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What would it take to transform dementia care?  While a lot of hope and money is being put into new monoclonal amyloid antibodies like lecanemab, the evidence is that while they are great in reducing amyloid in the brain for those with early Alzheimer’s disease, the effects are at best modest in slowing down the decline in cognition and function (more to be said on that in an upcoming podcast). In order to truly transform dementia care we need to think much broader than the amyloid hypothesis.  So on today's podcast we invite four brilliant individuals to talk about their perspective on how to change how we as a society and health care system partner with individuals with dementia. These amazing guests include: Susan McFadden, PhD, retired professor emerita (psychology and gerontology) at the University of Wisconsin, Oshkosh, an experienced researcher and practitioner in the field of dementia, and creator of the Fox Valley Memory Project. Her most recent book is Dementia Friendly Communities: why we need them and how we can create them  Anne Basting, PhD, a MacArthur Genius Grant awardee and professor (English/Theatre), University of Wisconsin, Milwaukee.  She created TimeSlips which we talk about in our podcast.  Her most recent book is Creative Care: a revolutionary approach to dementia and elder care  Abhilash Desai, MD, geriatric psychiatrist, adjunct associate professor in the department of psychiatry at University of Washington School of Medicine, and poet!  He wrote a book titled “Psychiatric consultation in long term care” that has a strengths based approach to staging dementia (how cool is that) Judy Long, MDiv, BCC, palliative care chaplain and educator at UCSF and caregiver.  She directs UCSF MERI’s patient, family, and clinician support with classes and consultation on resiliency, well-being, and grief. We discuss the importance of viewing individuals with dementia from a lens of resilience, the importance of creative engagement (as noted in Anne and Susan’s wonderful article on this subject), the role of collaborative care, and what we can do to improve inclusivity for individuals with dementia in our community and health care systems.    
Assisted Living Communities (no longer preferable to call them Assisted Living Facilities, as we learned on the podcast) are…what, exactly?  That’s the central question on today’s podcast.  The problem is the tremendous heterogeneity in services offered and quality of care.  If you’ve seen one Assisted Living Community you’ve seen one Assisted Living Community.  To address this question, we talk with Sheryl Zimmerman, author of a recent study in JAMA Network Open that used a Delphi process to ascertain what experts thought were the essential services an Assisted Living Community should offer to residents.  The experts settled on a range of key services, from more palliative care focused (e.g. end of life care and advance care planning) to more geriatrics focused (e.g. toenail trimming) to things in between (e.g. staff training in person centered care).  The problem, as Kenny Lam and Ken Covinsky, authors of an accompanying editorial, state on the podcast: there is an inherent tension between the motives of the corporations that own most Assisted Living Facilities (profit) and the ideal services offered in Assisted Living Facilities.   We additionally firmly establish that the song How to Save a Life by the Fray was a product of the aughts (2005, to be exact), not the 90’s ): Enjoy! -@AlexSmithMD (still on Twitter at present)
Health care professionals are human, and as humans we experience loss both in and out of work.  You’d imagine though that our professional expertise and experiences in helping patients and families cope with loss and grief would be helpful in managing our own personal losses.  Turns out, it’s maybe not. That was the lesson I learned from reading a new book edited by Matt Loscalzo along with Marshall Forstein called “Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals”.  It’s a collection of personal stories of a small number of health professionals, including Craig Blinderman and Susan Block, who have been struck by personal illness and loss. On today’s podcast, we’ve invited Matt Loscalzo and Craig Blinderman to talk about their book and the process they used to create these stories, which all stood out for their openness in talking about things that we as healthcare professionals often keep so very private.   We also brought in Vickie Leff to talk about the work she does with Wellness Debriefings.  These debriefings create a safe outlet for health care professionals to talk about the feelings resulting from their work.  Vickie worked with CAPC to create tools, including a facilitator guide, to encourage clinicians and their organizations to adopt debriefings.  So take a listen and check out some of these resources for healthcare provider loss, grief, and wellness: Loss and Grief: Personal Stories of Doctors and Other Healthcare Professionals Dates & registration info about debriefings offered by CAPC The CAPC Debrief Facilitator Training Manual we developed: PDF Download. Jared Rubensteins' "Token of Appreciation" video A great website for dealing with loss and grief: refugeingrief.com SPONSOR: 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 for 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
