GeriPal - A Geriatrics and Palliative Medicine Podcast

Can routine initiation of goals of care discussions by a palliative care social worker improve prognostic understanding, elicit advanced care preferences, and influence care plans for high-risk patients discharged after a heart failure hospitalization? That is the question we attempt to answer with this weeks podcast guest, Arden E. O'Donnell. kbez8pby

This week's guest is Doug White, Professor of Critical Care Medicine at the University of Pittsburgh and lead author of a randomized controlled study of a nurse-led intervention to provide emotional support to families of seriously ill patients in the ICU and improve the quality of communication, published in the NEJM.

How do patients come to the decision regarding whether or not to initiate dialysis? Well, that is the question that we talk about with Keren Ladin on this week's podcast. Keren is a social science researcher, bioethicist, and assistant professor in the department of Occupational Therapy at Tufts. What becomes clear when you look at Keren's research is the for many patients, there isn't a decision that is made.

This week, Eric and I talked with Melissa Wachterman, a physician researcher from the Dana Farber Cancer Institute and Harvard Medical School. Melissa used a national dataset of people receiving hemodialysis linked to Medicare claims for older adults who died.

In this week's GeriPal podcast we talk with Cynthia Boyd, Professor of Medicine and Geriatrician at Johns Hopkins University School of Medicine about how physicians communicate with home health agencies. Home health plays a critical role in caring for persons residing at home, and in the best of circumstances extend a seamless network of care from the primary care physician's office to the home. Sadly, reality is not so rosy. The major form of communication between physicians and home health nurses is, well, a form. CMS Form 485 to be specific. In a recent study published in Annals of Internal Medicine, Dr. Boyd revealed that most primary clinicians barely read what the home health nurses write on the form, don't find the form useful, and rarely does it change management. It's the 21st century people. Can we move beyond lame forms and communicate with each other, perhaps using some modern technology? Or even 20th century technology, such as phones, if not 21st Century technology, such as video chats? Listen or read more to learn more. Enjoy!

There is a lot of discussion about the right to die. Although most of these have to do with Physician Assisted Death (PAD). What about in those who are not dying but express a dire to end their lives in the absence of a diagnosable mental illness? Do they have the same right? Well, on today's podcast we are going to step into this tricky topic with our guest, Dr. Meera Balasubramaniam, a Geriatric Psychiatrist from NYU. Meera wrote a paper for JAGS titled "Rational Suicide in Elderly Adults: A Clinician's Perspective". We talk with Meera about her article, including how she would define rational suicide, how can we help best explore these thoughts that patients consider rational, and how society and baby boomers are changing the way we think about this. We also dive into some other interesting topics include agism. I really love this quote from Meera, so I'll post it here, but for the full transcript read below or listen to the podcast: Ageism is a very interesting and distinct concept. It's fear of growing old or fear of being in that state. It's so distinct from something like racism or sexism. If a person is racist about a certain other race, it's less likely that they are going to be part of the other race that they are having negative connotations about. Similarly, if you are sexist, it's less likely less likely that you are going to belong to the other gender. When it comes to age, it's quite fascinating that most of us are actually going to get to that stage that we're being ageist about. What it is about growing old and about being down in the future that scares most of us has been sort of the crux of part of my work from a society perspective.

In this weeks podcast we talked with David Wang about how palliative care can join forces with the emergency department to improve care for the serious ill. This conversation was motivated in part by a recent expert consensus statement on key knowledge and skills standards about hospice and palliative medicine for emergency medicine providers. What should the core training be? How do emergency providers feel about palliative care? How can palliative care services that are typically available bankers hours work with the emergency department, open 24-7?

On todays podcast, we will be talking with Brooke Namboodri and we have Tim Platts-Mills from the University of North Carolina at Chapel Hill about their new article in the Journal of American Geriatric Society (JAGS) on "Elder abuse identification in the prehospital setting, an examination of state EMS protocols." We talk with Brooke and Tim about the state of EMS protocols in the US and how often the mention elder abuse in them (spoiler alert: not very often), how this compares to mentions of child abuse, the role EMS should play in elder abuse identification and management, and the role of potential screening tools for elder abuse.

