Stay ConnectedA geriatrics and palliative medicine podcast for every health care professional.
Two UCSF doctors, Eric Widera and Alex Smith, invite the brightest minds in geriatrics, hospice, and palliative care to talk about the topics that you care most about, ranging from recently published research in the field to controversies that keep us up at night. You’ll laugh, learn, and maybe sing along.
CME and MOC credit available (AMA PRA Category 1 credits) at www.geripal.org
Copyright: © 2020 GeriPal. All rights reserved.
How do people react when they hear they have a serious illness? Shock, "like a car is rushing straight at me" (says Bill Gardner on our podcast). After the shock? Many people strive, struggle, crawl even back toward a "normal" life. And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness.
Today we talk with deep thinkers about this issue. Bill Gardner is a psychologist living with advanced cancer who blogs "I have serious news," Brad Stuart is an internist and former hospice director whose book is titled, "Facing Death: Spirituality, Science, and Surrender at the End of Life," and Juliet Jacobson is a palliative care doc who wrote a paper finding that geriatricians do NOT consider aging a serious illness. We have a wide ranging conversation that touches on how to place aging, disability, and multimorbidity in the context of serious illness conversations, "striving toward normal," stoicism, existentialism, psychedelics, the goals of medicine, medical aid in dying and more. We could have talked for hours! And I get to play a Bob Dylan song that's been on my bucket list to learn.
Enjoy!
-@AlexSmithMD
Additional links:
Bill Gardner's article about MAID in Comment Magazine https://comment.org/death-by-referral/
Bill Gardner's articles about living with terminal cancer in Mockingbird Magazine: https://mbird.com/art/cancer-in-advent/ https://mbird.com/religion/testimony/in-the-electors-school/
Brad Stuat's website: https://bradstuartmd.com
Juliet mentioned: On existential threat and terror management: The Worm at the Core: On the role of death in life by Soloman, Greenberg, and Pyszczynski
On how existential threat is stored in the brain. https://pubmed.ncbi.nlm.nih.gov/31401240/
Papers on "striving toward normalcy" in the setting of serious illness https://pubmed.ncbi.nlm.nih.gov/36893571/ https://pubmed.ncbi.nlm.nih.gov/35729779/
I hear the word dignity used a lot in the medical setting, but I'm never sure what people mean when they use it. You'd imagine that as a seasoned palliative care doc, I'd have a pretty good definition by now of what "maintaining dignity" or "loss of dignity" means, but you'd be sadly wrong.
Well that all changes today as we've invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast. Harvey is probably best known for his work in developing dignity therapy, a psychological intervention designed specifically to address many of the psychological, existential, and spiritual challenges that patients and their families face as death approaches.
We talk with Harvey about how he defines "dignity" and how we can understand what it means to our patients. We also talk about easy and quick ways to address dignity and personhood by using the Patient Dignity Question (PDQ), which asks "what do I need to know about you as a person to give you the best care possible." In addition, we talk with Harvey about some other recent publications he has written, including one on "Intensive Caring" and one on the "Platinum Rule" (do unto others as they would want done unto themselves).
So take a listen and if you are interested in learning more, check out these wonderful links:
Harvey's latest book is called, Dignity in Care: The Human Side of Medicine
Michael J. Fox gives patients hope there may be a place that illness doesn't touch
It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab). Praised by the FDA, Alzheimer's Association (AA), and Pharma as a "game changer", but derided by others for the drug's lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words "rife with irregularities". Instead of Biogen's expected billions of dollars of revenue from Aduhelm, they brought in only $3 million in revenue for all of 2021 (here is my Twitter summary of this fiasco).
The outlook on amyloid antibodies are looking brighter though in 2023. Phase III studies for lecanemab and donanemab have been published showing less worsening of cognition and function receiving these agents versus placebo. This led the FDA to give full approval for lecanemab, which will likely be followed by full approval of donanemab sometime this year. However, as noted in our editorial published with the donanemab trial, the modest benefits of amyloid antibodies would likely not be questioned by patients, clinicians, or payers if amyloid antibodies were low risk, inexpensive, and simple to administer. However, they are none of these.
