Robert Gramling

University of Rochester, Rochester, New York, United States

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Publications (56)186.37 Total impact


  • No preview · Article · Feb 2016
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    ABSTRACT: Understanding the characteristics of communication that foster patient-centered outcomes amid serious illness are essential for the science of palliative care. However, epidemiological cohort studies that directly observe clinical conversations can be challenging to conduct in the natural setting. We describe the successful enrollment, observation and data collection methods of the ongoing Palliative Care Communication Research Initiative (PCCRI). The PCCRI is a multi-site cohort study of naturally occurring inpatient palliative care consultations. The 6-month cohort data includes directly observed and audio-recorded palliative care consultations (up to first 3 visits); patient/proxy/clinician self-report questionnaires both before and the day after consultation; post-consultation in-depth interviews; and medical/administrative records. One hundred fourteen patients or their proxies enrolled in PCCRI during Enrollment Year One (of Three). Seventy percent of eligible patients/proxies were invited to hear about a communication research study (188/269); 60 % of them ultimately enrolled in the PCCRI (114/188), resulting in a 42 % sampling proportion (114/269 eligible). All PC clinicians at study sites were invited to participate; all 45 participated. Epidemiologic study of patient-family-clinician communication in palliative care settings is feasible and acceptable to patients, proxies and clinicians. We detail the successful PCCRI methods for enrollment, direct observation and data collection for this complex "field" environment.
    Full-text · Article · Dec 2015 · BMC Palliative Care
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    ABSTRACT: Context: As endorsed by the palliative care Measuring What Matters initiative, capturing patients' direct assessment of their care is essential for ongoing quality reporting and improvement. Fostering an environment where seriously ill patients feel heard and understood is of crucial importance to modern health care. Objectives: To describe the development and performance of a self-report field measure for seriously ill patients to report how well they feel heard and understood in the hospital environment. Methods: As part of a larger ongoing cohort study of inpatient palliative care, we developed and administered the following point-of-care item: "Over the past two days, how much have you felt heard and understood by the doctors, nurses and hospital staff?" (completely, quite a bit, moderately, slightly, not at all). Participants completed the measure before and the day following palliative care consultation. For the post-consultation version, we changed the time frame from "past two days" to "today." Results: One hundred sixty patients with advanced cancer completed the pre-consultation assessment and 87% of them completed the post-consultation version. Responses encompassed full use of the ordinal scale, did not exhibit ceiling or floor effects, and showed improvement from pre- to post-assessments. The item was quick to administer and easy for patients to complete. Conclusion: The "Heard & Understood" item is a promising self-report quality measure for the inpatient palliative care setting.
    No preview · Article · Nov 2015 · Journal of pain and symptom management
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    ABSTRACT: Palliative care promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for palliative care referral. However, very little is empirically known about the content or process of goal expression in the natural setting of palliative care. To describe the frequency, types and determinants of goal expression in palliative care consultations. This was a cross-sectional, direct observation study of 71 AU: 71 OR 72? audio-recorded palliative care consultations with hospitalized patients (and families) referred for palliative care "goals of care clarification" or "end-of-life decision making." We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data. Goal expressions occurred frequently in palliative care consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals. Goal communication is common in palliative care decision-making settings and strongly influenced by existential suffering. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · May 2015 · Journal of pain and symptom management
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    ABSTRACT: Being able to identify expressions of emotion is crucial to effective clinical communication research. However, traditional linguistic coding systems often cannot represent emotions that are expressed nonlexically or phonologically (i.e., not through words themselves but through vocal pitch, speed/rhythm/tempo, and volume). Using audio recording of a palliative care consultation in the natural hospital setting, two experienced music scholars employed Western musical notation, as well as the graphic realization of a digital audio program (Piano roll visualization), to visually represent the sonic features of conversation where a patient has an emotional "choke" moment. Western musical notation showed the ways that changes in pitch and rate correspond to the patient's emotion: rising sharply in intensity before slowly fading away. Piano roll visualization is a helpful supplement. Using musical notation to illustrate palliative care conversations in the hospital setting can render visible for analysis several aspects of emotional expression that researchers otherwise experience as intuitive or subjective. Various forms and formats of musical notation techniques and sonic visualization technologies should be considered as fruitful and complementary alternatives to traditional coding tools in clinical communications research. Musical notation offers opportunity for both researchers and learners to "see" how communication evolves in clinical encounters, particularly where the lexical and phonological features of interpersonal communication are concordant and discordant with one another. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Full-text · Article · May 2015 · Patient Education and Counseling
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    ABSTRACT: Abstract Background: Many heart failure (HF) patients experience high symptom burden, but palliative care (PC) services have been used infrequently in this population. Objective: The specific aim of this study was to identify individual-level factors associated with PC referral. Methods: The study sample included adult patients hospitalized at an academic medical center with a primary diagnosis of HF between January 2005 and June 2010. Inpatient records were merged with the PC database to identify HF patients who received PC consultations. The analytical sample included 2647 HF admissions. We used descriptive statistics to characterize HF patients who received and did not receive PC services. Logistic regression analyses were used to identify patient characteristics that predict PC referral. Results: Just over 6% of patients with HF were referred to PC during their hospitalization. We identified the following statistically significant determinants of PC referral: secondary diagnosis of Alzheimer's disease, receipt of thoracentesis, intensive care unit (ICU) stay, and prior HF-related hospitalizations. Conclusions: Currently, only a fraction of HF patients who are at high risk for morbidity and mortality receive PC services. Additional research is needed to identify factors associated with PC referral that can be prospectively identified, and to develop better prediction models to identify HF patients who may benefit from PC referral.
    No preview · Article · Jul 2014 · Journal of Palliative Medicine

