GeriPal - A Geriatrics and Palliative Care Podcast

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:   Cynda Rushton, PHD, MSN, RN — Transforming Moral Distress into Moral Resilience https://www.youtube.com/watch?v=L1gE5G8WnTU Tricia Hersey: Rest & Collective Care as Tools for Liberation https://www.youtube.com/watch?v=7OuXnLrKyi0 Beyond resiliency: shifting the narrative of medical student wellness https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/ 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 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

We’ve talked about Brain Death before with Robert (Bob) Troug and guest-host Liz Dzeng, and in many ways today’s podcast is a follow up to that episode (apologies Bob for mispronouncing your last name on today’s podcast!). Why does this issue keep coming up?  Why is it unresolved?  Today we put these questions to Winston Chiong, a neurologist and bioethicist, and Sean Aas, a philosopher and bioethicist.  We talk about many reasons and ways forward on this podcast, including: The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI.  (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a  re-evaluation of what it means to be human, or deserving of moral standing). The moral questions at stake vs the biologic questions (and links between them) The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story) What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others. Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions. As we joke about at the start - talking with philosophers and bioethicists, you almost always get a response along the lines of, “well that’s a good question, but let’s examine a deeper more fundamental question.”  Today is no different. And the process of identifying the right questions to ask is absolutely the best place to start.   Eventually, of course, everything must cease.   -@AlexSmithMD

Anti-Asian hate incidents rose dramatically during COVID, likely fueled by prominent statements about the “Chinese virus.”  VIewed through the wider lens of history, this was just the latest in a long experience of Anti-Asian hate, including the murder of Vincent Chin, the Chinese Exclusion Act, and the internment of Japanese Americans during WWII.  For those who think that anti-Asian hate has receded as the COVID has “ended,” just two days prior to recording this episode a Filipino woman was pushed to her death on BART in San Francisco. These incidents are broadcast widely, particularly in Asian News outlets. Today we talk about the impact of anti-Asian hate on the health and well being of older adults with Russell Jeung, sociologist, Professor of Asian Studies at San Francisco State, and co-founder of Stop AAPI-Hate, Lingsheng Li, geriatrician/palliative care doc and T32 fellow at UCSF, and Jessica Eng, medical director of On Lok, a PACE, and Associate Professor in the UCSF Division of Geriatrics.  We discuss: What is considered a hate incident, how is it tracked, what do we know about changes over time The wider impact of Anti-Asian hate on older Asians, who are afraid to go out, leading to anxiety, social isolation, loneliness, decreased exercise, missed appointments and medications. Lingsheng (and I) recently published studies on this in JAMA Internal Medicine, and JAGS. Ongoing reports from patients about anti-Asian hate experiences  Should clinicians screen for Anti-Asian hate? Why? Why not? Proposing the clinicians ask a simple follow up question to the usual “do you feel safe at home?” question used to screen for domestic violence.  Add to this, “do you feel safe outside the home?” This question, while providing an opportunity to talk about direct and indirect experiences, can be asked of all patients, and opens the door to conversations about anti-semitism, islamophobia, or anti-Black racism. See also guides for how to confront and discuss anti-Asian hate in these articles in the NEJM and JGIM. And to balance the somber subject, Lingsheng requested the BTS song Dynamite, which was the group’s first English language song, and was released at the height of the COVID pandemic.  I had fun trying to make a danceable version with electronic drums for the audio-only podcast.  Maybe we’ll get some BTS followers to subscribe to GeriPal?!?   -@AlexSmithMD  

