GeriPal - A Geriatrics and Palliative Care Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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