reflections on being on the other side, to reflect on the process of living with serious illness.  His reflections are illuminating and inspiring.

We talk with Randy about his experience being in the patient role, rather than the physician or researcher role.  We ask if knowing the prognosis for his subtype of ALS is helpful to him, and if he’s seeing a palliative care clinician.  We talk with Randy about his legacy, principally his focus on mentoring.  We talk about how his approach to his life, his clinical work, and research has shifted in the face of living with serious illness.  We end by talking about our favorite “Randy Curtis” studies.

Thank you Randy for modeling vulnerability and willingness to talk about ALS. Thank you for your mentoring which has nurtured a veritable forest of trainees, and for your research which has improved care for people living with serious illness and their families.

And here’s to your song choice: a “good life” indeed, by any measure.

Links:

-Prior GeriPal podcast with Randy Curtis on an earlier study of the JumpStart patient-priming intervention for goals of care discussion

-ICU family meetings: Increased proportion of family speech is associated with increased satisfaction

-Alterations in translated ICU family meetings

-A communication strategy and brochure for ICU family meetings

-Practical guidance for ICU family meetings

-Empathy in life support decisions

-Cambia Center of Excellence for Palliative Care Research

-Cambia Sojourns Scholars Leadership Program

 

-@AlexSmithMD

alliative care has a diversity problem.  The workforce of palliative care looks nothing like the patient population that we care for in the hospital and in our clinics.   For example, in 2019-2020 academic year only 4% of Hospice and Palliative Care fellows identified as black, compared to 12% of the overall US population using the most recent census information.   These issues are similar for hospice and geriatrics.

On today’s podcast we talk about this diversity problem with Lindsay Bell, Tessie October, and Riba Kelsey. Lindsay, Riba, and Tessie recently published an article in JPSM that found that trainees at historically black colleges and universities and residents at institutions with the highest percentage of black medical students lack access to palliative care training.

Riba Kelsey is the Family Medicine residency director at Morehouse School of Medicine, and we talk with her about the implications of these findings at historically black colleges and universities (HBCUs), as well as what we can do in the field of palliative care in general to improve our workforce issues.

One shining example we discuss in depth is the ongoing collaboration between the University of Pittsburgh Palliative care group and Morehouse School of Medicine.  We hope that collaborations like these will lead to a wider pipeline of palliative care informed trainees from diverse backgrounds, and someday soon, greater diversity in the palliative care workforce.

 

Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients.  Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different.  She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other.  

There are many reasons this essay likely touched so many people (it seemed to be all over Twitter).  One is that there’s a silence around this experience of death.  Krista’s essay opens up a space to talk about it.  Another is that the experience of grief is in fact universal, whether it’s the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of “a return to normal” following COVID.  

Krista wanted to add a couple of things not mentioned in the podcast that she found helpful.  First, she treasures videos she has of her loved ones recorded before death.  Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck.

We talk with Krista about these and many other things on this week’s podcast.  Let’s keep the conversation going.

Links:

• Making Space for Grief in Academia, JAMA
• The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs
• Live Discharge from Hospice Isn’t Graduating - It’s Getting Expelled, JAGS
• Griefcast podcast
• RadioLab: The Queen of Dying Podcast
• The Dougy Center Grief Out Loud Podcast
• On Being Podcast
• The Five Invitations by Frank Ostaseski
• Resilient Grieving by Lucy Hone 
• The Art of Losing (poems)
• When Things Fall Apart by Pema Chodron

-@AlexSmithMD

 

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

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

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

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

By: Eric Widera

 

 

 

Today’s podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings.  

Why are we doing a podcast on #academiclifehacks?   You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the  Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation.  As part of this award he presented a talk titled "Confessions of an Unfocused Researcher."  We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex’s award and talk about some of the topics he brought up in his talk, as well as other tips and tricks.  

