GeriPal - A Geriatrics and Palliative Medicine Podcast

In this week's GeriPal podcast we talk with Cynthia Boyd, Professor of Medicine and Geriatrician at Johns Hopkins University School of Medicine about how physicians communicate with home health agencies. Home health plays a critical role in caring for persons residing at home, and in the best of circumstances extend a seamless network of care from the primary care physician's office to the home. Sadly, reality is not so rosy. The major form of communication between physicians and home health nurses is, well, a form. CMS Form 485 to be specific. In a recent study published in Annals of Internal Medicine, Dr. Boyd revealed that most primary clinicians barely read what the home health nurses write on the form, don't find the form useful, and rarely does it change management. It's the 21st century people. Can we move beyond lame forms and communicate with each other, perhaps using some modern technology? Or even 20th century technology, such as phones, if not 21st Century technology, such as video chats? Listen or read more to learn more. Enjoy!

There is a lot of discussion about the right to die. Although most of these have to do with Physician Assisted Death (PAD). What about in those who are not dying but express a dire to end their lives in the absence of a diagnosable mental illness? Do they have the same right? Well, on today's podcast we are going to step into this tricky topic with our guest, Dr. Meera Balasubramaniam, a Geriatric Psychiatrist from NYU. Meera wrote a paper for JAGS titled "Rational Suicide in Elderly Adults: A Clinician's Perspective". We talk with Meera about her article, including how she would define rational suicide, how can we help best explore these thoughts that patients consider rational, and how society and baby boomers are changing the way we think about this. We also dive into some other interesting topics include agism. I really love this quote from Meera, so I'll post it here, but for the full transcript read below or listen to the podcast: Ageism is a very interesting and distinct concept. It's fear of growing old or fear of being in that state. It's so distinct from something like racism or sexism. If a person is racist about a certain other race, it's less likely that they are going to be part of the other race that they are having negative connotations about. Similarly, if you are sexist, it's less likely less likely that you are going to belong to the other gender. When it comes to age, it's quite fascinating that most of us are actually going to get to that stage that we're being ageist about. What it is about growing old and about being down in the future that scares most of us has been sort of the crux of part of my work from a society perspective.

In this weeks podcast we talked with David Wang about how palliative care can join forces with the emergency department to improve care for the serious ill. This conversation was motivated in part by a recent expert consensus statement on key knowledge and skills standards about hospice and palliative medicine for emergency medicine providers. What should the core training be? How do emergency providers feel about palliative care? How can palliative care services that are typically available bankers hours work with the emergency department, open 24-7?

On todays podcast, we will be talking with Brooke Namboodri and we have Tim Platts-Mills from the University of North Carolina at Chapel Hill about their new article in the Journal of American Geriatric Society (JAGS) on "Elder abuse identification in the prehospital setting, an examination of state EMS protocols." We talk with Brooke and Tim about the state of EMS protocols in the US and how often the mention elder abuse in them (spoiler alert: not very often), how this compares to mentions of child abuse, the role EMS should play in elder abuse identification and management, and the role of potential screening tools for elder abuse.

In this weeks GeriPal/JAGS Podcast we talked witk Kei Ouchi, an emergency medicine physician, internist, and researcher at the Brigham and Women's Hospital and Harvard Medical School in Boston. We recorded this podcast in the hallways of the annual meeting. We talked about outcomes following intubation in the emergency department. Kei published a paper in JAGS that is notable for several things, but perhaps most of all for the innovative use of color imagery to convey a message. The image in the @AGSJournal tweet above is from Dr. Ouchi's article - this tweet went viral by the way - and notice what it does: (1) convey the main message that outcomes are worse with advancing age, and are not good in general overall; (2) grab your attention and make you want to learn more. Kei is very thoughtful about how these data should be used - not on the spot in the ED, when a patient is gasping for air, and you pull up the color figure on your iphone Twitter app - no, not then. Better to use this information in advance, when things are calm, outside the ED, for people at risk of going to the ED in extremis. This is the first in a series of GeriPal podcasts on the GeriPal - ED interface. ED stands for Emergency Department by the way. Enjoy! -By @AlexSmithMD

On this week's podcast, we talk with the authors of a Journal of the American Geriatrics Society (JAGS) article titled Should We Bury "The Good Death"? As luck may have it, one of the authors is co-host Alex Smith, and the other is a leader in geriatrics and palliative care, VJ Periyakoil. Alex and VJ's critique of the 'good death' was published alongside a paired commentary from Age and Ageing from the British Geriatrics Society.

