GeriPal - A Geriatrics and Palliative Medicine Podcast

In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine. In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging. In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry. As with aging, poetry operates on multiple levels within the palliative care space. Poetry puts us in our patient's shoes. As Redwing's poem says, "why not live as long as possible?" Poetry holds us in that liminal space so many of our patients are in. Paradox. The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I'm paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go. Or as in Mark Nepo's poem Adrift, I am so sad and everything is beautiful. Poetry helps us grapple with our own experiences of illness. Redwing, who is a cancer survivor, shares poems about her experiences with cancer. Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis. We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality. And along the way, we really felt like we got to the heart of things. To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide. -@AlexSmithMD Links to Redwing's poetry workshops: Food for Thought Poetry for Resiliency Loss, Losing and Loosening, poetry for grief and loss Wounded Healer poetry sessions Advance Care Planning Links to Redwing Keyssar's poetry collections Redwing's website: www.redwingkeyssar.com Institute for Poetic Medicine Mike Rabow's Comprehensive Care Team randomized trial of outpatient palliative care Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out). In addition to Redwing's own songs and poems, other poems read by Mike and Redwing during the podcast: In Blackwater Woods by Mary Oliver Therapy by John Wright Adrift by Mark Nepo Talk Before Sleep by Elizabeth Berg Late Fragment by Raymond Carver

Buprenorphine. It's been around for a long time but is acting like the hot new kid in town. Just look at this year's AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now. But does this drug really live up to the hype? On today's podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care). We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes). And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles: Learn more about caring for those with substance use disorder: Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness Learn about using the low dose buprenorphine patch: Low-Dose Buprenorphine Patch for Pain - Fast Fact Learn about how to initiate buprenorphine: Sublingual Buprenorphine Initiation: The Traditional Method - Palliative Care Network of Wisconsin Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach Good review on buprenorphine for pain Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

In her essay "Why Read a Poem in a Time Like This?", Marilyn McEntyre writes: All of us need it. We need it because good poems do something prose can't do. They invite and enable us to notice the precarious fissures in what we think is solid ground. They direct us toward the light at the edge of things — the horizon, the fragment of dream before dawn, the feeling that's hard to name, and can only be accurately captured by metaphor. They take us to the edge of "what can't be said," and ambush us into feeling before we think, so that we can't simply and complacently "believe everything we think." Poetry deals in surprise and subversion and turns old words to new purposes. Marilyn is joined by Guy Micco to talk about why poetry is important in general, why it's important in medical or nursing education, and why it's important for people who care for older adults. Along the way, they read poems, talk about poems, and sing a song by John Prine. We talk about how poetry can surprise, how poems can be playful, how they unlock dimensions and emotions that are otherwise locked away. How sometimes good poetry can be like a needed punch. And maybe, just maybe, we convince that poetry skeptic Eric Widera that there is a place for poetry in medicine after all. Enjoy! -@AlexSmithMD Links to essays and books by Marilyn McEntyre Why A Poem in a Place Like This? Why Read a Poem in a Time Like This? Patient Poets: Illness from the Inside Out Caring for Words in a Culture of Lies Links to Songs/Poems from the Podcast: Hello in There by John Prine After Apple Picking by Robert Frost Sonnet 73: That Time of Year Thou Mayest in me Behold by Shakespear Jane by George Bilgere Long Life by Elaine Feinstein Sonnet 60 by Pat Schneider (not online)

One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, "Can We Agree to Disagree?" And today our guests agree to disagree. And yet, and yet… They also agree across a whole range of issues, some of which surprised us. This is the latest in our series of podcasts on concerns about, and potential of advance care planning. If you're new to this discussion, don't start with this podcast! Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki. On today's podcast we ask our guests about areas in which there might be agreement or disagreement, including: The Best New York style bagels are made in California. Assigning a surrogate decision maker is important for everyone, including those who don't have serious illness. Where does POLST fit in with this debate? All decisions are made in advance, the question that we are debating is how far in advance and what to call it Completion of advance directives and billing codes for advance care planning as quality metrics Among other topics. I'm heartened that we could have this discussion as a field, as it shows that we've grown to the point where we can agree to disagree respectfully with each other. We can work it out! Links to a few couple items mentioned on the podcast: Objectives for Advance Care Planning 2018 Systematic Review of Systematic Reviews on ACP -@AlexSmithMD

If you develop dementia, odds are you will spend the last months to years of your life in a nursing home or assisted living facility. While we like to think about how our goals and preferences will influence what that life looks like, including whether you will get potentially burdensome interventions, your fate is probably influenced more by factors like where you live and what nursing home you happen to end up in. On today's podcast we dive into drivers of invasive procedures and hospitalizations in advanced dementia by talking to some pretty brilliant nursing and nurse practitioner researchers focused on dementia, geriatrics, and palliative care in nursing homes: Ruth Palan Lopez, Caroline Stephens, Joan Carpenter, and Lauren Hunt. We start off discussing the findings of Ruth Palan Lopez's publication in JAMA IM on the ADVANCE study. This study explored nursing home organizational factors and staff perceptions that are associated with the variation in care for residents with advanced dementia. Now when I say variation, I'm not talking about small little clinically questionable variations. I'm talking about some nursing homes with no residents with advanced dementia being tube fed, and some with nearly half of their residents with advanced dementia being tube fed. We go on to talk about other findings of this study including that staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in ACP and preferred more aggressive care, issues with the skilled nursing facility benefit ("rehabbing to death"), the palliative care needs of nursing home residents, and so much more. For a deeper dive, check out some of these other studies and resources we talked about in the podcast: The Influence of Nursing Home Culture on the Use of Feeding Tubes. Archives of Internal Medicine 2010 The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia Rehabbed to Death. NEJM Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block A Podcast with Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion

A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken's post is still one of the most searched and viewed posts on GeriPal. This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today. Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade - what happens over the next 10, 20, 30 years? And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation. In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission. Lauren uses her magic wand to address the measurement issue: we're not measuring function, frailty, and cognition routinely in hospitalized older adults. We wouldn't dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure. Additional links: GeriPal podcast with Lauren Ferrante and Nathan Brummel on geriatricizing the ICU GeriPal podcast with Tom Gill on the Precipitating Events Study, distressing symptoms, disability, and hospice GeriPal podcast with Linda Fried on frailty Shunichi Nakagawa's Tweet that went viral on responding a patient request to drink ice water before death. And a note- on the podcast you'll hear a drum track on the song (!). I'm taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills. Bear with me! I'm having fun working on these songs from home during COVID.

