GeriPal - A Geriatrics and Palliative Medicine Podcast

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  

A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken’s post is still one of the most searched and viewed posts on GeriPal. This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today.  Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade - what happens over the next 10, 20, 30 years?   And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation.  In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission.  Lauren uses her magic wand to address the measurement issue: we’re not measuring function, frailty, and cognition routinely in hospitalized older adults.  We wouldn’t dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure. Additional links: GeriPal podcast with Lauren Ferrante and Nathan Brummel on geriatricizing the ICU GeriPal podcast with Tom Gill on the Precipitating Events Study, distressing symptoms, disability, and hospice GeriPal podcast with Linda Fried on frailty Shunichi Nakagawa’s Tweet that went viral on responding a patient request to drink ice water before death. And a note- on the podcast you’ll hear a drum track on the song (!).  I’m taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills.  Bear with me!  I’m having fun working on these songs from home during COVID.  

There is a lively debate going on in academic circles about the value of Advance Care Planning (ACP).  It’s not a new debate but has gathered steam at least in palliative care circles since Sean Morrisons published a JPM article titled “Advance Directives/Care Planning: Clear, Simple, and Wrong.”  Since then there has been a lot of back and forth, with even a couple of podcasts from us, several JAMA viewpoints, and most recently a series of published replies from leaders in the field on why ACP is still valuable (see below for references).   Despite all of these publications, I’m still left at a loss of what to think about it all.  Most of the debate seems rather wonky, as honestly it feels like we are getting stuck in the weeds of semantics and definitions, like what counts as ACP versus in the moment decisions.  But the consequences are real, from research funding dollars to health systems investment.   So in today's podcast, we have invited Juliet Jacobsen and Rachelle Bernacki to talk about what all the fuss is about.  Juliet and Rachelle are two of the authors of a recent JAMA viewpoint titled “Shifting to Serious Illness Communication.”   We discuss the debate, how to think about definitions of ACP vs serious illness communication, what should go into high quality conversations, the evidence for and against any of this, and ultimately where we go from here.    Also see the image from Alex’s forthcoming editorial in JAGS, a Venn diagram of advance care planning and serious illness communication (please go to GeriPal.org to view the image). So check out the podcast and if you are interested in diving into this debate, here are some great links to learn more: What’s Wrong With Advance Care Planning? JAMA 2021 Controversies About Advance Care Planning. JAMA 2022 (a reply to the above) Shifting to Serious Illness Communication. JAMA 2022 Our podcast with Sean Morrison titled “Advance Care Planning is Wrong” Our podcast with Rebecca Sudore and Ryan McMahan titled “Advance Care Planning is So Right” Our podcast with Rachelle Bernacki and Jo Paladino on the Serious Illness Conversation Guide    

My mom is an Asian woman in her 70s with osteoporosis.  She tried an oral bisphosphonate and had horrible esophagitis.  She said never again, though she eventually tried an IV bisphosphonate.  She had terrible flu-like symptoms.  She said never again.  But based on reports that symptoms are worse the first time, she tried the IV again the next year and fortunately experienced no symptoms.  (Story used with permission, thanks mom!).   I tell this story because these issues don’t typically register as more than a nuisance for clinicians, who frequently don’t understand why their older patient with osteoporosis is not taking a bisphosphonate.  But our patients are walking with their feet, and adherence to bisphosphonates for osteoporosis is poor and decreases with time. When we have a medication with up front harms and downstream benefits, it’s critical that we consider the time to benefit, or how long it will take an individual to benefit from a test or treatment.  Think of the 10 years it takes to benefit from colon or breast cancer screening, which is designed to detect slow growing cancers.  For individuals with a life expectancy less than the time to benefit, the up front harms outweigh the downstream benefits.   In this context, we talked this week with James Deardorff and Sei Lee about their study of time to benefit of bisphosphonates for osteoporosis, published in JAMA IM. What they found somewhat surprised us: it’s pretty short, about 1 year!   Which makes me feel better about urging my mom to get treatment.  Bisphosphonates are pretty darn effective, and act quickly. We also discuss discontinuing bispohsophantes, and if we can use the same logic we consider when starting them.   Toward the end we talk about the launch of ePrognosis’ new Time to Benefit tool.  This tool provides a clinical recommendation for starting/stopping medications and cancer screening based on the prognosis of the patient in front of you.  See screenshot below.  You can either access it directly here.  I you use the Lee Schonberg prognostic index for community dwelling older adults you will be directed to the tool, and it will automatically place the life expectancy at the calculated prognostic estimate.   James and Sei requested a terrific song - Bad to the Bone - much better than the Hannah Montana Bone Dance song they threatened me with (maybe next time). Enjoy! -@alexSmithMD

