GeriPal - A Geriatrics and Palliative Medicine Podcast

Many of you listened to our prior podcast with Jim Wright and David Grabowski about COVID in long term and post acute care settings. In this follow up podcast, we talk about the situation in long term and post acute care in Indiana with Kathleen Unroe, Associate Professor at Indiana University, a scientist at the Regenstief Institute, and a PI of Optimistic and founder of Probari, and Ellen Kaehr, Assistant Professor of Clinical Medicine at Indiana University and geriatrician and medical director of a nursing home. A few highlights to wet your appetite: - About 2/3 of the Ellen's nursing home is COVID positive. This has led to so many challenges - how did this happen? (asymptomatic staff). How to cohort? Issues with PPE, with transitions to the hospital, with visitors. - We talked about the unique impact of COVID on people with dementia. For example, mobile persons with dementia wander, which has negative aspects, but does keep them functional/mobile. Now they're confined to their rooms and at much higher risk for debility/decline. They're also noticing a loss of orientation due to lack of structured activities. - We talk about the impact on Assisted Living Facilities, something that Kathleen has been thinking about increasingly from a policy perspective. There are twice as many people living in assisted living facilities as nursing homes. And yet assisted living facilities have received scant attention in this epidemic. - Impact on providers. This has been so hard. And clinicians and staff are working so hard to meet this challenge. How can we support each other during this difficult time? And they chose an AWESOME song, Paradise by the late great singer songwriter John Prine, who sadly died of COVID related illness. I couldn't help but overlay a few harmonies on the vocal track. Sing along! -@AlexSmithMD

We were asked by Sean Morrison, Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, to compose a brief GeriPal video of thanks, support, and gratitude for all of the hard work they are doing in New York. These videos are played every Friday during the Mt. Sinai's Town Hall. Prior guests include Tom Brokaw, Mandy Patinkin, Martha Stewart, and Liz Gilbert. August company indeed! Here is our video link: https://youtu.be/xQT6xK4QjRw - This one is probably better watched as a video than as a podcast, though either will work. At GeriPal, we are happy to do what we can to support, inform, and entertain those working hard on the front lines, whether it be in New York, Detroit, Seattle, New Orleans, Indiana, Chicago, or wherever you may be. Special guests from UCSF include: Rebecca Sudore, Steve Pantilat, Pei Chen, Natalie Young, Louise Walter, Brie Williams, Anne Fabiny, Ken Covinsky, and Sandra Moody. -@AlexSmithMD

The peak hospitalizations and deaths in New York City hit around April 7th. Life though in hospitals in New York though have not returned to normal. What were previously operating rooms, post-hip fracture units, or cardiac cath labs, are now units dedicated to the care of individuals hospitalized with COVID. We talk with two NYU clinicians, Ab Brody and Audrey Tan about what life is like right now in this new state of limbo as both palliative care clinicians and as their role as either a NP hospitlist or Emergency department physician. Ab Brody is the Associate Director of the Hartford Institute for Geriatrics Nursing at NYU. Audrey is the Director of Emergency of Medicine and Palliative Care in the Department of Emergency Medicine at NYU. We are also welcoming back our guest host Nauzley Abedini from UCSF. A couple of topics that we talk about include: - What's life like right now at NYU post-surge? - What's it like to look at the COVID crises in the lens of a palliative care consultant and their role as a primary provider in the ED or the hospital? - Geriatric issues that they are seeing in the ED or the wards. - How they are recognizing and dealing with morel distress? - The worry about PTSD and the worry for our workforce post this pandemic. - The stress that not only comes with work but also what it's like to go home by: Eric Widera (@ewidera)

In today's podcast we talk with Zara Cooper, Rachelle Bernacki, and Ricky Leiter about the state of COVID at the Brigham and Women's hospital and Dana Farber Cancer Center in Boston. While they have flattened the curve somewhat in Boston, they're still seeing huge numbers of seriously ill Covid patients in Massachusetts. They have 143 out of their ~1000 bed hospital filled with COVID19 patients, including 78 Covid patients in ICU, many of which are followed by palliative care. This has resulted in the need to drastically restructure the palliative care team, including: - Embedding palliative care in the ED. They quickly found that if they waited for consults, they got not calls, and had to proactively go out and find consults in the ED. By demonstrating their usefulness, acceptance has increased. - Embedding palliative care in the ICU. These experiences are hard. Zara Cooper, who works as an intensivist in the ICU (as well as surgeon, as well as palliative care doc, as well as researcher, as well as superwoman) relates the ethical dilemmas and moral distress associated with providing care in the ICU. Ricky Leiter talks about how hard it is emotionally for the palliative care teams, how the cadence of our usually palliative care consult becomes compressed in these cases, and how their teams are dealing with the challenges of prognostic uncertainty, video meetings, and not being able to see patients in person. - Their first instinct was to protect the fellows from COVID19 patients. The fellows rebelled. They wanted to be involved, and now they are, and are functioning as an integral part of the response. All of this and more, including forgiving yourself if due to these extreme circumstances you can't give "gold star" palliative care, but maybe "bronze star" is enough? For links to the Pallicovid.app, Covid Protocols, and the Ariadne Labs COVID Response Toolkit, please visit our Covid page at https://www.geripal.org/p/covid.html or our website at GeriPal.org. -@AlexSmithMD

