GeriPal - A Geriatrics and Palliative Medicine Podcast

Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure.  Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain.  But these outcomes represent a thin view of the human experience.  What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose.  Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales. In this week’s podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities.  Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression’s ability to participate in meaningful activities.  Most people think that a good quality of life isn’t possible for people with these conditions. Anna’s study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities. Theresa’s qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same.  Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities.  Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care. -@AlexSmithMD  

The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD).  Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE?  Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials? In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab: Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions.  Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab. For more podcasts on aducanumab, check out these two: All things Amyloid, including Aducanumab and Amyloid PET scans with Gil Rabinovici Aducanumab (Aduhelm) for the Treatment of Alzheimers: A Podcast with Aaron Kesselheim and Jason Karlawish

“The take home message of this study is NOT that primary palliative care does not work.”  So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer. And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts)  - is it time to start to question the effectiveness of primary palliative care?  We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness.  But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is “good enough” to impact outcomes. That’s one interpretation.  Another is that we need a “stronger dose” of primary palliative care.  In Yael and Bob’s study nurses averaged 2.2 visits, hardly robust longitudinal palliative care.  Patients who had 3 visits had better outcomes. Unpacking negative studies is just as interesting as unpacking positive studies.  Knowing what doesn’t work is just as important as knowing what does. Links: Negative multi-national study of primary palliative care in nursing homes Negative ICU primary palliative care intervention Project ENABLE Podcast on palliative care’s diversity problem Systematic review of palliative care  

Time-limited trials. We’ve all probably used them before. We meet with patients and families.  We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments.  If not, we stop them.  At least that is how it’s supposed to go.  On today’s podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter.  Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units.   Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire.    We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive.  The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention).  We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast).  If you want to read more about time-limited trials, check out these articles as well:  Paula Spans NY Times article on Time limited trials titled “I need to know I tried”  The JAMA IM study and editorial on time-limited trials Tim Quill and Robert Holloways article in JAMA on Time-Limited Trials from 2011 And lastly our nudging podcast that we brought up several times  

I’m going to start this introduction the way Eric ended our podcast. You are a GeriPal listener.  Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness.  This is hard, complex, and deeply important work we’re engaged in.  Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice?  We will assume that you are doing the same right now if you haven’t done so already, though we suppose you are free to choose not to if you don’t believe in the mission of helping seriously ill older adults. Ha! Gotcha. Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of “nudging,” or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice.  Jenny just published a terrific book on the topic, “Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.”  Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. “In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?”). Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I’m a believer in the GeriPal mission too, we’re on the same side), appealing to ego (you’re a good person because you believe in an important cause), and changing the defaults (you’re giving us a five star rating right now unless we hear otherwise).   We distinguish between nudges and coercion, mandates, and incentives.  We talk about how clinicians are constantly, inescapably nudging patients.  We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.   Nudges are powerful.  At best, nudges can be used to promote care that aligns with a patient’s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote “doctor knows best” paternalism, and to “strongarm” patients into care that doesn’t align with their deeply held wishes.   What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don’t have deeply held preferences, goals and values? Hmmm....  Hey, have you completed your five star rating of GeriPal yet? -@AlexSmithMD Other citations: -Randy Curtis and Robert Burt on unilateral DNR and informed assent -GeriPal podcast with Angelo Volandes about using video to improve choices

Randy Curtis, a paragon of palliative care research, was diagnosed with ALS in March.   Randy is in a unique position as someone who studies and cares for people living with serious illness, who now shares his reflections on being on the other side, to reflect on the process of living with serious illness.  His reflections are illuminating and inspiring. We talk with Randy about his experience being in the patient role, rather than the physician or researcher role.  We ask if knowing the prognosis for his subtype of ALS is helpful to him, and if he’s seeing a palliative care clinician.  We talk with Randy about his legacy, principally his focus on mentoring.  We talk about how his approach to his life, his clinical work, and research has shifted in the face of living with serious illness.  We end by talking about our favorite “Randy Curtis” studies. Thank you Randy for modeling vulnerability and willingness to talk about ALS. Thank you for your mentoring which has nurtured a veritable forest of trainees, and for your research which has improved care for people living with serious illness and their families. And here’s to your song choice: a “good life” indeed, by any measure. Links: -Prior GeriPal podcast with Randy Curtis on an earlier study of the JumpStart patient-priming intervention for goals of care discussion -ICU family meetings: Increased proportion of family speech is associated with increased satisfaction -Alterations in translated ICU family meetings -A communication strategy and brochure for ICU family meetings -Practical guidance for ICU family meetings -Empathy in life support decisions -Cambia Center of Excellence for Palliative Care Research -Cambia Sojourns Scholars Leadership Program   -@AlexSmithMD

