INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 6(3), 1975
MEETING THE PSYCHOSOCIAL NEEDS OF PACEMAKER PATIENTS
KATHERINE A. FRANK HESSE, MSW Department of Medical Social Service New Britain General Hospital
ABSTRACT
A review of the literature concerning patients who have received permanently implanted cardiac pacemakers indicates that a substantial number of these patients experience difficulties in adjusting to their medical condition. Common feelings among these patients are anxiety and depression. It is suggested that difficulties often arise from the patient’s misconceptions about the pacemaker and inadequate psychosocial support. To assist such patients in their adjustment, the Pacemaker Support Program was developed to provide psychosocial counseling and pacemaker education from the preoperative phase through to the outpatient pacemaker follow-up clinic phase. In the year of the program’s operation a marked decline in adjustment problems has been observed, the program has been readily integrated into the hospital routine, and it has been enthusiastically accepted by both the hospital staff and the patients.*
Permanent cardiac pacemaker implantation is considered a relatively minor surgical procedure involving an uncomplicated prosthesis. The psychosocial implications for the patient, however, are often major. Reactions of individuals to life-sustaining devices reveal that their new dependence on the prosthesis requires immense physical, psychological and social adaptation [l] . While less physical adaptation may be necessary for the pacemaker patient compared to the amputee or the kidney dialysis patient, the psychosocial adaptations to the prosthesis may be significant. When the decision to implant a permanent pacemaker is made, the patient is seldom psychologically prepared for his future dependence on a machine. Although there is ample literature detailing the effects of heart disease and heart surgery on the psychosocial adjustment of the patient and his family,
*
This program was developed in cooperation with Charles Leach, Jr., M.D., Director of Cardiology, New Britain General Hospital, New Britain, Connecticut. 359
0 1976, Baywood Publishing Co., Inc.
doi: 10.2190/68EL-UAHR-2QF3-8Y9W http://baywood.com
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only a few studies have dealt specifically with the adjustment problems of the pacer patient, indicating that the majority of such patients successfully adjust after what has been termed a “testing stage” [2]. There remains, however, an important minority of pacer patients who experience serious and continuing psychosocial difficulties. While several authors have recognized the need for a comprehensive program of psychosocial supports for these patients, no such a program has been reported in the literature. Because of the adjustment and management difficulties of many of our pacemaker patients, the Medical Social Service Department, in conjunction with the Department of Cardiology at the New Britain General Hospital, implemented a program aimed at providing for the needs of these patients.
Psychosocial Factors in Heart Disease and Cardiac Surgery The possibility of postoperative psychosis accompanies any major surgery [3]. Because of the fantasies and myths associated with the heart, patients undergoing heart surgery appear even more prone than most to a wide range of maladaptive behavior such as psychosis, delirium, depression, anxiety and agitation [4-71. Kennedy and Baskt examining the cardiac patient’s reactions during hospitalization, concluded that anxiety was the root of the patient’s maladaptive behavior [8]. Faced with a “threefold payload of anxiety”-pain, impairment or death, and restrictions or limits in the future-the patient unable to cope successfully with any of these factors can manifest maladap tive behavior which may adversely influence the outcome of his treatment. Patients who successfully adjusted to their cardiac condition were observed by Kimball to exhibit only a moderate amount of anxiety, an absence of prolonged depressions, a strong relationship with the present and a strong orientation to the future [9]. The psychologically healthy patient is aware of and can accept his illness by maintaining a psychological “hyperpreparedness” for the imminent struggle and a realistic view of his survival and recovery expectations [ 101 . Other investigators have noted the involvement of organic factors in maladaptive behavior: drug reactions, blood gas and electrolyte disorders, sleep deprivation, sensory deprivation or over-inclusion, and nutritional disorders [3, 7, 113. Organic central nervous system disorders caused by cardiac arrhythmias have also been implicated in abnormal behavior [12]. These maladaptive reactions, whether temporary or long-term, mild or extreme, pose immediate problems for the hospital staff in maintaining effective and efficient medical management of the cardiac patient and may also interfere with the patient’s eventual reintegration into family and community and their continued medical care. Although these unusual behaviors have been reported primarily in patients who have undergone open-heart
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surgery, our experience indicated that pacemaker patients undergo many of the same ordeals and react with many of the same psychological patterns.
Psychosocial Aspects of Pacemaker Adaptation Early studies of pacemaker patients dealt exclusively with the pacemaker itself and surgical techniques. The first report of psychosocial factors [13] evaluated the physical rehabilitation of ninety-seven pacemaker patients and also judged that 69 per cent of the surviving patients had successfully adjusted, 4 per cent demonstrated severe anxiety, 18 per cent used excessive denial, and 9 per cent were markedly depressed (thus, an estimated 31 per cent of the surviving patients exhibited maladaptive behavior patterns). Depression and anxiety reactions can occur in pacer patients at the time of the initial operation, during clinic visits or at the time of battery replacement. As observed by Goldman et al. [14], much could be done to alleviate the patient’s anxiety and to promote a more optimistic outlook if the medical staff would make the effort to ensure that the patient and his family fully understand the pacer and its functions. Realistic reassurance in response to the patient’s obviously anxious queries is a simple, but often overlooked therapeutic technique; in their view, the staff must acquire an increased awareness of these unique problems of this group of patients in order to effectively identify and respond to their psychological disturbances. STAGES IN ADJUSTMENT
Other studies of psychosocial factors in pacemaker adjustment focus on stages. Green and Moss [2] divided the patient’s recovery into two periods: 1. the acute adjustment phase, from the time of pacer implantation to one
week post-operative, and 2. the subacute phase, lasting from one week to six months after implantation. The primary affect indicating a patient’s difficulty in adjusting during the acute phase was anxiety. Twenty-one per cent of the patients showed “relative” concern over their condition. Six per cent first rejected, then regretted the decision to have a pacemaker implanted, stating that they would rather die than be dependent on the pacemaker (shortly after their operation one-half of these patients did expire). In all, the researchers concluded that 27 per cent of the patients adjusted poorly during t h i s acute phase. During this acute phase most patients, even the successfully adjusting patients, showed clinical symptoms of depression. The researchers described this as a testing period during which the patients awaited the reassurance by experience that they would not have continued symptoms. Even the welladjusted group showed “relative” concern over their pacemakers’ functioning,
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particularly the batteries and their replacement, and such physiological reactions as diaphragmatic contractions. Men were often concerned about the pacemakers enlarging their breast area, and some women were frightened by the sight of the incision. During the subacute stage approximately three-fourths of the patients were judged to have successfully adapted: many patients resumed their hobbies, and re-established interpersonal relationships, and some resumed sexual activity. The quarter who experienced psychosocial problems expressed primarily anger and depression in response to unanticipated pacemaker problems such as wire breakage, repositioning, battery failure and skin erosion over the battery site, and anticipated problems such as checkups and battery changes. In general, the research group concluded that positive pacemaker adjustment requires three factors: 1. ancillary good health, 2. effective pacemaker functioning, and 3. meaningful interpersonal relationship with either a spouse or attentive children.
They observed that the patient who had symptoms for a long period of time adjusted better to his pacer than the patient with short, prodromal symptoms and suggested that the patient’s ability to adjust to the pacemaker may have paralleled his previous adjustment to other prostheses such as false teeth, hearing aids, or artificial limbs. Blacher and Basch divided the pacemaker patient’s progress into three phases of adaptation [15]. During the first period, preoperative and during the hospital stay, the patient deals with “life and death” matters, often concerned with the machinery that now “controls” the heart and listening for the pacer and watching the monitor and its electrodes. In the second phase, post-discharge, he begins to feel safe from continual symptoms and adjusts his activities to the limitations of the pacemaker, often fantasizing about the pacemaker’s function. He is often quite preoccupied with trying to cover up the characteristic pacemaker bulge and depression is often quite evident. In the third phase the patient learns to integrate the pacemaker into everyday life. Patients who are adjusting successfully to the pacer return to maximum daily activity with only minimum concern over the pacemaker. Those who are experiencing difficulty with adjustment center their entire lives around the “machine” and prepare themselves for their future medical appointments and battery changes. The researchers identified feelings of depression and loss of mastery as common reactions. Few of the patients could actually conceptualize the function of the pacer in realistic terms, attributing other concerns such as impotence or increases in sexual activity to the presence of the pacemaker.
