Robert M Arnold

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (425)2076.55 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making. We sought to measure decisional conflict in surrogates of critically ill patients and examine whether prior advance care planning is associated with less decisional conflict. We performed a secondary data analysis of a multicenter, prospective cohort study from five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured by the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had any prior advance care planning conversations with their loved one. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning. Moderate or high levels of decisional conflict (score ≥ 25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict compared to those who had not (scored a mean of 3.3 points lower (95% CI: -6.4 to -0.2) on the decisional conflict scale; p=0.03). Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorate the burden placed on patients' loved ones who act as surrogates.
    08/2015; DOI:10.1513/AnnalsATS.201504-253OC
  • Daniel E Hall · Barbara H Hanusa · Michael J Fine · Robert M Arnold
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    ABSTRACT: Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms.
    Journal of Surgical Research 03/2015; 197(1). DOI:10.1016/j.jss.2015.03.058 · 2.12 Impact Factor
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    Jared Chiarchiaro · Robert M Arnold · Douglas B White
    JAMA The Journal of the American Medical Association 03/2015; 313(11):1103-1104. DOI:10.1001/jama.2015.0569 · 30.39 Impact Factor
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    ABSTRACT: Although misperceptions about prognosis by surrogates in ICUs are common and influence treatment decisions, there is no validated, practical way to measure the effectiveness of prognostic communication. Surrogates' subjective ratings of quality of communication have been used in other domains as markers of effectiveness of communication. We sought to determine whether surrogates' subjective ratings of the quality of prognostic communication predict accurate expectation about prognosis by surrogates. We performed a cross-sectional cohort study. Surrogates rated the quality of prognostic communication by survey. Physicians and surrogates gave their percentage estimate of patient survival on ICU day 3 on a 0-100 probability scale. We defined discordance about prognosis as a difference in the physician's and surrogate's estimates of greater than or equal to ±20%. We used multilevel logistic regression modeling to account for clustering under physicians and patients and adjust for confounders. Medical-surgical, trauma, cardiac, and neurologic ICUs of five U.S. academic medical centers located in California, Pennsylvania, Washington, North Carolina, and Massachusetts. Two hundred seventy-five patients with acute respiratory distress syndrome at high risk of death or severe functional impairment, their 546 surrogate decision makers, and their 150 physicians. None. There was no predictive utility of surrogates' ratings of the quality of communication about prognosis to identify inaccurate expectations about prognosis (odds ratio, 1.04 ± 0.07; p = 0.54). Surrogates' subjective ratings of the quality of communication about prognosis were high, as assessed with a variety of questions. Discordant prognostic estimates were present in 63.5% (95% CI, 59.0-67.9) of physician-surrogate pairs. Although most surrogates rate the quality of prognostic communication high, inaccurate expectations about prognosis are common among surrogates. Surrogates' ratings of the quality of prognostic communication do not reliably predict an accurate expectation about prognosis.
    Critical Care Medicine 03/2015; 43(3):542-548. DOI:10.1097/CCM.0000000000000719 · 6.15 Impact Factor
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    ABSTRACT: Patients often struggle to express their emotional concerns to their oncology providers and may therefore experience unmet needs. This paper describes the development and implementation of an online program that teaches patients how to communicate their emotions to their oncology providers. The intervention was developed by a multidisciplinary team consisting of palliative care physicians, psychologists, and an intervention software developer and included input from patients. It incorporated elements of Social Cognitive Theory and validated cognitive behavioral strategies for communication skills training. Strategies to increase intervention adherence were implemented midway through the study. The intervention consists of four interactive, online modules to teach patients strategies for expressing emotional concerns to their providers and asking for support. In addition to skill-building, the intervention was designed to raise patients' expectations that expressing emotional concerns to providers would be helpful, to enhance their self-efficacy for doing so, and to help them overcome barriers to having these conversations. After implementing strategies to improve adherence, usage rates increased from 47 to 64 %. This intervention addresses an unmet educational need for patients with advanced cancer. Strategies to increase adherence led to improvements in usage rates in this population of older patients. We are currently evaluating the intervention in a randomized clinical trial to determine its efficacy in increasing patient expression of emotional concerns and requests for support. If successful, this intervention could serve as a model for future online patient education programs.