There is a lively debate going on in academic circles about the value of Advance Care Planning (ACP). It's not a new debate but has gathered steam at least in palliative care circles since Sean Morrisons published a JPM article titled "Advance Directives/Care Planning: Clear, Simple, and Wrong." Since then there has been a lot of back and forth, with even a couple of podcasts from us, several JAMA viewpoints, and most recently a series of published replies from leaders in the field on why ACP is still valuable (see below for references). Despite all of these publications, I'm still left at a loss of what to think about it all. Most of the debate seems rather wonky, as honestly it feels like we are getting stuck in the weeds of semantics and definitions, like what counts as ACP versus in the moment decisions. But the consequences are real, from research funding dollars to health systems investment. So in today's podcast, we have invited Juliet Jacobsen and Rachelle Bernacki to talk about what all the fuss is about. Juliet and Rachelle are two of the authors of a recent JAMA viewpoint titled "Shifting to Serious Illness Communication." We discuss the debate, how to think about definitions of ACP vs serious illness communication, what should go into high quality conversations, the evidence for and against any of this, and ultimately where we go from here. Also see the image from Alex's forthcoming editorial in JAGS, a Venn diagram of advance care planning and serious illness communication (please go to GeriPal.org to view the image). So check out the podcast and if you are interested in diving into this debate, here are some great links to learn more: What's Wrong With Advance Care Planning? JAMA 2021 Controversies About Advance Care Planning. JAMA 2022 (a reply to the above) Shifting to Serious Illness Communication. JAMA 2022 Our podcast with Sean Morrison titled "Advance Care Planning is Wrong" Our podcast with Rebecca Sudore and Ryan McMahan titled "Advance Care Planning is So Right" Our podcast with Rachelle Bernacki and Jo Paladino on the Serious Illness Conversation Guide

My mom is an Asian woman in her 70s with osteoporosis. She tried an oral bisphosphonate and had horrible esophagitis. She said never again, though she eventually tried an IV bisphosphonate. She had terrible flu-like symptoms. She said never again. But based on reports that symptoms are worse the first time, she tried the IV again the next year and fortunately experienced no symptoms. (Story used with permission, thanks mom!). I tell this story because these issues don't typically register as more than a nuisance for clinicians, who frequently don't understand why their older patient with osteoporosis is not taking a bisphosphonate. But our patients are walking with their feet, and adherence to bisphosphonates for osteoporosis is poor and decreases with time. When we have a medication with up front harms and downstream benefits, it's critical that we consider the time to benefit, or how long it will take an individual to benefit from a test or treatment. Think of the 10 years it takes to benefit from colon or breast cancer screening, which is designed to detect slow growing cancers. For individuals with a life expectancy less than the time to benefit, the up front harms outweigh the downstream benefits. In this context, we talked this week with James Deardorff and Sei Lee about their study of time to benefit of bisphosphonates for osteoporosis, published in JAMA IM. What they found somewhat surprised us: it's pretty short, about 1 year! Which makes me feel better about urging my mom to get treatment. Bisphosphonates are pretty darn effective, and act quickly. We also discuss discontinuing bispohsophantes, and if we can use the same logic we consider when starting them. Toward the end we talk about the launch of ePrognosis' new Time to Benefit tool. This tool provides a clinical recommendation for starting/stopping medications and cancer screening based on the prognosis of the patient in front of you. See screenshot below. You can either access it directly here. I you use the Lee Schonberg prognostic index for community dwelling older adults you will be directed to the tool, and it will automatically place the life expectancy at the calculated prognostic estimate. James and Sei requested a terrific song - Bad to the Bone - much better than the Hannah Montana Bone Dance song they threatened me with (maybe next time). Enjoy! -@alexSmithMD

This week many of our listeners will gather for the annual American Academy of Hospice and Palliative Medicine (AAHPM) & Hospice and Palliative Nursing Association (HPNA) annual meeting. While the majority of this meeting is focused on subspecialty care in the US, the majority of individuals who are in need of palliative care live in low and middle-income countries without even basic access to palliative care. On this week's podcast, we talk with three leaders in helping improve palliative care worldwide: Kathy Foley, Stephen Connor, and Eric Krakauer. I don't think I can really sum up these three guests in a sentence each, but I'll give you how we introduced them in our podcast. Kathy Foley is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative (IPCI). Stephen Connor is a licensed clinical psychologist and executive director of the Worldwide Hospice and Palliative Care Alliance. Eric Krakauer is an Associate Professor of Medicine and of Global Health & Social Medicine at Harvard Medical School, an attending physician in the Division of Palliative Care & Geriatrics at Massachusetts General Hospital, and a former medical officer for palliative care at the World Health Organization. The podcast tries to cover a lot of topics including: Why is addressing worldwide needs of palliative care important? What are the needs of palliative care worldwide? How do you quantify worldwide suffering and what is the serious health related suffering index? What are some of the main barriers to palliative care? What are the models of palliative care worldwide? What are some of the resources to improve palliative care? I encourage you to take a listen, and if you want to learn more check out some of these resources: Worldwide Hospice Palliative Care Alliance (WHPCA) Open Society Foundation's International Palliative Care Initiative Global Atlas of Palliative Care International Association for Hospice and Palliative Care JPSM's issue on the The International Palliative Care Initiative eHospice - a globally run news and information resource

In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness. We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University. We discuss: What are the differences between structural, institutional, and interpersonal racism? Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest's personal experiences. The importance of attention to religion and spirituality Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making. Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference). Co-opting of disparities issues by the Alzheimer's Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here). Action Item: Please submit a comment to CMS about aducanumab coverage today. Feel free to express your outrage at the lack of diversity in the trials. We could have continued talking with our guests for hours. We will continue to address the issue of racism in future podcasts. -@AlexSmithMD

Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant. Outcomes are worse among those who are frail. Symptoms are common, including pain, ascites, encephalopathy, and pruritus. Patients with end stage liver disease are often some of the most disadvantaged patients we care for. Caregiver burden is immense; divorce is common. Some will go on to receive a transplant, but many will not. Many are confused about the diagnosis and feel poorly supported. Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list. Advance care planning is rare (or serious illness communication for those of you who don't consider this advance care planning). Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain. In this week's podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective. We talk about the tension patients face between putting on the "best face" to be listed for transplant (e.g. full code, goals focused on extending life). We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease. We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance. And…Radiohead! Great request…thank you Nneka! -@AlexSmithMD

More Health Policy this week! Today, we discuss "SNPs" but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life. We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society). We discuss: Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new "Hospice Carve-In" This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick's and Dr. Rick Gilfillan's critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients. Alex plays The Purchaser's Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl's dog.

