What is death anxiety?  We spend the first 15 minutes of the podcast addressing this question.  And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on therapeutic presence and the angry patient).  After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss!

Several key points stood out to me from this podcast, your key points may differ:

• The “anxiety” in “death anxiety” is not a pathological phenomenon or a DSM diagnosis;  it references an existential concern that is fundamental to the human experience .  To me,” awareness of mortality” might be a better term, but in fairness, the idea of “death anxiety” was coined well before the formal establishment of “anxiety disorders.”

• The ways in which death anxiety manifests in our patient’s choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no “one size fits all” approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient  in remission from cancer any pain might signal return of cancer. 

• Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience.  

• Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can’t define (sorry Dani and Keri!), but also through our own unexamined fears about death.

• As clinicians who regularly care for people who are dying, we might find ourselves becoming “used to” death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients.

I mean, don’t fear the reaper, right?  Sorry, no cowbell in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version.

Here are some resources for listeners wanting to learn more about this topic:

Books:

• Yalom ID. Existential Psychotherapy. New York, NY: Basic Books; 1980.

• Yalom ID. Staring at the Sun: Overcoming the Terror of Death. San Francisco, CA: Jossey-Bass; 2008.

• Solomon S, Greenberg J, Pyszczynski T. The Worm at the Core: On the Role of Death in Life. New York, NY: Random House; 2015.

• Becker E. The Denial of Death. Free Press; 1973.

Articles:

• Emanuel LL, Solomon S, Chochinov HM, et al. Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care. J Palliat Med. 2023;26(2):235-243.

• Chochinov HM, McClement SE, Hack TF, et al. Death anxiety and correlates in cancer patients receiving outpatient palliative care. J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052.

• Clark D. Between hope and acceptance: the medicalisation of dying. BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905.

• Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. The terror management of medical decisions: The effect of mortality salience and religious fundamentalism on support for faith-based medical intervention. J Pers Soc Psychol. 2009;97(2):334–350.

• Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomized controlled trials. J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00

• Brown TL, Chown P, Solomon S, Gore G, De Groot JM. Psychosocial correlates of death anxiety in advanced cancer: A scoping review. Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068.

• Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. Top Ten Tips Palliative Care Clinicians Should Know About Attending to the Existential Experience. J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453.

What’s the ideal blood pressure target for older adults with hypertension? Should we aim for a systolic BP of 120 mmHg in all older adults, as suggested by the SPRINT trial? Or should we be more flexible—especially for those who are frail or among the oldest old?

This week on the GeriPal Podcast, we explore the nuances of managing blood pressure in older adults with our guests Dr. Mark Supiano, Dr. Mitra Jamshidian, and Dr. Simon Ascher. 

Now, some of our astute GeriPal listeners may say, “wait, didn't you already talk about this with Mark Supiano in a 2017 podcast titled How Low Should We Go with Blood Pressure in Older Adults?”  Yes, we sure did, but we decided to revisit this topic as Mitra Jamshidian and Simon Ascher published a new JAGS research study focused on developing a framework to individualize the net benefit of intensive blood pressure control based on the results of the SPRINT trial.  Their key finding: most community-dwelling older adults in the SPRINT trial experienced greater benefits than harms from more aggressive blood pressure targets—even those who were older, frail, or on multiple medications.

Join us for an in-depth discussion on balancing risks, benefits, and patient preferences in hypertension management for older adults. Plus, we might just sneak in a little Frank Sinatra for good measure.

In this week’s episode, we dig into two deceptively simple questions: When does someone become a cancer survivor, and should palliative care be in the business of caring for them? Spoiler: It’s more complicated than it seems.

We’ve invited two palliative care doctors to talk about survivorship with us: Laura Petrillo, a physician-researcher at Mass General Hospital and Harvard Medical School, and Laura Shoemaker, an outpatient palliative care doctor at the Cleveland Clinic. This episode is a must-listen for those navigating the evolving landscape of cancer care, and asking not just how we treat cancer, but how we support people who are living with it. 

If you want some further reading on survivorship, check out some of these articles:

• A NEJM article titled “Time to Study Metastatic-Cancer Survivorship”

• A ASCO publication that includes a section on survivorship - Patient-Centered Palliative Care for Patients With Advanced Lung Cancer

• A webinar on survivorship - Blending Survivorship and Palliative Care (NCI)

June Lunney famously characterized the end of life functional course of people with dementia as a slow dwindle over time. Tom Gill later found that people with dementia do indeed have persistent severe disability throughout the last year of their lives.

But from our clinical work, many of us are familiar with people with dementia who experience sudden shocks to their health, think hip fracture, think hospitalization for pneumonia.  Those disruptive events or shocks often portend a major decline in function from which people with dementia never fully recover.  And they’re often a sign of (or cause of?) worsening prognosis.

