Monday, September 25, 2017

Palliative Wound Care: A New Frontier

By Jeffrey M. Levine MD, AGSF, CWS-P

I recently completed the revised chapter on pressure injuries for the Geriatrics Review Syllabus (GRS-10) which will be coming out shortly.  Part of the content addressed the topic of palliative care for chronic wounds.  In my text I claimed that a palliative approach can reduce suffering, improve quality of life, and decrease health care costs by eliminating expensive and/or painful procedures and treatments, but found little corroborating evidence. In the process of revision I did an informal poll of colleagues from coast to coast, and found nobody addressing palliative care for wounds.  Research in this area thus presents a wide open career opportunity for a young palliative care specialist.  

Those of us who care for patients with pressure ulcers know that some wounds will not heal, and cure is an unrealistic goal.  Pressure ulcers can also herald the terminal stage of illness.  As the number of people living with chronic illness soars, it is increasingly recognized that there are limited benefits of curative treatment. This is where palliative care offers an alternative to aggressive wound healing interventions by changing to the focus to wound stabilization, symptom management and patient well-being.

Wound-healing strategies incorporate turning schedules, pressure redistribution devices, nutritional support, pain management, a variety of dressings, and an array of surgical procedures. Some patients, because of underlying illness or personal preference, cannot tolerate one or more of these measures. For example, turning and positioning is painful for patients with metastatic cancer. Repositioning may be restricted in patients with severe contractures, morbid obesity, or life support modalities. Patients with lung disease, congestive heart failure, vent support, or tube feedings require the head of their bed elevated which restricts mobility and increases pressure and shear forces on the sacral area. Negative Pressure Wound Therapy (NPWT) for persons with malnutrition has the risk of further decreasing serum albumin which increases third spacing, which interrupts oxygen and nutrient delivery and impedes healing. 

Nonetheless, palliative concepts have not yet penetrated deeply into the wound care world. Surgical procedures such sharp bedside debridements, operative interventions with attempted flap reconstructions, and skin grafts are too often performed when there is little to no chance of healing.  Operative debridements are often performed without communicating to families that there is little realistic chance of healing.  I know of numerous patients on hospice who received one or more sharp debridements only days before expiring.  

The wound care market is a rapidly growing sector currently worth in excess of $18 billion. There is a confusing array of wound care products with proof of efficacy lacking even in healthier populations. Negative Pressure Wound Therapy (NPWT) is an expensive cure-oriented treatment that is frequently overused in situations where treatment is hopeless. This is an opportunity to prove that aggressive intervention is often futile, and palliative care alternatives can cut down on unnecessary pain, suffering, and healthcare expenditures.  

Palliative wound care involves symptom control with stabilization of existing wounds while preventing additional wounds and infectious complications.  While many modalities are currently in use, the palliative formulary needs to be explored for optimum efficacy and cost savings.  More research is needed to define when a wound is not expected to heal, and in which clinical situations palliative care needs to be offered.  Surgical subspecialties as well as palliative care specialists require training to recognize when procedures are medically futile, and when realistic patient and family education needs to be implemented.  

One strategy I would like to see explored is co-management of chronic wounds, with geriatricians or palliative care specialists collaborating with the surgical team.  This model has proven successful in hip fractures and cancer, and could easily and effectively be implemented with chronic wounds.  

Medical science and technology have come a long way, yet there are many clinical situations when cure is not a realistic goal. Palliative care offers an alternative that focuses on controlling symptoms while promoting the best quality of life for both the patient and family.  Partnering with the patient and family to take a palliative approach to chronic wounds rather than an aggressive plan for healing can potentially reduce suffering, avert painful procedures, and reduce re-hospitalizations. Although this makes intuitive sense, research is required to take this concept to the next level. 

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Tuesday, September 12, 2017

Songs that Inspire, Move, or Make Us Think about Geriatrics or Palliative Care

Back in 2009, Pallimed created one of my favorite podcast posts titled "Top 10 Contemporary Palliative Care Songs".  In it, they made a list of "contemporary" songs from many different genres that have palliative themes.   For todays podcast, we aim to update this list with songs that inspire, move, or make us think about geriatrics or palliative care.

As with the Pallimed post, this is all personal preference.   So we would love to hear from you.  What one song would you have included in this podcast if you were sitting in the studio?  Put it in the comments section of this post!

Listen to GeriPal Podcasts on:

by: Eric Widera (@ewidera)


We don't have a transcript for the podcast today, but here is the list of songs picked by our studio audience:

Alex Smith: Dennis Kamakahi - Wahine 'Ilikea

Jen Olenik: Let It Be by the Penn Med Ultrasounds

Leah Witt: Legacy by JAY-Z 

Emily Taplin: Nick of Time by Bonnie Raitt

Kai RomeroFlorence + The Machine - Stand By Me (yes, not the Ben E King version)

Anne Kelly: 
Warren Zevon - Keep Me In Your Heart

Eric Widera:  I picked I Don't Want to Die in the Hospital from Conor Oberst and the Mystic Valley band.  I first heart it when I attended a great session at the 2008 AAHPM meeting titled Palliative Themes in Music: An Educational and Self-Care Exercise where I fell in love with it.

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Monday, September 11, 2017

Long Term Aspirin and the Risk of Bleeding Complications in Older Adults

by: Allen Tong MD

As a geriatrician, removing unneeded or inappropriate medications from a patient’s drug list is something that brings me a lot of professional satisfaction.  Reducing drug burden, adverse drug effects or drug-drug interactions, is an important aspect of providing high quality care.  Proton pump inhibitors (PPIs), often prescribed for “stomach protection” is a common target for me to consider de-prescribing.  They are often continued indefinitely when a 4-8 week course is more appropriate.  But a recent study published in the Lancet (1), puts a new twist into the risk-benefit analysis of long term PPI therapy, specifically as it relates to preventing upper gastrointestinal bleeds in patients on anti-platelet blood thinners such as aspirin or clopidogrel (brand name Plavix).


Anti-platelet therapies are commonly prescribed for primary and secondary prevention of vascular disease (heart attack, stroke, peripheral arterial disease).  But the long term bleeding risks of these drugs are lacking, especially in older adults.  Most trials were done in younger individuals, age less than 75, and for follow-up periods between 2 and 4 years.  The potential long term benefit of PPIs or histamine receptor antagonists (H2 blockers) to prevent bleeding has also not been studied fully in older adults.  Researchers tried to address this void in the geriatric literature.  

