Mindfulness for patients undergoing surgery
This paper was published in The British Journals of Anaesthesia. You can download the paper here.
A Cost-Effective and Potentially Underrated Tool for Improving Outcomes
Oscar Emanue [1], Kate Greenslade, Matt Lechner [2], Nicholas Eynon-Lewis [2]
Lister Hospital, East and North Herts NHS Trust
Royal London Hospital, Barts Health NHS Trust
Introduction
Mindfulness is defined on the NHS website as “knowing directly what is going on inside and outside ourselves, moment by moment”(1). The links on the website page direct patients to information on depression, anxiety, anger management, seasonal affective disorder, panic attacks and mood self-assessment. There is no mention of surgery on the page, but this is not a ‘notable’ absence as mindfulness is not usually considered as part of the management of the surgical patient. Yet anxiety is an understandable and natural emotion encountered by surgical patients(2), many of whom will regard surgery as a major life event. Pre-operative counselling on the nature and complications of surgery is of course essential and required in order to gain informed consent(3). We consider the potential benefits of providing pre-operative instruction on mindfulness.
Anxiety and Surgery
Surgery is known to be associated with the development of anxiety both before and after the operation(2). Many patients may have underlying anxiety and depression and this is compounded by the stress associated with having to undergo either elective or emergency surgery. This can be even more severe if the patient develops a complication.
The benefits of optimising a patient’s state of mind has been demonstrated with pain and quality of life scores in patients with chronic diseases and may also reduce post-operative pain in the surgical patient(4). Current clinical guidelines could do more to optimise post-operative pain management strategies through non-opioid-based therapies such as mindfulness(4). A study of 85 ambulatory hand surgery patients showed that higher pre-operative pain catastrophising scores (PCS) were linked to higher post-operative pain scores and consequently increased use of opioid pain relief(5). This is not surprising, however, those patients who selected to adopt mindfulness techniques pre-operatively reported lower pain scores at one week and lower opioid use. Opioids can be used pre-operatively to inhibit cortisol release and curb the physiological effects of stress and anxiety immediately before an operation(6). Given the significant side effect profile of opioids and their addictive qualities, employing mindfulness as a tool to decrease the overall use of opioids seems an attractive prospect. Furthermore, from a financial point of view, fewer opioid prescriptions result in fewer concomitant prescriptions of anti-emetics and laxatives.
The benefits of reducing anxiety pre-operatively are not merely limited to improving pain management however. An association was seen between anxiety and post-operative haemodynamic instability in a cohort of 75 patients undergoing cardiac surgery(7). Interestingly, the same study noted a statistically significant link between pre-operative depression and post-operative nausea, agitation, increased time of intubation and sensorineural deficit. A longitudinal study of 698 patients who underwent coronary artery bypass graft in University Hospital Adelaide showed even greater evidence of the dangers of unaddressed pre-operative anxiety. Patients diagnosed with generalised anxiety disorder (GAD) experienced a higher rate of post-operative major adverse cardiovascular and cerebrovascular events (MACCE), with a hazard ratio of 2.79(8). This is perhaps not surprising given the established links between GAD and coronary heart disease(9).
Of course, the majority of patients who undergo surgery will not have a diagnosis of GAD and their anxiety both pre and post-operatively would be considered appropriate to their situation. However, it does certainly seem feasible and even likely that their anxiety will influence their recovery.
Other complications may also be mitigated with the management of anxiety in the surgical patient. Increased anxiety may be related to a higher risk of surgical site infection, with a lower incidence among patients who receive treatment for anxiety preoperatively. Of 130 patients with anxiety undergoing abdominal hysterectomy, those who received 10mg diazepam on the night before surgery and one hour before surgery experienced less post-operative anxiety and fewer surgical site infections(10). This is an interesting low-cost intervention that demonstrates the possible utility of pharmacological pre-operative anxiety management although there are obvious drawbacks to using anxiolytics routinely, particularly in patients before they have been admitted to hospital . In fact it was relatively common practice to use an anxiolytic as part of the ‘pre-med’ in the UK until relatively recently. Non-pharmacological interventions such as mindfulness may replicate or even give more sustainable improvements in outcomes or may prove to serve as a useful adjunct to anxiolytic medication used in the pre-operative period.
The potential benefits of practicing mindfulness techniques described above may depend on the medium through which mindfulness is delivered in a pre-hospital setting. Systematic reviews of these eHealth packages based around mindfulness and relaxation techniques demonstrate their worth in the setting of chronic disease(11), but more research is needed to evaluate their potential in a pre-surgical setting.
Mindfulness has also been used post-operatively with some success. Breast cancer patients enrolled in weekly mindfulness training programmes have seen statistically significant improvements in sleep and anxiety and depression(12), while other QOL measures showed positive trends in the same study which, although promising, was limited by its sample size. Another pilot study suggested that the incidence of post-operative confusion could be reduced using a perioperative approach to mindfulness coaching, with the additional benefit of improved global patient satisfaction relating to their hospital stay(13). However, data on patient outcomes specific to surgical patients remains limited despite the anecdotal evidence discussed above.
The Anxious Surgical Patient
Pre-operative anxiety very often peaks before the patient’s admission(14). Somewhat surprisingly, only a small percentage of patients may reach their peak anxiety levels on the day of surgery(15). In one study anxiety levels in the afternoon before the day of surgery were found to correlate with anxiety levels in the immediate pre-operative period(16).
In-hospital pre-operative counselling, regardless of the ability of the clinician, may therefore be less effective. Mindfulness can be patient-led and can take place before a patient is admitted to hospital for their surgery.
