GeriPal - A Geriatrics and Palliative Medicine Podcast

"Diagnose and adios." That's the sad phrase that I've heard quoted more than once, representing caregivers' sentiment of what it's like to be told by a clinician that your loved one has dementia. This week we talked with Zaldy Tan, Geriatrician and Director of the Memory and Aging program at Cedars Sinai in Los Angeles. With David Reuben at UCLA and others working LA realized that current caregiver training programs were lacking. Caregivers for people with dementia are stressed, short on time, and thirsty for high impact information and skills training that can be delivered efficiently. To meet this need they launched a new caregiver "bootcamp" 1-day training (with the help of Archstone Foundation which also funds GeriPal). We cover many topics, including dissemination of the bootcamp to Spanish-speaking caregivers, converting to video boot camp during COVID, and ways you can partner with them to create your own boot camp. Listen to the podcast to learn more! (And "Remember Me" from Coco - great song choice) JAGS article on caregiver boot camp Dementia caregiver IcareD website (including upcoming bootcamp calendar) CAPC website on caregiver support -@AlexSmithMD

What does it mean to create a cultural shift to the end of life experience? Is it even possible? How do you even start something like that? On today's podcast, we talk to Shoshana Ungerleider about her experience making that change. Shoshana is one of those amazing advocates for palliative and end of life care. She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care education. She is Executive Producer of the Academy Award-nominated end of life documentaries, Extremis and Netflix's End Game. Oh yah. She also started End Well back in 2017 which brought together people from all different backgrounds and professions with a goal to talk about end of life care. This year she is taking the conference virtual with "Take 10" on December 10th. Take 10 brings names like Maria Shriver, Taraji P. Henson, Andy Cohen, Justin Baldoni, and Atul Gawande to speak about issues within palliative care, caregiving, geriatric medicine, and end-of-life care, all in light of what we can learn from the COVID crisis. And best of all it's free. So take a listen to the podcast and sign up for Take 10 here: Date: December 10, 2020 Time: 10:00am PST - 2:00pm PST Location: https://endwellproject.org/ Register for free here thru 12.10.2020: https://endwellproject.org/take-10-end-well-2020/#register

How long does it take to see a benefit of statin therapy for primary prevention of cardiovascular events in adults aged 50 to 75 years? That's the question we try to answer with our two guests today, Drs Lindsey Yourman and Sei Lee, the lead and senior author of a JAMA IM study that tried to answer this question. In this podcast Drs. Yourman and Lee define what time to benefit is, why it is important in regards to decision making for older adults, and common lag time to benefits for common preventative interventions. We then take a deep dive into the JAMA IM meta-analysis of 8 trials, which showed 2.5 years were needed to avoid 1 cardiovascular event for 100 patients aged 50 to 75 years of age treated with a statin. So give it a listen and tell us what you think on either our Twitter or Facebook posts about this podcast.

An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults. These needs are categorized around the 4 M's - Medication, Mentation, Mobility, and What Matters Most. But we cannot achieve the ideal of an age friendly health system without, well, changing systems. In this week's podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M's. We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF. Enjoy! -@AlexSmithMD

The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient. Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so. There often is limited information about the patient, their functional status, or their prognosis. These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!) So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals? We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question. Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled "Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure." We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on "Work Grief: A Practical Primer for Emergency Medicine Providers".

In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness, published in JAMA. We also talk with Krista Harrison, first author of an accompanying editorial. JAMA editors cut out some of my favorite parts of Krista's editorial, possibly because they were more like a blog post than a JAMA editorial. (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited: "As with many people's best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders' English hospice programs. Dr. Mount coined the term "palliative care" to connote the core goals of the service: to improve quality of life and to mitigate sources of distress. The field of palliative care was born. The year was 1975. Forty-five years later, palliative care retains its central focus on improving quality of life for people living with serious, life-limiting illnesses and their families by addressing physical and psychological symptoms, social and spiritual needs, and aligning patient and family values with available care options." In our podcast, we talk about the surprising finding in Keiran's study that palliative care for noncancer illness was associated with a modest improvement in symptoms, reduced hospitalization and emergency department use, increased advance care planning but not improved quality of life. How can palliative care, since inception designed to improve quality of life, not improve quality of life? Listen to the podcast to find out! -@AlexSmithMD

There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and As a current palliative care fellow and former hospitalist on UCSF's Advanced Heart Failure service, I have a strong interest in this question. This week I was lucky to have Alex and Eric let me join in interviewing Haider Warraich, Associate Director of Heart Failure at the Boston Veterans Affairs Hospital and Associate Professor at Brigham and Women's Hospital, a cardiologist trained in advanced heart failure and with a strong interest in palliative care who has written multiple books (Modern Death: How Medicine Changed the End of Life, State of the Heart: Exploring the History, Science, and Future of Cardiac Disease), op eds, and research articles on the subject. In the podcast we talk about all things heart failure - from the culture of cardiology, how to impart palliative care on trainees, and practical tips on helping predict prognosis and symptom management. For more reading be sure to check out Haider's article in JPM on Top 10 Tips for Palliative Care Clinicians Caring for Heart Failure Patients and his article with Diane Meier in NEJM on Serious Illness 2.0 - Meeting the Needs of Patients with Heart Failure. - Anne Rohlfing

On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine. Now with COVID among us, Lauren talks to us about her recently published JAGS article titled Home Video Visits: 2‐D View of the Geriatric 5‐Ms. In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework: mind, mobility, medications, multicomplexity, and what matters most. Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine. One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article: "I recommend that you discourage patients and families from using the backgrounds of outer space, peaceful woods and lakes, or other fancy pictures that are available on Zoom, Webex, and other virtual meetings. Doing so will hide what could be extremely valuable information when assessing the M's of geriatrics." So take a listen and maybe even sing along to Alex's version of "Video Killed the Radio Star."

Last month we published a podcast with Sean Morrison that garnered a great deal of attention, in which Sean Morrison argued that Advance Care Planning is an idea that is "clear, simple, and wrong." This week, we have a fresh updated counterpoint from Rebecca Sudore and Ryan McMahan. These two published a paper this week in the Journal of the American Geriatrics Society, or JAGS, that argues that the field of advance care planning has come a long way. Early studies of advance care planning evaluated it with advance directives, and studies of advance directives showed little to no difference. However, In their review they find recent (since 2010) high quality trials demonstrate the potential of advance care planning by using modern conceptions of advance care planning as a longitudinal conversation to help surrogates prepare for in the moment decision making. These studies evaluated a broader (and more fitting) range of outcomes than prior work, including surrogate preparedness. My take away is that if we're looking for advance care planning to result in "goal concordant care" - we're asking too much of it. That doesn't mean it's not useful. It's primary use is helping surrogates feel like they are prepared and satisfied with the difficult choices they have to make for seriously patients. Doesn't that matter too, and, some would argue, just as much? The surrogates live with these decisions the rest of their lives. So the issue is nuanced. One of my favorite parts of the podcast is when Rebecca Sudore returns to Sean Morrison's Ford Pinto analogy and really uncover the real world complexities of how it should be applied to advance care planning. That Ford Pinto analogy just keeps on giving! Enjoy! -@AlexSmithMD

In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria. Over the next 50 years, the debate over the concept of brain death has never really gone away. Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria. On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Troug. Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School. He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA: - The 50-Year Legacy of the Harvard Report on Brain Death - Understanding Brain Death - Brain Death—Moving Beyond Consistency in the Diagnostic Criteria In addition to talking about how Robert got interested in the topic of brain death, we discuss the history of the concept of brain death, how we diagnose it and the variability we see around this, the recent JAMA publication from the World Brain Death Project, why brain death is not biologic death (and what is it then) and what the future is for the concept of brain death.

