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