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.
On the one hand, every year we are fortunate to have new medications that help older adults and people living with serious illness. New treatments for lung cancer with remarkable survival outcomes come to mind, for example.
On the other hand, the tremendous growth in medications has led to an explosion of prescribing, polypharmacy, with attendant side effects and harms.
In this week's podcast, we talk with Nagham Ailabouni, a pharmacist and researcher joining us from Australia (song choice: Down Under!) about her review of major articles on medication safety and quality for older adults. Dr. Ailabouni summarized the top four hardest hitting in a recent publication in the Journal of the American Geriatrics Society, or JAGS. The four articles are:
Dr. Ailabouni's pet peeve medication she sees prescribed to hospice patients? High dose metformin. Listen to the podcast for more!
-@AlexSmithMD
Most of us know we are going to die. How often though do we actually let ourselves really internalize that understanding? To imagine it? To feel it? To try to accept it?
On today's podcast we invited BJ Miller back on our podcast to talk about death using as our guide his recent NY Times editorial What Is Death? How the pandemic is changing our understanding of mortality. In addition to being the author of this NY Times article, BJ is a Hospice and Palliative Care doc, and the founder of Mettle Health which aims to provide personalized, holistic consultations for any patient, caregiver or clinician who need help navigating the practical, emotional and existential issues that come with serious illness and disability.
We start off with BJ appropriately picking the song "Ebony Eyes" as our intro song, which is a good analogy to talking about death, as it was initially banned by the BBC from airplay as its lyrics were considered too upsetting to play on the radio. We then go into his thoughts on how we picture our deaths and dealing with those emotions we feel when we do, how we "live with death", and...
Also check out BJ's article that is geared towards kids/students - https://www.nytimes.com/2021/01/06/learning/how-do-you-view-death.html. As BJ put it in an email to us: "It's fascinating to me how they're taking care to reach out to younger minds, further proof that the idea that no one wants to think or talk about death - especially youngsters - is bunk.
Many of us in geriatrics and palliative care assume that we are the experts in health care when it comes to understanding the caregiver experience. Every once in a while, we are humbled and reminded of what we don't know.
Jessica Zitter had such an experience. Jessica, as many of you know, is an award winning author (link to our podcast about her book Extreme Measures) and was featured in an Academy Award winning film titled Extremis. She sought out to make another movie about the story of one of her patients who enrolled in hospice. The idea was it would be a film about all of the support that hospice provides and how it's a transformative experience. What she realized, however, is that the real story in this film is about the caregiver in the film, who is overworked, overburdened, and has few options for supportive to care for his wife's daily needs.
The film is titled Caregiver: A Love Story. See links below about how to view it. It's not yet widely available via a major distributor, so your best bet is to view a screening locally or arrange for a showing to your hospital/hospice/palliative care team/social work group combined with a discussion with Jessica Zitter. The movie is less than 30 minutes, so leaves plenty of time in an hour for discussion.
-@AlexSmithMD
Link to Trailer Link to Caregiver: A Love Story website
If you want info on the film or any stills to use for promotion, you can take a look at our PR folder.
Available virtual screenings:Dec 18-Jan 28th at the Roxie Theater (link) Jan 1-Feb 4th at the Laemmle Theater (link)
Education:CME program using the film plus education module, provides credits for physicians, social workers, and nurses (link)
Jessica can also offer the CME program live.
We also have a live educational program for family caregivers.
To arrange any live event, you can reach out to caregiver@jessicazitter.com
Info on Jessica Zitter:Website Book: Extreme Measures: Finding a Better Path to the End of Life Social media: Facebook Twitter
Surrogate decision‐making around life-sustaining treatments in the hospital even in the best of circumstances is hard. It's maybe even harder when caring for those who are conserved or have a professional guardian. The conservator may not have known the patient prior to them losing capacity, they may not know their values or goals that can help guide decisions, and they may be restricted by state statutes on what decisions they can make without getting a judge's approval.
The prevailing wisdom is all of the barriers to decision making while under guardianship likely leads to delays in decision making or one that errs on choosing high‐intensity treatment even if it is unlikely to benefit the patient. But is that really the case?
On today's podcast, we talk with Andy Cohn, lead author of a recent Journal of the American Geriatrics Society (JAGS) paper titled "Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes" and Liz Dzeng, the lead author of the accompanying editorial to the paper.
The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians. We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results. We also talk to Liz about whether substituted judgement is really all that it's cracked up to be.
