To my teenagers, climate change is an existential crisis.  It’s the end of the world as we know it.  They decry the lack of serious attention and prioritization this issue has in the US.  My kids ask - why don’t adults care about this issue the same way that they and their friends care about it?  My kids have taught me that the emphasis on personal responsibility (reduce your carbon footprint!) was supported by the fossil fuel industry, because it shifted responsibility for change from...

There is a growing push to change how we define Alzheimer's disease from what was historically a clinically defined syndrome to a newer biological definition based on the presence of positive amyloid biomarkers. This proposed new definition, championed by the Alzheimer's Association (AA) and the National Institute on Aging (NIA), proposes that the disease exists when the earliest manifestation of Alzheimer’s pathophysiology can be detected (amyloid), even though onset of symptoms may be years...

Coaching is in.  During the later stages of the pandemic, it seemed every other person, and particularly the junior faculty in our Division, were either being coached, in training to coach, or coaching others.  When I was a junior faculty, coaching wasn’t a thing.  Sure, Atul Gawande wrote about coaching in surgery - having someone observe you and coach you on your technical skills- but that’s a far cry from the coaching programs focused on empowerment that are exploding around the country...

What does the future hold for geriatrics? I’ve seen this question come up a lot since finishing fellowship nearly two decades ago. Historically, answers generally lamented the ever increasing need for geriatrics without a corresponding growth in the number of specialists in the field. But, it's also hard not to be bullish on the future of the field to see the consistent strides geriatrics has made in the last two decades in improving care for older adults. For example, I never would have...

Often podcasts meet clinical reality.  That’s why we do this podcast- to address real world issues in palliative care, geriatrics, and bioethics.  But rarely does the podcast and clinical reality meet in the same day. Within hours of recording this podcast, I joined a family meeting of an older patient who had multiple medical problems including cancer, and a slow but inexorable decline in function, weight, and cognition.  Physical therapy had walked with him that day and noted improvement...

What level of evidence do we need for POLST to use it ourselves, to advocate for wider usage, and for establishing POLST completion as a quality metric?  The answers to these questions will vary.  Reasonable people will disagree.  And today, on our podcast, our guests disagree.  Firmly.  AND we are delighted that our guests modeled respectful disagreement.  With no hard feelings.  Respectful disagreement is in short supply these days. Our guests today are Kelly Vranas, pulm crit care doc who...

For surgeons and patients, deciding if and when to operate can be challenging. Often, the way surgeons communicate about these decisions doesn’t make things any easier for themselves or their patients. And, surgeons often spend the majority of their conversations with patients describing anatomical details and exactly how they plan to ‘fix it’, with little discussion of what that ‘fix’ will do for a patient’s overall goals. Instead, what if your surgeon told you that the operation she was...

Communicating about a serious illness is hard. Last week’s podcast we talked about the challenge around miscommunication in serious illness. This week we dive into the challenges with communication when it comes to life sustaining treatments and CPR. Take for example the simple question: “If her breathing gets any worse, she will need to be intubated.” This seems like an innocuous statement of fact, but does she really “need” to be intubated if, for example, her primary goals are to be...

Medical communication is tough, although fundamentally at its most basic unit of delivery, it includes really only three steps. First, a clinician’s thoughts must be encoded into words, then transmitted often via sounds, and finally decoded back to thoughts by a patient or family member. Simple, right? Not so much, as each one of these steps is fraught with miscommunication. For example, a surgeon may want to convey that all visible tumors were removed during surgery, but transmits that...

The proportion of people living with dementia who identify as Black/African Americans is on the rise, and so too are the proportion of caregivers who identify as Black/African American.  As our guests talk about today, caregiving for people living with dementia takes a tremendous toll, and when this toll is set atop the challenges of racism in all its forms, the reality of caregiving while Black can be overwhelming. Today we talk with Fayron Epps and Karen Moss, two nurse researchers who...

Hospitals are hazardous places for older adults. These hazards include delirium, malnutrition, falls, infections, and hospital associated disability (which about ⅓ of older adults get during a hospital stay).  What if, for at least some older adults who need acute-level care, instead of treating them in the hospital, we treat them at home? That’s the focus of the hospital-at-home movement, and the subject we talk about in this week’s podcast. We talk with Bruce Leff and Tacara Soones about...