Dr. Faith Fitzgerald once quipped that prognostic modeling is the “punctilious quantification of the amorphous.”  She has a point.  Prognosis is inherently uncertain.  As Alex Lee says on our podcast today, all prognostic models will be wrong (in some circumstances and for some patients); our job is to make prognostic models that are clinically useful.  As Sei Lee notes, the argument for developing prognostic models has won the day, and we increasingly use prognostic scores in clinical decision making.  What makes prognostic models for mortality different from models used for anticoagulation or risk of renal injury?  James Deardorff replies that there is something inherently different about predicting mortality.  Death is different.  For some reason clinicians who might be perfectly comfortable using an anticoagulation risk calculator might be skeptical of a mortality risk calculator (see this recent terrific JAMA IM study from Nancy Shoenborn on this issue).  And yet, the only thing that may be worse than a prognostic calculator is a clinician relying solely on their clinical intuition. Today our guests Alex Lee, James Deardorff, and Sei Lee, talk to us about the uses, limitations, and clinical use cases for prognostic models.  As a springboard for this conversation we discuss new prognostic models developed to predict (simultaneously) mortality, disability, and mobility impairment (Alex Lee first author, JAGS) and mortality for people with dementia residing in the community (James Deardorff first author, JAMA IM).   Both new models are now available and free to use on ePrognosis.   And Sei and Eric reminisce about slow dancing to “Forever Young” by Alphaville in their teenage years. Enjoy! -AlexSmithMD
The Department of Health and Human Services helps to guide billions of dollars in investment and direction in research, policy, and health care. The Assistant Secretary for Planning and Evaluation (ASPE), within the HHS, is the principal advisor to the Secretary of HHS on health policy, ranging from legislation to strategic planning to research. How does this relate to aging policy and research? How does coordination occur between the federal, state and local level in aging health policies? And, who within ASPE guides aging policy and connects policy to every day health challenges experienced by patients and clinicians?    On today today’s podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome Dr. Tisamarie Sherry (Deputy Assistant Secretary for the Office of Behavioral Health, Disability, and Aging Policy (BHDAP), appointed by the Biden administration). This office is tasked with providing aging policy research and recommendations within ASPE, including long term care and the National Alzheimer’s Project Act.  Dr. Sherry shares her expertise in aging health policy and helps us make sense of the role of her Office and how she coordinates with the multitude of federal agencies aligned around the goal of advancing aging research, policy, and health. For the policy buffs and policy newbies out there, we hope this podcast is an essential primer to government in action.    We talk about:  The structure of federal agencies and how they coordinate  Priorities of the National Alzheimer’s Project Act, and the unique role of ASPE and BHDAP in guiding the agenda and long-term goals The recent focus on nursing facilities and long term supportive services during the pandemic, along with key gaps How HHS and ASPE solicit input from clinicians, community leaders, and older adults and how much it impacts policy decisions (spoiler alert: this involvement is CRUCIAL)  How to make your voice heard and get involved    We also touch briefly on topics discussed in prior podcasts such as loneliness and federal responses to the pandemic in relation to long-term care. Tune to hear Alex’s rendition of 'With a Little Help from My Friends'!   - Ashwin Kotwal, MD, MS  
