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).  

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

 

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

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

• The history of the hospital-at-home movement.

• The practicalities of how it works including who are good candidates, where does it start (the ED?), what happens at home, do you need a caregiver, what happens if they need something like imaging?

• How is it financed and what comes next?

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

• Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Int Med. 2020

• Hospital at Home-Plus: A Platform of Facility-Based Care. JAGS

• Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Network Open

 

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

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

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

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

• What is a practical geriatric assessment and how can busy oncologists actually do one? (hint: 80% can be done in advance by patients or caregivers)

• Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars?

• What can you do with the results of a geriatric assessment?

• How does the geriatric assessment lead to improved completion of advance directives, when the assessment doesn't address advance care planning/directives at all?

• How does palliative care fit into all this?  Precision medicine?

• What groups are being left out of trials?

• What are the incentives to get oncologists and health systems to adopt the geriatric assessment?  

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

Aloha,
-@AlexSmithMD

 

Additional Links:

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

 

 

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

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

Enjoy!

-@AlexSmithMD

 

Additional links:

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

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

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

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

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

 

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

 

 

I hear the word dignity used a lot in the medical setting, but I'm never sure what people mean when they use it.  You'd imagine that as a seasoned palliative care doc, I'd have a pretty good definition by now of what "maintaining dignity" or "loss of dignity" means, but you'd be sadly wrong.

Well that all changes today as we've invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast.  Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches.

We talk with Harvey about how he defines "dignity" and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks "what do I need to know about you as a person to give you the best care possible."  In addition, we talk with Harvey about some other recent publications he has written, including one on "Intensive Caring" and one on the "Platinum Rule" (do unto others as they would want done unto themselves).

So take a listen and if you are interested in learning more, check out these wonderful links:

• Harvey's latest book is called, Dignity in Care: The Human Side of Medicine

• Intensive Caring: Reminding Patients They Matter 

• Michael J. Fox gives patients hope there may be a place that illness doesn't touch

• Depression is a Liar

• Why is Being a Patient Such a Difficult Pill to Swallow

• Better Patient Care Calls for a 'Platinum Rule' to Replace the Golden One. Scientific American 

• Letter to the Editor: Response to Downar et al. Medical Assistance in Dying and Palliative Care: Shared Trajectories 

 

It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab).  Praised by the FDA, Alzheimer's Association (AA), and Pharma as a "game changer", but derided by others for the drug's lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words "rife with irregularities". Instead of Biogen's expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco).

The outlook on amyloid antibodies are looking brighter though in 2023.  Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer.  However, they are none of these. 

So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them?  We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation).

Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease.  There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one.  One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp

By: Eric Widera

Insomnia. We've all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you're not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more.

For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia.

We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

There's a saying, "never let a crisis go to waste."  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others.  So now that the emergency response has ended, what's to be done? 

In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness.  This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world.  Now is the time to act, dear listeners!  You can:

• Write an Op-Ed to your local paper as Carly Zapata and colleagues did.  Start with a story as Carly did in her Op Ed.  Stories trump data.

• Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home

• Write to the DEA, with guidance from AAHPM's comments to the DEA March 2023.

• Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf

Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth.  Enjoy!

-@AlexSmithMD

Today's podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention.  On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations.  Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+.  They found a difference of 4% in documented goals of care discussions.  Is 4% meaningful?  You'll have to decide for yourself, though it likely is meaningful on a population basis.  Intriguingly, in a sub-analysis, they found a much higher rate of difference among minoritized older adults - more like 10%.  In a compelling editorial, Doug White and Sarah Anderson argue that even a 4% difference is important on a population basis, and that higher rates of difference among minoritized older adults demonstrate the potential of the intervention to address long-standing disparities in goals of care.

Randy Curtis was first author of the JAMA paper.  Randy died February 26, 2023.  We begin today's podcast asking his co-authors Erin Kross, Bob Lee, and Ruth Engelberg, all from the University of Washington and the Cambia Palliative Care Center of Excellence, to reflect on Randy and his dedication to seeing this work completed while living with ALS.  Eric and I also reflect on the podcast Randy generously did with us on his experience living with and studying serious illness.  We have lost a giant.  He is sorely missed, and celebrated.

And…the guests torture me about songs I can't play with the word Jump.

-@AlexSmithMD

 

You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it?  What about State Departments of Aging or state master plans for aging?  Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions?  No?  Ok, what about Aging and Disability Resource Connection (ADRC) services?

Well, if you are like me, you've probably heard of these programs but are at a loss to know exactly what they do.  On today's podcast we dive deep into how state and local governments are addressing the needs of older adults, answering all of these questions and more thanks to our three amazing guests: Susan DeMarois (the Director of California Department of Aging), Greg Olsen (the Director of the New York State Office for the Aging), and Lindsey Yourman (the Chief Geriatric Officer for the County of San Diego).

It's a fun podcast with our guest bringing in a ton of knowledge and passion for the work that they do.  If there is one take-away from the podcast, it is something Dr. Yourman emailed me after we met:

"My hope is that every geriatrics clinician/Geriatrics Department/Division that listens to our podcast will be motivated to reach out to their Area Agency on Aging (if they haven't done so previously) to ask for a meet and greet and to learn about their resources, services, and recommended community-based organizations for older people."

To learn more about what we talked about, check out the following links:

• Eldercare Locator, a public service of the U.S. Administration on Aging connecting you to services for older adults and their families

• California's Master Plan for Aging

• New York's Master Plan for Aging

 

I don't know 'bout religion
I only know what I see
And in the end when I hold their hand
It's both of us set free

These are the ending lyrics to Bonnie Raitt's song "Down the Hall", an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week's podcast we interviewed the medical director and the chaplain of the prison's hospice unit (Hospice in Prison Part 1).  This week we turn our attention to the inmates.

Pastoral Care Workers are inmates who volunteer time to care for the dying who come from all around California to spend their last days, weeks or months in the prison's hospice unit, fulfilling a mission that "no prisoner dies alone."

On today's podcast we talk with three of these Pastoral Care Workers, Jerry Judson, Jeffrey Maria, and Allan Krenitzky. We discuss with them why they decided to volunteer for the hospice unit, what a day in the life of a Pastoral Care Worker looks like, and among other things their thoughts on forgiveness, redemption, rehabilitation, and compassionate release.

We also had the pleasure to take a walk through the hospice unit garden with Mr. Gerald Hite. He taught us a little about the different flowers and plants, and along the way a little about why he does what he does.

While this is a podcast about volunteers in a prison hospice, I think it also serves as a lesson for us all about how we make meaning to our own lives and define ourselves by not only what we have done in the past, but what we do now.  One story that Allan told perfectly sums this up. He said one day his son asked his wife what he does for a living, and his wife said "Papa helps sick people."

 

 

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

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

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

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

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

• Insomnia (Doxepin is an alternative, trazodone and melatonin are not?!?)

• Diabetes management 

• PPI for GERD

• Treatments for pain, including NSAIDS, COX2, and gabapentinoids

• Cannabis

• Deprescribing,org - terrific Canadian website (no tariff to use)

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

-Alex Smith

 

 

 

In the early 1990's, California Medical Facility (CMF) created one of the nation's first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release.  Many are there until they die.

Today's podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls. 

We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services.  We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population.  We also talk about the eligibility for the unit, what makes it run including the interdisciplinary team and the inmate peer workers, and the topic of compassionate release.

Afterwards, we chat with the prison's chaplain, Keith Knauf.  Keith per many reports, is the heart and sole of the hospice unit and oversees the Pastoral Care Workers.  These are inmates that volunteer to work in the hospice unit, serving a mission that "no prisoner dies alone."   We chat with Keith about how hospice in prison is different and similar to community hospice work, the selection process and role of the peer support workers, the role of forgiveness and spirituality in the care of dying inmates, and what makes this work both rewarding and hard.

Part two of the podcast, which comes next week, is solely focused on the Pastoral Care Workers.  We interview three of them in the hospice unit and take a little tour of the hospice gardens.

