As far as we’ve come in the 50 years since Balfour Mount and Sue Britton opened the first palliative care at the Royal Victoria Hospital in Quebec, have we lost something along the way?

In today’s podcast we welcome some of the early pioneers in palliative care to talk about the roots of palliative care. Sue Britton was the first nurse hired on that palliative care unit. Michael Kearney on a transformational meeting in Cicely Saunders’s office, with Balfour Mount at her side and a glass of sherry. Justin Sanders wants to be sure the newer generations of palliative care clinicians understand the early principles and problems that animated the founders of hospice and palliative care, including:

• Origins of the word “palliative” - it’s not what I thought! Yes, it means “to cloak,” but there’s more…

• Whole-person-care

• Total pain

• Healing as a process distinct from the deterioration of the body

• Sympomatologists

• The patient and family as the unit of care

Our guests referenced many articles on this podcast, linked above and below. If you read just one, read Palliative Medicine - Just Another Specialty? by Kearney. I promise it’s short. 2 pages. Here’s a taste:

…While there is an abusive and useless dimension to illness, pain and suffering which needs to be removed if at all possible, there is also potential in such experience…If we in palliative medicine fail to accept this view, a view which allows that there may also be a potential in the suffering of the dying process, if we sell out completely to the literalism of the medical model with its view that such suffering is only a problem, we will be in danger of following a pattern which could significantly limit our scope for development and lead to our becoming ’symptomatologists’, within just another specialty.

And love that Jim Croce choice. What’s in a name? I’ve got a name.

Enjoy!

-Alex Smith

Links

• Link to the McGill National Grand Rounds Series on Palliative Care, Michael Kearney as initial presenter, and registration for future events. No, you don’t need to be Canadian. Canadians are welcoming.
• Palliative Medicine - Just Another Specialty? In Palliative Medicine By Kearney
• Joe Wood’s book on Total Pain
• Balfour Mount’s memoir Ten Thousand Crossroads paper on Healing Connections in JPSM and Healing and Palliative Care in Palliative Medicine
• Cicely Saunders: A Life and Legacy, by David Clark
• Self-Care of Physicians Caring for Patients at the End of Life, by Michael Kearney and colleagues in JAMA Perspectives on Care at the Close of Life series
• Twycross on Readdressing Balance in Hospice

Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.

Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:

• Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?”

• Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in JPSM.

• What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).

• When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?

• Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?

• And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…

Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!

Sometimes the drugs don’t work.

-Alex: @alexsmithmd.bsky.social

Trauma is a universal experience, and our approach as health care providers to trauma should be universal as well. That’s my main take-home point after learning from our three guests today when talking about trauma-informed care, an approach that highlights key principles including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity.

With that said, there is so much more that I learned from our guests for this trauma-informed care podcast. Our guests include Mariah Robertson, Kate Duchowny, and Ashwin Kotwal. Mariah discussed her JAGS paper on applying a trauma-informed approach to home visits. Kate and Ashwin talked about their research on the prevalence of lifetime trauma and its association with physical and psychosocial health among adults at the end of life. We also explored several questions with them, including how to define trauma, its prevalence in older adults, the impact of past traumatic experiences, the potential triggers of trauma screening, and the application of trauma-informed principles in clinical practice.

If you want a deeper dive, check out the following resources:

• Our “Nature of Suffering” podcast with BJ Miller and Naomi Saks

• Dani Chammas’ Annals paper on countertransference and why we shouldn’t say “that the patient was difficult rather than that I felt frustrated.”

• A great Curbsiders podcast episode on Trauma-informed care with Megan Gerber

• CAPC’s Trauma-informed care toolkit

• Mariah’s article on Home-Based Care for LGBTQ or another diverse gender identity Older Adults

In today’s podcast we were delighted to be joined by the presenters of the top scientific abstracts for the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Medicine Nurses Association (HPNA). Eric and I interviewed these presenters at the meeting on Thursday (before the pub crawl, thankfully). On Saturday, they formally presented their abstracts during the plenary session, followed by a wonderful question and answer session with Hillary Lum doing a terrific job in the role of moderator.

Our three guests were Marie Bakitas, who conducted a trial of tele/video palliative care for Black and White inpatients with serious illness hospitalized in the rural south; Yael Shenker, for a trial of patient-directed Prepare-for-your-care vs. facilitated Respecting Choices style advance care planning interventions; and, Na Ouyang, who studied the relationship between prognostic communication and prolonged grief among the parents of children who died from cancer. From just the abstracts we had so many questions. We covered some of our questions on the podcast, others you can ponder on your own or in your journal clubs, including:

• Marie’s tele/video palliative care intervention was tailored/refined with the help of a community advisory board. Does every institution need to get a community advisory board to tailor their rural tele-palliative care initiative (or geriatrics intervention) to the local communities served? Who would/should be on that board? How to be sensitive to the risks of stereotyping based on recommendations from the few members of the board to the many heterogeneous patients served?

• Advance care planning has taken a beating. For the purposes of a thought exercise, no matter what you believe, let’s assume that there are clear important benefits. Based on the results of Yael’s study, should resources be allocated to resource intensive nurse facilitated sessions (Respecting Choices), which had significantly better engagement, or to low resource intensive patient-facing materials (Prepare), which had significantly less engagement but still plenty of engagement (e.g. 75% vs 61% advance directive completion)?

