Four percent of deaths in Canada are due to Medical Assistance in Dying (MAID).  Four percent. The number of people who have used MAID in Canada since it was legalized in 2016 has increased year on year from about 1,000 people in the first year to over 13,000 people in 2022. California, which has a similar population size as Canada and legalized MAID around the same time, has fewer than 1000 deaths per year from MAID.  In further contrast to the United States, MAID in Canada is almost entirely administered by a clinician, whereas in the United States patients must self administer.   To be eligible in Canada patients must have a “grievous and irremediable” condition,  including disability; they do not have to have a terminal illness with a prognosis of less than 6 months.  They could have a prognosis of years, or decades.  A planned expansion of MAID to include people with mental illness was placed on hold until March 2024. The Canadian parliament will soon hear a report on potentially expanding MAID to “mature minors.” A recent Human Rights podcast discussed the story of a Canadian seeking MAID because he could not afford to stay housed. Today we talk about these issues with Bill Gardner, a psychologist at the University of Ottawa who is living with cancer,  Leonie Herx, a palliative care physician at the University of Calgary, and Sonu Gand, a psychiatrist at the University of Toronto and former president of the Canadian Psychiatric Association. We talk about how Canada got to this point, including the degree to which offering MAID to anyone who is eligible has become standard practice in many places. We hear Bill Gardner's experience being told that his cancer could not be treated and immediately offered two options: palliative care or MAID. We talk about the role of palliative care and lack of access for many people living with serious illness in Canada. We go in depth about ethical issues raised by the planned expansion of MAID to people with mental illness. Much of the criticism of the explosion of MAID in Canada is coming from people like, our guests, who feel that MAID should be an option for a select few, rather than coming from under-no-circumstance opponents.  To many this rapid expansion will represent autonomy run amok. It is the slippery slope made real. To others MAID represents a seemingly easy and inexpensive mechanism to address failures of the system to address potentially reversible sources of suffering on a systemic level, from difficult conversations at the bedside, to meeting basic needs like housing. For those listening to the podcast, credit to Kai for guitar on Neil Young’s Cortez the Killer (my left hand is still broken at the time of this recording). You get me with one-finger-chords on the guitar if you're watching on YouTube (best I could manage). -@AlexSmithMD Overview of MAID in Canada Bill Gardner’s article about MAID in Comment Magazine https://comment.org/death-by-referral/ Bill Gardner’s articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/ https://mbird.com/religion/testimony/in-the-electors-school/

We’ve talked a lot about comprehensive dementia care on the GeriPal podcast but while the evidence is clear that these programs work, the uptake has been limited largely because there hasn't been a strong financial case for it. Don’t get me wrong, the evidence points to cost savings, but as Chris Callahan and Kathleen Unroe pointed out in a JAGS editorial in 2020 “in comprehensive dementia care models, savings may accrue to Medicare, but the expenses accrue to a fluid and unstable network of local service providers, patients, and their families.” The good news is that the financial case for comprehensive dementia care is changing thanks to a new Center for Medicare and Medicaid Innovation (CMMI) alternative payment model (APM) called Guiding an Improved Dementia Experience (GUIDE) Model.  This model will give participating programs a per-member-per-month payment to offer care management, care coordination, and other services such as caregiver training, disease education, and respite. On today's podcast we talk with Malaz Boustani of Indiana University, as well as Diane Ty, the senior director of the Milken Institute Center for the Future of Aging, about the GUIDE model.  We’ll cover why the GUIDE model is important (hint - it all comes down to funding), how it was developed, what components will it include, and how it will be evaluated. To read more about the GUIDE model, check out the following links: Diane’s article in Health Affairs titled “A Promising Turning Point For Dementia Care: The GUIDE Model” Another Health Affairs article titled “Applying An Evidence-Based Approach To Comprehensive Dementia Care Under The New GUIDE Model” The CMS site if you are interested in learning more or applying to be a site (the application period will close on January 30, 2024)    

