Philippe Pinel remarked in 1800 that "It is an art of no little importance to administer medicines properly, but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them." This insight remains profoundly relevant today, especially in hospice care, where inappropriate prescribing is a common issue. Studies show that 20%–70% of hospice patients receive at least one unnecessary medication near the end of life, including drugs like antihypertensives, statins, and vitamins.

In this episode of the GeriPal Podcast, we tackle the pressing topic of deprescribing at the end of life with expert guests Jennifer Tjia, Jon Furuno, and Simon Mooijaart. The conversation focuses on identifying medications that should almost always be discontinued—such as statins, osteoporosis meds, finasteride, and vitamins, which offer minimal benefit for patients with limited life expectancy. We also delve into more nuanced cases, such as antithrombotics, which present complex decisions that challenge clinicians, particularly when prognosis spans the many weeks to months range.

Finally, we explore practical strategies for engaging patients and families in deprescribing conversations. Our guests highlight tools such as the FRAME mnemonic (Focus on the goals of care, Review current medications, Assess each medication's risk/benefit, Minimize the medication burden, and Evaluate regularly) and the Goal Concurrent Prescribing tool, which helps ensure medication decisions align with patients' values and end-of-life priorities.

By: Eric Widera

Other resources discussed in the podcast

• Prevalence and Factors Associated With Receiving a Prescription for Antithrombotic Therapy on Hospice Admission," JAGS. 2025

• Discontinuation of Anticoagulants and Occurrence of Bleeding and Thromboembolic Events in Vitamin K Antagonist Users with a Life-limiting Disease. 2025

• Effects of the discontinuation of antihypertensive treatment on neuropsychiatric symptoms and quality of life in nursing home residents with dementia (DANTON): a multicentre, open-label, blinded-outcome, randomised controlled trial. 2024

• Perspectives on deprescribing in palliative care. Expert Review of Clinical Pharmacology. 2023

• Developing a decision support tool for the continuation or deprescribing of antithrombotic therapy in patients receiving end-of-life care: Results of a European Delphi study. Thrombosis Research. 2025

• Human-Centered Design Development and Acceptability Testing of a Goal Concordant Prescribing Program in Hospice. JPM 2025

• Reduction of Antihypertensive Treatment in Nursing Home Residents. NEJM 2025

Do you think your hospital should allow unilateral DNR orders? Under what circumstances? Through what process? Do you think that when you obtain the assent of a family to not code their loved one, that assent DNR should be counted as a unilateral DNR order? Should we document unilateral DNR and the rationale? Why for DNR, when we don't document unilateral dialysis not offered, or unilateral no ECMO offered? Is the assent of a family member to a statement that we will not code their loved one a nudge, and is the assent approach ethical? Reasonable people will disagree, as we do on this podcast.

Our guests today are Gina Piscitello, Erin DeMartino, and Will Parker, authors of a terrific viewpoint in JAMA about the need to address inadequate documentation of unilateral DNR orders. You might recall Gina was a guest on our lively podcast about slow codes, and we pick up where that podcast left off.

We highlight the many clinical, practical, and ethical issues at stake, including Gina's finding that during Covid, 3% of critically ill patients receiving pressors had a unilateral DNR order. Black patients and those who spoke Spanish had higher rates of unilateral DNR. That variation should trouble those in favor of unilateral DNR orders. We talk about variation Gina found at the state and health system level, and what exactly is concerning, the variation itself, or the lack of thought and care that went into some of these policies.

Are you a heartbreaker? Dream Maker? Love taker? Don't you mess around with me. (song hint)

-Alex

The idea of embedding various forms of non-emergency care in the emergency department makes a WORLD of sense. If an older adult comes into the ED with a fall, the minimum the ED has to do is address the fall injury and send them out. But many emergency providers realize this is often a band aid. They see that patient again the next time they fall. And again. And again. The same could be said for the patient who is malnourished and dehydrated and admitted for "failure to thrive," again. And again.