This week many of our listeners will gather for the annual American Academy of Hospice and Palliative Medicine (AAHPM) & Hospice and Palliative Nursing Association (HPNA) annual meeting.  While the majority of this meeting is focused on subspecialty care in the US, the majority of individuals who are in need of palliative care live in low and middle-income countries without even basic access to palliative care.   On this week's podcast, we talk with three leaders in helping improve palliative care worldwide: Kathy Foley, Stephen Connor, and Eric Krakauer.  I don't think I can really sum up these three guests in a sentence each, but I’ll give you how we introduced them in our podcast. Kathy Foley is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative (IPCI). Stephen Connor is a licensed clinical psychologist  and executive director of the Worldwide Hospice and Palliative Care Alliance.  Eric Krakauer is an Associate Professor of Medicine and of Global Health & Social Medicine at Harvard Medical School, an attending physician in the Division of Palliative Care & Geriatrics at Massachusetts General Hospital, and a former medical officer for palliative care at the World Health Organization.  The podcast tries to cover a lot of topics including: Why is addressing worldwide needs of palliative care important? What are the needs of palliative care worldwide? How do you quantify worldwide suffering and what is the serious health related suffering index? What are some of the main barriers to palliative care? What are the models of palliative care worldwide? What are some of the resources to improve palliative care? I encourage you to take a listen, and if you want to learn more check out some of these resources: Worldwide Hospice Palliative Care Alliance (WHPCA) Open Society Foundation’s International Palliative Care Initiative  Global Atlas of Palliative Care International Association for Hospice and Palliative Care JPSM’s issue on the The International Palliative Care Initiative eHospice - a globally run news and information resource      

In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness.   We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University.  We discuss: What are the differences between structural, institutional, and interpersonal racism? Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest’s personal experiences. The importance of attention to religion and spirituality  Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making. Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference). Co-opting of disparities issues by the Alzheimer’s Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here).  Action Item: Please submit a comment to CMS about aducanumab coverage today.  Feel free to express your outrage at the lack of diversity in the trials. We could have continued talking with our guests for hours.  We will continue to address the issue of racism in future podcasts. -@AlexSmithMD

Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant.  Outcomes are worse among those who are frail.  Symptoms are common, including pain, ascites, encephalopathy, and pruritus.  Patients with end stage liver disease are often some of the most disadvantaged patients we care for.  Caregiver burden is immense; divorce is common.  Some will go on to receive a transplant, but many will not.  Many are confused about the diagnosis and feel poorly supported.  Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list.  Advance care planning is rare (or serious illness communication for those of you who don’t consider this advance care planning).  Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain.   In this week’s podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective.  We talk about the tension patients face between putting on the “best face” to be listed for transplant (e.g. full code, goals focused on extending life).  We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease.  We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance. And…Radiohead! Great request…thank you Nneka! -@AlexSmithMD

More Health Policy this week! Today, we discuss “SNPs” but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life.  We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society).  We discuss:  Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new “Hospice Carve-In” This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick’s and Dr. Rick Gilfillan’s critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients.  Alex plays The Purchaser’s Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl’s dog.