Investor money and venture capital funding is pouring into Medicare Advantage (MA) plans. Enrollment in MA plans has more than doubled from 12 million members in 2011 to 26 million in 2021. What does this mean for us and our patients? Do these plans deliver better care for vulnerable older adults? Or are they a money making machine driving up healthcare costs in the name of profit? On today's podcast, we are joined by UCSF geriatrics fellow Alex Kazberouk to talk with Dr. Don Berwick (founder of the Institute for Healthcare Improvement, former administrator of Center for Medicare and Medicaid Services) and Dr. Richard Gilfillan (former CEO of Geisinger Health Plan and Director of the Center for Medicare and Medicaid Innovation). Their recent two part post on the Health Affairs Blog about the Medicare "Money Machine" has stirred up a debate about challenges and misaligned incentives within Medicare Advantage. We talk about: What Medicare Advantage is all about - its history, operations, potential benefits, and what it means for us and our patients Rick and Don's Health Affairs post on the downsides of MA plans and the Medicare "Money Machine" Policy solutions to improve the system without throwing the baby out with the bathwater We also touch upon prior podcast topics such as the area deprivation index and population health. As a special, Alex plays a superb rendition of this song which is definitely not a Rickroll. This is part one of a two part series on Medicare Advantage and healthcare financing. We have a follow-up with Claire Ankuda and Cheryl Philips on Special Needs Plans and the Medicare Advantage Hospice Carve-In coming soon.

Three months ago we did a podcast with Randy Curits about his recent diagnosis of ALS in March and what it was like for someone who studies and cares for people living with serious illness, to now be someone who is living with serious illness. It was one of our favorite podcasts we've done, but also got us to think "wait, how come we've never done a podcast on ALS?" We fix that on today's podcast. We've invited Elizabeth Lindenberger and Kara Bischoff to talk about what every geriatrician and palliative care clinician should know about ALS. Topics include: prognosis in ALS, disease modifying therapies (and when/if to discontinue, advance care planning in ALS, the role of embedding geriatrics/palliative care in ALS clinics, interventions in ALS (noninvasive ventilation, PEG tubes, and trachs), and symptom management as the disease progress. So take a listen and if you want to take a deeper dive, take a look at these articles: Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned Top Ten Tips Palliative Care Clinicians Should Know About Amyotrophic Lateral Sclerosis

It's GeriPal's 200th episode. Yup, we started the podcast in 2016 and over the years we have grown from basically podcasting for Alex's mom to now getting over 25,000 plays per month. So to celebrate our 200th, and given that the last two years kinda sucked in a lot of ways, we are going to pivot to appreciative inquiry. We have invited leaders in geriatrics and palliative care to quickly share: One thing that you are grateful for in Geriatrics and Palliative Care (other than GeriPal!) One thing you are hopeful for in 2022 The guests we had were an awesome group that included Rachelle Bernacki (@rbernack), Kim Curseen (@Curseen), William Dale (@WilliamDale_MD), Helen Fernandez (@hfernandez01), Lynn Flint (@lynnmomdoc), Anne Kelly, Allison Kestenbaum (@ARKestenbaum), Christopher Langston (@calangst), Nancy Lundebjerg (@nlundebjerg), Mary Lynn McPherson (@mlmcpherson), Sean Morrison, Christine Ritchie (@RitchieCS), Christian Sinclair (@ctsinclair), Wendy-Jo Toyama(@WJSvetanoff), James Tulsky (@jatulsky), and Haider Warraich (@haiderwarraich). We also invite you to join us in this discussion. Go to either our Twitter account or youtube channel and share your answers to these two questions. Eric

Geriatric Oncology has arrived. Yes, Louise Walter has been leading the fight to improve cancer screening in older adults for years. But when it came to geriatricizing the way we assess and treat older adults with cancer, the evidence was thin. In our prior podcast with Supriya Mohile and William Dale on geriatric assessment in oncology, we couldn't say for certain if a geriatric assessment was helpful for patients with cancer. Well now we can. We are joined by Melisa Wong, a geriatric oncologist, and Louise Walter, a geriatrician and leader in cancer screening for older adults, to talk about the shifting landscape of geriatric oncology, including: How to think about cancer screening in older adults, moving beyond a one-size-fits all age-based approach to individualize cancer screening decisions. We also talk about the importance of thought pieces in driving a field forward. 2 landmark trials of the geriatric assessment in oncology, one in JAMA Oncology (first author Daneng Li) and the other in the Lancet (first author Supriya Mohile) (William Dale senior author for both studies). In both studies, grade 3+ toxicity was reduced in the geriatric assessment arm. Melisa Wong's study in JAGS finding a constriction of life space for older adults with cancer, and discussion of patient centered outcomes beyond traditional outcomes such as grade 3+ chemotherapy toxicity. Links of Interest: Association of Community Cancer Center site on Geriatric Oncology Cancer and Aging Research Group And as a bonus, you get to hear Louise on piano and vocals and I cover Wouldn't It be Loverly, from My Fair Lady. -Enjoy!

Geriatric anesthesia is a thing. The average age of people getting surgery is increasing. Anesthesiologists and surgeons feel that with new techniques and approaches they can perform surgery on patients at ever older ages, patients who they previously would have excluded from surgery. One of the key advances in geriatric anesthesia is the use of spinal anesthesia, a form of regional anesthesia that also includes epidurals and peripheral nerve blocks. When older adults experience a hip fracture, there's a growing consensus that spinal anesthesia offers superior outcomes compared to general anesthesia. It's surprising therefore, to talk with Mark Neuman about the results of his randomized trial in NEJM, which finds essentially no difference between general anesthesia and spinal. Importantly, as a primary outcome Mark selected walking ability based on feedback from older adults - this is the outcome our patients care about most. But he finds no difference in primary outcome or secondary outcomes, including (surprisingly) delirium. We break down potential reasons, with thoughtful commentary from Liz Whitlock and Cindy Hsu, two anesthesiologists with experience caring for older adults with hip fracture. Liz is a friend of the pod and researcher who we interviewed previously about "pumphead." Cindy is...my wife. She also helps me out with the accompaniment on piano as it's tough for me to play guitar with a broken clavicle. Thank you dear wife! We had fun learning to play/sing Drivers License by Olivia Rodrigo. Ah...teen angst...the angst!!! -@AlexSmithMD

