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Cancer screening is designed to detect slow growing cancers that on average take 10 years to cause harm.  The benefits of mammography breast cancer screening rise with age, peak when women are in their 60s, and decline thereafter. That is why the American College of Physicians recommendation regarding mammography for women over age 75 is:  In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer. Today we talk with Mara Schonberg, who has been tackling this issue from a variety of angles: building an index to estimate prognosis for older adults, writing about how to talk with older adults about stopping screening, a randomized trial of her decision aid, and how to talk to older adults about their long term prognosis.  In the podcast she gives very practical advice with language to use, and references her decision aid, which is available on ePrognosis here. Mara keeps working at it, and the more she works, the closer we are to fine. -@AlexSmithMD
There are a lot of old myths out there about managing urinary tract symptoms and UTI’s in older adults.  For example, we once thought that the lower urinary tract was sterile, but we now know it has its own microbiome, which may even provide protection against infections. So giving antibiotics for a positive urine culture or unclear symptoms may actually cause more harm than good.   On today’s podcast, we are gonna bust some of those myths.  We’ve invited some very special guests to talk about the lower urinary tract - Christine Kistler and Scott Bauer.   First, we talk with Christine, a researcher and geriatrician from the University of North Carolina, who recently published a JAGS article titled Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.  We discuss with her how we should work-up and manage “urinary tract infections” (I’ve added air quotes to “UTI” in honor of Tom Finucane’s JAGS article titled “Urinary Tract Infection”—Requiem for a Heavyweight in which he advocated to put air quotes around the term UTI due to the ambiguity of the diagnosis.) Then we chat with Scott Bauer, internist and researcher at UCSF, about how to assess and manage lower urinary tract symptoms in men.  We also discuss Scott’s recently published paper in JAGS that showed that older men with lower urinary tract symptoms have increased risk of developing mobility and activities of daily living (ADL) limitations, perhaps due to greater frailty phenotype.    
In the US, geriatrics “grew up” as an academic profession with a heavy research base.  This was in part due to the tremendous support of the National Institute on Aging.  Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population.  Palliative care, in contrast, saw explosive growth in US hospitals.  In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized “home” at the National Institutes of Health.  The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need. Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care.  Kate’s journey is in a way emblematic of the lack of centralized funding for palliative care: she’s received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC. We talk with Kate about how despite how far we’ve come in palliative care research, we still don’t have answers to some fundamental questions, such as: Who should get specialized palliative care?  Should eligibility and access be determined by clinician referral? By diagnosis?  By prognosis?  By need? If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged?  Can nudges help?  (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern) When should people get palliative care?  What does “early” really mean?  We can’t possibly meet the needs of all people with newly diagnosed serious illness How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings?  What’s the role of implementation science? What is a pragmatic trial? What outcomes should we measure? We cover a lot of ground!  Working on a mystery.  Going wherever it leads.  Runnin down a dream… -@AlexSmithMD
We are two and a half years into the COVID pandemic.  We’ve lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU’s overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the “zoom meeting.”  But what have we really learned over this seemingly endless pandemic other than how to make a quarantini?  Well, on today’s podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease. Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital.  In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post.  Some call her an optimist or maybe a pragmatist, but I’d call her someone who inherently understands the value in harm reduction when it’s clear harm elimination just ain’t gonna happen. So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list: Medscape article on how “COVID-19 Vaccines Work Better and for Longer Than Expected Across Populations, Including Immunocompromised Individuals” Stat news article about variants/COVID becoming more predictable A good twitter criticism of the CDC 1 in 5 COVID survivors have long COVID study NIH study about long COVID published the day before in Annals of Internal Medicine Evusheld and how it works against BA4 and BA5 Our World in Data COVID graphs
It’s been a while since we’ve done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here).  But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations.   This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity.  They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities.  The basis of their argument is the ethical notion of “reciprocity” - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action.  Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion. To be sure, Paxlovid is no longer as scarce as it was a few months back.  But the argument is important because, as we’ve seen, new treatments are almost always scarce at the start.  Evusheld is the latest case in point.  Sometimes, you can’t always get what you want… -@AlexSmithMD