 

 

 

Artificial Intelligence, or AI, has tremendous potential.  We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF.

• Social companions to address the epidemic of loneliness among older adults

• Augmenting ability of clinicians by taking notes

• Searching the electronic health record for data

• Predicting mortality and other outcomes
  
  

We talk also about the pitfalls of AI, including:

• Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities

• Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?  

• Hallucinations, or when the AI lies or bullshits, then denies it

• When the AI approaches sentience, is it ethical to unplug it?
  
  

I'm sure this is a subject we will return to, given the rapid progress on AI.

Enjoy!

-@AlexSmithMD  

 

Links:

Papers on AI and palliative care and concerns about bias:
https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/
https://academic.oup.com/jamia/article/27/12/2020/5859726

Comparison of machine learning vs traditional prognostic methods based on regression:
https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011

Other links on the issue of AI and racial or ethnic bias:

Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare
https://www.nber.org/papers/w30700
https://www.science.org/doi/10.1126/sciadv.add2704
https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168

MD Calc approach to inclusion of race https://www.mdcalc.com/race

 

Diabetes is common.  When I'm on nursing home call, the most common page I receive is for a blood sugar value.  When I'm on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications. 

Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue.  Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone).  And yet we're also in a different place in diabetes monitoring and management.

To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home.

And we invited Tamryn Gray from the Dana Farber joins us to ask insightful questions, including:

What blood sugar range should we target for patients in the nursing home or hospice?  How high is too high?  Should considerations differ for people with dementia? What are the risks and rewards of new classes of medications?  How do caregivers fit into this? Continuous glucose monitoring (CGM)  is commonplace in Type 1 and gaining traction in Type 2. We debate the merits of use of CGM in the nursing home and other late life settings (Eric and I argue against CGM and lose).  Ozempic is a new fancy med that, by the way, leads to weight loss among celebrities, resulting in shortages of the drug from people using it off-label for that purpose.  Should we use Ozempic (if we can find it) in patients with serious illness, which often results in undesirable and profound weight loss? 

Listen in to learn more!

-@AlexSmithMD

Additional Links: 

-Fingerstick monitoring in VA nursing homes (too common!)

-Improving diabetes management in hospice

-Continuous Glucose Monitoring complicating end of life care

 

 

Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP).  Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP.  Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes.  Others cited the call from communities to meet them where they are - be they senior centers, Black-owned businesses, or churches (we have a podcast planned in the fall with Fayron Epps and Karen Moss on the church setting).  It does seem that if communities, particularly historically marginalized communities, are interested in ACP, that fact should carry some weight in how resources are allocated to research and health care financing. 

We additionally have a debate/discussion about which outcomes of ACP matter most, including Terri Fried's commentary in JAGS that caregiver outcomes matter more than goal concordant care (the "holy grail"), completion of advance directives, or changes in health care services use.  Did the caregiver feel heard and understood?  Did they have PTSD? Complicated grief? Depression? 

Group visits are one way of reaching diverse communities to which advance care planning has not traditionally been targeted.  In a group visit there is a social norming effect - "if my neighbor is doing it, perhaps I should be doing it to?" 

Please tune in to hear more, and listen to the whistle of the "Friendship train!"  

-@AlexSmithMD 

 

Links:

Community Based Participatory Research and ACP in Latinx communities: https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18236

Community based ACP in the Black Community: https://link.springer.com/article/10.1007/s11606-023-08134-2

ACP in the Chinese American Community: https://www.sciencedirect.com/science/article/pii/S0885392423000982

Group ACP in primary care: https://www.annfammed.org/content/14/2/125.short and https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16694

Project Talk Website: www.ProjectTalkTrial.org

Project Talk Trial Protocol Paper: https://journals.sagepub.com/doi/pdf/10.1177/1049909116656353

Hello Article (including Black churches): https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2765685

Communication Quality Analysis: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819

Conceptualizing Surrogate Decision Making: https://www.tandfonline.com/doi/abs/10.1080/19312458.2022.2099819

What counts as a surrogate decision: https://journals.sagepub.com/doi/abs/10.1177/10499091231168976

 

For e-training modules on ACP group visits: https://cuelearning.org

Click on the Register link (upper right corner). A pop-up box will appear and enter your email address and set up your password. For Registration Code, enter: ENACT (not case sensitive).

The ACP Group visit implementation guide is available here: www.coloradocareplanning.org. Scroll down to "Innovations in ACP page"

Hot off the press is a brand spanking new updated 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.  The Beers Criteria is one of the most frequently cited reference tools in geriatrics, detailing potentially inappropriate medications to prescribe to older people.

We've invited two members who helped update the criteria including Todd Semla and Mike Steinman.   We discuss a little history of the Beers criteria, including the original Beers Criteria that was published by the late Dr. Mark Beers, and how it has evolved over the last three decades.  We also discuss specifics about how to use and not use the Beers Criteria, how medications are selected for inclusion in the criteria, and specifics about certain medications.

And of course, take a deep dive by downloading the JAGS paper on the updated Beers Criteria or any of the great links from AGS including the:

• 2023 AGS Beers Criteria App 

• Beers pocket card

 

We've had multiple GeriPal episodes about treatments for dementia, including aducanumab (here, here, and here) and lecanemab (here).  As today's guest, Kristine Yaffe notes, part of the reason for that emphasis is that in the US we prioritize treatment, whereas other countries are ahead of us in prioritizing prevention.  Deb Barnes and Kristine Yaffe published a landmark paper in Lancet Neurology finding that up to half of dementia risk is due to modifiable factors.  If we focused on prevention, from a public health standpoint, we would achieve far more than spending millions billions on treatment.

Today we talk about steps we can and should take to reduce the risk of dementia, including:

• Education and cognitive games (I reveal my embarrassingly poor average time on the NYT mini cross word)

• Physical activity

• Sleep

• Depression

• Smoking

• Social isolation

• Blood pressure control (listen also to our podcast on Sprint Mind with Jeff Williamson)

We also delve into an exciting new trial Kristine led with others on the impact of risk factor reduction on cognition - here's a link to press about the trial from a fall meeting presentation - article forthcoming. 

And because we can't resist, we dip into aducanumab and lecanemab at the end. 

-@AlexSmithMD

 

I haven't worked with many adolescents and young adults (AYA, roughly teens to twenties).  But when I have, I find that they're often some of the hardest patients to care for.  Why?  We talk about why it's so hard with Abby Rosenberg (chief of PC at DFCI and Boston Childrens), Nick Purol (clinical social worker at DFCI and Boston Childrens), Daniel Eison (pediatric PC doc and co-host of PediPal).  We are grateful to Andrea Thach (PC doc at Sutter East Bay) for bringing this topic to our attention and for asking questions as a guest host.  Here are just a few of the explanations for why it's so hard:

• They are closer in age to some of us (younger clinicians).  Countertransference hits hard.

• There's an in-between space between adolescence and adulthood - and there's something that we identify with in that in-between space, tugging at our heart strings

• Everyone has been a teenager.  Everyone has lived through their early 20s.  Every member of the interdisciplinary team.  Adolescence and young adulthood is a romanticized time of life in our culture.  We remember bucking the rules, figuring out who you are, hair on fire, feeling invulnerable, trying to figure out who you are - and now those adolescents are stuck in the hospital, with doctors and parents telling them what to do, having their autonomy crushed by the medical institution, realizing they're not invulnerable.

We talk about these issues and more - what resources to leverage, how to cope as a team.  We in geriatrics and adult palliative care clinicians have so much to learn from our colleagues in pediatrics - and though many of these lessons are specific to adolescents and young adults - many of the lessons are valuable for the care of patients in older life stages.

