GeriPal - A Geriatrics and Palliative Care Podcast

A geriatrics and palliative care podcast for every health care professional. We 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. Hosted by Eric Widera and Alex Smith. CME available!

Palliative Care Nursing: Podcast with Betty Ferrell about ELNEC 04/26/2024

The Promise and Pitfalls of AI in Medicine: Bob Wachter 04/18/2024

Ambivalence in Decision-Making: A Podcast with Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby & Olubukunola Dwyer 04/11/2024

Surrogate Decision Making: Bernie Lo and Laurie Dornbrand 04/04/2024

Surrogate Decision Making: Bernie Lo and Laurie Dornbrand In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative . In 1988, Cruzan’s parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan’s was who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc). In 1990 the Supreme Court ruled…for the state of Missouri. On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions. Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan’s eventually cleared. Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients. Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan. We use Bernie’s as a springboard for discussion. We discuss, among other things: How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions And validating the importance of the advance directive forms in some circumstances, and in starting conversations The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use? Is the POLST useful? How? Under what circumstances? Should we abandon the term, “comfort measures?” In case you miss the introductions at the start of the podcast, Bernie and Laurie are married, and offer wonderful reminiscence of their clinical practice over the last several decades. So when Bernie says, “I’ve heard you take these phone calls in the middle of the night, Laurie…” Now you know why! And great song choice: Both Sides Now by Joni Mitchell. Joni suffered a stroke and had to completely . Her comeback performances are inspirational, such as this one at the , attended by another influential GeriPal couple, Sean Morrison and Diane Meier. You get to hear my stripped down Hawaiian slack key style version of Both Sides Now (easy to play with 2 fingers, still in rehab for broken hand, hoping to have full use again soon). Enjoy! -@AlexSmithMD /episode/index/show/geripal/id/30671353

PC Trials at State of Science: Tom LeBlanc, Kate Courtright, & Corita Grudzen 03/28/2024

PC Trials at State of Science: Tom LeBlanc, Kate Courtright, & Corita Grudzen One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans. Well, as a kick off to this year’s first in-person plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented. Today we interview the authors of these 3 abstracts about their findings: Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety) Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support) Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization) Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” - more to say that we’ve reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data. We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties. I believe these issues were more than made up for by our guests' forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one). Enjoy! -@AlexSmithMD /episode/index/show/geripal/id/30571533

Electronic Frailty Indexes: Kate Callahan, Ariela Orkaby, & Dae Kim 03/21/2024

Electronic Frailty Indexes: Kate Callahan, Ariela Orkaby, & Dae Kim What is frailty? Kate Callahan relates a clear metaphor on today’s podcast. A frail person is like an origami boat: fine in still water, but can’t withstand a breeze, or waves. Fundamentally, frailty is about vulnerability to stress. In 2021 we talked with . Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty. What is the difference, you ask? George Kushel probably explained it in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers. Damage to those critical functions and the bridge can collapse. Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK. But miss a bunch and things fall apart. Resilience is the ability of the bridge to withstand stress, like bridge traffic, wind, waves, and the occasional earthquake (hey it’s California!). Frailty research has come a long way. We’re now at a point where frailty can be measured automatically, or electronically, as we put in the title. Kate created an that measures frailty based on the electronic health record (EHR) data. Ariela created a based on the EHR of veterans. And Dae created an . Today we’re beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients. We should not get too hung up on battles over frailty. As Kate writes in her JAGS , “If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed.” To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings. It’s called , check it out now! Did I cheat and play the guitar part for Sting’s Fragile at ⅔ speed then speed it up? Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break! -@AlexSmithMD Additional Links: eFrailty website is: ( is fine). Dae’s Frailty indexesCGA-based frailty index web calculator for clinical use: The Medicare claims-based frailty index program for research: Ariela’s VA-FI:Original VA frailty index: ICD-10 version Link to the code for investigators (included in the appendix): As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource () Recent validation against clinical measures of frailty: Kate’s eFrailty Index our original eFI paper & on eFI and surgery editorial in JAGS /episode/index/show/geripal/id/30467008