A patient is on morphine and you want to convert it to another opioid like hydromorphone (dilaudid).   How do you do that?  Do you do what I do, pull out a handy-dandy opioid equianalgesic table to give you a guide on how much to convert to?  Well on today’s podcast we invited Drew Rosielle on our podcast who published this Pallimed post about why opioid equianalgesic tables are broken and why we shouldn't use them, as well as what we need to move to instead. But wait, before you throw out that equianalgesic table, we also invited Dr. Mary Lynn McPherson, PharmD extraordinaire who published this amazing book, Demystifying Opioid Conversions, 2nd Ed., which advocates for an updated, wait for it… equianalgesic table!  Oh boy, what should we do?  Should we throw out the equianalgesic table like some are advocating we do with advance directives (see here), or should we just modernize it for the times with updated data?   Listen to this spicy podcast with these wonderful guests to make up your own minds (I’m sticking with the equianalgesic table for now). If you want to take a deeper dive into some of the references, here you go: Pallmed Post on why “Opioid Equianalgesic Tables are Broken” Pallimed post on “Simplifying Opioid Conversions” Dr. Akhila Reddy and colleagues study looking at converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone. Our previous podcast with Mary Lynn titled “All the Questions You Had About Opioids But Were Afraid To Ask”  
In today’s podcast we talk with Dr. Rajagopal (goes by “Raj”), one of the pioneers of palliative care in India.  Raj is an anesthesiologist turned palliative care doctor.  He is also author of the book, “Walk with the Weary: Lessons in Humanity in Health Care,” and was featured in this Atlantic article.  Raj is the founder of Pallium, an organization dedicated to improving palliative care throughout India.  We are joined by guest-host Tom McNally, a rehab and pediatric palliative care doc at UCSF. In this podcast, we cover a great deal of ground, including: Early challenges Dr. Raj faced in pain management: access to opioids, corruption, a system that doesn’t see addressing suffering as a priority Prognosis communication and the subtle ways we may communicate it without intention Social pain and loneliness Community-based palliative care networks  Raj’s reflections on the state of palliative care in the US How definitions bind us, for example the division between chronic pain and palliative pain in much of the US Ways listeners can learn more and contribute (see this link in the US) Because the song request was the short theme-song for Pallium, I recorded it two ways.  The intro is the upbeat guitar driven version.  The outro is the synthesizer (new toy!) slowed down version. Enjoy! -@AlexSmithMD 
Think about the last time you attended a talk on communication skills or goals of care discussions.  Was there any mention about the impact that hearing loss has in communication or what we should do about it in clinical practice?  I’m guessing not.  Now square that with the fact that age-related hearing loss affects about 2/3rd of adults over age 70 years and that self-reported hearing loss increases during the last years of life.   Screening for addressing hearing loss should be an integral part of what we do in geriatrics and palliative care, but it often is either a passing thought or completely ignored.  On today's podcast, we talk to Nick Reed and Meg Wallhagen about hearing loss in geriatrics and palliative care.  Nick is an audiologist, researcher, and Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. Meg is a researcher and professor of Gerontological Nursing and a Geriatric Nurse Practitioner in the School of Nursing at UCSF. We talk with Nick and Meg about: Why hearing loss is important not just in geriatrics but also for those caring for seriously ill individuals How to screen for hearing loss Communication techniques we can use when talking to individuals with hearing loss The use of assistive listening devices like pocket talkers and hearing aids Their thoughts on the approval and use of over the counter hearing aids If you want to take a deeper dive into this subject and read some of the articles we discussed in the podcast, check out the following: Hearing Loss: Effect on Hospice and Palliative Care Through the Eyes of Practitioners COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers Association of Sensory and Cognitive Impairment With Healthcare Utilization and Cost in Older Adults Over-the-counter hearing aids: What will it mean for older Americans? Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic  
Comics. Cartoons. Graphic Novels. Graphic Medicine.  I’m not sure what to title this podcast but I’ve been looking forward to it for some time.  Heck, I’m not even sure to call it a podcast, as I think to get the most out of it you should watch it on YouTube. Why, because today we have Nathan Gray joining us.  Nathan is a Palliative Care doctor and an assistant professor of Medicine at Johns Hopkins. He uses comics and other artwork to share his experiences in palliative care and educate others about topics like empathy and communication skills.  His work has been published in places like the L.A. Times, The BMJ, and Annals of Internal Medicine.   We go through a lot of his work, including some of the comics you can see on our blog post. However if you want to take a deeper dive, check out his website “The Ink Vessel” or his amazing twitter feed which has a lot of his work in it.  