(We couldn’t resist when Miguel Paniagua proposed this podcast idea and title. And no, you’ll be relieved to hear Eric and I did not imitate the interview style of Zach Galifiniakis). We’ve talked a good deal on this podcast about what happens before death, today we talk about what happens after.  Our guest today is Thomas Lynch, a poet and undertaker who practiced for years in a small town in Michigan.  I first met Thomas when he visited UC Berkeley in the late 90’s after publishing his book, “The Undertaking: Stories from the Dismal Trade.” We cover a wide range on this topic, weaving in our own stories of loss with Thomas’s experiences, stories, and poems from years of caring for families after their loved one’s have died. We cover: The cultural shift from grieving to celebration, the “disappearance” of the body and death from funerals The power of viewing the body and participating in preparing the body, including cremation The costs of funerals  The story of why Thomas became an undertaker A strong response to Jessica Mitford’s scathing critique of the American Funeral Industry published in “The American Way of Death” Our own experiences with funerals and burial arrangements for our loved ones Shifting practices, with a majority of people being cremated after death, a dramatic increase This podcast was like therapy for us.  And I got to sing Tom Waits’ Time, one of my favorites.   

What is a healthy diet and how much does it really matter that we try to eat one as we age?  That’s the topic of this week's podcast with three amazing guests: Anna Pleet, Elizabeth Eckstrom, and Emily Johnston. Emily Johnston is a registered dietitian, nutrition researcher, and Assistant professor at NYU.  Anna Pleet is an internal medicine resident at Allegheny Health Network who has a collection of amazing YouTube videos on aging and the Mediterranean diet. Elizabeth Eckstrom is a geriatrician, professor of medicine at OHSU, and author of a new book, the Gift of Aging. I love this podcast as while we talk about the usual topics in a medical podcast, like the role of screening, energy balance, and evidence-based for specific diets, we also talk about what a Mediterranean diet actually looks like on a plate and pepper our guests with questions about their favorite meals to convince Alex and me to eat more like a Sardinian. Eric PS.  NEJM just published a great summary of diets summing up adherence to the Mediterranean diet and the following improved health outcomes: death from any cause, cardiovascular diseases, coronary heart disease, myocardial infarction, cancer, neurodegenerative diseases, and diabetes    

We are dusting off our crystal balls today with three amazing guests who have all recently published an article on prognosis over the last couple months: Kara Bischoff, James Deardorff, and Elizabeth Lilley. To start us off we talk with Kara Bischoff about the article she just published in JAMA Network on a re-validation of the Palliative Performance Scale (PPS) in a modern day palliative care setting.  Why do this?  The PPS  is one of the most widely used prognostic tools for seriously ill patients, but the prognostic estimates given by the PPS are based on data that is well over a decade old. ePrognosis now includes the modern validation of the PPS. Next, we talk with James Deardorff about whether we can accurately predict nursing home level of care in community-dwelling older adults with dementia.  Spoiler alert, he published a study in JAMA IM on a prognostic index that does exactly that (which is also on eprognosis.org) Lastly, we invite Liz Lilley to talk about her paper in Annals of Surgery about prognostic allignment, including why as palliative care and geriatrics teams we need to take time to ensure that all disciplines and specialities are prognostically aligned before a family meeting.  

The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies?  Should it?  If so, how do we screen and who do we screen? On this week’s podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist.  Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia. In addition to the questions asked above, we also cover the following topics with our guests: What is dementia screening?  Who should get it if anyone? What should we use to screen individuals? What happens after they test positive? And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.  

