In today’s podcast we set the stage with the story of Dax Cowart, who in 1973 was a 25 year old man horribly burned in a freak accident. Two thirds of his body was burned, most of his fingers were amputated, and he lost vision in both eyes. During his 14 month recovery Dax repeatedly demanded that he be allowed to die. The requests were ignored. After, he said he was both glad to be alive, and that the doctors should have respected his wish to be allowed to die.

But that was 1973, you might say. We don’t have such issues today, do we?

Louise Aronson’s recent perspective about her mother in the NEJM, titled, “Beyond Code Status” suggests no, we still struggle with this issue. And Bill Andereck is still haunted by the decision he made to have the police break down the door to rescue his patient who attempted suicide in the 1980s, as detailed in this essay in the Cambridge Quarterly of HealthCare Ethics. The issues that are raised by these situations are really hard, as they involve complex and sometimes competing ethical values, including:

• The duty to rescue, to save life, to be a “lifeguard”

• Judgements about quality of life, made on the part of patients about their future selves, and by clinicians (and surrogate decision makers) about patients

• Age realism vs agism

• The ethics of rationale suicide, subject of a prior GeriPal episode

• Changes in medical practice and training, a disconnect between longitudinal care and acute care, and frequent handoffs

• The limitations of advance directives, POLST, and code status orders in the electronic health record

• The complexities of patient preferences, which extend far beyond code status

• The tension between list vs goals based approaches to documentation in the EHR

And a great song request, “The Cape” by Guy Clark to start and end.

Enjoy!

-@AlexSmithMD

Serious illness communication is hard. We must often deliver complex medical information that carries heavy emotional weight in pressured settings to individuals with varying cultural backgrounds, values, and beliefs. That’s a hard enough task, given that most of us have never had any communication skills training. It feels nearly impossible if you add another degree of difficulty, whether it be a crying interpreter or a grandchild from another state who shows up at the end of a family meeting yelling how you are killing grandma.

On today’s podcast, we try to stump three VitalTalk expert faculty, Gordon Wood, Holly Yang, Elise Carey, with some of the most challenging communication scenarios that we (and some of our listeners) could think up.

During the podcast, we reference a newly released second-edition book that our guests published titled “Navigating Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope.” I’d add this to your “must read” list of books, as it takes readers through the VitalTalk method that our guests use so effectively when addressing these challenging scenarios.

If you are interested in learning more about VitalTalk, check out their and some of these other podcasts we’ve done with three of the other authors of this book (and VitalTalk co-founders):

• Our podcast with Tony Back as well as Wendy Anderson on “Communication Skills in a Time of Crises”

• Our podcast with James Tulsky on “The Messiness of Medical Decision-Making in Advanced Illness.”

• Any one of our podcasts with Bob Arnold, including this one on the language of serious illness or this one on books, to become a better mentor.

Lastly, I reference Alex’s Take Out the Trash video, where he uses communication skills learned in his palliative care training at home with his wife. The results are… well… let’s just say less than perfect.

By: Eric Widera

We’ve talked about Brain Death before with Robert (Bob) Troug and guest-host Liz Dzeng, and in many ways today’s podcast is a follow up to that episode (apologies Bob for mispronouncing your last name on today’s podcast!).

Why does this issue keep coming up? Why is it unresolved? Today we put these questions to Winston Chiong, a neurologist and bioethicist, and Sean Aas, a philosopher and bioethicist. We talk about many reasons and ways forward on this podcast, including:

• The ways in which advancing technology continually forces us to re-evaluate what it means to be dead - from the ability of cells/organs to revive, to a future in which organs can be grown, to uploading our consciousness to an AI. (I briefly mention the Bobiverse series by Denise Taylor - a science fiction series about an uploaded consciousness that confronts the reader with a re-evaluation of what it means to be human, or deserving of moral standing).

• The moral questions at stake vs the biologic questions (and links between them)

• The pressures the organ donation placers on this issue, and questioning if this is the dominant consideration (as Winston notes, organ donation was not central to the Jahi McMath story)

• What we argue about when we argue about death - the title of a great recent paper from Sean - which argues that “we must define death in moralized terms, as the loss of a significant sort of moral standing,” - noting that those why are “dead” have something to gain - the ability to donate their organs to others.

• Winston’s paper on the “fuzziness” around all definitions of brain death, titled, Brain Death without Definitions.

As we joke about at the start - talking with philosophers and bioethicists, you almost always get a response along the lines of, “well that’s a good question, but let’s examine a deeper more fundamental question.” Today is no different. And the process of identifying the right questions to ask is absolutely the best place to start.

Eventually, of course, everything must cease.

-@AlexSmithMD

Anti-Asian hate incidents rose dramatically during COVID, likely fueled by prominent statements about the “Chinese virus.” VIewed through the wider lens of history, this was just the latest in a long experience of Anti-Asian hate, including the murder of Vincent Chin, the Chinese Exclusion Act, and the internment of Japanese Americans during WWII. For those who think that anti-Asian hate has receded as the COVID has “ended,” just two days prior to recording this episode a Filipino woman was pushed to her death on BART in San Francisco. These incidents are broadcast widely, particularly in Asian News outlets.

Today we talk about the impact of anti-Asian hate on the health and well being of older adults with Russell Jeung, sociologist, Professor of Asian Studies at San Francisco State, and co-founder of Stop AAPI-Hate, Lingsheng Li, geriatrician/palliative care doc and T32 fellow at UCSF, and Jessica Eng, medical director of On Lok, a PACE, and Associate Professor in the UCSF Division of Geriatrics.