  • No preview · Article · Mar 2014 · Palliative Medicine
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    ABSTRACT: Abstract Background: Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations. Objectives: To describe the types and frequency of emotional distress that patients and loved ones express and how providers respond to these emotions during PC decision-making consultations with seriously ill hospitalized patients. Methods: We used a quantitative descriptive approach to analyze 71 audio-recorded inpatient PC decision-making consultations for emotional distress and clinicians' responses to those emotions using reliable and established methods. Results: A total of 69% of conversations contained at least one expression of emotional distress. The per-conversation frequency of expressions of emotional distress ranged from 1 to 10. Anxiety/fear were the most frequently encountered emotions (48.4%) followed by sadness (35.5%) and anger/frustration (16.1%). More than half of the emotions related to the patient's feelings (53.6%) and 41.9% were related to the loved ones' own emotions. The majority of emotions were moderate in intensity (65.8%) followed by strong (20.7%) and mild (13.5%). Clinicians responded to a majority of emotions with a compassionate response (75.7%) followed by those with medical content (21.9%) and very few were ignored (1.3%). Conclusions: Expressions of emotional distress are common during PC consultations and are usually met with compassionate responses by the clinician.
    Full-text · Article · Mar 2014 · Journal of palliative medicine
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    Michael Hoerger · Robert Gramling · Ronald Epstein