Chris Callahan (of Indiana University) and Lee Jennings (University of Oklahoma) have some righteous anger. Why do we have comprehensive cancer care centers and not comprehensive dementia care centers? We have a body of evidence dating back 30 years to support people with dementia and their caregivers with Comprehensive Dementia Care. Lee Jennings added to this robust body of work with a study published in the Journal of the American Geriatrics Society demonstrating that a comprehensive dementia care program based out of UCLA reduced ED visits, hospital length of stay, increased hospice enrollment, and delayed time to admission to long term care. As Chris Callahan notes in his accompanying editorial in JAGS, a fundamental problem with our healthcare system is that savings from Comprehensive Dementia Care accrues not to the dementia care program, but to the hospital and Medicare (ED visits, hospital length of stay) or Medicaid (long term care admission). Our fragmented healthcare system lacks the coordinated big picture financial incentives to make this happen for our patients. One more major point - Chris Callahan emphasizes in the podcast that we as clinicians need to stop saying, "there's nothing that we can do for dementia; nothing works." That's simply not true. While we lack Comprehensive Dementia Care programs in nearly every region of the US, we have tremendous community resources for people with dementia and their caregivers. The Alzheimer's Association is a great place to start. The song request was This Land is Your Land, classic Woodie Guthrie as Lee Jennings works at the University of Oklahoma. Chris Callahan rewrote the lyrics to address the topic, and if you listen to the very end of the podcast, you'll get this version: This land needs dementia care Comprehensive dementia care From California to Indiana From Oklahoma to the New York Island We need dementia care for our families As I sought clearly, the research to frame I saw clear data of the triple aim I saw the workforce, we need to train We need dementia care for our families -@AlexSmithMD

Every year, about a third of older adults fall. About one in five of those falls result in moderate to severe injury. What can we do to help not only prevent those falls but also the complications of them? On todays podcast, we talk to Tom Gill, one of the authors of the recent Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study published in the NEJM. The STRIDE study was huge, 5,451 patients in 86 primary care clinics from 10 different health care systems. Individuals assigned to the interventions worked with a "falls care manager" whose goal was to help identify and make plans about risk factors for falls and fall-related injuries. What did it show? Well, the conclusion of the NEJM abstract states that this multifactorial intervention "did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care." We talk to Tom about whether that is the right take home from this pragmatic study and how should we think about fall prevention in our own clinical practices.

No dear listeners and readers, that is not a typo. Eric Widera is indeed our guest today to discuss his first author publication in the New England Journal of Medicine, Family Meetings on Behalf of Patients with Serious Illness. Our other guests include other authors James Frank, Wendy Anderson, Lekshmi Santhosh, me and actress and frequent GeriPal guest-host Anne Kelly. There's a story behind this one folks. One day, Ken Covinsky walked into our office and said, "You know how the NEJM has this Videos in Clinical Medicine series? With videos like, 'How to insert a central venous catheter?' You should send them a video of your palliative care 'intervention' - how to conduct a family meeting." Brilliant idea. Well...that was 2014...a funny thing happened on the way to the theater. After several iterations, videos, reviews, a rejection, and lessons in persistence, we finally published. We were helped by an outstanding cast who role played the family meeting in the video (including Wendy as the physician and Anne as the social worker). The video introduces clinicians to core family meeting skills such as the importance of the pre-meeting, a structured approach to the meeting, and pointers on how to respond to emotion. On the podcast, we go around the "zoom room" and discuss our favorite teaching points on how to conduct family meetings. And a bonus feature! Eric requested any song from the Movie "The Descendants," and I was fortunate to be joined by my kids Kai and Renn on guitar and ukulele on the traditional Hawaiian song "Hi'ilawe." Grateful also to Jeff Peterson for pointers on the Hawaiian pronunciation. You may notice when you listen that I purchased some recording equipment for my home study, as this COVID thing doesn't seem to have an end in sight...I may have gone overboard with the production, forgive me listeners! Enjoy! -Alex

COVID-19 has created a perfect storm in nursing homes. As noted in a recent Journal of the American Geriatrics Society (JAGS) article by Joe Ouslander and David Grabowski, the storm is created by the confluence risks, including a vulnerable population that develop atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources including testing and personal protective equipment (PPE), and lack of effective treatments. The result? Nearly half of COVID-19-related deaths in the US occur in people cared for in nursing homes and assisted living facilities, and about a quarter of all facilities have had at least one COVID case. On this weeks podcast, we talk to Dr. Ouslander about his JAGS article on this perfect storm, as well as strategies that one can take from a clinical, public health, and policy interventions to help calm the storm. In particular Joe summarizes a lot of research published in JAGS lately on COVID-19 (visit GeriPal.org for links to these research articles).

Sean Morrison dropped a bomb. It's a perspective I've heard before from outside of palliative care, most clearly by bioethicists Angie Fagerlin and Carl Schnieder in their landmark article Enough: The Failure of the Living Will. But Sean Morrison, Director of the National Palliative Care Research Center and Chair of the Department of Geriatrics and Palliative Medicine at Mt. Sinai, former President of the American Academy of Hospice and Palliative Medicine, is about as inside palliative care as one can get. Sean argues in his Journal of Palliative Medicine piece that we should stop putting resources into making advance care planning and advance directives work. For decades, we have tried and tried, pouring $300 million dollars into research, untold intellectual capitol, at the expense of those resources going toward other areas of need such as disparities in access and outcomes for people with serious illness. And what do we have to show for it? 1660 studies and 80 systematic reviews providing weak low quality evidence that advance care planning and advance directives impact outcomes. Sean likens this to his family's efforts to fix their fundamentally flawed Ford Pinto, an analogy we take to new heights in this week's podcast. We challenge Sean about his perspective in the podcast, as I'm sure many of you are eager to do. We love it when people write perspectives or do research that challenges accepted geriatrics or palliative care practice/dogma. This article should force us to think deeply and do some serious reflection about our clinical and research priorities, and the extent to which advance care planning and advance directives should be ranked highly among them. And, of course, great song choice: Won't be Fooled Again by the WHO. If you watch the Youtube video to the end, you get to see me do my best Pete Townshend impression. Enjoy! -Alex Smith

In this week's GeriPal podcast we talk with Louise Aronson, author of the Pulitzer prize finalist Elderhood (https://www.amazon.com/Elderhood-Redefining-Transforming-Medicine-Reimagining/dp/1620405466). Louise has been one of the (sadly) few voices beating a loud and urgent drum in the medical and lay press about the insidious ageism taking place in the time of COVID. In a prior podcast we discussed the ways in which structural racism contributed to vast disparities in COVID, and similarly in this podcast we talk about the ways in which COVID exposes existing ageist assumptions, attitudes, and systematic forms of discrimination. To give a sense about how prolific Louise Aronson has been writing about ageism, here are links to just a sampling of her articles in the NEJM, New York Times 1 and 2, VOX, Forbes, and the Atlantic. She also mentions this terrific piece by Nathan Stall and Samir Sinha during the podcast. And wow - love the song choice - It's the End of the World As We Know It by REM. Sure seems like it these days. -Alex Smith

