GeriPal - A Geriatrics and Palliative Medicine Podcast

Surrogate decision‐making around life-sustaining treatments in the hospital even in the best of circumstances is hard. It's maybe even harder when caring for those who are conserved or have a professional guardian. The conservator may not have known the patient prior to them losing capacity, they may not know their values or goals that can help guide decisions, and they may be restricted by state statutes on what decisions they can make without getting a judge's approval. The prevailing wisdom is all of the barriers to decision making while under guardianship likely leads to delays in decision making or one that errs on choosing high‐intensity treatment even if it is unlikely to benefit the patient. But is that really the case? On today's podcast, we talk with Andy Cohn, lead author of a recent Journal of the American Geriatrics Society (JAGS) paper titled "Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes" and Liz Dzeng, the lead author of the accompanying editorial to the paper. The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians. We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results. We also talk to Liz about whether substituted judgement is really all that it's cracked up to be. So take a listen and also check out these articles to read more about it: Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes. We Need a Paradigm Shift Around End‐of‐Life Decision Making. Guardianship and End-of-Life Decision Making

"Diagnose and adios." That's the sad phrase that I've heard quoted more than once, representing caregivers' sentiment of what it's like to be told by a clinician that your loved one has dementia. This week we talked with Zaldy Tan, Geriatrician and Director of the Memory and Aging program at Cedars Sinai in Los Angeles. With David Reuben at UCLA and others working LA realized that current caregiver training programs were lacking. Caregivers for people with dementia are stressed, short on time, and thirsty for high impact information and skills training that can be delivered efficiently. To meet this need they launched a new caregiver "bootcamp" 1-day training (with the help of Archstone Foundation which also funds GeriPal). We cover many topics, including dissemination of the bootcamp to Spanish-speaking caregivers, converting to video boot camp during COVID, and ways you can partner with them to create your own boot camp. Listen to the podcast to learn more! (And "Remember Me" from Coco - great song choice) JAGS article on caregiver boot camp Dementia caregiver IcareD website (including upcoming bootcamp calendar) CAPC website on caregiver support -@AlexSmithMD

What does it mean to create a cultural shift to the end of life experience? Is it even possible? How do you even start something like that? On today's podcast, we talk to Shoshana Ungerleider about her experience making that change. Shoshana is one of those amazing advocates for palliative and end of life care. She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care education. She is Executive Producer of the Academy Award-nominated end of life documentaries, Extremis and Netflix's End Game. Oh yah. She also started End Well back in 2017 which brought together people from all different backgrounds and professions with a goal to talk about end of life care. This year she is taking the conference virtual with "Take 10" on December 10th. Take 10 brings names like Maria Shriver, Taraji P. Henson, Andy Cohen, Justin Baldoni, and Atul Gawande to speak about issues within palliative care, caregiving, geriatric medicine, and end-of-life care, all in light of what we can learn from the COVID crisis. And best of all it's free. So take a listen to the podcast and sign up for Take 10 here: Date: December 10, 2020 Time: 10:00am PST - 2:00pm PST Location: https://endwellproject.org/ Register for free here thru 12.10.2020: https://endwellproject.org/take-10-end-well-2020/#register

How long does it take to see a benefit of statin therapy for primary prevention of cardiovascular events in adults aged 50 to 75 years? That's the question we try to answer with our two guests today, Drs Lindsey Yourman and Sei Lee, the lead and senior author of a JAMA IM study that tried to answer this question. In this podcast Drs. Yourman and Lee define what time to benefit is, why it is important in regards to decision making for older adults, and common lag time to benefits for common preventative interventions. We then take a deep dive into the JAMA IM meta-analysis of 8 trials, which showed 2.5 years were needed to avoid 1 cardiovascular event for 100 patients aged 50 to 75 years of age treated with a statin. So give it a listen and tell us what you think on either our Twitter or Facebook posts about this podcast.

An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults. These needs are categorized around the 4 M's - Medication, Mentation, Mobility, and What Matters Most. But we cannot achieve the ideal of an age friendly health system without, well, changing systems. In this week's podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M's. We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF. Enjoy! -@AlexSmithMD

The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient. Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so. There often is limited information about the patient, their functional status, or their prognosis. These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!) So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals? We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question. Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled "Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure." We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on "Work Grief: A Practical Primer for Emergency Medicine Providers".