Our two guests today, Liz Goldberg and Lauren Southerland, both emergency medicine physician-researchers, have had enough. On our podcast today they discuss how these sorts of experiences led them to argue that other services that can address the underlying causes that lead to ED visits. Liz Goldberg developed the GAPcare model to address falls, which includes a physical therapist and pharmacist seeing patients on the spot in the ED. Lauren Southerland got Columbus Ohio Office of Aging staff to re-locate from their desks to the emergency department, where they could sign patients up for home delivered meals, medical transportation, adult day services, home modification such as grab bars, and utility assistance for electricity, gas, and water bills.

With GAPcare, Liz saw a 66% drop in ED visits for fall over 6 months from her pilot (subsequent fall outcomes of the GAPcare II study will be linked here when published). Remarkable, particularly in the context of the primary care STRIDE intervention, which did not reduce injurious falls (e.g. the type that would result in an ED visit). Maybe the ED is just a better place to intervene? Patients are motivated to change. Get the physical therapist and pharmacist in there!

In a study published in JAGS, Lauren found 50% of participants were linked to a new Office of Aging service initiated during the ED visit, with no increase in ED length of stay or hospital admission rate. See also this terrific JAGS editorial on Lauren's paper by Liz. Putting on my JAGS editor hat - both the study and editorial have terrific color figures. A great way to increase your odds of review and acceptance at JAGS is to include one or more high-impact color figures that convey the main findings or points of your manuscript.

We talk about the potential downsides, real and perceived in embedding care in the ED. Should everything be embedded? We talk about how these interventions relate to geriatric ED certification. Lauren talks about a remarkable model in Australia that includes a geriatric RN embedded in the ED.

Most encouraging is that Liz and Lauren are finding other adopting these interventions. Word is spreading. Other emergency providers have had enough of the endless cycle. Enough.

And I got to belt out Gravity, by John Mayer!

-Alex

Today we interviewed Bob Wachter about his book, "A Giant Leap: How AI Is Transforming Healthcare and What That Means for Our Future." You may recall we interviewed Bob in April 2024 about AI, and at that time he was on the fence about AI - more promise or more peril for healthcare? As his book's title suggests, he's come down firmly on the promise side of the equation. On our podcast we discuss:

• Why Bob wrote this book, at this time, and concerns about writing a static book about AI and Healthcare, a field that is dynamic and shifting rapidly. He's right though - we've not had a "ChatGPT"-launch type moment recently.

• Top 5 or so ways in which Bob uses AI for work, from clinical care to book writing

• Concerns about job losses in healthcare, and will we still need doctors?

• AI for diagnosis, and the recent NEJM Clinical Case in which recent GeriPal guest and superstar clinician-educator Gurpreet Dhaliwal beats an AI.

• UpToDate vs OpenEvidence

• Trust issues - should we trust AI after being let down before? Clinicians felt burned by their experience with the hype and promise of EHRs - but they've been much less a game changer and much more a soul sucking chore designed to maximize billing rather than improve patient care. Yet early returns on AI have largely been positive. Time saved from writing notes, prior authorizations, and summarizing charts…all to the good!

Sadly, we didn't have Bob on piano singing the song for this one. He was in the office, not home. So I made do with ChatGPT's choice, Handle With Care, which has some surprisingly pertinent lyrics about AI in healthcare, including:

"Been beat up and battered aroundBeen sent up, and I've been shot downYou're the best thing that I've ever foundHandle me with care"

Enjoy!

-Alex Smith

Recent randomized controlled trials have shown that routine perioperative palliative care does not improve outcomes for patients undergoing curative-intent cancer surgery. No, that wasn't a typo. Regardless of how the data were analyzed, the findings remained consistent: perioperative palliative care DID NOT improve outcomes in the only two randomized controlled trials conducted in this area—the SCOPE and PERIOP-PC trials.

Null trials like these often receive less attention in academic and clinical settings, but they can be profoundly practice-changing. Consider the Shannon Carson study on palliative care for chronically critically ill patients. While some have argued it "wasn't a palliative care study," I've always regarded it as one of the most significant studies for understanding not what works—but what doesn't—for palliative care in specific patient populations.

