Discussion prior to and during
The aim of the preparatory
discussion with the doctor before stressful diagnostic and therapeutic
interventions is to achieve a procedure with as little stress and few
complications as possible. This has a preventative aspect in
cases where the particularly stressful investigation or therapeutic method
will have to be repeated. In these cases, discussion should prevent putting
off or refusal of further procedures.
The patient's reaction during
a stressful medical intervention almost inevitably has an effect on the
investigator; anxiety, defensiveness and reaction to pain create a tense
and irritable atmosphere, which makes it difficult for the doctor to maintain
his mastery and controlled approach from which there is likely to be both
a negative and positive feed-back mechanism.
The best way to appreciate
how the patient will react to a certain investigation or method of therapy
is to undergo it oneself. This way is naturally not much used. However
the basic condition for effective preparation is to respond empathetically
to the effect of the intervention from the patient's point of view. It
must always be remembered that there will be large discrepancies between
the subjective awareness of danger, threat and stress experienced
by the patient and that which can be measured objectively. For example,
although from the point of view of nuclear medicine, a bone scintigram
is considered to be a harmless minor investigation, lying on a hard board
under a gamma camera can be extremely stressful for a patient with bone
F. Anschütz presented
679 patients with a questionnaire in order to quantify the pain experienced
during invasive diagnostic procedures (simple venipuncture, coloscopy,
coronary angiography etc.). The questionnaire was presented immediately
after each procedure, and again 24 hours later (when the results were in
fact similar). The subjective pain experienced was graded in 10 levels
of severity. For example grade 1 pain was felt but it could be ignored.
Grade 5 was medium to severe pain, which led to physical and intellectual
distress with pronounced discomfort as well as defensive and evasion reactions,
until the merciful conclusion. Grade 10 was used for the most severe pain
with fear of imminent death and destruction.
The investigation showed
that the experience of pain during the procedures varied tremendously,
and that the doctor estimated this differently to the patient. Least
pain was experienced by the patient during uncomplicated venipuncture,
renal biopsy as well as simple gastroscopy, and the greatest during coloscopy,
rectoscopy and sternal puncture.
It should not be taken
for granted that the simplistic "lots of information = good preparation"
is always true. Extensive information and intensive preparation do not,
on their own, inevitably bring about a better effect. An optimal procedure
(according to L.R. Schmidt) depends on the combination of strategies for
solving conflicts, as well as a series of variable personality traits,
and previous experiences of the patient with medical procedures.
The patient's "experience"
of the procedure has been found to have a positive effect if it has to
be repeated. Salm (1982) found that disturbances occurred in 12 of the
59 patients who underwent cardiac catheterization for the first time (inexperienced),
compared to only one case out of 21 in those who were "experienced". Salm
described two types of typical patient reaction when faced with
a stressful examination or treatment procedure. These polarize from "active
skepticism" on one hand to "blind trust" on the other, and from "obvious
panic" to "conscious acceptance". The first type of personality approaches
the intended examination or procedure with a cognitive-intellectual attitude,
either by consciously assuming critical behaviour or using avoidance techniques.
The approach of the second type is mostly characterized by emotional reactions.
Preparation should depend far more on the "patient-type".
Salm (1982) wrote: "It appears
obvious that patients with "open panic" with regard to the procedure are
those that need special care: they are the ones that experience the procedure
as the most stressful, and disturbances are more likely to arise during
their investigation. Anxiety about the results play a particular role.
Probably the anxiety is about a future operation, and this must be taken
into account in the preparation of the patient for the procedure."
On the other hand, patients
with "blind trust" create the least difficulties. They are cooperative
and never voice negative feelings or a particular thirst for knowledge,
or doubts about the ability of the doctor typical of the "active skeptic".
They are "ideal" patients who best fulfill one's expectations. It might
be however that these patients reach the limits of their capabilities under
a heavy stress and become overstretched.
It appears that the patient
with "active skepticism" is particularly in need of information, as he
requires this for the assurance that he has intellectually understood the
situation and has "a grip on it". He is able to think about extremely trying
situations without panic. One need not worry whether or not he can cope
with threatening information, but should instead supply him with all that
he needs to know. His disbelief and mistrust can disturb the doctor, and
lead to him feeling that the patient is unpleasant (a feeling that he does
not experience with the patient with "blind acceptance" who supports him).
