Robert M Arnold

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (467)2327.04 Total impact

  • Sonia Malhotra · Robert Arnold

    No preview · Article · Feb 2016

  • No preview · Article · Feb 2016
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    ABSTRACT: The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.
    No preview · Article · Jan 2016 · Supportive and Palliative Care
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    ABSTRACT: Objectives: Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists. Design: Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists' and intensivists' use of task-focused communication and relationship building. Setting: Single academic medical center ICU. Subjects: Palliative care specialists and intensivists. Interventions: None. Measurements and main results: We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians' mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36-0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89-2.46; p = 0.13) compared with intensivists. Conclusions: We found that palliative care specialists engage in less task-focused communication when managing conflict with surrogates compared with intensivists. These differences may help explain the benefit of palliative care involvement in conflict and could be the focus of interventions to improve clinicians' conflict resolution skills.
    No preview · Article · Jan 2016 · Critical care medicine
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    ABSTRACT: Objectives: Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences. Design: We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication. Setting: An urban academic children's medical center with a 45-bed level IV neonatal ICU. Subjects: Neonatal ICU parents and clinicians. Interventions: None. Measurements and Main Results: We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue. Conclusions: We collected a novel repository of audiorecorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
    Full-text · Article · Dec 2015 · Pediatric Critical Care Medicine
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    ABSTRACT: Purpose . To assess use, screening, and disclosure of perinatal marijuana and other illicit drugs during first obstetric visits. Design . Observational study that qualitatively assesses provider screening and patient disclosure of substance use. Setting . Study sites were five urban outpatient prenatal clinics and practices located in Pittsburgh, Pennsylvania. Participants . Pregnant patients and obstetric providers were recruited as participants. Methods . We audio recorded patient-provider conversations during first obstetric visits and obtained patient urine samples for drug analyses. Audio recordings were reviewed for provider screening and patient disclosure of illicit drug use. Urine analyses were compared with audio recordings to determine disclosure. Results . Four hundred and twenty-two pregnant patients provided complete audio recordings and urine samples for analyses. Providers asked about illicit drug use in 81% of the visits. One hundred twenty-three patients (29%) disclosed any current or past illicit drug use; 48 patients (11%) disclosed current use of marijuana while pregnant. One hundred and forty-five samples (34%) tested positive for one or more substances; marijuana was most commonly detected (N = 114, 27%). Of patients who tested positive for any substance, 66 (46%) did not disclose any use; only 36% of patients who tested positive for marijuana disclosed current use. Conclusion . Although marijuana is illegal in Pennsylvania, a high proportion of pregnant patients used marijuana, with many not disclosing use to their obstetric care providers.
    Full-text · Article · Nov 2015 · American journal of health promotion: AJHP
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    ABSTRACT: Institutional Review Boards (IRBs) are intended to protect those who participate in research. However, because there is no established measure of IRB quality, it is unclear whether these committees achieve their goal. The IRB Researcher Assessment Tool is a previously validated, internally normed, proxy measure of IRB quality that assesses 45 distinct IRB activities and functions. We administered this instrument to a sample of investigators and IRB members at a large urban VA Medical Center. We describe a systematic approach to analyze and interpret survey responses that can identify the IRB activities and functions most in need of quality improvement. The proposed approach to empirical data analysis and presentation could inform local initiatives to improve the quality of IRB review.
    No preview · Article · Nov 2015 · Journal of Empirical Research on Human Research Ethics

  • No preview · Article · Oct 2015 · Cancer

  • No preview · Article · Oct 2015 · American Journal of Respiratory and Critical Care Medicine

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Purpose: There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease. Materials and methods: We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking. Results: Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users. Conclusions: There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.
    No preview · Article · Sep 2015 · Journal of critical care
  • Yael Schenker · Robert Arnold

