I’m going to begin with a wonderful quote from a recent editorial in Bioethics by our guests Parker Crutchfield & Jason Wasserman. This quote illustrates the tension between the widely held view in bioethics that slow codes are unethical, and the complexity of real world hospital practice: “Decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas.”

Gina Piscitello, our third guest, recently surveyed doctors, nurses and others at 2 academic medical centers about slow codes. In a paper published in JPSM, she found that two thirds had cared for a patient where a slow code was performed. Over half believed that a slow code is ethical if they believed the code is futile.

Slow codes are happening. The accepted academic bioethics stance that slow codes are unethical is not making it through to practicing clinicians. Our 3 guests were panelists at a session of the American Society of Bioethics and the Humanities annual meeting last year, and their panel discussion was apparently the talk of the meeting.

Today we talk about what constitutes a slow code, short code, show code, and “Hollywood code.” We talk about walk don’t run, shallow compressions, and…injecting the epi into the mattress! We explore the arguments for and against slow codes: harm to families, harm to patients, moral distress for doctors and nurses; deceit, trust, and communication; do outcomes (e.g. family feels code was attempted) matter more than values (e.g. never lie or withhold information from family)? We talk about the classic bioethics “trolley problem” and how it might apply to slow codes (for a longer discussion see this paper by Parker Crutchfield). We talk about the role of the law, fear of litigation, and legislative overreach (for more see this paper by Jason Wasserman). We disagree if slow codes are ever ethical. I argue that Eric’s way out of this is a slow code in disguise.

One thing we can all agree about: the ethics of slow codes need a rethink.

Stop! In the name of love. Before you break my heart. Think it over…

-Alex Smith

This is the second GeriPal podcast we’ve recorded live using this format, see this link to our prior podcast at the Center to Advance Palliative Care (CAPC) meeting in Philadelphia. Also look for our upcoming podcast recorded live from the São Paulo Geriatrics & Gerontology Congress, click here to register.

Today we join you from beautiful Banff, Alberta, Canada at the National Palliative Care Research Center (NPCRC) annual Kathleen Foley retreat. This meeting was bittersweet. I’ve been fortunate to attend every meeting in one capacity or another since 2006. The NPCRC made an enormous impact on the growth and capacity for palliative care research nationally. Personally, NPCRC funding was essential support as I was a new faculty member and had not yet secured longer term career development funding.

More than anything, though, I will miss the NPCRC community. I treasure those meals, hikes, sing-alongs with others dedicated to improving care of people with serious illness through research.

On today’s podcast, we invited Dio Kavalieratos, Prasanna Ananth, and Alexi Wright to join us to talk about three articles that spoke to them. For each I leave you with a teaser of a hard question that was raised that we couldn’t really answer.

1. Prasanna chose an article by Abby Rosenberg about being fired in palliative care. We talked about why palliative care clinicians get fired, with Prasanna, a pediatric oncologist, raising the issue that it’s more problematic when you’re the oncologist providing primary palliative care and you get fired than if the consultant specialty palliative care provider is fired.

2. Dio chose an article about the economic benefits of palliative care internationally, a call to action. We talked about the needs of palliative care internationally, and Alexi raised the question: should the highest standard of palliative care (e.g. in the US) apply to palliative care in every country, a la the Partners in Health model pioneered by the late Paul Farmer? Or should we “settle” for access to affordable opioids?

3. Alexi chose an article about cancer care in prison. Alexi used it as a springboard to talk about other populations at compounded risk for poorer care in the current political environment.

We hope you enjoy this one as much as we did, dear listeners. We’re always trying to improve, and welcome your suggestions for how to improve upon this new “live” format. So far we’ve heard we need to be better at summarizing the articles for the audience/listeners, and finding ways to involve our live audience to a greater extent than the occasional question. Please let us know if you have other suggestions!

Final note - check out the wonderful video NPCRC created about their impact on the field of palliative care (Eric and I were filmed recording GeriPal).

-Alex Smith

This episode of the GeriPal Podcast is sponsored by UCSF’s Division of Palliative Medicine, an amazing group doing world class palliative care. They are looking for physician faculty to join them in the inpatient and outpatient setting. To learn more about job opportunities, please click here: https://aprecruit.ucsf.edu/apply/JPF05811

Eric and I had the pleasure of doing a GeriPal Live! Podcast as the closing keynote for the recent Center to Advance Palliative Care (CAPC) National Assembly in Philadelphia PA.

For this podcast, we invited 3 guests to each select an article of interest to them, and engage in a discussion about the article, including questions from the CAPC attendees in the audience.

Our guests chose the following articles (in the order discussed)

• Matt Gonzales used AI to select an article by Ravi Parikh on algorithm based nudges to default patients with advanced cancer into a palliative care consult, published in JAMA Network Open, finding 44% in the intervention arm received palliative care consults, vs 8% in the control arm. We discussed use of AI to select the article, nudges, sludge, and the impressive though still less than 50% rate of PC consults.

• Kim Curseen selected an article by Harry Han in JPSM that surveyed palliative care fellowships, finding that clinical fellows spent 5 weeks in outpatient care and 24 weeks in inpatient care, on average. We discussed the mismatch between outpatient training, and the needs of people with serious illness who spend most of their lives outside the hospital, and training in inpatient care, where most hospitals have robust services and needs. Training in non-onc palliative care was particularly low.

• Karen Bullock selected a letter she first authored in response to Ira Byock’s white paper on a path forward in hospice and palliative care. We discussed the need to view all issues in geriatrics, hospice, and palliative care through an equity lens, particularly in view of the disparate impact on historically marginalized communities of concerning practices and trends in hospice and palliative care (e.g. private equity gobbling up hospices).

And at the end, we sang a tribute to the Lady Gaga of Palliative Care, with the whole Assembly singing along!

Stay tuned for future GeriPal Live! Podcasts, including recordings at the NPCRC Foley Retreat in Banff, and the São Paulo Geriatrics & Gerontology Congress, click here to register.

-Alex Smith