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Xia Q, Kularatna M, Virdun C, Button E, Close E, Carter HE. Preferences for Palliative and End-of-Life Care: A Systematic Review of Discrete Choice Experiments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1795-1809. [PMID: 37543206 DOI: 10.1016/j.jval.2023.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/20/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Understanding what matters most to patients and their caregivers is fundamental to delivering high-quality care. This systematic review aimed to characterize and appraise the evidence from discrete choice experiments eliciting preferences for palliative care. METHODS A systematic literature search was undertaken for publications up until August 2022. Data were synthesized narratively. Thematic analysis was applied to categorize attributes into groups. Attribute development, frequency, and relative importance were analyzed. Subgroup analyses were conducted to compare outcomes between patient and proxy respondents. RESULTS Seventeen studies spanning 11 countries were included; 59% of studies solely considered preferences for patients with cancer. A range of respondent groups were represented including patients (76%) and proxies (caregivers [35%], health providers [12%], and the public [18%]). A total of 117 individual attributes were extracted and thematically grouped into 8 broad categories and 21 subcategories. Clinical outcomes including quality of life, length of life, and pain control were the most frequently reported attributes, whereas attributes relating to psychosocial components were largely absent. Both patients and proxy respondents prioritized pain control over additional survival time. Nevertheless, there were differences between respondent cohorts in the emphasis on other attributes such as access to care, timely information, and low risk of adverse effects (prioritized by patients), as opposed to cost, quality, and delivery of care (prioritized by proxies). CONCLUSIONS Our review underscores the vital role of pain control in palliative care; in addition, it shed light on the complexity and relative strength of preferences for various aspects of care from multiple perspectives, which is useful in developing personalized, patient-centered models of care for individuals nearing the end of life.
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Affiliation(s)
- Qing Xia
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Mineth Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Claudia Virdun
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Elise Button
- Cancer and Palliative Care Outcomes Centre, Centre for Healthcare Transformation, School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, School of Law, Faculty of Business and Law (Close), Queensland University of Technology, Brisbane, QLD, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Mroz EL, McDarby M, Kutner JS, Arnold RM, Bylund CL, Pollak KI. Empathic communication between clinicians, patients, and care partners in palliative care encounters. PATIENT EDUCATION AND COUNSELING 2023; 114:107811. [PMID: 37244131 PMCID: PMC10526983 DOI: 10.1016/j.pec.2023.107811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Palliative care encounters often involve empathic opportunities conveyed by patients and their care partners. In this secondary analysis, we examined empathic opportunities and clinician responses with attention to how presence of multiple care partners and clinicians shapes empathic communication. METHODS We used the Empathic Communication Coding System (ECCS) to characterize emotion-focused, challenge-focused, and progress-focused empathic opportunities and responses in 71 audio-recorded palliative care encounters in the US. RESULTS Patients expressed more emotion-focused empathic opportunities than did care partners; care partners expressed more challenge-focused empathic opportunities than did patients. Care partners initiated empathic opportunities more frequently when more care partners were present, though they expressed fewer as the number of clinicians increased. When more care partners and more clinicians were present, clinicians had fewer low-empathy responses. CONCLUSION The number of care partners and clinicians present affect empathic communication. Clinicians should be prepared for empathic communication focal points to shift depending on the number of care partners and clinicians present. PRACTICE IMPLICATIONS Findings can guide development of resources to prepare clinicians to meet emotional needs in palliative care discussions. Interventions can coach clinicians to respond empathically and pragmatically to patients and care partners, particularly when multiple care partners are in attendance.
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Affiliation(s)
- Emily L Mroz
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, United States.
| | - Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, United States
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, United States
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, United States
| | - Carma L Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, United States
| | - Kathryn I Pollak
- Cancer Prevention and Control, Duke Cancer Institute, Duke University, United States; Department of Population Health Sciences, Duke University School of Medicine, United States
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Stout M, Thaper A, Xu V, Singer EA, Saraiya B. Early Integration of Palliative Care for Patients Receiving Systemic Immunotherapy for Renal Cell Carcinoma. JOURNAL OF CANCER IMMUNOLOGY 2023; 5:5-12. [PMID: 37292242 PMCID: PMC10249482 DOI: 10.33696/cancerimmunol.5.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Megan Stout
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, USA
| | | | - Vivien Xu
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, USA
| | - Eric A. Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, USA
| | - Biren Saraiya
- Rutgers Robert Wood Johnson Medical School, USA
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, USA
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Cheung KL, Smoger S, Tamura MK, Stapleton RD, Rabinowitz T, LaMantia MA, Gramling R. Content of Tele-Palliative Care Consultations with Patients Receiving Dialysis. J Palliat Med 2022; 25:1208-1214. [PMID: 35254866 PMCID: PMC9347393 DOI: 10.1089/jpm.2021.0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Little is known about the content of communication in palliative care telehealth conversations in the dialysis population. Understanding the content and process of these conversations may lead to insights about how palliative care improves quality of life. Methods: We conducted a qualitative analysis of video recordings obtained during a pilot palliative teleconsultation program. We recruited patients receiving dialysis from five facilities affiliated with an academic medical center. Palliative care clinicians conducted teleconsultation using a wall-mounted screen with a camera mounted on a pole and positioned mid-screen in the line of sight to facilitate direct eye contact. Patients used an iPad that was attached to an IV pole positioned next to the dialysis chair. Conversations were coded using a preexisting framework of themes and content from the Serious Illness Conversation Guide (SICG) and revised Edmonton Symptom Assessment System-Renal. Results: We recruited 39 patients to undergo a telepalliative care consultation while receiving dialysis, 34 of whom completed the teleconsultation. Specialty palliative care clinicians (3 physicians and 1 nurse practitioner) conducted 35 visits with 34 patients. Median (interquartile range) duration of conversation was 42 (28-57) minutes. Most frequently discussed content included sources of strength (91%), critical abilities (88%), illness understanding (85%), fears and worries (85%), what family knows (85%), fatigue (77%), and pain (65%). Process features such as summarizing statements (85%) and making a recommendation (82%) were common, whereas connectional silence (56%), and emotion expression (21%) occurred less often. Conclusions: Unscripted palliative care conversations in outpatient dialysis units through telemedicine exhibited many domains recommended by the SICG, with less frequent discussion of symptoms. Emotion expression was uncommon for these conversations that occurred in an open setting.
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Affiliation(s)
- Katharine L. Cheung
- Divisions of Nephrology, Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA.,Address correspondence to: Katharine L. Cheung, MD, PhD, Division of Nephrology, Department of Medicine, Larner College of Medicine at The University of Vermont, 1 South Prospect Street, 2309 UHC Med-Nephrology, Burlington, VT 05401, USA
| | - Samantha Smoger
- Department of Biology, The University of Vermont, Burlington, Vermont, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Geriatric Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Renee D. Stapleton
- Divisions of Pulmonary and Critical Care, and Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Terry Rabinowitz
- Department of Psychiatry, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Michael A. LaMantia
- Divisions of Geriatrics, Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
| | - Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont, USA
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Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. PATIENT EDUCATION AND COUNSELING 2022; 105:2671-2682. [PMID: 35459530 DOI: 10.1016/j.pec.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The present mixed-method systematic review identifies facilitators and barriers in palliative care communication among health professionals and older people. METHODS The review process was conducted by three reviewers who searched studies in four different databases (January 2009-January 2022), exploring experiences of communication among health professionals and older people without cognitive impairments. Relevant articles were quality assessed with a standardized tool. RESULTS Twenty-eight articles were included and the following 5 clusters were identified: 1) training and education for health professionals, 2) team working and coordination among health professionals, 3) communication skills, 4) time and availability, 5) emotional, cultural and psychological factors. The articles highlighted the need for greater preparation of health professionals around the management of palliative care communication with older people. CONCLUSION Palliative care communication among health professionals and older people are characterized by several challenges. However, there are facilitating aspects that may be considered to improve the quality of communication. PRACTICE IMPLICATIONS Facilitators are promising approaches to support health professionals in providing high-quality palliative care communication to older people, developing a person-centred practice. Facilitators include palliative care training and educational opportunities for health professionals, like ELNEC Geriatric Curriculum, permitting them to develop specific competences in communication and aging.
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Affiliation(s)
- Michela Saretta
- Polibienestar Research Institute, University of Valencia, Valencia, Spain.
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Tarbi EC, Blanch-Hartigan D, van Vliet LM, Gramling R, Tulsky JA, Sanders JJ. Toward a basic science of communication in serious illness. PATIENT EDUCATION AND COUNSELING 2022; 105:1963-1969. [PMID: 35410737 DOI: 10.1016/j.pec.2022.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.
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Affiliation(s)
- Elise C Tarbi
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA.
| | | | | | - Robert Gramling
- University of Vermont. Department of Family Medicine, Burlington, USA.
