Special John

R. Peteet,

Phyllis

MD

Truesdell,

#{149} Paul

MSW

C. Stomper,

#{149} Walter

MD

Denise

Murray

#{149}

Moczynski,

Ross,

RN,

Index

terms:

Neoplasms,

CT

#{149} Special

reports

O

Radiology

1992;

VER the

past tomographic

ticipating

the

with

emotional

From

the Division of Diagnostic (D.M.R.), and

and Chaplaincy Cancer Institute Hospital,

ceived

Harvard

18; revision Radiology, and Carlton C RSNA,

of Psychiatry Radiology Social Work

(J.R.P.);

De-

(P.C.S.), (V.C., PT.);

Service (W.M.), Dana-Farber and Brigham and Women’s

Medical School, Boston. Rerevision requested June received August 1; accepted August reprint requests to P.C.S., Diagnostic Roswell Park Cancer Institute, Elm Sts, Buffalo, NY 14263. 1992

April 25, 1991;

5. Address

of pa-

Cotton,

MSW

study

AND was

Cancer Interviews

semistructuned

conducted

METHODS at the

Dana-

Farber Cancer Institute, a comprehensive cancer center and teaching hospital for Harvard Medical School. The study sample consisted of 79 patients with cancer who had recently undergone body CT scanning at the institute. Patients undergoing body CT were questing an interview of the CT examination.

given a letter reafter the completion Patients who did

Who

interviews.

intenrater

reliability

ens, a sample transcribed

To

among

audiotaped and then

ascertain

the

interview-

interview reviewed by

was each

interviewer; agreement among observers on their recorded assessments of patient responses

was

86%.

The

study

instrument

was a set of 17 questions that the interviewer asked about reactions of the patients to their first CT examination (usually at an outside center) and most recent CT examination at our institute, the sources

of their anxiety and their ways of with it, their interaction with radi-

dealing obogy

staff,

and

the

way

they

received

the

results. Questions ranged in format from forced-choice (eg, “Rate your anxiety on a scale of 1 to 5”) to open-ended (eg, “What

was your greatest source of anxiety?”). Most of the questions required specific responses. Patients gave more than one response to several questions; thus, the percentage of these answers totals more than 100%. During the period of the study, all patients

undergoing

CT were

cared

for in

the routine manner. The technologists and radiologists were blinded as to which patients were participating in the study. A CT technologist explained the procedure and communicated with the patient via intercom throughout the duration of the procedure, including giving breath-holding instructions. Interaction between the diagnostic

182:99-102

This

I

needs

cancer.

MATERIALS

partments Nursing

with

15 years, computed (CT) scanning has become widespread as the standard means of staging and reassessing many forms of cancer. Like other highly technical on dramatic diagnostic procedures such as magnetic resonance (MR) imaging (1,2), it has been associated with several types of distress. Anecdotal reports refer to physicab discomfort, claustrophobia, an.xiety about the procedure itself, and apprehension about receiving the mesults. Little information, however, has been available about the frequency and severity of these reactions or what methods patients find most useful in dealing with them. Radiologists have recently called greater attention to their interaction with patients (3,4), including their role in reporting results (5-7). Data about the experience and pnefenences of patients in these areas have been limited as well. This study of cancer patients undergoing CT was undertaken to learn how patient experiences during CT can be improved and to assist diagnostic radiologists, technobogists, and supporting staff in antients

Victoria

#{149}

MDiv

Emotional Support for Patients Are Undergoing CT: Semistructured ofPatients at a Cancer Institute’ To understand and improve the experience of cancer patients undergoing computed tomography (CT), 79 patients who underwent CT at a cancer institute participated in semistruclured interviews about their experiences with CT. All patients had previousby undergone CT; 75% (n = 59), three times or more. Anxiety about results was the most common concern during first and subsequent CT examinations. Technical aspects were a common concern during initial scanning, but not subsequently. Methods of relaxation most used by patients during CT were following instructions (56% [n = 44J), meditating and visualizing (44% [n = 351), and praying (42% [n = 331). Patients suggested several ways in which the radiology staff can support them during the evaluation of their malignancy. Fifty-five (70%) of the patients said they would like the radiologist to tell them the results of their scanning. Optimal care of patients with cancer who undergo CT goes beyond technical to emotional and spiritual support.

MA

Report

radiologist

and

each

patient

was at the discretion

of the diagnostic

diobogist

the examination.

monitoring

ra-

Oral contrast medium consisting of a mixtune of fruit punch and iodinated contrast material was administered over a period of 45-60 minutes before the examination. Intravenous

contrast

material

istered

selectively

for body

cretion

of the radiologist

was

admin-

CT at the dis-

and was not ad-

ministered

for most

of the recent

examinations performed

(ie, those at our institution) in this study.