In celebration of National Poetry Month, we are delighted to share with you the second podcast in our series on poetry and medicine.  In the first podcast, we talked with Guy Micco and Marilyn MacEntyre about poetry and aging. In this second part in our series, we welcome Mike Rabow and Redwing Keyssar to talk about palliative care and poetry.   As with aging, poetry operates on multiple levels within the palliative care space.   Poetry puts us in our patient’s shoes. As Redwing’s poem says, “why not live as long as possible?”   Poetry holds us in that liminal space so many of our patients are in. Paradox.  The impossiblity which is life, which is everything, and death, which is the end of life. As Mary Oliver tells us In Blackwater Woods, and I’m paraphrasing here, we must to hold it to our bones, knowing our lives depend on it, and when the time comes, to let it go. To let it go.   Or as in Mark Nepo’s poem Adrift, I am so sad and everything is beautiful. Poetry helps us grapple with our own experiences of illness.  Redwing, who is a cancer survivor, shares poems about her experiences with cancer.  Mike Rabow shares his award winning poem about coming out to the world about his diagnosis with multiple sclerosis.   We talk not only about reading poetry, but also writing poetry, and using poetry in medical education as a healing modality. And along the way, we really felt like we got to the heart of things.  To the deeper emotions - of loss and grief, of wonder and transcendence - that are at the heart of the complex care we provide. -@AlexSmithMD  Links to Redwing’s poetry workshops: Food for Thought Poetry for Resiliency  Loss, Losing  and Loosening, poetry for grief and loss   Wounded Healer poetry sessions  Advance Care Planning Links to Redwing Keyssar’s poetry collections  Redwing’s website: www.redwingkeyssar.com Institute for Poetic Medicine Mike Rabow’s Comprehensive Care Team randomized trial of outpatient palliative care Look also for a forthcoming article by Mike and Redwing in Journal of Pain and Symptom Management on poetry as a healing modality, to be published mid May (will add link when out). In addition to Redwing’s own songs and poems, other poems read by Mike and Redwing during the podcast: In Blackwater Woods by Mary Oliver Therapy by John Wright Adrift by Mark Nepo Talk Before Sleep by Elizabeth Berg Late Fragment by Raymond Carver  
Buprenorphine.  It’s been around for a long time but is acting like the hot new kid in town.  Just look at this year’s AAHPM meeting, where it felt like every other session was talking about how hot buprenorphine is right now.  But does this drug really live up to the hype? On today’s podcast we talk with three experts on buprenorphine on why, when, and how to use it in serious illness. Our experts include Katie Fitzgerald Jones (palliative nurse practitioner and doctoral student at Boston College), Zachary Sager (palliative care physician at the Boston VA and Dana-Farber Cancer Institute), and Janet Ho (physician at UCSF in addiction medicine and palliative care). We try to cover a lot in a 45 minute podcast, but if there is one take-away, it's that all of us who prescribe opioids should learn how to use buprenorphine and that we should all sign up for a DEA X-waiver at www.getwaivered.com or at www.buprenorphine.samhsa.gov (now you can treat up to 30 patients without completing the additional educational training, so signing up takes about 5 minutes).  And if you want to learn more about buprenorphine from these amazing palliative care clinicians and others, check out of some of these articles: Learn more about caring for those with substance use disorder:  Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness  Learn about using the low dose buprenorphine patch:  Low-Dose Buprenorphine Patch for Pain - Fast Fact Learn about how to initiate buprenorphine:  Sublingual Buprenorphine Initiation: The Traditional Method  - Palliative Care Network of Wisconsin Low Dose Initiation of Buprenorphine: A Narrative Review and Practical Approach Good review on buprenorphine for pain Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion  
