GeriPal - A Geriatrics and Palliative Medicine Podcast

Two major shifts are transforming the landscape of hospice. First, private equity firms are gobbling up hospices.  As Melissa Aldridge, a health services researcher and former banker explains, we should be very concerned.  Private equity firms try to turn companies as profitable as possible within 3-5 years.  Thus, they have little in the way of long term vision for hospices, instead focused on cutting costs and maximizing profits.  Second, Hospice was originally designed for patients with advanced cancer, but the fastest growing admitting diagnosis is dementia.  People with dementia make up about half of hospice admissions.  And yet, we know little about the clinical experience of people with dementia in hospice.  Krista Harrison found, to her surprise, that caregivers of people with dementia who died rated hospice as well as similar patients without dementia who died on hospice.  And yet, disenrollment from hospice, either due to patient/family revoking the benefit or stabilization of illness (extended prognosis) is remarkably high for people with dementia among some hospices.  In fact, as Lauren Hunt found, the average likelihood that a person will be disenrolled from one hospice vs. another is two. In other words, which hospice you enroll in has a tremendous influence on whether you’re going to be disenrolled from hospice, which often feels to patients and families like being expelled. And I had a blast playing Take the Money and Run! -@AlexSmithMD

Today we have the honor of interviewing Susan Block, MD, one of the pioneering leaders in the fields of palliative care, particularly psychosocial aspects of palliative care.  Susan led the Project on Death in America’s Faculty Scholars program, used her dual training in internal medicine and psychiatry to shine a light on psychosocial aspects of palliative care, and founded the Department of Psychosocial Care at the Dana Farber Cancer Institute and Brigham and Women’s Hospital.   We talk with Susan about how far the field has come, from early days when the attending physician would decide which patients were DNR and place a black “no code” dot in the chart.  We talk about challenges facing the field today.  In particular, she reminds us that when we think about the most challenging of our patient encounters, they almost always involve a complex psychosocial dynamic, and this has received far less attention than communication and symptom management issues.   We delighted to be joined by Brian Block, pulmonary/critical care faculty at UCSF and frequent guest host on GeriPal…and also nephew to Susan. -@AlexSmithMD  Links: -PDIA Faculty Scholars Program -Serious Illness Conversation Guide podcast -Therapeutic presence in the time of covid podcast

A year ago we did our first “Deprescribing Super Special”.  Today we are coming back for more (or less given the content), talking about the following articles with their lead authors: First up, we talk with Ariel Green about her article in JAMA Network on preferred phrases a clinician may use to explain why they should reduce or stop the medication.   My take home from this is that while the most preferred explanation for deprescribing statins and sedative-hypnotics is one focused on the risk of side effects, we also need to individualize it to the patient and the medication that they are taking. Next up, we chat with Liz Bayliss about her JAMA IM article that studied whether increasing awareness about deprescribing prior to primary care visits can reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment.  While the study was largely negative, it does bring up important implications about how we should think about deprescribing in older adults (added bonus too - all of the resources used in the study can be found on the US Deprescribing Research Network website). Lastly, we talk with Kevin McConeghy about one deprescribing intervention that was hugely successful, although somewhat atypical.  Kevin’s study looks at a period of time in the COVID pandemic when a large multistate nursing home provider created a “nonessential medication on hold” (NEMOH) policy in order to conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact.  Although the policy was not originally envisioned as a deprescribing intervention, 54% of held medications were discontinued.  That’s huge!  While it’s unlikely this will be repeated, we talk about lessons we can learn from this natural experiment.   

We are fortunate today to interview two oncologists whose research has catapulted palliative care forward: Jennifer Temel, author of the landmark NEJM study on early outpatient palliative care for patients with advanced lung cancer; and Areej El-Jawahri, author of the landmark JAMA article on inpatient palliative care for patients with blood cancers undergoing stem cell transplant.   Jennifer’s study is most widely known for the “kicker” - not only did it improve quality of life, palliative care was associated with a couple months longer survival.   Areej’s study is remarkably novel in that it is, to our knowledge, the first study of palliative care during curative treatment.   We cover a huge amount of ground today, including: Jennifer’s reaction when she unblinded the study and found that palliative care was associated with prolonged life Differences between inpatient and outpatient palliative care for cancer What’s in the secret sauce of palliative care?  (hint: coping) What’s the right dose of palliative care? Do we need separate palliative care models for each cancer? What is next for these two?  Celine Dion Additional links: Editorial on Areej’s study Palliative care in lung and GI cancers GeriPal post on qualitative study of the Temel RCT GeriPal post on “fast food” style palliative care in chronic critical illness JAMA paper on remote symptom monitoring in cancer  