In this weeks GeriPal/JAGS Podcast we talked witk Kei Ouchi, an emergency medicine physician, internist, and researcher at the Brigham and Women's Hospital and Harvard Medical School in Boston. We recorded this podcast in the hallways of the annual meeting. We talked about outcomes following intubation in the emergency department. Kei published a paper in JAGS that is notable for several things, but perhaps most of all for the innovative use of color imagery to convey a message. The image in the @AGSJournal tweet above is from Dr. Ouchi's article - this tweet went viral by the way - and notice what it does: (1) convey the main message that outcomes are worse with advancing age, and are not good in general overall; (2) grab your attention and make you want to learn more. Kei is very thoughtful about how these data should be used - not on the spot in the ED, when a patient is gasping for air, and you pull up the color figure on your iphone Twitter app - no, not then. Better to use this information in advance, when things are calm, outside the ED, for people at risk of going to the ED in extremis. This is the first in a series of GeriPal podcasts on the GeriPal - ED interface. ED stands for Emergency Department by the way. Enjoy! -By @AlexSmithMD

On this week's podcast, we talk with the authors of a Journal of the American Geriatrics Society (JAGS) article titled Should We Bury "The Good Death"? As luck may have it, one of the authors is co-host Alex Smith, and the other is a leader in geriatrics and palliative care, VJ Periyakoil. Alex and VJ's critique of the 'good death' was published alongside a paired commentary from Age and Ageing from the British Geriatrics Society.

For this week's GeriPal podcast we are honored to be joined by Tim Quill, palliative care physician and bioethicist from the University of Rochester, New York. Dr. Quill has pushed our nation to seriously grapple with the issue of physician aid in dying with a remarkably thoughtful and measured approach. We talk with Dr. Quill on this podcast about voluntary stopping eating and drinking, and a paper on this topic he recently published in JAMA Internal Medicine. As noted in the podcast, I am deeply ambivalent about physician aid in dying. I find voluntary stopping eating and drinking (VSED) to be far more acceptable. Some of this has to do with the acceptability of positive and negative acts (positive act - giving a patient a prescription for lethal medication; negative act - not inserting a feeding tube in a patient who refuses to eat and drink). Some of this just has to do with the time course: patients who stop eating and drinking must have the resolve and dedication over time. And they can change their minds. We address many aspects of this issue on the podcast, including: Who is VSED appropriate for? What can patients expect? How does VSED compare to other "options of last resort?" What is the role of palliative care? Should hospice's deem a patient eligible if they would not have a less than six month prognosis if they continued to eat and drink? When should a psychiatrist be involved? What if the suffering is not physician, but social or psychological? Is VSED legal? Should clinicians routinely offer VSED to all patients with serious illness as an option? How do you feel about this topic? Feel free to respond in the comments, or on Twitter!

For this weeks podcast, we talk with Laura Petrillo, lead author of a recent paper published in JAMA IM titled "Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes". Laura is a palliative care physician and researcher at Massachusetts General Hospital and Harvard Medical School. Laura's finding should serve as a wakeup call for anyone caring for individuals on hospice living in nursing homes. They found that 1 in 9 nursing home patients with type 2 diabetes experienced hypoglycemia. So take a listen an tell us what you think in the comment section on this GeriPal post.

Many in palliative care (including us) have argued that the default care model in nursing homes should be a palliative approach. Revealing indeed, therefore, to talk with nurse researcher Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion for nearly 200 residents of 3 San Francisco area nursing homes, finding: 70% of nursing home residents were palliative care-eligible, but other than 2 patients on hospice, none were receiving consultative palliative care 99% of residents had completed a POLST, but almost no one remembered filling it out Listen to the podcast for more, including answer to questions: What does palliative-care eligible mean? How could they fill out a POLST but not remember it, did they all have dementia? What is Campbell's law, and does it have anything to do with his soup? We're joined on this podcast by Sei Lee, MD, regular guest host and as it happens senior author on the nursing home study, and Lynn Flint, MD, palliative care physician with extensive experience working in nursing home settings. Enjoy!

