GeriPal - A Geriatrics and Palliative Care Podcast

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  

I have to start with the song.  On our last podcast about urinary incontinence the song request was, “Let it go.”  This time around several suggestions were raised.  Eric suggested, “Even Flow,” by Pearl Jam.  Someone else suggested, “Under Pressure,” but we’ve done it already.  We settled on, “Oops…I did it again,” by Britney Spears. In some ways the song title captures part of the issue with urinary incontinence.  If only we lived in a world in which much of urinary incontinence was viewed as a natural part of aging, the normal response wasn’t embarrassment and shame, but rather an ordinary, “Oops…I did it again.”  And if only we lived in a world in which this issue, which affects half of older women and a third of older men, received the research and attention it deserves. We shouldn’t have therapeutic nihilism about those who seek treatment, yet urinary incontinence is woefully understudied relative to its frequency and impact, and as we talk about on the podcast, basic questions about urinary incontinence have yet to be addressed. I don’t see those perspectives as incompatible. Today we talk with George Kuchel and Alison Huang about: Urinary incontinence as a geriatric syndrome and relationship to frailty, disability, and cognitive decline Assessment of incontinence: the importance of a 48 hour voiding diary, when to send a UA (only for acute changes) How the assessment leads naturally to therapeutic approaches Non-pharmacologic approaches including distraction, scheduled voiding, and pelvic floor therapy “Last ditch” pharmacologic treatments.  Landmark studies by Neil Resnick and Joe Ouslander.   Enjoy! -@AlexSmithMD   

I always find cachexia in serious illness puzzling. I feel like I recognize it when I see it, but I struggle to give a clear definition or provide effective ways to address it. In today's podcast, we had the opportunity to learn from a renowned expert in palliative care, Eduardo Bruera, about cachexia and anorexia in serious illness. Eduardo established one of the first palliative care programs in 1984, created the Edmonton Symptom Assessment Scale (ESAS), and significantly contributed to the evidence base for palliative care symptoms that many of us rely on daily. During our discussion with Eduardo, we delved into how we can define cachexia and anorexia, why they occur in conditions like cancer, how to assess for them, and explored the interventions that are helpful and those that are not in the treatment of these conditions.

As Eric notes at the end of today’s podcast, we talk about many difficult issues with our patients.  How long they might have to live. Their declining cognitive abilities. What makes their lives meaningful, brings them joy, a sense of purpose.  But one issue we’re not as good at discussing with our patients is sexual health. On today’s podcast Areej El-Jawahri, oncologist specializing in blood cancers at MGH, says that sexual health is one of the top if not the top issue among cancer survivors.  Clearly this issue is important to patients.  Sharon Bober, clinical psychologist at DFCI, notes that clinicians can get caught in an anxiety cycle, in which they are afraid to ask, don’t ask, then have increased anxiety about not asking.  Like any other conversation, you have to start, and through experience learn what language is comfortable for you.  Don Dizon, oncologist specializing in pelvic malignancies at Brown, suggests speaking in plain language, starting by normalizing sexual health issues, to paraphrase, “Many of my patients experience issues with intimacy and sexual health. Is that an issue for you? I’m happy to talk about it at any time.”  All guests agree that clinicians feel they need to have something they can do if they open Pandora's box.  To that end, we talk about practical advice, including: The importance of intimacy over and above physical sexual function for many patients Common causes and differential diagnoses of sexual concerns in patients with cancer and survivors Treatments for erectile dysfunction - first time the words “cock ring” have been uttered on the GeriPal Podcast - and discuss daily phosphodiesterase 5 inhibitor therapy vs prn The importance of a pelvic exam for women experiencing pain What is “pelvic physical therapy?” Treatments for vaginal dryness and atrophy ACS links, NCCN links, Cancersexnetwork, and a great handout that Areej created And I get to sing Lady Gaga, also a first for GeriPal!  And let me tell you, there’s nothing like the first time (sorry, I couldn’t help it!).

