GeriPal - A Geriatrics and Palliative Medicine Podcast

A geriatrics and palliative medicine podcast for every health care professional. Two UCSF doctors, Eric Widera and Alex Smith, invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You'll laugh, learn, and maybe sing along. CME and MOC credit available (AMA PRA Category 1 credits) at www.geripal.org

We Need a Care Revolution: Victor Montori 07/31/2025

We Need a Care Revolution: Victor Montori 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 that. For what, you ask? Well, for everything! Digital burden is real. Think about what we ask patients to do: charge your device, remember your password, 2 factor authentication, each interface is different, wait…where do you enter your fingersticks again? Victor is an endocrinologist who often provides care for older patients with multiple chronic conditions, polypharmacy, and complex social situations. He’s “one of us.” Some might argue that these circumstances call for incremental change. Not Victor. He argues that we need a revolution. In particular, he argues that the revolution must come from patients to be successful. On this podcast we discuss: Why do we need a revolution? What made him get to this point of arguing for a revolt? Why should the revolution be patient led, rather than clinician led? What role do clinicians have to play? What is (a term Victor coined with Carl May and Francis Mair in 2009)? How does shared decision making fit into the revolution? What’s the matter with guidelines? What’s the role of standardization? We suspect that most geriatrics and palliative care providers feel like they’ve escaped many of the issues Victor describes, trading less glamorous and remunerative work for more satisfying time spent caring for patients; focusing on what matters, goals of care, and attention to emotion and social well-being. Are we deluding ourselves? If you’d like to join the revolution, please check out Victor’s website, And I believe this is the first Peter Gabriel song request! I think Peter Gabriel’s album So was the first cassette tape I purchased. About time, 350+ podcasts in. My son Kai turns this very non-guitar friendly song into an acoustic jam for the audio-only podcast version; you get my weaker attempt on YouTube :) Finally, a quick plug for the in Portland OR. Victor and I had a terrific time bonding at this year’s lecture series. While not strictly geriatrics and palliative care focused, the lectures seem targeted at a broad audience, with something for everyone. And yes, I made them sing parody songs :) -Alex Smith /episode/index/show/geripal/id/37613245

System Wide Goals of Care Implementation: A Podcast with Ira Byock, Chris Dale, and Matt Gonzales 07/24/2025

Death Anxiety: Dani Chammas & Keri Brenner 07/17/2025

Death Anxiety: Dani Chammas & Keri Brenner 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 pathological phenomenon or a DSM diagnosis; it references an existential concern that is fundamental to the human experience . To me,” awareness of mortality” might be a better term, but in fairness, the idea of “death anxiety” was coined well before the formal establishment of “anxiety disorders.” The ways in which death anxiety manifests in our patient’s choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no “one size fits all” approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient in remission from cancer any pain might signal return of cancer. Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience. Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can’t define (sorry Dani and Keri!), but also through our own unexamined fears about death. As clinicians who regularly care for people who are dying, we might find ourselves becoming “used to” death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients. I mean, don’t fear the reaper, right? Sorry, no in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version. Here are some resources for listeners wanting to learn more about this topic: Books: Yalom ID. . New York, NY: Basic Books; 1980. Yalom ID. . San Francisco, CA: Jossey-Bass; 2008. Solomon S, Greenberg J, Pyszczynski T. . New York, NY: Random House; 2015. Becker E. . Free Press; 1973. Articles: Emanuel LL, Solomon S, Chochinov HM, et al. . J Palliat Med. 2023;26(2):235-243. Chochinov HM, McClement SE, Hack TF, et al. . J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052. Clark D. . BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905. Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. . J Pers Soc Psychol. 2009;97(2):334–350. Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. . J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00 Brown TL, Chown P, Solomon S, Gore G, De Groot JM. . Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068. Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. . J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453. /episode/index/show/geripal/id/37433200

Individualizing Blood Pressure Goals in Older Adults: A Podcast with Mitra Jamshidian, Simon Ascher and Mark Supiano 07/10/2025

Should Palliative Care be in the Survivorship Business? A Podcast with Laura Petrillo, Laura Shoemaker 07/03/2025

Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho 06/26/2025

Health and Wealth Shocks: Lauren Hunt, Rebecca Rodin, Tsai-Chin Cho 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 of?) worsening prognosis. Today we talk about disruptive events, or health and wealth shocks. We start with Lauren Hunt, who described the and of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia. We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in . Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries. Tsai-Chin’s article, published in found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function. Wait, so one key message is that social health is linked to physical and cognitive health?!? And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners. And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics! -Alex Smith Additional links mentioned by Tsai-Chin Cho: - - /episode/index/show/geripal/id/37152850

Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt 06/19/2025

Transgender Health, Aging, and Advocacy: A Podcast with Noelle Marie Javier and Jace Flatt 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 of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having because they included transgender participants. We cover many topics, including: Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+ Gender affirming care Major health and medical issues associated with aging as a transgender person Allostatic load Accelerated aging What can clinicians do - pointers, pearls, and attitudes Dementia Caregiver issues Hormone replacement therapy at the end of life Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely Mentioned: Harvey Chochinov’s , and our prior podcast on s with Carey Candrian and Angela Primbas So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast. -Alex Smith Many links! -: Jace Flatt’s research site. - - gender affirming trans health services -: organization for health professional advancing LGBTQ+ equality - - -: focus on impact of Medicaid cuts -s: resource guide /episode/index/show/geripal/id/37061510

What You Should Know About Radiation Oncology: A Podcast with Anish Butala, Emily Martin and Evie Kalmar 06/12/2025

Implementing Palliative Care in Nursing Homes 06/05/2025

Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson 05/29/2025

Lucid Episodes: Andrea Gilmore-Bykovskyi & Andrew Peterson 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 Gilmore-Bykovskyi, a nurse researcher, and Andrew Peterson, a philosopher. We had a wide ranging discussion that touched on (among many things): A consensus definition developed at an NIH conference, organized by the recently retired NIA program officer (we will miss you Basil!). Andrew complicates this , stating is raises more questions than answers. Hospice nurses know that terminal lucidity “is a thing” and have pretty much all seen it Family and caregiver of lucid episodes and what they meant to them, including early glimpses into a Andrea is doing using video to capture episodes and show them to family. Potential for experiences to elicit “false hope”, misunderstanding/misinterpreting, and changing say code status from DNR to full code (). ’s work on brain activity during CPR and near death episodes Ethical issues these lucid episodes raise Should clinicians treat people with dementia as always lucid? Having some level of awareness? Parallels between how we treat people with advanced dementia, who may or may not be lucid, and , who may or may not be conscious, or experiencing paradoxical lucidity on their way to full consciousness. I try to say please and thank you to the AI I interact with other than Alexa, who is obviously way behind. The , featuring Anne Bastings, Jason Karlawish, Elizabeth Donnarumma, and Justin Clapp Was Andrew’s song choice, “I can see clearly now” better than Eric’s suggestion “Silent Lucidity” by Queensryche? Enjoy! -Alex Smith /episode/index/show/geripal/id/36735955

Music as Medicine: Jenny Chen, Tyler Jorgensen, & Theresa Allison 05/22/2025

Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh 05/15/2025

Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh Our main focus today was on 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: What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases. Prior podcasts on the , and a different trial conducted by Kate and Scott in which the . 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. Examples of nudges, some based in health care, others in coffee. This specific , 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: Usual care Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect 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. Both the prognosis and comfort care nudge. A few key points of discussion: Is an EHR prompt a nudge or sludge? The intervention was a negative study for the primary outcome, hospital length of stay. Why? 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? 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? ! - /episode/index/show/geripal/id/36568335

Psilocybin in Serious Illness: A Podcast with James Downar, Ali John Zarrabi and Margaret Ross 05/08/2025

HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene 05/01/2025

HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene Peter Selwyn, one of today’s guests, has been caring for people living with HIV for over 40 years. In that time, care of people with HIV has changed dramatically. Initially, there was no treatment, then treatments with marginal efficacy, complex schedules, and a tremendous burden of side effects and drug-drug interactions. The average age at death was in the 30s. Now, more people in the US die with HIV rather than from HIV. Treatment regimens are simplified, and the anti-viral drugs are well tolerated. People are living with HIV into advanced ages. The average age at death is likely in the 60s. Nearly half of people living with HIV are over age 55. One in 10 people with newly diagnosed HIV is an older adult. Our second guest, Meredith Greene, is a geriatrician and researcher who focuses on care of older adults living with HIV, in the US and Africa. On today’s podcast we discuss: Implications of aging with HIV for clinical care Loneliness and social isolation among older adults living with HIV Persistence of stigma Need to consider HIV in the differential diagnosis for older adults Screening for HIV Screening for osteoporosis in people living with HIV Dementia and cognitive impairment risk in people living with HIV When to stop anti-virals near the end of life Toward the end we speak to the moment. More older adults live with HIV in SubSaharan Africa and the global South than anywhere else in the world. Funding for research and clinical care is at risk, as USAID and PEPFAR (which is under USAID), are shuttered. Millions of lives are at stake. Meredith wore a shirt that said . Eric gave me the hook during my live cover of One, by U2, a song released in 1992 whose proceeds went entirely to AIDS research. I couldn’t help it, forgive me dear listeners, I had to do a longer than usual cut at the start! -Alex Smith Useful links: Peter's article on the evolution of HIV: Peter’s book PEPFAR: Articles: Management of Human Immunodeficiency Virus Infection in Advanced Age About Act-up for those who might know the Silence=Death t-shirt reference: /episode/index/show/geripal/id/36377765

Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan 04/24/2025

Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan More and more people are, “” Self-identified experts and influencers on (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals. An increasing number of federal have a of endorsing such products. We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently. Ivermectin to treat cancer. Stem cell treatments. Chelation therapy. Daneila Lamas wrote about this issue in the -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube. Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken). We discuss an for the American Journal of Hospice and Palliative Medicine, including: What makes a PULET a PULET? Key ingredients are both potentially unsafe and low evidence. If it’s low evidence but not unsafe, not generally an issue. Think vitamins. If it’s potentially unsafe, but has robust evidence, well that’s most of the treatments we offer seriously ill patients! Think chemo. What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity. What counts as low-evidence? Animal studies? Theoretical only? Does PULET account for avoiding known effective treatments? Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR. How does integrative medicine fit in with this? Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this. How ought clinicians respond? Hint: If you’re arguing over the scientific merits of a research study, you’re probably not doing it right. Instead, think , REMAP, and uncover and align with the emotion behind the request. Does the approach shift when it’s a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child? For more, Laura suggests a book titled, . And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give , and the conversations I had with Adam and Laura during the visit. We love it when listeners engage with us to suggest topics that practicing clinicians find challenging. And I get to sing Bon Jovi’s Bad Medicine, which is such a fun song! -Alex Smith /episode/index/show/geripal/id/36286590

Loss of DEI Hurts Everyone: Farah Stockman, Ali Thomas, Ken Covinsky 04/17/2025

Loss of DEI Hurts Everyone: Farah Stockman, Ali Thomas, Ken Covinsky I read Farah Stockman’s article in the NYT on , and thought, “Yes, and ‘everyone’ includes harm to our healthcare workforce, our patients, and their families.” So we’re delighted that Farah Stockman, pulitzer prize winning journalist, author of , and editorial board member at the New York TImes joins us to set the bigger picture for this discussion. Farah provides clear examples from the Biden administration, in which having the most diverse cabinet in history was critical to building bridges, empathy, and inspiring others to feel included. We are also pleased to welcome Ali Thomas, a hospitalist, member of the Baha'i Faith, leader of anti-racism efforts in the Pacific Northwest, and founder of the . Ali talks about the history of affirmative action, which started as a , the importance of diversity in the healthcare , the history of allyship and cross cultural collaboration, and his own efforts to provide opportunity and support for historically oppressed groups in his own community to obtain healthcare careers. And Ken Covinsky, avid baseball fanatic, joins us and notes that the day we record (April 15) is . Many may be familiar with the story of Jackie Robinson breaking the color barrier in major league baseball in 1947, but may not be aware of the tremendous adversity Jackie Robinson faced, and persistence he displayed, off the field. We address many things, including: The movement in Corporate America and institutes of higher education to implement DEI programming in the wake of George Floyd The general agreement in America of the value of diversity, and disagreement, unpopularity, and backlash about DEI as it was implemented How the pursuit of diversity and excellence are not in tension, they are aligned and necessary for each other What we can do to build bridges across differences There was so much we hoped to talk about and didn’t get to, but I will link to now, including: Ali’s mom’s personal history with and study of , Farah’s mom’s pioneering work as a , and Ken’s perspectives on the importance of studying . What a Wonderful World could be sung in irony at this moment. I hope we all take it literally, with the hope this podcast ends with. The podcast follows the arc towards hope of this from the National Center for Race Amity, courtesy of Ali Thomas (his dad is featured). -Alex Smith /episode/index/show/geripal/id/36188605

RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest 04/10/2025

RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department. I 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 for seriously ill patients, but they didn’t have the knowledge, skills, or experience to do it. Today we focus on an , 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 . 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 for the primary (hospitalization) and all secondary outcome (e.g. hospice use). Why to emergency clinicians, this study was a wild 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 , Randy Curtis’s , Lieve Van den Block’s negative study of . 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 /episode/index/show/geripal/id/36075960

