1. Dellosso, Michael PTA

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After 12 years of being a clinician I found myself the patient. I was diagnosed with stage III colon cancer at 35 years old, and, rather than delivering healthcare, I was on the receiving end. Test after test, poked, prodded, examined, I experienced it all. And then came surgery and an ileostomy to deal with. Hospital stays, home care nurses, multiple trips to the emergency department. I ran the gamut. And one common denominator that stuck through all of it was anxiety.


My first breakdown happened sitting at the dining room table waiting for the oncology office to call and schedule my initial appointment. Nobody told me how long it would take so as the days ticked by, I could only imagine the monster inside me growing, spreading. I just wanted it out. Anxiety got the best of me and I panicked.


My next breakdown came in the hospital after my first surgery, a colectomy with ileostomy. It was too much to handle: the stoma, the abdominal incision, the pain, the lack of sleep. I wanted to click my heels and put it all behind me. I wanted to go home. But when I got home it didn't get much better. Yes, a nurse came twice a week to check up on me, but now I was responsible for taking care of the stoma and changing my appliance and emptying my bag. And I still had this huge incision that was stapled shut and all I could think about was that thing popping open and my intestines littering the floor. My wife and three daughters would be aghast in disgust and horror.


All patients experience some level of anxiety. It comes with the turf; it's the nature of the healthcare beast. Our job as clinicians is to (1) do everything within our control to avoid increasing patients' anxiety and (2) do everything within our control to reduce their level of anxiety. Home healthcare presents its own challenges when it comes to patients and anxiety. It's true, there's no place like home. But home is not a hospital or rehabilitation center; there is no nurse call button. Doctors don't stop by on a daily basis. Vitals are not constantly monitored. There's a sense of being stranded, even abandoned. There's also often family dynamics to deal with, unannounced visitors, spouses, children, grandchildren, pets to care for, transportation problems to work out. And on top of that there are strangers coming and going, giving instructions, suggestions, handouts to keep track of, more schedules to accommodate, phone calls to make. And the anxiety rises again.


So, with patients in mind, here are a few practical things we can do to decrease their anxiety. Remember, we are strangers in their home. The saying goes, a man's home is his castle. For patients, home is often where they feel safest. It's their place of comfort and security. Their front door is a barrier to the outside world. When we walk through it, we are entering their safe place. We are intruders, crossing that line and bringing with us the unknown. For any of us, our anxiety automatically increases when a stranger enters our home. Our patients' vulnerability only heightens that anxiety.


To lessen this effect, be mindful of body language; it speaks volumes. Avoid sudden, unpredictable movements. Speak softly and kindly. Smile often. Position yourself on the patients' level (sitting or kneeling) and avoid looming over them. Ask permission before touching them and explain what you're doing and why.


Respect their home. If you've been in home care for any length of time, you know there is a wide variety of homes in all shapes and sizes and degrees of cleanliness and orderliness. But regardless of how we feel about a patient's home we need to realize that it is their home, the place where they feel comfortable, where memories are made, where family visits, where tears are shed and laughter echoes in the halls. Show respect for not only their home but for their possessions. Never show distaste or disgust. Do not make disparaging comments about the condition of their home. Be careful not to appear uncomfortable (unless, of course, there is an appropriate reason to be uncomfortable and then you should respond accordingly). They are graciously allowing us into their domain and we need to respect that.


Allow them to take the lead. We would do well to master the art of being in control without taking control. Although we may be the experts, we are still only visitors in their home and they need to know that we recognize that.


Education plays a key role in reducing anxiety. Explain the reasons behind decisions and educate the patient on the "whys and hows" of what you do and are asking them to do. And don't be afraid to explain the science behind it in terms they can understand. Knowledge reduces anxiety.


Do not be demanding. Don't tell them what to do, rather convince them why they should do it. We know why they should do what we ask them to do; we know the science behind it, the medical sense of it. We need to do the work of sharing that knowledge with them, giving them that control, so they come to the same conclusion. The more control they have (or at least think they have), the less anxiety they experience.


Also, allow them to play an integral part in the development of their treatment plan and goals. Gently guide them through the process so goals and expectations are in line with their desires, but realistic and attainable. Then tailor treatment around what they feel is important for them.


Use appropriate humor. Laughter releases endorphins and can have a direct and almost immediate impact on reducing anxiety. Be careful not to use off-color or vulgar humor, though. Not everyone finds that funny and it can easily have the opposite effect. Avoid sarcasm as well; it's a jaded brand of humor that is often a tough sell. Everybody likes a good clean joke, a genuine smile, and a light outlook on life. Funny anecdotes also go over well. Don't be afraid to laugh with your patients. It shows them that you enjoy the time you spend with them and that you see them as more than a patient. Appropriate humor at appropriate times is a vital tool to reduce anxiety.


As clinicians in patients' homes, our goal should always be to lessen anxiety, not add to it. By doing a few simple things and adjusting a few simple behaviors, we can greatly minimize the amount of anxiety our patients feel.