In her essay “Why Read a Poem in a Time Like This?”, Marilyn McEntyre writes: All of us need it. We need it because good poems do something prose can’t do. They invite and enable us to notice the precarious fissures in what we think is solid ground. They direct us toward the light at the edge of things — the horizon, the fragment of dream before dawn, the feeling that’s hard to name, and can only be accurately captured by metaphor. They take us to the edge of “what can’t be said,” and ambush us into feeling before we think, so that we can’t simply and complacently “believe everything we think.” Poetry deals in surprise and subversion and turns old words to new purposes. Marilyn is joined by Guy Micco to talk about why poetry is important in general, why it’s important in medical or nursing education, and why it’s important for people who care for older adults. Along the way, they read poems, talk about poems, and sing a song by John Prine.  We talk about how poetry can surprise, how poems can be playful, how they unlock dimensions and emotions that are otherwise locked away.  How sometimes good poetry can be like a needed punch. And maybe, just maybe, we convince that poetry skeptic Eric Widera that there is a place for poetry in medicine after all. Enjoy! -@AlexSmithMD   Links to essays and books by Marilyn McEntyre Why A Poem in a Place Like This? Why Read a Poem in a Time Like This? Patient Poets: Illness from the Inside Out Caring for Words in a Culture of Lies Links to Songs/Poems from the Podcast: Hello in There by John Prine After Apple Picking by Robert Frost Sonnet 73: That Time of Year Thou Mayest in me Behold by Shakespear Jane by George Bilgere Long Life by Elaine Feinstein Sonnet 60 by Pat Schneider (not online)  
One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, “Can We Agree to Disagree?”  And today our guests agree to disagree.   And yet, and yet… They also agree across a whole range of issues, some of which surprised us. This is the latest in our series of podcasts on concerns about, and potential of advance care planning.  If you’re new to this discussion, don’t start with this podcast!  Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki.   On today’s podcast we ask our guests about areas in which there might be agreement or disagreement, including: The Best New York style bagels are made in California. Assigning a surrogate decision maker is important for everyone, including those who don’t have serious illness. Where does POLST fit in with this debate? All decisions are made in advance, the question that we are debating is how far in advance and what to call it Completion of advance directives and billing codes for advance care planning as quality metrics Among other topics.  I’m heartened that we could have this discussion as a field, as it shows that we’ve grown to the point where we can agree to disagree respectfully with each other.   We can work it out! Links to a few couple items mentioned on the podcast: Objectives for Advance Care Planning 2018 Systematic Review of Systematic Reviews on ACP -@AlexSmithMD
