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We’ve covered psychedelics on the podcast before—first in 2019 with Ira Byock, where we explored their potential role in medicine, and then again in 2023 with Stacy Fischer, Brian Anderson, and Theora Cimino, focusing on the reasons to approach psychedelic use in patients with caution.
In today’s episode, we’re taking a closer look at the current state of the science around one specific psychedelic: psilocybin. We'll discuss three recent clinical trials involving patients with serious illness, joined by our guests James Downar, Ali John Zarrabi, and Margaret Ross.
We begin with a refresher on psilocybin—what it is, how it might work, what conditions it may help treat (including demoralization), and how it’s typically administered. What makes this episode especially compelling is our deep dive into the three studies, which highlight two different approaches to using psilocybin: daily microdosing, similar to traditional antidepressants, and a more intensive model known as psilocybin-assisted therapy. This latter approach involves three structured phases—preparation, the dosing session, and post-session integration with trained therapists.
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Peter Selwyn, one of today’s guests, has been caring for people living with HIV for over 40 years. In that time, care of people with HIV has changed dramatically. Initially, there was no treatment, then treatments with marginal efficacy, complex schedules, and a tremendous burden of side effects and drug-drug interactions. The average age at death was in the 30s.
Now, more people in the US die with HIV rather than from HIV. Treatment regimens are simplified, and the anti-viral drugs are well tolerated. People are living with HIV into advanced ages. The average age at death is likely in the 60s. Nearly half of people living with HIV are over age 55. One in 10 people with newly diagnosed HIV is an older adult. Our second guest, Meredith Greene, is a geriatrician and researcher who focuses on care of older adults living with HIV, in the US and Africa.
On today’s podcast we discuss:
Implications of aging with HIV for clinical care
Loneliness and social isolation among older adults living with HIV
Persistence of stigma
Need to consider HIV in the differential diagnosis for older adults
Screening for HIV
Screening for osteoporosis in people living with HIV
Dementia and cognitive impairment risk in people living with HIV
When to stop anti-virals near the end of life
Toward the end we speak to the moment. More older adults live with HIV in SubSaharan Africa and the global South than anywhere else in the world. Funding for research and clinical care is at risk, as USAID and PEPFAR (which is under USAID), are shuttered. Millions of lives are at stake. Meredith wore a shirt that said Silence=death.
Eric gave me the hook during my live cover of One, by U2, a song released in 1992 whose proceeds went entirely to AIDS research. I couldn’t help it, forgive me dear listeners, I had to do a longer than usual cut at the start!
-Alex Smith
Useful links:
Peter's article on the evolution of HIV: https://link.springer.com/article/10.1007/s11524-011-9552-y
Peter’s book Surviving the Fall: Personal Journey of an AIDS Doctor
PEPFAR: Global Health Policy | KFF
Articles:
Geriatric Syndromes in Older HIV-Infected Adults - PMC
Loneliness in Older Adults Living with HIV
Management of Human Immunodeficiency Virus Infection in Advanced Age
https://pmc.ncbi.nlm.nih.gov/articles/PMC3684249/About Act-up for those who might know the Silence=Death t-shirt reference:
https://www.npr.org/2021/06/16/1007361916/act-up-a-history-of-aids-hiv-activismhttps://www.newyorker.com/magazine/2021/06/14/how-act-up-changed-america
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More and more people are, “doing their own research.” Self-identified experts and influencers on podcasts (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals. An increasing number of federal leaders have a track record of endorsing such products.
We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently. Ivermectin to treat cancer. Stem cell treatments. Chelation therapy. Daneila Lamas wrote about this issue in the New York Times this week -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube.
Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken). We discuss an article they wrote about PULET for the American Journal of Hospice and Palliative Medicine, including:
What makes a PULET a PULET? Key ingredients are both potentially unsafe and low evidence. If it’s low evidence but not unsafe, not generally an issue. Think vitamins. If it’s potentially unsafe, but has robust evidence, well that’s most of the treatments we offer seriously ill patients! Think chemo.
What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity.
What counts as low-evidence? Animal studies? Theoretical only?
Does PULET account for avoiding known effective treatments?
Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR.
How does integrative medicine fit in with this? Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this.
