GeriPal

Despite being in the field over 15 years, I've never felt so far outside my comfort zone as as palliative care provider as I have felt in the last four months.  A worldwide pandemic of a novel virus had me questioning how I communicate prognostic information when uncertainty was one of the few things I was certain about.  It also pushed me to have these conversations via telemedicine, something I was previously more than happy to leave as a tool for only outpatient providers.  The pandemic and the murder of George Floyd brought to the forefront the systemic racism that permeates our society and my own inadequacies in discussing the trauma that these killings and mistreatment have on black Americans. 

We grow though when we are pushed outside of our comfort zones.  I'm pretty sure Tony Back, the co-founder of VitalTalk, would probably say that I have found my "learning edge".  Lucky for me, we have Tony, along with another VitalTalk guru, Wendy Anderson, on today…

If you looked at the academic literature, you would think that elder abuse and neglect, collectively called elder mistreatment, did not exist before the 1990s.  Of course that's not true at all, it was hidden, covered, and not a major subject of research.  Several pioneers have placed elder mistreatment firmly on the map, including XinQi Dong, Mark Lachs, and today's GeriPal podcast guest, Dean Laura Mosqueda (@MosquedaMD) of the Keck School of Medicine at the University of Southern California and Director of the National Center of Elder Abuse.  Archstone Foundation, who funds our podcast, was a critical early investor in efforts to raise awareness, study, and intervene to prevent elder mistreatment.

Today we learn about what a long term care Ombudsman is, about the impact of Covid19 on elder mistreatment, and ethical issues at the core of elder mistreatment (autonomy vs. safety and public health).  
One major take home point that I'd like to emphasize here are three ques…

This was a remarkable podcast during this moment in which our country is hurting in so many ways.  
Today's topic is the impact of COVID19 on minority communities, but we start with a check in about George Floyd's murder and subsequent protests across the country.  Our guest Monica Peek, Associate Professor of Medicine and Director of Research at the MacLean Center of Clinical Medical Ethics at the University of Chicago, notes right off the bat: COVID19 and the reaction to Floyd are related.  The covid epidemic has created an economic crisis, a heightened level of worry, and a disproportionate number of deaths among the African American community.  When we add COVID on top of the long history of police brutality that has been heightened over the last several years that has been ignored by the federal government - in that context, it's not surprising that we're seeing protesters put their lives on the line to stand up for what they believe in.  These protesters are put…

The question of who should get limited supplies of drugs that treat COVID-19 is not a theoretical question, like what seems to have happened with ventilators in the US.  This is happening now.  Hospitals right now have limited courses of remdesivir.  For example the University of Pittsburgh hospital system has about 50 courses of remdsivir.  They expect it to last to mid-June, enough for about 30% of patients who will present in the next 3 weeks.   Who do you give it to?   The first that present to the hospital (give it all away in the first week)?   Random lottery?  Or something else that also accounts for the greater impact of COVID-19 has on disadvantaged communities ?

On today's Podcast we talk with Colette DeJong, 3rd year medicine resident at UCSF, and Alice Hm Chen, Deputy Secretary for Policy and Planning at the California Health and Human Services Agency, who were two of the authors of a recently published JAMA article titled "An Ethical Framework for Allocatin…

Immune Checkpoint Inhibitors.   They are revolutionary and transforming cancer care.  They shrink tumors and extend lives.  Plus they have a better side effect profile than traditional therapies for conditions like metastatic lung cancer, so when those with really poor performance status can't tolerate traditional chemotherapy, immune checkpoint inhibitors are an attractive option.  But should they be?

We talk on today's podcast with Laura Petrillo, a palliative medicine clinician and investigator at Massachusetts General Hospital and Harvard Medical School.  Laura was the first author of a paper published in Cancer titled "Performance Status and End-Of-Life Care Among Adults With Non-Small Cell Lung Cancer Receiving Immune Checkpoint Inhibitors."

In this study, Laura looked at 237 patients with advanced non-small cell lung cancer who initiated immune checkpoint inhibitors from 2015 to 2017.  She found that those with impaired performance status had significantly s…

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 …