The great resignation is upon us. One in five health-care workers has left their job since the pandemic started. Geriatrics and palliative care are not immune to this, nor are we immune to the burnout that is associated with providers leaving their jobs. In today's podcast, we talk with Janet Bull and Arif Kamal about what we can do to address burnout and increase resiliency, both from an institutional and individual perspective. Janet Bull is the Chief Medical Officer and Chief Innovations officer at Four Seasons Hospice and Arif Kamal is an oncologist, palliative care doctor and researcher at Duke. We discuss Arif's and Janet's article published in JPSM on the prevalence and predictors of burnout among hospice and palliative care clinicians, as well as Arif's Health Affairs article on the policy changes that are key to promoting sustainability and growth of specialty palliative care workforce. In that later article, Arif found that among many things: Burnout was reported by approximately one-third of physicians, nurses, social workers, and other respondents in the specialty of hospice and palliative care The presence of burnout was associated with increased odds of intending to leave early If you want to learn more about what you can do to promote wellness on your team, check out this article Arif published with other colleagues in JPSM titled the "Top Ten Tips Palliative Care Clinicians Should Know about Implementing a Team Wellness Program." Eric

I don't consider myself spiritual. For some in palliative care, this would be considered heresy as we are told "everyone is spiritual." But, hey, I'm not. So there. However, despite not being spiritual, I do believe that spiritual care is fundamental to the care I give patients and families. I also recognize it is the one palliative care domain I am most uncomfortable with and the one that as a field, we actually don't support very well (odds are, if your palliative care team doesn't have a full interdisciplinary team, the discipline you are likely missing is chaplaincy). So, on today's podcast, we break down spiritual care in palliative care with three leaders in the field: Allison Kestenbaum, Katy Hyman, and Paul Galchutt. We ask these experts a veritable smorgasbord of questions on spiritual care that includes: What the heck is spirituality and is the term itself inherently religious? What is the difference between a "spiritual care history" vs "spiritual screening" vs a "spiritual assessment" and why does it matter What do you do if your spiritual screen or assessment uncovers something? How do we ask our patients if they would like to see a chaplain? Should we ask or just like any of our other team members just have them stop by? What does spiritual care for the non-religious look like? What are some specific communication tips to take a deeper dive into patient/family/caregiver suffering. Can you research spirituality? Also, for all you palliative practitioners and researchers, here is a link to freely join the Hospice-Palliative Spiritual Care Research Network (HPSCRN) with Transforming Chaplaincy The HPSCRN is a space to connect, inform, explore, and coordinate for all interprofessionals.

Though "breath" is in the title of Wes Ely's book (and his song choice by the Police), relationships are its beating heart. The book operates on two levels. On one level, Wes Ely's book is an autobiography of a critical care doctor's horror and shame at discovering that his ICU practice of heavily sedating patients for days on end was leading to lifelong physical, cognitive, and psychological harm; and the arc of his redemptive journey to find a better way to care for patients in the ICU. But this book also operates on a second, much deeper level. On this deeper level the book is a story of Wes Ely's journey toward rediscovering the humanity in medicine by forging deep, lasting connections with his patients. We begin and end today's podcast at this deeper level, talking about the spiritual connections, that doctors can forge caring for critically ill patients. (quick plug: next week's podcast is with Chaplains on Spirituality and Palliative Care). We are joined today by Lekshmi Santhosh, head of UCSF's post-COVID and post-ICU clinic, to interview Wes about these themes that animate his book, and more, including how we lost our way in treating ICU patients during COVID, returning to the practice of heavily sedating patients for days on end. Of note, Wes is donating proceeds from his book to the CIBS center, to benefit research and patient care to improve care for people with critical illness, during and after the ICU stay. -@AlexSmithMD

Anyone who cares for individuals with serious illness must live in a messy space where tough conversations about treatment decisions are common and complicated. On today's podcast we talk with James Tulsky about living in this messy space of medical decision making and the challenges that come with communication around advanced treatment decisions. We talked about James' path to the work that he has done, including early studies he did that included audio recording DNR discussions between physicians and patients, to his most recent study looking at the "Triadic agreement about advanced cancer treatment decisions." In this last study, James' group surveyed 70 triads of patients, caregivers, and their oncologists shortly after making a cancer treatment decision and found that only 40% of triads completely agreed on the goal of treatment. In all of the remaining cases, at least one member of the triad disagreed about the goal of treatment. So take a listen and also check out this wonderful ACP article that James did with Joshua Lakin and Rachelle Bernacki titled "Time Out Before Talking: Communication as a Medical Procedure" which we also discuss on the podcast.

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

Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure. Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain. But these outcomes represent a thin view of the human experience. What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose. Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales. In this week's podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities. Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression's ability to participate in meaningful activities. Most people think that a good quality of life isn't possible for people with these conditions. Anna's study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities. Theresa's qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same. Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities. Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care. -@AlexSmithMD

The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD). Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE? Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials? In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab: Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions. Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab. For more podcasts on aducanumab, check out these two: All things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici Aducanumab (Aduhelm) for the Treatment of Alzheimers: A Podcast with Aaron Kesselheim and Jason Karlawish

"The take home message of this study is NOT that primary palliative care does not work." So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer. And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts) - is it time to start to question the effectiveness of primary palliative care? We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness. But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is "good enough" to impact outcomes. That's one interpretation. Another is that we need a "stronger dose" of primary palliative care. In Yael and Bob's study nurses averaged 2.2 visits, hardly robust longitudinal palliative care. Patients who had 3 visits had better outcomes. Unpacking negative studies is just as interesting as unpacking positive studies. Knowing what doesn't work is just as important as knowing what does. Links: Negative multi-national study of primary palliative care in nursing homes Negative ICU primary palliative care intervention Project ENABLE Podcast on palliative care's diversity problem Systematic review of palliative care

Time-limited trials. We've all probably used them before. We meet with patients and families. We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments. If not, we stop them. At least that is how it's supposed to go. On today's podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter. Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units. Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire. We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive. The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention). We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast). If you want to read more about time-limited trials, check out these articles as well: Paula Spans NY Times article on Time limited trials titled "I need to know I tried" The JAMA IM study and editorial on time-limited trials Tim Quill and Robert Holloways article in JAMA on Time-Limited Trials from 2011 And lastly our nudging podcast that we brought up several times

I'm going to start this introduction the way Eric ended our podcast. You are a GeriPal listener. Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness. This is hard, complex, and deeply important work we're engaged in. Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice? We will assume that you are doing the same right now if you haven't done so already, though we suppose you are free to choose not to if you don't believe in the mission of helping seriously ill older adults. Ha! Gotcha. Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of "nudging," or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice. Jenny just published a terrific book on the topic, "Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics." Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. "In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?"). Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I'm a believer in the GeriPal mission too, we're on the same side), appealing to ego (you're a good person because you believe in an important cause), and changing the defaults (you're giving us a five star rating right now unless we hear otherwise). We distinguish between nudges and coercion, mandates, and incentives. We talk about how clinicians are constantly, inescapably nudging patients. We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge. Nudges are powerful. At best, nudges can be used to promote care that aligns with a patient's goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote "doctor knows best" paternalism, and to "strongarm" patients into care that doesn't align with their deeply held wishes. What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don't have deeply held preferences, goals and values? Hmmm.... Hey, have you completed your five star rating of GeriPal yet? -@AlexSmithMD Other citations: -Randy Curtis and Robert Burt on unilateral DNR and informed assent -GeriPal podcast with Angelo Volandes about using video to improve choices

