GeriPal - A Geriatrics and Palliative Medicine Podcast

In April 2022, the National Academies of Sciences, Engineering and Medicine (NASEM) issued a report on how the United States delivers, regulates, finances, and measures the quality of nursing home care. It's massive with over 600 pages detailing everything from the history of nursing home care in the United States to the latest issues that nursing homes have had to face with COVID-19. On today's podcast we invited Jasmine Travers, Alice Bonner, Isaac Longobardi, and Mike Wasserman to talk about the report. Jasmine was one of the committee members for the NASEM report, and Alice and Isaac are chairing and directing a coalition called Moving Forward tasked with taking the goals identified in the NASEM report and identifying specific and practical initiatives, test concepts, and promote their adoption for lasting improvements. We could have gone on for a couple hours for this podcast, but alas time ran out. But if you want to learn more, check out these links: The report by NASEM titled "The National Imperative to Improve Nursing Home Quality" The website for the Moving Forward We will also link to the JAGS articles co-authored by seven committee members that focus on specific recommendations of the NASEM report when they get published (stay tuned).

Acute Care for Elders (ACE Units) have been around for over a quarter of a century. Randomized trials of ACE units date back to 1996 when Seth Landefeld and colleagues published a study in NEJM showing that they improve basic activities of daily living at discharge and can reduce the frequency of discharge to long-term care institutions. But if ACE units are so great, why do so few hospitals have them? On today's podcast we talk about ACE units with geriatricians Kellie Flood and Stephanie Rogers. They recently published a paper in JAGS looking at the current landscape of ACE units in the US. In the podcast we go over these issues and more: What are ACE units and what structural elements go into them (see the picture below for a nice summary)? Which patients are eligible to go to an ACE unit? What are the benefits of an ACE unit? If ACE units are so great, why are they not so common? What does the future look like for ACE units and how does it differ (if at all) from Age Friendly Health Systems? If you want to do a deeper dive in ACE units, check out some of the following articles: The original NEJM paper on ACE units from 1996 Kellie Flood's paper in JAMA IM showing that not only ACE units deliver better care, but also help with the hospitals bottom line