Anxiety influences the management of the anaesthetic and has physiological implications for patients on the operating table(17). These may manifest as pre-operative tachycardia and hypertension resulting from stimulation of the sympathetic nervous system(18). In contrast to anxiety, mindfulness techniques, when properly and regularly practiced, can elicit a “relaxation response” which, even in the absence of a detectable change in blood pressure or heart rate, may result in reduced noradrenaline end-organ responsivity(19).
Mindfulness in Illness – Psychological and Physical
Mindfulness has already shown promise in its wide-reaching applications. Its ability to improve symptoms of anxiety has been demonstrated in meta-analyses(20, 21). Patients who receive mindfulness experience fewer life stressors and the perceived severity of those stressors is decreased(22). There is significant evidence to suggest that it helps patients with depression, such that it has been combined with cognitive behavioural therapy (CBT), a digital form of which should be offered to all young patients presenting with mild depression according to NICE guidelines(23). This combination in the form of mindfulness-based cognitive behavioural therapy (MBCBT) may be as effective as maintenance anti-depressant therapy at preventing relapse and recurrence of depression according to a two-year RCT(24). Mindfulness-based interventions (MBIs) and CBT, although effective together as just discussed, have different utilities depending on the patient. One meta-analysis of 10 studies suggested MBIs were better suited to addressing internalising and distress than control interventions, yet failed to produce a statistically significant improvement in fear symptoms. CBT on the other hand was better than MBIs for fear symptoms but not for internalising and distress(21).
Mindfulness has also proven effective as a treatment option for patients with chronic diseases. A systematic review of 17 studies, 16 of which involved web-based mindfulness and relaxation techniques and 1 iPod-based, involving 1855 patients showed improvements in general health and psychological wellbeing in patients with irritable bowel syndrome, chronic fatigue syndrome, cancer, chronic pain and hypertension(11). Such eHealth interventions have been proven to be cost-effective in patients with somatic diseases in the majority of studies analysed by a systematic review and meta-analyses(25).
Scoring systems have evolved through the quantification of mindfulness, allowing one systematic review to correlate higher mindfulness scores with improved quality of life as demonstrated in patients with osteoarthritis of the knees(26). This is corroborated by another study of patients with knee osteoarthritis which suggests patients with a higher total mindfulness were significantly more likely to respond to non-pharmacologic exercise interventions(27). Interestingly, one case report showed an improvement both clinically and in quality of life measures and also a reduction in thyroid antibodies in a patient with Hashimoto’s thyroiditis treated with an integrative approach involving daily mindfulness techniques and vitamin supplementation(28).
There is evidence to suggest that mindfulness and meditation may alter brain structure. The most dependably replicable results throughout imaging studies show morphological differences in the left rostrolateral prefrontal cortex, anterior/mid-cingulate cortex, anterior insula, primary/secondary somatomotor cortices, left inferior temporal gyrus, and hippocampus(29). The significance of these structural differences, however, remains unclear(30).
Practical Mindfulness Techniques
One of the authors (KG) describes some of the core mindfulness techniques used in her practice.
Meditation: This is the bedrock of mindfulness and forms the core of the work I do. This brings awareness to ourselves, others and our environments. Once clients have a regular meditation practice they will start to notice how it acts as a ‘reset’ button for the mind and their wellbeing as a whole.
Awareness: Merely witnessing and noticing brings us increased joy.
Acceptance: When we struggle with our situation it prolongs our suffering.
Taking charge of our lives. What is important to us? What do we want to change?
Breathing techniques: The only way you can regulate your stress and achieve calm is by breathing as it dampens the parasympathetic nervous system. When we slow and control our breath with focused awareness, we physically calm the CNS which brings us back to equanimity.
Freedom and choice: Taking charge of our lives. What is important to us? What do we want to change?
A Body Scan exercise to increase awareness of physiological sensations and help to ground us in the here and now.
‘The Observer’ technique: enables us to watch our thoughts but not overly identify with them.”
Practicing mindfulness teaches you to catch yourself before you step onto that fight or flight path. With practice, bringing yourself back to equanimity can become your automatic reaction when you’re under stress and settle the fight/flight response when you don’t need it.
Delivering Mindfulness to the Patient
Mindfulness techniques can be taught to patients either in person or online via video conferencing in their own homes. The latter allows for patients to schedule a convenient time for their sessions and feel safe and secure in a familiar environment. Delivery by professionals, where possible one-to-one and with a consistent tutor, allows patients to understand and apply the techniques they learn. It is not possible to learn mindfulness from simply reading about it, you have to experience it and practice it to have any real effect. Early initiation of sessions is possible in the setting of planned elective surgery, allowing time for patients to practice between sessions. It is also possible that during recovery, novel anxieties may occur which were not present during the pre-op period. Mindfulness sessions may be beneficial post-operatively in these cases. There is also scope to offer access to mindfulness techniques to patient relatives who may be caring for the patient during their post-operative recovery following discharge from hospital.
Conclusion
Mindfulness has shown considerable success in improving patients’ quality of life in a wide range of chronic diseases. Its utility in psychiatry is such that it makes up a core part of clinical guidelines for notable conditions such as depression. As a low-risk, low-cost intervention, it may be prudent to use it in a surgical setting. Although the supporting literature is limited, mindfulness techniques may help the surgical patient. It is not a substitute for proper pre-operative counselling by a practitioner experienced in the procedure, but may combat pre-operative anxiety and lessen the need for anxiolytics and other anaesthetic requirements in the immediate pre-operative period due to its availability in a pre-hospital setting, potentially through electronic delivery. It has further potential as a substitute or adjunct to pharmacological treatment by reducing post-operative pain scores and the burden on opioids and other analgesics.
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