I’m going to begin with a wonderful quote from a recent editorial in Bioethics by our guests Parker Crutchfield & Jason Wasserman. This quote illustrates the tension between the widely held view in bioethics that slow codes are unethical, and the complexity of real world hospital practice: “Decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas.”
Gina Piscitello, our third guest, recently surveyed doctors, nurses and others at 2 academic medical centers about slow codes. In a paper published in JPSM, she found that two thirds had cared for a patient where a slow code was performed. Over half believed that a slow code is ethical if they believed the code is futile.
Slow codes are happening. The accepted academic bioethics stance that slow codes are unethical is not making it through to practicing clinicians. Our 3 guests were panelists at a session of the American Society of Bioethics and the Humanities annual meeting last year, and their panel discussion was apparently the talk of the meeting.
Today we talk about what constitutes a slow code, short code, show code, and “Hollywood code.” We talk about walk don’t run, shallow compressions, and…injecting the epi into the mattress! We explore the arguments for and against slow codes: harm to families, harm to patients, moral distress for doctors and nurses; deceit, trust, and communication; do outcomes (e.g. family feels code was attempted) matter more than values (e.g. never lie or withhold information from family)? We talk about the classic bioethics “trolley problem” and how it might apply to slow codes (for a longer discussion see this paper by Parker Crutchfield). We talk about the role of the law, fear of litigation, and legislative overreach (for more see this paper by Jason Wasserman). We disagree if slow codes are ever ethical. I argue that Eric’s way out of this is a slow code in disguise.
One thing we can all agree about: the ethics of slow codes need a rethink.
Stop! In the name of love. Before you break my heart. Think it over…
-Alex Smith
This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://aprecruit.ucsf.edu/apply/JPF05811
** NOTE: To claim CME credit for this episode, click here **
Eric 01:03
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 01:05
This is Alex Smith.
Eric 01:07
And Alex, we are going to be talking about slow codes today. You may heard of a partial code show codes, light blue codes, placebo codes, Hollywood codes. We’re going to talk about what that is. But before we do, who do we have on with us to talk about this great subject?
Alex 01:22
We are delighted to welcome Gina Piscitello, who’s a palliative care doc at the University of Pittsburgh. Gina, welcome to the GeriPal Podcast.
Gina 01:32
Thanks for having me.
Alex 01:33
And we’re delighted to welcome Parker Crutchfield, who is a bioethicist at the Western Michigan University Homer Stryker School of Medicine. Parker, welcome to the GeriPal Podcast.
Parker 01:44
Hi there. Glad to be here.
Alex 01:46
And we’re delighted to welcome Jason Wasserman, who is also a bioethicist at Oakland University’s William Beaumont School of Medicine. Jason, welcome to GeriPal.
Jason 01:56
Hey, thanks. Great to be here.
Eric 01:58
So we’ve got a lot to talk about. The ethics of slow codes, are they ever. Okay, maybe a little defense of the slow code. But before we go into that, Jason, do you have the song request, or is it Parker who has a song request for Alex?
Jason 02:12
Parker?
Eric 02:13
Parker?
Parker 02:14
Yep.
Eric 02:15
What song are you going to request today?
Parker 02:18
Stop in the Name of Love by the Supremes.
Eric 02:21
Why did you decide to pick this song?
Parker 02:25
Well, I thought of it from the perspective of the patient who, instead of a slow code, might be getting a. A full, sincere code that they don’t want and might eventually break their heart as well.
Alex 02:38
I love it and I love The Motown. Having grown up in Michigan and East Lansing and went to Michigan, I love a little bit of the Supremes. So here’s a little bit.
Alex 02:59
(singing)
Parker 03:58
That’s a perfect song.
Eric 04:00
I love it.
Eric 04:06
Well, we’re going to think over slow codes, whether we should stop doing how often we’re doing them. But before we get into that, maybe we can actually define what is a slow code. Again, you may have heard of this as partial codes, show codes, Hollywood codes. Jason, what is a slow code?
Jason 04:26
Yeah, so there’s kind of two uses of the term. I mean, technically speak, like in a. In a narrower sense, a slow code is a situation in which a team takes its sweet time responding to an arrest because they’re motivated by or they have a reticence to resuscitate the patient. So they kind of take their time because they don’t really want to engage in full board cpr.
Alex 04:50
The walk, don’t run there.
Jason 04:52
Yeah, exactly. Right. So one of my colleagues earliest experiences in medical school, his first code blue, he comes running out of the room, running towards the stairwell, busting through the door, and he looks over and his attending is, you know, reading a paper and waiting on the elevator, you know, and it’s like. And it was kind of a, you know, that hidden curriculum and a little bit of an education. And so that’s technically the narrower definition of a slow code.
But the term is often used as an umbrella term to capture any kind of insincere effort at CPR that’s motivated by that sort of resistance to actually wanting to do those things on a patient, usually in whom CPR would be futile or medically inappropriate in the estimation of the team. And it can therefore capture these other kinds of things which have, again, their more particular meanings. So a Hollywood code or a show code is when you do the attempt, you might hurry to the bedside and you might look like you’re doing the attempt, but your compressions are too shallow. I’ve. I’ve been told by a resident that they’ve seen epinephrine injected into the mattress and not the patient.
Alex 05:59
Oh, boy.
Eric 06:01
Really?
Parker 06:02
Wow. Okay.
Jason 06:03
And. And then there are other things. Right. A family code, indic. And these intersect. But a family code might indicate that the CPR attempt is being done perfunctorily for the. But for the family, it kind of calls out those motivations and so forth. So there’s just a range of kinds of insincerity. And slow code is one type in a narrow sense, but an umbrella term for all of these insincere types as we.
Eric 06:27
Yeah. So kind of we’re doing, you know, you get these medical professionals, they’re kind of symbolically appearing to do ACLs in the hospital, but we’re not really doing full ACLs. We may be doing, you know, light chest compressions. We may do a bill for a very short period of time. Just. Let’s just do three cycles and we’ll call it a day. So already setting a time limit at the start, moving slower, shooting. Epidemic mattress is one thing.
Jason 07:03
Yeah, that was a good one. I will say there is another kind of thing that’s generally seen as distinct from a slow code or an insincere code, which is a time limited or in one article at least referred to as an appropriate code. And that is when you engage in a CPR attempt to protocol, knowing that it’s likely futile or inappropriate that you wouldn’t otherwise do, and then you cut it short.
Parker and I are actually working on a piece because we don’t see how that sometimes people say you engage in a sincere but time limited CPR attempt in response to a situation where it’s actually futile. And, you know, we have questions about whether that’s actually sincere. Like you’re not actually being sincere when you do that. But there is another thing out there that people try to say is an alternative to a slow code, which is a time limited or a quote unquote, appropriate code that we can even talk about.
Eric 07:52
Yeah. What do you think about that, Parker? Because that kind of feels like you’ve already set. Like it kind of feels a little showy to me. Performative, like you’ve already set a time or a number of cycles that you’re going to do, knowing that is not going to work. And you’re kind of just. It feels like I often see that in performance for the family members to show them that we’re trying to follow their wishes.
Parker 08:15
Yeah. My view is that it might actually be the worst of all options because. So I’m. I’m motivated by trying to avoid harm. Harm is a. As the sort of A moral fundamental that we want to prevent in as much as we can. And a short code might cause all of the harms that are associated with futile cpr, but with zero chance of actually doing anything. So if, if.
Let’s just suppose, and I don’t think there, there’s some evidence, maybe not, maybe not as strong as we like, but it’s admittedly difficult to gather that the harms to the patient from cpr, much of them are, upon commencement or within the first few minutes of performing it, they aggregate as, as it continues. But it’s not like the, the first few minutes are harm free.
Alex 09:03
The harms you’re talking about, like intubation, chest compressions where you might fracture ribs, those sorts of harms that happen immediately. Upfront harms.
Parker 09:14
Yep, exactly. So if, if we care about avoiding harm, the short code might be the worst of all options. It might be worse than harming the family by unilaterally refusing the request. And it harms the patient in ways that are avoidable by, for example, the slow code.
Jason 09:30
That’s particularly important, I think, because people offer it as a counter to the slow code, which fundamentally is a harm reduction attempt. Whether you think it’s ethical or not, that’s the goal is to do this thing, avoid aggrieving the family, but also avoid or mitigate the harms that might be associated to the patient. And some people say, well, this time limited code is sincere because it’s to.
To protocol, but it’s also harm reductive because we just do it for a little while. And I think we take issue with the fact that a, it doesn’t seem sincere if you don’t believe it can be therapeutic and the family is holding onto that hope. That’s not engaging in sincerity, in my view. And then as Parker said, it’s not actually harm reductive or certainly not as harm reductive as a, as a slick code.
Eric 10:13
Because it is interesting. And I love your thoughts about this, Gina. Like, I think about, like, when do we call a code, like in somebody who we think it’s not futile, we think that there is a chance that it may help. It’s when, like, we’re out of ideas of what can make this reversible anymore. They’re irreversibly dead. So we call them, we call the code, and we pronounce them as dead because we don’t think that there’s anything else. And that could happen at 45 minutes. That can happen at 30 minutes. Heck, that can happen at like 30 seconds.
The example or even two seconds. The example I always give is like, if there was an industrial saw accident, like, my head gets chopped off. My head’s on one side of this room, my body is on the other side. A minute ago I was adamant, I want to be full code. I don’t know of anybody who would do a show code or slow code or any code on me if my body and my head were separated. And we often see that. We don’t see that, but we see like people with metastatic cancer dying in the icu, septic on three presses already basically getting two weeks of a code.
Blood pressure drops, heart rate drops, and then they code like that’s pretty close to saw happening. Cutting off my head, body over there, head over there. What do you think about that, Gina?
Gina 11:32
Yeah, I think that’s a really good point. And when we’ve looked at this in the past about why are people doing slow codes to begin with? So some people say it’s like to help support the family. But a lot of people are saying it’s for legal reasons that they feel that their state laws are obligating them to perform cpr.
So even in that situation that you mentioned about like your head being in one spot, your body being in another, you know, like, could people interpret that to be like, oh, I need, you know, if your EMS arriving at the site, do I need like the medical director to tell me not to do a code in this situation? So I think a lot of it is legal. And the doctors and the who are deciding to do these flow codes, they’re doing it because they feel like they are obligated to do it by their state law.
Eric 12:08
Are there state. I know New York, I think, had one for a while, but got rid of it. Are there any state laws or laws saying that you have to do? I don’t know of any that says you have to do cpr. I know like in places like the va. So there’s hospital policies where we can’t unilaterally change somebody’s code status. But they’re also very explicit that you don’t have to provide non beneficial care. So you have to keep them full code, but you have to make an assessment and then you can call the code at any time.
Gina 12:38
Yeah, I recently worked on a study that looked at unilateral decision making that would include physicians. When are they allowed to say, I’m not going to provide CPR in every state? They are wildly different in how they approach these things. Sometimes it has to be totally like physiologically futile. For you to be able to withhold cpr. Others, it’s more broad. It’s like for your conscience. If the physician’s conscience goes against your conscience to provide cpr, they can withhold it.
But there are some states, like North Carolina, they do not have anything in their statute saying that it’s okay for a clinician to withhold or withdraw, like there’s any treatment like cpr. So physicians in those settings, they might feel very uncomfortable doing it. And I’ve heard, I mean nationally, I’ve heard many clinicians say we are doing this for this purpose. It is because of our state law. That’s why we are doing the slow code.
Jason 13:22
And if I could just tag onto that, the ambiguity and how some of, even some of those laws that are in states where it’s theoretically permissive of clinician judgment in these ways, sometimes the wording of healthcare law is so poor that it gives physicians a lot of hesitancy. In the state of Michigan, for example, there’s a guardian law that while CPR is a medical order and therefore in theory is up to the clinician, there’s also language in our guardianship law that says that guardians have the power to initiate, revoke or amend a DNR order.
Now, if you put that together with other elements of the law, it doesn’t mean that patient consent is, or family consent is required for dnr. But I’ve seen judges who are had particular political persuasions interpret it that way. And so I think physicians are rightly worried about how the law is written and how it’s going to be interpreted in court.
Eric 14:13
So it’s interesting because there’s this concept of unilateral dnr, whether or not we can do a unilateral dnr. And that may change by state, it may change by hospital.
Jason 14:24
My judge, our judge.
Eric 14:26
Right, but then let’s just imagine if, if we can’t change, somebody’s just, just like in the VA system, you can’t change. You can’t go against families. A decision around codes. F they want to be full code, they have to stay full code. But even in the va, they’re very specific that you don’t actually have to perform like chest compressions. You don’t have to provide interventions that are non beneficial. So you can, you can call the code, you can end the code at any point where you no longer think it is beneficial.
Alex 15:00
Eric wants you to tell him his approach is okay and it’s okay to push back on Eric and say, eric, you’re deluding yourself that is also a slow code.
Eric 15:13
It is, right?
Alex 15:14
It’s a short code, poorly problematic.
Eric 15:16
It’s super short. It’s 0 sec, 1 second long.
Parker 15:20
Well, so I’ll happily push back because I think what gets. One of the common arguments against the slow code is this, that you have these policies that permit unilateral decision making. And although that may be the best medicine for the patient, it also neglects the harms that are going to inevitably occur when you refuse a family. So if we, if you view, if we view a harm as just something that makes a person’s life worse than it otherwise would have been, when you tell a family, no, we are not going to do what you want to your loved one that harms them and the degree of harm could vary case to case, but it’s, it’s a frustration of their desires and a diminishment of their well being.
Eric 16:11
So any empirical evidence around whether or not seeing a family member go through CPR and die is worse than telling them we’re not going to do CPR from a harms perspective. Do you think it’s worth it or do you think like it’s so individual it doesn’t really matter to do those studies?
Parker 16:33
So it’s that. But also, how could you. I mean it, it just seems like a study that’s impossible to conduct because.
Eric 16:39
Like the, the, the randomize some slow code. Well, let’s talk about that. Like, you know, I’ve read a lot of articles in preparation for this. Most of the articles are not in defense of slow codes. It’s. Slow codes are morally abhorrent. They’re ethically wrong that we should never do them because multiple different reasons, including lying to family members, is bad. So pretty much it’s all over the place. I’m assuming that a lot of the teaching is don’t do that. How often are slow codes happening? Like in real life? Are people following these, you know, bioethicists and thought leaders?
Alex 17:26
Sounds like. Is that a question for Gina about how often is this happening?
Eric 17:29
You did a study looking at this, right?
Alex 17:31
Yeah, Gina, right. Before we get to there, I just want to comment on something else Eric said about what people say in journals. And Parker and Jason, you wrote a beautiful commentary that I’m going to link to on our show Notes associated with this podcast where you said, decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas.
Speaker 6 17:59
I love that sentence.
Alex 18:02
I love that sentence because that’s why.
Parker 18:04
We’Re talking about this right here. Right?
Alex 18:06
Like we’re moving from this. Like, like, you know, it’s easy to say this argument, that argument, but hey, this is happening as Gina is about to tell us, and this is a problem.
Eric 18:15
Well, is it happening?
Jason 18:17
Yeah. Well, Gina’s work actually gave rise to our project in a, in a, in one very significant way. I’m sorry for jumping in, but like on the one hand, as you point out, the literature over the past 40 years has been incredibly dogmatic on the issue. It’s just like, don’t do them. Lying is wrong, it’ll hurt public trust and we don’t have to do them if we just improve communication and strengthen our non beneficial care policies. We don’t think any, we don’t, we disagree with the first two premises at least as kind of unilateral statements and not sure about the second two, that they’re accurate, that those are going to resolve all those situations.
So while the literature had been dogmatically against SLOCOS for the past 40 years, there had been one notable article kind of making a little sliver of an exception to. And all 14 commentaries or 13 commentaries on that article were against. Like, there wasn’t one that was like, hey, they got it right, even a little. And at the same time, so we see this dogmatic literature and then at the same time we come across Gina and her colleague’s article that shows a pretty significant prevalence of these, at least one that complicates the ethics view.
Eric 19:24
Gina, what did, what did you do in your article? Let’s hear how are these happening at all in real life?
Gina 19:31
They are. And the reason I did this article was because people didn’t believe me. Like I didn’t believe this was a thing until I saw it as a resident, I thought, holy crap, what is this? So people didn’t believe me outside of medicine. So I had to, you know, prove it. So with colleagues, we looked at two different medical centers. We interviewed or we surveyed internal medicine residents.
Eric 19:49
And what year was this? This is like in 2020. 2020, not long ago. We can’t say. Like this is recent. Okay.
Gina 19:59
You interviewed, we surveyed internal medicine residents, nurses, critical care nurses, pulmonary critical care physicians, cardiology physicians, fellows, about how often are these happening at their hospital? First are they happening and then how often are they happening? And what we found is that about 69% they said that they are happening at their hospital and that they have been involved in one slow code in the past year. Some people said, though up to 10. They’ve been involved in 10 slow codes in the past year. So it varied by participant. But many people have been actively involved in these slow codes.
Alex 20:35
And what did you find out about that? They’re thinking about the ethics of these slow codes.
Gina 20:40
That’s what I think. That shocked me to the core, because over half of the people we surveyed, they thought that they can be ethical even in situations where you think, well, the case that we gave was a situation where the patient is perceived to be medically futile. CPR is not going to really help this patient in those situations. Is it ethical to perform it? And about 52% said, yes, it is. And the other people said, no, it’s not.
Alex 21:05
Perform it, meaning perform a slow code.
Gina 21:07
Perform a slow code. Yeah. And I think, you know, we. We explained to them, we gave them a definition of the slow code. Many of the people who said it’s ethical. Perform. They said that if you are going to perform it, you need to tell the patient’s family that you’re performing a slow code, which. That goes against the slow code. The slow code is a performance. It’s a trick. You’re tricking the family to think that you’re actually doing the work and you’re not. So that’s, you know, that’s part of.
Eric 21:32
Nobody in real life actually tells the family about a show code.
Alex 21:36
Yeah, I’m doing a performative cp. I’ve never heard. That’s. That’s weird.
Eric 21:41
Yeah, I guess you could say. So this is the problem with definitions, right? Like if, like Jason was talking about, there’s a wide definition. Right, Jason, that could include. We are going to do 2 minutes, 5 minutes, 3 rounds. So maybe like this partial slow or short code.
Jason 22:01
Yeah. There is a thing called a transparent or transparent slow code. Transparent code or transparent slow code.
Eric 22:07
We’re going to read our paper up on the elevator and take a while. They’re probably not saying that. Right.
Jason 22:11
Well, so we actually had a case in our system that gave rise to our colleague Abe Brummet’s piece that’s forthcoming on this. But it was a case where a family was insisting on cpr, but the patient was still capacitated and just couldn’t bring himself to confront the family about his decision to want to be dnr. And so one option, which we didn’t need to pursue in the end, but was an agreement with the patient to slow code him.
Eric 22:36
Well, I gotta ask Gina. I’m gonna go back to you. So before you did this study, nobody believed you. After you did the study, you have this survey. Do they believe you now?
Gina 22:47
They do and they’re very upset about it. The people that I talk to, like in the community, they’re very upset that why are doctors doing this? Like, this is totally not what we would want our doctor to be. To be doing to us.
Alex 22:57
Oh, interesting.
Eric 22:59
Well, if I remember correctly, Parker, you also cited a study that asked the lay public about was it. I read so many articles, I don’t remember if it was Parker or Jason’s or somebody else’s article that there was a brief survey. It was like a convenience sample survey of the lay public. Jason, you’re nodding your head like this sounds familiar. I’m not making this up.
Jason 23:19
Right.
Parker 23:20
One of the entries in the special issue is a survey of laypeople and the level of trust they would have or mistrust they would have in the event of a slow code. And one argument against slow codes is that they erode public trust. And this, this article provides some bit of evidence that. Well, maybe that’s not the case.
Eric 23:41
Yeah, a higher than expected proportion of people thought it was okay to do a slow coat.
Parker 23:47
Yeah. Yeah.
Jason 23:49
A significantly higher. You know, it’s, it’s certainly the general public doesn’t seem to be as uniform and homogeneous in their view of this as the bioethicists have been.
Parker 24:00
Yeah, yeah.
Eric 24:01
Well, maybe we can also just summarize, like roundtable discussion, like what are the, what are the clear arguments against a slow code? And then we’ll talk about kind of lightning round. What are the, what are the arguments for a slow code? Is it over? Okay, so what are the main arguments against a slow code?
Parker 24:18
It’s dishonest.
Eric 24:19
Number one, we are lying to people and lying is bad. Okay, what else?
Jason 24:26
You know, as is pointed out by, in another article in our special issue, and I think is somewhat obvious when you think about it, we are deceptive in all sorts of ways throughout health care and in sometimes that decision.
Eric 24:37
Wait, wait, wait.
Alex 24:38
We’re doing. Aren’t we doing first?
Eric 24:40
Yeah, you got to get back to. We’ll get back to. Is it. Okay, we’ll get to that.
Alex 24:43
Jason, lightning round.
Eric 24:46
Everybody just throw in ideas why slow codes are bad, lying is bad, we’re hurting trust. They will not trust us. If the New York Times publishes an expose that, you know, 50% of doctors are doing slow codes, the public may actually react to that. And how would we feel about that?
Jason 25:04
Yeah. So there’s the argument that lying is wrong just in a sort of a patient care setting. And then there’s the argument that lying has bad consequences for the profession and decreases in public trust. I think a more convincing argument actually that is in our special issue as well, is that slow codes treat the patient as an object, as a means to an end, to sort of either satiate the worry and anxiety about conflict that might be held on the part of the medical team or to sort of acquiesce to the unrealistic expectations of the family on the other. But it’s not about the patient, it’s about others in one way, shape or form. And that. That’s disrespectful.
Alex 25:43
That’s a good one.
Jason 25:44
That’s actually an argument I find rather convincing.
Parker 25:48
One of the more frustrating arguments, at least for me, is that slow codes are wrong because you should have done otherwise. You should have done better.
Eric 25:55
You should have been a better communicator.
Parker 25:57
About a better communicator.
Alex 25:59
Well, we’ll get to why that’s frustrating.
Jason 26:02
We’re strengthening our non beneficial care policies in response especially to our op ed that we put out in concert with the special issue of so many people. There was a TikTok video from some healthcare tiktoker was like, well, we just need to do a better job showing families how unrealistic CPR is. And you know, it’s like, it’s a bit insulting actually because like I think a lot of our physicians do a really good job of that and it sometimes just doesn’t get us all the way there. It just doesn’t. And it’s not going to all the time.
Alex 26:33
Gina, you got one?
Gina 26:34
Yeah, and I’ll say this has already been discussed, but I think harms to the patient and especially bringing up the point like I remember CPR when we’ve been doing it and the patient’s awake, they are awake during the compressions, we stop for the pulse and rhythm check, they’re no longer awake. People can feel it. And I think that’s the concern. Another one is true harms of the patient physically.
Parker 26:52
Yeah.
Jason 26:53
And also can I add to that, I’ve had so many clinicians who wanted to just say, I’m not going to argue with the family. I’m just going to do the full cpr. They want it. And by the way, if the patient’s dead, they’re not going to feel it anyway. And it turns out this is actually not accurate. Even in patients that are unconscious, there’s like 1 to 2%. There’s some evidence that there’s about a 1 to 2% CPR induced consciousness rate. Now maybe that’s small, but it’s not zero harm just because they’re dead, so to speak. And I hear that a lot.
Alex 27:23
Eric, you got one?
Eric 27:24
Yeah, I’m going to bring up my other one. That there is no requirement to do non beneficial interventions. Like if somebody asks for ivermectin for their cancer or chemotherapy to treat their pneumonia, we don’t have to do it if we don’t think it’s beneficial. Even in settings where you can’t change their unilaterally change their code status.
Alex 27:47
I have one, and this is that slow codes are built on a premise of futility. And futility is not an agreed upon ethical argument. In fact, most bioethicists would argue that futility is not a practical concept that’s actionable and that reasonable people will disagree about what constitutes futile treatment. And then often when we initiate CPR or not often, not infrequently, if we initiate CPR in a patient for whom we think it’s futile, sometimes there will be return of circulation.
Eric 28:26
Wow.
Alex 28:27
Okay. So who are we to judge when something’s futile?
Parker 28:31
So for some of these arguments, can I just add that some of them don’t undermine the slow code. They undermine in some case the unilateral decision. So in your example, Alex, that would undermine unilaterally using the patient. And your example, Eric, of you don’t, you don’t have to do it, that would undermine the performance of sincere cpr. So these don’t necessarily rebut the position that slow codes are permissible. They rebut more forcefully the other options that a physician faces.
Eric 29:05
Yeah, well, I would argue that even if we do full CPR and we don’t think it’s going to work, we’re doing a performative. Performative, A rite, a ritual at the end of life.
Parker 29:17
Yep.
Jason 29:18
That’s our point about this claim that time limited codes in the context of futile or inappropriate CPR are sincere but short. There doesn’t seem anything sincere about doing a code if you don’t believe it’s therapeutic.
Parker 29:34
One of the something you just said, Eric, maps onto one of the narrative pieces in the special issue from a physician who was a resident in the 80s. And it talks exactly about this idea that everyone who dies gets coded and no one who gets coded leaves the hospital. So it’s just like something. It’s just part of the culture of dying in a hospital that you get.
Eric 29:57
And the moral distress that we face doing these interventions to people knowing that it is not going to help them. But like you said, Parker, Harm. There is going to be harms. Harms not just the patient. Maybe harms to the family, certainly harms to the medical team.
Alex 30:15
Have we transitioned into our slow codes ever?
Eric 30:19
Okay, right.
Jason 30:20
Can we respond to some of those arguments, please?
Eric 30:23
You can attack every single one of them.
Jason 30:25
Well, so let’s start with the idea that we just don’t have to do it. My article, which is on slow codes as a form of ethical disobedience, was motivated by a case in which a probate judge issued a temporary restraining order against our hospital for its DNR orders, where we had done good communication, bent over backwards to work with the family on a compromise for a month or more and run through our policy exactly where we thought it was inappropriate and harmful to a patient. And a judge comes along and says, nope, temporary restraining order. So now we have a choice. In theory, we don’t have to do it. But as our lawyer friend said, the master of the law in a courtroom is a judge. So whether it conforms to the statute or not is almost irrelevant. We’ve been ordered by a judge.
Eric 31:18
But it’s interesting. You’ve been ordered to keep them full code.
Jason 31:21
Right.
Eric 31:21
So now becomes the ethical dilemma. Do you do a performative code for the judge and the family, or do you just call the code 5 seconds and do it if their ET tube didn’t fall out or there was no reversible clause, Just end it. Because you can end it. It’s up to the doctors in the room when to end the code.
Jason 31:43
I think technically, but I think that that sort of ignores too much about the legitimate worries. And Lia, in that situation and the practice in that situation, I’m like, hey, I’m not going to put all this to the test with this judge. They clearly have a view here. And I’m not going to be on the.
Eric 32:00
I’m not going to risk my own job, my. My performance.
Jason 32:03
Yeah, why wouldn’t they? And let me say, also, like, it’s not just the legal system. It’s even where the laws may favor clinical judgment. The specter of liability is real, and I think we need to be sensitive to that. And then additionally, as Parker alluded to the culture around cpr, it’s a default. There’s a prevailing public belief that it’s a relatively innocuous and super effective intervention. And you just get it after nearly drowning on the beach, and then you get back to your surfboard, and we.
Eric 32:35
Teach people how to do it mannequins.
Jason 32:38
And it’s a default presumption. So I don’t think sociologically, while, while ethically it may be, I don’t think sociologically it’s like other non beneficial interventions like Ivermectin. I think there are a lot of other sociological factors that complicate the picture.
Gina 32:53
Yeah, and I was going to add to that. You know, Eric, I think to your point like that the doctor could stop in, in five seconds. Well, where is the doctor? The doctor could be at home in bed. You know, it’s the nurse who has to implement the doctor’s order that’s going to be there on the body doing these chest compressions until the doctor shows up. And like, how awful for them to have to go through that and hear the attending doctor say, hey, I know this code isn’t gonna work, but you need to physically get on that body and do that.
Eric 33:19
That’s a great point.
Jason 33:20
So then on the veracity point, I’ll just. Now, since we’re at the, at the time when it. We can do this defense.
Eric 33:29
What was that?
Jason 33:30
Yeah, we do, we do a lot of deceptive stuff in medicine. Some of it we think is ethically justified. Well, we withhold information from patients for therapeutic purposes. Sometimes we withhold information from surrogates when we think we’re protecting a patient. You know, we may not explain all the options.
Eric 33:48
Hey, there’s this thing called ECMO that we haven’t tried yet.
Jason 33:52
Right. Especially when we’re not offering those options. Right. Like, you know, the idea that like we, we refuse to offer and even explain an infinite set of possible interventions every single clinical encounter.
Parker 34:07
Yeah.
Eric 34:09
So omissions happen all the time.
Alex 34:11
Yeah, and he does some direct patients.
Jason 34:15
Are routinely deceived for their own good. I mean, there’s all sorts of deception. My colleague, again, Abe Brummett, has a whole litany of examples of ethical deception in medicine. So the burden on people who want to say the slow code is wrong because it’s deceptive is to show why it’s deceptive in ways that are impermissible. Just merely saying it’s deceptive is not enough because there’s lots of things that are deceptive and ethically permissible.
Eric 34:43
Well, Gina, I got a question for you. What do you think makes code so special then CPR so special? Because you ask a surgeon, I see this all the time, so. And so has cancer of the liver, but it’s also metastasized everywhere. Family wants the surgeon to take the liver out and they just say no, they’re not going to do it, or they’re too high risk for a particular surgery, even if the cancer is localized, they’re just not going to offer it or they’re not going to do cabg because they’re too high risk. They will just say no. Why do you think it’s that doctors don’t say no around, like, we’re just not going to offer CPR to someone?
Gina 35:22
Yeah, I think part of it’s legal. I think part of it is, you know, learning the history of cpr. CPR was never intended to be done on every patient. It was done in the operating room on patients that they thought could medically benefit from it. And somehow it got extrapolated to everyone. And I think one of my teachers in my ethics fellowship, Dan Bronner, he’s wrote a lot about this. And, you know, some people say that because there’s a billable diagnosis, we can bill for cpr, Therefore it went wide to everyone. Other people say because, like, the law has come down and people.
Doctors are so worried about getting sued. That’s why everyone gets it. So I think there’s a lot of reasons why it’s happening. Why does it happen? And surgeons are able to say no, and other doctors aren’t. From my perspective, and I’m internal medicine trained, I really think it’s like I was just trained differently. When I hear the surgeon speak about informed consent and offering procedures, I was just fundamentally trained different. We provide that care to patients, and I wonder if that’s part of the training of it. It’s just like, for me, as an internal medicine doctor, this is just. You don’t have the right to say no to people.
Alex 36:19
Yeah, it’s like, normative within internal medicine. Whereas there are a different set of ethical standards in surgery. For example, Parker, you look like you want to jump in here.
Parker 36:29
So two things. One, Dan Browner is now my colleague, and he’s got a wonderful book on. On this about the history of CPR and its relation to. To billing codes, but also for other procedures and treatments. They aren’t on the banner in epic. And so there’s no, like, default cabbage on the banner or ECMO by default or dialysis by default. There is CPR by default, although the presence of it in the medical record in that specific location might be new. I think it reveals something special about CPR that we think about it differently than we. Whatever the explanation is, it indicates the fact that we do think about it differently. And I think. I think it is, as Gina said, along with many others.
Eric 37:14
I read one article. I love this line, recognizing this symbolic Importance might allow us to better understand some of the inexplicable quirkiness in the way we talk about and perform cpr. Like it is quirky. It’s a, it’s a weird, weird because we’re not doing informed consent. Like we’re, it’s just odd.
Alex 37:34
It’s a ritual that is taken on added significance in our culture because of the ways in which it’s portrayed. In which, you know, James Tulsky article Miracles and Misinformation watched all of er, Chicago Hope and found success rates were like 2/3 when in reality they’re much lower.
Parker 37:53
So also, also consider that of most other treatments it’s extremely personal and close. So it requires a lot of personal force with an individual who you are very close to. And both of those factors have been shown repeatedly in the moral psychology literature to alter our moral judgments. And so you don’t get that with other treatments.
Alex 38:17
So when you say close you mean like your physically pumping on the patient’s.
Parker 38:22
Chest and doing so with a lot of vigor if you’re doing it sincerely.
Alex 38:27
And so this is the potential to create moral distress in the provider because of the closeness and force with which they’re acting upon the body?
Parker 38:37
Yes. Yeah. And not, not just distress but it alters sort of the cognitive or I guess emotional response to the task.
Eric 38:46
Okay, I want to go back to. So we’ve refuted some of the arguments against slow codes. Like what’s the argument that a slow code is actually maybe preferable.
Alex 38:58
Are we going trolley problem?
Jason 39:00
Let’s start with.
Parker 39:01
That’s what my article is. It uses the trolley problem.
Alex 39:04
Let’s go to trolley problem. I know we only have eight minutes left.
Eric 39:07
Yeah. So we got to keep it short.
Alex 39:08
We’re going to go fast trolley problem.
Parker 39:10
Fast trolley problem. You got, you’re an observer at a switch. People go on a runaway trolley. If you do nothing, trolley’s going to run off the cliff, everyone’s going to die. If you pull the switch, it’s going to divert the trolley into another track. And however you explain the problem, it’s going to hit a track worker, kill them, but everyone on the trolley will be safe. And so if you take slow cut out of the situation, that’s the dilemma between, or maps onto the dilemma between unilateral refusal of CPR or sincere cpr.
But there’s also pretty good evidence from moral psychology that if you include a third option that is basically a third track, so you pull a different switch and it, it’s a harm free track variety of ways you can talk. Talk about it. But say a sloping spur track. So it sloped, it slopes gently up a hill, comes to a rest, and no one ends up being hurt.
Eric 40:00
No harm track.
Parker 40:01
No harm. No harm. Everybody’s going to choose that track and everyone does. And so except for the, I think, you know, 93% of the psychopaths are like, so weird.
Alex 40:12
7% don’t choose that track.
Parker 40:14
Yeah. So either they were incompetent survey takers or psychopaths.
Eric 40:21
And there’s no right answer to the first two. Right. If you just have those two tracks. Is that right answer?
Parker 40:27
I. I think there is. And. And pretty consistently 85% of the people will pull the switch.
Eric 40:32
Oh, yeah. So they’ll be an actor, one worker.
Alex 40:34
In save the most people.
Eric 40:36
Yeah.
Parker 40:36
Yeah. And so my view is that the slow code is like that sloping spur track. And so if the sloping spur track is the best option in the this probably problem trilemma, then it’s the best option.
Eric 40:47
And really is that because there’s no harm?
Parker 40:49
Because it’s the least. It’s the most harm reductive. Yeah.
Eric 40:52
Tell me why.
Parker 40:54
Because it prevents harm to the patient. It prevents harm primarily to the family, once we take their well being into account, and it harms, to a lesser degree, the staff. So there’s no, I guess, I guess there’s no harm free option in these situations, but it’s the least harmful option.
Eric 41:12
Because there’s still the harm that you may lose trust with family if they find out or if the public finds out. Or like we did a podcast nationally about slow codes and people listen to it and they say, oh my God, slow codes happen all the time.
Parker 41:26
Yeah. Or maybe it violates sort of the social cohesion of the team.
Eric 41:31
Gia, what are your thoughts on that? Yeah, this, this idea. It’s the least harmful.
Gina 41:36
Yeah. I don’t buy it. I really appreciate the thought experiment. I love hearing people argue for the slow code. I don’t buy it. Personally, I cannot think of one situation where slow code is a better option.
Alex 41:48
Oh, say more.
Gina 41:50
I think if for me, the reason why I became decided to become a physician is I want to have honesty and integrity. And if people can’t trust me in like one realm of what I do in my practice, like, why would you trust me in any realm of that? So I think for me, you know, we’re going to have a patient where we think that CPR will not benefit them. I think it’s important to be honest and say either we’re going to do this code full out or we’re not going to do it at all. I think those are the options. This low code option for me is just, it’s not honest. And if anyone found out that I did that, why would you trust me in any other realm of what I’ve been doing in my professional career if I’m willing to, you know, be disingenuine in that way?
Eric 42:30
Parker, Jason, rebuttal.
Parker 42:31
Well, so I appreciate the comment and I’m not sure it’s a resolvable disagreement because if you listen to Gina’s justification, my justification, they boil down to ultimately the disagreement between utilitarianism and deontology, which.
Eric 42:45
If you can summarize that in one.
Parker 42:47
Sentence, because I didn’t understand that Gina, Gina cares about rules and I care about benefits, so.
Jason 42:55
Or the.
Eric 42:56
Or avoidance of harms, it sounds like.
Parker 42:58
Yeah, well, I care about welfare. She cares about principles, both well known ways of making moral decisions, but also notoriously difficult to reconcile.
Eric 43:10
So it seems like the main, like the reason to do a slow code is this is symbolic expression that we are, we are in this together. We’re not going to give up. It’s giving the family that. That feeling that we are going to do everything for their loved one to keep them alive. Even if we’re not really doing it, they’ll think we’re doing it. And Parker, my reading it right, that that minimizes harms to the family because they’ll feel like we’ve done everything. It minimizes harms to us because we’re not really doing everything. So we’re not having the moral distress and it minimizes harms to the patient because we’re not really doing real chest compressions.
Parker 43:48
Yeah, correct. And the cost of that is non maleficence violating that principle.
Eric 43:53
Jason, you’ve been quiet. What do you think about all this?
Jason 43:55
Well, so I think there’s other considerations. As I mentioned, I think sometimes we effectively face mandates from state law or judges. That’s what I mentioned my article is about. But what I wanted to say, and I think it ties to what I said before, even though there’s a fundamental disagreement that has really just emerged in this conversation about the ethicality of slow codes. I think we’re not as far apart necessarily. I mean, maybe Parker’s harms analysis moves him a little further away, but for me at least we’re not as far apart on the question.
Even if you think slow codes are wrong. And I think that they can be permissible from my point of view. And again, I Write about this. Slow codes are permissible in the context of state and judicial overreach at least. And what I say is it’s a response to a non ideal situation. So I actually am supportive of most of the arguments against slow codes in a vacuum. Right. In principle, I don’t think that those people are wrong. But we don’t live in principle. We live in reality. And we can be forced into bad situations. And I think a non ideal bioethics takes a look at what. What kinds of choices we have that make the world a little less bad, like that make life a little less worse for people.
Eric 45:13
So.
Jason 45:13
And it’s okay to navigate that kind of practical situation.
Eric 45:17
Moving from the ivory tower of academics telling us what we should do to the real life of Gina is showing us is that this happens all the time.
Jason 45:25
Yeah. So I think that like, you know, for the most part, we all wish for a world in which slow codes were unnecessary. And we should all work towards that world by strengthening laws and educating judges about clinical judgment and doing better communication.
Eric 45:40
One last pushback. One last pushback on that. Jason. Imagine the judge either found out that you called the code at five seconds and he gonna get mad or you did a show code where you.
Jason 45:54
Yeah.
Eric 45:55
Which would piss him off. Work through.
Jason 45:57
Yeah, Work through. An analysis of ethical disobedience. That a framework. I think you’re very unlikely to be caught. So I think. And I think that that matters. All right, now I’m shaking your head. Please include this in the. In the production. Okay. I’m going to never recommend it.
Parker 46:13
Lightning round.
Eric 46:13
Then we’ll get to Alex’s song. You’re going to make one last argument for your case. You gotta do it real briefly. Show codes, good or bad. Gina, I’m gonna start with you. You were shaking your head.
Gina 46:23
Yes, slow codes are bad. Doctors should be honest with their patients and families.
Alex 46:29
Great.
Parker 46:29
Parker, Slow codes are okay when they minimize harms.
Eric 46:35
Wonderful.
Jason 46:35
Jason, Slow codes are a non ideal, but nonetheless practical way to respond to a world that doesn’t sufficiently respect clinical judgment.
Parker 46:45
Okay, I’ll go.
Jason 46:46
And I never recommend them in practice, by the way.
Parker 46:48
Just say that.
Alex 46:49
Here’s mine. Eric does slow codes and recommends them, though he doesn’t want to admit it.
Eric 46:56
It’s not a slow code. A slow code, you know, it’s not going to work. I just want them to make sure that like, the oxygen didn’t fall out, like there’s no irreversible issue that’s going on. And a slow code, you know, there’s no like, you know, protest. Too loud. I doth protest. Alex. Bring us home. We’ll Motown.
Alex 47:27
(singing)
Eric 48:25
Gina Parker. Jason, thanks for being on. We’re gonna have to have you on again because I know I’m gonna get a million comments from this. It was great. So thank you very much, Alex. I think we’re still on Echo. And a big thank you to everybody who is listening to this podcast. We’re gonna have a ton of the articles on the show Notes. So go to the GeriPal website and show Notes.
And big thank you to all of our GeriPal listeners for your continued support.
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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose. Guest Gina Piscitello, Parker Crutchfield, and Jason Wasserman have no relationships to disclose.
Accreditation
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The post Rethinking Slow Codes: Gina Piscitello, Parker Crutchfield, Jason Wasserman appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
This is the second GeriPal podcast we’ve recorded live using this format, see this link to our prior podcast at the Center to Advance Palliative Care (CAPC) meeting in Philadelphia. Also look for our upcoming podcast recorded live from the São Paulo Geriatrics & Gerontology Congress, click here to register.
Today we join you from beautiful Banff, Alberta, Canada at the National Palliative Care Research Center (NPCRC) annual Kathleen Foley retreat. This meeting was bittersweet. I’ve been fortunate to attend every meeting in one capacity or another since 2006. The NPCRC made an enormous impact on the growth and capacity for palliative care research nationally. Personally, NPCRC funding was essential support as I was a new faculty member and had not yet secured longer term career development funding.
More than anything, though, I will miss the NPCRC community. I treasure those meals, hikes, sing-alongs with others dedicated to improving care of people with serious illness through research.
On today’s podcast, we invited Dio Kavalieratos, Prasanna Ananth, and Alexi Wright to join us to talk about three articles that spoke to them. For each I leave you with a teaser of a hard question that was raised that we couldn’t really answer.
We hope you enjoy this one as much as we did, dear listeners. We’re always trying to improve, and welcome your suggestions for how to improve upon this new “live” format. So far we’ve heard we need to be better at summarizing the articles for the audience/listeners, and finding ways to involve our live audience to a greater extent than the occasional question. Please let us know if you have other suggestions!
Final note – check out the wonderful video NPCRC created about their impact on the field of palliative care (Eric and I were filmed recording GeriPal).
-Alex Smith
This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://aprecruit.ucsf.edu/apply/JPF05811
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:53
Welcome to the GeriPal Podcast. I’m Eric Widera.
Alex 00:57
I’m Alex Smith.
Eric 01:01
And Alex, where are we today?
Alex 01:02
Today we are in Banff. We are at the Kathleen Foley Palliative Care Retreat and Research Symposium. Beautiful Banff.
Eric 01:11
Beautiful Banff. We’ve done some great hiking. We’ve listened to some great talks.
Alex 01:14
And I did a painting class today.
Eric 01:18
And today we’re gonna do something that we tried out at CAPC in Philly just not too long ago, which is we’re gonna mix up just a little bit about how we do the GeriPal Podcast. So, as usual, we’ve invited guests, but I love pbs. We’re in Canada right now, but I love the fact that in the US we do have this station called PBS, and they have this show in some locales which is called Check, Please. Anybody ever listen to Check, Please? We got a Check please.
Alex 01:45
Oh, good.
Eric 01:46
Okay, we got a couple hands where they invite three guests to be on the show, and each guest picks their favorite restaurant. All three guests then go to the restaurant, eat a meal, come back, and they share their experiences. Starting off with the first guest, like, why did you pick this restaurant? And then all the guests talk about their experiences with that restaurant. We’re going to do the same, but with research studies or articles that we’ve invited three guests.
They could pick any article that they want. They could pick their own. They could pick other articles. All of our guests then will read all three articles. We talk about why it’s important, why did they pick this article? So, and then we’ll kind of hash it out together. Alex and I are going to be usually the hosts, but we’re going to ask all of you to be the hosts, too. So we have two microphones out there so you can ask questions too importantly, the key thing is make sure your question ends with a question mark. So it always should be a question.
Alex 02:47
It’s like Jeopardy. Yeah. It’s not a statement, it’s a question.
Eric 02:51
It’s a question to our three guests about the article. Why do they choose it, what’s important about it, but do bring it in.
Alex 02:58
And you can include commentary, but you gotta keep it brief.
Eric 03:01
Yeah, brief. Because we only have about 15 minutes for each article.
Eric 03:06
And as usual, we’re gonna start off with a song. But before we do, we’re going to do introductions slightly different, Alex.
Alex 03:13
Yeah. We’re going to ask our guests to introduce themselves to reduce complexity here. Prasanna, why don’t you go first?
Prasanna 03:18
Hi, everybody. My name’s Prasanna Ananth. I am a pediatric oncologist at Yale.
Alex 03:23
Great. And Dio?
Dio 03:24
Hi, folks. I’m Dio Kavalieratos. I’m a health services researcher and the division chief of palliative medicine at Emory University.
Alex 03:29
Great. Alexi?
Alexi 03:31
Hi. I’m a medical gyno and oncologist at Dana Farber Cancer Institute and a health services researcher.
