Patients perception about Coronary Artery Bypass Graft (CABG) surgery during waiting period: A Phenomenological study

http://doi.org/10.33698/NRF0330-Dimple Kathania, Neena Vir Singh, Sukhpal Kaur, Rupesh Kumar

Abstract:

Introduction: Coronary Artery Bypass Graft (CABG) is a surgical intervention for patients with Coronary Artery Disease (CAD) who are refractory to medical treatment. Prolonged surgery waiting time due to long waiting lists can further impact the patient’s health. Objective: To explore the patient’s perception about Coronary Artery Bypass (CABG) surgery during waiting time. Material and methods: A phenomenological approach was used. Purposive sampling technique was used to include the participants in the study. Ethical clearance was obtained from the Institute Ethics Committee. Using a pre-validated interview guide, data was obtained from the participants regarding the patient’s perception about Coronary Artery Bypass Graft (CABG) surgery by conducting in-depth interviews. Interviews were recorded with permission from participants. Saturation of data was achieved after interviewing 17 participants. The analysis was done by Colaizzi’s method. Results: The themes generated were “Patient`s perception about surgery” and “Lack of information regarding surgery”. The ndings indicate that during the waiting time of the surgery, patients have a unique viewpoint about the illness and surgery. Conclusion: Waiting for CABG surgery is a complex and stressful experience because patients have abundant time to think about their concerns and anticipate threats. So, they require constant supportive and educative care from health care providers.

Keywords: Coronary Artery Bypass Graft; Coronary Artery Disease Patients; Perception, Phenomenological; Waiting Time.

Correspondence at:

Neena Vir Singh Lecturer,

NINE, PGIMER, Chandigarh, India. Email-neenasingh_2@yahoo.co.in Mobile no-8146552482

Introduction

A Coronary Artery Bypass Graft (CABG) is a recommended surgical intervention for

patients with Coronary Artery Disease ( CAD) whose condition no longer controlled with medical interventions.1 Approximately 8 million open cardiac surgeries are performed worldwide and the incidence of CABG surgery has increased annually.2 The number of bypass surgeries is increasing in India. About 60,000 coronary bypass surgeries are done annually in India.3 CABG surgery bypasses the blocked arteries. Its purpose is to maintain normal circulation to the heart. Diagnosed with CAD and then planned for C A B G i s a s s o c i a t e d w i t h m a n y psychological issues and concerns regarding surgery. Every patient shows individual subjective psychological concerns, emotional responses, and perceptions about surgery. The patient may interpret cardiac surgery as a fearful event and experience anxiety. Anxiety is extremely high for patients with CABG surgery when they are on the waiting list and at each follow-up given with the next dates. Patients have a fear of dying before, rather than during surgery, and their level of anxiety was highly affected by that fear.4 The literature shows that negative emotional states, such as anxiety, depression and long term stress are related to poor cardiac outcomes.5-7

Most available published studies on individuals waiting for CABG have been conducted in Western countries. There is a paucity of knowledge regarding the lived experience of Indian patients who are on CABG waitlists as there is not enough knowledge and understanding of the lived experiences of patients before and after surgery.

Frasure-Smith et al. assessed the impact of depression on mortality of acute myocardial infarction patients for a period of 1 year. Higher depression scores were signicantly linked for both the genders to cardiac mortality (the odds ratio for women was 3.29, for men, was 3.05).8 Barefoot et al. at the time of diagnostic coronary angiography, tested 1250 patients with reported cardiovascular heart disease (CHD) using the Zung Self-Report Depression Scale and followed patients for up to 19.4 years. Reports showed that patients with moderate to extreme depression were at 69% higher risk of heart failure and a 78% higher risk of all-cause mortality.9

Psychological problems such as depression and anxiety are widely reported soon after CABG surgery. Poor psychological adjustment following surgery can increase the likelihood of new coronary events, further hospitalizations, and even death.10 Literature review shows that poor illness understanding, a negative perception of the consequences, and low personal and treatment control are related to high anxiety and depression levels.11 So, understanding of the CAD patients perception about surgery would be helpful for healthcare workers to provide better services to patients and education planning.

Objective

To explore the patient’s perception about Coronary Artery Bypass Graft (CABG) surgery.

Material and Methods

The phenomenological research design was used to guide this study. The research was conducted in a tertiary care hospital of North India. The data was collected from patients waiting for CABG surgery during July-September 2019. Patients willing to give consent for participation, waiting for CABG surgery for 3 months or more, having no cognitive decits, no hearing and speech disabilities, age between 18-75 years and both genders were selected by purposely sampling technique. Interview schedule, Interview guide, and audio recorder were used as tools for data collection. The interview schedule included sociodemographic prole of the patients including name, age, sex, C.R.No. address, mobile no., no. of family members, family type, educational status, occupation, monthly income, per-capita income, etc.

