GeriPal - A Geriatrics and Palliative Medicine Podcast

Do opioids improve breathlessness? A simple question that unfortunately doesn't seem to have a simple answer. We get into the nitty-gritty of potential answers to this question with a preeminent researcher in this field, David Currow. David is a Professor of Palliative Medicine at University of Technology Sydney. His research has challenged common practices in Hospice and Palliative Care, including randomized control trials on oxygen for breathlessness, octreotide for malignant bowel obstruction, and antipsychotics for delirium in palliative care patients. His most recent study was published in Thorax titled "Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial." It showed no differences between those that got sustained-release morphine and those that got placebo in regards to breathlessness, but the intervention arm did use less rescue immediate-release morphine. We talk to David about how to interpret these results, as well as what to make out of the broadened inclusion criteria and whether there was an issue with the primary outcome. Other articles we reference in the podcast include: * The safety study: No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness * And the oxycodone SA study: Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. by Eric Widera, @ewidera

In this weeks podcast we talk with Kirsten Bibbins-Domingo, general internist, Professor of Medicine and Epi/Biostats at UCSF, and chair of a National Academies of Sciences task force on Integrating Social Care into the Delivery of Health Care. See Kirsten's JAMA paper summary here (https://jamanetwork.com/journals/jama/article-abstract/2752359), and the full report here (http://nationalacademies.org/hmd/Reports/2019/integrating-social-care-into-the-delivery-of-health-care). This podcast spans the gamut from the individual clinician's responsibility to be aware of the social needs of their patients and impacts on health (think homeless person with no place to store their insulin), and adjustment to meet these needs (such as keeping on oral medications), to larger health policy issues including the need to integrate health and social policy. This was a fun podcast, as you'll hear. This is a topic that lends itself well to discussion. Eric really pushes this issue: to what extent are meeting the our patient's needs for housing, transportation, and food a health issue? Are these issues that a doctor should care about, and why? And our rendition of "Waiting on the World to Change" was perfect in every possible way!!! Enjoy! by: Alex Smith, @AlexSmithMD GeriPal is funded by Archstone Foundation (https://archstone.org/). Archstone Foundation is a private grantmaking foundation whose mission is to prepare society in meeting the needs of an aging population

On this weeks podcast we talk to Julie Bynum on the question "Do Nurses Die Differently?" based on her recent publication in JAGS titled "Serious Illness and End-of-Life Treatments for Nurses Compared with the General Population." Julie is a Professor of Geriatric and Palliative Medicine at the University of Michigan, and Geriatric Center Research Scientist at the Institute of Gerontology, as well as a deputy editor at the Journal of the American Geriatrics Society. Overall, Julie's study found small differences in end of life care for both dementia and CHF as seen in the chart on our blog post at https://www.geripal.org/2019/12/do-nurses-die-differently-podcast-with.html One can think of these numbers as so small of a difference that there really isn't a difference. With that said, my favorite part of this interview is Julie's take on this difference, which is that while the difference is small, there is a difference ("There is a signal!"). This means "I know it can be different, because it is different." by: Eric Widera

We have had some amazing guests on our Podcast. True luminaries in geriatrics and palliative care. This week we are fortunate to be joined by none other than Mary Tinetti, MD, to talk about her recent JAMA Internal Medicine trial of Patient Priorities Care (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2752365). In this study of older adults with multiple chronic conditions, patients are guided through a process of identifying their health priorities and objectives, and this information is communicated to their primary care physicians. The trail resulted in more medications discontinued, fewer self-managment and diagnostic tests, and less report of treatment burden. This podcast builds on our prior podcast on this topic with Aanand Naik (awesome song choice, Lumineers' Gun Song). We talk with Mary Tinetti about what exactly Patient Priorities Care is, how it differs from geriatrics and palliative care (or does it?), and how to disseminate this program widely (hint: start by going to their amazing website at patientprioritiescare.org). And...ah...Mary made me sing Joni Mitchell's Ladies of the Canyon. My deepest apologies to fans of Joni Mitchell... by: @AlexSmithMD