Alex 03:36
Terrific.
Alexi 03:37
Thanks for having us.
Eric 03:38
And then we always start off with song requests. Who has the song request? Prasanna.
Prasanna 03:44
So about a month ago, Eric and Alex had told us that we should think about a song that reflected Canada, so Canadian sing. So I was thinking about my song choices. There are a lot of different songs to choose from. And about a month ago, my son came back from school and said, hey, in writing, we learned about irony. What is irony? So I spent a while fumbling through an explanation, and then I said, I know a really good song. So we are going to sing Ironic by Alanis Morissette.
Alex 04:19
That’s right.
Eric 04:21
And notice the we. So we, Alex.
Dio 04:25
We.
Eric 04:26
What does the we mean?
Alex 04:27
“We” means everybody. So Eric’s going to put the lyrics up here. When I told Sean Morrison we were going to do this song, what is last week or so, he was like, so deeply disappointed. Sean’s sitting here in the front row and we didn’t show. Choose a different song by any of a number of fabulous Canadian singers. And we will do this one, and we’re going to do it great. Everybody’s going to sing along and sing it out. We practiced it a little bit last night. For those of you who joined the sing along,
Alex 05:06
(singing)
Dio 06:02
Well done.
Alex 06:05
I’ve heard you.
Eric 06:07
It’s like rain on your wedding — that’s not ironic [laughter]
Dio 06:13
Right?
Eric 06:15
A black fly in your Chardonnay.
Alex 06:17
Awesome.
Alexi 06:18
Irony.
Eric 06:19
What’d you tell your…was it son or daughter?
Prasanna 06:22
Son.
Eric 06:23
Son.
Dio 06:23
Yeah.
Eric 06:24
That’s a hard one. Because there’s debate over irony. Whether or not this is truly irony in this song, it’s true. But we’re not talking about Alanis Morissette. Sean, Is that why you’re upset at Alanis Morissette? He acknowledges. [laughter]
Alex 06:37
Yeah.
Eric 06:38
Not maybe this is irony. Well, we’re not talking about that. We’re talking about three articles. So we’re gonna start off with the first one, why Good Palliative Care Clinicians Get Fired. We have two of the authors of this article published in JAMA in the audience. I’m wondering, why did you choose this article?
Prasanna 06:59
So a couple of months ago, I had been thinking for the purposes of my research about therapeutic alliance, which what contributes to a robust therapeutic alliance. And by that I really mean the relationship between a clinician or a clinician team and patients and families. And then conversely, what also contributes to fractures beneath the surface or irreparable damage to a therapeutic alliance. And it led me to reflect on a couple of instances in my own career, both in training and then as a faculty member, where I have been fired.
And it was in this context that I came across this piece in Jamaica, written by my colleagues and friends, Drs. Abby Rosenberg, Elliot Rabinowitz, and Bob Arnold. What really resonated with me, and I think resonates with many of us who practice clinically, is how it sheds the curtain on what could otherwise be a very isolating and lonely experience. So when I was first fired as a fellow in pediatric oncology training, it was incredibly embarrassing, and I was very upset. However, I had this whole structure with a program director and, you know, an associate program director, all of whom got on the phone and talked to me and walked me through this experience and then shared their own experiences, leaving me to feel a lot less alone. Fast forward a few years.
When I was fired as an attending, it felt much more embarrassing in many ways And I did not have the courage to really share that experience with other people. And so what this piece talks about is why palliative care clinicians in particular might be especially susceptible to being fired. I’m not a palliative care clinician. I practice primary palliative care. But I am a practicing pediatric oncologist. And I still see so much in this piece that resonates with me. For example, they cite a number of studies that reflect on how patients favor clinicians who present a more optimistic outlook rather than realistic. And we are taught in our communication training to balance pragmatism and realism with optimism and hope. I think that we are all vulnerable to this and we ought to be sharing more openly and being more vulnerable about our own experiences so that we don’t feel so isolated and we don’t feel burned out by these experiences.
Eric 09:32
Alexi, you’re an oncologist. Did this resonate with you? Because the interesting thing is this was published in jama. This is not a specialty journal, but it’s about a specialty care palliative care clinicians getting fired. Which surprised me that it got published. But it seemed to resonate with a lot of people. The comments were like, if you go to the website, all of our listeners who are just listening, we’ll have links to our show notes, but you can go there, we’ll have links to it and you can see the amount of people that commented, which is impressive.
Alexi 09:59
Yeah, I think that, like Prasanna, I’m an oncologist and I have also been fired. And it’s very isolating and lonely and often caused me to reflect back on, like, what could I have done differently? You know, And I’m sure there are things that I could have done differently, but some of it is that you’re often a harbinger of bad news, at least from the family’s perspective. One thing that’s been interesting to me is sometimes I’ve seen colleagues who are palliative care physicians who choose very optimistic oncologists or medical care teams despite being well trained in palliative care. And I’m wondering what you guys make of that.
Prasanna 10:45
Any thoughts?
Alexi 10:47
I mean, I’ll take a stab at that instead of throwing you guys. I do think probably a lot of us have had time to think about what we would want and are often very clear. I mean, you never know until you’re in the situation, but sometimes have real clarity about what we would want and what compromises we’re willing to make. And you Know, for us, it may be doing everything possible, even if at times we’ve seen people suffer from that or it may be. Be otherwise. I guess that’s. That’s the way that I’ve kind of come to terms with that. But others may have other ideas.
Alex 11:25
So I’ll jump in here. Can we do a show of hands? If you’re a clinician, please raise your hand and keep it up. If you haven’t been fired, lower your hand. Okay. I would say, like, a third of the hands went down. Most of the hands stayed up. Thank you. I think this is really common, and it’s common across. We have all sorts of people here in this audience at the Foley retreat. We have people who are palliative care clinicians, we have geriatricians, we have pediatricians, we have people who are social workers, we have people who are nurses, nurse practitioners, people who are in cancer, people who are in geriatrics, all sorts of specialties. And it’s just so common across specialties. I say my own experience.
I got fired a lot when I was a palliative care fellow. I mean, like, so it’s kind of hard to say that, but it’s true because I talked to my co fellows who were great, like Kathy Silvagi, Jane de Lima, like, you know, like Juliet Jacobson, and they didn’t get fired as often as I got fired. So I was like, what’s going on here? What’s happening? Why is this? And I think in my case, I drunk the wrong kool Aid. I drunk this Kool Aid of, like, I know better, like, these experiences. James Tulsky, in his. One of the opening talks, was talking about this experience of coding patients in the hospital again and again and the moral distress that that causes. And I have to say, like, I felt that, and I felt like I was on a mission, like, to help patients, like, understand what the dangers were of this.
And I think I pushed too hard on trying to get them to know, to understand what I had learned, and that resulted in me being fired a number of times. And I think it’s important to learn about this. So kudos to Abby and colleagues for writing this up and being brave enough to talk about it and for prasannath, for bringing it up here and for talking about it today.
Eric 13:27
Well, I guess one question for you, Dio, as you think about this as a palliative care specialist, like, they talk about this tightrope, this balance between. We’re doing like good palliative care providers are doing, invitations to talk about these really hard things about making sure there’s safety involved in these discussions, but also that we go into the place of vulnerability. How do you think about that tightrope from your perspective as a palliative care provider?
Dio 13:57
First, I’m not a palliative care provider. Oh, yeah. Just to make sure. So I’m not overspeaking here.
Eric 14:02
All right.
Dio 14:03
But as a scientist, I mean. Yeah, go for it.
Prasanna 14:06
I think that, you know, there’s a line in the piece about if you as a clinician are never fired, maybe you’re not being provocative enough. And then if you’re always being appendecting.
Eric 14:19
Like if you got. Don’t do enough appendectomies, I think it’s. That’s my old school medical. That was before they had imaging, apparently.
Alex 14:30
Yeah.
Prasanna 14:31
And then the reverse is if you’re always being fired, then you have to also.
Alex 14:35
She looks at me. Yeah.
Eric 14:40
Well, I guess the other question I have is the quote, our job is not to be liked. It’s to advance the conversation and advance the care. Yeah, it was something like that. I may have misquoted that, but in general, that was the theme. What do you think about that?
Alexi 14:56
Yeah, I think that’s really important. I mean, I think you have to hear the people that you’re talking with, But I think this concept that social desirability can be very addictive. But when you’re actually putting the patient in front of you, I think you absolutely have to try to hear them. But it’s not to be liked at the end of the day. It’s to help them clarify their values.
Eric 15:19
But don’t we want to be liked? Like, I also. I have actually gotten fired by referral teams, by surgeons and medicine teams, and my job is kind of to be liked by them because I need them to refer in the future to me for the good of our service, so that there is this balance. Not even just emotionally. I kind of want people to like me, but I also need them to refer to me. And it is this delicate balance. What do you think about that?
Alex 15:46
And as you’re thinking about response to that, we’d also invite people to line up at the two microphones if you have a question. We didn’t want to discourage questions. We want to hear from you. So please come up to the mic, and when we call on you, make sure you introduce yourself for our listeners. Any thoughts on what Eric’s question or should we get to our first question from the audience?
Alexi 16:06
I mean, I think come work at the Farber because we need more Palliative care people. I feel like there’s a glut, meaning there’s a glut of referrals and enough workforce. So I. I guess I’m an oncologist, not a palliative care provider. So.
Eric 16:20
Have you ever fired a palliative care provider?
Alexi 16:22
I mean, I haven’t.
Eric 16:26
Yes, we have. Our first MIC question.
Audience Participant 16:28
Hi, I’m Kelly Michelson. I’m a PICU doctor from Chicago. I have a used to work with a chaplain who used to talk about how she would go to visit her patients or their families. And oftentimes it’s related to the teenagers. She would go and see if they wanted anything and they would kick her out and they wanted nothing to do with her. And she used to talk about that as an important intervention in their process. And I’m curious if there’s anything related to that that applies here.
Eric 16:59
What do we think?
Alexi 17:00
I mean, that’s really interesting. I have to say, as an oncologist, pretty much every time I bring up palliative care, I cite Jennifer Temel with my patients. And I say there’s clear evidence. It doesn’t extend to GYN cancers, but the people live longer when they get palliative care. And so I don’t know if that per se relates, but I think there are these important markers along disease courses. And I guess I try to move away from thinking of palliative care as hospice, but it’s interesting to think about a chaplain showing up in the room as. I don’t know. I guess I wanna have deeper trail marks than these subtleties. I don’t know.
Alex 17:45
Okay, can I defend myself now? I get fired. I haven’t been fired in a long time. I can’t even remember the last time I’ve been fired. And I think that. Thank you. Thank you. Do learn the hard way from our mistakes. We learn. And I think it’s because I focus more on listening and forming a relationship, like, deep listening and forming a relationship, like, that’s the most important thing. Understanding, like getting to know them is much more important that they know what I know.
Eric 18:19
But I think the interesting thing of this article that impacted me was even if you are the best, even if you’re doing everything right, even if you’re following vital talk perfectly, you’re listening. You are doing everything right, you still will get fired.
Speaker 7 18:38
Right?
Alex 18:40
I’m probably not being fired enough now.
Eric 18:42
You’re not challenging them enough, Alex. Right. That was also a point of this article. Are we there also maybe to challenge, to move the conversation forward what do you think about that?
Prasanna 18:54
I think so. In the circumstances that you were sharing, Eric, about surgery teams or other teams that might fire you, it’s an opportunity to have a conversation about what went wrong or what could be done differently, what sort of triggered that firing. And so to have a broader professional discussion so that palliative care is more accepted in those particular care contexts.
Dio 19:20
Yeah.
Alex 19:21
Any questions from our audience about this? This is your last chance. Yes. Please introduce yourself. We know who you are, but please introduce yourself.
Dio 19:28
Oh. Oh, boy.
Eric 19:29
I’m Ali. John Zarabi. I’m from Atlanta. Thinking about patient centered care and putting the patient and family first. Is it ever a good thing for.
Dio 19:39
The patient to fire us?
Alex 19:41
Oh, good for.
Dio 19:43
Yeah.
Alex 19:43
Could you clarify? Good for who?
Eric 19:46
For them?
Alex 19:47
Hmm.
Prasanna 19:48
Well, I don’t know. I mean, it might give them a sense of agency in my context. You know, I take care of kids, and it’s often not the kids, but in my experience, it hasn’t been the children who are firing us. It’s their parents or their family members. And so it might be the one thing they can control in a circumstance that is, you know, that they can’t control anything else. And so you often find in pediatrics, parents who are. Whose children have serious illness will fixate on nutrition or, you know, or different service providers, because that’s something they had some agency over.
Alex 20:27
I’ll say that one thing I learned from Susan Block when I was in fellowship training, and what a wonderful person to help me debrief this, and we wrote a piece about this way back when, is that maybe it’s better they get mad at us than they get mad at their primary team. Like we’re the consultant, you know, like they need to take it out on somebody and that we can be an avenue for that and we can hold that. We can process that.
Eric 20:52
Yeah.
Prasanna 20:52
I guess the one challenge there is what if you’re the primary palliative care provider? Like you’re in a subspecialty and you’re being fired.
Alex 21:00
Yeah. So when I said we, I meant palliative care consultants. I should have clarified. Yeah, good point, Prasanna. Yeah.
Eric 21:07
And there’s the argument around the short versus the long game. While in the short term, if you give hard prognostic information, satisfaction may decrease, but in the long term, we don’t know what the outcomes as far as satisfaction is. And Tony Bach talked a little bit about this in another. I think we had him on a podcast. We talked a little bit about that. Any other thoughts on this article before we move on. Or any other questions from the audience. Okay, let’s move on to our second article. Dio, I think you brought up this article which is about economic case for palliative care globally.
Alex 21:44
This.
Eric 21:46
Why did you choose this article?
Dio 21:47
Yeah, great question. So I chose it for, I think, two reasons. One was a little selfish, right? So I study models of palliative care, and I’ve been guilty of having a very sort of US Centric frame of mind and thinking about models of palliative care. And so this was sort of a nice article, which comes from a larger who piece, thinking about palliative care globally. I think the second reason was, and I apologized last night to y’, all, that I was gonna get a little political with this. So forgive me, but I think given the current times where we are in the US and thinking about health and social policy and investment, it makes me.
I think it’s a good reflection point to think about what is going on globally and how does that relate to what we have in this country. I think many of us are really worried about cuts to reimbursement and access to care as well as many of us are also worried about cuts to research funding, both of those things together. Thinking as well, the privilege that we have in this country that we have a really robust model of palliative care. If we quote CAPCI data, for example, basically almost every large hospital in the country has palliative care services. 82% of hospitals with over 50 beds have palliative care services versus what we see globally, where most of the world does not have access to essential, primary, even palliative care. And so it was a nice reflection point to think about sort of where we are here and juxtapose that with where the rest of the world is.
Eric 23:18
I’m wondering from our other guests, did anything surprise you or catch your eye from this article?
Alexi 23:23
I mean, I will say, and I forewarned you about this, you know, I am astonished that basic pain relief is not available in other countries and that it’s even controversial to treat cancer pain with opioids sometimes in some settings. And there’s a part of me that kind of thinks about Paul Farmer, the late Paul Farmer, who said it’s not enough to give people substandard care. And there’s a part of me that wonders, are we aiming too low if we’re just going for kind of basic palliative care packages overseas?
Dio 24:06
I mean, I think that’s a really fair point. Right. And another reason why I chose this article, in thinking about models of palliative care was it made me think about what are the essential components of pallia is the essence of palliative care. And for example, from the article, they talk about essential palliative care packages in a lower income country that cost, I believe it was $2.16 per capita. Right. And so thinking about such an affordable model of care versus many of the sort of deluxe Cadillac interventions that we’re thinking about in the U.S. now, it seems like there’s a contradiction there perhaps.
I think that there’s a spot in the middle. Right. I don’t think anyone’s talking about giving subs, but we are trying to reinforce access to care. I think the other point just to sort of this might seem like a tangent, but I promise it’ll connect at one point. But you know, I think the article also made me think about the inequities that we might face in this country given where policy is right now. And while I mentioned that we have privilege in this country of having palliative care accessible to many, most people in this country, you know, I think a lot about historically disenfranchised populations. Right. I think about cuts to Medicaid, for example. I think about decreased access for rural population. And so just thinking about what can we adopt from an article like this and thinking about again, what are the essential components of palliative care that all should get and how do we scale those? Perhaps instead of thinking about super fancy, deluxe, technologically savvy models of care.
Alex 25:33
That’s great. I think we have a question from Laura Hansen. Laura, if you could introduce yourself.
Eric 25:38
Sorry, Alex, jumped the gun there.
Alexi 25:40
You just know too many people. Laura Hansen from the University of North Carolina. This is such a powerful article to select and thank you for doing so. I really wanted the panelists to really think carefully or talk about your perspective on the implications for populations that we fail to reach in the United States of America. There are so many of those populations and I’m curious if you have any imagination that you can share with us from what you’ve seen in caring for those populations. How should we be changing our models?
Eric 26:28
I’m going to throw out something I learned from this article. Again, we’ll have link to this article on our show notes. But in Rwanda they had a tri. They talked about this in this article. A tribal village where they elected community kind of health workers. So I’m not sure how much training they got, but they delivered palliative care in addition to other care to their village, which I thought was absolutely fascinating. But Also made me think, Dio, how are we even defining this palliative care intervention and is it a palliative care intervention? But that was one model of bringing whatever this palliative care intervention was to the community.
Prasanna 27:11
And in the cancer care world, there are some studies, some trials in the United States employing lay health workers into rural communities to deliver bits and pieces of oncology care. So you know that that is a model that is tried and tested in other in various diseases and could be applied more broadly in terms of the delivery of palliative care.
Eric 27:39
So let me ask you a question, because this is a point of hot topic in palliative care. Like, what is palliative care? Is it a philosophy of care? Is it a model of care? If it’s a model of care, how much of palliative care needs to be involved? How many team members, what kind of dose? All of that. Like, when you think about that oncology first, the community health worker that’s going out, do you think that’s an oncology intervention? Are you in oncology? Are they struggling with the words like, we struggle with it in palliative care?
Speaker 9 28:07
What are your thoughts?
Alexi 28:11
I know you’re a PhD, but now.
Speaker 9 28:12
The time.
Eric 28:16
I mean, I think, I mean, I’m going to go back to so Dio, a great paper. What, five years ago in Jama, almost 10. I was almost 10. Holy smokes. It was like over a pandemic ago. Meta analysis looking at palliative care interventions which showed a lot of positive outcomes. But the question is, how are we defining what palliative care is? Because there was a lot of you could have lumped or you could have split, but there was a lot of lumping of palliative care interventions that were not necessarily specialty palliative care. So I wonder how you thought about that and how do you think about that in the context of this article?
Dio 28:55
Yeah, you’re seeing me smile because I’m reflecting back 10 years ago, thinking about putting that article, article together and looking out and seeing some of the co authors in the room and thinking like, how much did we stress over that definition? It was really challenging. Right. So what we did in that article was we used the national Consensus project domains of palliative care, and we said that a study needed to comprise at least two of the eight domains at that time of palliative care. Again, that was a tough decision. We chose two at least because we didn’t want trials that are interventions that just gave opioids for a symptom, and that was it. We needed something more than that. But even that was a dicey definition.
Right. And I remember even we had back and forth in the comments after we were published of why wasn’t this intervention covered? Why did you exclude that? We had to make decisions at a certain point. But I think it does bring back the point that I think is also resonates in this article that I chose, which is again, like, what is that essential component? Is it communication? Is it symptom management? Is it goals? What is it that makes a palliative care intervention, palliative care? I will also say I do think that we run the risk of having interventions define the entire field.
And I worry a little bit about that because all of these interventions are different and they should achieve different purposes, more or less depending on the population, the indication and that point in that patient’s disease trajectory at which we’re intervening. So I think it’s a complicated issue.
Eric 30:19
I’m going to push back a little bit because I struggled with this article because it talks a lot about the benefits of palliative care. It cites some of the people that we see here, Jennifer Temel’s article about the benefits of palliative care. That was a very specific palliative care model. That wasn’t just philosophy of palliative care. Let’s just see what happens when we do the philosophy of palliative care. It was a palliative care model that was implemented with high fidelity. Do we run the risk when an article like this says, oh, look at all the benefits that palliative care does? And if we just implement any philosophy of palliative care, you’re gonna get those same benefits?
Dio 31:00
I think that’s an implementation science issue. Right? In many ways. Right. So we study one thing, and then when we see it actually out in the real world, it’s gonna look different in a different healthcare system for a different population, for a different country. Exactly. And so I do think that we need more nuance in our discussion of palliative care. We can call my personal opinion. It’s a philosophy. And we have palliative interventions. They’re all gonna look a little different. But I worry about us, again, holding the entire specialty up to an RCT. For example, we don’t see trials of nephrology care. We don’t see trials of pediatrics, at least I’m not aware of. And so it seems a little bit unfair that we hold palliative care to that same standard.
Alex 31:41
I’ll interject. And then we have two questions from our audience what is palliative care and whether something can be called an intervention, a service, can be called PA care, ought to be called palliative care. It’s a question. Means like nothing, right? Because what we care about most is the patient’s well being. Right. What happens to the people who have serious illness. And it means, like, everything at the same time. When we were at capsi, there’s great concern about palliative care Light.
And we have a couple podcasts that we’re planning about that, which is, you know, person goes out with a checklist of questions that they ask, you know, patients with serious illness, and there is no follow up, no feedback, no, you know, and that’s it. They’ve delivered palliative care. Right. So the concern is if that gets labeled palliative care, then we own that. Right. All the bad outcomes do and all the problems and complaints as well. So it means something. Is what we. There. This is really. We’ll do many podcasts about this. Stephen, actually, she’s first. Okay. Please, Marie. Oh, please introduce yourself.
Audience Participant 32:46
Thanks, Alex. I’m Marie Bacaitis. I’m here from University of Alabama at Birmingham Dio. I love the fact that you picked this article because of the idea of global attention, but it’s a little perplexed. I haven’t read the article about the economic benefits of investment in palliative care. I’m glad that Diane is here and capsi, and for many of us starting palliative care programs a billion years ago, one of the cases that we could make to convince our administrators was that palliative care could save money. And we could cite Sean’s article, we could cite other people’s articles to say that palliative care saved money.
And then the light bulb came onto me and said, well, it doesn’t always. And why are we trying to make the case for something about money when the case that really is about suffering and relief of suffering and what is the price tag for suffering? So having not read the article, I’m just wondering is what the conclusions are in terms of economic benefits in the investment when we should really be caring about my own personal opinion about the quality of life benefits to investing in palliative care. So I’d love it if you could address that.
Dio 34:11
Yeah, no, that’s a great question. And I fully agree with you. Right. We should not hold palliative care just to sort of one outcome in particular, an economic outcome. I think what I took away from the article and the bottom line for me was that, you know, palliative care does not need to be some very complicated fancy model of care that will be very expensive. It can be essential components. And that as well that the article does not just talk about economic outcomes. It also talks about sort of the other outcomes that are important, like quality of life, like caregiver outcomes as well to from investing in palliative care. So I think it does a really nice job of balancing those and not just tying palliative care to economic outcomes.
Eric0 34:56
Steve Stephen Connor, Worldwide Hospice Palliative Care alliance so it’s ironic that we’re one of the only fields in medicine that needs a definition, first of all. So we have to call back, reflect on that. To paraphrase Cicely Saunders, there’s a lot of need for diversity in this field. Go out into your own circumstances and figure out how best to deliver palliative care. And I think that we have seen some really marvelous examples out of Kerala and a lot of other places of palliative care being done differently than we do it here in higher income countries with pretty good outcomes, it seems. My question to you is we have avoided the idea of asking who to create an international standard for palliative care. We’ve been a little bit afraid of that. But do you think it’s a good idea is the question.
Eric 35:55
I’m going to turn to our models of care person first, what do you think? International standards? We’re going to also have Ira Byock on a podcast too, thinking about should there be a minimum standard of care for palliative care in the United States. What do you think?
Dio 36:07
Diya I think it’s a really great question. I think it sort of depends on how it plays out right. And what the standards look like. Is it competencies? Is it specific tasks? Is it, you know, I think the devil’s in the details. I do think that there probably needs to be a baseline so that you can say I did deliver palliative care to this patient, I did that. But I do also agree that there will be a need for a lot of flexibility, recognizing differences in financing in each country, recognizing differences in culture and other factors that are important too. So I wouldn’t want to see us over standardize because I do think then we lose the beauty of palliative care.
Eric 36:45
All right, Prasanna, I’m going to turn to you. As an oncologist, you probably don’t have debates over what is oncology. But the hard part is there’s no study saying, oh, oncology saves money, economic impact. But it also doesn’t make Any sense, because oncology is not the intervention that you’re doing. It’s usually about type of drug or the model of care. Potentially in oncology, if we’re talking about evidence based economic benefits, again, this article is just focused on economic benefits. They do acknowledge that is a side benefit that is not the main benefit. But don’t we have to focus on like a specific model of care when we’re talking about economic benefits rather than a philosophy of care?
Speaker 9 37:32
Yes.
Prasanna 37:32
And one of the challenges that I found in reading this article was that they were projecting a lot of data collected in the west on low and middle income countries. You know, they were saying a lot about the costs of care in the last, you know, weeks to months of life. All of those data are from the United States or from North America, not from low and middle income countries where I imagine a lot of people don’t even make it to the hospital to die.
Alex 38:01
So.
Prasanna 38:04
It is a policy piece. So it’s not super expansive in scope. But that was one of the challenges that I found in reading this, that I felt like you can’t translate that intervention or harness those data in a completely different setting where it might not be applicable.
Eric 38:26
So both the setting and the model. We’ve got another question from the audience. Please introduce yourself.
Audience Participant 38:32
Tom Smith from Johns Hopkins for the past 14 years, but Virginia Commonwealth University and Medical College of Virginia for 28 years before that and back before many of you were born. In 1988, 1989, a young oncologist and myself, Chris Desch, met with two advanced practice nurses, Cindy Simonson and Nancy Kane, who taught us to do a needs assessment where you actually go in and ask people what they want before you decide what you’re going to provide. And so we looked at the map of Virginia where people were dying unnecessarily compared to the rest of the state of Virginia and the rest of the country.
And it was all the rural areas except central Richmond, which we couldn’t help. But we went to those areas and using my sort of business school background and engineering background, I thought we had to think really broadly about what we had to measure to make sure that this was going to be a valued component. So what we did was we went to each of these five different very rural hospitals, each at least 100 miles away. And we met with them, usually at a Chinese restaurant and had dinner and asked them, well, what do you want then? We want to have our surgery done here.
We want our MRIs done here. We want our CT scans done here. We’d love to be able to do chemotherapy here. We’d love to be able to do good pain management here because we don’t know anything about that. And we’d love to increase the use of hospice. Remember this was back in 1988. 89. And so we set up a program where we would go like old Methodist circuit riders from one place to another, usually a paravitz at each place. And what we showed in the first two years was 700% increase in the use of morphine as pain management from zero. Pretty easy to go up from that. We showed going from 100% mastectomy to 30% mastectomy and then 70% followed by radiation oncology, which is as a breast oncologist, that’s the best way to treat breast cancer. We showed for the local communities over 2 million miles of patient travel each year.
Eric 41:09
I think that’s the really interesting thing, Tom, is that and that’s going to bring us to our next article, because I want to get to the next article before we run out of time, is that there are communities in the United States that have very little access to palliative care, which we will talk about. I’m wondering in the last 10 seconds, any other thoughts?
Speaker 7 41:26
Tom we saved each. We made a profit for each of the rural hospitals of one to two million dollars a year by keeping their surgery awards busy, their MRIs.
Eric 41:40
And that wasn’t your primary goal.
Speaker 7 41:44
Palliative care was never about saving money. It was always about providing better care. But if you can do as Diane Meyer says, mission alignment, and you can save money for the community, save miles of travel for the community and teach people in the community to provide the right oncology and palliative care, it actually works. It’s continued to this day. Every hospital in Virginia has a palliative care plan.
Eric 42:08
Let me move on to our next one because I think this connects really well. Alexi, this is your article talking about a specific patient population where we don’t have a lot of access to palliative care. Everybody in the audience, everybody listeners, just think about what population this is. Is it nursing homes?
Alex 42:25
Is it?
Eric 42:26
What is it? Alexi, what article did you pick?
Alexi 42:29
Yeah, and I want to say this is my article, but it’s really not my article. This is really an article that was spearheaded, ideated, created by Chris Manns, who’s one of my mentees. And it’s one of the reasons. So I chose this article for several reasons. One is I think we’re in a period of time when a lot of marginalized populations maybe disappeared. And I see that in interventions that I’m doing where people who are undocumented are not showing up to get care. So we can’t enroll them in the interventions because they’re afraid of being sent and deported to other countries. But I also see this in places like prisons.
Eric 43:09
And for our listeners, the article is Cancer Screening, Diagnosis and Treatment of Vulnerable patients and incarcerated U.S. person.
Alexi 43:16
Yeah, so because of the particular political moment we’re in, this feels very salient. But it’s also a hopeful story in that I think a lot of what we’ve talked about today has been people reflecting upon the way that their mentors give to them. And I got this grant and it enabled me to do this, and the mentors are what did it. But on the flip side of this, this was not in an area that I was studying at all. I had definitely fangirled Bri Williams, who’s also, you know, I think the world of her and the work that she’s, you know, doing.
I had taken care of a patient in particular who had ovarian cancer and, you know, presented with a 30 centimeter mass in prison and got surgery from a gynonc and then had a wound dehis and was essentially sent to a local hospital and shackled for the entire time that her wound was healing. And I had seen that personally, but I had not thought about studying this population until this mentee came to me and said, I really want to find out what’s happening in prisons. And little did I know, actually, that cancer is the leading cause of death in prisons. And as we began to explore this together. Interviewing and he did the interviews. Interviewing, you know, lots of different PCPs and medical directors, palliative care physicians, oncologists who care for these patients.
We learn that these things that we take for granted, like knowing when your next chemotherapy appointment will be, well, it turns out if you’re imprisoned, it’s a security risk to let someone know when they’re gonna get their next cycle of chemotherapy because they might actually, you know, their family might help do a jailbreak. You know, having families present for fundamental family meetings, understanding that someone is actually has cancer, is dying from cancer. This is also they’re excluded. And the fact that this is happening, you know, in our country and in our systems was really eye opening to me. And so that’s, at this particular moment, why I chose that article.
Eric 45:25
I’m learning from our other guests. Is there anything surprised you about reading this article when you read it?
Prasanna 45:30
I was struck by the report from some of the physicians in the prisons who were saying that patients could only get supportive care medicines at certain times of the day. So they have to present to the physician, I don’t know, three times a day. And so if they needed medication, they needed an antiemetic a little bit more frequently, they wouldn’t have access to that. And they might not have access to opioids, in fact, at all. Didn’t have access to opioids. Yeah, exactly. Just was really sobering.
Dio 46:04
Yeah. I think other pieces that definitely struck me too. I think connecting it back to your article too, just making me think about delays in care and delays in communication and how that actually might play out with communication with oncologists, for example, or palliative care teams sort of not availing patients of that early opportunity for conversations. Any clarity about their diagnosis and their trajectory forward.
Alex 46:27
What stood out to you, Eric?
Eric 46:29
I think a couple of things. First was, luckily I work with a great interprofessional team and they have to constantly remind me, which I should know. This is like Alex admitting something like getting fired too much. I often forget to include family members because I’m so focused on getting my work done. And I get reminded, like, have we thought about who the family members? Are the family members gonna come? Are we talking to the family members every day?
Because they’re so integral to the care in the lives of our patients and we are 100% relying on them once they’re discharged or once the patient loses capacity and then we turn to them. But we’ve never included them before. I was shocked that they are really not included at all here in many of these places explicitly, they cannot be included in these discussions with their primary care doctor, their oncology team, because of security reasons. And that part shocked me. How do you deliver patient centered care without including family?
Prasanna 47:27
Yeah.
Alexi 47:27
And then I would add to that that often security guards are present. So you’re having this reverse thing where there’s an inherent power dynamic where this person is a security guard and you’re asked to be vulnerable without any family support to try to understand, and you can’t get any privacy.
Eric 47:46
What shocked you, Alex?
Alex 47:48
The use of correctional officers and security guards as intermediaries. Right. Like they’re the ones who can determine so many aspects of care, whether to report somebody’s in pain, whether to, you know, navigating, whether they are able to consent, who’s going to be shackled, all these sorts of things. Are they equipped to do that? These are huge intractable issues. And there’s so Many other populations, as you were saying, Alexei, that this makes you think about, like currently speaking to today, people who are held by ice. Right. There’s one of the Greenwall faculty scholars is interested in this.
You know, how ought we treat them and how can we work towards better care for those people? I see we. Oh, before you take the question, I also want to plug our two prior podcasts. We did a podcast in prison with some terrific people who volunteer in the prison. We talked to the chaplain, we talked to, but to many people. Michelle De Thomas, who runs the palliative care program for palliative care and hospice in California. And also our podcast with Bri Williams and two formerly incarcerated people during COVID Please introduce yourself.
Alexi 48:56
Hi, I’m Judith Baggs from Oregon Health and Science. And as I think about this, I think about the care providers in those situations. And we didn’t sign up to give bad care. And obviously this is bad care. And it’s not just physicians, because a lot of the care that’s delivered in prison is delivered by nurses or by nurse practitioners. So I wonder if that was considered at all when the paper was done. I want to actually respond to that. I actually don’t think that these are. I think the. The care, the system is incorrectly aligned.
But one of the things that was striking about reading some of the transcripts of this and analyzing the data is these care providers often went to extreme lengths to try to care for patients, to make sure. For example, it turns out the only time in this country that health care is a right is actually when you’re in prison. So very ironically, some patients come to prison and haven’t ever had healthcare. Thank you for coming. And then they get in prison and then they’re released and they don’t have healthcare again. And many of the oncologists we talked to or primary care doctors worked very, very, very hard to try to make sure that they were connected. So I actually think these were more. What struck me was there were incredible people struggling mightily against a system that was stacked against them.
Eric 50:28
So the care is really good, but the system, no, I’m not saying the.
Alexi 50:33
Care is how do you have really good care when you don’t have family presence?
Eric 50:37
But this kind of goes back to the last article about what is standard of care. And it depends a little bit on the systems. The models that we’re working in, and the providers that I know that work in these systems are very passionate or very good. But I also see that we have an expert at the microphone, Bri Williams Yes, Bri, could you introduce yourself briefly?
Audience Participant 51:01
Bri Williams, professor of Medicine at ucsf, and I direct the Aging Research and Criminal Justice Health Network, which is funded by the nia. Thank you so much, Lexi, for including this article. It’s timely, it’s important. Just a couple things to remember. At our worst, 1 in 100Americans were incarcerated. 100American adults. That number has gone down precipitously over the last decade, but is actually going up if you count ICE facilities now. So a lot of people are incarcerated. What that means is 1 in 2Americans have a loved one who’s incarcerated or has been incarcerated recently. That is a staggering number. So this is really part of the fabric of the experience of being an American at this point.
And so not understanding, not knowing what’s happening inside these closed facilities is. Is really a problem. I think one thing that you said, Eric, that I think is really important to underscore is this question about policies and procedures and what’s allowed, that sometimes the families are not even allowed to be contacted. And what’s important to remember, especially for those of us who might take care of a patient, never in a prison, but actually in a community hospital where people go to get care, is that a lot of the policies and procedures that we are told are absolute are actually not absolute. And some of the work that our team has done is actually look at the policies and procedures that are communicated to healthcare professionals inside and outside of prisons.
And in fact, it’s all like lore. It’s like urban legend. It’s not even true. If you look at the policy. If you look at the procedure, actually the policy says you should contact the family, and everybody has decided you’re not supposed to contact the family. And so it’s actually because it’s such a part of the fabric of American society, it’s very easy for us as Americans, I think, to just become correctional, to take on this assumption of what it means to be incarcerated and what it means to have limits around the care of people who are incarcerated. So I would just say that I think that this paper is really interesting because it’s 32 healthcare professionals and their perspectives. And the next step is really to ask, how do perspectives misalign with actual reality? And remind ourselves to constantly question when you’re told what the limits are and what is available and allowable to say, is that really true or not?
Dio 53:24
That’s great.
Alex 53:24
Thank you, Bri.
Speaker 6 53:25
Thank you, Bri.
Alexi 53:25
That’s a great point, Bri. Thank you. I will say that there are two subsequent papers that will come out, one of which is looking at barriers and other strategies. And I think there is a lot of low hanging fruit to solutions. But as usual, Bri, I hadn’t thought of that one.
Eric 53:42
Well, Prasanna, Dio. Alexi, thank you for joining us on this GeriPal podcast. Before we end…Alex is having a moment, but he also is going to take a moment.
Alex 53:58
Okay, thank you. So I wanted to change it up for the closing song and I had planned to play a song that Randy Curtis had requested for the GeriPal podcast. But I couldn’t get through the song, much less talking about it without tearing up. So instead maybe we could have a moment of silence for those who aren’t with us today.
Alex 54:25
Thank you. And now to Joy. I encourage you all to read Daniel Free’s terrific essay about Joy. Joy through music is what she writes about playing Beethoven’s Ninth. Joy is resistance. Joy as resistance. A great article. And so in that spirit, please join with me in singing this song. This song is dedicated to the Mick Jagger of palliative care, Sean Morrison.
Alex 55:03
This first part is call and response and then everybody join in after that. Can I kick it?
Eric 55:11
Yes, you can.
Alex 55:12
(singing)
Alex 56:29
Thank you once again to our guests. Thank you to our listeners. Good night, Banff.
The post GeriPal Live! at NPCRC Foley Retreat: Dio Kavalieratos, Prasanna Ananth, Alexi Wright appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
Eric and I had the pleasure of doing a GeriPal Live! Podcast as the closing keynote for the recent Center to Advance Palliative Care (CAPC) National Assembly in Philadelphia PA.
For this podcast, we invited 3 guests to each select an article of interest to them, and engage in a discussion about the article, including questions from the CAPC attendees in the audience.
Our guests chose the following articles (in the order discussed)
And at the end, we sang a tribute to the Lady Gaga of Palliative Care, with the whole Assembly singing along!
Stay tuned for future GeriPal Live! Podcasts, including recordings at the NPCRC Foley Retreat in Banff, and the São Paulo Geriatrics & Gerontology Congress, click here to register.
-Alex Smith
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:00
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:04
This is Alex Smith.
Eric 00:06
And Alex, where are we today?
Alex 00:08
We are in the beautiful city of Philadelphia, the Center to Advanced Palliative Care annual meeting. In person. First in person meeting in six years.
Eric 00:25
It’s been a while since I’ve been on the CAPC stage. I think the last time I was here, I was with Matt Gonzalez and we were peach farmers giving a L review. And I’m actually very excited. We thought we would do something a little bit different for this GeriPal podcast. Does. Does anybody ever watch PBS? Check, please. Any check, please. I’m a PBS nerd and NPR nerd. For all the NPR nerds out there.
Eric 00:54
So the format is. Check, please. Is each. They invite three guests. One guest picks their favorite restaurant. So each guest actually picks their favorite restaurant. And then all the other guests have to actually go to the restaurant. And then they come together, they talk about it. So we decided to do a similar thing where we invite three amazing leaders in palliative care. They pick one article that they thought was delicious. I’m not sure if I used that word, delicious, but one article that they thought was delicious. All of us then read the article and then we talk about it on stage. So we’ve also thought, you know what, we have another host here, too. This is kind of exciting.
Alex 01:37
Breaking the fourth wall.
Eric 01:39
Fifth wall. Fourth wall. How many walls are there?
Alex 01:41
Fourth wall. Between ourselves and the audience, right?
Eric 01:44
Yeah. So we’re going to invite all of you to be a guest host with us as we talk about these different article. So I want you to think about that. We’ll tell you how that works. But before we do that, maybe we can do some introductions.
Alex 01:56
Great.
Eric 01:57
How do you want to do introductions, Alex?
Alex 01:58
So to reduce complexity, we’re going to have our guests introduce themselves. Let’s start with Kim.
Kim 02:04
Hi, I’m Kim Curseen, and I’m an outpatient palliative care provider at Emory Healthcare in Atlanta.
Alex 02:11
Terrific. And Karen.
Karen 02:13
I’m Karen Bullock. I’m a licensed clinical social worker and I’m in Boston on faculty at Boston College. I also have an appointment at Dana Farber, and I’m affiliate faculty for capc.
Alex 02:23
Great. And Matt.
Matt 02:24
Howdy, folks. My name’s Matt Gonzalez. I’m the chief Medical officer for the Institute for Human Caring at Providence. And I will say I just learned for the very first time the inspiration for why we’re doing this. Like as each of us picking an article. So thanks for the background.
Eric 02:41
Yeah. NPR, PBS.
Eric 02:46
So we always start off with a song. Who has the song request for Alex? Karen, what song did you choose for Alex to sing?
Karen 02:57
I chose On My own by Patti LaBelle, who is a Philadelphia native, with Michael McDonald.
Eric 03:06
Wonderful. Alex is signaling me because I always forget how these podcasts work. Karen, why did you choose this? Is it just because it’s a Philadelphia native?
Karen 03:19
No, I chose it well because Patti LaBelle is a Philadelphia native, and I thought, you know, there’s so many artists from Philadelphia. But I also chose it because this song, to me, is about life and relationships and how while we might expect that we’ll have someone in our lives forever, when we don’t have that person in our lives. We need to figure out how we can live on our own without that person.
Alex 03:42
Great. Wonderful choice. So this is soul song. Beautiful song. Going to play it on acoustic guitar. I love it. If we could break that wall and the audience could sing along, particularly on the chorus. It’s very simple. It goes. On my own on my own on my own on my own Four times
Alex 04:03
so many times
Alex 04:08
you said it was.
Karen 04:10
Forever.
Alex 04:16
Said our love would always be.
Kim 04:19
True.
Alex 04:22
Something in my heart Always knew I’d be lying here beside you Here we go. On my own it’s here. CAPC. On my. Yeah, louder. On my own One more time. On my own.
Eric 05:06
All right, before we go to the articles, I want a reminder. So you all are our guest hosts. So we have two microphones up in the audience. If you got a question for one of our esteemed guests, come up to the microphone. You can ask that question anytime. Alex and I will do our best to keep an eye out for those two microphones. When you ask the question, just say your name and keep the question relatively brief. But we’d really encourage you to jump into there anytime. Okay. Any other housekeeping? Alex?
Alex 05:42
I think we’re good.
Eric 05:43
We’re good to go. So we’re going to go to our first article. This one. Algorithm based palliative care in patients with cancer. A cluster randomized controlled trial. This one. Matt, you picked this one.
Matt 05:57
That’s mostly true. I did put it into this set. But full disclosure, I didn’t choose this article. I had AI choose this article for me.
Eric 06:09
You had AI Choo.
Matt 06:11
As many of you know, like, I was a software engineer nerd before I was a doctor, and I’ve been, like, really fascinated by the opportunity to use AI in different ways. And so when you guys called and said, like, we need to choose an article, I outsourced that to AI and had it read like 4900 abstracts in 11 minutes to try to figure out what we could use to be able to think about our time together today. And this was one of the top articles, and I loved it.
Eric 06:42
How many articles did it?
Matt 06:44
4900 in 11 minutes. It was like, enough time for me to, like, walk away, make a cup of coffee, come back, and like, look at the curated list of three articles that I should select. And then you guys change the criteria a little bit. Like, it can’t be something that we’ve already covered. So I had to go back and, like, ask it to do something again.
Alex 07:05
At first suggested a bunch of articles that we’d already covered that you’d already covered. Because it ate Jerry Pal.
Eric 07:11
It literally went through all of our podcasts.
Matt 07:16
That’s right. You don’t own your intellectual property anymore. Sorry, guys.
Eric 07:19
Okay, so you used AI to pick this article. Why did this one in particular?
Matt 07:26
Yeah, well, I love this article because I think it’s practical. And I think we all need some bit of practicality in our lives right now. And that’s not to say that we shouldn’t dream big, but I think I wanted people to be able to leave here with something that they could take forward and do within their own clinical practice and their own settings pretty quickly. And this article is great. So, I mean, the headline is, this is a randomized controlled trial done at community cancer centers in Tennessee where they basically took and randomized clinics.
And they had two groups, one that got usual standard care and the other group that had a nudge towards palliative care. And they had an algorithm, of course. Um, the algorithm, unlike a lot of these papers, was like, not overly precious, which I loved. Like, it wasn’t hard to code for. It’s like pretty easy. It’s like, do you have lung cancer or a non colorectal GI cancer that’s stage 3 or 4? And then some risk factors that I think we all would find important. Like you’re older than 70 or you’re younger than 40, or you have severe metastatic disease. And in all of those pieces, they add up to a scoring system that if you screened in, your oncologist was given an opportunity to refer you, or a nudge really to refer you to palliative care.
Alex 08:44
Nudge.
Matt 08:45
I know it’s your favorite word our.
Alex 08:47
Listeners will be familiar with.
Eric 08:49
Jimmy, remind me what a nudge is? Alex. No.
Alex 08:54
Not that there are many types of nudges. Most GeriPal listeners have given GeriPal a five star rating in their podcast service of choice.
Eric 09:07
That’s a Nudge.
Alex 09:09
That is a nudge. That is a social desirability nudge.