Today's podcast may be a stretch for our listeners. Please stick with us. No matter what your position on medical aid in dying (I'm ambivalent) or abortion (I'm pro-choice), this is a bioethics podcast, and I hope that we can all agree that the ethical issues at stake deserve a critical re-think. All three of today's guests are well established bioethicists. Let me start by quote/paraphrasing one of today's guests, Mara Buchbinder, who puts her finger on the issue we talk about today: "Typically when we think about conscience in medical ethics we think about it in terms of a negative claim of conscience, where a clinician refuses (or objects) to provide care. But what we know from my research and those of others, people also articulate a positive claim of conscience: they feel compelled to provide a service - whether it's abortion provision or medical aid in dying - because of a deeply held conviction that this is the right thing to do." I'll continue by quoting Lisa Harris, who wrote in the NEJM: Bioethicists have focused on defining conditions under which conscientious refusals are acceptable but, with rare exceptions, have neglected to make the moral case for protecting the conscientious provision of care. Indeed, there is a real asymmetry between negative duties (to not do something) and positive duties (to do something) and, accordingly, between negative and positive claims of conscience. Violations of negative claims are considered morally worse than violations of positive ones.However, as bioethicist Mark Wicclair argues, the moral-asymmetry thesis does not provide adequate ethical justification for current conscience law, which protects only conscience-based refusals. Moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs. Lisa was writing about providing abortion care, but she just as easily could have been writing about providing medical aid in dying in states where it is illegal. Today we wrestle with this issue of conscientious provision. We start by talking with Robert Brody, an internist who recalls physicians helping patients die during the height of the AIDS epidemic in San Francisco. Robert was first asked by one of his own patients for assistance in dying in 1991, far before aid in dying was legalized in California in 2016. Robert went on to be the founding chair of the board of Compassion and Choices, the major national advocacy organization for medical aid in dying. Today, medical aid in dying is legal in some 10 states, and illegal in others. Also today, in the wake of the Supreme Court's recent Dobbs decision, some 13 states ban abortion. To examine how clinicians might act in the face of such bans, we turn to Lori Freedman, who wrote a book about clinicians (primarily Ob-Gyn's) who work in Catholic Hospitals. She describes the "workarounds" these clinicians used to skirt the rules in order to provide reproductive care for women. We talk about the parallels between these issues at the beginning and end of life, and areas in which these parallels fall apart. For example, Jack Kevorkian excepted, clinicians have not been prosecuted for providing aid in dying in states where it is illegal. In contrast, there is a justified fear of prosecution of providing abortion care in states where it is illegal. It took contemplation on a bike ride to put my finger on why I "wrestle" with the notion of conscientious provision. On the one hand, when I hear of Ob-Gyn's in Catholic Healthcare systems using "workarounds" to provide reproductive care, I'm standing up and cheering on the inside. On the other hand, when I hear of workarounds to assist patients to die, or even euthanize them, I worry that we've gone back to a time when the doctor or nurse knows best - and should be morally permitted to do whatever they think is right, according to their conscience. Do we really trust all doctors and nurses so far? Would you, with your parents, trust any doctor or nurse to make such life or death decisions, regardless of the law? There have to be limits to conscientious provision, just as there are limits placed on conscientious objection. In conscientious objection, there are general rules, such as: the patient must be given time to seek a clinician who is willing to provide the treatment; and clinicians can only object to specific treatments under specific circumstances. And yet, I worry about explicitly creating ethical rules for conscientious provision. Ought we, in bioethics, create ethical rules for providing care that is illegal? Who will follow them, and what would be their incentive for doing so? Would such ethical guidelines foster or feed suspicion of the motivations of bioethics? We could have talked for hours. We may reconvene for another podcast as we see how these issues continue to unfold. Oh life. It's bigger. It's bigger than you and you are not me. -@AlexSmithMD Many links: Mara Buchbinder's book - Scripting Death: Stories of Assisted Dying in Americahttps://www.ucpress.edu/book/9780520380202/scripting-death Lori Freedman's book (forthcoming) - Bishops and Bodies: Reproductive Care in American Catholic Hospitalshttps://www.rutgersuniversitypress.org/bishops-and-bodies/9781978828865 Lisa Harris piece mentioned on podcasthttps://www.nejm.org/doi/full/10.1056/NEJMp1206253 Alta Charo piece mentioned on podccasthttps://www.nejm.org/doi/full/10.1056/nejmp058112 Yvonne Lindgren article mentioned on podcasthttps://dc.law.utah.edu/cgi/viewcontent.cgi?article=1002&context=ulr Art Caplan piece mentioned on podcasthttps://www.thehastingscenter.org/abortion-law-lessons-from-medical-aid-in-dying/ George Annas piece mentioned on podcasthttps://dsc.duq.edu/cgi/viewcontent.cgi?article=3090&context=dlr https://muse.jhu.edu/pub/1/article/722811 https://journalofethics.ama-assn.org/article/why-post-roe-era-requires-protecting-conscientious-provision-we-protect-conscientious-refusal-health/2022-09 https://www.amazon.com/Doctors-Conscience-Struggle-Provide-Abortion/dp/0807021016/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1670624994&sr=1-1 SPONSOR: This episode of the GeriPal Podcast is sponsored by UCSF's Division of Palliative Medicine, 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: https://palliativemedicine.ucsf.edu/job-openings

From discussing "taking away the keys to the car" for a cognitively impaired older adult to decisions to limit life sustaining treatments at the end of life, conflict and disagreement permeate everything that we do in medicine. How well though are we taught to handle conflict and disagreement? I'd say not well as I don't think I've ever received a formal talk on the issue. On today's podcast we take a deep dive into the topic of Negotiation and Dispute Resolution training with Lee Lindquist and Alaine Murawski. We've had Lee on before to talk about her Plan your Lifespan project. We invited her back along with Alaine to talk about their work around negotiation training, including their work on NegotiAge, an online, AI based training intervention designed to teach negotiation skills to caregivers. For an ever deeper dive into the subject of negotiation and dispute resolution, check out the following links (and for any caregivers interested in participating in the randomized clinical trial of the NegotiAge training, feel free email the NegotiAge Research Team at negotiage@northwestern.edu): Getting to Yes: Negotiating Agreement without Giving In by Roger Fisher, William Ury, and Bruce Patton Getting Past No: Negotiating in Difficult Situations by William Ury Negotiation Training for Case Managers to Improve Older Adult Acceptance of Services. Prof Case Manag. 2021 Training Hospitalists in Negotiations to Address Conflicts with Older Adults around Their Social Needs. Geriatrics. 2020 Conflicts Experienced by Caregivers of Older Adults With the Health-Care System. Journal of Patient Experience. December 2020 Dealing with conflict in caring for the seriously ill: "it was just out of the question". JAMA 2005