When I’m on service these days there is inevitably a moment when a resident says “Patient so-and-so is on X” - and I have absolutely no idea what X is.  Modern subspecialist practice advances at such a remarkably rapid pace, it can be hard to keep up. In this context, we’re excited to hear from infectious disease experts and nephrologists about updates in the care of older adults.  Sonali Advani and Lona Mody talk about their recent JAGS article highlighting three recent articles that every clinician caring for older adults should be aware of in the treatment of infectious diseases (hint: I’ve never finished a course of antibiotics, and maybe your patients don’t need that full course either).  Devika Nair and Rasheeda Hall talk about their JAGS article highlighting updates from nephrology in the care of older adults, including a link to this new eGFR calculator that does NOT include race.  We have a discussion about the decision to remove race, a social construct, from clinical risk calculators (though I’m not 100% sold that race should always be removed - if removal is likely to worsen disparities for example - at least until a superior race-blind calculator can be developed). These articles are part of a new series called Clin-Star Corner, a new series in JAGS that reviews practice changing articles in the care of older adults.  And yeah, they made me sing a Miley Cyrus song…(but not this hilarious parody about UTIs). Enjoy! -@AlexSmithMD
Earlier this year palliative care was the correct response to the following clue on the game show Jeopardy: From a Latin word for “to cloak”, it’s the type of care given to seriously ill patients to provide comfort without curing What struck me most was not that palliative care was a question, nor that it made it seem that palliative care isn’t provided alongside care directed at curing, nor was it that hospice was the first buzzed in response, but it was that palliative care was the $2000 question in the Double Jeopardy round!  The fact that palliative care was the hardest of questions told me that we have a massive messaging problem in our field. So what do we do about it?  Well, on today’s podcast we talk with Marian Grant and Tony Back, who with support form the John A Hartford Foundation and the Cambia Health Foundation, have done a deep dive into the research on layperson perceptions of palliative care, hospice, and advance care planning.  The result is a new toolkit to help us fix our messaging & engage the public: seriousillnessmessaging.org  Questions we talk about include: What do we know about the public’s perception of palliative care, hospice, and advance care planning? What’s wrong with the “pictures of hands clasping each other” as our palliative care meme? How can we bring in marketing strategies into our public messaging? Don't palliative care clinicians already know how to explain things with empathy? Why is this different from clinical communication skills? If we avoid talking about death, is it just contributing to the public death denial that is rampant in American culture? Related Links Public Perceptions of Advance Care Planning, Palliative Care, and Hospice: A Scoping Review https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0111 Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust https://www.liebertpub.com/doi/full/10.1089/jpm.2020.0719 Effective Messaging Strategies: A Review of the Evidence. Communicating to Advance the Public's Health: Workshop Summary https://www.ncbi.nlm.nih.gov/books/NBK338333/  
Have you had difficulty managing a particular type of cancer pain?  For me it’s radiation induced mucositis/esophagitis.  Janet Abrahm is one of the world’s experts in pain and symptom management for patients with cancer joins us to talk about (among other things): Ketamine for hyperalgesia and allodynia, how to treat dissociative side effects Lidocaine: worth the hype? Strengths and weaknesses of buprenorphine for cancer pain Fentanyl patch: often missed issues Hypnosis: uses and how to get training via the American Society of Clinical Hypnosis Janet is the author of the 4th edition of the book Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, along with co-authors Molly Collins and BR Daubman. This book is terrific, truly comprehensive, and is a go to resource for when I’m “stuck” taking care of patients with cancer.   And yes, this would be a great one for CME.  Eric and I are working on it…maybe by 2023?   Finally, can you believe this is our 236th podcast and, I believe, the first request for the Grateful Dead?!?   Enjoy! -@AlexSmithMD
Have you ever had that moment when talking to a patient, when you realized that the phrase you just uttered, which you’ve uttered a hundred times before, came out rote and scripted?  Maybe some phrase you learned from a prominent podcast or VitalTalk?  And in response, the family or patient looked at you like you were from another planet?  Yeah, I’ve been there too. Josh Briscoe, our guests on today’s podcast, argues that you’ve entered the Uncanny Valley.  In robotics, the Uncanny Valley is that strange almost-human-but-not-quite territory in which humanoid appearing robots repulse us with their close yet still “off” appearance.  Coming off as rote and scripted during a serious illness conversation can have a similar off-putting impact on patients and families.  Today we talk with Josh about how to anticipate and avoid the uncanny valley.  And talk about times when we’ve fallen into it.   Key message: Listen to the music.  All the time. ;) Links: -Uncanny Valley post on Josh’s fantastic substack Notes from a Family Meeting -Anticipatory corpse book mentioned several times on the podcast -GeriPal post about teaching using YouTube (some links are old and don’t work, but you get the idea, I recently gave a spontaneous talk to the palliative care fellows and was able to find the video snippets) -Ira Byock’s 4 things that matter most -@AlexSmithMD
