GeriPal - A Geriatrics and Palliative Medicine Podcast

Difficulty managing money is often one of the earliest signs of Alzheimer's disease and related dementias, frequently appearing years before an official diagnosis. This loss of financial capacity leaves individuals vulnerable to costly mistakes and exploitation, threatening the financial security and quality of life of entire families. In this episode, we sit down with Dr. Lauren Hersch Nicholas, Dr. Duke Han, and Dr. Jason Karlawish to examine the intersection of cognitive decline, financial decision-making, and patient protection. We covered a lot of topics, including these key ones: The Financial Prodrome: Dr. Nicholas shares her health economics research showing that missed payments and credit score drops can appear up to six years before a dementia diagnosis —causing major wealth loss long before healthcare providers catch the issue, especially in lower-income communities. Brain Function & Social Buffers: Dr. Han discusses new neuroimaging research on how cognitive decline impairs financial judgment and explains how strong social connections can serve as a critical protective buffer. Clinical & Policy Solutions: Dr. Karlawish outlines the medical, policy, and financial-sector interventions needed to safeguard vulnerable patients. For a deeper dive on some of the articles we discussed, check out these references: My first JAMA paper on Finances in the Older Patient With Cognitive Impairment Lauren's plant money podcast on how your bank account might predict dementia Lauren's article on Management of Financial Assets by Older Adults With and Without Dementia or Other Cognitive Impairments Jason's editorial on the Importance of Asking Older Adults Whether They Are Having Difficulty Managing Finances . Jason's article on Desktop Medicine and the Practice of Wealth Care Duke's article on Financial exploitation vulnerability and social connectedness in middle-aged and older adults without dementia https://www.tandfonline.com/doi/full/10.1080/13607863.2025.2475331

GLP-1 receptor agonists (the "Ozempics of the world") have been a truly revolutionary pharmacological advance in modern medicine. In randomized controlled trials (RCTs), these agents have been shown to do much more than just reduce weight, including significantly reducing cardiovascular events, lowering all-cause mortality in patients with type 2 diabetes, and even slowing the progression of chronic kidney disease. But as we see their use rapidly expand among older adults, we have to ask: at what cost? In geriatrics, weight loss is rarely simple. In older bodies, GLP1s carry increased risks, including accelerated muscle loss, functional decline, and possibly decreased bone density. So are we just trading weight loss for frailty? To help us untangle this complex web, we sit down with three expert geriatricians in obesity: Dr. John Batsis, Dr. Shen Dewar, and Dr. Aruna Josyula. What We Discuss in This Episode: How age-related changes alter the distribution of fat and muscle, even when body weight stays exactly the same. What are sarcopenia (muscle loss) and sarcopenic obesity, and why are they so dangerous for independence? A discussion on what happens to fat, muscle, and bone during standard weight loss versus weight loss accelerated by GLP-1s. Whether GLP-1-induced muscle loss a direct biological side effect from suppressed muscle protein synthesis, or is it simply the indirect result of a massive caloric deficit and dropping protein intake? A broad, geriatric-focused approach to weight, including a vital review of common medications that might actually be causing weight gain in the first place. Practical, actionable strategies to protect muscle mass and function when prescribing GLP1s A discussion of red flags in older adults, where we should have major hesitation before ever writing a prescription for a GLP-1 We cover this and more in the podcast. There is a forthcoming article in JAGS that addresses this topic, and we will add the link here once published. If you want to take a deeper dive, take a look at some of the following references we discuss: Aruna's article in JAGS titled " One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults " John's Annal's article on the " Effect of Incretin-Based and Nonpharmacologic Weight Loss on Body Composition: A Systematic Review " John's article on the "Unintended risks of sarcopenic obesity during weight-loss interventions in older people" in Nature Med. An article titled " The Effects of Incretin Mimetic Therapies on Muscle and Bone Health in Older Adults " A systematic review of the effect of weight loss on muscle-based indices An article on "Treating Sarcopenic Obesity in the Era of Incretin Therapies: Perspectives and Challenges" Shen's article describing "The Optimal Health Weight and Lifestyle (OHWL) Clinic" Shen's article titled " A Geriatrician's Approach to Managing the Complex Older Adult with Obesity" Another JAGs article on "Older Adults with Obesity: The Need for a 4Ms Age-Friendly Approach to Care" Lastly, CMS's information on the GLP1 bridge program

