GeriPal - A Geriatrics and Palliative Medicine Podcast

One marker of the distance we've traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans. Well, as a kick off to this year's first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented. Today we interview the authors of these 3 abstracts about their findings: Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety) Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support) Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization) Wow! I'm just stunned even writing that! We've come so far as a field. This isn't to say we've "made it" - more to say that we've reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data. We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties. I believe these issues were more than made up for by our guests' forced accompaniment to the song "Feel Like Making Science." (Credit to the Beeson singing crew for coming up with that one). Enjoy! -@AlexSmithMD

What is frailty? Kate Callahan relates a clear metaphor on today's podcast. A frail person is like an origami boat: fine in still water, but can't withstand a breeze, or waves. Fundamentally, frailty is about vulnerability to stress. In 2021 we talked with Linda Fried about phenotypic frailty. Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty. What is the difference, you ask? George Kushel probably explained it best in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers. Damage to those critical functions and the bridge can collapse. Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK. But miss a bunch and things fall apart. Resilience is the ability of the bridge to withstand stress, like bridge traffic, wind, waves, and the occasional earthquake (hey it's California!). Frailty research has come a long way. We're now at a point where frailty can be measured automatically, or electronically, as we put in the title. Kate created an eFrailty tool that measures frailty based on the electronic health record (EHR) data. Ariela created a VA frailty index based on the EHR of veterans. And Dae created an index using Medicare Claims. Today we're beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients. We should not get too hung up on battles over frailty. As Kate writes in her JAGS editorial, "If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed." To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings. It's called eFrailty, check it out now! Did I cheat and play the guitar part for Sting's Fragile at ⅔ speed then speed it up? Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break! -@AlexSmithMD Additional Links: eFrailty website is: efrailty.hsl.harvard.edu (efrailty.org is fine). Dae's Frailty indexesCGA-based frailty index web calculator for clinical use: https://www.bidmc.org/research/research-by-department/medicine/gerontology/calculator The Medicare claims-based frailty index program for research: https://dataverse.harvard.edu/dataverse/cfi/ Ariela's VA-FI:Original VA frailty index: https://academic.oup.com/biomedgerontology/article/74/8/1257/5126804 ICD-10 version https://academic.oup.com/biomedgerontology/article/76/7/1318/6164923 Link to the code for investigators (included in the appendix): https://github.com/bostoninformatics/va_frailty_index As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource (CIPHER) Recent validation against clinical measures of frailty: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18540 Kate's eFrailty Index https://doi.org/10.1093/gerona/glz017 our original eFI paper https://doi.org/10.1111/jgs.17027 & https://doi.org/10.1001/jamanetworkopen.2023.41915 on eFI and surgery https://doi.org/10.1111/jgs.17510 editorial in JAGS

Almost a decade ago, our hospice and palliative care team decided to do a "Thickened Liquid Challenge." This simple challenge was focused on putting ourselves in the shoes of our patients with dysphagia who are prescribed thickened liquids. The rules of the challenge were simple: fluids must be thickened to "honey consistency" using a beverage thickener for a 12-hour contiguous period. All of us failed the challenge. We then decided to challenge others and asked them to post their videos online using the hashtag #thickenedliquidchallenge. Here are some of the results of those videos: https://geripal.org/the-thickened-liquid-challenge/ On today's podcast, we revisit dysphagia and thickened liquids with two researchers and speech-language pathologists, Raele Donetha Robison and Nicole Rogus-Pulia. We talk with them about the epidemiology, assessment, and management of dysphagia, including the role of modifying the consistency of food and liquids, feeding tubes, and the role of dysphagia rehabilitation like tongue and cough strengthening. We also talk about the importance of a proactive approach to involving speech-language pathologists in the care of individuals early on with neurodegenerative diseases like dementia and ALS. If you want to take a deeper dive, take a look at these articles: A nice overview of swallowing disorders in the older adults published in JAGS A study in JAGS showing that 89% of feeding tubes inserted during hospitalization were in patients with no preexisting dysphagia Nicole's article on shifting to a proactive approach of dysphagia management in neurodegenerative disease

