Geripal-podcast

In a JAMA 2020 systematic review of palliative care for non-cancer serious illness, Kieran Quinn found many positives, as we discussed on our podcast and in our editorial.  He also found gaps, including very few studies of patients with lung disease, and little impact of trials on quality of life.  The article we discuss today, also published in JAMA, addresses these two gaps. David Bekelman conducted a RCT of a nurse and social worker telephone intervention (ADAPT intervention) for people with heart failure and lung disease (COPD or ILD).  David has been conducting outpatient trials in this space for some time, such as the CASA study he mentions today, learning important lessons along the way.  This is the first study that is unequivocally positive, improving overall quality of life and depression.  Today we unpack this study, with the help of Lyndsay Degroot, a postdoc and nurse researcher focused on identifying the core aspects of the study and eventually testing the study in more diverse populations.  In

The CDC’s Guideline for Prescribing Opioids for Chronic Pain excludes those undergoing cancer treatment, palliative care, and end-of-life care. In doing so, it seems to give the impression that pain seen in cancer is inherently different than pain seen in other conditions and that those with cancer may not have the same risk for opioid use disorder as compared to other conditions. Today's podcast tackles these issues and more with three amazing guests: Katie Jones, Jessica Merlin, and Devon Check.   We start off the conversation by talking about whether patients with cancer and cancer pain are really that different, and their paper that was just published on January 11th in JAMA Oncology showing that substance use disorder is not uncommon in individuals with cancer. After discussing screening options for substance use disorder, we go on to talk about both the treatments for it and the issues that arise.  In particular, we talk about Katie’s and Jesica’s paper in NEJM titled “Juggling Two Full-Time Jobs — Met

Four percent of deaths in Canada are due to Medical Assistance in Dying (MAID).  Four percent. The number of people who have used MAID in Canada since it was legalized in 2016 has increased year on year from about 1,000 people in the first year to over 13,000 people in 2022. California, which has a similar population size as Canada and legalized MAID around the same time, has fewer than 1000 deaths per year from MAID.  In further contrast to the United States, MAID in Canada is almost entirely administered by a clinician, whereas in the United States patients must self administer.   To be eligible in Canada patients must have a “grievous and irremediable” condition,  including disability; they do not have to have a terminal illness with a prognosis of less than 6 months.  They could have a prognosis of years, or decades.  A planned expansion of MAID to include people with mental illness was placed on hold until March 2024. The Canadian parliament will soon hear a report on potentially expanding MAID to “m

We’ve talked a lot about comprehensive dementia care on the GeriPal podcast but while the evidence is clear that these programs work, the uptake has been limited largely because there hasn't been a strong financial case for it. Don’t get me wrong, the evidence points to cost savings, but as Chris Callahan and Kathleen Unroe pointed out in a JAGS editorial in 2020 “in comprehensive dementia care models, savings may accrue to Medicare, but the expenses accrue to a fluid and unstable network of local service providers, patients, and their families.” The good news is that the financial case for comprehensive dementia care is changing thanks to a new Center for Medicare and Medicaid Innovation (CMMI) alternative payment model (APM) called Guiding an Improved Dementia Experience (GUIDE) Model.  This model will give participating programs a per-member-per-month payment to offer care management, care coordination, and other services such as caregiver training, disease education, and respite. On today's podcast we t

One of the things I love about Liz Dzeng’s work is the way in which it draws upon, echoes, and advances our understanding of the influence of culture on the end of life experience.  This field is not new. In his book The Hour of our Death Philip Aries described a long evolution in western civilization of cultural attitudes towards dying.  More recently Sharon Kaufman 's book And a Time to Die described the ways in which physicians, nurses, hospital systems, and payment mechanisms influenced the hour and manner of patient's deaths. Similarly Jessica Zitter, an intensivist and palliative care doctor analogized the inevitable clinical momentum toward highly aggressive intensive care in US hospitals as a conveyor belt. Today Liz Dzeng discusses her journey towards studying this issue in detail. Having trained in different institutions within the United States and in the United Kingdom, and as both a sociologist and a hospitalist physician, Liz brings a unique perspective and set of skills to this issue. On th

To my teenagers, climate change is an existential crisis.  It’s the end of the world as we know it.  They decry the lack of serious attention and prioritization this issue has in the US.  My kids ask - why don’t adults care about this issue the same way that they and their friends care about it?  My kids have taught me that the emphasis on personal responsibility (reduce your carbon footprint!) was supported by the fossil fuel industry, because it shifted responsibility for change from industry to individuals.  Voting and emailing congress to advocate for systemic change (e.g. less reliance on fossil fuels) likely has a greater impact than recycling your newspaper. Today we find inspiration for my kids: there are adults who care deeply about this issue, particularly for older adults who are much more vulnerable to health effects of climate change. Karl Pillemer is a sociologist and gerontologist who studies this issue and has created a platform called, “Aging and Climate Change Clearinghouse,” that is a wide

There is a growing push to change how we define Alzheimer's disease from what was historically a clinically defined syndrome to a newer biological definition based on the presence of positive amyloid biomarkers. This proposed new definition, championed by the Alzheimer's Association (AA) and the National Institute on Aging (NIA), proposes that the disease exists when the earliest manifestation of Alzheimer’s pathophysiology can be detected (amyloid), even though onset of symptoms may be years in the future. On today's podcast we talk about the benefits and drawbacks of redefining Alzheimers to a biological definition with three experts in the disease: Heather Whitson, Jason Karlawish, and Lon Schneider. In particular we spend a good deal of time talking about what this means for asymptomatic patients who may have an abnormal biomarker, which by the proposed new definition would mean they would now have Alzheimer's disease.  If you are interested in learning more about the draft guidelines and the response fro

