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

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

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

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

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).

In fellowship, one of the leaders at MGH used to quote Balfour Mount as saying, “You say you’ve worked on teams? Show me your scars.”  Scars, really?  Yes. I’ve been there. You probably have too. On the one hand, I don’t think interprofessional teamwork needs to be scarring. On the other hand, though it goes against my middle-child “can’t we all get along” nature, disagreement is a key aspect of high functioning teams.  The key is to foster an environment of curiosity and humility that welcomes and even encourages a diversity of perspectives, including direct disagreement.

Today we talk with DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace about the notion that we should revolutionize our education programs, training programs, teams, incentive structures, and practice to be intentionally interprofessional in all phases.  The many arguments, theories, & approaches across settings and conditions are explored in detail in the book they edited, “Intentionally Interprofessional Palliative Care” (discount code AMPROMD9). Of note: these lessons apply to geriatrics, primary care, hospital medicine, critical care, cancer care, etc, etc.

And they begin on today’s podcast with one clinical ask: everyone should be a generalist and a specialist. In other words, in addition to being a specialist (e.g. social worker, chaplain), everyone should be able to ask a question or two about spiritual concerns, social concerns, or physical concerns.

Many more approaches to being interprofessional on today’s podcast.  But how about you! What will you commit to in order to be more intentionally interprofessional?

If we build this dream together, standing strong forever, nothing’s gonna stop us now…

-@AlexSmithMD

 Interprofessional organizations that are not specific to palliative care are doing excellent work

• National Center for Interprofessional Practice and Education: https://nexusipe.org/

• National Collaborative for Improving the Clinical Learning Environment https://ncicle.org/

• Interprofessional Education Collaborative (home of the IPEC Competencies) https://www.ipecollaborative.org/

• American Interprofessional Health Collaborative (sponsor of the biennial meeting "Collaborating Across Borders") https://aihc-us.org/index.php/

• Health Professions Accreditors Collaborative https://healthprofessionsaccreditors.org/

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world-class palliative care.  They are looking to build on both their research and clinical programs and are interviewing candidates for the Associate Chief of Research and for full-time physician faculty to join them in the inpatient and outpatient setting.  To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

** NOTE: To claim CME credit for this episode, click here **

Can death be portrayed as beautiful?

In this episode, we share the joy of talking with Wendy MacNaughton (artist, author, graphic journalist) and Frank Ostaseski (Buddhist teacher, author, founder of the Metta Institute and Zen Hospice Project) about using drawings and images as tools for creating human connections and processing death and dying.

You may know Wendy as the talented artist behind Meanwhile in San Francisco or Salt Fat Acid Heat. Our focus today, however, was on her most recently published book titled How to Say Goodbye. This beautiful book began as a very personal project for Wendy while she was the artist-in-residence at Zen Hospice. As BJ MIller writes in the foreword, “May this book be a portal -- a way for us to move beyond the unwise territory of trying to ‘do it right’ and into the transcendent terrain of noticing what we can notice, loving who we love, and letting death -- like life --surprise us with its ineffable beauty.”

Some highlights from our conversation:  

• The role of art in humanizing the dying process. 

• How the act of drawing can help us sloooow down, pay attention to the people and world around us, and ultimately let go… 

• The possibility of incorporating drawings in research and even clinical care. 

• The wisdom and experiences of hospice caregivers (who are often underpaid and undervalued).

• How to use the “Five Things” as a framework for a “conversation of love, respect, and closure” with someone who is dying.

And finally, Wendy offers a drawing lesson and ONE-MINUTE drawing assignment to help us (and our listeners) be more present and connect with one another. You can read more about this blind contour exercise from Wendy’s DrawTogether Strangers project. The rules are really quite simple: 

• Find another person.

• Sit down and draw each other for only one minute.

  • NEVER lift up your pen/pencil (draw with a continuous line) 

  • NEVER look down at your paper

That’s it! While the creative process is what truly matters, we think that the outcome is guaranteed to be awesome and definitely worth sharing. We invite you to post your drawings on twitter and tag us @GeriPalBlog!

Happy listening and drawing,

Lingsheng @lingshengli 

Additional info: 

• For weekly lessons on drawing and the art of paying attention from Wendy, you can subscribe to her Substack DrawTogether with WendyMac and join the Grown-Ups Table (GUT)! 

• To learn more about Frank’s teaching and philosophy on end-of-life care, read his book The Five Invitations 

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world-class palliative care.  They are looking to build on both their research and clinical programs and are interviewing candidates for the Associate Chief of Research and for full-time physician faculty to join them in the inpatient and outpatient setting.  To learn more about job opportunities, please click here: https://palliativemedicine.ucsf.edu/job-openings

** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.

If palliative care was a drug, one question we would want to know before prescribing it is what dose we should give.  Give too little - it may not work.  Give too much, it may cause harm (even if the higher dose had no significant side effects, it would require patients to take a lot of unnecessary additional pills as well as increase the cost.)

So, what is the effective dose of palliative care? On today’s podcast, we talk about finding an evidence-based answer to this dosing question with three leaders in palliative care: Jennifer Temel, Chris Jones, and Pallavi Kumar.  All three of our guests were co-authors of a randomized control trial on “Stepped Palliative Care” published in JAMA this year.