GeriPal Takeover! Nancy Lundebjerg and Annie Medina-Walpole 04/03/2025

Pragmatic Trial of ACP: Jennifer Wolff, Sydney Dy, Danny Scerpella, and Jasmine Santoyo-Olsson 03/27/2025

Pragmatic Trial of ACP: Jennifer Wolff, Sydney Dy, Danny Scerpella, and Jasmine Santoyo-Olsson A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice. Outcomes are typically assessed from available records. Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations. Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying . We spend the last portion of the podcast discussing the surprising finding of the study. In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group. What?!? Not a typo. We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including: Disconnect between relatively low rates of (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control). Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions? Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent . Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings. My goals will differ if I think I probably have 2 years to live vs 10 years. Comparison to a trial Yael Shenker discussed in our podcast on (also used the Respecting Choices intervention, outcome differed). Implications for the larger over the value of advance care planning, and additional research into advance care planning. As I say on the podcast, I’m sure would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful. And I got to sing in Spanish for the time. I hope my pronunciation is better than my , or ! -Alex Smith /episode/index/show/geripal/id/35879760

Hastening Death by Stopping Eating and Drinking: Hope Wechkin, Thaddeus Pope, & Josh Briscoe 03/20/2025

Hastening Death by Stopping Eating and Drinking: Hope Wechkin, Thaddeus Pope, & Josh Briscoe Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (), and multiple episodes about the ethical issues surrounding medical aid in dying (). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life? To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit. We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medications and their respective on the topic. We discussed what makes an illness “terminal”, what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers. -Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host) Articles referenced in this discussion: by Hope Wechkin et al in JPSM by Thaddeus Pope and Lisa Brodoff in JAGS also in JAGS by Joshua Briscoe and Eric Widera Past GeriPal Podcast Episodes on MAID: MAID podcasts Past GeriPal Podcast Episode about VSED: /episode/index/show/geripal/id/35781165

The Roots of Palliative Care: Michael Kearney, Sue Britton, and Justin Sanders 03/13/2025

The Roots of Palliative Care: Michael Kearney, Sue Britton, and Justin Sanders As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way? In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care. Sue Britton was the first nurse hired on that palliative care unit. on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry. Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including: Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more… Whole-person-care as a process distinct from the deterioration of the body The as the unit of care Our guests referenced many articles on this podcast, linked above and below. If you read just one, read ? by Kearney. I promise it’s short. 2 pages. Here’s a taste: …While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty. And love that Jim Croce choice. What’s in a name? Enjoy! -Alex Smith Links Link to the , Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming. In Palliative Medicine By Kearney Joe Wood’s book on Balfour Mount’s memoir paper on in JPSM and in Palliative Medicine , by David Clark Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series Twycross on /episode/index/show/geripal/id/35663665