Randy Curtis, a paragon of palliative care research, was diagnosed with ALS in March. Randy is in a unique position as someone who studies and cares for people living with serious illness, who now shares his reflections on being on the other side, to reflect on the process of living with serious illness. His reflections are illuminating and inspiring. We talk with Randy about his experience being in the patient role, rather than the physician or researcher role. We ask if knowing the prognosis for his subtype of ALS is helpful to him, and if he's seeing a palliative care clinician. We talk with Randy about his legacy, principally his focus on mentoring. We talk about how his approach to his life, his clinical work, and research has shifted in the face of living with serious illness. We end by talking about our favorite "Randy Curtis" studies. Thank you Randy for modeling vulnerability and willingness to talk about ALS. Thank you for your mentoring which has nurtured a veritable forest of trainees, and for your research which has improved care for people living with serious illness and their families. And here's to your song choice: a "good life" indeed, by any measure. Links: -Prior GeriPal podcast with Randy Curtis on an earlier study of the JumpStart patient-priming intervention for goals of care discussion -ICU family meetings: Increased proportion of family speech is associated with increased satisfaction -Alterations in translated ICU family meetings -A communication strategy and brochure for ICU family meetings -Practical guidance for ICU family meetings -Empathy in life support decisions -Cambia Center of Excellence for Palliative Care Research -Cambia Sojourns Scholars Leadership Program -@AlexSmithMD

alliative care has a diversity problem. The workforce of palliative care looks nothing like the patient population that we care for in the hospital and in our clinics. For example, in 2019-2020 academic year only 4% of Hospice and Palliative Care fellows identified as black, compared to 12% of the overall US population using the most recent census information. These issues are similar for hospice and geriatrics. On today's podcast we talk about this diversity problem with Lindsay Bell, Tessie October, and Riba Kelsey. Lindsay, Riba, and Tessie recently published an article in JPSM that found that trainees at historically black colleges and universities and residents at institutions with the highest percentage of black medical students lack access to palliative care training. Riba Kelsey is the Family Medicine residency director at Morehouse School of Medicine, and we talk with her about the implications of these findings at historically black colleges and universities (HBCUs), as well as what we can do in the field of palliative care in general to improve our workforce issues. One shining example we discuss in depth is the ongoing collaboration between the University of Pittsburgh Palliative care group and Morehouse School of Medicine. We hope that collaborations like these will lead to a wider pipeline of palliative care informed trainees from diverse backgrounds, and someday soon, greater diversity in the palliative care workforce.

Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients. Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different. She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other. There are many reasons this essay likely touched so many people (it seemed to be all over Twitter). One is that there's a silence around this experience of death. Krista's essay opens up a space to talk about it. Another is that the experience of grief is in fact universal, whether it's the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of "a return to normal" following COVID. Krista wanted to add a couple of things not mentioned in the podcast that she found helpful. First, she treasures videos she has of her loved ones recorded before death. Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck. We talk with Krista about these and many other things on this week's podcast. Let's keep the conversation going. Links: Making Space for Grief in Academia, JAMA The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs Live Discharge from Hospice Isn't Graduating - It's Getting Expelled, JAGS Griefcast podcast RadioLab: The Queen of Dying Podcast The Dougy Center Grief Out Loud Podcast On Being Podcast The Five Invitations by Frank Ostaseski Resilient Grieving by Lucy Hone The Art of Losing (poems) When Things Fall Apart by Pema Chodron -@AlexSmithMD

Today's podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings. Why are we doing a podcast on #academiclifehacks? You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation. As part of this award he presented a talk titled "Confessions of an Unfocused Researcher." We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex's award and talk about some of the topics he brought up in his talk, as well as other tips and tricks. So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine. In particular we focused on several key issues that new faculty need to address as they start their careers including: Academic focus and goals Mentorship (and mentoring up) Academic scholarship & writing Collaboration & Networking Work / Life Balance We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet.

"Loneliness is different than isolation and solitude. Loneliness is a subjective feeling where the connections we need are greater than the connections we have. In the gap, we experience loneliness. It's distinct from the objective state of isolation, which is determined by the number of people around you." - Vivek Murthy, two time (and current) Surgeon General. We have heard a lot about loneliness and social isolation, particularly during the pandemic with enforced social distancing and near imprisonment of older adults in nursing homes. In this context, we bring in two experts on these topics, Carla Perissinotto and Ashwin Kotwal, to explain: How loneliness and social isolation overlap and are distinct How common these measures of social well being are in geriatrics and palliative care Why we should care as clinicians How we can ask about them How we should respond to care for patients who are lonely or isolated Some key references from among the many we discuss on the podcast: Loneliness in older adults predicts functional decline and death (JAMA IM 2012) The epidemiology of loneliness and social isolation during the last years of life (JAGS 2021) Use of high risk medications among lonely older adults (JAMA IM 2021) Integrating social care into healthcare: GeriPal podcast with Kirsten Bibbens-Domingo Coalition to end social isolation and loneliness -@AlexSmithMD