Proton pump inhibitors are one of the most widely used medications. As I note in the podcast below, I was in my local drug store the other day, and an entire shelf segment, top to bottom, was filled with medications for "heartburn," and most of them were proton pump inhibitors. And those are just the over the counter variety. So wouldn't it be a public health disaster if proton pump inhibitors, or PPIs, increased a persons risk for dementia? Even if the increase in dementia risk is only slight, on a population level, given the vast number of people using PPIs, the consequences would be disastrous. A major study in JAMA showed just such a linkage, raising serious alarm about this issue. So with this urgent question in mind, we talk with two authors about their more recent studies in JAGS suggesting that there is no such linkage. We talked with Shelly Gray, from the School of Pharmacy and the University of Washington, and Felicia Goldstein from Emory University, about their studies, the current evidence as a whole, and what an individual on PPI's should think at this time about his or her risk of dementia. Here is the bottom line, for those who can't wait. In response to Eric asking what advice they would give their 75 year old neighbor who is taking PPI's, Dr. Gray said: I would tell her that the information is conflicting, but some really high quality studies have been done and have not found an association, and if this medication is necessary to manage her condition, that she should continue taking it. However, I will say that we do know that these medications are overused, and so I still believe in the tenet of geriatric medicine that we try to deprescribe when possible, so I would try to reassure her and let her know that it's not a done deal and that the high quality studies do indicate that there doesn't seem to be an association.

Today we have Lee Lindquist with us on the GeriPal podcast to talk about planning for the "4th quarter" of life. Dr. Lindquist is a geriatrician and chief of geriatrics at Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine in Chicago. Dr. Lindquist developed a website called PlanYourLifespan.org to help older adults create strategies for dealing with health crises, such as hospitalization, a serious fall, and dementia. Using the website, older adults can think about what services they may need in the last 10 or 15 years of their lives, what choices they can make now, and how to access these services when needed. Her work was also recently published in a a Journal of Hospital Medicine paper showing that the website helped older adults plan for posthospital discharge needs before a hospitalization occurs. So give it a listen and comment below on what you think should be address in the last quarter of life.

We have a great podcast this week exploring the advance care planning needs for hospitalized adults and what palliative care teams are doing (and not doing) to meet these needs. We've invited Kara Bischoff, a palliative care doctor and Assistant Professor at UCSF in the Department of Hospital Medicine, who published a paper in JAMA Internal Medicine on this very topic. Why was this JAMA IM paper so important for those who work in our field? This was a real world study, looking at over 73,000 consultations from the Palliative Care Quality Network (PCQN). They found palliative care teams consistently identified surrogates for patients, often addressed their preferences regarding life sustaining treatments, including code status, and frequently found a preference regarding life sustaining treatments that was different than what was previously documented before the consult. But rarely completed advance directives (only 3.2% of patients seen by palliative care teams) or Physicians Orders for Life-Sustaining Treatment (POLST) forms (12.3% of patients seen by palliative care teams).

Our guests this week are Lena Makaroun, MD, a research fellow at the VA Pudget Sound, and Sei Lee, MD, Associate Professor of Medicine at UCSF and frequent co-host on this podcast. They recently wrote a paper in JAMA Internal Medicine on wealth disparities in the US and England, and implications for mortality and disability. Major take home points: "It's not that great to be rich, but it really sucks to be poor." Those in the bottom quintile of wealth had the greatest difference in disability and mortality (ie worse). Differences between those in the highest quintile of wealth and the next highest were relatively minor in comparison. "Rather than saying universal healthcare doesn't help, I would just say it's not enough." Worse disability and mortality with lower wealth were observed in the US and England, both before and after age 65. Does this mean National Health Service isn't working? The authors expected to find less difference in England where universal coverage is, well universal, and not just after age 65 in the US (Medicare). The authors give thoughtful responses.

