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

In this week's episode, we delve into the powerful documentary The Chaplain and The Doctor with two extraordinary guests: Betty Clark, the chaplain at the heart of the film, and Dr. Jessica Zitter, the physician and filmmaker who brought this story to the screen.

The film provides a deeply moving look into the ways personal stories and biases shape our interactions in healthcare. Through our conversation with Betty and Jessica, I gained a valuable insight: the narratives we carry within ourselves—whether conscious or unconscious—act as invisible forces that influence how we engage with patients and colleagues. I also learned that recognizing these stories and the biases they may produce, rather than avoiding them, can foster more genuine and empathetic care. They also may lead to deep friendships, as is clearly shown between Betty and Jessica.

I love both this podcast episode and the film itself, as they shine a light on the deeply human—and oftentimes flawed—experience of working in healthcare. They remind us of the vital role of storytelling in shaping how we care for patients, and the often-overlooked yet essential contributions of chaplains in healthcare settings. Betty and Jessica's reflections underscore how chaplains bring compassion and humanity to the medical team, offering emotional and spiritual support to patients and providers alike.

If you're interested in watching The Chaplain and The Doctor during its festival tour, or would like to host a screening at your own institution, I encourage you to visit the film's website at TheChaplainandTheDoctor.com.

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

** NOTE: To claim CME credit for this episode, click here **

In June of 2025, hospice and palliative care pioneer Ira Byock published a white paper outlining the urgent challenges facing the field today. In a nutshell, he expressed concerns that the quality of hospice care in the United States has become highly variable, with disturbing frequency of unethical practices and avaricious owners. He also raised concern that the rapid increase in palliative care program growth during the first two decades of this century has stalled, leaving us with understaffed programs that are often inadequately trained.

Along with Ira, we've invited Kristi Newport, a palliative care doctor and Chief Medical Officer of the American Academy of Hospice and Palliative Medicine, and Brynn Bowman, Chief Executive Officer of the Center to Advance Palliative Care, to discuss these issues and outline a strategic path forward for the field.

In particular we talk about Ira's four-part solution to transform the field and restore its integrity: (1) publishing clear clinical and programmatic standards, (2) making meaningful data publicly available to ensure transparency and accountability, (3) fostering quality-based competition among providers, and (4) embracing the authentic brand of hospice and palliative care—expert care that alleviates suffering and fosters well-being.

So take a listen and dive a little deeper with these resources, and dont forget, you too can get involved in AAHPM (click here for opportunities):

• Ira's paper titled "A Strategic Path Forward for Hospice and Palliative Care: A White Paper on the Potential Future of the Field"

• Our previous podcast on "Is Hospice Losing Its Way"

• Our previous podcast on Private Equity Gobbling Up Hospices plus Hospice and Dementia with Melissa Aldridge, Krista Harrison, & Lauren Hunt

• CAPC's Serious Ilness Scorecard - a state-by-state look at palliative care capacity

• CAPC's second annual Palliative Pulse survey offers insight into how palliative care professionals across the country are feeling this year and what they're focused on

• National Hospice Locator and TCMTalks Podcast by Chris Comeaux and Cordt Kassner

Today's topic on palliative care for sickle cell disease may raise eyebrows with some of you. You might think, wait, now we're doing sickle cell? On top of liquid cancer and transplant, kidney disease, liver disease, and survivorship? Where does it end? Do we have staff for all of this?

Well I implore you, dear listeners, to keep an open mind and listen to this podcast. Our guests do a fabulous job of stating the case for palliative care in sickle cell disease, to the point that we ask: why haven't we been doing this all along?

Our guests today are Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa, three palliative care docs who have been advancing the practice in palliative care for sickle cell for a long time. Our discussion ranges from what is sickle cell; to outcomes; to social determinants and discrimination; to PCAs, ketorolac, and bupenorphine; and to the importance of the interdisciplinary team.

I would also encourage you to check out Eberechi's NEJM Perspective on Involving Palliative Care to Improve Outcomes in Sickle Cell, which includes a table of the challenges and action items needed to move the field forward. I'd also encourage you to sample this AAHPM Flight on the same topic (we learned that a flight is similar to a flight of drinks - a quick sampling).

As Eberechi notes at the start, we should be grateful for the community of people who are advancing palliative care in sickle cell. Thank you for being a friend (song hint!).

-Alex Smith

Last month, the "Billing Boys"—Chris Jones and Phil Rodgers—joined the GeriPal podcast to demystify medical billing and coding in palliative care. This month, we're back with part two, shifting the focus to geriatrics. While billing and coding may not be the most exciting topic, they're essential for ensuring fair reimbursement for the complex care we provide and for supporting the work of our interprofessional teams, many of whom can't bill directly for their services. When we underbill or leave money on the table, we not only shortchange ourselves but also devalue the critical role of geriatrics in the healthcare system.

This time, we're joined by experts Peter Hollmann, Ken Koncilja, and Audrey Chun to dive into key questions: Why does billing matter, and who does it benefit? What's the difference between CPT, E&M, and ICD-10 codes (if you need a refresher, check out our chat with the Billing Boys here)? We explore how to think about billing for complexity versus time, and unpack new and impactful codes like the Cognitive Assessment and Care Plan Services code (99483), advance care planning (ACP) billing codes, and G2211, which acknowledges the added work of managing patients with chronic conditions. We also highlight the new APCM G-codes for 2025, a set of HCPCS codes that could provide substantial financial support for interdisciplinary teams in geriatrics.

Finally, we discuss the advocacy behind these codes. The American Geriatrics Society (AGS) plays a vital role on the AMA's RUC committee, helping to improve reimbursement for the complex care of older adults. Tune in to this week's GeriPal podcast for expert advice, practical strategies, and insights that will help you optimize your billing practices and sustain the future of geriatrics!

Here are some of the resources we also talked about:

• The physician fee schedule look up tool Wwere you can find out CMS expected charge based off where you practice

• AGS's annual coding update

• Geriatrics at Your Fingertips, which has a one-pager on billing

• Medicare Claims Processing Manual

👉 NOTE:
Eric and Alex are giving UCSF Geriatrics Grand Rounds on Wednesday November 5, 4-5pm Pacific Time. The topic is, "What we've learned from nearly 400 GeriPal podcasts." Join us! This will be highly interactive. If you'd like to join via Zoom, you can use this link: https://ucsf.zoom.us/webinar/register/WN_qLJSlL0wSlq3SwASXw_S4w. Or join in person, grand rounds are open to all! We will be speaking at the main UCSF Campus, 500 Parnassus Ave, in the Health Sciences West Building, 3rd floor, room 303. You can ask for directions when you arrive at UCSF, or email Alex to arrange for someone to meet you at the front (https://profiles.ucsf.edu/alexander.smith).

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