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.
We are fortunate today to interview two oncologists whose research has catapulted palliative care forward: Jennifer Temel, author of the landmark NEJM study on early outpatient palliative care for patients with advanced lung cancer; and Areej El-Jawahri, author of the landmark JAMA article on inpatient palliative care for patients with blood cancers undergoing stem cell transplant.
Jennifer's study is most widely known for the "kicker" - not only did it improve quality of life, palliative care was associated with a couple months longer survival.
Areej's study is remarkably novel in that it is, to our knowledge, the first study of palliative care during curative treatment.
We cover a huge amount of ground today, including:
Additional links:
The science of balancing safety and independence of older drivers has come a long way. Some key points from our podcast today with Emmy Betz (emergency physician-researcher) and Terri Cassidy (occupational therapist and certified driving rehab specialist) include:
We learned this and much more, and I had a great time making engine noises singing the Woody Guthrie song "driving in my car."
Additional Links:
(A to Z – under driving)https://decisionaid.ohri.ca/cochsystem.html
(OT programs)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347878/
An Advance Directive for When Driving Becomes Unsafehttps://geripal.org/an-advance-directive-for-when-driving/
ADED (Association for Driver Rehabilitation Specialists)https://www.aded.net/search/custom.asp?id=2046
"Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You're short on gowns and facemasks. You're short on nurses and nurse aids so now you have to help deliver meals."
This was the opening paragraph that I wrote in March of 2020 when introducing a podcast we did with Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond. That was his literally his life during those spring months of 2020 and it scared the hell out of me.
Lucky, Jim and many others like him were willing to come on to our podcast those first several months of the pandemic and share their experiences and lessons learned caring for COVID positive patients and their family members.
On today's podcast, we look back to those early months of the pandemic and look forward to the future. We invited Jim back with us along with Darrell Owens, DNP, MSN, who is the head of palliative care for the University of Washington's Northwest campus.
For those who didn't listen to our podcast with Darrell, when most of us were still trying to figure out what COVID was, he created an on call 24/7 palliative care service to have goals of care conversations with elderly patients in the emergency department under investigation for COVID, and also established an admitting inpatient palliative care service at his hospital for patients on exclusively comfort measures. What I loved about this March 2020 podcast was that Darrell pushed us to think differently:
"Expect that it's not business as usual. Very first thing, you're going to have to do things differently, so be open to that. Be totally open-minded. Now the old, "We're not an admitting service or we don't do that and we don't do this," don't start with what you don't do. Start with what you can do, what's your capacity.
So take a walk down memory lane with us and hear from both Darrell and Jim where they think we are going.
On today's podcast we welcome back Haider Warraich to talk about pain. Now this may surprise our frequent listeners as we have had Haider on before to talk about heart failure as well as palliative inotropes, so why are we having him come on to talk about pain? .
Well, Haider has an intimate relationship with pain, having experienced chronic pain himself and now having dove deep into the latest research on pain for his new book The Song of Our Scars: The Untold Story of Pain.
We discussed the nature of pain, what makes chronic pain different from acute pain, what's the difference between proprioception, pain, and suffering, and so much more. So take a listen and if you are up for it, check out some of Haider's other books including Modern Death: How Medicine Changed the End of Life and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.
You have a patient with dementia severe enough that she cannot recognize relatives. She falls and breaks her hip. Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation? Should she be treated non-operatively, with aggressive symptom management? A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia.
In today's podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia. Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what's to be done about the pressure and incentives our health system exerts to operate, operate, operate.
-@AlexSmithMD
Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm. The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is:
In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer.
Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis. In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here.
Mara keeps working at it, and the more she works, the closer we are to fine.
-@AlexSmithMD
There are a lot of old myths out there about managing urinary tract symptoms and UTI's in older adults. For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.
On today's podcast, we are gonna bust some of those myths. We've invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.
First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. We discuss with her how we should work-up and manage "urinary tract infections" (I've added air quotes to "UTI" in honor of Tom Finucane's JAGS article titled "Urinary Tract Infection"—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.)
Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men. We also discuss Scott's recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.
In the US, geriatrics "grew up" as an academic profession with a heavy research base. This was in part due to the tremendous support of the National Institute on Aging. Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population.
Palliative care, in contrast, saw explosive growth in US hospitals. In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized "home" at the National Institutes of Health. The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need.
Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care. Kate's journey is in a way emblematic of the lack of centralized funding for palliative care: she's received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC.
We talk with Kate about how despite how far we've come in palliative care research, we still don't have answers to some fundamental questions, such as:
We cover a lot of ground! Working on a mystery. Going wherever it leads. Runnin down a dream…
-@AlexSmithMD
We are two and a half years into the COVID pandemic. We've lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU's overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the "zoom meeting."
But what have we really learned over this seemingly endless pandemic other than how to make a quarantini? Well, on today's podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease.
Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital. In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post. Some call her an optimist or maybe a pragmatist, but I'd call her someone who inherently understands the value in harm reduction when it's clear harm elimination just ain't gonna happen.
So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list:
It's been a while since we've done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here). But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations.
This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity. They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities. The basis of their argument is the ethical notion of "reciprocity" - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action. Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion.
To be sure, Paxlovid is no longer as scarce as it was a few months back. But the argument is important because, as we've seen, new treatments are almost always scarce at the start. Evusheld is the latest case in point.
Sometimes, you can't always get what you want…
-@AlexSmithMD
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