On June 7th, 2021 FDA approved the amyloid beta-directed antibody aducanumab (Aduhelm) for the Treatment of Alzheimers. This approval of aducanumab was not without controversy. Actually, let me restate that. The approval of aducanumab was a hot mess, inside a dumpster fire, inside a train wreck. After the approval, three members of the FDA advisory panel, which unanimously was not in favor of the approval of aduhelm, quit. One of them, Aaron Kesselheim (who we have on our podcast today) described it as "the worst drug approval decision in recent U.S. history" in his resignation letter. Then the FDA had to revise the label one month after publishing it because the original didn't even come close to looking like the population in which treatment was initiated in clinical trials. Then, wait for it, after a firestorm of criticism the FDA's commissioner had to ask for an independent investigation to look into the interactions between Biogen representatives and FDA members. And now CMS is deciding if and how to cover Aduhelm, a drug that will cost at least $56,000 a year per patient not incluiding the doctor's visits, amyloid PET scans, and frequent MRIs that will be necessary to monitor for side effects. On today's podcast we talk all about aducanumab with Aaron Kesselheim, Professor of Medicine at Harvard Medical School and previous member of that now famous FDA advisory committee, as well as Jason Karlawish, Professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. I'd love to point you to the journal articles for the two phase III trials on aducanumab, but as of yet, they are unpublished (this should tell you a little about the faith Biogen has on its drug data), so I'll leave you with these resources instead: Our podcast with Gil Rabinovici on "All things Amyloid, including Aducanumab and Amyloid PET scans" AGS's preliminary advice on prescribing Aducanumab - Jason Karlawish's book, The Problem of Alzheimer's, and the previous podcast that we did on it FDA's document dump on Aduhelm Biogen's open letter to the Alzheimer's disease community complaining about the "turn outside the boundaries of legitimate scientific deliberation" that has occurred with aduhelm (while ignoring the fact that the trials have not been published yet). CMS's request for public comment for their National Coverage Determination analysis to determine whether Medicare should cover the drug and any other monoclonal antibodies directed at amyloid The last one is particularly important as whether you are for or against the coverage of aducanumab, your voice matters. There is a letter being circulated by physicians who care for people with Alzheimer's Disease urging CMS not to cover aducanumab given the limited clinical evidence for benefit, known harms, and exorbitant cost. You can find the letter here. If you would like to sign the letter, you can add your name by clicking this link.

Cannabis use by older adults has increased substantially over the last decade, a trend that has paralleled the legalization of its use for medical and recreational purposes. In that same time, there has been a decreased perceived risk associated with cannabis use in older adults as noted in a recent study published in JAGS. On today's podcast we talk with Drs. Bree Johnston and Ben Han about what the health care providers role is in cannabinoid prescribing and advising when caring for older adults. We try to cover a lot in this podcast, including some of these topics: Epidemiology of cannabis used by older adults (including aspects of the JAGS study) The basic pharmacology and dosing of cannabinoids The latest evidence for the efficacy of cannabis Specific risks and side effects that providers should be aware about, and how we should monitor patients using cannabinoid products Drug interactions we should be aware about

In a new study in JAGS, Matthew Growdon found that the average number of medications people with dementia took in the outpatient setting was eight, compared to 3 for people without dementia. In another study in JAGS, Anna Parks found that among older adults with atrial fibrillation, less than 10% of disability could be explained by stroke over an almost 8 year time period. She also talked about the need for a new framework for anti-coagulation decisions for patients in the last 6 months of life, based on an article she authored in JAMA Internal Medicine with Ken Covinsky. In today's podcast we talk with Matthew and Anna, joined by co-author Mike Steinman, to talk about polypharmacy, deprescribing, where we are and what we need to do to stop this freight train of ever more medications for older adults and those living with serious illness. We start by addressing the root cause of the problem. Clinicians want to "do something" to help their patients. And one thing we know how to do is prescribe. It's much harder psychologically for clinicians to view deprescribing a medication as "doing something." This attitude needs to change. It will take teamwork to get there, with robust involvement of pharmacists, and likely activating patients to advocate for themselves. And Eric might have mentioned aducanumab a time or two… -AlexSmithMD

Older adults often turn to institutional settings like nursing homes when they need more help than they can get at home. However, since the 1970s, there has been a program that allows older adults to receive nursing home-level care outside of nursing homes. That model of care is known as the Program of All-inclusive Care for the Elderly, or PACE. On today's podcast, we discuss PACE with two leaders in the PACE community, Dan Drake and Jay Luxenberg. Dan is the President and CEO of Trinity Health PACE, the second largest provider of PACE in the country, and Jay is the Chief Medical Officer of On Lok, the very first PACE demonstration site in the nation. We talk with Dan and Jay about all things PACE, including: What is PACE and what is included in it that makes it able to care for nursing home level care in peoples homes? How is PACE paid for, what does it need to cover, and who is eligible? How did PACE start and what's the evidence that it works? What are the challenges to PACE implementation and what do they think the future has in store for PACE? Why should you work at a PACE program?

We have made remarkable progress in reducing the use of feeding tubes for patients with advanced dementia. This has been due to the leadership of people like Susan Mitchell and Joan Teno, among others. One might hope that this reduction in use of feeding tubes has been in part due to advance care planning discussions that helped align care and treatment with patients goals. How then, do we explain the concerning findings in a pair of recent papers demonstrating high rates of mechanical ventilation among patients with dementia? In today's podcast, we talk with Rashmi Sharma, who in JAGS found that rates of mechanical ventilation rose from 4% to 12% among whites with advanced dementia and 9% to 22% among blacks between 2001 and 2014. One in five blacks with advanced dementia admitted from a nursing home received mechanical ventilation. That's startling. And Zhi Jia found in a Medicare sample that Asians were more likely to receive mechanical ventilation than whites, and disparities were higher for older Asians with dementia compared to cancer. We have made progress, due to the leadership of GeriPal superstars. But even as we make progress in feeding tubes, it doesn't seem to have translated across the board to mechanical ventilation, a burdensome and potentially non-beneficial treatment for patients with dementia. The fact that rates are highest among older blacks and Asians is particularly concerning. Though the reasons behind this are complex, it's likely that structural racism plays a major role in these growing inequalities. We have more work to do. -@AlexSmithMD

While palliative care most traditionally grew up with a strong association with cancer care and end-of-life care, more and more evidence is coming out about how to integrate palliative care into a variety of serious illnesses from heart failure to chronic lung conditions. Another emerging field is the integration of neurology and palliative care, something that has been coined as "neuropalliative care." We had Benzi on a previous GeriPal podcast to talk about palliative care in Parkinson's disease. On this week's podcast we go much deeper into the field of neuropalliative care by inviting leaders of the new field and in the International Neuropalliative Care Society (INPCS), Benzi Kluger, Edward Richfield, and Christine Ritchie. INPCS connects clinicians, researchers, interdisciplinary team members, people living with neurological illness, family members, and advocates at the intersection of neurology and palliative care. In addition to talking about why INPCS was developed, we talk with these leaders about: What are the unique palliative care needs of patients with neurological conditions and their family members? Do we really need a society focused on a subspecialty in palliative care and do we need it for every subspecialty in palliative care? How can palliative care be integrated into neurology practice? What are the gaps in the field of palliative care when addressing the needs of patients with neurological diseases? What are some key lessons learned doing neuropalliative care on how to care for patients with neurological diseases? One other big shout out too for INPCS is for their inaugural Annual Meeting on November 4-6, 2021. The online conference will offer attendees the opportunity to learn from experts, hear updates in practice patterns, review the state of the science in neuropalliative care, and network with others interested in this growing field. Best part, it's free! So sign up.