• One interpretation of Na’s study is that clinicians can lean on the high levels of trust and high ratings of communication to engage with parents of children with cancer about prognosis. Another interpretation is that clinicians avoided telling the parents prognosis in order to bolster their ratings of trust and communication quality. Which is it?

• Bonus: Simon says he composed the song Sounds of Silence in a dark echoing bathroom about his concerns that people had stopped listening to each other in the 1960s (still resonates, right?). Garfunkel says Simon was writing about Garfunklel’s friend and college roomate Sandy, who was blind. Who’s got the right of it?

Enjoy!

-Alex Smith

Things are changing quickly in the Alzheimer’s space. We now have biomarkers that can reasonably approximate the degree of amyloid build-up in the brain with a simple blood test. We have two new FDA-approved medications that reduce that amyloid buildup and modestly slow down the progression of the disease. So, the question becomes, what, if anything, should we do differently in the primary care setting to diagnose the disease?

On today’s podcast, we’ve invited Nathaniel Chin back to the GeriPal podcast to talk about what primary care needs to manage this new world of Alzheimer’s disease effectively. Nate is a geriatrician and clinician-scientist at the University of Wisconsin, as well as the host of the Wisconsin ADRC's podcast, "Dementia Matters." In each bi-weekly episode, he interviews Alzheimer's disease experts about research advances and caregiver strategies. Nate also wrote a NEJM piece last year on “Alzheimer’s Disease, Biomarkers, and mAbs — What Does Primary Care Need?”

We address the following questions with Nate:

• Has anything changed for the primary care doctor when diagnosing Alzheimer’s? How should we screen for cognitive impairment?

• Does a good history matter anymore?

• What’s the role of assessing function?

• What do we do with those who have only subjective cognitive complaints?

• Can’t we skip all this and just send some blood-based biomarkers?

• What is the role of the amyloid antibody treatments?

Lastly, take a look at the following if you want to take a deeper dive into some of the other articles and podcasts we discuss:

• First, two competing definitions of what is Alzheimer’s:

• • Alzheimer Disease as a Clinical-Biological Construct—An International Working Group (IWG) Recommendation

  • Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup

• Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD): Executive summary of recommendations for primary care

• Podcasts we mentioned

• • Prevention of Dementia: A Podcast with Kristine Yaffe

  • Screening for Dementia: A Podcast with Anna Chodos, Joseph Gaugler and Soo Borson

It is a battle royale on this week’s GeriPal podcast. In one corner, weighing in at decades of experience, well known for heavy hits of bedside assessments, strong patient-family relationships, and a knockout punch of interdisciplinary collaboration, we have in-person palliative care consults. But watch out! Travel time can leave this champ vulnerable to fatigue and no-shows. In the other corner, we have the young upstart, able to reach patients across vast distances when delivering palliative care, all in the comfort of wearing pajamas, we have telehealth delivered palliative care. However, lack of physical presence may make this contender struggle to land the emotional support punch that is at the very heart of palliative care.

Who will emerge victorious? Will in-person palliative care use its experience and bedside manner to overwhelm telehealth palliative care, or will telehealth deliver the knockout blow of efficiency and accessibility?

Find out on this week’s podcast where we invite Joseph Greer, Simone Rinaldi, and Vicki Jackson to talk about their recent JAMA article on “Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer - A Multisite Randomized Clinical Trial.”

Additionally, here are some of the resources we talked about during the podcast:

• Eduardo Bruera’s editorial that accompanies the JAMA paper titled “Improving Palliative Care Access for Patients With Cancer”

• Our podcast on Stepped Palliative Care with Jennifer Temel, Chris Jones, and Pallavi Kumar

• The book “What's in the Syringe? Principles of Early Integrated Palliative Care” by Juliet Jacobsen, Vicki Jackson, Joseph Greer, and Jennifer Temel

Lastly, don’t forget about attending some of the sessions Vicki mentioned at the end of the podcast during the HPNA/AAHPM annual meeting in Denver, as well as the GeriPal #HPMParty Pub Crawl!

It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes.

In our first segment, we discuss a study led by Constance Fung and her team, which investigated the use of a masked tapering method combined with augmented cognitive behavioral therapy for insomnia (CBTI) to help patients discontinue benzodiazepines. The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts.

Next, we turn to Emily McDonald, the director of the Canadian Medication Appropriateness and Deprescribing Network, to discuss her study on the impact of direct-to-consumer educational brochures on gabapentin deprescribing. Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see here for the brochure). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use.

In our third segment, we explore Amy Linsky’s study that examined the effect of patient-directed educational materials on clinician deprescribing of potentially low-benefit or high-risk medications, such as proton pump inhibitors, high-dose gabapentin, or risky diabetes medications. The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click here for the brochure). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety.

Finally, we discuss Michelle Odden’s study, which used a target trial emulation approach to investigate the effects of deprescribing antihypertensive medications on cognitive function in nursing home residents. The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast (DANTE and OPTIMIZE) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the DANTON study adds more questions to that conclusion.

Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research!