For this weeks podcast, we talk all about prognostication with Christian Sinclair. Christian is a palliative care physician at University of Kansas Medical Center, past president of AAHPM, recent AAHPM "Visionary" awardee, and Pallimed social media guru. We go over a lot of topics at the heart of prognostication in hospice and palliative care including: - The importance that prognostication plays in daily practice, especially in goals of care discussions - Helpful tools and skills to estimate prognosis - How prognosis changes the way we think about prescribing opioids - How to think about prognosis when it comes to hospice eligibility and why it may be that one of the most important tools used for prognostication in the hospice setting, the hospice eligibility guidelines, were last updated over two decades ago. So we have a ton to talk about and we would love for you to continue this discussion in the comment section of this blog, on Facebook or on twitter.

In this week's GeriPal podcast, we talk with Jessie Merlin, Palliative Care Faculty at the University of Pittsburgh, who is addressing another important aspect of this issue: the role of palliative care in chronic pain. We disucss issues such as: - Do outpatient palliative care providers see patients with chronic pain currently? (please take this survey to help Jessie figure this out!) - Should palliative care fellowship training include management of chronic pain? - Is there really a distinction between "cancer pain" and "non-cancer pain?" - To what extent is or should prognosis be a factor in determining treatment of pain? - Everybody Hurts by REM (and a hack rendition)

In this week's GeriPal Podcast, sponsored also by the Journal of the American Geriatrics Society, we talk with Tom Gill, MD, Professor of Medicine at Yale. With guest co-host Dan Matlock, MD, from the University of Colorado, we talk with Tom about his recent JAGS publication on the relationship between distressing symptoms, disability, and hospice enrollment. Tom conducted this study in a long running cohort of older adults that has made a number of outstanding contributions to the GeriPal literature (see links on the GeriPal website). Tom's song request? Stairway to Heaven. This podcast was recorded at the recent Beeson meeting, an aging research meeting, near Albuquerque, New Mexico. At the end, you hear about 30-40 of us singing the end of Stairway around a campfire. As in singing, "And as we wind on down the road...:" Nailed it!

On this week's podcast, we have invited Dr. Kimberly Curseen to talk about how implicit bias influences us as providers in geriatrics, hospice, and palliative care, as well as the role of that cultural competence and cultural humility should play in our practice. Kimberly Curseen, M.D. is an Associate Professor of Internal Medicine at Emory School of Medicine and Director of Outpatient Supportive/Palliative Care, Emory Healthcare.

On this GeriPal podcast we discuss the value of "scenario planning" in informed decision making with Gretchen Schwarze, Associate Professor in the Division of Vascular Surgery at the University of Wisconsin. Dr. Schwarze is a board-certified vascular surgeon and medical ethicist who recently wrote an article on this subject in the New England Journal of Medicine (NEJM). Scenario planning comes from the economics literature, but Dr. Schwarze advocates for its use in medicine, giving healthcare providers the tools to say "I cannot predict the future, but if all goes well, this is what is likely to follow, and if things go poorly, this is what we can expect." The aim is not to develop the "correct" scenario, but to describe a range of stories illustrating how the future might unfold.

Back in 2009, Pallimed created one of my favorite posts titled "Top 10 Contemporary Palliative Care Songs". In it, they made a list of "contemporary" songs from many different genres that have palliative themes. For todays podcast, we aim to update this list with songs that inspire, move, or make us think about geriatrics or palliative care. As with the Pallimed post, this is all personal preference. So we would love to hear from you. What one song would you have included in this podcast if you were sitting in the studio? Put it in the comments section on www.geripal.org

On this weeks podcast, we have Sarah Hooper, J.D., the Executive Director of the UCSF/UC Hastings Consortium on Law, Science and Health Policy, an interprofessional partnerships in education, research, and clinical training and service. We talk with Sarah about her work creating the Medical-Legal Partnership for Seniors Clinic (MLPS) in which law students and faculty provide free legal assistance to low-income older patients at the UCSF Medical Center and at the San Francisco VA.