The interview guide was developed after extensive literature review and consultation with guides and experts in the eld of nursing and cardio-thoracic and vascular surgery. The interview guide consisted of a set of open-ended questions. A pilot study was conducted on participants from the population under study. The results of the pilot study showed that participants were available at the time of data collection and there was no difculty in the administration of tools. After conducting the pilot study some questions were added in the interview guide.

For conducting  the  interview  each p a r t i c i p a n t w a s p r o v i d e d w i t h a comfortable and congenial environment for sitting. Informed written consent was taken from each participant after explaining the objective and needs of the study. Their anonymity and condentiality were ensured. The participants were given full autonomy to participate in the research study or withdraw from the study at any time. The duration of each interview was from 20-40 minutes. Permission was taken from participants for recording their interviews. Interviews were recorded simultaneously. Saturation of data was achieved after interviewing 17 participants. Colaizzi`s steps were used for analysis which included reading and re-reading the transcribed verbatims of the participants, extracting meaningful statements, formulating meaning of each meaningful statement, categorizing formulated meanings into a themed cluster, and integrating ndings into an exhaustive description.

The data was analyzed following all the above-said steps independently by the researcher. Then the similar process of transcribing, reading, and rereading, extracting signicant statements, and formulation of themes was done by another researcher separately Following this, both the researchers sat together and discussed the meanings, the themes, and the subthemes and arrived at the common consensus.

Results

The participants were in the age group of 47-70 years with mean age(yrs.) ±SD of 60.47±7.64 years. Around half of them were male (58.8%) and Hindu (58.8%). 88.2% were married and 11.8% widows. More than half of participants had primary level education and 5.9% were illiterate. 35.3% of women were housewives and 23.5% of men were not working. Half of the participants were from nuclear families and had a monthly income of up to 10000 INR. Colaizzi`s steps were used for analysis which included reading and re-reading the transcribed verbatims of the participants, extracting meaningful statements, formulating meaning of each meaningful statement, categorizing formulated meanings into a themed cluster, integrating ndings into an exhaustive description. The themes generated were “Future prospective about CABG surgery and “Information about CABG surgery”.

Table 1: Cluster of themes/subthemes

N=17

 

Sr. no.	Themes	Subthemes	f (%)
1.	Future prospective about CABG surgery	Positive perception about surgery after meeting post-CABG Patients Surgery only way out Nonacceptance for surgery Hope of relief after surgery Uncertainty and ambivalence about surgery Negative perception about surgery after meeting post-CABG Patients	13(76.4) 07(41.1) 02(11.7) 02(11.7) 02(11.7) 01(5.8)
2.	Information about CABG surgery	No information about surgery Inappropriate information about surgery Information from post CABG Patients	05(29.4) 02(11.7) 02(11.7)

 

Table 1 depicts cluster of themes and subthemes. The theme of ‘Future prospective about CABG surgery’ included the patients’ way of thinking, perceiving and expectations from surgery. Every individual is unique hence everyone had their unique subjective way of thinking.41.1% perceives that surgery is the only way to get rid of the disease. 11.7% were showing nonacceptance for surgical intervention. However, meeting and communicating with their post CABG relatives and friends ,76.4% were feeling better and relieved. They were aware about the need and benet of surgery and were ready to be get operated. Only 5.8% were having negative perception about surgery after meeting post-CABG patients. 11.7 % were having future plans after the surgery and had belief that symptoms will be relieved after surgery.

Second theme ‘Information about CABG surgery’ highlights the importance of information and communication from health care providers during waiting for the CABG surgery as about 40% of participants either did not have any information about CABG surgery that ‘what will be done’ or they had inappropriate information about the surgery. Only 11.7% participants had stated that they had Information from post CABG Patients.

Discussion

CABG surgery is the main concern during the waiting time as patients have to wait due to long waiting lists. So, they have abundant time to think about the prospective of surgery. Sometimes their concerns about illness and surgery are visible but at other times it may be deep-rooted and hidden. So, to bring those deep-rooted feelings to conscious awareness and for ventilation of patients’ feelings, these phenomenological studies do wonder. Hence, there is a need for such studies to understand the patients’ concerns and their perceptions about the illness and surgery. This study was conducted to explore their feelings about the surgery during the waiting time.