Dysphagia Revisited: A Podcast with Raele Donetha Robison and Nicole Rogus-Pulia 03/14/2024

End-of-Life Doulas: A Podcast with Jane Euler, Beth Klint, and John Loughnane 03/07/2024

GeriPal 300th Episode: Ask Me Anything Hot Ones Style 02/29/2024

Psychological Issues in Palliative Care: Elissa Kozlov and Des Azizoddin 02/22/2024

Psychological Issues in Palliative Care: Elissa Kozlov and Des Azizoddin In our podcast with palliative care pioneer , she identified the psychological/psychiatric aspects of palliative care as the biggest are of need for improvement. As she said, when you think about the hardest patients you’ve cared for, in nearly all cases there was some aspect of psychological illness involved. That rings true to me. Today we talk with two psychologists who are deeply invested in addressing psychological aspects of care for people living with serious illness. Elissa Kozlov, a geropsychologist and director of a new at Rutgers, , and found that doctors reported major shortcomings in level of comfort and knowledge caring for patients with psychological illness. She conducted a of 38 palliative care trials, finding that many excluded people with serious illness, and a lack of impact on psychological outcomes. Analyzing the Health and Retirement Study, she found in the last year of life (related study ). Des Azizoddin is a psychologist at the University of Oklahoma primarily focused on pain for people with cancer. Des delivered a plenary at this year’s National Palliative Care Research Center’s Foley retreat. She began by asking, “Raise your hand if you think there is a psychological component to cancer pain.” All hands go up. Then, “Keep your hand up if you frequently refer patients with cancer pain to a psychologist?” All hands go down. Unfortunately, we lack the financial structures to reimburse psychologists that would incentivize widespread inclusion on palliative care teams. Because we live in the world as it is, not as it should be, Des has helped develop an (!) to help people with cancer pain engage in cognitive behavioral therapy in bite sized 3-4 minute sessions (there are other apps available developed in the VA, who have been leaders in the psychology/palliative care space). Des additionally studied associated with opioid use among patients with cancer in the context of the opioid epidemic; , and opioid use among people with cancer. And, we talk about these issues and more (with far more nuance than I can include in this post). Kudos and credit to my son Renn, age 15, for the guitar on Heartbeats (hand still broken at time of recording). /episode/index/show/geripal/id/30056908

EMS Intervention to Reduce Falls: Carmen Quatman and Katie Quatman-Yates 02/15/2024

EMS Intervention to Reduce Falls: Carmen Quatman and Katie Quatman-Yates We've talked about Falls a couple of times on this podcast, most recently with Tom Gill about the and before that with . A takeaway from those podcasts is that fresh innovative thinking in the falls prevention space is welcome. Today we talk with the twin sister power duo of Carmen Quatman and Katie Quatman-Yates about an intervention that is both brilliant and (in retrospect) should have been obvious. The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient’s homes. They were stunned by the number of calls for lift assistance for older adults who had fallen. Going into patient's homes was eye opening. There were trip hazards, loose carpets, some people were hoarders. And yet, after assisting the older adult to their feet, the EMS providers would leave. Their job was done. It's not surprising that the number of repeat calls for falls is . Addressing the root environmental causes of falls was not part of EMS providers' job description. In addition to stigma, practical barriers to older adults addressing environmental issues themselves abound. For example, Carmen and Katie found thousands of grab bars on Amazon (overwhelming), and when they called installation companies (handypersons), received different quotes if the person calling was a . So Carmen and Katie developed an EMS Community Partnership . EMS providers were trained to provide practical home modifications: installation of grab bars, removal of carpets, removal of other obstacles. They created a seamless link between this Community Partnership program and . People who had grab bars installed through the program called their neighbors and say, hey you should get this too. Word of mouth spread rapidly. And the number of calls for falls . Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community. In addition to the podcast, you can see more about this in . Thanks to my wife Cindy Hsu for piano on Eye of the Tiger. Enjoy! -@alexsmithMD /episode/index/show/geripal/id/29959303