How ought clinicians respond? Hint: If you’re arguing over the scientific merits of a research study, you’re probably not doing it right. Instead, think VitalTalk, REMAP, and uncover and align with the emotion behind the request.
Does the approach shift when it’s a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child?
For more, Laura suggests a book titled, How to Talk to a Science Denier.
And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give Grand Rounds, and the conversations I had with Adam and Laura during the visit. We love it when listeners engage with us to suggest topics that practicing clinicians find challenging.
And I get to sing Bon Jovi’s Bad Medicine, which is such a fun song!
-Alex Smith
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I read Farah Stockman’s article in the NYT on why attacks on DEI will cost us all, and thought, “Yes, and ‘everyone’ includes harm to our healthcare workforce, our patients, and their families.”
So we’re delighted that Farah Stockman, pulitzer prize winning journalist, author of American Made: What Happens to People When Work Disappears, and editorial board member at the New York TImes joins us to set the bigger picture for this discussion. Farah provides clear examples from the Biden administration, in which having the most diverse cabinet in history was critical to building bridges, empathy, and inspiring others to feel included.
We are also pleased to welcome Ali Thomas, a hospitalist, member of the Baha'i Faith, leader of anti-racism efforts in the Pacific Northwest, and founder of the BIPOC Health Careers Ecosystem. Ali talks about the history of affirmative action, which started as a program for Whites, the importance of diversity in the healthcare workforce, the history of allyship and cross cultural collaboration, and his own efforts to provide opportunity and support for historically oppressed groups in his own community to obtain healthcare careers.
And Ken Covinsky, avid baseball fanatic, joins us and notes that the day we record (April 15) is Jackie Robinson day. Many may be familiar with the story of Jackie Robinson breaking the color barrier in major league baseball in 1947, but may not be aware of the tremendous adversity Jackie Robinson faced, and persistence he displayed, off the field.
We address many things, including:
The movement in Corporate America and institutes of higher education to implement DEI programming in the wake of George Floyd
The general agreement in America of the value of diversity, and disagreement, unpopularity, and backlash about DEI as it was implemented
How the pursuit of diversity and excellence are not in tension, they are aligned and necessary for each other
What we can do to build bridges across differences
There was so much we hoped to talk about and didn’t get to, but I will link to now, including: Ali’s mom’s personal history with and study of school desegregation in South Carolina, Farah’s mom’s pioneering work as a speech language pathologist, and Ken’s perspectives on the importance of studying ageism and racism in research.
What a Wonderful World could be sung in irony at this moment. I hope we all take it literally, with the hope this podcast ends with. The podcast follows the arc towards hope of this video on Race Amity from the National Center for Race Amity, courtesy of Ali Thomas (his dad is featured).
-Alex Smith
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Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department. I asked emergency medicine clinicians what they thought when a patient who is seriously ill and DNR comes to the ED, and some responded, (paraphrasing), what are they doing here? This is not why I went into emergency medicine. I went into emergency medicine to act. I can’t do the primary thing I’ve been trained to do: ABC, ABC, ABCs. Most emergency providers wanted to do the right thing for seriously ill patients, but they didn’t have the knowledge, skills, or experience to do it.
Today we focus on an intervention, published in JAMA, that gave emergency clinicians basic palliative care knowledge, training, and skills. We talk with Corita Grudzen and Fernanda Bellolio about their cluster stepped wedge randomized trial of a palliative care intervention directed at emergency clinicians. They got training in Vital Talk and ELNEC. They got a decision support tool that identified hospice patients or those who might benefit from a goals of care discussion. They got feedback.
So did it matter? Hmmm….it depends. We are fortunate to have Tammie Quest, emergency and palliative trained and long a leader in this space, to help us unpack and contextualize these findings.
Today we discuss:Why the study was negative for the primary (hospitalization) and all secondary outcome (e.g. hospice use).
Why to emergency clinicians, this study was a wild success because they had the skills they wanted/needed to feel like they could do the right thing (during the onset of Covid no less).
Why this study was a success due to the sheer size (nearly 100,000 patients in about 30 EDs) of the study, and the fact that, as far as the investigators know, all study sites continue to employ the clinical decision support tool.
