GeriPal - A Geriatrics and Palliative Medicine Podcast

The question of who should get limited supplies of drugs that treat COVID-19 is not a theoretical question, like what seems to have happened with ventilators in the US. This is happening now. Hospitals right now have limited courses of remdesivir. For example the University of Pittsburgh hospital system has about 50 courses of remdsivir. They expect it to last to mid-June, enough for about 30% of patients who will present in the next 3 weeks. Who do you give it to? The first that present to the hospital (give it all away in the first week)? Random lottery? Or something else that is also accounts for the greater impact of COVID-19 has on disadvantaged communities ? On today's Podcast we talk with Colette DeJong, 3rd year medicine resident at UCSF, and Alice Hm Chen, Deputy Secretary for Policy and Planning at the California Health and Human Services Agency, who were two of the authors of a recently published JAMA article titled "An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US". We also bring on our repeat guest, Doug White, who authored the University of Pittsburgh model hospital policy for fair allocation of scarce COVID-19 medications, which can be found here. The University of Pittsburgh allocation strategy doesn't use a first-come, first-served or random allocation, but rather a waited lottery that is aimed at reducing the impact of social inequities on COVID-19 outcomes in disadvantaged communities. In particular, the following groups receive heightened priority in this framework: Individuals from disadvantaged areas, defined as residing at an address with an Area Deprivation Index score of 8 to 10 (range 1-10; with higher numbers meaning worse deprivation) Essential workers, defined by the state's list of essential businesses that are required to continue physical operations during the pandemic, which include lower-paid workers who may be socially and economically vulnerable, such as grocery store clerks, bus drivers, agricultural workers, and custodial workers. Of note, the Area Deprivation Index was developed in large part by Amy Kind, Geriatrician at the University of Wisconsin, and recipient of the 2019 American Geriatrics Society Thomas and Catherine Yoshikawa Award for Excellence in Scientific Achievement. by: Eric Widera NOTE: Links to the papers discussed above can be found on our blog site at GeriPal.org

Immune Checkpoint Inhibitors. They are revolutionary and transforming cancer care. They shrink tumors and extend lives. Plus they have a better side effect profile than traditional therapies for conditions like metastatic lung cancer, so when those with really poor performance status can't tolerate traditional chemotherapy, immune checkpoint inhibitors are an attractive option. We talk on today's podcast with Laura Petrillo, a palliative medicine clinician and investigator at Massachusetts General Hospital and Harvard Medical School. Laura was the first author of a paper published in Cancer titled "Performance Status and End-Of-Life Care Among Adults With Non-Small Cell Lung Cancer Receiving Immune Checkpoint Inhibitors." (https://acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/cncr.32782) In this study, Laura looked at 237 patients with advanced non-small cell lung cancer who initiated immune checkpoint inhibitors from 2015 to 2017. She found that those with impaired performance status had significantly shorter survival after treatment with these medications that those with a bettter performance status. They also receive immune checkpoint inhibitors near death more often than those with better performance status, and they found that those recieving immune checkpoint inhibitors near the end of life had lower hospice use and an increased risk of death in the hospital. Along with how we should think about the findings of this study, we talk about common side effects of immune checkpoint inhitors that geriatricians and palliative care clinicians should know about, the cost of theses medications, and the differences with different types of cancer treatments like "targeted therapies". by: Eric Widera

As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay (https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim), one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU. And look at where we are today. Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal. What a difference a year makes. This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care. Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service. Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults (https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204). Their service peaked at 50 consults per day, and as they note, that is likely an undercount. About half of the consults were in the ED. Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay. Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper. And (bonus!) you get to sing along to "Call Me Maybe." - Alex Smith

Parkinson disease affects 1% to 2% of people older than 65 years. Most known for its distinctive motor symptoms, other distressing symptoms are pain, fatigue, depression, and cognitive impairment. About 2/3rds of individuals with Parkinson's will die from disease-related complications, making it the 14th leading cause of death in the United States. While there are great palliative care needs for this population, little has been published on how best to meet these needs. On today's podcast we talk with Benzi Kluger from the University of Rochester Medical Center and the lead author of a JAMA Neurology paper that compares outpatient integrated palliative care with standard care alone in 210 patients and 175 caregivers. Every 3 months for a year, participants received palliative care visits either in person or via telemedicine from a neurologist, social worker, chaplain, and nurse with guidance from a palliative medicine specialist. Benzi's study demonstrated the palliative care group had better quality of life, symptoms burden, and advance directive completion. In addition to talking about the study, we get tips on how best to care for Parkinson's patients, both in palliative care and geriatrics. We also discuss some of these other helpful articles (visit our blog post at https://bit.ly/3c1EkwE for the links): - Implementation issues relevant to outpatient neurology palliative care. Ann Palliat Med. 2018 - Top Ten Tips Palliative Care Clinicians Should Know About Parkinson's Disease and Related Disorders. J Palliat Med. 2018 - Palliative care and Parkinson's disease: outpatient needs and models of care over the disease trajectory. Ann Palliat Med. 2020 - Palliative Care and Parkinson's Disease: Caregiver Perspectives. J Palliat Med. 2017 - Parkinson disease patients' perspectives on palliative care needs: What are they telling us?

