GeriPal

by: Terry E. Hill, Taejoon Ahn, Rebecca Rozen, Joe Greaves  

For some of us, the cruelest month was mid-March to mid-April, during which our warnings about COVID-19 infections in long-term care (LTC) seemed to get little response. Here in one Bay Area county, that changed when hospital nurses engaged LTC facilities and triggered county-wide public-private coordination. As a result, an opportunity for creativity rather than finger-pointing has emerged.

The wakeup call that everyone should have heard came from a March 18th report of the index nursing home in King County, Washington: 81 of 130 residents had been infected, of whom 46 were hospitalized and 22 died. According to the follow-up New England Journal of Medicine paper, those numbers quickly grew to 101 residents infected, of whom 55 were hospitalized and 34 died, in addition to 50 infections among health care workers and 16 among visitors. COVID-19 infections had spread to 30 other LTC facilities in the county.

Two days af…

As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay, one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU.  And look at where we are today.  Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal.  What a difference a year makes.

This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care.  Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service.   Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults.  Their service peaked at 50 consults per day, and as they note, that is likely an undercount.…

Parkinson disease affects 1% to 2% of people older than 65 years. Most known for its distinctive motor symptoms, other distressing symptoms are pain, fatigue, depression, and cognitive impairment. About 2/3rds of individuals with Parkinson's will die from disease-related complications, making it the 14th leading cause of death in the United States. While there are great palliative care needs for this population, little has been published on how best to meet these needs.

On today's podcast we talk with Benzi Kluger from the University of Rochester Medical Center and the lead author of a JAMA Neurology paper that compares outpatient integrated palliative care with standard care alone in 210 patients and 175 caregivers. Every 3 months for a year, participants received palliative care visits either in person or via telemedicine from a neurologist, social worker, chaplain, and nurse with guidance from a palliative medicine specialist.  Benzi's study demonstrated the palliative…

Eight of the 10 largest outbreaks in the US have been in correctional facilities.  Physical distancing is impossible in prisons and jails - they're not built for it.  Walkways 3 feet wide.  Bunk beds where you can feel your neighbor's breath.  To compound the issue, prisoners are afraid that if they admit they're sick they will be "put in the hole" (solitary confinement).  So they don't admit when they're sick.

Many people think of prisons as disconnected from society.  Like a cruise ship.  "It's happening between those walls, behind the barbed wire, not out here."  But for every two people in a correctional facility there's about 1 person who works in the correctional facility and lives in the community.  The workers are bringing whatever they've been exposed to in prison out into the community, and bringing whatever they've been exposed to in the community into the prisons. This is a national problem, not a prison or a jail pro…

One million inpatient falls occur annually in U.S. acute care hospitals.  Sitters, also referred to as Continuous Patient Aids (CPA's) or safety attendants, are frequently used to prevent falls in high-risk patients.  While it may make intuitive sense to use sitters to prevent falls, it does beg the question, what's the evidence that they work?

We discussed with Drs. Adela Greeley and Paul Shekelle from the West Los Angeles Veterans Affairs Medical Center their recent systematic review published in Annals of Internal Medicine.   Their review identified 20 studies looking at this issue (none of which are randomized trials).  To sum up their findings, there were only two studies comparing sitters to usual care and they came up with conflicting conclusions (in one, the fall rate was lowered; in the other, it was not).  In the other 18 studies, alternatives to sitter use were evaluated.   The only thing that seems to have some evidence for was video monitoring (fall rates either …

We are rationing in the US.  We may not be explicitly rationing, as we're going to discuss on this podcast, but we are rationing - in the way we allocate fewer tests and less PPE to nursing homes compared to hospitals, in the way we allow hospitals and states to "fend for themselves" resulting in those hospitals/states with better connections and more resources having more PPE and testing availability.