Links to resources for working with AYA, from Nick Purol):

The Courageous Parents Network has a wealth of information/resources/videos/articles on many overlapping issues and topics related to caring for children/adolescents/young adults with serious illness (from both the provider and clinician perspective): https://courageousparentsnetwork.org

Courageous Parents Network

Empowering parents caring for children with serious illness through video, shared community, professional guidance, and palliative care. You are Not Alone.

courageousparentsnetwork.org

 

Voicing My Choices is a wonderful tool for discussing goals/wishes and introducing advance directives in the context of serious illness. It's based off 5 Wishes and validated for AYA through direct feedback from the population: https://store.fivewishes.org/ShopLocal/en/p/VC-MASTER-000/voicing-my-choices

The Oxford Textbook of Palliative Social Work has several chapters relating to working with AYA (either due to family illness or their own), with many psychosocial clinicians in our field contributing: https://www.amazon.com/Oxford-Textbook-Palliative-Social-Work/dp/0197537855

Same is true for the Interdisciplinary Pediatric Palliative Care Textbook: https://www.amazon.com/Interdisciplinary-Pediatric-Palliative-Joanne-Wolfe/dp/0190090014/ref=sr_1_1?crid=33YG2UAKDZ8DO&keywords=interdisciplinary+pediatric+palliative+care&qid=1682288312&s=books&sprefix=interdisciplinary+pediatric+palliative+car%2Cstripbooks%2C101&sr=1-1&asin=0190090014&revisionId=&format=4&depth=1

-@AlexSmithMD

We have a special extra podcast this week.  During the last AAHPM - HPNA meeting in Montréal, we went around asking attendees what one thing that they are most worried about and one thing they are most hopeful for when thinking about the future of our field. 

We couldn't fit everyone's responses in but came up with the big themes for questions and edited them into this weeks podcast / YouTube video. 

Eric and Alex

 

DISCLAIMER

While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly. 

Palliative Care the Next Generation: How the Service May Grow and Evolve
https://hospicenews.com/2023/04/14/palliative-care-the-next-generation-how-the-service-may-grow-and-evolve/

AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers.

"We've got a very large palliative care practice," Rodgers told PCN. "What we've seen to make it really work is you either have to be in the hospital, where we've taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective]."

 

In 1990 11% of homeless persons were older than 50.  Today half are over age 50.  Today we talk with Margot Kushel about how we got here, including:

• That sense of powerlessness as a clinician when you "fix up" a patient in the hospital, only to discharge them to the street knowing things will fall apart.

• Chronic vs acute homelessness

• What is the major driver of homelessness in general?  

• What is the major driver of the increase in older homeless persons?

• Why do we say "over 50" is "older" for homeless persons, why not 65? 

• To what extent is the rise of tech in San Francisco to blame for our local rise in homelessness? 

• What are the structural factors and individual factors that contribute to homelessness?

• How has the history of redlining and the federal tax subsidy of wealthy (mostly white) people in the form of a mortgage interest deduction contributed to racial inequalities in homelessness?

• What can we do about it?  What are the highest yield interventions and policy changes?

• What should we call it - homeless or unhoused?

We were fortunate to make it to the end of this podcast before Margot lost power.  It's storming again in the Bay Area at the time we record this.  So much harder than for the older homeless people on the streets with no power to lose.  A mad world out there (song hint).

Key references: 

-Margot Kushel's UCSF Grand Rounds 

-JAMA IM paper on mortality among older homeless persons

-NEJM perspective arguing that interventions to address homelessness shouldn't be evaluated on cost savings.

 

-@AlexSmithMD

 

Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing social isolation, the objective lack of contact with friends, family, or the community, or loneliness, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down?

On today today's podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and Neuroscience at Brigham Young University, an international expert on loneliness, social isolation, and social interventions, who has served on the National Academy of Sciences committee on social isolation and loneliness and advised the UK Loneliness Campaign, 2) Dr. Thomas Cudjoe, Assistant Professor of Medicine at Johns Hopkins University, who has conducted groundbreaking work on the measurement of social isolation and mechanisms of impact on health, and 3) Dr. Carla Perissinotto, Professor of Medicine at UCSF, who has pioneered the clinical and policy approach to addressing loneliness and social isolation.  

We talk about:  

• Their personal and clinical inspiration for studying loneliness and social isolation, and hurdles encountered in bringing these needs to the clinical world. 

• The Listening "EAR" approach that simplifies assessment of loneliness and social isolation in clinical settings, and other practical pointers. 

Check out some of their recent work, including:

• Dr. Holt-Lunstad's and Dr. Perissinotto's powerful perspective piece in the New England Journal of Medicine which provides a clinical framework for addressing loneliness and social isolation. 

• Dr. Cudjoe's recent work demonstrating the impact of social isolation on dementia risk, populations at risk, and how our social lives "getting under our skin."

• Dr. Kotwal's work showing how social isolation impacts end-of-life health care use, including hospice and acute care.

We touch briefly on (and build on) topics discussed in prior podcasts such as loneliness during the pandemic. Tune in to hear Alex's acoustic rendition of Outkast's Hey Y'All!  

-Ashwin Kotwal

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

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

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

Resources mentioned in the podcast include:

• A story about one medical student's experience with a day in the museum using multiple museum-based education exercices

• A Journal Article published in the Journal of Palliative Medicine titled "Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs" 

• A journal article on "Twelve Tips for Starting a Collaboration with an Art Museum."

• A handout from the 2025 AAHPM/HPNA preconference gives examples of museum-based education exercises and resources for further training. 

• Alex's summary of some prompts we discussed for the "Personal Responses Tour", which is a reflective exercise where participants choose artwork based on a personal prompt, then share with a small group. The prompts include:

• Find a work of art that reminds you of a patient

• Find a work of art that reflects a challenging clinical situation

• Find a work that speaks to an experience you have had in your palliative medicine training that taught you about the impact of bias or racism

• Find a work that connects to the path you took into palliative care or geriatrics

• Find a piece that makes you think about community

• Find a piece that reflects your idea of what a "good death" is

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

 

 

Do we need an RCT to establish the worth of chaplaincy?

Einstein once said, "Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted."

A friend of GeriPal, and prior guest, Guy Micco commented today that we need an RCT for chaplaincy is like the idea that the humanities need to justify their value in medical training: "It's like being told to measure the taste of orange juice with a ruler."

On the other hand, all of our guests agree that chaplains are often the most vulnerable to being cut from hospital and health system budgets.  These studies are important.

Today we have a star-studded lineup, including Lexy Torke of Indiana University, who discusses her RCT of a chaplaincy intervention for surrogates of patients in the ICU, published in JPSM and plenary presentation at AAHPM/HPNA.  To provide context, we are joined by Karen Steinhauser, a social scientist at Duke who has been studying spirituality for years (and published one of the most cited papers in palliative care on factors considered important at the end of life, as well as one of my favorite qualitative papers to give to research trainees).  We are also joined by LaVera Crawly, a physician turned chaplain, now VP of Spiritual Care at Common Spirit Health (and author of another of my favorite and most cited papers on palliative care in the African American Community).

We dive into the issues of measuring spirituality, chaplaincy, the need for an expanded vocabulary around spirituality, spiritual assessments, spiritual history, LaVera's journey from physician to chaplain (listen to her compelling answer to the magic wand question at the end).

For further context, please check out our prior podcast on spirituality, and this discussion of the RCT by Lexy that I helped moderate for Transforming Chaplaincy.

Thanks to my son Kai for playing the guitar part in 5/4 with strange chords on Riverman by Nick Drake!

-Alex

 

Two weeks ago on the GeriPal podcast we talked about why and how to write for the general public.  This week we've invited three guests to share their stories about storytelling that's written for healthcare providers.

The first guest is Liz Salmi.  Liz wrote a fabulous perspectives piece in the NEJM titled "Deciding on My Dimples" which talks about her experience as a patient doing shared decision making during neurosurgery for resection of an astrocytoma.   In addition to this being a fascinating story, Liz brings in a great perspective as a patient, advocate, researcher, and a punk rocker.

Our second guest is a recurring star of GeriPal, Anne Kelly.  She just published an essay for JAMA Piece of My Mind titled "The Last Visit".  In this piece Anne describes her experience with the expressions of love she and her mother shared in the last days of her mothers life.

