GeriPal - A Geriatrics and Palliative Care Podcast

• Potentially Unsafe Low-evidence Treatments: Adam Marks, Laura Taylor, & Jill Schneiderhan

  More and more people are, “doing their own research.”  Self-identified experts and influencers on podcasts (podcasts!) and social media endorse treatments that are potentially harmful and have little to no evidence of benefit, or have only been studied in animals.  An increasing number of federal leaders have a track record of endorsing such products. We and our guests have noticed that in our clinical practices, patients and caregivers seem to be asking for such treatments more frequently.  Ivermectin to treat cancer.  Stem cell treatments. Chelation therapy.  Daneila Lamas wrote about this issue in the New York Times this week -after we recorded - in her story, a family requested an herbal infusion for their dying mother via feeding tube. Our guests today, Adam Marks, Laura Taylor, & Jill Schneiderhan, have coined a term for such therapies, for Potentially Unsafe Low-evidence Treatments, or PULET. Rhymes with mullet (On the podcast we debate using the French pronunciation, though it sounds the same as the French word for chicken).  We discuss an article they wrote about PULET for the American Journal of Hospice and Palliative Medicine, including: What makes a PULET a PULET?  Key ingredients are both potentially unsafe and low evidence.  If it’s low evidence but not unsafe, not generally an issue.  Think vitamins. If it’s potentially unsafe, but has robust evidence, well that’s most of the treatments we offer seriously ill patients!  Think chemo. What counts as potentially unsafe? They include what might be obvious, e.g. health risks, and less obvious, e.g. financial toxicity. What counts as low-evidence?  Animal studies? Theoretical only? Does PULET account for avoiding known effective treatments? Do elements of care that are often administered to seriously ill patients count? Yes. Think chemotherapy to imminently dying patients, or CPR. How does integrative medicine fit in with this?  Jill Schneiderhan, a family medicine and integrative medicine doc, helps us think through this. How ought clinicians respond?  Hint: If you’re arguing over the scientific merits of a research study, you’re probably not doing it right.  Instead, think VitalTalk, REMAP, and uncover and align with the emotion behind the request. Does the approach shift when it’s a caregiver requesting PULET for an older relative who lost capacity? How about parents advocating for a child? For more, Laura suggests a book titled, How to Talk to a Science Denier.   And I am particularly happy that the idea for this podcast arose from my visit to Michigan to give Grand Rounds, and the conversations I had with Adam and Laura during the visit.  We love it when listeners engage with us to suggest topics that practicing clinicians find challenging. And I get to sing Bon Jovi’s Bad Medicine, which is such a fun song! -Alex Smith  

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• Loss of DEI Hurts Everyone: Farah Stockman, Ali Thomas, Ken Covinsky

  I read Farah Stockman’s article in the NYT on why attacks on DEI will cost us all, and thought, “Yes, and ‘everyone’ includes harm to our healthcare workforce, our patients, and their families.” So we’re delighted that Farah Stockman, pulitzer prize winning journalist, author of American Made: What Happens to People When Work Disappears, and editorial board member at the New York TImes joins us to set the bigger picture for this discussion.  Farah provides clear examples from the Biden administration, in which having the most diverse cabinet in history was critical to building bridges, empathy, and inspiring others to feel included. We are also pleased to welcome Ali Thomas, a hospitalist, member of the Baha'i Faith, leader of anti-racism efforts in the Pacific Northwest, and founder of the BIPOC Health Careers Ecosystem.  Ali talks about the history of affirmative action, which started as a program for Whites, the importance of diversity in the healthcare workforce, the history of allyship and cross cultural collaboration, and his own efforts to provide opportunity and support for historically oppressed groups in his own community to obtain healthcare careers. And Ken Covinsky, avid baseball fanatic, joins us and notes that the day we record (April 15) is Jackie Robinson day.  Many may be familiar with the story of Jackie Robinson breaking the color barrier in major league baseball in 1947, but may not be aware of the tremendous adversity Jackie Robinson faced, and persistence he displayed, off the field. We address many things, including: The movement in Corporate America and institutes of higher education to implement DEI programming in the wake of George Floyd The general agreement in America of the value of diversity, and disagreement, unpopularity, and backlash about DEI as it was implemented How the pursuit of diversity and excellence are not in tension, they are aligned and necessary for each other What we can do to build bridges across differences There was so much we hoped to talk about and didn’t get to, but I will link to now, including: Ali’s mom’s personal history with and study of school desegregation in South Carolina, Farah’s mom’s pioneering work as a speech language pathologist, and Ken’s perspectives on the importance of studying ageism and racism in research. What a Wonderful World could be sung in irony at this moment.  I hope we all take it literally, with the hope this podcast ends with. The podcast follows the arc towards hope of this video on Race Amity from the National Center for Race Amity, courtesy of Ali Thomas (his dad is featured). -Alex Smith