On today's podcast we take a moment to celebrate 100 episodes of the GeriPal podcast. Yes, 100 episodes that have covered everything from cranberry juice for UTIs to medical aid in dying. In this episode, Anne Kelly, Lynn Flint and Ken Convinsky lead us down memory lane, asking Alex and me hard hitting questions about the birth of the podcast, our favorite episodes, and our most memorable moments. We also take time to listen to the feedback that we received from our call in listener line (929-GeriPal) and maybe, just maybe, a song is sung to celebrate the occasion. Lastly, we also have two very special thank you's. First is to Archstone foundation, who just became GeriPal's first sponsor! It's really is an honor to be backed by such a wonderful organization with a mission so aligned with our podcast. We also want to thank all of our listeners for your support and encouragement. It is really touching every time we hear some feedback about our shows and we love it when we hear that you are sharing our show with others. So join us for this episode (warning - there is audience participation in a song at the end) by: Eric Widera (@ewidera)

Nursing homes are a tough place to do palliative care. There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice. So what can we do to improve the palliative care outlook in nursing homes? On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week. Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries. Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes. I struggle with just trying to improve palliative care in one site! We discuss with Lieve the results of the study, her take on why they got the outcomes that they did, and her view on a path forward to improving palliative care in these settings. We also have the authors of the accompanying JAMA IM editorial with us too (that was easy, it was Alex and our recurring guest host Lauren Hunt.) So take a listen and tell us what you think in the comments below, on social media, or on our GeriPal phone # (929-GeriPal).

A recent study by Vince Mor published in JAMA Oncology found that veterans with advanced lung cancer treated in Veterans Affairs (VA) Medical Centers with high hospice use were more likely to receive concurrent cancer care and also less likely to receive aggressive care. On top of that, veterans treated at facilities with high levels of hospice use also incurred lower costs of care. This is a strong case for the concept of concurrent care in which individuals can avoid the "terrible choice" between hospice and life prolonging therapies. On this weeks podcast, we interview the lead author, Vince Mor, about this study and whether concurrent care is ready for prime time outside of a integrated health care system like the VA. We also put a plug in the end for the NIA Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory that Vince is helping to lead. If you want to learn more about the collaborators, please check out our GeriPal website at https://geripal.org for links to this and other info. by: Eric Widera

Do you remember the scene from the movie The Graduate where Ben's dad says, "One word: Plastics"? Well, I write this blog post from the National Palliative Care Research Center's annual Foley retreat, a who's who of palliative care researchers. The words on everyone's lips: "Lay Health Navigators." This is not to draw equivalency between environmentally destructive materials and people who help those with serious illness and caregivers navigate our complex health care system. Rather, it's to point out that revolutions occur in palliative care research just as they do in business. In this week's podcast, we talk with Kate Possin, PhD and Sarah Dulaney, RN CNS of UCSF about the Care Ecosystem project. In this remarkable study, published in JAMA Internal Medicine, lay health workers helped caregivers of persons with dementia navigate the health care system by providing support, education, and care coordination with dementia specialists. The intervention was mainly by telephone, with about 1 phone call per month. Results were remarkable, including improved quality of life for persons with dementia, reduced emergency department visits, and reduced caregiver depression and burden. As Nick Dionne-Odom pointed out yesterday, "Caregiving in dementia is a monumental task. There is tremendous room for improvement." Listen or read on for more! Also - be sure to check out the outstanding Care Ecosystem website: https://memory.ucsf.edu/research-trials/professional/care-ecosystem. The training materials are all FREE to use! by: @AlexSmithMD

Before we get into this week's topic, would you please take 1 MINUTE to complete this GeriPal survey! It will really help us out. We swear, only 1 minute! Click the link below to access the survey (or copy and paste in your browser). Thank you! GERIPAL SURVEY https://ucsf.co1.qualtrics.com/jfe/form/SV_esS7pUAOgSIbNGZ Now on to this week's topic... Alex: What do you get when you mix a doctor and an architect? Eric: An Archidoc? Alex: No a Dochitect. What do you get when you mix a gerontologist with an architect? Eric: A gerontolitect? Alex: No an environmental gerontologist. OK, so we didn't have that EXACT conversation on this podcast, but something close to it. There is a growing recognition that many of the settings where older adults receive healthcare are not designed to meet the needs of older adults. The early part of this movement resulted in the Americans with Disabilities Act, which mandated such things as accessibility for persons with wheelchairs. But it so much more than that. The architecture of health care buildings can actually impair the health of older adults or people living with serious illness - think lack of windows, rooms designed around beds, and placement close to noisy workspaces. Can you say delirium??? Re-designed spaces also have the potential to improve outcomes for older adults and people with serious illness. Further, redesigned spaces can improve quality of life for healthcare providers, and those benefits may be passed on to our patients. To discuss these fascinating issues we talked with Dochitect Diana Anderson, MD, M. Arch (UCSF geriatrics fellow) and Emi Kiyota, PhD, environmental gerontologist. Click here (http://www.dochitect.com/) to learn more about Diana and links to her publications, and here (https://ibasho.org/) to learn more about Emi and her website Ibasho, Japanese for "a place where one can feel at home and be oneself." Enjoy! by: @AlexSmithMD

