Preoperative Patient Education in Thoracic Surgery

General preoperative education 

At the initial consultation, the surgeon usually provides an explanation of the proposed procedure. Retention of this information is highly variable and depends on the rapport between the surgeon and patient; the surgeon's willingness to provide information; and the patient's curiosity, emotional state of mind, intelligence, and knowledge base. An intellectually sophisticated patient with a background in the medical sciences who presents to the office with an Internet printout of all the latest lung cancer clinical trials is likely to be handled differently than a poorly educated patient who has done no background investigations. Similarly the emotional state of the patient must be taken into account because it is likely that an emotionally upset patient hearing the diagnosis of “cancer” for the first time may have less retention than someone who is being provided a second opinion or someone who is seeing the surgeon after a course of preoperative chemotherapy.

At the conclusion of the preoperative process, all patients need to have some retained understanding of the planned procedure, why it is being recommended, what its risks are, whether there are alternatives, and how their active participation in the surgical process can make a difference in recovery. Although this information is generally covered, at some level, by the surgeon, the surgical nurse often has to review it with the patient and focus on areas where retention was inadequate.

Respiratory hygiene 

Many of the common complications after thoracic surgery—atelectasis, pneumonia, and pulmonary embolism—are pulmonary in nature. Although pulmonary embolism cannot be prevented through improvement in pulmonary hygiene, atelectasis and pneumonia can be prevented through active patient involvement. Coughing, deep breathing, using an incentive spirometer, walking, sitting to eat, and performing other seemingly minor activities all can contribute to improved pulmonary hygiene and a decreased incidence of postoperative pneumonia. Although coughing per se is painful and controversial in terms of its ability to prevent pneumonia, avoidance of sputum retention is desired. Patients can be taught to splint the operative side to minimize pain with coughing. Deep breathing can open collapsed alveoli and prevent overt atelectasis. Walking and use of an incentive spirometer aim for the same goals—improved aeration of the lungs and avoidance of alveolar and segmental collapse. Eating in bed should be avoided because the often semirecumbent posture predisposes to aspiration and regurgitation.

Although all of these respiratory hygiene measures can be addressed in the postoperative period, it is best to address these concepts initially in the preoperative period. Setting expectations is important, and in the postoperative period, when the patient's sensorium may be clouded by pain and narcotics, learning is suboptimal. Teaching proper use of an incentive spirometer is far more effective preoperatively than postoperatively when inhalation is compromised by pain. When patients are taught how to use this device preoperatively, they have a relevant basis from which to compare their postoperative inspiratory effort and function. Convincing patients that they can do much better is difficult if they have never seen the device until the evening after surgery.

Pain 

One of the most frightening things for patients facing surgery is the expectation of pain. Other frightening concepts include loss of personal control and death. Because death is usually unlikely, and loss of control is unavoidable, the expectation of pain often becomes a major source of anxiety. In the preoperative period, the anxiety surrounding pain, rather than the pain itself, is the problem. Effective preoperative teaching can allay these fears, reduce the anxiety, and provide a framework for realistic expectations regarding postoperative pain [1], [2].

A discussion of narcotic analgesics, patient-controlled analgesia, nonsteroidal analgesics, and epidural anesthesia (continuous, intermittent, and patient controlled) is appropriate. Side effects, including nausea, gastrointestinal dysfunction, and the potential for a lack of efficacy, should be discussed. The goal of postoperative analgesia also should be discussed. Patients should not expect to be oblivious to the fact that they just had surgery, but the goal of postoperative analgesia should be pain control that provides patients with an ability to function and interact with their environment effectively.

Family members should be cautioned that patient-controlled analgesia is for patients, not family members, to control. Family members also should be cautioned that narcotics may have undesirable side effects, such as somnolence, respiratory depression, dysphoria, disorientation, and even delirium. Family members should be advised that these side effects generally resolve quickly after discontinuation of narcotics, and that the physicians and nurses need to be made aware if these side effects occur.