In the last several years, I've seen more and more articles about end-of-life doulas (like this NY Times article from 2021). Despite this, in my 20-year career as a palliative care physician, I have yet to see a death doula in the wild. I'm unsure what they do, how often they're used, and who pays for their work. So, on today's podcast, we try to get to the bottom of what exactly is an end-of-life doula. We've invited two death doulas, Jane Euler and John Loughnane (who is also a family doc and palliative care physician), to talk about the role of a doula at the end of life. We also invited Beth Klint to speak about the doula's role within a traditional hospice organization. Why Beth? In addition to being a palliative and hospice RN, she is the Executive Director for Goodwin Hospice, a large non-profit hospice that added end-of-life doula care to their services in collaboration with Jane and John's doula organization, Present for You. If you are interested in learning more about death doulas, check out the following links Goodwin Hospice's article on the collaboration with Present for You A HospiceNews article talking about the value proposition of death doulas for hospices NHPCO's End-of-Life Doula Council page that includes a lot of great links

Today we celebrate eight years, around 2 million listens, and 300 podcasts! Eric and I take questions from you, our listeners, about: why we podcast, our most controversial podcast, which podcast changed our practice, favorite song request, should all nursing home residents complete the POLST, expanding access to durable medical equipment, palliative care in rural regions, do we have an advance directive, what we'd do to improve healthcare with 7 trillion dollars, treatment for poor appetite, and Eric on how to make a latte. Thank you to Lynn Flint and Anne Kelly who serve as hosts for this episode, asking us the tough questions. We answer your questions hot ones style. I borrowed some screaming hot sauces from my friends Jerome Kim and Tony Le, and added them to my small collection of extra mild sauces. Every two questions we ate a chicken wing covered in hot sauce. The hot sauces progressed from mild to extreme (and I mean extreme) heat. Can I just say…it works? Being asked a question with your mouth on fire, sweat streaming down your face, feeling the most awake and terrified you have ever been in your life, forces you to give an unadorned answer, straight from the heart. Don't take my word for it, listen for yourself! Or better yet, watch the video of this one on YouTube. Some of the funniest parts are caught on video, in the background. We will be re-watching this one for years to come. Thank you, dear listeners, for sending us your questions, for your enthusiasm, and for your support. Enjoy! -@AlexSmithMD

In our podcast with palliative care pioneer Susan Block, she identified the psychological/psychiatric aspects of palliative care as the biggest are of need for improvement. As she said, when you think about the hardest patients you've cared for, in nearly all cases there was some aspect of psychological illness involved. That rings true to me. Today we talk with two psychologists who are deeply invested in addressing psychological aspects of care for people living with serious illness. Elissa Kozlov, a geropsychologist and director of a new population aging MPH at Rutgers, surveyed AAHPM members, and found that doctors reported major shortcomings in level of comfort and knowledge caring for patients with psychological illness. She conducted a systematic review and meta-analysis of 38 palliative care trials, finding that many excluded people with serious illness, and a lack of impact on psychological outcomes. Analyzing the Health and Retirement Study, she found 60% of older adults screened positive for depression in the last year of life (related study here). Des Azizoddin is a psychologist at the University of Oklahoma primarily focused on pain for people with cancer. Des delivered a plenary at this year's National Palliative Care Research Center's Foley retreat. She began by asking, "Raise your hand if you think there is a psychological component to cancer pain." All hands go up. Then, "Keep your hand up if you frequently refer patients with cancer pain to a psychologist?" All hands go down. Unfortunately, we lack the financial structures to reimburse psychologists that would incentivize widespread inclusion on palliative care teams. Because we live in the world as it is, not as it should be, Des has helped develop an app (link to pilot trial hot off the press!) to help people with cancer pain engage in cognitive behavioral therapy in bite sized 3-4 minute sessions (there are other apps available now developed in the VA, who have been leaders in the psychology/palliative care space). Des additionally studied stigma associated with opioid use among patients with cancer in the context of the opioid epidemic; depression, pain catastrophizing, recent surgery and opioid use among people with cancer. And, we talk about these issues and more (with far more nuance than I can include in this post). Kudos and credit to my son Renn, age 15, for the guitar on Heartbeats (hand still broken at time of recording).