Eric 09:12
So most people are doing it. Any other examples of nudges?
Matt 09:20
Well, I think this is a good example of a nudge. Right. So they like basically emailed the oncologist and said, you know, your patient likely qualifies for palliative care. We’re going to to refer them to palliative care unless you opt out.
Alex 09:34
Right.
Matt 09:34
And so they made it really easy for that to happen. It was like the default move towards. And what happens? Well, there was an incredible increase in the number of palliative care consults, like a quadrupling. So in one arm it went from I think something like 8% all the way up to 44% in the arm that got nudges. And that’s like remarkable to me.
Alex 09:53
Wait, what was the nudge?
Kim 09:54
Oh, yeah, Kim, I realized I just raised my hand. Go and zoom all the time. But with those nudges, if you opted out, you had to give a justification.
Matt 10:07
Yeah.
Karen 10:08
Yeah.
Kim 10:09
So I wonder how that might feel to community oncologists to have to justify whether not choosing that was a nudge too.
Eric 10:19
Right. What do they call that? Nudge? Didn’t you remember accountability?
Matt 10:23
Justification.
Kim 10:24
Yeah.
Matt 10:26
And Kim, to your point, I feel like it was interesting because, like, although they got 44% of the folks having consults, that still leaves over half that didn’t get seen by palliative care.
Alex 10:37
Right. Wait, but before we get to that, can we stick on the nudge for a second? Could we poll the audience? Like if you, if you’re like, imagine you’re a, what, outpatient provider. Right. Like a pcp.
Eric 10:51
This is all outpatient clinics and you.
Alex 10:53
Get a pop up window that says your patient is being referred to palliative care. If you disagree, please tell us and then fill out this box to tell us why there’s something called a nudge. Right. And that’s like our cognitive biases, we don’t think logically. We are influenced by what the default is, ordering effects. What’s first? All of these heuristics. Right. So is that a nudge which falls into that category, or is it sludge? Right.
Sludge is like those that prior Auth video we saw in the first plenary session. Right. Like you have all of these barriers to trying to do what you want to do. So let’s see a show of hands. Everybody has to vote. You can only vote once. And you either say this is a nudge or this is sludge. This pop up window, how many Say nudge, raise your hand. Okay. And how many? Say sludge, raise your hand. Oh, that’s like almost even, I would say.
Matt 12:01
I wonder though, if we did this in like an ASCO meeting, how they would feel. I mean, no offense to the ASCO folks. I’m just like, this is really important to us. I’ll tell you. A few years ago we put like a BPA in of like referring to palliative care. And I will tell you, the first time I logged into someone’s chart and I got it as the palliative care consultant and couldn’t move forward on the screen, I was like super frustrated and I was like, I built this thing and I’m having anger at it. So I think done well, they can work, but they have to be thoughtful.
Alex 12:34
And I sense that there’s frustration with the number of pop up windows that people are getting too. I think both are true.
Eric 12:40
Well, do we have to be careful with nudges? Like, is this an ethical construct to do? Because what we’re trying to do is we’re trying to shift behavior. We’re still giving people a choice, which is by definition a nudge. You’re not removing choice, but you’re just making it easier to make the quote unquote right decision via here an algorithm, something that’s working in the background that automatically does this with no human intervention. Like, is that, is that our future there? I mean, soon it’ll be AI doing this for us. How comfortable are we with this?
Kim 13:19
Well, I think if you’re practicing in a busy practice and you have 15 minutes with a patient, you know, it’s not that people don’t want their patients to feel better. They just may not think of it. There’s a lot of things you have to cover. So if you have something automated that just reminds you, because you remember your group who were, who were prompted actually had less systemic therapy at the end.
So I just wonder if bringing that to mind actually reminded them maybe to have to think about the patient differently. Like, oh, this qualifies for a palliative care patient. My patient might not do so well and maybe I should have some other conversations or think a little bit more about where they are. Because the grind of the day is the grind of the day. So I think that’s sometimes what’s happen in these clinics versus people not recognizing. You take care of somebody for a really long time. Sometimes you just don’t see it. Yeah.
Karen 14:19
And I would add that I think the other piece is that there are folks on one side of the discussion who think that it’s great, it’s automated, and so it removes some of the human elements that can cause us to overlook or miss or not include some patients. But then there’s still a human element to it. And so we know with clinical trials that people of color are less likely to participate in clinical trials. And so for me, as I read the article, I wondered, who are the patients?
There’s still a human quality to asking. And I remember a discussion with the physician who said, sometimes I don’t ask my African American patients because I know they’re going to say no because they don’t participate in clinical trials. And so I think, on the one hand, some of us feel that the automation of things mean that it’ll remove some of the biases that humans bring into spaces, but at the same time, AI is perpetuating some of those same kinds of biases.
Eric 15:24
Yeah, totally. The algorithm itself could perpetuate those biases, especially where it’s getting that information, who is creating the algorithm. So it sounds like we should also be mindful of looking at the outcomes of those and making sure that they’re equitable. Is that right?
Karen 15:42
Yes. Yeah.
Alex 15:44
Yeah.
Matt 15:45
I mean, I think that. I mean, that resonates for me, for sure. Like, everything that we do has to be seen through a lens of equity and making sure that we’re not worsening the disparities that already terribly exist within our society. And so I just, I truly appreciate you bringing that.
Karen 16:02
You’re welcome. And I think to the point that Ken made about the daily grind and what we’re doing, sometimes when it may be obvious or apparent that, yeah, we’re missing some people or that there are gaps, but what do we do about it? I mean, who among us hasn’t read articles where it started with race and ethnicity is really important as a variable that influences xyz.
And then by the time you get to the samples, looking at the sample, and the Overall sample is 80 to 90% white, and they don’t really address race or ethnicity in the methodology or in any of the analysis. And then they write a section, the limitations section, saying, oh, and make sure you include underrepresented populations in the future. So that’s. It is. I mean, we do need to look at it, But I still feel that far too often in medical journals or in any journals and science in general, we explain away these inequities in a section called Limitations.
Alex 17:05
Yeah.
Eric 17:10
And then it was brought up about the. While this study, this algorithm worked, the defaulting people to Palliative care worked significantly, increasing referrals. Only half of the people actually saw a palliative care provider who got the default intervention. Is that right?
Matt 17:31
Yeah. You know, it’s interesting. I think one of the pieces that I sometimes I wish that, like, the supplemental materials for a journal were, like, actually in the real thing, because they had these lists of, like, accountability justifications. And to your point, Kim, earlier, some of the reasons for not referring, like, one of them was like a big capital N O. And I’m like, what were you thinking?
Alex 17:57
That’s loaded.
Matt 18:00
And others. Others were more balanced. Right. It was like, my patient’s been up on opdivo for seven years and is totally stable and has no symptoms, and so there’s no need. Right. And so, like, I think there’s a lot more to dig into around this, around the granularity of it. I would also just say that one of the key points that I want to talk about is, you know, it’s clear that the palliative care programs that they referred to were staffed well enough to accommodate the increased volume. And I think that’s a really, really important piece for us to talk about because there aren’t enough of us.
And so choosing the right patients and making sure that when we try to systematize the influence of palliative care, that we’re mindful not to overburden the people that are doing the real work of sitting with patients and families. And they didn’t see that in this trial, but I think that’s because they probably invested upfront to make sure that they had bandwidth to get people in. So one minor caution is like, I wouldn’t just go and do this unless your teams feel like they’re adequately staffed to respond to patients and families needs.
Kim 19:12
But I think another question, like, when you get. No, we think we kind of the default in our brains are, well, they don’t believe in palliative care, and they, you know, they don’t understand it. Sometimes they do understand it, but the other question is, what’s the quality of the palliative care that they’ve received or what has been their experience with us? So I think, at least where we practice, you know, because there’s no standard of what’s a palliative care offering, Right.
You just hang a shingle like, I’m providing palliative care, I’m here. And so if they’re not getting what they need from the service, we just have to have our minds to think that sometimes it is them, but sometimes it’s Us. And so. Yeah. So that. No, there’s probably some things behind that. No.
Karen 20:00
Yeah, yeah.
Eric 20:01
And I thought the most interesting thing Is while only 50% of them saw palliative care, I think most of that not seeing palliative care was not physicians opting out, it was patients, them getting lost, neither not wanting to go to these clinics or lost a follow up or no shows. It’s unclear what it was, but we see that in our clinic, which is that there’s a significant no show rate despite the oncologist referring to our clinics. It’s sometimes very hard to get them. Kim, you have an outpatient clinic. Does that ring true?
Kim 20:37
Well, yeah. I mean, you think about what a patient with cancer has to go through. They got. Maybe they’re getting radiation and chemo, and, you know, we live in fee for service. So you eat what you kill. So that means that now they have to have another visit. They gotta pay for parking, they gotta drive down there, they gotta try to coordinate.
And even if it’s in another video visit, it’s a lot that we ask people to do. So if you’re nudged for palliative care and nobody told you why you were going, you may not see the reason for the visit. If you feel like you’re doing okay, and then you Google it and it says hospice, and then you think everybody lied to you. So it’s a lot. It’s not like, I mean, we can be the answer to the question, but you got to remember it’s one more thing they have to do. And we cost money.
Eric 21:25
I think we have a guest host with us. Who is our guest host?
Alex 21:29
All right.
Karen 21:30
I’m Ruth Wagner. I’m a physician with Masonic Village Hospice. I used to work at an oncology palliative care clinic. I feel like what I’m not seeing with this nudge is it’s not a nudge for conversation with our patients. It sounds like it’s being. It’s sent to the provider, and it’s the provider making this decision. But it’s not a nudge. You know, hey, talk to your patient about palliative care, what that service is, and how even if you’re doing fine, it might benefit you. Like, I take away even that, like, conversation about our caregivers and the benefit that they get when they come into our palliative meetings.
And we approach it from that family perspective. And, like, I think there’s a missed opportunity, that it should be a nudge for conversation, not me sitting at my. And deciding as the oncologist, like, Is my patient doing okay? Like, have they actually asked that question to their patient? Are they doing okay? Or is their patient just telling them what they want to hear? You know, I feel like it’s the wrong type of nudge.
Eric 22:32
What do you feel about that? Is the wrong type of nudge?
Matt 22:35
I don’t know that it’s the wrong type, but I love this idea.
Eric 22:38
Right?
Matt 22:38
Like, gosh, nudge is, like, turning out. This is like another nudge podcast. But, like, I don’t. I don’t know what the right one is. I don’t think any of us know exactly what the right one is. Like, is it a nudge to the oncology nurse that’s giving them the infusion? Is it a nudge to their oncologist? Is it a nudge to a patient and family? I mean, I think there’s a lot of interesting research around this, and that’s kind of why I felt like this was an important thing for us to begin thinking about.
I was like, how can we move referrals to our specialty from ad hoc and clinician dependent? Did they think about it? How do they feel about us? How busy is their day to something that makes it more routine and who we target that to? I think that’s a very open question to your point. So there’s a lot more to do there.
Eric 23:37
Well, Alex, most podcast hosts at this point would move to the next.
Alex 23:45
Are we like most podcasts or do we run counter to the stream?
Eric 23:51
Well, I think the next one actually fits in really nicely with this one, because this was an outpatient oncology intervention leading to palliative care and requires a good amount of outpatient palliative care. Like, you have to have a palliative care clinic in order to actually run this study. And if you want to create an algorithm that pushes people towards outpatient palliative care, we need people who know how to do it. Right, Kim?
Karen 24:19
Yeah. Yeah.
Eric 24:20
So, Kim, you picked this article, which is Outpatient Training during Hospice and Palliative Medicine Fellowship, a national survey written by first author Harry Hahn.
Alex 24:30
Harry Hahn.
Eric 24:33
Why did you pick this article?
Kim 24:36
I picked this article. I have lots of emotions, so I’m going to try to calm them down. This is me excited.
Kim 24:45
I have to tell
Kim 24:50
the beautiful thing about our profession and how smart we were. We were smart about marketing. We were really, really smart about the spaces that we have been in and all of our research. But the thing that I don’t think we have done well is that we have offered ourselves in spaces that are important, but we didn’t train nobody how to be in that space. And so we continue to educate people how to take care of the dying, and it’s wonderful, and we do a great job, and that is incredibly important. I would never back away from that. But when you have to see people early, that’s different.
That’s different. And, you know, when Harry and his team did the survey of fellowship directors and people who are in training, you know, the basic crux is that maybe they got four weeks of training and outpatient, and they didn’t feel quite prepared. And now they’re asked to go out into the world and take care of folks. And when you’re taking care of somebody who has six to three months, maybe even a year, that’s a different kind of care. And you sit in that suffering with them. When you take care of somebody for five years, who you have to sit in that suffering for a really long time. And if you take care of somebody that has chronic, serious illness and our treatments are really good, you have to sit with it that that might be your patient for life.
And anybody who’s ever read fellowship applications, what a fellowship application say, they say, I want to walk somebody through the journey. Every story is about somebody who profoundly. Who was profoundly affected by their illness, and they ended up passing away. And either it was a wonderful experience or it was a difficult experience. I have yet to read the thing that says, yes, I want to take care of a patient who is addicted to benzodiazepines and has substance use disorder and has no food and no light. And I want to be there by myself with no IBTT for 10 years.
Kim 27:12
But the truth is, those people exist and those patients exist, but we are not training a workforce to take care of those patients. But we continue to market ourselves like we can. So all of these healthcare organizations invest because we told them they could. So I’m not sure we’re at the table. I’m not sure we can deliver. And all of us gray hairs keep coming up with amazing studies and things. And every time we come up with one of these studies, then we obligate the whole entire profession to do it. And yet to train them, and we don’t even ask them. And I learned that the hard way in my clinic. I was just seeing folks thinking it was amazing. And then I got all these junior faculty, and they were looking like, what do I do? This patient came and just talked to.
Karen 28:05
Me.
Kim 28:08
And they were like. And, you know, they didn’t have any symptoms. That wasn’t a good use of my Time. And in my mind I’m like, well, nobody drives to the clinic, pays the copay, pays to park and sits down in your chair to come see you. Because there wasn’t an issue. And what you did was the exact thing we say we do is that they’re having a really hard time. And you listened and when they left, you felt better. So the palliative intervention was you. But they weren’t trained to understand that it’s two doctor center.
Karen 28:48
So.
Kim 28:48
Oh, and we don’t even have. And we don’t fund our IDT. Everything is very Dr. Centric. So think about it. We get trained. How much did you put into our training? And then when the RN or APP comes, we put them in a car, they shadow like they say at a Holiday Inn Express last night, and then they go out and they actually are taking care of the bulk of the patients, right? And then we, they were upset when it didn’t go well. But we didn’t bother to invest in training for the people who are actually seeing the patient. So I think that’s why I chose this. Like, if we’re going to do all of this, we need to train a workforce that is prepared and that can deliver. Because if not, we put our profession in jeopardy.
Eric 29:32
We can’t just create algorithms and pretend everything’s gonna be fine. Al.
Kim 29:36
No, you got it.
Karen 29:37
No, Ella. But I think I wanna add that this is part of the reason why this conference is as this summit is as successful as it is. People are here to learn to try to fill in some of those gaps. As we presented in our sessions, I mean, the rooms were crowded, people were there like waiting for information because there’s so much that needs to be filled in and it can’t all be done in the training programs or what. So we have to sort of figure out how am I going to continue to learn and grow.
And I know in the sessions that we were in, it was very apparent that people were like, okay, I want to take this back and how do I do this? I mean, Brittany and I had a converse. Facilitated a discussion about navigating difficult conversations, right? Like, great. We offer that people really are having some difficult conversations without really knowing, like how, you know, what are some evidence based practices. And so when I read this article, for me it was like, okay, there’s so much that’s not there to the point, like, this is what is available, but there’s so much more that people need in order to feel effective at what they’re doing. And so I appreciate that.
Eric 30:47
So it’s almost like we have, we need minimum competencies. What those minimum competencies is and should it be different than how we thought about it back in 2008 when we created these fellowships? For example, how much time do they, a quarter of people die in nursing homes. How much time do our trainees, our fellows spend in nursing homes? Very little.
Alex 31:11
Very little.
Eric 31:12
Why aren’t we integrated there? So I guess the question to all.
Alex 31:17
Three of you is, should we summarize the article?
Eric 31:20
I guess we’re talking about the article. Kim did a pretty good job in the beginning. So I think the Kim you said that the big difference was.
Kim 31:30
The big difference was that they pointed out that the fellowship directors didn’t feel like they received enough training and the trainees didn’t feel like they received enough training. And the reason why Harry wrote this article is because he went out and tried to practice and he became a little upset and kind of a little bit enraged and demoralized because he didn’t feel like he had the tools in his toolbox to be able to care for the people who were coming into the clinic.
Matt 31:58
So I relate to that very much. I mean, I had the privilege of like doing a fellowship at ucsf and I mostly took a job at UCSF as my first year attending because I felt not quite ready to fly on my own. And that’s not to say anything about the folks that trained me, but I was like, gosh, another year with the social worker and chaplain to be able to continue learning. Of course. But here’s my question. I totally agree that we need more outpatient training, but in a year long fellowship, what goes? Because it already felt busy enough.
And so I found when I was reading this, does this mean that we need to actually increase the amount of time people are doing training? Like, I look around this room when I was here, whatever, a few days ago, was it just yesterday? No, it was Monday. And the number of first time attendees at this conference like, really, really stunned me. And then as I’ve been talking to people, I’ve been realizing that a lot of folks said, like, when I graduated fellowship, I had no idea how to run a palliative care program. And yet I’m being asked to do so. And so I think a whole nother gap besides outpatient and long term care is learning the language of healthcare that we all need to speak in order to be able to help our programs to grow.
I think that’s why a lot of folks are here and that’s why this is so popular and it Makes me wonder if you could cobble together enough of these things to make the training more robust. And I realized there were reasons for keeping it short, but I don’t know.
Kim 33:42
But if you are doing that, they have to learn how to lead a team and they have to know something about finance. There’s a lot of things that the outpatient doctors have to understand. If you don’t understand those things, it’s really difficult. And I think that, again, is demoralizing. Just the nuts and bolts of how to do an outpatient clinic.
Alex 34:04
Yeah, I think these are great points. You know, at ucsf, we often have geriatrics fellows and palliative care fellows rotating with us at the same time. And you really see that the geriatric fellows, where there’s a mandate that they see, they have a longitudinal panel in nursing home, they have a longitudinal outpatient panel. They have more outpatient experiences than the palliative care fellows. And that’s great.
And there’s a cost in that they feel here, there and everywhere and not in one place. So I think the point that we absolutely need more outpatient training is true and we need to make sure we structure it thoughtfully. And I think what you might be hinting at, Matt, is should palliative care fellowship be more than one year maybe. And I know there were some people in the field who felt like it was a mistake early on that we have a one year fellowship and not a longer fellowship like some other specialists, because one year is just a short time. And maybe it does a disservice to the field and the tremendous amount of knowledge it takes and experience to get that longitudinal experience right. Following people over time.
Kim 35:15
In an average clinic, you see a cancer patient, patient with dementia, patient with renal failure, patient with a disease that you had never heard of, that you have to go to the Google for. But and the thing we don’t tell, it’s like you can’t understand how to palliate something if you don’t know what it is. And you don’t. And you can’t tell the difference between sick and well. And you know, and you know, I’ve been doing this for 20 years and my colleagues, my young junior faculty who come will. Kim, you always know what to do. Yeah, it took me 20 years. Yeah, I can do this. Yeah, I’ve seen so many things. But if they only trained in cancer or they only trained in dementia, but they’re asked to see everyone, it is possible. There’s ways to teach that. But you know, we’re so far Advanced. The treatments are far advanced. You got to know the medicines, you got to know the physiology. You have to know what it is.
Eric 36:11
Yeah. And I think the important thing in this article is most of these fellowship programs were training in a mostly single disease center, like a cancer center that only saw cancer. I see some guest hosts over here.
Alex 36:24
Yes. Oh, we have multiple, multiple questions. Quick then.
Kim 36:28
I’m Katie Brownstein. I’m a nurse practitioner for Samaritan Life Enhancing Care. I also do research for the Baccalini Institute. And part of what I do is I help train new nurse practitioners within palliative medicine.
Karen 36:40
And so we’ve just started a fellowship.
Kim 36:42
Which is really exciting.
Karen 36:43
I think it’s really robust. We’re doing lots of role play, lots.
Kim 36:49
Of didactics, lots of one on one mentoring. But the issue that I’m coming into.
Karen 36:54
Is I have not been able to.
Kim 36:57
Find the people who want to stay with us long term, despite the training. So my ask to you guys is, how do I build on this and how do I recruit the right people?
Eric 37:08
Great question. Thoughts from our guests.
Alex 37:12
What do we do in this?
Kim 37:13
I think the people who want to do this are out there, but I think sometimes we’re swimming in the wrong pool. So if I’m looking for an outpatient provider, what I’m looking for are people who have the tolerance to sit and think about longitudinal care. So people who are working in family practice and internal medicine and addiction medicine, the wiring is a little bit different. And so their expectation isn’t to have like a terminal end. They’re okay with that complexity now. They’re not okay with some of the other things that we have to teach. So I think sometimes, you know, casting our net and where we go to find people. So I think our profession’s big enough, but I think we have to be strategic about marketing to people who are like in primary care. And what are they saying? They’re like, gosh, I really love this. But it’s 30 patients. If I had more time with my patient, that’s the person.
Alex 38:18
Great. Next question.
Kim 38:19
Where do I find them though?
Eric 38:24
Thank you so much, Dr. Kerstein. That really resonates. I’m Greg Van Keith. I’m a palliative care physician of the generation who made mid career transition. So I had many years of work as a primary care provider before moving into palliative care. And so the continuity in the longitudinal work you’re talking to is second nature. From the background that I have, my question is, as I see my younger colleagues come in who went Straight from residency into fellowship. How do we take the concepts and principles of longitude, whether it be primary care or whatever sort of long term care focus and integrate that in the one year fellowship? Because I think it can be done. It may be less disease specific and may be more process specific. How do you develop the ethos of a longitudinal relationship as opposed to a consultant based short term relationship? Like much of our inpatient training is geared towards.
Alex 39:19
Anyone.
Kim 39:22
This is so cathartic for me. No, I think it’s the difference in how you train and trying to get at the what is the real root of the problem. So teaching people how to have the conversation that you have on the inpatient is going to be different than the conversation that you have on the outpatient. So the expectation that you’re going to start slow, the idea that you don’t have to have all the answers.
Karen 39:51
Really.
Kim 39:51
Doing a lot of self reflection and a lot of work, like if you’re tired and you’re frustrated, what are you really frustrated about? Can’t be the patient. You know, that’s something that the anxiety that you don’t have. The answer is really, really important. And I can’t tell you how much that resonates watching people. The idea that when you are on the inpatient side, you know what the answer is. The answer is, you know, we’re gonna make you comfortable. You’ve got the medicines down. You understand when somebody’s sitting in front of you problem that they saw 10 doctors, how are you now going to be the person that’s going to fix it? So we have to reprogram that. You know, you are not there to fix it, you are there to bear it and you are there to make it a little bit better.
Eric 40:41
I’m going to add one more editorial. It’s often like, because I’ve done education for a lot of times and like we see, like even in medicine, we see people complaining, why aren’t our residents choosing primary care? Instead of saying what structural things have we created that made it. Our residents are not choosing palliative care. What are the things that we are making it seem like that lifestyle is not something that they want. And oftentimes it’s the structure that we’ve created. It’s the fact that now they got to run back and forth between their wards. They still have 13 other things to do. They are caring for this longitudinal panel and also trying to, you know, care for people in the icu. Similar to how we think about outpatient palliative care. What structures have we in place that push people away from that, including like in this article, very little time doing outpatient palliative care. 4 weeks versus 24 for inpatient palliative care.
Alex 41:36
Last question quick. And then we got to move on to our last article.
Karen 41:39
Yeah. So I’m Jessica McFarlane. I made a mid career switch from inpatient palliative care to outpatient palliative care about a year ago. Hardest thing that I’ve done, but it’s actually been so fulfilling. And I wonder, Eric, to kind of add on to what you said, what is our responsibility as a profession to go to these training programs, family medicine, internal medicine, neurology. I’m a neurologist. And help make a case or help support them as they try to get better outpatient experiences. Because everyone is so geared towards subspecialty care. But to really help support them in focusing on more outpatient time, maybe bringing their trainees into our outpatient clinics so that they can see that, so they’re prepared for the future in these outpatient specialties. Outpatient heavy specialties.
Kim 42:30
I think we missed some great opportunity because two people said mid career and I think that’s a really misplaced because when you think about people who are starting to think about palliative care, but they’re mid career and we ask them to give up everything to do in one year. Fellowsh. So I think if we really lean into that, we can have primary care providers, people who’ve been practicing for a really long time, they don’t have to learn that part and we teach them our skills. So I think that’s one way to think about it and one way to lean in. Because when there’s something about being here a little bit and you learn some things makes this a little easier than when you’re coming out fresh where it can be. Where it can be jarring.
Alex 43:20
And we should note that this article is kind of physician centric. Right. It’s talking about physician specialty training and palliative care. And there are whole other conversations and other podcasts we can and should have about training for nurses, chaplains, social workers.
Karen 43:33
Absolutely.
Eric 43:35
So importantly, the structures that we create make the outcomes that we either desire or we don’t. And sometimes it creates some uncomfortable truths. Which goes to our next article. So, Karen, you actually didn’t choose this article, but it was an important article that came out. I’ll get to which one you chose. This is one by Iraq, A Strategic Path Forward for Hospice and Palliative Care, a white paper on Potential Future of the Field in which he Talked about embracing the uncomfortable truths of hospice and palliative care.
Like talking about the things that we may not want to talk about in the field, the things that may not be going very well in hospice and palliative care. And we’re going to have a different podcast with Ira. So I’m just going to quickly summarize the five key things that I remember from the article, which was a, that we should have absolutely no tolerance for abuse, fraud in our field. And then the four key strategic path forwards that he brought up was we want, we need to create a clinical programmatic standards, including minimum competencies, minimum staff ratios, what’s the minimum makeup of our palliative care teams, that we should have meaningful data available to everyone, including patients.
So if they’re being referred to a hospice, that they have idea of how to select hospices. Not just questions, but also seeing data, what works and what doesn’t, that we’re driving competition based on quality data. And then lastly, we’re embracing authentic brand of palliative care. And Ira was talked about the importance of well being. So that was Ira’s article. Really encourage everybody to read it and we’ll do a podcast with Ira. But Karen, this was not the one that you picked. You picked a response to Ira’s article, a strategic path forward for hospice and palliative care that must be focused on equity. Karen, why did you pick this arc?
Karen 45:51
I picked this article because I thought it would be a great opportunity to center health equity in the space. Because we’re experiencing, we’re living at a time which lots of words are now being erased and undone. And we’re all trying to figure out how do we continue to care for populations that have been historically marginalized and minoritized and without the language, if we can’t talk about what it is we’re doing, can we actually do it? And so when I read this article, you know, I agree with all the things that were said, like in terms of the path forward and making sure that we have these standards, et cetera.
But what was glaringly missing for me was health equity. So I phoned a friend, Dr. Kimberly Johnson, and I said, have you read the article? Have you read this article? And so shared it with a couple of folks. Marisset Hassan, who’s here, you know, we usually do these things in teams because it takes a lot of courage to respond to an article that’s written so well and so clearly states really important aspects of hospice and palliative care and what we need to be paying attention to. But Sometimes we have to position ourselves so we can add one more thing to that or remind people not to lose sight of populations that we’re hearing very loudly that we need not name, we need not identify, and possibly not care for, because I don’t know how we can continue to care for historically marginalized and minoritized populations if we can’t even say the words.
And I know that organizations are challenged to figure out, what do we do? Do we have to forego this program? I have colleagues who are saying I can’t continue my research. I’ve been told by my institution that I can’t do that research anymore. So I thought this was an opportunity for us to think about how do we add to the literature. And Ramona Rhodes is someone who, we all are health equity practitioners, and we felt that we had a duty to respond to this and to say, and we do say in here we agree. However, as we talk about uncomfortable truths, another uncomfortable truth is that we are collectively being told, given directives that we need to undo many of the services and programs that we know that we need, and we need to target populations that are underrepresented.
Representation matters for a host of reasons, not just the ones that I said earlier about literature. We read the articles, and it’s great research, it’s rigorous, but we look at the samples continuously. And that’s another article that we wrote about representation. We did a systematic review of thousands of articles. And what we found is consistently there was a minimization of race, ethnicity, and attending to factors that we know in palliative care and other aspects of medicine haven’t been well attended to. And so we talked about, should we write a response to this? And we agreed that we should write a response to this. And so we were very clear that we weren’t trying to critique what. Or that we weren’t opposed to what was said or the direction that is proposed.
But we really felt, and we do feel that it’s important that we center health equity. There are populations currently who are afraid to even come in to get care now, who are afraid to answer the questions that are essential to the care that we provide because they are afraid that they respond to the question they might be deported or someone, they might be a knock at their door after they leave their doctor’s office, and people are suffering. And so. So it’s important as often as we can to center health equity to talk about historically marginalized populations. And, you know, in a session yesterday, it talked about the fact that we all know that U.S. health care systems and settings were legally, racially segregated until 1965. That was very recent, and it was well into the 70s before many of those settings complied.
So I feel that every opportunity we have to remind people that, especially those of us who are caring for older adults, that’s been their lived experience. And so we were getting a little closer to being able to recognize that we needed equity and we needed to do things differently to ensure that people who had been historically denied can now get the care that they need. But we know that those populations are still afraid. We know that those are the populations that are most likely not to receive this amazing, incredible gold standard of care that we all provide. And so we felt that we were making progress towards that. And then something happened and all of that was being undone.
And then this article came out. So really, it was our goal to center health equity and to tell the community of practitioners that in each of these areas in which we’re identified, that we need to be mindful of the fact that there’s a risk to no longer talking about health equity, especially no longer doing health equity, because if we can’t talk about it, then we can’t do it either, or we can’t do it. Well, it was really to center health equity. And so our argument is that we must not have a pathway forward, and it can be strategic, but without centering equity in what we do, it’s a missed opportunity and will continue to perpetuate many of the challenges and problems that we’re seeing seeing currently.
Alex 51:35
You know, I suppose there might be some who say, wait, this article was about, like, you know, for profit invasion of hospice and private equity’s takeover and gobbling up hospices and all that poor care does every aspect of whatever, you know, intervention or policy change we consider have to involve equity equity.
Karen 51:56
Yes, yes, yes, yes. And actually, we say in this article also, if you look at historically marginalized people, those are the ones who are most likely to be harmed. I mean, everyone can be harmed. But if we look disproportionately at who’s more likely or overrepresented in those populations, it’s those same people who we consider or who we label as or who have experienced historical marginalization are the ones that are at the greatest risk, even for those for profit.
Alex 52:28
And this comes back to that opening plenary session where Sachin Jain was talking about the moral bankruptcy of leaders in palliative care. I think one of the guiding principles that we need to hold tightly to is that any policy change, any issue, any thought piece that we consider must have an equity lens to it. Right. This goes back to John Rawls and Norm Daniels. Just healthcare. We need to make sure that whatever policy we are doing is aimed at addressing equity, addressing disparities, addressing history of historical marginalization.
That’s a North Star that we can hold to as leaders in our field in whatever way we do, and we have the power to do that. And yes, there are trade offs, as Kim so eloquently said the other day, and that sometimes you have to maybe use different language and find a way toward that. But I’m reminded of the words of the great late, great John Lewis. Right. Who you mentioned. Like, this is not a struggle of today. This is a struggle of generations. Right. Take the longer view about this. Yes. Thank you for writing this.
Matt 53:38
Yeah, that’s what I was just going to say is like, thanks for the courage to do this because it really, it’s so, so, so important. And I think it’s a clear answer to your question of like, should this be a part of everything we do? And the answer is very clearly, yes. You know, in this time, it takes courage to stand up. And I’m just, I’m grateful to be here with you. And I think we all are. And so thank you from the bottom of my heart from like, amplifying and adding.
Alex 54:09
Can I ask one question before we.
Eric 54:10
Get to our question from the audience?
Alex 54:13
One quick question is. So one of the other things in Ira’s article he talks about is like, patient activation. Like, patient professional societies should urge patients to ask when they’re being referred to hospice, like, what’s the ownership structure of this hospice? How many nursing visits will I get these sort of questions, probing questions. If we can activate all people, the people will have so much more power to institute change. I just wonder if there are ways in which we could incorporate some questions around equity. And I don’t know what those questions are, and it’s probably a failure of imagination on my part. I don’t know if anybody has any ideas, but I think like, along the lines of like, prepare for your care activates patients. There’s probably a way there and it probably takes some creativity.
Eric 54:59
Any thoughts on questions like questions that.
Kim 55:03
We should ask patients.
Alex 55:04
Yeah. Patients to ask their providers, especially like.
Eric 55:07
Ira was talking about when selecting hospices.
Kim 55:09
You said it, you know, are you going to come? Are you going to come? Is there a nurse in my area? How long will it take to get there? Because, Karen, you’re absolutely right. And I think one of the things that is hard is that you had to write that after all of this, you had to write that. And we continue to have to write that. So it would be wonderful if we can get to a point in our profession where we don’t have to, where it’s, you know, we don’t have to add it on. And everybody’s like, yes, it should be there, but after all of this, it’s still an afterthought. And that. And that’s a little. And that’s a little rough.
Alex 55:56
Yeah. The allies stand up. Come on.
Eric 55:59
Well, we got some people standing up. I want to turn to our last.
Karen 56:03
I just want to add that Ira did respond to us and thanked us for writing this. And I just want to say that. And agreed with Asa. And so it’s like, I think we’re all in this together. And so we have to lean in where we have expertise and speak up and lend our voice. And so I just want to add that he was responsive and very positively and favorably responsive.
Alex 56:27
Thank you.
Eric 56:27
We’re going to turn to our guest hosts. Thanks very much. I’m Jennifer Ballantyne with the Coalition for Compassionate Care of California. And I just wanted to invite all of you to continue this conversation. We have an annual summit coming up on October 6th, and Ira will be keynote, noting that conference with a message from his paper followed by a panel discussion.
Matt 56:50
If you can’t come in person, there is a live stream opportunity.
Eric 56:54
So visit our website@ CoalitionCC.org there will be questions taken from the live stream audience at the panel discussion.
Matt 57:03
So we’d love to have you with us. Thank you for that.
Eric 57:07
I see Sonia.
Karen 57:09
Hi, friends, patients up there on the stage, Sonia Malhotra from Tulane. I think activation takes a lot of privilege and many of our patients don’t feel like they have the privilege to be able to ask things and request things. So I encourage us all to improve our skills around health equity so we can do that and not to forget populations that often do get forgotten. I’m from the great state of Louisiana, the second prison industrial complex, the largest one in the world. Not to forget our incarcerated patients and those who are now in detention and also women’s reproductive rights. As we see more women and their children who don’t have access to quality care and suffering that they’re going through.
Eric 57:53
It’S nice to have questions about which hospice to choose, but if you don’t have a hospice to choose, it’s kind of pointless.
Kim 58:00
Yeah.
Eric 58:01
Yeah. Last question. Hi, I’m Sherica Newman from the great state of Atlanta. Like Sonya thinks The great state is Louisiana, but the great state of Georgia. I like what Alex mentioned. And so I think self advocacy and teaching patients and families to self advocate is a big, big key to health equity. And so I’ve been promoting on my platforms that everyone needs to leave every.
Karen 58:27
Doctor’S appointment with their diagnosed treatment and follow up.
Eric 58:31
And it seems so simple to us because it makes sense to us. But the world at large doesn’t understand that, especially our marginalized communities, because a lot of them approach healthc very scared or very overwhelmed, especially if they have a serious illness. I was wondering what you guys thought about using self advocacy or us promoting self advocacies within our communities and with our organizations to leverage some of the health equity and make it better.
Kim 59:02
I know we’re close to time, but that is really important and not just asking. When I see patients in clinic, part of what I talk to them about is what should not happen and what is not. Right? Yeah. And, you know, like, if you call and you don’t get a response, you know, that’s probably not the way it should go. When I make a referral to hospice, I’m very clear that if it does not go the way it should go, then you need to call me and then it will go the way it should go. So us as palliative care providers, when we give our patients out to the world, we need to arm them with the tools to understand what is true and what is and what is not true.
Eric 59:48
That was wonderful. Our time is up. I want to thank all three of our guests for coming up here, picking these articles, joining us for the GeriPal live session.
Eric 1:00:02
We will have this on GeriPal in a couple weeks. So you can also, if you want to re listen to it, you can listen to it there. And a big shout out to all of our guest hosts for joining us on this GeriPal podcast. Very much appreciate it. But before we end, we always end with a little bit of a song. Alex, you want to take us out?
Alex 1:00:20
All right, CAPC. You got to commit to this one. Okay. I’m going to change things up a little bit. Michelle’s probably going to kill me for doing this, but this is going to bring it back to the beginning. This song has some like, maybe palliative carriage lyrics. I want your disease I want your love this song is for Diane Meyer. This is for the Lady Gaga of palliative care. This is bad romance. Please sing along with me.
Alex 1:01:03
(singing)
Eric 1:02:16
Thank you everyone. Thank you, CAPC
The post GeriPal Live! at CAPC: Karen Bullock, Kim Curseen, Matt Gonzales appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
We love getting requests from listeners for podcast topics. This request came from geriatricians we met at the annual American Geriatrics Society meeting in Chicago. They wanted to know more about what a geriatrician should do in a pre-operative risk assessment. So we invited Vicky Tang and Houman Javedan, two geriatricians and leaders in the pre-operative assessment and prehab space, to talk with us.
As is our style, we backed up to some bigger questions, including:
-Why do patients need a geriatric assessment pre-operatively?
-Why are our surgical colleagues asking us? Is it due to liability concerns?
-Why do we do them? Recognizing we may have different motivations than our consultants (hint: stealth geriatrics)
-How does the comprehensive geriatric assessment fit int? Do the 4Ms fit into pre-operative assessment if at all? (an entertaining disagreement ensued)
-Must a geriatrician do this?
-What is the Geriatric Surgery Verification Program?
-What’s the most important part of
Many links from our guests below.
And please forgive my Spanish on the song, I tried! Thanks to sons Kai and Renn on Ukulele and Bass for making it sound better.
-Alex
From Vicky:
From Houman:
Geriatric Surgical Co-management Evidence
Sub Topics
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:16
Welcome to the GeriPal Podcast. This is Eric Widera,
Alex 00:24
This is Alex Smith.
Eric 00:26
And Alex, who do we have with us today?
Alex 00:28
We are delighted to welcome Houman Javedan, who is a geriatrician and director of inpatient geriatric medicine at the Brigham and Women’s Hospital where I trained and associate program director of the Geriatric Fellowship at Harvard Medical School. Houman, welcome to the GeriPal Podcast.
Houman 00:48
Thank you. This is very exciting for me. I’ve been listening to this podcast for a while.
Alex 00:51
We love to hear that. We’re also delighted to welcome back Vicky Tang who is a geriatrician, researcher and coach. Listen to our prior podcast with Vicky about coaching and she is at the University of Texas Houston where she is the Roy M. And Phyllis Gough Huffington Chair in Gerontology. Vicky, welcome back to the GeriPal Podcast.
Vicky 01:15
Thank you.
Eric 01:17
So we’ve got a lot to talk about. We’re going to be talking about perioperative or preoperative assessment in older adults. But before we get into that topic, we always do a song request. Houman, I think you have a song request for Alex.
Houman 01:28
Yeah, there’s a song by Alex Kuba called Aura, which I mean there’s two reasons I explained I really like this song. The first phrase says I’m loyal to the life that I have chosen, which I think represents sort of the feeling a Jurition has mid career and onwards. And the second, which was interesting was Alice Kuba Houmanself said it took Houman 13 years to complete this song because he sort of learned to be present in the time and sort of appreciate that sort of geriatric wisdom about the now and not being worried about the future.
Alex 02:01
Beautiful message.
Eric 02:02
Have you been practicing the song for 13 years, Alex?
Alex 02:05
I have not, but I did record it for those of you who are listening to the audio only with my son’s Kai on ukulele and Ren on bass. And here I’m going to try it on guitar. We’ll see what happens.
Alex 02:15
(singing)
Eric 03:37
That was great, Alex.
Houman 03:38
Thank you. Wow. Well done. I’m impressed
Alex 03:39
I apologize to those of you watching on YouTube.
Eric 03:43
I kind of want to hear the ukulele version.
Alex 03:45
Yeah, it’s much better. Listen to the audio only.
Eric 03:47
Who’s playing the ute?
Alex 03:48
Kai’s playing the ukulele and I forgot to bring my ukulele to work. You forgot your notes. We’re winging it today. We are winging it.
Eric 03:55
Let me try them out again. Preoperative assessment. I got a question. And we actually got some questions from our listeners, but I think the biggest one is why do we even bother with this? Why do we do preoperative assessments? Is it just like a legal formality? We’re just saying, hey, we’ve cleared this person for surgery, or is there more going on here? Houman, I’m start off with you, your thoughts on this.
Houman 04:21
Yeah, so I guess I’ll sort of need to share that. I started life as a surgeon, right. And. And I need to share the couple of anecdotes, the sort of. I, I love geriatrics in med school. Then people said, no, you don’t want to do that. And then I really enjoyed the teamwork on surgery and being in the or, and then started life as a, you know, my basic surgical training was in Scotland, so netting, mercury and Glasgow. But it was always the older patients where I felt like people were. It didn’t, it didn’t make sense. People were missing things and people were very binary about it. In my days, it was this attitude of like, you don’t operate on anybody over 85 or you do absolutely everything and if they don’t do well, well, they were old. And I specifically remember one case where it’s. Maybe it’s, you know, was.
Was a little bit traumatizing. There was a general surgeon in Glasgow who would sort of haze his fellows by bringing in sort of terminal patients and they wouldn’t last very long. And I broke rank. I broke rank and confronted Houman and he said, well, they were old, they’re going to die anyway. So, like, what’s, you know. And something just sort of in me said, no, that’s it, I can’t do this. That’s not a good enough answer anymore. So I really sort of leaned into aging and sort of geriatric assessments for surgical patients. And 13 years later, that’s kind of my career to. Basically, the answer to your question is it’s not just a legal thing. It’s actually identifying the amount of aging and disease a patient has before you subject them to surgical insult so that you can have the best outcome. And that is the core of all of it, it’s sort of like it’s taken me 13 years to be able to come and say this in a podcast, but that is really the answer is surgeons just don’t know.
Like nobody has that training and skill. The geriatricians to, to quant, you know, to really assess the amount of aging and disease that a patient may have. So they can then decide what the surgical insult will do and if it’s appropriate, inappropriate, and how to modify it. Which is what I’m more interested in going forward is how do we do it better?
Eric 06:38
So should we do surgery or should we not? But even more like if we go ahead with the surgery, how do we actually improve their outcomes? By thinking about it beforehand.
Houman 06:46
That’s right. And there’s a lot you can do in the or there’s so many things you can do. Like there are surgeries that may be appropriate for a 50 year old, but inappropriate for the same functional outcomes in a frail like 85 year old. Like, you can get the same functional outcomes, but the actual surgery and interventions are different to get the same outcomes.
Eric 07:08
Vicky, you’ve done both outpatient preoperative assessment in older adults. You’ve done inpatient or doing inpatient preoperative assessments in older adults. How do you think about the why question? Why do you do it?
Vicky 07:21
Yeah, so I’ll actually share. What my surgical colleagues tell me is they feel very uncomfortable doing surgery on older adults and not being certain that they’re going to get the outcomes for the patient that the patient would want. Right. And so they’re not sure how to have these conversations. A lot of surgeons will, you know, are the ones that were referring to me in the pre op select group.
Eric 07:52
Of people who are referring to you?
Vicky 07:54
Yeah, they’re like, you know, I don’t think the outcomes are going to go well. I don’t really know how to assess, you know, what’s going to happen to this older adult. So I’m just going to refer to geriatrician and geriatrics will, you know, kind of suss it out. And so, and so I’m like, yeah, sure, thank you. You know, and using that opportunity to like what human was saying, you know, there’s a lot of stuff we can optimize before surgery so that we can increase the likelihood of a positive outcome in older adults, or slash and have the conversation about, you know, what’s most important to the patient and how does this surgery potentially impact that?
Does it actually fit with, you know, what the goals of the patient is and deciding, hey, Maybe surgery is not the thing to go. Maybe there’s something else to offer. So, yeah, that’s what I would say.
Eric 08:55
Maybe for our audience we can take a step back. Probably a lot of people have, you know, either done or seen kind of preoperative assessments. What’s different in older adults when we think about the preoperative cooperative assessment, human. I’ll start off.
Houman 09:10
Do you want me to go first? Yeah. So it actually kind of tags along beautifully from. Sorry, I’ve listened to a number of your podcasts, but the comprehensive. I’m going to plug it. Whoever didn’t listen to the comprehensive geriatric one, go back and listen to that one. Because the comprehensive geriatric assessment, I think, is critical to the role of elucidating the value of the knowledge base of geriatrics and geriatricians. And the key element, I think, is this.
I’ve sort of had the privilege of working with Ken around developing our frailty index, where I view it as a Trojan horse for a cga. Basically, if you can sort of come up with an algorithm for a CGA on your sort of deficit accumulation frailty, it’s a way of sort of communicating to others your CGA in a numeric manner.