Despite being in the field over 15 years, I've never felt so far outside my comfort zone as as palliative care provider as I have felt in the last four months. A worldwide pandemic of a novel virus had me questioning how I communicate prognostic information when uncertainty was one of the few things I was certain about. It also pushed me to have these conversations via telemedicine, something I was previously more than happy to leave as a tool for only outpatient providers. The pandemic and the murder of George Floyd brought to the forefront the systemic racism that permeates our society and my own inadequacies in discussing the trauma that these killings and mistreatment have on black Americans. We grow though when we are pushed outside of our comfort zones. I'm pretty sure Tony Back, the co-founder of VitalTalk, would probably say that I have found my "learning edge". Lucky for me, we have Tony, along with another VitalTalk guru, Wendy Anderson, on today's GeriPal Podcast, to give some tips on how to approach communication skills in a time of crises. I'd like to highlight some of the exceptional Vitaltalk resources that we talked about on the podcast that can help to improve our communication skills, including (note: links to the following resources can be found on GeriPal.org). - Vital Talk COVID resources - A graphical version of the VitalTalk COVID playbook by Tony and Nathan Gray published in BMJ - Communication Skills in the Age of COVID-19 paper in Annals of Internal Medicine and the video commentary - Vital Talk's Communication skills for bridging inequity - Decompress, the podcast (Apple podcast link here) I'd also like to mention one other great resource that I came across by Drs. Marva Robinson and - Keisha Ross from the St. Louis VA, and Dr. Maurice Endsley from the Hines VA: - Discussing Community Trauma in Response to Killings and Mistreatment ofBlack and Brown Americans by: Eric Widera

If you looked at the academic literature, you would think that elder abuse and neglect, collectively called elder mistreatment, did not exist before the 1990s. Of course that's not true at all, it was hidden, covered, and not a major subject of research. Several pioneers have placed elder mistreatment firmly on the map, including XinQi Dong, Mark Lachs, and today's GeriPal podcast guest, Dean Laura Mosqueda (@MosquedaMD) of the Keck School of Medicine at the University of Southern California and Director of the National Center of Elder Abuse. Archstone Foundation, who funds our podcast, was a critical early investor in efforts to raise awareness, study, and intervene to prevent elder mistreatment. Today we learn about what a long term care Ombudsman is, about the impact of Covid19 on elder mistreatment, and ethical issues at the core of elder mistreatment (autonomy vs. safety and public health). One major take home point that I'd like to emphasize here are three questions that Dean Mosqueda asks of all of her patients by way of screening: 1. Is anybody hurting you? 2. Are you afraid of anybody? 3. Is anybody using your money without your permission? Finally, June 15th is Elder Abuse Awareness Day, and here's a link to find out more about how you can get involved. And great song choice - Veronica by Elvis Costello - check out this YouTube video of Elvis talking about his grandmother who had Alzheimer's dementia and how talking with her he would "bounce around the years." Enjoy! - Alex Smith

This was a remarkable podcast. Eric and I were blown away by the eloquence of our guests, who were able to speak to this moment in which our country is hurting in so many ways. Today's topic is the impact of COVID19 on minority communities, but we start with a check in about George Floyd's murder and subsequent protests across the country. Our guest Monica Peek, Associate Professor of Medicine and Director of Research at the MacLean Center of Clinical Medical Ethics at the University of Chicago, notes right off the bat: COVID19 and the reaction to Floyd are related. The covid epidemic has created an economic crisis, a heightened level of worry, and a disproportionate number of deaths among the African American community. When we add COVID on top of the long history of police brutality that has been heightened over the last several years that has been ignored by the federal government - in that context, it's not surprising that we're seeing protesters put their lives on the line to stand up for what they believe in. These protesters are putting their lives on the line due to the twin risks of reprisals from police or national guard, as well as the risk of acquiring COVID during a protest. As we turn later to the topic of COVID19 and impact on minority communities, Alicia Fernandez, Professor of Medicine at UCSF and Director of the UCSF Latinx Center of Excellence, notes that so many people reach for a biologic rationale for the excess exposure and mortality among minority communities - it's a genetic factor, it's racial/ethnic differences in ACE receptors, or it's the higher rates of diabetes and kidney disease among minority communities. How is it then that Latinos, and immigrants in particular, who tend to be younger and healthier, have higher mortality rates? What COVID19 is exposing are the underlying disparities in social determinants of health. For example, Africans Americans and Latinos represent a disproportionate share of essential workers, are more likely to live together in multigenerational households, and may reside in areas with less access to testing and high quality hospital care. We turn finally, to what we can do. As Monica says, "This is the fight of our lives. And this may be our last fight." Alicia notes that we need better reporting about detailed race, ethnicity, and language of people impacted by COVID for public health reasons. We talk about the need for professional interpreters for all goals of care conversations with patients (and Yael Shenker and Alicia's must read article for all clinicians on this topic). And we return to Doug White's framework that persons who reside in areas with a high Area of Deprivation Index score get a boost in their chances of obtaining scarce treatments for COVID. Finally, I encourage you all to watch this YouTube video of the song Seriously (song choice for the Podcast), sung by Leslie Odom Junior (Aaron Burr in the original Hamilton), about how Barak Obama might have reacted aloud to the 2016 election. It's speaks to this moment as well. The link is https://www.youtube.com/watch?v=hI8TCA3fJcs - Alex Smith

The question of who should get limited supplies of drugs that treat COVID-19 is not a theoretical question, like what seems to have happened with ventilators in the US. This is happening now. Hospitals right now have limited courses of remdesivir. For example the University of Pittsburgh hospital system has about 50 courses of remdsivir. They expect it to last to mid-June, enough for about 30% of patients who will present in the next 3 weeks. Who do you give it to? The first that present to the hospital (give it all away in the first week)? Random lottery? Or something else that is also accounts for the greater impact of COVID-19 has on disadvantaged communities ? On today's Podcast we talk with Colette DeJong, 3rd year medicine resident at UCSF, and Alice Hm Chen, Deputy Secretary for Policy and Planning at the California Health and Human Services Agency, who were two of the authors of a recently published JAMA article titled "An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US". We also bring on our repeat guest, Doug White, who authored the University of Pittsburgh model hospital policy for fair allocation of scarce COVID-19 medications, which can be found here. The University of Pittsburgh allocation strategy doesn't use a first-come, first-served or random allocation, but rather a waited lottery that is aimed at reducing the impact of social inequities on COVID-19 outcomes in disadvantaged communities. In particular, the following groups receive heightened priority in this framework: Individuals from disadvantaged areas, defined as residing at an address with an Area Deprivation Index score of 8 to 10 (range 1-10; with higher numbers meaning worse deprivation) Essential workers, defined by the state's list of essential businesses that are required to continue physical operations during the pandemic, which include lower-paid workers who may be socially and economically vulnerable, such as grocery store clerks, bus drivers, agricultural workers, and custodial workers. Of note, the Area Deprivation Index was developed in large part by Amy Kind, Geriatrician at the University of Wisconsin, and recipient of the 2019 American Geriatrics Society Thomas and Catherine Yoshikawa Award for Excellence in Scientific Achievement. by: Eric Widera NOTE: Links to the papers discussed above can be found on our blog site at GeriPal.org