The Nature of Suffering: BJ Miller and Naomi Saks 02/08/2024

RCT of Default Inpatient PC Consults: Kate Courtright & Scott Halpern 02/02/2024

RCT of Default Inpatient PC Consults: Kate Courtright & Scott Halpern Last week we talked about a trial of a published in JAMA. This week, we talk about the other major palliative care trial of for hospitalized older adults with COPD, kidney disease, or dementia, published in the same issue of JAMA. (See also our accompanying , first author Ashwin Kotwal who joins today as a co-host, and a I recorded with JAMA editor Preeti Malani). For context, listen to the prior podcast with Scott on “” and prior podcast with Kate on . Three things I love about this podcast, and why you should listen. First, in our editorial, we expressed concern about the length of stay metric not being patient centric, though important for health systems focused on cost savings. It was refreshing to hear Scott and Kate express similar sentiments. Second, we wanted to know how the palliative care clinicians felt about the increased workload - and we had some glimpses into those experiences (and hope for a future publication that fleshes it out further). Finally, we heard about next steps and lessons learned, as though this was the largest pragmatic trial of palliative care to date, it isn’t their last. Much more to come. And next time maybe we really will play the game where every time the word pragmatic is mentioned you have to drink 🙂 And I get to play Phish, who Scott has seen about 100 times in concert. I saw them only twice. Once as an undergraduate at Michigan, in 1994. They and I signed up to be an usher. Can you imagine trying to usher Phish Heads to stay in their assigned seats? Yeah, no. Gave up at some point and joined them. Full electric experience. Second time was with at the Shoreline Amphitheater, California in 1998. That concert, entirely acoustic, was impressive in its sheer musical virtuosity. You're kind of naked playing acoustic like that. On today’s podcast you get me, not naked, though still only with 2 left fingers (hand still broken) on the guitar, playing “Miss You.” -@AlexSmithMD Additional links: Trey Anasatsio playing alone and acoustic, start around 21 minutes for the lead in Original article describing the potential for default options to improve health care delivery: Scott on goals of care as the elusive holy grail outcome of palliative care trials (we discussed toward the end): The protocol paper for REDAPS: Big recently funded PCORI trial comparing specialist PC delivered by default vs. generalist PC following CAPC training + a different EHR nudge: Kate’s “Palliative Connect” RCT: /episode/index/show/geripal/id/29757388

RCT of Palliative Care for Heart Failure and Lung Disease: David Bekelman and Lyndsay DeGroot 01/25/2024

Substance Use Disorder in Aging and Serious Illness: A Podcast with Katie Fitzgerald Jones, Jessica Merlin, Devon Check 01/18/2024

What is going on with MAID in Canada? Bill Gardner, Leonie Herx, & Sonu Gaind 01/11/2024