    Supportive Care Cancer 02/2015; DOI:10.1007/s00520-015-2656-2 · 2.50 Impact Factor
  • 02/2015; 12(4). DOI:10.1513/AnnalsATS.201411-495OC
  • Journal of Pain and Symptom Management 02/2015; 49(2):384-385. DOI:10.1016/j.jpainsymman.2014.11.138 · 2.74 Impact Factor
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    ABSTRACT: Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood. This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences. Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care. Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists. Copyright © 2015 by American Society of Clinical Oncology.
    Journal of Pain and Symptom Management 02/2015; 49(2):393-394. DOI:10.1016/j.jpainsymman.2014.11.157 · 2.74 Impact Factor
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    ABSTRACT: Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values. Prospective, cross-sectional study. Five ICUs of two hospitals. Fifty-four physicians and 159 surrogates for 71 patients. We audio-recorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient's preferences or values. In 30% of conferences, there was no discussion about the patient's previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences, there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD, 4.3; range, 0-16%) of words spoken pertained to patient preferences or values. In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
    Critical Care Medicine 01/2015; 43(4). DOI:10.1097/CCM.0000000000000772 · 6.15 Impact Factor
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    ABSTRACT: Abstract Background: Specialty palliative care is not accessible for many patients with advanced cancer. There is a need to find alternative palliative care strategies in oncology clinics. Objective: The objective of the study was to assess the feasibility, acceptability, and perceived effectiveness of an oncology nurse-led care management approach to improve primary palliative care. Methods: The study design was a single-arm pilot trial of the Care Management by Oncology Nurses (CONNECT) intervention, in which registered oncology nurses receive specialized training and work closely with oncologists to (1) address symptom needs; (2) engage patients and caregivers in advance care planning; (3) provide emotional support; and (4) coordinate care. The subjects were 23 patients with advanced cancer, 19 caregivers, and 5 oncologists from a community oncology clinic in western Pennsylvania. Feasibility was assessed through enrollment rates, outcome assessment rates, and visit checklists. Patients, caregivers, and oncologists completed three-month assessments of acceptability and perceived effectiveness. Results: The consent-to-approach rate was 86% and enrolled-to-consent rate, 77%. CONNECT was implemented according to protocol for all participants. No participants withdrew after enrollment. Four patients died during the study; three-month outcome assessments were completed with all remaining participants (83%). Patients and caregivers reported high satisfaction with CONNECT and perceived the intervention as helpful in addressing symptoms (85%), coping (91%), and planning for the future (82%). Oncologists unanimously agreed that CONNECT improved the quality of care provided for patients with advanced cancer. Conclusion: An oncology nurse-led care management intervention is feasible, acceptable, and was perceived to be effective for improving provision of primary palliative care. A randomized trial of CONNECT is warranted.
    Journal of Palliative Medicine 12/2014; 49(2). DOI:10.1089/jpm.2014.0325 · 2.06 Impact Factor
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    ABSTRACT: Despite growing concern that institutional review boards (IRBs) impose burdensome delays on research, little is known about the time required for IRB review across different types of research. To measure the overall and incremental process times for IRB review as a process of quality improvement. After developing a detailed process flowchart of the IRB review process, 2 analysts abstracted temporal data from the records pertaining to all 103 protocols newly submitted to the IRB at a large urban Veterans Affairs medical center from June 1, 2009, through May 31, 2011. Disagreements were reviewed with the principal investigator to reach consensus. We then compared the review times across review types using analysis of variance and post hoc Scheffé tests after achieving normally distributed data through logarithmic transformation. Calendar days from initial submission to final approval of research protocols. Initial IRB review took 2 to 4 months, with expedited and exempt reviews requiring less time (median [range], 85 [23-631] and 82 [16-437] days, respectively) than full board reviews (median [range], 131 [64-296] days; P = .008). The median time required for credentialing of investigators was 1 day (range, 0-74 days), and review by the research and development committee took a median of 15 days (range, 0-184 days). There were no significant differences in credentialing or research and development times across review types (exempt, expedited, or full board). Of the extreme delays in IRB review, 80.0% were due to investigators' slow responses to requested changes. There were no systematic delays attributable to the information security officer, privacy officer, or IRB chair. Measuring and analyzing review times is a critical first step in establishing a culture and process of continuous quality improvement among IRBs that govern research programs. The review times observed at this IRB are substantially longer than the 60-day target recommended by expert panels. The method described here could be applied to other IRBs to begin identifying and improving inefficiencies.
