"Rabbi, who sinned, this man or his parents, that he was born blind?" Jesus answered, "Neither this man nor his parents sinned; he was born blind so that God's works might be revealed in him." - (John 9:2-3, NRSV)

When this event occurred, the disciples had already seen Jesus do many miracles. Despite what they had witnessed, it didn't occur to them that Jesus could heal this man. The disciples had a misconception about the cause of the man's condition (sin) and the ability of Jesus to heal him. Had Jesus not intervened, the disciples' misunderstanding would have been a significant barrier to the man receiving healing.

As nurses, we encounter people with misunderstandings about illness. Patients can have misinformation and wrong ideas about the cause of their symptoms or disease. Some, to their detriment, mistakenly believe the treatments they need to get better are causing their problems. In the same way that the disciples didn't think to ask Jesus to heal the man, some of our patients discontinue life-saving treatments because they have misconceptions about risks and side effects. Nurses are challenged in compassion to help people understand the truth about their illnesses and treatments. As they offer their patients truth, they free them to get better.

UNITED STATES: 21st CENTURY

"Dina, Ms. Murphy is here for a nurse visit."

Jill appeared anxious when I entered the room. She furrowed her brows and twisted her hands. Jill began, "Dina, you may not believe this, but this new medicine is making me jittery too."

"Jill, knowing you have high blood pressure has been hard on you, hasn't it?"

"Yes. I don't like taking pills. I see all the side effects listed on television ads and the list at the drugstore. But with high blood pressure, I worry about dying of a heart attack. I have three young children, and I want to see them grow up. My aunt died of a heart attack; I don't want to do the same."

"And when you take one of the pills, you remember your worries?"

"Exactly!! The pills make me more anxious."

"Jill, anxiety is not a recognized side effect of the three medications you've taken. It is possible to have an unexpected side effect with one medicine, but to have the same unrecognized side effect with three different medicines is not likely. Do you think the anxiety is more related to your fear of high blood pressure and pills in general than to these specific medications?"

"Maybe you're right, Dina. The idea of taking pills for the rest of my life bothers me, and the chance that I could have a heart attack bothers me more."

How often do our clients experience negative symptoms they believe are caused by their medications when the symptoms have other causes? What factors contribute to this problem? How can we help patients recognize the truth about these symptoms so they will take the medicines they need to keep them healthy? Do biblical principles exist to help Christian nurses address this problem?

In every healthcare setting, professionals have the opportunity to teach patients about their prescribed medications and treatments. Nurses educate and answer questions when medications are prescribed and administered. They provide detailed medication information at discharge from treatment or hospitalization. Understanding how best to educate patients about their meds is crucial to helping them maintain their course of treatment.

THE PLACEBO EFFECT

The placebo effect, a term familiar to most, is the apparent benefit that occurs when an ineffectual substance-a "sugar pill"-is given and seems to help. It is an apparent benefit unrelated to the medication. Because we recognize this phenomenon, pharmaceutical studies always include a placebo group for comparison with the experimental group. The placebo group receives a "sugar pill," whereas the experimental group receives the actual drug. No matter what treatment or what disease is studied, some patients in both groups get better and some get worse. Only by comparing the groups statistically can we discern what effects the proposed treatment (i.e., drug) has. However, the placebo is much more than a "control medicine" in a clinical trial. An understanding of placebo effect can be very helpful in clinical practice.

The psychological aspect of the placebo effect relates in part to our ability to deceive ourselves. Jeremiah 17:9 states, "The heart is deceitful above all things and desperately wicked; who can know it?" (KJV). For example, some of our grandparents wore copper bracelets for arthritis, believing the bracelets helped them because they felt better when they wore the copper bangles. However, the improvement was not because the copper bracelet had an effect on their arthritis.

We cannot always trust ourselves and our impressions to determine whether a treatment is effective. We may become firmly convinced that it worked, when in fact our apparent response was more psychological than physical.