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More bizarre “complaints” such as increased radio static and television interference were not uncommon. A few patients expressed a feeling of “differentness” after their implantation and were self-conscious about their pacemaker. The reports of these researchers clearly indicate that the patients require more information about their condition in order to reduce their misconceptions. THE ELDERLY POPULATION
It is generally recognized that most pacemaker patients will be 60 years of age or older, yet little has been mentioned in the literature about the specific difficulties encountered by these geriatric patients. In 1971 Timmis et al. observed that the advent of the transvenous endocardial pacing system enabled the geriatric patient to be considered for a permanent pacemaker [16]. Bain noted that the advanced age of pacemaker patients and their resulting physical state may be responsible for non-critical but nevertheless important problems in their medical management, citing one difficulty as the possible breakdown of the delicate aging skin covering the battery under such minimal irritation as bra strap friction [17]. In assessing the problems encountered with cardiac pacemakers in the aged, Witt concluded that the ultimate success of the procedure depends on a combination of surgical skills and emotional support [18]. Recognizing that permanent pacemakers are indicated most often in geriatric patients, Kos and Culbert confronted the issue of teaching the geriatric patient about his pacemaker by taking into account the various cognitive decrements accompanying the aging process [19]. Our experiences at the New Britain General Hospital have been mainly with the elderly patient. During the first year of our program 11 per cent of the pacemaker patients were under sixty-five years old, 32 per cent between sixtyfive and seventy-five years, and 57 per cent older than seventy-five years. The ages ranged from fifty-three to eighty-nine with an average of seventy. While the adaptive patterns of the oldest group were similar to the younger, there were observable differences in their reactions to the pacemaker. Following their operations, the majority adjusted successfully when compared to Kimball’s criteria [9]. Many simply expressed their thankfulness that even though they might be nearing the end of their lives they could be relieved of their symptoms and possibly be granted an extension of their lives. While many showed a lively curiosity about the “gadget,” a number stated that they did not want to be bothered with even a simple explanation, for they were “too old to understand” such things. There was only moderate anxiety about side effects and battery replacements in the over seventy-five age group and overt depression was not common. A few patients, though, were convinced that the decision for their pacemaker implantation was wrong, that it went against God, that they were too old and sick to benefit, or that they wanted to die in peace without the
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pain. The most troublesome difficulty experienced appeared to be postoperative confusion, exhibited by about one-fourth of this age group and usually lasting, at the most, only a few days. While such confusion is an accepted phenomenon in elderly surgical patients, it is, nevertheless, the cause of great anxiety to the staff, the patient and his family [20]. In the younger age group, the majority adjusted successfully, but there was a noticeably greater anxiety about side effects, possible pacemaker failure and battery replacements. More overt depression and vocalization about possible death was also noticed. Concerns about activities were prevalent, and the phrase “Can I .?” was heard often. Although there were fewer problems of rejection, some patients needed to be convinced that the pacemaker was medically indicated for their condition. There was usually an intense interest in the pacemaker, the procedure and the experiences of their peers. In general, the oldest patients were more passive in their acceptance of the pacemaker but displayed more behavior resembling psychosis. The youngeraged group exhibited more anxiety and depression while showing more concern about returning to a limit-free life without diminished capacity for activities.
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Pacemaker Support Program The research reviewed here suggests that one-fourth to one-third of the patients receiving permanent pacemakers experienced serious difficulties adjusting to their medical condition. The maladaptive behaviors of these patients often interfere with their hospital management and recovery, as well as their reintegration into family and community. Anxiety and depression, along with denial, fantasizing and dependency are all behaviors which are commonly seen in the pacemaker patients. The anxiety expressed by the patient may be a manifestation of fear of the unknown, unfamiliar hospital procedures and surroundings, unpredictable medical course, unknown future and possible death. Further, pacemaker patients often experience a period of depression after implantation, usually seen as a result of his loss of control. He has little influence on the hospital routine that proceeds around him, family and financial concerns may be outside of his control, even his bodily functions may be controlled by drugs and, finally, his heart beats are controlled by a machine. While some of the extremes in behavior may be organic in basis, psychological causes may be at the root of most patients’ maladaptive behavior. Even if organic causes are implicated, psychological intervention may reduce the degree of the undesired behavior. Several authors offer suggestions as to why these behaviors are prevalent [2, 5 , 11, 21, 221, as summarized in the following two statements: 1. The patient does not have enough information or sufficient understanding of his medical condition to deal realistically with the present or future.
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2. The patient does not have the psychosocial supports which would enable him to cope effectively. In an attempt to facilitate the patient’s medical management and recovery, and in order to.assist in his functional reintegration into family and community, we have offered pacemaker education and psychological counseling through a Pacemaker Support Program at the New Britain General Hospital. EDUCATION PHASE
The typical pacemaker patient, unfamiliar with or only partially informed about the mechanisms of the heart and the pacemaker, frequently fantasizes about heart/pacemaker function and consequently takes inappropriate precautions. The goal of the pacemaker education program at New Britain General Hospital (NBGH) is to inform the patient about his heart and his pacemaker so he can take full advantage of the pacemaker in his daily life and still appreciate its limitations. The program begins when the medical staff decides that a pacemaker is the treatment of choice and continues until the patient and his family have no further questions or concerns. The program is carried out in the coronary care unit, on the medical floor, in the pacemaker clinic, and, more recently, in rest homes, convalescent homes, and public health nursing associations. The rate at which the teaching proceeds takes into consideration both the mental and emotional state of the patient. Many of the geriatric patients have experienced a significant decline in their cognitive integration and memory, some may have visual or auditory handicaps, and several of our foreign-born elderly patients speak limited English. The program is individualized to the needs of each patient [ 181 , instruction is continued at a rate at which the patient can comprehend and participate, and the intellectual level and the psychological strengths of the patient and his family are also taken into account. We have observed that it is extremely important to assess the extent to which the patient may be using denial as a psychological defense mechanism. Although evidence indicates that the moderate use of denial by the cardiac patient is correlated with a healthy course of adjustment, problems often accompany excessive use of denial [23]. When a patient is heavily dependent upon denial for stability, our efforts may trigger other nonfunctional behavior, and we proceed only as long as the patient can tolerate the information without breaking his defense. One example of this approach involved a younger female patient, described by her family as noticeably depressed after a series of pacemaker failures and replacements. Since she allowed only superficial discussion of the pacemaker and her experiences, denying any concern about her hospitalization and insisting that her doctor knew everything that was necessary, no further attempt was made to continue pacemaker education at
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that time. Instead, she was given the Heart Association booklet on pacemakers without comment and was visited while hospitalized in a friendly, supportive manner by the hospital personnel. It was not until her visits to the outpatient clinic that she slowly began to express her concerns as others at the clinic described their fears and anxieties about the possibility of pacemaker failure. Subsequently, she became more interested in the indications for her pacemaker and actively solicited more information. When possible, we include the patient’s spouse or concerned relatives in the education phase since they often provide a major source of psychological support, and since their knowledgeability about the pacemaker can prevent later unfortunate restrictions or overlooked precautions. An example of misplaced family concern observed at our hospital was an elderly but active man whose uninformed wife prohibited him from using any electrical equipmeqt such as the television or light switches. The NBGH education program is conducted by a team composed of the social worker, nurses and doctors who are directly concerned with the patient, with the social worker assuming the major coordinating role. The personnel on the team have familiarized themselves with the physiological indications for pacing, the mechanism of the pacemaker used and the procedure and environment in which the pacemaker operation is performed. They are also kept informed about the precautions for pacemaker patients, the side effects they may experience, the reasons for common complications and finally, the follow-up procedure used in the community. We have concluded that a patient’s successful adjustment requires that he be familiar with several basic concepts of cardiovascular and pacemaker function: a) the basic function of the heart, b) the concept of “heart block” or the patient’s individual medical indication for the pacemaker, c) the function of the pacemaker, d) specific terminology relating to the patient’s medical condition, and e) the technique of counting one’s pulse if recommended by the physician. In addition, the patient should be informed of the importance of regular physical activity, the limitations which should be observed, and the importance of adhering to the medical follow-up regimen (similar suggestions have been made by Kos and Culbert [19]). When patients are scheduled for visits to the pacemaker clinic they are also made aware of the purpose of such follow-up, i.e., detecting premature pacer failures and extending the life of the pacemaker units when possible. Before this information was available to the patients, numerous misconceptions were prevalent; now the incidence of patient fantasies has noticeably declined. Although it is not often used, a model pacemaker is available to the staff, and can help to clarify to a patient practical matters such as size, shape, and composition. Further, it adds to the reality of the patient’s experience by allowing him to visualize what will be a part of his body [18]. Patients may also request a copy of the American Heart Association’s booklet entitled