The same holds true for the SCOPE and PERIOP-PC trials. Both were null, but their findings are deeply relevant to clinical practice. That's why we invited the lead authors, Rebecca Aslakson (PERIOP-PC) and Myrick "Ricky" Shinall (SCOPE), to share insights into what they did in their studies and why they think they got the results that they did.

One key takeaway for me from this discussion was the idea that patients undergoing curative-intent surgery might simply be too early in their cancer trajectory to derive meaningful benefits from palliative care, and maybe the focus should be more on geriatrics. I especially appreciated the closing discussion about the future of research in this area: if routine perioperative palliative care doesn't improve outcomes, what should the next generation of studies focus on?

Eric Widera

Studies we talk about during the podcast

• Aslakson et al. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open. 2023

• Shinall et al. Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer: A Randomized Clinical Trial. JAMA Surg. 2023

• Carson et al. Effect of Palliative Care–Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA. 2016

• Holdsworth et al. Patient Experiences of Specialty Palliative Care in the Perioperative Period for Cancer Surgery. JPSM. 2024

• Williams et al. Patient Perceptions of Specialist Palliative Care Intervention in Surgical Oncology Care. Am J Hosp Palliat Care. 2025

• Yefimova et al. Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surg. 2020

"I just want to say one word to you. One word. Plastics… There's a great future in plastics."

This iconic line from the movie The Graduate is at the top of my mind when I think about where we are heading in healthcare. I've interpreted "plastics" as symbolizing a dystopian, mass-produced future of medicine—where artificiality and inauthenticity dominate in the pursuit of efficiency and profit margins. After listening to today's podcast on the growth of community-based palliative care, I find my perspective shifting on this quote. Perhaps the advice given for a future in plastics reflects the past generation's established worldview, failing to recognize a countercultural revolution seeking transformation and meaningful change, even if it may come across as a little brash.

In this thought-provoking episode of the GeriPal podcast, we are joined by Alan Chiu (Chief of Palliative Care at Monogram Health), Mindy Stewart-Coffee (National Vice President of Palliative Care at Optum Home and Community), and Ben Thompson (National Medical Director for Hospice and Palliative Care at Gentiva) to discuss this revolution happening in palliative care. The conversation centers around the rapid growth and investment in community-based palliative care, which has emerged as a key area of innovation and opportunity to meet the largely unmet needs of patients living with serious illnesses. With a focus on expanding access, improving outcomes, and addressing workforce shortages, the guests explore how value-based care models are reshaping palliative care delivery.

The discussion highlights the differences between traditional fee-for-service models and newer value-based care approaches, including how they incentivize care. We take a deep dive into the risks and benefits of these models, emphasizing the importance of maintaining high standards of care while fostering innovation. We also delve into the role of for-profit organizations and private equity in driving change, acknowledging concerns about motivations while recognizing that these entities can help spur innovation and improve access when led by clinicians committed to patient-centered care.

Ultimately, this podcast serves as a call to action for the palliative care community to help shape not just the "Wild West" of community-based care, but palliative care 3.0 as a whole. Do we sit back and wait for a future dominated by a plastic version of palliative care, or do we help lead this revolution to ensure it maintains the authentic heart of what brought us to this field? As Diane Meier aptly warns, "if you are not at the table, you're on the menu."

Eric Widera

Of Note: the views expressed in this podcast are our guests' own opinions and not representative of their organizations.

The only certainty in medicine is uncertainty. It touches every aspect of clinical practice, from diagnosis to treatment to prognosis. Despite this, many clinicians view uncertainty as something to tolerate at best or eliminate at worst. But what if we need to rethink and reframe our relationship with uncertainty in medicine?

In this episode, we sit down with Jonathan Ilgen and Gurpreet Dhaliwal, co-authors of the New England Journal of Medicine article, "Educational Strategies to Prepare Trainees for Clinical Uncertainty." Together, we explore the nature of uncertainty in clinical practice, its effects on trainees and seasoned clinicians, and strategies to embrace it as a fundamental part of medical reasoning rather than a regrettable byproduct.