The Study:

This was a prospective cohort study of 3166 patients who were started or continued on anti-platelet therapy after transient ischemic attacks, ischemic strokes or myocardial infarctions.  The majority of patients (>94%) were on aspirin monotherapy.  Half of the patients (n=1582) were aged 75 and older and 18% (n=577) were 85 and older.  Patient taking anticoagulants were excluded.  Researchers reported bleeding events as well as functional outcomes.  Study participants were followed for 10 years.

Of note, to try and capture a more accurate tally of bleeding events, the researchers used not only administrative coding data, which is what the majority of previous trials used, but also hospital admission, primary care and blood transfusion records.


405 bleeding events occurred during 13,509 patient years of follow-up.  46% (n=187) were considered major bleeds.  40% (n=162) were upper gastrointestinal bleeds.  The study focused specifically on upper gastrointestinal bleeds as they could potentially be reduced with PPIs or H2 blockers.  After their vascular event, 24% of patients on anti-platelet therapy were also on either a PPI or H2 blocker.

Most notable from a geriatric standpoint - the annual risk for major and fatal bleeding increased steeply with age, after age 75 (figure 1).  

Figure 1

Compared with younger patients, those aged 75 and older were more likely to experience nonfatal major bleeds (HR 2.62), fatal bleeds (HR 5.53) and disabling bleeds (HR 7.6). At age 85, the annual risk of major bleeding reached 4.1%.

And from the additional data in the supplementary appendix, the time to harm, for ASA to cause bleeding, is almost immediate and again, most pronounced in older adults (figure 2).

Figure 2: Age specific risks of upper gastrointestinal bleeding events
The authors concluded that the risk of major bleeding attributable to antiplatelet therapy approached the risk of ischemic events protected in adults aged 75 and older and was even more pronounced in those aged 85 and older.

And specifically for upper gastrointestinal bleeds, the long term risk of disabling or fatal bleed was 10x higher for older adults versus younger (HR 10.26).  53% of older adults (31of 59 patients) had new or sustained disability after upper gastrointestinal bleed vs 14% (3 of 21) in younger adults.  And the number of disabling or fatal upper gastrointestinal bleeds substantially outnumbered disabling or fatal intracranial bleeds (n=45 vs n=18).

The researchers then calculated the number needed to treat (NNT) to prevent one disabling or fatal upper gastrointestinal bleed after 5 years of PPI therapy.  Assuming PPIs reduce the risk of upper gastrointestinal bleed by 74%, a NNT of 338 was calculated for younger adults whereas a NNT of 39 was calculated for patients aged 75-84 and 25 for patients aged 85 and older.

The Take Home

The bleeding risks of long term antiplatelet therapy in older adults has been understudied and underappreciated.  This study provides some real numbers to this risk-benefit analysis, at least for ASA monotherapy in the secondary prevention of vascular events. Through a prospective study, the authors reasonably conclude that the risk of bleeding is significantly increased in adults aged 75 and older and is much more likely to lead to both disability and death.  Disability associated with upper gastrointestinal bleeds is another understudied and underappreciated area of the geriatric literature which this study highlights.  The authors conclude with encouraging co-prescription of PPIs for older adults on long term anti-platelet therapy, calculating a NNT of 39 for adults aged 75-84 and 25 for those 85 and older.

As noted in the accompanying editorial (2), clinicians “obsess" over the balance between the risks and benefits of starting anti coagulation for patients with newly diagnosed atrial fibrillation, using risk calculators such as CHADS2-Vasc and HAS-BLED.   Perhaps we should be equally obsessive about evaluating this balance in our older adult population on long term ASA therapy.

What do you think?  Does this study change your clinical practice?  How do you determine when to start or stop ASA in older adults?  What about PPIs/H2 blockers?


1. Li L et al.  Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: A population-based cohort study.  Lancet 2017 July 29.
2. Diener, Hans-Christopher.  Preventing major gastrointestinal bleeding in elderly patients.  Lancet 2017 July 29.

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Wednesday, September 6, 2017

Sarah Hooper on Medical Legal Practice Clinics for Seniors

On this weeks podcast, we have Sarah Hooper, J.D., the Executive Director of the UCSF/UC Hastings Consortium on Law, Science and Health Policy, an interprofessional partnerships in education, research, and clinical training and service.  

We talk with Sarah about her work creating the Medical-Legal Partnership for Seniors Clinic (MLPS) in which law students and faculty provide free legal assistance to low-income older patients at the UCSF Medical Center and at the San Francisco VA.

Here is a short excerpt of the podcast in which Sarah talks about the state of affairs for MLPS in the realm of geriatrics and palliative care:
"There are almost 400 medical legal partnerships around the country now, at least one in almost every state. The vast majority of them are focused on kids and families, which is incredibly, incredibly important; but I think that because of the demographic need and just the nature of the complex needs that people have in geriatrics and palliative care, there should be more of us. The medical legal partnership for seniors is one of less than a handful of these models around the country, but they are out there. We're trying to grow."

If you are interested in diving down deeper into the subject, here are some of the links to resources we mentioned during the podcast:
by: Eric Widera (@ewidera)

Listen to GeriPal Podcasts on:


Transcript of the podcast:

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who's in the studio with us today?

Alex: In the studio today, we have Sarah Hooper, who is Executive Director of the UCSF/UC Hastings Consortium on Law, Science, and…

Sarah: Health Policy.

Alex: Health Policy!

Sarah: We went for brevity. Thanks for having me.

Eric: Really looking forward to talk more about all three of those things, but before we do, do you have a song for Alex to sing?

Sarah: Yes, it's a song by the boss, Bruce Springsteen, "How Can A Poor Man Stand Such Times and Live.”

Alex sings “How Can A Poor Man Stand Such Times and Live” by Bruce Springsteen.

Eric: Any reason you picked that song?

Sarah: The lyrics are apropos, the patient is left with a big bill and he's not totally sure what to do next and that's what we're talking about today.

Alex: Great.

Eric: Is that common?

Sarah: Yes, actually.

Eric: I'm gonna start us off by asking a question. What is this consortium?

Sarah: Yeah, so the consortium is a formal partnership between UCSF and UC Hastings College of the Law. Our mission is really to create interprofessional partnerships in education, research, and clinical training and service.

Eric: We just had Anna Chodos on who was talking about her work with the GWEP of creating partnerships with a bunch of different organizations in the community, academics, nonprofits. You're part of that, too, right?

Sarah: We are, so we are one of the community partners in the optimizing aging center and so, in our attempt to geriatricize primary care, as Anna likes to say, we are providing the legal expertise. What are the legal needs of older adults in our community and how can we work with healthcare providers and social service providers to enhance the capacity of all providers to provide care for this population?

