Send letter to journal:
Re: It's good to talk

Dear Editor,

In his editorial on ‘Alternative treatments for angina,’ Dr Lanza makes no mention of the value of rehabilitation, especially patient and carer education, in improving quality of life. Given the central role of patient education in [refractory] angina management, this requires comment.

Damaging misconceptions are common in angina sufferers and their carers, and education is a potent and critically important intervention that can have profound effects on understanding, behaviour and quality of life (1,2). It is for this reason that both the ESC and the AHA/ACC/ACIP/ASM stable angina management guidelines recommend a continuous process of identifying and clarifying misconceptions throughout care (3,4). Similarly it is why the ESC Refractory Angina Study Group came to the same conclusion (5). It is perhaps because rehabilitation and patient education is not regarded as ‘treatment’ that this most important aspect of good clinical care is so often neglected.
It is of great concern that this oversight seems to characterise each point of the patient’s journey. The AHA/ACC guidance has observed that, “…healthcare providers tend to focus on diagnostic and therapeutic interventions, often overlooking critically important aspects of high- quality care. Chief among these neglected areas is the education of patients.”(4)
This point was vividly illustrated in an editorial on the British Cardiac Intervention Society website in 2001, when it was observed that, “The under-provision of cardiologists, out-patient facilities, hospital beds, cardiac catheterisation laboratories, and importantly, IT personnel and hardware in the average UK intervention centre frequently results in the patient arriving on the day of the procedure, having never been seen previously, and in many cases, not having met the interventional cardiologist before arriving in the catheterisation laboratory.”(6)

It may be that clinicians do not put much store in clinical guidelines, however authoritative, but what is intriguing about this failure to educate patients is that it is not simply a minor clinical governance issue. Education is a decisive intervention for patients with angina and has the force of law. The requirement to ensure that patients are fully informed has been a necessary element of valid consent for decades but as recently as 2001, the BMA consent working party was able to conclude that “current awareness of the relevant ethical and legal principles relating to consent among the medical profession is largely inadequate” (7). In order to clarify the guidance on consent, the Parliamentary Ombudsman and the President of the Society of Cardiac Surgeons produced a joint recommendation on consent practice which emphasises the need to ensure full disclosure of facts (8). The joint statement reflects the trend away from the notion that doctors can decide what it is necessary for the patient to know, towards the North American standard of disclosing what a ‘prudent patient’ would wish to take into account in making a decision about treatment. More recently the GMC’s update of ‘Good Medical Practice’ makes explicit the requirement to ensure that patients fully understand their condition to enable them to be full and active participants in the decision-making process (9).

In our experience many of the problems encountered by refractory angina patients and their carers are iatrogenic, arising from a deficient ‘education’ process, often involving many different healthcare professionals over many years. The perceived referral criterion for specialist refractory angina management is when no further intervention is possible, and this point in the patient’s career marks a significant moment when patients views about their condition can be adversely influenced by poorly communicated information.
We frequently meet patients who, having been told that further revascularisation is not feasible, erroneously believe that their lives are threatened by their stable angina. The terms in which this message is delivered to patients often involve such colourful phrases as: ‘I am sorry but your narrowings are just too far gone and there is nothing more that can be done’; ‘he’s a walking time bomb’; ‘you must take things very easy’; 'the artery is hanging by a thread.’

Much of our work involves treating the damaging consequences of cardiac misconceptions with individually targeted education. Careful dissection of angina patients’ beliefs and misconceptions about their condition is rewarding for health professionals and benefits patients in terms of quality of life, frequency and duration of hospital admissions and frequency and severity of pain. The alternative to patient education raises for doctors the risk that they may be open to challenge for having given treatment to patients who have given consent on the basis of fundamental misconceptions about the nature of their condition.

References

1. Health related quality of life of patients with refractory angina before and one year after enrolment onto a refractory angina program.
Moore RK et al.
Eur J Pain. 2005 Jun;9(3):305-10

2. A Brief Cognitive-Behavioral Intervention Reduces Hospital Admissions in Refractory Angina Patients.
Moore RK et al.
J Pain Symptom Manage. 2007 Mar;33(3):310-316

3. www.escardio.org/knowledge/guidelines/Guidelines_list.htm?hit=quick (2006 update)

4. www.americanheart.org/presenter.jhtml?identifier=3006769 (2002 update)

5. The problem of chronic refractory angina Report from the ESC Joint Study Group on the Treatment of Refractory Angina
Mannheimer al.
European Heart Journal (2002) 23, 355–370

6. www.bcis.org.uk/news/News1588 (last accessed 23.04.07)

7. www.bma.org.uk/ap.nsf/Content/Reportoftheconsentworkingparty

8. Parliamentary and Health Service Ombudsman, and the President of the Society of Cardiothoracic Surgeons of Great Britain and Ireland a joint report. ‘Consent in cardiac surgery: a good practice guide to agreeing and recording consent’
May 2005
www.ombudsman.org.uk/improving_services/best_practice/cardiac05/index.html