The comprehensive geriatric assessment is one of the cornerstones of geriatrics.  But does the geriatric assessment do anything?  Does it improve outcomes that patients, caregivers, and clinicians care about? Evidence has been mounting about the importance of the geriatric assessment for older adults with cancer, the subject of today’s podcast.  The geriatric assessment has been shown in two landmark studies (Lancet and JAMA Oncology) to reduce high grade toxicity, improve patient and...

How do people react when they hear they have a serious illness?  Shock, “like a car is rushing straight at me” (says Bill Gardner on our podcast).  After the shock?  Many people strive, struggle, crawl even back toward a “normal” life.  And some people, in addition or instead, engage in deep introspection on how to make meaning or live with or understand this experience of serious illness.  Today we talk with deep thinkers about this issue.  Bill Gardner is a psychologist living with...

I hear the word dignity used a lot in the medical setting, but I’m never sure what people mean when they use it.  You’d imagine that as a seasoned palliative care doc, I’d have a pretty good definition by now of what “maintaining dignity” or “loss of dignity” means, but you’d be sadly wrong. Well that all changes today as we’ve invited the world's foremost expert in dignity at the end of life, Dr. Harvey Max Chochinov, to join us on the podcast.  Harvey is probably best known for his work in...

It's been over two years since one of the worst product launches of all time - Aduhelm (aducanumab).  Praised by the FDA, Alzheimer’s Association (AA), and Pharma as a “game changer”, but derided by others for the drug’s lack of clinical efficacy, risk of severe adverse effects, absence of diversity in trial populations, high costs, and an FDA approval process that was in the kindest words “rife with irregularities”. Instead of Biogen’s expected billions of dollars of revenue from Aduhelm,...

Insomnia. We’ve all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you’re not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more. For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today's podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia. We...

There’s a saying, “never let a crisis go to waste.”  The pandemic was horrific in many ways.  One positive change that came about was the lifting of restrictions around the use of telemedicine.  Clinicians could care for patients across state lines, could prescribe opioids without in person visits, could bill at higher rates for telemedicine than previous to the pandemic.  Many patients benefited, not only those isolating due to covid, but also patients in rural areas, patients who are...

Today’s podcast is a follow up to our 2018 podcast with Randy Curtis about the Jumpstart intervention.  On that podcast he and collaborators tested a combined patient and clinician facing communication priming intervention to promote goals of care conversations.  Today we discuss a new paper in JAMA that tests a stripped down version of the clinician only facing intervention in a pragmatic randomized trial for older adults with serious illness and those 80+.  They found a difference of 4% in...

You may have heard of Area Agencies on Aging, but do you really know what they do or how they do it?  What about State Departments of Aging or state master plans for aging?  Do you know how these agencies fit in with programs like Meals-on-Wheels or other nutritional support programs? Is your brain hurting yet with all these questions?  No?  Ok, what about Aging and Disability Resource Connection (ADRC) services? Well, if you are like me, you’ve probably heard of these programs but are at a...

I don't know 'bout religion I only know what I see And in the end when I hold their hand It's both of us set free These are the ending lyrics to Bonnie Raitt’s song “Down the Hall”, an ode to the Pastoral Care Workers who care for their fellow inmates in the hospice unit at the California Medical Facility in Vacaville, California. On last week’s podcast we interviewed the medical director and the chaplain of the prison’s hospice unit (Hospice in Prison Part 1).  This week we turn our...

    In the early 1990’s, California Medical Facility (CMF) created one of the nation’s first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release.  Many are there until they die. Today’s podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice...

Artificial Intelligence, or AI, has tremendous potential.  We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF. Social companions to address the epidemic of loneliness among older adults Augmenting ability of clinicians by taking notes Searching the electronic health record for...

Diabetes is common.  When I’m on nursing home call, the most common page I receive is for a blood sugar value.  When I’m on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications.  Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast...

Our guests today present an important rejoinder to the argument that we should refocus away from advance care planning (ACP).  Sarah Nouri, Hillary Lum, and LJ Van Scoy argue that diverse communities are asking for ACP.  Sarah Nouri gives an example from her work in the LGBTQ+ community of a trans woman who was buried as a man because existing laws/rules did not protect her wishes.  Others cited the call from communities to meet them where they are - be they senior centers, Black-owned...