What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)? I've never been in one. I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support. For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home. And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF. In his JAGS study of about 14,000 patients admitted to LTACs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities). One third died in an LTAC, never returning home. So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs? Right? Wrong. 3% were seen by a geriatrician during their LTAC stay, and 1% by a palliative care clinician. Ouch. Plenty of room for more research and improvement. Read or listen for more! See also this nice write up by Paula Span in the New York Times, and this prior study on geographic variation in LTAC also by Anil. Please also note that our 100th podcast approaches! Please call 929-GERI-PAL to let us know what is working and what can be better about GeriPal. You might make it on the air! by: Alex Smith @AlexSmithMD

Ok, I'll admit it. When I hear the phrase "the biology of aging" I'm mentally preparing myself to only understand about 5% of what the presenter is going to talk about (that's on a good day). While I have words like telomeres, sirtuins, or senolytics memorized for the boards, I've never been able to see how this applies to my clinical practice as it always feels so theoretical. Well, today that changed for me thanks to our podcast interview with John Newman, a "geroscientist" and geriatrician here at UCSF and at the Buck Institute for Research on Aging. In this podcast, John breaks down what geroscience is and how it impacts how we think about many age-related conditions and diseases. For example, rather than thinking about multimorbidity as the random collection of multiple different clinical problems, we can see it as an expression of the fundamental mechanisms of aging. This means, that rather than treating individuals diseases, targeting aging pathways may be a better way to prevent or ameliorate multimorbidity. We talk with John about this, and current trials underway to test this hypothesis, along with so much more! If you're interested in taking a deeper dive in the subject, take a look at these papers that John co-authored: - From discoveries in ageing research to therapeutics for healthy ageing. Nature 2019 - Creating the Next Generation of Translational Geroscientists. JAGS 2019 by: Eric Widera (@ewidera) Note: To view the YouTube version, links to the research papers, and/or the transcript for this episode, please visit our GeriPal website at: https://www.geripal.org/2019/10/geroscience-and-its-impact-on-human.html

Joanne Lynn, a geriatrician and palliative care physician who leads Altarum's work on eldercare, wrote a recent JAGS editorial titled The "Fierce Urgency of Now": Geriatrics Professionals Speaking up for Older Adult Care in the United States" which is very much a call to action for those who care for older adults. We talk with Joanne about this article and some meaningful things clinicians in both geriatrics and palliative care can do to be advocates for a growing population of older adults. One way I would like to plug to better advocate for our patients is through our national societies. To learn more what both AAHPM and AGS are doing to improve care for older adults and those with serious illness, and to learn how you can help lead change, check out the following links: - AAHPM's advocacy page - http://aahpm.org/advocacy/overview - AGS's Health in Aging Advocacy Center - http://cqrcengage.com/geriatrics/ So check out the podcast and pick one thing that you can do to better advocate for older adults or those living with serious illness. Eric (@ewidera)