What is a cluster stepped wedge randomized trial?
Were they surprised by the negative findings?
How do we situate this study in the context of other negative primary palliative care interventions, outside the ED? E.g. Yael Shenker’s negative study of primary palliative care for cancer, Randy Curtis’s negative study of a Vital Talk-ish intervention, Lieve Van den Block’s negative study of primary PC in nursing homes. Why do so many (most, all??) primary palliative care interventions seem to fail, whereas specialized palliative care interventions have a relatively robust track record of success. Should we give up on primary palliative care? What’s next for primary palliative care interventions in the ED?
And if your Basic Life Support training certification is due, you can practice the correct chest compression rate of 110 beats per minute to Another One Bites the Dust.
-Alex Smith
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Whelp, goodbye folks! Eric and I have been DOGE’d.
In a somewhat delayed April Fools, Nancy Lundebjerg and Annie Medina-Walpole have taken over podcast host duties this week.
Their purpose is to interview me, Eric, and Ken Covinsky about your final AGS literature review plenary session taking place at the Annual Meeting in Chicago this May (for those attending, our session is the plenary the morning of May 10). We discuss our favorite articles, parody songs, and memories from AGS meetings past, with a little preview of a song for this year’s meeting.
We covered:
The first parody song I wrote, for AGS 2018 in Orlando, about this article by Nancy Schoenborn on how to discuss stopping cancer screening.
Ken’s favorite articles, including
The Impact of Rudeness on Medical Team Performance: A Randomized Trial
Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization
Eric’s favorite article on the effect of chair placement on physicians’ behavior and patients’ satisfaction
Tim Anderson’s study on the intensification of older adults’ outpatient blood pressure treatment at hospital discharge
Nancy’s favorite topic and parody song, Aducanumab, which won Drug of the Year in 2021.
Enjoy! And maybe, just maybe, Eric and I will be reinstated and return as hosts next week…
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A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice. Outcomes are typically assessed from available records. Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations.
Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine.
We spend the last portion of the podcast discussing the surprising finding of the study. In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group. What?!? Not a typo.
We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including:
Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control). Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions?
Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care.
Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings. My goals will differ if I think I probably have 2 years to live vs 10 years.
Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed).
Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning. As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful.
And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French!
-Alex Smith
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Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (VSED), and multiple episodes about the ethical issues surrounding medical aid in dying (MAID). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life?
To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of Minimal Comfort Feeding (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit.
We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medical aid in dying medications and their respective articles on the topic. We discussed what makes an illness “terminal”, what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers.
-Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host)
“Mr. Smith Has No Mealtimes”: Minimal Comfort Feeding for Patients with Advanced Dementia by Hope Wechkin et al in JPSM Medical Aid in Dying to Avoid Late-Stage Dementia by Thaddeus Pope and Lisa Brodoff in JAGS Law not loopholes: Medical aid in dying for those with dementia also in JAGS by Joshua Briscoe and Eric Widera
Articles referenced in this discussion:Past GeriPal Podcast Episodes on MAID:
MAID podcasts
https://geripal.org/what-is-going-on-with-maid-in-canada-bill-gardner-leonie-herx-sonu-gaind/
https://geripal.org/conscientous-provision-of-maid-and-abortion-robert-brody-lori-freedman-mara-buchbinder/
https://geripal.org/assisted-dying-podcast-with-lewis-cohen/
https://geripal.org/dilemmas-in-aid-in-dying-podcast-with/
Past GeriPal Podcast Episode about VSED:
https://geripal.org/tim-quill-vsed/
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As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way?
In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care. Sue Britton was the first nurse hired on that palliative care unit. Michael Kearney on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry. Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including:
Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more…
Whole-person-care
Total pain
Healing as a process distinct from the deterioration of the body
Sympomatologists
The patient and family as the unit of care
Our guests referenced many articles on this podcast, linked above and below. If you read just one, read Palliative Medicine - Just Another Specialty? by Kearney. I promise it’s short. 2 pages. Here’s a taste:
…While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty.
And love that Jim Croce choice. What’s in a name? I’ve got a name.
Enjoy!