THE NOCEBO EFFECT

The nocebo effect is the opposite of the placebo effect. Instead of good things happening, the nocebo effect involves bad things happening that are unrelated to the pharmacologic properties of a medication. Jill became jittery when she took her blood pressure medicine and believed the medication caused anxiety. In reality, Jill's anxiety came from her fear of the medicine and fear of having a heart attack. Negative beliefs can generate nocebo effects that offer an explanation for psychogenic side effects and illnesses.

In practical terms, how do nocebo effects happen? Like the placebo effect, the psychological component of the nocebo effect is the result of misunderstanding what we feel. A patient in our practice called to ask if his cholesterol medication had caused him to catch a cold. As healthcare professionals, we recognize that this is medically absurd. Viruses cause colds, and cholesterol medications do not produce viruses or affect the ability of our bodies to resist viruses. Many questions about side effects are more subtle but equally groundless. Over the course of 3 days, how many of us will have muscle aches, a headache, or more fatigue than usual? If I've just started taking a new pill, it is easy to blame the medication.

A more dangerous situation occurs when a client experiences a new problem and fails to seek medical attention because he or she believes a new medication is the cause. Patients may stop their medication rather than seek medical attention. Clients in our practice have stopped their medicines when they had dangerous problems with their vision or even stroke symptoms.

Sometimes a patient will have a preexisting problem that recurs or worsens, with the patient blaming the problem on the medicine. For example, Mrs. Jones may complain that a new medication is causing fatigue or joint pain. A review of her chart shows that she has been reporting the same symptoms for the past 5 years.

ADVERSE EVENT OR NOCEBO EFFECT?

How can we distinguish between true adverse events from a medication or treatment and nocebo effects? To recognize real and pseudo side effects, we need a thorough knowledge concerning the genuine potential side effects of medications and the likelihood of their occurrence. Package inserts and the Physicians Desk Reference (2008) provide specific information and rates for the occurrence of potential side effects, both serious and minor in nature.

For example, consider the reported side effects for the drug amlodipine besylate (Norvasc), a calcium-channel blocker used for treating hypertension and chronic stable angina. Approximately 1.5% of the patients receiving Norvasc in controlled clinical trials discontinued taking the medication due to symptoms such as dizziness, flushing, and palpitations, but 1 percent of the patients in the placebo group also stopped their pills. The most common side effect was headache (7.3%), but 7.8% of patients in the placebo group also experienced headache. On the other hand, edema was about three times more common with Norvasc than with placebo. The side effects were more common among women than among men in both the drug and placebo groups (Physicians Desk Reference, 2008). Knowing this kind of information is important for educating patients about their medications and responding to their concerns, including reports of side effects.

The nocebo effect can become a barrier that prevents clients from receiving the best treatment. If a patient believes a medicine is making him or her feel bad, he or she will not want to take it. What are specific therapeutic methods we can use to help patients get around this barrier?

SPEAKING THE TRUTH IN LOVE

The best antidote for deception is always truth. Ephesians 5 states, "Walk as children of light (for the fruit of the light consists in all goodness and righteousness and truth), trying to learn what is pleasing to the Lord" (Ephesians 5:8-10, NASB). The nocebo effect is a deception, so the light of truth will expose it.

In the case of Mrs. Jones, showing her that she has reported the same fatigue or joint pain for the past 5 years generally convinces her that the symptom did not start with the new medicine. In Jill's case, she has enough insight to see that she is anxious about her diagnosis. When faced with the reality that three different medicines are unlikely to cause the same side effect, Jill is able to see the truth about her real problem-fear and anxiety.

The client who reads the package insert often needs more education about the nature of placebo and nocebo effects. Find information in the Physician's Desk Reference (2008) that lists side effects and percentages for the drug compared with placebo. Often, a symptom the client is experiencing occurs for the same percentage of patients in the placebo group as in the drug group, as noted earlier with the medication Norvasc. Most people have heard of the placebo effect, so when they see this information, they can understand the symptom probably is not drug related.

Speaking the truth in love (Ephesians 4:15) means letting patients know we care about their symptoms and want to hear their concerns, that we want to work with them to find the cause and the cure. Sometimes we may need to do more tests to reassure them that the medication is not the cause, possibly including a trial of withholding the drug for a week or two to see what happens.

