GeriPal - A Geriatrics and Palliative Medicine Podcast

I had the privilege of learning from fellow Greenwall Faculty Scholar Lisa Harris about a term she termed, "dangertalk."  As an ob/gyn and abortion provider, Lisa found the debate around the legality of abortion so polarizing that it created a false dichotomy: you're either for or against.  Any talk about misgivings, uncertainty, ambiguity, or ambivalence was silenced.  Talking about these issues in the face of polarization was deemed dangerous and undermining to one side or another. "How could you?" For Lisa's work in finding common ground and embracing nuance she was awarded the 2023 Bernard Lo Award for forging connections across divisions.
In today's podcast we focus on the equivalent experience of moral uncertainty, distress, and residue among prescribers of medical aid in dying.  We are joined by Carly Zapata and Dani Chammas, prescribers of medical aid in dying in California. We discuss:
Their journey prescribing medical aid in dying, and reasons for choosing to prescribe

The legality of prescribing in California.  We compare California to Canada, as we have previously on this podcast. We discuss new limited survey data suggesting that legal barriers may not explain the remarkable 20 fold differences in use of medical aid in dying between California and Canada; rather, Canada has 6x the number of providers per capita as California, and much greater awareness of the legality of medical aid in dying. We talk about cases that are not as clear - e.g. people who have voluntarily stopped eating and drinking.  

Moral issues, including ambiguity and ambivalence, distress and residue. For example the moral distress created when a patient requests medical aid in dying due to what is clearly a systems failure (see this Atlantic article for clear examples from Canada).  We ask if they sometimes feel frustrated that more people who are in favor of medical aid in dying are not prescribing, instead leaving prescribing responsibility to a relatively small group of clinicians.  

How core ethical ideas might lead to very different conclusions about medical aid in dying, and ways Dani teaches ethics to trainees.  

Psychological models that can help navigate this complex terrain with patients and families, including formulations and countertransference.  


And I can't believe I haven't played, "I will follow you into the dark" previously - but google couldn't find it - really?  In 400+ GeriPal podcasts?  Great song.  So fitting.  My son Renn plays guitar on the audio only version.
-Alex Smith
 
Additionally, some take home points, sent by Dani after recording:
(1) Holding the dialectic: On one hand, people deserve the highest level of attention to their personhood and their suffering—an effort that, at times, can soften or even resolve a desire for hastened death. And on the other hand, some people will authentically experience this as the most values-aligned way of dying, given their circumstances.
(2) Learning to accept that while laws create the safety rails, within those boundaries, morality is pluralistic. Both patients and clinicians bring deeply held moral frameworks to these decisions—and those frameworks deserve to be acknowledged and respected.
(3) We have to be willing to ask the hard questions—and to show up for one another as we do. Because this work, more than almost any other, has taught us the profound impact of not feeling alone when navigating grey terrain.
I view the discussion as an invitation for our field to not necessarily to become more certain, but to be willing to wrestle with the hard questions—while still showing up with rigor and compassion.
And to remember that our patients are people before they are cases. If we can stay close enough to truly know them, we're much more likely to respond in ways that honor both their suffering and their dignity—whatever path that ultimately leads to.

While we have previously discussed brain death criteria on the GeriPal Podcast, we have yet to explore the complex landscape families face regarding organ donation. In this episode, we dive into the nuances of Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), and clarify the essential role of healthcare providers who are not part of an organ procurement organization.
In this episode of the GeriPal Podcast, we step into a space in serious illness care that is often misunderstood, overlooked, or reduced to a simple "call the organ donation network" checklist item.
Joining us are three experts to help us understand the process and our role in it: 
Samantha (Sam) Taylor, a Donation Support Specialist and expert trainer on the donation request conversation

Dr. Nikole Neidlinger, an abdominal transplant surgeon and medical director for the organ and tissue donation program at the University of Washington

Dr. Toby Campbell, palliative care physician and host of the Extraordinary Conversations podcast, which is focused on organ donation for its first season.

We'd also like to send a big thank you to Toby as he was the one who recommended doing this podcast, and we'd encourage all of our listeners to check out Extraordinary Conversations.  I personally love episodes like this as it opens up a black box that I otherwise dont think about (similar to our Undertaker podcast with Thomas Lynch where we talk about what happens after someone dies).