We talk about what stepped palliative care is, how it is different from usual care or intensive palliative care, why these palliative care dosing questions are important, and dive deep into the results of their trial.  We also discuss some of the other important trials in palliative care, including Jennifer Temel’s landmark NEJM study on outpatient palliative care and another study that gave an intervention we dubbed “fast-food palliative care” in an older GeriPal blog post.

** NOTE: To claim CME credit for this episode, click here **

Well-being and resilience are so hot right now. We have an endless supply of CME courses on decreasing burnout through self-care strategies. Well-being committees are popping up at every level of an organization. And C-suites now have chief wellness officers sitting at the table. I must admit, though, sometimes it just feels off… inauthentic, as if it's not a genuine desire to improve our lives as health care providers, but rather a metric to check off or a desire to improve productivity and billing by making the plight of workers a little less miserable.

On today’s podcast, we talk with Jane Thomas, Naomi Saks, and Ishwaria Subbiah about the concepts of wellness, well-being, resilience, and burnout, as well as what can be done to truly improve the lives of healthcare providers and bring, I dare say it, joy into our work.

For more on resources for well-being, check out the following:

1. Cynda Rushton, PHD, MSN, RN — Transforming Moral Distress into Moral Resilience https://www.youtube.com/watch?v=L1gE5G8WnTU

1. Tricia Hersey: Rest & Collective Care as Tools for Liberation https://www.youtube.com/watch?v=7OuXnLrKyi0

1. Beyond resiliency: shifting the narrative of medical student wellness https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/

1. Fostering resilience in healthcare professionals during and in the aftermath of the COVID-19 pandemic https://www.cambridge.org/core/journals/bjpsych-advances/article/fostering-resilience-in-healthcare-professionals-during-and-in-the-aftermath-of-the-covid19-pandemic/0ADCA3737D12CAF308567A7F59EFC267

1. The Greater Good Science Center studies the psychology, sociology, and neuroscience of well-being and teaches skills that foster a thriving, resilient, and compassionate society. https://ggsc.berkeley.edu/?_ga=2.230263642.712840261.1724681290-1268886183.1680535323

** NOTE: To claim CME credit for this episode, click here **

In today’s podcast we set the stage with the story of Dax Cowart, who in 1973 was a 25 year old man horribly burned in a freak accident. Two thirds of his body was burned, most of his fingers were amputated, and he lost vision in both eyes.  During his 14 month recovery Dax repeatedly demanded that he be allowed to die. The requests were ignored. After, he said he was both glad to be alive, and that the doctors should have respected his wish to be allowed to die.

But that was 1973, you might say. We don’t have such issues today, do we? 

Louise Aronson’s recent perspective about her mother in the NEJM, titled, “Beyond Code Status” suggests no, we still struggle with this issue. And Bill Andereck is still haunted by the decision he made to have the police break down the door to rescue his patient who attempted suicide in the 1980s, as detailed in this essay in the Cambridge Quarterly of HealthCare Ethics.  The issues that are raised by these situations are really hard, as they involve complex and sometimes competing ethical values, including:

• The duty to rescue, to save life, to be a “lifeguard”

• Judgements about quality of life, made on the part of patients about their future selves, and by clinicians (and surrogate decision makers) about patients

• Age realism vs agism 

• The ethics of rationale suicide, subject of a prior GeriPal episode

• Changes in medical practice and training, a disconnect between longitudinal care and acute care, and frequent handoffs

• The limitations of advance directives, POLST, and code status orders in the electronic health record

• The complexities of patient preferences, which extend far beyond code status

• The tension between list vs goals based approaches to documentation in the EHR

And a great song request, “The Cape” by Guy Clark to start and end.

Enjoy!

-@AlexSmithMD

** NOTE: To claim CME credit for this episode, click here **

Serious illness communication is hard. We must often deliver complex medical information that carries heavy emotional weight in pressured settings to individuals with varying cultural backgrounds, values, and beliefs. That’s a hard enough task, given that most of us have never had any communication skills training. It feels nearly impossible if you add another degree of difficulty, whether it be a crying interpreter or a grandchild from another state who shows up at the end of a family meeting yelling how you are killing grandma.

On today’s podcast, we try to stump three VitalTalk expert faculty, Gordon Wood, Holly Yang, Elise Carey, with some of the most challenging communication scenarios that we (and some of our listeners) could think up.

During the podcast, we reference a newly released second-edition book that our guests published titled “Navigating Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope.”  I’d add this to your “must read” list of books, as it takes readers through the VitalTalk method that our guests use so effectively when addressing these challenging scenarios.

If you are interested in learning more about VitalTalk, check out their and some of these other podcasts we’ve done with three of the other authors of this book (and VitalTalk co-founders):

• Our podcast with Tony Back as well as Wendy Anderson on “Communication Skills in a Time of Crises”

• Our podcast with James Tulsky on “The Messiness of Medical Decision-Making in Advanced Illness.”

• Any one of our podcasts with Bob Arnold, including this one on the language of serious illness or this one on books, to become a better mentor.

Lastly, I reference Alex’s Take Out the Trash video, where he uses communication skills learned in his palliative care training at home with his wife.  The results are… well… let’s just say less than perfect. 

By: Eric Widera