PC for People Experiencing Homelessness: Naheed Dosani 03/06/2025

PC for People Experiencing Homelessness: Naheed Dosani I was very proud to use the word “” on today’s podcast. See if you can pick out the moment. I say something like, “Palliative care for people experiencing homelessness is, in many ways, the apotheosis of great palliative care.” And I believe that to be true. When you think about the early concepts that shaped the field, you can see how palliative care for persons experiencing homelessness fits like a hand in a glove: total pain envisioned by Cicely Saunders, which even its s included social suffering like loneliness; or Balfour Mount, who coined the term “palliative care,” lamenting the , and the desperate need to create programs to reach more people experiencing suffering. Today we talk with Naheed Dosani, a palliative care physician at St. Michael’s Hospital in Toronto, and health justice activist. His story, which he shares on today’s podcast, is remarkable. Just out of fellowship, Naheed built a palliative care program for homeless persons called the Palliative Education and Care for the Homeless (PEACH) Program. This podcast is a complement to our prior podcast on with Margot Kushel. Today we discuss: What is the best terminology? Homeless? Homelessness? Houseless? Marginally housed? What makes palliative care for people experiencing homelessness challenging? What makes it rewarding? What is unique about the practice of palliative care for people experiencing homelessness? We discuss the principles of harm reduction, social determinants of health, and trauma informed care. Major overlap with substance use disorder issues, which we have covered recently (and frequently) on this podcast. How are the health systems designed or not designed to meet the needs of people experiencing homelessness? What are the equity issues at stake, and at risk of being cut, both in Canada and the US? Many more links below. And I had a blast playing Blinding Lights by that Toronto band The Weekend. Enjoy! -Alex End Well Talk Resources on the PEACH Program Program Review Paper – A recent publication in Longwoods Healthcare Quarterly reviewing the PEACH model. Promising Practice Recognition – PEACH was named a Promising Practice in equity-oriented palliative care as part of a national initiative funded by Health Canada, operated by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. Toronto Star Feature CityNews Toronto Feature Psychosocial Interventions at PEACH In addition to medical care, PEACH also runs two key psychosocial interventions for our clients: PEACH Grief Circles – Structured spaces for workers in the homelessness sector to process grief. CBC covered this a few years ago, including a radio segment feature on CBC White Coat, Black Art (which you can access at the below link). PEACH Good Wishes Program – A program that provides meaningful gifts for unhoused individuals who are terminally ill. Kensington Hospice & 'Radical Love' Equity-Oriented Hospice Palliative Care Naheed Dosani also serves as the Medical Director of Kensington Hospice, Toronto’s largest hospice. There, he helps run an innovative program called 'Radical Love' Equity-Oriented Hospice Palliative Care, which provides low-threshold, low-barrier access to hospice care for structurally vulnerable individuals (e.g., those experiencing homelessness). The program also operates via a partnership with the PEACH Program. As a result of the 'Radical Love' program at Kensington Hospice: At any given time, Kensington Hospice has evolved from caring for structurally vulnerable individuals <2% of the time...to now serving structurally vulnerable people 40–50% of the time. Canadian Press Feature – A powerful and widely shared piece on our work. Promising Practice Recognition – Kensington Hospice’s Radical Love program was also recognized as a Promising Practice by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. National Canadian Efforts in Equity-Oriented Palliative Care Canada is investing in equity-oriented palliative care through the Improving Equity in Access to Palliative Care (IEAPC) Collaborative. This is a multi-year funded initiative that supports 23 equity-oriented palliative care models for people experiencing homelessness and structural vulnerabilities across Canada. /episode/index/show/geripal/id/35549595

PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers 02/27/2025

PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers Much like , we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder , , , and . Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address: Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?” Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in . What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment). When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control? Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay? And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming section… Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue! Sometimes . -Alex: /episode/index/show/geripal/id/35443525

Trauma-Informed Care: A Podcast with Mariah Robertson, Kate Duchowny, and Ashwin Kotwal 02/20/2025

Plenary Abstracts at AAHPM/HPNA: Yael Schenker, Na Ouyang, Marie Bakitas 02/13/2025

Plenary Abstracts at AAHPM/HPNA: Yael Schenker, Na Ouyang, Marie Bakitas In today’s podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of Hospice and Palliative Medicine () and the Hospice and Palliative Medicine Nurses Association (). Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully). On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of moderator. Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed vs. facilitated style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer. From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including: Marie’s tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served? Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served? Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let’s assume that there are clear important benefits. Based on the results of Yael’s study, should resources be allocated to resource intensive nurse facilitated sessions (), which had significantly better engagement, or to low resource intensive patient-facing materials (), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)? One interpretation of Na’s study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis. Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality. Which is it? Bonus: he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?). Garfunkel says Simon was writing about . Who’s got the right of it? Enjoy! -Alex Smith /episode/index/show/geripal/id/35264790

How to Make an Alzheimer's Diagnosis in Primary Care: A Podcast with Nathaniel Chin 02/06/2025

Telehealth vs In-Person Palliative Care: Guests Joseph Greer, Lynn Flint, Simone Rinaldi, and Vicki Jackson 01/30/2025

Deprescribing Super Special III: Constance Fung, Emily McDonald, Amy Linsky, and Michelle Odden 01/23/2025

Deprescribing Super Special III: Constance Fung, Emily McDonald, Amy Linsky, and Michelle Odden It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes. In our first segment, we discuss a study led by Constance Fung and her team, which investigated the . The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts. Next, we turn to Emily McDonald, the director of the , to discuss her . Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see ). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use. In our third segment, we explore Amy Linsky’s . The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click ). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety. Finally, we discuss Michelle Odden’s . The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast ( and ) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the study adds more questions to that conclusion. Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research! /episode/index/show/geripal/id/34964275

Caring for the Unrepresented: A Podcast with Joe Dixon, Timothy Farrell, Yael Zweig 01/16/2025

Palliative Care for Mental Illness: A Podcast with Dani Chammas and Brent Kious 12/19/2024

GeriPal - A Geriatrics and Palliative Medicine Podcast

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