Alex: You have a particular focus on the care needs and the legal needs of persons with dementia. Is that right?

Sarah: I do, so my research and teaching is in the law of aging and in dementia in particular and at UC Hastings, we have something called the medical legal partnership for seniors, which is a clinic in which our law students and faculty provide free legal assistance to low-income older patients at UCSF Med Center and here at the San Francisco VA.

Eric: That's terrific, so can you tell us a little bit, in terms of setting this up; but what is the need for legal assistance in older adults with dementia?

Sarah: Yeah, so the disease, of course, raises a whole host of questions about decision-making, so as dementia progresses, an individual will need more and more support with decision-making, with ADLs, and with IADLs, and will gradually become entirely dependent on others for decision-making and for providing for basic needs. The legal questions that that raises are, "What is the legal decision-making infrastructure that we can create for this person and for this family?"

Eric: We're fine, we do advanced care planning, we ask everybody about their advanced directives, whether it's been done and about life sustaining treatments at the end of life, shouldn't that cover? Shouldn't we be done?

Sarah: That's an excellent question, Eric, so that is really just the tip of the iceberg, so the first part of that is we usually think of advanced care planning as being about decisions about death. In dementia, decisions about death are an important piece of that; but what we're really trying to focus on are decisions about the moment of incapacity or that gray area where we're not sure if the person has capacity for decision-making. What do we do about that moment and what do we do about the prospect that this individual is going to live potentially multiple years with a need for supported decision-making or for someone to simply be making decisions for them? The medical decision-making is part of that, but we also need a plan for personal care decisions, for financial and legal decision-making, whether the person's going to live, a whole host of things. Think about all of the decisions that you make in your life and now suddenly we have to come up with a plan for how someone else is eventually going to make those decisions.

Eric: What stage do you typically get involved? Are you talking about people who have mild cognitive impairment, who have early stage dementia, who have advanced dementia and caregivers are coming, to all of the above?

Sarah: Yeah.

Eric: Is there a primary focus?

Sarah: The medical legal partnership model is meant to be an upstream model, so the goal is really for lawyers and healthcare providers to work together to prevent acute legal needs basically. A lot of legal care is emergency medical care and so, conservatorship is an example of emergency medical care or trying to unwind elder financial abuse, that's something we prefer not to do. We would prefer to get in as early as possible to prevent this situation, so how do you do that? You do that before the individual has lost capacity, so if a patient has MCI, that's a good time to get in. Early stage dementia is a good time to get in. There are legal needs that arise in advanced dementia and they're usually caregiver-focused, but again, that's not the time that we would prefer to be intervening. We would prefer to meet with a patient who's in a position who can articulate their goals of care, their goals for financial legal decision-making, their goals for their families. We can really optimize their ability to engage in decision-making and come up with a good plan and be really thoughtful about it.

Eric: Are you finding that patients with early stage dementia are typically able to continue to be involved in these decisions?

Sarah: Of course, so this is preaching to the choir; but capacity, of course, is not an all or nothing proposition and diagnosis of dementia does not mean that somebody now lacks capacity to make decisions. Capacity is highly variable and decision-specific and that's increasingly recognized in the law. It's certainly recognized in California and so, a person may not be able to independently manage their finances. They might make some bad decisions, but that doesn't mean that they lack capacity to choose a financial agent for instance, or to say where they want to live, or to hire an attorney who can help them navigate the insane patchwork of benefits that older adults have to navigate in order to access long-term care or just basic needs.

Eric: Yeah, that's a really fundamental point and we may be the choir; but I think there are a lot of folks out there who have misunderstandings about the capacity of people with dementia to make these decisions that if they're not managing their finances correctly, then they can't engage in doing the financial advanced care planning, legal advanced care planning that you're talking about.

Sarah: It certainly raises the potential and the prospect for undue influence and so, that's not to say we shouldn't be very careful in assisting persons with dementia with decision-making; but it's not the same as saying that they don't have any legal or clinical ability to weigh in or make these decisions.

Eric: What should the doctor's role be with all these decisions? Because we get no training on financial decision-making, assessing financial capacity, will stress, none of that.

Sarah: Yeah, so the first thing you can do is help screen for and identify these needs in patients and families. I think that Medicare and other funders or payers are increasingly interested in incentivizing this kind of whole person care planning. There's a new Medicare CPT code that reimburses for care planning with persons with cognitive impairment.

Eric: That doctors can use?

Sarah: That doctors can use or nurses. There's a whole host of healthcare team members that can use it.

Eric: But not social workers, I think.

Sarah: Not social workers. Correct, unfortunately, and not lawyers unfortunately; but maybe lawyers should be reimbursed for this as well. But part of that CPT code reimburses for assessing not only for cognitive impairment, but for social needs of both the patient and the caregiver. A lot of those needs are actually legal needs or have a legal dimension to them and so, not getting reimbursed is no longer an excuse. There is a mechanism for doing this and for the training piece of it, if you don't have a medical legal partnership in your medical center, you can partner with people in the community who can help train on this. I would say the first thing to do is think about your patient population, think about who in that population is at risk of cognitive impairment or decline in the next six months to a year, and target those people and educate them about the need for an advanced directive and for financial and legal planning.

Eric: When I think of our palliative care population, we're often working with people who may have months, maybe years, that they have to live or that they may lose capacity at some point, even for a short period of time. I think in geriatrics, we're coming around to the idea of medical legal practice clinics and the importance of them, at least partnering with lawyers. I don't get the same sense we're doing that in palliative care. Is that right?

Sarah: Yeah, so there are almost 400 medical legal partnerships around the country now, at least one in almost every state. The vast majority of them are focused on kids and families, which is incredibly, incredibly important; but I think that because of the demographic need and just the nature of the complex needs that people have in geriatrics and palliative care, there should be more of us. The medical legal partnership for seniors is one of less than a handful of these models around the country, but they are out there. We're trying to grow.

Eric: What does it actually look like? Are you hanging out with the physician while they're seeing patients?

Sarah: Yes.

Eric: Yeah?

