GeriPal - A Geriatrics and Palliative Medicine Podcast

Gabapentin is the 10th most prescribed drug in the United States and use is increasing. In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin). By 2015 that number increased to 4% of US adults. There are a lot of reasons that may explain the massive increase in use of these drugs. One thing is clear, it is not because people are using it for FDA approved indications. The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications. On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer. It's a big episode covering a lot of topics. First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug). Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later). Donovan discusses the growth of "mood stabilizers/antiepileptics" (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin). Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug. This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial. I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies: Gabapentin in the Perioperative setting: Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022 Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022 Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort. JAMA Surgery 2018 Gabapentin and mood stabilizers in the Nursing Home Setting: Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022 Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020 Efficacy of Gabapentinoids: Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019 Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017 The Illegal Marketing Practices by Pharma promoting ineffective: The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009 Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006

You know when you walk out of a patient's room and have that sense, "This isn't going to go well." The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle. Should you stop at "no?" Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn't stop at "no." We owe it to the patient to explore the reasons behind the "no," commonly not wanting to be a burden to their family. In such cases, we owe it to the patient to use persuasion, for example, "I hear that you don't want to be a burden. And I'm worried that there may come a time when you have trouble making decisions for yourself. We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you're sick, that you're hospitalized, that you're in the ICU, and that you can't make your own decisions? That's a huge amount of news all at once. It would help her to prepare if we could start talking with her now." We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent. Consent is often viewed as "all or nothing" for any specific decision. Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision. I'd hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone. Emily's expanded notion of consent is grounded in the concept of "relational autonomy." Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another. Emily's notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent. Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making. My favorite line from Emily's paper: "Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care." Enjoy! -@AlexSmithMD

Think about the last time a patient yelled at you in anger. How did you react? The last time this happened to me I immediately went on the defensive despite years of training in serious illness communication skills. Afterwards, I thought there must be a better way. Well on today's podcast we invite two of our favorite palliative care psychiatrists, Dani Chammas and Keri Brenner, to teach us about going beyond simple communication skills like naming the emotion when interacting with the angry patient (see our podcast on avoiding the uncanny valley for a deeper dive into the dangers of becoming too rote and scripted). As Keri put it in the podcast, we must go beyond "a hammer and a nail" philosophy to approaching anger by developing a toolkit for anger that is vast and varied. Dani and Kery present three steps for interacting with an angry patient: Look within: What is this anger bringing up in me? How is this anger making me feel, think, and react? Ask why: What is underneath the anger for this particular patient? Creating a "formulation" for the patient Act mindfully: Decide what can we do, and how we can respond therapeutically (and no there is no mnemonic for this step) Here are some other great references we discussed in the podcast: Shalev D, Rosenberg LB, Brenner KO, Seaton M, Jacobsen JC, Jackson VA. Foundations for Psychological Thinking in Palliative Care: Frame and Formulation. J Palliat Med. 2021;24(10):1430-1435. doi:10.1089/jpm.2021.0256 Rosenberg LB, Brenner KO, Jackson VA, et al. The Meaning of Together: Exploring Transference and Countertransference in Palliative Care Settings. J Palliat Med. 2021;24(11):1598-1602. doi:10.1089/jpm.2021.0240 Brenner KO, Rosenberg LB, Cramer MA, et al. Exploring the Psychological Aspects of Palliative Care: Lessons Learned from an Interdisciplinary Seminar of Experts. J Palliat Med. 2021;24(9):1274-1279. doi:10.1089/jpm.2021.0224 Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887. doi:10.1056/NEJM197804202981605 What's in the Syringe?: Principles of Early Integrated Palliative Care And for those interested in other podcast we did with Dani and Keri, check out the following: Therapeutic Presence in the Time of COVID Improving Serious Illness Communication by Developing Formulation What is Emotional PPE?

