GeriPal - A Geriatrics and Palliative Care Podcast

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

In this 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.

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