And in some parts of the world, ICU and ventilator resources are scare, and they are rationing by age.  We talked on our last podcast about decisions Italy made to ration by age, and on this podcast we talk about two countries in South America we have heard are using age as a criteria for rationing ventilators.

In this context, we are fortunate to welcome Tim Farrell, Associate Professor of Geriatrics at the University of Utah and Vice Chair of the American Geriatrics Society (AGS) Ethics Committee, and returning guest Doug White, Vice Chair and Professor at the Universit…

The cross-over episode is an American tradition that is near and dear to my heart.   My childhood is filled with special moments that brought some of my very favorite characters together.  Alf crossed over with Gilligan's Island.  The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time.  To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast!


The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman.  Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina.  She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Z…

We are delighted to have Dani Chammas, psychiatrist and palliative care physician, back on the GeriPal podcast to talk about emotional PPE.  None of us can recall who originated the term, but we've all heard it bandied about much needed for front line providers treating patients with coronavirus.  Headlines about the New York emergency room doctor committing suicide are likely only the tip of the iceberg in terms of the trauma, distress, and moral injury taking place.

We talk with Dani about key issues and questions, including:
What is trauma?  What is moral injury?Is this a big deal?  What evidence do we have?What can we do about it?  Dani goes over 3 broad buckets of responses, organized with the letter C: Connection, Culture, and Coping.Normalizing rather than stigmatizing clinicians seeking mental health support We also decided to add a page to GeriPal titled "emotional PPE" with a list of resources for providers caring for patients with COVID, and we will link to th…

What's the role of geriatrics and palliative care in the care of individuals with COPD? We talk this week with Anand Iyer, the lead author of this weeks JAMA IM article on this subject.   It's a little off from our ongoing COVID topics, but given that his along with his co-authors (Randy Curtis and Diane Meier) JAMA IM piece just got published, we figured now is the right time to highlight #PalliPulm.  

What is #PallPulm? #PalliPulm is something that Anand Iyer founded, and is an online community of clinicians, investigators, patients, and others interested in the intersection of palliative care and geriatrics.  Anand is also an Assistant Professor in  Division of Pulmonary, Allergy, and Critical Care Medicine at the University of Alabama at Birmingham (UAB) and faculty at the Center for Palliative and Supportive Care at UAB.

Anands research on this subject has shown a  lot of things, including that COPD patients are often referred too late to palliative care and hospice, …

by: Bridget Blitz, LCSW

The death had nothing to do with COVID-19 and the funeral had everything to do with the virus. To lose a young member of the family with no warning or preparation is emotionally wrenching. To lose this same bright and eager person during social distancing limitations felt like a supreme torture as all the usual rituals were marred by masks, distance, rules and fear.

Each attendee to the funeral service wore a mask and stood at a distance of at least six feet from another guest, unless the guests came together from the same family. Clusters of family members gathered in the cold wind and tried to express the loss, love and appreciation for the person who had left us. We caught up in small bunches and discussed how everyone was managing this loss, work, loss of employment and social distancing. Some families came separately from younger, independent family members who returned home from lonely urban apartments whose occupants had fled to their own paren…

Many of you listened to our prior podcast with Jim Wright and David Grabowski about COVID in long term and post acute care settings.  In this follow up podcast, we talk about the situation in long term and post acute care in Indiana with Kathleen Unroe, Associate Professor at Indiana University, a scientist at the Regenstrief Institute, and a PI of Optimistic and founder of Probari, and Ellen Kaehr, Assistant Professor of Clinical Medicine at Indiana University and geriatrician and medical director of a nursing home.  A few highlights to wet your appetite:
About 2/3 of the Ellen's nursing home is COVID positive.  This has led to so many challenges - how did this happen? (asymptomatic staff).  How to cohort?  Issues with PPE, with transitions to the hospital, with visitors.We talked about the unique impact of COVID on people with dementia.  For example, mobile persons with dementia wander, which has negative aspects, but does keep them functional/mobile.  Now they're confined t…