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80.  The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.    On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.    We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes.  What they found was fascinating: Most programs require that DNR status be temporarily rescinded for the procedure.  The time required before DNR was reinstated varied substantially among programs (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them.  They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!) Here are more resources if you want to take a deeper dive into the subject: Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022 The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017 Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021  
Holly Prigerson recalls the moments in which she started investigating prolonged grief disorder.  She recalls being “a social scientist [Holly] in room a full of psychiatrists,” who recognized a diagnostic gap in people experiencing profound and potentially harmful grief far after the death of a loved one.  This led her on a remarkable journey.  Holly has accumulated mountains of evidence for the diagnosis of prolonged grief disorder as a specific condition primarily notable for a yearning over a year after the death.  Prolonged grief is associated with increased risk of suicide and other negative health outcomes.  This accumulation of data over her career led ultimately to the inclusion of Prolonged Grief Disorder first in the ICD, then in the DSM-V.   And yet, despite mountains of evidence, Holly has taken a tremendous amount of heat for this work.  “Everyone has experienced grief, which makes everyone the expert.”  Today we offer Holly a chance to answer her critics, including assertions that: Grief is love; how can love be wrong? Pathologizing grief leads to overmedicalization of a natural condition  Prolonged grief disorder is a tool made for the pharmaceutical industry  Prolonged grief disorder does not account for cultural variation in mourning practices Along the way we talk about other related studies Holly has conducted, including a validation of DABDA - Elizabeth Kubler Ross’s famous stages of grief. And a song choice from the great lyricist Tom Waits. Enjoy! -@AlexSmithMD
In day-to-day practice, It’s hard to imagine providing excellent hospice or palliative care services without access to a team social worker.  Social workers augment a team’s ability to provide whole-person care, often aiding to identify and meaningfully address the wide variety of challenges and unmet needs faced by individuals and families facing serious illness. But are we really taking full advantage of ALL social workers have to offer our field? On today’s podcast, we are talking with Barbara Jones – a national hospice and palliative care social work leader whose many accolades include being a founding member of the Social Work in Hospice and Palliative Care Network (SWHPN), a Professor of Direct Social Work Practice and Associate Dean for Health Affairs at the Steve Hicks School of Social Work at UT Austin. Barbara highlights social workers’ inherent leadership qualities and tasks us to consider whether our own team and organizational structures are allowing for optimal social work engagement and influence. Whether in direct practice or in research and academia, we should work together to help Hospice and Palliative Care Social Work meet its full potential.  by: Anne Kelly, LCSW, APHSW-C
Two major shifts are transforming the landscape of hospice. First, private equity firms are gobbling up hospices.  As Melissa Aldridge, a health services researcher and former banker explains, we should be very concerned.  Private equity firms try to turn companies as profitable as possible within 3-5 years.  Thus, they have little in the way of long term vision for hospices, instead focused on cutting costs and maximizing profits.  Second, Hospice was originally designed for patients with advanced cancer, but the fastest growing admitting diagnosis is dementia.  People with dementia make up about half of hospice admissions.  And yet, we know little about the clinical experience of people with dementia in hospice.  Krista Harrison found, to her surprise, that caregivers of people with dementia who died rated hospice as well as similar patients without dementia who died on hospice.  And yet, disenrollment from hospice, either due to patient/family revoking the benefit or stabilization of illness (extended prognosis) is remarkably high for people with dementia among some hospices.  In fact, as Lauren Hunt found, the average likelihood that a person will be disenrolled from one hospice vs. another is two. In other words, which hospice you enroll in has a tremendous influence on whether you’re going to be disenrolled from hospice, which often feels to patients and families like being expelled. And I had a blast playing Take the Money and Run! -@AlexSmithMD