So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine.  In particular we focused on several key issues that new faculty need to address as they start their careers including:

• Academic focus and goals 
• Mentorship (and mentoring up)
• Academic scholarship & writing
• Collaboration & Networking
• Work / Life Balance

We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet. 

 

“Loneliness is different than isolation and solitude.  Loneliness is a subjective feeling where the connections we need are greater than the connections we have.  In the gap, we experience loneliness.  It’s distinct from the objective state of isolation, which is determined by the number of people around you.” - Vivek Murthy, two time (and current) Surgeon General.

We have heard a lot about loneliness and social isolation, particularly during the pandemic with enforced social distancing and near imprisonment of older adults in nursing homes.  In this context, we bring in two experts on these topics, Carla Perissinotto and Ashwin Kotwal, to explain:

• How loneliness and social isolation overlap and are distinct
• How common these measures of social well being are in geriatrics and palliative care
• Why we should care as clinicians
• How we can ask about them
• How we should respond to care for patients who are lonely or isolated

Some key references from among the many we discuss on the podcast:

• Loneliness in older adults predicts functional decline and death (JAMA IM 2012)
• The epidemiology of loneliness and social isolation during the last years of life (JAGS 2021) 
• Use of high risk medications among lonely older adults (JAMA IM 2021) 
• Integrating social care into healthcare: GeriPal podcast with Kirsten Bibbens-Domingo 
• Coalition to end social isolation and loneliness 

-@AlexSmithMD

On June 7th, 2021 FDA approved the amyloid beta-directed antibody aducanumab (Aduhelm) for the Treatment of Alzheimers. This approval of aducanumab was not without controversy.   Actually, let me restate that.  The approval of aducanumab was a hot mess, inside a dumpster fire, inside a train wreck. 

After the approval, three members of the FDA advisory panel, which unanimously was not in favor of the approval of aduhelm, quit.  One of them, Aaron Kesselheim (who we have on our podcast today) described it as “the worst drug approval decision in recent U.S. history" in his resignation letter. Then the FDA had to revise the label one month after publishing it because the original didn't even come close to looking like the population in which treatment was initiated in clinical trials.  Then, wait for it, after a firestorm of criticism the FDA’s commissioner had to ask for an independent investigation to look into the interactions between Biogen representatives and FDA members.  And now CMS is deciding if and how to cover Aduhelm, a drug that will cost at least $56,000 a year per patient not incluiding the doctor’s visits, amyloid PET scans, and frequent MRIs that will be necessary to monitor for side effects.

On today's podcast we talk all about aducanumab with Aaron Kesselheim, Professor of Medicine at Harvard Medical School and previous member of that now famous FDA advisory committee, as well as Jason Karlawish, Professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine.

I’d love to point you to the journal articles for the two phase III trials on aducanumab, but as of yet, they are unpublished (this should tell you a little about the faith Biogen has on its drug data), so I’ll leave you with these resources instead:

• Our podcast with Gil Rabinovici on “All things Amyloid, including Aducanumab and Amyloid PET scans”
• AGS’s preliminary advice on prescribing Aducanumab - 
• Jason Karlawish’s book, The Problem of Alzheimer's, and the previous podcast that we did on it 
• FDA’s document dump on Aduhelm 
• Biogen’s open letter to the Alzheimer’s disease community complaining about the
  “turn outside the boundaries of legitimate scientific deliberation” that has occurred with aduhelm (while ignoring the fact that the trials have not been published yet).
• CMS’s request for public comment for their National Coverage Determination analysis to determine whether Medicare should cover the drug and any other monoclonal antibodies directed at amyloid

The last one is particularly important as whether you are for or against the coverage of aducanumab, your voice matters. There is a letter being circulated by physicians who care for people with Alzheimer's Disease urging CMS not to cover aducanumab given the limited clinical evidence for benefit, known harms, and exorbitant cost. You can find the letter here.  If you would like to sign the letter, you can add your name by clicking this link.