GeriPal - A Geriatrics and Palliative Medicine Podcast

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 no hard feelings. Respectful disagreement is in short supply these days. Our guests today are Kelly Vranas, pulm crit care doc who published a systematic review in JAGS of the evidence for POLST (as well as other articles here, here,and here); Abby Dotson, who is Executive Director for National POLST and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of National POLST; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a Viewpoint in JAMA 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 JGIM article on POLST in California nursing homes, hospitalization, and nursing home care Karl's GeriPal post on appropriate use of POLST Enjoy! -@AlexSmithMD

For surgeons and patients, deciding if and when to operate can be challenging. Often, the way surgeons communicate about these decisions doesn't make things any easier for themselves or their patients. And, surgeons often spend the majority of their conversations with patients describing anatomical details and exactly how they plan to 'fix it', with little discussion of what that 'fix' will do for a patient's overall goals. Instead, what if your surgeon told you that the operation she was discussing could help with only 4 things: live longer, feel better, prevent disability, or obtain a diagnosis? And, what if your surgeon openly discussed the expected 'bad stuff' of post-operative recovery, instead of rotely reciting a list of possible complications? We invited Gretchen Schwarze and Justin Clapp to discuss with us these communication strategies, which are the focus of a series of 4 Viewpoints recently published in JAMA Surgery. I love this series of articles because each presents a component of a practical, patient-centered approach to patient-surgeon communication and decision making, and language surgeons (and surgical trainees) can start using in their next patient visit. We hope you enjoy this episode. Take a look at some of these links to learn more: Innovations in Surgical Communication series: Provide Your Opinion, Don't Hide It Focus on the Goals of Surgery Promote Deliberation, Not Technical Education Present the Downsides of Surgery, Not Just Risks Dr. Schwarze's article, "Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention'' in which surgeons used "fix-it" language in 92% of conversations and did not establish an overall goal of treatment 80% of the time. South Park "Underpants Gnomes" Orthopaedics vs Anesthesia By: Alexis Colley

Communicating about a serious illness is hard. Last week's podcast we talked about the challenge around miscommunication in serious illness. This week we dive into the challenges with communication when it comes to life sustaining treatments and CPR. Take for example the simple question: "If her breathing gets any worse, she will need to be intubated." This seems like an innocuous statement of fact, but does she really "need" to be intubated if, for example, her primary goals are to be comfortable and die at home? Of course not. We've invited Jacqueline Kruser and Bob Arnold on this week's podcast to talk about their recently published JAMA Viewpoint article titled "Reconsidering the Language of Serious Illness." I love this article as it specifically discusses what's wrong with "need" statements and how we can shift our communication and thinking to create space for deliberation about patients' priorities and the best course of action. We've also invited Sunita Puri to talk about the language of life sustaining treatments, in particular CPR. Sunita recently published a wonderful New Yorker article titled The Hidden Harms of CPR arguing among other things that these conversations "are procedures, demanding the same precision of everything else in medicine." So take a listen and check out some of these other links to dive deeper: Our first podcast in the series of 3 podcasts "Miscommunication" A great article on why you shouldn't ask what patients "want" Sunita's book That Good Night: Life and Medicine in the Eleventh Hour The paper Jacky talked about regarding the ingrained pattern of focusing on the "need" for specific life-sustaining interventions, typically as the reason to admit a patient to the ICU Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016 Cardiopulmonary Resuscitation on Television — Miracles and Misinformation Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

Medical communication is tough, although fundamentally at its most basic unit of delivery, it includes really only three steps. First, a clinician's thoughts must be encoded into words, then transmitted often via sounds, and finally decoded back to thoughts by a patient or family member. Simple, right? Not so much, as each one of these steps is fraught with miscommunication. For example, a surgeon may want to convey that all visible tumors were removed during surgery, but transmits that message to the patient by saying "we got it all" only to have the patient hear an entirely different message that the cancer is gone and they are now cancer free. On today's podcast we talk with three communication experts, Abby Rosenberg, Don Sullivan, and Shunichi Nakagawa about the concept of miscommunication, including examples of it and ways we can mitigate this issue. This podcast was inspired by Abby and Don's recent JAMA Oncology paper titled Miscommunication in Cancer Care—Do You Hear What I Hear? We also ask Shunichi Nakagawa about some of the amazing communication pearls he posts on his Twitter account (don't tell me to call it X). Lastly, we also plan to have two more podcasts coming up on communication, one on the language of life sustaining treatments and one on surgical communication, so stay tuned! Eric Note: For more reading on this subject, check out these links: Shunichi Nakagawa's Twitter account Miscommunication in Cancer Care—Do You Hear What I Hear? Patient Values: Three Important Questions-Tell me more? Why? What else? A "Three-Stage Protocol" for Serious Illness Conversations: Reframing Communication in Real Time

