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As an ex-cardiac surgery patient who had an aortic valve replacement in 1997 and whose clinical experience has been entirely on the receiving end, I very much welcome the paper on ‘Coronary artery bypass surgery discharge planning for successful recovery’, by two Australian researchers, Karen Theobald and Anne McMurray. This paper directly addresses the difficulties of patients and carers following discharge, an area that until recently has not received enough attention.

For me the weeks and months following discharge held some daunting problems, but apart from my GP, a few leaflets and eight exercise sessions at the local hospital there was little support to call on; and as for my husband, it didn't seem to occur to anyone that he too might have difficulties!

This was also the experience of most of the people who wrote to me about their own stories when I was gathering information for my book Take Heart! (MacLachlan 2001), which follows the encounters with valve and/or bypass surgery, and its aftermath, of some 50 ex-patients who were treated in various hospitals in Scotland, England, Canada and the USA. Almost all commented on lack of support after discharge, though there were some exceptions, notably Ottawa Heart Institute which addressed patients' needs directly through a system of individualized rehabilitation programmes, although even here little attention was given to their carers.

Theobald and McMurray (2004) addresses the needs of both, by a structured series of interviews with 30 patients and their family carers at two stages: the first shortly after discharge, and the second a year later.

Many patients experienced the operation as ‘a huge personal shock’, while their carers found themselves with unanticipated feelings, practical problems and lifestyle changes that were difficult to deal with. My impression is that the shock element came as something of a surprise for Theobald and McMurray too. They comment, ‘The impact proved to be enormous for both patient and carer, and this requires further nursing consideration. No other studies of coronary artery bypass graft (CABG) surgery were found that reported this feeling of being overwhelmed by the unexpectedness of the sudden decision to proceed with CABG surgery’. Perhaps the clue here may be that while for clinical staff CABG is a routine operation with statistically good outcomes, the individual patient and family may be plunged without much warning into what seems literally a matter of life and death, with no individual certainty as to the result. The prospect of your heart being stopped is especially frightening, because in any other circumstances it inevitably means death. Furthermore, in everyday language and in almost every age and civilization the heart has been seen as a cultural icon representing the individual's distinctive emotions and personality, and therefore different from every other organ of the body and – a pertinent point – all this is equally applicable when the patient is a doctor or a nurse!

Theobald and McMurray's study found that worry, physical changes, continuing pain and loss of confidence were all experienced as problems by patients, and no doubt these are part of normal recuperation; finances could be an added problem, and support was at best patchy.

While patients might be expected to need support after discharge for both physical and emotional reasons, the problems of family carers which the paper also documents have been less well signalled. However willing and responsible carers may be, they carry a heavy burden, and one which is sometimes beyond their capability: for instance, one of my respondents in Take Heart! was being cared for by two teenage daughters. It can be incredibly difficult for people with no clinical training or experience to decide which symptoms need urgent medical attention, and which just have to be coped with. Equally important is the emotional impact on carers themselves, the changed roles they are called on to undertake, and the physical drain on their capabilities.

One commendable suggestion cited by Theobald and McMurray is for community telephone networks, which could be a valuable backup system, available from the moment a patient is discharged and dissolving the isolation felt by so many.

Another idea that is already of proven value might be cardiac support groups. These usually come into play later, when the patient has recovered, and are a fine support system at that stage. But they can be more than that: for instance the Sheffield Open Heart Club (SHOC for short) is a UK-registered charity whose ex-cardiac patient members go into hospitals as volunteers and visit patients the day before their surgery to give support to them and their families. Other clubs could do the same, but at present they are a seriously under-used resource.

Recently there have been some hopeful developments. For instance, the Royal Infirmary of Edinburgh, where I had my surgery, now contacts patients 10 days after discharge to monitor their situation, and information packs are given out by the Cardiac Rehab departments which have been organized in local hospitals. In 2002 the Scottish Executive published its Coronary Heart Disease and Stroke Strategy for Scotland, and among other initiatives this has led to managed clinical networks currently being set up in Scottish health board areas to examine practice across a range of services, from the patients' point of view; the aim here is to organize care around ‘the journey of the patient’. Crucially this includes the period after discharge, and addresses the needs of carers as well as patients. The work is still in its early stages so results will not filter through to the consumer for some time – but here too carers and their problems are being identified as an issue.

Change is coming, then, and the close professional attention paid by Theobald and McMurray to the postdischarge experiences of both patients and carers is well timed. This valuable paper demonstrates an area of clear need, and provides building blocks for progress. Their findings should be acted on widely, and with speed.

References

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  2. References
  • MacLachlan M. (2001) Take Heart! a Guide to Coping with Cardiac Surgery, for Patients and Their Families. Librario Publishing Ltd, UK, http://www.librario.com.
  • Theobald K. & McMurray A. (2004) Coronary artery bypass surgery: discharge planning for successful recovery. Journal of Advanced Nursing 47(3), 483491.DOI: 10.1111/j.1365-2648.2004.03127.x