Lastly, but certainly not least, we've invited Preeti Malani.  Preeti is the editor for JAMA's Piece of My Mind section.  We've asked Preeti to come on to describe what happens behind the curtain when evaluating these stories, including what makes those few that get accepted stand out.

We've also love to hear from you on twitter and facebook your own experiences writing for the medical world (and please include links!)

In November of 2022, Ava Kofman published a piece in the New Yorker titled "How Hospice Became a For-Profit Hustle."  Some viewed this piece as an affront to the amazing work hospice does for those approaching the end of their lives by cherry picking stories of a few bad actors to paint hospice is a bad light. For others, this piece, while painful to read, gave voice to what they have been feeling over the last decade - hospice has in some ways lost its way in a quest of promoting profit over care.

On today's podcast, live from the American Academy of Hospice and Palliative Medicine Annual Meeting, we invite two thought leaders in the field, Ira Byock and Joseph Shega, to discuss among other things:

• Is hospice losing its way?
• Is there a difference between for-profit and not-for-profit when it comes to quality of care?
• What is our role as hospice and palliative care providers in advocating for high-quality hospice care?

If you are interested in signing the position statement "Core Roles and Responsibilities of Physicians in Hospice Care", click here. For a deeper diver into these issues, check out some of the following links:    

• Ira's Stat new article "Hospice care needs saving"

• GeriPal's episode on the growing role of private equity in hospice care

• Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA IM 2021

• Hospice Acquisitions by Profit-Driven Private Equity Firms. JAMA Health Forum. 2021

• Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences.  JAMA IM 2023

• A shout-out to my NPR episode on 1A titled the "State of Hospice Care"

 

DISCLAIMER

While we filmed in Montreal during the Annual Assembly, all opinions expressed in this podcast are independent of AAHPM and HPNA, or the Annual Assembly.  Furthermore, direction to external websites is not an endorsement from AAHPM or HPNA, or the Annual Assembly. 

 

---------------------------

 

So you want to write a book.

So you want to write a book! 

So…you want to write a book?!?

Today we talk with two geriatricians: Rosanne Leipzig, author of Honest Aging: An Insider's Guide to the Second Half of Life; and Louise Aronson, author of Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. (You can hear our prior podcast on Louise's book here).  We talk with them about writing for the lay public, including:

• Why write a book for the lay public?

• Why write about aging? Was there pushback from publishers (hint: hell yes)

• What terms to use to describe the "old age" time period?

• How did they start writing a book?

• How do you find time to write and also be doctors and academic professors?

• Revisions and working with editors

• Writing an Op Ed - how to start, what to write, where to send it 

• TheOpEdProject as a resource for learning more
  
  

We look forward to the books and op-eds our listeners will write!  

In all seriousness, you don't actually have to want to write a book to be interested in this podcast.  You don't have to want to play professional basketball to appreciate The Last Dance, which documents the final season of Michael Jordan with the Chicago Bulls.  These are inherently interesting interviews because the motivations, process, and struggle of monumental undertakings are interesting in and of themselves.

Enjoy!

-@AlexSmithMD

Psychedelics are having a moment.  Enthusiasm is brimming.  Legalization is moving forward in several states, following the lead of Oregon and Colorado.  FDA is considering approval, shifting away from Schedule I restrictions, paving the way for use in clinical practice.  Potential use in palliative care, chronic pain, and for mood disorders is tantalizing. Early data on efficacy in patients with anxiety and demoralization are promising.  Research is exploding.  Two of our guests today, Stacy Fischer and Brian Anderson, are involved in large multicenter trials of psychedelics for patients with advanced cancer (Fischer) or life-limiting illness (Anderson).  Theora Cimino conducted an observational study (publication in the works) of marginally housed/homeless persons many of whom had experience with psychedelics.

And yet there are reasons for caution.  In our prior podcast with Ira Byock on psychedelics in 2019 we talked primarily about the potential of psychedelics.  Today we largely focus on reasons for caution, including:

• We know almost nothing about psychedelics in older adults - only about 1% of patients in published trials were older adults, much less older adults with multiple chronic conditions, multiple medications, and frailty.  Bree Johnston and Brian Anderson wrote a terrific summary of the evidence (or lack thereof) in older adults.

• There is a marked lack of diversity in published trials.  Most participants are White and well-resourced. 

• Psilocybin, the most commonly used psychedelic, increases heart rate and blood pressure, which may potentially lead to cardiovascular events.

• The efficacy of psychedelics without therapy, and the impact of variations in therapy type, training, duration, is unknown.

• Ethical issues, including colonization of psychedelics by big pharma. Psychedelics have been used by communities around the globe for hundreds of years (or more). 

We cover these issues and more in today's podcast.

Note, I butchered the chorus on the YouTube version - please listen to the podcast for my souped up version with drums and bass!

-@AlexSmithMD

 

Gabapentin is the 10th most prescribed drug in the United States and use is increasing.  In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin).  By 2015 that number increased to 4% of US adults.

There are a lot of reasons that may explain the massive increase in use of these drugs.  One thing is clear, it is not because people are using it for FDA approved indications.  The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications.

On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer.   It's a big episode covering a lot of topics.

First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug).  

Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later). 

Donovan discusses the growth of "mood stabilizers/antiepileptics" (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin).

Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug.  This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial.

I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies:

• Gabapentin in the Perioperative setting:

• Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022

• Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022

• Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort.  JAMA Surgery 2018

• Gabapentin and mood stabilizers in the Nursing Home Setting:

• Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022

• Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020

• Efficacy of Gabapentinoids:

• Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019

• Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017

• The Illegal Marketing Practices by Pharma promoting ineffective:

• The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009

• Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006

 

You know when you walk out of a patient's room and have that sense, "This isn't going to go well." The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle.  Should you stop at "no?" 

Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn't stop at "no."  We owe it to the patient to explore the reasons behind the "no," commonly not wanting to be a burden to their family.  In such cases, we owe it to the patient to use persuasion, for example, "I hear that you don't want to be a burden.  And I'm worried that there may come a time when you have trouble making decisions for yourself.  We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you're sick, that you're hospitalized, that you're in the ICU, and that you can't make your own decisions?  That's a huge amount of news all at once. It would help her to prepare if we could start talking with her now." 

We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent.  Consent is often viewed as "all or nothing" for any specific decision.  Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision.  I'd hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone.  Emily's expanded notion of consent is grounded in the concept of "relational autonomy."  Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another.  Emily's notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent.  Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making.

My favorite line from Emily's paper: "Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care."

Enjoy!

-@AlexSmithMD

 

Think about the last time a patient yelled at you in anger.  How did you react?  The last time this happened to me I immediately went on the defensive despite years of training in serious illness communication skills.  Afterwards, I thought there must be a better way.

Well on today's podcast we invite two of our favorite palliative care psychiatrists, Dani Chammas and Keri Brenner, to teach us about going beyond simple communication skills like naming the emotion when interacting with the angry patient (see our podcast on avoiding the uncanny valley for a deeper dive into the dangers of becoming too rote and scripted).  As Keri put it in the podcast, we must go beyond "a hammer and a nail" philosophy to approaching anger by developing a toolkit for anger that is vast and varied.

Dani and Kery present three steps for interacting with an angry patient: 

1. Look within: What is this anger bringing up in me? How is this anger making me feel, think, and react?

2. Ask why: What is underneath the anger for this particular patient? Creating a "formulation" for the patient

3. Act mindfully: Decide what can we do, and how we can respond therapeutically (and no there is no mnemonic for this step)

Here are some other great references we discussed in the podcast:

• Shalev D, Rosenberg LB, Brenner KO, Seaton M, Jacobsen JC, Jackson VA. Foundations for Psychological Thinking in Palliative Care: Frame and Formulation. J Palliat Med. 2021;24(10):1430-1435. doi:10.1089/jpm.2021.0256

• Rosenberg LB, Brenner KO, Jackson VA, et al. The Meaning of Together: Exploring Transference and Countertransference in Palliative Care Settings. J Palliat Med. 2021;24(11):1598-1602. doi:10.1089/jpm.2021.0240

• Brenner KO, Rosenberg LB, Cramer MA, et al. Exploring the Psychological Aspects of Palliative Care: Lessons Learned from an Interdisciplinary Seminar of Experts. J Palliat Med. 2021;24(9):1274-1279. doi:10.1089/jpm.2021.0224

• Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887. doi:10.1056/NEJM197804202981605

• What's in the Syringe?: Principles of Early Integrated Palliative Care

And for those interested in other podcast we did with Dani and Keri, check out the following:

• Therapeutic Presence in the Time of COVID

• Improving Serious Illness Communication by Developing Formulation

• What is Emotional PPE?

