GeriPal - A Geriatrics and Palliative Care Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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