Whelp, goodbye folks!  Eric and I have been DOGE’d.

In a somewhat delayed April Fools, Nancy Lundebjerg and Annie Medina-Walpole have taken over podcast host duties this week.

Their purpose is to interview me, Eric, and Ken Covinsky about your final AGS literature review plenary session taking place at the Annual Meeting in Chicago this May (for those attending, our session is the plenary the morning of May 10).  We discuss our favorite articles, parody songs, and memories from AGS meetings past, with a little preview of a song for this year’s meeting.  

We covered:

• The first parody song I wrote, for AGS 2018 in Orlando, about this article by Nancy Schoenborn on how to discuss stopping cancer screening.

• Ken’s favorite articles, including

• The Impact of Rudeness on Medical Team Performance: A Randomized Trial

• Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization

• Eric’s favorite article on the effect of chair placement on physicians’ behavior and patients’ satisfaction

• Tim Anderson’s study on the intensification of older adults’ outpatient blood pressure treatment at hospital discharge

• Nancy’s favorite topic and parody song, Aducanumab, which won Drug of the Year in 2021. 

Enjoy! And maybe, just maybe, Eric and I will be reinstated and return as hosts next week…

-Alex Smith

A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice.  Outcomes are typically assessed from available records.  Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations.

Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine.

We spend the last portion of the podcast discussing the surprising finding of the study.  In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group.  What?!?  Not a typo.

We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including:

• Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control).  Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions?

• Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care.

• Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings.  My goals will differ if I think I probably have 2 years to live vs 10 years.

• Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed).

• Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning.  As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful.

And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French!

-Alex Smith

Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (VSED), and multiple episodes about the ethical issues surrounding medical aid in dying (MAID). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life?

To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of Minimal Comfort Feeding (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit.

We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medical aid in dying medications and their respective articles on the topic. We discussed what makes an illness “terminal”, what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers.

-Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host)

Articles referenced in this discussion:

• “Mr. Smith Has No Mealtimes”: Minimal Comfort Feeding for Patients with Advanced Dementia by Hope Wechkin et al in JPSM
• Medical Aid in Dying to Avoid Late-Stage Dementia by Thaddeus Pope and Lisa Brodoff in JAGS
• Law not loopholes: Medical aid in dying for those with dementia also in JAGS by Joshua Briscoe and Eric Widera

Past GeriPal Podcast Episodes on MAID:

MAID podcasts

https://geripal.org/what-is-going-on-with-maid-in-canada-bill-gardner-leonie-herx-sonu-gaind/

https://geripal.org/conscientous-provision-of-maid-and-abortion-robert-brody-lori-freedman-mara-buchbinder/

https://geripal.org/assisted-dying-podcast-with-lewis-cohen/

https://geripal.org/dilemmas-in-aid-in-dying-podcast-with/

Past GeriPal Podcast Episode about VSED:

https://geripal.org/tim-quill-vsed/

As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way?

In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care.  Sue Britton was the first nurse hired on that palliative care unit. Michael Kearney on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry.  Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including:

• Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more…

• Whole-person-care

• Total pain

• Healing as a process distinct from the deterioration of the body

• Sympomatologists

• The patient and family as the unit of care 

Our guests referenced many articles on this podcast, linked above and below.  If you read just one, read Palliative Medicine - Just Another Specialty? by Kearney. I promise it’s short. 2 pages.  Here’s a taste: 

…While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty. 

And love that Jim Croce choice.  What’s in a name? I’ve got a name.

 Enjoy!

 -Alex Smith

Links

• Link to the McGill National Grand Rounds Series on Palliative Care, Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming.
• Palliative Medicine - Just Another Specialty? In Palliative Medicine By Kearney
• Joe Wood’s book on Total Pain 
• Balfour Mount’s memoir Ten Thousand Crossroads paper on Healing Connections in JPSM and Healing and Palliative Care in Palliative Medicine
• Cicely Saunders: A Life and Legacy, by David Clark
• Self-Care of Physicians Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series
• Twycross on Readdressing Balance in Hospice

I was very proud to use the word “apotheosis” on today’s podcast.  See if you can pick out the moment.  I say something like, “Palliative care for people experiencing homelessness is, in many ways, the apotheosis of great palliative care.”  And I believe that to be true.  When you think about the early concepts that shaped the field, you can see how palliative care for persons experiencing homelessness fits like a hand in a glove: total pain envisioned by Cicely Saunders, which even its earliest sketches included social suffering like loneliness; or Balfour Mount, who coined the term “palliative care,” lamenting the cruel irony of our care for the dying, and the desperate need to create programs to reach more people experiencing suffering.