For this week's GeriPal podcast we are honored to be joined by Tim Quill, palliative care physician and bioethicist from the University of Rochester, New York. Dr. Quill has pushed our nation to seriously grapple with the issue of physician aid in dying with a remarkably thoughtful and measured approach. We talk with Dr. Quill on this podcast about voluntary stopping eating and drinking, and a paper on this topic he recently published in JAMA Internal Medicine. As noted in the podcast, I am deeply ambivalent about physician aid in dying. I find voluntary stopping eating and drinking (VSED) to be far more acceptable. Some of this has to do with the acceptability of positive and negative acts (positive act - giving a patient a prescription for lethal medication; negative act - not inserting a feeding tube in a patient who refuses to eat and drink). Some of this just has to do with the time course: patients who stop eating and drinking must have the resolve and dedication over time. And they can change their minds. We address many aspects of this issue on the podcast, including: Who is VSED appropriate for? What can patients expect? How does VSED compare to other "options of last resort?" What is the role of palliative care? Should hospice's deem a patient eligible if they would not have a less than six month prognosis if they continued to eat and drink? When should a psychiatrist be involved? What if the suffering is not physician, but social or psychological? Is VSED legal? Should clinicians routinely offer VSED to all patients with serious illness as an option? How do you feel about this topic? Feel free to respond in the comments, or on Twitter!

For this weeks podcast, we talk with Laura Petrillo, lead author of a recent paper published in JAMA IM titled "Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes". Laura is a palliative care physician and researcher at Massachusetts General Hospital and Harvard Medical School. Laura's finding should serve as a wakeup call for anyone caring for individuals on hospice living in nursing homes. They found that 1 in 9 nursing home patients with type 2 diabetes experienced hypoglycemia. So take a listen an tell us what you think in the comment section on this GeriPal post.

Many in palliative care (including us) have argued that the default care model in nursing homes should be a palliative approach. Revealing indeed, therefore, to talk with nurse researcher Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion for nearly 200 residents of 3 San Francisco area nursing homes, finding: 70% of nursing home residents were palliative care-eligible, but other than 2 patients on hospice, none were receiving consultative palliative care 99% of residents had completed a POLST, but almost no one remembered filling it out Listen to the podcast for more, including answer to questions: What does palliative-care eligible mean? How could they fill out a POLST but not remember it, did they all have dementia? What is Campbell's law, and does it have anything to do with his soup? We're joined on this podcast by Sei Lee, MD, regular guest host and as it happens senior author on the nursing home study, and Lynn Flint, MD, palliative care physician with extensive experience working in nursing home settings. Enjoy!

Proton pump inhibitors are one of the most widely used medications. As I note in the podcast below, I was in my local drug store the other day, and an entire shelf segment, top to bottom, was filled with medications for "heartburn," and most of them were proton pump inhibitors. And those are just the over the counter variety. So wouldn't it be a public health disaster if proton pump inhibitors, or PPIs, increased a persons risk for dementia? Even if the increase in dementia risk is only slight, on a population level, given the vast number of people using PPIs, the consequences would be disastrous. A major study in JAMA showed just such a linkage, raising serious alarm about this issue. So with this urgent question in mind, we talk with two authors about their more recent studies in JAGS suggesting that there is no such linkage. We talked with Shelly Gray, from the School of Pharmacy and the University of Washington, and Felicia Goldstein from Emory University, about their studies, the current evidence as a whole, and what an individual on PPI's should think at this time about his or her risk of dementia. Here is the bottom line, for those who can't wait. In response to Eric asking what advice they would give their 75 year old neighbor who is taking PPI's, Dr. Gray said: I would tell her that the information is conflicting, but some really high quality studies have been done and have not found an association, and if this medication is necessary to manage her condition, that she should continue taking it. However, I will say that we do know that these medications are overused, and so I still believe in the tenet of geriatric medicine that we try to deprescribe when possible, so I would try to reassure her and let her know that it's not a done deal and that the high quality studies do indicate that there doesn't seem to be an association.