You're the attending physician on a teaching service. Your resident says we shouldn't order a CT because CT's are over-used for this condition, and represent overuse, waste, and low-value care. In this case, however, you suspect that's not the resident's real reason. The real reason behind the resident's decision is that they are serial minimizers - residents who make little of potentially important findings. You feel they might be hiding their minimizing behind the sexy, trendy notion of providing "high value care." Does this sound familiar to you? It did to me. I've been in the awkward situation of being the consulting palliative care physician saying to the primary team, I know they have cancer and that's the most likely explanation for this abdominal pain. I also worry that this pain is out of proportion and different from other pain I've seen, and I think it should be evaluated with further testing. Kind of strange to say that as the palliative care doctor. Kind of strange as well to hear that perspective exposed by Chris Moriates and Vinny Arora, who spend most of their academic careers fighting against wasteful low-value tests and treatments (they run a non-profit called Costs of Care). To be sure, they note this problem is not as great as overuse of consultants, tests, and treatment. The challenge, as Stephanie Rogers our guest host (and guest fiddle player!) points out, is coming up with the right words to teach "right sizing" care to the patient in front of us. And what are the root causes of minimizing? Blame the house staff would be the easy way out, but Chris and Vinny don't take that road. Read more about their thoughts in this article in the Journal of Hospital Medicine and listen to or read our podcast! -Alex @AlexSmithMD Note: For links to referenced articles as well as a transcript of this episode, please visit our blog page at geripal.org/2019/09/hiding-behind-high-value-care-podcast.html

On this weeks podcast, we talk with Krista Harrison about the life of individuals living with moderate dementia, as well as what we know about their caregivers. Krista is is an Assistant Professor in the Division of Geriatrics at UCSF, a social scientist, and something that we learned in this podcast, someone who knows a thing or two about singing opera. Krista recently published a JAGS paper titled "Care Settings and Clinical Characteristics of Older Adults with Moderately Severe Dementia." In this paper, which we discuss in the podcast, she gives us a snapshot of older adults in the United States who have experienced the onset of moderately severe dementia within the past year. We learn that 2/3'rds of these individuals are living in the community. Interestingly, older adults living at home were 2 to 5 times more likely to be members of disadvantaged populations and had more medical needs. In the podcast we discuss some potential reasons why this may be the case, along with what role geriatricians and palliative care doctors can play in the care of these individuals. So take a listen and let us know what you think. Also, take a peek at Joanne Lynn's editorial on Krista's paper, which includes a suggestion to create a default path similar to how obstetrics works. Eric (@ewidera)

In this week's podcast we talk with Lew Cohen, MD, about his new book "A Dignified Ending: Taking Control Over How We Die." Eric and I approached reading this book with trepidation. We feared it would be a polemic defending physician aid in dying. It is not. Dr. Cohen does not hide his beliefs and opinions. He also does not shy away from the complexity of the issue - he interviews leading disability rights activists and challenges leaders of the aid in dying movement. His book is filled with stories of the people and family, doctors and activist who have defined this movement. As Eric says, he takes the controversy meter up to 11 with notions of approving aid in dying and euthanasia for progressive neurological conditions such as dementia (with thoughtful safeguards). We challenge Lew, somewhat forcefully at times. Personally, I disagree with many of his stances (as you will hear/read), but I can respect how thoughtfully he's gone about putting together his study of the issue. As Dr. Cohen notes, no issue seems to activate the strong emotion centers of our brain like aid in dying. In this time of extreme polarization, it's critical that we engage in thoughtful and respectful communication about aid in dying. - Alex Smith, MD

In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer. The issue of lay health navigators raises several issues that we discuss, including: - What is a lay health navigator? - What do they do? How are they trained? - What do lay health navigators offer that specialized palliative care doesn't? Are they replacing us? - What makes the health navigator intervention particularly appropriate for Latinos and rural individuals? For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why). Enjoy! Alex Smith, MD

This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End." As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care. His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times. As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement. The book he and Berger wrote is filled to the brim with practical advice. I mean, nuts and bolts practical advice. Things like: - How to clean out not only your emotional house but your physical house (turns out there are services for that!) - Posting about your illness on social media (should you post to Facebook) - What is the difference between a funeral home and mortuary - Can I afford to die? How much will it cost? We focus our discussion with BJ on his reasons for writing the book, sexuality and serious illness, and priming people to check the instincts of a medical system that favors aggressive/intensive/invasive care and crappy deaths. And BJ came up with some nice harmonies to "Tonight, You Belong to Me." Enjoy! AlexSmithMD

This weeks podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang. Vicky is an assistant professor and researcher here at UCSF. We talk about her local and national efforts focused on this intersection, including: * Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. * Prehab clinics and how ACP fits into these clinics * The Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgery * How frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and enjoy this informative podcast. You can also check out associated links that can be found in this podcast on our website at: https://www.geripal.org/2019/06/advance-care-planning-before-major-surgery.html

There are few names more closely associated with palliative care than Diane Meier. She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC). We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including: * What keeps her up at night? * Does palliative care need a national strategy and if so why and what would it look like? * The history of CAPC and the leadership centers * Advice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careers * What she imagines palliative care will look like in 10 or 15 years? * What is the biggest threat facing palliative care? We hope you join us for this great podcast!