-Alex Smith
Links
Link to the McGill National Grand Rounds Series on Palliative Care, Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming. Palliative Medicine - Just Another Specialty? In Palliative Medicine By Kearney Joe Wood’s book on Total Pain Balfour Mount’s memoir Ten Thousand Crossroads paper on Healing Connections in JPSM and Healing and Palliative Care in Palliative Medicine Cicely Saunders: A Life and Legacy, by David Clark Self-Care of Physicians Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series Twycross on Readdressing Balance in Hospice
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I was very proud to use the word “apotheosis” on today’s podcast. See if you can pick out the moment. I say something like, “Palliative care for people experiencing homelessness is, in many ways, the apotheosis of great palliative care.” And I believe that to be true. When you think about the early concepts that shaped the field, you can see how palliative care for persons experiencing homelessness fits like a hand in a glove: total pain envisioned by Cicely Saunders, which even its earliest sketches included social suffering like loneliness; or Balfour Mount, who coined the term “palliative care,” lamenting the cruel irony of our care for the dying, and the desperate need to create programs to reach more people experiencing suffering.
Today we talk with Naheed Dosani, a palliative care physician at St. Michael’s Hospital in Toronto, and health justice activist. His story, which he shares on today’s podcast, is remarkable. Just out of fellowship, Naheed built a palliative care program for homeless persons called the Palliative Education and Care for the Homeless (PEACH) Program. This podcast is a complement to our prior podcast on aging and homelessness with Margot Kushel. Today we discuss:
What is the best terminology? Homeless? Homelessness? Houseless? Marginally housed?
What makes palliative care for people experiencing homelessness challenging? What makes it rewarding?
What is unique about the practice of palliative care for people experiencing homelessness? We discuss the principles of harm reduction, social determinants of health, and trauma informed care. Major overlap with substance use disorder issues, which we have covered recently (and frequently) on this podcast.
How are the health systems designed or not designed to meet the needs of people experiencing homelessness?
What are the equity issues at stake, and at risk of being cut, both in Canada and the US?
Many more links below. And I had a blast playing Blinding Lights by that Toronto band The Weekend.
Enjoy!
-Alex
End Well Talk
https://www.youtube.com/watch?v=eG4QE-hfPQU
Resources on the PEACH ProgramProgram Review Paper – A recent publication in Longwoods Healthcare Quarterly reviewing the PEACH model.
https://pubmed.ncbi.nlm.nih.gov/37144698/Promising Practice Recognition – PEACH was named a Promising Practice in equity-oriented palliative care as part of a national initiative funded by Health Canada, operated by Healthcare Excellence Canada & the Canadian Partnership Against Cancer.
https://www.healthcareexcellence.ca/media/z3jifqqd/pp-peach-en-2024-v2.pdfToronto Star Feature
https://www.thestar.com/life/together/people/dr-naheed-dosani-started-peach-to-provide-palliative-care-for-homeless-and-vulnerably-housed-populations/article_c56d8f45-cbe9-522e-9554-46778bf50407.htmlCityNews Toronto Feature
https://toronto.citynews.ca/2022/08/08/peach-team-palliative-health-care-homelessness/
Psychosocial Interventions at PEACHIn addition to medical care, PEACH also runs two key psychosocial interventions for our clients:
PEACH Grief Circles – Structured spaces for workers in the homelessness sector to process grief. CBC covered this a few years ago, including a radio segment feature on CBC White Coat, Black Art (which you can access at the below link).
https://www.cbc.ca/radio/whitecoat/palliative-care-team-helps-the-homeless-die-with-dignity-a-healing-circle-helps-them-grieve-1.5048409PEACH Good Wishes Program – A program that provides meaningful gifts for unhoused individuals who are terminally ill.
https://www.cbc.ca/news/canada/toronto/toronto-homeless-palliative-holidays-1.5407360
Kensington Hospice & 'Radical Love' Equity-Oriented Hospice Palliative CareNaheed Dosani also serves as the Medical Director of Kensington Hospice, Toronto’s largest hospice. There, he helps run an innovative program called 'Radical Love' Equity-Oriented Hospice Palliative Care, which provides low-threshold, low-barrier access to hospice care for structurally vulnerable individuals (e.g., those experiencing homelessness). The program also operates via a partnership with the PEACH Program.