Zara Cooper the Need to Integrate Geriatrics and Palliative Care into Trauma Surgery by Alex Smith and Eric Widera

How to have a code status conversation with Laura Petrillo and a live studio audience by Alex Smith and Eric Widera

Vicki Jackson and David Ryan: Living with Cancer by Alex Smith and Eric Widera

The Veterans Healthcare System is the largest integrated healthcare system in the United States and one that trains the majority of physicians who practice in the US. We interview journalist and author Suzanne Gordon about the battle that is going on for the $70 billion spent on Veterans health every year.

We interview Anna Chodos, Assistant Professor in the Department of Medicine and Division of Geriatrics at UCSF, about her work in creating the Optimizing Aging Collaborative. The collaborative's goal is to enhance and unify care of older adults in the community by creating a unique partnerships between public, human service, and academic organizations. The Optimizing Aging Collaborative at UCSF, which was founded in July 2015 as a Geriatric Workforce Enhancement Program (GWEP) by the U.S. Health Resources and Services Administration (HRSA). The collaborative includes a broad array of experts to provide education and innovative services that address older adults' health, social, and legal needs, that hopefully other cities can replicate.

On today's podcast, we interview Steve Pantilat about his new book "Life After the Diagnosis: Expert Advice on Living Well with Serious Illness for Patients and Caregivers." Steve is a Professor of Medicine, the Department of Medicine at UC San Francisco, Kates-Burnard and Hellman Distinguished Professor in Palliative Care, and Founding Director, the UCSF Palliative Care Program. In his book, Steve writes to patients and family members coping with serious illnesses about the difficult decisions they face in a convoluted medical system, giving them practical advice on a wide range of common concerns. We talk with Steve about how he came up with the idea of the book, his views on living well and what a "good death is", the role that hope plays in decision making, and the language that we use in medicine that can easily be misunderstood.

This week's GeriPal Podcast features NY Times journalist Paula Span about what we can do as educators, as researchers, and as clinicians, to collaborate with the media. During Paula's extensive career as a reporter, she has written for the Washington Post, Philadelphia Inquirer, the Boston Globe, the Wall Street Journal, Newsweek, New York Magazine, Esquire, Parenting, Glamour, Ms and several city magazines. Paula currently writes at The New York Times for The New Old Age, and trains the next generation of journalists at the Columbia University Graduate School of Journalism.

What should you say to your older patient when it's time to stop cancer screening? This week's GeriPal Podcast features Nancy Shoenborn, Assistant Professor of Medicine at Johns Hopkins. Dr. Shoenborn published a paper in JAMA Internal Medicine this week on older adults perspectives on cancer screening cessation, and using life expectancy to justify stopping screening.

Today's GeriPal Podcast features Vanessa Grubbs, a nephrologist and Associate Professor of Medicine at UCSF. Vanessa talks with us about her forthcoming book titled, "Hundreds of Interlaced Fingers," to be released June 13, but available for pre-order now. Dr. Grubbs' book tells the story of her journey from primary care to nephrology to palliative care, of falling in love with a man to donating a kidney to him to marriage, and of the journeys of the diverse, older, complex patients she's cared for with chronic kidney disease, who sometimes choose not to start dialysis.

For this week's GeriPal podcast we talk with Sandra Moody, MD, about her experiences in geriatrics and palliative care in Kamogawa City, Japan. Sandra helped to start the hospice and palliative care service at the San Francisco Veterans Affairs Medical Center prior to moving to Japan. We spoke with Sandra about differences between geriatrics and palliative care as practiced in the US vs. Japan.

We talked with Rebecca about the results of The Prepare Trail, a randomized controlled trial of an easy-to-read advance directive PLUS a web-based decision aid vs the easy-to-read advance directive alone in 414 older veterans with chronic disease

A study published in JAGS reported approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. We discuss with the studies author about how he became interested in transitions and why this is important.