In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life. Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously." In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness. Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th. We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody). This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey in medicine and as a geriatrician facing burnout, aging and death of family members, filled with stories of patients, etc. We focus therefore on the main things we think our listeners and readers will be interested in. First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"? Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking? We focus on Louise's delectable takedown of Ezekiel Emanuel's Atlantic Article "Why I hope to Die at 75" Third- Louise's throws down the guantlet to the field of geriatrics. She argues that we have held too narrow a view of ourselves as clinicians for the oldest old and frailest frail. Instead, we should expand our vision of the field to include all older adults - including healthy 60/70 year olds & healthy aging - and become the default clinicians for all people entering life's last stage. Elderhood is a terrific read, and you are listeners/readers will all be inspired by the ideas, moved by the stories (you will identify with them), and challenged to re-imagine our clinical practice. (apologies - I had a cold so sort of struggle through the singing, far different from my usual perfect rendition!) Enjoy!

In this week's GeriPal podcast we discuss the research into delirium with a focus on prevention. We are joined by internationally acclaimed delirium researcher Sharon Inouye, MD, MPH. Dr Inouye is Professor of Medicine at Harvard Medical School and Director of the Aging Brain Center in the Institute for Aging Research at Hebrew SeniorLife.

Estimating prognosis is hard and clinicians get very little training on how to do it. Maybe that is one of the reasons that clinicians are more likely to be optimistic and tend to overestimate patient survival by a factor of between 3 and 5. The question is, aren't we better as palliative care clinicians than others in estimating prognosis? This is part of our training and we do it daily. We got to be better, right?

On today's podcast we talk with one of the national experts on multimorbidity, Melissa Wei. Dr. Wei is an Assistant Professor and physician researcher at the University of Michigan. In addition to destroying the lyrics to Bohemian rhapsody, we talk to Dr. Wei about how we should conceptualize multi morbidity, it's impact on older adults, and about her recent JAGS publication titled "Multimorbidity and Mental Health-Related Quality of Life and Risk of Completed Suicide."

In this weeks GeriPal podcast we take a deeper dive into this issue of language and medicine. We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.

Our first live podcast at the annual meeting for the American Academy of Hospice and Palliative Medicine! We invited Rachelle Bernacki and Jo Paladino to discuss their two papers published today on the the Serious Illness Care Program.

As Eric notes in the introduction, this recent study in JAMA by Jeff Williamson and colleagues led to some very contradictory headlines. Some headlines proclaimed that lowering blood pressure prevents dementia, and others stated the opposite, that lowering blood pressure does not prevent dementia. So what exactly did the study show? Do these results apply to patients we commonly see in Geriatrics? What should we make of the fact that after the trial was stopped early the blood pressures in the lower blood pressure target group rose - does this mean you can't achieve intensive blood pressure lowering "in the real world"?

In the 1990s, Susan Tolle helped create the POLST. Now she and Elizabeth Eckstrom want to change it. And personally, I think they're right.

On this week's podcast we have Bridget Sumser, a clinical palliative care social worker, board member for the Advanced Palliative Hospice Social Worker certification exam, and now co-author of a new book "Palliative Care: A Guide for Health Social Workers".

Three reasons you should listen to this podcast: The issue of patients cycling back and forth between the hospital and skilled nursing facilities near the end of life is common, will ring true to those of you who are clinicians, and has largely been ignored in the literature. It's about a hot off the press article published today in the NEJM. Lynn Flint, Palliative care doc at UCSF in the Division of Geriatrics, first author, and our guest, makes me sing "Hit Me Baby One More Time" by Brittany Spears. This moment is either a new high or a new low for the GeripPal podcast, I can't tell which. You really need to listen to the final seconds when Eric joins in singing, "still believe" in high falsetto.