The landscape of options for treating people with kidney failure is shifting.  It used to be that the “only” robust option in the US was dialysis.  You can listen to our prior podcast with Keren Ladin talking about patients who viewed dialysis as their only option, and structural issues that led to this point (including this takedown of for profit dialysis companies by John Oliver).  One of the problems was a lack of an alternative robust option to offer patients.  As one of our guests says, you have to offer them something viable as an alternative to dialysis. Today we interviewed Sam Gelfand, dually trained in nephrology and palliative care, Kate Sciacca, a nurse practitioner (fellowship trained in palliative care), and Josh Lakin, palliative care doc, who together with a social worker and other team members started KidneyPal at DFCI/BWH, a palliative care consult service for people with advanced kidney disease.  As a team, they provide a robust alternative to dialysis for patients with kidney failure: conservative kidney management. And “conservative,” as they note, can mean not only a “conservative approach,” as in non-invasive/less aggressive, but also an effort to “conserve” what kidney function remains. We get right down to the nitty gritty of kidney supportive care techniques they incorporate in clinic, including: Communication about the choice between dialysis and conservative kidney management: what are the tradeoffs?  Function often declines after initiating dialysis, at least among nursing home residents. Dialysis may extend life, but those “additional” days are often spent in the hospital or dialysis, away from home. Symptoms are common in both options, though more anxiety and cramping in dialysis, more pruritus and nausea in conservative kidney management.. Introducing the idea of hospice early, at the time of diagnosis with kidney failure. Listen also to our prior podcast with Melissa Wachterman on hospice and dialysis. Approaches to treating fatigue Approaches to treating pain - the second most common symptom (!) - and the answer isn’t tramadol (or tramadon’t) - rather think buprenorphine patch or methadone, and how to dose gabapentin and pregabalin. Also, don’t count out the NSAIDS! Approaches to treating itching/pruritus Approaches to treating nausea Our guests were deeply grateful to their colleagues Dr. Frank Brennan, Dr. Mark Brown, and clinical nurse consultant Elizabeth Josland of the renal supportive care team at St. George Hospital in Sydney, Australia (down under) for teaching them the ropes of palliative care in kidney failure.  And we got to learn some new vocabulary, including the meaning of “chunder.”  Enjoy! -@AlexSmithMD  

Who gets to decide on what it means to have a disease? I posed this question a while back in reference to Alzheimer's disease. I’ll save you from reading the article, but the main headline is that corporations are very much the “who” in who gets to define the nature of disease. They do this either through the invention of disease states or, more often, by redrawing the boundaries of what is considered a disease (think pre-diabetes). On today's podcast, we invite Adriane Fugh-Berman to discuss the influence of industry, whether it be pharma or device manufacturers, on healthcare. Adriane founded PharmedOut, a Georgetown University Medical Center project that “advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices.” I’ve listened to a lot of Adriane’s talks. It is clear to me that she is not anti-medicine or even anti-pharma but is very much against both the visible and hidden influences that pharma and device manufacturers use to sell their products.  This could be through overt marketing like advertisements or drug rep visits, or more covert measures like unrestricted grants to advocacy organizations, funding of CME, paying “key opinion leaders,” or the development of “disease awareness campaigns.” So take a listen and dont worry, while GeriPal podcasts offer CME, we never take money from industry. By: Eric Widera      

On today’s podcast, we’ve invited four hospice and palliative care social media influencers (yes, that’s a thing!), all of whom focus their efforts on educating the general public about living and dying with a serious illness. Their work is pretty impressive in both reach (some of their posts are seen by millions of viewers) and breadth of work.  We’ve invited: Julie McFadden (aka Hospice Nurse Julie): Julie is a social media superstar, with 1.5 million subscribers on TikTok, another 400,000 subscribers on her YouTube channel, and another 350k followers on Instagram. She covers topics on death, dying, and hospice from a hospice nurse perspective, and she also has a book coming out called “Nothing to Fear: Demystifying Death to Live More Fully,” which is now available for pre-order.   Matt Tyler (aka Pallidad for those on Twitter): Matt is the Hospice and Palliative care doctor who created How To Train Your Doctor, which helps patients living with serious illness find tips on “owning” their healthcare plan on his Instagram and  YouTube pages.  He was also the one who we have to thank for suggesting this podcast! Hsien Seow & Samantha (“Sammy”) Winemaker: Hsein and Sammy's goal was to start a revolution with their podcast “The Waiting Room Revolution,” which is now in its 7th season! The hope was by going directly to those living with a life-changing illness, we could directly tackle the question that comes up so many times - “Why didn’t anyone tell me that sooner…”  They also just published a book,” Hope for the Best, Plan for the Rest,” and Sammy is a TikTok star in her own right, with some posts having over a million views. We covered a lot of topics in the podcast from::  What motivated them to create public-facing social media channels? Why focus on the public rather than other health care providers? How do they deal with professional barriers and the barrage of comments? Advice for others who might want to dabble in social media outreach   So, take a listen and check out their social media sites to get inspired. Just don't let Alex make me do another TikTok dance…   Eric Widera  