In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness, published in JAMA. We also talk with Krista Harrison, first author of an accompanying editorial. JAMA editors cut out some of my favorite parts of Krista's editorial, possibly because they were more like a blog post than a JAMA editorial. (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited: "As with many people's best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders' English hospice programs. Dr. Mount coined the term "palliative care" to connote the core goals of the service: to improve quality of life and to mitigate sources of distress. The field of palliative care was born. The year was 1975. Forty-five years later, palliative care retains its central focus on improving quality of life for people living with serious, life-limiting illnesses and their families by addressing physical and psychological symptoms, social and spiritual needs, and aligning patient and family values with available care options." In our podcast, we talk about the surprising finding in Keiran's study that palliative care for noncancer illness was associated with a modest improvement in symptoms, reduced hospitalization and emergency department use, increased advance care planning but not improved quality of life. How can palliative care, since inception designed to improve quality of life, not improve quality of life? Listen to the podcast to find out! -@AlexSmithMD

There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and As a current palliative care fellow and former hospitalist on UCSF's Advanced Heart Failure service, I have a strong interest in this question. This week I was lucky to have Alex and Eric let me join in interviewing Haider Warraich, Associate Director of Heart Failure at the Boston Veterans Affairs Hospital and Associate Professor at Brigham and Women's Hospital, a cardiologist trained in advanced heart failure and with a strong interest in palliative care who has written multiple books (Modern Death: How Medicine Changed the End of Life, State of the Heart: Exploring the History, Science, and Future of Cardiac Disease), op eds, and research articles on the subject. In the podcast we talk about all things heart failure - from the culture of cardiology, how to impart palliative care on trainees, and practical tips on helping predict prognosis and symptom management. For more reading be sure to check out Haider's article in JPM on Top 10 Tips for Palliative Care Clinicians Caring for Heart Failure Patients and his article with Diane Meier in NEJM on Serious Illness 2.0 - Meeting the Needs of Patients with Heart Failure. - Anne Rohlfing

On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine. Now with COVID among us, Lauren talks to us about her recently published JAGS article titled Home Video Visits: 2‐D View of the Geriatric 5‐Ms. In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework: mind, mobility, medications, multicomplexity, and what matters most. Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine. One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article: "I recommend that you discourage patients and families from using the backgrounds of outer space, peaceful woods and lakes, or other fancy pictures that are available on Zoom, Webex, and other virtual meetings. Doing so will hide what could be extremely valuable information when assessing the M's of geriatrics." So take a listen and maybe even sing along to Alex's version of "Video Killed the Radio Star."

Last month we published a podcast with Sean Morrison that garnered a great deal of attention, in which Sean Morrison argued that Advance Care Planning is an idea that is "clear, simple, and wrong." This week, we have a fresh updated counterpoint from Rebecca Sudore and Ryan McMahan. These two published a paper this week in the Journal of the American Geriatrics Society, or JAGS, that argues that the field of advance care planning has come a long way. Early studies of advance care planning evaluated it with advance directives, and studies of advance directives showed little to no difference. However, In their review they find recent (since 2010) high quality trials demonstrate the potential of advance care planning by using modern conceptions of advance care planning as a longitudinal conversation to help surrogates prepare for in the moment decision making. These studies evaluated a broader (and more fitting) range of outcomes than prior work, including surrogate preparedness. My take away is that if we're looking for advance care planning to result in "goal concordant care" - we're asking too much of it. That doesn't mean it's not useful. It's primary use is helping surrogates feel like they are prepared and satisfied with the difficult choices they have to make for seriously patients. Doesn't that matter too, and, some would argue, just as much? The surrogates live with these decisions the rest of their lives. So the issue is nuanced. One of my favorite parts of the podcast is when Rebecca Sudore returns to Sean Morrison's Ford Pinto analogy and really uncover the real world complexities of how it should be applied to advance care planning. That Ford Pinto analogy just keeps on giving! Enjoy! -@AlexSmithMD