Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh
GeriPal - A Geriatrics and Palliative Medicine Podcast
Release Date: 05/15/2025
What Makes a Good Death? Karen Steinhauser, Rasa Mikelyte, Edison Vidal
GeriPal - A Geriatrics and Palliative Medicine Podcast
What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful? Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers. In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We...
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Medical Billing and Coding with the "Billing Boys"
GeriPal - A Geriatrics and Palliative Medicine Podcast
A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following: Billing is complicated, but it isn’t hard. Effectively billing helps pay for the interprofessional team members who often can't bill We should know our worth and bill for it. Just because a visit didn’t feel HARD to a well-trained provider doesn’t mean it wasn’t complex or valuable. Many of us have long suffered from low professional self-esteem when it comes to money, and it’s high...
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Is Geriatrics-focused Primary Care (GeriPACT) Better? A Podcast with Nicki Hastings, Kristie Hsu, and Ken Covinsky
GeriPal - A Geriatrics and Palliative Medicine Podcast
On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program. It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population. We unpack the intriguing findings of a recent , looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT). While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn't...
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Do Dementia Care Management Programs Work? A Podcast with David Reuben and Greg Sachs
GeriPal - A Geriatrics and Palliative Medicine Podcast
With all the attention focused on Alzheimer's biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA. We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — and — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the...
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Comprehensive Geriatric Assessment: Benefits, Cost-Effectiveness, and Who It Helps Most - Eric Wong and Thiago Silva
GeriPal - A Geriatrics and Palliative Medicine Podcast
In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including: What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment? Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it? Who is the comprehensive geriatrics assessment for?...
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What instead? Alternatives to Beers: Todd Semla and Mike Steinman
GeriPal - A Geriatrics and Palliative Medicine Podcast
On a we talked with Todd Semla and Mike Steinman about the update to the of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel). One of the questions that came up was - well if we should probably think twice or avoid that medication, what should we do instead? Today we talk with Todd and Mike about their new recommendations of , and also presented at the 2025 AGS conference in Chicago (and available ). We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers...
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Art Museum-Based Medical Education: Amy Klein, Laura Morrison, and Gordon Wood
GeriPal - A Geriatrics and Palliative Medicine Podcast
Health care trainees rotate through a variety of different settings. ICUs, hospital wards, and outpatient clinics. If they're lucky, they might even spend time in a nursing home. But on today’s podcast, we’re adding one more setting to that list: your local art museum. In this thought-provoking episode, we explore how art museum teaching is being integrated into the education of medical professionals—and why it's making a profound difference. Our guests, , , and , share their journey of integrating art into medical training, along with practical strategies you can use if you're inspired...
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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
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
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...
info_outlineOur main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine.
To start. we review:
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What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.
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Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.
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What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge.
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Examples of nudges, some based in health care, others in coffee.
This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups:
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Usual care
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Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect
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Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies.
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Both the prognosis and comfort care nudge.
A few key points of discussion:
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Is an EHR prompt a nudge or sludge?
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The intervention was a negative study for the primary outcome, hospital length of stay. Why?
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The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?
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The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? Imagine!