 

 

Amber Barnato is an expert in simulation studies.  A health services researcher and palliative care physician, Amber lauds the ability of simulation studies to isolate one variable in a study.  For example, we spend the first half talking about a RCT simulation study of clinician verbal and non-verbal communication with a seriously ill patient with cancer. In one room the physician under study interacts with a white patient-actor, and in another room interacts with a Black patient-actor.  They found no differences in verbal communication, but clear differences in non-verbal rapport building communication: physicians stood farther away, crossed their arms, didn't touch the Black patient as frequently.  Amber tells the moving story of how these findings led a clinical colleague, her chief, to question and change his behavior. Of note, we talked about implicit bias in depth in this podcast with Kimberely Courseen. 

As we've written about on GeriPal when we were a blog (a decade ago!) these simulation studies can be used to study language, such as patient or surrogate choices when we use the terms "allow natural death" vs "do-not-resuscitate."  This change in framing is a nudge, more evidence that the choices we make to use one phrase or another, or the order in which we present options, are all nudges that influence patient choice - listen to our podcast on the ethics of nudging with Jenny Blumenthal-Barby and Scott Halpern for more.  

 

Additional links to simulation studies:

https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-495OC

https://journals.lww.com/ccmjournal/Abstract/2011/07000/A_randomized_trial_of_the_effect_of_patient_race.9.aspx

https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0089

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687021/

https://journals.sagepub.com/doi/pdf/10.1177/0272989X14522099

Theoretical underpinnings:
https://home.csulb.edu/~cwallis/382/readings/482/nisbett%20saying%20more.pdf

Sometimes you read a book and get a flash of insight - that "ah ha!" moment - about yourself and the ways you interact with others.  That happened to me when reading "Range: Why Generalists Triumph in a Specialized World."  It helped me to understand and justify my interest in (this won't surprise you) EVERYTHING related to geriatrics or palliative care.  Also hat tip to Matthew Growdon for recommending the book.

Today we talk with Bob Arnold, who has a long list of recommendations for books that have the potential to generate an "ah ha!" moment.  The podcast is ostensibly focused on becoming a better mentor, but as you'll hear, we discuss techniques that can help you cope with anxiety, stress, your spouse…the list goes on.  In reality, insights from these books can help you be a better teacher, a more curious person, as well as a better mentor or mentee.

Bob urges you to buy these books from your local bookstore.  To that end, we're not including links with the titles below.  Please shop locally.

As a bonus, Lauren Hunt, frequent guest on GeriPal, heard we recorded this podcast and wanted to add a couple books to Bob's list (she saw Bob give a talk about these books at the NPCRC Foley retreat).  Her list will strongly resonate with women in academics. See below for Lauren's two additions to Bob's list, with her personal commentary.

Enjoy!

-@AlexSmithMD

 

Bob's booklist:

• Lori Gottlieb, Maybe You Should Talk to Somebody: A Therapist, Her Therapist, and Our Lives Revealed
• Ethan Kross, Chatter: The Voice Inside Our Head, Why It Matters, and How to Harness It
• Eric Barker, Plays Well With Others: The Surprising Science Behind Why Everything You Know About Relationships Is (Mostly) Wrong
• Stephanie Foo, What My Bones Know: A Memoir of Healing From Complex Trauma
• Jennifer L. Eberhardt, Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do
• Claude M. Steele, Whistling Vivaldi: How Stereotypes Affect Us and What We Can Do
• Marcus Buckingham, Nine Lies About Work: A Freethinking Leader's Guide to the Real World
• Marshall Goldsmith, What Got You Here Won't Get You There
• Adam Grant, Give and Take: Why Helping Others Drives Our Success
• David Epstein, Range: How Generalists Triumph in a Specialized World
• Douglas Stone, Thanks for the Feedback: The Science and Art of Receiving Feedback Well
• Douglas Stone, Difficult Conversations: How to Discuss What Matters Most
• Kerry Patterson, Crucial Conversations: Tools for Talking When Stakes Are High
• Kerry Patterson, Crucial Accountability: Tools for Resolving Violated Expectations, Broken Commitments, and Bad Behavior
• Anne Lamott, Bird by Bird: Some Instructions on Writing and Life
• James Clear, Tiny Changes, Remarkable Results, Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones
• Michael Bungay Stanier, The Coaching Habit: Say Less, Ask More & Change the Way You Lead Forever
• Peter Bergman, You Can Change Other People: The Four Steps to Help Your Colleagues, Employees--Even Family--Up Their Game
• Doug Lemov, The Coach's Guide to Teaching
• Doug Lemov, Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to College
• Doug Lemov, Practice Perfect: 42 Rules for Getting Better at Getting Better

 

​​From Lauren:

The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It by Valerie Young 

I was inspired to read this book after reading a post on the 80,000 hours blog. I had heard of course heard of imposter syndrome in the past but I didn't make the connection to myself until I read this article and saw my thoughts printed on the page. You would think that after several years of a number of career successes, the imposter syndrome would have abated for me, but rather I found it getting worse! I thought that I should know more of what I was doing by this point in my career, but instead I often felt like I had no idea what I was doing! 

So I came across this book and found it very helpful. Young defines people who have imposter syndrome as those who have a "persistent belief in their lack of intelligence, skills, or competence. They are convinced that other people's praise and recognition of their accomplishments is undeserved, chalking up their achievements to chance, charm, connections, and external factors. Unable to internalize or feel deserving of their success, they continually doubt their ability to repeat past successes." 

I certainly related to the point that instead of successes alleviating feelings of fraudulence, the opposite happens, because it increases pressures to uphold one's reputation. The pressures can be intense, leaving one wondering if it's all worth it, and prompting fantasies of leaving the charade behind. 

One thing I really liked about this book is that it places the imposter syndrome into the context of a patriarchal, misogynistic, racist society and organizations that create cultures that cultivate self-doubt (ahem academia). Imposter syndrome is a rationale response to a crazy world. We exist in a society and culture that actually judges women to be less competent at work (the studies she details are SUPER disturbing). It is not surprising we would internalize these norms. Also that being underrepresented in a field creates pressures not only to represent just oneself, but an entire gender.  She focuses on women, but these concepts obviously apply to people of color and other disadvantaged social groups. And of course men can have imposter syndrome too. 

Another part I liked about the book is digging into the notion that one's success is due to luck, or being in the right place at the right time. She dispels these notions by pointing out that, first of all, luck is always present, even for people who are enormously talented and second, being the right place at the right time, having the right connections, and having a winning personality can sometimes actually be the result of skills or abilities, often the result of hard-work, hustling, and efforts to develop one's socioemotional capacity.  

This is a self-help book, so throughout she offers some useful rules and self-talk for responding to imposter syndrome thoughts. She details different ways to respond to thoughts based on your competence type. For example, if you are a perfectionist, she recommends reframing to a "good enough" quality standard—a mantra I adopted from colleague during the pandemic and has been incredibly helpful for me over the past few years. For the rugged individualist who equate true competence equals solo, unaided achievement, the reframe is "competence means knowing how to identify the resources needed to get the job done." 