Immune Checkpoint Inhibitors. They are revolutionary and transforming cancer care. They shrink tumors and extend lives. Plus they have a better side effect profile than traditional therapies for conditions like metastatic lung cancer, so when those with really poor performance status can't tolerate traditional chemotherapy, immune checkpoint inhibitors are an attractive option. We talk on today's podcast with Laura Petrillo, a palliative medicine clinician and investigator at Massachusetts General Hospital and Harvard Medical School. Laura was the first author of a paper published in Cancer titled "Performance Status and End-Of-Life Care Among Adults With Non-Small Cell Lung Cancer Receiving Immune Checkpoint Inhibitors." (https://acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/cncr.32782) In this study, Laura looked at 237 patients with advanced non-small cell lung cancer who initiated immune checkpoint inhibitors from 2015 to 2017. She found that those with impaired performance status had significantly shorter survival after treatment with these medications that those with a bettter performance status. They also receive immune checkpoint inhibitors near death more often than those with better performance status, and they found that those recieving immune checkpoint inhibitors near the end of life had lower hospice use and an increased risk of death in the hospital. Along with how we should think about the findings of this study, we talk about common side effects of immune checkpoint inhitors that geriatricians and palliative care clinicians should know about, the cost of theses medications, and the differences with different types of cancer treatments like "targeted therapies". by: Eric Widera

As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay (https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim), one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU. And look at where we are today. Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal. What a difference a year makes. This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care. Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service. Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults (https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204). Their service peaked at 50 consults per day, and as they note, that is likely an undercount. About half of the consults were in the ED. Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay. Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper. And (bonus!) you get to sing along to "Call Me Maybe." - Alex Smith

Parkinson disease affects 1% to 2% of people older than 65 years. Most known for its distinctive motor symptoms, other distressing symptoms are pain, fatigue, depression, and cognitive impairment. About 2/3rds of individuals with Parkinson's will die from disease-related complications, making it the 14th leading cause of death in the United States. While there are great palliative care needs for this population, little has been published on how best to meet these needs. On today's podcast we talk with Benzi Kluger from the University of Rochester Medical Center and the lead author of a JAMA Neurology paper that compares outpatient integrated palliative care with standard care alone in 210 patients and 175 caregivers. Every 3 months for a year, participants received palliative care visits either in person or via telemedicine from a neurologist, social worker, chaplain, and nurse with guidance from a palliative medicine specialist. Benzi's study demonstrated the palliative care group had better quality of life, symptoms burden, and advance directive completion. In addition to talking about the study, we get tips on how best to care for Parkinson's patients, both in palliative care and geriatrics. We also discuss some of these other helpful articles (visit our blog post at https://bit.ly/3c1EkwE for the links): - Implementation issues relevant to outpatient neurology palliative care. Ann Palliat Med. 2018 - Top Ten Tips Palliative Care Clinicians Should Know About Parkinson's Disease and Related Disorders. J Palliat Med. 2018 - Palliative care and Parkinson's disease: outpatient needs and models of care over the disease trajectory. Ann Palliat Med. 2020 - Palliative Care and Parkinson's Disease: Caregiver Perspectives. J Palliat Med. 2017 - Parkinson disease patients' perspectives on palliative care needs: What are they telling us?

Eight of the 10 largest outbreaks in the US have been in correctional facilities. Physical distancing is impossible in prisons and jails - they're not built for it. Walkways 3 feet wide. Bunk beds where you can feel your neighbor's breath. To compound the issue, prisoners are afraid that if they admit they're sick they will be "put in the hole" (solitary confinement). So they don't admit when they're sick. Many people think of prisons as disconnected from society. Like a cruise ship. "It's happening between those walls, behind the barbed wire, not out here." But for every two people in a correctional facility there's about 1 person who works in the correctional facility and lives in the community. The workers are bringing whatever they've been exposed to in prison out into the community, and bringing whatever they've been exposed to in the community into the prisons. This is a national problem, not a prison or a jail problem. We learned about these critical issues in our podcast with Brie Williams, Professor of Medicine in the UCSF Division of Geriatrics and Director of Amend (https://amend.us/), a program to change correctional culture; Adnan Khan, Executive Director of Re:store Justice (https://restorecal.org/), a justice advocacy organization; and Eric Maserati-E Abercrombie, a singer/songwriter and filmmaker through First Watch (https://restorecal.org/firstwatch/), a media project of currently and formerly incarcerated filmmakers. Adnan and Eric Maserati-E are former inmates of San Quentin prison. What can we do about this? The major response should be decarceration. Reduce the crowding in our overcrowded correctional facilities. If prisoners have less than a year left, let them out. If they have a long sentence and are low risk to society, and a place to go, let them go home with an ankle bracelet and return later to complete their sentence. Brie reminds us that people in prison can make an advance care plan, they can sign an advance directive, they have the right to engage in goals of care decisions, and a right to elect someone to be their health care proxy. And everybody, including prisoners, has a right to say goodbye to their loved one, though it may be by phone or video. We learn about these and other critical steps we need to take as a society and as hospice and palliative care clinicians. Eric Maserati-E does the music for this one. He needs to be discovered! If you know someone in the music industry, make them listen to him. Check out and subscribe to Eric's YouTube channel (https://www.youtube.com/channel/UCZN4YxjDR41RL_xIlDysU8Q). Also, listen to this terrific podcast, Ear Hustle (https://www.earhustlesq.com/), produced from inside San Quentin, the latest episode featuring Eric's music. - Alex Smith

One million inpatient falls occur annually in U.S. acute care hospitals. Sitters, also referred to as Continuous Patient Aids (CPA's) or safety attendants, are frequently used to prevent falls in high-risk patients. While it may make intuitive sense to use sitters to prevent falls, it does beg the question, what's the evidence that they work? We discussed with Drs. Adela Greeley and Paul Shekelle from the West Los Angeles Veterans Affairs Medical Center their recent systematic review published in Annals of Internal Medicine. Their review identified 20 studies looking at this issue (none of which are randomized trials). To sum up their findings, there were only two studies comparing sitters to usual care and they came up with conflicting conclusions (in one, the fall rate was lowered; in the other, it was not). In the other 18 studies, alternatives to sitter use were evaluated. The only thing that seems to have some evidence for was video monitoring (fall rates either stayed the same or improved, with a decrease in sitter usage). We also talk about multi-component interventions and how we should think about them. One intervention that is sometimes included in multicomponent interventions are bed alarms, which we discussed in our very first GeriPal podcast. It's also the podcast where we dreamed up the "anti-bed alarm" that would alert patients who haven't gotten out of bed yet. Now that's a fall intervention that that I can get behind. by: Eric Widera / Twitter @ewidera

We are rationing in the US. We may not be explicitly rationing, as we're going to discuss on this podcast, but we are rationing - in the way we allocate fewer tests and less PPE to nursing homes compared to hospitals, in the way we allow hospitals and states to "fend for themselves" resulting in those hospitals/states with better connections and more resources having more PPE and testing availability. And in some parts of the world, ICU and ventilator resources are scare, and they are rationing by age. We talked on our last podcast about decisions Italy made to ration by age, and on this podcast we talk about two countries in South America we have heard are using age as a criteria for rationing ventilators. In this context, we are fortunate to welcome Tim Farrell, Associate Professor of Geriatrics at the University of Utah and Vice Chair of the American Geriatrics Society (AGS) Ethics Committee, and returning guest Doug White, Vice Chair and Professor at the University of Pittsburgh School of Medicine. In our prior podcast with Doug we talked about his University of Pittsburgh (and colleagues) policy for allocation of scarce resources that has been adopted by over a hundred hospitals. Today's podcast is focused on the release of the AGS guidelines for allocation of scarce resources and the accompanying paper that explains the ethical rationale behind the AGS ethics committee's decisions. Both papers are available now on the Journal of the American Geriatrics Society (JAGS) COVID19 webpage. We talk about how the AGS and Pittsburgh guidelines are far more similar than different, and the ethical principles that led them to make the choices they made, and how these choices have evolved over time. The two issues we cover in depth are: (1) Should age be used to ration scarce resources? How should age be used, if at all, as an "up front" consideration, or a "tiebreak?" And (2) How should we account for socioeconomic determinants of health in resource allocation decision making? Stay healthy and safe, and keep doing the good work that you're doing, GeriPal listeners. -@AlexSmithMD

