GeriPal - A Geriatrics and Palliative Medicine Podcast

It's been a while since we've done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here). But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations. This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity. They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities. The basis of their argument is the ethical notion of "reciprocity" - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action. Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion. To be sure, Paxlovid is no longer as scarce as it was a few months back. But the argument is important because, as we've seen, new treatments are almost always scarce at the start. Evusheld is the latest case in point. Sometimes, you can't always get what you want… -@AlexSmithMD

A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid). How do you do that? Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to? Well on today's podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead. But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table! Oh boy, what should we do? Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data? Listen to this spicy podcast with these wonderful guests to make up your own minds (I'm sticking with the equianalgesic table for now). If you want to take a deeper dive into some of the references, here you go: Pallmed Post on why "Opioid Equianalgesic Tables are Broken" Pallimed post on "Simplifying Opioid Conversions" Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone. Our previous podcast with Mary Lynn titled "All the Questions You Had About Opioids But Were Afraid To Ask"

In today's podcast we talk with Dr. Rajagopal (goes by "Raj"), one of the pioneers of palliative care in India. Raj is an anesthesiologist turned palliative care doctor. He is also author of the book, "Walk with the Weary: Lessons in Humanity in Health Care," and was featured in this Atlantic article. Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India. We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF. In this podcast, we cover a great deal of ground, including: Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn't see addressing suffering as a priority Prognosis communication and the subtle ways we may communicate it without intention Social pain and loneliness Community-based palliative care networks Raj's reflections on the state of palliative care in the US How definitions bind us, for example the division between chronic pain and palliative pain in much of the US Ways listeners can learn more and contribute (see this link in the US) Because the song request was the short theme-song for Pallium, I recorded it two ways. The intro is the upbeat guitar driven version. The outro is the synthesizer (new toy!) slowed down version. Enjoy! -@AlexSmithMD

Think about the last time you attended a talk on communication skills or goals of care discussions. Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice? I'm guessing not. Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life. Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored. On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care. Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF. We talk with Nick and Meg about: Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals How to screen for hearing loss Communication techniques we can use when talking to individuals with hearing loss The use of assistive listening devices like pocket talkers and hearing aids Their thoughts on the approval and use of over the counter hearing aids If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following: Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults Over-the-counter hearing aids: What will it mean for older Americans? Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic

Comics. Cartoons. Graphic Novels. Graphic Medicine. I'm not sure what to title this podcast but I've been looking forward to it for some time. Heck, I'm not even sure to call it a podcast, as I think to get the most out of it you should watch it on YouTube. Why, because today we have Nathan Gray joining us. Nathan is a Palliative Care doctor and an assistant professor of Medicine at Johns Hopkins. He uses comics and other artwork to share his experiences in palliative care and educate others about topics like empathy and communication skills. His work has been published in places like the L.A. Times, The BMJ, and Annals of Internal Medicine. We go through a lot of his work, including some of the comics you can see on our blog post. However if you want to take a deeper dive, check out his website "The Ink Vessel" or his amazing twitter feed which has a lot of his work in it.

In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine. In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging. In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry. As with aging, poetry operates on multiple levels within the palliative care space. Poetry puts us in our patient's shoes. As Redwing's poem says, "why not live as long as possible?" Poetry holds us in that liminal space so many of our patients are in. Paradox. The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I'm paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go. Or as in Mark Nepo's poem Adrift, I am so sad and everything is beautiful. Poetry helps us grapple with our own experiences of illness. Redwing, who is a cancer survivor, shares poems about her experiences with cancer. Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis. We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality. And along the way, we really felt like we got to the heart of things. To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide. -@AlexSmithMD Links to Redwing's poetry workshops: Food for Thought Poetry for Resiliency Loss, Losing and Loosening, poetry for grief and loss Wounded Healer poetry sessions Advance Care Planning Links to Redwing Keyssar's poetry collections Redwing's website: www.redwingkeyssar.com Institute for Poetic Medicine Mike Rabow's Comprehensive Care Team randomized trial of outpatient palliative care Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out). In addition to Redwing's own songs and poems, other poems read by Mike and Redwing during the podcast: In Blackwater Woods by Mary Oliver Therapy by John Wright Adrift by Mark Nepo Talk Before Sleep by Elizabeth Berg Late Fragment by Raymond Carver