What if there was a tool that could break down a neighborhood's socioeconomic measures, like income, education, employment and housing quality, to give us a sense of how those factors influence overall health, and maybe even inform where to target health resources and social interventions. On today's podcast we talk with Dr. Amy Kind from the University of Wisconsin School of Medicine and Public Health, who developed that tool, the Neighborhood Atlas. The Neighborhood Atlas uses the "Area Deprivation Index," which includes 17 measures of education, housing quality and poverty, and can be used free by anyone by going to the Neighborhood Atlas website (https://www.neighborhoodatlas.medicine.wisc.edu/). In addition to talking with Amy about the Atlas, we discuss some of the following questions: What is neighborhood disadvantage and what health outcomes is it linked to? How should providers use neighborhood disadvantage when caring for patients? How should health care systems use neighborhood disadvantage? How does the Atlas also identify areas of resilience in communities? So take a listen and if you want to read more about it, check out Amy's NEJM article on the topic - https://www.nejm.org/doi/full/10.1056/NEJMp1802313

Harm reduction, as so clearly described by our guest Monica Gandhi on this podcast, began as a public health approach that guided management of HIV. Harm reduction represented an alternative to an abstinence-only approach, which clearly did not work. In the harm reduction model, you acknowledge that people will take some risks, and that the goal is to decrease risk, not eliminate it. And yet, here we are with a fear-not-facts approach to the COVID-19 pandemic. Some are advocating for the use of masks in schools, hospitals, and nursing homes in perpetuity. As in, forever. Sounds eerily like an abstinence-only approach, right? Science would dictate that now that we have vaccines, which Monica describes as "the solution," we don't need to engage in masking (with a few exceptions). Monica Gandhi, an infectious disease doctor at UCSF, has advocated strongly for a fact-based approach to school opening, early masking and now dropping masking, and global access to vaccinations (and temporarily dropping vaccine patents), among other things. You can and should follow her: @MonicaGandhi9 And from Ashwin Kotwal, geriatrician and palliative care doc-researcher, we hear about experiences caring for patients who are afraid to return to normal after a year of masking and forced isolation, despite the toll these experiences have taken on them (documented in his recent paper in the Journal of the American Geriatrics Society). It's time to get back where we once belonged. (song choice hint) -@AlexSmithMD

In your clinical experience, you may have cared for patients receiving palliative chemotherapy and wondered, hmmm, why is that called "palliative" chemotherapy? We've written about this issue previously here at GeriPal ("a term that should be laid to rest") as has Pallimed ("an oxymoron"). Well, now we have "palliative" inotropes for people with heart failure. And we have to ask, is this a fitting term? And the answer is...complex...more so than you might think. Recall that in one of our earliest podcasts, we talked with Nate Goldstein who memorably proclaimed "the best palliative care for heart failure is treatment for heart failure." To unpack the issue of palliative inotropes, we welcome back Haider Warraich, a cardiologist with a strong interest in palliative care. We are joined again by Anne Rohlfing, palliative care fellow at UCSF who spent last year as a hospitalist on the heart failure service. Please tune in to hear more about the role of palliative care in inotrope therapy, inotropes in hospice, Haider's study on palliative needs of patients with heart failure, and a bit about Left Ventricular Assist Devices (including a shout out to Dan Matlock's decision aids) and Haider's Journal of Palliative Medicine paper on top 10 tips for palliative care clinicians on caring for patients with LVADs. -@AlexSmithMD

What is a care manager? In this week's podcast we talk with Chanee Fabius, who after a personal experience caring for a family member with dementia, became a care manager. Chanee explains in clear terms what a care manager is, what training is required, and what training is required. In essence, a care manager is a "glue person" who hold things together. After observing major race/ethnic disparities in caregiving, Chanee was inspired to obtain a doctoral degree in gerontology, and her research is now directed toward reducing disparities in caregiving, particularly for patients with dementia. See for example, her recent paper in the Gerontologist describing Black and White differences in caregiving. We are also joined by Halima Amjad, a geriatrician-researcher, who, like Halima, is at Hopkins. Halima is very interested in improving care for people with dementia. As she notes, when we talk about outcomes for older adults, we often talk about the characteristics of the patient as predictors, but rarely do we consider how caregiver factors might influence important outcomes for older adults. In a paper published in JAGS, Halima found that caregiver factors predict hospitalization. For example, caregivers who are new to the caregiving role are more likely to care for someone who is subsequently hospitalized than someone who has been caregiving for longer. We talk about all things caregivers, including research issues around the need to assess the needs of caregivers, health policy issues such as how to provide more support for caregivers, and clinical issues, such as the fact that the identity and contact information for caregivers are not routinely captured in the EHR. -@AlexSmithMD

A September 2000 New York Times article titled, "Sometimes Saving the Heart Can Mean Losing the Memory" describes a relatively newly described phenomena of difficulty with memory and other cognitive tasks six months after cardiac bypass graft surgery, or CABG. The syndrome was termed "pump head." A doctor is quoted in the article as stating that older patients he might have previously considered CABG for he would try to manage medically, with a stent. Data on the impact of CABG on cognitive function over the subsequent 20 years has been mixed. The problem with these prior studies is they enrolled patients at the time of the CABG. They didn't have a sense of what the cognitive trajectory was before the procedure. In this context, enter Liz Whitlock's study published this week in JAMA comparing cognitive trajectories before and after CABG versus stenting procedures. Liz finds no difference in the decline in memory before or after CABG vs PCI - in other words - their memory continued to decline at the same rate after each procedure as before. Furthermore, a newer procedure intended to spare patients the risks of bypass, called "off pump" CABG, was found in this study to be associated with greater memory decline than on pump CABG. Pump head, it seems, is not a thing. Those who get CABGs likely also had vascular disease in the brian that was leading to a steady cognitive decline before the procedure. To contextualize these findings for practicing geriatricians and other PCPs, we are joined by Mike Rich, one of the early movers and shakers in the field of geriatric cardiology. We are doing these cardiac procedures on ever older and older patients. What should we be concerned about? How should we counsel our patients? Listen to find out! -@AlexSmithMD

Frailty. What the heck is it? Why does it matter? How do we recognize it and if we do recognize it, is there anything we can do about it? On today's podcast we talk to Linda Fried, Dean of Columbia University's Mailman School of Public Health and world renown frailty researcher about all things frailty. We talk to Dr. Fried about how she first got interested in frailty, how we define it including the difference between phenotypic frailty and a "deficit accumulation model' frailty index", and how we should think about assessing frailty and managing it. We also talk with Dr. Fried about how she thinks about resiliency and the analogy put forth by George A. Kuchel in a wonderful article published in the Journal of American Geriatrics Society (JAGS) that uses the Golden Gate Bridge to explain different definitions of frailty.