Eric 09:56
And for all our listeners, CGA is comprehensive geriatric assessment.
Houman 09:59
Yes. Thank you. Sorry. To be honest, I think it’s the multi domain evaluation, which includes function, cognition, comorbidities. And then I would say that in the case of surgical assessment, what you really want to know is how much are those comorbidities actually subtracting from the physiological reserve of the patient? The ultimate answer when you finish is what is the physiological reserve of the person in front of you and how much of that reserve is determined by a disease process and how much it is determined by their unique aging and where they are in that sort of physiological journey. And once you have that, then you can look at, okay, what sort of insults can this person tolerate?
And it fits in with a lot of these notions about with frailty we have notions of resilience, which is recovering from injury, and then the robustness, which is sort of the antonym of frailty. Like, are you robust enough to tolerate? And then what you can do is choose the surgical options that are there. You can take some surgical options maybe are beyond, like, I’ll just talk about orthopedics, which I know best. So a good example is someone may need a revision surgery, or someone may just need sort of an open reduction and fixation with plates and screws, which ends up with a much less sort of surgical insult compared to a major revision, which would be you have to hammer all the hardware out, you know, re sort of align everything and hammer everything back in and cement it in place, which is a much bigger insult.
So I would say in the most simple way that is sort of what the geriatric assessment does. But I do want to say that the downstream it can’t sit on itself in isolation. I have a very close relationship with my surgeons and we both speak our language now of once you do the assessment, they tell me what the surgical sort of variety and options are and we come together to understand what’s best for the person.
Eric 12:05
So it’s not just you’re cleared for this surgery. No, the word ongoing discussion.
Houman 12:10
I know clear is a term that I talk about. Yeah. Clear is a term I recommend everybody stay away from.
Eric 12:18
Yeah.
Vicky 12:19
Though I do worry that it will end up being that way as you know. Right. Like, so right now we’ve got these surgeon partners. I mean, who, man, I’m sure the folks I refer to you are like really into it. They believe it, they buy it. But I’m sure, you know, pre op care used to be that way too until it became, you know, required in a way. And so I don’t, I’m just saying it shouldn’t be a legal thing. And it may become that way with all the kind of regulations that are happening with geriatric surgery verification program or like Medicare measure happening, you know, we’re.
Eric 12:58
Going to talk about the geriatric surgical verification program. But before we go do that, I’m just trying to put my head around the concept of this preoperative assessment. Does, does every surgery that an older adult goes through need a preoperative assessment? Like if they’re getting cataract surgery, which this is exceptionally low risk surgery, do they even need any of this or should everybody. Independent of what they go through this.
Houman 13:27
Yeah. So the answer is no. And I think when you talked about, you asked this question in the CGA podcast too, and we actually agree we have screening processes in place. So we actually have early sort of like frail screening processes. So if someone’s a robust 85 year old, to your point, but, but then no, no, they don’t, they don’t need. And it’s all about what is the insult that they’re going to withstand. So like to your point, cataract surgery, but it depends on how frail they are and what the risks are. Right. So what you need to do is you need to have that Frailty screen in place because we know that you can’t eyeball it. You’re, you know, 30% of the time. They did a study beautifully. Got to go back to the study and like, it was in 2005, where I think surgeons were right 30% of the time, which isn’t great about whether.
Eric 14:16
Or not they’re frail. Is that the question?
Houman 14:17
Yeah. And we’re actually doing a study right now, the eyeball test. We’re doing another eyeball test with video between the US And Holland. We’re in the process doing the study of giving essentially the history and a video of a patient to orthopedic surgeons and geriatricians here and in Holland and see how well they can eyeball it just. And what they anchor on.
Alex 14:38
I gotta ask, why Holland?
Houman 14:41
Because our researchers in the ortho geriatric trauma are from Holland.
Alex 14:49
It’s not that you have a hypothesis that in Holland. Oh, that is so much better at the eyeball test.
Eric 14:55
We got better eyeballs in Holland.
Houman 14:57
No, it was just. It’s also a different medical system, which I think is important to look at as well, because there is. I mean, let’s be honest, there is a pressure for people to do as much surgery as possible as well. Surgeons are under the gun to like or time is the most valuable amount of time in the system. And I think that you also had a fantastic podcast with Victor Monteri about the industrialized medical health care system, and I think this feeds into it very, very well as well, is that those pressures are particularly harmful to, I think, the aging population. Right?
Eric 15:36
Yeah.
Houman 15:36
So that’s the other part of this element is you need screens in place, you need to identify the right patients, and then you need to do the more extensive evaluations. And that’s what we’ve done in our system.
Alex 15:48
And just to make explicit, what you were just talking about in the podcast with Victor Montori is that there’s a potential. And what’s happening is beyond potential. It’s happening now. The industrialization of our system and within that industrialization, the surgical time is one of the most valuable commodities for making money for each healthcare system. So there’s a tremendous profit incentive. And we are one of the checks on that system. And we can be. And we can be agents of change.
Eric 16:18
Czechs or cogs.
Alex 16:19
Ah, we’re both. We are cogs. We can be Czechs.
Houman 16:25
We’re strong cogs, Eric. We’re strong Cox.
Eric 16:29
So real quick, so all older adults in your system, do they go to surgery? Do they get a Frailty screen.
Houman 16:36
Yeah. So on the orthopedic side, when they come to see the orthopedic surgeon, they get that quick sort of fr. We’ve sort of melded all these different tools. We just happen to use the frail screen that John Morley came up with a while ago. And primarily, it’s also primarily because it was. Trying to get another screen into a busy surgical clinic is hard. And that one was relatively easy to train everybody to do. And we also tested it in our hip fracture population, and it did a great job of separating robust from non robust, but didn’t do a great job of separating degrees like, from pre frail to model it or severely. It didn’t do a very good job of separating frailty, but it did isolate the robust patients really well.
Eric 17:21
And that’s not. The frailty screen is not should I or should I not do surgery? It’s should I or should I not do a more comprehensive geriatric assessment.
Houman 17:31
Exactly.
Eric 17:31
Get the geriatrician involved.
Houman 17:33
Exactly.
Eric 17:35
Vicky, do you do a similar thing? How do you think about the preoperative assessment in older adults?
Vicky 17:40
You know what’s so funny? I feel like human and I are both thinking, correct me if I’m wrong, but in my mind it’s like, oh, this is such a Trojan horse to do the cga. Like, this is. Exactly. And so when the Jerry fellows called me, like, hey, oh, my gosh, I have to do a. I have to start a pre op, you know, clinic, or, you know, what am I? How do I do it? I was like, look, this is all just so that you can do a geriatric assessment on the patient. And so however you want to couch it, that works for the surgeon, like, do it. So for me, what I like to do is say, like, look, these older adults, they can have their high risk of delirium. And if you do the delirium, I mean, all the things that can cause delirium, it’s essentially a cgi, Right.
So do hearing, vision, cognition. Right. Geriatric syndromes. So I do the delirium screen. I mean, that’s my delirium assessment and how to optimize potentially. And then a huge component of what I think is important to talk about is the goals of care. What’s the surgical goal here? How does that fit within the bigger picture of this person’s life?
Eric 18:53
So, like, why do you want the hip replacement? People just don’t want the intervention. They want the outcome. Maybe it’s so they can golf again, kneel down to be with their grandchildren.
Vicky 19:05
That’s exactly right.
Eric 19:06
But it’s also important to do that assessment because if before they weren’t getting out of bed at all, I’ve had.
Vicky 19:14
Patients where I’m like, hey, what are you hoping to get out of this intervention, this surgery? They’re like, oh, I want to run a marathon again. I’m like, but you were. This is not the. Even the surgery related to, you know, that that’s not going to get. So then I’m like, hey, surgeon, you know, colleague. Like, this is what they’ve told me. I think we need to have a group conversation about, you know, I mean, and the other pitch that is like, hey, you know, you’re getting knee surgery. Great. It’s not going to kill you. Let’s talk about acp. This is the perfect time.
Eric 19:46
Advanced care.
Alex 19:47
Advanced care plan.
Eric 19:48
Yeah, sorry, it’s not the American College of Physicians.
Vicky 19:50
Sorry. No, no.
Alex 19:52
So I’m hearing a lot of concepts here, and you reminded me of another that has gone unsaid. But I think I’ll say it. Comprehensive geriatric assessment is one sort of framework. I just heard advanced care planning as another sort of framework. I heard frailty, pre frailty, robust, different levels of frailty. And also what you just said about, like, what their goals are reminds me of the 4ms. Framework and the what matters most. And I wonder. That’s a lot of frameworks for people to hold onto. And I like how you’re linking them conceptually. And I also just want to make sure our listeners don’t get lost in this. In all these concepts, how do you think about the forums or do you in relationship to preoperative assessment?
Eric 20:39
Because the forums kind of makes us more accessible. Right.
Alex 20:42
I think that was the goal is like, we have all these concepts. Let’s simplify it for people. Four M’s.
Houman 20:48
Yeah. Yeah. But to be honest, I think forums is geriatrics for non geriatricians. Right. Yeah. I mean, honestly, from my perspective, the other thing I would say, and you know, I’m a little controversial, but I’ll.
Alex 20:59
Be honest with you, like, we like controversy.
Eric 21:02
Sorry.
Vicky 21:03
I love it.
Eric 21:04
This is going to be on our great talk.
Houman 21:06
Yeah. So forums is a wonderful way to try to sort of dumb it down for non geriatricians. And that’s great and I love it. And I’m all about age friendly and I’m all about bringing about the domains of sort of understanding and aging that we need to pay attention to. But I would say this, and Vicky, and maybe you can back me up on This a little bit is always when it comes to surgical. And maybe this is the surgeon side of me coming out is when it comes to going under surgery, you need a lot more granular sort of assessment because you, this is not, this is not like this. This could ruin your life if you’re not. If someone.
My point to you, it’s like saying there are times you need an MRI and there’s times you need an X ray. Right. And surgery is one of those things where you need a very granular idea of what your physiological reserve is, especially in the context of aging. And it brings me back to that sort of my early experiences as a surgeon where everybody sort of just had this, sorry, I know it’s a little bit rough, but it’s true. They had sort of a sort of mercenary approach. I grew up in a world where there were a lot of people from like, you know, they used to subscribe to these mercenary magazines and they had this slogan that said shoot them all and let God sort them out. And that approach to surgery is not correct.
Alex 22:30
Right.
Houman 22:31
That is not the way to go about it. And also, with all due respect, the Forams just doesn’t cut it. The fifth M matters. But even more than that, you need an actual person with sort of rigorous understanding of aging versus disease to know whether your blood pressure lability is due to bad blood pressure management or is it actually sort of advancing cardiovascular frailty and stiffness that is causing this lability that may or may not be clinically relevant.
Alex 23:02
Yeah, I appreciate that spirited defense of the geriatrician’s role here. Vicky, anything you want to add?
Vicky 23:08
I hear you Humen as a legit, you know, card carrying geriatrician for sure. And I also want to make sure that as many older adults can get the care that they should be getting gets it. And so even if they don’t have.
Eric 23:26
Access to a jar, even if they’re.
Alex 23:28
Seeing a nurse practitioner. Nurse assistant, family practice. Yeah, yeah.
Houman 23:33
But we, that that’s a systems issue that we can solve.
Eric 23:36
Yeah.
Houman 23:37
And we can get into like we can get into. I mean let’s be honest that that’s a financial issue.
Eric 23:42
Yeah.
Houman 23:42
More than I think a, a geriatrician issue.
Eric 23:47
That’s a separate podcast we could talk about.
Houman 23:49
I know, I warned you guys. You guys have already brought me on and I’m like building these programs so.
Eric 23:56
When we think about the four M’s you have mind. So it’s one thing just to do a brief screening test for a mini cog on somebody mind it’s another to think rationally about preoperative assessment. What does it mean to have some cog impairment? Did they have delirium in a past hospital stay? Because that’s the strongest marker whether or not they have a delirium in the next one. All of those things which is part of that real comprehensive preoperative assessment. Am I getting that right?
Houman 24:25
So, Eric, I’ll come back at you as a surgeon on that. What do I do with these four ends? Yeah, that’s the surgical. The surgical approach is give me something I can use that will tell me how I can proceed with my surgery and the management of that patient around surgery. It’s a very different mentality than the sort of. The more medical approach, where if you’re approaching a hospitalist, the 4N 5M approach may be more helpful and it’s gentle and it’s sort of more sort of. It doesn’t insult them and sort of gets them going down the rain.
But when it comes to surgery, you got to get surgical. And when they get surgical, they want to be like, dude, what do I do? Like, like, tell me what needs to be done for this person. That’s the surgical approach, and it’s very different. And the truth is, when people are that abrupt, you need the, like, you really need the strongest granular assessment to give them a very clear idea of what to do. Because if you get surgeon forums, they’re just going to, like, look at it and think of it as check and move on.
Eric 25:27
Check, check, check. Frailty assessment. Check, check.
Alex 25:30
Right. Yeah.
Eric 25:31
So then what do you do? So you do a frailty assessment. You.
Vicky 25:35
I’ll push back.
Alex 25:35
Yeah, please, please. We love. We love disagreement. We welcome.
Vicky 25:40
You know, I’m in Texas now, so, you know, I’m not sure that’s. That’s entirely true. I mean, you have protocols, right, that you can follow. It’s not necessarily a check. Right. Like, ultimately, who Men. You’re like, oh, yes, this person’s frail. This is a percentage or this is a thing. So then you can say like, hey, based on this, this is your likelihood of risk of having a bad outcome post op. So I think it’s still. While we want to make it sound, I guess my concern is like, well, we want to make. I am pro geriatrics for sure. Yes. We should all do fellowships if you want to do geriatrics, you know, so on and so forth.
But I don’t want it to be over complicated. It doesn’t need to be for most cases. And my concern is then we make it unaccessible to people. So it’s like, yeah, you do what matters most. Okay, well, if, you know, somebody says I want to, you know, be able to do a marathon again and the surgery is not going to accomplish that, then no, you’re not having surgery. We’re going to do something else. Right. If they have a high delirium risk. Okay. We’re going to have a conversation. You okay with that patient. We’re going to proceed like this is what might happen. Yes. Okay, well, we’re going to set measures in place to, you know, prevent delirium from happening or if delirium is happening, then we’re going to put in all the things that we can do to minimize bad outcomes from this patient. You know, kind of like. So I do think that with the 4Ms, yes, it’s not like very granular, but we can still have actionable items come out of that assessment.
Houman 27:27
So the problem with that from a surgical perspective is you can give the surgeon all of that and they’re going to come back with, so can I operate on them or no. And sorry, I’ll just, I need to.
Vicky 27:39
I can answer that for the most part though.
Houman 27:43
Yeah, I mean, but so, yeah, I mean, but that, what I’m saying is that’s probably what they’re looking for. Yeah, but in all fairness, as a geriatrician, for me to answer that question with sort of more certainty, I need a comprehensive geriatric assessment to get a sense of where their deficits are and whether those deficits are going to put them in at harm for the type of insult that is planned for them. I’m not, and don’t, don’t get me wrong, I’m not saying the forums are wrong and I’m not saying. And also maybe, you know, and the robust 85 year olds, like there’s certain pathways we need to put in place. Right. There’s certain things that need to happen. Like the 24 hour opiate dosing has been well known. Frank Sieber published it like years ago, but it’s not well known to everybody.
But there are other fine tuning things like the prostaglandin mechanism of free water excretion and the collecting documents may not be something people will know and they don’t realize that NSAIDs, right, NSAIDs and all these things around surgery can be a lot more harmful than you think. Toradol may not be such a safe med around surgery in older patients. And that level of detail and understanding is something that I think also gives us A little bit of credibility, like, you have skill, I have skill. And the idea is together we can take care of this person. And Eric, I actually agree with you when you said the very severely frail probably, like the reserve is so gone that probably your dosing is not going to make a difference. And your robust, probably with just a simple checklist of don’t do dumb things due to basic acing changes will work. You don’t need the whole CGA or a geriatrician involved. But it’s that middle group, it’s that sort of moderate to severely group and that sort of mild to moderate group where that’s where the geriatrician has its value.
And the idea of where do you deploy geriatricians? That’s where you deploy geriatricians. That’s where the value is. And then other people can do the rest. And by geriatricians, by the way, we are teams like geriatric MPs, geriatricians, people who are. My point is, my answer to everybody is, and especially when it comes to geriatrics, I’m like, how rigorously do you know the physiology of aging? And do you know it well enough that you can make medical decisions based on that understanding so that you can have different clinical outcomes in the person in front of you? If we ask that of a pediatrician, nobody would question that a pediatrician was appropriate for children. Imagine having doctors who know nothing about normal growth treating kids. Come on.
There’s a point where we got to draw the line and say that, listen, the knowledge base and skills of aging is required and needed. And if we can, if we can develop cath labs in every hospital over the course of five years, I think we can solve the need for training geriatricians in the country. And with virtual care, we can, we can, we can find the transition to get there. I just, I’m tired of these naysayers because I’ve done it. I’ve done it. When I went, sorry, I shouldn’t be saying this, but 13 years ago when I went into my hospital, there were no geriatricians. They didn’t even know geriatrics was a.
Alex 30:54
Specialty, right When I trained there, no geriatricians.
Houman 30:56
That’s right. There was no geriatric. They didn’t even know. Now they can’t imagine functioning without geriatricians.
Eric 31:03
I got a question. This is all, I love your passion. It makes a lot of sense to me, but do we have any data that doing these comprehensive geriatric assessments before surgery improves outcomes yes, thank you for asking, Eric.
Houman 31:20
I knew you’d be asking me. All right, so which data do you want? The first Data I did 10 years ago in my group was we showed the utility of mini cog in fracture patients. When I first did the mini cog on the inpatient side, all the geriatric. Everybody that neurologists want to kill me. Why are you doing a mini cog in the acute setting? I’m not using as a dementia screen. I’m doing it as a cognitive stress test on my patients to get an idea of what their level of cognition is.
Eric 31:45
It’s like the treadmill test you’re using.
Houman 31:47
That’s right. Just as we. I guess what we published that it’s a great test for assessing cognitive vulnerability in delirium. But we also sort of threw in there the fact that since we got a geriatrician, our mortality rates dropped to 18% and our delirium rates dropped to 10.5%. They used to be 25%, and now there is. There’s a recent study that came out of the UK which showed that if you get a geriatrician involved in trauma patients, the mortality significantly decreases in the care of those patients. Well, you did it in hip fractures, but can you do it?
Or can you do it in this hospital? Can you do it everywhere in the world? This is pretty much ortho. Geriatrics has demonstrated that you bring the concepts of geriatrics to this. The other one is, then we did elective joints, then with elective joints, what we showed. By the way, I’ve been very lucky, and this is the interesting. I’ve been very lucky because the orthopedic surgeons I work with are very clever and very resourceful. They have the resources.
Vicky 32:43
Right.
Houman 32:44
But they actually looked at, if you saw geriatrician, within 90 days of the surgery, your ED readmissions drop. And we published that, and that was with Antonia Chan. And by the way, the problem is most of this literature is in the Journal of Orthopedic Trauma. It’s in trauma. It’s an injury. It’s in all the surgical journals. So a lot of people may not be as aware, but I got to be honest, it’s just easier to get this stuff out there in the surgical journals and the resources that people have on surgery to show these outcomes are greater. So I’m in the middle of the authorship, huh?
Vicky 33:18
I was gonna say I publish all my stuff in surgery journals. It’s fine. That’s your audience, you know.
Alex 33:23
Yeah, right. That’s Your audience. Vicky, what evidence would you add for Prehab and other elements of the comprehensive geriatric?
Vicky 33:31
So I really wanna be like I’m, I love humans energy. So we recently did a systematic review with the ASA group and looking at Prehab. So I’ll talk about Prehab.
Alex 33:47
So it’s American Society of Anesthesia.
Vicky 33:49
Thank you.
Alex 33:49
Go ahead, go on, go on.
Vicky 33:50
Vicky, I was forgetting.
Houman 33:52
Yeah, yeah.
Eric 33:53
What is Prehab?
Vicky 33:55
So Prehab is essentially the idea is for elective surgical cases you can pre habilitate, which is like, kind of like rehabilitate, but before they decline and basically build up or optimize either their functional level, their cognitive level, their nutrition status so that after surgery, when they take that hit of surgery, they have more kind of reserve to I guess use up, you know. And that’s I guess what I think of when I think of Prehab. So the literature has been mixed.
Everybody’s got a different definition of Prehab. And so it’s kind of left a question as to like does it work, does it not work? And which patient population versus not. I’m always in the pro Prehab world. I think, I also think that everybody would benefit from a geriatrician. We can always find something to help and optimize. So that’s the short answer for Prehab. It’s plus, still pending a really good large study where there’s a good definition of Prehab.
Eric 35:09
And let me ask you this because it does feel like the tide is changing as far as surgeons because I feel like there is a lot of interest in things like frailty from the surgical side. Yeah, I’ve started to hear about this geriatric surgical verification kind of like this age friendly movement that we’re seeing everywhere but in surgery. Do you feel like that there is this change in the absolute.
Vicky 35:35
Yeah, absolutely. And I’m happy to speak to that. So the geriatric surgery verification program was developed with the American College of Surgeons with the support of John A. Hartford back in 2019. They started right before the pandemic. And the idea here was that hospitals that applied to be a geriatric surgery verified program would need to meet certain criteria really around pre op assessments. What we’re, we’ve been talking about making sure what matters most is asked, making sure we have function, function assessment and physical like PT assessment after surgery, before surgery, when possible.
And so now we’re up to 80 hospitals that have signed up for the Geriatric surgery Verification program nationally. And it fits very well with the CMS medical care measures and the 4Ms. As well. But their big sell is, you know, hey, we’re gonna help your hospital system meet this Medicare measure. We’re gonna help decrease the rates of delirium post op. And I think that really the most awesome part to me about it is this requirement to have goals of care discussions with patients and their family members, making sure advance care planning is done. And yeah, that’s great.
Alex 37:05
Thank you.
Eric 37:05
We’ll have a link to the geriatric surgical verification website, the great website I was looking at yesterday.
Vicky 37:14
Sorry, can I also do a quick pitch too? So ACS has nisqip, the National Surgical. I don’t remember exactly. Nsqip. Yeah. And so the folks that did gsv, they’ve put in some outcomes that older adults would be interested in. Like given, you know, all these risk factors you plug in, you know, after surgery for this type of procedure, what is your likelihood of going to a skilled nursing facility or a nursing home after?
Eric 37:45
Yeah, so they prognostic index for pre, for the pre surgical.
Vicky 37:52
Yeah. Conversation for older adults. Yeah. So that’s been really neat to see.
Eric 37:57
We’ll have a link to that on our show notes too. Uman, you were going to say something?
Houman 38:01
No, I think what I would say to people is having sort of been the first acumen center to try to implement GSV is don’t be discouraged. I mean, I think the first pass of GSV has a huge, hugely demanding sort of bar. And may I say that, you know, the only feedback, I would say it’s slightly too academic. I think that a lot of the backlash is that it makes it look like that there’s all these incredibly sort of demanding, resource intensive things that you have to do.
While in reality what it just boils down to is you need a geriatrician to know about aging and disease. And then you can use the GSV outline to sort of move the bar forward in terms of your protocols and outlines of your institution so that older patients can be assessed and risk stratified correctly with the right perioperative and post operative management so that they can have better outcomes. And GSV is done in almost exhaustive sort of, you know, I think it’s.
Vicky 39:00
There’s a mini version now. There’s a mini version.
Houman 39:05
Someone who’s actually been involved and you know, and I’m the one that’s advocating. But I would say like, I think the GSV is fantastic, but it’s exhaustive in the sense that I think people should look at it. I would say invest in the people who want to actually focus and care about older surgical patients and use GSV as an outline. And then the nice thing about it is that it gives you credit if you put the resources in place. And that’s a whole nother podcast is the finances of all of this and the industrial complex of all of this.
But having said that, Vicky, I think it’s very important to be positive that surgery is actually a space which is a revenue generating space where Trojan Geriatrics is exactly the term I use. Vicky has demonstrated its efficacy and its clinical validity. And I think we should use that in the United States as one of the ways which sort of we can lift geriatrics up in our country. I genuinely do. I feel like it’s a fantastic opportunity.
Eric 40:08
Okay, well, Alex sets up real quick. I have one last question. If you had a magic wand you can change anything that happens around the preoperative assessment for older adults or the perioperative management, what would you use that magic wand on? One thing that our listeners could think about, Vicky, go to you first.
Vicky 40:26
I feel like I’m going to use Human’s line is everybody needs to get geriatricians in their hospital doing pre op assessments today. Do I get it?
Houman 40:35
Yeah. So, Eric, I would answer that because recently I had a procedure and I guess when you come out of anesthesia very lucid. But for me, my new mission is I’ve reached a stage where I want every older patient to have access to someone with the knowledge base and skill for aging so they can get the care they deserve.
Eric 40:54
And that’s beautiful.
Houman 40:55
That’s really it.
Eric 40:56
That’s much better. Last time I had a procedure, I think I was talking about surgery in the post. The pacu. Sorry, Sushi. Sushi. That’s much deeper than my.
Alex 41:06
He was talking about sushi.
Eric 41:07
Yeah, that’s not a thing. Well, Alex, you want to finish us off?
Alex 41:11
Okay, here’s a little bit. (singing)
Eric 42:34
Vicky Human, thank you for joining us on this GeriPal Podcast.
Houman 42:38
Thank you for inviting us. This was fun.
Eric 42:41
And to all of our listeners, thank you for supporting the GeriPal Podcast.
The post Pre-Operative Geri Assessment: Vicky Tang and Houman Javedan appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful?
Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers.
In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We are also joined by Rasa Mikelyte and Edison Vidal, co-authors of a recent study comparing the perspectives of people with dementia in the UK and Brazil on what constitutes a good death.
In addition to exploring the nature of a good death and their individual studies, we will discuss:
Key references we discuss include:
Lastly, if you would like to join Eric, Edison, and I in Brazil on April 6, 2026, for the São Paulo Geriatrics & Gerontology Congress, click here to register.
-Alex Smith
** NOTE: To claim CME credit for this episode, click here **
Eric 00:06
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:12
This is Alex Smith.
Eric 00:13
And Alex, we’re going to be talking about a good death today. Good death, good death. Who do we have on to talk about this?
Alex 00:20
We are so pleased to welcome back Karen Steinhauser, who is a social scientist, professor of population health sciences and medicine at Duke and a health scientist at the Durham VA Health System. Karen, welcome back to the GeriPal Podcast.
Karen 00:34
Thank you. Glad to be here.
Alex 00:36
And we’re delighted to welcome Edison Vidal, who’s a geriatrician and palliative care physician and professor of geriatric medicine at the medical school Botucatu at Sao Paulo State University in Brazil. Edison, welcome to GeriPal.
Edison 00:50
Wonderful. Thank you.
Alex 00:51
And Rasa Mikelyte, who is a postdoctoral research fellow at the University of Kent in the UK. Rasa, welcome to the GeriPal podcast.
Rasa 01:03
Thank you for having me.
Eric 01:04
We’ve got a lot to cover on the good death. Maybe we could define what a good death is. Can we define what a good death is? Is it useful concept at Wal? Maybe we’ll go back a little bit in history about this concept and what the future looks like. But before we get into all of that, Edison, I think you have a song request for Alex.
Edison 01:23
Yes, pretty much. I’d like Waters of March.
Eric 01:28
Why Waters of March?
Edison 01:30
So there are several layers for this response and I’ll choose just the first two, but if you want, I can tell you more later on. So first, this is one of the most beloved Brazilian songs and it plays, it’s around the flow of life. So the singer speaks about several random objects and things that pass in life and death is one of them and it just passes by. So it integrates death and life as they are intertwined in real life. That’s one of the beauties. The other one is that’s an example of a cross cultural adaptation. It’s not a literal translation. There’s a Brazilian version.
The song was originally written in Brazil by Antonio Carlos Jobin, who spent a significant time of his life living in the US who made a brilliant partnership with Frank Sinatra. They have a Wonderful City CD about this work. And so there are some terms in the song that they exist in English but not in Portuguese and vice versa. So it’s a beautiful song and I.
Eric 02:38
Love this because we’re going to also be talking about your paper on a good death, looking at two different Countries, we’ll get into the topic of that, but also how we think about a good death from a cross cultural perspective. Alex, are you going to do the Portuguese version?
Alex 02:51
I am not doing the Portuguese version. I thought about it, I tried, but the words just come fast and furious. So I’m going to sing this one in English. I’m sorry, Edison. And for those of you listening to the audio only podcast, you get my son Ren on guitar and bass and he did the Bassanova version. For those of you watching on YouTube, you get me doing this in what my kids describe as Bassanova meets Green Day.
Alex 03:20
(singing)
Eric 04:08
That was great. Alex and I are actually going to Sao Paulo in April.
Alex 04:12
We are. Thanks to Edison. Yeah, thanks for inviting us to Sao Paulo.
Eric 04:16
Sao Paulo Geriatrics and Gerontology Congress in April.
Eric 04:30
So I’m going to turn back time. Alex, we actually did a podcast on Good Death. Do you remember we had DJ Periyakoil on?
Alex 04:38
Yeah, yeah.
Eric 04:39
And you and DJ published an article on…it’s titled should the Concept of a Good Death be Buried.
Alex 04:46
Ah, you like that? It’s punny.
Eric 04:49
Good pun, Good pun. So we’ll have a link to that in our show notes. But you know, the gist of that is, and I think probably everybody kind of agrees that the good death is hard because it’s so individual. What a good death looks like to somebody is so individual. But maybe their themes. That was the kind of big takeaway I took away from that podcast, I think, back in 2018. But I’m going to rewind before 2018. We’re going to go back a quarter of a century. 25 years ago, Karen, you published probably one of the most important papers in palliative care circles. I still reference it.
Alex 05:29
Me too, all the time. Every single grant.
Eric 05:32
It was in Jama 2000. The title was factors considered important at the end of life by patients, family physicians and care providers. And man, they’re just looking at the co authors. You got like folks like Nicholas Christakis and James Tulsky, just superpowers right there. Why did you decide to do this project 25 years ago? I guess before 25 years ago?
Karen 05:58
Yeah, sure. Because the context, I think is so hugely important both to the title and what drove it. Just to give you context, this was. Right. We published it in 2000, but we were collecting the data in 97, 98. And it was right after the support study had come out. And the huge results said that we weren’t doing well in terms of end of life care. Patients dying in pain, dying alone. And so much money was put into education around end of life care. The American Medical association identified it as a high priority. The VA became an early player.
Lots of folks, the Robert Wood Johnson foundation was looking into it and I started a postdoc with James Tulsky and he said, I have a project that I want to do, but I don’t really have time to do it. Would you like to write this grant and do it? And having never written a grant, I said, oh sure, I’ll do that. Fortunately, he’s a great grant writer. So. And I learned, you know, from the best. And we wrote this grant. It was actually part of a study trying to see if we could create a measure of a good death or of quality of dying. That’s what we called it. That’s what we set out to do. And we thought, as we looked at the literature, we thought we don’t really have good data that comes from all the people around the bedside.
It was mostly physician expert driven panels that had come up with anything that was out there at the time, which was very little, a couple of instruments. But then there, and then there were lots of quality of life instruments, but they didn’t address any of the needs associated with end of life. So we thought, let’s start with square one, and got a grant from the va, who was one of the early funders before the NIH got in and PCRC was just getting started or about to get started. And we wrote this to have two steps. One, a qualitative component and then a quantitative follow up and the qualitative component. We decided yes, we’ll interview physicians, but we also want the perspective of nurses and social work and chaplaincy, hospice volunteers, patients and bereaved family members.
All the patients had either cancer or CHF or COPD and were sort of the surprise question, had enough medical characteristics that they were in serious illness, probably in the. And the end of life. So I put, I put that out there just as we’re setting up our populations to compare later between all these studies. That, that was a, you know, that was the setting and the population. And we were able to do that because of working in the va. So we had these databases that we could connect with national samples of patients and bereaved family members. So that was the context.
Eric 09:02
And I love that study because what I remember when I teach about it, you can tell me if I’m teaching anything wrong, is that there were some factors that pretty much most, not 100%, but most people agreed with. I think it was greater than 90% that it was important to do to be pain free. It was important to have a doctor who one can trust or a nurse who can communicate with.
There are things that people universally kind of agreed with, not universally, close. Universally agreed with. There were things that they had pretty big differences. So the one that pops out to me always is being mentally aware. Doctors and nurses did not rate that very high, but patients sure did. And that just reminds me of our everyday practice. We think, oh, a good death is getting pain 100%. Let’s just give them meds, meds, meds to make them comfortable. But what’s important to most patients is also being mentally clear.
Alex 10:02
This came up today. I’m attending on palliative care right now. Came up today, this exact issue.
Eric 10:07
Yeah. Is that a good summary of your finding?
Karen 10:11
Yeah, no, that was from the JAMA paper. I was thinking also the other one, the qualitative study was in Annals that sort of looked at the domains, but the factors. Absolutely. That was one. The other one that really jumped out. And I’ve still had sometimes physicians say to me, oren and palliative care. There’s no way that’s true. And it’s that when we had rate, are you at peace?
And we asked where patients ranked it, and they ranked it on equal footing with being free of pain. Now, doctors ranked it quite a bit lower and clinicians in general put it quite a bit lower. Well, that’s pretty important to know, right, that patients and families are kind of holding those components of that sense of peace and coming to terms with what’s going on for both Sides as being as important as being free of pain.
Edison 11:02
Wow.
Eric 11:03
Yeah. And you know, I guess the big question is, you started out of this project, you said to think about like, can you create a quality measure around this? And I’m wondering, did you? Could you?
Karen 11:16
So we did, but we kind of shifted gears partway through it because we changed the language around a good death because it was so challenging. And we started and good dying and we started to think about what’s quality of life at the end of life. Then after this study was done, the JAMA study, we then wrote another grant that the VA supported to create a measure of quality of life. We call it the qual e that was built off these components and psychometrically sounds and so forth.
And the other thing that I will say, particularly from the qualitative pieces, we started out analyzing the data and we thought, okay, we’ll put them in the buckets. That are discipline driven. Like, here are your physical concerns, here are your social. Here are your psychological. Then when we looked at the data, it didn’t fit how patients and families talked about the experience at all. That’s why we had really different categories like completion or clear decision making. Because people don’t come in and say, let me, let me review my psychological concerns for you and then let’s do a physical function assessment for me. You know, they just don’t.
Alex 12:28
Right, right.
Karen 12:30
Much more. Can I do things that help me feel normal?
Alex 12:33
Yes, go ahead, Edison.
Edison 12:35
There’s one thing that I remember from reading your studies, Karen, which have been a great inspiration for us, especially in the beginning of my career as a palliative care physician. And that was defining that it was important for people to feel that they were still contributing and giving to others. That’s something that I found so valuable that didn’t occur to me before. And because there are so many opportunities to help people, patients to see that even being sick and severely ill, that they can still contribute even by giving the example about how they are facing the biggest challenges in the lives of someone which is facing death. And that’s something that’s changed the way that I see things.
Karen 13:20
Thank you. That was one of the beautiful things that came out in the data. Kind of really hearing that again and again that we had been so focused on patients in particular and families too, being recipients of care and sort of what can we do for you? But if you’re going to sort of be together a bit in this process, not just do for, but be with. That’s understanding the ways in which people have to give throughout their lifetime. And I’ll share with you too that my two great colleagues and mentors in the process, James Tulsky, you know very well, and his great contributions to the field. And then also Elizabeth Jody Klipp, who was a developmental psychologist and nurse. So she really thought about lifespan too.
Eric 14:09
And I also love the one that surprised me always. And I still use this when I’m on my ethics committee or I’m thinking, talking to patients and they say they’re worried about being a burden to their family members. And the amount of times I hear the response, oh, don’t worry, you’re not a burden. Oh, you couldn’t be a burden. Like, this is a value that they’re expressing deeply to you. I don’t want to be a burden to my family or I don’t want to be a burden to society. Those two things came up. I still remember reading your article.
Those two things came up. As far as one of those discrepancies, healthcare providers value it low, patients valued it very high. And I still think about how I should respond to those situations. Instead of pooh, poohing. A deeply held value is actually hear more about it, Tell me more. This is something that they’re willing to share with you. We should hold that value with them.
Alex 15:00
Yeah.
Karen 15:01
Building on that, the other thing that was really surprising, sort of along those lines, was that we asked people to rank order 9 items of most to least important ranking and the kind of literature and anecdotally people would throw out, oh, 90% of people want to die at home by patients and families. It got ranked last.
Edison 15:23
Last.
Karen 15:24
From our qualitative data, we knew that that didn’t mean that it’s really, for some people, it’s very important to die at home. But for other people, to your point about burden, it could be that they’re worried that dying at home really represents a huge burden to their family and so. Or there might be other issues of caregiving. So as you’re saying. Exactly. Clinically, it’s about really understanding what’s important to that person, what’s their context.
Alex 15:51
Yeah. This was such a, this is such a tremendously important study and I’m glad that Edison and Rasa are continuing this work. And I wonder, before we move on to Edison and Rasa, if you could say a little bit more about how you decided to transition away from the language of a good death towards quality of care at the end of life and sort of what, what were the reasons behind that?
Karen 16:14
Some of it was related to how patients saw Things versus how those around patients. Those around patients were more comfortable just in our study. This may not hold true now, but back in our study, more comfortable talking about the death of that person and the bereavement period and thereafter. But when we talk to patients, they were very focused on, I want to live as fully as possible for as long as I live. And yes, I want these things about dying, but I really. It’s like that Snoopy’s character kind of cartoon that I’ve seen that Charlie Brown says one day we will all die.
And then Snoopy says something like, and on all the other days we won’t. And it was the idea that again, patients were really focused on how do I live as fully as I can. I’m not ignoring that I’m dying, but I really want to. Let’s just not talk about death that as much as we start dying. So does that make sense?
Eric 17:19
How much is that? As. As health care providers, we think about death being like a process, not a moment, not an not. I mean, sometimes an outcome when we’re doing research, but it’s a process. Like it’s. It’s maybe a day, it may be months, it may be years for some people when we’re thinking about the process. But when it sounds like when patients are thinking about family members, death is like, oh, like in my last hours or days, I’m in my bed and I’m dying or the moment I die.
Alex 17:51
The death versus dying, the moment versus living until.
Karen 17:55
Right, right. And I think the other is that providers have an Anna of thousands. So you know the process that’s going to be at place whereas the patient, they have experiences from friends or family, but really they have an n of 1. And so that’s what we heard again, we’d love to explore it again, but that’s at the time what we found. And so that really caused us to try to have patient focused language.
Alex 18:24
Yeah, I guess one of the things that it’s so intuitive to do studies on the good death and what that means to clinicians, for example, or to researchers, and it may not be to patients, family members. And it’s so revealing that there are these differences between the way that we would rank order these things. And one of the other pieces that came out to me about your study was the heterogeneity and that there is tremendous variation.
And so the point is both that these priorities might be not what we expect and they might differ between clinicians versus patients and that there’s tremendous variation and you can’t Shortcut to assume that highly prevalent attitudes apply to individuals and that might mistakenly lead to policies like, I don’t know, Liverpool Care Pathway. I’m trying to bait Rasa into saying something here. Prioritizing death at home or a tremendous focus on advanced care planning and the Patient Self Determination Act. And if we only could plan, for example.
Karen 19:31
I heard that from so many. I can remember that nurse who said to me, we have to be really careful to not have implied to patients, hey, you’re not dying the right way. You need to do this, this and this. Even things like peace, where huge portions. A majority of people talk about wanting to find some peace, but of course the people who aren’t and they have been sort of fighters and whatever and it’s not going to go out with a bow tied up. So again, what you’re saying, Alex, there’s as much heterogeneity within is between and really doing the work of that.
Alex 20:10
I also want to say I appreciate the title of your. I think it was the Annals piece, was the qualitative piece. In Search of a Good Death. Was that the title?
Karen 20:17
Yeah.
Alex 20:18
Yeah, because you could have titled it I Found the Good Death, but that wouldn’t have been right because the Good Death, it’s like ultimately unknowable, inscrutable. This is something that we continually strive towards an understanding of that is so highly individual. And one of the great mysteries.
Eric 20:38
I’d like to get into that. But before we get into is there value in the label a good death, Maybe we can talk about, because your study included people with cancer, heart failure. What do these themes look like when you’re dealing with maybe diseases that have longer periods of frailty and cognitive impairment, incapacity. And I think that this leads us. And how does it apply to different cultures? Because Karen’s study was in Veterans. Right. Does it apply to other cultures? And Edison, I’m going to start off with you. Why did your group decide to do your study?
Edison 21:19
Well, I think I’d like to pass it through. Rasa.
Eric 21:22
All right. Yeah, Rasa.
Edison 21:24
Yeah.
Rasa 21:26
It’s not fair, Edison, but okay, I’ll give this a stab and then you can add more to it.
Karen 21:32
So.
Rasa 21:32
Well, partly opportunism because a bunch of us were in Brazil kind of trying to figure out. We knew we wanted to do research and ideally comparative research on something to do with palliative care. But exactly what it was going to be and what we want to look at took a minute to arrive at. And I don’t think, Edison, correct me if I’M wrong because this again has been a while back now, but we didn’t land on the exact idea while we were in Botuka 2, the kind of core team, we came up with it like nine months later on, I think Skype back then, some of us joining from Nottingham, some from Brazil, where eventually we kind of found that the one thing that really bound us was that the voices of people living with dementia in the what is a good death Debate was sorely lacking.
And when multiple groups of people were included, usually the voices of professionals or caregivers were so much more prominent. And we very specifically wanted to ask that question, but we also wanted to see if there was going to be cultural differences between our two settings. And boy did we find some.
Eric 22:45
So you actually included individuals with dementia? I’m guessing not advanced dementia totally.
Rasa 22:53
Well, we never had ethics clearance to test or assess someone’s level of dementia, but on the basis that people who took part in the interviews were had cognitive capacity and mental capacity to consent to taking part in the interview, that tends to indicate people had either mild or moderate dementia. So we were asking people to imagine their futures. And I guess another important point here is that we weren’t interviewing patients, although all of us are patients. Right? We were interviewing patients, people.
We were asking people from their lived experience point of view. And we did ask some questions about what good care may look like, what their worries about care were. But the focus very much was on the lived experience of dementia as a person and the imagined good death as well as a bad death, because it’s impossible to ask that question and not hear stories of what bad looks like.
Eric 23:54
Was it hard to create a survey questions around good deaths and bad deaths when you’re dealing with two different languages from Portuguese?
Rasa 24:04
Very good question. And I’m going to hand over to Edison, because I think Edison remembers this more clearly. But you brought up some points about how do we talk about the process of dying versus the moment of death. And that was one of the points that we really struggled to translate. Well, in a sense way that there would be parity. But Edison, you remember that story better, I think.
Edison 24:28
Yeah. So just take a sec. I just would like to take a step back because this. So we had a meeting in Brazil that was funded by a collaboration between the Newton Fund from the UK and FatPesp here in Sao Paulo, the state of Sao Paulo. And so there were researchers from the UK and Brazil meeting together to figure out possible grant proposals and research projects together in collaborations. That’s how Rasa and I And a friend of ours, Karen, who is also in the uk, who is a nurse who also works with the mansion, met together to figure out a research project.
And there was Francis, also from another side of Brazil here, and we were trying to figure out a research project. And while we are talking, and those conversations are so enriching. So Karen. So I had been doing research in advanced health planning here in Brazil, and Karen had done a PhD in the UK, interviewing people with dementia. And that was fascinating to me because the typical Brazilian outlook on people with dementia is that we would never be able to interview them for anything. And that’s something that changed. So our views about people with dementia changed dramatically because of our conversations with our friends from the uk, because even diagnosing dementia there, even though we claim to use the same criteria, it’s a different process here in Brazil, people tend to be diagnosed much later on than in the uk.
That’s a complex issue. So it fascinated me that Karen has interviewed people about care preferences in the uk, people with dementia. And then because I had read Karen’s work and when I was doing my PhD, I had to, for a discipline on qualitative studies, I had to write a draft proposal about any study using qualitative methods. I drew from Karen’s work and I thought, well, it would be amazing to do a research in Brazil, asking Brazilian older people what would a good death mean for them. And then Karen brought this information that we could ask people if they mentioned, which was kind of a revolution to me, and they said, so this is a perfect idea, we should do this. But I realized that just in the last day of the meeting, and it was later on that we started writing it and Karen wrote the first draft in the uk. And then when we were working.
Eric 27:09
On.
Edison 27:10
The qualitative questionnaire on the semi. Better place, the semi structured interview guide there was. So it was first written in the uk, then we translated it into Portuguese, but you had to adapt it. And this question about what’s a good death mean? So I don’t remember exactly the question, but when you die, it’s just something about when you die. And here in Brazil, when you ask when you die, people usually think about the moment of death. And then the question becomes much more important about what happens later on. And we couldn’t use that wording because it wouldn’t work here. So we had to move to asking about your last days and hours of life.
Eric 27:58
Do you think it’s anything different in other. Like when I think of. I think in the us, I think Like I was saying before, I think there’s a difference between healthcare providers, how they think about death and family members. I think they think about those last moments. Like from the paintings that you see in art galleries to TV shows of people sitting around someone’s deathbed versus. It sounds like from a healthcare provider standpoint, it’s a longer process.