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• RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest

  Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department.  I asked emergency medicine clinicians what they thought when a patient who is seriously ill and DNR comes to the ED, and some responded, (paraphrasing), what are they doing here? This is not why I went into emergency medicine. I went into emergency medicine to act. I can’t do the primary thing I’ve been trained to do: ABC, ABC, ABCs.  Most emergency providers wanted to do the right thing for seriously ill patients, but they didn’t have the knowledge, skills, or experience to do it. Today we focus on an intervention, published in JAMA, that gave emergency clinicians basic palliative care knowledge, training, and skills.  We talk with Corita Grudzen and Fernanda Bellolio about their cluster stepped wedge randomized trial of a palliative care intervention directed at emergency clinicians.  They got training in Vital Talk and ELNEC.  They got a decision support tool that identified hospice patients or those who might benefit from a goals of care discussion.  They got feedback. So did it matter?  Hmmm….it depends.  We are fortunate to have Tammie Quest, emergency and palliative trained and long a leader in this space, to help us unpack and contextualize these findings. Today we discuss: Why the study was negative for the primary (hospitalization) and all secondary outcome (e.g. hospice use). Why to emergency clinicians, this study was a wild success because they had the skills they wanted/needed to feel like they could do the right thing (during the onset of Covid no less). Why this study was a success due to the sheer size (nearly 100,000 patients in about 30 EDs) of the study, and the fact that, as far as the investigators know, all study sites continue to employ the clinical decision support tool. What is a cluster stepped wedge randomized trial?  Were they surprised by the negative findings? How do we situate this study in the context of other negative primary palliative care interventions, outside the ED?  E.g. Yael Shenker’s negative study of primary palliative care for cancer, Randy Curtis’s negative study of a Vital Talk-ish intervention, Lieve Van den Block’s negative study of primary PC in nursing homes. Why do so many (most, all??) primary palliative care interventions seem to fail, whereas specialized palliative care interventions have a relatively robust track record of success. Should we give up on primary palliative care?  What’s next for primary palliative care interventions in the ED? And if your Basic Life Support training certification is due, you can practice the correct chest compression rate of 110 beats per minute to Another One Bites the Dust. -Alex Smith

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• GeriPal Takeover! Nancy Lundebjerg and Annie Medina-Walpole

  Whelp, goodbye folks!  Eric and I have been DOGE’d. In a somewhat delayed April Fools, Nancy Lundebjerg and Annie Medina-Walpole have taken over podcast host duties this week. Their purpose is to interview me, Eric, and Ken Covinsky about your final AGS literature review plenary session taking place at the Annual Meeting in Chicago this May (for those attending, our session is the plenary the morning of May 10).  We discuss our favorite articles, parody songs, and memories from AGS meetings past, with a little preview of a song for this year’s meeting.   We covered: The first parody song I wrote, for AGS 2018 in Orlando, about this article by Nancy Schoenborn on how to discuss stopping cancer screening. Ken’s favorite articles, including The Impact of Rudeness on Medical Team Performance: A Randomized Trial Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization Eric’s favorite article on the effect of chair placement on physicians’ behavior and patients’ satisfaction Tim Anderson’s study on the intensification of older adults’ outpatient blood pressure treatment at hospital discharge Nancy’s favorite topic and parody song, Aducanumab, which won Drug of the Year in 2021.  Enjoy! And maybe, just maybe, Eric and I will be reinstated and return as hosts next week… -Alex Smith  

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• Pragmatic Trial of ACP: Jennifer Wolff, Sydney Dy, Danny Scerpella, and Jasmine Santoyo-Olsson

  A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice.  Outcomes are typically assessed from available records.  Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations. Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine. We spend the last portion of the podcast discussing the surprising finding of the study.  In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group.  What?!?  Not a typo. We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including: Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control).  Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions? Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care. Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings.  My goals will differ if I think I probably have 2 years to live vs 10 years. Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed). Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning.  As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful. And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French! -Alex Smith  

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