As Betty Ferrell says on our podcast today, nurses play an essential role in care of people with serious illness.  Who spends the most time with the patient in the infusion center? Doing home care? Hospice visits? In the ICU at the bedside?  Nurses. ELNEC (End-of-Life Nursing Education Consortium) celebrates it’s 25th anniversary in 2025.  We talk today with Betty Ferrell, who has been a nurse for 47 years, and is the founder and PI of ELNEC. As I argue on the podcast, ELNEC has likely done more to lift the primary palliative care skills of clinicians than any other initiative.  Full stop.  Some numbers to back it up: ELNEC has trained more than 48,000 providers in a train the trainer model Over 1.5 million clinicians have been educated in ELNEC  ELNEC curricula are integrated int 1180 undergraduate and 394 graduate Schools of Nursing ELNEC has been taught in over 100 countries Today we talk about the origin story of ELNEC, the special role of nurses in palliative care, empowering as well as educating nurses, interprofessional ELNEC training, and opportunities and challenges ELNEC faces over the next 25 years. Enjoy! -@AlexSmithMD  

Eric asks the question that is on many of our minds - is the future of AI more Skynet from Terminator, in which AI takes over the world and drives humanity to the brink of extinction, or Wall-E, in which a benevolent and empathetic AI restores our humanity? Our guest today is Bob Wachter, Chair of Medicine at UCSF and author of the Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.  Bob recently wrote an essay in JAMA on AI and delivered a UCSF Grand Rounds on the same topic.  We discuss, among other things: Findings that in several studies AI was rated by patients as more empathetic than human clinicians (not less, that isn’t a typo). Turns my concern about lack of empathy from AI on its head - the AI may be more empathetic than clinicians, not less. Skepticism on the ability of predictive models to transform healthcare Consolidation of EHR’s into the hands of a very few companies, and potential for the drug and device industry to influence care delivery by tweaking AI in ways that are not transparent and already a sort of magical black box. AI may de-skill clinicians in the same way that autopilot deskilled pilots, who no longer new how to fly the plane without autopilot A live demonstration of AI breaking a cancer diagnosis to a young adult with kids (VITAL Talk watch out) Use cases in healthcare: Bob predicts everyone will use digital scribes to chart within two years Concerns about bias and other anticipated and unanticipated issues And a real treat- Bob plays the song for this one!  Terrific rendition of Tomorrow from the musical Annie on piano (a strong hint there about Bob’s answer to Eric’s first question).  Enjoy! -@AlexSmithMD  

Ambivalence is a tough concept when it comes to decision-making. On the one hand, when people have ambivalence but haven't explored why they are ambivalent, they are prone to bad, value-incongruent decisions. On the other hand, acknowledging and exploring ambivalence may lead to better, more ethical, and less biased decisions. On today's podcast, Joshua Briscoe, Bryanna Moore, Jennifer Blumenthal-Barby, and Olubukunola Dwyer discuss the challenges of ambivalence and ways to address them. This podcast was initially sparked by Josh’s “Note From a Family Meeting” Substack post titled “Ambivalence in Clinical Decision-Making,” which discussed Bryanna’s and Jenny’s 2022 article titled “Two Minds, One Patient: Clearing up Confusion About Ambivalence." Bryanna’s and Jenny’s article is particularly unique as it discusses these “ambivalent-related phenomena” and that these different kinds of “ambivalence” may call for different approaches with patients, surrogates (and health care providers): In addition to defining these “ambivalent related phenomena” we ask our guests to cover some of these topics: Is ambivalence good, bad, or just a normal part of decision-making? Does being ambivalent mean you don’t care about the decision? What should we be more worried about in decision-making, ambivalence or the lack thereof? The concern about resolving ambivalence too quickly, as it might rush past important work that needs to be done to make a good decision. What about ambivalence on the part of the provider?  How should we think about that? How do you resolve ambivalence? Lastly, the one takeaway point from this podcast is that the next time I see ambiguity (or have it myself), I should ask the following question: “I see you are struggling with this decision. Tell me how you are feeling about it.”  

