GeriPal - A Geriatrics and Palliative Medicine Podcast

The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians? On today today's podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the National Alzheimer's Project Act. Dr. Sherry shares her expertise in aging health policy and helps us make sense of the role of her Office and how she coordinates with the multitude of federal agencies aligned around the goal of advancing aging research, policy, and health. For the policy buffs and policy newbies out there, we hope this podcast is an essential primer to government in action. We talk about: The structure of federal agencies and how they coordinate Priorities of the National Alzheimer's Project Act, and the unique role of ASPE and BHDAP in guiding the agenda and long-term goals The recent focus on nursing facilities and long term supportive services during the pandemic, along with key gaps How HHS and ASPE solicit input from clinicians, community leaders, and older adults and how much it impacts policy decisions (spoiler alert: this involvement is CRUCIAL) How to make your voice heard and get involved We also touch briefly on topics discussed in prior podcasts such as loneliness and federal responses to the pandemic in relation to long-term care. Tune to hear Alex's rendition of 'With a Little Help from My Friends'! - Ashwin Kotwal, MD, MS

When I'm on service these days there is inevitably a moment when a resident says "Patient so-and-so is on X" - and I have absolutely no idea what X is. Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up. In this context, we're excited to hear from infectious disease experts and nephrologists about updates in the care of older adults. Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I've never finished a course of antibiotics, and maybe your patients don't need that full course either). Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race. We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I'm not 100% sold that race should always be removed - if removal is likely to worsen disparities for example - at least until a superior race-blind calculator can be developed). These articles are part of a new series called Clin-Star Corner, a new series in JAGS that reviews practice changing articles in the care of older adults. And yeah, they made me sing a Miley Cyrus song…(but not this hilarious parody about UTIs). Enjoy! -@AlexSmithMD

Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy: From a Latin word for "to cloak", it's the type of care given to seriously ill patients to provide comfort without curing What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn't provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round! The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field. So what do we do about it? Well, on today's podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning. The result is a new toolkit to help us fix our messaging & engage the public: seriousillnessmessaging.org Questions we talk about include: What do we know about the public's perception of palliative care, hospice, and advance care planning? What's wrong with the "pictures of hands clasping each other" as our palliative care meme? How can we bring in marketing strategies into our public messaging? Don't palliative care clinicians already know how to explain things with empathy? Why is this different from clinical communication skills? If we avoid talking about death, is it just contributing to the public death denial that is rampant in American culture? Related Links Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0111 Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0719 Effective Messaging Strategies: A Review of the Evidence. Communicating to Advance the Public's Health: Workshop Summary https://www.ncbi.nlm.nih.gov/books/NBK338333/

Have you had difficulty managing a particular type of cancer pain? For me it's radiation induced mucositis/esophagitis. Janet Abrahm is one of the world's experts in pain and symptom management for patients with cancer joins us to talk about (among other things): Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects Lidocaine: worth the hype? Strengths and weaknesses of buprenorphine for cancer pain Fentanyl patch: often missed issues Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I'm "stuck" taking care of patients with cancer. And yes, this would be a great one for CME. Eric and I are working on it…maybe by 2023? Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!? Enjoy! -@AlexSmithMD

Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you've uttered a hundred times before, came out rote and scripted? Maybe some phrase you learned from a prominent podcast or VitalTalk? And in response, the family or patient looked at you like you were from another planet? Yeah, I've been there too. Josh Briscoe, our guests on today's podcast, argues that you've entered the Uncanny Valley. In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still "off" appearance. Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families. Today we talk with Josh about how to anticipate and avoid the uncanny valley. And talk about times when we've fallen into it. Key message: Listen to the music. All the time. ;) Links: -Uncanny Valley post on Josh's fantastic substack Notes from a Family Meeting -Anticipatory corpse book mentioned several times on the podcast -GeriPal post about teaching using YouTube (some links are old and don't work, but you get the idea, I recently gave a spontaneous talk to the palliative care fellows and was able to find the video snippets) -Ira Byock's 4 things that matter most -@AlexSmithMD

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80. The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time. On today's podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure. We also discuss Gwen and Ashok's mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes. What they found was fascinating: Most programs require that DNR status be temporarily rescinded for the procedure. The time required before DNR was reinstated varied substantially among programs (38% 30 days post-discharge). Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them. They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!) Here are more resources if you want to take a deeper dive into the subject: Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022 The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017 Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021

Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder. She recalls being "a social scientist [Holly] in room a full of psychiatrists," who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one. This led her on a remarkable journey. Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death. Prolonged grief is associated with increased risk of suicide and other negative health outcomes. This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V. And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work. "Everyone has experienced grief, which makes everyone the expert." Today we offer Holly a chance to answer her critics, including assertions that: Grief is love; how can love be wrong? Pathologizing grief leads to overmedicalization of a natural condition Prolonged grief disorder is a tool made for the pharmaceutical industry Prolonged grief disorder does not account for cultural variation in mourning practices Along the way we talk about other related studies Holly has conducted, including a validation of DABDA - Elizabeth Kubler Ross's famous stages of grief. And a song choice from the great lyricist Tom Waits. Enjoy! -@AlexSmithMD

In day-to-day practice, It's hard to imagine providing excellent hospice or palliative care services without access to a team social worker. Social workers augment a team's ability to provide whole-person care, often aiding to identify and meaningfully address the wide variety of challenges and unmet needs faced by individuals and families facing serious illness. But are we really taking full advantage of ALL social workers have to offer our field? On today's podcast, we are talking with Barbara Jones – a national hospice and palliative care social work leader whose many accolades include being a founding member of the Social Work in Hospice and Palliative Care Network (SWHPN), a Professor of Direct Social Work Practice and Associate Dean for Health Affairs at the Steve Hicks School of Social Work at UT Austin. Barbara highlights social workers' inherent leadership qualities and tasks us to consider whether our own team and organizational structures are allowing for optimal social work engagement and influence. Whether in direct practice or in research and academia, we should work together to help Hospice and Palliative Care Social Work meet its full potential. by: Anne Kelly, LCSW, APHSW-C

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