Avsnitt
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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
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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)
“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
Articles referenced in this discussion: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/
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Saknas det avsnitt?
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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
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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 ProgramProgram 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.pdfToronto 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.htmlCityNews Toronto Feature
https://toronto.citynews.ca/2022/08/08/peach-team-palliative-health-care-homelessness/
Psychosocial Interventions at PEACHIn 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-1.5048409PEACH 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 CareNaheed 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
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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
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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
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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
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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
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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!
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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
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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?”
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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.”
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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.
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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:
nonjudgmentally observe their coping
wonder about the impacts of their coping
prioritize helping patients maintain their psychological integrity
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 podcastDani’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 **
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Falls are very common among older adults but often go unreported or untreated by healthcare providers. There may be lots of reasons behind this. Patients may feel like falls are just part of normal aging. Providers may feel a sense of nihilism, that there just isn't anything they can do to decrease the risk of falling. On this week's podcast, we try to blow up this nihilism with our guest Sarah Berry.
Sarah is a geriatrician at Hebrew SeniorLife in Boston where she does research on falls, fractures, and osteoporosis in older adults. We pepper Sarah with questions ranging from:
Why should we care about falls?
What are ways we should screen for falls?
What are evidence based interventions to decrease the risk of falls?
What about Vitamin D and falls???
How should we assess for fracture risk?
What are some evidence-based ways to decrease fracture risk?
When should we prescribe vs deprescribe bisphosphonate therapy? How does life expectancy fit in with all of this?
If you want to do a deeper dive into some of the articles we discuss, take a look at the following:An awesome JAMA review by Sarah on fall risk assessment and prevention in community-dwelling adults.
The Fracture Risk Assessment in Long term care (FRAiL) website
James Deardorff’s JAMA IM article on “Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis
Sarah’s article on “Controversies in Osteoporosis Treatment of Nursing Home Residents”, which includes this helpful flow chart on starting/stopping osteoporosis drugs in nursing homes
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We recently published a podcast on palliative care for kidney failure, focusing on conservative kidney management. Today we’re going to focus upstream on the decision to initiate dialysis vs conservative kidney management.
As background, we discuss Manju Kurella Tamura’s landmark NEJM paper that found, contrary to expectations, that function declines precipitously for nursing home residents who initiate dialysis. If the purpose of initiating dialysis is improving function - our complex, frail, older patients are likely to be disappointed.
We also briefly mention Susan Wong’s terrific studies that found a disconnect between older adults with renal failure’s expressed values, focused on comfort, and their advance care planning and end-of-life care received, which focused on life extension; and another study that found quality of life was sustained until late in the illness course.
One final briefly mentioned piece of background: John Oliver’s hilarious and disturbing takedown of the for profit dialysis industry, focused on DaVita.
And the main topic of today is a paper in Annals of Internal Medicine, Maria first author, that addressed the tradeoffs between initiating dialysis vs continued medical/supportive management. Turns out, in summary people who initiate dialysis have mildly longer lives, but spend more time in facilities, away from home. We also discuss (without trying to get too wonky!) immortal time bias and target emulation trials. Do target trials differ from randomized trials and “ordinary” observational studies, or do they differ?!? Eric is skeptical.
Bottom line: if faced with the decision to initiate dialysis, waiting is generally better. Let it be (hint hint).
-Additional link to study with heatmaps of specific locations (hospital, nursing home, home) after initiating dialysis.
-@AlexSmithMD
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In March 2020, we launched our first podcast on COVID-19. Over the past four years, we’ve seen many changes—some positive, some negative. While many of us are eager to move past COVID (myself included), it’s clear that COVID is here to stay.
This week, we sit down with infectious disease experts Peter Chin-Hong and Lona Mody to discuss living with COVID-19. Our conversation covers:
The current state of COVID
Evidence for COVID boosters, who should get them, and preferences between Novavax and mRNA vaccines
COVID treatments like Molnupiravir and Paxlovid
Differences in COVID impact on nursing home residents and those with serious illnesses
We wrap up with a “magic wand” question. My wish was for better randomized evidence for vaccines and treatments, though I worry this might not be feasible. In the meantime, there’s significant room to improve vaccine uptake among high-risk groups, particularly nursing home residents. Currently, only 1 in 5 nursing home residents in the US have received the COVID booster, compared to over 50% in the UK.
By: Eric Widera
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Cannabis is complicated. It can mean many things, including a specific type of plant, the chemicals in the plant, synthetic analogs, or products that have these components. The doses of the most widely discussed pharmacologically active ingredients, THC and CBD, vary by product, and the onset and bioavailability vary by how it is delivered. If you believe the evidence for efficacy to manage symptoms like neuropathic pain, how do you even start to think about recommending these products to patients?
On today’s podcast, we answer that question with our guests, David Casarett and Eloise Theisen. David is a physician who wrote the book “Stoned: A Doctor's Case for Medical Marijuana” and gave a TED talk on “A Doctor's Case for Medical Marijuana” that was watched over 3 million times. Eloise is a palliative care NP at Stanford and co-founder of The Radicle Health Clinician Network.
So, take a listen and check out the following resources to learn more about medical cannabis:
Radicle Health’s curriculum and modules for healthcare professionals on cannabis
NEJM Catalyst article on integrating medical cannabis into clinical care
David’s TED talk on “A Doctor's Case for Medical Marijuana”
A JPSM systematic review of current evidence for cannabis in palliative care
Our past GeriPal episode with Bree Johnston and Ben Han on cannabis in older adults
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When treating heart failure, how do we distinguish between the expanding list of medications recommended for “Guideline Directed Medical Therapy” (GDMT) and what might be considered runaway polypharmacy? In this week’s podcast, we’ll tackle this crucial question, thanks to a fantastic suggestion from GeriPal listener Matthew Shuster, who will join us as a guest host.
We’ve also invited two amazing cardiologists, Parag Goyal and Nicole Superville, to join us about GDMT in heart failure with reduced ejection fraction (HFrEF) and in Heart Failure with preserved EF (HFpEF). We talk about what is heart failure, particularly HFpEF, how we treat it (including the use of sodium–glucose cotransporter-2 inhibitors (SGLT2’s), and how we should apply guidelines to individual patients, especially those with multimorbidity who are taking a lot of other medications.
I’d also like to give a shout out to a recent ACP article on HFpEF with an outstanding contribution from Ariela Orkaby, geriatrician extraordinaire (we also just did a podcast with her on frailty).
- Visa fler