So what is the role of individuals like geriatricians in prescribing amyloid antibodies and caring for individuals who are receiving them? We invited three geriatricians and memory care doctors, Nate Chin, Sharon Brangman, and Jason Karlawish, to talk about this question and many others swirling around on how to safely prescribe these drugs and manage patients on them (like what to do about anticoagulation).
Lastly, we also spend a little bit of time talking about the NIA-AA draft statement on redefining Alzhiemers disease. There is a lot to digest with these draft clinical guidelines but the big change from the 2018 guideline is moving Alzheimers to a biological diagnosis (biomarker evidence only) not just for a research framework but now from a clinical one. One outcome would be a very large population of older adults with normal cognition could now be classified as having Alzheimer's disease (maybe about a 1/3 of cognitively normal 75 year olds based on PET). So if you have thoughts on the matter, please give your feedback here to the NIA and AA. https://aaic.alz.org/nia-aa.asp
By: Eric Widera
Insomnia. We've all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you're not falling asleep as you have a busy day coming up. Insomnia sucks. Chronic insomnia sucks even more.
For those with serious illness, sleep problems and insomnia are all too common. Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia.
We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).
There's a saying, "never let a crisis go to waste." The pandemic was horrific in many ways. One positive change that came about was the lifting of restrictions around the use of telemedicine. Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic. Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are homebound, and many others. So now that the emergency response has ended, what's to be done?
In this podcast, Joe Rotella, Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, Brook Calton, Palliative Care doc at Massachusetts General Hospital and Medical Director at Devoted Health, and Carly Zapata, Palliative Care doc at UCSF and fellowship director, talk about the importance of maintaining access to telehealth for the good of patients with serious illness. This DEA is taking 6-months to consider how to move forward vis a vis restrictions and requirements for telehealth in a post-pandemic world. Now is the time to act, dear listeners! You can:
Write an Op-Ed to your local paper as Carly Zapata and colleagues did. Start with a story as Carly did in her Op Ed. Stories trump data.
Write to your congressperson. See the AAHPM Legislative Action Center https://www.votervoice.net/AAHPMORG/home
Write to the DEA, with guidance from AAHPM's comments to the DEA March 2023.
Advocate for the CONNECT for Health Act, which would permanently expand access to telehealth for Medicare beneficiaries: https://www.schatz.senate.gov/imo/media/doc/connect_for_health_act_2023_summary1.pdf
Much more on this podcast, including puzzling out who the characters in Space Oddity by David Bowie might represent in an extended analogy to telehealth. Enjoy!
-@AlexSmithMD
Today's podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention. On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations. Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+. They found a difference of 4% in documented goals of care discussions. Is 4% meaningful? You'll have to decide for yourself, though it likely is meaningful on a population basis. Intriguingly, in a sub-analysis, they found a much higher rate of difference among minoritized older adults - more like 10%. In a compelling editorial, Doug White and Sarah Anderson argue that even a 4% difference is important on a population basis, and that higher rates of difference among minoritized older adults demonstrate the potential of the intervention to address long-standing disparities in goals of care.
Randy Curtis was first author of the JAMA paper. Randy died February 26, 2023. We begin today's podcast asking his co-authors Erin Kross, Bob Lee, and Ruth Engelberg, all from the University of Washington and the Cambia Palliative Care Center of Excellence, to reflect on Randy and his dedication to seeing this work completed while living with ALS. Eric and I also reflect on the podcast Randy generously did with us on his experience living with and studying serious illness. We have lost a giant. He is sorely missed, and celebrated.
And…the guests torture me about songs I can't play with the word Jump.
-@AlexSmithMD
You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it? What about State Departments of Aging or state master plans for aging? Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions? No? Ok, what about Aging and Disability Resource Connection (ADRC) services?