Eight of the 10 largest outbreaks in the US have been in correctional facilities. Physical distancing is impossible in prisons and jails - they're not built for it. Walkways 3 feet wide. Bunk beds where you can feel your neighbor's breath. To compound the issue, prisoners are afraid that if they admit they're sick they will be "put in the hole" (solitary confinement). So they don't admit when they're sick. Many people think of prisons as disconnected from society. Like a cruise ship. "It's happening between those walls, behind the barbed wire, not out here." But for every two people in a correctional facility there's about 1 person who works in the correctional facility and lives in the community. The workers are bringing whatever they've been exposed to in prison out into the community, and bringing whatever they've been exposed to in the community into the prisons. This is a national problem, not a prison or a jail problem. We learned about these critical issues in our podcast with Brie Williams, Professor of Medicine in the UCSF Division of Geriatrics and Director of Amend (https://amend.us/), a program to change correctional culture; Adnan Khan, Executive Director of Re:store Justice (https://restorecal.org/), a justice advocacy organization; and Eric Maserati-E Abercrombie, a singer/songwriter and filmmaker through First Watch (https://restorecal.org/firstwatch/), a media project of currently and formerly incarcerated filmmakers. Adnan and Eric Maserati-E are former inmates of San Quentin prison. What can we do about this? The major response should be decarceration. Reduce the crowding in our overcrowded correctional facilities. If prisoners have less than a year left, let them out. If they have a long sentence and are low risk to society, and a place to go, let them go home with an ankle bracelet and return later to complete their sentence. Brie reminds us that people in prison can make an advance care plan, they can sign an advance directive, they have the right to engage in goals of care decisions, and a right to elect someone to be their health care proxy. And everybody, including prisoners, has a right to say goodbye to their loved one, though it may be by phone or video. We learn about these and other critical steps we need to take as a society and as hospice and palliative care clinicians. Eric Maserati-E does the music for this one. He needs to be discovered! If you know someone in the music industry, make them listen to him. Check out and subscribe to Eric's YouTube channel (https://www.youtube.com/channel/UCZN4YxjDR41RL_xIlDysU8Q). Also, listen to this terrific podcast, Ear Hustle (https://www.earhustlesq.com/), produced from inside San Quentin, the latest episode featuring Eric's music. - Alex Smith

One million inpatient falls occur annually in U.S. acute care hospitals. Sitters, also referred to as Continuous Patient Aids (CPA's) or safety attendants, are frequently used to prevent falls in high-risk patients. While it may make intuitive sense to use sitters to prevent falls, it does beg the question, what's the evidence that they work? We discussed with Drs. Adela Greeley and Paul Shekelle from the West Los Angeles Veterans Affairs Medical Center their recent systematic review published in Annals of Internal Medicine. Their review identified 20 studies looking at this issue (none of which are randomized trials). To sum up their findings, there were only two studies comparing sitters to usual care and they came up with conflicting conclusions (in one, the fall rate was lowered; in the other, it was not). In the other 18 studies, alternatives to sitter use were evaluated. The only thing that seems to have some evidence for was video monitoring (fall rates either stayed the same or improved, with a decrease in sitter usage). We also talk about multi-component interventions and how we should think about them. One intervention that is sometimes included in multicomponent interventions are bed alarms, which we discussed in our very first GeriPal podcast. It's also the podcast where we dreamed up the "anti-bed alarm" that would alert patients who haven't gotten out of bed yet. Now that's a fall intervention that that I can get behind. by: Eric Widera / Twitter @ewidera