In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative state.  In 1988, Cruzan’s parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan’s was Ken Starr, who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc). In 1990 the Supreme Court ruled…for the state of Missouri.  On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions.  Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan’s eventually cleared.  Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients. Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan.  We use Bernie’s NEJM Perspective as a springboard for discussion.  We discuss, among other things: How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions And validating the importance of the advance directive forms in some circumstances, and in starting conversations The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use? Is the POLST useful? How? Under what circumstances?  Should we abandon the term, “comfort measures?” In case you miss the introductions at the start of the podcast, Bernie and Laurie are married, and offer wonderful reminiscence of their clinical practice over the last several decades.  So when Bernie says, “I’ve heard you take these phone calls in the middle of the night, Laurie…” Now you know why! And great song choice: Both Sides Now by Joni Mitchell.  Joni suffered a stroke and had to completely re-learn how to play guitar.  Her comeback performances are inspirational, such as this one at the Newport Folk Festival, attended by another influential GeriPal couple, Sean Morrison and Diane Meier. You get to hear my stripped down Hawaiian slack key style version of Both Sides Now (easy to play with 2 fingers, still in rehab for broken hand, hoping to have full use again soon). Enjoy! -@AlexSmithMD  

One marker of the distance we’ve traveled in palliative care is the blossoming evidence base for the field. Ten years ago we would have been hard pressed to find 3 clinical trial abstracts submitted to the annual meeting, much less high quality randomized trials with robust measures, sample sizes, and analytics plans.  Well, as a kick off to this year’s first in-person State of the Science plenary, held in conjunction with the closing Saturday session of the AAHPM/HPNA Annual Assembly, 3 randomized clinical trials were presented. Today we interview the authors of these 3 abstracts about their findings: Tom LeBlanc about a multisite trial of palliative care for patients undergoing Stem Cell Transplant for blood cancers (outcomes = quality of life, depression, anxiety) Kate Courtright about a pragmatic trial of electronic nudges to prognosticate and/or offer comfort-focused treatment to mechanically ventilated ICU patients/surrogates (outcomes = lengths of stay, hospice, time to discontinuation of life-support) Corita Grudzen on a pragmatic trial of two palliative care approaches for patients with advanced cancer or organ failure discharged from the ED: a nurse-led telephone intervention or outpatient specialty palliative care clinic (outcomes = quality of life, symptom burden, loneliness, healthcare utilization) Wow! I’m just stunned even writing that! We’ve come so far as a field. This isn’t to say we’ve “made it” - more to say that we’ve reached a new stage of maturation of the field - in which the evidence we are discussing is frequently high quality randomized trial level data.  We recorded this on Friday during the annual assembly, and Eric and I were a littttttle off our game due to the residual effects of the GeriPal pub crawl the night before, which were only compounded by technical difficulties.  I believe these issues were more than made up for by our guests' forced accompaniment to the song “Feel Like Making Science.” (Credit to the Beeson singing crew for coming up with that one). Enjoy! -@AlexSmithMD  

What is frailty? Kate Callahan relates a clear metaphor on today’s podcast.  A frail person is like an origami boat: fine in still water, but can’t withstand a breeze, or waves.  Fundamentally, frailty is about vulnerability to stress. In 2021 we talked with Linda Fried about phenotypic frailty.  Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty.  What is the difference, you ask?  George Kushel probably explained it best in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers.  Damage to those critical functions and the bridge can collapse.  Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK.  But miss a bunch and things fall apart.  Resilience is the ability of the bridge to withstand stress, like bridge traffic,  wind, waves, and the occasional earthquake (hey it’s California!). Frailty research has come a long way.  We’re now at a point where frailty can be measured automatically, or electronically, as we put in the title.  Kate created an eFrailty tool that measures frailty based on the electronic health record (EHR) data.  Ariela created a VA frailty index based on the EHR of veterans.  And Dae created an index using Medicare Claims.  Today we’re beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients. We should not get too hung up on battles over frailty.  As Kate writes in her JAGS editorial, “If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed.” To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings.  It’s called eFrailty, check it out now! Did I cheat and play the guitar part for Sting’s Fragile at ⅔ speed then speed it up?  Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break! -@AlexSmithMD    Additional Links: eFrailty website is: efrailty.hsl.harvard.edu (efrailty.org is fine). Dae’s Frailty indexesCGA-based frailty index web calculator for clinical use: https://www.bidmc.org/research/research-by-department/medicine/gerontology/calculator The Medicare claims-based frailty index program for research: https://dataverse.harvard.edu/dataverse/cfi/ Ariela’s VA-FI:Original VA frailty index: https://academic.oup.com/biomedgerontology/article/74/8/1257/5126804 ICD-10 version https://academic.oup.com/biomedgerontology/article/76/7/1318/6164923 Link to the code for investigators (included in the appendix): https://github.com/bostoninformatics/va_frailty_index  As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource (CIPHER) Recent validation against clinical measures of frailty: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18540 Kate’s eFrailty Index https://doi.org/10.1093/gerona/glz017 our original eFI paper https://doi.org/10.1111/jgs.17027 &  https://doi.org/10.1001/jamanetworkopen.2023.41915 on eFI and surgery https://doi.org/10.1111/jgs.17510 editorial in JAGS  