Well, if you are like me, you've probably heard of these programs but are at a loss to know exactly what they do. On today's podcast we dive deep into how state and local governments are addressing the needs of older adults, answering all of these questions and more thanks to our three amazing guests: Susan DeMarois (the Director of California Department of Aging), Greg Olsen (the Director of the New York State Office for the Aging), and Lindsey Yourman (the Chief Geriatric Officer for the County of San Diego).
It's a fun podcast with our guest bringing in a ton of knowledge and passion for the work that they do. If there is one take-away from the podcast, it is something Dr. Yourman emailed me after we met:
"My hope is that every geriatrics clinician/Geriatrics Department/Division that listens to our podcast will be motivated to reach out to their Area Agency on Aging (if they haven't done so previously) to ask for a meet and greet and to learn about their resources, services, and recommended community-based organizations for older people."
To learn more about what we talked about, check out the following links:
I don't know 'bout religion I only know what I see And in the end when I hold their hand It's both of us set free
These are the ending lyrics to Bonnie Raitt's song "Down the Hall", an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week's podcast we interviewed the medical director and the chaplain of the prison's hospice unit (Hospice in Prison Part 1). This week we turn our attention to the inmates.
Pastoral Care Workers are inmates who volunteer time to care for the dying who come from all around California to spend their last days, weeks or months in the prison's hospice unit, fulfilling a mission that "no prisoner dies alone."
On today's podcast we talk with three of these Pastoral Care Workers, Jerry Judson, Jeffrey Maria, and Allan Krenitzky. We discuss with them why they decided to volunteer for the hospice unit, what a day in the life of a Pastoral Care Worker looks like, and among other things their thoughts on forgiveness, redemption, rehabilitation, and compassionate release.
We also had the pleasure to take a walk through the hospice unit garden with Mr. Gerald Hite. He taught us a little about the different flowers and plants, and along the way a little about why he does what he does.
While this is a podcast about volunteers in a prison hospice, I think it also serves as a lesson for us all about how we make meaning to our own lives and define ourselves by not only what we have done in the past, but what we do now. One story that Allan told perfectly sums this up. He said one day his son asked his wife what he does for a living, and his wife said "Papa helps sick people."
In the early 1990's, California Medical Facility (CMF) created one of the nation's first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release. Many are there until they die.
Today's podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls.
We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services. We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population. We also talk about the eligibility for the unit, what makes it run including the interdisciplinary team and the inmate peer workers, and the topic of compassionate release.
Afterwards, we chat with the prison's chaplain, Keith Knauf. Keith per many reports, is the heart and sole of the hospice unit and oversees the Pastoral Care Workers. These are inmates that volunteer to work in the hospice unit, serving a mission that "no prisoner dies alone." We chat with Keith about how hospice in prison is different and similar to community hospice work, the selection process and role of the peer support workers, the role of forgiveness and spirituality in the care of dying inmates, and what makes this work both rewarding and hard.
Part two of the podcast, which comes next week, is solely focused on the Pastoral Care Workers. We interview three of them in the hospice unit and take a little tour of the hospice gardens.
Artificial Intelligence, or AI, has tremendous potential. We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF.
Social companions to address the epidemic of loneliness among older adults
Augmenting ability of clinicians by taking notes
Searching the electronic health record for data
Predicting mortality and other outcomes
We talk also about the pitfalls of AI, including:
Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities
Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?
Hallucinations, or when the AI lies or bullshits, then denies it
When the AI approaches sentience, is it ethical to unplug it?
I'm sure this is a subject we will return to, given the rapid progress on AI.
Enjoy!
-@AlexSmithMD
Links:
Papers on AI and palliative care and concerns about bias: https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/ https://academic.oup.com/jamia/article/27/12/2020/5859726
Comparison of machine learning vs traditional prognostic methods based on regression: https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011
Other links on the issue of AI and racial or ethnic bias:
Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare https://www.nber.org/papers/w30700 https://www.science.org/doi/10.1126/sciadv.add2704 https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168
MD Calc approach to inclusion of race https://www.mdcalc.com/race
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