Sarah: Yes, the difference between medical legal partnership and a referral into the community is that the legal team is actually integrated into the care of the patient and so, where that starts is with joint education. For instance, in our clinic, our students are trained by geriatricians at UCSF and in the community about the health needs of older adults. We do joint training on capacity, so what's the clinical view of capacity and then, what's the legal view of capacity. How do you reconcile the two of those in an individual patient client? It starts with training, making sure that the healthcare team and the legal team have some sort of common overlapping base of knowledge. With that knowledge, the providers are equipped to now start recognizing legal needs in their patients. Now, healthcare providers are in a position where they can say, "Hey, I think that this is really important to your healthcare if you actually sort out how you're going to access long-term care supports and services that are going to support your goal of care to stay in your home." Right?

Eric: Yeah.

Sarah: It's one thing to say, "You have a goal of care. It's another thing to have the resources to make that a reality and I think my friend down the hall is a lawyer who can provide free legal assistance to help you understand and unpack a lot of those stuff." The other technical piece of this is there's information and data sharing that can happen, so if people are worried about HIPAA, you should be; but medical legal partnerships have worked out a way to work within HIPAA to permit a certain amount of data sharing between the legal team and the healthcare team, in order to maximize our ability to advocate together for the patient, for whatever their needs might be.

Eric: That's terrific, so one thing comes up off and in dementia, is the incredibly high cost not of a healthcare; but of the need for a personal assistance, living arrangements, or supportive housing for people who develop dementia and/or have progressive dementia. Is part of what you do educating patients and families about what's ahead prognostically - not in terms of life expectancy as much, but in terms of financially what they need to prepare for?

Sarah: Financially, yes. In a medical legal partnership, what's helpful is to be able to have the clinical team educate about prognosis and the progression of disease because we can absorb some of that by osmosis.

It helps us do our jobs better, but we're not trained to do that piece, so what we are trained to do is talk about the financial and legal mechanisms, in other words, benefits, rights to pensions, those sorts of things, how to navigate the patchwork of financial and legal resources to access the benefits that you will need, how to think ahead about it.

A big piece of that is also elder financial abuse prevention because we have a gap in coverage as you've noted. Medicare does not pay for the majority of services that families need in dementia and Medicaid ends up being the number one payer of long-term care supports and services, but many families overestimate the role of Medicare in paying for their costs.

They haven't planned and they have no idea about the role of Medicaid in long-term care. A lot of people perceive Medicaid as that program for poor people, right? With stigma embedded in that and don't realize that Medicaid ends up being the safety net for the middle class and sometimes the safety net for higher income people who have been victims of elder financial abuse in the marketplace and have lost a lot of assets.

It plays an outsize role in care of this population, but out-of-pocket costs are also enormous.

Eric: Yeah.

Sarah: One thing that an attorney can do is educate about your rights within certain programs, so the social security program, the VA host of benefits, certainly, the Medicaid program, because Medicaid is essentially a series of subprograms. It can become very complex for people who don't understand how to navigate that, so a lot of legal aid offices will educate families about what those programs are, the benefits that might be available to them, and thinking ahead. You can pay out-of-pocket using X number of resources for so long and then, what's the strategy going to be. For the 10% of people who actually buy long-term care policies, they often need help navigating those policies because unfortunately they don't offer the range of benefits or supports that families thought they were going to receive. Sometimes, legal advocacy and education can be really helpful there as well.

Eric: Just a New York Times article on the ethics of, I think, asset protection to qualify for Medicaid and giving away your assets to qualify for Medicaid, even for those who are upper middle class high earners. Did you see that article?

Sarah: Yeah.

Eric: Do you have any thoughts on what should our role be in helping people think about, for instance, asset protection and the need for qualifying for Medicaid?

Sarah: I'm really glad you asked that question, so I think a good form of medical planning is to take a whole person approach. I'm sorry I keep saying Medi-Cal because that's our program in California, but by MediCal, I mean Medicaid generally in other states as well. Why do you want to be on the Medicaid program? There are many reasons where you might not want to be on the Medicaid program and paying out-of-pocket would give you more options, but if you don't understand the Medicaid program, or what it means to be on the Medicaid program, or what that will mean for your assets and wealth, then you will have a harder time making that decision.

I think of it, first of all, as just an educational tool. What is the program? Do you understand what this is?

Do you understand some of the practical limitations of being on the Medicaid program? Even though many forms of discrimination are unlawful, for people on the Medicaid program, they do happen.

Part of an attorney's job is to tell you both your theoretical rights and how those play out locally and what you might want to keep in mind in terms of access to various services, but I guess I would also respond to that by asking you a question, which is, have you ever been to a tax planner?

Eric: No, but my wife is a tax attorney.

Sarah: Well, why do you think I asked that question?

Eric: I don't know.

Sarah: This is entirely my opinion. I'm not speaking for UCSF Medical Center or UC Hastings College of the Law. This is entirely my opinion. There are a lot of mechanisms by which wealthier individuals can get information and assistance in understanding how to protect the wealth that they have accumulated over their lifetime for themselves and for their families. Those are very well-accepted services and mechanisms, but for some reason, when it comes to lower income people and middle class people, there's the stigma about getting information about how to protect your resources. My view is that we should at least be internally consistent about our views of the rights of different people to get information and assistance in making decisions about how to manage their resources, whether that's for high-income people or for low-income people.

Eric: Yeah, we see it a lot where somebody doesn't have a lot of money, maybe it's $20,000 that they have left. They make enough to qualify or not qualify for Medicaid, but their number one goal more than anything is that they want to make sure that that $20,000 goes to a certain family member upon their death. They will do anything to protect that $20,000 and it surprised me a lot. It just happened to us a week ago on our palliative care consult service.

Sarah: It happens a lot and I think I do see it as a social justice issue, so Amy Kelley and colleagues have a really sobering paper in annals of internal medicine that I really, really recommend. They essentially looked at the cost of dementia care in the last five months of life and they found the average cost of dementia care was a little over $60,000 in the last five months of life and that was entirely out-of-pocket.

This represented about 30% of patients' wealth in dementia as compared to other diseases, so in the non-dementia group, the out-of-pocket costs were about 11%. It has a disproportionate impact on certain communities, so they found that in African-American patients, the out-of-pocket cost represented about 60% of their wealth.

Two-thirds of their wealth went to paying for long-term care supports and services. For single women, so women who were widowed or unmarried, it represented about 58% of their wealth. With people with less than a high school education, I think it was about 58% of their wealth, so if you think about all of your income and assets that you've worked so hard for over your whole life and for vulnerable populations, you literally had to scrape together, that now is going to just provide for your basic needs and your basic care.

This is an untenable situation for a lot of people in our community and I think because of our national and state policies, we've setup an environment that is a highly complex decision-making environment. We've essentially said, "Good luck to you. Go figure out how to marshal the resources to pay for this care that you need."

