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.)

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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. 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. 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.

   1. Political Appointees Take Control of Grant Awards (§200.205);

   2. Peer Review Is No Longer Binding (§200.205(d));

   3. Active Grants Can Be Terminated at Any Time, for Any Reason (§200.340);

   4. DEI, Gender Research, and Related Topics Banned as Grant Conditions (§200.300);

   5. Prohibition on International Scientific Collaboration (§200.220);

   6. Conference Attendance Now Requires Express Agency Pre-Approval (§200.432);

   7. Publication Costs and Open Access Fees Presumptively Unallowable (§200.461)

3. 3: Explain the concrete harm. What would happen to your patients and their families if this provision takes effect?

4. 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