"It's not about perfection...it's about connection." - Keri Brenner This week's podcast features a dynamic duo of palliative care psychiatrists, Dr. Keri Brenner from Stanford, and Dr. Dani Chammas from UCSF. Dani was a huge hit as a guest on one of our earliest podcasts talking about "Formulations in Palliative Care." This week, Keri and Dani talk about "Therapeutic Presence," an important concept in both psychiatry and palliative care (links to articles about this concept and application at https://bit.ly/2VpXxS7. They describe 3 key ingredients of therapeutic presence, including being deeply attentive, naming (I'd call it complex naming), and creating a safe "holding space" for patients' emotions. But come on, you might say, we're in the midst of a pandemic. How can we maintain a therapeutic presence in a zoom meeting with family members you've never met, or with a patient who has a disease that could spread to you and infect not only you but your family. Keri and Dani speak to the challenge of taking on the strong emotions we're all feeling during this pandemic - anxiety, fear, and the unique vulnerability this disease places on us as health care providers. They note high rates of depression, anxiety, and other adverse mental health outcomes for healthcare workers in China who dealt with COVID. This was an awesome podcast. It was like a therapy session for our collective GeriPal souls. I hope you enjoy it as much as we did. To stay up to date on relevant links, check out our new COVID page at https://www.geripal.org/p/covid.html -@AlexSmithMD

The vast majority of hospice services are delivered in patient's homes or other places of residence like nursing homes. This makes the traditional model of hospice care vulnerable in this coronavirus pandemic, especially in the era of social distancing and limited personal protective equipment (PPE). So how are hospice's responding to the COVID-19 pandemic? On this weeks podcast, we talk to two leaders of two large hospice agencies, Drs. Kai Romero and Todd Cote, to get their views on this question. Kai is the Chief Medical Office of Hospice by the Bay in California. Todd is the Chief Medical Officer at Bluegrass Care Navigators in Kentucky. It's inspiring to hear how these hospices and others are stepping up to the challenge of caring for both COVID positive and non-COVID positive patients during this time. Among subjects we talk about include: - The variability how this pandemic is affecting hospices in how they are responding to COVID (even if they take COVID positive patients) - Supply limitations (PPE, medications, etc) - The role of telemedicine in hospice visits and the challenges with trying to do some hospice visits virtually - How COVID influences prognostic eligibility to hospice - Special issues in vulnerable populations like homeless and rural populations Check out our new COVID page at https://www.geripal.org/p/covid.html for important links we talk about in this podcast as well as previous COVID podcasts.

Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You're short on gowns and facemasks. You're short on nurses and nurse aids so now you have to help deliver meals. This is what Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond is living through right now. I felt overwhelmed just listening to Jim talk about his experience since mid-March, and am so grateful that he joined to talk about COVID in the long term care setting, along with David Grabowski, author of the JAMA piece titled "Postacute Care Preparedness for COVID-19 - Thinking Ahead." A couple key points that I learned from Jim's experience. The first point is that half of patients who tested positive were asymptomatic, so you really don't know who has it or who doesn't unless you test everyone. The only thing you really know is that if you have 5 symptomatic patients who test positive for COVID, assume there are at least 5 asymptomic patients. The second point is that there seems to be different clinical courses for those who are symptomatic that David summarized as the following: - Indolent course, deadly: Initial 24-28 hours of fever and severe respiratory symptoms. Then Stabilization for 3-5 days. Then decompensation on days 5-7 with death within 24 hours - Indolent course, convalescence 1. Fortunately, the majority of our patients. Same course as indolent to death although continued improvement over 7-10 days. - Acute respiratory failure: Symptoms begin with fever and acute respiratory failure with death within 6-12 hours. - Sepsis-like picture: Sudden onset of AMS, hypoxia and hypotension without fever. A small subset of patients in our experience. All have tested positive for COVID (may simply have been asymptomatic carriers who developed sepsis independently In the second half of the podcast David Grabowski walks us through the challenges facing nursing facilities and potential solutions to the looming crisis in long term care, including - creating COVID only specialized post acute care settings - increasing the level of home health care and hospital-at-home model - whether nursing homes that don't yet have COVID should be forced to take COVID+ patients form hospitals. So listen up and comment below. Also, check out some of our past COVID podcasts and new resources on our new COVID page at https://www.geripal.org/p/covid.html.