In these cases it is helpful to understand that even mistrust has a role
in coping with anxiety in these patients, and does not personally involve
the doctor's competence.
The following guide-lines
should be utilized during discussions before and during the procedure:
of the procedure should be made as clear as possible to the patient.
This has a strong motivating effect, which leads to a more favourable outcome.
of the procedure should be described firstly in general terms, with
only those that are relevant for the patient. The desire for information
and the information that the patient already has must be individually assessed,
due to large variations. Whilst the patient with "active skepticism" can
hardly be satisfied, the patient with "blind trust" will require relatively
little information. The room for variation may depend on the legal requirements
for such an explanation.
length of time that the procedure will entail should be estimated and
told to the patient. This relieves the patient's mind during his internal
preparation. This is because a less stressful procedure which the patient
presumed would only last a few minutes, but actually lasts 45 minutes,
can be more stressful than a subjectively stressful procedure which lasts
a longer period of time, but for which the patient knows the time required.
||The patient should
be informed of various side effects which occur, as well as those
that do not occur. Examples are that there is no pain associated
with biopsy of the stomach wall, and that a properly carried out bronchoscope
is not accompanied by a feeling of suffocation. However premedication leads
to lethargy, and instillation of a local anaesthetic into the bronchial
tree can lead to a desire to cough. These measures prevent anxiety due
to unfounded anticipations, as well as defensive mechanisms due to insufficient
||It is very important
that the patient is given the feeling that he can intervene during the
procedure. It can be agreed beforehand that the patient can signal
(with his hand for example in procedures during which he cannot speak such
as bronchoscope) so that his desire for air, pain, or a need for rest can
be recognized. Warnings about pain can be dealt with positively in this
way. The alarm signal is especially important. This should be able
to characterize the time, extent, quality and the duration of the pain
as far as possible. Of course, the "all clear" signal should also be made
clear. The chance of giving an alarm, related to a real or presumed control
over the procedure, can considerably alleviate the procedure. Many patients
are helped by the feeling that they themselves want the procedure carried
out even if it is painful or stressful and that they can have some influence
over the procedure when the stress appears insupportable.
personal anxieties should be elucidated and extinguished one by one.
Patients often have irrational presumptions, brought on due to misunderstandings,
which can produce severe anxieties. Such anxieties ("can this cause the
lungs to rupture?", "what happens when air gets into the heart?") should
be openly discussed and removed by empathetic rational arguments.
||The date and
time of the procedure should be given to the patient as early as possible,
and whenever possible should be maintained. To be left to wait,
with unexplained delays, creates unnecessary additional stress.
the technique or difficulties during the procedure can easily mean that
the patient is "forgotten", and feels even more isolated and dependent.
Therefore continual verbal contact should be maintained which can
be by brief inquiry after the patient's feeling or by a little joke, a
hint that the present stress will soon be over, or that the investigation
is drawing to a close. Non-verbal contact (stroking, holding a hand)
may be equally important and effective for some patients.
and his helpers should speak as little as possible with one another
during the procedure. Continual swapping of medical information is
a copious source of misunderstandings for the patient. Obviously small
talk should be absolutely taboo during a procedure which is markedly stressful
for the patient.
||Forms of speech
which lead to uncertainty (i.e. "if we are lucky, we can manage
it the first time...", "we have this problem every time we introduce the
catheter") have to be avoided.
||Finally it can
be very helpful to bring the patient into contact with "an experienced
patient", providing that he is able to present the examination method
knowledgeably and without raising further anxieties.
before and during stressful examination
the objective (motivation!)
||Present the major
steps of the procedure
||Assess the extent
of the need for information ("skepticism"?, "blind trust"?)
||Say how long
the procedure will last
||Draw out and
eliminate specific anxieties
to the extent that it is required legally
appointment time; no delay or change if at all possible
with experienced patient
|2. During procedure
the patient the feeling he can intervene
for intervention (hand signs etc)
when pain is to be expected and when the danger is past, with painful
||Sparing but continual
contact, non-verbal contact
||Do not forget
amongst the team to the absolute minimum
||No remarks that
that create anxiety
||Do not unnecessarily
or interrupt the procedure
||Calm and sympathetic
approach with defensive or panic reactions
|3. Follow-up discussion
|Discuss the procedure
and findings later with the patient (especially if short-acting narcosis
was given when the patient may not have heard an immediate explanation).