Amber Barnato is an expert in simulation studies. A health services researcher and palliative care physician, Amber lauds the ability of simulation studies to isolate one variable in a study. For example, we spend the first half talking about a RCT simulation study of clinician verbal and non-verbal communication with a seriously ill patient with cancer. In one room the physician under study interacts with a white patient-actor, and in another room interacts with a Black patient-actor. They found no differences in verbal communication, but clear differences in non-verbal rapport building communication: physicians stood farther away, crossed their arms, didn't touch the Black patient as frequently. Amber tells the moving story of how these findings led a clinical colleague, her chief, to question and change his behavior. Of note, we talked about implicit bias in depth in this podcast with Kimberely Courseen. As we've written about on GeriPal when we were a blog (a decade ago!) these simulation studies can be used to study language, such as patient or surrogate choices when we use the terms "allow natural death" vs "do-not-resuscitate." This change in framing is a nudge, more evidence that the choices we make to use one phrase or another, or the order in which we present options, are all nudges that influence patient choice - listen to our podcast on the ethics of nudging with Jenny Blumenthal-Barby and Scott Halpern for more. Additional links to simulation studies: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-495OC https://journals.lww.com/ccmjournal/Abstract/2011/07000/A_randomized_trial_of_the_effect_of_patient_race.9.aspx https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0089 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687021/ https://journals.sagepub.com/doi/pdf/10.1177/0272989X14522099 Theoretical underpinnings: https://home.csulb.edu/~cwallis/382/readings/482/nisbett%20saying%20more.pdf

