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RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest

GeriPal - A Geriatrics and Palliative Medicine Podcast

Release Date: 04/10/2025

We Need a Care Revolution: Victor Montori show art We Need a Care Revolution: Victor Montori

GeriPal - A Geriatrics and Palliative Medicine Podcast

In his book, “,” Victor Montori decries the industrialization of healthcare.  We’ve become a healthcare factory, beholden to health systems motivated by profit. In particular, he laments the loss of the “care” aspect of healthcare. Clinicians are under the clock to churn through patients.  Patients are tasked with doing work outside of the clinic. Patients are tasked with hours and hours of work to self manage, obtain and manage medications, track weights and fingersticks, not to mention scheduling visits and waiting around for the visit to start. Now we have an app for...

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System Wide Goals of Care Implementation: A Podcast with Ira Byock, Chris Dale, and Matt Gonzales show art System Wide Goals of Care Implementation: A Podcast with Ira Byock, Chris Dale, and Matt Gonzales

GeriPal - A Geriatrics and Palliative Medicine Podcast

Most health care providers understand the importance of goals-of-care conversations in aligning treatment plans with patients’ goals, especially for those with serious medical problems. And yet, these discussions often either don't happen or at least don't get documented. How can we do better? In today’s podcast, we sit down with Ira Byock, Chris Dale, and Matthew Gonzales to discuss a multi-year healthcare system-wide goals of care implementation project within the Providence Health Care System. Spanning 51 hospitals, this initiative was recently described in NEJM Catalyst, showing truly...

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Death Anxiety: Dani Chammas & Keri Brenner show art Death Anxiety: Dani Chammas & Keri Brenner

GeriPal - A Geriatrics and Palliative Medicine Podcast

What is death anxiety?  We spend the first 15 minutes of the podcast addressing this question.  And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on and the ).  After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss! Several key points stood out to me from this podcast, your key points may differ: The “anxiety” in “death anxiety” is not a...

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Individualizing Blood Pressure Goals in Older Adults: A Podcast with Mitra Jamshidian, Simon Ascher and Mark Supiano show art Individualizing Blood Pressure Goals in Older Adults: A Podcast with Mitra Jamshidian, Simon Ascher and Mark Supiano

GeriPal - A Geriatrics and Palliative Medicine Podcast

What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the ? Or should we be more flexible—especially for those who are frail or among the oldest old? This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher.  Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled ”  Yes, we sure...

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Should Palliative Care be in the Survivorship Business? A Podcast with Laura Petrillo, Laura Shoemaker show art Should Palliative Care be in the Survivorship Business? A Podcast with Laura Petrillo, Laura Shoemaker

GeriPal - A Geriatrics and Palliative Medicine Podcast

In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems. We’ve invited two palliative care doctors to talk about survivorship with us: , a physician-researcher at Mass General Hospital and Harvard Medical School, and , an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we...

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Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho show art Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho

GeriPal - A Geriatrics and Palliative Medicine Podcast

famously characterized the end of life functional course of people with dementia as a slow dwindle over time. later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives. But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia.  Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover.  And they’re often a sign of (or cause...

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Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt show art Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt

GeriPal - A Geriatrics and Palliative Medicine Podcast

Happy Pride Month GeriPal listeners! Transgender issues are in the news. Just today (June 17th) as we record this podcast: Ezra Klein released a wonderful , the first openly transgender member of congress A judge ruled that focused on minority groups, including transgender people, were illegal and ordered the government to restore funding.  It’s Pride month, and our guests remind us of the in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation. Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story...

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What You Should Know About Radiation Oncology: A Podcast with Anish Butala, Emily Martin and Evie Kalmar show art What You Should Know About Radiation Oncology: A Podcast with Anish Butala, Emily Martin and Evie Kalmar

GeriPal - A Geriatrics and Palliative Medicine Podcast

If you’re anything like me, you might find the process of what happens to patients when they visit a radiation oncologist somewhat mysterious. During my training, I didn’t receive much education about radiation oncology, and I’m not entirely sure what some of the terms mean (hypofractionated means fewer sessions, right?). Well, today’s podcast aims to clear up all these uncertainties. We’ve invited , and , a palliative care doctor and past president of the Society for Palliative Radiation Oncology (SPRO), to explain everything we should know about radiation oncology. Additionally, ,...

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Implementing Palliative Care in Nursing Homes show art Implementing Palliative Care in Nursing Homes

GeriPal - A Geriatrics and Palliative Medicine Podcast

The need for better palliative care in nursing homes is significant. Consider this: the majority of the 1.4 million adults residing in U.S. nursing homes grapple with serious illnesses, and roughly half experience dementia. Many also suffer from distressing symptoms like pain. In addition, about 25% of all deaths in the United States occur within these facilities. Despite these substantial needs, specialized palliative care beyond hospice is rare in nursing homes. Furthermore, only about half of nursing home residents nearing the end of life receive hospice care. So, how can we improve...

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Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson show art Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson

GeriPal - A Geriatrics and Palliative Medicine Podcast

Have any of you watched the movie “”?  At the end, one of the characters, who has dementia, experiences an episode of lucidity.  When I watched it, between tears (I’m a complete softie) I remember thinking, “Oh no! This will give people false hope!  That their loved one is ‘in there.’ If only they could find the right key to unlock the lock and let them out.” Today we talk about lucid episodes and what they might mean to the person with dementia, their family and loved ones, to philosophers, to clinicians, to neuroscientists. Our guests are Andrea...

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Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department.  I asked emergency medicine clinicians what they thought when a patient who is seriously ill and DNR comes to the ED, and some responded, (paraphrasing), what are they doing here? This is not why I went into emergency medicine. I went into emergency medicine to act. I can’t do the primary thing I’ve been trained to do: ABC, ABC, ABCs.  Most emergency providers wanted to do the right thing for seriously ill patients, but they didn’t have the knowledge, skills, or experience to do it.

Today we focus on an intervention, published in JAMA, that gave emergency clinicians basic palliative care knowledge, training, and skills.  We talk with Corita Grudzen and Fernanda Bellolio about their cluster stepped wedge randomized trial of a palliative care intervention directed at emergency clinicians.  They got training in Vital Talk and ELNEC.  They got a decision support tool that identified hospice patients or those who might benefit from a goals of care discussion.  They got feedback.

So did it matter?  Hmmm….it depends.  We are fortunate to have Tammie Quest, emergency and palliative trained and long a leader in this space, to help us unpack and contextualize these findings.

Today we discuss:

  • Why the study was negative for the primary (hospitalization) and all secondary outcome (e.g. hospice use).

  • Why to emergency clinicians, this study was a wild success because they had the skills they wanted/needed to feel like they could do the right thing (during the onset of Covid no less).

  • Why this study was a success due to the sheer size (nearly 100,000 patients in about 30 EDs) of the study, and the fact that, as far as the investigators know, all study sites continue to employ the clinical decision support tool.

  • What is a cluster stepped wedge randomized trial? 

  • Were they surprised by the negative findings?

  • How do we situate this study in the context of other negative primary palliative care interventions, outside the ED?  E.g. Yael Shenker’s negative study of primary palliative care for cancer, Randy Curtis’s negative study of a Vital Talk-ish intervention, Lieve Van den Block’s negative study of primary PC in nursing homes. Why do so many (most, all??) primary palliative care interventions seem to fail, whereas specialized palliative care interventions have a relatively robust track record of success. Should we give up on primary palliative care?  What’s next for primary palliative care interventions in the ED?

And if your Basic Life Support training certification is due, you can practice the correct chest compression rate of 110 beats per minute to Another One Bites the Dust.

-Alex Smith