Another really important idea she raises is that women often have difficult choices to make about their career and its impact on other parts of their families and their other social networks that aren't as pronounced for men in our society. Sometimes it is difficult to disentangle these questions from feelings of imposter syndrome. For example, is reluctance to take on more responsibility at work or relocate because you feel inadequate or is it because of genuine concern about the impact on your family? Moreover, women (generalizing here) tend to place lower value on traditional measures of work success (e.g. money, power, influence) and greater value on connection and meaning. It can require a lot of soul searching to figure out whether one is avoiding career "success" out of fear or that certain paths are just truly not aligned with our values.  

Finally, towards the end of the book, she introduces the idea of "faking it till you make it" and having chutzpah—i.e going for it. Of course, she's not advocating for a George Santos approach (no lying) but just having a little bit more of a mindset that you'll figure it out once you're on the job. 

I'd definitely recommend this book if you've ever struggled with similar feelings or mentor people who might. She's got a breezy and relatable writing style that's easy to read, lots of great real-world stories, and piquant quotes.

 

The No Club:  Putting a Stop to Women's Dead-End Work by Linda Babcock, Brenda Peyser, Lise Vesterlund, and Laurie Weingart 

Summary of the book's premise: 

• Work activities fall on a spectrum from promotable and non-promotable (NPT). 

• Promotable activities are those that advance one's career. They use the word "advance" quite broadly to encompass various outcomes, like earning a promotion, getting plum assignments, increasing compensation, and enhancing marketability for other jobs. Promotable tasks are visible to others and increase the organization's currency. Some tasks may be indirectly promotable—they help you develop skills that have the potential to enhance your future success or access to future promotable work. 

• NPT's are important to your organization but will not help to advance your career. These tasks have low visibility (think committees and other service). 

• Too many NPT's can lead to work/work imbalance where promotable tasks get pushed to the side and advancement slows, or work-life imbalance, where advancement continues but at the expense of time in one's personal life (or both). 

• Although not exclusively a problem for women, women are more likely to take on NPT's at work. This is because they are both asked more often and are more likely to say yes when asked. 

• They propose both bottom-up (women saying no to more things) and top-down solutions (organizations making efforts to divide up NPT's more fairly and ensuring everyone is pitching in). 

Before I read this book, I didn't fully grasp the idea that an activity would be helpful to the organization but not to my own career. Sometimes requests for participation in these activities come with a veneer or prestige and lots of feel-good gratitude. I personally feel a lot of guilt and worry about disappointing people when I say no to things. Even declining to review an article for a journal is accompanied by some stomach knots (it's so hard to find reviewers!) I also place a lot of value in collaboration and working in teams, and the idea of working in a culture where everyone is only looking out for themselves is not appealing to me.  But I'm also worried at the level of overwhelm I experience at times and perhaps some of you have experienced as well. How do we ensure that we are on sustainable path where we can stay in and build the world we want to live and work in?  

The book also got me thinking about what is promotable or not in academia, i.e. what is the currency. I think we all know that grants and publications are promotable activities, but even within that there are hierarchies. Some of these hierarchies I think I understand: a data-based paper in a high-impact journal has higher promotability than an editorial in a lower-impact journal. Some of them I'm not sure about: is an NIH project grant more promotable than a foundation grant and if so why (bc higher indirects?)  Also, things like mentorship seem gray to me: senior-authored articles are evidence of independence and potential track to mentoring awards, but people often seem to place mentorship in the NPT category. I think having more transparency and discussion about what is promotable or not would be very useful.   

Highly recommend this book for women, men, people in leadership, and employees. It's extremely well-written, nuanced, and eye-opening.

 

SPONSOR:   

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

 

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

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

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

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

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

On this podcast we discuss:

• Why do we need a revolution? What made him get to this point of arguing for a revolt?

• Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play?

• What is minimally disruptive medicine (a term Victor coined with Carl May and Francis Mair in 2009)?

• How does shared decision making fit into the revolution?

• What's the matter with guidelines? What's the role of standardization?

• We suspect that most geriatrics and palliative care providers feel like they've escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being.  Are we deluding ourselves?

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

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

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

-Alex Smith

 

The Covid epidemic laid bare two major structural issues.  First, Black and Latinx persons experienced much higher rates of mortality than other groups.  Second, as we discussed in last week's podcast, older adults, particularly those in nursing homes, were far more likely to die than younger individuals.  These are structural issues because the fundamental causes of these issues were not biological issues, they were social.  These worse outcomes were not due to differences in genes, they are due to structural racism and ageism. 

In today's podcast we talk about the intersection of racism and ageism.  We use the Covid pandemic and lack of diversity in trials for recently approved Alzheimer's drugs aducanumab and (to a lesser extent) lecanemab as springboards for discussion.  Our guests Tim Farrell, Ramona Rhodes, and Nancy Lunderbjerg wrote an article in JAGS on this issue, and Sharon Brangman wrote a separate JAGS article on the need to achieve diversity in study populations. In a third piece, Ramona Rhodes wrote about efforts to improve diversity, equity, and inclusion at JAGS (in the journal itself, including content and editorial leadership).  The article was titled, "Change is coming" - which also gives you a hint as to today's song request.

One final note: at the start of today's podcast we thank one of our generous donors, Meg Wallhagen, and ask her why she donated to GeriPal.  A prior guest on GeriPal, Meg is a tireless advocate and researcher for hearing impairment issues affecting older adults.  She has a study that is open to recruitment for any adult - hearing impaired or not - please see the blurb below to learn more and participate.

Enjoy!

-@Alex Smith

From Meg Wallhagen: The Federal Drug Administration (FDA) now allows hearing aids to be sold Over-the-Counter (OTC-HAs) to adults with mild to moderate hearing loss. We – Meg Wallhagen from UCSF and Nick Reed from John Hopkins University - are interested to learn what people like you know about OTC-HAs and if you would consider buying them. The survey should only take about 10-20 minutes to complete. If you are willing to consider taking the survey, please click on the following link to learn more.  https://ucsf.co1.qualtrics.com/jfe/form/SV_9ZbReHYH72m82gK

In April 2022, the National Academies of Sciences, Engineering and Medicine (NASEM) issued a report on how the United States delivers, regulates, finances, and measures the quality of nursing home care. It's massive with over 600 pages detailing everything from the history of nursing home care in the United States to the latest issues that nursing homes have had to face with COVID-19.

On today's podcast we invited Jasmine Travers, Alice Bonner, Isaac Longobardi, and Mike Wasserman to talk about the report.  Jasmine was one of the committee members for the NASEM report, and Alice and Isaac are chairing and directing a coalition called Moving Forward tasked with taking the goals identified in the NASEM report and identifying specific and practical initiatives, test concepts, and promote their adoption for lasting improvements.

We could have gone on for a couple hours for this podcast, but alas time ran out.  But if you want to learn more, check out these links:

1. The report by NASEM titled "The National Imperative to Improve Nursing Home Quality"
2. The website for the Moving Forward

We will also link to the JAGS articles co-authored by seven committee members that focus on specific recommendations of the NASEM report when they get published (stay tuned).

 

Acute Care for Elders (ACE Units) have been around for over a quarter of a century. Randomized trials of ACE units date back to 1996 when Seth Landefeld and colleagues published a study in NEJM showing that they improve basic activities of daily living at discharge and can reduce the frequency of discharge to long-term care institutions.  But if ACE units are so great, why do so few hospitals have them?

On today's podcast we talk about ACE units with geriatricians Kellie Flood and Stephanie Rogers.  They recently published a paper in JAGS looking at the current landscape of ACE units in the US. In the podcast we go over these issues and more:

• What are ACE units and what structural elements go into them (see the picture below for a nice summary)? 
• Which patients are eligible to go to an ACE unit?
• What are the benefits of an ACE unit?
• If ACE units are so great, why are they not so common? 
• What does the future look like for ACE units and how does it differ (if at all) from Age Friendly Health Systems?

If you want to do a deeper dive in ACE units, check out some of the following articles:

• The original NEJM paper on ACE units from 1996
• Kellie Flood's paper in JAMA IM showing that not only ACE units deliver better care, but also help with the hospitals bottom line

Today's podcast may be a stretch for our listeners.  Please stick with us.  No matter what your position on medical aid in dying (I'm ambivalent) or abortion (I'm pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think.  All three of today's guests are well established bioethicists.  