What is going on with MAID in Canada? Bill Gardner, Leonie Herx, & Sonu Gaind of deaths in Canada are due to Medical Assistance in Dying (MAID). Four percent. The number of people who have used MAID in Canada since it was legalized in 2016 has increased year on year from about 1,000 people in the first year to . California, which has a similar population size as Canada and legalized MAID around the same time, has fewer than In further contrast to the United States, MAID in Canada is almost entirely administered by a clinician, whereas in the United States patients must self administer. To be eligible in Canada patients must have a “” condition, including ; they do not have to have a terminal illness with a prognosis of less than 6 months. They could have a prognosis of years, or decades. A planned expansion of MAID to include people with mental illness was placed on hold until March 2024. The Canadian parliament will soon hear a report on potentially expanding MAID to “.” A recent discussed the story of a Canadian seeking MAID because he could not afford to stay housed. Today we talk about these issues with Bill Gardner, a psychologist at the University of Ottawa who is living with cancer, Leonie Herx, a palliative care physician at the University of Calgary, and Sonu Gand, a psychiatrist at the University of Toronto and former president of the Canadian Psychiatric Association. We talk about how Canada got to this point, including the degree to which offering MAID to anyone who is eligible has become standard practice in many places. We hear Bill Gardner's being told that his cancer could not be treated and immediately offered two options: palliative care or MAID. We talk about the role of palliative care and lack of access for many people living with serious illness in Canada. We go in depth about ethical issues raised by the planned expansion of MAID to people with mental illness. Much of the criticism of the explosion of MAID in Canada is coming from people like, our guests, who feel that MAID should be an option for a select few, rather than coming from under-no-circumstance opponents. To many this rapid expansion will represent autonomy run amok. It is the slippery slope made real. To others MAID represents a seemingly easy and inexpensive mechanism to address failures of the system to address potentially reversible sources of suffering on a systemic level, from difficult conversations at the bedside, to meeting basic needs like housing. For those listening to the podcast, credit to Kai for guitar on Neil Young’s Cortez the Killer (my left hand is still broken at the time of this recording). You get me with one-finger-chords on the guitar if you're watching on YouTube (best I could manage). -@AlexSmithMD Bill Gardner’s article about MAID in Comment Magazine Bill Gardner’s articles about living with terminal cancer in Mockingbird Magazine: /episode/index/show/geripal/id/29432118

Guiding an Improved Dementia Experience (GUIDE) Model: A Podcast with Malaz Boustani and Diane Ty 12/21/2023

Influence of Hospital Culture on Intensity of Care: Liz Dzeng 12/14/2023

Aging and Climate Change: Karl Pillemer, Leslie Wharton, & Ruth McDermott-Levy 12/07/2023

Aging and Climate Change: Karl Pillemer, Leslie Wharton, & Ruth McDermott-Levy To my teenagers, climate change is an existential crisis. It’s the . They decry the lack of serious attention and prioritization this issue has in the US. My kids ask - why don’t adults care about this issue the same way that they and their friends care about it? My kids have taught me that the emphasis on personal responsibility (reduce your carbon footprint!) was , because it shifted responsibility for change from industry to individuals. Voting and emailing congress to advocate for systemic change (e.g. less reliance on fossil fuels) likely has a greater impact than recycling your newspaper. Today we find inspiration for my kids: there are adults who care deeply about this issue, particularly for older adults who are much more . Karl Pillemer is a sociologist and gerontologist who studies this issue and has created a platform called, “,” that is a wide tent with room for older adults, researchers, and organizations. As a researcher, I found the bibliography fascinating, including this by the gerontologist Rick Moody on the moral obligation of older adults to address climate change. Leslie Wharton is a leader in the 26,000 member grassroots organization , which organizes older adults to create communities engaged in making a difference at local, state, and national levels. As she notes, these volunteer activities can bring meaning and purpose, in the face of a seemingly insurmountable problem, to the elders in her organization. And we talk with Ruth McDermott-Levy, who wrote a practical guide for (example - a generator safety checklist). Ruth advocates for and teaches about aging and climate change at Villanova, and calls on and other health researchers to study . -@AlexSmithMD Additional links: JAMA paper on Health Care Without Harm: Practice Green Health: Global Consortium for Climate and Health Education: /episode/index/show/geripal/id/28963273

Redefining Alzheimer's Disease: A Podcast with Heather Whitson, Jason Karlawish, Lon Schneider 12/01/2023

