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

What is a “good death”? How should we define it, and who gets to decide? Is the concept of a “good death” even useful?

Twenty-five years ago, Karen Steinhauser published a groundbreaking study in JAMA that transformed my understanding of what it means to have a good death and questioned the usefulness of the term itself. This study examined the factors that are important at the end of life for patients, families, physicians, and other healthcare providers.

In today’s podcast, we are honored to have Karen join us to discuss this pivotal study and the nature of a “good death”. We are also joined by Rasa Mikelyte and Edison Vidal, co-authors of a recent study comparing the perspectives of people with dementia in the UK and Brazil on what constitutes a good death.

In addition to exploring the nature of a good death and their individual studies, we will discuss:

• Whether an external criterion for a good death exists, or if it is entirely dependent on the perspective of the dying individual.

• The role of culture and spirituality in defining a good death.

• The role of healthcare providers in the discussion about the nature of a good death.

Key references we discuss include:

• Our previous GeriPal podcast, “Should the Concept of ‘The Good Death’ Be Buried?” with VJ Periyakoil.

• Karen’s 2000 JAMA article, “Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers.”

• Rasa and Edison’s article, “Comparing the Views of People with Dementia in the UK and Brazil about a Good Death.”

• A short video from the EPEC project that Edison mentioned during the recording of an interview with Cicely Saunders, where she shares her advice for anyone going into medicine or palliative care and her views about the principles of palliative care.

Lastly, if you would like to join Eric, Edison, and I in Brazil on April 6, 2026, for the São Paulo Geriatrics & Gerontology Congress, click here to register.

-Alex Smith

A podcast on medical billing and coding??? Ok, hear us out as we were skeptical too. We’ve invited the Billing Boys, Chris Jones and Phil Rodgers, who convinced us of the following:

1. Billing is complicated, but it isn’t hard.

2. Effectively billing helps pay for the interprofessional team members who often can't bill

3. We should know our worth and bill for it. Just because a visit didn’t feel HARD to a well-trained provider doesn’t mean it wasn’t complex or valuable. Many of us have long suffered from low professional self-esteem when it comes to money, and it’s high time we stop that.

4. While exclusively billing on time may have been right 20 years ago, we must now understand complexity and advance care planning (ACP).

We can't cover everything in the 45 minutes we are together, so here are some of the resources we reference in the podcast:

• Chris’s and Phil’s consulting contact info via Lightning Bolt Partners

• CAPC resources:

• • CAPC’s Billing and Coding Toolkit

  • CAPC’s Monthly office hours in Inpatient and Community-Based PC Billing and Coding run by Andy Esch, Phil Santa Emma, and Chris Jones

  • CAPC’s 2025 Annual Billing and Coding Update done by Phil and Chris each year

• Advance Care Planning resource from the Medicare Learning Network

• Top Ten Tips for Using Advance Care Planning Codes

• CPT 2025 Professional Edition. This is the book that has the Complexity Grid in it. The answers are all here! And your coders will likely share.

On today’s podcast, we talk about an innovative specialized primary care model for older veterans called the Geriatric Patient Aligned Care Team (GeriPACT) program. It’s designed with smaller patient panels and enhanced social worker and pharmacist involvement, and its approach is aimed at improving care and outcomes for our aging population.

We unpack the intriguing findings of a recent JAMA Network Open study authored by one of our guests, Susan “Nicki” Hastings, looking at GeriPACT that compares it to a traditional Patient Aligned Care Team (PACT). While GeriPACT successfully delivered more attention to geriatric conditions, it surprisingly didn't translate into expected improvements like more time at home or better self-rated health.

We discuss the potential reasons behind this with our other two guests, one a geriatrics fellow, Kristie Hsu, and the other a recurring guest and host of the podcast, Ken Covinsky. Was it just that it didn’t work, or were there other things going on, from the intensity of "usual care" to the challenges of measuring complex health outcomes and the possibility that 18 months simply wasn't long enough to see the full benefits?

Despite what was ostensibly a negative trial, we highlight some reassuring aspects and future hopes for GeriPACT and how we can all incorporate some of these components into the care of our patients. We'll also pose critical questions for future research, emphasizing why continued development and evaluation of new care models are essential for the health of our older population.

With all the attention focused on Alzheimer's biomarkers and amyloid antibodies, it’s easy to forget that comprehensive dementia care is more than blood draws and infusions. On today’s podcast, we buck this trend and dive into the complexities and challenges of comprehensive dementia care with the authors of two pivotal articles recently published in JAMA.

We’ve invited David Reuben and Greg Sachs to talk about their two respective trials, published in JAMA — D-CARE and IN-PEACE — aimed at improving the evidence for care models supporting individuals diagnosed with dementia. D-CARE tested the comparative effectiveness of health system-based dementia care, a community-based program, and usual care, while IN-PEACE assessed the addition of palliative care to dementia care programs for individuals with moderate to severe dementia.

Despite their pragmatic trial designs and high expectations, both studies' primary outcomes were negative, although there were some intriguing positive secondary outcomes. We discuss how some critical questions about the integration of these findings into practice, and how they fit in with previous research that did show benefits (see this past podcast on using health navigators to improve dementia care).

If you want to learn more about comprehensive dementia care, check out these past podcasts:

• Our previous podcast on comprehensive dementia care with Lee Jennings and Chris Callahan

• Our podcast on the GUIDE Model with Malaz Boustani and Diane Ty

• Our podcast on Transforming the Culture of Dementia Care with Anne Basting, Ab Desai, Susan McFadden, and Judy Long

Lastly, here is the link to Greg Sachs' NEJM article that describes his maternal grandmother decline from Alzheimer's disease.

In today’s podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including:

• What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment?

• Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it?

• Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle.

• Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions)

• How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)?

• How long does it take to conduct a comprehensive geriatrics assessment?

• What’s the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment?

• What are the outcomes we hope for from the comprehensive geriatrics assessment?

That final point, about outcomes, bring’s us to Eric Wong’s study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics).

As an aside, as the editor at JAGS who managed this manuscript, I will say that we don’t ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated’ means).

We published this article because its bottom line is of great interest to geriatricians. In Eric’s study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting.

And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it’s cost effective for the health care system).

I’ll close with a couple of “mic drop” excerpts from Thiago’s accompanying editorial:

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab.

Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population.

-Alex Smith