We discuss:

• What is considered a hate incident, how is it tracked, what do we know about changes over time

• The wider impact of Anti-Asian hate on older Asians, who are afraid to go out, leading to anxiety, social isolation, loneliness, decreased exercise, missed appointments and medications. Lingsheng (and I) recently published studies on this in JAMA Internal Medicine, and JAGS.

• Ongoing reports from patients about anti-Asian hate experiences

• Should clinicians screen for Anti-Asian hate? Why? Why not?

• Proposing the clinicians ask a simple follow up question to the usual “do you feel safe at home?” question used to screen for domestic violence. Add to this, “do you feel safe outside the home?” This question, while providing an opportunity to talk about direct and indirect experiences, can be asked of all patients, and opens the door to conversations about anti-semitism, islamophobia, or anti-Black racism.

See also guides for how to confront and discuss anti-Asian hate in these articles in the NEJM and JGIM.

And to balance the somber subject, Lingsheng requested the BTS song Dynamite, which was the group’s first English language song, and was released at the height of the COVID pandemic. I had fun trying to make a danceable version with electronic drums for the audio-only podcast. Maybe we’ll get some BTS followers to subscribe to GeriPal?!?

-@AlexSmithMD

(We couldn’t resist when Miguel Paniagua proposed this podcast idea and title. And no, you’ll be relieved to hear Eric and I did not imitate the interview style of Zach Galifiniakis).

We’ve talked a good deal on this podcast about what happens before death, today we talk about what happens after. Our guest today is Thomas Lynch, a poet and undertaker who practiced for years in a small town in Michigan. I first met Thomas when he visited UC Berkeley in the late 90’s after publishing his book, “The Undertaking: Stories from the Dismal Trade.”

We cover a wide range on this topic, weaving in our own stories of loss with Thomas’s experiences, stories, and poems from years of caring for families after their loved one’s have died.

We cover:

• The cultural shift from grieving to celebration, the “disappearance” of the body and death from funerals

• The power of viewing the body and participating in preparing the body, including cremation

• The costs of funerals

• The story of why Thomas became an undertaker

• A strong response to Jessica Mitford’s scathing critique of the American Funeral Industry published in “The American Way of Death”

• Our own experiences with funerals and burial arrangements for our loved ones

• Shifting practices, with a majority of people being cremated after death, a dramatic increase

This podcast was like therapy for us. And I got to sing Tom Waits’ Time, one of my favorites.

What is a healthy diet and how much does it really matter that we try to eat one as we age? That’s the topic of this week's podcast with three amazing guests: Anna Pleet, Elizabeth Eckstrom, and Emily Johnston.

Emily Johnston is a registered dietitian, nutrition researcher, and Assistant professor at NYU. Anna Pleet is an internal medicine resident at Allegheny Health Network who has a collection of amazing YouTube videos on aging and the Mediterranean diet. Elizabeth Eckstrom is a geriatrician, professor of medicine at OHSU, and author of a new book, the Gift of Aging.

I love this podcast as while we talk about the usual topics in a medical podcast, like the role of screening, energy balance, and evidence-based for specific diets, we also talk about what a Mediterranean diet actually looks like on a plate and pepper our guests with questions about their favorite meals to convince Alex and me to eat more like a Sardinian.

Eric

PS. NEJM just published a great summary of diets summing up adherence to the Mediterranean diet and the following improved health outcomes: death from any cause, cardiovascular diseases, coronary heart disease, myocardial infarction, cancer, neurodegenerative diseases, and diabetes

We are dusting off our crystal balls today with three amazing guests who have all recently published an article on prognosis over the last couple months: Kara Bischoff, James Deardorff, and Elizabeth Lilley.

To start us off we talk with Kara Bischoff about the article she just published in JAMA Network on a re-validation of the Palliative Performance Scale (PPS) in a modern day palliative care setting. Why do this? The PPS is one of the most widely used prognostic tools for seriously ill patients, but the prognostic estimates given by the PPS are based on data that is well over a decade old. ePrognosis now includes the modern validation of the PPS.

Next, we talk with James Deardorff about whether we can accurately predict nursing home level of care in community-dwelling older adults with dementia. Spoiler alert, he published a study in JAMA IM on a prognostic index that does exactly that (which is also on eprognosis.org)

Lastly, we invite Liz Lilley to talk about her paper in Annals of Surgery about prognostic allignment, including why as palliative care and geriatrics teams we need to take time to ensure that all disciplines and specialities are prognostically aligned before a family meeting.

The US Preventive Services Task Force (USPSTF) concluded back in 2000 that there is insufficient evidence to recommend for or against routine screening for dementia in older adults. Are there, though, populations that it may be helpful in, or should that change with the advent of the new amyloid antibodies? Should it? If so, how do we screen and who do we screen?

On this week’s podcast we talk with three experts in the field about screening for dementia. Anna Chodos is a geriatrician at UCSF and the Principal Investigator of Dementia Care Aware, a California-wide program to improve the detection of dementia in older adults who have Medi-Cal benefits. Joseph Gaugler is the Director of the Center for Healthy Aging and Innovation at the University of Minnesota, director of the BOLD Public Health Center of Excellence on Dementia Caregiving, and Editor-in-Chief of the Gerontologist. Lastly, Soo Borson is a self-described primary care leaning geriatric psychiatrist, developer of the Mini-Cog, and co-leads the CDC-funded BOLD Center on Early Detection of Dementia.

In addition to the questions asked above, we also cover the following topics with our guests:

• What is dementia screening?

• Who should get it if anyone?

• What should we use to screen individuals?

• What happens after they test positive?

And if you are interested in learning more about the Guiding an Improved Dementia Experience (GUIDE) Model for dementia, check out this podcast.