Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine.

To start. we review:

• What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.

• Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.

• What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge.

• Examples of nudges, some based in health care, others in coffee.

This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups:

1. Usual care

2. Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect

3. Comfort care nudge - EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies.

4. Both the prognosis and comfort care nudge.

A few key points of discussion:

• Is an EHR prompt a nudge or sludge?

• The intervention was a negative study for the primary outcome, hospital length of stay. Why?

• The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?

• The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? Imagine!

-Alex Smith

We’ve covered psychedelics on the podcast before—first in 2019 with Ira Byock, where we explored their potential role in medicine, and then again in 2023 with Stacy Fischer, Brian Anderson, and Theora Cimino, focusing on the reasons to approach psychedelic use in patients with caution.

In today’s episode, we’re taking a closer look at the current state of the science around one specific psychedelic: psilocybin. We'll discuss three recent clinical trials involving patients with serious illness, joined by our guests James Downar, Ali John Zarrabi, and Margaret Ross.

We begin with a refresher on psilocybin—what it is, how it might work, what conditions it may help treat (including demoralization), and how it’s typically administered. What makes this episode especially compelling is our deep dive into the three studies, which highlight two different approaches to using psilocybin: daily microdosing, similar to traditional antidepressants, and a more intensive model known as psilocybin-assisted therapy. This latter approach involves three structured phases—preparation, the dosing session, and post-session integration with trained therapists.

Peter Selwyn, one of today’s guests, has been caring for people living with HIV for over 40 years. In that time, care of people with HIV has changed dramatically. Initially, there was no treatment, then treatments with marginal efficacy, complex schedules, and a tremendous burden of side effects and drug-drug interactions. The average age at death was in the 30s.

Now, more people in the US die with HIV rather than from HIV. Treatment regimens are simplified, and the anti-viral drugs are well tolerated. People are living with HIV into advanced ages. The average age at death is likely in the 60s. Nearly half of people living with HIV are over age 55. One in 10 people with newly diagnosed HIV is an older adult. Our second guest, Meredith Greene, is a geriatrician and researcher who focuses on care of older adults living with HIV, in the US and Africa.

On today’s podcast we discuss:

• Implications of aging with HIV for clinical care

• Loneliness and social isolation among older adults living with HIV

• Persistence of stigma

• Need to consider HIV in the differential diagnosis for older adults

• Screening for HIV

• Screening for osteoporosis in people living with HIV

• Dementia and cognitive impairment risk in people living with HIV

• When to stop anti-virals near the end of life

Toward the end we speak to the moment. More older adults live with HIV in SubSaharan Africa and the global South than anywhere else in the world. Funding for research and clinical care is at risk, as USAID and PEPFAR (which is under USAID), are shuttered. Millions of lives are at stake. Meredith wore a shirt that said Silence=death.

Eric gave me the hook during my live cover of One, by U2, a song released in 1992 whose proceeds went entirely to AIDS research. I couldn’t help it, forgive me dear listeners, I had to do a longer than usual cut at the start!

-Alex Smith

Useful links:

Peter's article on the evolution of HIV: https://link.springer.com/article/10.1007/s11524-011-9552-y

Peter’s book Surviving the Fall: Personal Journey of an AIDS Doctor

PEPFAR: Global Health Policy | KFF

Articles:

Geriatric Syndromes in Older HIV-Infected Adults - PMC

Loneliness in Older Adults Living with HIV

Management of Human Immunodeficiency Virus Infection in Advanced Age
https://pmc.ncbi.nlm.nih.gov/articles/PMC3684249/

About Act-up for those who might know the Silence=Death t-shirt reference:
https://www.npr.org/2021/06/16/1007361916/act-up-a-history-of-aids-hiv-activism

https://www.newyorker.com/magazine/2021/06/14/how-act-up-changed-america