As Diane Meier remarks to start today's podcast, palliative care has come a long way from the days when we were the "brink of death" consult. We're seeing patients earlier and earlier in the course of illness. In fact, the evidence base for specialist palliative care is arguably stronger in the outpatient setting than the inpatient setting. In some ways, as Eric remarked, we are a victim of our own success. We've pushed on the boundaries of seeing patients earlier in the course of illness, we've demonstrated remarkable value to our colleagues and health systems: now they want us to see more and more patients, with conditions we would not have previously considered core to palliative care practice. Our guests modeled respectful disagreement, and we were somewhat surprised that there was more agreement than we expected. I'm sure you will all have strong feelings about the opinions expressed, please let us know! In addition to Diane Meier, we welcome back Bob Arnold and Justin Sanders to talk through these issues, including: We agree specialist palliative care is for people with "serious illness" - but what constitutes "serious illness" Is a limited prognosis part of the definition of serious illness? We discuss the Center to Advance Palliative Care definition of palliative care and Amy Kelley's oft-cited definition of serious illness . Many patients with conditions that overlap with palliative care would benefit from our help, e.g. chronic pain, opioid use disorder, mental illness. Our health system is not meeting their needs. Should palliative care see them, in the absence of a clear life-limiting illness? How limited a prognosis should we consider here - months, years…decades? We have a tremendous workforce shortage. There are not enough specialist palliative care providers to see all patients with advanced cancer , much less the many other conditions whose guidelines now say should include palliative care. The reality does not match the mission. Does that change our mission? Should local workforce issues dictate who should see palliative care? See this article by Pelleg in which clinicians at Mt Sinai agreed that patients with serious illness and high risk of mortality should be prioritized, explicitly excluding patients with chronic pain or psychosocial distress in the absence of serious illness. What is the role for Patient Reported Outcomes (PROs)? e.g. patients regularly reporting pain or other symptoms and an escalation in symptoms triggering a palliative care intervention. How is the definition of who should see palliative care expanding in Canada, and is there a linkage to who is eligible for medical aid in dying in Canada . Justin makes a good plug for the McGill National Palliative Care Grand Rounds Programme What is our vision for where palliative care should be 10 years from now? Population health specialists, or healing patients one visit at a time? To be sure, these are not mutually exclusive. How long should palliative care fellowship be - should we expand it to 3 years so palliative care specialists can care for people with a wider range of conditions? What is Precision Palliative Care? Diane mentions this article by Ramy Sedhom on a couple of occasions. Should palliative care see patients with sickle cell disease ? How about survivorship clinics? How about very elderly patients with multiple mild chronic conditions (e.g. mild heart failure, mild COPD, mild cognitive impairment, arthritis, diabetes, hypertension)? And much more! Please listen to the audio only version of Stand by Me - my son Renn added an upright base, snap, and triangle parts - it's much better than the live version for YouTube that I accidentally started in a much too high key!

Up until just a couple years ago, an 85-year-old patient presenting with gradual, amnestic memory loss was almost automatically presumed to have Alzheimer's disease. However, new biomakers and the recognition of conditions like Limbic-predominant age-related TDP-43 encephalopathy (LATE) are reshaping our understanding of cognitive decline in older adults. It's looking more clear that pure Alzheimers dementia is rare in older adults, and co-occurring pathologies that may include Alzheimer's, LATE, Lewy Body, and vascular neuropatholigies, are the rule rather than the exception. In this episode of the GeriPal Podcast, we sit down with Sterling Johnson and Nate Chin from the University of Wisconsin. Sterling is a clinical neuropsychologist and researcher who leads the CLARiTI study , which is attempting to uncover the intersecting causes of dementia. Nate is the medical director and Clinical Core Co-Leader for the Wisconsin Alzheimer's Disease Research Center (ADRC), the host of the Dementia Matters podcast , and author of a new book When Memory Fades . We tackle the real-world complexity of mixed dementia and its major diagnostic and clinical treatment dilemmas. We also go in deep to discuss LATE, from what it is, to how it presents, to whether it should change how we think about using newly approved disease-modifying therapies when a patient has confirmed amyloid positivity alongside suspected LATE.