In this episode of the GeriPal podcast, we dive into the fascinating world of geriatric dermatology, or "GeriDerm," with two exceptional guests: Dr. Daniel Butler from the University of Arizona and Dr. Eleni Linos from Stanford University. 
First, we tackle the big question: how do we keep our skin healthy as we age? I see this on a daily basis with my own skin, but I'm unsure what to do about it, including whether we all need to use sun protection and moisturizers, and if so, which ones?  
Then we explore the lag time to benefit in dermatology by examining whether we need to treat every actinic keratosis and basal cell carcinoma aggressively, or whether there are cases where we can opt for watchful waiting. 
We also explore chronic itch with Daniel, covering the three main sources of itch and how our management should change accordingly. Importantly, antihistamines were not a prominent part!
We finally asked Eleni whether artificial intelligence (AI) and digital tools can revolutionize the way we diagnose and manage skin conditions, especially in older adults. 
For a deeper dive into the topic, check out these two papers that we talk about on the podcast
Daniel's JAMA paper on Chronic Pruritus

Elani's JAMA IM paper on Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma

Eric and I were delighted to be invited to Brazil to give a series of presentations in Sao Paulo at their annual geriatrics meeting.  We met people doing important, interesting, and innovative work in Brazil and throughout Latin America. We got the audience to sing along, including (in another talk) the magnificent Brazilian song Sozinho by Caetano Veloso in Portuguese, with my son Renn playing guitar.
For our final talk, a podcast in front of a live conference audience, we asked our 3 guests, Eduardo Ferriolli, Marlon Aliberti, & Edison Iglesias to select a recent article to discuss.  We talked about:
Intrinsic capacity (selected by Eduardo).  What is it? What is it used for? How do you measure it?  (hint ICOPE).  Eduardo emphasized that intrinsic capacity is a positive aspect of aging, focused on potential rather than deficit.  We asked him to work intrinsic capacity into George Kushel's famous analogy using the golden gate bridge to describe phenotypic frailty (pillars), deficit accumulation frailty (cable supports), and resilience (withstand stress of wind and cars).  Eduardo says intrinsic capacity would be the car, and would vary by type of car and intended purpose.  I loved Eduardo's selected article, which percentiles intrinsic capacity, in order to use within individuals to assess how they're tracking over time, and at a public health level, to identify regions or groups of people with lower intrinsic capacity.  He draws the analogy to growth curves in pediatrics - if you're consistently at 80% - then drop off - your primary care provider should take notice and investigate/intervene.

Geriatric syndromes in hospitalized older adults (selected by Marlon).  If intrinsic capacity is for primary care, our guests argue that the comprehensive geriatric assessment, which takes a long time to administer, should be reserved for specialist geriatrics.  And yet, this paper finds that a limited shorter version of the comprehensive geriatrics assessment can document geriatric syndromes in hospitalized older adults.  Accumulation of multiple geriatric syndromes is associated with increased mortality, and presents an opportunity for risk stratification, goals of care discussions, and intervention. 

Advance care planning across Latin America (selected by Edison).  Back around 2005, when Edison first heard about advance care planning, he says, "it sounded like science fiction."  In Brazil, as with Latin America, medicine was highly hierarchical and patriarchal.  Doctors knew best.  The doctor decided.  If there was no patient choice, why would there be a system to protect the decisions of patients made in advance?  In the intervening years, Edison and others have worked to incorporate and adapt advance care planning to the Latin American context, which is much more focused on family-centered relational autonomy than individual, and incorporates spirituality to a much greater extent.  Edison has been mindful too of not repeating the mis-steps of the advance care planning and advance directive movements in the US.

We took questions from our audience and sang "Imagine" in Portuguese together. Enjoy!
-Alex Smith

Lynn Flint and Anne Kelly join as hosts in a reprise of last year's ask us anything format.  Thank you for sending in your terrific questions!  Lynn and Anne condensed them to about 20, and we ran through them rather rapid fire.  Also on fire? Our mouths.  As with our 300th episode, we did this Hot Ones-style. Every few questions, we had to eat a chicken wing slathered in hot sauce.  The hot sauces got progressively hotter, though as we discovered, the ordering may have been a littttttle bit off.  Still, by the time we hit the really hot ones, our mouths were on fire, we were blowing our noses, gulping down milk, and terrified of what the next hot wing would bring…
We covered so much in this podcast, including:
Coffee or tea? What jokes do you make with patients?

Where do we see ageism?

Why are we still advocating for advance care planning?

Concerns about expansion of medical aid in dying

Should doctors reveal that they're using AI in clinical care (thanks for the question mom!)

The future of geriatrics and palliative care

What we'd do differently about the podcast if we could start over, or what we could do that is new going forward. Surprises in terms of who is listening, our audience.

Ideas for others to build community as we do at GeriPal

Influence of our own spirituality and religion on our clinical practice

Lasting practice changes from prior podcasts, or from Covid experience

Why PC in the ED hasn't taken off

And more!

 
Looking back on 10 years and 400 podcasts, Eric and I are filled with gratitude for you, dear listeners.  You sustain us.  You keep us going.  Please stay involved, send us messages about show ideas, and introduce yourself to us at national meetings.
Thank you!
-Alex Smith