I think in that environment and I think reasonable people can disagree about the best way to provide a system of long-term care supports and services, but I think we should be transparent about the fact that we have put the onus on patients and families to figure this out. We've put this onus on them at a time when they're losing cognitive function and they're highly stressed.

It's not a good decision-making environment, so it's no wonder that almost 50% of persons with dementia experience at least one form of elder abuse. These are really highly stressful situations, so direct legal education and assistance is something we can do to help them, to help mitigate that stress and help support decision-making and hopefully prevent outcomes that are really detrimental to health, like conservatorship and elder abuse.

Eric: That's terrific. We'll include a link to the Amy Kelley paper, fantastic paper, in the GeriPal post or the company's podcast. I wanted to ask you about caregivers because they're just a huge part of this story in dementia and the burden on caregivers, physically, emotionally, and financially. I want to ask how you work with caregivers in particular to support them through this process.

Sarah: An important thing that I've discovered in my work, well, this isn't news to a lot of people; but caregivers are navigating a huge number of decisions on a daily basis in addition to grappling with the emotional and psychosocial dimensions of caring for someone with dementia. One piece that we can do on the legal side is, for instance, helping to educated them about their role as a decision-maker for the older adult.

I have found in my work that a lot of caregivers don't really understand basic concepts, the difference between an agent and a conservator, the types of powers that they have. I hear a lot of people confusing powers under an advanced directive with powers for financial decision-making.

We're not supporting and we're not preparing caregivers to make these decisions and it can lead to suboptimal decision-making and in some cases, allegations of undue influence and abuse. Another piece is ensuring that the caregiver themselves has secure housing, stable housing, that they are not being discriminated against in the workplace or place of education because of their caregiving responsibilities, so advocating on that front to help ensure that they're at least getting what they're entitled to in terms of work protection.

There's a whole host of things that we can do. If caregivers themselves are economically insecure, we can assess their benefits and obviously, if they're spouses, a lot of these things, you're talking about these things in tandem; but for older children, it's a little bit of a different approach to advocacy.

Eric: It sounds like one thing we should all be thinking about doing is setting up a medical legal practice clinic. If we're not there yet or it's logistically impossible, two or three things that listeners can start doing in their practice to make sure we're addressing some of these needs.

Sarah: Again, identifying your at risk population.

Eric: Do you have specific tools that may help with that or questions that we should ask?

Sarah: Think about who is at risk of cognitive impairment in the next six months to a year and think about if that individual has an advanced directive. If they don't have an advanced directive, they probably don't have any of their other financial or legal planning in place. If they do have their advanced directive, it doesn't necessarily mean they have all their other ducks in a row; but then, ask the question, "Have you done any financial or legal planning?"

Eric: If the answer is no?

Sarah: If the answer is no, then refer them to legal aid in the community, so the Older Americans Act provides free legal resources to individuals over the age of 60, at least, in theory, in every state, in every community. One reality about accessing legal aid is that they are incredibly overworked and underfunded and often, unfortunately, cannot prioritize low urgency needs like advanced planning.

This is one of the needs that in MLP we're trying to bridge is rather than wait until we're defending an eviction, can we get in earlier? Right? But some communities won't have that luxury, but you can try, so start with a free legal service with the Older Americans Act provider in your community. If they are unable to take the client, then refer them to your local state bar referral service, to an elder law attorney.

The state planner doesn't necessarily have expertise in the things like Medicaid for long-term care and so, referring to someone who has experience with older people or people with disabilities is an important thing to keep in mind. I also really recommend against making direct referrals to private attorneys in the community. It's much better to go to the state bar regulated referral service, so that they can do some intake and make sure that the person is directed to the right attorney.

Eric: Let's say I don't have a medical legal practice clinic or MLP, but I want to start one. Are there resources for me to do so?

Sarah: There are really fabulous resources on the National Center for Medical Legal Partnership website. The best resources are going to be right in your community, so there are legal aid attorneys and in many places, law schools that are doing this kind of work and connecting your work is going to make a lot of sense, both for training of professionals and for better serving the client and patients that we all work with.

There are some promising things that I can mention in terms of funding, so HERSA has determined that civil legal services can be paid for using HERSA dollars. Some community health centers are doing that, some health centers have said, "We see a return on investment in these programs." For instance, some MLPS have demonstrated a reduction in hospital readmissions and a reduction in overall utilization, cost of care.

Some MLPs, one in palliative care, actually, in Nebraska, has demonstrated a return on investment. The medical center is actually paying for their legal services, providing those to their patients. There's currently a proposed macro rule that would allow screening for health-harming legal needs to be considered one of the factors in MIPS scoring, so screening for health-harming needs if the rule is passed would be something that could positively impact your MIPS score.

Other mechanisms, the VA is currently very interested in medical legal partnerships. We're still looking for a sustainability mechanism through the VA, but certainly there are opportunities to expand to VAs as well. At the policy and systems levels, there are mechanisms that are emerging. The national center has done really great work around to enable health systems to adopt MLPS.

Eric: Wonderful. Well, maybe with that, I want to really thank you for sharing your time with us today.

Alex: Thank you so much, Sarah.

Eric: For the great things that you're doing out there. Alex, sing Sarah a different song. What are we gonna do?

Alex: Can we try that again?

Sarah: Yeah.

Alex: I'll try it again. Alright, I'm gonna try to get it right this time.

Alex sings “How Can A Poor Man Stand Such Times and Live” by Bruce Springsteen.

produced by: Sean Lang-Brown
by: Eric Widera

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Friday, September 1, 2017

Geripal Podcast: Zara Cooper on Trauma Surgery and Geripal

If you were talking to a geriatric trauma surgeon, wouldn't you think you'd be talking about surgery in older adults who experience trauma?  Fascinating, therefore, to talk with our GeriPal Podcast guest Dr. Zara Cooper, a palliative medicine and trauma surgeon, and critical care doctor at the Brigham and Women's Hospital and Harvard Medical School.

Turns out most geriatric trauma patients don't have surgery.  The major focus of the geriatric trauma service is improving quality of life.  This is an area that is squarely at that surgery/geriatrics/palliative medicine interface.

Trauma is so different from other forms of "serious" illness in older adults, because it comes on so suddenly.  You don't have any of those 4 classic archetypal trajectories (sudden death is the closest).  You have sudden advanced illness.  Implications are profound, from differences in the approach to advance care planning, to estimating prognosis, to the families emotional reaction, to having a breaking bad news and prognosis discussion all at once.