Today we have the honor of interviewing Susan Block, MD, one of the pioneering leaders in the fields of palliative care, particularly psychosocial aspects of palliative care.  Susan led the Project on Death in America’s Faculty Scholars program, used her dual training in internal medicine and psychiatry to shine a light on psychosocial aspects of palliative care, and founded the Department of Psychosocial Care at the Dana Farber Cancer Institute and Brigham and Women’s Hospital.   We talk with Susan about how far the field has come, from early days when the attending physician would decide which patients were DNR and place a black “no code” dot in the chart.  We talk about challenges facing the field today.  In particular, she reminds us that when we think about the most challenging of our patient encounters, they almost always involve a complex psychosocial dynamic, and this has received far less attention than communication and symptom management issues.   We delighted to be joined by Brian Block, pulmonary/critical care faculty at UCSF and frequent guest host on GeriPal…and also nephew to Susan. -@AlexSmithMD  Links: -PDIA Faculty Scholars Program -Serious Illness Conversation Guide podcast -Therapeutic presence in the time of covid podcast
A year ago we did our first “Deprescribing Super Special”.  Today we are coming back for more (or less given the content), talking about the following articles with their lead authors: First up, we talk with Ariel Green about her article in JAMA Network on preferred phrases a clinician may use to explain why they should reduce or stop the medication.   My take home from this is that while the most preferred explanation for deprescribing statins and sedative-hypnotics is one focused on the risk of side effects, we also need to individualize it to the patient and the medication that they are taking. Next up, we chat with Liz Bayliss about her JAMA IM article that studied whether increasing awareness about deprescribing prior to primary care visits can reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment.  While the study was largely negative, it does bring up important implications about how we should think about deprescribing in older adults (added bonus too - all of the resources used in the study can be found on the US Deprescribing Research Network website). Lastly, we talk with Kevin McConeghy about one deprescribing intervention that was hugely successful, although somewhat atypical.  Kevin’s study looks at a period of time in the COVID pandemic when a large multistate nursing home provider created a “nonessential medication on hold” (NEMOH) policy in order to conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact.  Although the policy was not originally envisioned as a deprescribing intervention, 54% of held medications were discontinued.  That’s huge!  While it’s unlikely this will be repeated, we talk about lessons we can learn from this natural experiment.   
We are fortunate today to interview two oncologists whose research has catapulted palliative care forward: Jennifer Temel, author of the landmark NEJM study on early outpatient palliative care for patients with advanced lung cancer; and Areej El-Jawahri, author of the landmark JAMA article on inpatient palliative care for patients with blood cancers undergoing stem cell transplant.   Jennifer’s study is most widely known for the “kicker” - not only did it improve quality of life, palliative care was associated with a couple months longer survival.   Areej’s study is remarkably novel in that it is, to our knowledge, the first study of palliative care during curative treatment.   We cover a huge amount of ground today, including: Jennifer’s reaction when she unblinded the study and found that palliative care was associated with prolonged life Differences between inpatient and outpatient palliative care for cancer What’s in the secret sauce of palliative care?  (hint: coping) What’s the right dose of palliative care? Do we need separate palliative care models for each cancer? What is next for these two?  Celine Dion Additional links: Editorial on Areej’s study Palliative care in lung and GI cancers GeriPal post on qualitative study of the Temel RCT GeriPal post on “fast food” style palliative care in chronic critical illness JAMA paper on remote symptom monitoring in cancer  
