Supporting patients with their psychological preparation for surgery and mental health optimisation
Professor Scarlett McNally
As a surgeon, I love the purity and logic of operations and the rituals that surround them. Staff who gravitate into perioperative specialities often like physicality and certainty and avoid getting involved in patients’ psychology. Yet staff have all had years of experience, and healthcare professionals have had education that includes psychology and the science and skills to be generalists as well as the specialists we have often become. I think that what holds us back from genuinely giving mental health parity with physical health is our perceived lack of knowledge or feeling under-confident. And lack of time.
Our role as senior health care professionals, is to take the long view. Coming to us should be like going to a financial advisor. We do not judge. No one can change the past. But we should advocate on behalf of the patient’s future self. We sometimes underestimate our power. We have value just by confirming that things are going as planned.
We should truly identify what matters to the patient. We should help set their expectations. Half the operations needing GA or Regional block are in people over age 65 in the UK. There is a huge range of fitness and expectations. We also need the patient on board as part of the team – to prepare themselves1 and reduce the risk of complications, a poor outcome or regret.
I worry that our services are set up for logic. We think one-stop-shops are the answer whereas most people need time to process. I feel sneaky not deciding but offering a follow up appointment such as ‘can I see you in 3 months and see if you still want the op’. We need to give patients information in a format they can use. I re-wrote dozens of patient information leaflets for my Trust when I was shielding. I often use these for education of students and new members of staff – if it is on the leaflet it is fair game to talk about. It helps define the standard pathway for the team as well as for service users. Our hip fracture leaflet gave comfort to loved ones who couldn’t visit. I ask the clinic team to give patients a leaflet to read in the waiting room before I see them if the diagnosis is fairly clear – that means the patient and I can concentrate the consultation on what matters to them rather than details about possible surgery. It is easy to make QR codes linking to leaflets – we have them on posters and laminated menus. (Top tip – search for ‘QR code monkey’, insert the weblink and save the picture.)
Summary of a recent excellent talk:
Patient priorities, expectations and outcomes after head and neck surgery: What do we know and how can we do better? by Associate Professor Roganie Govender.
There is a Dual Process theory with First response (system 1 processing) of fear and System 2 – a more reasoned, deliberate, rational response. There are contradictions and dissonance depending on which response predominates. 14% of patients express regret about having gone through surgery. We need to align expectations and reality. We should personalise our discussions with older people avoiding pressure from family. We must avoid surgeon bias – just because they may be fit enough for surgery doesn’t mean they should have it. The Multi-Disciplinary Team model (MDT) can reinforce a cycle of paternalism – the MDT meet without patient presence and make a plan with a clinician tasked to convey the best option to the patient who agrees from a position of disempowerment. True engagement is not possible if the patient role is restricted to acceptance or refusal of a single recommendation. What works is Shared Decision Making and ensuring patients feel included. Decision aids can be helpful and patients benefit from being signposted to patient support groups.
My general suggestions.
As self-selected surgical logical beings, we need to convey that we understand how hugely impactful an operation is. We can do this without being paternalistic. We can use our logic. Shared Decision Making means we should want our patients to ask about ‘BRAN’ the Benefits, Risks, Alternatives and Non-operative options. The staff who know the alternatives and natural history need to consciously go through this -surgeons, anaesthetists, geriatricians, GPs, clinical nurse specialists, etc. This helps the patient have choice. It reduces uncertainty. If there is a complication, we can all rewind our thinking and know we did the right thing at the time.
I also recommend giving patients some certainty, for example about how the pathway is likely to progress, and some things that they can actively do.
Some personal detail
I have also been a patient and offer some ideas. The WhatsApp group for doctors with cancer covers a huge range of issues with everyone’s ups and downs. In healthcare, I feel it is important to acknowledge where someone is at psychologically. All healthcare staff can show that they understand. Sometimes listening is needed, or direction to support services. But for healthcare staff, their job is not to be passive either. The healthcare staff help by giving options and explaining the general aspects of the pathway with the individualised aspects.
As a human, emotions are real. It is normal to have a range of feelings when you, or a loved one, is going to have an operation. Many people feel anxiety or stress. You might keep worrying about things. Different feelings and thoughts can be especially troublesome if you think of yourself as an organised or logical person. Everyone is different. As humans, we are sometimes bad at looking after our future self. It can take time to process information. Having a new diagnosis can be like a bereavement, worrying about the life you have suddenly lost. You may go through phases of denial, bargaining, anger and acceptance.
Some people face chemotherapy, medications and radiotherapy as well as surgery. Uncertainty can feel dreadful. You can hold onto moments that feel positive. Chemotherapy comes with steroids that can make people feel very intense.
These are some suggestions on the psychology of being a patient:
- Know that it is normal to have feelings that seem irrational
- Make time for yourself
- Try to get some sleep – keep your phone away from the bedroom
- Get some fresh air
- Get some exercise
- Eat healthy foods – fruit vegetables and protein
- Try not to drink too much alcohol
- Connect with friends
- Be kind to your future self
- Many decisions don’t need to be made straight away
- When you get a difficult thought, acknowledge it, but you don’t have to believe it
- Be aware that some decisions are difficult – you don’t have to know the right way forward. Your medical team will try to give
- You are allowed to ask if something is bothering you
- It may be helpful to trust yourself and know that you can only do your best. The intensity of emotions will pass. You may feel you are stepping out of yourself to set the next step.
- A new diagnosis may change how your friends or family react.
- You can tell people how you want to interact with them.
- Be aware of your stressors. You might want to be ready if you are asked questions.
- You don’t have to answer other people’s questions.
- Time makes things feel different.
- Try to go for a walk.
- Think about how you react to things.
- When you have some energy, make some plans to get you through the tough times.
- Some people are helped by having a safety plan – some clear things to remember when you are feeling very low, or a number you can call.
- Macmillan
In summary, psychological preparation should be given far more attention – by patients and staff.
REFERENCE:
- Smoking cessation
- Exercise: https://www.cpoc.org.uk/guidelines-and-resources/resources/exercise
- Nutrition: https://www.cpoc.org.uk/guidelines-and-resources/resources/nutrition
- Alcohol moderation
- Medication review/senior review
- Psychological preparation and mental health optimisation
- Practical preparation