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“Living with Your Pacemaker”; all patients receive a copy of the booklet which accompanies their pacemaker. Some preoperative patients seriously doubt their ability to survive the pacemaker implantation operation, while others doubt their postoperative ability to lead reasonably normal lives. In many cases these fears may best be allayed by observing and conversing with an individual who has successfully adjusted to the pacemaker experience [24]. The NBGH is fortunate to have a staff physician who has a pacemaker and who has been helpful in this manner. COUNSELING PHASE
The goal of the counseling phase of the pacemaker support program is to assist the patient in making the best possible psychosocial adjustment to his medical situation, allowing the patient to maintain his or her personal interests, goals, and social relationships. The counseling staff can reassure the patient and his family that many uncomfortable emotions they are experiencing are normal, can offer support to them during the expected period of adjustment, and can be available when special difficulties arise. As with the education program, contact with the patient is made prior to surgery when the patient’s anticipatory anxiety appears greatest. The interviewing social worker explains the purposes and structure of the program, emphasizing to the patient that these services are offered to all pacemaker patients during and after hospitalization, and that his concerns may not be unusual for a pacemaker patient. This visit offers an opportunity for the patient to express his fears and can often serve as a forum to discuss situations which must be resolved before surgery proceeds. An example follows: Mr. F, 68, was a tense, anxious man whom his family doctor had recommended for a pacemaker for alternating bradycardic/tachycardic attacks. After his admission while awaiting surgery, he became increasingly agitated. When his cardiologist explained that the pacemaker would prevent only the bradycardia and he would remain on medication, he began to express paranoid feelings. He attempted to play staff members against each other to find discrepancies in their instructions and he threatened to leave against medical advice unless he could be guaranteed relief from his symptoms. During the preoperative ,social work interview it was discovered that Mr. F was an intelligent, though uneducated man and had read all literature available to him on pacemakers and medication. It was clear that he felt he had been tricked into giving his consent for the operation, and that the issue at the root of his behavior was control. The social worker and the cardiologist carefully discussed the patient’s cardiac condition and pacemaker therapy with him, along with possible prognoses and problems, and opportunity was given for his many, very sophisticated questions. He was then left with his family, who had previously approached the social worker about his behavior, to decide
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himself about pacemaker surgery. He consented and the procedure was performed that afternoon. Although Mr. F is still a tense appearing man and still experiences some symptoms, he talks positively of his pacemaker decision. His physician has continued to allow Mr. F as much control as possible in his medical management. At NBGH the social worker has accepted the primary responsibility for assessing the psychosocial adjustment of all patients. In making the evaluation, the following factors have been shown to be of primary importance [4] : 1. the personality structure of the patient and how he utilizes psychosocial defense mechanisms; 2. the patient’s attitude toward his illness and the meaning of his illness in his life; 3. the patient’s expectation of what the operation will do for him; 4. the network of his relationships with relatives and friends, and their reliability.
The patient’s adjustment pattern is continuously compared to Kimball’s criteria for successful adjustment by assessing the patient’s level of anxiety and depression and his relationship to the present and the future [9]. Counseling is offered to those patients who exhibit extremes in any of these parameters or whose adjustment in any of these areas is causing them distress. The counseling situations which have arisen since the program was initiated have been varied in both content and depth. One elderly patient was discovered weeping after his implant. The cause was finances: he did not realize Medicare would cover the procedure and the prosthesis. Another patient, not yet eligible for Medicare and ineligible for Medicaid benefits, was having difficulty meeting the cost of the pacemaker clinics. A brief explanation of Medicare reassured the elderly patient; a discussion of the hospital credit plan and referral to possible private financial resources succeeded in lessening the latter patient’s anxiety. Although a patient’s concerns about disability and dependence on the prosthesis are most often resolved through time and the absence of further symptoms, many of the more active patients have responded to counseling as an opportunity to explore their fears that the pacemaker will limit their lifestyles. It is occasionally necessary to provide support for a patient who is faced with the possibility of early retirement. The counseling program has also helped the hospital staff deal more effectively with patients who experience confusion following their implant or those who have experienced psychiatric difficulties in the past. For those patients whose pacemaker therapy is unsuccessful or whose death is approaching for other reasons, counseling can provide the opportunity for release of their grief and, commonly, their anger at the failure of the “life-saving device.” It occasionally becomes clear that family members contribute to the
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patient’s maladaptive behavior or are themselves having difficulties. In one family, the daughter of an elderly depressed patient displayed her impatience and embarrassment about her mother’s slow unsure activities while her mother continued to withdraw even further into inactivity. In counseling, the daughter was offered the opportunity to ventilate her anger at her added responsibility because of her mother’s declining condition and to express her concerns for her mother’s health; she began to better understand the process of aging and appreciate more realistically the limitations as well as the possibilities of her mother’s condition. The positive effects of family members’ cooperation in offering support and reassurance to the patients cannot be overlooked. PACEMAKER CLINIC
To ensure that the patient’s medical and emotional condition will continue to improve, a third phase of the program has been established for the hospital outpatient. Each patient is seen in the pacemaker clinic regularly after his initial implantation after the first, sixth, twelfth, and eighteenth month, and thereafter each month until the pacemaker is replaced. At these regular checkups the education and counseling phases of the program also continue. For the occasional patients who, through denial, neglect to follow medical advice or avoid visiting the clinic until serious problems have arisen [14], the medical social worker can be available as an outreach worker for the clinic, facilitating medical follow-up. When the pacemaker clinic was first initiated, the social worker met individually with the approximately ten patients and their families at each clinic to assist with any concerns that they might have had. As the size of the clinic increased to approximately thirty individuals, an informal group education and counseling experience was organized for patients to share common experiences and problems, offer each other support for individual concerns, and discuss their progress. New members are welcomed enthusiastically and assured by the group that the clinic examination is both important and uncomplicated. This informal group has proven so successful that we have now formalized it by offering a coffee hour for the patients and their families following their examination. AUXl LlARY SERVICES
It is important that the unique medical and psychological needs of discharged patients be recognized by the appropriate auxiliary services. For the patient returning home, the Medical Social Service Department coordinates with the hospital‘s Home Care Department, the Visiting Nurses’ Association in the community, and community counseling resources to meet a patient’s special needs. For some patients many auxiliary services must be mobilized:
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After undergoing four battery replacements due to continued painful infections, Mr. L, a 66-year-old Spanish speaking man, refused a fifth pacemaker. Although he had a regular heart rate of less than 50 he was still able to function, albeit with severe limits on his activities. When his wife learned that he had refused further surgical treatment, she became highly agitated; they had been married less than two years, this being their second marriage each, and Mrs. L had just experienced a heart attack. The social worker and a Spanish-speaking social work assistant initially worked intensively with this family around the multiple issues involved: 1) Mr. L‘s conflicts about dependency, 2) Mrs. L’s fears of loss and death, 3) the realities of their physical conditions, and 4) their future care (independent living versus placement). Auxiliary services were involved as plans were made for them to remain in an independent living situation with family assistance. A community counseling agency aided the couple in finding suitable housing and stimulated the involvement of their families. The Visiting Nurses’ Association provided emotional support and physical monitoring for the couple. Arrangements were made through a community mental health agency for a Spanish speaking psychiatrist to be available to Mrs. L. Transportation for clinic appointments was also arranged through a local agency. When a patient is discharged to an extended care facility or to a rest home, the Social Service Department staff informs the personnel in these facilities of the patient’s unique requirements by involving them, when appropriate, in team conferences about the patients who will be discharged to their care. The Social Service Department, in cooperation with the Home Care and Cardiology Departments of the hospital, has been available to present special educational programs for these agencies upon request.
