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Showing posts from April, 2020

Proactive Integration of Geriatrics and Palliative Care Principles Into COPD: Podcast with Anand Iyer

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 ho

Grieving at a Distance

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

The Outsized Impact of COVID in Nursing Homes & in Dementia: Guests Kathleen Unroe & Ellen Kaehr

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

Love letter to Mt. Sinai

We were asked by Sean Morrison, Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, to compose a brief GeriPal video of thanks, support, and gratitude for all of the hard work they are doing in New York.  These videos are played every Friday during the Mt. Sinai's Town Hall.  Prior guests include Tom Brokaw, Mandy Patinkin, Martha Stewart, and Liz Gilbert.  August company indeed! Here is our video .   This one is probably better watched as a video, but we've supplied the audio podcast version below as well. At GeriPal, we are happy to do what we can to support, inform, and entertain those working hard on the front lines, whether it be in New York, Detroit, Seattle, New Orleans, Indiana, Chicago, or wherever you may be. Special guests from UCSF include: Rebecca Sudore, Steve Pantilat, Pei Chen, Natalie Young, Louise Walter, Brie Williams, Anne Fabiny, Ken Covinsky, and San

Updates in Prognosis for COVID: Is it really true that 88% of patients on ventilators don't make it?

There has been a lot of talk about a new study in JAMA on the outcomes of hospitalized patients in the New York City area.  The headline was shocking in the news: mortality for those who received mechanical ventilation was 88%.  However, lets take a little bit of a deeper dive before we use this number when we talk to patients and family members about prognosis after mechanical ventilation due to COVID. If I had to sum it up the prognosis for mechanically ventilated patients in this NY study, I would say something very different: out of the 1,147 patients over the age of 18 who were mechanically ventilated, 3% were discharged alive, 25% died, and 72% were still alive in the hospital.  So, we really don't know what the outcomes are as the follow-up time for most patients still alive in the hospital was so short (about 5 days).  We do know though that overall mortality will be somewhere between 25% and 97%, and worse for those who are elderly (see graph below

Life Right After the Surge: A Podcast with NYU Clinicians Ab Brody and Audrey Tan

The peak hospitalizations and deaths in New York City hit around April 7th .  Life though in hospitals in New York though have not returned to normal.   What were previously operating rooms, post-hip fracture units, or cardiac cath labs, are now units dedicated to the care of individuals hospitalized with COVID.  We talk with two NYU clinicians, Ab Brody and Audrey Tan about what life is like right now in this new state of limbo as both palliative care clinicians and as their role as either a NP hospitlist or Emergency department physician. Ab Brody is the Associate Director of the Hartford Institute for Geriatrics Nursing at NYU.  Audrey is the Director of Emergency of Medicine and Palliative Care in the Department of Emergency Medicine at NYU.  We are also welcoming back our guest host Nauzley Abedini from UCSF. A couple of topics that we talk about include: What's life like right now at NYU post-surge? What's it like to look at the COVID crises in the lens of a p

Palliative Care In the Era of Covid

by: Helen Kao My sister, who is immune-compromised from breast cancer treatment, confided to me a few weeks ago, “I’m afraid if I get Covid, I’m going to die alone, in a cold hospital bed, suffocating on my own sputum.” As a palliative care specialist, the first thought in my mind was “How in this country would we allow someone to die alone, suffocating?” Our country has focused considerable attention on the valid question of whether we have enough ventilators. But as a palliative care physician, the additional questions I ask are: Does every critical Covid patient want a ventilator? For whom does a ventilator provide no benefit? Or cause harm? And how will we care for an upsurge of dying patients in this country? For decades, palliative care specialists have been asking questions like these by supporting patient-driven care. The foundation of such care is honest discussion when certain medical interventions will not be helpful based on someone’s baseline health cond

The State of COVID19 in Boston: Podcast with Zara Cooper, Rachelle Bernacki, and Ricky Leiter

In today's podcast we talk with Zara Cooper , Rachelle Bernacki , and Ricky Leiter about the state of COVID at the Brigham and Women's hospital and Dana Farber Cancer Center in Boston.  While they have flattened the curve somewhat in Boston, they're still seeing huge numbers of seriously ill Covid patients in Massachusetts.  They have 143 out of their ~1000 bed hospital filled with COVID19 patients, including 78 Covid patients in ICU, many of which are followed by palliative care. This has resulted in the need to drastically restructure the palliative care team, including: Embedding palliative care in the ED.  They quickly found that if they waited for consults, they got not calls, and had to proactively go out and find consults in the ED.  By demonstrating their usefulness, acceptance has increased. Embedding palliative care in the ICU.  These experiences are hard.  Zara Cooper, who works as an intensivist in the ICU (as well as surgeon, as well as palliative ca