Geriatrics teaches us that older adults with infections often present with non-specific symptoms rather than typical localizing symptoms of infection present in younger adults. Sometimes they present with fever, delirium, malaise, or fatigue. In today's GeriPal/JAGS joint podcast, Jeff Caterino challenges this common teaching by examining the extent to which non-specific symptoms are predictive of infection for older adults presenting to the emergency department. Turns out - they're not so predictive as you might think!

May Hua's study addresses the still unanswered question - do specialized palliative care consults in the ICU do anything? She looked a number of outcomes comparing ICU patients in hospitals with and without palliative care consults. While most outcomes were similar, rates of hospice use were higher in hospitals with palliative care teams.

On todays Podcast we talk with Marian (Emmy) Betz about firearm safety, including how to counsel individuals with dementia about guns. Emmy is an Associate Professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, and has written some pretty amazing papers on the subject of firearm safety.

In this week's GeriPal podcast we talk with Tim Girard, Plumonary Critical Care physician-researcher at the University of Pittsburgh about his study NEJM study of Haloperidol vs. Ziprasidone vs. Placebo for ICU delirium in critically ill patients.

On this weeks podcast we are talking with Aanand Naik about his recent JAGS article titled "Development of a Clinically Feasible Process for Identifying Individual Health Priorities".

We thought it would be an excellent time to talk about substance use in older adults as many of us gather around the Thanksgiving dinner table with our extended families. We invited Ben Han, a geriatrician and Assistant Professor of Medicine in Geriatrics at NYU, to talk about the research that he has done in this area. In particular, we talked with Ben about the recent increase in substance use in older adults with the rising baby boomer generation, including use of alcohol, marijuana, heroin and prescription opiate misuse, and other drugs.

In this week's GeriPal podcast we interview Randy Curtis, Professor of Medicine and Pulmonary Critical Care and Director of the Palliative Care Center of Excellence at the University of Washington. We address the question: how do we get more patients with chronic and serious illness to engage in goals of care conversations with their doctors.

On this weeks podcast, we invited Rebecca Sudore to talk about the results of her PREPARE randomized trial that was published in JAMA Internal Medicine this week. The trial enrolled nearly 1,000 English and Spanish speaking older adults being cared for in a public hospital. The headline results showed that after reviewing the PREPARE For Your Care online program and the easy-to-read advance directive, 98% of older adults reported increased engagement in advance care planning (ACP) and 43% had new ACP documentation in their medical record. Even more good news, PREPARE worked equally well among English and Spanish-speakers and across health literacy levels.

In this week's GeriPal podcast we talk with Guy Micco, MD, a longtime bioethicists, internist, hospice physician, teacher in the UC Berkeley and UCSF Joint Medical Program, mentor, and friend. Guy and I wrote an article recently for the journal Perspectives in Biology and Medicine about the intersection and issues between the fields of geriatrics, palliative care, and bioethics. The main thrust of the paper is that we need a workforce that is trained in the principles of all three fields to take the best care of the very sick, the very frail, and the very old. And for those of you who listen, Guy sings a great rendition of Hello in There, by John Prine: sweet, sad, and sentimental. Chorus: You know that old trees just grow stronger And old rivers grow wilder every day Old people just grow lonesome Waiting for someone to say, "Hello in there, Hello." Enjoy!

All the Questions You Had About Opioids But Were Afraid To Ask: A Podcast with Mary Lynn McPherson by Alex Smith and Eric Widera

How do you teach communication in serious illness? Can you? Do you teach it the same way to doctors and nurses in training? What level trainee do you target - medical students, interns, residents? How do we know our teaching is working? We discuss these and other bread and butter communication issues with Dr. Wendy Anderson, a palliative care physician at UCSF, director of the Bay Area Hub for Vitaltalk, and leader of IMPACT-ICU, a project to train ICU nurses in communication. Enjoy! -@AlexSmithMD

In this week's podcast we talk with Helen Kales, Professor of Psychiatry at the University of Michigan the VA Center for Clinical Management and Research. We've spent a great deal of effort in Geriatrics describing what we shouldn't do to address behavioral symptoms in dementia: physical restraints, antipsychotics, sedating antidepressants. Helen Kales was lecturing around the country about all of these things we shouldn't do a few years back, and people would raise their hands and ask, "Well, what should we do?" She realized she needed to give caregivers tools to help. Dr. Kales went on to develop the DICE approach to managing behavioral and psychiatric symptoms in dementia. Listen or read the full podcast to learn more! You'd be "crazy" not to! (hint: song choice).