Patients should be advised that postoperative early ambulation is desirable. The upright posture has many advantages in terms of pulmonary function, although multiple attachments such as chest tubes, urinary catheters, epidural catheters, and infusion pumps often make ambulation difficult. Effective preoperative counseling sets the expectations, which can be reinforced in the postoperative period.

Smoking cessation 

In thoracic surgical practice, many of the relevant diseases, particularly lung cancer and emphysema, are smoking related. Although many patients have quit smoking by the time they come to the thoracic surgeon, others continue to smoke because the addictive qualities of nicotine outweigh the intellectual knowledge that smoking is harmful. Faced with an upcoming operation, the patient may use smoking as a method of coping with anxiety and fear. Patients should be counseled vigorously, however, to stop smoking in preparation for surgery. Cigarette smoking impairs the mucociliary clearance mechanisms of the tracheobronchial tree and may predispose to postoperative pulmonary complications. The optimal time for smoking cessation is unclear, and one article even suggested an increase in perioperative pulmonary complications when smoking cessation occurred immediately before surgery [3], [4]. Most surgeons encourage patients to stop smoking in preparation for thoracic surgery. Whether surgery should be denied to patients who continue to smoke is controversial. Every effort should be made preoperatively to persuade the patient to stop smoking.

Diet and nutrition 

Preoperative patient education should cover nutritional issues routinely but is particularly important in two classes of patients: (1) patients who have recently experienced a significant weight loss and (2) patients who are to undergo preoperative chemotherapy or radiation therapy. The first group includes many patients with esophageal cancer in whom dysphagia or odynophagia have limited their oral intake and resulted in a long-standing caloric deficiency. Although significant weight loss is common in patients with metastatic disease, such patients frequently are identified through preoperative staging tests and often do not come to the attention of the surgeon. The second group involves patients who ideally should be seen by the surgeon before the neoadjuvant therapy is started. In these patients, nutritional deficiencies can be expected and consequently preempted. Patient questions regarding nutritional supplementation (including herbal or other nontraditional forms of treatment) often arise at this time and can be dealt with appropriately.

Wound care and drains 

Although most thoracic surgery patients require little or no postdischarge wound care, the preoperative visit is a reasonable time to raise this issue. Patients often have negative expectations about wound care and often are pleasantly surprised to learn that care is usually minimal. Occasionally, patients are discharged home with tubes or drains still in place. Because percutaneous tubes and drains are an integral part of modern surgical care and their use has become ubiquitous, health care providers may become numb to their invasiveness and the patient's sense of a loss of personal image. Patients should be taught about the uses and benefits of percutaneous tubes and drains as early as possible. In years past, patients routinely were kept in the hospital until all drains and tubes were out: mastectomy patients stayed in the hospital, on intravenous antibiotics, until the Jackson-Pratt drains were removed. Now, as a result of “best practice” analysis, evidence-based medicine, and changes in reimbursement policies, practices have changed, and patients are taught that it is acceptable to go home with a small drain.

Postdischarge social issues 

Although it may seem premature to enter into a discussion of postdischarge psychosocial issues in the preoperative phase, such a discussion is not inappropriate. Postdischarge issues, such as family involvement in postoperative convalescence, job-related concerns, and expectations regarding physical limitations, including appetite, sleep irregularity, and sexual function, can be broached in the preoperative period and brought up again in more detail later. Issues that potentially may delay discharge from the hospital may become apparent in these discussions (which are frequently left to the nursing staff), and it is helpful to address these issues early so that they do not become problems later. In dealing with the patient and family, cultural sensitivity and family dynamics may play crucial roles in effecting a smooth postoperative recovery.

Contact numbers 

Part of the preoperative teaching process is to effect seamless communication between the patient and the surgeon. Because many surgeons delegate much of the preoperative teaching to resident physicians, nurses, and other nonphysician staff, it is crucial to provide patients with a reliable method of contacting the surgeon or his or her designee. Patient satisfaction has an increasing role in determining where patients go for their care, and one of the simplest methods for improving patient satisfaction is providing them with a reliable conduit to the surgeon and his or her staff.

