If palliative care was a drug, one question we would want to know before prescribing it is what dose we should give. Give too little - it may not work. Give too much, it may cause harm (even if the higher dose had no significant side effects, it would require patients to take a lot of unnecessary additional pills as well as increase the cost.)

So, what is the effective dose of palliative care? On today’s podcast, we talk about finding an evidence-based answer to this dosing question with three leaders in palliative care: Jennifer Temel, Chris Jones, and Pallavi Kumar. All three of our guests were co-authors of a randomized control trial on “Stepped Palliative Care” published in JAMA this year.

We talk about what stepped palliative care is, how it is different from usual care or intensive palliative care, why these palliative care dosing questions are important, and dive deep into the results of their trial. We also discuss some of the other important trials in palliative care, including Jennifer Temel’s landmark NEJM study on outpatient palliative care and another study that gave an intervention we dubbed “fast-food palliative care” in an older GeriPal blog post.

Well-being and resilience are so hot right now. We have an endless supply of CME courses on decreasing burnout through self-care strategies. Well-being committees are popping up at every level of an organization. And C-suites now have chief wellness officers sitting at the table. I must admit, though, sometimes it just feels off… inauthentic, as if it's not a genuine desire to improve our lives as health care providers, but rather a metric to check off or a desire to improve productivity and billing by making the plight of workers a little less miserable.

On today’s podcast, we talk with Jane Thomas, Naomi Saks, and Ishwaria Subbiah about the concepts of wellness, well-being, resilience, and burnout, as well as what can be done to truly improve the lives of healthcare providers and bring, I dare say it, joy into our work.

For more on resources for well-being, check out the following:

1. Cynda Rushton, PHD, MSN, RN — Transforming Moral Distress into Moral Resilience
   https://www.youtube.com/watch?v=L1gE5G8WnTU

1. Tricia Hersey: Rest & Collective Care as Tools for Liberation
   https://www.youtube.com/watch?v=7OuXnLrKyi0

1. Beyond resiliency: shifting the narrative of medical student wellness
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10500407/

1. Fostering resilience in healthcare professionals during and in the aftermath of the COVID-19 pandemic
   https://www.cambridge.org/core/journals/bjpsych-advances/article/fostering-resilience-in-healthcare-professionals-during-and-in-the-aftermath-of-the-covid19-pandemic/0ADCA3737D12CAF308567A7F59EFC267

1. The Greater Good Science Center studies the psychology, sociology, and neuroscience of well-being and teaches skills that foster a thriving, resilient, and compassionate society.
   https://ggsc.berkeley.edu/?_ga=2.230263642.712840261.1724681290-1268886183.1680535323

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