Today we talk with Naheed Dosani, a palliative care physician at St. Michael’s Hospital in Toronto, and health justice activist. His story, which he shares on today’s podcast, is remarkable.  Just out of fellowship, Naheed built a palliative care program for homeless persons  called the Palliative Education and Care for the Homeless (PEACH) Program.  This podcast is a complement to our prior podcast on aging and homelessness with Margot Kushel. Today we discuss:

• What is the best terminology? Homeless? Homelessness? Houseless? Marginally housed?

• What makes palliative care for people experiencing homelessness challenging? What makes it rewarding? 

• What is unique about the practice of palliative care for people experiencing homelessness? We discuss the principles of harm reduction, social determinants of health, and trauma informed care.  Major overlap with substance use disorder issues, which we have covered recently (and frequently) on this podcast.

• How are the health systems designed or not designed to meet the needs of people experiencing homelessness? 

• What are the equity issues at stake, and at risk of being cut, both in Canada and the US?

Many more links below.  And I had a blast playing Blinding Lights by that Toronto band The Weekend.

Enjoy!

-Alex

End Well Talk

https://www.youtube.com/watch?v=eG4QE-hfPQU

Resources on the PEACH Program

• Program Review Paper – A recent publication in Longwoods Healthcare Quarterly reviewing the PEACH model. https://pubmed.ncbi.nlm.nih.gov/37144698/

• Promising Practice Recognition – PEACH was named a Promising Practice in equity-oriented palliative care as part of a national initiative funded by Health Canada, operated by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. https://www.healthcareexcellence.ca/media/z3jifqqd/pp-peach-en-2024-v2.pdf

• Toronto Star Feature https://www.thestar.com/life/together/people/dr-naheed-dosani-started-peach-to-provide-palliative-care-for-homeless-and-vulnerably-housed-populations/article_c56d8f45-cbe9-522e-9554-46778bf50407.html

• CityNews Toronto Feature https://toronto.citynews.ca/2022/08/08/peach-team-palliative-health-care-homelessness/

Psychosocial Interventions at PEACH

In addition to medical care, PEACH also runs two key psychosocial interventions for our clients:

• PEACH Grief Circles – Structured spaces for workers in the homelessness sector to process grief. CBC covered this a few years ago, including a radio segment feature on CBC White Coat, Black Art (which you can access at the below link). https://www.cbc.ca/radio/whitecoat/palliative-care-team-helps-the-homeless-die-with-dignity-a-healing-circle-helps-them-grieve-1.5048409

• PEACH Good Wishes Program – A program that provides meaningful gifts for unhoused individuals who are terminally ill. https://www.cbc.ca/news/canada/toronto/toronto-homeless-palliative-holidays-1.5407360

Kensington Hospice & 'Radical Love' Equity-Oriented Hospice Palliative Care

Naheed Dosani also serves as the Medical Director of Kensington Hospice, Toronto’s largest hospice. There, he helps run an innovative program called 'Radical Love' Equity-Oriented Hospice Palliative Care, which provides low-threshold, low-barrier access to hospice care for structurally vulnerable individuals (e.g., those experiencing homelessness). The program also operates via a partnership with the PEACH Program.

• As a result of the 'Radical Love' program at Kensington Hospice: At any given time, Kensington Hospice has evolved from caring for structurally vulnerable individuals

Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently.  Substance use disorder is one of those complex issues in which clinical practice is changing rapidly.  You can listen to our prior podcasts on substance use disorder here, here, here, and here.

Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness.  We address:

• Why is caring for patients with this overlap so hard?  Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?” 

• Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not).  See Sach’s write up about setting up this clinic in JPSM.

• What is harm reduction and how can we implement it in practice?  One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).

• When to consider bupenorphine vs methadone?  Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?

• Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then?  Or when it progresses - will hospice pay?

• And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…

Thanks to the many questions that came in on social media from listeners in advance of this podcast.  We all have questions.  We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!

Sometimes the drugs don’t work.

-Alex: @alexsmithmd.bsky.social

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!