In today's podcast we talk with Audrey Chun, Professor in the Department of Geriatrics and Palliative Medicine at Mount Sinai, and Sheila Barton, a social worker in the Geriatrics practice at Mt. Sinai. Mt. Sinai has a HUGE outpatient geriatrics service, with a mean age of 85. We talk with Audrey and Sheila about the challenges they face in overcoming obstacles. Everything is harder now, such as how to get basic needs met for older adults isolating in the community, such as food and assistance with basic activities with daily living. Higher order concerns are challenging as well, including conducting advance care planning conversations with patients and family members over the phone, and finding a home hospice agency willing to care for a COVID positive patient. We talked as well about this article by Jason Karlawish arguing that caregivers are essential health workers who should be allowed into hospitals to care for their older at-risk-of-delirium relatives. Oy. Tough times. One thing Audrey and Sheila emphasize repeatedly is how supported they feel by their health system, by volunteers, and even from their own patients who message them with words of encouragement and kindness. New Yorkers are tough, but they also have big hearts and rally around one another time and time again when faced with challenges. On additional note, if you'd like to sign up for palliative care COVID discussions, here's a link to sign up to participate in weekly chats, thanks to Zachary Sager and Leslie Blackhall. -@AlexSmithMD

In the latest in our series of talking with front line providers in the midst of the COVID pandemic, we talk with Drs. Craig Blinderman, Shunichi Nakagawa, and Ana Berlin of the palliative care service at Columbia University Irving Medical Center. We cover a host of topics, including the urgent need to conduct advance care planning with our outpatients (including Craig's new Epic dotphrase below, and guide to COVID advance care planning); the need to be flexible to suit shifting demands; to stock up on iPads to engage patients/family members in goals of care discussions from outside the room. We mention the new JAMA papers on "informed assent" to DNR/I orders by Randy Curtis and colleagues (and Craig's prior JAMA paper), and on rationing scarce resources by Doug White and Bernie Lo (see also our prior podcast on rationing with Doug with links to the practical framework). I cried after this one. Maybe it was Ana talking about how hard it was have an agenda when discussing goals of care with the family of a 90 year old woman with dementia. We're taught in palliative care to match patient/family goals, and to not bring an agenda. But we do have an agenda now, as Ana says. The patient will not survive a code or prolonged intubation. Coding her would expose Ana's colleagues to COVID, and use scarce PPE and ICU resources, including a ventilator. We can't check that agenda at the door anymore. This is hard. You can hear their moral distress as they talk through these experiences. Maybe it was the three of them talking about the pace of change. Last week they felt "impotent" as they awaited the coming storm. Then the ICU called; they want palliative care. Then the ED called; they want palliative care. Today Shunichi spent the entire day having goals of care conversations with likely COVID patients and their families in the crowded ED. Today they say they want a new inpatient palliative care service, ASAP, maybe even tomorrow. They thought they would have until next week. The tsunami hit Wednesday. Maybe it was Ana saying her daughter had a fever and might have COVID, and that one thing she is thankful for is that kids are spared serious illness. Maybe it was the song choice, the Ghost of Tom Joad by Bruce Springsteen, with its inspirational and haunting message. Craig says he chose this song because the lyrics are about standing up to meet the challenges faced by the most vulnerable. As he notes, COVID is the AIDS crisis of our day. We're all in this together. -@AlexSmithMD FYI - for links to referenced material, please visit our website at GeriPal.org

New York is the current epicenter of the COVID-19 outbreak in the US, with over 30,000 confirmed cases as of March 25th. Hospitals and ED's are seeing a surge of patients, and geriatrics and palliative care providers, like Cynthia Pan, are doing their best to meet the needs of these patients and their family members. Today, we talk with Dr. Pan, the Chief of the Division of Geriatrics and Palliative Care Medicine, and the current attending on the palliative care service at New York-Presbyterian Queens, located in Flushing, New York. In our discussion we talk about what it is like to be on the front lines right now, lessons learned during this surge, and how she is managing the distress in caring for these patients.