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
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Geriatric anesthesia is a thing. The average age of people getting surgery is increasing. Anesthesiologists and surgeons feel that with new techniques and approaches they can perform surgery on patients at ever older ages, patients who they previously would have excluded from surgery.
One of the key advances in geriatric anesthesia is the use of spinal anesthesia, a form of regional anesthesia that also includes epidurals and peripheral nerve blocks. When older adults experience a hip fracture, there's a growing consensus that spinal anesthesia offers superior outcomes compared to general anesthesia.
It's surprising therefore, to talk with Mark Neuman about the results of his randomized trial in NEJM, which finds essentially no difference between general anesthesia and spinal. Importantly, as a primary outcome Mark selected walking ability based on feedback from older adults - this is the outcome our patients care about most. But he finds no difference in primary outcome or secondary outcomes, including (surprisingly) delirium.
We break down potential reasons, with thoughtful commentary from Liz Whitlock and Cindy Hsu, two anesthesiologists with experience caring for older adults with hip fracture. Liz is a friend of the pod and researcher who we interviewed previously about "pumphead." Cindy is...my wife. She also helps me out with the accompaniment on piano as it's tough for me to play guitar with a broken clavicle. Thank you dear wife! We had fun learning to play/sing Drivers License by Olivia Rodrigo. Ah...teen angst...the angst!!!
-@AlexSmithMD
The great resignation is upon us. One in five health-care workers has left their job since the pandemic started. Geriatrics and palliative care are not immune to this, nor are we immune to the burnout that is associated with providers leaving their jobs.
In today's podcast, we talk with Janet Bull and Arif Kamal about what we can do to address burnout and increase resiliency, both from an institutional and individual perspective. Janet Bull is the Chief Medical Officer and Chief Innovations officer at Four Seasons Hospice and Arif Kamal is an oncologist, palliative care doctor and researcher at Duke.
We discuss Arif's and Janet's article published in JPSM on the prevalence and predictors of burnout among hospice and palliative care clinicians, as well as Arif's Health Affairs article on the policy changes that are key to promoting sustainability and growth of specialty palliative care workforce. In that later article, Arif found that among many things:
If you want to learn more about what you can do to promote wellness on your team, check out this article Arif published with other colleagues in JPSM titled the "Top Ten Tips Palliative Care Clinicians Should Know about Implementing a Team Wellness Program."
Eric
I don't consider myself spiritual. For some in palliative care, this would be considered heresy as we are told "everyone is spiritual." But, hey, I'm not. So there. However, despite not being spiritual, I do believe that spiritual care is fundamental to the care I give patients and families. I also recognize it is the one palliative care domain I am most uncomfortable with and the one that as a field, we actually don't support very well (odds are, if your palliative care team doesn't have a full interdisciplinary team, the discipline you are likely missing is chaplaincy).
So, on today's podcast, we break down spiritual care in palliative care with three leaders in the field: Allison Kestenbaum, Katy Hyman, and Paul Galchutt. We ask these experts a veritable smorgasbord of questions on spiritual care that includes:
Also, for all you palliative practitioners and researchers, here is a link to freely join the Hospice-Palliative Spiritual Care Research Network (HPSCRN) with Transforming Chaplaincy The HPSCRN is a space to connect, inform, explore, and coordinate for all interprofessionals.
Though "breath" is in the title of Wes Ely's book (and his song choice by the Police), relationships are its beating heart.
The book operates on two levels.
On one level, Wes Ely's book is an autobiography of a critical care doctor's horror and shame at discovering that his ICU practice of heavily sedating patients for days on end was leading to lifelong physical, cognitive, and psychological harm; and the arc of his redemptive journey to find a better way to care for patients in the ICU.
But this book also operates on a second, much deeper level. On this deeper level the book is a story of Wes Ely's journey toward rediscovering the humanity in medicine by forging deep, lasting connections with his patients. We begin and end today's podcast at this deeper level, talking about the spiritual connections, that doctors can forge caring for critically ill patients. (quick plug: next week's podcast is with Chaplains on Spirituality and Palliative Care).
We are joined today by Lekshmi Santhosh, head of UCSF's post-COVID and post-ICU clinic, to interview Wes about these themes that animate his book, and more, including how we lost our way in treating ICU patients during COVID, returning to the practice of heavily sedating patients for days on end.
Of note, Wes is donating proceeds from his book to the CIBS center, to benefit research and patient care to improve care for people with critical illness, during and after the ICU stay.
Anyone who cares for individuals with serious illness must live in a messy space where tough conversations about treatment decisions are common and complicated.
On today's podcast we talk with James Tulsky about living in this messy space of medical decision making and the challenges that come with communication around advanced treatment decisions.
We talked about James' path to the work that he has done, including early studies he did that included audio recording DNR discussions between physicians and patients, to his most recent study looking at the "Triadic agreement about advanced cancer treatment decisions."
In this last study, James' group surveyed 70 triads of patients, caregivers, and their oncologists shortly after making a cancer treatment decision and found that only 40% of triads completely agreed on the goal of treatment. In all of the remaining cases, at least one member of the triad disagreed about the goal of treatment.
So take a listen and also check out this wonderful ACP article that James did with Joshua Lakin and Rachelle Bernacki titled "Time Out Before Talking: Communication as a Medical Procedure" which we also discuss on the podcast.
"The secret sauce of the Transitions, Referral and Coordination (TRAC) team was including a lawyer." This is brilliant and will ring true to those of us who care for complex older adults who end up in the hospital for long, long, long admissions.
