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The psychological care of patients following a myocardial infarction

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Miriam Gaston, BSc, MSc (Nursing), RN, RNT, RNCT, DipCounselling.

Lecturer in Nursing, University of Salford

The link between depression and increased mortality (Jones and West, 1995; Thomas, 1995; Moser and Dracup, 1995; Crowe et al, 1996) has led to increased concern about a patient's psychological well-being in the aftermath of having a myocardial infarction (MI). Monitoring the psychological status of patients in cardiac rehabilitation is part of the role of the multidisciplinary team, yet there is limited evidence of the best methods of providing psychological support.
The link between depression and increased mortality (Jones and West, 1995; Thomas, 1995; Moser and Dracup, 1995; Crowe et al, 1996) has led to increased concern about a patient's psychological well-being in the aftermath of having a myocardial infarction (MI). Monitoring the psychological status of patients in cardiac rehabilitation is part of the role of the multidisciplinary team, yet there is limited evidence of the best methods of providing psychological support.

Counselling is one way of doing this and can be delivered by a range of health-care professionals, including specialist nurses, occupational therapists and practice nurses. However, the time available for these professional groups to offer such support may be limited owing to their clinical responsibilities (Thomas et al, 2001). The inclusion of a counsellor in the multidisciplinary team enables other health staff to continue with their work, while providing a service that offers the patient a supportive and empathic relationship.

The analysis of a patient's journey during a period of ill health has become an integral part of process mapping to underpin improvements in the quality of care provided (Department of Health, 2002). Implicit in this process is acknowledgement that the patient's experience of the NHS may be very different from the perceptions of professionals.

This paper considers aspects of the patient journey following an MI from a psychological perspective to gain insight into how various processes affect their perception of care. Patients may have difficulty understanding or recalling information provided in hospital, for example.

Exploration of the patient journey following an MI highlights the fact that patients may be confronted with feelings of multiple loss (Robinson and McKenna, 1998) in relation to marital breakdown or existing health conditions such as diabetes. Some patients find it difficult to live with such losses, on top of attending an outpatient clinic and waiting for decisions about treatment. The difficulty in providing psychosocial support to cardiac patients is compounded by limited evidence of how the needs of their carers are identified and addressed.

Anxiety and depression
Having an MI is a frightening and unwelcome intrusion that disrupts any sense of control a patient may have over his or her life. Patients experience a 'biographical disruption' - an unavoidable and enforced alteration of their life (Holloway et al, 2000) and often recall a sense of numbness in the context of their hospital admission. This is similar to that experienced by people with post-traumatic stress (Owens et al, 2001).

Coping with such a sudden and frightening event requires patients to make major psychological adjustments. While most can meet this challenge with relative equanimity (Moser and Dracup, 1995), a proportion may experience transient episodes of anxiety or depressed mood (Goble and Worcester, 1999). At least 20% will have more persistent symptoms of clinical anxiety or depression (Jones and West, 1995; Thomas, 1995; Moser and Dracup 1995; Crowe, et al, 1996).

Reducing the incidence of depression in patients following MI is crucial, as depression increases the risk of mortality (Frasure-Smith et al, 1995; Crowe, et al, 1996). An anxious patient may complain of physical symptoms such as palpitations, breathlessness or chest pain, which may give rise to panic attacks that will affect the patient's psychosocial recovery. Assisting patients to overcome the symptoms involves helping them to understand the experience and to provide relaxation or cognitive behavioural approaches to cope with the feelings of anxiety in real-life situations (Palmer and Dryden, 1995).

In addition, patients often have problems concentrating and may fail to comprehend, accept or recall information provided in hospital. During cardiac rehabilitation they will need appropriate information to enable them to participate in planning treatment. Goble and Worcester (1999) suggest this may be most effectively achieved by providing patient education, counselling and behavioural interventions in small groups.

Health-care professional/patient relationship
Improving the way health-care staff relate to, and communicate with, patients is high on the health agenda. The NHS Plan: Personal action plans (DoH, 2003) suggests that nurses should not only encourage patients to tell their stories but also try to put themselves in the patient's shoes to inform and improve the quality of care they offer.

Nurses may find it difficult to be empathetic if they feel frustrated at being unable to fulfil a patient's expectations (Holloway et al, 2000). Health-care professionals are in a position of trust and patients may expect them to make decisions on their behalf. However, this can also invoke feelings of fear and anger, and expectations of outcomes that the nurse may not be able to deliver. Difficulty in the interpersonal relationship between a health-care professional and a patient may compound these feelings.

Psychological interventions
The main focus of psychological interventions is to assist the patient to adapt to change, become self-empowered and regain control of their life (Thomas et al, 2001). This involves helping them work through issues related to the concept of loss. Loss has been described as a central feature of our lives and an unavoidable and inextricable part of being human (Tschudin, 1997).

In clinical practice nurses routinely meet patients who are experiencing some form of loss. However, Robinson and McKenna (1998) found that, as a concept, loss was rarely analysed in nursing or health-related literature. They suggested that there were three perspectives that could be used to explain the process of loss.

