GeriPal - A Geriatrics and Palliative Medicine Podcast

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 What they found was fascinating: Most programs require that DNR status be temporarily rescinded for the procedure.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

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.