Have you had one of those consults in which you're thinking, huh, sounds like the patient's goals are clear, it's really that the clinician consulting us disagrees with those goals? To what extent is it our job as consultants to navigate, manage, or attend to clinician distress? What happens when that clinician distress leads eventually to conflict between the consulting clinician and the palliative care team?

Today our guests Sara Johnson, Yael Schenker, & Anne Kelly discuss these issues, including:

• A recent paper first authored by Yael asking if attending to clinician distress is our job, published in JPSM. See also the wonderful conversation in the response letters from multidisciplinary providers (e.g. of course that's our job! And physicians may not be trained in therapy, but many social workers and chaplains are, and certainly psychologists).

• A SPACE pneumonic for addressing clinician conflict developed by Sara Johnson, Anne Kelly and others. They presented this at a recent AAHPM/HPNA meeting. See below for what SPACE stands for.

• We referenced a prior episode on therapeutic presence and creating a holding space with Kerri Brenner and Dani Chammas, and this article by Kerri.

• We talked about the role of the consultant, including this classic paper on consultation etiquette by Diane Meier and Larry Beresford.

Enjoy!

-Alex Smith

SPACE: Navigating Conflict with Colleagues

"Between stimulus and response there is a space. In that space is our power to choose our response." -Viktor E. Frankl

SPACE: Conflict Navigation Toolkit

• Self-awareness: Pause & Notice Before Responding
• What am I feeling? Take own temperature.
• Where am I coming from? What do I need?
• Perspective-Taking: Ask-Tell-Ask
• Where are they coming from? Check your understanding with them.
• "Tell me how you're thinking about this?"
• "I hear you are concerned about…is that right?"
• Agenda: Yours and theirs, then focus on common ground
• Where are we going together?
• "It seems like we both want…"
• Curiosity: Reframe and explore to understand
• Am I missing anything?
• Why is this kind, smart & hard-working colleague thinking differently than I am?
• "To help me better understand, what is your biggest concern about…?"
• Empathy:
• For others: Empathic statements around the situation & silence
• For self: Your feelings are valid, reflect on it later.
• You will misstep in tense moments: apologize, learn from it. Eating helps.

Authors:

Ethan Silverman MD
University of Pittsburgh

Anne Kelly LCSW
San Francisco VA Health Care System

Jasmine Hudnall DO
Gundersen Health System

Cassie Shumway MS, RN, OCN, CHPN
UW Health Hospitals & Clinics

Andrew O'Donnell RN
University of Wisconsin

Sara K. Johnson MD
University of Wisconsin

In this week's podcast, we sit down with Drs. Sarguni Singh, Christian Furman, and Lynn Flint, three authors of the recent Journal of the American Geriatrics Society article, "Rehab and Death: Improving End-of-Life Care for Medicare Skilled Nursing Facility Beneficiaries."

The authors dive into the challenges facing seriously ill older adults discharged to Skilled Nursing Facilities (SNFs), where fragmented care transitions, misaligned Medicare policies, and inadequate access to palliative care often result in burdensome hospitalizations and goal-discordant care.

The discussion highlights key barriers in Medicare's SNF and hospice benefits, including the inability to access concurrent hospice and SNF care, and explores solutions to improve care. Among the recommendations is leveraging Medicare's Patient Driven Payment Model (PDPM) to reimburse SNFs for providing palliative care, commissioning a Government Accountability Office (GAO) report on SNF utilization at the end of life, and piloting a model that allows time-limited concurrent hospice and rehabilitation care.

Also, check out these two resources if you want a deeper dive:

• Our past podcast we did, now nearly 6 years ago, on the original NEJM paper, Rehabbed to Death.

• Joan Carpenter's article titled "Forced to Choose: When Medicare Policy Disrupts End-of-Life Care" in the Journal of Aging & Social Policy

👉 This episode of the GeriPal Podcast is sponsored by IU Health's Geriatrics Department, in partnership with Indiana University's School of Medicine, an amazing group, rich in innovative Geriatric Medicine. They are looking for physician faculty to join them in the inpatient and outpatient settings. To learn more about job opportunities, please click the following links:

• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at Eskenazi Hospital
• Physician & Advanced Provider Job Opportunity | Geriatrician opportunity at IU Health Fishers Hospital

Six years ago we had John Newman on GeriPal to talk about Geroscience (Song choice Who Wants to Live Forever by Queen, perfect selection). John explained the basics of geroscience, what is it, what are the key theories in geroscience, what is senescence, why people who provide clinical care for older adults should care about geroscience, and potential therapeutics like metformin and rapamycin.

Today we bring on three rising stars in Geroscience, Brian Andonian, Sara LaHue, Joe Hippensteel, to talk about one of the key pillars of Geroscience: inflammaging. We use this terrific paper they published in Geroscience as a springboard. We discuss:

• What is inflammaging? Chronic progressive low grade inflammation with aging.

• I try to get one of them to stake a claim that inflammaging should be the organizing principle of geroscience

• How does inflammaging operate in rheumatologic conditions like rheumatoid arthritis (Brian), neurologic conditions like traumatic brain injury (Sara), and critical illness (Joe). We talk about Post-ICU Syndrome (PICS) and relate inflammaging to our prior podcast with Wes Ely about his book Every Deep Drawn Breath. We also talk about how inflammaging is not just a factor in chronic conditions like diabetes or inflammatory bowel disease, which make intuitive sense, but also in acute conditions, like sepsis or traumatic brain injury in older adults.

• The state of the science on clinical and research tests for inflammaging - ready for prime time? What is the state of the science for therapeutics? Why should some anti-inflammatory therapeutics make us nervous in frail older adults? Inflammation developed evolutionarily for a reason. E.g. tthink of drugs that wipe out the immune system.

• The outsized discrepancy between non-FDA products marketed to consumers as anti-inflammaging and the state of academic Geroscience. We announce GeriPal's new lineup of skin care anti-inflammaging products!

• We discuss lifestyle interventions such as exercise, meditation, caloric restriction and intermittent fasting, and strength/resistance training.

• \We recognize the efforts of ClinStar in bringing together multidisciplinary aging researchers to advance aging research, including our guests.

And what a joy to sing Billy Joel! Here's a link to the documentary I mentioned, which is on my list to see.

-Alex Smith