On todays podcast, we interview Dr. Samir K. Sinha, MD on how he has influenced local and national policy to redesign the care we give to older adults. Dr. Sinha is the Director of Geriatrics at the Sinai Health System, an Associate Professor of Medicine at the University of Toronto, and Assistant Professor of Medicine Johns Hopkins University School of Medicine. Among his many accomplishments is that he lead Ontario's "seniors care strategy" and is now involved in the development of a National Seniors Strategy.

On this weeks podcast, we interview Michael D. Fratkin, a palliative care clinician and founder of ResolutionCare, a palliative care service for rural and resource poor areas in Northern California. We discuss the barriers and benefits of providing specialty level palliative care for areas that generally have no access to these services. We also discuss novel approaches, including in-home video conferencing.

Today's GeriPal podcast features Sean Morrison, Geriatrician and Palliative Medicine physician, director of the National Palliative Care Research Center and the Hertzberg Palliative Care Institute at Mount Sinai in New York. We talk with Sean about a new report titled, "How We Work: Trends and Insights in Hospital Palliative Care." This report was co-produced by the National Palliative Care Research Center and the Center to Advance Palliative Care. The report summarizes the current state of palliative care practice in the US.

Today's GeriPal podcast features Laura Hanson, Geriatrician and Palliative Medicine physician at the University of North Carolina, Chapel Hill. Laura discusses her recent JAMA RCT of a goals of care intervention for nursing home residents with advanced dementia.

We discuss with geriatrician, palliative care clinician, professor of medicine at Harvard Medical School, and author Muriel Gillick about the state of our current health care system for older adults as they journey through our health care system.

In this GeriPal Podcast we talk with Dr. Mark A. Supiano about a blood pressure management in older adults in the light of new evidence from the Systolic Blood Pressure Intervention Trial (SPRINT). In particular, we talk about a recent paper he co-author with Jeff Williamson in the Journal of the American Geriatrics Society (JAGS) titled "Applying the Systolic Blood Pressure Intervention Trial Results to Older Adults."

We talk with Dr. Jessica Zitter, a pulmonary critical care and palliative medicine physician, and author of Extreme Measures: Finding a Better Path to the End of Life. We talk with Jessica about her experience transitioning from being an ICU doctor to an ICU/Palliative doctor, how she is treated differently when she sees patients as an ICU attending vs a palliative care attending, the Big 3 (CPR, mechanical ventilation, and feeding tubes), and most importantly WHO she is wearing to the Oscars!

On todays podcast we interview Nathan Goldstein, MD, Chief of the Division of Palliative Care for Mount Sinai Beth Israel. We discuss his experiences and research focused on improving communication and the delivery of palliative care to patients with advanced heart failure.

On todays podcast, we talk with Vicki Jackson, Chief of the Palliative Care Division at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, about her work in building the evidence base for palliative care.

Nursing home residents are often sent to the hospital for care that often offers little hope of improving quality of life or changing the course of illness. Some facilities though seem to do much better in preventing these "potentially burdensome hospitalizations". We discuss with Andrew Cohen, the lead author of a recent JAMA IM paper on this subject, to learn a little about what is in the secret sauce of these exceptional nursing homes.

Clinical formulations, something that few of us outside of mental health providers know about, but are critical in improving communication skills, especially around serious illness. Learn about them from our special guest, Dani Chammas, who makes the case that the single most valuable thing clinicians can do to improve communication is to get into the practice of developing a formulation.

On todays podcast, we talk with Angelo Volandes about the use of video to improve advance care planning.

Just in time for Thanksgiving, we are having an episode dedicated to the humble cranberry. We discuss the use of cranberries to preventing urinary tract infections with Dr. Manisha Juthani-Mehta. In addition to hearing about something called proanthocyanidin, we discuss her recent publication in JAMA on whether cranberry capsules decrease the presence of bacteriuria plus pyuria in older women living in nursing homes.

There are a lot of ways one can imagine on how to integrate palliative care into the intensive care unit (ICU). Today, we talk with ICU doctor and researcher, Bill Ehlenback, about his recent study of a proactive palliative care rounding intervention.