One of the things I love about Liz Dzeng’s work is the way in which it draws upon, echoes, and advances our understanding of the influence of culture on the end of life experience.  This field is not new. In his book The Hour of our Death Philip Aries described a long evolution in western civilization of cultural attitudes towards dying.  More recently Sharon Kaufman 's book And a Time to Die described the ways in which physicians, nurses, hospital systems, and payment mechanisms influenced the hour and manner of patient's deaths. Similarly Jessica Zitter, an intensivist and palliative care doctor analogized the inevitable clinical momentum toward highly aggressive intensive care in US hospitals as a conveyor belt. Today Liz Dzeng discusses her journey towards studying this issue in detail. Having trained in different institutions within the United States and in the United Kingdom, and as both a sociologist and a hospitalist physician, Liz brings a unique perspective and set of skills to this issue. On this podcast we talk about her paper in JAMA Internal Medicine which studied three hospitals that varied in the intensity of care they provided to seriously ill patients. We discuss the moral distress that clinicians felt including, as one physician put it, a sense of your soul being ripped out. At the end we also pay tribute to Randy Curtis, senior author on this paper and mentor to Liz. Eric and I are joined today on this podcast by Anne Kelly palliative care social worker to discuss these issues with Liz. -@alexsmithMD   Additional links: From Liz: “policies that are too restrictive can actually have an opposite of hindering ethically and clinically appropriate practices whereas policies that allow for flexibility and transparency to act ethically can promote high quality end-of-life care” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/   Other papers that are relevant:  JAMA IM 2015: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265 JPSM LAT France paper: https://www.jpsmjournal.com/article/S0885-3924(21)00399-7/pdf ICM paper policies: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8883558/ JPSM aggressive care: https://www.jpsmjournal.com/article/S0885-3924(17)30425-6/fulltext BMJ QS moral distress ethical climate: https://qualitysafety.bmj.com/content/27/10/766.long    

To my teenagers, climate change is an existential crisis.  It’s the end of the world as we know it.  They decry the lack of serious attention and prioritization this issue has in the US.  My kids ask - why don’t adults care about this issue the same way that they and their friends care about it?  My kids have taught me that the emphasis on personal responsibility (reduce your carbon footprint!) was supported by the fossil fuel industry, because it shifted responsibility for change from industry to individuals.  Voting and emailing congress to advocate for systemic change (e.g. less reliance on fossil fuels) likely has a greater impact than recycling your newspaper. Today we find inspiration for my kids: there are adults who care deeply about this issue, particularly for older adults who are much more vulnerable to health effects of climate change. Karl Pillemer is a sociologist and gerontologist who studies this issue and has created a platform called, “Aging and Climate Change Clearinghouse,” that is a wide tent with room for older adults, researchers, and organizations.  As a researcher, I found the bibliography fascinating, including this gem by the gerontologist Rick Moody on the moral obligation of older adults to address climate change.  Leslie Wharton is a leader in the 26,000 member grassroots organization Elders Climate Action, which organizes older adults to create communities engaged in making a difference at local, state, and national levels.  As she notes, these volunteer activities can bring meaning and purpose, in the face of a seemingly insurmountable problem, to the elders in her organization.  And we talk with Ruth McDermott-Levy, who wrote a practical guide for discharge planning in the era of climate change (example - a generator safety checklist).  Ruth advocates for and teaches about aging and climate change at Villanova, and calls on nurse scientists and other health researchers to study climate change. -@AlexSmithMD    Additional links: JAMA paper on clinical research risks, climate change, and health Geriatric medicine in the era of climate change  Health Care Without Harm: https://noharm.org/ Practice Green Health: https://practicegreenhealth.org/ Global Consortium for Climate and Health Education: https://www.publichealth.columbia.edu/research/programs/global-consortium-climate-health-education