Summary The psychosocial difficulties experienced by the pacemaker patients adapting to their dependence on a prosthesis have been documented in the literature and observed at our hospital. The difficulties they experience have interfered with their medical management and with their future adjustment. Their successful adjustment may be further complicated by their advanced age. The New Britain General Hospital pacemaker support program was instituted to offer comprehensive psychosocial support for the pacemaker patient by ensuring that the patient is properly educated about his medical condition and that his adjustment is evaluated on a continuing basis. When patients experience difficulty in adjustment, a program of psychological and social intervention is available. The pacemaker clinic not only deals with the mechanical aspects of the pacemaker, but also provides patients with a valuable opportunity to explore their unique problems with a peer group. The
PSYCHOSOCIAL NEEDS OF PACEMAKER PATIENTS / 371
cooperation of other departments and agencies serving the pacemaker patient is also an important facet of the program. During the Six months prior to the beginning of the program twenty patients were hospitalized for pacemaker-related procedures: thirteen new implants, three revisions and four replacements. No coordinated attempt was made to instruct these patients; those patients exhibiting psychosocial difficulties were referred to the Social Services Department after significant problems had developed. Of these twenty patients, nine or 45 per cent were referred for social work involvement. During the first year of the program a total of thirty-five pacemaker patients were hospitalized. Sixteen patients received new implants, six received revisions and thirteen were admitted for replacements. Virtually all patients were seen by the hospital staff for instructions regarding their pacemakers, and 80 per cent were interviewed by the social worker. Of these thirty-five patients, only five or 15 per cent were engaged in formal counseling for problems relating to their pacemaker experience. The support program was implemented at a modest cost and was offered without charge to the patients, incorporated into the ongoing structure of the Medical Social Service Department with the cooperation of the Department of Cardiology. The staff time required by the program was also modest and varied with the number of currently active pacemaker cases. The program has been accepted enthusiastically by the medical staff, nursing staff, auxiliary services and by the patients themselves. The favorable reception this program has received indicates that a similar program could be readily implemented at other general hospitals to provide a beneficial service by better preparing the patient for his prosthesis and by being prepared to intervene with patients, families and hospital staff as psychosocial concerns arise. REFERENCES
1. M. Aronson, How to Help Patients Accept Life-sustaining Devices, Med. Sur. Rev., 12, pp. 34-43, 1970. 2. W. A. Green and A. J. MOSS, Psychosocial Factors in the Adjustment of Patients with Permanently Implanted Cardiac Pacemakers, Ann. Intern. Med., 70, pp. 897-902, 1969. 3. M. D. Altschule, Post Operative Psychosis, Surg. Clin. North A m . , 49, pp. 677-682, 1969. 4. Clinical Conference, Roosevelt Hospital: Psychological Aspects of Cardiac Surgery, Int. J. Psychiat. in Med., 3, pp. 239-250, 1972. 5 . S. S. Heller, K. A. Frank, J. R. Malm, et al., Psychiatric Complications of Open Heart Surgery: A Reexamination, N e w Engl. J. Med., 279, pp. 13651370, 1968. 6. C. P. Kimball, Psychological Responses to the Experience of Open Heart Surgery, Amer. J. Psychiat., 126, pp. 348-359, 1969.
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7. D. S. Kornfield, S. Zimberg and J. R. Malm, Psychiatric Complications of Open Heart Surgery, New Engl. J. Med., 273, pp. 287-292, 1965. 8. J. A. Kennedy and H. Bakst, The Influence of Emotions on the Outcome of Cardiac Surgery: A Predictive Study, Bull. Acad. Med., 42, pp. 81 1845, 1966. 9. C. P. Kimball, A Predictive Study of Adjustment to Cardiac Surgery, J. Thorac. Cardiovasc. Surg., 58, pp. 891-896, 1969. 10. B. M. Dlin, H. K. Fischer and B. Huddell, Psychological Adaptation t o the Pacemaker and Open Heart Surgery, Arch. Gen. Psychiat., 19, pp. 599-608, 1968. 11. C. P. Kimball, The Experience of Open Heart Surgery, Arch. Gen. Psychiat., 19, pp. 599-608, 1968. 12. H. T. Tufo, A. M. Ostfeld and R. Shekelle, Central Nervous System Dysfunction Following Open Heart Surgery, JAMA, 212, pp. 1333-1339, 1972. 13. M. C. Becker, I. R. Zucker, V. Parsonnet and L. Gilbert, Rehabilitation of the Patient with Permanent Pacemaker, Geriatrics, 22, pp. 106-1 11, 1967. 14. B. S. Goldman, E. J. Noble and D. C. MacGregor, Pacemaker Panic, Amer. J. Cardiol., 30, p. 705, 1972. 15. R. S. Blacher and S. H. Basch, Psychological Aspects of Pacemaker Implantation, Arch. Gen. Psychiat., 22, pp. 3 19-323, 1970. 16. G. Timmes, S. Gordeon and R. Ramos, Heart-block in the Aged: Is the Patient Too Old to be Permanently Paced?, Chest, 60, pp. 113-1 14, 1971. 17. B. Bain, Pacemakers and the People who Need Them, Amer. J. Nurs., 71, pp. 1582-1586, 1971. 18. C. Witt, Problem With Cardiac Pacemakers in the Aged, Geriatrics, 27, pp. 92-95, 1972. 19. B. A. Kos and P. A. Culbert, Teaching the Patient with the Pacemaker, Cardiovasc. Nurs., 6, pp. 57-60, 1970. 20. K. Newton and H. Anderson, Geriatric Nursing, Mosby, St. Louis, 1966. 21. N. H. Cassem and T. P. Hackett, Psychiatric Consultation in the Coronary Care Unit, Ann. Intern. Med., 75, pp. 9-14, 1971. 22. T. P. Hackett, N. H. Cassem and H. A. Wishnie, The Coronary Care Unit: An Appraisal of its Psychological Hazards, New Engl. J. Med., 279, pp. 1365-1370, 1968. 23. W. D. Gentry, S. Foster and T. Hanay, Denial as a Determinant of Anxiety and Perceived Health Status in the Coronary Care Unit, Psychosom. Med., 34, pp. 39-44, 1972. 24. C. Williams, The CCU Nurse Has a Pacemaker, Amer. J. Nurs., 27, pp. 900-902, 1972.