Can simple, evidence-based video decision aids—paired with structured clinician training—improve Advance Care Planning (ACP) documentation and goal-concordant care? That's the question we pose in this week's podcast with Dr. Joshua Lakin and Dr. Kei Ouchi. We break down the methodologies behind two major clinical trials in which they were involved that implemented this video-enhanced approach. The f irst study, published in JGIM, was a multicenter, parallel randomized trial of 598 seriously ill older adults in emergency departments (EDs). It tested whether watching a 5-minute video and having a short, 10-minute structured clinical conversation during acute ED visits could establish longitudinal care preferences. The researchers found that this intervention not only increased ACP documentation at 3 months (45.6% vs. 31.3%), but also significantly increased goal-concordant care in a subset of study participants who died in the hospital. The second study, published in JAMA Network Open , was a multicenter, stepped-wedge trial involving 13,800 older adults with advanced cancer across 29 outpatient oncology clinics. Practices in the trial received patient video tools and VitalTalk clinician training. The bundled intervention led to a statistically significant increase in electronic health record (EHR) ACP documentation (25.3% vs. 20.8% with usual care). Both studies provide strong evidence that combining video-enhanced ACP with clinician training improves documentation of these discussions. What I loved most, though, is that the JGIM paper offers some of the first evidence that combining these approaches directly helps patients receive care aligned with their true values.

The longevity industry is booming. Influencers are promoting this and that as promoting healthy aging, longevity, and healthspan, and it's hard for us, much less our patients, to make sense of it. To be sure, we should always start by recommending exercise, nutritious foods, good sleep habits, and meaningful social interaction. We wanted to go beyond that to talk about the promise and potential and risks/harms of "biohacks." Today we talk with Mahtab Jafari, PharmD, and John Newman, MD, PhD, and to discuss: How we clinicians should think about this movement, knowing many of our patients (and ourselves) also prize living as long as we can as healthy as we can, and at the same time acknowledge that a high quality of life, growth, and a meaningful life are possible with support in states of disability or dementia. How animal models can leading to promising therapeutics but must be tested in humans What it takes for a drug to obtain approval for longevity or healthspan indications when we cannot realistically wait around 40 years for a result We ask them to rate the evidence for many treatment on the scale of very promising, meh, or snake oil/avoid, including creatine, metformin, GLP1, SGLT2i, NAD+, testosterone/estrogen, red light therapy, rapamycin, and rodeola rosea. And I get to sing Wake Me Up by Avicii - an uplifting song with lyrics that could have multiple meanings - makes you think! -Alex Smith

Who's better at delivering palliative care to patients with liver disease: palliative care specialists, or hepatologists who have received liver disease-specific palliative care training? That's the question we take a deep dive into on this week's podcast by breaking down the PAL-LIVER trial, published this year in JAMA Internal Medicine. We've invited three of the trial's authors, Manisha Verma , Chris Woodrell , and Marie Bakitas , to discuss this cluster-randomized clinical trial spanning 19 U.S. medical centers. We'll discuss: Why was this trial done? Do we really need to run a separate palliative care trial for every single organ disease? What kind of specialized palliative care training did the hepatologists receive? What exactly is meant by the finding that hepatologists were not statistically superior, but were shown to be statistically non-inferior? Lastly, we discuss whether these results change anyone's practice, and whether healthcare systems should decide which type of palliative care model to fund (primary vs. specialty.) —- References we discussed Developing palliative care interventions in liver disease using formative and summative qualitative evaluation. Hepatology 2026 Palliative Care for Advanced Liver Disease: Hepatology and Palliative Care Specialists Experiences. J Pain Symptom Manage 2026

Emergency Podcast! Our guests Sean Morrison, Ken Covinsky, and Stacy Fischer believe that you should care deeply about the proposed shakeup at the National Institutes of Health. Major proposed rules changes at the Office of Management and Budget, would affect a huge range of government grants, from Headstart to Transportation to the National Science Foundation, as well as the National Institutes of Health (NIH), the subject of today's podcast. You dear listeners should all care. You should care because you care for older adults, or you're a researcher who studies palliative care, or you're a chaplain who visited with the family of a patient who died today. You should care because these rule changes are so sweeping that they would remove standard components of the scientific review process and instead put them in the hands of political appointees. You should care because if rules like this were in place in the 1980s, we might not have developed treatments to stop the HIV/AIDS epidemic. You should care because if these rules go into effect we will not be able to work with researchers in other countries studying outbreaks of Ebola or Hauntavirus. You should care because these rules silence federal research into groups of people we care for daily. And if you're not a researcher, your voice is even more important here. As Sean says, researchers who protest these proposed rule changes might come across as self-serving. Clinicians who are not researchers - who can say that these rules will negatively impact the science that improves care of older adults living with chronic conditions and their families - your voices may resonate even more. What can you do? Most of these rule changes are open for public comment here until July 13, 2026. Every comment will be read and requires a response. It's ok to respond anonymously. Personalized stories matter more than form responses. Tips: 1: Say (or just describe to keep anonymous) who you are and why you are qualified to comment. Telling the story of how patients and families you care for or study is enough. Get your partner and parents to respond too. Simply being a concerned citizen is perfectly fine. 2: List the exact provision #s that concern you, and explain what they would do. You do not need to quote the rule directly. Just explain what you understand it to mean in plain terms. Political Appointees Take Control of Grant Awards (§200.205); Peer Review Is No Longer Binding (§200.205(d)); Active Grants Can Be Terminated at Any Time, for Any Reason (§200.340); DEI, Gender Research, and Related Topics Banned as Grant Conditions (§200.300); Prohibition on International Scientific Collaboration (§200.220); Conference Attendance Now Requires Express Agency Pre-Approval (§200.432); Publication Costs and Open Access Fees Presumptively Unallowable (§200.461) 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect? 4: Closing: State clearly what you want OMB to do. This can be as simple as: "I urge OMB to withdraw these specific provisions: §200.340, §200.202, §200.205." or "I urge OMB not to finalize this rule." Submit your comment in opposition here : The deadline is July 13, 2026. You can also email your congressperson or senator. Times they are a changin'.

