I always find cachexia in serious illness puzzling. I feel like I recognize it when I see it, but I struggle to give a clear definition or provide effective ways to address it. In today's podcast, we had the opportunity to learn from a renowned expert in palliative care, Eduardo Bruera, about cachexia and anorexia in serious illness. Eduardo established one of the first palliative care programs in 1984, created the Edmonton Symptom Assessment Scale (ESAS), and significantly contributed to the evidence base for palliative care symptoms that many of us rely on daily. During our discussion with Eduardo, we delved into how we can define cachexia and anorexia, why they occur in conditions like cancer, how to assess for them, and explored the interventions that are helpful and those that are not in the treatment of these conditions.

As Eric notes at the end of today’s podcast, we talk about many difficult issues with our patients.  How long they might have to live. Their declining cognitive abilities. What makes their lives meaningful, brings them joy, a sense of purpose.  But one issue we’re not as good at discussing with our patients is sexual health. On today’s podcast Areej El-Jawahri, oncologist specializing in blood cancers at MGH, says that sexual health is one of the top if not the top issue among cancer survivors.  Clearly this issue is important to patients.  Sharon Bober, clinical psychologist at DFCI, notes that clinicians can get caught in an anxiety cycle, in which they are afraid to ask, don’t ask, then have increased anxiety about not asking.  Like any other conversation, you have to start, and through experience learn what language is comfortable for you.  Don Dizon, oncologist specializing in pelvic malignancies at Brown, suggests speaking in plain language, starting by normalizing sexual health issues, to paraphrase, “Many of my patients experience issues with intimacy and sexual health. Is that an issue for you? I’m happy to talk about it at any time.”  All guests agree that clinicians feel they need to have something they can do if they open Pandora's box.  To that end, we talk about practical advice, including: The importance of intimacy over and above physical sexual function for many patients Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors Treatments for erectile dysfunction - first time the words “cock ring” have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn The importance of a pelvic exam for women experiencing pain What is “pelvic physical therapy?” Treatments for vaginal dryness and atrophy ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created And I get to sing Lady Gaga, also a first for GeriPal!  And let me tell you, there’s nothing like the first time (sorry, I couldn’t help it!).

Sam Gelfand, a dual expert in nephrology and palliative care, Kate Sciacca, a nurse practitioner with a focus on kidney treatments, and Josh Lakin, a palliative care doctor, unite to discuss innovative approaches to kidney failure. They introduce KidneyPal, which provides alternatives to traditional dialysis through conservative kidney management. The conversation highlights the importance of empowering patients with choices, addressing misconceptions about dialysis, and exploring holistic care options that enhance quality of life, while expertly managing the symptoms of kidney disease.

In this conversation with Adriane Fugh-Berman, an expert on pharmaceutical marketing and disease definition, she dives into how corporations shape our understanding of diseases. From the rebranding of pre-diabetes to the medicalization of menopause, Adriane highlights the insidious influence of pharma on health narratives. The discussion reveals how marketing strategies distort disease definitions and impact prescribing practices, all while advocating for transparency in healthcare. A thought-provoking chat that questions who controls our health decisions!

On today’s podcast, we’ve invited four hospice and palliative care social media influencers (yes, that’s a thing!), all of whom focus their efforts on educating the general public about living and dying with a serious illness. Their work is pretty impressive in both reach (some of their posts are seen by millions of viewers) and breadth of work.  We’ve invited: Julie McFadden (aka Hospice Nurse Julie): Julie is a social media superstar, with 1.5 million subscribers on TikTok, another 400,000 subscribers on her YouTube channel, and another 350k followers on Instagram. She covers topics on death, dying, and hospice from a hospice nurse perspective, and she also has a book coming out called “Nothing to Fear: Demystifying Death to Live More Fully,” which is now available for pre-order.   Matt Tyler (aka Pallidad for those on Twitter): Matt is the Hospice and Palliative care doctor who created How To Train Your Doctor, which helps patients living with serious illness find tips on “owning” their healthcare plan on his Instagram and  YouTube pages.  He was also the one who we have to thank for suggesting this podcast! Hsien Seow & Samantha (“Sammy”) Winemaker: Hsein and Sammy's goal was to start a revolution with their podcast “The Waiting Room Revolution,” which is now in its 7th season! The hope was by going directly to those living with a life-changing illness, we could directly tackle the question that comes up so many times - “Why didn’t anyone tell me that sooner…”  They also just published a book,” Hope for the Best, Plan for the Rest,” and Sammy is a TikTok star in her own right, with some posts having over a million views. We covered a lot of topics in the podcast from::  What motivated them to create public-facing social media channels? Why focus on the public rather than other health care providers? How do they deal with professional barriers and the barrage of comments? Advice for others who might want to dabble in social media outreach   So, take a listen and check out their social media sites to get inspired. Just don't let Alex make me do another TikTok dance…   Eric Widera  