Direct reprint requests to: Katherine A. Frank Hesse, M.S.W. Box HC 35 University of Connecticut Health Center Farmington, Connecticut 06032
MEETING THE PSYCHOSOCIAL NEEDS OF PACEMAKER PATIENTS
KATHERINE A. FRANK HESSE, MSW Department of Medical Social Service New Britain General Hospital
ABSTRACT
A review of the literature concerning patients who have received permanently implanted cardiac pacemakers indicates that a substantial number of these patients experience difficulties in adjusting to their medical condition. Common feelings among these patients are anxiety and depression. It is suggested that difficulties often arise from the patient’s misconceptions about the pacemaker and inadequate psychosocial support. To assist such patients in their adjustment, the Pacemaker Support Program was developed to provide psychosocial counseling and pacemaker education from the preoperative phase through to the outpatient pacemaker follow-up clinic phase. In the year of the program’s operation a marked decline in adjustment problems has been observed, the program has been readily integrated into the hospital routine, and it has been enthusiastically accepted by both the hospital staff and the patients.*
Permanent cardiac pacemaker implantation is considered a relatively minor surgical procedure involving an uncomplicated prosthesis. The psychosocial implications for the patient, however, are often major. Reactions of individuals to life-sustaining devices reveal that their new dependence on the prosthesis requires immense physical, psychological and social adaptation [l] . While less physical adaptation may be necessary for the pacemaker patient compared to the amputee or the kidney dialysis patient, the psychosocial adaptations to the prosthesis may be significant. When the decision to implant a permanent pacemaker is made, the patient is seldom psychologically prepared for his future dependence on a machine. Although there is ample literature detailing the effects of heart disease and heart surgery on the psychosocial adjustment of the patient and his family,
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This program was developed in cooperation with Charles Leach, Jr., M.D., Director of Cardiology, New Britain General Hospital, New Britain, Connecticut. 359
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doi: 10.2190/68EL-UAHR-2QF3-8Y9W http://baywood.com
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only a few studies have dealt specifically with the adjustment problems of the pacer patient, indicating that the majority of such patients successfully adjust after what has been termed a “testing stage” [2]. There remains, however, an important minority of pacer patients who experience serious and continuing psychosocial difficulties. While several authors have recognized the need for a comprehensive program of psychosocial supports for these patients, no such a program has been reported in the literature. Because of the adjustment and management difficulties of many of our pacemaker patients, the Medical Social Service Department, in conjunction with the Department of Cardiology at the New Britain General Hospital, implemented a program aimed at providing for the needs of these patients.
Psychosocial Factors in Heart Disease and Cardiac Surgery The possibility of postoperative psychosis accompanies any major surgery [3]. Because of the fantasies and myths associated with the heart, patients undergoing heart surgery appear even more prone than most to a wide range of maladaptive behavior such as psychosis, delirium, depression, anxiety and agitation [4-71. Kennedy and Baskt examining the cardiac patient’s reactions during hospitalization, concluded that anxiety was the root of the patient’s maladaptive behavior [8]. Faced with a “threefold payload of anxiety”-pain, impairment or death, and restrictions or limits in the future-the patient unable to cope successfully with any of these factors can manifest maladap tive behavior which may adversely influence the outcome of his treatment. Patients who successfully adjusted to their cardiac condition were observed by Kimball to exhibit only a moderate amount of anxiety, an absence of prolonged depressions, a strong relationship with the present and a strong orientation to the future [9]. The psychologically healthy patient is aware of and can accept his illness by maintaining a psychological “hyperpreparedness” for the imminent struggle and a realistic view of his survival and recovery expectations [ 101 . Other investigators have noted the involvement of organic factors in maladaptive behavior: drug reactions, blood gas and electrolyte disorders, sleep deprivation, sensory deprivation or over-inclusion, and nutritional disorders [3, 7, 113. Organic central nervous system disorders caused by cardiac arrhythmias have also been implicated in abnormal behavior [12]. These maladaptive reactions, whether temporary or long-term, mild or extreme, pose immediate problems for the hospital staff in maintaining effective and efficient medical management of the cardiac patient and may also interfere with the patient’s eventual reintegration into family and community and their continued medical care. Although these unusual behaviors have been reported primarily in patients who have undergone open-heart
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surgery, our experience indicated that pacemaker patients undergo many of the same ordeals and react with many of the same psychological patterns.
Psychosocial Aspects of Pacemaker Adaptation Early studies of pacemaker patients dealt exclusively with the pacemaker itself and surgical techniques. The first report of psychosocial factors [13] evaluated the physical rehabilitation of ninety-seven pacemaker patients and also judged that 69 per cent of the surviving patients had successfully adjusted, 4 per cent demonstrated severe anxiety, 18 per cent used excessive denial, and 9 per cent were markedly depressed (thus, an estimated 31 per cent of the surviving patients exhibited maladaptive behavior patterns). Depression and anxiety reactions can occur in pacer patients at the time of the initial operation, during clinic visits or at the time of battery replacement. As observed by Goldman et al. [14], much could be done to alleviate the patient’s anxiety and to promote a more optimistic outlook if the medical staff would make the effort to ensure that the patient and his family fully understand the pacer and its functions. Realistic reassurance in response to the patient’s obviously anxious queries is a simple, but often overlooked therapeutic technique; in their view, the staff must acquire an increased awareness of these unique problems of this group of patients in order to effectively identify and respond to their psychological disturbances. STAGES IN ADJUSTMENT
Other studies of psychosocial factors in pacemaker adjustment focus on stages. Green and Moss [2] divided the patient’s recovery into two periods: 1. the acute adjustment phase, from the time of pacer implantation to one
week post-operative, and 2. the subacute phase, lasting from one week to six months after implantation. The primary affect indicating a patient’s difficulty in adjusting during the acute phase was anxiety. Twenty-one per cent of the patients showed “relative” concern over their condition. Six per cent first rejected, then regretted the decision to have a pacemaker implanted, stating that they would rather die than be dependent on the pacemaker (shortly after their operation one-half of these patients did expire). In all, the researchers concluded that 27 per cent of the patients adjusted poorly during t h i s acute phase. During this acute phase most patients, even the successfully adjusting patients, showed clinical symptoms of depression. The researchers described this as a testing period during which the patients awaited the reassurance by experience that they would not have continued symptoms. Even the welladjusted group showed “relative” concern over their pacemakers’ functioning,
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particularly the batteries and their replacement, and such physiological reactions as diaphragmatic contractions. Men were often concerned about the pacemakers enlarging their breast area, and some women were frightened by the sight of the incision. During the subacute stage approximately three-fourths of the patients were judged to have successfully adapted: many patients resumed their hobbies, and re-established interpersonal relationships, and some resumed sexual activity. The quarter who experienced psychosocial problems expressed primarily anger and depression in response to unanticipated pacemaker problems such as wire breakage, repositioning, battery failure and skin erosion over the battery site, and anticipated problems such as checkups and battery changes. In general, the research group concluded that positive pacemaker adjustment requires three factors: 1. ancillary good health, 2. effective pacemaker functioning, and 3. meaningful interpersonal relationship with either a spouse or attentive children.
They observed that the patient who had symptoms for a long period of time adjusted better to his pacer than the patient with short, prodromal symptoms and suggested that the patient’s ability to adjust to the pacemaker may have paralleled his previous adjustment to other prostheses such as false teeth, hearing aids, or artificial limbs. Blacher and Basch divided the pacemaker patient’s progress into three phases of adaptation [15]. During the first period, preoperative and during the hospital stay, the patient deals with “life and death” matters, often concerned with the machinery that now “controls” the heart and listening for the pacer and watching the monitor and its electrodes. In the second phase, post-discharge, he begins to feel safe from continual symptoms and adjusts his activities to the limitations of the pacemaker, often fantasizing about the pacemaker’s function. He is often quite preoccupied with trying to cover up the characteristic pacemaker bulge and depression is often quite evident. In the third phase the patient learns to integrate the pacemaker into everyday life. Patients who are adjusting successfully to the pacer return to maximum daily activity with only minimum concern over the pacemaker. Those who are experiencing difficulty with adjustment center their entire lives around the “machine” and prepare themselves for their future medical appointments and battery changes. The researchers identified feelings of depression and loss of mastery as common reactions. Few of the patients could actually conceptualize the function of the pacer in realistic terms, attributing other concerns such as impotence or increases in sexual activity to the presence of the pacemaker.