Let me start by quote/paraphrasing one of today's guests, Mara Buchbinder, who puts her finger on the issue we talk about today:  

"Typically when we think about conscience in medical ethics we think about it in terms of  a negative claim of conscience, where a clinician refuses (or objects) to provide care.  But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it's abortion provision or medical aid in dying -  because of a deeply held conviction that this is the right thing to do."  

I'll continue by quoting Lisa Harris, who wrote in the NEJM:

Bioethicists have focused on defining conditions under which conscientious refusals are acceptable but, with rare exceptions, have neglected to make the moral case for protecting the conscientious provision of care. Indeed, there is a real asymmetry between negative duties (to not do something) and positive duties (to do something) and, accordingly, between negative and positive claims of conscience. Violations of negative claims are considered morally worse than violations of positive ones.However, as bioethicist Mark Wicclair argues, the moral-asymmetry thesis does not provide adequate ethical justification for current conscience law, which protects only conscience-based refusals. Moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs.

Lisa was writing about providing abortion care, but she just as easily could have been writing about providing medical aid in dying in states where it is illegal.  

Today we wrestle with this issue of conscientious provision.  We start by talking with Robert Brody, an internist who recalls physicians helping patients die during the height of the AIDS epidemic in San Francisco.  Robert was first asked by one of his own patients for assistance in dying in 1991, far before aid in dying was legalized in California in 2016.  Robert went on to be the founding chair of the board of Compassion and Choices, the major national advocacy organization for medical aid in dying.  Today, medical aid in dying is legal in some 10 states, and illegal in others.  

Also today, in the wake of the Supreme Court's recent Dobbs decision, some 13 states ban abortion.  To examine how clinicians might act in the face of such bans, we turn to Lori Freedman, who wrote a book about clinicians (primarily Ob-Gyn's) who work in Catholic Hospitals.  She describes the "workarounds" these clinicians used to skirt the rules in order to provide reproductive care for women.  

We talk about the parallels between these issues at the beginning and end of life, and areas in which these parallels fall apart.  For example, Jack Kevorkian excepted, clinicians have not been prosecuted for providing aid in dying in states where it is illegal. In contrast, there is a justified fear of prosecution of providing abortion care in states where it is illegal.  

It took contemplation on a bike ride to put my finger on why I "wrestle" with the notion of conscientious provision.  On the one hand, when I hear of Ob-Gyn's in Catholic Healthcare systems using "workarounds" to provide reproductive care, I'm standing up and cheering on the inside.  On the other hand, when I hear of workarounds to assist patients to die, or even euthanize them, I worry that we've gone back to a time when the doctor or nurse knows best - and should be morally permitted to do whatever they think is right, according to their conscience.  Do we really trust all doctors and nurses so far?  Would you, with your parents, trust any doctor or nurse to make such life or death decisions, regardless of the law?  There have to be limits to conscientious provision, just as there are limits placed on conscientious objection. In conscientious objection, there are general rules, such as: the patient must be given time to seek a clinician who is willing to provide the treatment; and clinicians can only object to specific treatments under specific circumstances.  And yet, I worry about explicitly creating ethical rules for conscientious provision. Ought we, in bioethics, create ethical rules for providing care that is illegal?  Who will follow them, and what would be their incentive for doing so?  Would such ethical guidelines foster or feed suspicion of the motivations of bioethics?   

We could have talked for hours. We may reconvene for another podcast as we see how these issues continue to unfold.

Oh life. It's bigger. It's bigger than you and you are not me.

-@AlexSmithMD

Many links:

Mara Buchbinder's book - Scripting Death: Stories of Assisted Dying in America
https://www.ucpress.edu/book/9780520380202/scripting-death

Lori Freedman's book (forthcoming) - Bishops and Bodies: Reproductive Care in American Catholic Hospitals
https://www.rutgersuniversitypress.org/bishops-and-bodies/9781978828865

Lisa Harris piece mentioned on podcast
https://www.nejm.org/doi/full/10.1056/NEJMp1206253

Alta Charo piece mentioned on podccast
https://www.nejm.org/doi/full/10.1056/nejmp058112

Yvonne Lindgren article mentioned on podcast
https://dc.law.utah.edu/cgi/viewcontent.cgi?article=1002&context=ulr

Art Caplan piece mentioned on podcast
https://www.thehastingscenter.org/abortion-law-lessons-from-medical-aid-in-dying/

George Annas piece mentioned on podcast
https://dsc.duq.edu/cgi/viewcontent.cgi?article=3090&context=dlr

https://muse.jhu.edu/pub/1/article/722811

https://journalofethics.ama-assn.org/article/why-post-roe-era-requires-protecting-conscientious-provision-we-protect-conscientious-refusal-health/2022-09

https://www.amazon.com/Doctors-Conscience-Struggle-Provide-Abortion/dp/0807021016/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1670624994&sr=1-1

 

SPONSOR:   

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

 

From discussing "taking away the keys to the car" for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine.  How well though are we taught to handle conflict and disagreement?  I'd say not well as I don't think I've ever received a formal talk on the issue.

On today's podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski.   We've had Lee on before to talk about her Plan your Lifespan project.  We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers.

For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge training, feel free email the NegotiAge Research Team at negotiage@northwestern.edu): 

• Getting to Yes: Negotiating Agreement without Giving In by Roger Fisher, William Ury, and Bruce Patton
• Getting Past No: Negotiating in Difficult Situations by William Ury
• Negotiation Training for Case Managers to Improve Older Adult Acceptance of Services. Prof Case Manag. 2021 
• Training Hospitalists in Negotiations to Address Conflicts with Older Adults around Their Social Needs. Geriatrics. 2020 
• Conflicts Experienced by Caregivers of Older Adults With the Health-Care System. Journal of Patient Experience. December 2020
• Dealing with conflict in caring for the seriously ill: "it was just out of the question".  JAMA 2005

 

We've talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA's decision to approve it.  

But wait, there's a shiny new anti-amyloid drug, lecanemab!  (No it's not just the French version of Aducanumab).  

In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo.  Wow!  Wow?  Wait, what?  

On today's podcast we talk with Jason Karlawish, who we've had on previously talking about his book The Problem of Alzheimer's and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky.  

They debate today's central question: is it time for geriatricians to get on board with lecanemab?  Along the way we address:

• Is this degree of slowed cognitive decline meaningful to patients or care partners?
• What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for brain swelling and bleeding, case report level risk of death?
• Did the study do enough to address issues of inclusion and diversity by age, race and ethnicity, and multimorbidity?
• What does this study say about the amyloid hypothesis?
• Should the FDA approve, and under what conditions?

Their answers may surprise you.  

As a preview of final thoughts at the end of the episode, Ken and Jason agree that the FDA should approve lecanemab conditional on a post-approval monitoring system and public access to study data, geriatricians should be prepared to have thoughtful conversations with patients about the risks and benefits of lecanemab in view of their values and priorities, and ultimately, that geriatricians should be open to prescribing it. 

Wow!

The times, they are a changin.

-@AlexSmithMD 

Eric and I weren't sure what to call this podcast  - storytelling and medicine? Narrative medicine?  We discussed it with today's guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet.  It wasn't until the end that the best term emerged - storycatching.  Because that really is what this is about.  Clinicians "catching" patient life stories.   

What's in a story?  Well, as we learned, everything.  Our patients aren't "the 76 year old with heart failure in room 202," as Heather Coats astutely noted.  They're people, and what makes us people if not our life's stories?  Our loves, our triumphs, our failures, our work, our families.  

Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin.  It's since spread to over 70 VAs.  VA "gets" the importance of storytelling in medicine, without the need for reams of research to back it up.  As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them documented, and for the clinicians who get to truely and deeply know their patients in far greater depth than "what brought you to the hospital?" Heather Coats is hard at work establishing the evidence base for the power of capturing patient stories in healthcare settings, for those health systems that need a little more convincing.   