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, USA; Brigham and Women's Hospital, Division of Palliative Medicine, Department of Medicine, Boston, USA.
| | - Justin J Sanders
- McGill University, Division of Palliative Care, Department of Family Medicine, Montreal, Canada.
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Gramling CJ, Durieux BN, Clarfeld LA, Javed A, Matt JE, Manukyan V, Braddish T, Wong A, Wills J, Hirsch L, Straton J, Cheney N, Eppstein MJ, Rizzo DM, Gramling R. Epidemiology of Connectional Silence in specialist serious illness conversations. PATIENT EDUCATION AND COUNSELING 2022; 105:2005-2011. [PMID: 34799186 DOI: 10.1016/j.pec.2021.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Human connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes. PURPOSE To describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer. METHODS We audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation. RESULTS Among all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (ORadj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations. CONCLUSIONS Connectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships. PRACTICE IMPLICATIONS Pauses offer important opportunities to advance the science of human connection in serious illness decision-making.
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Affiliation(s)
| | | | | | - Ali Javed
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | - Jeremy E Matt
- Complex Systems & Data Science, University of Vermont, Burlington, VT, USA
| | | | - Tess Braddish
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Ann Wong
- University of Vermont, Burlington, VT, USA
| | | | | | | | - Nicholas Cheney
- Department of Computer Science, University of Vermont, Burlington, VT, USA
| | | | - Donna M Rizzo
- Department of Civil Engineering, University of Vermont, Burlington, VT, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
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Clarfeld LA, Gramling R, Rizzo DM, Eppstein MJ. A general model of conversational dynamics and an example application in serious illness communication. PLoS One 2021; 16:e0253124. [PMID: 34197490 PMCID: PMC8248661 DOI: 10.1371/journal.pone.0253124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 05/29/2021] [Indexed: 11/19/2022] Open
Abstract
Conversation has been a primary means for the exchange of information since ancient times. Understanding patterns of information flow in conversations is a critical step in assessing and improving communication quality. In this paper, we describe COnversational DYnamics Model (CODYM) analysis, a novel approach for studying patterns of information flow in conversations. CODYMs are Markov Models that capture sequential dependencies in the lengths of speaker turns. The proposed method is automated and scalable, and preserves the privacy of the conversational participants. The primary function of CODYM analysis is to quantify and visualize patterns of information flow, concisely summarized over sequential turns from one or more conversations. Our approach is general and complements existing methods, providing a new tool for use in the analysis of any type of conversation. As an important first application, we demonstrate the model on transcribed conversations between palliative care clinicians and seriously ill patients. These conversations are dynamic and complex, taking place amidst heavy emotions, and include difficult topics such as end-of-life preferences and patient values. We use CODYMs to identify normative patterns of information flow in serious illness conversations, show how these normative patterns change over the course of the conversations, and show how they differ in conversations where the patient does or doesn’t audibly express anger or fear. Potential applications of CODYMs range from assessment and training of effective healthcare communication to comparing conversational dynamics across languages, cultures, and contexts with the prospect of identifying universal similarities and unique “fingerprints” of information flow.
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Affiliation(s)
- Laurence A. Clarfeld
- Department of Computer Science, University of Vermont, Burlington, VT, United States of America
- * E-mail:
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, United States of America
| | - Donna M. Rizzo
- Department of Civil and Environmental Engineering, University of Vermont, Burlington, VT, United States of America
- Vermont Complex Systems Center, University of Vermont, Burlington, VT, United States of America
| | - Margaret J. Eppstein
- Department of Computer Science, University of Vermont, Burlington, VT, United States of America
- Vermont Complex Systems Center, University of Vermont, Burlington, VT, United States of America
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Gramling R, Straton J, Ingersoll LT, Clarfeld LA, Hirsch L, Gramling CJ, Durieux BN, Rizzo DM, Eppstein MJ, Alexander SC. Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations. J Pain Symptom Manage 2021; 61:246-253.e1. [PMID: 32822753 DOI: 10.1016/j.jpainsymman.2020.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development. OBJECTIVES To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice. METHODS We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation. RESULTS Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes. CONCLUSION Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.