Almost a decade ago, our hospice and palliative care team decided to do a “Thickened Liquid Challenge.”  This simple challenge was focused on putting ourselves in the shoes of our patients with dysphagia who are prescribed thickened liquids.  The rules of the challenge were simple: fluids must be thickened to “honey consistency” using a beverage thickener for a 12-hour contiguous period. All of us failed the challenge. We then decided to challenge others and asked them to post their videos online using the hashtag #thickenedliquidchallenge.  Here are some of the results of those videos: https://geripal.org/the-thickened-liquid-challenge/ On today’s podcast, we revisit dysphagia and thickened liquids with two researchers and speech-language pathologists, Raele Donetha Robison and Nicole Rogus-Pulia.  We talk with them about the epidemiology, assessment, and management of dysphagia, including the role of modifying the consistency of food and liquids, feeding tubes, and the role of dysphagia rehabilitation like tongue and cough strengthening.  We also talk about the importance of a proactive approach to involving speech-language pathologists in the care of individuals early on with neurodegenerative diseases like dementia and ALS. If you want to take a deeper dive, take a look at these articles: A nice overview of swallowing disorders in the older adults published in JAGS A study in JAGS showing that 89% of feeding tubes inserted during hospitalization were in patients with no preexisting dysphagia Nicole’s article on shifting to a proactive approach of dysphagia management in neurodegenerative disease  

In the last several years, I’ve seen more and more articles about end-of-life doulas (like this NY Times article from 2021). Despite this, in my 20-year career as a palliative care physician, I have yet to see a death doula in the wild. I’m unsure what they do, how often they’re used, and who pays for their work. So, on today’s podcast, we try to get to the bottom of what exactly is an end-of-life doula. We’ve invited two death doulas, Jane Euler and John Loughnane (who is also a family doc and palliative care physician), to talk about the role of a doula at the end of life.  We also invited Beth Klint to speak about the doula's role within a traditional hospice organization. Why Beth?  In addition to being a palliative and hospice RN, she is the Executive Director for Goodwin Hospice, a large non-profit hospice that added end-of-life doula care to their services in collaboration with Jane and John’s doula organization, Present for You. If you are interested in learning more about death doulas, check out the following links Goodwin Hospice’s article on the collaboration with Present for You A HospiceNews article talking about the value proposition of death doulas for hospices NHPCO’s End-of-Life Doula Council page that includes a lot of great links  

Today we celebrate eight years, around 2 million listens, and 300 podcasts!    Eric and I take questions from you, our listeners, about: why we podcast, our most controversial podcast, which podcast changed our practice, favorite song request, should all nursing home residents complete the POLST, expanding access to durable medical equipment, palliative care in rural regions, do we have an advance directive, what we’d do to improve healthcare with 7 trillion dollars, treatment for poor appetite, and Eric on how to make a latte.  Thank you to Lynn Flint and Anne Kelly who serve as hosts for this episode, asking us the tough questions. We answer your questions hot ones style.  I borrowed some screaming hot sauces from my friends Jerome Kim and Tony Le, and added them to my small collection of extra mild sauces.  Every two questions we ate a chicken wing covered in hot sauce. The hot sauces progressed from mild to extreme (and I mean extreme) heat. Can I just say…it works?  Being asked a question with your mouth on fire, sweat streaming down your face, feeling the most awake and terrified you have ever been in your life, forces you to give an unadorned answer, straight from the heart. Don’t take my word for it, listen for yourself! Or better yet, watch the video of this one on YouTube. Some of the funniest parts are caught on video, in the background. We will be re-watching this one for years to come. Thank you, dear listeners, for sending us your questions, for your enthusiasm, and for your support. Enjoy! -@AlexSmithMD