GeriPal - A Geriatrics and Palliative Care Podcast

• Hastening Death by Stopping Eating and Drinking: Hope Wechkin, Thaddeus Pope, & Josh Briscoe

  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/  

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• The Roots of Palliative Care: Michael Kearney, Sue Britton, and Justin Sanders

  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

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• PC for People Experiencing Homelessness: Naheed Dosani

  I was very proud to use the word “apotheosis” on today’s podcast.  See if you can pick out the moment.  I say something like, “Palliative care for people experiencing homelessness is, in many ways, the apotheosis of great palliative care.”  And I believe that to be true.  When you think about the early concepts that shaped the field, you can see how palliative care for persons experiencing homelessness fits like a hand in a glove: total pain envisioned by Cicely Saunders, which even its earliest sketches included social suffering like loneliness; or Balfour Mount, who coined the term “palliative care,” lamenting the cruel irony of our care for the dying, and the desperate need to create programs to reach more people experiencing suffering. Today we talk with Naheed Dosani, a palliative care physician at St. Michael’s Hospital in Toronto, and health justice activist. His story, which he shares on today’s podcast, is remarkable.  Just out of fellowship, Naheed built a palliative care program for homeless persons  called the Palliative Education and Care for the Homeless (PEACH) Program.  This podcast is a complement to our prior podcast on aging and homelessness with Margot Kushel. Today we discuss: What is the best terminology? Homeless? Homelessness? Houseless? Marginally housed? What makes palliative care for people experiencing homelessness challenging? What makes it rewarding?  What is unique about the practice of palliative care for people experiencing homelessness? We discuss the principles of harm reduction, social determinants of health, and trauma informed care.  Major overlap with substance use disorder issues, which we have covered recently (and frequently) on this podcast. How are the health systems designed or not designed to meet the needs of people experiencing homelessness?  What are the equity issues at stake, and at risk of being cut, both in Canada and the US?   Many more links below.  And I had a blast playing Blinding Lights by that Toronto band The Weekend. Enjoy! -Alex   End Well Talk https://www.youtube.com/watch?v=eG4QE-hfPQU Resources on the PEACH Program Program Review Paper – A recent publication in Longwoods Healthcare Quarterly reviewing the PEACH model. https://pubmed.ncbi.nlm.nih.gov/37144698/ Promising Practice Recognition – PEACH was named a Promising Practice in equity-oriented palliative care as part of a national initiative funded by Health Canada, operated by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. https://www.healthcareexcellence.ca/media/z3jifqqd/pp-peach-en-2024-v2.pdf Toronto Star Feature https://www.thestar.com/life/together/people/dr-naheed-dosani-started-peach-to-provide-palliative-care-for-homeless-and-vulnerably-housed-populations/article_c56d8f45-cbe9-522e-9554-46778bf50407.html CityNews Toronto Feature https://toronto.citynews.ca/2022/08/08/peach-team-palliative-health-care-homelessness/ Psychosocial Interventions at PEACH In addition to medical care, PEACH also runs two key psychosocial interventions for our clients: PEACH Grief Circles – Structured spaces for workers in the homelessness sector to process grief. CBC covered this a few years ago, including a radio segment feature on CBC White Coat, Black Art (which you can access at the below link). https://www.cbc.ca/radio/whitecoat/palliative-care-team-helps-the-homeless-die-with-dignity-a-healing-circle-helps-them-grieve-1.5048409 PEACH Good Wishes Program – A program that provides meaningful gifts for unhoused individuals who are terminally ill. https://www.cbc.ca/news/canada/toronto/toronto-homeless-palliative-holidays-1.5407360 Kensington Hospice & 'Radical Love' Equity-Oriented Hospice Palliative Care Naheed Dosani also serves as the Medical Director of Kensington Hospice, Toronto’s largest hospice. There, he helps run an innovative program called 'Radical Love' Equity-Oriented Hospice Palliative Care, which provides low-threshold, low-barrier access to hospice care for structurally vulnerable individuals (e.g., those experiencing homelessness). The program also operates via a partnership with the PEACH Program. As a result of the 'Radical Love' program at Kensington Hospice: At any given time, Kensington Hospice has evolved from caring for structurally vulnerable individuals Canadian Press Feature – A powerful and widely shared piece on our work. https://www.cbc.ca/news/canada/toronto/ont-homeless-palliative-1.6901396 Promising Practice Recognition – Kensington Hospice’s Radical Love program was also recognized as a Promising Practice by Healthcare Excellence Canada & the Canadian Partnership Against Cancer. https://www.healthcareexcellence.ca/media/gxmf021n/pp-kensington-hospice-en-2024-v3.pdf National Canadian Efforts in Equity-Oriented Palliative Care Canada is investing in equity-oriented palliative care through the Improving Equity in Access to Palliative Care (IEAPC) Collaborative. This is a multi-year funded initiative that supports 23 equity-oriented palliative care models for people experiencing homelessness and structural vulnerabilities across Canada.  https://www.healthcareexcellence.ca/en/what-we-do/all-programs/improving-equity-in-access-to-palliative-care/  

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  46:46
• PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers

  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

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  51:26
• Trauma-Informed Care: A Podcast with Mariah Robertson, Kate Duchowny, and Ashwin Kotwal

  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

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