The proportion of people living with dementia who identify as Black/African Americans is on the rise, 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 racism in all its forms, the reality of caregiving while Black 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 stakeholder, 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 tailored for this group? Feyron has centered her work in Black/African American faith communities and churches - a program she titled Alter. Why this focus? Karen has a Cambia Sojourns 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 nurse 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

Hospitals are hazardous places for older adults. These hazards include delirium, malnutrition, falls, infections, and hospital associated disability (which about ⅓ of older adults get during a hospital stay). What if, for at least some older adults who need acute-level care, instead of treating them in the hospital, we treat them at home? That's the focus of the hospital-at-home movement, and the subject we talk about in this week's podcast. We talk with Bruce Leff and Tacara Soones about the hospital-at-home movement, which has been shown to reduce costs, improve outcomes and improve the patient experience. In addition to discussing these outcomes, we also discuss: The history of the hospital-at-home movement. The practicalities of how it works including who are good candidates, where does it start (the ED?), what happens at home, do you need a caregiver, what happens if they need something like imaging? How is it financed and what comes next? If you are interested in learning more and meeting a community of folks interested in hospital-at-home, check out the hospital-at-home user group at hahusersgroup.org or some of these publications: Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Int Med. 2020 Hospital at Home-Plus: A Platform of Facility-Based Care. JAGS Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Network Open

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 (Lancet and JAMA Oncology) 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 here). Based on this surge in evidence, the American Society of Clinical Oncologists recently updated their guidelines 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 Journal of Clinical Oncology, 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 JAGS, and John Simmons, a retired heme/onc doctor, cancer survivor, and patient advocate. We talk about: What is a practical geriatric assessment 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 Hawaii Red Cross here. Aloha, -@AlexSmithMD Additional Links: Brief ASCO Video of how to conduct a practical geriatrics assessment Brief ASCO Video of how to use the results of a practical geriatrics assessment Time to stop saying the geriatric assessment is too time consuming

How do people react when they hear they have a serious illness? Shock, "like a car is rushing straight at me" (says Bill Gardner on our podcast). After the shock? Many people strive, struggle, crawl even back toward a "normal" life. And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness. Today we talk with deep thinkers about this issue. Bill Gardner is a psychologist living with advanced cancer who blogs "I have serious news," Brad Stuart is an internist and former hospice director whose book is titled, "Facing Death: Spirituality, Science, and Surrender at the End of Life," and Juliet Jacobson is a palliative care doc who wrote a paper finding that geriatricians do NOT consider aging a serious illness. We have a wide ranging conversation that touches on how to place aging, disability, and multimorbidity in the context of serious illness conversations, "striving toward normal," stoicism, existentialism, psychedelics, the goals of medicine, medical aid in dying and more. We could have talked for hours! And I get to play a Bob Dylan song that's been on my bucket list to learn. Enjoy! -@AlexSmithMD Additional links: Bill Gardner's article about MAID in Comment Magazine https://comment.org/death-by-referral/ Bill Gardner's articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/ https://mbird.com/religion/testimony/in-the-electors-school/ Brad Stuat's website: https://bradstuartmd.com Juliet mentioned: On existential threat and terror management: The Worm at the Core: On the role of death in life by Soloman, Greenberg, and Pyszczynski On how existential threat is stored in the brain. https://pubmed.ncbi.nlm.nih.gov/31401240/ Papers on "striving toward normalcy" in the setting of serious illness https://pubmed.ncbi.nlm.nih.gov/36893571/ https://pubmed.ncbi.nlm.nih.gov/35729779/

I hear the word dignity used a lot in the medical setting, but I'm never sure what people mean when they use it. You'd imagine that as a seasoned palliative care doc, I'd have a pretty good definition by now of what "maintaining dignity" or "loss of dignity" means, but you'd be sadly wrong. Well that all changes today as we've invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast. Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches. We talk with Harvey about how he defines "dignity" and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks "what do I need to know about you as a person to give you the best care possible." In addition, we talk with Harvey about some other recent publications he has written, including one on "Intensive Caring" and one on the "Platinum Rule" (do unto others as they would want done unto themselves). So take a listen and if you are interested in learning more, check out these wonderful links: Harvey's latest book is called, Dignity in Care: The Human Side of Medicine Intensive Caring: Reminding Patients They Matter Michael J. Fox gives patients hope there may be a place that illness doesn't touch Depression is a Liar Why is Being a Patient Such a Difficult Pill to Swallow Better Patient Care Calls for a 'Platinum Rule' to Replace the Golden One. Scientific American Letter to the Editor: Response to Downar et al. Medical Assistance in Dying and Palliative Care: Shared Trajectories

It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab). Praised by the FDA, Alzheimer's Association (AA), and Pharma as a "game changer", but derided by others for the drug's lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words "rife with irregularities". Instead of Biogen's expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco). The outlook on amyloid antibodies are looking brighter though in 2023. Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer. However, they are none of these. So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them? We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation). Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease. There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one. One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp By: Eric Widera