Therapeutic Presence in the Time of COVID: Podcast with Keri Brenner and Dani Chammas

"It's not about's about connection." - Keri Brenner This week's podcast features a dynamic duo of palliative care psychiatrists, Dr. Keri Brenner from Stanford, and Dr. Dani Chammas from UCSF.  Dani was a huge hit as a guest on one of our earliest podcasts talking about " Formulations in Palliative Care ." This week, Keri and Dani talk about "Therapeutic Presence," an important concept in both psychiatry and palliative care (links to articles about this concept and application  here , here , and here ).  They describe 3 key ingredients of therapeutic presence, including being deeply attentive, naming (I'd call it complex naming), and creating a safe "holding space" for patients' emotions. But come on, you might say, we're in the midst of a pandemic.  How can we maintain a therapeutic presence in a zoom meeting with family members you've never met, or with a patient who has a disease that coul

How are hospices responding to the COVID pandemic? Podcast with Kai Romero and Todd Cote

The vast majority of hospice services are delivered in patient's homes or other places of residence like nursing homes.   This makes the traditional model of hospice care vulnerable in this coronavirus pandemic, especially in the era of social distancing and limited personal protective equipment (PPE).  So how are hospice's responding to the COVID-19 pandemic? On this weeks podcast, we talk to two leaders of two large hospice agencies, Drs. Kai Romero and Todd Cote, to get their views on this question.  Kai is the Chief Medical Office of Hospice by the Bay in California .  Todd is the Chief Medical Officer at Bluegrass Care Navigators in Kentucky .  It's inspiring to hear how these hospices and others are stepping up to the challenge of caring for both COVID positive and non-COVID positive patients during this time.   Among subjects we talk about include: The variability how this pandemic is affecting hospices in how they are responding to COVID (even if they ta

Catastrophic Thinking and COVID19

by: Sarah Stroe I’m going to cut right to the chase- I am not doing well with the pandemic we are facing. A little knowledge is a dangerous thing, as the old adage goes, and it’s hard for me to not picture loved ones on ventilators, as I’ve seen for the past years as a palliative care social worker. The image of someone I love in a hospital bed isn’t a sterilized, televised hospital room. It’s my work place. My patients are replaced by the faces of people in my life, now transformed into medical record numbers as my coworkers determine what is best for them, talk about if they will pull through. That is the inside of my very anxious brain. When I’m in that state of mind, I describe it as unspooling. It’s like the future winds away, distant from its origin in reality. The end result is the worst case scenario. If I’m being honest, it feels good to go there. It’s like scratching an itch; it’s comfortable, well trodden territory for me to wonder “how bad could this get?

COVID in Long Term Care: Podcast with Jim Wright and David Grabowski

Imagine that you are the medical director of a large (>150 bed) nursing home.  Two-thirds of the patients in the home now have COVID-19.  Seventeen of your patients are dead.  The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients.  You're short on gowns and facemasks.  You're short on nurses and nurse aids so now you have to help deliver meals. This is what Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond is living through right now.  I felt overwhelmed just listening to Jim talk about his experience since mid-March, and am so grateful that he joined to talk about COVID in the long term care setting, along with David Grabowski, author of the JAMA piece titled " Postacute Care Preparedness for COVID-19 - Thinking Ahead ." A couple key points that I learned from Jim's experience.  The first point is tha

What is the prognosis of COVID-19?

by: Eric Widera ( @ewidera ) ------ Note: for the most up-to-date information on prognosis in COVID, please go to the GeriPal COVID Prognosis page (now including some outcomes on CPR in COVID). ------ COVID-19 data out of Washington for older adults is sobering : only 1 out of 10 cases are in individuals who are 80 years and older, yet this age group accounts for 55% of all deaths. If you group all adults over 60, they make up a third of the confirmed cases and a staggering 93% of all deaths. Data from around the US also shows that age is a strong risk factor for hospitalization, ICU admission, and mortality. The following is data coming from CDC looking at US cases from February 12 to March 16th . Around the world, the numbers look about that same too, with a case fatality rate around 15-20% for those 80 years and older (data from Lancet and JAMA ). Case fatality rates are defined as the number of deaths in persons who tested positive for SARS-CoV2 div