As a result of the 'Radical Love' program at Kensington Hospice: At any given time, Kensington Hospice has evolved from caring for structurally vulnerable individuals
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Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.
Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:
Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?”
Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in JPSM.
What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).
When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?
Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?
And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…
Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!
Sometimes the drugs don’t work.
-Alex: @alexsmithmd.bsky.social
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Trauma is a universal experience, and our approach as health care providers to trauma should be universal as well. That’s my main take-home point after learning from our three guests today when talking about trauma-informed care, an approach that highlights key principles including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity.
With that said, there is so much more that I learned from our guests for this trauma-informed care podcast. Our guests include Mariah Robertson, Kate Duchowny, and Ashwin Kotwal. Mariah discussed her JAGS paper on applying a trauma-informed approach to home visits. Kate and Ashwin talked about their research on the prevalence of lifetime trauma and its association with physical and psychosocial health among adults at the end of life. We also explored several questions with them, including how to define trauma, its prevalence in older adults, the impact of past traumatic experiences, the potential triggers of trauma screening, and the application of trauma-informed principles in clinical practice.
If you want a deeper dive, check out the following resources:
Our “Nature of Suffering” podcast with BJ Miller and Naomi Saks
Dani Chammas’ Annals paper on countertransference and why we shouldn’t say “that the patient was difficult rather than that I felt frustrated.”
A great Curbsiders podcast episode on Trauma-informed care with Megan Gerber
CAPC’s Trauma-informed care toolkit
Mariah’s article on Home-Based Care for LGBTQ or another diverse gender identity Older Adults
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In today’s podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Medicine Nurses Association (HPNA). Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully). On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of moderator.
Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed Prepare-for-your-care vs. facilitated Respecting Choices style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer. From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including:
Marie’s tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served? Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served?
Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let’s assume that there are clear important benefits. Based on the results of Yael’s study, should resources be allocated to resource intensive nurse facilitated sessions (Respecting Choices), which had significantly better engagement, or to low resource intensive patient-facing materials (Prepare), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)?
One interpretation of Na’s study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis. Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality. Which is it?
Bonus: Simon says he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?). Garfunkel says Simon was writing about Garfunklel’s friend and college roomate Sandy, who was blind. Who’s got the right of it?
Enjoy!
-Alex Smith
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Things are changing quickly in the Alzheimer’s space. We now have biomarkers that can reasonably approximate the degree of amyloid build-up in the brain with a simple blood test. We have two new FDA-approved medications that reduce that amyloid buildup and modestly slow down the progression of the disease. So, the question becomes, what, if anything, should we do differently in the primary care setting to diagnose the disease?
On today’s podcast, we’ve invited Nathaniel Chin back to the GeriPal podcast to talk about what primary care needs to manage this new world of Alzheimer’s disease effectively. Nate is a geriatrician and clinician-scientist at the University of Wisconsin, as well as the host of the Wisconsin ADRC's podcast, "Dementia Matters." In each bi-weekly episode, he interviews Alzheimer's disease experts about research advances and caregiver strategies. Nate also wrote a NEJM piece last year on “Alzheimer’s Disease, Biomarkers, and mAbs — What Does Primary Care Need?”
We address the following questions with Nate:
Has anything changed for the primary care doctor when diagnosing Alzheimer’s? How should we screen for cognitive impairment?
Does a good history matter anymore?
What’s the role of assessing function?
What do we do with those who have only subjective cognitive complaints?
Can’t we skip all this and just send some blood-based biomarkers?
What is the role of the amyloid antibody treatments?
Lastly, take a look at the following if you want to take a deeper dive into some of the other articles and podcasts we discuss:First, two competing definitions of what is Alzheimer’s:
Alzheimer Disease as a Clinical-Biological Construct—An International Working Group (IWG) Recommendation
Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup
Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): Executive summary of recommendations for primary care
Podcasts we mentioned
Prevention of Dementia: A Podcast with Kristine Yaffe
Screening for Dementia: A Podcast with Anna Chodos, Joseph Gaugler and Soo Borson
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It is a battle royale on this week’s GeriPal podcast. In one corner, weighing in at decades of experience, well known for heavy hits of bedside assessments, strong patient-family relationships, and a knockout punch of interdisciplinary collaboration, we have in-person palliative care consults. But watch out! Travel time can leave this champ vulnerable to fatigue and no-shows. In the other corner, we have the young upstart, able to reach patients across vast distances when delivering palliative care, all in the comfort of wearing pajamas, we have telehealth delivered palliative care. However, lack of physical presence may make this contender struggle to land the emotional support punch that is at the very heart of palliative care.