Should you have a coach? Greg Pawlson, Beth Griffiths, & Vicky Tang 11/09/2023

Should you have a coach? Greg Pawlson, Beth Griffiths, & Vicky Tang Coaching is in. During the later stages of the pandemic, it seemed every other person, and particularly the junior faculty in our Division, were either being coached, in training to coach, or coaching others. When I was a junior faculty, coaching wasn’t a thing. Sure, Atul Gawande wrote about coaching in surgery - having someone observe you and coach you on your technical skills- but that’s a far cry from the coaching programs focused on empowerment that are exploding around the country today. Today we learn more about coaching from 3 coaches: Greg Pawlson, and former president of the American Geriatrics Society, Vicky Tang, geriatrician-researcher at UCSF and , and Beth Griffiths, primary care internist at UCSF and coach. We address: What is coaching? How does it differ from therapy? How does it differ from mentoring What is typically covered in coaching sessions? What is the evidence (see many links below, sent by Beth) What are the standards for becoming a coach? Who is coaching for? My take: coaching has tremendous potential. There seems to be a gender story here as well - coaching may be of particular benefit to women who are at higher risk for burnout. Note, for example, the hot off the press trial which demonstrated modest benefits across a range of outcomes was conducted exclusively in female resident physicians. , a physician-researcher and coach, has a terrific podcast I highly recommend everyone listen to, though it is targeted at women of color in academic medicine. On the other hand, there is a concerning side, described in this Guardian article titled, See also the long list of disclosures in the . Our guests note, rightly, that the same profit motive and concerns are true about colleges. Still, I remain concerned when I see that the Life Coach School ; when the founder of the Life Coach School’s goal is to ; and when my spidey sense tells me there’s something cultish about the empowerment industry. So, I see the potential of coaching, particularly for groups that face challenges in academic medicine; and I worry about the injection of profit-motives and the goals of industry leaders pushing the meteoric rise of the life coach industry. -@AlexSmithMD 1. Hot off the presses RCT in JAMA October 2023: Study that looks at 1000 female resident physicians at 26 sites that showed that coaching improved each outcome assessed (burnout, moral injury, imposter syndrome, self-compassion, and flourishing). 2. An RCT for female residents published in JAMA May 2022: This was the initial pilot single institution study by the same team as above. Their findings concluded that it was feasible to implement an online coaching program for female residents and that coaching improved emotional exhaustion, imposter syndrome and self-compassion. 3. A March 2022 study of Stanford offering coaching as a benefit to their physicians and finding improved self-compassion and burnout. 4. The initial RCT published on physician coaching in JAMA in 2019 showing that coaching improves quality of life. This is the first RCT that was available for coaching in physicians. 5. A 2020 RCT of coaching for primary care physicians shows that coaching improves burnout well-being during the intervention and has a sustained duration at 6 months of follow up. From Beth Israel and UNC. 6. The Business Case for Investing in Physician Wellness, again in JAMA. This paper includes coaching as a sign of a more mature physician wellness program and states it has a positive return on investment. /episode/index/show/geripal/id/28560428

The Future of Geriatrics: A Podcast with Jerry Gurwitz, Ryan Chippendale, and Mike Harper 11/02/2023