Jonathan and Gurpreet share insights from research and clinical experience, offering practical methods to help trainees and clinicians recognize, manage, and even embrace uncertainty. Key topics we discuss include:

• The paradoxical nature of uncertainty: When perceived as a threat, it can provoke anxiety or fear; yet when framed as an opportunity, it can inspire hope and optimism.

• Why uncertainty is inevitable in medical practice and its impact on clinicians.

• Is uncertainty a state or a trait?

• The distinction between epistemic uncertainty (knowledge gaps) and aleatoric uncertainty (randomness in outcomes).

• How experienced clinicians utilize strategies such as forward planning and monitoring to navigate uncertainty.

• Communicating uncertainty with patients: how to do it effectively without eroding trust.

• How to integrate uncertainty into medical education.

During the conversation, we explore the emotional responses to uncertainty and how these reactions can influence clinical practice and decision-making.

Importantly, Jonathan and Gurpreet emphasize the importance of openly communicating uncertainty with colleagues, supervisors, and patients—a practice that, contrary to common belief, actually strengthens trust, fosters transparency, and encourages collaboration. By normalizing and embracing uncertainty, clinicians can better manage the complexities of medicine and build confidence in their ability to care for patients in the face of the unknown.

👉 We're thrilled that Meg Wallhagen, Professor of Nursing at UCSF, has recorded an intro to this week's podcast. Any listener who contributes $1000+ is invited to record an intro to a GeriPal podcast! You can donate here, any amount is appreciated. Also, Meg is looking for practicing or student clinicians (physicians and nurses) who are willing to participate in a study on how a simulation of hearing loss promotes a greater appreciation of the experience of hearing loss. Participation should take no more than one to one and one half hour and you will receive a gift card in acknowledgement of your time. If interested, please contact her directly at [email protected].

For more info, click the following link to open the flyer (PDF format): Information_Flyer_Practitioneer

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

In a recent episode of the GeriPal podcast, we explored whether the field of palliative care is in need of saving—and, if so, how to save it—with guests Ira Byock, Kristi Newport, and Brynn Bowman. Today, we shift focus to one actionable way to improve palliative care: through quality improvement (QI) collaboratives, registries, and benchmarking.

To guide this discussion, we've invited three leading experts in the field—Drs. Steve Pantilat, David Currow, and Arif Kamal—who bring invaluable experience as pioneers in developing QI collaboratives and registries. Together, they authored a recent paper in JPSM titled "The Case for Collaboration to Optimize Quality," which underscores the importance of these efforts.

In this episode, Dr. David Currow shares lessons from Australia's Palliative Care Outcomes Collaborative (PCOC), a national model for standardized data collection and benchmarking that has driven measurable improvements in palliative care. Meanwhile, Drs. Steve Pantilat and Arif Kamal reflect on the history of the Palliative Care Quality Collaborative (PCQC), a U.S.-based initiative formed in 2019 by merging the National Palliative Care Registry (NPCR), the Palliative Care Quality Network (PCQN), and the Global Palliative Care Quality Alliance (GPCQA). Although the PCQC had ambitious goals, it ultimately closed earlier this year. Together, the panelists unpack the reasons behind its closure and discuss the lessons future registries can take away from its challenges.

Throughout the conversation, we tackle some of the field's biggest questions about registries and QI collaboratives: What data should be collected to create meaningful quality indicators? How can we minimize the administrative burden of data collection on clinicians? And how do we balance the risk of becoming narrowly focused "symptomatologists" with the need to maintain holistic, person-centered care? By addressing these questions, the panel highlights the immense potential of QI initiatives to enhance palliative care while remaining true to the field's core mission: ensuring that patients and their families feel deeply cared for during life's most vulnerable moments.

Have you had one of those consults in which you're thinking, huh, sounds like the patient's goals are clear, it's really that the clinician consulting us disagrees with those goals? To what extent is it our job as consultants to navigate, manage, or attend to clinician distress? What happens when that clinician distress leads eventually to conflict between the consulting clinician and the palliative care team?

