Thank you for visiting Heart Care Matters. We are beginning the ‘Open Heart Surgery Series’ with the introductory topic ‘Open Heart Surgery Patient Preparation Guide Part I’. In this segment we will explore the importance of the patient’s emotional and psychological state of mind preoperatively as documented through fascinating research studies. Please keep in mind that these studies were focusing at the emotional stressors and their impact on various postoperatively indicators and not necessarily addressing factors such as patients who smoked, had other medical conditions and complications. My hope in sharing this research is to show you the importance of managing stress and anxiety prior to surgery and the positive effects it may have during recovery. The goal is to learn from these studies and not necessarily predict how each patient will respond as each person is highly individualized both physically and emotionally. And as always, if you have any medical questions please refer to your health care provider.
Common Emotional Responses
If you are here you most likely have been informed that you will be having open heart surgery sometime in the near future. The emotions you might be feeling may include feeling overwhelmed, scared, fearful, worried, stressed, and anxious. Please know that these are very real and understandable reactions to having open heart surgery. Surgery is itself a very threatening experience with multiple stressful components. You may be concerned about your physical condition, your ability to recover, the postoperative pain and worries about survival. It is understandable to experience extremely high levels of stress and anxiety during this time.
As I reflected on our emotional state we too were extremely stressed and anxious. And although we reached out to a support group via Heart Valve Surgery I later learned that psychosocial support is but one of the components that helps in coping and reducing anxiety. Therefore, I was immediately interested to find out if there was anything else that patients can do to help with their emotional state and perhaps help with their recovery. In the following section, I will summarize what research discovered and share some thoughts about how their studies can be applied to you as the patient about to undergo open heart surgery.
Research Studies and Recovery Implications
• It is worth beginning with Contrada et al (1994). The research they conducted argued that the association between surgical preparation and outcome is clinically meaningful. Simply stated the patient that is equipped and informed tends to show more positive outcomes. In this study, they gave the patients the following: information, coping skills training, and psychosocial support. A combination of all three methods showed greater results than those patients only given one method. One would think that every patient going through open heart surgery would be exposed to these methods but the clinical reality is quite the opposite. Therefore, most patients do their own research to better understand their condition and surgery. However many find it challenging coping with the reality of surgery and the emotional turmoil.
• While it is important to be informed, other studies found that it is equally important that the patient understands himself/herself in light of how they cope with their diagnosis in respect to receiving information. In other words, does the patient cope by reading everything and being informed of every detail or does the patient prefer to have the information limited and filtered? If the patient falls under the latter category, it is important to express those preferences to the health care providers and caregivers as studies have shown that too much information is not helpful (Miller, 1992; Prokop, Bradley, Burish, Anderson & Fox, 1991). This is also important because it will be your guide as to how much information you read.
• Furthermore, several studies demonstrated that patients with higher anxiety and stress levels prior to surgery experienced higher levels of pain (Johnston, 1988; Mathews & Ridgeway, 1981). And with more pain, distressed patients tended to be less compliant to walk, cough and do deep breathing exercises which are essential to recovery. (Mathews & Ridgeway, 1981).
• So what exactly did researchers use to help patients? An interesting study in 1964 by Egbert et al visited patients the night before to teach them relaxation techniques and to provide information about typical post surgical physical sensations. These patients left the hospital 2.7 days sooner and used approximately 50 % less morphine than patients without the information and relaxation techniques.
• Some studies such as in Devine’s work in 1992 gave their patients group format support groups, booklets, manuals, audiotapes, and videotapes. They found that these individuals in comparison to the control group had decreased psychological distress, less pain and shorter hospital stays. Compared to controls Devine noted that treatment patients spent an average of 1.5 days fewer in the hospital.
• Another fascinating study by Johnston and Vogele in 1993 showed a strong correlation between major forms of psychological interventions (procedural intervention, sensory information, behavioral instruction, cognitive intervention, relaxation hypnosis and emotion-focused intervention) and outcomes. They concluded in published and unpublished studies that negative affect, pain, pain medication, length of stay, behavioral and clinical indexes of recovery, physiological indexes and satisfaction showed significant benefit. They also noted that procedural information and behavioral instruction produced the greatest improvement whereas relaxation studies showed benefits for all indicators except behavioral recovery.