Speaking the truth in love means we avoid the easy way out by simply changing a medication without properly educating the patient. In our practice, we often have to reeducate patients who tell us they cannot take a certain cholesterol medication. They may say, "Dr. Stuart told me to stop this because it made my knee hurt." Like prescribing unneeded antibiotics rather than explaining why they aren't necessary, stopping medicine because of a nocebo effect can be the easy way out for the healthcare provider. We must investigate and educate patients before stopping or changing their medications. Simply agreeing with the patient to save our time and energy can do them more harm than good.

Sometimes clients forget why they are taking their medication. For our clients with coronary disease, for example, cholesterol-lowering medications increase longevity. Allowing pseudo side effects to keep them from these drugs cheats them and their families from best care. Understanding the purpose of their medications is sometimes the most important part of their education. If they understand that the medicine will help them live longer, they may be willing to accept a few problems, whether physical or because of a nocebo effect.

Some people are reluctant to believe that a problem is not a side effect of their medicine. The nocebo effect can arouse powerful emotions because it relates to self-deception. Convincing a client to take a medicine he has decided he wants to stop creates issues of control that can be hard to overcome. Working through these issues with clients, as a part of their team, is a positive way to approach the discussion. We need to consider patients as partners in their care instead of dictating their treatment to them. In our practice, we use statements such as "I wish it were the medicine-that would be an easy problem to solve." In this way, we identify with the person's viewpoint, and acknowledge our reluctance to contradict it. We want our clients to understand that nothing would be easier for us than to change or stop the medicine. The only benefit we get from educating them is the knowledge that we have done the right thing. Once we get through their defense mechanisms, it is easier to present the facts about medications and treatments.

SOLVING A DIFFERENT PROBLEM

"Jill, since you learned about your high blood pressure, do you feel you know how you're going to die?"

"Yes, Dina, I do. I just know I'm going to die of a heart attack."

"Jill, many people who experience high blood pressure or high cholesterol feel as you do. They become anxious or depressed and preoccupied with their health. In reality, knowing you have high blood pressure helps us reduce your risk of having a heart attack. But there is something positive about your feelings, too."

"What's that?"

"We see people in our office every day who think that they are never going have a health problem. Suddenly, they have a heart attack or stroke. The reality is that any of us can experience a serious health problem at any time or even die. Having high blood pressure doesn't have to be that big of a deal, but you know now that you're not invincible. Try using this to focus on the things that are really important, such as your children."

Helping patients identify true underlying issues of concern is helpful in addressing nocebo effects. Exploring alternative ways to address or cope with these underlying issues can help patients stay on their medications.

CURE SOME, COMFORT ALL

We will not be able to cure everyone the way Jesus cured the man blind from birth. However, we can give the best possible care by being honest with our patients and addressing any nocebo effects. Most importantly, however, it has long been a value in healthcare to "cure some and comfort all." We can provide comfort to all our clients by compassionately telling the truth, showing the same love and understanding that God has shown us. When the nocebo effect springs from a sense of vulnerability, we may have an opportunity to remind our clients that all of us are vulnerable. That reality can drive us to think about more than our physical health.

We recognize the nocebo effect by having a thorough knowledge concerning the potential side effects of medications and a thorough knowledge of our patients and the symptoms they are experiencing. We treat nocebo effects by sharing the truth in love. In the same way that Jesus relieved the blind man's guilt and corrected the disciples' prejudice, we can help free patients from self-deceptions that interfere with their health.

a Glance

@ Theplacebo effectis apparent benefit that occurs unrelated to a medication.

@ Thenocebo effectis apparent harm that occurs unrelated to a medication.

@ Placebo/noceboeffects relate to our ability to deceive ourselves

@ Knowledge ofmedication side effects, patient history, and predisposing factors helps distinguish between true adverse events and nocebo effects.

@ Speaking the truth in love to patients (Ephesians 4:17) is key to managing nocebo effects.