    12/2014; 150(2). DOI:10.1001/jamasurg.2014.956
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    ABSTRACT: The aim of this study was to develop an evidence-based communication skills training workshop to improve the communication skills of critical care fellows. Pulmonary and critical care fellows (N = 38) participated in a 3-day communication skills workshop between 2008 and 2010 involving brief didactic talks, faculty demonstration of skills, and faculty-supervised small group skills practice sessions with simulated families. Skills included the following: giving bad news, achieving consensus on goals of therapy, and discussing the limitations of life-sustaining treatment. Participants rated their skill levels in a pre-post survey in 11 core communication tasks using a 5-point Likert scale. Of 38 fellows, 36 (95%) completed all 3 days of the workshop. We compared pre and post scores using the Wilcoxon signed rank test. Overall, self-rated skills increased for all 11 tasks. In analyses by participant, 95% reported improvement in at least 1 skill; with improvement in a median of 10 of 11 skills. Ninety-two percent rated the course as either very good/excellent, and 80% recommended that it be mandatory for future fellows. This 3-day communication skills training program increased critical care fellows' self-reported family meeting communication skills. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Critical Care 12/2014; 30(2). DOI:10.1016/j.jcrc.2014.11.016 · 2.19 Impact Factor
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    ABSTRACT: Depressive symptoms and pain are common in patients on chronic hemodialysis (HD), yet their associations with quality of life (QOL) are not fully understood. We sought to characterize the longitudinal associations of these symptoms with QOL. As part of a trial comparing two symptom management strategies in patients receiving chronic HD, we assessed depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9), and pain using the Short Form McGill Pain Questionnaire (SF-MPQ) monthly over 24 months. We assessed health-related QOL (HR-QOL) quarterly using the Short Form 12 (SF-12) and global QOL (G-QOL) using a single-item survey. We used random effects linear regression to analyze the independent associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with HR-QOL and G-QOL. Overall, 286 patients completed 1417 PHQ-9 and SF-MPQ symptom assessments, 1361 SF-12 assessments, and 1416 G-QOL assessments. Depressive symptoms were independently and inversely associated with SF-12 physical HR-QOL scores (β = −1.09; 95% confidence interval [CI]: −1.69, −0.50, P < 0.001); SF-12 mental HR-QOL scores (β = −4.52; 95% CI: −5.15, −3.89, P < 0.001); and G-QOL scores (β = −0.64; 95%CI: −0.79, −0.49, P < 0.001). Pain was independently and inversely associated with SF-12 physical HR-QOL scores (β = −0.99; 95% CI: −1.30, −0.68, P < 0.001) and G-QOL scores (β = −0.12; 95%CI: −0.20, −0.05, P = 0.002); but not with SF-12 mental HR-QOL scores (β = −0.16; 95%CI: −0.050, 0.17, P = 0.34). In patients receiving chronic HD, depressive symptoms and to a lesser extent pain, are independently associated with reduced HR-QOL and G-QOL. Interventions to alleviate these symptoms could potentially improve patients' HR-QOL and G-QOL.
    Hemodialysis International 12/2014; 19(2). DOI:10.1111/hdi.12247 · 1.36 Impact Factor
  • Journal of Palliative Medicine 09/2014; 17(10). DOI:10.1089/jpm.2014.0268 · 2.06 Impact Factor
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    ABSTRACT: Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality.
    Clinical Journal of the American Society of Nephrology 07/2014; 9(9). DOI:10.2215/CJN.00220114 · 5.25 Impact Factor
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    ABSTRACT: Rationale, aims and objectivesMEDLINE offers the Core Clinical Journals filter to limit to clinically useful journals. To determine its effectiveness for searching and patient-centric decision making, this study compared literature used for Morning Report in Internal Medicine with journals in the filter.Method An EndNote library with references answering 327 patient-related questions during Morning Report from 2007 to 2012 was exported to a file listing variables including designated Core Clinical Journal, Impact Factor, date used and medical subject. Bradford's law of scattering was applied ranking the journals and reflecting their clinical utility. Recall (sensitivity) and precision of the Core Morning Report journals and non-Core set was calculated. This study applied bibliometrics to compare the 628 articles used against these criteria to determine journals impacting decision making.ResultsAnalysis shows 30% of clinically used articles are from the Core Clinical Journals filter and 16% of the journals represented are Core titles. When Bradford-ranked, 55% of the top 20 journals are Core. Articles <5 years old furnish 63% of sources used. Among the 63 Morning Report subjects, 55 have <50% precision and 41 have <50% recall including 37 subjects with 0% precision and 0% recall.Conclusions Low usage of publications within the Core Clinical Journals filter indicates less relevance for hospital-based care. The divergence from high-impact medicine titles suggests clinically valuable journals differ from academically important titles. With few subjects demonstrating high recall or precision, the MEDLINE Core Clinical Journals filter may require a review and update to better align with current clinical needs.