alliative care has a diversity problem.  The workforce of palliative care looks nothing like the patient population that we care for in the hospital and in our clinics.   For example, in 2019-2020 academic year only 4% of Hospice and Palliative Care fellows identified as black, compared to 12% of the overall US population using the most recent census information.   These issues are similar for hospice and geriatrics. On today’s podcast we talk about this diversity problem with Lindsay Bell, Tessie October, and Riba Kelsey. Lindsay, Riba, and Tessie recently published an article in JPSM that found that trainees at historically black colleges and universities and residents at institutions with the highest percentage of black medical students lack access to palliative care training. Riba Kelsey is the Family Medicine residency director at Morehouse School of Medicine, and we talk with her about the implications of these findings at historically black colleges and universities (HBCUs), as well as what we can do in the field of palliative care in general to improve our workforce issues. One shining example we discuss in depth is the ongoing collaboration between the University of Pittsburgh Palliative care group and Morehouse School of Medicine.  We hope that collaborations like these will lead to a wider pipeline of palliative care informed trainees from diverse backgrounds, and someday soon, greater diversity in the palliative care workforce.  

Much has been written in geriatrics and palliative care about anticipatory grief, about the grief of caregivers, and even the grief clinicians experience following the deaths of their patients.  Krista Harrison, in a Piece of My Mind essay in JAMA, writes about something different.  She writes about coping, as an academic hospice and palliative care researcher, with personal grief from the deaths of her dad and step-dad within 5 months of each other.   There are many reasons this essay likely touched so many people (it seemed to be all over Twitter).  One is that there’s a silence around this experience of death.  Krista’s essay opens up a space to talk about it.  Another is that the experience of grief is in fact universal, whether it’s the loss of a loved one, the loss of a colleague or mentor to illness or a move, the loss of “a return to normal” following COVID.   Krista wanted to add a couple of things not mentioned in the podcast that she found helpful.  First, she treasures videos she has of her loved ones recorded before death.  Second, she made fingerprint imprints of her two dads and keeps the fingerprint impressions in a locket around her neck. We talk with Krista about these and many other things on this week’s podcast.  Let’s keep the conversation going. Links: Making Space for Grief in Academia, JAMA The Hidden Curriculum of Hospice: Die Fast, Not Slow, Health Affairs Live Discharge from Hospice Isn’t Graduating - It’s Getting Expelled, JAGS Griefcast podcast RadioLab: The Queen of Dying Podcast The Dougy Center Grief Out Loud Podcast On Being Podcast The Five Invitations by Frank Ostaseski Resilient Grieving by Lucy Hone  The Art of Losing (poems) When Things Fall Apart by Pema Chodron -@AlexSmithMD  

Today’s podcast is on academic life hacks, those tips and tricks we have seen and developed over the years to succeed in academic medicine in fields that are somewhat generalist in nature. While the podcast is meant for fellows and junior faculty, we hope some of it applies to the work that all of our listeners do, even in non-academic settings.   Why are we doing a podcast on #academiclifehacks?   You will notice that at the start of the podcast, we spent a couple minutes to recognize my co-host, Alex Smith, for a particularly important award he received at the 2021 AGS meeting – the  Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation.  As part of this award he presented a talk titled "Confessions of an Unfocused Researcher."  We (and when I say we, everyone on this podcast except for Alex who we kept in the dark) thought it would be a good idea both to celebrate Alex’s award and talk about some of the topics he brought up in his talk, as well as other tips and tricks.   So we asked Lynn Flint and Ken Covinsky from UCSF, and Christopher Langston from Archstone foundation to join Alex and me to talk about our shared tips and tricks to succeed in academic medicine.  In particular we focused on several key issues that new faculty need to address as they start their careers including: Academic focus and goals  Mentorship (and mentoring up) Academic scholarship & writing Collaboration & Networking Work / Life Balance We would also love to see your own academic life hacks by sharing them on twitter and adding the hashtag #academiclifehacks to the tweet.   

“Loneliness is different than isolation and solitude.  Loneliness is a subjective feeling where the connections we need are greater than the connections we have.  In the gap, we experience loneliness.  It’s distinct from the objective state of isolation, which is determined by the number of people around you.” - Vivek Murthy, two time (and current) Surgeon General. We have heard a lot about loneliness and social isolation, particularly during the pandemic with enforced social distancing and near imprisonment of older adults in nursing homes.  In this context, we bring in two experts on these topics, Carla Perissinotto and Ashwin Kotwal, to explain: How loneliness and social isolation overlap and are distinct How common these measures of social well being are in geriatrics and palliative care Why we should care as clinicians How we can ask about them How we should respond to care for patients who are lonely or isolated Some key references from among the many we discuss on the podcast: Loneliness in older adults predicts functional decline and death (JAMA IM 2012) The epidemiology of loneliness and social isolation during the last years of life (JAGS 2021)  Use of high risk medications among lonely older adults (JAMA IM 2021)  Integrating social care into healthcare: GeriPal podcast with Kirsten Bibbens-Domingo  Coalition to end social isolation and loneliness  -@AlexSmithMD