There is a growing push to change how we define Alzheimer's disease from what was historically a clinically defined syndrome to a newer biological definition based on the presence of positive amyloid biomarkers. This proposed new definition, championed by the Alzheimer's Association (AA) and the National Institute on Aging (NIA), proposes that the disease exists when the earliest manifestation of Alzheimer’s pathophysiology can be detected (amyloid), even though onset of symptoms may be years in the future. On today's podcast we talk about the benefits and drawbacks of redefining Alzheimers to a biological definition with three experts in the disease: Heather Whitson, Jason Karlawish, and Lon Schneider. In particular we spend a good deal of time talking about what this means for asymptomatic patients who may have an abnormal biomarker, which by the proposed new definition would mean they would now have Alzheimer's disease.  If you are interested in learning more about the draft guidelines and the response from AGS to these guidelines, check out the following links: Revised Criteria for Diagnosis and Staging of Alzheimer's Disease: Alzheimer’s Association Workgroup  AGS’s response to the revised criteria  

Coaching is in.  During the later stages of the pandemic, it seemed every other person, and particularly the junior faculty in our Division, were either being coached, in training to coach, or coaching others.  When I was a junior faculty, coaching wasn’t a thing.  Sure, Atul Gawande wrote about coaching in surgery - having someone observe you and coach you on your technical skills- but that’s a far cry from the coaching programs focused on empowerment that are exploding around the country today. Today we learn more about coaching from 3 coaches: Greg Pawlson, coach and former president of the American Geriatrics Society, Vicky Tang, geriatrician-researcher at UCSF and coach, and Beth Griffiths, primary care internist at UCSF and coach.  We address: What is coaching? How does it differ from therapy? How does it differ from mentoring What is typically covered in coaching sessions?  What is the evidence (see many links below, sent by Beth) What are the standards for becoming a coach? Who is coaching for? My take: coaching has tremendous potential.  There seems to be a gender story here as well - coaching may be of particular benefit to women who are at higher risk for burnout.  Note, for example, the hot off the press JAMA Network Open trial which demonstrated modest benefits across a range of outcomes was conducted exclusively in female resident physicians.  Kemi Doll, a physician-researcher and coach, has a terrific podcast I highly recommend everyone listen to, though it is targeted at women of color in academic medicine.  On the other hand, there is a concerning side, described in this Guardian article titled, I’m a life coach, you’re a life coach: rise of an unregulated industry.  See also the long list of disclosures in the JAMA Network Open study.  Our guests note, rightly, that the same profit motive and concerns are true about colleges.  Still, I remain concerned when I see that the Life Coach School costs $21K; when the founder of the Life Coach School’s goal is to grow a $100 million/year business; and when my spidey sense tells me there’s something cultish about the empowerment industry.  So, I see the potential of coaching, particularly for groups that face challenges in academic medicine; and I worry about the injection of profit-motives and the goals of industry leaders pushing the meteoric rise of the life coach industry. -@AlexSmithMD 1.  Hot off the presses RCT in JAMA October 2023: Study that looks at 1000 female resident physicians at 26 sites that showed that coaching improved each outcome assessed (burnout, moral injury, imposter syndrome, self-compassion, and flourishing).  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810135 2. An RCT for female residents published in JAMA May 2022: This was the initial pilot single institution study by the same team as above. Their findings concluded that it was feasible to implement an online coaching program for female residents and that coaching improved emotional exhaustion, imposter syndrome and self-compassion. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791968?fbclid=IwAR0taY5CGpUa5eyfleNIl7RfXLT7qVt0GakKPGlT9ESIPLn0yCKWG9obrZo 3. A March 2022 study of Stanford offering coaching as a benefit to their physicians and finding improved self-compassion and burnout. https://www.mayoclinicproceedings.org/article/S0025-6196(22)00038-6/fulltext 4. The initial RCT published on physician coaching in JAMA in 2019 showing that coaching improves quality of life. This is the first RCT that was available for coaching in physicians.  https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740206  5. A 2020 RCT of coaching for primary care physicians shows that coaching improves burnout well-being during the intervention and has a sustained duration at 6 months of follow up.  From Beth Israel and UNC.  https://pubmed.ncbi.nlm.nih.gov/32297776/ 6. The Business Case for Investing in Physician Wellness, again in JAMA. This paper includes coaching as a sign of a more mature physician wellness program and states it has a positive return on investment. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2653912    