We've talked about Falls a couple of times on this podcast, most recently with Tom Gill about the STRIDE study and before that with Sarah Szanton about the CAPABLE study. A takeaway from those podcasts is that fresh innovative thinking in the falls prevention space is welcome. Today we talk with the twin sister power duo of Carmen Quatman and Katie Quatman-Yates about an intervention that is both brilliant and (in retrospect) should have been obvious. The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient's homes. They were stunned by the number of calls for lift assistance for older adults who had fallen. Going into patient's homes was eye opening. There were trip hazards, loose carpets, some people were hoarders. And yet, after assisting the older adult to their feet, the EMS providers would leave. Their job was done. It's not surprising that the number of repeat calls for falls is alarmingly high. Addressing the root environmental causes of falls was not part of EMS providers' job description. In addition to stigma, practical barriers to older adults addressing environmental issues themselves abound. For example, Carmen and Katie found thousands of grab bars on Amazon (overwhelming), and when they called installation companies (handypersons), received different quotes if the person calling was a man or a woman. So Carmen and Katie developed an EMS Community Partnership program. EMS providers were trained to provide practical home modifications: installation of grab bars, removal of carpets, removal of other obstacles. They created a seamless link between this Community Partnership program and 911 calls for falls. People who had grab bars installed through the program called their neighbors and say, hey you should get this too. Word of mouth spread rapidly. And the number of calls for falls dropped. Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community. In addition to the podcast, you can see more about this in Carmen's TEDx talk. Thanks to my wife Cindy Hsu for piano on Eye of the Tiger. Enjoy! -@alexsmithMD

In 1982 Eric Cassell published his landmark essay: On the Nature of Suffering and the Goals of Medicine. Though his narrow definition of suffering as injured or threatened personhood has been critiqued, the central concept was a motivating force for many of us to enter the fields of geriatrics and palliative care, Eric and I included. Today we talk about suffering in the many forms we encounter in palliative care. Our guests are BJ Miller, palliative care physician and c-founder of Mettle Health, and Naomi Saks, chaplain at UCSF. We discuss: How to respond when a nurse or trainee says, "I think this patient is suffering," but the family does not share that perception The trap in comparing one person's suffering to another person's suffering How to respond to suffering, from naming to rebirth Ways in which suffering can bring meaning and purpose, or at the very least co-exist alongside growth and transformation The extent to which elimination of suffering ought to be a goal of palliative medicine (with a nod to Tolstoy) A simple 2 sentence spiritual assessment Credit to my son Kai Smith on guitar on Everybody Hurts for those listening to audio only (hand still splinted at time of this recording) -@AlexSmithMD Additional links: Screening for suffering: https://pubmed.ncbi.nlm.nih.gov/27714532/ and https://pubmed.ncbi.nlm.nih.gov/35195465/ and https://pubmed.ncbi.nlm.nih.gov/31387655/ Evans CB, Larimore LR, Grasmick VE. Hospital Chaplains, Spirituality, and Pain Management: A Qualitative Study. Pain Manag Nurs. 2023 Dec 20:S1524-9042(23)00202-3. doi: 10.1016/j.pmn.2023.11.004. Epub ahead of print. PMID: 38129210. Kleinman, A. (2020). The illness narratives suffering, healing, and the human condition. Accepting This Poem by Mark Nepo https://marknepo.com/poems_accepting.php Saks, N., Wallace, C.L., Donesky, D., & Millic, M. (in preparation). "Profession-specific Roles in Palliative Care." In Donesky, D., Wallace, C.L., Saks, N., Milic, M. & Head, B. (eds.), Textbook on Interprofessional Palliative Care. Oxford University Press.