Key quotes to tempt you to listen (or read if you must) to the full podcast:

I think that one of the things that makes trauma, and critical care, but trauma a really perfect incubator for the marriage between GeriPal and surgery, is that trauma is, by it's nature, a multi-disciplinary practice. Unlike many other areas of surgery, where it's still the surgeon alone is the captain of the ship, in trauma, we lean more heavily on other discipline

One of the things where our geriatricians have been so helpful have been around the prognostic piece. Understanding their overall trajectory is so helpful in goal setting and decision-making, and it's something that we as surgeons are not at all trained or equipped to do. I'll tell you a lot of surgeons don't realize that dementia is a terminal diagnosis. I think there's a lot of education to go around, and it's a really important opportunity for partnership.

I guess one other thing I would say is that we're not ... I think that a lot of the stereotypes persist and  ... surgeons really care about their patients. I think that, particularly in the palliative care community, this kind of bogie of thirty day mortality, which I know is particularly relevant in fields like CT surgery and transplant, has really kind of clouded opportunities for collaboration and understanding between the two fields. We really do care about our patients and, sometimes, it's in a way that can be not patient centered. I don't think it comes from the wrong place, in most cases. I would really urge folks in geriatrics and palliative care to really look for opportunities to collaborate with surgeons. I am happy to help or discuss that with anybody in the audience.


Produced by: Eric Widera, @EWidera
Post by: Alex Smith, @AlexSmithMD


Listen to GeriPal Podcasts on:
Transcript of the podcast:

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who's our guest today?

Alex: We have a wonderful guest today. We have Zara Cooper, who is a trauma surgeon, critical care doctor and palliative care doctor, and is also Associate Professor of Surgery at Brigham Women's Hospital at Harvard Medical School. Welcome to the GeriPal Podcast, Zara.

Zara: Thanks. It's a pleasure to be here.

Eric: So, we start off with a song request. Zara, you got a song for Alex?

Zara: Yes. I'm a huge Rolling Stones fan. I think they're under played and under appreciated these days. So, Alex, I would love it if you would play something from the Stones.

Alex: Totally agree. You can't always get what you want, though.

Alex sings “You can’t always get what you want” by The Rolling Stones.

Zara: Thank you. Nice. Thanks, Alex.

Alex: We say, I sang that with Christian St. Clair, who is, you know, president of

AHPM, last year at a conference. And our favorite line is, 'cause we're both, you know, we're palliative care docs, is "I sung my song to Mr. Jimmy. Yeah, and he said one word to me." And then Christian says, he just yells it, "And that was 'dead'." Ah, palliative care humor.

So we want to talk with you about your fascinating mixture of fields here. You are one of a few people who are both surgeons and geriatics ... interested in surgery and GeriPal, geriatric and palliative care. So Zara, tell us how you got interested in geriatics, palliative care and trauma surgery. What an interesting mix.

Zara: I think my interest really started during my critical care fellowship and, over the years, I have recognized that there's really been a dramatic increase in the number of older patients who are coming under my care. I did a palliative care fellowship at Dana Carver and what was interesting for me was when I was rounding on our patients with advanced cancer, I realized these folks look a lot like my trauma patients. A lot of that is because we have such high rates of frailty among our trauma patients, and our geriatric trauma patients in particular. I realized that there were lessons that I could learn from palliative care and geriatrics, especially around prognostication. You know, goal setting, symptom management, that would be really relevant to my trauma patients as well.

Alex: So, so, paint a picture for us of what the patients that you're seeing, at sort of this GeriPal-trauma intersection, look like.

Zara: So, I think it's no surprise to this audience that the number of older patients who are falling is rising. But, the folks who come to my attention are those that are more severely injured. So patients who have rib fracture, cervical spine fractures, traumatic brain injury, you know, and other internal organ injuries related to their falls will end up in the trauma service. The numbers of those patients are escalating rapidly. So now you have trauma centers like mine where, you know, either almost 50% or even over 50% of the patients on the trauma service are geriatric. And the vast majority of those are frail elders.

Alex: Over 50 percent?

Zara: Yeah. So, in folks, in places like Florida and Arizona, you have centers where the majority of their patients are geriatric trauma. And those number are increasing. And it's interesting 'cause actually the biggest burden is not being borne by the trauma centers, it's by the non-trauma centers and, acute care hospitals.

Alex: Interesting. So, what are the needs and the barriers ... you're talking about, you alluded to this a little bit before about prognosis, symptoms, setting goals of care. Can you tell us a little bit more about what the, the sort of geriatric and palliative care needs are of this population?

Zara: Right. Right. So if you take patients who are frail elders who either it's their first fall of they've had multiple falls, they have severe injuries that are then going to adversely affect their function, their quality of life, they're gonna have, you know, acute and which will eventually turn into chronic pain, or these were formerly independent people who are now going to be functionally dependent and need to live in nursing facilities. You know, those are major life changes. And for many of these patients, that's exactly what they're facing after what we as trauma surgeons have learned are seemingly minor injuries like a few rib fractures, or even a cervical spine fracture. But, in a frail elder, those are devastating injuries. And so the goal setting, the prognostication, family meetings and, then we also have to think about end-of-life care and care planning, advanced care planning and the end-of-life care that we provide in the hospital. I will say that, on average, in-hospital mortality for trauma patients is about 5%...

Alex: Mm-hmm (affirmative).

Zara: But for elder patients, it's twice that. So typically we're dealing with older patients who may have end-of-life issues that are actually related to their underlying health status, their frailty, multi-morbidity, as opposed to just the injury that they recently sustained.

Alex: It might help for our readers ... this is fascinating, this field, to sort of crystallize for them if you have any cases or stories of patients, either successful or, "Wow! We really could've used GeriPal-a GeriPal approach here.”

Zara: Well, I will say that in our center, we have had a lot of success recently because about three years ago, we went to a triggered consultation model and our service now has a 50% FTE geriatrician who routinely rounds on our geriatric trauma patients. And so I will say that, actually, our rates of MOLST completion are actually higher than on the oncology service. I'm really ...

Alex: MOLST fbeing like the Massachusetts version of POLST.

Zara: Yes. Exactly.

Alex: Mm-hmm (affirmative).