We are rationing in the US. We may not be explicitly rationing, as we're going to discuss on this podcast, but we are rationing - in the way we allocate fewer tests and less PPE to nursing homes compared to hospitals, in the way we allow hospitals and states to "fend for themselves" resulting in those hospitals/states with better connections and more resources having more PPE and testing availability. And in some parts of the world, ICU and ventilator resources are scare, and they are rationing by age. We talked on our last podcast about decisions Italy made to ration by age, and on this podcast we talk about two countries in South America we have heard are using age as a criteria for rationing ventilators. In this context, we are fortunate to welcome Tim Farrell, Associate Professor of Geriatrics at the University of Utah and Vice Chair of the American Geriatrics Society (AGS) Ethics Committee, and returning guest Doug White, Vice Chair and Professor at the University of Pittsburgh School of Medicine. In our prior podcast with Doug we talked about his University of Pittsburgh (and colleagues) policy for allocation of scarce resources that has been adopted by over a hundred hospitals. Today's podcast is focused on the release of the AGS guidelines for allocation of scarce resources and the accompanying paper that explains the ethical rationale behind the AGS ethics committee's decisions. Both papers are available now on the Journal of the American Geriatrics Society (JAGS) COVID19 webpage. We talk about how the AGS and Pittsburgh guidelines are far more similar than different, and the ethical principles that led them to make the choices they made, and how these choices have evolved over time. The two issues we cover in depth are: (1) Should age be used to ration scarce resources? How should age be used, if at all, as an "up front" consideration, or a "tiebreak?" And (2) How should we account for socioeconomic determinants of health in resource allocation decision making? Stay healthy and safe, and keep doing the good work that you're doing, GeriPal listeners. -@AlexSmithMD

The cross-over episode is an American tradition that is near and dear to my heart. My childhood is filled with special moments that brought some of my very favorite characters together. Alf crossed over with Gilligan's Island. The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time. To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast! The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman. Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina. She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Zara Cooper, and Diane Meier. That's an amazing lineup. We also welcome Joe Lin as a co-host for this topic. Joe is a surgery resident and palliative care fellow at UCSF. We talk to both Joe and Red about - How they got interested in the intersection of surgery and palliative care - How the culture of surgery and palliative care differ (and the misconceptions that both fields have of each other) - What the day in the life of a surgical palliative care physician looks like - A recent article in JAMA Surgery titled "Palliative Care and End-of-Life Outcomes following High-Risk Surgery" - What palliative care skills all surgeons should have (primary palliative care) - And lots of other topics! So take a listen and check out Red's Surgical Palliative Care Podcast (https://thesurgicalpalliativecarepodcast.buzzsprout.com/)

We are delighted to have Dani Chammas, psychiatrist and palliative care physician, back on the GeriPal podcast to talk about emotional PPE. None of us can recall who originated the term, but we've all heard it bandied about much needed for front line providers treating patients with coronavirus. Headlines about the New York emergency room doctor committing suicide are likely only the tip of the iceberg in terms of the trauma, distress, and moral injury taking place. We talk with Dani about key issues and questions, including: - What is trauma? What is moral injury? - Is this a big deal? What evidence do we have? - What can we do about it? Dani goes over 3 broad buckets of responses, organized with the letter C: Connection, Culture, and Coping. - Normalizing rather than stigmatizing clinicians seeking mental health support We also decided to add a page to GeriPal titled "emotional PPE" with a list of resources for providers caring for patients with COVID, and we will link to that page once it's up. Please visit GeriPal.org for the following important mental health resources for providers: - The NYC COVID Worker Care Network - Pro-Bono Counseling for Frontline Physicians and APCs - Physician Support Line. - Disaster Distress Help Line - How to be a Catalyst of Calm in COVID19 -@AlexSmithMD

What's the role of geriatrics and palliative care in the care of individuals with COPD? We talk this week with Anand Iyer, the lead author of this weeks JAMA IM article on this subject. It's a little off from our ongoing COVID topics, but given that his along with his co-authors (Randy Curtis and Diane Meier) JAMA IM piece just got published, we figured now is the right time to highlight #PalliPulm. What is #PallPulm? #PalliPulm is something that Anand Iyer founded, and is an online community of clinicians, investigators, patients, and others interested in the intersection of palliative care and geriatrics. Anand is also an Assistant Professor in Division of Pulmonary, Allergy, and Critical Care Medicine at the University of Alabama at Birmingham (UAB) and faculty at the Center for Palliative and Supportive Care at UAB. Anands research on this subject has shown a lot of things, including that COPD patients are often referred too late to palliative care and hospice, pulmonologists often equate hospice with palliative care, there is high symptom and emotional needs in COPD patients, and that patients and family members feel palliative care should be integrated early on in the care of COPD. Links to the following articles can be found on this blog post at https://www.geripal.org/2020/04/integration-of-geriatrics-and-palliaitve-care-in-COPD.html: - A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease - A Formative Evaluation of Patient and Family Caregiver Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease across Disease Severity - End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease We also talk about this podcast with David Currow on the use of opioids in dypsnea: -Opioids for Breathlessness: A Podcast with David Currow So take a listen and join the conversation at #PalliPulm! by: @ewidera