Sometimes you read a book and get a flash of insight - that "ah ha!" moment - about yourself and the ways you interact with others. That happened to me when reading "Range: Why Generalists Triumph in a Specialized World." It helped me to understand and justify my interest in (this won't surprise you) EVERYTHING related to geriatrics or palliative care. Also hat tip to Matthew Growdon for recommending the book. Today we talk with Bob Arnold, who has a long list of recommendations for books that have the potential to generate an "ah ha!" moment. The podcast is ostensibly focused on becoming a better mentor, but as you'll hear, we discuss techniques that can help you cope with anxiety, stress, your spouse…the list goes on. In reality, insights from these books can help you be a better teacher, a more curious person, as well as a better mentor or mentee. Bob urges you to buy these books from your local bookstore. To that end, we're not including links with the titles below. Please shop locally. As a bonus, Lauren Hunt, frequent guest on GeriPal, heard we recorded this podcast and wanted to add a couple books to Bob's list (she saw Bob give a talk about these books at the NPCRC Foley retreat). Her list will strongly resonate with women in academics. See below for Lauren's two additions to Bob's list, with her personal commentary. Enjoy! -@AlexSmithMD Bob's booklist: Lori Gottlieb, Maybe You Should Talk to Somebody: A Therapist, Her Therapist, and Our Lives Revealed Ethan Kross, Chatter: The Voice Inside Our Head, Why It Matters, and How to Harness It Eric Barker, Plays Well With Others: The Surprising Science Behind Why Everything You Know About Relationships Is (Mostly) Wrong Stephanie Foo, What My Bones Know: A Memoir of Healing From Complex Trauma Jennifer L. Eberhardt, Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do Claude M. Steele, Whistling Vivaldi: How Stereotypes Affect Us and What We Can Do Marcus Buckingham, Nine Lies About Work: A Freethinking Leader's Guide to the Real World Marshall Goldsmith, What Got You Here Won't Get You There Adam Grant, Give and Take: Why Helping Others Drives Our Success David Epstein, Range: How Generalists Triumph in a Specialized World Douglas Stone, Thanks for the Feedback: The Science and Art of Receiving Feedback Well Douglas Stone, Difficult Conversations: How to Discuss What Matters Most Kerry Patterson, Crucial Conversations: Tools for Talking When Stakes Are High Kerry Patterson, Crucial Accountability: Tools for Resolving Violated Expectations, Broken Commitments, and Bad Behavior Anne Lamott, Bird by Bird: Some Instructions on Writing and Life James Clear, Tiny Changes, Remarkable Results, Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones Michael Bungay Stanier, The Coaching Habit: Say Less, Ask More & Change the Way You Lead Forever Peter Bergman, You Can Change Other People: The Four Steps to Help Your Colleagues, Employees--Even Family--Up Their Game Doug Lemov, The Coach's Guide to Teaching Doug Lemov, Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to College Doug Lemov, Practice Perfect: 42 Rules for Getting Better at Getting Better ​​From Lauren: The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It by Valerie Young I was inspired to read this book after reading a post on the 80,000 hours blog. I had heard of course heard of imposter syndrome in the past but I didn't make the connection to myself until I read this article and saw my thoughts printed on the page. You would think that after several years of a number of career successes, the imposter syndrome would have abated for me, but rather I found it getting worse! I thought that I should know more of what I was doing by this point in my career, but instead I often felt like I had no idea what I was doing! So I came across this book and found it very helpful. Young defines people who have imposter syndrome as those who have a "persistent belief in their lack of intelligence, skills, or competence. They are convinced that other people's praise and recognition of their accomplishments is undeserved, chalking up their achievements to chance, charm, connections, and external factors. Unable to internalize or feel deserving of their success, they continually doubt their ability to repeat past successes." I certainly related to the point that instead of successes alleviating feelings of fraudulence, the opposite happens, because it increases pressures to uphold one's reputation. The pressures can be intense, leaving one wondering if it's all worth it, and prompting fantasies of leaving the charade behind. One thing I really liked about this book is that it places the imposter syndrome into the context of a patriarchal, misogynistic, racist society and organizations that create cultures that cultivate self-doubt (ahem academia). Imposter syndrome is a rationale response to a crazy world. We exist in a society and culture that actually judges women to be less competent at work (the studies she details are SUPER disturbing). It is not surprising we would internalize these norms. Also that being underrepresented in a field creates pressures not only to represent just oneself, but an entire gender. She focuses on women, but these concepts obviously apply to people of color and other disadvantaged social groups. And of course men can have imposter syndrome too. Another part I liked about the book is digging into the notion that one's success is due to luck, or being in the right place at the right time. She dispels these notions by pointing out that, first of all, luck is always present, even for people who are enormously talented and second, being the right place at the right time, having the right connections, and having a winning personality can sometimes actually be the result of skills or abilities, often the result of hard-work, hustling, and efforts to develop one's socioemotional capacity. This is a self-help book, so throughout she offers some useful rules and self-talk for responding to imposter syndrome thoughts. She details different ways to respond to thoughts based on your competence type. For example, if you are a perfectionist, she recommends reframing to a "good enough" quality standard—a mantra I adopted from colleague during the pandemic and has been incredibly helpful for me over the past few years. For the rugged individualist who equate true competence equals solo, unaided achievement, the reframe is "competence means knowing how to identify the resources needed to get the job done." Another really important idea she raises is that women often have difficult choices to make about their career and its impact on other parts of their families and their other social networks that aren't as pronounced for men in our society. Sometimes it is difficult to disentangle these questions from feelings of imposter syndrome. For example, is reluctance to take on more responsibility at work or relocate because you feel inadequate or is it because of genuine concern about the impact on your family? Moreover, women (generalizing here) tend to place lower value on traditional measures of work success (e.g. money, power, influence) and greater value on connection and meaning. It can require a lot of soul searching to figure out whether one is avoiding career "success" out of fear or that certain paths are just truly not aligned with our values. Finally, towards the end of the book, she introduces the idea of "faking it till you make it" and having chutzpah—i.e going for it. Of course, she's not advocating for a George Santos approach (no lying) but just having a little bit more of a mindset that you'll figure it out once you're on the job. I'd definitely recommend this book if you've ever struggled with similar feelings or mentor people who might. She's got a breezy and relatable writing style that's easy to read, lots of great real-world stories, and piquant quotes. The No Club: Putting a Stop to Women's Dead-End Work by Linda Babcock, Brenda Peyser, Lise Vesterlund, and Laurie Weingart Summary of the book's premise: Work activities fall on a spectrum from promotable and non-promotable (NPT). Promotable activities are those that advance one's career. They use the word "advance" quite broadly to encompass various outcomes, like earning a promotion, getting plum assignments, increasing compensation, and enhancing marketability for other jobs. Promotable tasks are visible to others and increase the organization's currency. Some tasks may be indirectly promotable—they help you develop skills that have the potential to enhance your future success or access to future promotable work. NPT's are important to your organization but will not help to advance your career. These tasks have low visibility (think committees and other service). Too many NPT's can lead to work/work imbalance where promotable tasks get pushed to the side and advancement slows, or work-life imbalance, where advancement continues but at the expense of time in one's personal life (or both). Although not exclusively a problem for women, women are more likely to take on NPT's at work. This is because they are both asked more often and are more likely to say yes when asked. They propose both bottom-up (women saying no to more things) and top-down solutions (organizations making efforts to divide up NPT's more fairly and ensuring everyone is pitching in). Before I read this book, I didn't fully grasp the idea that an activity would be helpful to the organization but not to my own career. Sometimes requests for participation in these activities come with a veneer or prestige and lots of feel-good gratitude. I personally feel a lot of guilt and worry about disappointing people when I say no to things. Even declining to review an article for a journal is accompanied by some stomach knots (it's so hard to find reviewers!) I also place a lot of value in collaboration and working in teams, and the idea of working in a culture where everyone is only looking out for themselves is not appealing to me. But I'm also worried at the level of overwhelm I experience at times and perhaps some of you have experienced as well. How do we ensure that we are on sustainable path where we can stay in and build the world we want to live and work in? The book also got me thinking about what is promotable or not in academia, i.e. what is the currency. I think we all know that grants and publications are promotable activities, but even within that there are hierarchies. Some of these hierarchies I think I understand: a data-based paper in a high-impact journal has higher promotability than an editorial in a lower-impact journal. Some of them I'm not sure about: is an NIH project grant more promotable than a foundation grant and if so why (bc higher indirects?) Also, things like mentorship seem gray to me: senior-authored articles are evidence of independence and potential track to mentoring awards, but people often seem to place mentorship in the NPT category. I think having more transparency and discussion about what is promotable or not would be very useful. Highly recommend this book for women, men, people in leadership, and employees. It's extremely well-written, nuanced, and eye-opening. 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