The pre-operative discussion
with the surgeon or anesthetist includes two aspects:
of the proposed procedure with the required legal agreement of the
Empirical and systematic
psychological research in the pre-, peri- and post-operative stages has
revealed a lot of interesting information, but unfortunately overall has
helped little to produce general guide-lines.
The initial work in this area
was performed by the American psychologist, Janis (1958).
sources of pre-operative anxiety (Spintge and Droh, 1981)
||Loss of consciousness
||Feeling of total
and complications (e.g. fear of awaking during the operation)
loud during the anesthesia, perhaps with revelation of personal secrets
experiences with anesthesia (e.g. ether)
||Gossip of others
of exceptional cases
results of the procedure
permanent injury or handicap
during operation (e.g. cancer) leading to changes in the procedure
treatment (e.g. bandage changing, stitch removal, injections, infusions,
drains, bladder catheterization)
||Tales of other
Patients faced with anesthesia
or operation were found to have a wide variety of anxieties. As
well as the anxious reactions brought about by the disease and hospitalization,
there were a series of specific sources of pre-operative anxiety
Already Janis's research
showed that the degree of information that the patient possessed
had an effect on the post-operative course. From his results, it appeared
that a moderate degree of concern was associated with the best post-operative
course. This "pre-operative concern" is to be seen as a necessary willingness
to come to terms with the imminent operation. Accordingly, it does not
appear sensible to try to remove every source of concern. More recent
findings (Mathews and Ridgeway, 1981) have shown that a very high level
of pre-operative anxiety is associated with more post-operative difficulties
and complications. There can also be a similarly poor effect on the post-operative
course if the patient has only very slight apprehension before the operation.
The psychological strategies
for dealing with pre-operative conflict are divided into two major
categories; on one side is the vigilant patient who over-reacts
even to the thought of an operation, and on the other hand those who evade.
Cohen and Lazarus (1973) came to the conclusion that "vigilant" patients
were more likely to have severe post-operative difficulties than the so-called
evaders. It now appears that limiting the amount of pre-operative information
to a relatively small amount, with an "avoidance" strategy in minor and
moderately severe operations promises the best outcome.
It is not easy to estimate
the right amount of information. On one hand, experience has shown
that the pre-operative discussion with the anesthetist and the surgeon
rarely come up to the patient's expectation. This can create unnecessary
anxiety. It is not unusual for the patient to then seek further information
about the forthcoming operation from nursing staff or other patients. On
the other hand, modern legal requirements for all-encompassing pre-operative
information may mean that the patient receives too much information, which
itself creates avoidable anxiety.
It would be a facade to use
the pre-operative conversation only to give information and satisfy legal
requirements. The majority of patients would like more explanation. This
can however not be disengaged from anxiety. The central topic is
the "unknown". The operation itself can be recognized qualitatively and
quantitatively as being an objective "stress factor". However pre-operative
anxiety depends to a large extent on the subjective weighing of
this stress. It is therefore very difficult to establish a generally acceptable
concept for the pre-operative discussion.
There are many indications
that the pre-operative discussion is most likely to be successful if the
individual psychosocial basis of the patient, as well as his personal
need for information are adequately taken into account.
The concept of step-wise
explanation arose from von Weissauer (lit. of Ch. Katz and S. Mann).
This includes two explanatory steps. In the first phase, the patient is
given general, easily comprehensible information sheets which summarize
the most important information with regard to the operation and the likely
risks. In a second stage, the patient is given the possibility of a personal
explanation. Katz and Mann have now shown that this sort of pre-operative
discussion has a positive effect both on the anxiety level and the level
of knowledge. The majority (90%) of patients prefer this step-wise explanation
to that of the solitary oral explanation.
a distinct danger in the pre-operative situation. The patient usually
has only very vague and often abstruse ideas of anatomy. Therefore detailed
explanations of operative procedures on individual organs are predestined
to create misunderstandings, false ideas and considerable anxiety. It is
therefore advisable, as far as allowed by legal requirements, not to go
into great detail but to describe the major steps in the procedure, and
to leave the patient free room to explore his own desire for further information.
Most of the psychological
research has been carried out on operations under general anesthesia;
regional anesthesia is growing in importance, and produces a completely
different psychological situation than that in which operative procedures
are carried out on the unconscious patient. Here the operation is actively
experienced, and intervention on the part of the patient is possible during
the procedure. There is as yet no firm consensus about how to inform the
patient about this pre-operatively.
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp23_stressful.html