The cross-over episode is an American tradition that is near and dear to my heart. My childhood is filled with special moments that brought some of my very favorite characters together. Alf crossed over with Gilligan's Island. The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time. To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast! The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman. Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina. She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Zara Cooper, and Diane Meier. That's an amazing lineup. We also welcome Joe Lin as a co-host for this topic. Joe is a surgery resident and palliative care fellow at UCSF. We talk to both Joe and Red about - How they got interested in the intersection of surgery and palliative care - How the culture of surgery and palliative care differ (and the misconceptions that both fields have of each other) - What the day in the life of a surgical palliative care physician looks like - A recent article in JAMA Surgery titled "Palliative Care and End-of-Life Outcomes following High-Risk Surgery" - What palliative care skills all surgeons should have (primary palliative care) - And lots of other topics! So take a listen and check out Red's Surgical Palliative Care Podcast (https://thesurgicalpalliativecarepodcast.buzzsprout.com/)

We are delighted to have Dani Chammas, psychiatrist and palliative care physician, back on the GeriPal podcast to talk about emotional PPE. None of us can recall who originated the term, but we've all heard it bandied about much needed for front line providers treating patients with coronavirus. Headlines about the New York emergency room doctor committing suicide are likely only the tip of the iceberg in terms of the trauma, distress, and moral injury taking place. We talk with Dani about key issues and questions, including: - What is trauma? What is moral injury? - Is this a big deal? What evidence do we have? - What can we do about it? Dani goes over 3 broad buckets of responses, organized with the letter C: Connection, Culture, and Coping. - Normalizing rather than stigmatizing clinicians seeking mental health support We also decided to add a page to GeriPal titled "emotional PPE" with a list of resources for providers caring for patients with COVID, and we will link to that page once it's up. Please visit GeriPal.org for the following important mental health resources for providers: - The NYC COVID Worker Care Network - Pro-Bono Counseling for Frontline Physicians and APCs - Physician Support Line. - Disaster Distress Help Line - How to be a Catalyst of Calm in COVID19 -@AlexSmithMD

What's the role of geriatrics and palliative care in the care of individuals with COPD? We talk this week with Anand Iyer, the lead author of this weeks JAMA IM article on this subject. It's a little off from our ongoing COVID topics, but given that his along with his co-authors (Randy Curtis and Diane Meier) JAMA IM piece just got published, we figured now is the right time to highlight #PalliPulm. What is #PallPulm? #PalliPulm is something that Anand Iyer founded, and is an online community of clinicians, investigators, patients, and others interested in the intersection of palliative care and geriatrics. Anand is also an Assistant Professor in Division of Pulmonary, Allergy, and Critical Care Medicine at the University of Alabama at Birmingham (UAB) and faculty at the Center for Palliative and Supportive Care at UAB. Anands research on this subject has shown a lot of things, including that COPD patients are often referred too late to palliative care and hospice, pulmonologists often equate hospice with palliative care, there is high symptom and emotional needs in COPD patients, and that patients and family members feel palliative care should be integrated early on in the care of COPD. Links to the following articles can be found on this blog post at https://www.geripal.org/2020/04/integration-of-geriatrics-and-palliaitve-care-in-COPD.html: - A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease - A Formative Evaluation of Patient and Family Caregiver Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease across Disease Severity - End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease We also talk about this podcast with David Currow on the use of opioids in dypsnea: -Opioids for Breathlessness: A Podcast with David Currow So take a listen and join the conversation at #PalliPulm! by: @ewidera

Many of you listened to our prior podcast with Jim Wright and David Grabowski about COVID in long term and post acute care settings. In this follow up podcast, we talk about the situation in long term and post acute care in Indiana with Kathleen Unroe, Associate Professor at Indiana University, a scientist at the Regenstief Institute, and a PI of Optimistic and founder of Probari, and Ellen Kaehr, Assistant Professor of Clinical Medicine at Indiana University and geriatrician and medical director of a nursing home. A few highlights to wet your appetite: - About 2/3 of the Ellen's nursing home is COVID positive. This has led to so many challenges - how did this happen? (asymptomatic staff). How to cohort? Issues with PPE, with transitions to the hospital, with visitors. - We talked about the unique impact of COVID on people with dementia. For example, mobile persons with dementia wander, which has negative aspects, but does keep them functional/mobile. Now they're confined to their rooms and at much higher risk for debility/decline. They're also noticing a loss of orientation due to lack of structured activities. - We talk about the impact on Assisted Living Facilities, something that Kathleen has been thinking about increasingly from a policy perspective. There are twice as many people living in assisted living facilities as nursing homes. And yet assisted living facilities have received scant attention in this epidemic. - Impact on providers. This has been so hard. And clinicians and staff are working so hard to meet this challenge. How can we support each other during this difficult time? And they chose an AWESOME song, Paradise by the late great singer songwriter John Prine, who sadly died of COVID related illness. I couldn't help but overlay a few harmonies on the vocal track. Sing along! -@AlexSmithMD

We were asked by Sean Morrison, Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, to compose a brief GeriPal video of thanks, support, and gratitude for all of the hard work they are doing in New York. These videos are played every Friday during the Mt. Sinai's Town Hall. Prior guests include Tom Brokaw, Mandy Patinkin, Martha Stewart, and Liz Gilbert. August company indeed! Here is our video link: https://youtu.be/xQT6xK4QjRw - This one is probably better watched as a video than as a podcast, though either will work. At GeriPal, we are happy to do what we can to support, inform, and entertain those working hard on the front lines, whether it be in New York, Detroit, Seattle, New Orleans, Indiana, Chicago, or wherever you may be. Special guests from UCSF include: Rebecca Sudore, Steve Pantilat, Pei Chen, Natalie Young, Louise Walter, Brie Williams, Anne Fabiny, Ken Covinsky, and Sandra Moody. -@AlexSmithMD

The peak hospitalizations and deaths in New York City hit around April 7th. Life though in hospitals in New York though have not returned to normal. What were previously operating rooms, post-hip fracture units, or cardiac cath labs, are now units dedicated to the care of individuals hospitalized with COVID. We talk with two NYU clinicians, Ab Brody and Audrey Tan about what life is like right now in this new state of limbo as both palliative care clinicians and as their role as either a NP hospitlist or Emergency department physician. Ab Brody is the Associate Director of the Hartford Institute for Geriatrics Nursing at NYU. Audrey is the Director of Emergency of Medicine and Palliative Care in the Department of Emergency Medicine at NYU. We are also welcoming back our guest host Nauzley Abedini from UCSF. A couple of topics that we talk about include: - What's life like right now at NYU post-surge? - What's it like to look at the COVID crises in the lens of a palliative care consultant and their role as a primary provider in the ED or the hospital? - Geriatric issues that they are seeing in the ED or the wards. - How they are recognizing and dealing with morel distress? - The worry about PTSD and the worry for our workforce post this pandemic. - The stress that not only comes with work but also what it's like to go home by: Eric Widera (@ewidera)