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Affiliation(s)
- Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
| | | | - Lukas T Ingersoll
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | | | | | | | | | - Donna M Rizzo
- Department of Civil & Environmental Engineering, University of Vermont, Burlington, VT, USA
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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Ann Emerg Med 2020; 76:751-756. [PMID: 32747084 DOI: 10.1016/j.annemergmed.2020.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 11/21/2022]
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Ross L, Danforth CM, Eppstein MJ, Clarfeld LA, Durieux BN, Gramling CJ, Hirsch L, Rizzo DM, Gramling R. Story Arcs in Serious Illness: Natural Language Processing features of Palliative Care Conversations. PATIENT EDUCATION AND COUNSELING 2020; 103:826-832. [PMID: 31831305 DOI: 10.1016/j.pec.2019.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Serious illness conversations are complex clinical narratives that remain poorly understood. Natural Language Processing (NLP) offers new approaches for identifying hidden patterns within the lexicon of stories that may reveal insights about the taxonomy of serious illness conversations. METHODS We analyzed verbatim transcripts from 354 consultations involving 231 patients and 45 palliative care clinicians from the Palliative Care Communication Research Initiative. We stratified each conversation into deciles of "narrative time" based on word counts. We used standard NLP analyses to examine the frequency and distribution of words and phrases indicating temporal reference, illness terminology, sentiment and modal verbs (indicating possibility/desirability). RESULTS Temporal references shifted steadily from talking about the past to talking about the future over deciles of narrative time. Conversations progressed incrementally from "sadder" to "happier" lexicon; reduction in illness terminology accounted substantially for this pattern. We observed the following sequence in peak frequency over narrative time: symptom terms, treatment terms, prognosis terms and modal verbs indicating possibility. CONCLUSIONS NLP methods can identify narrative arcs in serious illness conversations. PRACTICE IMPLICATIONS Fully automating NLP methods will allow for efficient, large scale and real time measurement of serious illness conversations for research, education and system re-design.
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Affiliation(s)
| | | | | | | | | | | | | | - Donna M Rizzo
- Department of Civil Engineering, University of Vermont, Burlington, VT, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, VT, USA.
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13
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Ingersoll LT, Alexander SC, Priest J, Ladwig S, Anderson W, Fiscella K, Epstein RM, Norton SA, Gramling R. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:1098-1103. [PMID: 30642715 DOI: 10.1016/j.pec.2019.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication. METHODS We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity. RESULTS In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others. CONCLUSION Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity. PRACTICE IMPLICATIONS Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America.
| | - Stewart C Alexander
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Jeff Priest
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Susan Ladwig
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Wendy Anderson
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Kevin Fiscella
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Ronald M Epstein
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Sally A Norton
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Robert Gramling
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
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Durieux BN, Gramling CJ, Manukyan V, Eppstein MJ, Rizzo DM, Ross LM, Ryan AG, Niland MA, Clarfeld LA, Alexander SC, Gramling R. Identifying Connectional Silence in Palliative Care Consultations: A Tandem Machine-Learning and Human Coding Method. J Palliat Med 2018; 21:1755-1760. [PMID: 30328760 DOI: 10.1089/jpm.2018.0270] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Systematic measurement of conversational features in the natural clinical setting is essential to better understand, disseminate, and incentivize high quality serious illness communication. Advances in machine-learning (ML) classification of human speech offer exceptional opportunity to complement human coding (HC) methods for measurement in large scale studies. Objectives: To test the reliability, efficiency, and sensitivity of a tandem ML-HC method for identifying one feature of clinical importance in serious illness conversations: Connectional Silence. Design: This was a cross-sectional analysis of 354 audio-recorded inpatient palliative care consultations from the Palliative Care Communication Research Initiative multisite cohort study. Setting/Subjects: Hospitalized people with advanced cancer. Measurements: We created 1000 brief audio "clips" of randomly selected moments predicted by a screening ML algorithm to be two-second or longer pauses in conversation. Each clip included 10 seconds of speaking before and 5 seconds after each pause. Two HCs independently evaluated each clip for Connectional Silence as operationalized from conceptual taxonomies of silence in serious illness conversations. HCs also evaluated 100 minutes from 10 additional conversations having unique speakers to identify how frequently the ML screening algorithm missed episodes of Connectional Silence. Results: Connectional Silences were rare (5.5%) among all two-second or longer pauses in palliative care conversations. Tandem ML-HC demonstrated strong reliability (kappa 0.62; 95% confidence interval: 0.47-0.76). HC alone required 61% more time than the Tandem ML-HC method. No Connectional Silences were missed by the ML screening algorithm. Conclusions: Tandem ML-HC methods are reliable, efficient, and sensitive for identifying Connectional Silence in serious illness conversations.