Today we talk about disruptive events, or health and wealth shocks.  We start with Lauren Hunt, who described the incidence and outcomes of hip fracture and hospitalization for pneumonia in a pair of publications in JAGS, comparing people with dementia who experience these events to people without dementia.  We then turn to social events, starting with Rebecca Rodin, who studied the effect of widowhood on mortality and function for people with dementia, cancer, and organ failure, published in JAMA Network Open.  Finally, we turn to Tsai-Chin Cho, who studied the impact of a wealth shock (loss of 75%+ of wealth in a short time period) on cognitive decline in 4 countries.  Tsai-Chin’s article, published in Lancet Healthy Longevity, found a tantalizing hint that countries with stronger safety nets had lower incidence of wealth shocks, and less of a deleterious impact of the wealth shock on cognitive function.

Wait, so one key message is that social health is linked to physical and cognitive health?!?  And the government can do something about that?!? Yes indeed, we like to hammer that home regularly, dear listeners.

And I enjoyed singing Leonard Cohent’s Who By Fire, about the many ways people might die…you know…typical uplifting GeriPal song lyrics!

-Alex Smith

Additional links mentioned by Tsai-Chin Cho:

-Wealth shocks and mortality in the US

-Change in marital status as a risk for wealth shock

Happy Pride Month GeriPal listeners!

Transgender issues are in the news. Just today (June 17th) as we record this podcast:

• Ezra Klein released a wonderful interview with Sarah McBride, the first openly transgender member of congress

• A judge ruled that cuts to NIH grants focused on minority groups, including transgender people, were illegal and ordered the government to restore funding. 

• It’s Pride month, and our guests remind us of the leadership of two trans women in the Stonewall riots, which started the modern fight for LGBTQI+ rights and liberation.

Today’s guests are Noelle Marie Javier, a geriatrician and palliative care doc who tells her story of transitioning as a faculty member at Mt. Sinai in New York, and Jace Flatt, who started their journey as a gerontology researcher at UCSF and is now faculty at UNLV. Jace was in the news recently for having multiple federal grants cancelled because they included transgender participants. We cover many topics, including:

• Terminology: gender identity, sexual orientation, gender expression, transgender, nonbinary, intersex, what’s in LGBTQI+

• Gender affirming care

• Major health and medical issues associated with aging as a transgender person

• Allostatic load

• Accelerated aging

• What can clinicians do - pointers, pearls, and attitudes

• Dementia risk 

• Caregiver issues

• Hormone replacement therapy at the end of life

• Sexual orientation and gender identity (SOGI) data, what is it, how to collect it respectfully and safely

• Mentioned: Harvey Chochinov’s Dignity Therapy question, and our prior podcast on LGBT Care for older adults and serious illness with Carey Candrian and Angela Primbas

So pleased to sing True Colors by Cyndi Lauper, with Kai on guitar for those of you listening to the podcast.

-Alex Smith

Many links!

-Rainbows of Aging: Jace Flatt’s research site.

-LGBTQcaregivers

-Callen-Lorde gender affirming trans health services

-GLMA: organization for health professional advancing LGBTQ+ equality

-Center of Excellence for Transgender Health at UCSF

-World Professional Association for Transgender Health

-Sage advocacy services for LGBTQ+ Elders: focus on impact of Medicaid cuts

-Trans bodies, Trans selves: resource guide 

If you’re anything like me, you might find the process of what happens to patients when they visit a radiation oncologist somewhat mysterious. During my training, I didn’t receive much education about radiation oncology, and I’m not entirely sure what some of the terms mean (hypofractionated means fewer sessions, right?). Well, today’s podcast aims to clear up all these uncertainties.

We’ve invited Anish Butala, the Chief of the Palliative Radiotherapy Service at Penn Medicine, and Emily Martin, a palliative care doctor and past president of the Society for Palliative Radiation Oncology (SPRO), to explain everything we should know about radiation oncology. Additionally, Evie Kalmar, who suggested today’s topic, will join us as one of our guest hosts.

Tune in and we will walk you through the patient’s journey from the initial planning visit to the final treatment, discuss common indications like bone and brain metastases, hear about when to consider steroid therapy, and highlight radiation therapy emergencies.

The need for better palliative care in nursing homes is significant. Consider this: the majority of the 1.4 million adults residing in U.S. nursing homes grapple with serious illnesses, and roughly half experience dementia. Many also suffer from distressing symptoms like pain. In addition, about 25% of all deaths in the United States occur within these facilities.

Despite these substantial needs, specialized palliative care beyond hospice is rare in nursing homes. Furthermore, only about half of nursing home residents nearing the end of life receive hospice care.

So, how can we improve palliative care for individuals in nursing homes? Today's podcast explores this crucial question with three leading experts: Connie Cole, Kathleen Unroe, and Cari Levy.

Our discussion delves into:

• The specific palliative care needs of nursing home residents.

• How to think about primary and specialized palliative care in this setting.

• The obstacles hindering referrals to palliative care services.

• Practical strategies to overcome these barriers and enhance care.

We also take a dive into these 2 articles that Connie first authored:

• Palliative care in nursing homes: A qualitative study on referral criteria and implications for research and practice. JAGS 2024

• Nursing Home Palliative Care Referral Process, Barriers, and Proposed Solutions: A Qualitative Study. 2024

If you are interested in learning more, check out some of our other palliative care in nursing home podcasts including:

• Discussion of a primary palliative care multinational trial with Lieve Van den Block

• Understanding the variability in nursing home care

• A podcast on Palliative Rehab?!? with Ann Henshaw, Tamra Keeney, and Sarguni Singh

Have any of you watched the movie “The Notebook”?  At the end, one of the characters, who has dementia, experiences an episode of lucidity.  When I watched it, between tears (I’m a complete softie) I remember thinking, “Oh no! This will give people false hope!  That their loved one is ‘in there.’ If only they could find the right key to unlock the lock and let them out.”

Today we talk about lucid episodes and what they might mean to the person with dementia, their family and loved ones, to philosophers, to clinicians, to neuroscientists. Our guests are Andrea Gilmore-Bykovskyi, a nurse researcher, and Andrew Peterson, a philosopher.

We had a wide ranging discussion that touched on (among many things):

• A consensus definition developed at an NIH conference, organized by the recently retired NIA program officer Basil Eldadah (we will miss you Basil!).

• Andrew complicates this definition, stating is raises more questions than answers.

• Hospice nurses know that terminal lucidity “is a thing” and have pretty much all  seen it

• Family and caregiver stories of lucid episodes and what they meant to them, including early glimpses into a study Andrea is doing using video to capture episodes and show them to family.

• Potential for experiences to elicit “false hope”, misunderstanding/misinterpreting, and changing say code status from DNR to full code (rare but happens).

• Sam Parnia’s work on brain activity during CPR and near death episodes

• Ethical issues these lucid episodes raise 

• Should clinicians treat people with dementia as always lucid? Having some level of awareness? 

• Parallels between how we treat people with advanced dementia, who may or may not be lucid, and how we treat AI, who may or may not be conscious, or experiencing paradoxical lucidity on their way to full consciousness.  I try to say please and thank you to the AI I interact with other than Alexa, who is obviously way behind.

• The Age of Aging podcast episode on lucidity, featuring Anne Bastings, Jason Karlawish, Elizabeth Donnarumma, and Justin Clapp

• Was Andrew’s song choice, “I can see clearly now” better than Eric’s suggestion “Silent Lucidity” by Queensryche?

   

Enjoy!

-Alex Smith

As you know, dear listeners, I love music. We start each podcast with a song in part to shift the frame, taking people out of their academic selves and into a more informal conversation.

Well, today’s guests love music at least as much if not more than me, and they each make a strong case for music as medicine. Jenny Chen is a palliative care fellow at Yale who regularly sings for her seriously ill patients. Look for Jenny to potentially appear on the show America’s Got Talent (no lie).

Tyler Jorgensen not only plays music for his patients, starting out with just pulling up a tune on his iPhone, he and others at UT Austin and Dell med now wheel a record player into patients rooms and play vinyl, taking patients back to the sounds and routines - think taking the record out of the sleeve, placing the needle in the groove - of younger days.  You can here Tyler and I having a great time singing together and sharing stories around his podcast My Medical Mixtape.

And Theresa Allison is a geriatrician and ethnomusicologist who studies the role of music for people with dementia. The ability to appreciate, recognize, and engage with music is preserved even until late stages of dementia, and Theresa is examining how music can be useful from the time of diagnosis, not only for the person with dementia, but their caregivers.

Many links today, including:

-Alive Inside Movie and Music and Memory movement

-Music and Creativity in Healthcare Settings - book by Hilary Moss

-Tyler Jorgensen’s article on  Bringing Music to patients at the Bedside in JGIM

-Tyler’s reflection/story comparing palliative medicine to jazz - something I arrived at independently and tell all new trainees!  This is not highly scripted orchestral music, people, it’s Jazz.

-Systematic review of music (and prognosis) in palliative care

-Review of music and dementia interventions (Theresa Allison author)

-Theresa Allison’s paper on Music Engagement in Dementia Caregiver Relationships in Gerontologist

-Jenny Chen’s YouTube channel.

Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care.  Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh.  Kate and Scott have additional training in palliative medicine. 

To start. we review:

• What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.

• Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.

• What is sludge?  I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners.  Sludge is apparently when you create barriers or extra work for someone.  For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge.  Prior-auth forms? Sludge.

• Examples of nudges, some based in health care, others in coffee. 

This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals.  Participants were critically ill and intubated.  Clinicians were randomized to 4 groups:

1. Usual care

2. Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect

3. Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies.

4. Both the prognosis and comfort care nudge.

A few key points of discussion:

• Is an EHR prompt a nudge or sludge?  

• The intervention was a negative study for the primary outcome, hospital length of stay.  Why? 

• The prognosis nudge did nothing.  What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?

• The nudge toward offering comfort care led to more hospice and early comfort-care orders.  Is this due to chance alone, given the multiplicity of secondary outcomes examined?  Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently?  Imagine!  

 -Alex Smith