In today's podcast we talk with Zara Cooper, Rachelle Bernacki, and Ricky Leiter about the state of COVID at the Brigham and Women's hospital and Dana Farber Cancer Center in Boston. While they have flattened the curve somewhat in Boston, they're still seeing huge numbers of seriously ill Covid patients in Massachusetts. They have 143 out of their ~1000 bed hospital filled with COVID19 patients, including 78 Covid patients in ICU, many of which are followed by palliative care. This has resulted in the need to drastically restructure the palliative care team, including: - Embedding palliative care in the ED. They quickly found that if they waited for consults, they got not calls, and had to proactively go out and find consults in the ED. By demonstrating their usefulness, acceptance has increased. - Embedding palliative care in the ICU. These experiences are hard. Zara Cooper, who works as an intensivist in the ICU (as well as surgeon, as well as palliative care doc, as well as researcher, as well as superwoman) relates the ethical dilemmas and moral distress associated with providing care in the ICU. Ricky Leiter talks about how hard it is emotionally for the palliative care teams, how the cadence of our usually palliative care consult becomes compressed in these cases, and how their teams are dealing with the challenges of prognostic uncertainty, video meetings, and not being able to see patients in person. - Their first instinct was to protect the fellows from COVID19 patients. The fellows rebelled. They wanted to be involved, and now they are, and are functioning as an integral part of the response. All of this and more, including forgiving yourself if due to these extreme circumstances you can't give "gold star" palliative care, but maybe "bronze star" is enough? For links to the Pallicovid.app, Covid Protocols, and the Ariadne Labs COVID Response Toolkit, please visit our Covid page at https://www.geripal.org/p/covid.html or our website at GeriPal.org. -@AlexSmithMD

"It's not about perfection...it's about connection." - Keri Brenner This week's podcast features a dynamic duo of palliative care psychiatrists, Dr. Keri Brenner from Stanford, and Dr. Dani Chammas from UCSF. Dani was a huge hit as a guest on one of our earliest podcasts talking about "Formulations in Palliative Care." This week, Keri and Dani talk about "Therapeutic Presence," an important concept in both psychiatry and palliative care (links to articles about this concept and application at https://bit.ly/2VpXxS7. They describe 3 key ingredients of therapeutic presence, including being deeply attentive, naming (I'd call it complex naming), and creating a safe "holding space" for patients' emotions. But come on, you might say, we're in the midst of a pandemic. How can we maintain a therapeutic presence in a zoom meeting with family members you've never met, or with a patient who has a disease that could spread to you and infect not only you but your family. Keri and Dani speak to the challenge of taking on the strong emotions we're all feeling during this pandemic - anxiety, fear, and the unique vulnerability this disease places on us as health care providers. They note high rates of depression, anxiety, and other adverse mental health outcomes for healthcare workers in China who dealt with COVID. This was an awesome podcast. It was like a therapy session for our collective GeriPal souls. I hope you enjoy it as much as we did. To stay up to date on relevant links, check out our new COVID page at https://www.geripal.org/p/covid.html -@AlexSmithMD

The vast majority of hospice services are delivered in patient's homes or other places of residence like nursing homes. This makes the traditional model of hospice care vulnerable in this coronavirus pandemic, especially in the era of social distancing and limited personal protective equipment (PPE). So how are hospice's responding to the COVID-19 pandemic? On this weeks podcast, we talk to two leaders of two large hospice agencies, Drs. Kai Romero and Todd Cote, to get their views on this question. Kai is the Chief Medical Office of Hospice by the Bay in California. Todd is the Chief Medical Officer at Bluegrass Care Navigators in Kentucky. It's inspiring to hear how these hospices and others are stepping up to the challenge of caring for both COVID positive and non-COVID positive patients during this time. Among subjects we talk about include: - The variability how this pandemic is affecting hospices in how they are responding to COVID (even if they take COVID positive patients) - Supply limitations (PPE, medications, etc) - The role of telemedicine in hospice visits and the challenges with trying to do some hospice visits virtually - How COVID influences prognostic eligibility to hospice - Special issues in vulnerable populations like homeless and rural populations Check out our new COVID page at https://www.geripal.org/p/covid.html for important links we talk about in this podcast as well as previous COVID podcasts.

Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You're short on gowns and facemasks. You're short on nurses and nurse aids so now you have to help deliver meals. This is what Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond is living through right now. I felt overwhelmed just listening to Jim talk about his experience since mid-March, and am so grateful that he joined to talk about COVID in the long term care setting, along with David Grabowski, author of the JAMA piece titled "Postacute Care Preparedness for COVID-19 - Thinking Ahead." A couple key points that I learned from Jim's experience. The first point is that half of patients who tested positive were asymptomatic, so you really don't know who has it or who doesn't unless you test everyone. The only thing you really know is that if you have 5 symptomatic patients who test positive for COVID, assume there are at least 5 asymptomic patients. The second point is that there seems to be different clinical courses for those who are symptomatic that David summarized as the following: - Indolent course, deadly: Initial 24-28 hours of fever and severe respiratory symptoms. Then Stabilization for 3-5 days. Then decompensation on days 5-7 with death within 24 hours - Indolent course, convalescence 1. Fortunately, the majority of our patients. Same course as indolent to death although continued improvement over 7-10 days. - Acute respiratory failure: Symptoms begin with fever and acute respiratory failure with death within 6-12 hours. - Sepsis-like picture: Sudden onset of AMS, hypoxia and hypotension without fever. A small subset of patients in our experience. All have tested positive for COVID (may simply have been asymptomatic carriers who developed sepsis independently In the second half of the podcast David Grabowski walks us through the challenges facing nursing facilities and potential solutions to the looming crisis in long term care, including - creating COVID only specialized post acute care settings - increasing the level of home health care and hospital-at-home model - whether nursing homes that don't yet have COVID should be forced to take COVID+ patients form hospitals. So listen up and comment below. Also, check out some of our past COVID podcasts and new resources on our new COVID page at https://www.geripal.org/p/covid.html.

In today's podcast we talk with Audrey Chun, Professor in the Department of Geriatrics and Palliative Medicine at Mount Sinai, and Sheila Barton, a social worker in the Geriatrics practice at Mt. Sinai. Mt. Sinai has a HUGE outpatient geriatrics service, with a mean age of 85. We talk with Audrey and Sheila about the challenges they face in overcoming obstacles. Everything is harder now, such as how to get basic needs met for older adults isolating in the community, such as food and assistance with basic activities with daily living. Higher order concerns are challenging as well, including conducting advance care planning conversations with patients and family members over the phone, and finding a home hospice agency willing to care for a COVID positive patient. We talked as well about this article by Jason Karlawish arguing that caregivers are essential health workers who should be allowed into hospitals to care for their older at-risk-of-delirium relatives. Oy. Tough times. One thing Audrey and Sheila emphasize repeatedly is how supported they feel by their health system, by volunteers, and even from their own patients who message them with words of encouragement and kindness. New Yorkers are tough, but they also have big hearts and rally around one another time and time again when faced with challenges. On additional note, if you'd like to sign up for palliative care COVID discussions, here's a link to sign up to participate in weekly chats, thanks to Zachary Sager and Leslie Blackhall. -@AlexSmithMD