Procedure-specific teaching 

In addition to the more general areas discussed earlier, each patient needs teaching directed toward the specific operation he or she is to undergo. Information that needs to be covered at this stage includes the size and location of the incision, the general outline of the operation, the expected postoperative physiologic state or deterioration from baseline, and a general overview of the risks of complications or death. Several common examples are detailed next.

Verbal instruction 

Verbal instruction is the cornerstone tool to preoperative teaching, and whoever conveys information verbally must be cognizant of the recipient's intellectual level, interest in acquiring the information, attention span, and emotional ability to handle the information. Multiple factors, such as language barriers, learning disabilities, and cultural barriers, can impair this knowledge transfer, and other strategies, including repetition, provision of written material, interpreters, and drawings, may be necessary. It is often surprising to find that patients, after what was thought to be a thorough preoperative discussion, continue to have basic questions that they are reluctant to discuss with the surgeon and that are asked to the preoperative nurse or other staff only after the surgeon has left.

Written material 

Complementing verbal instruction and direction is the dissemination of written material. Nonprofit organizations have a variety of patient education materials available at relatively low cost. The American Cancer Society has a telephone hotline for information that can be sent to patients free of charge. The information covers general cancer care and preparation for surgery, including topics such as “what questions to ask the doctor” and “what are the risks and side effects of surgery.” The American Lung Association has a large amount of free and low-cost written material on smoking cessation and lung health, including pulmonary function testing, bronchoscopy, lung cancer, and lung transplantation. Lastly, information packets for commonly performed operations can be bought or made “in house”; the latter has the advantage of providing information specific to the institution and surgeons.

Manufacturers of commercial products often provide free product-specific patient education packets or booklets. One example is Axcan Pharmaceuticals, which supplies patient education material on photodynamic therapy for lung and esophageal cancer and Barrett's esophagus. Another example is Denver Biomedical, which provides written information and a patient video on its PleurX pleural catheter. Other companies, such as Bristol-Myers-Squibb Oncology and Aventis Pharmaceuticals, supply product-specific and disease-specific patient information and more general cancer care information on topics such as nutrition and exercise in the form of books and pamphlets.

Web-based material 

Much of the information described in this article, in addition to a wealth of additional information, is also available online. The American Cancer Society and the American Lung Association have extensive websites with large amounts of patient-oriented information. In addition, for cancer patients, the National Cancer Institute provides a detailed and user-friendly website (www.cancer.gov) with a wealth of material aimed at the patient level. The University of Pennsylvania (www.oncolink.upenn.edu) also provides an outstanding patient-centered website that is relatively free of institutional and commercial bias. Additional patient-oriented information on clinical trials is available through the Coalition of National Cancer Cooperative Groups (www.cancertrialshelp.org). Numerous pharmaceutical company websites also offer disease-specific information on disease prevention, diagnosis, causes, and treatment. With the ubiquity of Web access, the authors caution patients that information obtained on the Web can be highly biased, poorly referenced, and even self-serving and promotional in nature, but that reputable sources can provide valuable insights into their disease and the treatment options that are available to them.

Audiovisual material 

Another opportunity for teaching includes provision of audiovisual material. Axcan Pharmaceuticals, the supplier of Photofrin, has created a video detailing the risks of photosensitivity and how to avoid such side effects. Diagrams and models also may be used. Commercially available lung models can help the surgeon or clinical nurse specialist explain the concepts of bronchopulmonary segments, lobectomy, and wedge resection. Diagrams, which can be hand-drawn or commercially obtained, can be used to explain anatomic concepts. Lastly, use of the patient's own radiographs can be an excellent teaching method, and patients generally pay a great deal of attention to their own radiographs. It takes relatively little time to explain the basics of a CT scan, and patients are often surprised that what is a “lung nodule” to one physician is a “worrisome mass” to another. Such teaching methods are particularly helpful when patients are to be followed radiographically for an indeterminate pulmonary nodule. As the saying goes, “a picture is worth a thousand words,” and 1 or 2 minutes spent with a real radiograph can take the place of and be more satisfying than a lengthy description of the films.