The Covid epidemic laid bare two major structural issues. First, Black and Latinx persons experienced much higher rates of mortality than other groups. Second, as we discussed in last week's podcast, older adults, particularly those in nursing homes, were far more likely to die than younger individuals. These are structural issues because the fundamental causes of these issues were not biological issues, they were social. These worse outcomes were not due to differences in genes, they are due to structural racism and ageism. In today's podcast we talk about the intersection of racism and ageism. We use the Covid pandemic and lack of diversity in trials for recently approved Alzheimer's drugs aducanumab and (to a lesser extent) lecanemab as springboards for discussion. Our guests Tim Farrell, Ramona Rhodes, and Nancy Lunderbjerg wrote an article in JAGS on this issue, and Sharon Brangman wrote a separate JAGS article on the need to achieve diversity in study populations. In a third piece, Ramona Rhodes wrote about efforts to improve diversity, equity, and inclusion at JAGS (in the journal itself, including content and editorial leadership). The article was titled, "Change is coming" - which also gives you a hint as to today's song request. One final note: at the start of today's podcast we thank one of our generous donors, Meg Wallhagen, and ask her why she donated to GeriPal. A prior guest on GeriPal, Meg is a tireless advocate and researcher for hearing impairment issues affecting older adults. She has a study that is open to recruitment for any adult - hearing impaired or not - please see the blurb below to learn more and participate. Enjoy! -@Alex Smith From Meg Wallhagen: The Federal Drug Administration (FDA) now allows hearing aids to be sold Over-the-Counter (OTC-HAs) to adults with mild to moderate hearing loss. We – Meg Wallhagen from UCSF and Nick Reed from John Hopkins University - are interested to learn what people like you know about OTC-HAs and if you would consider buying them. The survey should only take about 10-20 minutes to complete. If you are willing to consider taking the survey, please click on the following link to learn more. https://ucsf.co1.qualtrics.com/jfe/form/SV_9ZbReHYH72m82gK

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