If you develop dementia, odds are you will spend the last months to years of your life in a nursing home or assisted living facility.   While we like to think about how our goals and preferences will influence what that life looks like, including whether you will get potentially burdensome interventions, your fate is probably influenced more by factors like where you live and what nursing home you happen to end up in.  On today’s podcast we dive into drivers of invasive procedures and hospitalizations in advanced dementia by talking to some pretty brilliant nursing and nurse practitioner researchers focused on dementia, geriatrics, and palliative care in nursing homes: Ruth Palan Lopez, Caroline Stephens, Joan Carpenter, and Lauren Hunt. We start off discussing the findings of Ruth Palan Lopez's publication in JAMA IM on the ADVANCE study.  This study explored nursing home organizational factors and staff perceptions that are associated with the variation in care for residents with advanced dementia.  Now when I say variation, I’m not talking about small little clinically questionable variations.  I’m talking about some nursing homes with no residents with advanced dementia being tube fed, and some with nearly half of their residents with advanced dementia being tube fed.   We go on to talk about other findings of this study including that staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in ACP and preferred more aggressive care, issues with the skilled nursing facility benefit (“rehabbing to death”), the palliative care needs of nursing home residents, and so much more. For a deeper dive, check out some of these other studies and resources we talked about in the podcast: The Influence of Nursing Home Culture on the Use of Feeding Tubes.  Archives of Internal Medicine 2010 The Lived Experience of Providing Feeding Assistance to a Family Member with Dementia Rehabbed to Death. NEJM Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block A Podcast with Caroline Stephens about her publication in JAGS where she studied palliative care-eligibility and POLST completion  
A little over a decade ago, Ken Covinsky wrote a GeriPal post about a Jack Iwashyna JAMA study finding that older adults who survive sepsis are likely to develop new functional and cognitive deficits after they leave the hospital. To this day, Ken’s post is still one of the most searched and viewed posts on GeriPal. This idea that for critically ill patients in the ICU, geriatric conditions like disability, frailty, multimorbidity, and dementia should be viewed through a wider lens of what patients are like before and after the ICU event was transformative for our two guests today.  Julien Cobert just published a study in Chest finding that even after accounting for the rising age of patients admitted to the ICU, rates of pre-existing disability, frailty, and multimorbidity increased over about a ten year period. Rise in these conditions occurred over a decade - what happens over the next 10, 20, 30 years?   And Lauren Ferrante has found in a study published in JAMA Internal Medicine that trajectories of disability in the year prior to ICU admission were highly predictive of disability post-ICU, on the same order of magnitude as mechanical ventilation.  In a separate study in Chest, Lauren found pre-ICU frailty was associated with post-ICU disability and new nursing home admission.  Lauren uses her magic wand to address the measurement issue: we’re not measuring function, frailty, and cognition routinely in hospitalized older adults.  We wouldn’t dream of not measuring oxygen saturation, yet function, which is highly predictive of outcomes older adults care about, many hospitals hardly measure. Additional links: GeriPal podcast with Lauren Ferrante and Nathan Brummel on geriatricizing the ICU GeriPal podcast with Tom Gill on the Precipitating Events Study, distressing symptoms, disability, and hospice GeriPal podcast with Linda Fried on frailty Shunichi Nakagawa’s Tweet that went viral on responding a patient request to drink ice water before death. And a note- on the podcast you’ll hear a drum track on the song (!).  I’m taking lessons with an audio producer in LA who is helping me to learn some new Logic Pro post-production skills.  Bear with me!  I’m having fun working on these songs from home during COVID.  