Palliative Rehab?!?: Ann Henshaw, Tamra Keeney, and Sarguni Singh 10/26/2023

Palliative Rehab?!?: Ann Henshaw, Tamra Keeney, and Sarguni Singh Often podcasts meet clinical reality. That’s why we do this podcast- to address real world issues in palliative care, geriatrics, and bioethics. But rarely does the podcast and clinical reality meet in the same day. Within hours of recording this podcast, I joined a family meeting of an older patient who had multiple medical problems including cancer, and a slow but inexorable decline in function, weight, and cognition. Physical therapy had walked with him that day and noted improvement compared to previous walks, suggesting that he should be discharged to a skilled nursing facility for rehabilitation on discharge. The patient's capacity to make decisions was marginal, and his sons were shouldering much of the responsibility. The sons were very focused on rehabilitation, and the patient gave his assent. In the meeting, I used the language suggested by Sarguni Singh, “I worry that going to SNF for rehab may not result in your being independent.” We additionally discussed hospice care as an option for care that might follow the trial of rehabilitation. Today we talk with Sarguni Singh, hospitalist-researcher at the University of Colorado, Ann Henshaw, Occupational Therapist who teaches at George Washington and works clinically at Georgetown, and Tamra Keeney, Physical Therapist-researcher at Mass General Hospital and Harvard Medical School. Lynn Flint, author of the NEJM perspective titled, “Rehabbed to Death,” joins Eric and I as co-host. We cover a lot of ground in this podcast, including an evidence based between therapy fields and palliative care, outcomes of (hint: not much hospice, lots of re-hospitalization), and a JAGS study on use of post-acute care among patients with . We also heard from Tamra about her in which she laments, “The role of rehabilitation is often myopically constrained to facilitation of efficient discharge planning.” Therapists are so much more. At the end of the day, I lamented that physical, occupational, and speech therapists aren’t more tightly integrated with palliative care teams. As Lynn says at the end of the podcast, to paraphrase, “Physical therapy, occupational therapy, speech therapy - all this therapy for older frail patients is a core part of good palliative care.” And our guests sing along with “Sweet Caroline” - so good, so good, so good! -@AlexSmithMD This episode of the GeriPal Podcast is sponsored by , an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: /episode/index/show/geripal/id/28425212

POLST Evidence and Update: Kelly Vranas, Abby Dotson, Karl Steinberg, and Scott Halpern 10/19/2023

POLST Evidence and Update: Kelly Vranas, Abby Dotson, Karl Steinberg, and Scott Halpern What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric? The answers to these questions will vary. Reasonable people will disagree. And today, on our podcast, our guests disagree. Firmly. AND we are delighted that our guests modeled respectful disagreement. With . Respectful disagreement is in short supply these days. Our guests today are Kelly Vranas, pulm crit care doc who published a of the evidence for POLST (as well as other articles , ,and ); Abby Dotson, who is Executive Director for and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of ; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a that was critical of the concept and evidence base for POLST (and argues little has changed). We had a full podcast, and I wasn’t able to give my take on the existing evidence for POLST, so I’ll write it here. I’m in the middle between Scott and Karl, where I suspect Kelly is, though we didn’t ask her explicitly. On the one hand, I agree with Scott that observational studies finding those who complete a POLST stating a preference for comfort oriented care and DNR are not go to the ICU says little about the effectiveness of POLST. Far more likely that those underlying preferences and values are what drove the findings than completion of the POLST form that codified the preferences into orders. On the other hand, I agree with Karl that the POLST has face validity, and anecdotal evidence is overwhelming. Certainly SOME of those avoided hospitalizations, CPR, and ICU stays were due to documentation of those orders in the POLST. The unanswered question is: HOW MUCH of the differences are due to the POLST? It’s not zero, as many of us have had cases in which we said, “Thank god we completed that POLST, it clearly stopped X from happening.” But is it a tiny, meaningless, fraction? Or a substantial proportion? My guess is a small but meaningful fraction of differences in observational studies is due to completion of the POLST, though the majority of differences are due to underlying preferences and values. Is that fraction due to POLST large enough that we should design quality metrics around completion of POLST? Absolutely not. Do we need better evidence, preferably from an RCT of POLST vs no POLST? Yes. Caveat as well that RCTs should not be placed on pedestal as the only answer- often patients enrolled in RCTs do not represent real world patients - observational studies do. For a trial to have value, it should not exclude patients over age 80, or those with dementia, or patients residing in nursing homes. And it must be powered to detect a small but meaningful difference, not the same level of effect seen in observational studies. OK, I’ll step off my soap box. Additional links mentioned in the podcast: Recent in California nursing homes, hospitalization, and nursing home care Karl’s on appropriate use of POLST Enjoy! -@AlexSmithMD /episode/index/show/geripal/id/28359887

Surgical Communication: A Podcast with Gretchen Schwarze, Justin Clapp and Alexis Colley 10/12/2023

The Language of Serious Illness: A Podcast with Sunita Puri, Bob Arnold, and Jacqueline Kruser 10/05/2023