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Affiliation(s)
| | - Cailin J Gramling
- School of Arts and Sciences, University of Vermont, Burlington, Vermont
| | | | | | - Donna M Rizzo
- Department of Civil and Environmental Engineering, University of Vermont, Burlington, Vermont
| | - Lindsay M Ross
- School of Engineering, University of Vermont, Burlington, Vermont
| | - Aidan G Ryan
- School of Engineering, University of Vermont, Burlington, Vermont
| | | | | | - Stewart C Alexander
- Department of Consumer Science and Public Health, Purdue University, West Lafayette, Indiana
| | - Robert Gramling
- Department of Family Medicine, University of Vermont, Burlington, Vermont
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15
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Gramling R, Stanek S, Han PK, Duberstein P, Quill TE, Temel JS, Alexander SC, Anderson WG, Ladwig S, Norton SA. Distress Due to Prognostic Uncertainty in Palliative Care: Frequency, Distribution, and Outcomes among Hospitalized Patients with Advanced Cancer. J Palliat Med 2018; 21:315-321. [DOI: 10.1089/jpm.2017.0285] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Susan Stanek
- School of Nursing, University of Rochester, Rochester, New York
| | - Paul K.J. Han
- Maine Medical Center Research Institute, Scarborough, Maine
| | - Paul Duberstein
- Department of Psychiatry, University of Rochester, Rochester, New York
| | - Tim E. Quill
- School of Nursing, University of Rochester, Rochester, New York
| | - Jennifer S. Temel
- Department of Medicine, Harvard University, Cambridge, Massachusetts
| | - Stewart C. Alexander
- Department of Consumer Science, Department of Medicine, Purdue University, West Lafayette, Indiana
| | | | - Susan Ladwig
- Division of Palliative Care, University of Rochester, Rochester, New York
| | - Sally A. Norton
- School of Nursing, University of Rochester, Rochester, New York
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16
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Kozlowski D, Hutchinson M, Hurley J, Rowley J, Sutherland J. The role of emotion in clinical decision making: an integrative literature review. BMC MEDICAL EDUCATION 2017; 17:255. [PMID: 29246213 PMCID: PMC5732402 DOI: 10.1186/s12909-017-1089-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/29/2017] [Indexed: 05/18/2023]
Abstract
BACKGROUND Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. METHODS A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. RESULTS Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. CONCLUSIONS Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.
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Affiliation(s)
- Desirée Kozlowski
- Discipline of Psychology, School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Marie Hutchinson
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - John Hurley
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Joanne Rowley
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Joanna Sutherland
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
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17
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Sinclair S, Norris JM, McConnell SJ, Chochinov HM, Hack TF, Hagen NA, McClement S, Bouchal SR. Compassion: a scoping review of the healthcare literature. BMC Palliat Care 2016; 15:6. [PMID: 26786417 PMCID: PMC4717626 DOI: 10.1186/s12904-016-0080-0] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/10/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Recent concerns about suboptimal patient care and a lack of compassion have prompted policymakers to question the preparedness of clinicians for the challenging environment in which they practice. Compassionate care is expected by patients and is a professional obligation of clinicians; however, little is known about the state of research on clinical compassion. The purpose of this scoping review was to map the literature on compassion in clinical healthcare. METHODS Searches of eight electronic databases and the grey literature were conducted to identify empirical studies published over the last 25 years. Eligible studies explored perceptions or interventions of compassionate care in clinical populations, healthcare professionals, and healthcare students. Following the title and abstract review, two reviewers independently screened full-texts articles, and extracted study data. A narrative approach to synthesizing and mapping the literature was used. RESULTS AND DISCUSSION Of 36,637 records, 648 studies were retrieved and 44 studies were included in the review. Less than one third of studies included patients. Six themes emerged from studies that explored perceptions of compassionate care: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Intervention studies included two compassionate care trials with patients and eight educational programs that aimed to improve compassionate care in clinicians and students. CONCLUSIONS This review identifies the limited empirical understanding of compassion in healthcare, highlighting the lack of patient and family voices in compassion research. A deeper understanding of the key behaviors and attitudes that lead to improved patient-reported outcomes through compassionate care is necessary.