There is a lively debate going on in academic circles about the value of Advance Care Planning (ACP).  It’s not a new debate but has gathered steam at least in palliative care circles since Sean Morrisons published a JPM article titled “Advance Directives/Care Planning: Clear, Simple, and Wrong.”  Since then there has been a lot of back and forth, with even a couple of podcasts from us, several JAMA viewpoints, and most recently a series of published replies from leaders in the field on why ACP is still valuable (see below for references).   Despite all of these publications, I’m still left at a loss of what to think about it all.  Most of the debate seems rather wonky, as honestly it feels like we are getting stuck in the weeds of semantics and definitions, like what counts as ACP versus in the moment decisions.  But the consequences are real, from research funding dollars to health systems investment.   So in today's podcast, we have invited Juliet Jacobsen and Rachelle Bernacki to talk about what all the fuss is about.  Juliet and Rachelle are two of the authors of a recent JAMA viewpoint titled “Shifting to Serious Illness Communication.”   We discuss the debate, how to think about definitions of ACP vs serious illness communication, what should go into high quality conversations, the evidence for and against any of this, and ultimately where we go from here.    Also see the image from Alex’s forthcoming editorial in JAGS, a Venn diagram of advance care planning and serious illness communication (please go to GeriPal.org to view the image). So check out the podcast and if you are interested in diving into this debate, here are some great links to learn more: What’s Wrong With Advance Care Planning? JAMA 2021 Controversies About Advance Care Planning. JAMA 2022 (a reply to the above) Shifting to Serious Illness Communication. JAMA 2022 Our podcast with Sean Morrison titled “Advance Care Planning is Wrong” Our podcast with Rebecca Sudore and Ryan McMahan titled “Advance Care Planning is So Right” Our podcast with Rachelle Bernacki and Jo Paladino on the Serious Illness Conversation Guide    
My mom is an Asian woman in her 70s with osteoporosis.  She tried an oral bisphosphonate and had horrible esophagitis.  She said never again, though she eventually tried an IV bisphosphonate.  She had terrible flu-like symptoms.  She said never again.  But based on reports that symptoms are worse the first time, she tried the IV again the next year and fortunately experienced no symptoms.  (Story used with permission, thanks mom!).   I tell this story because these issues don’t typically register as more than a nuisance for clinicians, who frequently don’t understand why their older patient with osteoporosis is not taking a bisphosphonate.  But our patients are walking with their feet, and adherence to bisphosphonates for osteoporosis is poor and decreases with time. When we have a medication with up front harms and downstream benefits, it’s critical that we consider the time to benefit, or how long it will take an individual to benefit from a test or treatment.  Think of the 10 years it takes to benefit from colon or breast cancer screening, which is designed to detect slow growing cancers.  For individuals with a life expectancy less than the time to benefit, the up front harms outweigh the downstream benefits.   In this context, we talked this week with James Deardorff and Sei Lee about their study of time to benefit of bisphosphonates for osteoporosis, published in JAMA IM. What they found somewhat surprised us: it’s pretty short, about 1 year!   Which makes me feel better about urging my mom to get treatment.  Bisphosphonates are pretty darn effective, and act quickly. We also discuss discontinuing bispohsophantes, and if we can use the same logic we consider when starting them.   Toward the end we talk about the launch of ePrognosis’ new Time to Benefit tool.  This tool provides a clinical recommendation for starting/stopping medications and cancer screening based on the prognosis of the patient in front of you.  See screenshot below.  You can either access it directly here.  I you use the Lee Schonberg prognostic index for community dwelling older adults you will be directed to the tool, and it will automatically place the life expectancy at the calculated prognostic estimate.   James and Sei requested a terrific song - Bad to the Bone - much better than the Hannah Montana Bone Dance song they threatened me with (maybe next time). Enjoy! -@alexSmithMD
This week many of our listeners will gather for the annual American Academy of Hospice and Palliative Medicine (AAHPM) & Hospice and Palliative Nursing Association (HPNA) annual meeting.  While the majority of this meeting is focused on subspecialty care in the US, the majority of individuals who are in need of palliative care live in low and middle-income countries without even basic access to palliative care.   On this week's podcast, we talk with three leaders in helping improve palliative care worldwide: Kathy Foley, Stephen Connor, and Eric Krakauer.  I don't think I can really sum up these three guests in a sentence each, but I’ll give you how we introduced them in our podcast. Kathy Foley is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative (IPCI). Stephen Connor is a licensed clinical psychologist  and executive director of the Worldwide Hospice and Palliative Care Alliance.  