GeriPal - A Geriatrics and Palliative Medicine Podcast

"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

On June 7th, 2021 FDA approved the amyloid beta-directed antibody aducanumab (Aduhelm) for the Treatment of Alzheimers. This approval of aducanumab was not without controversy. Actually, let me restate that. The approval of aducanumab was a hot mess, inside a dumpster fire, inside a train wreck. After the approval, three members of the FDA advisory panel, which unanimously was not in favor of the approval of aduhelm, quit. One of them, Aaron Kesselheim (who we have on our podcast today) described it as "the worst drug approval decision in recent U.S. history" in his resignation letter. Then the FDA had to revise the label one month after publishing it because the original didn't even come close to looking like the population in which treatment was initiated in clinical trials. Then, wait for it, after a firestorm of criticism the FDA's commissioner had to ask for an independent investigation to look into the interactions between Biogen representatives and FDA members. And now CMS is deciding if and how to cover Aduhelm, a drug that will cost at least $56,000 a year per patient not incluiding the doctor's visits, amyloid PET scans, and frequent MRIs that will be necessary to monitor for side effects. On today's podcast we talk all about aducanumab with Aaron Kesselheim, Professor of Medicine at Harvard Medical School and previous member of that now famous FDA advisory committee, as well as Jason Karlawish, Professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania Perelman School of Medicine. I'd love to point you to the journal articles for the two phase III trials on aducanumab, but as of yet, they are unpublished (this should tell you a little about the faith Biogen has on its drug data), so I'll leave you with these resources instead: Our podcast with Gil Rabinovici on "All things Amyloid, including Aducanumab and Amyloid PET scans" AGS's preliminary advice on prescribing Aducanumab - Jason Karlawish's book, The Problem of Alzheimer's, and the previous podcast that we did on it FDA's document dump on Aduhelm Biogen's open letter to the Alzheimer's disease community complaining about the "turn outside the boundaries of legitimate scientific deliberation" that has occurred with aduhelm (while ignoring the fact that the trials have not been published yet). CMS's request for public comment for their National Coverage Determination analysis to determine whether Medicare should cover the drug and any other monoclonal antibodies directed at amyloid The last one is particularly important as whether you are for or against the coverage of aducanumab, your voice matters. There is a letter being circulated by physicians who care for people with Alzheimer's Disease urging CMS not to cover aducanumab given the limited clinical evidence for benefit, known harms, and exorbitant cost. You can find the letter here. If you would like to sign the letter, you can add your name by clicking this link.

Cannabis use by older adults has increased substantially over the last decade, a trend that has paralleled the legalization of its use for medical and recreational purposes. In that same time, there has been a decreased perceived risk associated with cannabis use in older adults as noted in a recent study published in JAGS. On today's podcast we talk with Drs. Bree Johnston and Ben Han about what the health care providers role is in cannabinoid prescribing and advising when caring for older adults. We try to cover a lot in this podcast, including some of these topics: Epidemiology of cannabis used by older adults (including aspects of the JAGS study) The basic pharmacology and dosing of cannabinoids The latest evidence for the efficacy of cannabis Specific risks and side effects that providers should be aware about, and how we should monitor patients using cannabinoid products Drug interactions we should be aware about