Last week we talked about a trial of a nurse and social worker outpatient palliative care intervention published in JAMA. This week, we talk about the other major palliative care trial of default palliative care consults for hospitalized older adults with COPD, kidney disease, or dementia, published in the same issue of JAMA. (See also our accompanying editorial, first author Ashwin Kotwal who joins today as a co-host, and a podcast I recorded with JAMA editor Preeti Malani). For context, listen to the prior podcast with Scott on "nudges" and prior podcast with Kate on who should get palliative care. Three things I love about this podcast, and why you should listen. First, in our editorial, we expressed concern about the length of stay metric not being patient centric, though important for health systems focused on cost savings. It was refreshing to hear Scott and Kate express similar sentiments. Second, we wanted to know how the palliative care clinicians felt about the increased workload - and we had some glimpses into those experiences (and hope for a future publication that fleshes it out further). Finally, we heard about next steps and lessons learned, as though this was the largest pragmatic trial of palliative care to date, it isn't their last. Much more to come. And next time maybe we really will play the game where every time the word pragmatic is mentioned you have to drink 🙂 And I get to play Phish, who Scott has seen about 100 times in concert. I saw them only twice. Once as an undergraduate at Michigan, in 1994. They played Hill auditorium and I signed up to be an usher. Can you imagine trying to usher Phish Heads to stay in their assigned seats? Yeah, no. Gave up at some point and joined them. Full electric experience. Second time was with Neil Young at the Bridge School Benefit at the Shoreline Amphitheater, California in 1998. That concert, entirely acoustic, was impressive in its sheer musical virtuosity. You're kind of naked playing acoustic like that. On today's podcast you get me, not naked, though still only with 2 left fingers (hand still broken) on the guitar, playing "Miss You." -@AlexSmithMD Additional links: Trey Anasatsio playing Miss You alone and acoustic, start around 21 minutes for the lead in Original article describing the potential for default options to improve health care delivery: https://www.nejm.org/doi/full/10.1056/NEJMsb071595 Scott on goals of care as the elusive holy grail outcome of palliative care trials (we discussed toward the end): https://www.nejm.org/doi/full/10.1056/NEJMp1908153 The protocol paper for REDAPS: https://www.atsjournals.org/doi/10.1513/AnnalsATS.201604-308OT Big recently funded PCORI trial comparing specialist PC delivered by default vs. generalist PC following CAPC training + a different EHR nudge: https://www.pcori.org/research-results/2023/comparative-effectiveness-generalist-versus-specialist-palliative-care-inpatients Kate's "Palliative Connect" RCT: https://clinicaltrials.gov/study/NCT05502861?term=katherine%20courtright&rank=1

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 accompanying editorial written by Ashwin Kotwal, Lauren Hunt, and the guy singing on today's podcast, we talk about the strengths and limitations of this study, something we "get into" with the authors toward the end of today's podcast. We are also joined by Diah Martina, a palliative care doctor trying to grow palliative care in Indonesia, in part by starting a palliative care podcast in Indonesian (she was observing today). You can also listen to an audio interview with Alex and JAMA Deputy Editor Preeti Malani about this study and the other RCT of default palliative care for hospitalized older adults with noncancer serious illness published in the same issue. Stay tuned for a GeriPal podcast with the authors of the other study next week. Credit to my wife Cindy for piano on the audio-only version of Ben Rector's The Best is Yet to Come. Enjoy! -@AlexSmithMD

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 — Methadone Clinic Engagement and Cancer Care," which described the difficulty in managing cancer pain and methadone for opioid use disorder. Lastly, we discuss Katie's paper on substance use disorder in an aging population and how one can incorporate the 5 Ms (ie, matters most, medications, mind, mobility, and multicomplexity) into a framework for age-friendly care for older adults with substance use disorder. If you want to do a deeper dive, here are some other references we talk about in the podcast: Previous podcasts on substance use disorder Buprenorphine Use in Serious Illness: A Podcast with Katie Fitzgerald Jones, Zachary Sager and Janet Ho Substance Use in Older Adults: A Podcast with Ben Han Palliative Care, Chronic Pain, and the Opioid Epidemic: GeriPal Podcast with Jessie Merlin Expert consensus-based guidance Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder

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 "mature minors." A recent Human Rights podcast discussed the story of a Canadian seeking MAID because he could not afford to stay housed. Today we talk about these issues with Bill Gardner, a psychologist at the University of Ottawa who is living with cancer, Leonie Herx, a palliative care physician at the University of Calgary, and Sonu Gand, a psychiatrist at the University of Toronto and former president of the Canadian Psychiatric Association. We talk about how Canada got to this point, including the degree to which offering MAID to anyone who is eligible has become standard practice in many places. We hear Bill Gardner's experience being told that his cancer could not be treated and immediately offered two options: palliative care or MAID. We talk about the role of palliative care and lack of access for many people living with serious illness in Canada. We go in depth about ethical issues raised by the planned expansion of MAID to people with mental illness. Much of the criticism of the explosion of MAID in Canada is coming from people like, our guests, who feel that MAID should be an option for a select few, rather than coming from under-no-circumstance opponents. To many this rapid expansion will represent autonomy run amok. It is the slippery slope made real. To others MAID represents a seemingly easy and inexpensive mechanism to address failures of the system to address potentially reversible sources of suffering on a systemic level, from difficult conversations at the bedside, to meeting basic needs like housing. For those listening to the podcast, credit to Kai for guitar on Neil Young's Cortez the Killer (my left hand is still broken at the time of this recording). You get me with one-finger-chords on the guitar if you're watching on YouTube (best I could manage). -@AlexSmithMD Overview of MAID in Canada 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/

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 talk with Malaz Boustani of Indiana University, as well as Diane Ty, the senior director of the Milken Institute Center for the Future of Aging, about the GUIDE model. We'll cover why the GUIDE model is important (hint - it all comes down to funding), how it was developed, what components will it include, and how it will be evaluated. To read more about the GUIDE model, check out the following links: Diane's article in Health Affairs titled "A Promising Turning Point For Dementia Care: The GUIDE Model" Another Health Affairs article titled "Applying An Evidence-Based Approach To Comprehensive Dementia Care Under The New GUIDE Model" The CMS site if you are interested in learning more or applying to be a site (the application period will close on January 30, 2024)

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 this podcast we talk about her paper in JAMA Internal Medicine which studied three hospitals that varied in the intensity of care they provided to seriously ill patients. We discuss the moral distress that clinicians felt including, as one physician put it, a sense of your soul being ripped out. At the end we also pay tribute to Randy Curtis, senior author on this paper and mentor to Liz. Eric and I are joined today on this podcast by Anne Kelly palliative care social worker to discuss these issues with Liz. -@alexsmithMD Additional links: From Liz: "policies that are too restrictive can actually have an opposite of hindering ethically and clinically appropriate practices whereas policies that allow for flexibility and transparency to act ethically can promote high quality end-of-life care" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/ Other papers that are relevant: JAMA IM 2015: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265 JPSM LAT France paper: https://www.jpsmjournal.com/article/S0885-3924(21)00399-7/pdf ICM paper policies: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/ JPSM aggressive care: https://www.jpsmjournal.com/article/S0885-3924(17)30425-6/fulltext BMJ QS moral distress ethical climate: https://qualitysafety.bmj.com/content/27/10/766.long

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 tent with room for older adults, researchers, and organizations. As a researcher, I found the bibliography fascinating, including this gem by the gerontologist Rick Moody on the moral obligation of older adults to address climate change. Leslie Wharton is a leader in the 26,000 member grassroots organization Elders Climate Action, which organizes older adults to create communities engaged in making a difference at local, state, and national levels. As she notes, these volunteer activities can bring meaning and purpose, in the face of a seemingly insurmountable problem, to the elders in her organization. And we talk with Ruth McDermott-Levy, who wrote a practical guide for discharge planning in the era of climate change (example - a generator safety checklist). Ruth advocates for and teaches about aging and climate change at Villanova, and calls on nurse scientists and other health researchers to study climate change. -@AlexSmithMD Additional links: JAMA paper on clinical research risks, climate change, and health Geriatric medicine in the era of climate change Health Care Without Harm: https://noharm.org/ Practice Green Health: https://practicegreenhealth.org/ Global Consortium for Climate and Health Education: https://www.publichealth.columbia.edu/research/programs/global-consortium-climate-health-education

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 from AGS to these guidelines, check out the following links: Revised Criteria for Diagnosis and Staging of Alzheimer's Disease: Alzheimer's Association Workgroup AGS's response to the revised criteria