Edison 28:27
Yeah. So people see it differently and the language plays a role here. So in Brazil, when you die. So how would you like to be cared for when you die? It’s meaningless.
Eric 28:39
Yeah.
Edison 28:40
Because when I die, I’m not there anymore.
Eric 28:42
If it’s a moment issue.
Rasa 28:44
Yeah, yeah. The difference, if I can interrupt Edison, is not, and I think you’re absolutely right, that people with lived experience, people who, you know, we would place on a palliative care register, don’t necessarily see themselves as dying.
Eric 29:00
Yeah.
Rasa 29:01
But the difference for us culturally was that when I was asking a question, when you’re dying in the uk, people were thinking about perhaps having the movement restricted, being on the bed, that kind of situation. Those were the pictures they were painting. Whereas for Edison and Edison, correct me if I’m wrong, but your participants understood it as the moment of death.
Edison 29:26
Yeah, exactly.
Rasa 29:27
And that in terms of translation, lexically was really interesting.
Eric 29:31
Yeah. Well, I want to jump because I want to. I want to jump to what did you, what did you find in your study.
Rasa 29:52
I’m going to say it from the perspective of a researcher. Perhaps that’s, that’s a more interesting story.
Eric 29:57
Yeah. But don’t get too wonky in it. Kind of big picture for our audience. What did you find?
Rasa 30:01
Okay, so we found that where you live matters. And it’s really unsurprising, you’re right, of course, in discussing how individual a good death is or ideas of what a good death would look like. Of course it is. But I think it would be short sighted to kind of think that our cultural, social, political, health and care contexts do not shape who we are and what futures we imagine for ourselves and what we want for ourselves at the end of our lives. So we found that it did matter.
And the thing I wanted to say from a researcher perspective is that we started expecting that not everything will be universal. We ended up being really surprised by just how near dichotomous some of those differences were. And because we did a lot of the analysis together, I guess we also really questioned our own biases. But if you want to hear More about.
Alex 31:03
So what did you find in the UK versus in Brazil?
Rasa 31:08
So we found in the UK what was really strong is that people wanted choice. People wanted control over the end of their lives. And that feeling out of control, which can be the experience of advanced dementia anyway, that was very fear provoking for people. So if you wanted to assuage fears, one way to do it, we theorize, is by offering more choice and control. As neoliberal agenda as that may be. It seems to have permeated the context. And what absolutely floored me is that this narrative was not just not as prominent in Brazil, it was nearly entirely absent. But I can’t tell the story. I wasn’t the custodian of those voices and that data from Brazil, Edison was. So Edison. What about choice and control in Brazil?
Edison 32:01
So choice and control in Brazil sounded in our interviews as almost impossible. We had to take a step back and explain what we meant by choice and control because so people would ask us what do you mean having control over death? That’s, that’s not possible. That’s something, that’s. That, that’s God’s work. And for example, we had to, to mention people. So to, to participants the possibility of advancing a planning as a way of explaining what was important to them as, and exercising some kind of control. And so it was a concept that was out of their reality.
Whereas the, the idea of religion and spirituality of having a God that’s in control and that’s that God is the one who’s going to decide everything and their decision will be always good. And that made people frame a good death around being at peace with God, being in a good relationship with God, which is almost absent from the uk. So that kind of contrast, it was so strong that it was a surprise for us. And I’m a Brazilian, I have lived here almost the most, the biggest part of my life. And I wasn’t aware because I’m embedded in that reality, in that culture, how religion and spirituality frames that kind of view and how strongly it protects people.
So it seems that religion and spirituality is buffered that kind of anxiety, it was a major means of emotional regulation for people. And that view was beautiful. And at the same time there were also. So besides those differences, there are also some striking commonalities between the two countries. So for example, what Eric mentioned earlier on about the fear of being a burden, it was present in the two countries. So people are worried. And I think that this is something that’s in palliative care. We still struggle how to address these Worries in an appropriate manner.
Some differences also were very remarkable about the meaning of dementia. So in both countries, dementia is a disease that has a very strong stigma. But in the uk, people internalized that stigma and they were afraid of being empty shells. Whereas in Brazil there are some, some participants would say, so when I become a child again, and with completely different language to address the loss of independence.
Rasa 34:46
But if I may jump in, Edison, those quotes weren’t from. So it wasn’t from the perspective of fearing to be infantilized, that it wasn’t a bad thing.
Edison 34:58
Yeah, exactly. So they were taking it as a natural moment in life and that made us reflect again about dementia because we change all the time. So the person that I am now is different from the person that I was 10 years ago or five years ago, or before my children were born. And people with dementia are also changing. Why is their previous self, before having a diagnosis with dementia, worthier than their current self with dementia? And that made us think, and that’s part of the beauty of this kind of cross cultural study, because we are, we have the opportunity to, to look at our own realities with different eyes. And, and that’s very beautiful.
Eric 35:46
Karen, I wonder, as you hear the results, did anything surprise you?
Karen 35:50
I would say, may I be a sociologist for a minute, please? Well, I just found myself thinking first, what a beautiful study to give us really fine examples of how culture is not some thin veneer, some window dressing, that, oh yeah, we have to pay attention to culture. But it’s like so deeply embedded, right, in how we construct reality, how we construct the meaning of this moment. And I think about, in sociology, we’ll say people do meaning making and meaning taking, and we take meaning from institutions, from culture, from religion, et cetera. And here you have this beautiful example of the uk, which cultural values, correct me if I’m wrong, but I think about as really valuing autonomy, valuing secular individualism.
Right. And then along with that, this. It should not surprise us then that these core concepts of choice and control and planning are preferenced. And in Brazil there’s more of a culture of collectivism and spirituality and maybe even divine surrender. Would that be correct, Edison? Potentially. And then we’ve got peace with God, acceptance, that’s what’s operative. And in the US we have this sort of hybrid autonomy, meaning making. Right. And so I think from a big culture perspective, wow, how instructive. But also to Alex’s earlier point, we have to think of all the subcultures within a population and what is the belief system of that family, of that right, based on their heritage, based on their practices and beliefs, so that we really understand those values deeply and then how that’s going to play out and what they want.
Edison 37:37
Yeah, Beautifully said, Karen. That brings me to think about one of the most beautiful sentences that I listened to when I was learning palliative care 20 years ago. That was an interview by CCD Saunders when she was asked about what was the most important advice that she would like to give to young people entering medicine or palliative care. And then she said, listen to your patients, listen to their needs, because they will tell you. They will tell you what they need, they will tell you what they can achieve.
And this is when you try to figure out a good effort. And to a large extent, the whole field of palliative care emerged to make this experience of dying better, less. Less of failure to address suffering as it had been throughout history. And the first step is not to impose to people what we believe about death is, but to be open to listen to them. And that’s something that’s working with Rasa and Karen. Karen and others from the UK and even from Brazil, that it helped me see that we can ask people if they mention so many things.
Alex 38:54
Yeah, right.
Edison 38:55
That we didn’t ask before because we thought we are.
Alex 38:59
We didn’t think it was possible. Right, right.
Edison 39:02
Wouldn’t say anything meaningful, but they can.
Alex 39:03
Say, right, we need to privilege their voices. Karen, you’re going to say something.
Karen 39:07
Yeah, I was just going to say that. That I think. But sometimes entering those conversations can feel thorny and a little overwhelming. Right. Because can I get out of my depth quickly? And that same team that wrote these papers, years later, we wrote a paper on am I at peace or are you at peace? And using that concept of peace, and I know that you tacked on that as well.
And if you ask people about that, what would it mean to be at peace? How might you get there? And hearing from them, the how might you get there? Tells you, they’ll tell you all about their values. I’ll get there when I have control over the timing, the place. Or. Or I’ll get there when I have. It’s my relationship with my family or with God. Eric.
Eric 39:54
Yeah, I guess I’m a little. I. I remain a little bit confused. Like how important you. You all have done studies around like, like pop. More. Bigger, not individual, but bigger population. You know, qualitative, quantitative on what is a good death. Like what’s important to people. How important is it to do that knowing. Because I’m also hearing from you. It’s so individual. The only way to find out what a good death is to someone is to ask them like are both true, are both important?
Karen 40:27
You know, I think that I’ll say this is where I’m just going to speak from our data.
Eric 40:32
Yeah, please.
Karen 40:33
From a long time ago. And you, everybody else can chime in. That I think is what was in our qualitative piece. We tried to say that in the piece in annals that are in search of a good death. It is ultimately really individual. But maybe there are some guideposts that we could use. In general, people find it really important to have their symptoms and pain managed. It’s hard to get to meaning making if you are a 9 out of a 10 with pain and clear decision making, that sort of preparation, more general preparation, what do they need to do that?
That’s why we did completion, contributing to others and really treating them as a whole person. So those were just the categories that came out of those data. But I think it is okay to have kind of a rubric, a heuristic for thinking about these are the things that generally matter and how you get there is different for every person. And then you get to always ask what else? What am I missing.
Rasa 41:36
This one. Yeah, I think, I think we also can’t take it as, you know, a thing in a vacuum or one snapshot in time, perhaps we could just default to everyone is beautifully individual and we just ask everyone if we didn’t base entire systems of care, delivery of policy, of everything else in aggregation.
Eric 41:58
Quality metrics. Right. And quality metrics like yeah, yeah.
Rasa 42:05
And in that case, if you’re going to do those kind of metrics, if you’re going to do aggregation, then making sure that a diverse set of voices is heard that we don’t, for example, exclude the global south or people from middle or lower income countries. If we think about what we built this on, other groups of people, marginalized subculture groups in any one given country or society. If we didn’t build the system on exclusion, then maybe we would just be having a conversation about how wonderfully individual everyone is. But yeah, structural factors play a role. So this discussion is still necessary. Anyway.
Edison 42:50
When you wrote the paper and when we were analyzing the data, we were worried that people could take our results as evidence that they shouldn’t listen to patients, to their patients with dementia and that they would just assume that because they are from Brazil, that religiosity is everything that they need and that they don’t have to worry about choice and control. So Brazil is huge. People are different, There are subcultures everywhere. And also in the uk, I’m sure there’s, there are people for whom religiosity is everything or is very important or as much important as control.
So the idea here is, and I think that’s, that’s something that comes already from Karen’s studies about. So the lesson is that the good death is multidimensional. And what our findings in Cairns and all of other people who have been researching this tell us, they raise our sensibility to issues that we should try to be aware of when you’re talking to patients, because unless I had read Karen’s study, I wouldn’t be aware that people, for some people being able to give to others, to be useful to others at the end of life would be important. And so it was under my, rather my radar. And so those, our findings and Karen’s and others, they tell us about things that we should start thinking about so that we can better listen to what people are trying to tell us, what’s important to them.
Eric 44:26
Beautifully said, Addison. Alex. Oh, go ahead, Karen.
Karen 44:30
I was just going to jump on because I loved what Russell said about, you know, we can’t be in this just wildly individualism space and we’ve certain we can go by the evidence. We’ve got a lot of data here in the United States, it’s the National Quality Forum, that’s put together areas that we can pay attention to and have quality metrics and we have other data. Absolutely. That can guide us in the general areas. And then still, I think when we went down the individualism path, it’s to say, even with those broad guidelines, we have to make sure we’re tuning in to the subtleties and the way that structure and agency kind of come together in creating, you know, a good experience.
Eric 45:13
Yeah, I know we’re running out of time. Can I ask you one last question, Karen, because you mentioned something earlier, is that patients, this may be their first time ever experiencing death, their family members experiencing death and dying. We’ve seen thousands if not tens of thousands of people dying of deaths. How do you think about this, this idea of a good death or quality of end of life and incorporating the patient’s values and experiences, but also that we’re guides too. We’ve seen this. Does our thoughts on a good death matter at all?
Karen 45:49
That’s why we had all in the studies and we looked at them, all the data, because we thought we can’t make conclusions when people have an n of 1, that voice is hugely important. And it’s so helpful to have the experiences of the nurse at the bedside and the social worker and the chaplain. And that was our experience that. That was hugely important so that you could get the wisdom of people who had cared for folks at the end of life, the community.
Alex 46:20
We should let Rasa go. It’s pretty late in the UK right now, Eric.
Eric 46:23
Okay, let’s get some more waters.
Alex 46:26
Waters in March.
Karen 46:27
Yeah.
Alex 46:27
Bossa Nova meets Green Day. For those of you watching on YouTube. Apologies, everyone in Brazil.
Alex 46:37
(singing)
Eric 47:24
Thank you for joining us on this podcast. Karen, loved your work. Edison Rasa, just beautiful study. We’ll have links to all of that in our show notes, but thank you very, very much.
Karen 47:38
Thank you, thank you.
Eric 47:40
And thank you to all of our listeners for your continued support.
Claim your CME credit for EP374 “What Makes a Good Death?”
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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose. Guest Karen Steinhauser, Rasa Mikelyte, and Edison Vidal have no relationships to disclose.
Accreditation
In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Designation
University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
MOC
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The post What Makes a Good Death? Karen Steinhauser, Rasa Mikelyte, Edison Vidal appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following:
We can’t cover everything in the 45 minutes we are together, so here are some of the resources we reference in the podcast:
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:01
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:04
This is Alex Smith.
Eric 00:05
And Alex, who do we have with us today?
Alex 00:06
We are delighted to welcome back Chris Jones, who’s a geriatrician and palliative care doc. And get this, for today’s podcast, a certified professional coder. Chris is clinical vice chief for outpatient palliative care at Duke. Chris, welcome back to the GeriPal Podcast.
Chris 00:21
Thank you.
Alex 00:22
And we’re delighted to welcome Phil Rodgers, who’s a palliative care doctor and family medicine doctor, and a dean, professor, and chair of family medicine at my alma mater, the University of Michigan. Go blue. Phil, welcome to GeriPal.
Phil 00:36
Happy to be here. Thanks for having us.
Lynn 00:39
And me.
Alex 00:40
Oh, yeah. [laughter].
Lynn 00:44
Wait, that was like a blooper. [laughter]
Alex 00:49
And we’re delighted to welcome back Lynn Flint, who’s a frequent guest and host on this podcast, today serving as a guest host. And Lynn Flint is a palliative care doctor from the office next door. Lynn, welcome back.
Lynn 01:01
Thank you very much.
Eric 01:03
So we’re going to be talking about medical billing and coding, the subject everybody wants to listen to on a podcast. I’ve actually seen Chris and Phil talk about this. They make this actually really exciting. And we’ll talk about why it’s important for everybody to know at least some components of billing and coding. But before we get into that topic. Who has the song request for Alex?
Chris 01:27
I think that’s me today.
Eric 01:28
Chris, what is the song request?
Chris 01:32
We really thought through what would be a valuable song request around billing, and it has to be If I Had a Million Dollars.
Alex 01:41
Great choice. Here’s a little bit.
Alex 01:51
(singing)
Eric 03:04
Llama or llama?
Lynn 03:06
I had the same question.
Alex 03:08
I don’t know.
Chris 03:12
We’re just hoping you can get a chaplain or a social worker with that million dollars.
Phil 03:18
Maybe a massage therapist. You don’t have to have a donor fund.
Eric 03:21
Well, let’s talk about that, because you know what? We’re talking about billing and coding and the importance of billing coding when we think about palliative care teams. But damn it, Phil, I am a doctor. I need to be doctoring. I’m not a slave to the C suite. Do I really have to? And does my team need to really know about billing and coding?
Phil 03:45
That’s an excellent question. And there’s a few things, having done this a while, that we find are important to make sure we say. And one of them is actually a line of Chris’s that I’m going to share with you, which is that palliative medicine pays for palliative care. And what I mean by that is that the primary people who are going to be coding on your team are the physicians and the advanced practice professionals. Right? Your MPs, your PAs, your docs.
Residents can bill under appropriate supervision. So can fellows, with few exceptions. The other extremely valuable members of your interprofessional team, your social worker, your nurse, your spiritual care provider, in some cases your psychologist, if you’re so lucky most of the time, cannot bill in a lot of the settings where we work. So ensuring that you optimize revenue for your services enables you to have the resources to support your interprofessional team. Did I get that right, Chris?
Chris 04:47
Yeah. When we talk about this with folks around the country, what I’ll often encourage, because you have to get people, you have to hook them when you’re trying to teach this stuff. And why does it matter? It matters because if you can get a bit more revenue, you can turn that into a social worker, you can turn that into a chaplain. So the work that you’re already doing as a provider, if you can turn that into a bit more money, it’s going to be more help for your patients. So this is not feeding some stock plan somewhere. This really does turn into the care part of palliative care.
Eric 05:24
And just to clarify, the folks who can bill, it sounds like, are the MDs and advanced practice nurses and physician assistants.
Phil 05:36
Right? So we use the term advanced practice professional to cover NPS. PAS. Also CRNAs are in there and other folks. But on palliative care teams, it’s NPs and PAs.
Eric 05:45
All right.
Chris 05:46
And on the outpatient side, I’ll just add, if you have a social worker who’s doing therapy, that’s available service. If you’ve got a psychologist in the clinic, that’s available service. But if you think about the breadth of true palliative care, if you’ve got a full idt, there are not a lot of the members of the IDT who can submit those bills to Medicare.
Eric 06:11
Okay.
Phil 06:12
Yeah.
Eric 06:13
All right. So my other question and me and Lynn had a chance to review your CAPSI slides and stuff. And I went to your last talk at ahpm. It was fabulous. We’ll have links to that on our show. Notes for everybody. But I remember one of your slides which was really helpful for me is like, how does this billing stuff work? And there’s all this Alphabet soup of words. As we think about the billing process, can you just real quick for our listeners, how does billing work in the steps that you’ve outlined?
Chris 06:48
Yeah, so real quick is going to be the goal and that’s what I’ll shoot for. So you see a patient, you prepare to write a note. What you have to do is somehow talk to or communicate with the payer what you did. Right. So there are, there are two kind of Alphabet soupy buckets. The first are the diagnoses you treated. Those are called ICD10 diagnoses, International Classification of disease. And that’s things like dyspnea or COPD or non small cell lung cancer. And those. Now ICD10 has the numbers and the letters.
So depending on what you treated, you pick a few ICD10 codes. Then you think about either how long you spent taking care of the patient or how complex the visit was and you turn that into a billing code. What’s called a CPT code or common procedural terminology. That’s the five digit code. If you run in the hospital, that’s 99233 for example, and 99233, that billing code counts as a high level or high complexity hospital visit and that turns into money.
So the way that I think about it is you see the patient as you’re writing your note, you think about your diagnoses, ICD10, you figure out what level or what the complexity of your visit was. That turns into a CPT code. And then that CPT code goes into the payer and then your institution will have a contract with the payer that turns that into a certain amount of money.
Eric 08:30
And this is all true. If I’m doing geriatric consults, palliative care consults in the hospital, kind of the process is the same and it’s similar process in the outpatient setting. Is that right?
Chris 08:40
Yep. Absolutely.
Phil 08:41
Yes. Only there’s only one set of CPT codes that Any clinician can use to describe the service that they deliver. One of those other Alphabet soup phrases are E and M codes. You might have seen that. Or E N, and that stands for evaluation and management. Those are the most commonly billed codes in cpt. All specialties use the same code. So in the outpatient setting, that’s 99202 through 99205 for new patients and 99212 and 99215 for return patients. Whether you’re a palliative care pediatrician or cardiologist, you use those same two codes to describe the work you do in that setting.
Eric 09:24
E, M is a part of cpt.
Phil 09:28
Correct. They are a subset of CPT codes and they are a minority. Here’s where those of us who do not procedural work have it a lot easier than our proceduralist colleagues. There are, you know, over 10,000 CPT codes. There are probably about 30 of those in the E&M space. Maybe 50 if you count the emergency department codes. Everything else are very, very detailed procedural codes. It’s whether or not you remove the stone from the proximal middle or the distal ureter. Right. There’s a lot of that complexity.
We don’t have to worry about most of that. I will say we’ll probably get into this. The advanced care planning codes, which are celebrating their 10th anniversary this year, are also considered evaluation and management code. So they’re under that E M umbrella.
Eric 10:18
So let me ask you one other question, because ICD10 always confuses me. So ICD10 are the diagnoses. Right. How important is it to be as specific as possible with those ICD10 codes? So let’s say Lynn comes to me as a patient. She has a wound in her leg. Should I put it as a wound in her leg? Or if I find out that she was bitten by an orca, whether or not I should use there is a nice.
Lynn 10:46
Orca.
Phil 10:47
Thumbs wouldn’t counter.
Eric 10:48
Yeah. How important is it to be that specific? Or can we just pick and choose kind of our ICD 10ish.
Chris 10:56
I don’t feel strongly about this. I usually pick the unspecified code because it’s fewer clicks for me. And I just lost my certified professional coder standing by saying that you’re supposed to go out to the seventh digit, the left, right up, down, thumb, forefinger.
Eric 11:13
What type of orca was it?
Phil 11:16
Right over 80.
Eric 11:18
Northern Pacific specific.
Phil 11:24
Exactly. When you think about one more, just nuance to that, if I could, and I’m going to Take off my clinician hat on. Because Chris is right. As long as you put a code in for the cpt, the payment is the same. I’m going to put an institutional hat on though for a second and say that actually the only way that we can describe how complex the patients you are seeing is in the ICD10 codes and in your documentation.
That really matters. We’re talking a lot about fee for service, Medicare today and commercial payers in the Medicare Advantage world, which is now in my market, 60 plus percent of patients. Having an accurate depiction of how complex our patients are actually makes a difference. So I will get off my, I will take my chair hat off for a second. But it does matter institutionally.
Lynn 12:12
Well, that relates to my question actually, because you talked about the beginning of the life cycle of a bill. So the provider puts all that info in and then it goes off somewhere and some person reads those codes. And is there somebody who in certain institutions might be tweaking them to reflect complexity? What does that look like on the other side?
Chris 12:35
So a lot of this on the hospital side, they will tweak complexity because the more complex the patient looks, the more they’re going to get paid by the payer. On the outpatient side, the complexity is more at the level of the code, not at the level of the patient. So did I do a high level visit, a moderate level visit, a low level visit?
It’s never a low level visit. In palliative care, what I always say is I am a level four patient when I go see my pcp. I, I have two chronic conditions, asthma from cats and I’m a little fat. So I have GERD and they refill my albuterol. That’s a level four visit. So if you as a palliative care doctor are seeing somebody weller than me, then they could be a level three. But you’re doing your clinic all wrong. So in the hospital, they try to build on the complexity of the patient because that does depend on how the hospital gets paid. But in the clinic, it really is the complexity of the visit rather than the complexity of the patient.
Lynn 13:37
Okay, got it.
Eric 13:38
Okay, I got another question, actually. Should we go to another question? Should I just read my, my first, our first case.
Lynn 13:44
Let’s get into the cases.
Eric 13:45
Let’s go to the case because I want to talk about this, this question about time versus complexity coding, which should I use? But I’m going to start off with the case just to get this a little bit clinical. So we got a new consult. It’s a 73 year old with metastatic pancreatic cancer in the hospital who pal of care was consulted on for goals of care. The fellow sees the patient, spends 60 minutes with them talking about goals of care, their cats, their asthma and their gerd. Afternoon the team meets with a fellow to discuss the case for 45 minutes together. I do some really amazing goals of care teaching with them. We talk about our cats.
Lynn 14:27
You show pictures of your kid?
Eric 14:29
Yeah. And then the attending, the fellow, the pharmacist and the social worker all come together and we walk to the patient’s room, we review kind of what was discussed with goals of care. For 15 minutes with the patient, we leave and we plan for a family meeting the next day. No new changes to meds. So I’m trying to think about the process of billing. So you said the first step is I’ve done my clinical encounter. Right. What do I do next with this?
Chris 14:54
Phil, do you want to drive this bus?
Phil 14:56
So a couple of clarifying questions that I will hand it off to Chris because he’s got a special power here. Did I hear you say that the fellow spent 60 minutes in the room alone?
Eric 15:08
Yes.
Phil 15:08
Before they came out and sat.
Eric 15:11
And then we talked about it, we reviewed it with the team, we talked about it amongst ourselves. Know they’re no cardiology, oncology, nobody else was involved. Then we go back, we Talk with patient, 15 minutes and we agree that, you know, we need a bigger family meeting.
Phil 15:25
Okay.
Eric 15:25
And then we leave.
Phil 15:26
And no symptom assessment, no symptom management. No.
Eric 15:30
Did all that. But when they talked to us, we’re all, no, we’re not going to focus on symptoms. Seems really well controlled. They’re not having your symptoms. So we just focused on, we need next step that we’re going to do as a team is a palliative care family meeting with a patient and maybe oncology.
Phil 15:45
Okay, a couple of things. One, fellows cannot bill on time. Just hear that only attending physicians and credentialed advanced practice professionals cannot. So fellows cannot bill on time, so their time doesn’t count. Fellows can bill on complexity. So I’m going to assume that this fellow, did your standard new patient consult on a palliative care patient who’s got all the things and did they reflected the complexity of the care that’s being delivered and not just the goals of care, but everything else.
And then if I got the kind of sequence right, you spent 15 minutes in the room with the patient. How much time did you personally spend outside the room talking about the patient’s care with either your team or the consulting team, does that include teaching about.
Eric 16:43
The case and patients, issues like care, discussion like talk and education for half an hour. The rest of the time, we spent 15 minutes in particular talking about this patient’s case. But half an hour talking about goals of care, how to run, how to have these family meetings.
Phil 16:59
If my compliance people are listening, you cannot count teaching time. You know, that’s, that’s a. That is a lot. Now where does teaching and clinical care, where does that, you know, that kind of charcoal gray area set. I will leave that up to your high ethical judgment, but it truly is your time. Now, what is now different? That I will point out. So we did a big overhaul of EM starting in the outpatient setting in 2021 and then all settings in 2023, pre2021. You could only count your time, maybe attending physician time in the room with the patient face to face.
What is now the case is time in any setting, outpatient, inpatient can count total time on day of service, whether in the presence of the patient or not. That can include everything that is, you know, record review time. That is, you know, talking to the consulting team to actually get their concern time. That’s what I like to call crazy uncle time. Right, like the time that you’re on the phone with the family member who just needs a lot of you. So you can count all of that up. That counts.
Strict teaching time gets carved out of that. So I think, and Chris, this is where I’ll hand it off to you. What it’ll come down to is what are all those minutes versus the note that your fellow writes to reflect what they did about the complexity of that. And then you need to add it up and decide which is which.
Lynn 18:31
What are ways to document complexity? Like what kinds of words document those complexity?
Phil 18:37
Dr. Jones?
Chris 18:38
Yeah. If you. I think back, Charles Von Gunton has been a mentor of mine for years. And what Charles says is, whenever you’re a question like that, or if you’re fighting with your coders, you have to return to the sacred texts. And the sacred text that answers your question is called the CPT book. That common procedural terminology.
Eric 18:58
Yeah, I got that right here.
Chris 18:59
Well, so here’s the thing. I do have a copy of it because I have to. But your coders have a copy. And this is where. When we teach 350 people at AHPM, and then they go back and said, but Joan said X, Y and Z. No, your coder does not care about me. What you have to say is, can we look at the CPT book together and interpret it together. So there’s a table in the first part of the CPT book in the 2025 version, it’s somewhere between page 10 and 15 where there’s a chart that looks at the diagnosis, the data, and the complexity of the risk of the patient.
And there are words like severe exacerbation of cancer, pain, severe progression of ILD. I personally interpreted an EKG. I discussed management of the patient with Dr. Smith from cardiology. The decision was made for a DNR today. All of those sorts of words are the high complexity things that we do in palliative care.
Eric 20:04
What did you say? Those three components, the diagnosis, diagnosis, data.
Chris 20:09
And risk, are the three columns. And if you end up, if you get a copy of the CPT book and you look at the high level component, and if you meet criteria in two of those three columns, so you don’t need all three, then you have a high level note. So I’ll estimate, when I do inpatient palliative care, I would estimate 90 to 95% of my initial consults are high level. We do a ton of cancer pain management here. We do a ton of advancing dyspnea from COPD and ILD and heart failure. Those things are all high complexity. If you write the right words because.
Eric 20:48
You have, you have, you have bad diagnoses, complex diagnoses, and because you’re changing around like pain medicine, IV opioids, particularly.
Chris 21:00
Vision regarding an IV opioid and you have a severe exacerbation of a thing. Those two things, just those two things together make it a high level note that day.
Eric 21:11
Yeah.
Lynn 21:11
Even, even if it took you 10 minutes with your expertise.
Chris 21:15
Yes.
Phil 21:16
So this is an opening for one of the other things that we want to make sure that we say, and we say this often enough in all of our presentations, just because something complex and valuable is easy for you to do as an experienced and trained palliative care clinician, like IV opioid dosing, like high dose opioid rotation, like concomitantly managing benzos and opioids, like things that are in our wheelhouse. Just because they don’t feel hard to you doesn’t mean they’re not complex and they’re not valuable. I can speak from my experience as both a primary care and a palliative care doctor.
We have kind of professionalized low self esteem just because we tend to get less than everyone else. Right. So we just walk around saying, well, maybe they’ll let me in the room today. No, like, you walk in there, they’ve asked you to come. People don’t call you unless the patient is sick. Like, by definition, as clinicians, something serious is happening. So that gets you in the door. And then you’re doing really important, complicated, high risk things. And you’re doing it at a very high level. And as you get good at it, you process it very quickly and easily. So it doesn’t feel like a heavy lift for you, but it sure as heck was a heavy lift for the referring team. That’s why they called you. So kind of own your expertise, know your value, and bill for it. Great.
Alex 22:39
I’ll ask a question. Lynn has many educator roles as well, including being director of our GeriPal Fellowship. Lynn, do you teach this to the fellows? And then we could turn to our guests and see to what extent they teach billing and coding.
Lynn 22:55
Great question. We do teach this to our Jerry fellows and palliative care fellows in a didactic way. Also in clinic, I have to make sure I’m teaching them everything correctly. And I would say, I often say those words, that you are seeing the most complex people. So you’re pretty much always going to be a very high level visit. And I also still, I can think of a visit yesterday where I did an opioid titration for somebody. It was really easy for me and I thought, oh, that didn’t really take me that long. And I probably coded it lower than I should have.
Phil 23:34
I’m not going to pick on surgeons, but they get paid the same whether the appendectomy is easy or hard.
Lynn 23:39
Right? That’s a good way to put it.
Phil 23:41
Yeah, right, like that. And, and, and that’s not their fault. That’s the system we have. I mean, you know, we should all start by invoking Barack Obama, who back when the ACA was out, said no one would build our system if they were starting from scratch. Right. This thing makes no sense in any way, but knowing this system we have and understanding how we can survive and even borderline thrive in this, I think is a responsibility we all have together.
Eric 24:06
So it sounds like that’s part of the reason why we should probably learn more about complexity based coding versus time based coding. So, for example, this case on the inpatient side, I only saw them for 15 minutes. I didn’t spend a whole lot of time reviewing the CPRs. Maybe 10 more minutes on top of that. So 25 minutes total. And then the fellow is then contacting the other team members to organize the family meeting. So spent 25 minutes with the patient you know, with my documentation, co signing. So it would be pretty low level of time. But if it was based on complexity, I actually may be able to bill at a much higher rate.
Chris 24:49
You actually have, you have two things there. Because the case that you gave us, because the fellow did some symptom assessment, even if it’s continue the ms, Cotton, continue the oxycodone, that is some symptom assessment. They’re managing the pain, they’re managing the dyspnea, the constipation that nobody manages. I once had a patient say, you’re the best doctor I ever had. I said, why do you say that? You’re 92, you’ve seen so many. She goes, you ask about the bowels every time. Right? Like that’s something we can bring to the clinical encounter. So if you do some symptom work, even if you’re not reinventing the wheel, and then you spend some time on goals, values and preferences.
Eric, you mentioned 15 minutes for your advanced care planning. I might encourage you to spend 16 minutes because you’re a member of the Medicare volunteer corps. At 16 minutes, you trigger 994, 497, which is the, the first advance care planning code, but yet you can go in the room one time and leave with two codes. If you do symptom assessment and management and also do advance care planning for 16 minutes or more.
Eric 25:57
Okay.
Phil 25:58
And one other small nugget about that particular case, Eric. Time based billing is even harder for initial encounters because the time thresholds are higher for the initial encounters than they are for the subsequent encounters. It takes more time to get to the higher level. So I’m going to guess that you would do better. You’re probably getting a 99204 at least maybe an 05. Out of your fellows work, you probably can only get a 992. Chris. What? At 25 minutes?
Chris 26:25
Well, these are probably inpatient. This is inpatient, Eric, or outpatient. Yeah, so the times are 75 minutes for the high level, 55 minutes for the moderate level, and then I think it’s 35 minutes for the low level.
Eric 26:40
So real quick, for what counts, what, what things can I look at as far as judging my time so face to face with the patient?
Chris 26:48
So I got you. It’s everything except for travel time and teaching in the generic. Okay, so looking through the chart, getting history from the nurse, talking to the patient, examining the patient, getting collateral, writing your note, writing your orders, looking at the ekg, teaching your team about hyponatremia when they have hyponatremia in the context of that individual patient’s care. All of that stuff is billable toward time. But remember, if you’re going to build advance care planning, you don’t want to bill your symptom work on time. You want to build it on complexity. That’s a bit of a nuance. That’s best practice.
Eric 27:29
And that is that true also in the outpatient setting, as far as all the things you mentioned, that counts for time.
Chris 27:34
Yep. The only thing in the outpatient setting, the home care teams get killed on this. The windshield time. You’re a volunteer, but everything else. It used to be you’d have to write your note in the house, even if the house was itchy. But now you can go in your car and write the note. Because anytime you’re doing time based service, it’s all time on day of service. So it’s not unit and floor time, it’s not in the house time, it’s all time on day of service.
Lynn 28:01
Okay. Should we move our patient to the outpatient world?
Phil 28:04
Yeah.
Lynn 28:05
Okay. So the same patient gets out of the hospital, they’re referred to the outpatient clinic for palliative care. The nurse for the clinic calls him a week ahead, does a nursing assessment for 45 minutes, talks with the caregiver, and then gets the patient an appointment in clinic. On the day of that appointment, on the consult, the patient sees the MD and the rn. Since the hospitalization, he’s now developed poor appetite, abdominal pain, and the MDNRN spends 60 minutes face to face. They do rapport building.
They evaluate symptoms, they order opioids, and then they review the advance care planning that was done in the hospital. Then they finish the visit. The doc then sends a teams message to the oncologist to let them know what they did. And then a few days later, the nurse follows up to check in with the caregiver and see how the symptom management plan went. And then a couple days after that, the palliative care pharmacist calls and checks in about the meds, provides more education. What do we do there?
Chris 29:11
I love this care. I’m going to make you so sad. So there’s so many bad things I’m about to tell you. Oh no, the first bad thing is because they were were seen by your inpatient team. If it’s the same practice group, same subspecialty, they are not a new patient in clinic, they are an established. Really? Yeah. So in clinic you get zapped with the the follow up codes. Essentially the established Codes.
Eric 29:38
Wait, can I ask you the other way? If outpatient was seeing them and then we see them on the inpatient side, is that a new patient?
Chris 29:44
Yes. So this is the interesting thing is on the inpatient side, hospital gip, hospice, and snf. Each time you get admitted to an inpatient setting, the first time a specialty sees you, you get an initial visit. But the way new patient is defined in the clinic as is, they’ve never been seen by anybody. Same specialty, same subspecialty in the practice group in three years.
Alex 30:10
Whoa.
Chris 30:11
So if someone. If you’re.
Eric 30:13
Wait, what’s considered a practice group? Can I just shunt Lynn off to a different practice?
Chris 30:18
It depends. There are some practices like my group here. Our inpatient and outpatient hospice are all the same practice group. So if somebody saw the patient two years and 11 months ago in the hospital and then they come in on fire to be in clinic, they’re an established patient. I know.
Phil 30:39
Yeah, I know. I think it’s the same, especially under the same tax ID number in the same enrollment group. I mean, that’s. That’s the back end, but it’s truly unfortunate. So, Chris, in what other ways are you going to disappoint our colleagues?
Chris 30:54
Yes, in other ways.
Eric 30:56
Breaking my heart.
Chris 30:57
Our end time is critical palliative care, but it’s not reimbursable. If you saw the patient in clinic and created a principal care management program or a chronic care management program, and you enrolled them in that, then your nurse or your social worker time would be payable. But that. This is what palliative care is. Please don’t. No show our appointment because we’re giving you a lot of time. That nursing call is free. We actually have that done by our volunteers at Duke because they wanted to be helpful and it’s. It’s an unbillable service.
Your pharmacist also. Telephone calls by pharmacists are not billable. Phone calls by nurses when people are outside of principal care management, chronic care management, or principal illness navigation, all of that is non billable. And that’s the thing we said at the beginning of all this is palliative medicine has to pay for palliative care. Because all of these other people who do such a sometimes more important job than I do when I’m fiddling with a methadone prescription, and they’re the ones dealing with the anticipatory grief about dying as a 30 year old with two kids. I don’t know how to do that. I’m not good at that. So they’re not.
Eric 32:14
When Lynn is deciding to choose the lower level because she said, oh, that didn’t take a lot of time or complexity, I’m just going to choose that versus the higher one. She should be thinking, this is for my team here. This is so I can continue to support the social worker.
Phil 32:29
Exactly right. Exactly right. And the other nuance about outpatient care, if we just now cone in on your time, Lynn, you can only count the time on the calendar day of the appointment, Right. So you know, midnight to 11:59. So if, for example, you know that there’s a complex patient coming in Tuesday and Monday afternoon, you do the deep dive on the chart. That’s volunteer time, unfortunately. So it truly is just total time on the calendar day of service on the inpatient side, because of the nature of how we do it, we tend to do each day’s work on that day. But you and all know how outpatient work can go. It can bleed over. And so just know it’s calendar day only in the outpatient setting. If you’re tracking time.
Lynn 33:21
Question about time. So if you do, if you want to bill for time using time, you’re going to document the time that you spent in the visit. If you want to bill on complexity, how do you document that? If you have a free form, a system that has kind of a freeform note, and then in a separate encounter form, do you do anything in your note?
Chris 33:42
I have so many thoughts on this.
Phil 33:44
Yes.
Lynn 33:44
All right.
Chris 33:45
So if you’re billing on time, you need a time statement. And the generic time statement is. And I’m going to speak in epic. So I’ll say start Star, star. I spent Star, Star, Star minutes providing care to this patient on the calendar day or on the day of service, face to face and non face to face period, separately billed, procedures not included or something like that to just push out the like if you’re doing a hip injection or something. Your other question, which I just forgot. Oh, if you’re going to build it on complexity. So technically, what they teach the coders is it’s the four corners of the note.
The problem is a note in EPIC prints out on average at eight and a half pages long. And the average coder has four minutes to code a note, so they can’t read the whole thing. It’s just impossible. So when Phil and I teach this around the country, what we teach is we teach a billing smartphrase. So I actually have what we call our medical decision making smartphrase, where you are picking the pieces from that Complexity table in the cpt. What did I do today? You’re putting them in one spot at the bottom of the note. So when the coder or the auditor looks at the note, they always go to the bottom first because they’re looking for the time statement. And then whether they find the time statement or all these complexity words, they know what you’re intending.
Eric 35:10
And the complexity words, do they, do they refer to those three things? The diagnosis, the data and the risk?
Chris 35:16
Yeah. What I always encourage is that you as a clinician, if you can learn the words or if you have a medical decision making pick list, what you want to do, you want to create for the auditor the most boring search award in the whole world. You want them to find the words. They’re looking for severe exacerbation decision regarding dnr. Because what you don’t want a coder to have to do is interpret or intuit anything. Their job is to translate the note into a code.
So if you give them the words that are in their rubric, then they’re going to know what you intend. Where if you just say bad CHF on a bunch of oxygen has an aki, they’re going to go, is that a severe exacerbation? I don’t know where. If you say severe exacerbation of CHF with an AKI and 6 liters nasal cannula, then they know. Okay, that’s high level in the diagnosis column.
Phil 36:11
Yeah. And just the other thing to underline, which I think has gotten a little bit internalized, which is great since the rule changes in 2021. If you’re billing on complexity, the only thing that matters is the medical decision making section. You may remember, Eric, and probably practicing years ago, where like six, the 12 points on the review of system and the family social history and then the.
Eric 36:36
Physical exam, you got to meet all those.
Phil 36:39
All of it’s gone.
Eric 36:40
Do I even have to document that stuff anymore?
Phil 36:43
Well, so the HPI and the physical exam is for your colleagues and your lawyers. Right. Like you want your colleagues to know what you did as good clinical care. And you do want to make sure that you actually reflect what happened. But you no longer have to go point by point by point by point, like that old review of the Systems. Negative times 14 should be expunged. Now. Our notes have not caught up like our notes. I think it’s going to take a generation for our notes to improve.
But ideally the notes can be tighter, smaller. But as Chris said, sort of if you can get to that language and get in the habit of using it. It actually makes things easier on you because you get more stock language. I don’t think we’ll ever get to templated palliative care notes because we want to tell our patient story. But we can get, I think, to more efficient documentation that accurately reflects the complexity of care that we have and then serves your billing purposes.
Lynn 37:37
So to be really, really granular, to reflect complexity in your. You do not talk about time in the note, no time statement. And you have an assessment and plan that contains these buzz phrases like severe exacerbation. We made a decision about a code status, those kinds of words. We titrated an opioid, as long as.
Chris 38:01
It’S parental decision regarding parenteral controlled substance.
Lynn 38:06
So the word decision is important. Got it?
Chris 38:10
Yeah. If you can. If you can reach out to your coder and say, hey, can you send me the complexity table from the front of the CPT book? Number one, they’ll think you were dropped from outer space because clinicians never ask them for that stuff. And you will realize all the answers were there the whole time. They were just never taught to you in a way that you were able to internalize. That’s kind of what Phil and I try to do is say, hey, there’s a book that on half of a page, it tells you what the answers are to billing. You’ve just never bought the book because it’s $138. Your coder will copy that page for you.
Eric 38:47
Is there a page on the Internet or do we have to. To get that book?
Chris 38:51
You should reach out to your coder so that they know that you care about this stuff.
Lynn 38:56
Okay, wait. We don’t have that much time left. I think we need to spend a few minutes on advanced care planning codes.
Alex 39:00
Yeah, we do.
Lynn 39:02
Okay.
Phil 39:02
Of course.
Lynn 39:06
Okay, so first advanced care planning code, we learned you need to talk at least 16 minutes. How do you document in your note to indicate to match up with that code?
Phil 39:18
Yeah. So there. There is actually no language in any of the. The code that. That prescribes this. CMS has provided us some guidance. Right. You should, in general, to document who is present in the discussion, because you can have the discussion with the patient or with their surrogate if the patient is not able to participate. In the early days, there was all this question of like, do you have to be in the room? Can you be outside? Can you be in the ICU lounge? Do you have to see the patient from here?
Chris 39:50
Right.
Phil 39:50
So. But in general, you need to be in the same side of service. You should broadly discuss what you shared with the patient and any decisions that the debtor made. Specifically, you don’t have to make any decisions. Right. You could say we’re going to continue care and revisit. You do not have to complete an advance directive, but you should document it if they were discussed, if you’re going to try to identify a legal decision maker, you know, a patient advocate in our state. So best practice, who was there, what did you talk about and what was the outcome of that? Even if it is simply to continue current plan and revisit and then you.
Eric 40:29
Can add that to your complexity code.
Phil 40:32
Yes. If you build on complexity, you can then also build the advanced care planning code. That’s the Chris Jones go in for one service, come out with to codes. Right now, best practice is to write a separate advance care planning note.
Chris 40:47
Right?
Phil 40:48
That is best practice to write a second separate note. If you’re going to include it in your note, segregated out very clearly from all of your other E and M documentation. Put it as an advanced care planning addendum, something like that. There’s actually an advance. I’m going to speak EPIC for a second because EPIC is of course the Walmart of health records outside the va. They actually have an advanced care planning note type which will flag and you can search. We use that because that’s where our colleagues go to see our work and it’s super valuable when they’re trying to figure out what’s going on.
Eric 41:19
Okay, another lightning question. A social determinants of health assessment. Is that a code? Is that. I hear that was a code.
Chris 41:27
Yeah, that’s a code in the clinic. It has to be an assessment. It isn’t just a survey. So you can’t just have them fill something out on paper and then it not be addressed with the clinician. If you find a social determinants need, you have to have a referral process in place. So you can’t just write, oh yeah, they don’t have any food and then move on with your day. And it is a code. It takes. It’s about a five minute code. It doesn’t pay very well. It’s about eight bucks. Eight or twelve bucks.
Phil 41:56
Yeah. It is not a lot of money.
Lynn 41:58
Okay. And then another lightning round when somebody goes onto hospice. But let’s say I’m an outpatient palliative care doc, I may be their geriatrician and I keep in touch with the patient and I’m doing some visits. Can I still Bill for those visits, even though they’ve now gone on to hospice.
Chris 42:15
This one stresses me out.
