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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussion prior to and during stressful interventions
The pre-operative discussion
Discussion prior to and during stressful interventions
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 metastases.

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:
The aim 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.
The steps 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.
The probable 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 preparation.
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.
Particular 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.
Fascination with 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.
The investigator 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.

Discussion before and during stressful examination
1. Preparatory phase  
 1. Explain the objective (motivation!)
 2. Present the major steps of the procedure
 3. Assess the extent of the need for information ("skepticism"?, "blind trust"?)
 4. Say how long the procedure will last
 5. Draw out and eliminate specific anxieties
 6. Explanation, to the extent that it is required legally
 7. Give exact appointment time; no delay or change if at all possible
 8. Arrange contact with experienced patient
2. During procedure 
 1. Give the patient the feeling he can intervene
 2. Discuss methods for intervention (hand signs etc)
 3. Indication when pain is to be expected and when the danger is past, with painful interventions
 4. Sparing but continual verbal contact, non-verbal contact
 5. Do not forget the patient
 6. Reduce conversation amongst the team to the absolute minimum
 7. No remarks that create uncertainty
 8. Minimize remarks that create anxiety
 9. Do not unnecessarily prolong or interrupt the procedure
10. 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).
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The pre-operative discussion
The pre-operative discussion with the surgeon or anesthetist includes two aspects:
1. The explanation of the proposed procedure with the required legal agreement of the patient.
2. Psychological stabilization.

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.

Specific sources of pre-operative anxiety (Spintge and Droh, 1981) 
Fear of death
Loss of consciousness and "pseudo-death"
Feeling of total surrender
Pre-operative waiting
Putting-off of the operation
Effectiveness and complications (e.g. fear of awaking during the operation)
Unfamiliar machines and apparatus
Masks, injections, infusions
Speaking out loud during the anesthesia, perhaps with revelation of personal secrets
Earlier unpleasant experiences with anesthesia (e.g. ether)
Gossip of others
Press reports of exceptional cases
Surgical procedures 
Possible results of the procedure
Temporary or permanent injury or handicap
Serious findings during operation (e.g. cancer) leading to changes in the procedure
Post-operative pain
Post-operative treatment (e.g. bandage changing, stitch removal, injections, infusions, drains, bladder catheterization)
Previous unpleasant experiences
Tales of other persons
Press reports of mistakes
The initial work in this area was performed by the American psychologist, Janis (1958).

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 (table).

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.

Terminology represents 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.

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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