• However, positive effects were not limited to formal interventions. One study suggested that even small environmental differences may affect the patient’s outcome. In 1984, Ulrich noted that patients with a hospital room with a view showed differences in the length of days in the hospital. They documented shorter hospital stays and fewer use of strong pain medications than those patient’s rooms without a view. A great reason to request a room with a view if at all possible!
• In 1996 Kulik et al illustrated the importance that whatever their content, many presurgical interventions are beneficial in part because they provide additional interpersonal support during a stressful time. The literature consistently demonstrates that social support can moderate the effects of psychological stress especially support from family ties (Keicolt-Glaser, Newton, et al., 1996; Uchino, Cacioppo, & Kiecolt-Glaser, 1996).
• Lastly, faith based positive religious coping styles may protect the psychological well-being of patients undergoing open heart surgery as researched by Dr. Amy L Ai. The study found that the positive effect was seen through enhanced hope and perceived social support prior to stressful experiences such as cardiac surgery.
• Please note that these studies highlighted the importance of effective pain control, particularly immediately following surgery. In addition, poorly controlled acute pain could retard wound healing and prolong the recovery period (Liebeskind, 1991; Page et al., 1994, in press). In other words, these studies showed a reduction in pain, not elimination. Please use all the medication being administered to you as needed and as prescribed by your surgeon especially right after surgery. You will be thankful you did.
Gap in Healthcare Providers Assisting Patients Cope
So what does this mean to you? These studies showed very promising results but in each case researchers provided their patients with psychological support, information or intervention. This causes me to reflect upon the fact that many cardiac patients proceed with open heart surgery with extremely high stress and anxiety levels. I know that was the case for Steve and I. We were both highly anxious about the surgery and potential outcomes. Unfortunately it was never brought to our attention that anxiety and stress could have such a remarkable impact on recovery. Perhaps in the future heart centers and cardiac units will provide preoperatively intervention techniques such as informative sessions, coping skills workshops, reading materials or a referral to a support group in order to better equip the patient both mentally and emotionally for their surgery.
How to Cope and Decrease Anxiety
In the meantime, what proactive steps can be taken? It starts by acknowledging that it is natural to feel anxious. Accepting your emotional response is very important. Secondly, as we learned it is possible to minimize distress and therefore help produce positive post operatively outcomes such as less pain, less distress, and shorter hospital stays. Therefore, it is very important to begin with understanding your coping mechanism and your ability to process information as you prepare for your surgery. Are you the type of person that wishes to know every detail or do you prefer to have information limited and filtered? In either case, it is important to communicate your preferences to your caregiver and your health care team. Next, as challenging as it is, be determined to take an active role in managing your emotional state by including any of the following practices in your preparations. However, you do not have to do this alone. Encourage your caregiver and your loved ones to assist you in maintaining these emotionally supportive practices.
Supportive Coping Strategies
• Join a support group either in a traditional setting or online
• Talk to others who have gone before
• Learn relaxation techniques or listen to audiotapes
• Read educational materials such as brochures and books such as The Open Heart Companion
• Maintain your times of prayer and scripture reading
• Surround yourself with your loved ones
• Seek professional help
• Yoga and meditation
• Exercise (only if permitted)
• Listen to music
• Write in a journal
• Read inspirational materials
As you empower and educate yourself, please remember that your emotional well-being is of utmost importance. The goal is to help minimize distress and anxiety to help promote a positive effect during your recovery period. If you find that something is not working out for you, by all means do something differently or practice what you know helps you cope and decrease anxiety. This is why I included meditation and exercise although they were not part of this particular research review. In our case, what we found the most helpful was reaching for support through the Heart Valve Surgery Journal, our faith, and our family and friends. If I had been better informed, I would have loved the opportunity to explore other means as it was truly a stressful time for us.
In closing I acknowledge that this article was more involved than I had originally planned but I felt compelled to share with you these findings so that you would see the positive correlation between minimizing stress and the potential to have a positive outcome. Please be aware that these studies focused on patient’s emotional well-being and several postoperative measures. They did not address some of the complications that may occur with open heart surgery. Nevertheless, it is encouraging to know that patients can be proactive and take steps for their emotional and physical well-being. In the next segment I will share the importance of getting second opinions, sample questions to ask your surgeon, choosing hospitals along with other personal considerations. My best to you and your loved one as your embark on this journey. Please feel free to contact me if you have any questions about this article or about your own preparations.
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