Emergency podcast! We’ve been asked by many people, mostly junior/mid career faculty, to quickly record a podcast on ageism and the elections.  People are feeling conflicted.  On the one hand, they have concerns about cognitive fitness of candidates for office.  On the other hand, they worry about ageism.  There’s something happening here, and what it is ain’t exactly clear. We need clear eyed thinking about this issue. In today’s podcast, Louise Aronson, author of Elderhood, validates that this conflict between being concerned about both fitness for the job and alarmed about ageism is exactly the right place to be.  We both cannot ignore that with advancing age the prevalence of cognitive impairment, frailty, and disability increase.  At the same time, we can and should be alarmed at the rise in ageist language that equates aging with infirmity, and images of politicians racing walkers or a walker with the presidential seal.  Ken Covinsky reminds us that we should not be making a diagnosis based on what we see on TV, and that if a patient’s daughter expressed a concern that their parent “wasn’t right,” we would conduct an in depth evaluation that might last an hour.  Eric Widera reminds us of the history of the Goldwater Act created by the American Psychological Association in the 1960s which states that psychiatrists should refrain from diagnosing public figures, and the American Medical Association code of ethics which likewise discourages armchair diagnosis (rule established in 2017). We frame today’s discussion around questions our listeners proposed in response to our Tweets, and are grateful for questions from Anand Iyer, Sandra Shi, Mike Wasserman, Ariela Orkaby, Karen Knops, Jeanette Leardi, Sarah McKiddy, Cecilia Poon, Colleen Christmas, and Kai Smith. We talk about positive aspects of aging, cognitive screening, the line between legitimate concerns and ageism, ableism, advice for a geriatrician asked to comment on TV, frailty and physical disability, images in the press, historical situations including , and an upper age limit for the Presidency, among other issues. Of note, we talk about candidates from all parties today.  We acknowledge concerns and speculation that others have raised about candidates across the political spectrum, current and former.  We do not endorse or disclose our personal attitudes toward any particular candidate.  Fitness for public office is a non-partisan issue that applies to all candidates for office, regardless of political party. There’s something happening here, and what it is ain’t exactly clear. Strong recommendation to also listen to this terrific podcast with another geriatrician all star, Jim Pacala, on MPR! -@AlexSmithMD  

In May we did a podcast on KidneyPal (the integration of palliative care in renal disease), which made us think, hmmm… one organ right next door is the liver. Maybe we should do a podcast on LiverPal? (or should we call it HepatoPal?) On today’s podcast, we do that by inviting four palliative care leaders who are integrating palliative care into the care of those with liver disease: Kirsten Engel, Sarah Gillespie-Heyman, Brittany Waterman, and Amy Johnson. It’s a jampacked 50 minutes, filled with pearls on taking care of patients with liver disease.  We cover: How each of their LiverPal teams are structured Why and how LiverPal differ from general palliative care or other palliative care specialty areas (KidneyPal, PalliPulm, etc) How to prognosticate in liver disease and how they communicate this with patients How to think about expectations of transplants and limitations of it How to manage complications and symptoms ranging from ascites, hepatic encephalopathy, pain, itching, cramps, and depression Also, if you want to take an ever deeper dive, check out our 2022 podcast on End Stage Liver Disease with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel

“Anxiety is a lot like a toddler. It never stops talking, tells you you’re wrong about everything, and wakes you up at 3 a.m.”  I’m not sure who wrote this quote, but it feels right to me. We’ve all had anxiety, and probably all recognize that anxiety can be a force of action or growth but can also spiral to quickly take over our lives and our sleep. How, though, do we navigate anxiety and help our patients who may end up in the anxiety spiral that becomes so hard to get out of? On today’s podcast, we’ve invited Alex Gamble and Brianna Williamson to talk to us about anxiety. Alex is a triple-boarded (palliative care, internal medicine, and psychiatry) assistant professor of medicine at Stanford. Brianna is one of UCSF’s palliative care fellows who just completed her psychiatry residency. We start by defining anxiety (harder said than done), move on to talking about when it becomes maladaptive or pathologic, and how DSM5 fits into all of this. We then walk through how we should screen for anxiety and how we should think about a differential.  Lastly, we talk about both non-pharmacologic and pharmacologic treatments. It’s a lot to cover in 45 minutes, so for those who like to take a deeper dive, here are some of the references we talked about: Alex Sable-Smith’s great BATHE video on YouTube:  Two books that Alex Gamble often recommends to patients can help build up your capacities to sit with anxiety (per Alex, both are from an Acceptance and Commitment Therapy framework) Things Might Go Terribly, Horribly Wrong: A Guide to Life Liberated from Anxiety The Reality Slap