We've talked at length on prior podcasts about the failures of aducnumab, Biogen, and the FDA's decision to approve it. But wait, there's a shiny new anti-amyloid drug, lecanemab! (No it's not just the French version of Aducanumab). In an article in the NEJM (a published article this time, wonder of wonders!) lecanemab was shown to slow the rate of cognitive decline by 0.45 points on an 18 point cognitive scale compared to placebo. Wow! Wow? Wait, what? On today's podcast we talk with Jason Karlawish, who we've had on previously talking about his book The Problem of Alzheimer's and with Aaron Kesselhim, to discuss FDA approval of Aducanumab, as well as frequent guest and host Ken Covinsky. They debate today's central question: is it time for geriatricians to get on board with lecanemab? Along the way we address: Is this degree of slowed cognitive decline meaningful to patients or care partners? What about the burdens, risks, and harms? Every 2 week visits for infusions, regular monitoring for brain swelling and bleeding, case report level risk of death? Did the study do enough to address issues of inclusion and diversity by age, race and ethnicity, and multimorbidity? What does this study say about the amyloid hypothesis? Should the FDA approve, and under what conditions? Their answers may surprise you. As a preview of final thoughts at the end of the episode, Ken and Jason agree that the FDA should approve lecanemab conditional on a post-approval monitoring system and public access to study data, geriatricians should be prepared to have thoughtful conversations with patients about the risks and benefits of lecanemab in view of their values and priorities, and ultimately, that geriatricians should be open to prescribing it. Wow! The times, they are a changin. -@AlexSmithMD

Eric and I weren't sure what to call this podcast - storytelling and medicine? Narrative medicine? We discussed it with today's guests Heather Coats, palliative care NP-scientist, and Thor Ringler, poet. It wasn't until the end that the best term emerged - storycatching. Because that really is what this is about. Clinicians "catching" patient life stories. What's in a story? Well, as we learned, everything. Our patients aren't "the 76 year old with heart failure in room 202," as Heather Coats astutely noted. They're people, and what makes us people if not our life's stories? Our loves, our triumphs, our failures, our work, our families. Thor Ringler helped start the My Life My Story project at the Madison VA in Wisconsin. It's since spread to over 70 VAs. VA "gets" the importance of storytelling in medicine, without the need for reams of research to back it up. As Thor notes, capturing patient stories has face validity as positively impacting the patients who share their stories and have them documented, and for the clinicians who get to truely and deeply know their patients in far greater depth than "what brought you to the hospital?" Heather Coats is hard at work establishing the evidence base for the power of capturing patient stories in healthcare settings, for those health systems that need a little more convincing. Wonderful work. Enjoy! Many links: VA Presents: My Life, My Story: George: A Voice To Be Heard on Apple Podcastshttps://podcasts.apple.com/us/podcast/id1529359511?i=1000489683280 Every Veteran has a story. Our mission is to help them tell it.https://www.va.gov/wholehealth/mylifemystory/ My Life, My Story: VA's healthcare improvements through deliberate storytelling - YouTubehttps://www.youtube.com/watch?v=fpzgVlExS20&ab_channel=VeteransHealthAdministration Storytelling Helps Hospital Staff Discover The Person Within The Patienthttps://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient A few data based publication links from Person-Centered Narrative Intervention Program of Research: Unpacking characteristics of spirituality through the lens of persons of colour living with serious illness: The need for nurse-based education to increase understanding of the spiritual dimension in healthcarehttps://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16055 Integration of Person-Centered Narratives Into the Electronic Health Record: Study Protocolhttps://pubmed.ncbi.nlm.nih.gov/32740306/ Bennett, C.R., Shive, N., Coats, H. (2020). What Mattered Then, Now, and Always: Illness Narratives From Persons of Color. Journal of Hospice and Palliative Nursing, 22 (5):392-400/ PMID: 32740304https://pubmed.ncbi.nlm.nih.gov/32740304/ Coats, H., Meek, P., Schilling, L., Akard, T., Doorenbos, A. (2020). Connection -- The Integration of a Person-Centered Narrative Intervention into the Electronic Health Record: An implementation study. Journal of Palliative Medicine, 23 (6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249456/ Coats, H., Crist, J., Berger, A., Sternberg, E., & Rosenfeld, A. (2015). African American elders' serious illness experiences: Narratives of "God did," "God will," and "Life is better." Qualitative Health Research. doi:10.1177/1049732315620153. PMID: 26701962https://journals.sagepub.com/doi/abs/10.1177/1049732315620153. Narrative Methods Textbook referenced in podcastNarrative Methods for the Human Sciences A few Dignity Therapy- Harvey Max Chochinov links https://dignityincare.ca/en/about-us.html About us - Dignity in Carehttps://dignityincare.ca/en/about-us.html Research Team - Dignity in Carehttps://dignityincare.ca/en/research-team.html Other links: Curiosity by Faith Fitgeraldhttps://www.acpjournals.org/doi/full/10.7326/0003-4819-130-1-199901050-00015 Eric's blog post on Dignity Therapy from 2011https://geripal.org/study-of-dignity-therapy-on-distress/

