GeriPal - A Geriatrics and Palliative Medicine Podcast

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

In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria. Over the next 50 years, the debate over the concept of brain death has never really gone away. Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria. On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Troug. Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School. He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA: - The 50-Year Legacy of the Harvard Report on Brain Death - Understanding Brain Death - Brain Death—Moving Beyond Consistency in the Diagnostic Criteria In addition to talking about how Robert got interested in the topic of brain death, we discuss the history of the concept of brain death, how we diagnose it and the variability we see around this, the recent JAMA publication from the World Brain Death Project, why brain death is not biologic death (and what is it then) and what the future is for the concept of brain death.

Chris Callahan (of Indiana University) and Lee Jennings (University of Oklahoma) have some righteous anger. Why do we have comprehensive cancer care centers and not comprehensive dementia care centers? We have a body of evidence dating back 30 years to support people with dementia and their caregivers with Comprehensive Dementia Care. Lee Jennings added to this robust body of work with a study published in the Journal of the American Geriatrics Society demonstrating that a comprehensive dementia care program based out of UCLA reduced ED visits, hospital length of stay, increased hospice enrollment, and delayed time to admission to long term care. As Chris Callahan notes in his accompanying editorial in JAGS, a fundamental problem with our healthcare system is that savings from Comprehensive Dementia Care accrues not to the dementia care program, but to the hospital and Medicare (ED visits, hospital length of stay) or Medicaid (long term care admission). Our fragmented healthcare system lacks the coordinated big picture financial incentives to make this happen for our patients. One more major point - Chris Callahan emphasizes in the podcast that we as clinicians need to stop saying, "there's nothing that we can do for dementia; nothing works." That's simply not true. While we lack Comprehensive Dementia Care programs in nearly every region of the US, we have tremendous community resources for people with dementia and their caregivers. The Alzheimer's Association is a great place to start. The song request was This Land is Your Land, classic Woodie Guthrie as Lee Jennings works at the University of Oklahoma. Chris Callahan rewrote the lyrics to address the topic, and if you listen to the very end of the podcast, you'll get this version: This land needs dementia care Comprehensive dementia care From California to Indiana From Oklahoma to the New York Island We need dementia care for our families As I sought clearly, the research to frame I saw clear data of the triple aim I saw the workforce, we need to train We need dementia care for our families -@AlexSmithMD

Every year, about a third of older adults fall. About one in five of those falls result in moderate to severe injury. What can we do to help not only prevent those falls but also the complications of them? On todays podcast, we talk to Tom Gill, one of the authors of the recent Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study published in the NEJM. The STRIDE study was huge, 5,451 patients in 86 primary care clinics from 10 different health care systems. Individuals assigned to the interventions worked with a "falls care manager" whose goal was to help identify and make plans about risk factors for falls and fall-related injuries. What did it show? Well, the conclusion of the NEJM abstract states that this multifactorial intervention "did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care." We talk to Tom about whether that is the right take home from this pragmatic study and how should we think about fall prevention in our own clinical practices.

No dear listeners and readers, that is not a typo. Eric Widera is indeed our guest today to discuss his first author publication in the New England Journal of Medicine, Family Meetings on Behalf of Patients with Serious Illness. Our other guests include other authors James Frank, Wendy Anderson, Lekshmi Santhosh, me and actress and frequent GeriPal guest-host Anne Kelly. There's a story behind this one folks. One day, Ken Covinsky walked into our office and said, "You know how the NEJM has this Videos in Clinical Medicine series? With videos like, 'How to insert a central venous catheter?' You should send them a video of your palliative care 'intervention' - how to conduct a family meeting." Brilliant idea. Well...that was 2014...a funny thing happened on the way to the theater. After several iterations, videos, reviews, a rejection, and lessons in persistence, we finally published. We were helped by an outstanding cast who role played the family meeting in the video (including Wendy as the physician and Anne as the social worker). The video introduces clinicians to core family meeting skills such as the importance of the pre-meeting, a structured approach to the meeting, and pointers on how to respond to emotion. On the podcast, we go around the "zoom room" and discuss our favorite teaching points on how to conduct family meetings. And a bonus feature! Eric requested any song from the Movie "The Descendants," and I was fortunate to be joined by my kids Kai and Renn on guitar and ukulele on the traditional Hawaiian song "Hi'ilawe." Grateful also to Jeff Peterson for pointers on the Hawaiian pronunciation. You may notice when you listen that I purchased some recording equipment for my home study, as this COVID thing doesn't seem to have an end in sight...I may have gone overboard with the production, forgive me listeners! Enjoy! -Alex

COVID-19 has created a perfect storm in nursing homes. As noted in a recent Journal of the American Geriatrics Society (JAGS) article by Joe Ouslander and David Grabowski, the storm is created by the confluence risks, including a vulnerable population that develop atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources including testing and personal protective equipment (PPE), and lack of effective treatments. The result? Nearly half of COVID-19-related deaths in the US occur in people cared for in nursing homes and assisted living facilities, and about a quarter of all facilities have had at least one COVID case. On this weeks podcast, we talk to Dr. Ouslander about his JAGS article on this perfect storm, as well as strategies that one can take from a clinical, public health, and policy interventions to help calm the storm. In particular Joe summarizes a lot of research published in JAGS lately on COVID-19 (visit GeriPal.org for links to these research articles).