On today's podcast we talk with Kenny Lam, Jessica Eng, Sarah Hooper, and Anne Fabiny about their successful interdisciplinary intervention to reduce prolonged admissions, published in NEJM Catalyst. Many of the problems that older adults face are not medical. How to find housing. How to stay in their homes. How to get a paid caregiver to help them stay at home. How to get someone to pay bills. How to assign a surrogate health care decision maker. The legal obstacles to accomplishing these tasks for complex older adults, particularly those who may have marginal decision making capacity, can seem insurmountable. Having a lawyer on the team is brilliant - in much the same way that having a handyperson on the team for project CAPABLE to keep people at home was brilliant. For more, listen also to our prior podcast with Sarah Hooper on medical-legal partnerships.
Most studies in geriatrics have used metrics such as survival time or disability in activities of daily living as their outcome measure. Many palliative care interventions are evaluated on the basis of ability to change symptoms such as pain. But these outcomes represent a thin view of the human experience. What older adults and those with serious illness often care about most is being able to do the activities that animate their lives with meaning and purpose. Participating in meaningful activities is central to quality of life, and yet is poorly captured in most outcome scales.
In this week's podcast, Ken Covinsky joins Eric Widera and I to talk with Anna Oh and Theresa Allison, two researchers who have taken very different approaches to studying meaningful activities. Anna conducted a quantitative study, getting a 30,000 foot view of older adults with dementia, disability, and depression's ability to participate in meaningful activities. Most people think that a good quality of life isn't possible for people with these conditions. Anna's study, published in JAMA IM, finds that most older adults with these conditions are still engaging in meaningful activities.
Theresa's qualitative study, published in JAMDA, delves deep into the lived experience of older adults with dementia and their caregivers. She finds that while they have had to adapt to support participation in meaningful activities, the underlying sources of meaning have remained the same. Interestingly, caregiver stress was higher when the people with dementia they cared for stopped participating in meaningful activities. Helping people with dementia and caregivers adapt to continue to engage in meaningful activities is a creative activity that is at the heart of good geriatric and palliative care.
-@AlexSmithMD
The FDA label for the amyloid antibody aducanumab (Aduhelm) started off exceedingly broad, basically including anyone with Alzheimer's disease, but was subsequently narrowed to to patients with mild cognitive impairment (MCI) or mild dementia due to Alzheimer disease (AD). Should, though, the label be even more restrictive to mirror the populations studied in the two still unpublished trials of the drug, EMERGE and ENGAGE? Or should CMS consider restricting coverage for aducanumab to populations meeting trial eligibility criteria and requiring additional evidence on clinical outcomes in groups excluded from the trials?
In today's podcast, we talk with Tim Anderson and Marco Canevelli, the authors of two recent articles published about the real world eligibility of aducanumab:
Tim Anderson was first author of a JAMA research letter that found that more than 92% of Medicare beneficiaries with Alzheimer's Dementia and 85% of those with MCI would have been excluded in the clinical trials of aducanumab based on their age or comorbid conditions.
Marco was first author of a JAGS letter to the editor that systematically applied the EMERGE and ENGAGE exclusions to 911 patients with cognitive complaints who went to A geriatric outpatient unit in Milan (Italy). Only six patients (i.e., 0.66%) of these patients would potentially be candidates to aducanumab.
For more podcasts on aducanumab, check out these two:
"The take home message of this study is NOT that primary palliative care does not work." So says Yael Schenker of the negative study of an oncology nurse-led primary palliative care intervention for people with advanced cancer.
And we pushed Yael and Bob Arnold (senior author) on this point - we have several negative studies of primary palliative care (see links below to podcasts) - is it time to start to question the effectiveness of primary palliative care?
We certainly all agree on the problem: we have only enough palliative care specialists to care for some small proportion of the population of people with serious illness. But when we move away from specialist palliative care to primary palliative care do we lose something critical? Perhaps we cannot train primary providers (front line nurses and doctors generally) to deliver palliative care that is "good enough" to impact outcomes.
That's one interpretation. Another is that we need a "stronger dose" of primary palliative care. In Yael and Bob's study nurses averaged 2.2 visits, hardly robust longitudinal palliative care. Patients who had 3 visits had better outcomes.
Unpacking negative studies is just as interesting as unpacking positive studies. Knowing what doesn't work is just as important as knowing what does.
Links:
Time-limited trials. We've all probably used them before. We meet with patients and families. We agree to either start or continue a particular treatment to see if it helps in some specific way over some defined period of time. If it works as hoped, great, we continue the treatments. If not, we stop them. At least that is how it's supposed to go.
On today's podcast we talk all about these time-limited trials with Dong Chang and Ricky Leiter. Dong was the lead author of a JAMA IM article looking at the outcomes of training staff to use time-limited trials as the default communication and care planning approach for critically ill patients in intensive care units. Ricky is the lead author of the accompanying editorial and palliative care physician extraordinaire.
We discussed with Dong and Ricky about the results of the JAMA IM study, which were pretty darn impressive. The intervention resulted in significant reductions in duration of ICU stay (7.4 v 8.7 days), fewer invasive procedures, but no change in mortality, and no change in family satisfaction rating (which was high before and after the intervention). We discuss potential reasons why the intervention worked, some limitations of the study, the role uncertainty plays in decision-making, and so much more (including nudging from our last podcast).
If you want to read more about time-limited trials, check out these articles as well:
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