What does the future hold for geriatrics? I’ve seen this question come up a lot since finishing fellowship nearly two decades ago. Historically, answers generally lamented the ever increasing need for geriatrics without a corresponding growth in the number of specialists in the field. But, it's also hard not to be bullish on the future of the field to see the consistent strides geriatrics has made in the last two decades in improving care for older adults. For example, I never would have imagined two decades ago the push for age-friendly health care systems and the growth of non-geriatricians, like surgeons and oncologists, adopting geriatric principles into their training and research. On today’s podcast, we are going to do a deep dive on the future of geriatrics with three amazing guests. First, we’ve invited Jerry Gurwitz to talk about his recently published article in JAMA titled The Paradoxical Decline of Geriatric Medicine as a Profession (while it’s not the most upbeat title for the future of geriatrics, Jerry sees it as a call to action). We’ve also invited Mike Harper, the Chair of the Board of Directors of the American Geriatrics Society (AGS) as well as past-president for the society (and my previous program director). Lastly, we’ve asked one of the brightest rising stars of geriatrics, Ryan Chippendale, to join us as well. I’m a huge fan of Ryan’s, in part for her work in co-creating the GERI-A-FLOAT (GERIAtrics Fellows Learning Online And Together). This is a great virtual curriculum designed to convene geriatric fellows nationwide for learning and peer support (and if you are interested in having your own fellows join, click here).  

Often podcasts meet clinical reality.  That’s why we do this podcast- to address real world issues in palliative care, geriatrics, and bioethics.  But rarely does the podcast and clinical reality meet in the same day. Within hours of recording this podcast, I joined a family meeting of an older patient who had multiple medical problems including cancer, and a slow but inexorable decline in function, weight, and cognition.  Physical therapy had walked with him that day and noted improvement compared to previous walks, suggesting that he should be discharged to a skilled nursing facility for rehabilitation on discharge.  The patient's capacity to make decisions was marginal, and his sons were shouldering much of the responsibility. The sons were very focused on rehabilitation, and the patient gave his assent. In the meeting, I used the language suggested by Sarguni Singh, “I worry that going to SNF for rehab may not result in your being independent.”  We additionally discussed hospice care as an option for care that might follow the trial of rehabilitation. Today we talk with Sarguni Singh, hospitalist-researcher at the University of Colorado, Ann Henshaw, Occupational Therapist who teaches at George Washington and works clinically at Georgetown, and Tamra Keeney, Physical Therapist-researcher at Mass General Hospital and Harvard Medical School.  Lynn Flint, author of the NEJM perspective titled, “Rehabbed to Death,” joins Eric and I as co-host. We cover a lot of ground in this podcast, including an evidence based toolkit to promote collaboration between therapy fields and palliative care, outcomes of rehabilitation for people with advanced cancer (hint: not much hospice, lots of re-hospitalization), and a JAGS study on use of post-acute care among patients with heart failure.  We also heard from Tamra about her opinion piece in which she laments, “The role of rehabilitation is often myopically constrained to facilitation of efficient discharge planning.”  Therapists are so much more. At the end of the day, I lamented that physical, occupational, and speech therapists aren’t more tightly integrated with palliative care teams.  As Lynn says at the end of the podcast, to paraphrase, “Physical therapy, occupational therapy, speech therapy - all this therapy for older frail patients is a core part of good palliative care.” And our guests sing along with “Sweet Caroline” - so good, so good, so good! -@AlexSmithMD   This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care.  They are looking for physician faculty to join them in the inpatient and outpatient setting.  To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric?  The answers to these questions will vary.  