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 for? My take: coaching has tremendous potential. There seems to be a gender story here as well - coaching may be of particular benefit to women who are at higher risk for burnout. Note, for example, the hot off the press JAMA Network Open trial which demonstrated modest benefits across a range of outcomes was conducted exclusively in female resident physicians. Kemi Doll, a physician-researcher and coach, has a terrific podcast I highly recommend everyone listen to, though it is targeted at women of color in academic medicine. On the other hand, there is a concerning side, described in this Guardian article titled, I'm a life coach, you're a life coach: rise of an unregulated industry. See also the long list of disclosures in the JAMA Network Open study. Our guests note, rightly, that the same profit motive and concerns are true about colleges. Still, I remain concerned when I see that the Life Coach School costs $21K; when the founder of the Life Coach School's goal is to grow a $100 million/year business; and when my spidey sense tells me there's something cultish about the empowerment industry. So, I see the potential of coaching, particularly for groups that face challenges in academic medicine; and I worry about the injection of profit-motives and the goals of industry leaders pushing the meteoric rise of the life coach industry. -@AlexSmithMD 1. Hot off the presses RCT in JAMA October 2023: Study that looks at 1000 female resident physicians at 26 sites that showed that coaching improved each outcome assessed (burnout, moral injury, imposter syndrome, self-compassion, and flourishing). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810135 2. An RCT for female residents published in JAMA May 2022: This was the initial pilot single institution study by the same team as above. Their findings concluded that it was feasible to implement an online coaching program for female residents and that coaching improved emotional exhaustion, imposter syndrome and self-compassion. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791968?fbclid=IwAR0taY5CGpUa5eyfleNIl7RfXLT7qVt0GakKPGlT9ESIPLn0yCKWG9obrZo 3. A March 2022 study of Stanford offering coaching as a benefit to their physicians and finding improved self-compassion and burnout. https://www.mayoclinicproceedings.org/article/S0025-6196(22)00038-6/fulltext 4. The initial RCT published on physician coaching in JAMA in 2019 showing that coaching improves quality of life. This is the first RCT that was available for coaching in physicians. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740206 5. A 2020 RCT of coaching for primary care physicians shows that coaching improves burnout well-being during the intervention and has a sustained duration at 6 months of follow up. From Beth Israel and UNC. https://pubmed.ncbi.nlm.nih.gov/32297776/ 6. The Business Case for Investing in Physician Wellness, again in JAMA. This paper includes coaching as a sign of a more mature physician wellness program and states it has a positive return on investment. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2653912

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 geriatrics, Jerry sees it as a call to action). We've also invited Mike Harper, the Chair of the Board of Directors of the American Geriatrics Society (AGS) as well as past-president for the society (and my previous program director). Lastly, we've asked one of the brightest rising stars of geriatrics, Ryan Chippendale, to join us as well. I'm a huge fan of Ryan's, in part for her work in co-creating the GERI-A-FLOAT (GERIAtrics Fellows Learning Online And Together). This is a great virtual curriculum designed to convene geriatric fellows nationwide for learning and peer support (and if you are interested in having your own fellows join, click here).

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 that might follow the trial of rehabilitation. Today we talk with Sarguni Singh, hospitalist-researcher at the University of Colorado, Ann Henshaw, Occupational Therapist who teaches at George Washington and works clinically at Georgetown, and Tamra Keeney, Physical Therapist-researcher at Mass General Hospital and Harvard Medical School. Lynn Flint, author of the NEJM perspective titled, "Rehabbed to Death," joins Eric and I as co-host. We cover a lot of ground in this podcast, including an evidence based toolkit to promote collaboration between therapy fields and palliative care, outcomes of rehabilitation for people with advanced cancer (hint: not much hospice, lots of re-hospitalization), and a JAGS study on use of post-acute care among patients with heart failure. We also heard from Tamra about her opinion piece in which she laments, "The role of rehabilitation is often myopically constrained to facilitation of efficient discharge planning." Therapists are so much more. At the end of the day, I lamented that physical, occupational, and speech therapists aren't more tightly integrated with palliative care teams. As Lynn says at the end of the podcast, to paraphrase, "Physical therapy, occupational therapy, speech therapy - all this therapy for older frail patients is a core part of good palliative care." And our guests sing along with "Sweet Caroline" - so good, so good, so good! -@AlexSmithMD 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