Who will emerge victorious? Will in-person palliative care use its experience and bedside manner to overwhelm telehealth palliative care, or will telehealth deliver the knockout blow of efficiency and accessibility?
Find out on this week’s podcast where we invite Joseph Greer, Simone Rinaldi, and Vicki Jackson to talk about their recent JAMA article on “Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer - A Multisite Randomized Clinical Trial.”
Additionally, here are some of the resources we talked about during the podcast:
Eduardo Bruera’s editorial that accompanies the JAMA paper titled “Improving Palliative Care Access for Patients With Cancer”
Our podcast on Stepped Palliative Care with Jennifer Temel, Chris Jones, and Pallavi Kumar
The book “What's in the Syringe? Principles of Early Integrated Palliative Care” by Juliet Jacobsen, Vicki Jackson, Joseph Greer, and Jennifer Temel
Lastly, don’t forget about attending some of the sessions Vicki mentioned at the end of the podcast during the HPNA/AAHPM annual meeting in Denver, as well as the GeriPal #HPMParty Pub Crawl! -
It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes.
In our first segment, we discuss a study led by Constance Fung and her team, which investigated the use of a masked tapering method combined with augmented cognitive behavioral therapy for insomnia (CBTI) to help patients discontinue benzodiazepines. The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts.
Next, we turn to Emily McDonald, the director of the Canadian Medication Appropriateness and Deprescribing Network, to discuss her study on the impact of direct-to-consumer educational brochures on gabapentin deprescribing. Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see here for the brochure). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use.
In our third segment, we explore Amy Linsky’s study that examined the effect of patient-directed educational materials on clinician deprescribing of potentially low-benefit or high-risk medications, such as proton pump inhibitors, high-dose gabapentin, or risky diabetes medications. The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click here for the brochure). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety.
Finally, we discuss Michelle Odden’s study, which used a target trial emulation approach to investigate the effects of deprescribing antihypertensive medications on cognitive function in nursing home residents. The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast (DANTE and OPTIMIZE) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the DANTON study adds more questions to that conclusion.
Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research!
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Many older adults lose decision-making capacity during serious illnesses, and a significant percentage lack family or friends to assist with decisions. These individuals may become “unrepresented,” meaning they lack the capacity to make a specific medical decision, do not have an advance directive for that decision, and do not have a surrogate to help.
In today’s podcast, we talk with Joe Dixon, Timothy Farrell, and Yael Zweig, authors of the AGS position statement on making medical treatment decisions for unrepresented older adults. We define “unrepresented” and address the following questions:
What is the scope of the unrepresented problem?
Why not use the older term “unbefriended”?
How should we care for unrepresented individuals in inpatient and outpatient settings?
What can we do to prevent someone from becoming unrepresented?
Find answers to these questions and more in this week’s podcast. Listen in, and if you’re interested, explore the topic further with the following resources:
AGS Position statement on making medical treatment decisions for unrepresented older adults
VA Policy on Advance Care Planning and on Informed Consent
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We’ve talked a lot before about integrating psychiatry into palliative care (see here and here for two examples). Still, we haven’t talked about integrating palliative care into psychiatry or in the care of those with severe mental illness.
On this week’s podcast, we talk with two experts about palliative psychiatry. We invited Dani Chammas, a palliative care physician and psychiatrist at UCSF (and a frequent guest to the GeriPal podcast), as well as Brent Kious, a psychiatrist at the Huntsman Mental Health Institute, focusing on the management of severe persistent mental illnesses.
We discuss the following:
What is Palliative Psychiatry (and how is it different from Palliative Care Psychiatry)?
What does it look like to take a palliative approach to severe mental illness?
Is "terminal" mental illness a thing?
