Artificial Intelligence: Charlotta Lindvall, Matt DeCamp, Sei Lee

06/15/23 • 49 min

GeriPal - A Geriatrics and Palliative Care Podcast

Artificial Intelligence, or AI, has tremendous potential. We talk on this podcast about potential uses of AI in geriatrics and palliative care with natural language processing guru Charlotta Lindvall from DFCI, bioethicists and internist Matt DeCamp from University of Colorado, and prognosis wizard Sei Lee from UCSF.

Social companions to address the epidemic of loneliness among older adults
Augmenting ability of clinicians by taking notes
Searching the electronic health record for data
Predicting mortality and other outcomes

We talk also about the pitfalls of AI, including:

Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities
Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?
Hallucinations, or when the AI lies or bullshits, then denies it
When the AI approaches sentience, is it ethical to unplug it?

I’m sure this is a subject we will return to, given the rapid progress on AI.

Enjoy!

-@AlexSmithMD

Links:

Papers on AI and palliative care and concerns about bias: https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/ https://academic.oup.com/jamia/article/27/12/2020/5859726

Comparison of machine learning vs traditional prognostic methods based on regression: https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011

Other links on the issue of AI and racial or ethnic bias:

Are Robots Racist? Greenwall Foundation Bill Stubbing lecture Are Robots Racist? Rethinking Automation and Inequity in Healthcare https://www.nber.org/papers/w30700 https://www.science.org/doi/10.1126/sciadv.add2704 https://theconversation.com/including-race-in-clinical-algorithms-can-both-reduce-and-increase-health-inequities-it-depends-on-what-doctors-use-them-for-206168

MD Calc approach to inclusion of race https://www.mdcalc.com/race

Social companions to address the epidemic of loneliness among older adults
Augmenting ability of clinicians by taking notes
Searching the electronic health record for data
Predicting mortality and other outcomes

We talk also about the pitfalls of AI, including:

Recapitulation bias by race and ethnicity, and other factors, exacerbating disparities
Confidentiality concerns: do those social companions also monitor older adults for falls? 24/7?
Hallucinations, or when the AI lies or bullshits, then denies it
When the AI approaches sentience, is it ethical to unplug it?

I’m sure this is a subject we will return to, given the rapid progress on AI.

Enjoy!

-@AlexSmithMD

Links:

Papers on AI and palliative care and concerns about bias: https://www.healthaffairs.org/do/10.1377/forefront.20200911.401376/ https://academic.oup.com/jamia/article/27/12/2020/5859726

Comparison of machine learning vs traditional prognostic methods based on regression: https://www.ingentaconnect.com/content/wk/mcar/2022/00000060/00000006/art00011

Other links on the issue of AI and racial or ethnic bias:

MD Calc approach to inclusion of race https://www.mdcalc.com/race

Previous Episode

Diabetes in Late Life: Nadine Carter, Tamryn Gray, Alex Lee

Diabetes is common. When I’m on nursing home call, the most common page I receive is for a blood sugar value. When I’m on palliative care consults and attending in our hospice unit we have to counsel patients about deprescribing and de-intensifying diabetes medications.

Given how frequent monitoring and prescribing issues arise in the care of patients with diabetes in late life, including the end of life, Eric and I were excited when Tamryn Gray emailed us requesting a follow up podcast on this issue. Our last podcast was with Laura Petrillo in 2018 - 5 years ago seems ancient history - though many of the points still apply today (e.g. Goldilocks zone). And yet we’re also in a different place in diabetes monitoring and management.

To answer our questions, we invited Nadine Carter, a current hospice and palliative care fellow at Dartmouth who previously worked as an NP in outpatient endocrinology, and Alex Lee, an epidemiologist at UCSF interested in diabetes monitoring and management in the nursing home.

And we invited Tamryn Gray from the Dana Farber joins us to ask insightful questions, including:

What blood sugar range should we target for patients in the nursing home or hospice? How high is too high? Should considerations differ for people with dementia? What are the risks and rewards of new classes of medications? How do caregivers fit into this? Continuous glucose monitoring (CGM) is commonplace in Type 1 and gaining traction in Type 2. We debate the merits of use of CGM in the nursing home and other late life settings (Eric and I argue against CGM and lose). Ozempic is a new fancy med that, by the way, leads to weight loss among celebrities, resulting in shortages of the drug from people using it off-label for that purpose. Should we use Ozempic (if we can find it) in patients with serious illness, which often results in undesirable and profound weight loss?

Listen in to learn more!

-@AlexSmithMD

Additional Links:

-Fingerstick monitoring in VA nursing homes (too common!)

-Improving diabetes management in hospice

-Continuous Glucose Monitoring complicating end of life care

Next Episode

Hospice in Prison Part 1: An interview with Michele DiTomas and Keith Knauf

In the early 1990’s, California Medical Facility (CMF) created one of the nation’s first licensed hospice units inside a prison. This 17-bed unit serves inmates from all over the state who are approaching the end of their lives. A few are let out early on compassionate release. Many are there until they die.

Today’s podcast is part one of a two-part podcast where we spend a day at CMF, a medium security prison located about halfway between San Francisco and Sacramento, and the hospice unit housed inside its walls.

We start off part one by interviewing Michele DiTomas, who has been the longstanding Medical Director of the Hospice unit and currently is also the Chief Medical Executive for the Palliative care Initiative with the California Correctional Healthcare Services. We talk about the history of the hospice unit, including how it was initially set up to care for young men dying of AIDS, but now cares for a very different demographic – the rapidly aging prison population. We also talk about the eligibility for the unit, what makes it run including the interdisciplinary team and the inmate peer workers, and the topic of compassionate release.

Afterwards, we chat with the prison’s chaplain, Keith Knauf. Keith per many reports, is the heart and sole of the hospice unit and oversees the Pastoral Care Workers. These are inmates that volunteer to work in the hospice unit, serving a mission that “no prisoner dies alone.” We chat with Keith about how hospice in prison is different and similar to community hospice work, the selection process and role of the peer support workers, the role of forgiveness and spirituality in the care of dying inmates, and what makes this work both rewarding and hard.

Part two of the podcast, which comes next week, is solely focused on the Pastoral Care Workers. We interview three of them in the hospice unit and take a little tour of the hospice gardens.