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 changed). We had a full podcast, and I wasn't able to give my take on the existing evidence for POLST, so I'll write it here. I'm in the middle between Scott and Karl, where I suspect Kelly is, though we didn't ask her explicitly. On the one hand, I agree with Scott that observational studies finding those who complete a POLST stating a preference for comfort oriented care and DNR are not go to the ICU says little about the effectiveness of POLST. Far more likely that those underlying preferences and values are what drove the findings than completion of the POLST form that codified the preferences into orders. On the other hand, I agree with Karl that the POLST has face validity, and anecdotal evidence is overwhelming. Certainly SOME of those avoided hospitalizations, CPR, and ICU stays were due to documentation of those orders in the POLST. The unanswered question is: HOW MUCH of the differences are due to the POLST? It's not zero, as many of us have had cases in which we said, "Thank god we completed that POLST, it clearly stopped X from happening." But is it a tiny, meaningless, fraction? Or a substantial proportion? My guess is a small but meaningful fraction of differences in observational studies is due to completion of the POLST, though the majority of differences are due to underlying preferences and values. Is that fraction due to POLST large enough that we should design quality metrics around completion of POLST? Absolutely not. Do we need better evidence, preferably from an RCT of POLST vs no POLST? Yes. Caveat as well that RCTs should not be placed on pedestal as the only answer- often patients enrolled in RCTs do not represent real world patients - observational studies do. For a trial to have value, it should not exclude patients over age 80, or those with dementia, or patients residing in nursing homes. And it must be powered to detect a small but meaningful difference, not the same level of effect seen in observational studies. OK, I'll step off my soap box. Additional links mentioned in the podcast: Recent JGIM article on POLST in California nursing homes, hospitalization, and nursing home care Karl's GeriPal post on appropriate use of POLST Enjoy! -@AlexSmithMD

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, patient-centered approach to patient-surgeon communication and decision making, and language surgeons (and surgical trainees) can start using in their next patient visit. We hope you enjoy this episode. Take a look at some of these links to learn more: Innovations in Surgical Communication series: Provide Your Opinion, Don't Hide It Focus on the Goals of Surgery Promote Deliberation, Not Technical Education Present the Downsides of Surgery, Not Just Risks Dr. Schwarze's article, "Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention'' in which surgeons used "fix-it" language in 92% of conversations and did not establish an overall goal of treatment 80% of the time. South Park "Underpants Gnomes" Orthopaedics vs Anesthesia By: Alexis Colley

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 sustaining treatments, in particular CPR. Sunita recently published a wonderful New Yorker article titled The Hidden Harms of CPR arguing among other things that these conversations "are procedures, demanding the same precision of everything else in medicine." So take a listen and check out some of these other links to dive deeper: Our first podcast in the series of 3 podcasts "Miscommunication" A great article on why you shouldn't ask what patients "want" Sunita's book That Good Night: Life and Medicine in the Eleventh Hour The paper Jacky talked about regarding the ingrained pattern of focusing on the "need" for specific life-sustaining interventions, typically as the reason to admit a patient to the ICU Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016 Cardiopulmonary Resuscitation on Television — Miracles and Misinformation Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

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 Shunichi Nakagawa about some of the amazing communication pearls he posts on his Twitter account (don't tell me to call it X). Lastly, we also plan to have two more podcasts coming up on communication, one on the language of life sustaining treatments and one on surgical communication, so stay tuned! Eric Note: For more reading on this subject, check out these links: Shunichi Nakagawa's Twitter account Miscommunication in Cancer Care—Do You Hear What I Hear? Patient Values: Three Important Questions-Tell me more? Why? What else? A "Three-Stage Protocol" for Serious Illness Conversations: Reframing Communication in Real Time

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 caregivers and people with dementia? Why should interventions be culturally tailored for this group? Feyron has centered her work in Black/African American faith communities and churches - a program she titled Alter. Why this focus? Karen has a Cambia Sojourns award to pilot an intervention in which Black/African American former caregivers are trained to provide peer support to current caregivers (Peer2Care). This seems like a triple win - the bereaved former caregiver has the opportunity to be generative, share their story, and give back; the current caregiver connects with someone similar who listens when so many people are tuning them out; the person with dementia benefits from the caregiver's improved sense of self-efficacy, decreased loneliness/social isolation, and better coping overall. Why are nurse researchers in particular critical to the study of these issues? And Karen brings a tambourine in the studio for I'll Fly Away (see YouTube version)! -@AlexSmithMD

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."

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

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