Takeaway
When my patients experience pre-procedural anxiety, I normalize the emotion and suggest ways to feel calm. Taking deep breaths together is often mutually beneficial for patients and clinicians.
Lifelong Learning in Clinical Excellence | October 25, 2022 | 4 min read
By Jillian Bybee, Michigan State University
Before I’d even walked into the room, I heard my next patient sobbing, “I don’t want to do this! I don’t want to die!”
It was a day like any other in our busy pediatric intensivist-led procedural sedation unit, and I had a short period of time to assent and consent the patient and her mother for sedation before her scheduled procedure. Knowing that I would need to win the patient’s trust, I took a deep breath before entering in order to regulate myself.
“Hello, I’m Dr. Jill,” I said, nodding to my patient and her mother, “I’ll be the doctor doing your sedation for your procedure today.”
The words had barely escaped my lips when my patient exclaimed, “I’m not going to do this! I don’t want to die!”
I nodded briefly and sat down on a stool at the edge of her bed. She wouldn’t make eye contact, instead staring down at her lap. I sat quietly next to her for a moment before continuing.
“I’ve been doing this job for several years, and we’ve never had anyone die,” I said, “But, I’m guessing that doesn’t help much, does it?”
She shook her head, finally looking up and holding my gaze.
“What does help when you feel anxious?” I asked.
As is the case for many of my patients, my current patient had a history of anxiety documented in her chart. I wondered if there were coping skills that she had learned which might help her today.
Before she could answer, her mother spoke for her, “Nothing. She’s always anxious. I told her she would be fine, but she won’t listen.”
I sat quietly for another moment, looking at my patient before saying, “It’s ok to be anxious. I get anxiety before procedures as well. But I have some things that have helped me and several other patients I’ve taken care of. Would you like to hear them?”
She nodded, so I explained my usual approach for someone with peri-procedure anxiety. It consists of a list of cognitive and behavioral techniques that patients can select from and includes purposeful distraction (like counting or talking about a subject of choice), guided imagery, and/or deep breathing. Each of these evidence-informed techniques serves to either promote executive function or enhance the parasympathetic nervous system, thus mitigating the effects of the stress response.
“Does one of those sound good for when I give the medicine?” I asked.
She hesitated, then replied, “I guess I choose breathing.”
“Ok,” I said, “We can breathe together.”
After completing my usual process of explaining sedation, obtaining assent and consent, and listening to our procedural time-out, I moved to induce sedation. As I moved closer to my patient, I heard her heartbeat skyrocket on the monitor. She was visibly trembling in the bed and began to cry. I put my hand on her shoulder and leaned down close to her, looking into her eyes.
“We are going to breathe together,” I said, “Ready?”
She nodded, eventually closing her eyes as I guided her through inhalation and exhalation. I heard her heartrate returning to normal on the monitor. And, soon after, she was asleep. Her mother stared at me for a few moments, seemingly in disbelief.
“You’re really good at that,” her mother said.
I smiled and thanked her before she was guided out of the room so the procedure could begin. As expected, the sedation and procedure proceeded without incident. My patient recovered and was subsequently discharged. I moved on to my next patient, turning my attention to the work of making that experience as good as it could be.
To my surprise, a few months later, a letter arrived from my patient’s mother. In it, she thanked me for taking time to sit, answer questions, and validate the anxiety that my patient had expressed.
“Most of all,” she wrote, “she really loved how you gave her options on how she would like to be put to sleep. It made her feel like she had a little control in a helpless situation.”
In reality, I had only taken a few extra minutes in order to address her fears. But by providing my list of evidence-informed cognitive and behavioral strategies, I had met my goal of making the experience as good as possible for my patient and her mother. We can make a difference for patients with anxiety by:
1. Normalizing anxiety.
Many people experience anxiety, even those without a formal diagnosis. Telling people not to worry or giving statistics about procedural safety is ineffective due to the “amygdala hijack” which activates the fight-or-flight response of the sympathetic nervous system during times of stress.
2. Providing an opportunity for autonomy.
Providing a choice about how to go to sleep and utilizing cognitive and behavioral strategies can help counteract sympathetic activity. This provides anxiolysis and a less traumatic experience.
3. Recognizing emotional contagion.
Your own emotional state affects your patients. By taking steps to regulate your own nervous system, you can help others regulate theirs via mirror neurons.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.