GeriPal - A Geriatrics and Palliative Care Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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