Reasonable people will disagree.  And today, on our podcast, our guests disagree.  Firmly.  AND we are delighted that our guests modeled respectful disagreement.  With no hard feelings.  Respectful disagreement is in short supply these days. Our guests today are Kelly Vranas, pulm crit care doc who published a systematic review in JAGS of the evidence for POLST (as well as other articles here, here,and here); Abby Dotson, who is Executive Director for National POLST and Director of the Oregon POLST registry; Karl Steinberg, geriatrician and palliative care doc and President of National POLST; and Scott Halpern, pulmonary critical care physician, bioethicists and palliative care researcher who was senior author of a Viewpoint in JAMA that was critical of the concept and evidence base for POLST (and argues little has changed).  We had a full podcast, and I wasn’t able to give my take on the existing evidence for POLST, so I’ll write it here. I’m in the middle between Scott and Karl, where I suspect Kelly is, though we didn’t ask her explicitly.  On the one hand, I agree with Scott that observational studies finding those who complete a POLST stating a preference for comfort oriented care and DNR are not go to the ICU says little about the effectiveness of POLST.  Far more likely that those underlying preferences and values are what drove the findings than completion of the POLST form that codified the preferences into orders.  On the other hand, I agree with Karl that the POLST has face validity, and anecdotal evidence is overwhelming.  Certainly SOME of those avoided hospitalizations, CPR, and ICU stays were due to documentation of those orders in the POLST. The unanswered question is: HOW MUCH of the differences are due to the POLST?  It’s not zero, as many of us have had cases in which we said, “Thank god we completed that POLST, it clearly stopped X from happening.” But is it a tiny, meaningless, fraction?  Or a substantial proportion?  My guess is a small but meaningful fraction of differences in observational studies is due to completion of the POLST, though the majority of differences are due to underlying preferences and values. Is that fraction due to POLST large enough that we should design quality metrics around completion of POLST? Absolutely not. Do we need better evidence, preferably from an RCT of POLST vs no POLST? Yes. Caveat as well that RCTs should not be placed on pedestal as the only answer-  often patients enrolled in RCTs do not represent real world patients - observational studies do.  For a trial to have value, it should not exclude patients over age 80, or those with dementia, or patients residing in nursing homes.  And it must be powered to detect a small but meaningful difference, not the same level of effect seen in observational studies. OK, I’ll step off my soap box. Additional links mentioned in the podcast: Recent JGIM article on POLST in California nursing homes, hospitalization, and nursing home care Karl’s GeriPal post on appropriate use of POLST  Enjoy! -@AlexSmithMD

For surgeons and patients, deciding if and when to operate can be challenging. Often, the way surgeons communicate about these decisions doesn’t make things any easier for themselves or their patients. And, surgeons often spend the majority of their conversations with patients describing anatomical details and exactly how they plan to ‘fix it’, with little discussion of what that ‘fix’ will do for a patient’s overall goals. Instead, what if your surgeon told you that the operation she was discussing could help with only 4 things: live longer, feel better, prevent disability, or obtain a diagnosis? And, what if your surgeon openly discussed the expected ‘bad stuff’ of post-operative recovery, instead of rotely reciting a list of possible complications? We invited Gretchen Schwarze and Justin Clapp to discuss with us these communication strategies, which are the focus of a series of 4 Viewpoints recently published in JAMA Surgery. I love this series of articles because each presents a component of a practical, patient-centered approach to patient-surgeon communication and decision making, and language surgeons (and surgical trainees) can start using in their next patient visit. We hope you enjoy this episode. Take a look at some of these links to learn more: Innovations in Surgical Communication series: Provide Your Opinion, Don’t Hide It Focus on the Goals of Surgery Promote Deliberation, Not Technical Education Present the Downsides of Surgery, Not Just Risks Dr. Schwarze’s article, “Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention'' in which surgeons used “fix-it” language in 92% of conversations and did not establish an overall goal of treatment 80% of the time. South Park “Underpants Gnomes” Orthopaedics vs Anesthesia   By: Alexis Colley