Phil 42:17
Yeah, yeah. So. So this is where I’ll step in because I don’t mind. As long as you do not have a financial relationship with the hospice. Right. As long as you’re not hospice position that you’re not employed to bed them, you’re not on contract. If you’re truly serving as this patient’s geriatrician, you can sign up to be their hospice and doctor, as long as you don’t take anything of value from the hospice itself. If you’re employed by the hospice, you cannot separately bill part B because you are to be paid under the hospice per diem.
Eric 42:48
All right, my last lightning iron question. Because we couldn’t cover everything, there’s so much more to learn about this. Clearly I understand that this is important. Where can I learn more?
Chris 42:57
Yeah. So there’s a couple of things you can pull down from online. Capsi has really leaned into this and Phil and I have helped them along with Andy, Ash and Bryn and her team.
Eric 43:08
We’ll have a link to that in our show notes. We’ll have a link.
Chris 43:10
Yep. Capsi. And then there’s two other things we did back in 2016 when the ACP codes came out. There’s a top 10 article about advanced care planning. That’s open access.
Eric 43:20
Great, we’ll link to that too.
Chris 43:22
Yep. And then the CPT book. You want to get the copy of the CPT book, those couple pages. And then the last thing about advanced care planning, the Medicare Learning Network has offered back in February or March of 25 some documentation guidelines and best practices around writing up your advance care planning documentation. So Medicare Learning Network advance care planning. If you Google those words, you’ll get a seven or eight page PDF from the government.
Eric 43:50
Great.
Phil 43:51
Yeah. And last thing I’ll say because Chris won’t every time he says Phil and I, what he really means is Chris Jones. So Chris is the brain behind the operation. He’s the Al Michaels. You know, whatever Chris Collins were through. I used to color. Chris does fabulous consulting on this. So you know he will not self promote, but I will promote him. If you have the interest in your organization, I would make the very strong case to have Chris Jones work with your team. He could do it virtually. He’ll. He’ll do it on site if you’re in the right place at the right time of year.
Eric 44:23
All right.
Phil 44:25
But that’s high value.
Eric 44:28
We have a link to you on our show notes as well.
Chris 44:31
Yeah, that’d be great.
Chris 44:35
And then my stuff is so important. And the thing is, it’s complicated, but it’s not hard. If you can manage hyponatremia, this is way easier than hyponatremia because you don’t have to figure out if they’re wet or dry.
Eric 44:49
I love this. I am convinced that this is going to make me $1 million. I want. My last question is, Alex, what are you going to do with the million dollars that we’ve just earned?
Alex 45:06
(singing)
Eric 46:16
You get a chaplain, a pharmacist. Chris, Phil, thank you for joining on this podcast.
Phil 46:23
Our pleasure.
Chris 46:24
Thank you. Thanks so much.
Lynn 46:25
That was fun.
Eric 46:26
Lynn, thanks for being our guest host.
Lynn 46:27
No problem.
Eric 46:28
And thank you to all of our listeners for your continued support.
The post Medical Billing and Coding with the “Billing Boys” – Chris Jones and Phil Rodgers appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program. It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population.
We unpack the intriguing findings of a recent JAMA Network Open study authored by one of our guests, Susan “Nicki” Hastings, looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT). While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn’t translate into expected improvements like more time at home or better self-rated health.
We discuss the potential reasons behind this with our other two guests, one a geriatrics fellow, Kristie Hsu, and the other a recurring guest and host of the podcast, Ken Covinsky. Was it just that it didn’t work, or were there other things going on, from the intensity of “usual care” to the challenges of measuring complex health outcomes and the possibility that 18 months simply wasn’t long enough to see the full benefits?
Despite what was ostensibly a negative trial, we highlight some reassuring aspects and future hopes for GeriPACT and how we can all incorporate some of these components into the care of our patients. We’ll also pose critical questions for future research, emphasizing why continued development and evaluation of new care models are essential for the health of our older population.
** NOTE: To claim CME credit for this episode, click here **
Eric 00:06
This is Eric Widera.
Alex 00:12
This is Alex Smith.
Eric 00:13
And Alex, who do we have with us today?
Alex 00:16
Today we are delighted to welcome Nicki Hastings, who is a geriatrician in chief of the Division of General Medicine at Duke in the great state of North Carolina. Nicki, welcome to the GeriPal Podcast.
Nicki 00:28
Thank you. Happy to be here.
Alex 00:29
We’re delighted to welcome back Ken Covinsky, a frequent guest and host on this podcast who’s a professor in the UCSF Division of Geriatrics. Ken, welcome back.
Ken 00:38
Good to be here, Alex.
Alex 00:39
And we’re delighted to welcome Kristie Hsu, who is graduating from our UCSF Geriatrics Fellowship and will soon be working in a short stay rehab at the VA in San Diego. Kristie, welcome to the GeriPal Podcast.
Kristie 00:54
Thanks for having me.
Alex 00:55
And my son Kai is here for a little bit to help me with the guitar. He is a college student at Swarthmore Home for the summer.
Eric 01:02
So we’re going to be talking about geriatric patient aligned care teams. Do they work and who should be getting them? But before we go into that topic, we always start off with a song request. Nicki, I think you have a song request for Alex.
Nicki 01:15
I do. My song request, Alex, is Carolina in My Mind by James Taylor.
Eric 01:21
Why did you pick this song?
Nicki 01:23
Well, it’s a great tribute song to my home state of North Carolina, first and foremost. But also this song really reminds me of longing for home. That’s what this song’s always kind of made me feel. And actually that was a really influential concept in how we chose some of the outcomes for the study we’re going to be discussing later.
Eric 01:45
Wonderful.
Alex 01:46
Here’s a little bit. Love this song. Thank you.
Alex 01:56
(singing)
Eric 02:51
Ken, you had a critical question about that song.
Ken 02:54
Well, I think you answered it, Nicki, but I was wondering, is that North Carolina, South Carolina or both? I guess it depends where James Taylor’s from.
Nicki 03:02
North Carolina.
Ken 03:03
North Carolina.
Nicki 03:04
That’s right.
Eric 03:07
Nicki. I’m going to start off by asking you this question. How did you get interested in this topic of outpatient geriatrics care and GeriPACT teams?
Nicki 03:18
Well, I got interested in the question because it’s what I was doing at the time. I was seeing patients in the outpatient geriatrics clinic at rva. In fact, I was the medical director of that clinic for about five years. I was going into the leadership of my hospital and really pitching them that we needed to grow the clinic and make it bigger. When I did that, they asked me, well, how do you know?
How is this kind of clinic better than other kinds of clinics and what are we going to get out of it, et cetera. I thought I would go to the literature and answer that question and I really couldn’t fully. I said, hold that thought, I’ll be back in seven years with an answer and went out and decided to do a research study to really look into some of these questions.
Eric 04:08
Actually tried to figure out do they work and if they do, kind of how do they work and who should get it. I love that. Before we even dive into this topic, maybe we can just describe what a geriatric Patient Aligned Care team is or a GeriPACTt team is. Can you take that?
Nicki 04:27
I was going to say who should take that one? We could all answer that one, I’m sure. Geriatrics Patient Aligned Care Team in the VA is a special variation of how all primary care is delivered in the VA through patient centered medical halls. So it’s a team based care model. And the Geriatrics Patient Aligned Care team was developed to be specifically for older veterans with complex care needs.
Kristie 04:54
Nicki, I wonder if you could tell us more about the specific aspects of GeriPACT that kind of differentiates it from sort of our standard regular primary care at the va.
Nicki 05:07
Yes, absolutely. The way this is implemented in VA is there are really three key ways that a GeriPACTt is different. One of them is the panel size is a little smaller. Another one is that the providers have special training in geriatrics. And then the third is that there’s additional effort for team members like pharmacists and social workers to participate in the care.
Ken 05:31
Nicki, this is like a really. This question is such a good question, but let me, let me throw a question at you just based on recent experience. It just so happens our primary care director at the San Francisco VA is on maternity leave. Yours truly is now in charge of handling all the requests for geriatric consultation and transfer to the geriatric primary care team.
Nicki 06:01
So.
Alex 06:05
If it’s anything like the way Ken approaches palliative care. They’re all going.
Ken 06:12
Well, we do have. I would like to accept them all, but we have limited capacity. We just don’t have that much primary care capacity in geriatrics. I notice, though, that the consults we get from primary care, it’s never like this patient is doing great, and we think they would just love to be seen by a geriatrician. There’s always something wrong, and they can’t quite articulate what’s wrong, but there’s something that’s not going right with the patient, and they’re becoming more complex, and it’s becoming like, a lot of hard work for the primary care provider.
Sometimes it’s a resident who’s moving on and saying, you know, I’m not sure this is a patient who really should be handled by an incoming resident. Maybe like an attending geriatrician or a geriatrics fellow should get this patient so that, you know. So I’m just sort of like the question about what brings somebody into the clinic. And this is maybe a little bit of a pre question for as we go into your study, because I now that I’m doing this, if you kind of told me you were going to assess the outcomes of patients in my clinic, I would have a little bit of fear because, you know, it’s like, well, wait a second. Is like they’re coming to us because they’re like, they’re not doing that great.
Eric 07:39
They’re pretty sick. Something is going on that triggers that Jerry packed kind of referral.
Ken 07:45
Yeah.
Eric 07:45
Is that usually how it gets into Nicki, like, to these GeriPACT?
Nicki 07:49
I mean, you said it exactly right, Ken. Right. It’s. It’s. There’s all sorts of reasons, and sometimes it is because patient or family knows about geriatrics, wants to get in. Sometimes providers leaving, and they’re kind of getting reassigned to the geriatrics based on age or other things. But other times it’s like a call for help. Right. Like, we need something to go differently for this patient.
So I totally get it. And it was a key thing that we took into consideration when we planned this study, because you can’t just look at geriatrics, primary care, and primary care without doing a lot of careful attention to selecting the right patients. Or you could get an incorrect inference about how that care is delivered. Right.
Eric 08:34
Christa, you’ve been doing this for a year as a geri-fellow working in a GeriPACT, right?
Kristie 08:39
That’s right.
Eric 08:40
Have you admitted new patients during that time?
Kristie 08:43
I have, and I think speaking to what Nicki was saying, there are a variety of reasons why I see patients referred to me. So I did inherit a retiring physician’s patients who had the highest in the va. It’s a can score or kind of some of our highest risk patients with the highest complexity. And a lot kind of like Ken was describing, coming from some of my colleagues, people who I was residents with previously, who were feeling a bit overwhelmed. And honestly, I can also kind of empathize with that feeling of overwhelm as a recent primary care resident when there is sort of that degree of complexity and the lack of training in the 4M’s framework to really approach that complexity in a sort of systematic and comprehensive way.
Eric 09:45
Yeah. And is that the problem that we’re trying to solve here with GeriPACT? Nicki, what is Jerry Pack trying to do?
Nicki 09:52
What GeriPACT’s trying to do is really focus on the fact that for some older patients. And I think that. That some. And who are those that would really especially benefit from this model of care is a big question. But for some older people who have complex, often interacting physical and social challenges, we need a model of care that can really think comprehensively about how to help them maintain their independence and quality of life. So that’s the basics behind this, that it’s gonna require an expanded team, additional time, more resources brought in to really serve this particular group of patients well.
Eric 10:30
And that expanded team. Social worker, pharmacist, and a geriatric specialist. Right, Those are the key team members.
Nicki 10:38
Yeah, you got it, Kristen. I think that’s another place where you do see. Sorry to interrupt you. Where you do see variation across the country, because those are like the key members. But like in our geriatrics geripi clinic at the va, we have a physical therapist and occupational therapist we’ve got integrated in the team.
Eric 10:58
Not just consulting, but integrated in the team.
Nicki 11:00
They’re co located while we’re in clinic, they’re in clinic. So you do see differences. And some GeriPACTs have been built out even beyond that sort of core with the social work and pharmacist. But those are the basics for what VA considers to be a Jerry packed nationwide.
Eric 11:18
Kristie, what does your clinic look like?
Kristie 11:21
I wish I had physical therapy and occupational therapy embedded. To be honest, it is very similar to my colleagues impact teams in terms of the team makeup. And so I did see kind of the VA handbook dream version of GeriPACT does have one dedicated pharmacist and one dedicated social worker. And so that FTE dedicated to the GeriPACT team and ours, you know, we do share with other teams and so it’s not sort of dedicated FTE in that way, although there may be some more nuances there since I only practice there half a day a week. And so of course I wonder if that plays into it.
Eric 12:10
All right, so I got a question. So we’re going to get into the study which is comparing Jerry pack to pact. We’ve defined what Jerry packed is. Kristie alluded to what packed teams are, but I’m still confused. Like what is a pack team and how does it differ than usual care older adults are getting outside of PAC teams? Nicki, do you know that?
Nicki 12:36
Well, I was going to say Ken or Kristie might have to take it because I think my first swing at it did not make it clear for you. That’s probably on me.
Eric 12:43
Well, who’s included in a PACT team?
Nicki 12:46
Well, on a PACT team in va, that’s everybody that’s enrolled in a primary care clinic. That is the model that VA is bought into. If you’re enrolled in primary care va, you’re connected to a PACT team, but.
Eric 13:02
Who actually cares for you in a PACT team.
Nicki 13:04
In a PAC team, your core is going to be your primary care provider and then you’re going to have a nurse, an ma. Those are going to be the kind of the core pieces and you’re going to have access generally to the same kinds of interdisciplinary team members that we’ve been talking about, but usually at much less fte. Right. So one social worker is a sort of quote unquote, regular PACT might cover all of the PACT teams. You know, in a, in a given clinic, whereas in GeriPACT you’re really supposed to sort of have your, your own.
So it’s still team based care. It’s still really meant. That’s a really important part of all of PACT is to be able to engage with the interdisciplinary team when needed. But they have higher patient panels, so they have less time to spend with patients and they have less amounts of effort of these different interdisciplinary team members to be involved in care. What do you guys think? Did I get the key points of that?
Ken 14:04
I think that’s well stated, Nicki. I’m going to guess you can tell me if I’m wrong. Alex. Eric, I am going to. I do that all the time. Eric, I’m going to guess what you are thinking is that one of the core principles of good geriatrics models of care and one of the cores of any geriatric model that works is the interdisciplinary nature. You know, so the concept that you have nurses, physicians, therapists, you know, mental health, all talking together and working together.
So that the PACT team at the VA and the VA system, the concept is similar, but it’s not applied just to geriatrics. It’s applied to all primary care. So part of the input of the PAC team is that you actually have a dedicated team that includes a nurse and a social worker, all who are integrated and presumably all know the patients together. So, and I. And I’m guessing what you were thinking, Eric, is that, well, is the PAC team already doing some elements of geriatric care that don’t exist outside the va?
Eric 15:07
Yeah. And what does it look like outside? Like, Kristie, you were a chief resident at ucsf. You were a primary care resident. What did primary care look like to you during your training outside of the VA system?
Kristie 15:21
Yes, I did practice outside of the VA system. And I will say, in general, kind of the feeling amongst even primary care residents is a bit of jealousy of our colleagues practicing in a VA PAC team or a regular VA primary care because of the abundance of resources. When it came to having a pharmacist, I did not have a pharmacist in my primary care clinic. Having social work at kind of panel size that was quite different from what our social worker was juggling in our primary care clinic and then kind of the ability to refer to our mental health services. Just as Nicki was saying, there is a lot of sort of social and psychosocial complexity when it comes to our patients, and we didn’t have sort of that robust mental health in that way.
Ken 16:18
And actually, can I take what you were both driving at? You can edit this out if you don’t want, but I’m going to make a little advertisement here. Let’s put this on the table. VA care is better than community care. That primary care delivered in the Department of Veterans affairs is already better than the standard that exists in the community. Like multiple studies show that. And it’s for reasons like this. There’s more availability for services, care is better aligned. So let’s just. I mean, just people need to know that VA deli, VA is not perfect, but VA delivers much better primary care than exists in the community.
Eric 16:58
Great point, Ken. And let’s talk about that. So this is a study, right, Nicki? So you did a study not comparing kind of general usual care for older adults to. To jerry pack. You’re looking at these VA packs versus jerry packs. Yes, the jerry pack sounds like you have some more kind of. It’s more resource intensive. Right? You have a Social worker, pharmacist. You have a geriatric specialist, geriatrician on board. They have smaller panel sizes. So when you went to your boss, your boss is probably thinking, why should I give Nicki all this stuff? Like this is really expensive. Does it do anything? And you sought out to answer that question, is it better?
Nicki 17:38
Yep, you got it.
Eric 17:40
What did you do in this study to figure that out?
Nicki 17:43
Well, the first thing I did was I went and found some other good researchers to get together with me to help tackle this. Because this is a tough question, right? We were not talking about doing a randomized clinical trial where we could control where people go. We were talking about trying to do a nationwide evaluation to figure out the average effect of this model. There were many, many pitfalls that we could have stepped into that would have really, as Ken was alluding to earlier, led us down the wrong path. We used a lot of methods that people sometimes refer to as target trial emulation methods.
Basically try to think really carefully about how we could make sure we were comparing apples and apples when we looked at these two patient groups. So the very short summary of what we did is we found GeriPACTS that were roughly similar across the country, about 57 of them. We recruited patients who were having care in the, in the GeriPACT setting and then we matched them with people who were still receiving care in traditional pact on a list of characteristics. And then that’s the two groups that we compared. The list of characteristics that we matched on was based on what you were talking about earlier, what drives people into gerripact? So what are the factors associated with going in? Because that’s what we really needed to control for to make those reasonable comparison groups.
Eric 19:17
One thing that is always incredibly hard in any EHR data and I think is probably a component of what drives people in is functional status and not the number of diseases, but the course, the decline, which I feel like functional status is probably a pretty good marker of the diseases are getting worse. Were you able to include functional status in your matching?
Nicki 19:47
We did. We included a measure that gets at functional status. It’s not really account of ADLs or IDLs. We use the GEN Frailty index. So it’s a claims based index, but it’s been validated against functional status. So the things that we matched on were like demographics and this comorbidity score that Kristie mentioned earlier, whether you’ve been in the hospital, because Ken mentioned that sometimes that’s what’s driving people to come in. And then this other measure of Frailty with score called for lt. But essentially it has been shown to predict functional ability. Those are the things that we matched up.
Alex 20:23
I can tell Ken is struggling.
Eric 20:25
Ken is jumping out.
Nicki 20:28
Is this where we’re going to say propensity score,
Nicki 20:34
distance function match, at least.
Eric 20:36
I don’t think we’re going to be talking about regression of mean, which is another favorite topic of Ken.
Ken 20:40
I don’t play poker because I lose a lot of money.
Ken 20:47
So.
Nicki 20:47
Yeah.
Ken 20:48
So, Nicki, like, what? This was like an exquisitely well done study. I mean, it’s like, it was like, you know, I learned about methods reading your study, and I even read your supplements because, like, I think if I do something like this, how am I going to do it? And like, if I was writing a grant, like, using like, observational methods, I’d say we’re going to use state of the art methods as described by Hastings. So it was really just beautifully done because it’s challenging because you’re trying to. It’s not randomized and you’re trying to equalize these groups as much as possible. And I think you did everything you could have done to control for what you could control for, and now the question is about what you can’t control for.
Nicki 21:36
You got it. You said it. I mean, first of all, being invited to participate in this conversation meant some people read my study. So already that was like the hallelujah chorus, right? And now you just said you read the supplement. So.
Kristie 21:49
Okay, Nicki, we nerded out on your study.
Alex 21:53
Kristie led the Journal Club in our division of geriatrics, and we nerded out about it. She was a great Journal Club.
Nicki 21:59
It’s incredible. Like, you know, I worked really closely with Courtney Van Houten, who’s a health economist, and Valerie Smith, who’s a biostatistician. These are brilliant scientists. And it took all three of our brains working together hard for a long time to come up with these methods. So thank you for the compliments. We did the best we could. And where Ken is also driving is, it’s still not perfect. Right? You could definitely still think of other things that we could have included in the models. And no observational study at the end can say we took care of all selection bias. It’s all gone. That’s just.
Alex 22:38
What are you most worried about, Ken?
Ken 22:39
Well, let me take it back to the initial discussion about how people get in and think, like, let’s one minute about what happens when somebody is seen for the first time in a geriatric clinic or a consult clinic. And Kristie you weigh in, because I’d be interested in what you do.
Alex 22:57
But.
Ken 22:58
So the central problem, the reason for referral, is patient not doing well. We can’t really describe why. So the first part of our assessment is actually to disarticulate not doing well and the why of that. So that actually involves, like, the tools and training of geriatrics. We do what’s known as geriatric assessment. And it’s a really critical look at the patient’s physical, cognitive, mental health and psychosocial functioning. And that identifies a lot of problems. So that part of the art of geriatrics care actually is putting a name or a condition to the reason somebody is not doing well.
So why does that matter? In a study like this, you can’t control for what you can’t measure. So we actually are now naming all the stuff that explained why the patient wasn’t doing well. And because it wasn’t named before, it could not have been included in the electronic record database. So it’s sort of, to me, one of the fallacies of all of this artificial intelligence machine learning is like, you know, there’s no algorithms that could deal with a measure that’s not there.
Ken 24:19
So I think that’s sort of like. So I think one of the fundamental questions here is like, how, you know, is that picked up by other stuff that you were able to measure and how important are all those stuff?
Nicki 24:32
Yeah, I think it’s such a great point. Like, in our study, what we did is we really, we looked at people who were in the VA and we’re seeing PACT providers, and then they transferred over to GeriPACT. So then we looked at the first sort of 18 months that they were in a GeriPACT. We designed it that way so that we could get our matching variables from the time point when they had not been exposed to GeriPACT. So presumably they were equally likely or unlikely to have had those conditions sort of named if they were present but not yet diagnosed. But that definitely also created another challenge in the study, which was we were able to look at the first 18 months they were in GeriPACT. I would love for somebody to tell me how long it takes primary care to change the true trajectory of health.
Eric 25:24
I got a question then.
Nicki 25:25
Right. But I think it’s like, we don’t know.
Eric 25:28
Going on top of kin. I love this design. This is what you’re talking about, like target trial. Everybody’s kind of getting the same thing, and then they get the intervention just like in a randomized control trial. So going to Kens, if you look at that. And then all of a sudden, the GeriPACT team has a bunch more geriatric syndromes. Is it that geriatric care teams don’t work, or is it that we’re just picking up all those syndromes? So how did you think about what is the right process, primary outcome you want to look at, given that they’re probably going to get more assessments and maybe even more diagnoses?
Nicki 26:02
Yeah, I mean, it’s a great question. So what we wanted to do is we wanted to look at two things. We wanted to look at just what you’re talking about, assessments, the process of care. And so we looked at were they getting screened for functional status? Were they getting screened for other geriatric syndromes, incontinence, falls, et cetera? Were they having advanced directives, conversations? Then for the outcomes part, we wanted to know some experience of care measures from the patients.
We want to know some patient reported outcomes for health and well being. But we also wanted to look at what we called home time as our primary outcome. Now we get to think back to Kai and Alex’s beautiful rendition of Caroline. My mind this is because in all my years of practicing geriatrics, the number of times that I’ve heard patients express to me that what they really valued was going home or staying home or being home. It’s just been a really consistent theme.
It’s not always, but we hear it a lot. What we were trying to do in the study was to create an outcome that would assess that. How well did being in Jerry packed help patients meet the goal of being at home more? So we looked at this home time as the primary outcome.
Eric 27:26
What consisted of non home time is this like hospitalizations, dialysis days? Just what was that concept we talked about, Alex, in another podcast, the Healthcare Footprint. Like the amount of time that they’re just seeing?
Nicki 27:42
Well, you know, we picked home time and we thought, well, that’s a nice, easy conceptual measure. Of course. No, it’s deeply complicated. Exactly as you said. What we ultimately landed on was using home time was days that you were not in the hospital, not in the skilled nursing facility, not in a rehabilitation clinic, not an emergency department. Okay, we’ve got lot.
We actually are doing lots of research now and doing some focus groups. Again, this is led by Courtney Van Halven, asking patients what should be in a home time measure. Because I think there’s a lot more to figure out there. You said it. With dialysis, outpatient surgery, there’s a lot of other stuff you could consider. But what we did was just those four that I knew.
Eric 28:25
Yeah, I remember I brought this up on another podcast, but Ken, during our literature updates, he talked about another study. Just looking at just the footprint that we have in medicine, the time that we ask older adults just to come for our lab tests, our outpatient visits. And it’s like amazing the number of days per year that is just allocated towards us. Is that a good summary, Ken?
Ken 28:51
Yeah, yeah. No, I mean, it was a substantial number. I can’t remember. There was over like 10% of patients spend more than one day a week with us, you know, over the course of a year or so.
Eric 29:02
Yeah, that’s not home time. That. I would not put that as home time. Right. That is, we are asking them to be away, but that wasn’t here. So you’re looking at hospitalizations. Eds, does geriatric Patient Aligned Care teams, do they work based on that outcome?
Nicki 29:18
To that question, I’m going to tell you what we found when we looked at that outcome. What we found is that for patients who had been exposed to GeriPACT for 18 months, they had no difference in the, in their home time compared to people who stayed in traditional packs. So there was no difference. Now, the reason I laughed and said, I’m not going to answer your question is because we didn’t really go into this to sort of ask this big existential question of like, you know, is geriatrics valuable or not valuable or anything like that like it is.
That’s not a question we’re poking at today. It really is, how do they work and what could they potentially. So for the outcomes we measured, we found no difference in home time. We did see a significant difference in the assessments, the assessments for falls and the other things that we mentioned earlier. So we definitely could see that care was delivered differently, but we could not observe that the outcomes were measurably different after this 18 months of exposure. Hmm.
Kristie 30:25
I am very interested in. I think you stated it so well. And I am wrestling as a trainee with practicing in GeriPACT. I have been trained to do the screenings, do the functional assessments, think about the falls, think about incontinence, and it’s amazing to see that that is borne out and that training works. I wonder if you could speak more to the discrepancy with the outcome measures and kind of what you think is driving the outcomes that you saw with the data.
Nicki 31:03
Sure. Well, I mean, you know, as a scientist and not a geriatrics evangelist, which I could be reasonably described as both on different days of the week, but you would have to say that one possible explanation is that GeriPACT did not work right. Or that did not have the intended effect, and that’s why we didn’t see the outcomes change. I’m more of the opinion that it could be an issue with time horizon. So if you think about assessments, then what ultimately happens as a result of doing these assessments that you just mentioned that we’re trained to do is it depends on the positivity rate, the actions that are taken in response to what you find.
And then, you know, it takes some, again, downstream time to sort of realize the effects of those interventions. So in our study, the people who were in GeriPACT for 18 months had about six visits total, so about six visits to have the assessment come back and maybe review the results of the assessment and then take some steps to intervene. And I think we just don’t know if there might be some downstream effects that we weren’t able to observe given the study timeframe. So that’s something for us to look into in the future. I think another thing for us to look into the future is what are other potential effects that our patients care about?
One of our geriatrics fellows, Chelsea Perfect, is joining our faculty soon, very happy to say, did another study where she looked at recognition of cognitive impairment. Same population, and she looked, and people who were exposed to GeriPACT were more likely to have a diagnosis of cognitive impairment or dementia. This is exactly what Ken was articulating when we were talking about the challenge of the study design. There could be downstream positive effects of that as well.
Alex 33:10
So to paraphrase Nicki, you suspect that if you could have looked out 10 years, which is like a really long time, granted, for like a study, the longest NIH study is usually five years. And some of that’s got to be analysis. So it’s really usually like a three year at most window. But if you could have gone out much further, then you suspect you would have seen differences. Even with the limitations of this study design.
Nicki 33:37
I think it’s possible. I think if NIH or VA would like to give me the money to do that, my door is open, and I hope that they will. I think we need to study it and answer the question. I think it’s possible.
Eric 33:49
How much do you think an observational study, even the best observational study, can really answer the question? Because this causality question, like, does Jerry pack improve this versus, like, we’re always going to be mired in this issue of. Well, the people who go into Jerry packing are inherently different than those who don’t like there is the same thing we see in these observational palliative care studies.
The reason they’re getting a palliative care consult is something’s happening. So unless you do a randomized control trial, you can’t answer that question. But we can answer other questions like, what are these components that are happening during these jerry packed interventions? What are we seeing with them? Maybe posing additional hypotheses. Thoughts?
Nicki 34:41
Well, as people have tried to study these questions with randomized controlled trials, and that’s not so perfect either because patients don’t always want to adhere to the randomization assignment of who their doctor is. Right. So people have tried to say randomize you to change clinics or stay, and people crossed over like mad because people like to kind of control that decision.
Right. So I think there are challenges no matter what the study design is. But I think that from my perspective, if we’re using the best observational methods that we have available so that we’re controlling bias to the best of our opinion, we’re still learning something and moving the field forward with these observational studies. I don’t think it’s a throw the baby out with a bathwater situation, but I’m watching Ken’s face now that I know he to see if he’s going to agree with me or not.
Alex 35:36
Looks like my puppy being ready that.
Eric 35:38
Wants to get outside.
Nicki 35:42
I’m so glad we’ve got video on this topic.
Ken 35:46
I don’t think I’ll comment on that observation.
Ken 35:52
Yeah, no, I agree with you, Nicki, and I think a few. I actually do wonder if the time is right for an RCT though. You’re right. It’s like, it’s hard, but it’s hard. It would take a lot of resources.
Eric 36:08
Well, our last podcast last week, so you can go, all of our listeners can go to it. We just published one on comprehensive dementia care. Two huge randomized controlled trials of comprehensive dementia care, one with the additional layer of palliative care, both negative on their primary outcomes with some interesting secondary outcomes that were positive. And even in that running mass control trial, like you’re trying to think, oh, you know, maybe we should be looking at these secondary outcomes as the importance. And like, what other. Like, I understand that RCTs are not end all be all. Yeah, Ken, you were going to say more.
Ken 36:45
No, I mean, I think like if they had given you unlimited resources, Nicki, to do this as an observational study, so for example, that I think it’s possible one might have had a different answer if you actually could have done a geriatric assessment in both groups and actually put all the stuff that we said you couldn’t measure, you actually could have adjusted for that. I think the other thing I wonder too is that the outcome you measured is certainly important. And I think it’s the kind of outcome we often take to the people who pay for health care.
Because I mean, obviously one of the motivations of this is if we could tell like the VA that oh, you’re going to save money on emergency room use or hospitalizations, like the clinic will pay for itself. Of course, we do a lot of things in health care. I sometimes object that geriatrics and palliative medicine, why do our interventions have to pay for itself if they do good for patients? The cardiologists never have to make that argument. So that said, I’m also wondering, a lot of the things that might happen that are good in a GeriPACT are things that were difficult to measure so that lifespace mobility, for example, so if they got the right therapy, we helped them get the mobility equipment they needed.
They actually could use their bathrooms and showers because we thought about putting pudding and grab bars. So that there’s a lot of aspects of quality of life that I wonder were better or like caregiver burden or caregiver stress. So that there’s a lot of other outcomes that I think maybe aren’t cost outcomes, but would have impacted quality of life. And those, of course, would have taken a lot of resources to measure.
Nicki 38:36
Yeah, and I think another really important point is sort of back to the beginning of the conversation. We have to remember the context in which we did the study which was in the va. So if we had compared this model outside of the VA and the comparison group did not have the things we talked about earlier of PAC teams, team based care, access to the interdisciplinary teams, we might have gotten a different result.
And in fact, some of the studies that have done comparisons of, I’ll say, intensive primary care models that have shown bigger effects than we observed here have done them in, for lack of a better word, fee for service model where there wasn’t team based care and they served greater effect. So we were comparing against a pretty high bar in terms of quality of primary care that was already in place.
Eric 39:30
Kristi, I want to give time for you to ask any questions that you have.
Kristie 39:35
Yeah, I think that again, I just learned so much from the methods and just so appreciate, Nicki, you taking the time to join us today. I guess a bigger picture question I have is knowing that there is a limited supply of geriatrics trained providers did looking at this data and thinking about this and presenting it to others, kind of what are your takeaways in terms of the best use of geriatrics trained providers and outpatient care? And this is open to anybody too, if you have other reflections on that question.
Nicki 40:12
Probably all have opinions on this, but now I’m getting into the can jump, jump mode. I really consider geriatrics a precious resource. Limited, limited precious resource. Right. What are there 7,500 geriatricians in the country right now? And that number is probably only going down. So I think it’s stable.
Eric 40:34
It’s stable. The latest data from AGS, it has been stable for the last 10 years.
Nicki 40:40
But I like the optimism and believe me, I’m doing everything I can to train more geriatricians and thank God for Christine. All the things I do think it’s a really valid question. And I think that to me, what the data made me double down on is geriatrics expertise. We know how to deliver really good care and so we should be involved in leadership and geriatricians should be involved in designing care models for older adults. For sure. In terms of the delivery like which older adults really need a geriatrician in the clinic every time they come to the clinic? I think that’s a question we have to keep pursuing.
Eric 41:22
And then there’s those key components, even those key components that we see with pact. So interprofessional care, there is a big focus on things like advanced care planning, but maybe including some of those other aspects for that primary geriatrics care delivered by anybody seems important.
Alex 41:40
Ken, how would you answer Kristie’s question?
Ken 41:43
Yeah, no, I think it is really one of the question of geriatrics is how do we spend our time to best advance patient care and is it best spend on an individual level or system planning level and is it guided towards those most in need or who are most vulnerable? I am not sure I have the answer to that because I think some of it is. We also have to teach people how to provide better geriatrics care and teach primary care providers.
I tend to think that, like I agree with you Nicki, that I think a lot of it has to be on the health system leadership level and getting these aspects of quality that are better in geriatrics moved into more primary care models. So that I know we’re discussing a study where the outcome for the primary outcome was negative. Nonetheless, I still believe that providing geriatric primary care for those who are most vulnerable and most needy Makes a difference.
Eric 42:53
Nicki, what’s next for you?
Nicki 42:55
Well, in terms of research, this is probably not what you meant, but where my mind is going is I’m now the Chief of General Medicine at Duke, which means I get to think about how to integrate geriatrics into primary care in a whole different way. That’s really exciting for me, and it’s made me think about the results of these studies in a whole different way.
But really, the research questions we want to dig into are exactly the ones that Ken was talking about. Who benefits the most from geriatrics primary care model so that we better deploy this precious resource for people who stand to benefit. That’s a $64,000 question, but we’re going to keep pushing towards it.
Eric 43:36
Well, I want to thank all of you for being on this podcast, but before we end, I think Alex got a little bit more. A little bit more Kai with you. Okay?
Alex 44:25
(singing)
Eric 44:50
Nicki, Kristie, Ken, thanks for joining us on this podcast.
Nicki 44:54
Come visit me in North Carolina.
Eric 44:56
All right, and thank you to all of our listeners for your continued support.
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Moderators Drs. Widera and Smith have no relationships to disclose. Guest Eric Wong and Thiago Silva have no relationships to disclose.
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The post Is Geriatrics-focused Primary Care (GeriPACT) Better? Nicki Hastings, Kristie Hsu, and Ken Covinsky appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
With all the attention focused on Alzheimer’s biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA.
We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — D-CARE and IN-PEACE — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the comparative effectiveness of health system-based dementia care, a community-based program, and usual care, while IN-PEACE assessed the addition of palliative care to dementia care programs for individuals with moderate to severe dementia.
Despite their pragmatic trial designs and high expectations, both studies’ primary outcomes were negative, although there were some intriguing positive secondary outcomes. We discuss how some critical questions about the integration of these findings into practice, and how they fit in with previous research that did show benefits (see this past podcast on using health navigators to improve dementia care).
If you want to learn more about comprehensive dementia care, check out these past podcasts:
Lastly, here is the link to Greg Sachs’ NEJM article that describes his maternal grandmother decline from Alzheimer’s disease.
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:01
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:03
This is Alex Smith.
Eric 00:04
And Alex, today we’re gonna be talking about comprehensive dementia care management. Does it work?
Eric 00:10
Who are our guests with us today?
Alex 00:12
Our guests today, we’re delighted to welcome back David Reubin, who’s a geriatrician, professor of medicine, director of the Alzheimer’s and Dementia Care Program, and director of the guide program at UCLA. David, welcome back to the GeriPal Podcast.
David 00:25
Glad to be here. Thank you.
Eric 00:26
It seems like a good guest for answering that question. We have another guest with us.
Alex 00:30
We also have Greg Sachs, who’s a geriatrician and palliative care doc and chief of general internal medicine and geriatrics at Indiana University. Greg, welcome to the GeriPal Podcast.
Greg 00:40
Thanks. It’s a pleasure to be here.
Eric 00:42
So recently we just got two JAMA publications authored by our guests that we have links to a podcast around this question about dementia care management programs. But before we go into this topic, Greg, I think you have a song request for Alex.
Greg 00:58
Yes. John Lennon’s Give Peace A Chance.
Eric 01:01
Why did you pick this song?
Greg 01:04
When my team and I were working on the pilot grant for this program where enough of us of an age where the Beatles and John Lennon sort of resonate. So this is the mug my team got me.
Eric 01:17
What does your mug say for our people listening on audio?
Greg 01:20
Give “in” peace a chance. The other side of the mug is not a picture of my face, but it’s John Lennon.
Eric 01:30
The trial was called In Peace. How long did it take you to come up with that acronym, In Peace?
Greg 01:37
Not long, because we had done a study previously at the University of Chicago called Peace Palliative Actions and Alzheimer’s Care Efforts. And when you move to Indiana, you can slap in on the beginning of anything.
Alex 01:52
That’s great. All right, here’s a little bit.
Alex 01:59
(singing)
Eric 03:01
Alright, very nice Alex. We will talk more whether or not we should give in peace a chance. But I was wondering maybe we could take a big step back. I’m going to start with you, Greg. How did you get interested in it sounds like you’ve been interested in this a while, this idea of comprehensive dementia care management.
Greg 03:19
Well, you could go back to an editorial I had the fortune of writing in the New England Journal in 2009, where I go into it in more depth. But basically I grew up watching my grandmother die from dementia, receiving very poor care, dying with no palliative care in place, and with lots of bad things happening to her eventually in the nursing home. And so for essentially decades, the idea of trying to improve care for people with dementia and their families has been a real core of what I’ve been driven by.
Eric 03:56
For our listeners who may have not read it, we will have a link to that New England Journal editorial if you can describe what were the biggest things that you were seeing that was wrong with the care that we were delivering.
Greg 04:09
Well, at that time, I think it was very frequent for people to end up in nursing facilities without any kind of supportive care. They were sedated or given psychotropic medications, and things were done to manage them at the convenience of the staff rather than trying to improve the quality of life with residents and support their families. And there was literally nothing in the way of palliative care or hospice that was provided to patients with dementia at that time. And that’s changed dramatically. And I think that’s a good thing. But it’s still is a piece that needs to be integrated into dementia care management programs. The palliative care part.
Eric 04:53
And we’ll talk about your trial in piece about layering that palliative care into these comprehensive care management programs before we do. Dave, you’ve also been doing this for quite a long time. How did you get interested in creating these programs?
David 05:08
Well, I’ve been doing basically kind of practice redesign research for close to 30 years, and I got a little sidetracked. I was doing a lot of work for the abim, including chairing its board. And when I stepped down from that, when I rotated off, my emails dropped in half and I said, geez, I have some time on my hands. Meanwhile, one of my patients, one of my partner’s patients, was a man whose wife had Alzheimer’s. I covered for her when she was on the inpatient service and he wanted to do something for Alzheimer’s disease.
And so I said, you know, that’s a very needy population. And as I learned more about it and looked at models, including the Indiana model, I realized just how much needs to be done and how terribly devastating this disease is. So I began to focus almost exclusively on dementia, little bit on falls but, well, mostly on dementia. And it’s been incredibly gratifying.
Eric 06:19
And both of you just published some really big studies that usually we wait a little while to dive into it. I think it’s important because I think it’s, as we think about kind of next steps moving forward, what we should learn from it. Maybe we can start off with your trial, David, thinking about what you’re doing at UCLA with this comprehensive DCARE trial. Is that DCare, right?
David 06:42
Yeah. DCare is the name of the study.
Eric 06:44
What does DCare stand for?
David 06:46
The Dementia Care Study. It’s not an acronym.
Eric 06:52
Real briefly, what did you do in this study?
David 06:55
So it wasn’t actually done at ucla. None of the clinical trial sites? The four clinical trial sites, two were in Texas, one was in Pennsylvania and one was in North Carolina. So we randomized dyads, basically persons living with dementia and their caregivers to one of three arms. One arm is health system dementia care, which is based off of the UCLA Alzheimer’s and Dementia Care program. It involved co management with a nurse practitioner or a physician’s assistant who is based in the healthcare system. Second arm was community based.
Eric 07:36
Before we go into that for that arm, did they have specific training on how to care for dementia or were they just.
David 07:42
Oh, yes, they got trained out the yin yang. Yeah. So they got trained, monitored fidelity, all sorts of fidelity things. The second arm was community based dementia care, and that was dementia care that was delivered in community based organizations. Could have been the Alzheimer’s association, it could have been senior center, but they had a dementia care special manager called a care consultant who was either a master’s in social work or a bachelor’s nurse.
And all of that care was delivered telephonically. And then the third arm was usual care and we threw in the 1, 800 Alzheimer’s association helpline that people can call.
Eric 08:29
And the difference between the healthcare system based and the community based, like was the content that they covered and they helped with similar.
David 08:39
The content was not different, it was who was providing it and how. In fact, we’re looking right now, in next two weeks we should finish up. We’re looking at all the quality indicators and see whether they differed or not. But basically the kind of care was very similar. It was who was doing it, how they were doing it.
Speaker 7 09:01
Yeah.
Eric 09:02
And I just want to also acknowledge that both of your studies took place during COVID I’m guessing that influenced a little bit of how, because right. Initially the healthcare system was supposed to be in person.
David 09:17
It was in person, yeah.
Eric 09:18
And did that Shift with COVID Oh, yes.
David 09:22
Nine months into the study, March 16, 2020, all clinical trial research stopped.
David 09:32
And across the country, not just in dementia care, but we got back into the field relatively soon in May. But we had to switch instead of in person care by the dementia care specialist in the healthcare system, ARM to telephone and virtual.
Eric 09:51
So does that mean that the two interventions started looking very similar?
David 09:56
They look more similar. It was different kinds of people delivering them and different access to the health healthcare records and such like that, and consultants, but they were not touching people.
Alex 10:10
Okay, and just back to the dyads, the people with dementia. How would you characterize them in terms of dementia severity?
David 10:19
They were relatively severe. We did a version of MOCA that was administered over the telephone, and they would be considered at least moderate to moderate severe on average. We had no criterion, exclusion criteria other than they had to have a diagnosis of dementia.
Eric 10:41
So you had this intervention. What were you hoping to change?
David 10:45
Well, our primary outcome was dual. We had two primary outcomes. We had hoped to reduce neurobehavioral symptoms in people who were living with dementia and reduce caregiver strain among the caregivers. Those were the two primary outcomes.
Speaker 7 11:04
Yeah.
Eric 11:05
And the npiq, which was the Neuropsychic Inventory, one measure of those behaviors. Did these people have high baseline levels of behavioral issues or caregiver strain?
David 11:19
Yeah, considerably higher than you or me. They had symptoms. I believe there are 15 items on the NPIQ. And, you know, they raised anything from apathy to aggression, agitation, sleep disorders. So most of the people had, you know, two or three symptoms.
Speaker 7 11:41
Okay.
Eric 11:42
Yeah, we’ll get to Greg’s article. Because, Greg, you used NPIQ as a primary outcome, right?
David 11:47
Yeah.
Eric 11:48
So let’s. Maybe we’ll hold off on the NPIQ question.
Alex 11:53
I was wondering if we were gonna get into that now. We’ll get into that in a little bit.
Eric 11:56
That’s quickly, because I want to talk about both of these articles. I think an interesting comparison. But real quick, David, what’d you find?
David 12:08
Okay. So we had kind of mixed outcomes. The two primary outcomes did not differ among the three groups. Not only did they not differ among the two interventions, but also the third group.
Eric 12:22
So no difference in behavioral outcomes for the patient. No difference in this caregiver distress strain.
David 12:30
Index or distress from behavioral symptoms or PHQ8, which is a depression. None of those differed. The one secondary outcome that differed, and it differed significantly with both interventions compared to usual care, was caregiver self efficacy.
Eric 12:47
What does that mean?
David 12:48
That they felt they were able to control, manage this disease better.
Eric 12:54
Okay, so they felt like they could do it better, but there was no difference in strain, no difference in depression symptoms, no difference in behavioral outcomes. What do you make out of that?
David 13:07
Well, there are many interpretations. One interpretation is that, and, well, I’m interested in Greg’s take on this, is maybe the neurobehavioral symptoms and distress responses is not the right outcome. You know, maybe that’s not, you know, maybe that’s too hard an outcome to move and maybe it’s not capturing the right things. So one of the questions is, are these the right outcomes? The second is, and this is a lesson I would give to all budding research, do not do a randomized clinical trial during a pandemic.
Eric 13:47
Right.
David 13:48
Not the right.
Eric 13:48
Should have known better, David. Should have known better.
David 13:52
Yeah, it’s wrong time to do this because. And I’m certain Greg ran into this as well, but you know, these community based services, as you want to refer people to closed. Right, the people who are living in assisted living, their family couldn’t visit them, they couldn’t get caregivers, you know, all sorts of things that really, what we anticipated would be parts of the intervention couldn’t be delivered, plus all the psychological overhead of the disease itself.