The first is drawn from psychoanalytical theory. This approach describes grief as a gradual withdrawal from the deceased on to someone or something else. The second is drawn from Heideggerian philosophy. This approach puts emphasis on the individual description and experience of grief as the bereaved person perceives a sense of alienation from the world and the need to create meaning out of grief. The third is derived from descriptive studies of grief and involves models that try to organise the psychological processes an individual undergoes when grieving. Bowlby (1981) hypothesised that people pass through a number of stages - numbness, yearning and searching, disorganisation and despair - before reaching a stage of reorganisation.

Worden (1991) criticised the models outlined above for suggesting that grief is a passive process, whereby bereaved people can do little to help themselves.

Loss is usually perceived as a negative experience that invokes varying degrees of fear, anxiety or depression in patients. However, by adapting to loss the patient may have an opportunity to re-evaluate personal values and beliefs, which in turn can lead to a sense of fulfilment.

For many people, suffering an MI is a multiple-loss experience, as cited above. Often patients during part or all of cardiac rehabilitation are on sick leave, unemployed or feel they are unemployable as a result of their illness. Employment is often central in the lives of people before an MI, bringing with it status and self-esteem (Jones and West, 1995).

However, the life changes that may occur after a heart attack can lead to a lower standard of living. The loss of status and self-esteem can amplify patients' biographical disruption, particularly if they were previously unemployed; had an existing chronic illness such as diabetes or a respiratory disorder; or were previously very independent but have become reliant on relatives.

Some patients will have had difficulties in their relationships before the MI and will be distrustful of forming new attachments and risking rejection at a time of vulnerability. This may be related to the level of control patients feel they exercise over their life and relationships (Moser and Dracup, 1995). Even clients with robust relationships can become frustrated and resentful towards partners. The unexpected disruption to family life often puts a strain on relationships (Jones and West, 1995). The Carers and Disabled Children's Act 2000 requires the carers' needs to be identified when a patient is discharged.

Feelings of hostility and anger are particularly strong in younger patients (Moser and Dracup, 1995). This is especially an issue for patients who led a healthy lifestyle before the acute cardiac event. They feel unable to blame their illness on their own behaviour and tend to blame their own body or redirect the blame elsewhere. Often these feelings are accompanied by intense jealousy of people who do not lead a healthy lifestyle, yet have not had an MI.

Myocardial damage is sustained internally so it does not show any visible effects. Patients are therefore unable to draw attention to it in the way they could in the case of a broken arm. The significance of the internal damage is thus more difficult for patients to understand and tends to be perceived as a threat. An angry response is a common reaction to the perceived threat of a future blighted by debilitation or death.

Anticipatory loss and previous trauma
For many clients the major fear is that of sustaining another heart attack - one that could be fatal. Worden (1991) used the term 'anticipatory grief' to describe the role reversal experienced by relatives of dying individuals. After an MI many patients undergo a similar process of anticipatory loss, fearing - wrongly or rightly - the risk of a fatal heart attack (Goble and Worcester, 1999).

Whether the loss is actual or anticipatory is irrelevant in taking a person-centred approach in counselling. What is important is to explore the patient's underlying feelings accompanying the loss. Patients often have a sense of yearning and searching (Bowlby, 1981), and strive to make the best of a future they perceive as precious, even when the outcome may be uncertain. Trying to accept the losses imposed by the disease process is thwarted by uncertainty for the future as patients often have to wait for further investigations before any medical decisions can be taken about treatment, adding to the sense of disorganisation.

Thomas et al (2001) states that at times the counsellor may be working with issues that appear to have little to do with the complaint. My experience of more than four years' standing of counselling patients post-MI confirms this. The patient's psychological distress is often rooted in previous experiences, which they may not have disclosed even to their closest relations. This may include childhood experiences of health care; child abuse; death of a parent, sibling, spouse or colleague; separation from a parent or relationship difficulties. Memories of these events will usually emerge once the counsellor-patient relationship has reached a level where the patient feels sufficiently supported to explore the emotions raised, thus revealing the connection between the previous experience and current psychological issues.

To encourage the patient to tell their story of 'biographical disruption', it is necessary to foster a supportive relationship. This will provide the patient with a platform from which to describe the feelings that underpin their sense of having lost their life's destination. During this time the counsellor reflects any underlying feelings, enabling the patient to explore the issues.

A significant part of the work involves helping the patient to work through issues related to the concept of loss, giving them an opportunity to re-evaluate personal values and beliefs. In describing the process of reorganisation in people with chronic back pain, Holloway et al (2000) stated that helping a patient adapt to change and regain control could lead the patient to accept their altered identity and learn to reorganise their life within the framework of their disability. The process is one that aims to promote self-empowerment and, in some patients, will foster a sense of fulfilment.

There is limited evidence on how best to provide a comprehensive cardiac rehabilitation programme to address the psychosocial needs of patients and carers (Goble and Worcester, 1999). However, using the patient's journey during a period of ill health has become a part of a strategy to improve quality of care (DoH, 2002). This paper has drawn on the work of a counsellor working in a multidisciplinary team to highlight aspects of this patient journey in order to consider how those psychological processes affect a patient's perception of the care provided.

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