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More bizarre “complaints” such as increased radio static and television interference were not uncommon. A few patients expressed a feeling of “differentness” after their implantation and were self-conscious about their pacemaker. The reports of these researchers clearly indicate that the patients require more information about their condition in order to reduce their misconceptions. THE ELDERLY POPULATION
It is generally recognized that most pacemaker patients will be 60 years of age or older, yet little has been mentioned in the literature about the specific difficulties encountered by these geriatric patients. In 1971 Timmis et al. observed that the advent of the transvenous endocardial pacing system enabled the geriatric patient to be considered for a permanent pacemaker [16]. Bain noted that the advanced age of pacemaker patients and their resulting physical state may be responsible for non-critical but nevertheless important problems in their medical management, citing one difficulty as the possible breakdown of the delicate aging skin covering the battery under such minimal irritation as bra strap friction [17]. In assessing the problems encountered with cardiac pacemakers in the aged, Witt concluded that the ultimate success of the procedure depends on a combination of surgical skills and emotional support [18]. Recognizing that permanent pacemakers are indicated most often in geriatric patients, Kos and Culbert confronted the issue of teaching the geriatric patient about his pacemaker by taking into account the various cognitive decrements accompanying the aging process [19]. Our experiences at the New Britain General Hospital have been mainly with the elderly patient. During the first year of our program 11 per cent of the pacemaker patients were under sixty-five years old, 32 per cent between sixtyfive and seventy-five years, and 57 per cent older than seventy-five years. The ages ranged from fifty-three to eighty-nine with an average of seventy. While the adaptive patterns of the oldest group were similar to the younger, there were observable differences in their reactions to the pacemaker. Following their operations, the majority adjusted successfully when compared to Kimball’s criteria [9]. Many simply expressed their thankfulness that even though they might be nearing the end of their lives they could be relieved of their symptoms and possibly be granted an extension of their lives. While many showed a lively curiosity about the “gadget,” a number stated that they did not want to be bothered with even a simple explanation, for they were “too old to understand” such things. There was only moderate anxiety about side effects and battery replacements in the over seventy-five age group and overt depression was not common. A few patients, though, were convinced that the decision for their pacemaker implantation was wrong, that it went against God, that they were too old and sick to benefit, or that they wanted to die in peace without the
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pain. The most troublesome difficulty experienced appeared to be postoperative confusion, exhibited by about one-fourth of this age group and usually lasting, at the most, only a few days. While such confusion is an accepted phenomenon in elderly surgical patients, it is, nevertheless, the cause of great anxiety to the staff, the patient and his family [20]. In the younger age group, the majority adjusted successfully, but there was a noticeably greater anxiety about side effects, possible pacemaker failure and battery replacements. More overt depression and vocalization about possible death was also noticed. Concerns about activities were prevalent, and the phrase “Can I .?” was heard often. Although there were fewer problems of rejection, some patients needed to be convinced that the pacemaker was medically indicated for their condition. There was usually an intense interest in the pacemaker, the procedure and the experiences of their peers. In general, the oldest patients were more passive in their acceptance of the pacemaker but displayed more behavior resembling psychosis. The youngeraged group exhibited more anxiety and depression while showing more concern about returning to a limit-free life without diminished capacity for activities.
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Pacemaker Support Program The research reviewed here suggests that one-fourth to one-third of the patients receiving permanent pacemakers experienced serious difficulties adjusting to their medical condition. The maladaptive behaviors of these patients often interfere with their hospital management and recovery, as well as their reintegration into family and community. Anxiety and depression, along with denial, fantasizing and dependency are all behaviors which are commonly seen in the pacemaker patients. The anxiety expressed by the patient may be a manifestation of fear of the unknown, unfamiliar hospital procedures and surroundings, unpredictable medical course, unknown future and possible death. Further, pacemaker patients often experience a period of depression after implantation, usually seen as a result of his loss of control. He has little influence on the hospital routine that proceeds around him, family and financial concerns may be outside of his control, even his bodily functions may be controlled by drugs and, finally, his heart beats are controlled by a machine. While some of the extremes in behavior may be organic in basis, psychological causes may be at the root of most patients’ maladaptive behavior. Even if organic causes are implicated, psychological intervention may reduce the degree of the undesired behavior. Several authors offer suggestions as to why these behaviors are prevalent [2, 5 , 11, 21, 221, as summarized in the following two statements: 1. The patient does not have enough information or sufficient understanding of his medical condition to deal realistically with the present or future.
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2. The patient does not have the psychosocial supports which would enable him to cope effectively. In an attempt to facilitate the patient’s medical management and recovery, and in order to.assist in his functional reintegration into family and community, we have offered pacemaker education and psychological counseling through a Pacemaker Support Program at the New Britain General Hospital. EDUCATION PHASE
The typical pacemaker patient, unfamiliar with or only partially informed about the mechanisms of the heart and the pacemaker, frequently fantasizes about heart/pacemaker function and consequently takes inappropriate precautions. The goal of the pacemaker education program at New Britain General Hospital (NBGH) is to inform the patient about his heart and his pacemaker so he can take full advantage of the pacemaker in his daily life and still appreciate its limitations. The program begins when the medical staff decides that a pacemaker is the treatment of choice and continues until the patient and his family have no further questions or concerns. The program is carried out in the coronary care unit, on the medical floor, in the pacemaker clinic, and, more recently, in rest homes, convalescent homes, and public health nursing associations. The rate at which the teaching proceeds takes into consideration both the mental and emotional state of the patient. Many of the geriatric patients have experienced a significant decline in their cognitive integration and memory, some may have visual or auditory handicaps, and several of our foreign-born elderly patients speak limited English. The program is individualized to the needs of each patient [ 181 , instruction is continued at a rate at which the patient can comprehend and participate, and the intellectual level and the psychological strengths of the patient and his family are also taken into account. We have observed that it is extremely important to assess the extent to which the patient may be using denial as a psychological defense mechanism. Although evidence indicates that the moderate use of denial by the cardiac patient is correlated with a healthy course of adjustment, problems often accompany excessive use of denial [23]. When a patient is heavily dependent upon denial for stability, our efforts may trigger other nonfunctional behavior, and we proceed only as long as the patient can tolerate the information without breaking his defense. One example of this approach involved a younger female patient, described by her family as noticeably depressed after a series of pacemaker failures and replacements. Since she allowed only superficial discussion of the pacemaker and her experiences, denying any concern about her hospitalization and insisting that her doctor knew everything that was necessary, no further attempt was made to continue pacemaker education at
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that time. Instead, she was given the Heart Association booklet on pacemakers without comment and was visited while hospitalized in a friendly, supportive manner by the hospital personnel. It was not until her visits to the outpatient clinic that she slowly began to express her concerns as others at the clinic described their fears and anxieties about the possibility of pacemaker failure. Subsequently, she became more interested in the indications for her pacemaker and actively solicited more information. When possible, we include the patient’s spouse or concerned relatives in the education phase since they often provide a major source of psychological support, and since their knowledgeability about the pacemaker can prevent later unfortunate restrictions or overlooked precautions. An example of misplaced family concern observed at our hospital was an elderly but active man whose uninformed wife prohibited him from using any electrical equipmeqt such as the television or light switches. The NBGH education program is conducted by a team composed of the social worker, nurses and doctors who are directly concerned with the patient, with the social worker assuming the major coordinating role. The personnel on the team have familiarized themselves with the physiological indications for pacing, the mechanism of the pacemaker used and the procedure and environment in which the pacemaker operation is performed. They are also kept informed about the precautions for pacemaker patients, the side effects they may experience, the reasons for common complications and finally, the follow-up procedure used in the community. We have concluded that a patient’s successful adjustment requires that he be familiar with several basic concepts of cardiovascular and pacemaker function: a) the basic function of the heart, b) the concept of “heart block” or the patient’s individual medical indication for the pacemaker, c) the function of the pacemaker, d) specific terminology relating to the patient’s medical condition, and e) the technique of counting one’s pulse if recommended by the physician. In addition, the patient should be informed of the importance of regular physical activity, the limitations which should be observed, and the importance of adhering to the medical follow-up regimen (similar suggestions have been made by Kos and Culbert [19]). When patients are scheduled for visits to the pacemaker clinic they are also made aware of the purpose of such follow-up, i.e., detecting premature pacer failures and extending the life of the pacemaker units when possible. Before this information was available to the patients, numerous misconceptions were prevalent; now the incidence of patient fantasies has noticeably declined. Although it is not often used, a model pacemaker is available to the staff, and can help to clarify to a patient practical matters such as size, shape, and composition. Further, it adds to the reality of the patient’s experience by allowing him to visualize what will be a part of his body [18]. Patients may also request a copy of the American Heart Association’s booklet entitled