Today's podcast is a natural follow up to our podcasts on Slow Codes and Unilateral DNR orders .Today we talk about a new study about how clinicians talk about potentially non-beneficial life-prolonging treatments , published in JAMA Network Open. Do they adhere to society guidelines, which allow as permissible approaches only shared decision-making and following institutional policy. Or do they take alternative approaches, like not offering interventions, not mentioning interventions, or simply stating a plan to limit interventions? Turns out doctors are using these alternative approaches frequently. Our guests are Jason Batten, Liz Dzeng, and Teva Brender, all clinicians, all of whom have been thinking about and wrestling with the ethical reasoning behind these approaches. We all admit to using these approaches. Are the alternative approaches wicked games (song hint), and our response should be to stop these behaviors, beginning with ourselves? After all, if you ask patients or surrogates, they're likely to say they want all the options and may not universally welcome recommendations . Or, as with slow codes, does the fact that these alternative approaches are in common use suggest that the guidelines should be revised? You listen and decide! -Alex Smith Additional links: Dzeng 2023 JAMA IM: The larger ethnographic study from which data was drawn with data drawn from high- medium- and low-intensity hospitals. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806959 Brender 2025 JAMA NO: Factors that exacerbate or mitigate moral distress related to potentially non-beneficial treatments. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835316 Dzeng 2015 JAMA IM: Study illustrating that more senior physicians feel more comfortable not offering or recommending against futile CPR. Relevant quote: "Experienced physicians at all sites generally were comfortable engaging in best interest decision making and, when clinically appropriate, not offering or making explicit recommendations against offering resuscitation." https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265 Weiss Goitiandia AJOB 2025: Reasons why some clinicians would hesitate to go to the ethics committee / futility process for these discussions: https://www.tandfonline.com/doi/10.1080/15265161.2025.2457734?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Axelrod AJOB 2025: Discusses some of the systemic consequences of using physiologic futility as a standard and how it might contribute to a healthcare system that imposes aggressive treatments on vulnerable patients. https://www.tandfonline.com/doi/full/10.1080/15265161.2025.2530715#d1e152

Today we revisit a topic we last discussed in a 2020 podcast with Laura Mosqueda : elder mistreatment. Our guests today are geriatricians Carrie Rubenstein and Julia Hiner, and Tony Rosen, an emergency medicine doctor. They talk about where we are now, in 2026, with elder mistreatment, including: Terminology: elder mistreatment vs. abuse and neglect The need to incorporate prevention and solutions into how we talk about mistreatment This is not rocket science. Studying elder mistreatment is much harder than rocket science. Highlighting the reasons they focus on elder mistreatment, including inspiring words for why this led them to geriatrics and aging research Should we screen for elder mistreatment? The US Preventive Services Task Force doesn't see enough evidence t o recommend screening. Our guests may differ… Which clinicians should assess for elder mistreatment? Hospitalists? ED docs? Primary care providers? Tony published a study in JAGS showing older adults who experienced elder mistreatment were as likely to visit primary care as those who did not, also great accompanying editorial by Mara Rosenberg and Lena Makaroun gets a shout out. Early evidence that supporting caregivers can reduce elder mistreatment (in one small study of the COACH intervention , rates of mistreatment were reduced to zero) Borrowing from pediatrics: many/most hospitals and emergency departments can call a Child Protective Services Team. Tony is piloting a parallel team for older adults - the Vulnerable Elders Protection Team (see JAGS paper). We talk about key members of interdisciplinary teams across sites, systems, and counties. Social workers get a big shout out. A one year fellowship in capacity assessment and elder mistreatment at UT Houston, directed by Julia. An Elder Abuse Curriculum for Medical Residents and Geriatric Medicine Fellows https://pmc.ncbi.nlm.nih.gov/articles/PMC10842324/ Kudos to my son Renn for recording 5 overlapping cello parts on Eleanor Rigby! -Alex Smith