Zara: And so I'm very proud of that. And, you know, we've also noticed that we've had increases in DNR-DNI orders. That in and of itself isn't so noteworthy as it is that the conversations are being ... are happening and are being documented because we've implemented geriatric kind of processes of care and palliative processes of care around these patients. That being said, there are still cases where there are folks who will slip through the cracks and, I think, at other trauma centers that don't have these processes in place, it's not unusual to have an older patient who comes in, you know they've fallen, they have a devastating cervical spine fracture, let's say it's a lower cervical spine fracture. They have spinal cord injury, and they're expected to be paraplegic, quadriplegic, certainly if they had a cervical cord injury it would be quadriplegic. There's just this assumption that now they're on this treadmill and they're going to get the most aggressive, life-prolonging care that they can without an evaluation of their goals and values up front-

Alex: Mm-hmm (affirmative).

Zara: Identifying healthcare proxies, trying to figure out if advance directives even exist, discussing code status and certainly for, you know, surgery, many of those patients may have unstable fractures that might be amenable to surgery, but recognizing that that's a palliative procedure. And then talking about what their trajectory looks like. I've certainly encountered families that I've taken care of in the ICU where they've been shocked to learn on day six or day seven, "What do you mean mom isn't coming home?"

Alex: Oh, yeah.

Eric: I could only imagine that for trauma patients, the need to act quickly is also there. More so than we even see in cancer patients or other patients on palliative care or geriatric service. Is that right?

Zara: Yeah. So, you know, I think one of the major challenges for surgery in general, for trauma and emergency surgery in particular, is that the time pressure is there and you feel need to act quickly, certainly if you're stabilizing somebody who is, you know, at risk of imminent death. There is certainly a need to act quickly. But, oftentimes you do have enough time to have some meaningful conversations with patients and their families. I mean, you have enough time to get consent for the surgery. So I would propose that, in fact, some of these conversations, if they're done well, can happen in a short period of time.

One of the things that is a major disadvantage for us is that we don't have a longitudinal relationship with our patients and families.

Alex: Mm-hmm (affirmative).

Zara: And it's really important for us to gain their confidence very quickly. So it makes a lot of surgeons and trauma clinicians very hesitant to start bringing in bad news, and discuss the adverse, possible adverse outcomes and poor prognostic outcomes for fear of taking away hope, but also not engendering confidence between the patient and their family.

Alex: That's really interesting. The issue you raise, which is there is a need to sort of geriatricize and palliatricize, is that a word? Palliatricize trauma surgeons, and yet there are also some historic, cultural barriers, if you will, to that geriatricization and palliatricization. And there may be a role for a specialist consultative care from a geriatrician as you say, or from a palliative care physician. What's the balance there in terms of sort of steeping the trauma surgeons and geriatric and palliative care principles, and a role for specialist palliative care or geriatrics consults?

Zara: Yeah. I think that's a great question and one that we're struggling with ourselves. I think there are a couple of issues. One is that obviously we know that there are not enough geriatricians and palliative care clinicians to go around. I'm fortunate to work in a quaternary academic medical center, but in most places these resources are just not available. And even within my hospital, we don't have a lot of geriatricians. So for those reasons, surgeons need to be able to do primary, what's been described as primary palliative care, much of which would really address the needs of this patient population.

I think the other issue is that what many of my colleagues worry about is that palliative care clinicians are not as well versed in sudden acute, what [Rodney Tucker and colleagues] have described as sudden advanced illness, and are not so comfortable with such an urgent trajectory.

Alex: Mm-hmm (affirmative).

Zara: So I think that there's a need for education on both sides, actually.

Alex: Yeah.

Zara: For palliative care clinicians and geriatricians to meet the needs of this population. Because these are conversations that are happening kind of in real time, they're not an iterative process, you don't necessarily get to re-visit them over and over, but they do have to happen, and you have to do it within the timeframe that you have.

Alex: The other tension it raises is, that you alluded to here, is this issue of in-patient versus outpatient. You see them in the hospital but those patients are gonna go on, many of them, to live lives outside of the hospital for some period of time. Who's gonna follow them? What's that continuity gonna be like? Who's gonna develop that relationship and see it through?

Zara: That's exactly right. We struggle with that because those outpatient resources are, there's really a dearth of resources for palliative care and geriatrics. One of the things to keep in mind about this population is the vast majority of them don't have surgery. They really are medical patients with injuries, and so the trajectory is quite similar.

Alex: That's interesting. So they may be on a trauma surgery service, but they may not have had surgery.

Zara: That's exactly right. I mean, the vast majority of them don't have surgery. One of the things where our geriatricians have been so helpful have been around the prognostic piece. Because that's been really important. Because understanding their overall trajectory is so helpful in goal setting and decision-making, and it's something that we as surgeons are not at all trained or equipped to do. I'll tell you a lot of surgeons don't realize that dementia is a terminal diagnosis. I think there's a lot of education to go around, and it's a really important opportunity for partnership.

Eric: What does it look like for ... so you maybe have somebody with multiple comorbidities, which there's been a lot written about with prognostication in those people, or with cancer, but for the trauma patient, how should we think about those patients and prognostication?

Zara: Right. Well, many of those patients are the same patients because it's geriatric syndromes that put them on the trauma service.

Eric: Yeah.

Zara: I mean, I think that's the first thing to realize. For a lot of these folks, why did they have burn injuries, for example? They have burn injuries because they forgot to turn off the stove. Or it's not even that they forgot, they didn't have awareness to turn off the stove. Why have they fallen? Because they've tripped over their walker. They have neurologic impairments like Parkinson's that have caused them to be unsteady on their feet. They have motor vehicle crashes because they've syncopized because of congestive heart failure and valvular disease. I think it's recognizing that a lot of these injuries really have a medical etiology, which is very different than the younger trauma patient population that we're used to.

Alex: Are there any resources or online calculators to help folks?

Zara: One thing that a handful of use in this surgical palliative care community have been doing is really been encouraging our colleagues to use e-prognosis.

Eric: Shameless plug by Alex there.

Zara: Yeah.

Alex: But I wonder if there are also disease, condition specific prognostic calculators for trauma.

Zara: Well, there are, but they're mostly focused on injury severity, which we find is less relevant in this population. Even relatively minor injuries, like a mild traumatic brain injury, has implications in an older patient that it may not in younger patient. So even the trauma scores that are typically used are not so relevant. There are two resources specific for trauma that are very, very useful. One, actually three, one is the frailty ... I'm sorry – the trauma-specific frailty index, which is a modification of the Rockwood approach. It's a screen for frailty which has been shown to be very correlated to adverse outcomes. The other is the Geriatric Trauma Outcome Score, which uses a number of physiologic variables that really can be assessed in the trauma bay and within the first twenty-four hours to identify patients who are at highest risk of in-hospital mortality. Then the trauma quality improvement program, from the American College of Surgeons, is coming out with standards. I shouldn't say standards, I should say guidelines, that were compiled by an expert panel, including experts in palliative care, trauma surgery, critical care, and other related disciplines, really guidelines for palliative care of the trauma patient. Much of that is most relevant to the geriatric population.