In the latest in our series of talking with front line providers in the midst of the COVID pandemic, we talk with Drs. Craig Blinderman, Shunichi Nakagawa, and Ana Berlin of the palliative care service at Columbia University Irving Medical Center. We cover a host of topics, including the urgent need to conduct advance care planning with our outpatients (including Craig's new Epic dotphrase below, and guide to COVID advance care planning); the need to be flexible to suit shifting demands; to stock up on iPads to engage patients/family members in goals of care discussions from outside the room. We mention the new JAMA papers on "informed assent" to DNR/I orders by Randy Curtis and colleagues (and Craig's prior JAMA paper), and on rationing scarce resources by Doug White and Bernie Lo (see also our prior podcast on rationing with Doug with links to the practical framework). I cried after this one. Maybe it was Ana talking about how hard it was have an agenda when discussing goals of care with the family of a 90 year old woman with dementia. We're taught in palliative care to match patient/family goals, and to not bring an agenda. But we do have an agenda now, as Ana says. The patient will not survive a code or prolonged intubation. Coding her would expose Ana's colleagues to COVID, and use scarce PPE and ICU resources, including a ventilator. We can't check that agenda at the door anymore. This is hard. You can hear their moral distress as they talk through these experiences. Maybe it was the three of them talking about the pace of change. Last week they felt "impotent" as they awaited the coming storm. Then the ICU called; they want palliative care. Then the ED called; they want palliative care. Today Shunichi spent the entire day having goals of care conversations with likely COVID patients and their families in the crowded ED. Today they say they want a new inpatient palliative care service, ASAP, maybe even tomorrow. They thought they would have until next week. The tsunami hit Wednesday. Maybe it was Ana saying her daughter had a fever and might have COVID, and that one thing she is thankful for is that kids are spared serious illness. Maybe it was the song choice, the Ghost of Tom Joad by Bruce Springsteen, with its inspirational and haunting message. Craig says he chose this song because the lyrics are about standing up to meet the challenges faced by the most vulnerable. As he notes, COVID is the AIDS crisis of our day. We're all in this together. -@AlexSmithMD FYI - for links to referenced material, please visit our website at GeriPal.org

New York is the current epicenter of the COVID-19 outbreak in the US, with over 30,000 confirmed cases as of March 25th. Hospitals and ED's are seeing a surge of patients, and geriatrics and palliative care providers, like Cynthia Pan, are doing their best to meet the needs of these patients and their family members. Today, we talk with Dr. Pan, the Chief of the Division of Geriatrics and Palliative Care Medicine, and the current attending on the palliative care service at New York-Presbyterian Queens, located in Flushing, New York. In our discussion we talk about what it is like to be on the front lines right now, lessons learned during this surge, and how she is managing the distress in caring for these patients.

Many of us with clinical roles are waiting for the other shoe to drop. Today we hear from Dr. Darrell Owens, DNP, MSN, head of palliative care for the University of Washington's Northwest campus, a community hospital in Seattle. The UW Northwest hospital has born the brunt of the COVID epidemic in one of our nation's hardest hit areas. Darrell has stepped up the the plate in remarkable, aspirational ways. First, he is on call 24/7 to have goals of care conversations with elderly patients in the emergency department under investigation for COVID who do not have an established a code status. On the podcast Darrell walks us through the language he uses to speak with these patients about the poor outcomes of CPR and ventilation among older adults with COVID. We note on the podcast that the Center to Advance Palliative Care recently put together Toolkit for COVID including a thoughtful communication guide spearheaded by Tony Back and our friends at VitalTalk. Second, Darrell has established an inpatient palliative care service at his hospital for patients on exclusively comfort measures. Darrell and his team admit and are first call for these patients. This service off-loads the hospitalists so they can care for other patients. Darrell talks with us about the challenges of titrating medications for symptomatic patients when you're trying to minimize using protective equipment going in and out of the room, and the challenges of returning home from work to his family after treating patients with COVID all day. By closing let me repeat two things from the podcast. First, we too can and should step up to the plate. By engaging patients in goals of care discussion at the time of admission we are likely to help patients reach different decisions than they otherwise might have made had discussions occurred with rushed and less skilled clinicians (i.e. the usual code status discussion). Before we get to rationing, we can and should engage patients in the highest quality informed goals of care discussions. The results of these informed discussions are likely to decrease the need for scarce ICU beds and ventilators. That is why Darrell is specifically on call for these conversations. Simply put, we do it better. We have the best skill. Further, like Darrell, we too can create or expand inpatient palliative care services to provide the best possible care for these patients and free up hospitalists and others to meet the growing clinical needs due to the pandemic. Second, Eric and I have never been prouder of our fields. Every day we hear stories of geriatricians, palliative care clinicians, and bioethicists rising to the occasion to meet needs of this moment. As Eric notes, we will found out a great deal about ourselves and what we stand for these next few weeks and months. Thank you for all that you do. -@AlexSmithMD

You are caring for two adults with COVID-19. One who is a previously healthy 70 year old. One is 55 with multiple medical comorbidities. Both are now requiring mechanical ventilation, but there is only one ventilator left in the hospital and all attempts to transfer the patients to another hospital for care have failed. Which patient would you give the life saving treatment to and why? On today's podcast with talk with Doug White, Professor of Critical Care Medicine at the University of Pittsburgh, and James Frank, Professor of Medicine and fellowship director for the UCSF Pulmonary and Critical Care Medicine Fellowship, about this type of tragic choice that we may soon be making if we do not flatten the curse on the COVID-19 pandemic (for more on that, check out our last podcast with Lona Mody). If you don't think that would be even remotely possible, just read this quote from a NEJM article that came out yesterday: Quote: "Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence — or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. 'This is not a nice thing to say,' he told me. 'You will just scare a lot of people.'" In our podcast we reference a fair amount of articles and resources. Links to the following articles and resources can be found on our website at GeriPal.org : - Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions. Annals of Internal Medicine - Principles for allocation of scarce medical interventions. Lancet 2009 Definitive Care for the Critically Ill During a Disaster: A Framework forAllocation of Scarce Resources in Mass Critical Care. Chest 2008 - Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest 2019 - Meeting the challenge of pandemic influenze: ethics guidance for leaders and health care professionals in the Veterans Health Administration - Ventilator Allocation Guidelines:New York State Task Force on Life and the LawNew York State Department of Health - NYT interview with Italian ICU director in Bergamo, Italy. Truly sobering and it's clear that many patients are dying after being triaged to no ICU/ventilation. - Flattening the curve infographic - Excellent illustration of how surge capacity will be increased as it relates to ICU staffing

Covid19 is changing the way we interact with each other (from 6 feet away or via Zoom) the way we care for out patients (increasingly by video or telephone) and for some unfortunate few, the way we die (alone, in a hospital for days, isolated from family and friends). This is the first podcast in a series of podcasts about Covid 19. In this first podcast we talk with Lona Mody, Professor of Medicine at Michigan Medicine and John Mills, Associate Epidemiologist with Michigan Medicine. We cover terminology, epidemiology of the disease, and what we can do to protect our older and vulnerable patients. We also provide a new suggestion for a 22 second song you can sing while washing your hands in lieu of happy birthday (some of us are sick of singing happy birthday so many times a day). Our next podcast, to be released tomorrow, will be with Doug White and James Frank on the ethics of rationing ventilators. In both podcasts, we refer to this New York Times Daily podcast with Dr. Marco in Milan Italy titled, "It's Like a War." Every day they admit 50-70 patients with severe pneumonia due to Coronavirus infection to their 1000 bed hospital. More than half of the hospital is filled with Coronavirus infections. 460 nurses are home sick or in home quarantine due to contact with infected patients. They're admitting their colleagues. 20 patients died from Coronavirus in one day. He talks about rationing ICU beds by age. He says, "My colleagues, both physicians and nurses, they cry everyday." Important take away from both podcasts: Flatten. The. Curve. Now. -@AlexSmithMD