Today our guests Sara Johnson, Yael Schenker, & Anne Kelly discuss these issues, including:

• A recent paper first authored by Yael asking if attending to clinician distress is our job, published in JPSM. See also the wonderful conversation in the response letters from multidisciplinary providers (e.g. of course that's our job! And physicians may not be trained in therapy, but many social workers and chaplains are, and certainly psychologists).

• A SPACE pneumonic for addressing clinician conflict developed by Sara Johnson, Anne Kelly and others. They presented this at a recent AAHPM/HPNA meeting. See below for what SPACE stands for.

• We referenced a prior episode on therapeutic presence and creating a holding space with Kerri Brenner and Dani Chammas, and this article by Kerri.

• We talked about the role of the consultant, including this classic paper on consultation etiquette by Diane Meier and Larry Beresford.

Enjoy!

-Alex Smith

SPACE: Navigating Conflict with Colleagues

"Between stimulus and response there is a space. In that space is our power to choose our response." -Viktor E. Frankl

SPACE: Conflict Navigation Toolkit

• Self-awareness: Pause & Notice Before Responding
• What am I feeling? Take own temperature.
• Where am I coming from? What do I need?
• Perspective-Taking: Ask-Tell-Ask
• Where are they coming from? Check your understanding with them.
• "Tell me how you're thinking about this?"
• "I hear you are concerned about…is that right?"
• Agenda: Yours and theirs, then focus on common ground
• Where are we going together?
• "It seems like we both want…"
• Curiosity: Reframe and explore to understand
• Am I missing anything?
• Why is this kind, smart & hard-working colleague thinking differently than I am?
• "To help me better understand, what is your biggest concern about…?"
• Empathy:
• For others: Empathic statements around the situation & silence
• For self: Your feelings are valid, reflect on it later.
• You will misstep in tense moments: apologize, learn from it. Eating helps.

Authors:

Ethan Silverman MD University of Pittsburgh

Anne Kelly LCSW San Francisco VA Health Care System

Jasmine Hudnall DO Gundersen Health System

Cassie Shumway MS, RN, OCN, CHPN UW Health Hospitals & Clinics

Andrew O'Donnell RN University of Wisconsin

Sara K. Johnson MD University of Wisconsin

In this week's podcast, we sit down with Drs. Sarguni Singh, Christian Furman, and Lynn Flint, three authors of the recent Journal of the American Geriatrics Society article, "Rehab and Death: Improving End-of-Life Care for Medicare Skilled Nursing Facility Beneficiaries."

The authors dive into the challenges facing seriously ill older adults discharged to Skilled Nursing Facilities (SNFs), where fragmented care transitions, misaligned Medicare policies, and inadequate access to palliative care often result in burdensome hospitalizations and goal-discordant care.

The discussion highlights key barriers in Medicare's SNF and hospice benefits, including the inability to access concurrent hospice and SNF care, and explores solutions to improve care. Among the recommendations is leveraging Medicare's Patient Driven Payment Model (PDPM) to reimburse SNFs for providing palliative care, commissioning a Government Accountability Office (GAO) report on SNF utilization at the end of life, and piloting a model that allows time-limited concurrent hospice and rehabilitation care.

Also, check out these two resources if you want a deeper dive:

• Our past podcast we did, now nearly 6 years ago, on the original NEJM paper, Rehabbed to Death.

• Joan Carpenter's article titled "Forced to Choose: When Medicare Policy Disrupts End-of-Life Care" in the Journal of Aging & Social Policy

👉 This episode of the GeriPal Podcast is sponsored by IU Health's Geriatrics Department, in partnership with Indiana University's School of Medicine, an amazing group, rich in innovative Geriatric Medicine. They are looking for physician faculty to join them in the inpatient and outpatient settings. To learn more about job opportunities, please click the following links:

• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at Eskenazi Hospital
• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at IU Health Fishers Hospital