    Journal of Evaluation in Clinical Practice 06/2014; 20(6). DOI:10.1111/jep.12190 · 1.58 Impact Factor
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    ABSTRACT: Objectives. We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. Methods. The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). Results. For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI −0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58–68%) and NPV (63–76%) was moderately dissimilar between clinicians, while sensitivity (25–80%), specificity (43–97%), and PPV (48–83%) varied. Conclusions. We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.
    Prehospital Emergency Care 05/2014; 18(4). DOI:10.3109/10903127.2014.916022 · 1.81 Impact Factor
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    ABSTRACT: Although critics have expressed concerns about cancer center advertising, analyses of the content of these advertisements are lacking.
    Annals of internal medicine 05/2014; DOI:10.7326/M14-0500 · 16.10 Impact Factor
  • Yael Schenker · Douglas B White · Robert M Arnold
    JAMA Internal Medicine 05/2014; 174(7). DOI:10.1001/jamainternmed.2014.1887 · 13.25 Impact Factor
  • Julie W Childers · Linda A King · Robert M Arnold
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    ABSTRACT: Objectives:To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0-Short Form [SOAPP-SF] scores), and urine drug screens. Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results.Conclusion:Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues.
    The American journal of hospice & palliative care 04/2014; 32(6). DOI:10.1177/1049909114531445 · 1.35 Impact Factor

Publication Stats

8k Citations
2,076.55 Total Impact Points


  • 2005–2015
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
    • Albert Einstein College of Medicine
      • Geriatrics
      New York City, NY, United States
    • University of Virginia
      • Division of Maternal Fetal Medicine
      Charlottesville, Virginia, United States
    • Fred Hutchinson Cancer Research Center
      Seattle, Washington, United States
    • National Cancer Institute (USA)
      • Division of Cancer Prevention
      Bethesda, MD, United States
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, IL, United States
    • Brigham and Women's Hospital
      • Department of Psychiatry
      Boston, Massachusetts, United States
  • 1989–2015
    • University of Pittsburgh
      • • Division of General Internal Medicine
      • • Department of Medicine
      • • Center for Research on Health Care
      • • Section of Palliative Care and Medical Ethics
      • • Institute for Doctor-Patient Communication
      Pittsburgh, Pennsylvania, United States
  • 2002–2014
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
    • New York Medical College
      New York City, New York, United States
  • 2012–2013
    • UPMC
      Pittsburgh, Pennsylvania, United States
  • 2005–2013
    • University of Washington Seattle
      • Department of Medicine
      Seattle, Washington, United States
  • 2008–2012
    • Johns Hopkins University
      • Department of Pediatrics
      Baltimore, MD, United States
    • The Children's Hospital of Philadelphia
      Filadelfia, Pennsylvania, United States
    • University of Rochester
      • Center for Ethics, Humanities, and Palliative Care
      Rochester, NY, United States
    • Medical College of Wisconsin
      • Palliative Care Center
      Milwaukee, WI, United States
  • 2002–2011
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2010
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
    • The Harvard Drug Group
      Ливония, Michigan, United States
  • 2009
    • University of Pennsylvania
      • Center for Health Equity Research
      Philadelphia, PA, United States
  • 2007
    • University of California, Irvine
      Irvine, California, United States
    • Harvard Medical School
      Boston, Massachusetts, United States
    • George Washington University
      Washington, Washington, D.C., United States
  • 2004–2007
    • Dana-Farber Cancer Institute
      • Department of Psychosocial Oncology and Palliative Care
      Boston, MA, United States
    • Duke University Medical Center
      • Department of Medicine
      Durham, North Carolina, United States
    • University of Toronto
      Toronto, Ontario, Canada
    • Hospital of the University of Pennsylvania
      • Department of Medicine
      Filadelfia, Pennsylvania, United States
  • 2006
    • National Institutes of Health
      • Division of Cancer Prevention
      Bethesda, MD, United States
  • 1993–2003
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2000
    • Pennsylvania State University
      • Department of Humanities
      State College, PA, United States
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
  • 1995
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States