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“Living with Your Pacemaker”; all patients receive a copy of the booklet which accompanies their pacemaker. Some preoperative patients seriously doubt their ability to survive the pacemaker implantation operation, while others doubt their postoperative ability to lead reasonably normal lives. In many cases these fears may best be allayed by observing and conversing with an individual who has successfully adjusted to the pacemaker experience [24]. The NBGH is fortunate to have a staff physician who has a pacemaker and who has been helpful in this manner. COUNSELING PHASE
The goal of the counseling phase of the pacemaker support program is to assist the patient in making the best possible psychosocial adjustment to his medical situation, allowing the patient to maintain his or her personal interests, goals, and social relationships. The counseling staff can reassure the patient and his family that many uncomfortable emotions they are experiencing are normal, can offer support to them during the expected period of adjustment, and can be available when special difficulties arise. As with the education program, contact with the patient is made prior to surgery when the patient’s anticipatory anxiety appears greatest. The interviewing social worker explains the purposes and structure of the program, emphasizing to the patient that these services are offered to all pacemaker patients during and after hospitalization, and that his concerns may not be unusual for a pacemaker patient. This visit offers an opportunity for the patient to express his fears and can often serve as a forum to discuss situations which must be resolved before surgery proceeds. An example follows: Mr. F, 68, was a tense, anxious man whom his family doctor had recommended for a pacemaker for alternating bradycardic/tachycardic attacks. After his admission while awaiting surgery, he became increasingly agitated. When his cardiologist explained that the pacemaker would prevent only the bradycardia and he would remain on medication, he began to express paranoid feelings. He attempted to play staff members against each other to find discrepancies in their instructions and he threatened to leave against medical advice unless he could be guaranteed relief from his symptoms. During the preoperative ,social work interview it was discovered that Mr. F was an intelligent, though uneducated man and had read all literature available to him on pacemakers and medication. It was clear that he felt he had been tricked into giving his consent for the operation, and that the issue at the root of his behavior was control. The social worker and the cardiologist carefully discussed the patient’s cardiac condition and pacemaker therapy with him, along with possible prognoses and problems, and opportunity was given for his many, very sophisticated questions. He was then left with his family, who had previously approached the social worker about his behavior, to decide
368 / KATHERINE A. FRANK HESSE
himself about pacemaker surgery. He consented and the procedure was performed that afternoon. Although Mr. F is still a tense appearing man and still experiences some symptoms, he talks positively of his pacemaker decision. His physician has continued to allow Mr. F as much control as possible in his medical management. At NBGH the social worker has accepted the primary responsibility for assessing the psychosocial adjustment of all patients. In making the evaluation, the following factors have been shown to be of primary importance [4] : 1. the personality structure of the patient and how he utilizes psychosocial defense mechanisms; 2. the patient’s attitude toward his illness and the meaning of his illness in his life; 3. the patient’s expectation of what the operation will do for him; 4. the network of his relationships with relatives and friends, and their reliability.
The patient’s adjustment pattern is continuously compared to Kimball’s criteria for successful adjustment by assessing the patient’s level of anxiety and depression and his relationship to the present and the future [9]. Counseling is offered to those patients who exhibit extremes in any of these parameters or whose adjustment in any of these areas is causing them distress. The counseling situations which have arisen since the program was initiated have been varied in both content and depth. One elderly patient was discovered weeping after his implant. The cause was finances: he did not realize Medicare would cover the procedure and the prosthesis. Another patient, not yet eligible for Medicare and ineligible for Medicaid benefits, was having difficulty meeting the cost of the pacemaker clinics. A brief explanation of Medicare reassured the elderly patient; a discussion of the hospital credit plan and referral to possible private financial resources succeeded in lessening the latter patient’s anxiety. Although a patient’s concerns about disability and dependence on the prosthesis are most often resolved through time and the absence of further symptoms, many of the more active patients have responded to counseling as an opportunity to explore their fears that the pacemaker will limit their lifestyles. It is occasionally necessary to provide support for a patient who is faced with the possibility of early retirement. The counseling program has also helped the hospital staff deal more effectively with patients who experience confusion following their implant or those who have experienced psychiatric difficulties in the past. For those patients whose pacemaker therapy is unsuccessful or whose death is approaching for other reasons, counseling can provide the opportunity for release of their grief and, commonly, their anger at the failure of the “life-saving device.” It occasionally becomes clear that family members contribute to the
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patient’s maladaptive behavior or are themselves having difficulties. In one family, the daughter of an elderly depressed patient displayed her impatience and embarrassment about her mother’s slow unsure activities while her mother continued to withdraw even further into inactivity. In counseling, the daughter was offered the opportunity to ventilate her anger at her added responsibility because of her mother’s declining condition and to express her concerns for her mother’s health; she began to better understand the process of aging and appreciate more realistically the limitations as well as the possibilities of her mother’s condition. The positive effects of family members’ cooperation in offering support and reassurance to the patients cannot be overlooked. PACEMAKER CLINIC
To ensure that the patient’s medical and emotional condition will continue to improve, a third phase of the program has been established for the hospital outpatient. Each patient is seen in the pacemaker clinic regularly after his initial implantation after the first, sixth, twelfth, and eighteenth month, and thereafter each month until the pacemaker is replaced. At these regular checkups the education and counseling phases of the program also continue. For the occasional patients who, through denial, neglect to follow medical advice or avoid visiting the clinic until serious problems have arisen [14], the medical social worker can be available as an outreach worker for the clinic, facilitating medical follow-up. When the pacemaker clinic was first initiated, the social worker met individually with the approximately ten patients and their families at each clinic to assist with any concerns that they might have had. As the size of the clinic increased to approximately thirty individuals, an informal group education and counseling experience was organized for patients to share common experiences and problems, offer each other support for individual concerns, and discuss their progress. New members are welcomed enthusiastically and assured by the group that the clinic examination is both important and uncomplicated. This informal group has proven so successful that we have now formalized it by offering a coffee hour for the patients and their families following their examination. AUXl LlARY SERVICES
It is important that the unique medical and psychological needs of discharged patients be recognized by the appropriate auxiliary services. For the patient returning home, the Medical Social Service Department coordinates with the hospital‘s Home Care Department, the Visiting Nurses’ Association in the community, and community counseling resources to meet a patient’s special needs. For some patients many auxiliary services must be mobilized:
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After undergoing four battery replacements due to continued painful infections, Mr. L, a 66-year-old Spanish speaking man, refused a fifth pacemaker. Although he had a regular heart rate of less than 50 he was still able to function, albeit with severe limits on his activities. When his wife learned that he had refused further surgical treatment, she became highly agitated; they had been married less than two years, this being their second marriage each, and Mrs. L had just experienced a heart attack. The social worker and a Spanish-speaking social work assistant initially worked intensively with this family around the multiple issues involved: 1) Mr. L‘s conflicts about dependency, 2) Mrs. L’s fears of loss and death, 3) the realities of their physical conditions, and 4) their future care (independent living versus placement). Auxiliary services were involved as plans were made for them to remain in an independent living situation with family assistance. A community counseling agency aided the couple in finding suitable housing and stimulated the involvement of their families. The Visiting Nurses’ Association provided emotional support and physical monitoring for the couple. Arrangements were made through a community mental health agency for a Spanish speaking psychiatrist to be available to Mrs. L. Transportation for clinic appointments was also arranged through a local agency. When a patient is discharged to an extended care facility or to a rest home, the Social Service Department staff informs the personnel in these facilities of the patient’s unique requirements by involving them, when appropriate, in team conferences about the patients who will be discharged to their care. The Social Service Department, in cooperation with the Home Care and Cardiology Departments of the hospital, has been available to present special educational programs for these agencies upon request.