Two retired luminaries in geriatrics join us today to share their personal experiences. First, John Burton, a geriatrician and Director of the Division of Geriatric Medicine at Johns Hopkins for some 35 years, shares his journey moving into a Continuing Care Retirement Community (CCRC) during Covid. You can read about John's early experiences in his JAGS commentary titled, "Waiting for the Other Shoe to Drop." The tone is bleak. John's experience since Covid, as you'll hear, is very positive. Many of the concerns he raised about isolation have been addressed. Second, we hear from Bill Applegate, Geriatrician, retired faculty at Wake Forest, and former Editor in Chief of JAGS (Bill recruited Eric and me to join JAGS as editors about 10 years ago). Bill had a distinctly negative experience in two assisted living facilities (ALFs), which you can read about in his JAGS essay, titled, " My Journey Through Assisted Living Facilities ." Bill is seriously concerned about the lack of national oversight, poor staffing, and financial motivations behind for-profit and private-equity owned ALFs. Finally, we hear from Melissa Aldridge, a former banker turned health services researcher, about the rise of private equity purchases of Assisted Living Facilities nationally. This is a follow up to our prior podcast on private equity gobbling up hospices with Melissa, Lauren Hunt, and Krista Harrison. Melissa is concerned that private equity has a very short time frame to turn acquisitions profitable, and cutting staff is often their first move. Further, private equity is financing these acquisitions with debt that is increasingly hard to trace and regulate. We talk about how private equity moving from purchasing fast food chains, toy stores, and hotels into CCRC, ALF, nursing home, and hospice ownership is a major concern. This is not the same as Blackstone buying the Hilton and turning a profit. These institutions provide healthcare, daily care needs, and community for a huge swath of older adults. These concerns should trigger a higher level of scrutiny, oversight, and regulation than other industries. What can you do about this, dear listeners? Listen to the end to find out! Thanks to Jerry Gurwitz for suggesting this podcast. We appreciate your suggestions. Keep 'em coming. -Alex Smith

Our focus today is on the search for the geriatrician identity, a continuation of the conversation we started with Jerry Gurtwitz on the Future of Geriatrics . Today's conversation is prompted by multiple articles in JAGS: (1) an article by Jerry Gurwitz with a title the same as this podcast; (2) an article by Helen Fernandez on " Med-Geri ", a new combined 4 year internal medicine residency and geriatrics fellowship track; and (3) an article by Mary Tinetti titled, " Mainstream or Extinction: Can Defining Who We Are Save Geriatrics ?" Of note, Mary's article is a follow up to her 2017 article in JAGS in which she wrote: Those outside the field have difficulty understanding what geriatrics is and what geriatricians do. We contribute to this lack of clarity. We are experts in complexity but are often bad at communicating simply. Our well-intentioned efforts to be inclusive and comprehensive lead to the creation of long, complex descriptions of what we do that further compromises understanding while eroding interest in, and support of, our field. Today we tackle this problem, discussing: A "funny if it wasn't so painful" video and JAGS article in which geriatricians from Johns Hopkins roamed the streets of Baltimore asking lay people "What is a geriatrician?" The responses (something to do with Ben and Jerry's ice cream? Jury-atrician?) will make you laugh and cry at the same time. 4 different types of geriatricians as described by Jerry in his JAGS paper: the complexivist, the healthful longevitist, the syndromist, and the contextualist. As with the 4Ms, Ken couldn't help but add a 5th, the "identityist", arguing that maybe Geriatricians worry too much in public about their identity, and should instead focus in public on what unites them: shared sense of purpose and mission to focus on whole person care and what matters most to older adults. Ken gave a rousing talk on being a Geriatrician at the Society of General Internal Medicine that received a lengthy standing-ovation ( and a Cubs Jersey with his name on it ). Innovative new programs such as Med-Geri and GeriPal fellowship as ways to bring more people into the profession. How to balance our effort between recruiting specialist geriatricians to the profession and teaching all clinicians geriatrics principles and skills. A paper in JAGS by Richard G. Stefanacci and Ankur Patel in JAGS making the argument that a geriatrician "yields per-patient annual net cost savings of approximately $3495 (specialist consultation avoidance +$1500; ED reduction +$45; hospitalization reduction +$1950)..." and "The reason fee-for-service fails geriatricians is not that their skills are wrong for primary care—it is that the payment model is wrong for their skills. Payvider programs operating under capitation invert every structural disadvantage of fee-for-service. Under capitation, there are no RVUs. There is no penalty for spending 40 min with a complex patient. There is no revenue loss when the patient is dual-eligible rather than commercially insured—the capitated payment is the same regardless of original coverage source. And every unnecessary specialist referral, every avoidable hospitalization, every ED visit that could have been managed in-house represents a cost to the organization rather than a revenue stream." Stay until the end when Mary has one of the best answers yet (in over 400 podcasts!) to Eric's "if you had a magic wand" question. Enjoy! -Alex Smith