So take a listen and also check out these articles to read more about it:
"Diagnose and adios." That's the sad phrase that I've heard quoted more than once, representing caregivers' sentiment of what it's like to be told by a clinician that your loved one has dementia.
This week we talked with Zaldy Tan, Geriatrician and Director of the Memory and Aging program at Cedars Sinai in Los Angeles. With David Reuben at UCLA and others working LA realized that current caregiver training programs were lacking. Caregivers for people with dementia are stressed, short on time, and thirsty for high impact information and skills training that can be delivered efficiently. To meet this need they launched a new caregiver "bootcamp" 1-day training (with the help of Archstone Foundation which also funds GeriPal). We cover many topics, including dissemination of the bootcamp to Spanish-speaking caregivers, converting to video boot camp during COVID, and ways you can partner with them to create your own boot camp.
Listen to the podcast to learn more!
(And "Remember Me" from Coco - great song choice)
JAGS article on caregiver boot camp
Dementia caregiver IcareD website (including upcoming bootcamp calendar)
CAPC website on caregiver support
-@AlexSmithMD
What does it mean to create a cultural shift to the end of life experience? Is it even possible? How do you even start something like that?
On today's podcast, we talk to Shoshana Ungerleider about her experience making that change. Shoshana is one of those amazing advocates for palliative and end of life care. She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care education. She is Executive Producer of the Academy Award-nominated end of life documentaries, Extremis and Netflix's End Game. Oh yah. She also started End Well back in 2017 which brought together people from all different backgrounds and professions with a goal to talk about end of life care.
This year she is taking the conference virtual with "Take 10" on December 10th. Take 10 brings names like Maria Shriver, Taraji P. Henson, Andy Cohen, Justin Baldoni, and Atul Gawande to speak about issues within palliative care, caregiving, geriatric medicine, and end-of-life care, all in light of what we can learn from the COVID crisis. And best of all it's free. So take a listen to the podcast and sign up for Take 10 here:
How long does it take to see a benefit of statin therapy for primary prevention of cardiovascular events in adults aged 50 to 75 years? That's the question we try to answer with our two guests today, Drs Lindsey Yourman and Sei Lee, the lead and senior author of a JAMA IM study that tried to answer this question.
In this podcast Drs. Yourman and Lee define what time to benefit is, why it is important in regards to decision making for older adults, and common lag time to benefits for common preventative interventions. We then take a deep dive into the JAMA IM meta-analysis of 8 trials, which showed 2.5 years were needed to avoid 1 cardiovascular event for 100 patients aged 50 to 75 years of age treated with a statin.
So give it a listen and tell us what you think on either our Twitter or Facebook posts about this podcast.
An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults. These needs are categorized around the 4 M's - Medication, Mentation, Mobility, and What Matters Most.
But we cannot achieve the ideal of an age friendly health system without, well, changing systems. In this week's podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M's. We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF.
Enjoy!
-@AlexSmithMD
The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient. Emergency physicians often don't have the time for in-depth discussions, nor have been trained on how to do so. There often is limited information about the patient, their functional status, or their prognosis. These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!)
So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals? We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question.
Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled "Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure." We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on "Work Grief: A Practical Primer for Emergency Medicine Providers".
In this week's podcast we talk with Kieran Quinn, author of a systematic review and meta-analysis of palliative care for non-cancer illness, published in JAMA. We also talk with Krista Harrison, first author of an accompanying editorial.
JAMA editors cut out some of my favorite parts of Krista's editorial, possibly because they were more like a blog post than a JAMA editorial. (I was senior author; go figure how it ended up reading like a blog post!) So here is the submitted introduction, unedited:
"As with many people's best ideas, inspiration struck in the shower. Dr. Balfour Mount, a urologic-cancer surgeon at the Royal Victoria Hospital in Quebec, Canada, needed a name to differentiate a new hospital-based service he created for people with serious life-threatening illness from Dr. Cicely Saunders' English hospice programs. Dr. Mount coined the term "palliative care" to connote the core goals of the service: to improve quality of life and to mitigate sources of distress. The field of palliative care was born. The year was 1975. Forty-five years later, palliative care retains its central focus on improving quality of life for people living with serious, life-limiting illnesses and their families by addressing physical and psychological symptoms, social and spiritual needs, and aligning patient and family values with available care options."
In our podcast, we talk about the surprising finding in Keiran's study that palliative care for noncancer illness was associated with a modest improvement in symptoms, reduced hospitalization and emergency department use, increased advance care planning but not improved quality of life. How can palliative care, since inception designed to improve quality of life, not improve quality of life?
Listen to the podcast to find out!
-@AlexSmithMD
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