The science of balancing safety and independence of older drivers has come a long way.  Some key points from our podcast today with Emmy Betz (emergency physician-researcher) and Terri Cassidy (occupational therapist and certified driving rehab specialist) include: It’s no longer gouache to say “taking away the keys” - which sound punitive and risks infantilizing  Instead the new lingo is “driving retirement” Driving retirement can be a process, similar to a harm reduction model, in which the activity is not eliminated all together but restricted to minimize harm: e.g. driving only during the day, or avoiding freeways. A JAGS randomized trial demonstrated that a free online tool that assess readiness to stop driving helped older drivers with the difficult decision about driving cessation. Often the work of the certified driving rehab specialist is to assess the older drivers goals, assess prognosis for driving, and help the family navigate discussions around driving cessation (hmmm…sounds like an approach to family meetings). There is a dearth of Certified Driving Rehab Specialists: 12 for the entire state of Colorado! We learned this and much more, and I had a great time making engine noises singing the Woody Guthrie song “driving in my car.”   Additional Links: (A to Z – under driving)https://decisionaid.ohri.ca/cochsystem.html (OT programs)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347878/ An Advance Directive for When Driving Becomes Unsafehttps://geripal.org/an-advance-directive-for-when-driving/ ADED (Association for Driver Rehabilitation Specialists)https://www.aded.net/search/custom.asp?id=2046  

“Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You’re short on gowns and facemasks. You’re short on nurses and nurse aids so now you have to help deliver meals.” This was the opening paragraph that I wrote in March of 2020 when introducing a podcast we did with Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond.  That was his literally his life during those spring months of 2020 and it scared the hell out of me.  Lucky, Jim and many others like him were willing to come on to our podcast those first several months of the pandemic and share their experiences and lessons learned caring for COVID positive patients and their family members.   On today’s podcast, we look back to those early months of the pandemic and look forward to the future.  We invited Jim back with us along with Darrell Owens, DNP, MSN, who is the  head of palliative care for the University of Washington’s Northwest campus.   For those who didn't listen to our podcast with Darrell, when most of us were still trying to figure out what COVID was, he created an on call 24/7 palliative care service to have goals of care conversations with elderly patients in the emergency department under investigation for COVID, and also established an admitting inpatient palliative care service at his hospital for patients on exclusively comfort measures.  What I loved about this March 2020 podcast was that Darrell pushed us to think differently: “Expect that it’s not business as usual. Very first thing, you’re going to have to do things differently, so be open to that. Be totally open-minded. Now the old, “We’re not an admitting service or we don’t do that and we don’t do this,” don’t start with what you don’t do. Start with what you can do, what’s your capacity. So take a walk down memory lane with us and hear from both Darrell and Jim where they think we are going.

On today’s podcast we welcome back Haider Warraich to talk about pain.  Now this may surprise our frequent listeners as we have had Haider on before to talk about heart failure as well as palliative inotropes, so why are we having him come on to talk about pain?  .   Well, Haider has an intimate relationship with pain, having experienced chronic pain himself and now having dove deep into the latest research on pain for his new book The Song of Our Scars: The Untold Story of Pain.   We discussed the nature of pain, what makes chronic pain different from acute pain, what’s the difference between proprioception, pain, and suffering, and so much more.  So take a listen and if you are up for it, check out some of Haider’s other books including Modern Death: How Medicine Changed the End of Life and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease. 

You have a patient with dementia severe enough that she cannot recognize relatives.  She falls and breaks her hip.  Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation?  Should she be treated non-operatively, with aggressive symptom management?  A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia. In today’s podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia.  Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what’s to be done about the pressure and incentives our health system exerts to operate, operate, operate.   -@AlexSmithMD

Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm.  The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is:  In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer. Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis.  In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here. Mara keeps working at it, and the more she works, the closer we are to fine. -@AlexSmithMD

There are a lot of old myths out there about managing urinary tract symptoms and UTI’s in older adults.  For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.   On today’s podcast, we are gonna bust some of those myths.  We’ve invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.   First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.  We discuss with her how we should work-up and manage “urinary tract infections” (I’ve added air quotes to “UTI” in honor of Tom Finucane’s JAGS article titled “Urinary Tract Infection”—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.) Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men.  We also discuss Scott’s recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.