I had the privilege of learning from fellow Greenwall Faculty Scholar Lisa Harris about a term she termed, " dangertalk ." As an ob/gyn and abortion provider, Lisa found the debate around the legality of abortion so polarizing that it created a false dichotomy: you're either for or against. Any talk about misgivings, uncertainty, ambiguity, or ambivalence was silenced. Talking about these issues in the face of polarization was deemed dangerous and undermining to one side or another. "How could you?" For Lisa's work in finding common ground and embracing nuance she was awarded the 2023 Bernard Lo Award for forging connections across divisions. In today's podcast we focus on the equivalent experience of moral uncertainty, distress, and residue among prescribers of medical aid in dying. We are joined by Carly Zapata and Dani Chammas, prescribers of medical aid in dying in California. We discuss: Their journey prescribing medical aid in dying, and reasons for choosing to prescribe The legality of prescribing in California. We compare California to Canada, as we have previously on this podcast . We discuss new limited survey data suggesting that legal barriers may not explain the remarkable 20 fold differences in use of medical aid in dying between California and Canada; rather, Canada has 6x the number of providers per capita as California, and much greater awareness of the legality of medical aid in dying. We talk about cases that are not as clear - e.g. people who have voluntarily stopped eating and drinking . Moral issues, including ambiguity and ambivalence, distress and residue. For example the moral distress created when a patient requests medical aid in dying due to what is clearly a systems failure (see this Atlantic article for clear examples from Canada). We ask if they sometimes feel frustrated that more people who are in favor of medical aid in dying are not prescribing, instead leaving prescribing responsibility to a relatively small group of clinicians. How core ethical ideas might lead to very different conclusions about medical aid in dying, and ways Dani teaches ethics to trainees. Psychological models that can help navigate this complex terrain with patients and families, including formulations and countertransference . And I can't believe I haven't played, "I will follow you into the dark" previously - but google couldn't find it - really? In 400+ GeriPal podcasts? Great song. So fitting. My son Renn plays guitar on the audio only version. -Alex Smith Additionally, some take home points, sent by Dani after recording: (1) Holding the dialectic: On one hand, people deserve the highest level of attention to their personhood and their suffering—an effort that, at times, can soften or even resolve a desire for hastened death. And on the other hand, some people will authentically experience this as the most values-aligned way of dying, given their circumstances. (2) Learning to accept that while laws create the safety rails, within those boundaries, morality is pluralistic. Both patients and clinicians bring deeply held moral frameworks to these decisions—and those frameworks deserve to be acknowledged and respected. (3) We have to be willing to ask the hard questions—and to show up for one another as we do. Because this work, more than almost any other, has taught us the profound impact of not feeling alone when navigating grey terrain. I view the discussion as an invitation for our field to not necessarily to become more certain, but to be willing to wrestle with the hard questions—while still showing up with rigor and compassion. And to remember that our patients are people before they are cases. If we can stay close enough to truly know them, we're much more likely to respond in ways that honor both their suffering and their dignity—whatever path that ultimately leads to.

While we have previously discussed brain death criteria on the GeriPal Podcas t, we have yet to explore the complex landscape families face regarding organ donation. In this episode, we dive into the nuances of Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), and clarify the essential role of healthcare providers who are not part of an organ procurement organization. In this episode of the GeriPal Podcast, we step into a space in serious illness care that is often misunderstood, overlooked, or reduced to a simple "call the organ donation network" checklist item. Joining us are three experts to help us understand the process and our role in it: Samantha (Sam) Taylor , a Donation Support Specialist and expert trainer on the donation request conversation Dr. Nikole Neidlinger , an abdominal transplant surgeon and medical director for the organ and tissue donation program at the University of Washington Dr. Toby Campbell, palliative care physician and host of the Extraordinary Conversations podcas t, which is focused on organ donation for its first season. We'd also like to send a big thank you to Toby as he was the one who recommended doing this podcast, and we'd encourage all of our listeners to check out Extraordinary Conversations . I personally love episodes like this as it opens up a black box that I otherwise dont think about (similar to our Undertaker podcast with Thomas Lynch where we talk about what happens after someone dies).