Alex: That's terrific. We can include links to those resources in the post that accompanies this podcast. Is the last report released?

Zara: It's not released yet, but I will let you know as soon as it is.

Alex: Okay.

Zara: Alex, did I hit everything? Was there any calculator that you were thinking of that I missed?

Alex: No. No. That's great. I actually didn't know, so it's helpful to hear there are some.

Eric: When you think about goals of care for these individuals, do you have a structure of how you think about that or how you talk about patients? In particular, trauma patients?

Zara: Yeah. I think that there are a number of issues really related to the time pressure around it and that it often is, as my colleague and dear friend Rachelle Bernacki has described it, as a "breaking bad news" conversation and a "goals of care conversation" all wrapped into one. Whereas in the kind of outpatient trajectory, those are different conversations that happen over time. I think the first approach is to really understand what the patient and family understand about their overall health, and then what their understanding is about the implications of this injury. I think that there's a lot better understanding among the public about the implications of a hip fracture, for example, than there is about a cervical spine fracture. I've often joked that this is the only country in the world where people think that and 85 year old can break their neck and be okay.

Eric: Mm-hmm (affirmative).

Zara: Right? So doing some expectation setting is really important, and just making sure that everyone's on the same page with that. Then I think it's really understand what the patient's overall goals are, just as you would in almost any setting. And then talking about the goals specific to the injury or the surgery, and what we hope we can achieve. And then describing what various treatment options, including palliative care, which is a challenge for a lot of surgeons who don't understand what that means, but including just a comfort-focused approach would be, and then making a recommendation based on how those treatment options can meet the patient's goals and values. I think for a lot of patients, if we could be more up front with them about the implications for their independence and their function and pain, I think they may make different choices.

Alex: Mm-hmm (affirmative). I'm hoping that there are folks who are developing or working on better techniques for treating the symptoms and improving quality of life for trauma patients so they can live each day as good as it can be and the emphasis there is on we have so much to offer you in terms of quality of life in this comfort-oriented approach. Is that the case?

Zara: Yeah. No, it is the case. I think that one of the things that makes trauma, and critical care, but trauma a really perfect incubator for the marriage between GeriPal and surgery, is that trauma is, by it's nature, a multi-disciplinary practice. Unlike many other areas of surgery, where it's still the surgeon alone is the captain of the ship, in trauma, we lean more heavily on other disciplines, including, in many cases, anesthesia for critical care, for example. There are also structures and processes of care in place for quality improvement, and measurement, and standard setting that I think lend themselves really nicely to palliative care.

The other thing about trauma is that we do care about the whole patient. As I said, most of these patients don't get surgery. Most trauma patients of any age don't have surgery. So, it's one area of surgery where were are also looking at function and quality of life and rehab. Where we've been doing it for the longest, I should say, and not just on geriatric patients. I think that there's a lot of overlap between what trauma surgeons do normally and what palliative care and geriatrics can offer.

One of my goals is to engage, and part of the reason I'm so grateful that you guys had me on, is because I'd really love to engage more geriatricians and palliative care in helping us think about the best way to improve quality of life. I don't think we can do it alone. I think it needs a multi-disciplinary approach.

Eric: Mm-hmm (affirmative).

Alex: And you mentioned quality and quality measures potentially. Are there ... I know in a lot of fields, like CT surgery, there is discussion about thirty day mortality rates. What does that mean in particular for palliative care patients where maybe they won't undergo specific surgeries because it may make a particular surgeon's thirty day mortality rates look worse? Is that a same issue in trauma patients?

Zara: Right. It's so interesting that you say that. So, yes. I mean yes, trauma centers are measured on their in-hospital, primarily in-hospital mortality and many of the metrics that are common to surgery at large are relevant in trauma surgery. But, I think as in the rest of surgery and medicine in general, there really is a push to start thinking about how we can better consider the longitudinal outcomes with respect to function and quality of life and symptom burden. So there is work in the field to figure out how to do that. Not specific to geriatrics and palliative care. There are folks like Karen Brasel, who is an expert in measuring quality of life, longitudinal quality of life in trauma patients, who have come up with scores. So there are ways that we do this. But I think specific for the geriatric population, there are measures that are lacking.

One thing that I will say is that we are about to come out with a paper, our group is about to come out with a paper, in a surgery journal unknown, really looking at the quality of end-of-life care among older patients who have severe brain injury and comparing high-mortality trauma centers versus all others. Or, I should say, low mortality trauma centers versus all others. What we found was that the low mortality trauma centers are actually more, are more likely to refer to hospice, have lower intensity of treatment, but also have better overall survival. So, the kind of historical surgical mantra of "you're killing my patient," actually what we find is that better end-of-life care, as we've found in other fields, does not equate with higher mortality. We're pretty excited about that 'cause we hope that'll help move the field forward.

I guess one other thing I would say is that we're not ... I think that a lot of the stereotypes persist and we're ... surgeons really care about their patients. I think that, particularly in the palliative care community, this kind of bogie of thirty day mortality, which I know is particularly relevant in fields like CT surgery and transplant, has really kind of clouded opportunities for collaboration and understanding between the two fields. We really do care about our patients and, sometimes, it's in a way that can be not patient centered. I don't think it comes from the wrong place, in most cases. I would really urge folks in geriatrics and palliative care to really look for opportunities to collaborate with surgeons. I am happy to help or discuss that with anybody in the audience.

Alex: How about just a couple words of advice how to do that? I think it sounds like the very first thing we should be doing is recognizing our stereotypes and how they actually may be wrong, and that we're all trying to do the best for the individual?

Zara: Yeah. So, I think that aside from kind of recognizing the stereotypes, I think it's also recognizing gaps in knowledge and areas where palliative care can be particularly helpful. So I personally think the larger challenge to palliative care as a field right now is to really better understand how it can be relevant or most relevant to patients outside of cancer. I think that this syndrome of sudden advance illness is really an important one for the palliative care community to embrace and to figure out how to provide the best possible care to our patients who find themselves in that situation. I think that trauma surgeons, emergency medicine physicians and intensivists are perfect folks to partner with to really examine that.

Eric: Well Alex, do you want to end us with a song?

Alex: All right. We'll do a little bit more.

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