Whelp, goodbye folks! Eric and I have been DOGE’d.

In a somewhat delayed April Fools, Nancy Lundeberg and Annie Medina-Walpole have taken over podcast host duties this week.

Their purpose is to interview me, Eric, and Ken Covinsky about your final AGS literature review plenary session taking place at the Annual Meeting in Chicago this May (for those attending, our session is the plenary the morning of May 10). We discuss our favorite articles, parody songs, and memories from AGS meetings past, with a little preview of a song for this year’s meeting.

We covered:

• The first parody song I wrote, for AGS 2018 in Orlando, about this article by Nancy Schoenborn on how to discuss stopping cancer screening.

• Ken’s favorite articles, including

• • The Impact of Rudeness on Medical Team Performance: A Randomized Trial

  • Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization

• Eric’s favorite article on the effect of chair placement on physicians’ behavior and patients’ satisfaction

• Tim Anderson’s study on the intensification of older adults’ outpatient blood pressure treatment at hospital discharge

• Nancy’s favorite topic and parody song, Aducanumab, which won Drug of the Year in 2021.

Enjoy! And maybe, just maybe, Eric and I will be reinstated and return as hosts next week…

-Alex Smith

A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice. Outcomes are typically assessed from available records. Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations.

Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine.

We spend the last portion of the podcast discussing the surprising finding of the study. In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group. What?!? Not a typo.

We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including:

• Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control). Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions?

• Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care.

• Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings. My goals will differ if I think I probably have 2 years to live vs 10 years.

• Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed).

• Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning. As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful.

And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French!

-Alex Smith

Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (VSED), and multiple episodes about the ethical issues surrounding medical aid in dying (MAID). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life?

To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of Minimal Comfort Feeding (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit.

We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medical aid in dying medications and their respective articles on the topic. We discussed what makes an illness “terminal”, what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers.

-Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host)

Articles referenced in this discussion:

• “Mr. Smith Has No Mealtimes”: Minimal Comfort Feeding for Patients with Advanced Dementia by Hope Wechkin et al in JPSM
• Medical Aid in Dying to Avoid Late-Stage Dementia by Thaddeus Pope and Lisa Brodoff in JAGS
• Law not loopholes: Medical aid in dying for those with dementia also in JAGS by Joshua Briscoe and Eric Widera

Past GeriPal Podcast Episodes on MAID:

MAID podcasts

https://geripal.org/what-is-going-on-with-maid-in-canada-bill-gardner-leonie-herx-sonu-gaind/

https://geripal.org/conscientous-provision-of-maid-and-abortion-robert-brody-lori-freedman-mara-buchbinder/

https://geripal.org/assisted-dying-podcast-with-lewis-cohen/

https://geripal.org/dilemmas-in-aid-in-dying-podcast-with/

Past GeriPal Podcast Episode about VSED:

https://geripal.org/tim-quill-vsed/