What would it take to transform dementia care? While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer's disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast). In order to truly transform dementia care we need to think much broader than the amyloid hypothesis. So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include: Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need them and how we can create them Anne Basting, PhD, a MacArthur Genius Grant awardee and professor (English/Theatre), University of Wisconsin, Milwaukee. She created TimeSlips which we talk about in our podcast. Her most recent book is Creative Care: a revolutionary approach to dementia and elder care Abhilash Desai, MD, geriatric psychiatrist, adjunct associate professor in the department of psychiatry at University of Washington School of Medicine, and poet! He wrote a book titled "Psychiatric consultation in long term care" that has a strengths based approach to staging dementia (how cool is that) Judy Long, MDiv, BCC, palliative care chaplain and educator at UCSF and caregiver. She directs UCSF MERI's patient, family, and clinician support with classes and consultation on resiliency, well-being, and grief. We discuss the importance of viewing individuals with dementia from a lens of resilience, the importance of creative engagement (as noted in Anne and Susan's wonderful article on this subject), the role of collaborative care, and what we can do to improve inclusivity for individuals with dementia in our community and health care systems.

Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly? That's the central question on today's podcast. The problem is the tremendous heterogeneity in services offered and quality of care. If you've seen one Assisted Living Community you've seen one Assisted Living Community. To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents. The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care). The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of the corporations that own most Assisted Living Facilities (profit) and the ideal services offered in Assisted Living Facilities. We additionally firmly establish that the song How to Save a Life by the Fray was a product of the aughts (2005, to be exact), not the 90's ): Enjoy! -@AlexSmithMD (still on Twitter at present)

Health care professionals are human, and as humans we experience loss both in and out of work. You'd imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses. Turns out, it's maybe not. That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called "Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals". It's a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss. On today's podcast, we've invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private. We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings. These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work. Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings. So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness: Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals Dates & registration info about debriefings offered by CAPC The CAPC Debrief Facilitator Training Manual we developed: PDF Download. Jared Rubensteins' "Token of Appreciation" video A great website for dealing with loss and grief: refugeingrief.com SPONSOR: This episode of the GeriPal Podcast is sponsored by UCSF's Division of Palliative Medicine, 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: https://palliativemedicine.ucsf.edu/job-openings

Dr. Faith Fitzgerald once quipped that prognostic modeling is the "punctilious quantification of the amorphous." She has a point. Prognosis is inherently uncertain. As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful. As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making. What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury? James Deardorff replies that there is something inherently different about predicting mortality. Death is different. For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue). And yet, the only thing that may be worse than a prognostic calculator is a clinician relying solely on their clinical intuition. Today our guests Alex Lee, James Deardorff, and Sei Lee, talk to us about the uses, limitations, and clinical use cases for prognostic models. As a springboard for this conversation we discuss new prognostic models developed to predict (simultaneously) mortality, disability, and mobility impairment (Alex Lee first author, JAGS) and mortality for people with dementia residing in the community (James Deardorff first author, JAMA IM). Both new models are now available and free to use on ePrognosis. And Sei and Eric reminisce about slow dancing to "Forever Young" by Alphaville in their teenage years. Enjoy! -AlexSmithMD