Eric Krakauer is an Associate Professor of Medicine and of Global Health & Social Medicine at Harvard Medical School, an attending physician in the Division of Palliative Care & Geriatrics at Massachusetts General Hospital, and a former medical officer for palliative care at the World Health Organization.  The podcast tries to cover a lot of topics including: Why is addressing worldwide needs of palliative care important? What are the needs of palliative care worldwide? How do you quantify worldwide suffering and what is the serious health related suffering index? What are some of the main barriers to palliative care? What are the models of palliative care worldwide? What are some of the resources to improve palliative care? I encourage you to take a listen, and if you want to learn more check out some of these resources: Worldwide Hospice Palliative Care Alliance (WHPCA) Open Society Foundation’s International Palliative Care Initiative  Global Atlas of Palliative Care International Association for Hospice and Palliative Care JPSM’s issue on the The International Palliative Care Initiative eHospice - a globally run news and information resource      
In prior podcasts we talked about racism and COVID, lack of diversity in the palliative care workforce, racial and ethnic differences in end of life care, and implicit bias in geriatrics and palliative care. Today our focus is on structural, institutional, and interpersonal racism, and how these different but related constructs negatively impact the care of older adults and people with serious illness.   We are joined by Deborah Ejem, a medical sociologist and Assistant Professor in the School of Nursing at the University of Alabama Birmingham, and Deep Ashana, a pulmonary critical care physician and Assistant Professor of Medicine at Duke University.  We discuss: What are the differences between structural, institutional, and interpersonal racism? Examples of how these forms of racism operate in the care of seriously ill patients, including from one of our guest’s personal experiences. The importance of attention to religion and spirituality  Clinician reluctance to engage in advance care planning with minoritized patients as a driver of disparities How abandoning support for advance care planning might foreground implicit biases inherent in the heuristics (or nudges, or short cuts in thinking) inherent to time-pressed in-the-moment decision making. Lack of diversity in the participants represented in AAHPM State of the Science presentations, as well as lack of focus on disparities (no link - see upcoming presentation by Deboarh Ejem at the virtual conference). Co-opting of disparities issues by the Alzheimer’s Association in their argument for CMS/Medicare coverage of aducanumab (see this Twitter thread by Jonathan Jackson here and article by Daniel George here).  Action Item: Please submit a comment to CMS about aducanumab coverage today.  Feel free to express your outrage at the lack of diversity in the trials. We could have continued talking with our guests for hours.  We will continue to address the issue of racism in future podcasts. -@AlexSmithMD
Patients with end stage liver disease and decompensated cirrhosis have an average life expectancy of 2 years without transplant.  Outcomes are worse among those who are frail.  Symptoms are common, including pain, ascites, encephalopathy, and pruritus.  Patients with end stage liver disease are often some of the most disadvantaged patients we care for.  Caregiver burden is immense; divorce is common.  Some will go on to receive a transplant, but many will not.  Many are confused about the diagnosis and feel poorly supported.  Prognosis is fraught, as the worse your prognosis (i.e. lower your chance of survival), the higher you move on the transplant list.  Advance care planning is rare (or serious illness communication for those of you who don’t consider this advance care planning).  Outcomes of in-hospital CPR are worse for patients with end stage liver disease than outcomes for patients with advanced cancer. Though integration of geriatrics and palliative care into the care of patients with end stage liver disease holds obvious potential, major barriers remain.   In this week’s podcast, we talk with Jen Lai, Ricky Shinall, Nneka Ufere, and Arpan Patel about end stage liver disease from a geriatrics and palliative care perspective.  We talk about the tension patients face between putting on the “best face” to be listed for transplant (e.g. full code, goals focused on extending life).  We talk about the potential and limitations of the MELD score for prognosis, and how frailty further stratified risk for older patients with end stage liver disease.  We discuss what is needed in terms of improved communication around the time of diagnosis, creating a safe space for serious illness communication, and resources for patients and caregivers (including this Canadian information resource). And we have a round robin about treatment of common and challenging symptoms – yogurt makes a surprise appearance. And…Radiohead! Great request…thank you Nneka! -@AlexSmithMD
Comments (1)

Loyal R

Thank you for this.

Mar 26th
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