Is hospice appropriate for people with serious mental illness (and does hospice have the skills to meet their needs?)
Controversy over Medical Aid in Dying for primary psychiatric illness (and for those with serious medical illness who have a comorbid psychiatric illness)
The level of provider moral distress that can be created in a system not designed to meet the needs of specific populations... and when we are asked to meet a need we don't feel equipped to meet.
Here are a couple of articles if you want to do a deeper dive:
Dani and colleagues article on “Psychiatry and Palliative Care: Growing the Interface Through Education.”
Dani and colleagues article on “Palliative Care Psychiatry: Building Synergy Across the Spectrum.”
Brent’s article on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?”
A NY Times article titled “Should Patients Be Allowed to Die From Anorexia?”
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Surrogate decision making has some issues. Surrogates often either don’t know what patients would want, or think they know but are wrong, or make choices that align with their own preferences rather than the patients. After making decisions, many surrogates experience regret, PTSD, and depressive symptoms. Can we do better?
Or, to phrase the question for 2024, “Can AI do better?” Follow that path and you arrive at a potentially terrifying scenario: using AI for surrogate decision making. What?!? When Teva Brender and Brian Block first approached me about writing a thought piece about this idea, my initial response was, “Hell no.” You may be thinking the same. But…stay with us here…might AI help to address some of the major issues present in surrogate decision making? Or does it raise more issues than it solves?
Today we talk with Teva, Dave Wendler, and Jenny Blumenthal-Barby about:
Current clinical and ethical issues with surrogate decision making
The Patient Preferences Predictor (developed by Dave Wendler) or Personalized Patient Preferences Predictor (updated idea by Brian Earp) and commentary by Jenny
Using AI to comb through prior recorded clinical conversations with patients to play back pertinent discussions; to predict functional outcomes; and to predict patient preferences based on prior spending patterns, emails, and social media posts (Teva’s thought piece)
A whole host of ethical issues raised by these ideas including the black box nature, the motivations of private AI algorithms run by for profit healthcare systems, turning an “is” into an “ought”, defaults and nudges, and privacy.
I’ll end this intro with a quote from Deb Grady in an editor’s commentary to our thought piece in JAMA Internal Medicine about this topic: “Voice technology that creates a searchable database of patients’ every encounter with a health care professional? Using data from wearable devices, internet searches, and purchasing history? Algorithms using millions of direct observations of a person’s behavior to provide an authentic portrait of the way a person lived? Yikes! The authors discuss the practical, ethical, and accuracy issues related to this scenario. We published this Viewpoint because it is very interesting, somewhat scary, and probably inevitable.”
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We’ve covered stories before. With Liz Salmi, Anne Kelly, and Preeti Malani we talked about stories written up in the academic literature, such as the JAMA Piece of My Mind series. We talked with Thor Ringler, who helped found the My Life My Story Project at the VA and beyond, and Heather Coats about the evidence base for capturing patient stories.
Today’s podcast is both similar and different. Similar in that the underlying theme of the power of stories. Different in that these storytelling initiatives, the Nocturnists and the Palliative Story Exchange, are focused on clinicians sharing stories with each other in small groups to heal. There’s something magical that happens in small group storytelling. It’s that mixture of intimacy and vulnerability, of shared clinical experiences, that fosters a sense of belonging. We model that small group storytelling experience today.
We discuss:
The “origin stories” of the Nocturnists Live Show and Podcast and the Palliative Story Exchange
The process for story creation and development, written in advance or not, feedback or not after the story, and the aims and goals of each initiative
And we each tell a short story, modeling the process for The Nocturnists and the Palliative Story Exchange for our listeners
These initiatives arose organically from clinicians as part of a journey away from burnout, moral distress, shame, and loneliness toward healing, wholeness, gratitude, and belonging. A journey taken one story at a time.
One final note on the song request: About 20 years ago I took an epidemiology course as part of a Masters program. The instructor, Fran Cook, gave all the students a survey without explanation. We answered the survey and handed it in. One of the questions was, “Can you name a song by the Tragically Hip?” It later turned out the survey was a prognostic index designed to determine if the respondent was Canadian.
-@AlexSmithMD
Here’s a link to an article about the Palliative Story Exchange.
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