The science of balancing safety and independence of older drivers has come a long way.  Some key points from our podcast today with Emmy Betz (emergency physician-researcher) and Terri Cassidy (occupational therapist and certified driving rehab specialist) include: It’s no longer gouache to say “taking away the keys” - which sound punitive and risks infantilizing  Instead the new lingo is “driving retirement” Driving retirement can be a process, similar to a harm reduction model, in which the activity is not eliminated all together but restricted to minimize harm: e.g. driving only during the day, or avoiding freeways. A JAGS randomized trial demonstrated that a free online tool that assess readiness to stop driving helped older drivers with the difficult decision about driving cessation. Often the work of the certified driving rehab specialist is to assess the older drivers goals, assess prognosis for driving, and help the family navigate discussions around driving cessation (hmmm…sounds like an approach to family meetings). There is a dearth of Certified Driving Rehab Specialists: 12 for the entire state of Colorado! We learned this and much more, and I had a great time making engine noises singing the Woody Guthrie song “driving in my car.”   Additional Links: (A to Z – under driving)https://decisionaid.ohri.ca/cochsystem.html (OT programs)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347878/ An Advance Directive for When Driving Becomes Unsafehttps://geripal.org/an-advance-directive-for-when-driving/ ADED (Association for Driver Rehabilitation Specialists)https://www.aded.net/search/custom.asp?id=2046  
“Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You’re short on gowns and facemasks. You’re short on nurses and nurse aids so now you have to help deliver meals.” This was the opening paragraph that I wrote in March of 2020 when introducing a podcast we did with Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond.  That was his literally his life during those spring months of 2020 and it scared the hell out of me.  Lucky, Jim and many others like him were willing to come on to our podcast those first several months of the pandemic and share their experiences and lessons learned caring for COVID positive patients and their family members.   On today’s podcast, we look back to those early months of the pandemic and look forward to the future.  We invited Jim back with us along with Darrell Owens, DNP, MSN, who is the  head of palliative care for the University of Washington’s Northwest campus.   For those who didn't listen to our podcast with Darrell, when most of us were still trying to figure out what COVID was, he created an on call 24/7 palliative care service to have goals of care conversations with elderly patients in the emergency department under investigation for COVID, and also established an admitting inpatient palliative care service at his hospital for patients on exclusively comfort measures.  What I loved about this March 2020 podcast was that Darrell pushed us to think differently: “Expect that it’s not business as usual. Very first thing, you’re going to have to do things differently, so be open to that. Be totally open-minded. Now the old, “We’re not an admitting service or we don’t do that and we don’t do this,” don’t start with what you don’t do. Start with what you can do, what’s your capacity. So take a walk down memory lane with us and hear from both Darrell and Jim where they think we are going.
On today’s podcast we welcome back Haider Warraich to talk about pain.  Now this may surprise our frequent listeners as we have had Haider on before to talk about heart failure as well as palliative inotropes, so why are we having him come on to talk about pain?  .   Well, Haider has an intimate relationship with pain, having experienced chronic pain himself and now having dove deep into the latest research on pain for his new book The Song of Our Scars: The Untold Story of Pain.   We discussed the nature of pain, what makes chronic pain different from acute pain, what’s the difference between proprioception, pain, and suffering, and so much more.  So take a listen and if you are up for it, check out some of Haider’s other books including Modern Death: How Medicine Changed the End of Life and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease. 
You have a patient with dementia severe enough that she cannot recognize relatives.  She falls and breaks her hip.  Should she have an operation, and risk the pain, potential complications, and attendant delirium associated with the operation?  Should she be treated non-operatively, with aggressive symptom management?  A huge part of this decision rests on (1) her previously stated wishes, values, and goals (prior to the onset of dementia); and (2) the outcomes of surgery for patients with dementia. In today’s podcast we talk with surgeon Samir Shah and Health Services Researcher Joel Weissman about a pair of JAGS articles they published on the outcomes of high risk surgery and advance care planning among persons with dementia.  Toward the end we get to hear from Samir about how he would approach decision making for a patient such as the above patient, and from Joel Weissman about what’s to be done about the pressure and incentives our health system exerts to operate, operate, operate.   -@AlexSmithMD
Comments (1)

Loyal R

Thank you for this.

Mar 26th
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