In this episode of the GeriPal podcast, we dive into the fascinating world of geriatric dermatology, or "GeriDerm," with two exceptional guests: Dr. Daniel Butler from the University of Arizona and Dr. Eleni Linos from Stanford University . First, we tackle the big question: how do we keep our skin healthy as we age? I see this on a daily basis with my own skin, but I'm unsure what to do about it, including whether we all need to use sun protection and moisturizers, and if so, which ones? Then we explore the lag time to benefit in dermatology by examining whether we need to treat every actinic keratosis and basal cell carcinoma aggressively, or whether there are cases where we can opt for watchful waiting. We also explore chronic itch with Daniel, covering the three main sources of itch and how our management should change accordingly. Importantly, antihistamines were not a prominent part! We finally asked Eleni whether artificial intelligence (AI) and digital tools can revolutionize the way we diagnose and manage skin conditions, especially in older adults. For a deeper dive into the topic, check out these two papers that we talk about on the podcast Daniel's JAMA paper on Chronic Pruritus Elani's JAMA IM paper on Active Surveillance as a Management Option for Low-risk Basal Cell Carcinoma

Eric and I were delighted to be invited to Brazil to give a series of presentations in Sao Paulo at their annual geriatrics meeting. We met people doing important, interesting, and innovative work in Brazil and throughout Latin America. We got the audience to sing along, including (in another talk) the magnificent Brazilian song Sozinho by Caetano Veloso in Portuguese, with my son Renn playing guitar . For our final talk, a podcast in front of a live conference audience, we asked our 3 guests, Eduardo Ferriolli, Marlon Aliberti, & Edison Iglesias to select a recent article to discuss. We talked about: Intrinsic capacity (selected by Eduardo). What is it? What is it used for? How do you measure it? (hint ICOPE). Eduardo emphasized that intrinsic capacity is a positive aspect of aging, focused on potential rather than deficit. We asked him to work intrinsic capacity into George Kushel's famous analogy using the golden gate bridge to describe phenotypic frailty (pillars), deficit accumulation frailty (cable supports), and resilience (withstand stress of wind and cars). Eduardo says intrinsic capacity would be the car, and would vary by type of car and intended purpose. I loved Eduardo's selected article, which percentiles intrinsic capacity , in order to use within individuals to assess how they're tracking over time, and at a public health level, to identify regions or groups of people with lower intrinsic capacity. He draws the analogy to growth curves in pediatrics - if you're consistently at 80% - then drop off - your primary care provider should take notice and investigate/intervene. Geriatric syndromes in hospitalized older adults (selected by Marlon). If intrinsic capacity is for primary care, our guests argue that the comprehensive geriatric assessment, which takes a long time to administer, should be reserved for specialist geriatrics. And yet, this paper finds that a limited shorter version of the comprehensive geriatrics assessment can document geriatric syndromes in hospitalized older adults. Accumulation of multiple geriatric syndromes is associated with increased mortality , and presents an opportunity for risk stratification, goals of care discussions, and intervention. Advance care planning across Latin America (selected by Edison). Back around 2005, when Edison first heard about advance care planning, he says, "it sounded like science fiction." In Brazil, as with Latin America, medicine was highly hierarchical and patriarchal. Doctors knew best. The doctor decided. If there was no patient choice, why would there be a system to protect the decisions of patients made in advance? In the intervening years, Edison and others have worked to incorporate and adapt advance care planning to the Latin American context, which is much more focused on family-centered relational autonomy than individual, and incorporates spirituality to a much greater extent. Edison has been mindful too of not repeating the mis-steps of the advance care planning and advance directive movements in the US. We took questions from our audience and sang "Imagine" in Portuguese together. Enjoy! -Alex Smith

Lynn Flint and Anne Kelly join as hosts in a reprise of last year's ask us anything format. Thank you for sending in your terrific questions! Lynn and Anne condensed them to about 20, and we ran through them rather rapid fire. Also on fire? Our mouths. As with our 300th episode, we did this Hot Ones-style . Every few questions, we had to eat a chicken wing slathered in hot sauce. The hot sauces got progressively hotter, though as we discovered, the ordering may have been a littttttle bit off. Still, by the time we hit the really hot ones, our mouths were on fire, we were blowing our noses, gulping down milk, and terrified of what the next hot wing would bring… We covered so much in this podcast, including: Coffee or tea? What jokes do you make with patients? Where do we see ageism? Why are we still advocating for advance care planning? Concerns about expansion of medical aid in dying Should doctors reveal that they're using AI in clinical care (thanks for the question mom!) The future of geriatrics and palliative care What we'd do differently about the podcast if we could start over, or what we could do that is new going forward. Surprises in terms of who is listening, our audience. Ideas for others to build community as we do at GeriPal Influence of our own spirituality and religion on our clinical practice Lasting practice changes from prior podcasts, or from Covid experience Why PC in the ED hasn't taken off And more! Looking back on 10 years and 400 podcasts, Eric and I are filled with gratitude for you, dear listeners. You sustain us. You keep us going. Please stay involved, send us messages about show ideas, and introduce yourself to us at national meetings. Thank you! -Alex Smith

