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State of Heart Failure & Palliative Care: Podcast with Haider Warraich

There are a lot of large numbers that involve heart failure, starting with the sheer number of patients diagnosed (6.5 million and counting), to the cost of their care (~$70 billion by 2030), to the amount of money invested by the NIH into research ($1 billion annually). But the smaller numbers deserve attention too - 50% of patients die within 5 years of their diagnosis, those older than 65 in the hospital die even sooner at ~2.1 years thereafter, the median survival on hospice since hospital discharge is 11 days, and <10% of patients with heart failure receive a palliative care consult. So what can we do to bridge the gap between heart failure and palliative care?As a current palliative care fellow and former hospitalist on UCSF's Advanced Heart Failure service, I have a strong interest in this question. This week I was lucky to have Alex and Eric let me join in interviewing Haider Warraich, Associate Director of Heart Failure at the Boston Veterans Affairs Hospital and Assoc…
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The Geriatric 5M Approach to Telemedicine Assessment: A Podcast with Lauren Moo

On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine.  Now with COVID among us, Lauren talks to us about her recently published JAGS article titled "Home Video Visits: 2‐D View of the Geriatric 5‐Ms."   In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework: mind, mobility, medications, multicomplexity, and what matters most.  Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine.   One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article:"I recommend that you discourage patients and families from using the backgrounds…

Advance Care Planning is So Right: Podcast with Rebecca Sudore and Ryan McMahan

Last month we published a podcast with Sean Morrison that garnered a great deal of attention, in which Sean Morrison argued that Advance Care Planning is an idea that is “clear, simple, and wrong.”This week, we have a fresh updated counterpoint from Rebecca Sudore and Ryan McMahan.  These two published a paper this week in the Journal of the American Geriatrics Society, or JAGS, that argues that the field of advance care planning has come a long way.  Early studies of advance care planning evaluated it with advance directives, and studies of advance directives showed little to no difference.  However, In their review they find recent (since 2010) high quality trials demonstrate the potential of advance care planning by using modern conceptions of advance care planning as a longitudinal conversation to help surrogates prepare for in the moment decision making.  These studies evaluated a broader (and more fitting) range of outcomes than prior work, including surrogate preparedness.  My …

Why You Should Never Mix Miralax (PEG) with Starch Based Thickend Liquids

By: Matthew Gonzales and Eric Widera
Many of us in the GeriPal community are dubious about the benefits of using thickened liquids for dysphagia. If you haven’t read prior posts on this, head on over to see a great analysis illustrating the limited evidence. (Side note – if you need a pick me up for these days of 2020, be sure you revisit this video of the GeriPal team trying thickened liquids for the #ThickenedLiquidChallenge). Despite the lack of robust data, dysphagia-based diets with thickened liquids remain a standard of care. The hope is that it is easier for people to coordinate swallowing with a thick liquid versus a thin liquid and thus less aspiration events occur. To achieve the desired thickness, one adds a powdered thickener to any thin liquid (water, juice, coffee, etc.), stir, and voilà you have a thickened version of that liquid. There are two types of powder typically used to thicken liquids. The original is starch based (i.e., cornstarch) while the newer one is…

Brain Death: A Podcast with Robert Truog

In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria.  Over the next 50 years, the debate over the concept of brain death has never really gone away.  Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria.  On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Truog.  Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School.  He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA:
The 50-Year Legacy of the Harvard Report on Brain Death Understanding Brain Death Brain Death—Moving Bey…

It's Time for Comprehensive Dementia Care: Podcast with Lee Jennings and Chris Callahan

Chris Callahan (of Indiana University) and Lee Jennings (University of Oklahoma) have some righteous anger.   Why do we have comprehensive cancer care centers and not comprehensive dementia care centers?  We have a body of evidence dating back 30 years to support people with dementia and their caregivers with Comprehensive Dementia Care. Lee Jennings added to this robust body of work with a study published in the Journal of the American Geriatrics Society demonstrating that a comprehensive dementia care program based out of UCLA reduced ED visits, hospital length of stay, increased hospice enrollment, and delayed time to admission to long term care.  As Chris Callahan notes in his accompanying editorial in JAGS, a fundamental problem with our healthcare system is that savings from Comprehensive Dementia Care accrues not to the dementia care program, but to the hospital and Medicare (ED visits, hospital length of stay) or Medicaid (long term care admission).  Our fragmented healthcare …

Reducing serious fall-related injuries: an interview with NEJM STRIDE Study author Tom Gill

