The Operating Theatre Journal - Journal - Page 16
The Wider Discussion
The association between psychological and physiological health and the
impact one may have on the other, is widely acknowledged (Levett
and Grimmett, 2019), and it is likely that pioneering interventions and
strategies such as prehabilitation programmes can assist in cancer
patients journey and could contribute to better postoperative outcomes
for patients. Rokachi and Rokachi (2013) convey that the preoperative
and postoperative periods promote the likelihood of experiencing
an egocentric psychological state and a reduction in capacity. It is
important to therefore consider ways in which experiences such as
this can be addressed during prehabilitation. Psychological preparation
through counselling could occur and realistic expectations may be
discussed. This may not prevent the occurrence but may help patients
to understand the feelings they are experiencing and allow them to
accept this as a normality in respect of undergoing surgery.
It is acknowledged that patients experience high levels of distress
throughout their cancer journey, and The National Institute for Clinical
Excellence (NICE) (2004) asserts that it not uncommon for patients with
a cancer diagnosis to experience feelings of anxiousness or depression.
Engel et al. (2003) explores how surgical outcomes can impact patients’
quality of life, noting that physiological adaptation can be a contributing
factor to an improved quality of life.
When considering a multimodal prehabilitation strategy for
implementation it is important to maintain a holistic approach which
can be achieved when encompassing a psychosocial consideration of the
patient and their families and/or carers during strategy design. Brown,
Lipscomb and Snyder, (2001) explore the burden of cancer and observe
that patients express concerns and worries surrounding their physical,
social and spiritual concerns relating to their diagnosis and treatment.
Prehabilitation intervention can incorporate psychological support and
counselling, physical and physiological optimisation and initiate referral
opportunities aligned to individual need and improve HRQoL, aligning
to what appears to be a holistic clinical intervention with the potential
for both short and long term pre and post operative benefits. As more
holistically driven or focused developments are made, and new and
improved cancer treatments become available, Jemal et al. (2011)
predicts that approximately 68% of cancer patients will survive to five
years or beyond from time of diagnosis.
Although this is a perceived positive outcome for many cancer patients,
the impact this may have on those around them can be profound and
should be addressed. Li and Loke (2013) consider how the burden of
prolonged life expectancy may affect caregivers and family members
of those living with cancer, and assert that sub optimal states of
psychological, social, and physical morbidity are a risk factor to this
category. This is likely to be a result of longer or more extensive support
provision which can take a mental and physical toll on caregivers or
family members alike.
Lack of understanding of treatment processes and knowing how to
effectively support someone undergoing cancer treatment can be a
challenging experience for many. Therefore, introducing prehabilitation
also means the likelihood of more appointments, meeting additional
expectations, and engaging in set tasks for the patient – but what does
this mean for those around them? Financially an impact may be felt
through loss of earnings, family members may need to take additional
work or take time away from work to help with appointments or
care (Singer, 2018). Indirect costs should also be considered, such as
transportation and products to assist with comfort. Hypothetically,
improved postoperative recovery and surgical outcomes imply a
faster return to function, meaning there is potential opportunity for
this burden to be reduced, but this is yet to be determined. When
considering the introduction of prehabilitation, these factors should
not be discounted.
Kaur (2014) depicts an increased need for self-management of patients,
families and carers throughout treatment and recover, insinuating a
greater feeling of empowerment may be obtained. Empowerment
allows patients, families, and carers to feel more in control and as
part of the decision-making team regarding health, and self-managed
interventions or treatment is an ideal opportunity to promote this.
Prehabilitation allows for opportunities to self-manage and has the
potential to be patient led in many respects, it may have directives to
follow for example performing exercises or dietary change but allows
patients to make informed decisions surrounding how and perhaps
where and when this is done.
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Prehabilitation strategies have the potential to involve patients
and families or carers in this phase of intervention and can promote
improved psychosocial aspects at an individual patient level. But the
challenge remains in designing and achieving a strategy that can be
adopted as a guideline or protocol.
Conclusion
Gaps in the research are still clear and therefore a requirement for
further study is recommended. Although research supports and
discusses indicators that prehabilitation could improve postoperative
outcomes, there are still no guidelines or protocols in place. A review of
the prehabilitation strategies could be conducted to ascertain whether
a different approach may be better suited. Another area to consider is
the long-term postoperative impact prehabilitation has on individuals’
postoperative health and attitude. For example, were modified exercise
behaviours maintained? Do participants understand the importance of,
or practice psychological wellbeing? Has improved diet and nutrition
continued? And what, if any, impact this has had on their postoperative
recovery. However, these studies would only be beneficial once more
research has taken place in line with the topic of discussion, as it is
evidently still in its infancy of exploration and no consistent approach
has been adopted.
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