As Betty Ferrell says on our podcast today, nurses play an essential role in care of people with serious illness.  Who spends the most time with the patient in the infusion center? Doing home care? Hospice visits? In the ICU at the bedside?  Nurses. ELNEC (End-of-Life Nursing Education Consortium) celebrates it’s 25th anniversary in 2025.  We talk today with Betty Ferrell, who has been a nurse for 47 years, and is the founder and PI of ELNEC. As I argue on the podcast, ELNEC has likely done more to lift the primary palliative care skills of clinicians than any other initiative.  Full stop.  Some numbers to back it up: ELNEC has trained more than 48,000 providers in a train the trainer model Over 1.5 million clinicians have been educated in ELNEC  ELNEC curricula are integrated int 1180 undergraduate and 394 graduate Schools of Nursing ELNEC has been taught in over 100 countries Today we talk about the origin story of ELNEC, the special role of nurses in palliative care, empowering as well as educating nurses, interprofessional ELNEC training, and opportunities and challenges ELNEC faces over the next 25 years. Enjoy! -@AlexSmithMD  

Bob Wachter, Chair of Medicine at UCSF, discusses the promise and pitfalls of AI in healthcare. Topics include AI's empathy, predictive models, consolidation of EHRs, de-skilling of clinicians, use cases like digital scribes, concerns about bias, and the role of AI in medicine. The conversation explores trust, accuracy, and human oversight in AI-generated medical content.

Ambivalence is a tough concept when it comes to decision-making. On the one hand, when people have ambivalence but haven't explored why they are ambivalent, they are prone to bad, value-incongruent decisions. On the other hand, acknowledging and exploring ambivalence may lead to better, more ethical, and less biased decisions. On today's podcast, Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby, and Olubukunola Dwyer discuss the challenges of ambivalence and ways to address them. This podcast was initially sparked by Josh’s “Note From a Family Meeting” Substack post titled “Ambivalence in Clinical Decision-Making,” which discussed Bryanna’s and Jenny’s 2022 article titled “Two Minds, One Patient: Clearing up Confusion About Ambivalence." Bryanna’s and Jenny’s article is particularly unique as it discusses these “ambivalent-related phenomena” and that these different kinds of “ambivalence” may call for different approaches with patients, surrogates (and health care providers): In addition to defining these “ambivalent related phenomena” we ask our guests to cover some of these topics: Is ambivalence good, bad, or just a normal part of decision-making? Does being ambivalent mean you don’t care about the decision? What should we be more worried about in decision-making, ambivalence or the lack thereof? The concern about resolving ambivalence too quickly, as it might rush past important work that needs to be done to make a good decision. What about ambivalence on the part of the provider?  How should we think about that? How do you resolve ambivalence? Lastly, the one takeaway point from this podcast is that the next time I see ambiguity (or have it myself), I should ask the following question: “I see you are struggling with this decision. Tell me how you are feeling about it.”  

In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative state.  In 1988, Cruzan’s parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan’s was Ken Starr, who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc). In 1990 the Supreme Court ruled…for the state of Missouri.  On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions.  Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan’s eventually cleared.  Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients. Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan.  We use Bernie’s NEJM Perspective as a springboard for discussion.  We discuss, among other things: How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions And validating the importance of the advance directive forms in some circumstances, and in starting conversations The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use? Is the POLST useful? How? Under what circumstances?  Should we abandon the term, “comfort measures?” In case you miss the introductions at the start of the podcast, Bernie and Laurie are married, and offer wonderful reminiscence of their clinical practice over the last several decades.  So when Bernie says, “I’ve heard you take these phone calls in the middle of the night, Laurie…” Now you know why! And great song choice: Both Sides Now by Joni Mitchell.  Joni suffered a stroke and had to completely re-learn how to play guitar.  Her comeback performances are inspirational, such as this one at the Newport Folk Festival, attended by another influential GeriPal couple, Sean Morrison and Diane Meier. You get to hear my stripped down Hawaiian slack key style version of Both Sides Now (easy to play with 2 fingers, still in rehab for broken hand, hoping to have full use again soon). Enjoy! -@AlexSmithMD  

One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans.  Well, as a kick off to this year’s first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented. Today we interview the authors of these 3 abstracts about their findings: Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety) Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support) Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization) Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” - more to say that we’ve reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data.  We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties.  I believe these issues were more than made up for by our guests' forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one). Enjoy! -@AlexSmithMD