Buprenorphine. It's been around for a long time but is acting like the hot new kid in town. Just look at this year's AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now. But does this drug really live up to the hype? On today's podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care). We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes). And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles: Learn more about caring for those with substance use disorder: Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness Learn about using the low dose buprenorphine patch: Low-Dose Buprenorphine Patch for Pain - Fast Fact Learn about how to initiate buprenorphine: Sublingual Buprenorphine Initiation: The Traditional Method - Palliative Care Network of Wisconsin Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach Good review on buprenorphine for pain Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

In her essay "Why Read a Poem in a Time Like This?", Marilyn McEntyre writes: All of us need it. We need it because good poems do something prose can't do. They invite and enable us to notice the precarious fissures in what we think is solid ground. They direct us toward the light at the edge of things — the horizon, the fragment of dream before dawn, the feeling that's hard to name, and can only be accurately captured by metaphor. They take us to the edge of "what can't be said," and ambush us into feeling before we think, so that we can't simply and complacently "believe everything we think." Poetry deals in surprise and subversion and turns old words to new purposes. Marilyn is joined by Guy Micco to talk about why poetry is important in general, why it's important in medical or nursing education, and why it's important for people who care for older adults. Along the way, they read poems, talk about poems, and sing a song by John Prine. We talk about how poetry can surprise, how poems can be playful, how they unlock dimensions and emotions that are otherwise locked away. How sometimes good poetry can be like a needed punch. And maybe, just maybe, we convince that poetry skeptic Eric Widera that there is a place for poetry in medicine after all. Enjoy! -@AlexSmithMD Links to essays and books by Marilyn McEntyre Why A Poem in a Place Like This? Why Read a Poem in a Time Like This? Patient Poets: Illness from the Inside Out Caring for Words in a Culture of Lies Links to Songs/Poems from the Podcast: Hello in There by John Prine After Apple Picking by Robert Frost Sonnet 73: That Time of Year Thou Mayest in me Behold by Shakespear Jane by George Bilgere Long Life by Elaine Feinstein Sonnet 60 by Pat Schneider (not online)

One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, "Can We Agree to Disagree?" And today our guests agree to disagree. And yet, and yet… They also agree across a whole range of issues, some of which surprised us. This is the latest in our series of podcasts on concerns about, and potential of advance care planning. If you're new to this discussion, don't start with this podcast! Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki. On today's podcast we ask our guests about areas in which there might be agreement or disagreement, including: The Best New York style bagels are made in California. Assigning a surrogate decision maker is important for everyone, including those who don't have serious illness. Where does POLST fit in with this debate? All decisions are made in advance, the question that we are debating is how far in advance and what to call it Completion of advance directives and billing codes for advance care planning as quality metrics Among other topics. I'm heartened that we could have this discussion as a field, as it shows that we've grown to the point where we can agree to disagree respectfully with each other. We can work it out! Links to a few couple items mentioned on the podcast: Objectives for Advance Care Planning 2018 Systematic Review of Systematic Reviews on ACP -@AlexSmithMD

If you develop dementia, odds are you will spend the last months to years of your life in a nursing home or assisted living facility. While we like to think about how our goals and preferences will influence what that life looks like, including whether you will get potentially burdensome interventions, your fate is probably influenced more by factors like where you live and what nursing home you happen to end up in. On today's podcast we dive into drivers of invasive procedures and hospitalizations in advanced dementia by talking to some pretty brilliant nursing and nurse practitioner researchers focused on dementia, geriatrics, and palliative care in nursing homes: Ruth Palan Lopez, Caroline Stephens, Joan Carpenter, and Lauren Hunt. We start off discussing the findings of Ruth Palan Lopez's publication in JAMA IM on the ADVANCE study. This study explored nursing home organizational factors and staff perceptions that are associated with the variation in care for residents with advanced dementia. Now when I say variation, I'm not talking about small little clinically questionable variations. I'm talking about some nursing homes with no residents with advanced dementia being tube fed, and some with nearly half of their residents with advanced dementia being tube fed. We go on to talk about other findings of this study including that staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in ACP and preferred more aggressive care, issues with the skilled nursing facility benefit ("rehabbing to death"), the palliative care needs of nursing home residents, and so much more. For a deeper dive, check out some of these other studies and resources we talked about in the podcast: The Influence of Nursing Home Culture on the Use of Feeding Tubes. Archives of Internal Medicine 2010 The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia Rehabbed to Death. NEJM Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block A Podcast with Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion