Trauma is a universal experience, and our approach as health care providers to trauma should be universal as well. That’s my main take-home point after learning from our three guests today when talking about trauma-informed care, an approach that highlights key principles including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity.

With that said, there is so much more that I learned from our guests for this trauma-informed care podcast. Our guests include Mariah Robertson, Kate Duchowny, and Ashwin Kotwal. Mariah discussed her JAGS paper on applying a trauma-informed approach to home visits. Kate and Ashwin talked about their research on the prevalence of lifetime trauma and its association with physical and psychosocial health among adults at the end of life. We also explored several questions with them, including how to define trauma, its prevalence in older adults, the impact of past traumatic experiences, the potential triggers of trauma screening, and the application of trauma-informed principles in clinical practice.

If you want a deeper dive, check out the following resources:

• Our “Nature of Suffering” podcast with BJ Miller and Naomi Saks

• Dani Chammas’ Annals paper on countertransference and why we shouldn’t say “that the patient was difficult rather than that I felt frustrated.” 

• A great Curbsiders podcast episode on Trauma-informed care with Megan Gerber

• CAPC’s Trauma-informed care toolkit

• Mariah’s article on Home-Based Care for LGBTQ or another diverse gender identity Older Adults

In today’s podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of  Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Medicine Nurses Association (HPNA).  Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully).  On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of moderator.

Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed Prepare-for-your-care vs. facilitated Respecting Choices style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer.  From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including:

• Marie’s tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served?  Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served?

• Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let’s assume that there are clear important benefits. Based on the results of Yael’s study, should resources be allocated to resource intensive nurse facilitated sessions (Respecting Choices), which had significantly better engagement, or to low resource intensive patient-facing materials (Prepare), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)?

• One interpretation of Na’s study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis.  Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality.  Which is it?

• Bonus: Simon says he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?).  Garfunkel says Simon was writing about Garfunklel’s friend and college roomate Sandy, who was blind.  Who’s got the right of it?

Enjoy!

-Alex Smith 

Things are changing quickly in the Alzheimer’s space. We now have biomarkers that can reasonably approximate the degree of amyloid build-up in the brain with a simple blood test.  We have two new FDA-approved medications that reduce that amyloid buildup and modestly slow down the progression of the disease.  So, the question becomes, what, if anything, should we do differently in the primary care setting to diagnose the disease?

On today’s podcast, we’ve invited Nathaniel Chin back to the GeriPal podcast to talk about what primary care needs to manage this new world of Alzheimer’s disease effectively.  Nate is a geriatrician and clinician-scientist at the University of Wisconsin, as well as the host of the Wisconsin ADRC's podcast, "Dementia Matters." In each bi-weekly episode, he interviews Alzheimer's disease experts about research advances and caregiver strategies. Nate also wrote a NEJM piece last year on “Alzheimer’s Disease, Biomarkers, and mAbs — What Does Primary Care Need?”

We address the following questions with Nate:

• Has anything changed for the primary care doctor when diagnosing Alzheimer’s?  How should we screen for cognitive impairment?

• Does a good history matter anymore?

• What’s the role of assessing function?

• What do we do with those who have only subjective cognitive complaints?

• Can’t we skip all this and just send some blood-based biomarkers?

• What is the role of the amyloid antibody treatments?

Lastly, take a look at the following if you want to take a deeper dive into some of the other articles and podcasts we discuss:

• First, two competing definitions of what is Alzheimer’s:

• Alzheimer Disease as a Clinical-Biological Construct—An International Working Group (IWG) Recommendation

• Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup

• Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): Executive summary of recommendations for primary care

• Podcasts we mentioned

• Prevention of Dementia: A Podcast with Kristine Yaffe

• Screening for Dementia: A Podcast with Anna Chodos, Joseph Gaugler and Soo Borson

It is a battle royale on this week’s GeriPal podcast. In one corner, weighing in at decades of experience, well known for heavy hits of bedside assessments, strong patient-family relationships, and a knockout punch of interdisciplinary collaboration, we have in-person palliative care consults. But watch out! Travel time can leave this champ vulnerable to fatigue and no-shows.  In the other corner, we have the young upstart, able to reach patients across vast distances when delivering palliative care, all in the comfort of wearing pajamas, we have telehealth delivered palliative care.  However, lack of physical presence may make this contender struggle to land the emotional support punch that is at the very heart of palliative care.

Who will emerge victorious? Will in-person palliative care use its experience and bedside manner to overwhelm telehealth palliative care, or will telehealth deliver the knockout blow of efficiency and accessibility?

Find out on this week’s podcast where we invite Joseph Greer,  Simone Rinaldi, and Vicki Jackson to talk about their recent JAMA article on “Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer - A Multisite Randomized Clinical Trial.”

Additionally, here are some of the resources we talked about during the podcast:

• Eduardo Bruera’s editorial that accompanies the JAMA paper titled “Improving Palliative Care Access for Patients With Cancer”

• Our podcast on Stepped Palliative Care with Jennifer Temel, Chris Jones, and Pallavi Kumar

• The book “What's in the Syringe? Principles of Early Integrated Palliative Care” by Juliet Jacobsen, Vicki Jackson, Joseph Greer, and Jennifer Temel

Lastly, don’t forget about attending some of the sessions Vicki mentioned at the end of the podcast during the HPNA/AAHPM annual meeting in Denver, as well as the GeriPal #HPMParty Pub Crawl!

It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes.

In our first segment, we discuss a study led by Constance Fung and her team, which investigated the use of a masked tapering method combined with augmented cognitive behavioral therapy for insomnia (CBTI) to help patients discontinue benzodiazepines. The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts.

Next, we turn to Emily McDonald, the director of the Canadian Medication Appropriateness and Deprescribing Network, to discuss her study on the impact of direct-to-consumer educational brochures on gabapentin deprescribing. Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see here for the brochure). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use.

In our third segment, we explore Amy Linsky’s study that examined the effect of patient-directed educational materials on clinician deprescribing of potentially low-benefit or high-risk medications, such as proton pump inhibitors, high-dose gabapentin, or risky diabetes medications. The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click here for the brochure). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety.

Finally, we discuss Michelle Odden’s study, which used a target trial emulation approach to investigate the effects of deprescribing antihypertensive medications on cognitive function in nursing home residents. The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast (DANTE and OPTIMIZE) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the DANTON study adds more questions to that conclusion.

Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research!

Many older adults lose decision-making capacity during serious illnesses, and a significant percentage lack family or friends to assist with decisions. These individuals may become “unrepresented,” meaning they lack the capacity to make a specific medical decision, do not have an advance directive for that decision, and do not have a surrogate to help.

In today’s podcast, we talk with Joe Dixon, Timothy Farrell, and Yael Zweig, authors of the AGS position statement on making medical treatment decisions for unrepresented older adults. We define “unrepresented” and address the following questions:

• What is the scope of the unrepresented problem?

• Why not use the older term “unbefriended”?

• How should we care for unrepresented individuals in inpatient and outpatient settings?

• What can we do to prevent someone from becoming unrepresented?

Find answers to these questions and more in this week’s podcast. Listen in, and if you’re interested, explore the topic further with the following resources:

• AGS Position statement on making medical treatment decisions for unrepresented older adults

• VA Policy on Advance Care Planning and on Informed Consent 

We’ve talked a lot before about integrating psychiatry into palliative care (see here and here for two examples). Still, we haven’t talked about integrating palliative care into psychiatry or in the care of those with severe mental illness.

On this week’s podcast, we talk with two experts about palliative psychiatry. We invited Dani Chammas, a palliative care physician and psychiatrist at UCSF (and a frequent guest to the GeriPal podcast), as well as Brent Kious, a psychiatrist at the Huntsman Mental Health Institute, focusing on the management of severe persistent mental illnesses.

We discuss the following:

• What is Palliative Psychiatry (and how is it different from Palliative Care Psychiatry)?

• What does it look like to take a palliative approach to severe mental illness?

• Is "terminal" mental illness a thing?

• Is hospice appropriate for people with serious mental illness (and does hospice have the skills to meet their needs?)

• Controversy over Medical Aid in Dying for primary psychiatric illness (and for those with serious medical illness who have a comorbid psychiatric illness)

• The level of provider moral distress that can be created in a system not designed to meet the needs of specific populations... and when we are asked to meet a need we don't feel equipped to meet.

Here are a couple of articles if you want to do a deeper dive:

• Dani and colleagues article on “Psychiatry and Palliative Care: Growing the Interface Through Education.”

• Dani and colleagues article on “Palliative Care Psychiatry: Building Synergy Across the Spectrum.”

• Brent’s article on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?”

• A NY Times article titled “Should Patients Be Allowed to Die From Anorexia?”

Surrogate decision making has some issues.  Surrogates often either don’t know what patients would want, or think they know but are wrong, or make choices that align with their own preferences rather than the patients.  After making decisions, many surrogates experience regret, PTSD, and depressive symptoms.  Can we do better?

Or, to phrase the question for 2024, “Can AI do better?” Follow that path and you arrive at a potentially terrifying scenario: using AI for surrogate decision making.  What?!?  When Teva Brender and Brian Block first approached me about writing a thought piece about this idea, my initial response was, “Hell no.”  You may be thinking the same.  But…stay with us here…might AI help to address some of the major issues present in surrogate decision making? Or does it raise more issues than it solves?

Today we talk with Teva, Dave Wendler, and Jenny Blumenthal-Barby about:

• Current clinical and ethical issues with surrogate decision making

• The Patient Preferences Predictor (developed by Dave Wendler) or Personalized Patient Preferences Predictor (updated idea by Brian Earp) and commentary by Jenny

• Using AI to comb through prior recorded clinical conversations with patients to play back pertinent discussions; to predict functional outcomes; and to predict patient preferences based on prior spending patterns, emails, and social media posts (Teva’s thought piece)

• A whole host of ethical issues raised by these ideas including the black box nature, the motivations of private AI algorithms run by for profit healthcare systems, turning an “is” into an “ought”, defaults and nudges, and privacy.

I’ll end this intro with a quote from Deb Grady in an editor’s commentary to our thought piece in JAMA Internal Medicine about this topic: “Voice technology that creates a searchable database of patients’ every encounter with a health care professional? Using data from wearable devices, internet searches, and purchasing history? Algorithms using millions of direct observations of a person’s behavior to provide an authentic portrait of the way a person lived? Yikes! The authors discuss the practical, ethical, and accuracy issues related to this scenario. We published this Viewpoint because it is very interesting, somewhat scary, and probably inevitable.”

-@alexsmithmd.bsky.social

We’ve covered stories before.  With Liz Salmi, Anne Kelly, and Preeti Malani we talked about stories written up in the academic literature, such as the JAMA Piece of My Mind series.  We talked with Thor Ringler, who helped found the My Life My Story Project at the VA and beyond, and Heather Coats about the evidence base for capturing patient stories.

Today’s podcast is both similar and different.  Similar in that the underlying theme of the power of stories.  Different in that these storytelling initiatives, the Nocturnists and the Palliative Story Exchange, are focused on clinicians sharing stories with each other in small groups to heal. There’s something magical that happens in small group storytelling. It’s that mixture of intimacy and vulnerability, of shared clinical experiences, that fosters a sense of belonging.  We model that small group storytelling experience today.

We discuss:

• The “origin stories” of the Nocturnists Live Show and Podcast and the Palliative Story Exchange

• The process for story creation and development, written in advance or not, feedback or not after the story, and the aims and goals of each initiative

• And we each tell a short story, modeling the process for The Nocturnists and the Palliative Story Exchange for our listeners

These initiatives arose organically from clinicians as part of a journey away from burnout, moral distress, shame, and loneliness toward healing, wholeness, gratitude, and belonging.  A journey taken one story at a time.

One final note on the song request: About 20 years ago I took an epidemiology course as part of a Masters program. The instructor, Fran Cook, gave all the students a survey without explanation.  We answered the survey and handed it in. One of the questions was, “Can you name a song by the Tragically Hip?”  It later turned out the survey was a prognostic index designed to determine if the respondent was Canadian.  

-@AlexSmithMD

Here’s a link to an article about the Palliative Story Exchange.

Denial. Substance use. Venting. Positive reframing. Humor. Acceptance. All of these are ways we cope with stressful situations. Some we may consider healthy or unhealthy coping strategies, but are they really that easy to categorize? Isn’t it more important to ask whether a particular coping behavior is adaptive or not for a particular person,in a particular time or situation?

We are going to tackle this question and so many more about coping on this week's podcast with Dani Chammas, a recurring GeriPal guest, psychiatrist, and palliative care doc at UCSF, and Amanda Moment, a Palliative Care Social Worker at Brigham and Women's Cancer Center. There are so many take-home points for me on this podcast, including this one on a framework for assessing coping in serious illness:

1. nonjudgmentally observe their coping

2. wonder about the impacts of their coping

3. prioritize helping patients maintain their psychological integrity

4. mindfully think through how we can serve their coping in ways that they can tolerate, always calibrating based on the person, the moment, and the setting in front of us.

Here are some more resources we’ve discussed in the podcast

• Dani’s NEJM article on coping: “Should I Laugh at That? Coping in the Setting of Serious Illness”

• Dani’s GeriPal podcast with us on “Improving Serious Illness Communication By Developing Formulations”

• A great journal article on “Formulation in Palliative Care: Elevating Our Potential for Therapeutic Communication”

• A study on how palliative care may work by enhancing patients’ ability to access adaptive coping - “Role of Patient Coping Strategies in Understanding the Effects of Early Palliative Care on Quality of Life and Mood

** NOTE: To claim CME credit for this episode, click here **