Wonderful work.  Enjoy!

Many links:

VA Presents: My Life, My Story: George: A Voice To Be Heard on Apple Podcasts
https://podcasts.apple.com/us/podcast/id1529359511?i=1000489683280

Every Veteran has a story. Our mission is to help them tell it.
https://www.va.gov/wholehealth/mylifemystory/

My Life, My Story: VA's healthcare improvements through deliberate storytelling - YouTube
https://www.youtube.com/watch?v=fpzgVlExS20&ab_channel=VeteransHealthAdministration

Storytelling Helps Hospital Staff Discover The Person Within The Patient
https://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient

A few data based publication links from Person-Centered Narrative Intervention Program of Research: 

Unpacking characteristics of spirituality through the lens of persons of colour living with serious illness: The need for nurse-based education to increase understanding of the spiritual dimension in healthcare
https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16055

Integration of Person-Centered Narratives Into the Electronic Health Record: Study Protocol
https://pubmed.ncbi.nlm.nih.gov/32740306/

Bennett, C.R., Shive, N., Coats, H. (2020). What Mattered Then, Now, and Always: Illness Narratives From Persons of Color. Journal of Hospice and Palliative Nursing, 22 (5):392-400/ PMID: 32740304
https://pubmed.ncbi.nlm.nih.gov/32740304/

Coats, H., Meek, P., Schilling, L., Akard, T., Doorenbos, A. (2020). Connection -- The Integration of a Person-Centered Narrative Intervention into the Electronic Health Record: An implementation study. Journal of Palliative Medicine, 23 (6)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249456/

Coats, H., Crist, J., Berger, A., Sternberg, E., & Rosenfeld, A. (2015). African American elders' serious illness experiences: Narratives of "God did," "God will," and "Life is better." Qualitative Health Research. doi:10.1177/1049732315620153.  PMID: 26701962
https://journals.sagepub.com/doi/abs/10.1177/1049732315620153. 

Narrative Methods Textbook referenced in podcast
Narrative Methods for the Human Sciences

A few Dignity Therapy- Harvey Max Chochinov links

https://dignityincare.ca/en/about-us.html

About us - Dignity in Care
https://dignityincare.ca/en/about-us.html

Research Team - Dignity in Care
https://dignityincare.ca/en/research-team.html

Other links:

Curiosity by Faith Fitgerald
https://www.acpjournals.org/doi/full/10.7326/0003-4819-130-1-199901050-00015

Eric's blog post on Dignity Therapy from 2011
https://geripal.org/study-of-dignity-therapy-on-distress/

 

What would it take to transform dementia care?  While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer's disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast).

In order to truly transform dementia care we need to think much broader than the amyloid hypothesis.  So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include:

• Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need them and how we can create them 
• Anne Basting, PhD, a MacArthur Genius Grant awardee and professor (English/Theatre), University of Wisconsin, Milwaukee.  She created TimeSlips which we talk about in our podcast.  Her most recent book is Creative Care: a revolutionary approach to dementia and elder care 
• Abhilash Desai, MD, geriatric psychiatrist, adjunct associate professor in the department of psychiatry at University of Washington School of Medicine, and poet!  He wrote a book titled "Psychiatric consultation in long term care" that has a strengths based approach to staging dementia (how cool is that)
• Judy Long, MDiv, BCC, palliative care chaplain and educator at UCSF and caregiver.  She directs UCSF MERI's patient, family, and clinician support with classes and consultation on resiliency, well-being, and grief.

We discuss the importance of viewing individuals with dementia from a lens of resilience, the importance of creative engagement (as noted in Anne and Susan's wonderful article on this subject), the role of collaborative care, and what we can do to improve inclusivity for individuals with dementia in our community and health care systems.

 

 

Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly?  That's the central question on today's podcast.  The problem is the tremendous heterogeneity in services offered and quality of care.  If you've seen one Assisted Living Community you've seen one Assisted Living Community. 

To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents.  The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care).  The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of the corporations that own most Assisted Living Facilities (profit) and the ideal services offered in Assisted Living Facilities.  

We additionally firmly establish that the song How to Save a Life by the Fray was a product of the aughts (2005, to be exact), not the 90's ):

Enjoy!

-@AlexSmithMD (still on Twitter at present)

Health care professionals are human, and as humans we experience loss both in and out of work.  You'd imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses.  Turns out, it's maybe not.

That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called "Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals".  It's a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss.

On today's podcast, we've invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.  

We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings.  These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work.  Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings. 

So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness:

• Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals
• Dates & registration info about debriefings offered by CAPC
• The CAPC Debrief Facilitator Training Manual we developed: PDF Download.
• Jared Rubensteins' "Token of Appreciation" video
• A great website for dealing with loss and grief: refugeingrief.com

SPONSOR:

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

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

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

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

1. Organizational Alignment: Integrating GOC documentation into the health system's mission, vision, and strategic objectives.

2. Clinical Leadership Partnership: Collaborating with clinical leaders to establish robust quality standards and metrics.

3. Ease of Documentation: Upgrading the electronic health record (EHR) system to streamline the documentation and retrieval of GOC conversations.

4. Communication Training: Conducting workshops based on the Serious Illness Conversation Guide to equip clinicians with the skills needed for impactful GOC conversations.

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

 

Dr. Faith Fitzgerald once quipped that prognostic modeling is the "punctilious quantification of the amorphous."  She has a point.  Prognosis is inherently uncertain.  As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful.  As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making.  What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury?  James Deardorff replies that there is something inherently different about predicting mortality.  Death is different.  For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue).  And yet, the only thing that may be worse than a prognostic calculator is a clinician relying solely on their clinical intuition.

Today our guests Alex Lee, James Deardorff, and Sei Lee, talk to us about the uses, limitations, and clinical use cases for prognostic models.  As a springboard for this conversation we discuss new prognostic models developed to predict (simultaneously) mortality, disability, and mobility impairment (Alex Lee first author, JAGS) and mortality for people with dementia residing in the community (James Deardorff first author, JAMA IM).  

Both new models are now available and free to use on ePrognosis.  

And Sei and Eric reminisce about slow dancing to "Forever Young" by Alphaville in their teenage years.

Enjoy!

-AlexSmithMD

The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians?    On today today's podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the National Alzheimer's Project Act.  Dr. Sherry shares her expertise in aging health policy and helps us make sense of the role of her Office and how she coordinates with the multitude of federal agencies aligned around the goal of advancing aging research, policy, and health. For the policy buffs and policy newbies out there, we hope this podcast is an essential primer to government in action.    We talk about: 

• The structure of federal agencies and how they coordinate 
• Priorities of the National Alzheimer's Project Act, and the unique role of ASPE and BHDAP in guiding the agenda and long-term goals
• The recent focus on nursing facilities and long term supportive services during the pandemic, along with key gaps
• How HHS and ASPE solicit input from clinicians, community leaders, and older adults and how much it impacts policy decisions (spoiler alert: this involvement is CRUCIAL) 
• How to make your voice heard and get involved   

We also touch briefly on topics discussed in prior podcasts such as loneliness and federal responses to the pandemic in relation to long-term care. Tune to hear Alex's rendition of 'With a Little Help from My Friends'!   - Ashwin Kotwal, MD, MS  

When I'm on service these days there is inevitably a moment when a resident says "Patient so-and-so is on X" - and I have absolutely no idea what X is.  Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up.

In this context, we're excited to hear from infectious disease experts and nephrologists about updates in the care of older adults.  Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I've never finished a course of antibiotics, and maybe your patients don't need that full course either).  Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race.  We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I'm not 100% sold that race should always be removed - if removal is likely to worsen disparities for example - at least until a superior race-blind calculator can be developed).

These articles are part of a new series called Clin-Star Corner, a new series in JAGS that reviews practice changing articles in the care of older adults. 

And yeah, they made me sing a Miley Cyrus song…(but not this hilarious parody about UTIs).

Enjoy!

-@AlexSmithMD