Eric 14:25
I got a question though, David. Let’s say that study was wildly positive. Would you say, though, the generalizability of it should be thrown out of the question because it occurred during a pandemic and post pandemic, we’re not in the same environment. Like, would the opposite have been true too?
David 14:43
Well, that, that would advocate for, you know, having more pandemics. Try to have a pandemic group going all the time, because those are the only conditions under which it works.
Greg 14:55
We’re working on that.
Alex 14:56
Right, right.
Eric 14:58
No, but the question is, like, when we do these studies, like maybe in an area in pandemic where there are not a lot of other resources, adding this extra layer of support actually helps in those times. But should we think differently?
Alex 15:11
Yeah, maybe it’s like a high bar to pass. Right. If you can. If this actually shows a change during a pandemic, then, wow, what’s it going to show outside of a pandemic?
Eric 15:20
Or will it show anything because the resources weren’t there?
Alex 15:23
There are two ways to look at it.
Eric 15:24
Yes, I do want to ask the question about the primary outcome. Yeah, we’ll get, we’ll get to that. But before we do, let’s actually talk about Greg’s study, because I think it’s going to be an interesting comparison between the two. Greg, so you did your study, which is comprehensive dementia care, but on top of that, layered palliative care, is that right? So this is the NP study.
Alex 15:48
What did you do?
Greg 15:49
So the layering of palliative care was essentially by having the interventionists, who were a nurse and a social worker, each caring for a group of dyads of patients with dementia and their family caregivers who were trained in palliative care in addition to the dementia care management model. And so the social worker had worked in hospice previously, the nurse had worked on another palliative care grant, and they were both trained in advanced care planning and goals of care conversations. So we had specific, you know, sort of modules that we wanted them to try to incorporate into their ongoing care.
And their intervention was contacting the family caregiver on a monthly basis and trying to pick up early on on changes in patient symptoms, caregiver distress, other kinds of clinical changes, so that we could intervene quickly and hopefully before people needed to go to the emergency room or hospital or even necessarily go to their clinician like their primary care doctor. And we’re a little bit different than what David described. We were doing this in central Indiana in two health systems collaborating with their primary care practitioners. And our entry criteria included that people had to have more advanced disease.
So we set it up so it had to be fast, stage five through seven, so at least significant impairments and activities of daily living. But it turned out we enrolled people with only stage six and seven, for the most part, there were only a couple of people in stage five. So we ended up.
Eric 17:31
These were all community dwelling people with.
Greg 17:33
Yes, they had to be community dwelling dementia that includes assisted living, but they couldn’t be in a nursing facility and their caregiver had to have regular contact with them on a weekly basis. And like David, we picked the NPIQ as our primary outcome. And the secondary outcomes included the caregiver distress from the neuropsychiatric symptoms, patient symptoms as measured by the smeold, which is measure of symptoms, latent dementia, the PHQ8.
So caregiver depression. And then, very importantly was a measure of, you could call it healthcare utilization, but from a palliative care perspective, keeping people out of the emergency room, in the hospital is a good thing and keeps them from being harmed and suffering all sorts of iatrogenic things. So the combined outcome of ED visits and hospitalizations was our last outcome.
Eric 18:32
David, did you look at that outcome too?
David 18:34
Utilization well, that’s. I was very interested in how Greg got these data. We are funded to look at utilization. That was one of the specific aims that the National Institute on Aging funded us for. However, there’s a problem getting that data out of Medicare. The claims data. Yeah, not so much for fee for service Medicare, but for ma. There’s a year and a half to two year delay and we are still in this waiting for Godot kind of situation.
Eric 19:13
All right, so hopefully we can see that data sometime soon.
Greg 19:16
So we did not want to deal with the nightmare of Medicare data and, or dealing with Medicaid, Medicare managed care. And so ours is based on the fact that we have a very robust health information exchange many decades old here in Indianapolis. And so there’s an arrangement where we could get the permission of the caregivers and patients to access their data through what’s called inpc, so the Indiana Network for Patient Care. And so we actually have. The nice thing about it is we could pick up on ED visits or hospitalizations throughout the region, not just in the two health systems where we were, you know, enrolling patients.
Eric 20:01
And David, can I ask what. I mean, Greg has one more question about your study. I guess David too, like when I think about, you know, a lot of the trials for drugs in dementia, it’s a super white wealthy population and they cite a lot of reasons why they can’t have more diverse populations. Same thing with yours. Super white wealthy?
Greg 20:23
No, we had almost 40% African American or black. And we’re fortunate.
Eric 20:30
Wait, so it can be done?
Greg 20:32
Yes, we made an effort, but we’re also fortunate to be building on a tradition here where we have one of our health systems is a safety net health system that’s very well trusted and loved in the community and has a history of having people participate in research. And so that’s some of the things. We had an old, very frail, home dwelling group of people with a high proportion of people who were black and from a resource poor community.
Eric 21:05
David, how about yours?
David 21:07
We are about 21% non Caucasian, non Latino, including African American, black and Latino. It’s about 21%. So pretty representative of the population.
Eric 21:28
So fascinating. I loved your studies and I think, Greg, I think your study shows, yes, we actually can enroll very diverse populations in these dimensions if we cared about it. Yeah, yeah.
Alex 21:43
What did you find?
Greg 21:45
So like the DCARE study, the NPIQ did not move. So we didn’t have benefit in the neuropsychiatric symptoms. We also did not have any benefit in the other symptoms for the patients. Or the caregiver distress or depression. But we had a pretty dramatic effect on ED visits and hospitalizations. We literally cut them in half, both individually and the combined endpoint were reduced in half, as you said, during a pandemic. So if we were able to have a pill that was the equivalent to Vinpeace, we’d be making billions of dollars in the sense of being able to reduce that kind of utilization.
Eric 22:29
Well, I guess the question for that is if this was a pill. I love this program, has great face validity, but if I was having this podcast about a pill, I would be saying, but the primary outcome was negative here. This was a negative study. The hypothesis that it would improve behavioral symptoms just was negative. And all the other distress didn’t change. These other things didn’t change. Are we just picking and choosing, hey, here’s a secondary outcome that’s positive. Would we have that same bar if it was a pill? I’d probably say no. What do you think about that?
David 23:05
I think you have to categorize these into two big categories. One is clinical benefit. And I would say that both of these studies showed less clinical benefit than had hoped. But I think that utilization is also a very important benefit because if it can reduce utilization, as the NP study showed, you know, that all boats rise, that means more money to do other things, to implement things like guide, et cetera, if you’re spending less money on recurrent emergency visits or hospitalizations. So either if you hit a home run, either way it still adds the score.
Greg 23:50
Yeah. And I think that we’re sort of, in some ways the drug paradigm and the FDA and highlighting primary outcomes is something that we’re kind of stuck with. But in some ways, you know, we could easily have picked the ED visit and hospitalization as the primary outcome. I mean, we wanted a home run where we made things better for patients, caregivers and the healthcare system.
And we have colleagues who are doing other kinds of studies like this where they flip it around and put the utilization as the primary output. So I don’t feel as strongly about like that we were like fishing for something else. I mean, this was a pre specified outcome. It was one of the main aims in the grant proposal. And it would be sort of silly to say, oh, it’s not important after we kept all these people out of the hospital.
Eric 24:42
Great point. I guess. Another question, because let’s talk about the npiq. So this neuropsychiatric inventory, like when I think about neuropsychic symptoms, I think about. We had Helen Kales on Helen Kales, who talked about management of behavioral symptoms in dementia. And she said, you can focus on three things. You can focus on the patient, you can focus on the environment, or you can focus on the caregiver. And what do we do as a healthcare system? All of our focus is on the patient, which is the one that we can’t change, generally the patient, and we ignore the caregiver and the environment.
And when I look at the npiq, so this neuropsychiatric inventory, when we look at the severity, I wonder, how much can we actually change? Like, is the patient impatient or cranky? How important is that to change? Can we change it? Should we change it? Do they have difficulty coping with delays or waiting on planned activities? Does the patient engage in repetitive activities, such as wandering around the house, handling buttons? Has the patient lost or gained weight? Like, how.
Alex 25:50
What about the happiness one?
Eric 25:51
Oh, yeah, there’s one on.
Alex 25:52
Like, are they excessively happy? Is that a problem? Do we need to fix that?
Eric 25:57
And if it’s a problem, whose problem is it?
Alex 26:00
That’s what we do as geriatricians and palliative care docs. We reduce excessive happiness.
Eric 26:05
So how important is the NPIQ to be modifiable? Because when I think about it from a geriatrics and palliative care perspective, like, if they’re wandering, I think about, okay, like, the patient’s wandering. How should I focus on the caregiver or the environment to help with that? Maybe less about the patient. Thoughts on that? I’m going to turn to you, David, first.
David 26:26
Yeah. And I think Helen says a couple things that she alluded to that are really important. Number one, these behavioral symptoms, particularly agitation, aggression, those kinds of things are remarkably difficult to treat. The literature supports that behavioral interventions are best for behavioral symptoms, but sometimes they don’t work. And when we turn to drugs, management of these symptoms, the drugs are lousy, they’re not very effective, they’re dangerous, et cetera.
Eric 27:04
Pretty much across the board.
David 27:06
Yeah. So if I had one wish for the holidays, it would be a drug that really worked for behavioral symptoms. But I don’t anticipate that gift coming. These are very, very difficult to modify.
Eric 27:23
What do you think, Greg?
Greg 27:24
Yeah, I would agree with that. And sometimes what we end up doing for families is helping them manage and cope with those things. And so we even have people who show up, not only in our trials, but in our clinic, where, you know, things are still just as chaotic and just as challenging. But the distress that the caregiver is having may have improved.
Because as David’s study focused on was their self efficacy, you know, their confidence, their ability to just handle these things may improve. So I also think that one of the things that we put in our paper and a subsequent letter was that our NPIQ baseline, we didn’t think it was that high. And it also didn’t change much in either the intervention or the usual care group. So it’s still possible that there are people who weren’t in our study who have much more distress and would have benefited more.
Eric 28:29
So if you enrolled people with higher degrees of distress, maybe.
Greg 28:32
Yeah. Even consider making that an entry criteria, at least for study.
Eric 28:38
Well, I guess another question for you, Greg, is this idea that going back to the secondary outcome, reduced utilization of ED and hospitalizations, that’s a big finding. How much of this is that? This idea that, you know, we probably can’t change much as far as the patient behaviors. Maybe we shouldn’t even be changed. Like, so they’re wandering. Like, make sure it’s safe. Like, make sure they’re like, so they’re excessively euphoric.
Like, okay, let’s talk about the caregiver. Why is that so stressful for you? Like, what bother? What’s bothering you about their apathy? How can we think about that from a caregiver distress standpoint? And maybe we can focus on that distress. With that said, your study didn’t show an improvement in distress, but it didn’t show a worsening distress. So you actually had these people. And this is. We talked.
Alex 29:29
Can I give this story? So you see, there’s a bike behind. That’s my bike, biked in today over Golden Gate Bridge. Beautiful commute to work. I think it was Greg Lamond who said, you work at this, you cycle, you cycle, but it never gets easier. You just go faster. And I think Ken said, for caregivers, they will always work themselves to the point of exhaustion. And if your study allows them to do more, they will do more.
They will do more care at home. If the patient’s not in the hospital, they will always work themselves to exhaustion. So he found it reassuring that they were able to feel like they knew what to do more from David’s study, and they weren’t going to the hospital and the emergency department as much. And there was no without increasing the caregiver distress because they will always work themselves to that point where they are exhausted.
Eric 30:22
And he also brought up this. So we had a podcast with David Kuro talking about dyspnea, and David brought up this fact that it’s really Hard to do a study on dyspnea because what happens similar to what Alex was talking about, people are going to push their function to the point of dyspnea.
So if you improve their dyspnea, they’re going to walk farther and they’re still going to have that 10 out of 10 dyspnea, but it happens maybe 50 yards down the line. So. Thoughts on that, Greg?
Greg 30:50
Yeah, I agree with that. And I think our original draft of the manuscript actually sort of put the notion of how we could see the lack of change in many of these symptoms as a positive outcome, that they were keeping people at home. Nearly more than three quarters of the people in the intervention site didn’t have a single ED visit in the two year study.
Alex 31:16
Wow.
Greg 31:17
Yeah, I mean, they really kept people at home.
Eric 31:19
What was the mortality rate again? Like 40%.
Alex 31:22
40%? Yeah, 40%.
Greg 31:25
So they were able to keep people at home, manage all of these very challenging behaviors and issues and advanced dementia.
Eric 31:33
During a pandemic without worsening distress or depression.
Greg 31:39
Yes, I think that’s remarkable.
Speaker 7 31:42
Yeah.
David 31:43
Yeah. One of one of our site PIs said, you know, what struck him the most about the data is that over a year and a half period of time with the aggression of dementia with COVID with all this other stuff, we didn’t see these precipitous declines. So maybe, you know, holding, holding steady is a good thing. But once again, the, the usual care group was similar.
Eric 32:08
That’s why it’s going to be interesting to see what happens with utilization in your study, David. Are you going to see potentially similar results? Which I guess moves us into what do we do with this data? We have these studies. It seems like we’re still waiting for some more data on your study, David. What does the future look like? How should we be using this data to move us forward and move comprehensive dementia care forward?
David 32:37
Well, big question. A lot of these kind of preliminary data for Guide and I think Guide by and large is on the right.
Eric 32:47
Track and real quick for our listeners. So we did do an episode on guide. We’ll have a link to it. But if you can summarize GUIDE in like one sentence.
David 32:55
Yeah, so GUIDE is a new program. It’s like a eight year demonstration program for fee for service Medicare beneficiaries. That is an alternative payment model. So it gives a monthly per beneficiary payment for managing the dementia care and it does something that Medicare has never done and that is to pay for respite care. It’s the first time they’ve ever done anything for caregivers. So there’s a lot of administrative work to get guide up and running and to deal with the CMS requirements. But it is a new way of thinking about and paying for this kind of care.
So they will evaluate it. It won’t be a clinical trial, but they will evaluate it in many ways, shapes or forms. But the point of the matter is, is that 74 million of US baby boomers are approaching very old age. In 2036, the first of baby boomers is going to be 90 years of age. And by when you reach 90 years of age, your chance of having dementia is about one in three. So there’s going to be this explosion in the number of people with dementia. You know, there’s this old saying, I think it was Mark Twain, but if you think education is expensive, try no education.
Speaker 7 34:33
Yeah.
David 34:34
Try ignorance. And indeed there will be additional updates on these models.
Eric 34:41
I think your study should influence those models.
David 34:45
I think our study shows, I think that the big take home message from our study, and we’ll know more about this when we look at the quality indicators, is that there are many ways to skin a cat and that one of these models is not better than another. They both provided very comparable care. And so it really depends upon the health care system, the kind of resources they have, which model to choose from.
But they’re better off with an established model, particularly one that has some evidence behind it. So they don’t make the same mistakes that Greg and I and many others have made over a number of years and that materials are ready and there’s people who can help you get these things started, et cetera.
Eric 35:29
And you have the trainings and you have the.
David 35:32
Yeah, dementia is not going away, you know.
David 35:36
Even in the best case scenario, the new drugs, et cetera, it’s not reversed. And none of the patients in Greg’s study, and very few of our patients would have been eligible for these drugs.
Alex 35:51
For the mabs.
David 35:52
Yeah.
Eric 35:53
So the amyloid antibodies, they’re not the ones.
Greg 35:57
Yeah. It’s only going to be even able to be used for a very small percentage of patients. There are some studies that put it well under 10%, perhaps under 5%.
Eric 36:10
And people still progress.
Greg 36:12
You’re not stopping them, you’re not eliminating.
Eric 36:15
The disease, progressing just slightly slower if I believe they.
Alex 36:19
And they will progress to the point of being ineligible. The big question is will they be deprescribed the medication or will they continue.
David 36:26
Though they think, oh, they will be deprescribed. In fact, One of the drugs is that if you don’t show clearing of amyloid a year, year and a half later, they won’t pay for the drug anymore. The drugs stopped.
Greg 36:42
But I think that back to what David first was saying about what we learned from these studies, I think it’s easy to pick on the primary outcome, not having been moved in both of them. But if you think about the environment in which our study took place, perhaps one of the other things is that we had enough going on in our environment where the usual care people, three quarters of them who died, ended up enrolled in hospice, and most of those people died at home.
So we may already be, you know, very different than from some places where literally they have nothing. And so David’s point about guide, that Medicare doesn’t pay for education of, you know, caregivers, it doesn’t provide a lot of wraparound supportive services, it’s never paid for respite. And even within managed care, it’s not so easy to get that sort of stuff. So I think that the guide program and our models are moving the field in the right direction, and we just need to figure out what are the things that are the right things for the people at different stages and with different kinds of issues that sort of come and go throughout the course of the illness so that we can tailor the intervention to the dyad.
Eric 38:03
Do you have an idea of costs? Like, we have an idea of what the amyloid antibody costs. I think 25 to $30,000, plus you have to add on per year? Per year, plus you have to add on all the MRIs, PET scans, and other things, probably close to $100,000 per.
Greg 38:19
Year for implementing our program. For 100 people who are in the intervention, it was a nurse, a social worker, and 10% of a document. And our sort of estimates, not using Medicare data, but using things from the literature, suggested that the ED visit and hospital utilization decreases would save something like $900,000, which would more than pay for the intervention. So I think it’s not as Sexy as antibody MRIs and other sorts of stuff, but it’s the sort of thing that what when we.
We haven’t published some of the qualitative data that we have. I mean, the people in the study were really sad when it ended. They had the same person calling them, like, every month for two years and was available to them, like at night and on the weekends or somebody covering for them so that they felt like they got a lot out of it that wasn’t measured by the NPIQ or other metrics we use.
Alex 39:27
So have health systems taken up this program and initiating it on their own?
Greg 39:34
Well, we’ve had one health system specifically come to us to talk about implementing it in managed care to decrease costs. And we have one large insurer that started some conversations with us again targeting their managed care practices. But I think that the guide model is being implemented in hundreds of systems or practices around the country. And I think part of what we want to be able to do with getting out the positive side of what’s been done in these and other studies is that these are things that other people could implement and that they are worthwhile implementing.
Eric 40:16
How important was it the layering of palliative care, though, in your intervention, you think? Was that at large part of the intervention?
Greg 40:24
Well, it was in the sense that we started off with advanced care planning and goals of care conversations for everybody in the intervention side, circled back to it on at least an annual basis. And when there was a major change in clinical status and had lots of discussions not only about should you go to the ER or the hospital, but even sometimes we field questions about does dad really need a colonoscopy, given everything going on?
Or the cardiologist is thinking that he might need a pacemaker and we’d help talk through some of these other kinds of decisions. And that’s not going to be reflected in the npiq, but I think it had an impact on the nature of the care of somebody with very advanced disease and an incurable condition.
Alex 41:13
David, what’s next for your study?
David 41:15
Dk I just wanted to address something you raised earlier about the costs. We actually looked at this in decare for the health system based dementia care, on average, it was about 1980 a year. Okay. Not a month a year.
Eric 41:31
1,980.
David 41:33
Yeah. Per person, per year. And then for the community based dementia care.
Eric 41:38
So like a tenth of the cost of just the drug for like a amyloid antibody.
David 41:44
Yeah, but, you know, I don’t know.
Eric 41:45
That’s probably comparison.
David 41:47
I’m not sure that’s a fair comparison. But the. And for the community based, it was $1,217 a year. So these are not hugely expensive interventions and certainly in line with what we would expect for, you know, shouldering costs for by Medicare. So what, what’s next for us? Well, next for us is a lot more analysis. We’re going to, you know, utilization data should be available by the end of the year. And, and looking at those, you know, certainly I think if it shows any benefits in terms of cost reduction, Medicare would be very interested in that.
But the other thing we’re doing, and we would love to have Greg aboard as well, is that we’re trying to help new guide track participants adopt established dementia care programs and spread dementia care, because to be honest with you, there are 7.2 million Americans who have Alzheimer’s disease alone, and GUIDE is only going to affect 200,000 of them.
Speaker 7 42:57
Yeah.
David 42:59
So that there are institutions that are not participating. Medicare Advantage is an exclusion for guide participants. So there’s a lot of work to be done.
Eric 43:12
Can I ask one other question for both of you? Because we’ve talked about these, some of the negative findings, some of the positive ones. How does this fit in with some of the other research that you’ve both have done? And I think about the CARE ecosystem. So we’ll have a link to that on the show. Notes Kate. How do you say Kate’s last name?
David 43:31
Posein. Posein.
Eric 43:33
And Sarah Delaney on our podcast a while back, and they showed positive improvement in quality of life. I think that was their primary outcome, like a pretty robust finding using these health navigators. How does this fit in with those studies and how should we be putting it all together in these guide models?
Greg 43:52
When we looked at trying to situate the inpiece results, we didn’t yet have the D cares, but we had a table where we were comparing internally these other studies, including Care Ecosystem. I think that it’s not that everybody has to have exactly the same thing. I think that depending on what’s in the environment, in the health system and what kind of dementia care practices is available, that many of these things can be adopted and adapted for use and you know, what fits best for a particular area with their resources and their personnel. So I would say that they all belong in the toolkit.
Speaker 7 44:31
Yeah.
Eric 44:32
Wonderful. Dave, any other thoughts on that before we end?
David 44:36
No. I think that there are at least seven programs that have evidence based, including Care Ecosystem and NPs, Alzheimer’s dementia care, but BRI Care, Consultation, Mind at Home and Integrated Memory Care. And they all have some data to support them and they all have great model developers who have been very generous in trying to help other institutions get something going. Because in the end, people with dementia affect all of us. Every person is touched by dementia. Yeah.
Alex 45:13
Yeah. And also to mention one other podcast that we did early on, that was a prior IU UCLA connection, and that was with Chris Callahan and Lee Jennings, who’s a mentee of David Rubens. She’s now, I think, in Oklahoma. And their podcast title was it’s time for comprehensive dementia care. And I think this is more evidence to that effect.
Eric 45:37
We just got to give it a chance.
Alex 45:39
That’s right. Give it a chance. Here we go. A little bit.
Alex 45:48
(singing)
Eric 46:50
Greg and David, thanks for being on this podcast with us. And you thank you for the great work that you’re doing and that your teams are doing, too.
David 46:58
And thank you for the great work that GeriPal is doing.
Eric 46:59
Thank you, and thank you to all of our listeners for your ongoing support.
The post Do Dementia Care Management Programs Work? A Podcast with David Reuben and Greg Sachs appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.
In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:
That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).
As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means).
We published this article because its bottom line is of great interest to geriatricians. In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.
And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system).
I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial:
Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer’s disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab.
Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.’s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.
-Alex Smith
** NOTE: To claim CME credit for this episode, click here **
Eric Widera 00:06
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:13
This is Alex Smith.
Eric Widera 00:14
And Alex, who do we have with us today?
Alex 00:17
Today we are delighted to welcome from the great state of Canada,
Alex 00:25
… I mean from the great country of Canada. [laughter]
Eric Widera 00:28
Oh, we’re gonna get a lot of comments on that one, Alex. [laughter]
Alex 00:33
We’re delighted to welcome Eric Wong, who is a geriatrician and researcher, PhD candidate at the University of Toronto, who practices geriatrics at St. Michael’s Hospital. Eric, welcome to the GeriPal podcast.
Eric Wong 00:46
Thank you. Thank you for inviting me.
Alex 00:47
And we’re delighted to welcome Thiago Silva, who’s a geriatrician from Brazil and is currently a T32 postdoctoral research fellow at UCSF in the Division of geriatrics. Thiago. Welcome to GeriPal.
Thiago 01:00
Thanks. Great to be here.
Eric Widera 01:02
So we’re going to be talking about comprehensive geriatric assessments. A topic that I have a vague, foggy idea exactly what it is, but we’re going to be talking about what it is, who should get it and what’s the evidence base. But before we go into all of that, Thiago, I think you have a song request for Alex.
Thiago 01:22
Yeah. Our song request today is Getting Older by Billie Eilish. And I like that song because it kind of shares a reflection on getting older, cumulative life experience. And that’s why I requested that song.
Eric Widera 01:41
Isn’t Billie Eilish like 18?
Thiago 01:47
Well, maybe in her soul she’s older.
Eric Wong 01:50
Little bit older.
Alex 01:59
It’s a great song. She’s such a good singer. Here’s a little bit of Getting Older.
Alex 02:17
(singing)
Eric Widera 04:23
Wonderful. Thank you, Alex.
Thiago 04:25
Pretty good.
Eric Widera 04:26
Good song, Thiago. All right, Eric, I gotta ask. What the heck is a comprehensive geriatric assessment?
Eric Wong 04:35
So the comprehensive geriatric assessment, in my view, is just sort of like the most common tool that a geriatrician uses to assess an older adult with complexity or with frailty. And there are a lot of definitions, and I think there was an umbrella review a few years ago discussing what the definition is because there’s so many out there. But I think the commonalities include it being multi dimensional. So it has to assess multiple domains, it has to identify geriatric issues, and it has to come up with a plan to manage those issues. That’s my impression.
Eric Widera 05:11
And Eric, you do CGAs in your practice, right? Comprehensive geriatric assessments?
Eric Wong 05:16
Yeah. Yeah.
Eric Widera 05:17
What does that look like for you?
Eric Wong 05:19
So basically, in our practice in Toronto, generally we mainly do CGA. So we mainly do consultations on new patients, whether they’re in the acute care setting, in the rehab setting, or in the clinic. And some of us, for the outpatient clinics, we will follow people longitudinally. So the comprehensive geriatric assessment would be the first visit where we do a longer assessment, and then the follow ups would be sort of more focused on. On the individual domains or issues that the patient has. But in general, we. We do the CG. Like, that’s basically our main practice is doing CGAs.
Thiago 05:55
Yeah.
Alex 05:56
What domains do you cover?
Eric Wong 05:59
We. So we do a lot of different domains, but I think the most common ones are cognition, falls, you know, mood, multimorbidity, polypharmacy, those kind of geriatric syndromes, and tiago.
Eric Widera 06:14
Did you do them in Brazil?
Thiago 06:16
Yeah, we do them in Brazil as well. And I guess one thing that I like about CGA is that I think it addresses one of the core principles of geriatrics, which is like establishing priorities. You know, you have these older adults, failure adults, very complex, a lot of things going on at the same time. And through a cga, you kind of have a. An objective measure of the problems that are going on, and then you can plan with your patient and their families, which should be addressed first and how to do that.
Eric Widera 06:48
So I got a question. So I remember going back to geriatrics fellowship. Like, I have my geriatrics clinic. I saw the patient individually, I talked with the attending, it came back. If I needed a social worker, I would get a social worker involved. Or if I needed the pharmacist, I would get the pharmacist involved. And I hear about these other. What I always thought was comprehensive geriatric assessments where, like, it was a big team, each individual, like they were being.
They were seen by the rn, a geriatric specialist, a geriatric pharmacist, a social worker. They were all coming up with their assessments, then they met together and then they came up with a plan. Like, it was this, like, half day, sometimes full day. Maybe it was more of the geriatric evaluation and management type clinic. Is that a comprehensive geriatric assessment or was Eric Widera just coming in there as the lone geriatrician doing his best to do an assessment?
Alex 07:42
Yeah, the half day, full day sounds like big C, putting the C in.
Eric Widera 07:46
Comprehensive, comprehensive versus the Eric. Maybe it was just the geriatric assessment without the C. No comprehensiveness in there.
Eric Wong 07:55
Yeah, no, I think the. So the definition that these authors came up with in 2018 included multidisciplinary as one of the requirements. I have to say that in Canada, and I can’t speak on behalf of all of the different practices because they’re quite diverse. There are some places where they do, in fact have that, like an outpatient geriatric assessment would have different visits. Whereas, you know, by one visit they do a pharmacist, do a med rec, and then they may get, you know, a nurse to do one of the histories sessions and then like PT and OT may see them separately and then the geriatrician brings it all together and then does the assessment and plan.
So there is that model, but I think the. The majority of geriatricians just kind of do most of the CJ themselves, or maybe with one or two allied health, but. But not with like a big team.
Eric Widera 08:47
Yeah. And in your experience, Thiago.
Thiago 08:50
Yeah, I think the multidimensional aspect of it is like the. Probably the central piece. And then there are different ways that you could do that, you know, by yourself or whether with a team. There are settings where there are geriatricians, as we’re going to discuss, and. And then you might have other professionals doing these assessments and you can even have like, short, targeted kind of CGAs, which is another approach as well.
Alex 09:17
So it sounds like comprehensive geriatrician assessment. It’s the comprehensive geriatrics assessment, which can be done by non geriatricians.
Thiago 09:26
Yeah, that’s right.
Eric Widera 09:28
But it also sounds like, there is a spectrum. Right. You can’t have a highly trained in multidisciplinary people with expertise in geriatrics, from geriatric pharmacists, geriatricians, like the whole works, seeing patients in different types of settings to the other end of the spectrum where it’s maybe less resource intensive than that, but potentially still doing the components of a comprehensive geriatric assessment. Maybe not as intensive as that other end of the spectrum.
Thiago 10:00
It might not be intensive, but like, you’re intentional, right? You’re having this look into things that many times people don’t really value in clinical care. And that’s where I think the CGA can help, that you’re intentionally evaluating these issues and then you can plan for interventions and. And care.
Eric Widera 10:22
Yeah. And the intentional part, like, are those the. So you. They may do screening tests beforehand, you know, report outs, cognitive screeners. You’re intentionally evaluating for geriatric support.
Thiago 10:36
Yeah. Okay.
Alex 10:38
And I’m still trying to figure out what’s in there. So are geriatric syndromes always assessed? Like, is that an essential component of a comprehensive geriatric assessment, like incontinence, for example? You mentioned falls, but are all.
Thiago 10:54
I think it varies a little bit.
Eric Wong 10:55
Right.
Thiago 10:56
But I think like Eric said, you always have cognition, you always have like, function. You’re going to have some, usually some, some measure of social support, nutrition, polypharmacy. There might be sometimes, you know, falls, history of falls, sometimes measure, you know, some kind of resource utilization, kind of, you know, whether they were admitted to the hostel or visited the ed, you know, recently. Sometimes it’s a part of it as well. And mobility, mood.
Alex 11:33
Eric, anything you’d add?
Eric Wong 11:35
Yeah, no, I agree. So they’re, you know, the five M’s. Like, I think, you know, as mentioned, like, those are great domains and yeah, I agree. Like in our CGAs, we also do a review of systems where we kind of go through those things that you might. That might not come out unless you directly elicit them, like urinary incontinence or constipation, appetite, sleep, weight loss, that kind of stuff. So, yeah, we include all those things. And then sometimes in the right context, we would do objective testing, so cognitive testing or objective mood testing in a scale. And also the physical, of course.
Alex 12:14
And I’m glad you mentioned the 5M because that was going to be my next question. Like, how does this relate to the 5M conceptually? Because we’re seeing this great uptake of the. What is it called? The age friendly health system framework. Right. Which Includes I think they have four M’s, but you know, you’re probably adding the five M’s. Five fifth M is what multi complexity.
Eric Widera 12:37
Mind mobility, medications what matters. And multi complexity. I looked that up because I want to make sure I got that right. I also never know am I supposed to use 4M’s or 5M’s?
Alex 12:54
Is that framework kind of replacing the comprehensive geriatric assessment? I’m just trying to figure out how they’re related. What’s the relationship between these two concepts?
Thiago 13:03
Yeah, I don’t think they’re replacing. Right. I think it’s like CGA is probably a tool, a resource to implement the 5Ms.
Eric Widera 13:12
Or is it specific population, A comprehensive geriatric assessment. The word comprehensive means that you’re doing a lot. Does everybody need a comprehensive assessment versus does every older adult need. We should focus on the 5Ms. For me, that almost feels a little bit different. What do you think, Eric?
Eric Wong 13:32
Yeah, I think it depends on the purpose in the context of where the practice is and the goals of the practice. But I think 5 Ms. Is sort of an easy way to disseminate geriatrics knowledge to say, non specialists to general practitioners and they can understand that, oh, these are actually core geriatric concepts that if you were to do, say internal medicine and you don’t think about this and you would completely miss very important geriatric syndromes.
And it’s easy to remember it’s a good mnemonic. And I like that. It also says matters most, which is we always factor in patient preferences into our consult. So I think it’s more of geriatricizing like big G, little G kind of, you know, of the entire healthcare system. But I think for a cga, we do a little bit more than that. And I think part of the problem is, you know, if you’re not systematic. Right. Sometimes you would miss issues. And so the CGA takes a long time because it’s a systematic approach so that, you know, we pick up on the issues that maybe others have missed. And I think a lot of the value that’s come from that.
Eric Widera 14:40
And I’m guessing, Eric, you’ve been doing this for some time. Do you just kind of remember everything? Do you have like a structured CGA assessment that you go through every single time?
Eric Wong 14:51
Oh yeah, like it definitely. And I’m admitting this online to all of my preceptors who may watch this. But it did take me a long time to actually memorize all the elements. Like even though, you know, in training, like in our geriatric residency, we do it all the time, but we use a template generally because it’s such a long consult. But I have to say, even after independent practice, it took me a bit of time to actually get it down. But now, of course, after doing it for a number of years, it’s more or less memorized. I could do it the best with a blank piece of paper.
Eric Widera 15:28
How long does your comprehensive geriatric assessment take?
Eric Wong 15:33
So as a standard in where I practice in Ontario, I think the standard is 90 minutes for a comprehensive geriatric assessment, but it does vary in some contexts. Some geriatricians may be a little bit more focused depending on the reason for the referral. And in a lot of cases, we end up taking a lot longer because there’s a lot of complexity, there’s a social aspect, there’s multiple family members, informants who we need to get different perspectives of. So it would not be surprising for us to take up to three hours. But in terms of the standard, as what the.
Because in Canada it’s a single payer health system, so all the billings go through the government. So the government’s requirement is 90 minutes for that CGA.
Thiago 16:24
Yeah, I agree that usually, like for us in Brazil, we usually take about an hour, but it will vary anywhere between 45 minutes and 2 hours depending on the patient.
Eric Widera 16:37
So does it work? What evidence do we have? And I think there’s probably some connection to the body of evidence we have for palliative care, because in that evidence is like, oh, does palliative care work? My response is, what do you mean by palliative care? What components do you have to include to be called a palliative care intervention? Is it primary palliative care specialty, palliative care? How many disciplines have to be involved?
How many domains of palliative care have to be involved till we call this like it reaches that bar? I’m getting a sense from a CGA too, like, there’s probably a lot of variability in the studies out there, but it makes sense. Tiago, does comprehensive geriatric assessment do anything from an evidence perspective?
Thiago 17:26
I think there’s pretty good evidence that it does do something and it’s usually good stuff. There are even more recent meta analysis and several studies on different settings looking into how integrating CGA into care affect outcomes. I think generally the results are pretty positive and improving length of stay, improving functional recovery, preventing longer hostile stays and readmissions. But there is some variability regarding the costs and results in these different scenarios.
So there are studies that were able in the inpatient setting to find benefits regarding functional outcomes. But then you might see some increase in costs. There are studies in the ED showing that they were able to decrease costs and decrease their stay in the ed, but then the revisit rates increase a bit. So the different approaches to how you do it and how you do it integrated into these different scenarios do affect the evidence. They’re heterogeneous. Yeah.
Eric Widera 18:57
I remember reading a meta analysis, BMJ, I think, back in 2011, did a meta analysis looking at inpatient comprehensive geriatric assessment. People were more likely to be alive and in home for those who got the comprehensive geriatric assessment. And it seemed like it was. Again, there’s the variability. What do we call that? Like, the more like, if it was its individual unit, I believe it actually maybe had a little bit more evidence than if it wasn’t. And again, this variability of like, how are we delivering this comprehensive geriatric assessment? Yeah, Eric, you want to say something?
Eric Wong 19:35
And I think. Yeah, no, I agree. And I think one of the factors is, you know, if you do the assessment, but then the recommendations don’t get implemented, then the effectiveness of that assessment would decrease. Right. And so in a geriatric unit, it makes sense because there is, you know, it’s sort of like you’re implementing everything that you recommend because you. The team works with you and you could carry that through all the way till the end.
And so that it makes sense. Right. But in some other models, maybe just a consultation is delivered and you rely on other providers to carry through those recommendations. And I think there have been some studies, especially in geriatric oncology, looking at what percentage of recommendations get implemented. And the numbers can vary quite a bit, can be low, and so then the effectiveness might not be as good.
Thiago 20:28
And I think that’s a really important message because I feel that when we talk about CGAs, we often focus on the assessments and less so on the, you know, the care plans. And that’s really why we’re doing it. Right. We’re not just there to, you know, time how long someone takes to, you know, get up and sit down, you know, and sit on the chair that’s supposed to be used for something. Yeah.
Eric Widera 20:55
So I’m hearing there is the assessment, there is the implementation. I also read a third key component for a geriatric assessment is screening and targeting the right individuals. So that’s really the first step is who benefits from this? Because I also read maybe there’s spectrums, like very, very healthy older adults may not Benefit it. Very, very sick. Older adults may not benefit from it. So is there a sweet spot? What do you think about that?
Alex 21:32
And I think that the very, very healthy is kind of intuitive. The very, very sick. I don’t quite understand and would love to have an explanation about that.
Eric Widera 21:41
If it’s true. If it’s true. What I read.
Eric Wong 21:45
Well, yeah, I mean, I agree. Right. So you have to choose the right people. And I think part of the issue is if you don’t do the assessment, you actually may not figure out all the issues that are hidden in somebody who otherwise appears healthy. So, you know, as St. Michael’s Hospital, we do automatic consults on people over the age of 65 with a hip fracture, and we also see people over the age of 65 with a trauma, and we do automatic consults on all these people. And this is pioneered by one of my colleagues, Dr. Camilla Wong, who started these services and that were.
Eric Widera 22:25
That’s a very select population. Right. Like the fact that they have a hip fracture.
Eric Wong 22:29
Yes.
Eric Widera 22:30
Means that something is going on. Like, these are not, like.
Eric Wong 22:34
Yes, they’re not general population. But the hip fracture is one thing, so there’s good evidence for that. Right. Ortho geriatric care. But the geriatric trauma is a little bit interesting. So, yes, a lot of them may have falls. Right. They may fall down the stairs and fall itself would be a geriatric syndrome. So there’s an inciting event and you’re selecting for people who present with the geriatric syndrome. But there are also traumas where it’s just a car accident, for example, not just a car accident, but it’s a car accident. And. And then you have to actually dig further to figure out, like, were they the driver, were they the passenger, what kind of injuries?
Thiago 23:07
And.
Eric Wong 23:07
But it’s. It’s actually surprising because a lot of these people, just by age alone, they actually have issues that we can address when we talk to the families. Like they may be struggling with some cognitive changes that, you know, because primary care is. There’s a crisis in Canada, it’s hard to find a family doctor. They may not have brought it up to anybody and the first time, because we saw them and it’s just that they’re older. Right. And we’re identifying these issues. So there’s a lot of cases where we could find something even in people who don’t specifically present with a geriatric syndrome.
Thiago 23:40
Yeah. I think we have to be careful as well when we say that something doesn’t work. We have to think on what kind of outcome is being used to say that it doesn’t work. Right. So Alex, when you say that, you know, I’ve heard that it, you know, CJ’s that don’t, don’t work for very old or very frail or adults. So what doesn’t it work for?
Eric Widera 24:03
So isn’t the primary thing everybody cares about patients is their length of stay and hospital utilization. That’s what matters most, right? That’s 5M. That’s the last profit margin for healthcare industrial complex.
Thiago 24:21
So there you go. Right? So then it’s probably not going to work. So there probably be, you know, throughout the lifespan and complexity, there probably be components in the CGA that will be, you know, stuff that you can intervene more or less depending on the patient. So you might not be able to improve their cognition, but you can, you know, identify social support problems and help them address those issues. So yeah, I love that point.
Eric Widera 24:54
It reminds me of Ken Kavinsky during our last updates at AGS where we were talking about hearing loss and the outcomes of like hearing aids with cognitive impairment. And ultimately like the, the main point I heard from Ken was, hey, just the fact that they can hear is an outcome that’s good enough, right? Like you don’t need to show like it prolongs life or it decreases cognitive impairment.
Speaker 5 25:24
Like they can hear.
Eric Widera 25:26
That’s important.
Thiago 25:28
Thanks, that was a really good point. Yeah.
Alex 25:30
And Tiago, we mentioned when we first were asking you about what is a comprehensive geriatric assessment, you were talking about like prioritization, which to me reminds me of the M what matters most. And I’m wondering if is that a part of the comprehensive geriatric assessment?
Thiago 25:48
It should definitely. It definitely should be. Right. And now that you explicitly ask and Eric can tell us about his experience, but I think it’s rare that a CGA model will explicitly have that there, that component, like ask your patient what matters most. It’s more like what you as the provider is identifying as what matters most. But that would be a very good point that we should include that, you know, that M more explicitly in the models.
Eric Widera 26:25
What do you think, Eric?
Eric Wong 26:27
Yeah, yeah, no, I agree. And so I think at the end of my consul notes, I often will try to have a point on future planning where I’ll in the right context talk about goals of care, advanced care planning, and also what their preferences are. And in some consult, it’s more important than others. Right. When we see people, for example, with malignancy or with other end stage diseases, it’s more important to Prioritize that and talk about those preferences. But sometimes even for my clinic patients, I will ask them, like, where do you see yourself aging?
Like, do you want to stay in place and age at home? Or do you want to move in with one of your children? Or do you want. And some people actually want to go to a retirement home. They’re like, I have friends who are in retirement home and they have a great time. And so how did it get me into one of those places? And so. But I do find that if I don’t ask that questions, people are either we’re so focused on medical issues that we forget about it, or they don’t know whether they should bring it up. But asking that specifically, I find it very helpful.
Thiago 27:32
Yeah.
Eric Widera 27:33
And again, I think where I was reading about the spectrum, the very, very healthy or low, the very, very sick is, is not like the little C comprehensive geriatric assessment. It was like the big C. Like you get all of these team members, very intensive comprehensive geriatric assessment, assessing for everything, maybe taking hours or longer from this versus kind of more kind of usual care. But I do think like even in hospice care, like these things are important falls, function, incontinence, like it matters. So that little C comprehensive geriatric assessment still applies, it seems like. Would you agree with that?
Thiago 28:23
Yeah, and I think, I think it’s something that Eric mentioned before, that the systematic aspect of, you know, looking into all these things, I think it’s what sets the CGAs apart. At the end of the day, I agree that it’s providing good care. It didn’t have to be CGAs. You could do all of that and look into all these issues without it calling it the CGA because it’s good clinical care. But then doing it systematically will help you not forget about all these.
Eric Widera 29:01
And it takes time, right? Like systematic. This is not a 10, 15 minute appointment for one medical problem. Like this is. I hear you, Eric. 90 minutes. Which for primary care they don’t have 90 minutes, no way. So then the question I have is when we think about prioritization, like who should be getting it and where, given that, like the way the system is not resource unlimited, we have to think about the resources and where we should put in the resources.
And it reminds me of the JAGS article that just came out, Eric, which Diago did the editorial on money does matter, right? Where we put our resources matter. Do you mind, Eric, just describing in a quick nutshell, we won’t get too methodsy on this, but in a quick nutshell, what you were hoping, Hoping to achieve with this JAGS article?
Eric Wong 30:03
Oh, I was actually just going to talk about methods. I thought that’s what the article. I wasn’t sure after.
Eric Widera 30:11
Yeah, let’s talk about it. Because I got really confused. I read it like three times. Something about dominant versus dominated. Yeah, dominated. I’m all, we. Is this about something else than medicine domination?
Eric Wong 30:26
And I, I know I, I heard some feedback. I didn’t go to ags, but I heard that this was discussed at AGS in some way.
Alex 30:34
We discussed it in the reviewing for JAGS workshop. Yeah, it’s a great learning piece for participants.
Eric Wong 30:44
Eric, what were you. We’re just so grateful that JAGS decided to accept the paper. And I’m very grateful to the editors and also to Tiago and to SEI for writing that editorial, which I think helps people understand some of the limitations of the work we did and also contextualizes why this is important. So the whole premise of the study is there’s a shortage of geriatricians. And the shortage of geriatricians is in Canada, for sure. Canada, we have a very low ratio per older adult compared to, say, the US or the uk, where there’s an absolute larger geriatric workforce. So for Canada, this becomes a problem as our population ages.
So one of the things that we thought about is, well, we always try to recruit more geriatricians. And I think there’s a lot of people around the world who’ve tried different things to do that, but there are also some limits to that. So we’re seeing that even with trying to get people interested, we’re not seeing as many people applying. So then the other solution is how do we optimize, how do we make, make good use of the existing workforce of geriatricians in a population that’s going to age in the coming 10, 20 years? And so the question that we, or the direction that we wanted to take wasn’t quite about models of care. So, you know, in, you know, earlier we talked a lot about, you know, is it an ACE unit or is it a geriatric evaluation unit? We didn’t focus on that because, you know, that’s been looked at. But it’s also a little bit harder, right, because it’s context specific.