Project ENABLE is a landmark palliative care intervention. And yet, I will admit (Eric did too) we didn't really understand what it was. So we interviewed ENABLE founder Dr. Marie Bakitas and ENABLE distinguished protégée Dr. Nick Dionne-Odom to learn more about ENABLE. During the interview, we learned a great deal about ENABLE, how it has evolved, iterated, and shifted over time to include persons with diseases other than cancer, minorities with serious illness, and caregivers. We break the results of ENABLE CHF-PC, a planned plenary abstract presentation for the State of the Science meeting that was supposed to happen next week (here's a link to the published abstract https://www.jpsmjournal.com/article/S0885-3924(19)30854-1/fulltext). About that State of the Science. Yeah. Well, as you probably know the State of the Science, the AAHPM/HPNA/SWHPN meeting, and the GeriPal/Pallimed pub crawl have been cancelled, for all the right reasons. Er, reason. Covid19. So sadly, this will not be an oral presentation next week, but you can still hear all about it here on this podcast! We'd like to express our gratitude to the organizers of AAHPM/HPNA/SWHPN and the SOS meeting, including the staff of these organizations, planning chairs, and committees. They put in countless hours preparing for what would have been the largest palliative care meeting of all time. Thank you for all you've done! And yes, Marie and Nick forced me to sing Taylor Swift. Sorry! -@AlexSmithMD

"Tell me about the problems you have with your medications." A simple open-ended question that is probably rarely asked, but goes beyond the traditional problems that clinicians worry about, like non-adherence, inappropriate prescribing, and adverse reactions. What do you find when you go deeper? Well we talk with Francesca Nicosia and Mike Steinman about the work they have done around deprescribing and medication related problems, including a recent JGIM study that attempts to better understand patient perspectives on medication-related problems. This study also gives a pretty fascinating picture of where the overlap and divergence is between what patients and physician see as medication related problems as shown in this figure from the article: In addition to medication related problems, we talk about some other important updates in deprescribing, including their work in the newly formed US Deprescribing Research Network and new pilot awards of up to $60,000 in funds to catalyze investigator initiated research projects around deprescribing. by: Eric Widera (@ewidera)

Home-based palliative care is booming. And with the growth of home-based palliative care come unique struggles and challenges: how can it be financed, what does the ideal team look like (or do you need a team?), retaining clinicians who may feel isolated doing this work, identifying patients who are most likely to benefit. In this week's podcast we talk about these and other issues with Brook Calton, home-based palliative care physician in the Division of Palliative Medicine at UCSF and Grant Smith, a recent graduate of UCSF's palliative medicine fellowship now faculty at Stanford. To supplement our podcast, Grant has written a series of thought pieces that flesh out and complement our discussion. His first reflection was published in the Journal of Palliative Medicine last month. We will post one additional reflection per day for the next three days. Hope you enjoy my attempt at a Southern drawl while singing! -@AlexSmithMD

On this week's podcast we have the honor of talking with David Reuben about health care for older adults and how it's time to think different. It really is a smörgåsbord of topics, ranging from how to think about population health for older adults (and how we as individuals providers can provide at least some level of population health), the UCLA Alzheimer's and Dementia Care Program and its outcomes, Medicare Advantage for All, working with community partners through voucher systems, and tips for leading change. Dr. Reuben is Director of the Multicampus Program in Geriatrics Medicine and Gerontology and Chief of the Division of Geriatrics at the University of California, Los Angeles (UCLA). He is also the Archstone Foundation Chair and Director of the UCLA Claude D. Pepper Older Americans Independence Center and the UCLA Alzheimer's and Dementia Care program. If you want to read more about some of the topics, check out these links on our website at geripal.org: - Patient and Caregiver Benefit From a Comprehensive Dementia Care Program: 1‐Year Results From the UCLA Alzheimer's and Dementia Care Program - The Effect of a Comprehensive Dementia Care Management Program on End‐of‐Life Care - UCLA Alzheimer's and Dementia Care Program Website

We had fun on this in-studio podcast with Dan Matlock, geriatrician and palliative care clinician researcher at the University of Colorado, and frequent guest and host on GeriPal. We most recently talked with Dan about Left Ventricular Assist Devices and Destination Therapy. Today we talked with Dan about Implantable Cardiac Defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT) - everything a geriatrician or palliative care clinician should know. Dan and his team have developed a number of terrific decision aids around ICD implantation (see patientdecisionaid.org), and have seen uptake and use of these decision aids skyrocket following CMS's mandate requiring an shared decision making interaction prior to ICD implantation. Enjoy! -@AlexSmithMD

In this week's podcast we talk about food insecurity in older adults with UCSF's Hilary Seligman, MD. Hilary has done pioneering work in this area. Some of this work was funded by Archstone Foundation (full disclosure: Archstone is a GeriPal funder). Hilary's expertise runs the gamut from federal nutrition programs (including SNAP), food banking and the charitable feeding network, hunger policy, food affordability and access, and income-related drivers of food choice. I have a confession. I knew almost nothing about food insecurity before this podcast. Is it hunger? Why should we think about food insecurity and health in the same sentence? Why is this an issue for older adults in particular? I was absolutely blown away by what I learned in this podcast. I have since quoted Hilary Seligman 4 or 5 times in other meetings. Food insecurity is one of those topics that people don't talk about but is likely far more critical to the health and well-being of the people we care about than other topics we spends gobs of time and money on (e.g. cholinesterase inhibitors for dementia). So take a listen and if you want to take a deeper dive in some of the topics we talked about, check out the links for this blog post at http://bit.ly/2vbEEZE or geripal.org. Enjoy! -@AlexSmithMD

Should Geriatric Assessments be part of the routine ontological care for older adults with cancer? On this weeks podcast we attempt to answer this question with national experts in Geriatric Oncology: Dr. Supriya Mohile from the University of Rochester and William Dale from City of Hope, as well as UCSF's Melissa Wong. Lucky for us, they also have a little evidence on their side thanks to a recently published JAMA Oncology article that they authored titled "Communication With Older Patients With Cancer Using Geriatric Assessment - A Cluster-Randomized Clinical Trial". We discuss not only the trial results, but also: - reasons why geriatric principles is important in oncology - what a geriatric assessment includes - who should do a geriatric assessment (including does it need a geriatrician?) We also talk about these resources if you want to take a deeper dive in geriatric oncology: - ASCO's Geriatric Oncology page - ASCO's guideline for geriatric oncology by: Eric Widera (@ewidera) P.S. Please visit our blog page at geripal.org for links to the referenced material above.

You've probably heard patients say, "Of course I'm depressed, I'm dying. Wouldn't you be?" This is a fundamental question - to what extent are depressive symptoms "normal" at the end of life? To what extent are they maladaptive, a fancy word for psychological conditions that have a negative impact on your life. In this week's GeriPal podcast we talked with Elissa Kozlov, a psychologist-researcher at Rutgers, and Claire Ankuda, a palliative care physician-researcher at Mt. Sinai about their JAGS paper describing the epidemiology of depressive symptoms in the last year of life. This was an interesting conversation, as Drs. Kozlov and Ankuda are pushing the boundaries of how we conceptualize depressive symptoms near the end of life. Their work suggests that depression is far more common than we suspect clinically. And they chose a great song - Hurt as arranged by Johnny Cash (not the Nine Inch Nails original). Enjoy! -@AlexSmithMD