Summary The psychosocial difficulties experienced by the pacemaker patients adapting to their dependence on a prosthesis have been documented in the literature and observed at our hospital. The difficulties they experience have interfered with their medical management and with their future adjustment. Their successful adjustment may be further complicated by their advanced age. The New Britain General Hospital pacemaker support program was instituted to offer comprehensive psychosocial support for the pacemaker patient by ensuring that the patient is properly educated about his medical condition and that his adjustment is evaluated on a continuing basis. When patients experience difficulty in adjustment, a program of psychological and social intervention is available. The pacemaker clinic not only deals with the mechanical aspects of the pacemaker, but also provides patients with a valuable opportunity to explore their unique problems with a peer group. The
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cooperation of other departments and agencies serving the pacemaker patient is also an important facet of the program. During the Six months prior to the beginning of the program twenty patients were hospitalized for pacemaker-related procedures: thirteen new implants, three revisions and four replacements. No coordinated attempt was made to instruct these patients; those patients exhibiting psychosocial difficulties were referred to the Social Services Department after significant problems had developed. Of these twenty patients, nine or 45 per cent were referred for social work involvement. During the first year of the program a total of thirty-five pacemaker patients were hospitalized. Sixteen patients received new implants, six received revisions and thirteen were admitted for replacements. Virtually all patients were seen by the hospital staff for instructions regarding their pacemakers, and 80 per cent were interviewed by the social worker. Of these thirty-five patients, only five or 15 per cent were engaged in formal counseling for problems relating to their pacemaker experience. The support program was implemented at a modest cost and was offered without charge to the patients, incorporated into the ongoing structure of the Medical Social Service Department with the cooperation of the Department of Cardiology. The staff time required by the program was also modest and varied with the number of currently active pacemaker cases. The program has been accepted enthusiastically by the medical staff, nursing staff, auxiliary services and by the patients themselves. The favorable reception this program has received indicates that a similar program could be readily implemented at other general hospitals to provide a beneficial service by better preparing the patient for his prosthesis and by being prepared to intervene with patients, families and hospital staff as psychosocial concerns arise. REFERENCES
1. M. Aronson, How to Help Patients Accept Life-sustaining Devices, Med. Sur. Rev., 12, pp. 34-43, 1970. 2. W. A. Green and A. J. MOSS, Psychosocial Factors in the Adjustment of Patients with Permanently Implanted Cardiac Pacemakers, Ann. Intern. Med., 70, pp. 897-902, 1969. 3. M. D. Altschule, Post Operative Psychosis, Surg. Clin. North A m . , 49, pp. 677-682, 1969. 4. Clinical Conference, Roosevelt Hospital: Psychological Aspects of Cardiac Surgery, Int. J. Psychiat. in Med., 3, pp. 239-250, 1972. 5 . S. S. Heller, K. A. Frank, J. R. Malm, et al., Psychiatric Complications of Open Heart Surgery: A Reexamination, N e w Engl. J. Med., 279, pp. 13651370, 1968. 6. C. P. Kimball, Psychological Responses to the Experience of Open Heart Surgery, Amer. J. Psychiat., 126, pp. 348-359, 1969.
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7. D. S. Kornfield, S. Zimberg and J. R. Malm, Psychiatric Complications of Open Heart Surgery, New Engl. J. Med., 273, pp. 287-292, 1965. 8. J. A. Kennedy and H. Bakst, The Influence of Emotions on the Outcome of Cardiac Surgery: A Predictive Study, Bull. Acad. Med., 42, pp. 81 1845, 1966. 9. C. P. Kimball, A Predictive Study of Adjustment to Cardiac Surgery, J. Thorac. Cardiovasc. Surg., 58, pp. 891-896, 1969. 10. B. M. Dlin, H. K. Fischer and B. Huddell, Psychological Adaptation t o the Pacemaker and Open Heart Surgery, Arch. Gen. Psychiat., 19, pp. 599-608, 1968. 11. C. P. Kimball, The Experience of Open Heart Surgery, Arch. Gen. Psychiat., 19, pp. 599-608, 1968. 12. H. T. Tufo, A. M. Ostfeld and R. Shekelle, Central Nervous System Dysfunction Following Open Heart Surgery, JAMA, 212, pp. 1333-1339, 1972. 13. M. C. Becker, I. R. Zucker, V. Parsonnet and L. Gilbert, Rehabilitation of the Patient with Permanent Pacemaker, Geriatrics, 22, pp. 106-1 11, 1967. 14. B. S. Goldman, E. J. Noble and D. C. MacGregor, Pacemaker Panic, Amer. J. Cardiol., 30, p. 705, 1972. 15. R. S. Blacher and S. H. Basch, Psychological Aspects of Pacemaker Implantation, Arch. Gen. Psychiat., 22, pp. 3 19-323, 1970. 16. G. Timmes, S. Gordeon and R. Ramos, Heart-block in the Aged: Is the Patient Too Old to be Permanently Paced?, Chest, 60, pp. 113-1 14, 1971. 17. B. Bain, Pacemakers and the People who Need Them, Amer. J. Nurs., 71, pp. 1582-1586, 1971. 18. C. Witt, Problem With Cardiac Pacemakers in the Aged, Geriatrics, 27, pp. 92-95, 1972. 19. B. A. Kos and P. A. Culbert, Teaching the Patient with the Pacemaker, Cardiovasc. Nurs., 6, pp. 57-60, 1970. 20. K. Newton and H. Anderson, Geriatric Nursing, Mosby, St. Louis, 1966. 21. N. H. Cassem and T. P. Hackett, Psychiatric Consultation in the Coronary Care Unit, Ann. Intern. Med., 75, pp. 9-14, 1971. 22. T. P. Hackett, N. H. Cassem and H. A. Wishnie, The Coronary Care Unit: An Appraisal of its Psychological Hazards, New Engl. J. Med., 279, pp. 1365-1370, 1968. 23. W. D. Gentry, S. Foster and T. Hanay, Denial as a Determinant of Anxiety and Perceived Health Status in the Coronary Care Unit, Psychosom. Med., 34, pp. 39-44, 1972. 24. C. Williams, The CCU Nurse Has a Pacemaker, Amer. J. Nurs., 27, pp. 900-902, 1972.
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