    No preview · Article · Sep 2015 · JAMA The Journal of the American Medical Association
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    ABSTRACT: This article aims to discuss the rapidly growing field of palliative medicine and its unique approach to treating depression in older adults.
    No preview · Article · Sep 2015 · Harvard Review of Psychiatry
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    ABSTRACT: Participating in a decision to limit life support for a loved one in the ICU is associated with adverse mental health consequences for surrogate decision makers. We sought to describe acutely bereaved surrogates' experiences surrounding this decision. Qualitative analysis of interviews with surrogates approximately 4 weeks after a patient's death in one of six ICUs at four hospitals in Pittsburgh, PA. Adults who participated in decisions about life support in the ICU. Not applicable. We collected participant demographics, previous advance care planning, and decision control preferences. We used qualitative content analysis of transcribed interviews to identify themes in surrogates' experiences. The 23 participants included the spouse (n = 7), child/stepchild (7), sibling (5), parent (3), or other relation (1) of the deceased patient. Their mean age was 55, 61% were women, all were whites, 74% had previous treatment preference discussions with the patient, and 43% of patients had written advance directives. Fifteen of 23 surrogates (65%) preferred an active decision-making role, 8 of 23 (35%) preferred to share responsibility with the physician, and no surrogates preferred a passive role. Surrogates report that key stressors in the ICU are the uncertainty and witnessed or empathic suffering. These factors contributed to surrogates' sense of helplessness in the ICU. Involvement in the decision to limit life support allowed surrogates to regain a sense of agency by making a decision consistent with the patient's wishes and values, counteracting surrogates' helplessness and ending the uncertainty and suffering. In this all-white sample of surrogates with nonpassive decision control preferences from a single US region, participating in decision making allowed surrogates to regain control, counteract feelings of helplessness, and end their empathic suffering. Although previous research highlighted the distress caused by participation in a decision to limit life support, the act of decision making may, counterintuitively, help some surrogates cope with the experience.
    No preview · Article · Aug 2015 · Critical care medicine
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    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.
    No preview · Article · Aug 2015 · Annals of the American Thoracic Society
  • Jennifer Pruskowski · Robert M Arnold
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    ABSTRACT: Tramadol has an important position as a Step II agent on the WHO pain ladder, where it is effective for a variety of syndromes in patients with mild to moderate pain intensity. Its recommended dosing adjustments, potential ceiling effect, cost, pertinent drug interactions, and risk for significant adverse drug reactions may limit its chronic use in patients with significant pain.
    No preview · Article · May 2015 · Journal of palliative medicine
  • Daniel E Hall · Barbara H Hanusa · Michael J Fine · Robert M Arnold
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    ABSTRACT: Background: 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. Methods: We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. Results: Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. Conclusions: The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need.
    No preview · Article · Mar 2015 · Journal of Surgical Research
  • Jared Chiarchiaro · Robert M Arnold · Douglas B White

    No preview · Article · Mar 2015 · JAMA The Journal of the American Medical Association
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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.
    No preview · Article · Mar 2015 · Critical Care Medicine
  • Jennifer Pruskowski · Robert M Arnold
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    ABSTRACT: Pregabalin has some pharmacokinetic advantages over gabapentin, but is much more costly. There are no clear data demonstrating improved clinical outcomes of one agent over the other.
    No preview · Article · Feb 2015 · Journal of Palliative Medicine

Publication Stats

10k Citations
2,327.04 Total Impact Points

Institutions

  • 1989-2016
    • University of Pittsburgh
      • • Division of General Internal Medicine
      • • Department of Medicine
      • • Center for Research on Health Care
      • • Institute for Doctor-Patient Communication
      • • Section of Palliative Care and Medical Ethics
      • • Department of Pediatrics
      Pittsburgh, Pennsylvania, United States
  • 2005-2015
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
    • Brigham and Women's Hospital
      • Department of Psychiatry
      Boston, Massachusetts, United States
    • University of Washington Seattle
      • Department of Medicine
      Seattle, WA, United States
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, Illinois, United States
    • American Association of Hospice and Palliative Medicine
      Американ Форк, Utah, United States
  • 2013
    • UPMC
      Pittsburgh, Pennsylvania, United States
  • 2002-2012
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
  • 2002-2011
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2010
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
    • The Harvard Drug Group
      Ливония, Michigan, United States
  • 2009
    • University of Pennsylvania
      • Center for Health Equity Research
      Philadelphia, PA, United States
  • 2008
    • University of Rochester
      Rochester, New York, United States
    • The Children's Hospital of Philadelphia
      Filadelfia, Pennsylvania, 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
    • University of Toronto
      Toronto, Ontario, Canada
    • Hospital of the University of Pennsylvania
      • Department of Medicine
      Filadelfia, Pennsylvania, United States
    • Duke University Medical Center
      • Department of Medicine
      Durham, North Carolina, United States
  • 1993-2003
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2000
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
  • 1995
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 1986
    • Rhode Island Hospital
      Providence, Rhode Island, United States