The ndings of the current study had suggested mixed feelings about the surgery. Some patients show nonacceptance about surgical treatment and some show readiness for surgery. When a patient meets post CABG patients it inuences their perception about the surgery. More than 50% of participants had a positive perception of surgery after meeting post-CABG patients. Some expected a better life after surgery, while others believe that their condition will worsen. Mendonca et al. have reported that the patients awaiting CABG face a broad range of psychological difculties. The individuals interviewed shared ambivalent feelings concerning their cardiac surgery. Anxiety is the most common symptom  before  surgery.12   Ambivalence toward the surgery was seen in patients. On each follow up, when the patients are given with next dates for surgery it led to anger and some planned activities like the marriage of their children, to visit religious places and desires such as to see grandchildren which they will fulll after surgery and recovery. They have also reported that they will be able to walk and eat properly and their current medicines will be reduced to fewer after surgery. While some were uncertain about the outcome after surgery, they believe everything is up to God now, and whatever happens, they will face. A study conducted by Auer et al shows that patients who have preoperative expectations from CABG surgery spent less time in hospital and it disappointment  in  them.13    One  participant highlight the importance of psychological said that “Toh usme maine bahuto ko pucha ki bhai by pass karane ke bad adami kaisa rahta kaisa nahi rahta hai, jo mere pas aate rahte hai unme se kaiyo ne bola ki by pass jaldi krani v nahi chahiye. Us se 5 se 7 sal apki life hoti hai, thik hai. Aur jab tak chalta hai begair bypass ke kra lo. Last me bypass to fir bhi hona hi hona hai, last to hai hi by pass isliye mai chal rha tha magar fir bich me kuch aise bhi aaye hai ki jinke by pass hue hue hai aur PGI se hi hue hai,wo kahte ki bhai bhut achaa chal rha hai. Unko to kafi din ho gye hai to abhi.” “I asked many people that after bypass how a person stays, some said don’t go for bypass early, because after the surgery life remains only for 5 to7 years. It goes well without bypass also. In the end bypass has to be done. The bypass is the last option so that’s why I am going like this. But in the middle, some came like they have a bypass in PGI, they said it is going very good brother, quite some time has passed.

In the current study, participants have shown optimism and hope for relief from illness if they get operated, and for this, they believe that surgery is the only way out. They have interventions.14 Uncertainty about life, disease, and surgery is prevalent in all the patients, however, variability was there in every patient according to their information and support system. A similar thing was explained in a study by McCormick et al. which suggests that uncertainty and anxiety were present at moderate levels and can lead to functional impairment. But it is possible to experience uncertainty as a danger and an opportunity simultaneously.15   One  participant  perceived uncertainty as danger and said that, “Abhi toh is bakt samjhta hu mai ki mai jo bol raha hu bhyi ki dwai khane se mujhe thik hi fayda hai na toh mai toh smjhta hu mai is time thik hu.ab iska ye nahi pta lagta hai ki kab daura padta hai,uska ye nahi pta lgta”

“This time I think what I am saying that I am fine after taking medicines. So, I think I am fine this time but I cannot predict heart attack, I don’t know about it.” While other were ready to face consequences and said, “Operation to baad hi pta chalega kya hona kya ni.filhal ta kuch ni .kya hona kuch v ho skda.. daar kada jo houga thk h dekha jauga”

“Only after the operation I will know what will happen or not, anything can happen, fear of what, what will happen is right and will be seen.

About 40% of participants either did not have any information about CABG surgery that what will be done or they had inappropriate information about the surgery. Their source of information was their known Post CABG relatives. Only one participant reported that he had information through the internet. Everyone reported that they haven’t received any information about the CABG surgery from health care providers. Nonacceptance for surgery and ambivalence was also there.

Study participants had very little information about the surgical procedure as their verbatims show that they are completely dependent upon the surgeon for all aspects of surgery.

One participant said, “Presan k baare mai.aaj tak hua nahi bhayi presan kaisa hota hai toh na humne koi baat suni presan hoga. logo presan dekha bhayi aisa presan bhi hota hai. wo nahi mereko pta ki kya kya krenge.mere ko nahi pta. baaki gyan nahi mere ko operation k baare mai na maine aaj tak dekha kisi ka na mera apna hua aj tak.”

“I did not get operated till date brother, so I don’t know how an operation is done. Not even we have heard anything for being operated. We saw people that how they got operated. I don’t know what will be done, I don’t know. I don’t have any knowledge about operation not even I have seen till date not even I had.” A systematic review was carried out by Kaur P et al. had reported that post-myocardial infarction patients did not have adequate knowledge about causes and risk factors, warning signs and symptoms of acute myocardial infarction.16

Conclusion

Every patient shows unique, subjective psychological concerns, emotional responses, and perceptions about surgery. The patients may interpret cardiac surgery as a fearful event and experience anxiety. Some patients interpret the surgery as danger so they don’t want to get operated while others interpret the surgery as opportunity to get relief from symptoms and live better life. Therefore, these patients must routinely be assessed for their negative perspectives about surgery during waiting time. When surgery is perceived as opportunity, patient is able to adapt the situation positively. So, support and information should be provided to convert the dangers into opportunities regarding the surgery.

Limitation of the study

It is a single centre study. The ndings may not be generalized to others.

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