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Affiliation(s)
- Shane Sinclair
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada. .,Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada. .,Manitoba Palliative Care Research Unit, CancerCare Manitoba, 3017 - 675 McDermot, Winnipeg, MB, R3E 0V9, Canada.
| | - Jill M Norris
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
| | - Shelagh J McConnell
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
| | - Harvey Max Chochinov
- Department of Psychiatry, University of Manitoba, 771 Bannatyne Avenue, Winnipeg, MB, R3E 3N4, Canada. .,Manitoba Palliative Care Research Unit, CancerCare Manitoba, 3017 - 675 McDermot, Winnipeg, MB, R3E 0V9, Canada.
| | - Thomas F Hack
- College of Nursing, Faculty of Health Sciences, University of Manitoba, Room CR3018, 369 Taché Ave, Winnipeg, MB, R2H 2A6, Canada. .,Manitoba Palliative Care Research Unit, CancerCare Manitoba, 3017 - 675 McDermot, Winnipeg, MB, R3E 0V9, Canada.
| | - Neil A Hagen
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
| | - Susan McClement
- College of Nursing, Faculty of Health Sciences, University of Manitoba, Room CR3018, 369 Taché Ave, Winnipeg, MB, R2H 2A6, Canada. .,Manitoba Palliative Care Research Unit, CancerCare Manitoba, 3017 - 675 McDermot, Winnipeg, MB, R3E 0V9, Canada.
| | - Shelley Raffin Bouchal
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
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18
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Gramling R, Sanders M, Ladwig S, Norton SA, Epstein R, Alexander SC. Goal Communication in Palliative Care Decision-Making Consultations. J Pain Symptom Manage 2015; 50:701-6. [PMID: 26025274 DOI: 10.1016/j.jpainsymman.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/09/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT Palliative care (PC) 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 PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC. OBJECTIVES To describe the frequency, types, and determinants of goal expression in PC consultations. METHODS This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC 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. RESULTS Goal expressions occurred frequently in PC 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. CONCLUSION Goal communication is common in PC decision-making settings and strongly influenced by existential suffering.
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Affiliation(s)
| | | | - Susan Ladwig
- University of Rochester, Rochester, New York, USA
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19
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Alexander SC, Garner DK, Somoroff M, Gramling DJ, Norton SA, Gramling R. Using music[al] knowledge to represent expressions of emotions. PATIENT EDUCATION AND COUNSELING 2015; 98:1339-1345. [PMID: 26160038 DOI: 10.1016/j.pec.2015.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE 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). METHODS 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. RESULTS 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. CONCLUSIONS 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. PRACTICE IMPLICATIONS 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.
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Affiliation(s)
- Stewart C Alexander
- Department of Consumer Science, Purdue University, West Lafayette, IN, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA; Health Services Research and Development Service, Durham VA Medical Center, Durham, NC, USA.
| | | | | | | | - Sally A Norton
- School of Nursing, University of Rochester, USA; Department of Family Medicine, University of Rochester, USA
| | - Robert Gramling
- School of Nursing, University of Rochester, USA; Department of Family Medicine, University of Rochester, USA
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20
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Gramling R, Gajary-Coots E, Stanek S, Dougoud N, Pyke H, Thomas M, Cimino J, Sanders M, Alexander SC, Epstein R, Fiscella K, Gramling D, Ladwig S, Anderson W, Pantilat S, Norton SA. Design of, and enrollment in, the palliative care communication research initiative: a direct-observation cohort study. BMC Palliat Care 2015; 14:40. [PMID: 26286538 PMCID: PMC4544824 DOI: 10.1186/s12904-015-0037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND 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). METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Robert Gramling
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Elizabeth Gajary-Coots
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Susan Stanek
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Nathalie Dougoud
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Heather Pyke
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Marie Thomas
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Jenica Cimino
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Mechelle Sanders
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Stewart C Alexander
- Purdue University, Matthews Hall, 812 West State Street, West Lafayette, IN, 47907-2060, USA.
| | - Ronald Epstein
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Kevin Fiscella
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - David Gramling
- University of Arizona, 301 Learning Services Building, 1512 East First St., Tucson, AZ, 85721, USA.
| | - Susan Ladwig
- Palliative Care Program, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY, 14642, USA.
| | - Wendy Anderson
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Stephen Pantilat
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Sally A Norton
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
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21
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Lokko HN, Stern TA. Sadness: diagnosis, evaluation, and treatment. Prim Care Companion CNS Disord 2014; 16:14f01709. [PMID: 25834755 DOI: 10.4088/pcc.14f01709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022] Open
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