Lynn Flint's guest appearances

Lynn Flint

GeriPal

John Newman

Scott Bauer

BJ Miller

Andy Cohen

Aaron Kesselheim

Louise Aronson

Haider Warraich

Lewis Cohen

Stephanie Rogers

Tim Anderson

Jessica Zitter

Susan Block

John Mills

Katie Fitzgerald

John Nelson

OwlTail

Emily Largent

Anne Rohlfing

Anne Kelly

You know when you walk out of a patient's room and have that sense, “This isn’t going to go well.” The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle.  Should you stop at “no?”  Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn’t stop at “no.”  We owe it to the patient to explore the reasons behind the “no,” commonly not wanting to be a burden to their family.  In such cases, we owe it to the patient to use persuasion, for example, “I hear that you don’t want to be a burden.  And I’m worried that there may come a time when you have trouble making decisions for yourself.  We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you’re sick, that you’re hospitalized, that you’re in the ICU, and that you can’t make your own decisions?  That’s a huge amount of news all at once. It would help her to prepare if we could start talking with her now.”  We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent.  Consent is often viewed as “all or nothing” for any specific decision.  Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision.  I’d hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone.  Emily’s expanded notion of consent is grounded in the concept of “relational autonomy.”  Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another.  Emily’s notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent.  Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making. My favorite line from Emily’s paper: “Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care.” Enjoy! -@AlexSmithMD

You know when you walk out of a patient's room and have that sense, “This isn’t going to go well.” The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle.  Should you stop at “no?”  Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a <a href="https://link.springer.com/article/10.1007/s11606-022-07913-7" rel="nofollow" target="_blank">JGIM article</a> on the reasons we shouldn’t stop at “no.”  We owe it to the patient to explore the reasons behind the “no,” commonly not wanting to be a burden to their family.  In such cases, we owe it to the patient to use persuasion, for example, “I hear that you don’t want to be a burden.  And I’m worried that there may come a time when you have trouble making decisions for yourself.  We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you’re sick, that you’re hospitalized, that you’re in the ICU, and that you can’t make your own decisions?  That’s a huge amount of news all at once. It would help her to prepare if we could start talking with her now.”  We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a <a href="https://pubmed.ncbi.nlm.nih.gov/36537275/" rel="nofollow" target="_blank">Hastings Center Report</a> for an expanded vision of patient consent.  Consent is often viewed as “all or nothing” for any specific decision.  Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision.  I’d hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone.  Emily’s expanded notion of consent is grounded in the concept of “relational autonomy.”  Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another.  Emily’s notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent.  Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making. My favorite line from Emily’s paper: “Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care.” Enjoy! -@AlexSmithMD

Involving the inner circle: Emily Largent, Anne Rohlfing, Lynn Flint & Anne Kelly

Claire Ankuda

Chris Woodrell

Ashwin Kotwal

As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay (https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim), one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU. And look at where we are today. Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal. What a difference a year makes. This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care. Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service. Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults (https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204). Their service peaked at 50 consults per day, and as they note, that is likely an undercount. About half of the consults were in the ED. Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay. Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper. And (bonus!) you get to sing along to "Call Me Maybe." - Alex Smith

As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay (<a href="https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim" rel="nofollow" target="_blank">https://www.acpjournals.org/doi/full/10.7326/M20-1982?journalCode=aim</a>), one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU. And look at where we are today. Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal. What a difference a year makes. This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care. Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service. Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults (<a href="https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204" rel="nofollow" target="_blank">https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0204</a>). Their service peaked at 50 consults per day, and as they note, that is likely an undercount. About half of the consults were in the ED. Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay. Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper. And (bonus!) you get to sing along to "Call Me Maybe." - Alex Smith

Ramping up Tele-GeriPal in a Pandemic: Claire Ankuda, Chris Woodrell, Ashwin Kotwal, & Lynn Flint

Three reasons you should listen to this podcast: The issue of patients cycling back and forth between the hospital and skilled nursing facilities near the end of life is common, will ring true to those of you who are clinicians, and has largely been ignored in the literature. It's about a hot off the press article published today in the NEJM. Lynn Flint, Palliative care doc at UCSF in the Division of Geriatrics, first author, and our guest, makes me sing "Hit Me Baby One More Time" by Brittany Spears. This moment is either a new high or a new low for the GeripPal podcast, I can't tell which. You really need to listen to the final seconds when Eric joins in singing, "still believe" in high falsetto.

Rehabbed to Death NEJM Perspective: Podcast with Lynn Flint