    Full-text · Article · Feb 2014 · Journal of Pain and Symptom Management
  • Sally A. Norton · Deborah Waldrop · Robert Gramling
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    ABSTRACT: Interprofessional teams are a standard for hospice and palliative care services. One strength of an interprofessional team approach is an explicit use of the varied perspectives that different disciplines bring to patients and families who are facing advanced and/or end stage illness. The deliberate use of multiple perspectives rounds out the breadth and depth of expertise in developing plans of care for patients and their families. Yet this strength may, at times, be the context for team conflict. The purpose of this chapter is to examine various ethical challenges that manifest among interprofessional palliative care teams and to suggest potential strategies for addressing these challenges. We focus on the roles of social workers, nurses, and physicians because these disciplines are ubiquitous among palliative care programs.
    No preview · Chapter · Jan 2014
  • Robert Horowitz · Robert Gramling · Timothy Quill
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    ABSTRACT: Medical educators in the USA perceive the teaching of palliative care competencies as important, medical students experience it as valuable and effective, and demographic and societal forces fuel its necessity. Although it is encouraged by the Association of American Medical Colleges, the only palliative care-related mandate in US medical schools is the Liaison Committee on Medical Education directive that end-of-life (EoL) care be included in medical school curricula, reinforcing the problematic conflation of EoL and palliative care. A review of US medical school surveys about the teaching of palliative and EoL care reveals varied and uneven approaches, ranging from 2 hours in the classroom on EoL to weeks of palliative care training or hospice-based clinical rotations. Palliative care competencies are too complex and universally important to be relegated to a minimum of classroom time, random clinical exposures, and the hidden curriculum. Given the reality of overstrained medical school curricula, developmentally appropriate, basic palliative care competencies should be defined and integrated into each year of the medical school curriculum, taking care to circumvent the twin threats of curricular overload and educational abandonment.
    No preview · Article · Jan 2014 · Medical Education
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    ABSTRACT: Prognostic communication is a primary component of goals of care conversations in palliative care (PC) practice. Little is known about these conversations in the natural setting. This study's aim was to describe the processes of prognostic communication in PC goals of care consultations. Using line-by-line qualitative analysis, we examined prognostic conversation in 66 audio-taped PC consultations. We identified five processes by which clinicians link prognoses, values, and goals of care: (1) signposting the crossroads; (2) closing off a goal; (3) clarifying current path; (4) linking paths and patients' values; and (5) choosing among paths. The findings add to our understanding of PC consultation by describing how prognoses link with patients' values and choices in goals of care conversations. © 2013 Wiley Periodicals, Inc. Res Nurs Health.
    Full-text · Article · Dec 2013 · Research in Nursing & Health
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    ABSTRACT: Background: Prognosis conversations are complex phenomena of substantial importance to palliative care (PC), yet these remain poorly understood. This study empirically identifies and describes major types of prognosis conversations that occur in the natural setting of PC consultation. Methods: We audio-recorded and coded 71 inpatient "goals of care" PC consultations at a large academic medical center in the northeastern United States. We used quantitative Latent Class Analyses for identifying discrete prognosis conversation types and qualitative Dimensional Analyses for more fully describing the process and content of the latent classes. Results and conclusions: We observed three discrete types of prognosis conversations, each placing different communication demands upon all participants for achieving goal-concordant care: Navigating Options & Goals (56% of consultations), Facilitating New Goals (23%) and Preparing for End-of-Life (21%). This study provides the first step for developing educational and clinical prognosis communication interventions that are tailored to common decision-making contexts facing seriously ill patients, their families, and PC clinicians.
    Full-text · Article · May 2013 · Journal of palliative medicine
  • Maureen Metzger · Sally A Norton · Jill R Quinn · Robert Gramling
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    ABSTRACT: Experts in both heart failure and palliative care recommend collaboration between the two disciplines as a mechanism to improve late-stage heart failure care. However, referral rates of heart failure patients to palliative care services remain low. The purpose of this study was to describe the perspectives of heart failure patients and their family members regarding the barriers to palliative care in late-stage heart failure care. We used qualitative content analysis to identify themes from 40 semistructured interviews with 24 hospitalized late-stage heart failure patients and 16 designated family members. Results indicated that participants often refused or deferred palliative care services if they viewed hospice and palliative care as synonymous. They perceived that a set of hospice "rules" existed and that they were "deal breakers" for heart failure patients as they impeded the goals of aggressively managing troubling symptoms and/or providing comfort at end of life. The findings from this study underscore the need to examine the current hospice guidelines and for clinicians to view palliative care as a philosophy of care that allows for the unpredictable trajectory of heart failure.
    No preview · Article · May 2013 · Journal of Hospice and Palliative Nursing
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    ABSTRACT: Background Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers. Methods/design The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years. Discussion The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes). Trial registration Clinical Trials Identifier: NCT01485627
    Full-text · Article · Apr 2013 · BMC Cancer
  • Robert G Holloway · Robert Gramling · Adam G Kelly
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    ABSTRACT: Prognosis can no longer be relegated behind diagnosis and therapy in high-quality neurologic care. High-stakes decisions that patients (or their surrogates) make often rest upon perceptions and beliefs about prognosis, many of which are poorly informed. The new science of prognostication-the estimating and communication "what to expect"-is in its infancy and the evidence base to support "best practices" is lacking. We propose a framework for formulating a prediction and communicating "what to expect" with patients, families, and surrogates in the context of common neurologic illnesses. Because neurologic disease affects function as much as survival, we specifically address 2 important prognostic questions: "How long?" and "How well?" We provide a summary of prognostic information and highlight key points when tailoring a prognosis for common neurologic diseases. We discuss the challenges of managing prognostic uncertainty, balancing hope and realism, and ways to effectively engage surrogate decision-makers. We also describe what is known about the nocebo effects and the self-fulfilling prophecy when communicating prognoses. There is an urgent need to establish research and educational priorities to build a credible evidence base to support best practices, improve communication skills, and optimize decision-making. Confronting the challenges of prognosis is necessary to fulfill the promise of delivering high-quality, patient-centered care.
    No preview · Article · Feb 2013 · Neurology
  • Maureen Metzger · Sally A Norton · Jill R Quinn · Robert Gramling
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    ABSTRACT: PURPOSE: To describe patients with HF and their family members' (FMs) experiences with, and perceptions of, inpatient PC consultations. METHODS: 40 semi-structured interviews were completed with 24 patients with late-stage HF and/or 16 designated FMs. Content analysis was used to derive themes from the data. RESULTS: Four main themes resulted. Participants: 1) were generally ill-prepared for the PC consult; 2) pursued a plan that reflected their own understanding of patient prognosis, rather than that of the clinician; 3) described a primarily supportive role for PC; 4) often rejected or deferred PC services if they viewed hospice and PC as synonymous. CONCLUSION: Lack of awareness of PC and the conflation of PC and hospice were barriers to PC, and many participants felt that PC services are needed to fill the gaps in their care. A collaborative model of care may best meet the complex needs of this group.
    No preview · Article · Dec 2012 · Heart & lung: the journal of critical care
  • Robert Gramling · Thomas Carroll · Ronald M. Epstein

    No preview · Article · Dec 2012
  • David Gramling · Robert Gramling

    No preview · Article · Nov 2012 · Journal of palliative medicine
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    Ronald M Epstein · Robert E Gramling
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    ABSTRACT: Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients' preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and "collaborative cognition" among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes ("whole mind") and involving others in exploring, clarifying, and co-constructing patients' preferences ("shared mind"). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.
    Full-text · Article · Oct 2012 · Medical Care Research and Review

Publication Stats

864 Citations
186.37 Total Impact Points

Institutions

  • 2008-2015
    • University of Rochester
      • • Department of Family Medicine
      • • Department of Community and Preventive Medicine
      Rochester, New York, United States
  • 2009
    • Boston University
      Boston, Massachusetts, United States
  • 2003-2008
    • Brown University
      • Department of Family Medicine
      Providence, Rhode Island, United States
    • Alpert Medical School - Brown University
      • Department of Family Medicine
      Providence, Rhode Island, United States
  • 2003-2007
    • Memorial Hospital of Rhode Island
      Pawtucket, Rhode Island, United States