So instead we wanted to look at a more sort of a broader picture of just the healthcare settings where there’s a little bit more similarity across the world. When somebody’s in acute care, we kind of have a good sense of what those patients look like when they’re in rehab, which is a post acute setting. We have a good sense and some similarities. And then in the community setting, coming into an outpatient clinic to see a doctor. So we wanted to focus on the settings and try to answer that question. If we could choose one or two settings or if we didn’t have enough people to staff all the settings, which healthcare settings should we prioritize? Geriatricians first. And so there’s a two part to this.
And so there’s a part of the study which was a systematic review and a network analysis that one we are working on updating but we ended up doing the cost effectiveness first. But that study informed the cost effectiveness where we designed a model. So it’s a computer simulation model and we looked at older adults in Canada, in Ontario specifically, and we simulated what happened when we put geriatricians focus on different settings or different combination of settings and what the overall outcome is for the population.
Eric Widera 33:36
And is this geriatricians or comprehensive geriatric assessments?
Eric Wong 33:40
Yes, so that’s a great question. So it’s actually also specifically it’s a geriatrician led comprehensive geriatric assessment. Yes. So the question is a little bit different than should we do a CGA in which setting? We don’t quite answer that question. What we’re answering is because there’s specifically a shortage of geriatricians. Right. So we want to know where we should put the geriatricians to do the cga. Hopefully that clarifies a little bit about the research question.
Eric Widera 34:08
And the question is where? Inpatient rehab, outpatient, where should we target these geriatrician led comprehensive geriatric assessments?
Eric Wong 34:19
Yes, that’s correct. And so then we, you know, we ran the model and so yes, there’s different terms and I did, you know, after getting some feedback, this is where.
Eric Widera 34:30
It gets a little 50 shades of gray, which I was not expecting.
Eric Wong 34:34
I know, I know. And I heard about this, the domination.
Eric Widera 34:39
I thought that was. That should be your title, 50 Shades of Gray. Where to insert geriatricians.
Eric Wong 34:44
Oh yeah, that would be better.
Eric Widera 34:45
All right, tell our audience because they haven’t read the paper probably. What did you find?
Eric Wong 34:51
Right, so in terms of the strategies, when we rank the different strategies and the strategy is just when we do the geriatric assessments in a certain setting. So we focus on one setting or we deliver it in combination. So for example, it’s either acute care only, rehab only, or acute community clinics only. Or we might combine them, say acute care and rehab, acute care and community Clinics and so forth. And so what we found was that the, the best strategy, the optimal strategy, if there was a shortage, is to deliver the CJ in a combination of acute care and rehab. So to.
Eric Widera 35:24
And this is what you call the dominant strategy. Dominant, right.
Eric Wong 35:30
Yeah, yeah, we called it. We actually called it the undominated strategy.
Eric Widera 35:35
Undominated, yes.
Eric Wong 35:36
I know, I know.
Eric Widera 35:37
It’s very non. Fifty Shades strategy.
Eric Wong 35:42
Yes, it is a safe one. So that one. Because what happens is we rank all the strategies by lowest to highest cost. So the acute care and rehab strategy happened to be the lowest cost, and there wasn’t a strategy that had a lower cost that delivered greater benefit. So therefore it was undominated. But there was a second strategy later on, which is the triple strategy. So it’s delivering the CJ in the acute care, rehab and community settings. So everywhere, if local resources permit. And if you were able to do that, then it was still cost effective because although the cost was higher, the benefit was also higher.
And then we use a cost effectiveness threshold to determine whether a new intervention is cost effective. And it was below this threshold. And so for that, the term is cost effective. So that strategy is cost effective. The acute care and rehab is undominated.
Thiago 36:38
Okay.
Eric Widera 36:39
So if you’re resource limited, focused on acute care and rehab, if you got a lot of resources and geriatricians, you can focus on the spectrum, the whole spectrum. Is that right?
Eric Wong 36:52
Yes, yes.
Eric Widera 36:53
Is there any place where it doesn’t.
Eric Wong 36:56
Where it doesn’t work? No. So actually we also did a separate ranking. So traditionally, cost effectiveness analysis, we rank all of the strategies by lowest to highest cost and then we compare each pair wise. So we always compare it one at a time and usually compare it with the previous best strategy. But we decided to do an alternative ranking based on somebody on my PhD committee’s suggestion. And we ranked each strategy against usual care, and every single one of the strategies is either dominant or is cost effective. So you can choose to deliver the CJ in any of those combinations or individual settings, and it would still be better than usual care.
Eric Widera 37:38
Tiaga, you were at the editorial.
Thiago 37:40
Yeah, that’s right.
Eric Widera 37:41
Thoughts on that paper.
Thiago 37:43
First of all, I want to, you know, jokes apart, I want to congratulate Eric and the co authors on the work and kudos for jags for bringing something that’s not in our usual kind of comfort zone. But I think it’s really important that we think about clinical care in terms that are very important as well, economic aspects and so on. I think the main message in the editorial say and I discuss a little bit of the methods, some of the caveats and limitations that are important to our interpretation of the results. But I think the main message there is that this is very interesting and good study showing that geriatricians doing one thing, TGAs, are cost effective and pretty good.
Well, actually, geriatricians do a lot of other stuff in addition to CGAs, so it’s reasonable to infer that the cost effectiveness and benefit is even greater than what was described. So it’s important that we optimize resource allocation, but even more important that we get more geriatricians out there so everyone that needs them can receive their care.
Eric Widera 39:09
Eric, your big picture. What should we do with this study?
Eric Wong 39:14
When I try to explain this to clinical audiences, and I know it’s confusing to understand, but this is for an example of how you can use this information. Say there was a new hospital or a new community setting where you’re building a hospital, and in that local setting, in that local hospital, you have all of these. You’re building an acute care hospital. There’s maybe an attached rehab unit and then there’s an outpatient clinic.
And you’re the first geriatrician there. Right? You decided to apply and work there and you’re trying to figure out, well, I have all these places that I want to be, but there’s only one of me and I can’t work, you know, I can’t staff everything. And you try to recruit and you can maybe only recruit one person or maybe it’s just that, or just yourself. And so you have to decide, like, where am I going to focus my time? Which is a realistic scenario. Even in Ontario, where we’re at, and we have all these hospitals who further from the main city that are looking for geriatricians.
And so for them, you can use the studies to sort of say, okay, so if I don’t have enough geriatricians, I should really focus on the acute care side first and then spend some time at rehab. But that outpatient clinic, maybe we could wait until we have enough geriatricians to have them go there. And in the meantime, you can use, say, other providers. So there may be nurse practitioners, or in Ontario, we have family doctors who have care of the elderly training, so they could also staff the clinic settings until you have enough geriatricians to help out there.
Eric Widera 40:42
I love it. Well, I want to thank both of you for being on this podcast. But before we end, we’re going to go to Alex to do Billie Eilish. What song was it again? Something about aging getting older, getting older.
Alex 40:56
Getting older in this case from 18 to 19. I think she’s a little older than that now.
Eric Widera 41:02
I’m going to Wikipedia. I’ll let you know after the song. Let’s see.
Alex 41:16
(singing)
Eric Widera 42:40
Eric, Thiago, thanks for joining us on this podcast.
Eric Wong 42:43
Thank you.
Thiago 42:43
Thank you for having us.
Eric Widera 42:44
And we will have links to the JAGS article, to both the article and the editorial on our show notes and so please check it out. And thank you to all of our listeners for your continued support.
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On a prior podcast we talked with Todd Semla and Mike Steinman about the update to the AGS Beers Criteria of potentially inappropriate medications in older adults (Todd and Mike co-chair the AGS Beers Criteria Panel). One of the questions that came up was – well if we should probably think twice or avoid that medication, what should we do instead?
Today we talk with Todd and Mike about their new recommendations of alternative treatments to the AGS Beers Criteria, published recently in JAGS, and also presented at the 2025 AGS conference in Chicago (and available on demand online).
We had a lot of fun at the start of the podcast talking about the appropriate analogy for how clinicians should use the AGS Beers Criteria. In our last podcast, the analogy was a stop sign. You should come to a stop before you prescribe or refill a medication on the Beers list, look around at alternatives, and consider how to proceed. You might in the end decide to proceed, as there are certainly situations in which it does make sense to start or continue a medication on the Beers list.
Today’s analogy had somewhat higher stakes, involving a driver, a pothole in the road, and a cyclist on the side who you’d hit if you swerved. Really upping the anti!!!
The podcast is framed around a case Eric crafted of a patient with most of the medications and conditions on the Beers list. We used this as a springboard to discuss the following issues (with links to prior GeriPal podcasts):
And I hope that the prescribing landscape is indeed getting better (thanks to Kai on guitar)!
** This podcast is not CME eligible. To learn more about CME for other GeriPal episodes, click here.
Eric 00:01
Welcome to the GeriPal Podcast. This is Eric Widera.
Alex 00:03
This is Alex Smith.
Eric 00:05
And Alex, who do we have with us today?
Alex 00:07
We are delighted to welcome back co-chairs of the AGS Beers criteria panel. First we have Todd Semla, who’s a clinical pharmacist and is at Northwestern University. Todd, welcome back to the GeriPal podcast.
Todd 00:24
Great to be here. Thank you, Alex and Eric for inviting us.
Alex 00:27
And we’re delighted to welcome Mike Steinman, who’s a geriatrician at UCSF and also a co-chair of the AGS Beers criteria panel and is co director of the U.S. deprescribing Research Network. Welcome back, Mike.
Mike 00:42
Thank you.
Eric 00:44
So we’re going to be talking about not an alternative to Beers criteria, but alternative treatments to the medications that the Beers criteria says we shouldn’t put people on. Before we go into that topic, I think who has a song request for Alex?
Mike 00:59
That was me.
Eric 01:00
Ah, Mike, what’s the song request?
Mike 01:03
How about Getting Better by the Beatles?
Eric 01:05
Why did you choose the song other than Alex likes singing the Beatles?
Mike 01:09
Well, that was one reason. Two other reasons. First is that, you know, the goal of the alternatives list is to help people get better, feel better, live longer, happier and more productive lives. And then the second thing is, you know, as clinicians and scientists, it’s been a rough few months and we can kind of hope for a note of optimism that things will get better as the months and years pass.
Alex 01:33
Love it. Here’s a little bit.
Alex 01:40
(singing)
Alex 02:22
Ah, Beatles are fun. Thank you, Mike.
Mike 02:24
You’ve got the education policy debates in there too.
Eric 02:31
Okay, so I’m going to start off with a case. We got an 80 year old patient who has a lot of medical problems, probably like many of the patients we care for. They have diabetes, they’re on a sulfuril metformin, they have insomnia, which they take Ambien pretty much daily for. They have GERD and they’ve been on a PPI for the last three years. They got lower back pain and they’re on pick your skeletal muscle relaxant that they’re on and PRN NSAIDs. They have neuropathic pain from their diabetes.
They’re on gabapentin and then they have seasonal allergies, which they take some over the counter drug you’re not 100% sure is, but you’re pretty sure it’s Benadryl. But they can’t really tell you what they’re taking. They’re just go to CVS and pick it up. Alex, any other ones that you want to throw out there? Does that sound pretty good?
Alex 03:27
You’re covering it pretty well there.
Eric 03:33
Yeah, yeah. The ambient is working pretty good. They love their ambient, though.
Todd 03:38
I just want to make sure we had delirium in there. Yeah, yeah, yeah.
Eric 03:41
Okay. When you hear about this list as a leader in the Beers criteria, what are you thinking? Well, before that, what is the Beers criteria and how does it apply to this list?
Todd 03:55
So the Beers criteria has been around since the 90s started out for nursing home patients about medications to avoid not to use or to use with extreme caution, particularly either by themselves or if the person has a comorbidity or condition that you could make worse by that medication. And. And for the past 12 or 15 years, the American Geriatric Society has been responsible for updating applies not just to nursing home patients, but to all older adults, with the exception of palliative care end of life situations.
But it really looks at medications that we really should think twice about using, maybe avoid using them at all together in older adults. Also drugs that need to be adjusted for renal function that people may forget about and drug. Drug interactions that could happen to anybody. But in an older adult, they’re more likely to cause morbidity or mortality. So they kind of rise to the top of the table. But the question’s been, what do we do instead?
Eric 05:06
If we’re going to say that we should have put somebody on this and I would push you, I actually think this applies very much in the palliative care and hospice practice too, because some of the things that we’re trying to avoid matter a ton in that population as far as maintaining cognition, deprescribing. So I love this alternative, even from this alternatives paper from a hospice and palliative care perspective as well.
Alex 05:31
And they’re frequently used with the justification that, oh, this is different at the end of life, it’s okay.
Eric 05:37
Yeah.
Alex 05:38
And maybe it’s not as okay as some of our clinicians might have been trained to think.
Todd 05:45
Well, there’s still a place for common sense.
Mike 05:48
Yeah. And it speaks to the larger issue that, you know, the breach criteria is one small slice of the larger landscape of drugs. You know, and every drug has reasons where it might be used appropriately. And every drug has reasons where it might not be the best choice for an older adult or just an adult in general. And so kind of applying common sense and clinical decision making throughout is going to be really important. Sort of of the Beers criteria as a starting point, but certainly not the ending point.
Eric 06:13
So it’s potentially inappropriate medicines. You’re not saying it’s absolutely inappropriate medicines.
Mike 06:19
Yeah, exactly. Every drug in the Beer’s criteria might have a reasonable use in a given individual. And lots of drugs not on the Beers criteria might not be the best choice for your older adult for other reasons.
Alex 06:29
Yeah, I really liked in our last podcast with you, I think it was 20, 23 when you last updated the criteria. You said that these criteria should be like a stop sign. Like you come up to it and you pause, you stop, you come to a complete stop and you look around for alternatives. And maybe you don’t, maybe you go with one of the alternatives and maybe not, and maybe you continue on with that. But this should be a wait check.
Mike 06:53
Hold on.
Alex 06:54
Before we continue, let’s really think about this.
Todd 06:57
Yeah. And Alex, I’ve updated my analogy. You know. Oh, I say that it’s like you’re driving down the street and there’s a pothole and you’ve got a choice. I can swerve and avoid the pothole, but I’m going to hit the person on the bicycle. Or I can just go right over the pothole and hope for the. Hope for the best. So, you know, the word avoid was kind of legacy language with the Beerus criteria, but, you know, you try to avoid the potholes.
Eric 07:26
Well, I’m not sure about that analogy because I don’t think I want to. Todd does not like bicyclists.
Alex 07:34
I think as a cyclist, As a.
Eric 07:36
Cyclist, stay away from Todd.
Todd 07:39
No, you don’t want to hit the bicycle, so you gotta hit the pot. You gotta hit the pothole. You gotta take the pothole.
Alex 07:43
These are your choices.
Eric 07:46
Always choose the bicyclist. I care about my car too much.
Alex 07:55
I kind of like the first analysis better.
Eric 08:01
Well, let’s move away from cyclists. Alex has PTSD from car accidents in the past.
Alex 08:08
I’m not driving around Evanston, Illinois. I mean, biking around Evanston anytime soon. That Chicago century off my list.
Eric 08:18
Alternatives, alternatives. So we have this 80 year old that we’re seeing. They have diabetes, insomnia, GERD, lower back pain, neuropathic pain. They have all this stuff. I’m going to start off with insomnia. Is there what’s the pothole here they’re on, they’re doing great. They love their Ambien, they feel great about it. You’re, you’re coming up to the pothole, you see Alex to the side on his bike. What do you do here? What’s, what’s the issue here?
Mike 08:51
Well, there are a lot of issues, you know, so the first thing to keep in mind is this person is suffering because they have insomnia. So, you know, our sort of foremost goal should be to help that person manage their insomnia and to do so in a way that’s most likely to be effective and most likely to be safe. And the reason that there’s a bunch of drugs on the beers criteria that are commonly used to treat insomnia, which often cause more harm than good, is because those drugs either are sort of, sort of effective but cause a lot of harms, or maybe they’re not very effective and they also cause harms.
And so can we find a better both pharmacologic or non pharmacological alternative to help manage that patient’s symptoms, which is the ultimate goal? The ultimate goal is not to, like, start any specific drug or stop any specific drug, is to help the patient with the symptom and do so in a way that’s safe and effective. So, like the different meds we might avoid, like in this case and others, include the benzodiazepines, include the Z drugs.
Eric 09:48
Which have Z drugs like Zolpidem, the ones that starts with Z’s, not for ZZ Sleep Easies.
Mike 09:55
Thank you. Exactly. Zolpidem, Zoloplon, Zopiclone, all the ones that are used to be.
Eric 09:59
Wow, that’s impressive, Mike.
Mike 10:01
I know, really. And then. But also, like, you know, first generation antihistamines, you know, your diphenhydramine, Benadryl, Advil, pms, tricyclic, antidepressants like amitriptyline and barbiturates, which are used less commonly but still, you know, are used sometimes. So those are the meds that we say, you know, most people don’t use because they cause more harm than good. But there are a bunch of things that we can do instead.
Eric 10:24
What are the things that we can do? So this person’s on Ambien we’re worried about. Or Zolpidem. Sorry for using the trade name, but I’m using the trade name in, in a way, you should take it off Zolpidem. What, what should you do? What’s the alternative here?
Mike 10:42
Well, it’s important. This is true. For a lot of the different alternative criteria, it just goes back to basic principles in good medicine, which is before you treat the symptom, try to figure out what’s causing the symptom in the first place and manage your therapy according to that. So the first step is to kind of evaluate that person for healthcare conditions and factors that are contributing to their poor sleep. Is it the environment in which they’re sleeping that’s causing problems? Are they having pain that’s trimming their sleep or nocturia? Are they having sleep apnea? Are they taking other medicines which are interrupting their sleep?
So before we even start thinking about therapy, just think about what’s the actual cause and can we direct our treatment to the cause? Once you get past that and it becomes more garden variety insomnia disorder without any obvious precipitant or other environmental factor you can fix? You know, the first widely recommended treatment, which is recommended by pretty much all the clinical practice guidelines for sleep, is non pharmacologic, which is cognitive behavioral therapy for insomnia. It’s safe, it’s effective, it is unambiguously first line treatment for management of insomnia.
Eric 11:46
It’s easily available.
Mike 11:48
Yes.
Todd 11:49
Multiple delivery methods.
Mike 11:51
Exactly. So it can be hard to get, you know, a trained cbti, sort of health psychologist or other trained provider. If you’re in the va, it’s more accessible. If you’re outside the va, you might be more out of luck. But like Todd was saying, there’s a bunch of different modalities. There’s a lot of digital apps, website based programs which have been shown to be effective and can really be tremendously useful for people who don’t have easy access to a trained therapist, I have.
Alex 12:21
To say, because we just recorded a podcast with Victor Montori, who is really worried about the burden of care that we place on our patients outside of clinic. You know, we’re asking him to do more and more and more and now he’s really concerned about the digital burden. You know, there’s an app for that. Well, there’s an app for everything. And they’re all of different interfaces and you have different passwords and you got two factor login. And it’s a lot for our older adults who are complex conditions and are probably delirious from this list of medications that they’re taking. And now you wanted to start an app.
I don’t know. I hear him and I worry about that. At the same time, I understand that there’s a shortage of trained therapists. And the answer maybe shouldn’t be always that there’s an app. Maybe it should be. We need more therapists. That’s me. I’ll get off my soapbox.
Mike 13:12
Well, but that’s true. That would be great. I ain’t holding my breath until that happens. So the patient comes to me tomorrow and you know, insomnia tends to really bother people. Like it is not a small thing for most people or many people at least. And so if I still gotta work.
Eric 13:28
Tomorrow, I still gotta do these things.
Mike 13:30
Yeah. If the framing is this symptom is really bothering you, we have a very effective safe solution that’s worked for a lot of people. It takes some work on your part, but it’s worth it because it will really help you. If people have motivation to improve their symptom, that can go a long way. And a lot of these apps are designed for people who aren’t super tech savvy. So totally hear what you’re saying.
But at the same time, like we should be helping people help themselves. It’s the same thing. Might be you could say the same thing true for exercise. Like it’s a pain in the ass to go out and exercise several times a week. You know, a lot of people don’t like it. It’s challenging, you know, but like it’s worth it. So I don’t think we should be shying away from encouraging sort of self help either.
Eric 14:16
Okay. So if you want to learn more about insomnia, we have an insomnia podcast we’ll have links to in our show notes. But when would you consider pharmacological therapies and what would the alternative be to the Z drugs or to the benzos?
Todd 14:29
So there, that gets to be a bit of a question. But the medications that. Which may be safer but not completely safe because that, that, that doesn’t exist are things such as low dose doxepin. And we’re talking up to 6 milligrams per dose. It comes as a 3 and 6 milligram formulation capsule. The dual orexin receptor antagonists are another option. And ramelteon. But we’re also looking at short term use for all these agents. They’re not necessarily chronic medications.
Eric 15:05
All right, I got to dive. I’m going to dive quickly into each one of them. Again, this doesn’t want to turn into an insomnia pod, but I got to say, doxepin, isn’t that a TCA anticholinergic, anti histaminergic, A promiscuous drug as far as receptors are concerned, medication like promiscuous it likes a lot of different receptors. Why Doxypan?
Todd 15:32
Yeah, it’s, it’s, it’s what we sometimes call a dirty drug. But we’re talking about very low doses. We’re talking three, six milligrams doses. It’s been studied in two studies in older adults and shown to be effective and safe. Where I think we get into trouble is when we have people trying to sort of cheat the system. And I fought this in the VA and I lost to try to get the 3 and 6 milligrams on formulary, but because people, people just want to use the 10 and they don’t realize that the 10 is more than three times the three.
Eric 16:10
And I heard, correct me if I’m wrong, Todd, I heard that its promiscuousness is only at the higher doses, but it’s exceptionally good at just targeting the H1 receptors, histaminergic receptors, at the very low dose. Is that right? Does that sound right?
Todd 16:25
That sounds right.
Eric 16:26
So not so anticholinergic at the low doses, maybe at the high doses, but at the low doses seems to work fairly well.
Todd 16:35
You know, you see the same thing with mirtazapine, you know, which is not one that really made the cut in terms of a recommended alternative, but it’s, you know, has its histaminic effects are at lower doses, but they get overridden by the alpha adrenergic effects at higher doses. So once you go above 30 milligrams per day, you’re, you’re, you’re losing the sedating property of mirtazapine.
Mike 16:59
Yeah. And then it kind of, it begs the question, why not trazodone? Why not melatonin? Why aren’t those things that.
Todd 17:04
Todd?
Eric 17:05
Oh, yeah, why not melatonin, you got.
Alex 17:08
Or Trazodone, which are probably far more prescribed.
Eric 17:12
Melteon. That’s like, that’s basically the pharma version of melatonin.
Mike 17:17
Right, right. And the difference is evidence, you know, like we, you know, there’s just really limited evidence for a lot of these things, including for trazodone, low dose potazepine, melatonin, other drugs of that ilk. You know, there’s just really limit evidence. It doesn’t mean they absolutely don’t work. Yeah, but we don’t have much evidence that they do work.
And particularly for melatonin, the evidence does not suggest it’s not super effective. They’re probably reasonably safe, but they’re not going to help people so much, except through maybe placebo effect for, for, for sort of you know, just general insomnia disorder. We’re not talking about more sort of specialized forms of insomnia. Go ahead, Don.
Todd 17:56
I think this gets back to the methodology of how we did the alternatives, which we haven’t really talked about yet. So we didn’t look for the primary evidence because we have a hard enough time with the Beers criteria finding primary evidence to support what we’re doing. It’s mostly observational cohort type studies. But to go out and find clinical trials for the alternatives that show that they’re in older adults is pretty rare.
Mike 18:23
Yeah.
Todd 18:24
So what we ended up, our subgroups, our panel ended up doing is looking at what are the recommendations from other societies and other clinical practice guidelines. And specifically we’re hoping to find those recommended for older adults. So when we start looking at, through the sleep recommendations, this is what other organizations and sleep guidelines were recommending.
Alex 18:46
And is it possible. I know we don’t want to turn it into an insomnia podcast. We got a lot of other topics we want to get to. And is it possible that some of those society guidelines were influenced by pharmaceutical industry conflicts of interest?
Mike 19:02
Yes, for sure. You know, it’s true for any, any guideline for members sort of have conflicts of interest, many of them.
Eric 19:09
So the Beers criteria alternative list, we.
Mike 19:13
Do have a series of disclosures. Most of our panelists do not have any, any conflicts to disclose. Some do. They tend to not directly be from drug manufacturers, but make your own judgment based on the description.
Eric 19:25
I got another question real quick. Insomnia. If you had somebody insomnia in the hospital, you try to do all those things, you can avoid the insomnia, us waking them up, all of that. You’re probably not going to be doing CBTI in them in the hospital. Like, is there a drug that you would use in this alternative list for them? Todd, are you thinking doxepin here, low dose, 3 milligrams, if you can get it.
Todd 19:48
Yeah, if you can get it. That’s. That’s the issue.
Eric 19:50
Yeah, yeah.
Todd 19:53
You know, you could also be looking at a dual orexion receptor antagonist, one of those agents, as well as another. Another possibility. The, the evidence from the clinical trials, the minimum, the effect on sleep latency and sleep length is pretty small compared to placebo. But you know, it may work well enough in those situations.
Eric 20:17
So I’m gonna refer all of our guests to the insomnia podcast. We’ll talk more about that in the insomnia podcast. But I wanna get into this 80 year old again. I think we’ve talked about his insomnia. Mike said, oh, you wanna make sure that nothing else is bothering them. Their sleep, you know, good history and exam. And they say, yeah, you know, it’s my pain. I got this neuropathic pain in my feet. I take gabapentin. I got lower back pain. I’m taking Flexeril or cyclobenzaprene for maybe they’re, I don’t know if they’re really working. They say, where are we now? We’re still, we’re seeing more potholes now. Alex is still next to us biking. Who wants to take that one?
Mike 21:01
I can maybe start. Paint’s really easy. We, we all have the easy solution.
Eric 21:06
Yeah, you tell us not to use anything.
Todd 21:07
Exactly.
Mike 21:08
I know the exact answer.
Eric 21:09
I’m just gonna not tell skeletal muscle relaxants. I mean you kind of avoid gabapentin.
Mike 21:16
Right.
Eric 21:16
And.
Mike 21:18
Right. So I mean, so I mean first thing like is setting realistic expectations about what you realistically can and can’t do and kind of helping to, you know, this I’m as palliative care experts not telling you anything you haven’t taught me, you know, 10 times over. You know, focus on, you know, understanding what’s a reasonable outcome for the pain, focusing on function, functional outcomes rather than expecting your pain’s going to get to zero. But you know, once we get beyond that, you know, it gets back to what we were talking about before about insomnia. It’s like, let’s see if there are underlying triggers of pain that we can address.
Probably not the only thing that we need to do, but at least it’s a good start. So looking at those environmental, other kind of contextual factors, other drugs, other conditions, lifestyle modifications, things like that, that can help with that pain. And then the other thing is there are other kind of non pharmacologic therapies. You know, pain, of course it’s a, you know, a lot of it lives in the head. You know, it’s, it’s how we process pain, how emotional reaction to pain.
Eric 22:17
It’s all in the head. Right. You don’t have a head, you don’t have pain. You have. No, exactly. Fiber’s going up. But pain is an experience.
Mike 22:24
Right. So what can we do with the non pharmacologic therapies that kind of help with these sort of our, are the way our brain processes pain. So education, intervention, exercise, and this is all evidence based stuff from the guidelines. Like Todd said, you know, we didn’t try to reinvent the wheel by reviewing every single primary Evidence.
We went back to the guidelines and saw what the guidelines said, you know, and so some effective things that tend to work across a variety of causes of different types of pain education, exercise therapy of different types, aerobic, aquatic strengthening, yoga, physical therapy, cognitive behavioral therapy, and then some other kind of non pharmacologic medical interventions like peripheral electric or magnetic stimulation, acupuncture, things like that. So those are things we should be thinking about rather than saying, okay, here we have a bad drug, let’s take off the bad drug, let’s find a better drug to put in place of the bad drug.
Eric 23:18
Not as bad, but still think that way.
Mike 23:20
Yeah, yeah. You know, go back to first principles. We remember very, we very well might need another drug, but that shouldn’t be our first reflex.
Eric 23:28
Yeah. So for like, lower back pain, there’s a lot of non pharmacological interventions that we can do to manage lower back pain.
Mike 23:36
Exactly.
Eric 23:37
And depending on the cause of the lower back pain too.
Todd 23:41
Right.
Mike 23:41
And one other thing to kind of keep in mind is that, you know, I think we’ve. The Beers criteria and other sort of guidance in older adults has sometimes led to an irrational fear of NSAIDs.
Eric 23:51
Yeah.
Mike 23:51
Like guidance in the AGS. Beers criteria basically says don’t use NSAIDs regularly for more than a month. If someone needs to take NSAIDs every once in a while, like to manage their pain, like, and it works like, that’s a pretty safe regimen. And if it works for you, it’s effective for you, then by all means. So it’s not like we should never use NSAIDs.
Todd 24:11
We just be cautious about using them regularly for long term and maybe be careful which NSAID you use.
Eric 24:17
Yeah, how so?
Todd 24:19
Well, you just don’t want to use ones that are more likely to cause ulcerogenic problems. So maybe stick with a COX2 inhibitor, which is less likely. Or if you need to put somebody on some type of gastroprotective regimen like an hidden histamine antagonist or even a PPI for short term use, you know, that’s, that’s okay.
Eric 24:39
All right, where are we with the COX2 inhibitors? You know, was that a decade ago? Weren’t they bad?
Alex 24:46
I feel like that was 15 years.
Mike 24:51
Well, the, the, the ones that were the highest risk.
Eric 24:56
Yeah, yeah.
Mike 24:57
I mean, so celecoxib is, you know, has a, is, has less specific affinity for the COX1 receptor. So it tends to have less of the problems that you got from adrenaline for coxidibiotics that had more affinity. You know, I think the, my understanding is that the evidence of, of heart, you know, benefits are certainly similar between sort of COX2 inhibitors and NSAIDs. And then the harms, you know, if you take a gastroprotective agent, they’re generally similar between the, the NSAIDs and the COX2 inhibitors, so. Which are still in the market. So take your pick. As long as you don’t, you avoid stuff like, like indomethacin, which is particularly risky.
Todd 25:35
And don’t forget we have another delivery system for NSAIDs, and that’s through the topical. So depending on, you know, is this the right knee that’s bothering this individual? And can you localize that treatment? And there are other topical agents that may also be helpful when the pain is lessened. You know, maybe you need the NSAID oral NSAIDS for flare ups.
Eric 25:56
Yeah. Or if this person, we said this person has diabetic neuropathy in bilateral legs. Capsaicin, lidocaine combo likes lidocaine, capsaicin.
Todd 26:08
They’re, they’re all pretty safe as long as you don’t put it in your eye or open wound, you know.
Eric 26:13
Yeah.
Todd 26:15
Worth a try.
Eric 26:16
Yeah. I, I got a question though. So this person is on a PPI for the last three years for a history of gerd. So we’re safe. Right. But I think PPI is maybe on the beers list too. Are they?
Todd 26:31
They are.
Eric 26:32
What are they on the beers list for? Because everybody’s on them.
Todd 26:35
Well, they’re on them specifically for things like gerd, in particular for chronic conditions like Barrett’s, esophagitis and other things. We don’t refer to them in the beers criteria. We recognize that they have a role there, but we’re really trying to avoid them because of the long term safety issues that can occur with these agents. Sets people up for C. Difficile infections, perhaps pneumonia. What else am I missing, Mike?
Mike 27:04
I think atypical femur fractures.
Todd 27:13
Side effects.
Eric 27:13
Yeah. So we want them off it. I also saw though that H2 blockers, maybe as a short term relief at night, aren’t H2 blockers not so great too? Or where do they fall into this?
Todd 27:28
They’re, they’re, they’re really more restricted in patients who have at risk or have a delirium. That’s what we’re more concerned with, with, with those agents.
Eric 27:38
Okay, so maybe if this is. We’re using NSAIDs, we decide to use NSAIDs. Mike. We could also consider a PPI for GI protection, but if it’s just GERD.
Mike 27:52
Yeah. If you look at the guidelines for uncomplicated GERD it’s basically treat for PPI for eight weeks and then stop. The guidelines do not say to continue forever because a lot of times your GERD symptoms will resolve or at least dramatically improve. And then you can use your either PPI as needed basis. Even though there’s some pathophysiologic theory, it doesn’t work. It seems like for some people it does work. Or just better yet, use an H2 block or an antacid or something as needed.
So if someone, you know, got started on a PPI three years ago because someone thought they were wearing GERD and then it’s kind of never stopped it like, and they don’t have an indication, they’re not taking a chronic nsaid, they don’t have Barrett’s esophagus, they’re not taking a chronic steroids. Don’t have a strong indication to keep using it. Like help to, you know, don’t stop it abruptly. Help to maybe wean that patient off of it. And there are guidelines about how to wean PPIs and other other commonly used meds.
Eric 28:43
Do you have a good place for those guidelines? Is this deprescribing.org or where are those guidelines deprescribing?
Mike 28:51
Deprescribing.org from our arch nemesis Canada.
Eric 28:55
Is there guidelines tariff now?
Todd 28:58
Yeah.
Eric 29:00
Good news. Well, you have to be 100% tariff, but 100% tariff on a free comes out free. So that’s good.
Mike 29:07
Yeah, no there. And those guidelines are super helpful because they’re very thoughtfully constructed, they’re evidence based based and they’re simple to use. They have these very simple to use kind of cheat sheet algorithms or you can just follow the algorithm down. It tells you when to deprescribe, how to do so safely and effectively, what to look out for. And it’s the kind of thing you can look at in 10 seconds and kind of know what to do and have information you can give to patients. So strongly recommended deprescribing.org and they have them for a series of different and.
Eric 29:36
We’Ll have links to that site plus our deep prescribing podcast with them on the show Notes. Go ahead, Alex.
Alex 29:43
Well, so one question that came up at the AGS session that you did, which was terrific, and we’ll include the link to it in our show notes, was one of the participants asked about the use of cannabinoids, which could be used for a variety of the topics that we’re discussing today, including say pain, insomnia, for example, thoughts about and why weren’t Cannabinoids on the alternatives list.
Todd 30:11
Well, we know that our pain group looked at that as alternatives for pain, but they couldn’t find anything in recommendations because the evidence really isn’t there. And it also goes back to the. When we talked about melatonin earlier, one of the concerns we have is the quality of products is what’s in the product on the label. Really what’s in the product. Unless it’s got like a USP seal on it, you really don’t know. And I don’t think the USP has been certifying cannabinoid products, at least not to my knowledge yet. And which, which cannabinoids? Which what, what ratio of THC to CBD do we need? Yeah, that’s also kind of under investigation right now.
Alex 30:56
And we’ll have a link to our cannabis podcast. I think that was within the last.
Todd 31:00
Year or so and it’s not available in all states. CBD even.
Eric 31:06
Yeah. All right, I got another question. This person also, this 80 year old, has been on metformin and the sulfon real for the last 20 years, doing really well with that. Per him. A1C is fantastic. 6.5.
Todd 31:22
Hi.
Eric 31:23
Is this a pothole?
Mike 31:27
Sure.
Eric 31:28
Oh, why?
Todd 31:29
Well, this kind of goes back to the original Beers criteria where I would present it at grand rounds or something and, and everybody would say, well, I’ve got patients that have been on these drugs for years and they’ve never had a problem. Well, you haven’t come up to the mile of road where that pothole is living just waiting for you. So that’s what you’re worried about?
Is this patient at some point going to start to develop hypoglycemia? Maybe they stop eating regularly or they get ill and they develop hypoglycemia or something. So it’s, it’s a concern. We have long term. Also a hemoglobin A1C of 60.5 in an 80 year old. That’s pretty low. I mean, what would it be like if they were just on metformin? I’d be curious to know.
Eric 32:15
Yeah. 6.8. Yeah.
Todd 32:20
And what’s the risk of hypoglycemia then? Yeah.
Eric 32:25
So it sounds like you’re worried not about the metformin in this case, you’re worried about the sulfonyl which is on the Beers criteria, Right?
Todd 32:31
Correct.
Mike 32:32
Yes. So it’s on the BS criteria as a medicine to avoid as first or second line treatment. Okay.
Eric 32:37
So it’s not. Never use a sulfonyurial. There are certain indications that you may want to consider it, but because of the risk for hypoglycemia, but it has a super long track record. Like, we know the risks and benefits of this drug versus some of the newer agents. We’re just kind of figuring them out. Right.
Todd 32:54
Well, we also, and we also recognize, because this came up when we, when we released the current edition of the Beers criteria, people were really concerned. That’s what their patients can afford. And if they need a second line agent or they can’t take metformin, this is what they can afford. And we recognize that. And that’s part of your decision as to whether you hit Alex on the bike or you hit the pothole.
Eric 33:17
It’s always Alex. Poor cyclist, easy choice.
Mike 33:22
And then the other thing to keep in mind, and this is true for all these drugs, it’s got to be good. A pretty process of shared decision making. It’s not like I, I, the clinician going to unilaterally stop the drug whether you like it or not. You know, we’re going to burn bridges that way. So, you know, there’s a whole literature and, and sort of area of expertise around how to have these deep prescribing conversations. But, you know, just, we need to be really thoughtful if for all these things.
Like we, you know, the, the, the, the framing needs to be like, we want to help you, we want to manage your symptoms, we want to help you live longer, happier, better. And that is my goal. And this is why I would make this recommendation. So going to help you meet that goal. And if the patient doesn’t buy in, then might be best to come back to another day.
Eric 34:02
Shoot. I looked at the wrong patient’s chart. Even when I see it’s not 6.5, it’s 8.4, and they’ve been having some hypoglycemic episodes. Is there an alternative? Should I just put them on insulin and call it day? How should I think about this?
Mike 34:23
Well, first thing is like, what’s their dose of metformin? You know, can that be raised? You know, if they’re having hypoglycemic episodes, that certainly ups the ante to kind of be more aggressive about stopping the sulfonylurea.
Eric 34:33
Yeah.
Mike 34:34
And then, you know, you mentioned, like, there are newer therapies, but even though they’re newer, some of them are not especially new. You know, a lot of them have been around for at least a while now, and others who had a few years of experience to be pretty safe and effective in older adults. I’m talking, you know, the DPP4s, the GLP1 receptor agonists, the SGLT2 inhibitors. And so all those have a much more robust, you know, track record of safety and effectiveness than sulfonylureas at this point.
So there are cost issues for sure, which are real and serious, but at the same time, like can we find a way to get a patient if they, if they, if their A1C really is above target and with afro thoughtful consideration of what that target should be, then yeah, I would definitely sort of see if we can, you know, maybe substitute in one of those medicines instead.
Eric 35:24
How do you choose between, did you do any quick advice? How do you choose between that for the GLP1 SGL2s? Like how do you.
Mike 35:34
It’s complicated. Not. I could.
Eric 35:36
It’s a long talk.
Mike 35:38
Long talk. Comorbidities, you know, some of these ones are better for CKD or heart failure or other conditions than others. So look at guidelines, okay?
Eric 35:51
So look at guidelines, okay? So you decide to put this person on a, they switch to a glp, they’re doing well over the next two years and then palliative care gets consulted for significant weight loss and wondering, hey, can we put this person on Megestrel for their continued weight loss? Because it seems like they’re getting more frail and they’re losing weight. This is actually I heard this happening to someone pal of care getting consulted for weight loss and somebody on a ozempic. Thoughts, Todd?
Todd 36:29
Well, first of all, Magesterol is on the Beers criteria because it’s associated with increased mortality in older adults, something we try to avoid. So I guess the question would be do they still need their ozembic or whatever they were on? Is this the reason why they’ve lost so much weight or they need a further workup? Yeah, there’s all sorts of non pharmacologic interventions that we want to look at. Are they still, are they having difficulty preparing their meals or shopping for food? You know, I once had a patient who we’re trying to get her to increase her calcium intake but she avoided the dairy aisle because it was too cold. You know, so look for things like that.
Mike 37:12
Yeah.
Eric 37:13
So hypothetically different case than when we’re thinking about appetite stimulants. Is there one that’s not on the Beers criteria that we could potentially choose or is this just all non pharmacological like look at other causes for their decreased PO intake or loss of appetite. Is there anything on that list, on the alternative list?
Todd 37:36
Well, some people would say if the person has depression that you might want to try mirtazapine as something to. To stimulate their. Yeah, their appetite. I don’t recall that. This is like the only thing the person didn’t have.
Eric 37:49
Yeah, they did not have depression.
Mike 37:53
Yeah.
Todd 37:53
And we know that mirtazapine isn’t really our sleep alternative, but some people might.
Eric 37:57
Still say, well, so no evidence for sleep or appetite outside of depression. But if they’re depression, maybe it’s a good drug to use from a side effect profile. Is that a good summary?
Todd 38:09
Yeah. Yes.
Eric 38:11
All right.
Alex 38:12
Anything else?
Todd 38:13
I’m not aware of other medications? Most of our other alternatives are off.
Eric 38:19
Farm cannabinoids, I guess. We already talked about cannabinoids. Marinol. Honestly, I’ve never seen somebody get better on Marinol for appetite. That sound about right?
Todd 38:31
Yep.
Alex 38:32
Yeah.
Mike 38:32
It’s certainly not. Not in sort of evidence based guidelines for weight loss.
Eric 38:37
Alex, any other palliative care symptoms coming up that you’re.
Alex 38:39
That behavioral symptoms in this, a different case? I don’t know that we could do everything in the one case, behavioral symptoms for people with dementia. Thoughts? Recommendations? Like, of course you’re gonna say non pharmacologic first. And they’ll say, we’ve tried that, we tried that, we tried that.
Eric 39:00
Geriatricians and they’re non pharmacologic.
Mike 39:03
Yeah.
Alex 39:03
Come on, give me something. Yeah, give me something.
Mike 39:07
Yeah. Well, I mean, the other thing to think about is not just like, did you use, like get into the person’s world and try to redirect, but also like, are they having other clinical conditions which are going. This is getting back to first principles. Things which are causing them to be agitated in the first place. Are they constipated, are they in pain, are they having urinary retention? Something else going on. So kind of making sure we’re ruling that stuff out.
You know, there is a role for antipsychotics in the management of agitation or aggression of people with dementia. You know, if the person’s at risk for themselves or others and the non pharmacologic stuff has failed. So it’s not like you should never use it. But you know, it’s again, going back to. I don’t want to use the swerving to Alex analogy.
Eric 39:49
Severe distressing hallucinations.
Mike 39:52
Yeah, exactly. But there’s a risk. I mean, they increase mortality. So we should be thinking about all the things that are safer and we know to be effective. But if those aren’t working and the person is desperate for therapy and they’re willing to take those risks, then yeah, it can be a reasonable thing to do. Or recognizing that, you know, some of them have been FDA approved for treatment of this and others have not, doesn’t necessarily mean the others are ineffective, but it just means there’s limited evidence for like say breakfast pipers all compared to some of the others.
Eric 40:24
All right, I got my last question for you. You’ve both been dealing with beer’s criteria for so long. What is your pet peeve? Like, what’s your. What’s like if that. That drug on the beers criteria that you. I hate that drug. And there’s, you know, this other alternative that you think is great, is there. Do you have one? Mike, do you have one?
Mike 40:46
I don’t have a single drug. I think the thing I hate most is like just people taking overly simplistic approach to it. Like this is a list of bad drugs, we should never use them and everything else is fine, which is not true. And so applying clinical judgment and just applying good clinical common sense to how we think of these lists and just going back to first principles, like figure out what’s causing the symptom. Let’s see if we can try a non pharmacologic strategy.
This is not rocket science, but as clinicians, we’re often so busy and overwhelmed, we kind of often skip past that stuff. So the thing I always try to remind myself, easier said than done, is just take a step back and let’s just go back to first principles before I just sort of act reflexively. Any of these lists.
Eric 41:30
All right. Todd, do you have one?
Todd 41:32
Yeah, it’s similar. Similar to what Mike’s saying. I think that people over interpret or oversimplify the criteria and they see a void and they don’t read the recommendation, they don’t read the rationale and apply that. So avoid means avoid at all costs. And sometimes that comes down to third party payers and others. But, you know, you never want to hit the bicyclist. I’m just gonna close with that.
Eric 41:57
Thank you.
Alex 42:00
Thank you.
Todd 42:00
I want to be clear about that.
Eric 42:02
But what if you have a really nice car? Alex has got a nice car.
Todd 42:09
We want to keep Alex in one piece.
Eric 42:11
All right, Alex, you can sing more now. You’re not gonna get hit.
Alex 42:20
It’s getting better all the time. Me used to be angry young man Me hiding me head in the sand. You gave me the word I finally heard I’m doing the best that I can. I’ve got to admit it’s getting better. A little better all the time. I have to admit it’s getting better it’s getting better since you be mine.
Eric 43:02
Wonderful. Mike, Todd, where can we find this article that you published as of this moment?
Mike 43:09
It will imminently be published in the Journal of the American Geriatric Society. And also these should be linked from the American geriatric society website, americangeriatrics.org.
Eric 43:19
There will be a link from the GeriPal website. So take a look at that. Todd, Mike, thanks for joining us on this GeriPal Podcast.
Todd 43:26
Thank you for having us.
Mike 43:27
Thank you.
Eric 43:28
And thank you to all of our listeners for your continued support.
The post What instead? Alternatives to Beers: Todd Semla and Mike Steinman appeared first on A Geriatrics and Palliative Care Podcast for Every Healthcare Professional.