Though origins of the term "moral injury" can be traced back to religious bioethics, most modern usage comes from a recognition of a syndrome of guilt, shame, and sense of betrayal experienced by soldiers returning from war. One feels like they crossed a line with respect to their moral beliefs. The spectrum of acts that can lead to moral injury is broad, ranging from killing of an enemy combatant who is shooting at the soldier (seemingly acceptable under wartime ethics), to killing of civilians or children (unacceptable). One need to witness the killing - dropping bombs or napalm can result in moral injury as well - nor need it be killing; harassment, hazing, and assault can result in moral injury, as can bearing witness to an event. While there is often overlap between moral injury and post-traumatic stress disorder (PTSD), they are not synonymous. Today we talk with Shira Maguen, psychologist and Professor at UCSF and the San Francisco VA. One of the many fascinating parts of our discussion is when we talk about the moral injury faced by healthcare workers during COVID. I encourage you to listen to the last podcast to hear what moral injury can sound like - being asked to care for patients under far less than ideal circumstances, care that is the best under the circumstances but is not standard of care, wondering if as a result patients may have been harmed or died. One common feature of moral injury in combat is a feeling of betrayal by superior officers who order soldiers to act in a way that contravenes their self-conception of right and wrong. One might say we in healthcare experienced a similar betrayal of leadership that flouted the science of mask wearing, stated that doctors were billing for COVID excessively to turn a profit, and touted unproven and potentially harmful medications as miracle cures. We also talk about treatment (and it's more than "I wanna hold your hand," song choice hint) Links: Moral Injury Fact Sheet: Moral Injury in Health Care Workers: Health and Human Services: Moral Injury for Healthcare Workers: Gender differences in Moral Injury Moral Injury in the Wake of Coronavirus: Attending to the Psychological Impact of the Pandemic on Healthcare Workers: Moral Injury

During the winter peak in coronavirus cases, things got busy in my hospital, but nothing close to what happened in places like New York City last spring or Los Angeles this winter. Hospitals in these places went way past their capacity, but did this strain on the system lead to worse outcomes? Absolutely. On today's podcast, we talk with Brian Block, lead author of a Journal of Hospital Medicine study that showed that patients with COVID-19 admitted to hospitals with larger COVID-19 patient surges had an increased odds of death. We talk about the findings in his study, which also included some variation in the surge hospitals as well as potential reasons behind these outcomes. We've also invited two other guests, Denise Barchas and Sunita Puri, to describe their hospital experiences in a COVID surge. Denise is a ICU nurse at UCSF who volunteered in New York during the spring surge of COVID cases. Sunita is the Medical Director of Palliative Medicine at USC's Keck Hospital & Norris Cancer Center in Los Angeles. She is also the author of numerous books and essays, including "That Good Night: Life and Medicine in the Eleventh Hour" (if you haven't read it yet you should!)

We know from study after study that most older adults would prefer to age in place, in their homes, with their families and embedded in their communities. But our health system is in many ways not particularly well set up to help people age in place. Medicare does not routinely require measurement or tracking of disability that leads many people to move out of their homes, and many interventions that support people to age in place are unfunded, underfunded, or funded by philanthropy rather than the government. Today we talk with Sarah Szanton, who created the CAPABLE multi-disciplinary model to help older adults stay at home, and Kenny Lam, who used a national study to examine the need for home-modification devices. And we preview another of the AGS songs for the literature update - this one to the tune of "My Get up and Go" by Pete Seeger. Enjoy! -@AlexSmithMD

There are no currently approved disease modifying drugs for Alzheimer's disease, but in a couple months that may change. In July of 2021, the FDA will consider approval of a human monoclonal antibody called Aducanumab for the treatment of Alzheimer's disease. If approved, it will not only make this drug the defacto standard of care for Alzheimer's disease, but will create a monumental shift in the usage of other currently limited diagnostic tests, including Amyloid PET scans and other biomarkers. On today's podcast, we talk about all things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici. Dr. Rabinovici is the Edward Fein and Pearl Landrith Endowed Professor in Memory & Aging at UCSF. I could talk to Gil all day long, but we try to fit all of these topics in this jam-packed podcast: The heterogeneity of dementia and potentially Alzheimer's disease Where are we now with disease modifying treatments for Alzheimer's disease The Role of Amyloid PET scans and other biomarkers both now and in the future The wild story Aducanumab and the controversy surrounding its pending FDA approval

One of our earliest COVID podcasts with Jim Wright and David Grabowski a year ago addressed the early devastating impact of COVID on nursing homes. One year ago Mike Wasserman, geriatrician and immediate past president of the California Long Term Care Association, said we'd have a quarter million deaths in long term care. A quarter of a million deaths. No one would publish that quote - it seemed inconceivable to many at the time. And now, here we are, and the numbers are going to be close. In this podcast we look back on where we've been over the last year, where we are now, and what's ahead. One theme that runs through the podcast is that if this level of death, confinement, and fear occured to any other population, change would have been swift. But nursing home residents, for the most part, don't have a voice, they're not able to speak up, they lack power to move politicians and policy. Mike Wasserman is a provocateur. He is a needed voice for the nursing home residents and the nursing home staff who often are not able to speak for themselves. He is regularly quoted in major news outlets, and was in the Washington Post about opening up nursing homes to visitation the day of our podcast. If you don't follow him on Twitter @Wassdoc you should! -Link to Wassmerm and Grabowski's article in the Health Affairs blog on the need for financial transparency in nursing homes. -Link to webinar about what to do about COVID in long term care from April 2020 -@AlexSmithMD

COVID has taken a devastated toll in nursing homes. Despite representing fewer than 5% of the total US events, at least 40% of COVID‐19–related deaths occurred in older individuals living in nursing homes. The good news is that with the introduction of COVID vaccines in nursing homes, numbers of infections and outbreaks have plummeted. However, only about 2/3rds of nursing home patients and only about ½ of nursing home staff have been vaccinated, largely due to hesitancy about taking the vaccine. On today's podcast we talk about vaccine hesitancy with Sarah Berry, Kimberly Johnson, and David Gifford and the lessons learned from their "town hall" intervention they did that was just published in the Journal of the American Geriatrics Society. A couple of take-home messages for me in this study was that vaccine misinformation was rampant, many nursing staff had lingering questions they wanted answered before getting the shot, and that sharing stories and personal experiences is an important way to overcome hesitancy. In addition to listening to the podcast, we really encourage everyone to take a look at the JAGS article as it has two great tables for anyone willing to do similar town halls. The first is a summary of the concerns of healthcare staff. The second is sample responses to address some of these concerns.