Rural populations in the United States face unique healthcare challenges. These communities tend to be older, have higher mortality rates, and experience higher rates of chronic conditions and physical disabilities compared to urban populations. Despite the increased need for palliative care in rural areas, access remains alarmingly limited. Even in hospital settings, where palliative care programs are more common in urban areas, only 35% of rural hospitals report having such programs, compared to 81% of urban hospitals. In this week's podcast, we explore the challenges and opportunities of delivering palliative care in rural communities with our esteemed guests Karl Bezak, Jeanie Youngwerth, Adie Goldberg, and Gregg Vandekieft. We begin by discussing what inspired each of them to focus on rural palliative care. From there, we dive into what rural palliative care looks like and examine how it differs from care provided in urban settings. Our guests also share insights into the challenges of delivering this care in resource-limited rural environments and explore innovative strategies to ensure patients and families receive the support they need (like providing remote fellowship training for docs living in rural areas!). We also tackle the role of telemedicine in rural palliative care, both the good part, connecting patients in remote areas with specialists who might otherwise be unavailable, and the bad part, the huge digital divide seen in rural areas. Join us for what I thought were some valuable insights our guests brought on how we can better serve rural populations and create a more equitable system for palliative care delivery. And if you want to learn more, check out some of these resources: University of Colorado's Community Hospice and Palliative Medicine (CHPM) Fellowship , which allows mid-career providers to obtain training while continuing to live and work in their community supported through online and distance learning technology Master of Science in Palliative Care Program: Master of Science Degree The Rural Health Information Hub's Rural Hospice and Palliative Care Overview Stratis Health's Rural Community-based Palliative Care resource center The Washington Rural Palliative Care Initiative website CAPC's Safety-Net and Rural Care website The paper validating the AI Algorithm used to identify patient in rural ED for the TeleGOC Pause Model at UPMC (SafeNET) A Google Site where Karl is hosting their most recent data related to the TeleGOC Pause Model

Today we're delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine . Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing). This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit. In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms. Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives . I'm going to cut to the pushback to this article right up front: The study's primary outcomes were advanced directives or completion of POLST forms - haven't we moved beyond thinking completion of forms should be the primary outcome of advance care planning research? There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention. People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention? Observed documentation - 13-20% - was low. Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms? Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself. Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade. And a fun fact about All You Need is Love - the verses are in 7/4 time! -Alex Smith

In 2025, the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals participating in the Hospital Inpatient Quality Reporting (IQR) program to report on a new "Age-Friendly Hospital Measure." The hope is that, by attesting to this measure, hospitals will develop evidence-based processes to improve care for older adults in hospital settings. On this week's podcast, we explore this new measure with Sheri Ling, CMS's Deputy Chief Medical Officer serving in the Center for Clinical Standards and Quality (CCSQ). We've also invited some returning guests from our past Age Friendly Health Systems podcast, Julia Adler-Milstein and Stephanie Rogers, to discuss how they are thinking about this new measure and how we should operationalize it. We go over everything you will want to know about the new measure, including: How does this CMS measure differ from both Age-Friendly Health Systems and the 4Ms movement we've been hearing about for years ( and that we did the podcast on in 2020 here ) Why is CMS finally making "Age-Friendly" a formal, structural requirement for hospitals now? What is an attestation measure vs outcome measure, and why is this one an attestation measure? A deeper dive into the 5 domains to the measure (Eliciting Patient Goals, Medication Management, Frailty Screening, Social Determinants of Health, and Leadership/Governance. Lastly, here are some great resources if you want to help get this started at your hospital: A report by JAHF, Julia and others on how to think about different dimensions of measure performance Health Affairs Scholar paper on related the 4Ms to the 5 domains Two CMS resources with detailed information on how to meet and report on the five domains of this measure: Age-Friendly Hospital Specifications (July 2025) Age-Friendly Hospital Measure Attestation Guide