Miscommunication in Medicine: A podcast with Shunichi Nakagawa, Abby Rosenberg and Don Sullivan 09/28/2023

Black/African American Caregivers of Older Adults Living with Dementia: Podcast with Fayron Epps and Karen Moss 09/21/2023

Black/African American Caregivers of Older Adults Living with Dementia: Podcast with Fayron Epps and Karen Moss The proportion of people living with dementia who identify as , and so too are the proportion of caregivers who identify as Black/African American. As our guests talk about today, caregiving for people living with dementia takes a tremendous toll, and when this toll is set atop the challenges of in all its forms, the reality of can be overwhelming. Today we talk with Fayron Epps and Karen Moss, two nurse researchers who are focused on improving the experience of Black/African American caregivers of persons living with dementia. We talk in particular about: Terminology. Acknowledging that the most sensitive terms shift over time, what terms are they using today and why? Black? African American? Black/African American? We also learn that the term , so common in research, should be avoided for its early usage as White colonialists staked out land taken from Native American peoples. Why a focus on Black/African American caregivers and people with dementia? Why should interventions be culturally for this ? Feyron has centered her work in Black/African American faith communities and churches - a program she titled . Why this focus? Karen has a Cambia award to pilot an intervention in which Black/African American former caregivers are trained to provide peer support to current caregivers (Peer2Care). This seems like a triple win - the bereaved former caregiver has the opportunity to be generative, share their story, and give back; the current caregiver connects with someone similar who listens when so many people are tuning them out; the person with dementia benefits from the caregiver’s improved sense of self-efficacy, decreased loneliness/social isolation, and better coping overall. Why are researchers in particular critical to the study of these issues? And Karen brings a tambourine in the studio for I’ll Fly Away (see YouTube version)! -@AlexSmithMD /episode/index/show/geripal/id/28097102

Hospital-at-Home: Bruce Leff and Tacara Soones 09/14/2023

Time for Geriatric Assessments in Cancer Care: William Dale, Mazie Tsang, and John Simmons 09/07/2023

Time for Geriatric Assessments in Cancer Care: William Dale, Mazie Tsang, and John Simmons The comprehensive geriatric assessment is one of the cornerstones of geriatrics. But does the geriatric assessment do anything? Does it improve outcomes that patients, caregivers, and clinicians care about? Evidence has been mounting about the importance of the geriatric assessment for older adults with cancer, the subject of today’s podcast. The geriatric assessment has been shown in two landmark studies ( and ) to reduce high grade toxicity, improve patient and caregiver satisfaction, and improve completion of advance directives (can listen to our prior podcast on this issue ). Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their for care of older adults to state that all older adults receiving systemic therapy (including chemo, immuno, targeted, hormonal therapy) should receive geriatric assessment guided care. We talk about these new guidelines today with William Dale, a geriatrician at City of Hope and lead author of the guideline update in the , Mazie Tsang, palliative care/heme/onc physician-researcher at Mayo Clinic Arizona who authored a study of geriatric and palliative conditions in older adults with poor prognosis cancers published in , and John Simmons, a retired heme/onc doctor, cancer survivor, and patient advocate. We talk about: What is a and how can busy oncologists actually do one? (hint: 80% can be done in advance by patients or caregivers) Why is it that some oncologists are resistant to conducting a geriatric assessment, yet have no problem ordering tests that cost thousands of dollars? What can you do with the results of a geriatric assessment? How does the geriatric assessment lead to improved completion of advance directives, when the assessment doesn’t address advance care planning/directives at all? How does palliative care fit into all this? Precision medicine? What groups are being left out of trials? What are the incentives to get oncologists and health systems to adopt the geriatric assessment? And Mazie, who is from Hawaii, requested the song Hawaii Aloha in honor of the victims of the wildfire disaster on Maui. You can donate to the . Aloha, -@AlexSmithMD Additional Links: /episode/index/show/geripal/id/27962976

GeriPal - A Geriatrics and Palliative Care Podcast

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