On this weeks podcast, we interview Dr. Joan Teno about her recently published study in JAMA titled "Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015." In 2013, Dr. Teno published a study that showed how good our health care system in the US promotes patient churn. Despite positive signs of more hospice use and decreased deaths in the hospital, Dr. Teno found the from 2000 to 2009 we "churned" patients through more ICU visits, more hospitalizations, and more late transitions that are burdensome to dying persons in their family. Dr. Teno's latest study shows us how we are doing now, extending that work to 2015 and now including Medicare Advantage (MA) plans. So what did she find? Well here is a summary quote from Dr. Teno of the good news: "So, we see a continued decline in people dying in acute care hospital. Increase gross of hospice to nearly half the decedents. And what got me excited about these findings was we saw burdensome patterns of care decreasing. So, people who spent less than three days of hospice decreased from 14.2% in 2009 to 10.8%. People having three or more hospitalizations the last 90 days in life decreased from 11.5 to 7.1. The other thing is transitions between a nursing home and hospital and hospital nursing home nearly had a 50% reduction." And here is the bad news (depending on how you look at it): "So if you just take a look at that, it looks like we're heading in the right direction. One thing that we didn't see a budge in was, the use of ICU in the last 30 days of life. Now, is the glass half empty or is the glass half full? I have to admit I was pretty excited that ICUs wasn't going up." But there is so much more to summarize, including the difference between traditional Medicare fee-for-service and Medicare Advantage plans that you should just listen to the whole podcast as Dr. Teno is always someone I learn a ton from. Also, for more on this subject, check out our past podcast with Shi-Yi Wang, Assistant Professor in the School of Public Health at Yale, on her JAGS paper: "End-of-Life Transition Patterns of Medicare Beneficiaries."

This week we talk with Charlie Wray, MD, Assistant Professor of Medicine at UCSF, about why clinicians should use social media in their professional lives. Charlie is a hospitalist and the Associate Social Media Editor for the Journal of Hospital Medicine. His arguments for using social media are germane to all clinicians, however. "Number Needed to Tweet" is the title of his recent grand rounds on this subject.

In this week's GeriPal podcast we talked with Dr. John Nelson, who has been Medical Director of Hospice of Humboldt for 17 years.

In this week's podcast we talked with Dr. Bernard Lo (Bernie as he is known). Dr. Lo is President of the Greenwall Foundation, a foundation dedicated to improving Bioethics research nationally. Prior to Greenwall, Dr. Lo was Professor of Medicine at UCSF and head of the Bioethics Program. He still maintains a primary care practice at UCSF. We talked with Bernie about several dilemmas in the area of physician aid in dying, with conversation jump started by his recent NEJM perspective on this topic

For today's GeriPal Podcast we talk with Drs. Nathan Brummel and Lauren Ferrante, both critical care physician-researchers, about integrating geriatrics principles in intensive care units.

Tramadol. Is it just a misunderstood opioid that is finally seeing its well deserved day in the sun, or is it as our podcast guest David Jurrlink would say, what would happen if "codeine and Prozac had a baby, and that baby grew into a sullen, unpredictable teenager who wore only black and sometimes kicked puppies and set fires."

On today's episode we talk to Larry Allen and Dan Matlock about decision making around destination therapy. No this has nothing to do with your summer vacation plans. Rather, we talk about how individuals with heart failure decide about whether or not to pursue "destination therapy" with an Left Ventricular Device, or LVAD.

In this weeks GeriPal podcast, we interview Dr. Barak Gaster, Professor of Medicine and General Internist at the University of Washington in Seattle. Dr. Gaster felt like there was hole in the advance directives landscape around future planning for people with dementia. People with dementia experience a fairly common set of complications and decisions around feeding, loss of independence, and loss of ability to make complex decisions. His dementia specific advance directive has specific sections for care preferences for persons who progress through stages of dementia, including descriptions of mild, moderate, or severe dementia.