Every year, about a third of older adults fall.  About one in five of those falls result in moderate to severe injury.  What can we do to help not only prevent those falls but also the complications of them?
On todays podcast, we talk to Tom Gill, one of the authors of the recent Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study published in the NEJM.   The STRIDE study was huge, 5,451 patients in 86 primary care clinics from 10 different health care systems.   Individuals assigned to the interventions worked with a “falls care manager” whose goal was to help identify and make plans about risk factors for falls and fall-related injuries. 
What did it show?   Well, the conclusion of the NEJM abstract states that this multifactorial intervention "did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care."   We talk to Tom about whether that is the right take home from this pragmatic study and how …

Virtual Resources for Older Adults during the COVID19 Pandemic

by: Kahli Zietlow,Serena P Wong, and Mitchell Heflin In a recent telehealth visit, a patient presented alongside her husband, who was concerned that she had become a “shell of herself.” She previously enjoyed reading, spending time with family, and attending a water aerobics class at her local YMCA. Since the pandemic began, she has suffered from isolation; her aerobic classes were suspended, and their children had stopped visiting in an effort to protect them from contracting COVID19. She hadn’t left the house in months, stopped reading books, and seemed disengaged when her family called. He observed that she spends her days watching television and sleeping, and he was concerned that her memory had dramatically worsened in the past four months.  Social engagement and intellectual stimulation are critical to one’s wellbeing, memory, and mood. Numerous observational studies demonstrate that social engagement and cognitive stimulation can delay or prevent onset of dementia. Even before t…

Family Meetings for Patients with Serious Illness: Podcast with Eric Widera

No dear listeners and readers, that is not a typo.  Eric Widera is indeed our guest today to discuss his first author publication in the New England Journal of Medicine, Family Meetings on Behalf of Patients with Serious Illness.  Our other guests include other authors James Frank, Wendy Anderson, Lekshmi Santhosh, me and actress and frequent GeriPal guest-host Anne Kelly.
There's a story behind this one folks.
One day, Ken Covinsky walked into our office and said, "You know how the NEJM has this Videos in Clinical Medicine series?  With videos like, 'How to insert a central venous catheter?'  You should send them a video of your palliative care 'intervention' - how to conduct a family meeting."  Brilliant idea. 
Well...that was 2014...a funny thing happened on the way to the theater.
After several iterations, videos, reviews, a rejection, and lessons in persistence, we finally published. We were helped by an outstanding cast who role played the family m…

The Perfect Storm of COVID‐19 in Nursing Homes: A Podcast with Joe Ouslander

COVID-19 has created a perfect storm in nursing homes.  As noted in a recent Journal of the American Geriatrics Society (JAGS) article by Joe Ouslander and David Grabowski, the storm is created by the confluence risks, including a vulnerable population that develop atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources including testing and personal protective equipment (PPE), and lack of effective treatments.   The result?  Nearly half of COVID-19-related deaths in the US occur in people cared for in nursing homes and assisted living facilities, and about a quarter of all facilities have had at least one COVID case.On this weeks podcast, we talk to Dr. Ouslander about his JAGS article on this perfect storm, as well as strategies that one can take from a clinical, public health, and policy interventions to help calm the storm.  In particular Joe summarizes a lot of research published in JAGS lately on COVID-19, including some of these studi…

Advance Care Planning is Wrong: Podcast with Sean Morrison

Sean Morrison dropped a bomb.  It's a perspective I've heard before from outside of palliative care, most clearly by bioethicists Angie Fagerlin and Carl Schnieder in their landmark article Enough: The Failure of the Living Will.  But Sean Morrison, Director of the National Palliative Care Research Center and Chair of the Department of Geriatrics and Palliative Medicine at Mt. Sinai, former President of the American Academy of Hospice and Palliative Medicine, is about as inside palliative care as one can get.  Sean argues in his Journal of Palliative Medicine piece that we should stop putting resources into making advance care planning and advance directives work.  For decades, we have tried and tried, pouring $300 million dollars into research, untold intellectual capitol, at the expense of those resources going toward other areas of need such as disparities in access and outcomes for people with serious illness.  And what do we have to show for it?  1660 studies and 80 syste…

Ageism in the Time of COVID: Podcast with Louise Aronson

In this week's GeriPal podcast we talk with Louise Aronson, author of the Pulitzer prize finalist Elderhood (listen/read our podcast with Louise on her book here).

Louise has been one of the (sadly) few voices beating a loud and urgent drum in the medical and lay press about the insidious ageism taking place in the time of COVID.  In a prior podcast we discussed the ways in which structural racism contributed to vast disparities in COVID, and similarly in this podcast we talk about the ways in which COVID exposes existing ageist assumptions, attitudes, and systematic forms of discrimination.  
To give a sense about how prolific Louise Aronson has been writing about ageism, here are links to just a sampling of her articles in the NEJM, New York Times 1 and 2, VOX, Forbes, and the Atlantic.  She also mentions this terrific piece by Nathan Stall and Samir Sinha during the podcast.
And wow - love the song choice - It's the End of the World As We Know It by REM.  Sure seems like i…