Coaching is in.  During the later stages of the pandemic, it seemed every other person, and particularly the junior faculty in our Division, were either being coached, in training to coach, or coaching others.  When I was a junior faculty, coaching wasn’t a thing.  Sure, Atul Gawande wrote about coaching in surgery - having someone observe you and coach you on your technical skills- but that’s a far cry from the coaching programs focused on empowerment that are exploding around the country today. Today we learn more about coaching from 3 coaches: Greg Pawlson, coach and former president of the American Geriatrics Society, Vicky Tang, geriatrician-researcher at UCSF and coach, and Beth Griffiths, primary care internist at UCSF and coach.  We address: What is coaching? How does it differ from therapy? How does it differ from mentoring What is typically covered in coaching sessions?  What is the evidence (see many links below, sent by Beth) What are the standards for becoming a coach? Who is coaching f

What does the future hold for geriatrics? I’ve seen this question come up a lot since finishing fellowship nearly two decades ago. Historically, answers generally lamented the ever increasing need for geriatrics without a corresponding growth in the number of specialists in the field. But, it's also hard not to be bullish on the future of the field to see the consistent strides geriatrics has made in the last two decades in improving care for older adults. For example, I never would have imagined two decades ago the push for age-friendly health care systems and the growth of non-geriatricians, like surgeons and oncologists, adopting geriatric principles into their training and research. On today’s podcast, we are going to do a deep dive on the future of geriatrics with three amazing guests. First, we’ve invited Jerry Gurwitz to talk about his recently published article in JAMA titled The Paradoxical Decline of Geriatric Medicine as a Profession (while it’s not the most upbeat title for the future of geriatric

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

What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric?  The answers to these questions will vary.  Reasonable people will disagree.  And today, on our podcast, our guests disagree.  Firmly.  AND we are delighted that our guests modeled respectful disagreement.  With no hard feelings.  Respectful disagreement is in short supply these days. Our guests today are Kelly Vranas, pulm crit care doc who published a systematic review in JAGS of the evidence for POLST (as well as other articles here, here,and here); Abby Dotson, who is Executive Director for National POLST and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of National POLST; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a Viewpoint in JAMA that was critical of the concept and evidence base for POLST (and argues little has

For surgeons and patients, deciding if and when to operate can be challenging. Often, the way surgeons communicate about these decisions doesn’t make things any easier for themselves or their patients. And, surgeons often spend the majority of their conversations with patients describing anatomical details and exactly how they plan to ‘fix it’, with little discussion of what that ‘fix’ will do for a patient’s overall goals. Instead, what if your surgeon told you that the operation she was discussing could help with only 4 things: live longer, feel better, prevent disability, or obtain a diagnosis? And, what if your surgeon openly discussed the expected ‘bad stuff’ of post-operative recovery, instead of rotely reciting a list of possible complications? We invited Gretchen Schwarze and Justin Clapp to discuss with us these communication strategies, which are the focus of a series of 4 Viewpoints recently published in JAMA Surgery. I love this series of articles because each presents a component of a practical,

Communicating about a serious illness is hard. Last week’s podcast we talked about the challenge around miscommunication in serious illness. This week we dive into the challenges with communication when it comes to life sustaining treatments and CPR. Take for example the simple question: “If her breathing gets any worse, she will need to be intubated.” This seems like an innocuous statement of fact, but does she really “need” to be intubated if, for example, her primary goals are to be comfortable and die at home?  Of course not.  We’ve invited Jacqueline Kruser and Bob Arnold on this week's podcast to talk about their recently published JAMA Viewpoint article titled “Reconsidering the Language of Serious Illness.” I love this article as it specifically discusses what’s wrong with “need” statements and how we can shift our communication and thinking to create space for deliberation about patients’ priorities and the best course of action.   We’ve also invited Sunita Puri to talk about the language of life s

Medical communication is tough, although fundamentally at its most basic unit of delivery, it includes really only three steps. First, a clinician’s thoughts must be encoded into words, then transmitted often via sounds, and finally decoded back to thoughts by a patient or family member. Simple, right? Not so much, as each one of these steps is fraught with miscommunication. For example, a surgeon may want to convey that all visible tumors were removed during surgery, but transmits that message to the patient by saying “we got it all” only to have the patient hear an entirely different message that the cancer is gone and they are now cancer free. On today’s podcast we talk with three communication experts, Abby Rosenberg, Don Sullivan, and Shunichi Nakagawa about the concept of miscommunication, including examples of it and ways we can mitigate this issue.  This podcast was inspired by Abby and Don’s recent JAMA Oncology paper titled Miscommunication in Cancer Care—Do You Hear What I Hear?  We also ask Shuni

The proportion of people living with dementia who identify as Black/African Americans is on the rise, and so too are the proportion of caregivers who identify as Black/African American.  As our guests talk about today, caregiving for people living with dementia takes a tremendous toll, and when this toll is set atop the challenges of racism in all its forms, the reality of caregiving while Black can be overwhelming. Today we talk with Fayron Epps and Karen Moss, two nurse researchers who are focused on improving the experience of Black/African American caregivers of persons living with dementia.  We talk in particular about: Terminology.  Acknowledging that the most sensitive terms shift over time, what terms are they using today and why? Black? African American? Black/African American?  We also learn that the term stakeholder, so common in research, should be avoided for its early usage as White colonialists staked out land taken from Native American peoples.  Why a focus on Black/African American care

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 co

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

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, existentiali

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 poss

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 t