CT

RESULTS

not decline to participate by returning a card were later telephoned and interviewed. Fifty percent of patients given a card were available for telephone interviews. Telephone interviews were conducted by psychosocial clinicians at the

Fifty-nine patients (75%) had undergone more than three CT examinations, including those at other

hospital

viewed

with

experience

in methods

of

institutions;

only

had

three

undergone

patients

only

inter-

one

pre-

vious CT examination. Reasons given for their most recent examination were routine follow-up (n = 33 [42%]), (n

assessment 20 [25%]),

=

to treatments assessment of abnormal and

It makes

said

that

effort to avoid patients (15%) 100

#{149} Radiology

Their

First

and Most

(i

=

test

initial

all the

Reaction

results

the

staff

and explain commented

Overall Felt Felt Felt Median Major

staging

difference

made

Recent No.

every

delays; on the

12

about

Fear and/or

of Patients First CT Examination

of 1-10)

results

curiosity

regarding

at

(n

No.

of Patients

Most Recent

at

CT

Examination

experiences,

being

32 (41) 38 (48) 9 (11) 53

49 (62) 19 (24) 11 (14) 3.5

18 (23)

20 (25)

sick

17 (22)

2 (3)

14 (18)

8 (10)

Claustrophobia

No major Note.-Numbers

2 Reasons

concern in parentheses

for Best

2 (3)

1 (i)

28 (35)

48 (6i)

are percentages.

and Worst

CT Examination

Experience No.

of Patients

Who

Responded

Best Reason

for Best

or Worst

(n

Experience

Getting or expecting positive/negative Explanation adequate/inadequate Examination comfortable or fast/uncomfortable or long Specific physical problems

results

Worst (n = 79)

= 79)

16 (20)

8 (10)

3 (4)

8 (10)

9 (ii)

8 (10)

Staff helpful/unhelpful

0 8 (10)

15 (19) 3 (4)

Worry,

0

5 (6) 1 (1) 31 (39)

anxiety

Wait for results short/long No specific response Note-Numbers rounding.

in parentheses

2 (3) 41 (52) are percentages.

needed to drink the oral contrast liquid; only two patients believed they had been kept waiting too bong. The only suggestion made by more than 10% of patients for improving the technical aspects of CT scanning was to provide more explanation of what to expect during the first CT examination (47% [n = 37] of patients gave this response). As one patient put it, “The first time, explain exactly what you’re doing, why you’re booking for it. Maybe take the patients back to the control room to see the TV pictures. Let people know it doesn’t hurt, that the drink isn’t too bad.” Other specific suggestions for accomplishing this were the use of a booklet (three patients [4%]) and pictures (two patients [3%]). Fifty patients (63%) had undergone intravenous administration of contnast material. Since this usually occurred during a previous CT examination outside our institution, the frequency of use of ionic or nonionic contrast material could not be determined. The patients rated this expentime

79)

=

tech-

nobogy

Physical

Table Major

CT Examinations

discomfort

fine, relaxed uncomfortable somewhere in between level of anxiety (scale concerns

Anxiety

in the

world.” Several patients commented that their first CT examination was the worst because they were anxious about their new diagnosis, because they did not know what to expect, or for other reasons (eg, “I was left waiting in the hall watching very ill patients wheeled in on stretchers for 2 hours.”). Patients reported using a variety of methods to help them relax during CT scanning. Following instructions for breath holding; meditating and visualizing; and praying were most commonly used. Table 3 shows the responses of patients when asked specifically whether they used four common approaches to reduce anxiety. There were few specific comments about the CT procedure itself. Several patients volunteered the comment that it was painless. One patient reponted that the table was uncomfortable, another that he could not urinate, and a third that he feared the radiation he had received. Several patients said they liked the fruit punch used for drinking the contrast medium better than more chalky solutions used elsewhere. When asked for suggestions about making the CT suite more comfortable or pleasant, several patients suggested music, television, a clock, or a more secure place to keep one’s valuables. Fifty-nine (75%)

during

Reactions

of mei5 [19%]),

Two-thirds of patients were accompanied by a friend or family member, and one-third came alone. Table 1 compares the reactions of cancer patients during their first and most recent CT examinations. Anxiety about results was the greatest concern during both examinations; fear and curiosity regarding technology was a common concern during the first CT examination but not during subsequent examinations. Table 2 compares the comments characterizing the best and worst patient experiences with CT examinations. The comments of one patient about her best experience were typical: “The last one was the best. The technologists were helpful, and the radiologist explained the mesults.

1

Patient

of symptoms assessment

sponse

(n = 8 [10%]), (n=3[4%]).

Table

Percentages

may

not add

ence as a median 1-5 (1 indicating

up to 100% because

of

of 2.4 on a scale of no discomfort and 5

indicating such severe discomfort that they would refuse to undergo intravenous

administration

teriab tients

again). rated

(24%)

rated

of contrast

Fifteen (30%) the experience it as 2, eight

ma-

of the paas 0-i, 12 (16%)

as 3,

five (10%) as 4, and eight (16%) as 5. Two (4%) of the patients who had undergone intravenous administnation of contrast material had no mesponse to the question. discomfort included

gling

in nine,

difficulty

vein in six, nausea tions to contrast vousness in four,

nate

Sources of flushes or tin-

in finding

a

in five, minor reacmaterial in four, nerand needing to un-

in three.

When asked scan, 51 (65%) 24 (30%) said

who interpreted their said the radiologist did, the clinical oncologist

did, five (6%) said both (11%) were uncertain. Most

patients

(n

=

did,

and

69 [87%])

nine me-

ceived the results of their most recent CT examination from their physician soon

after

the

procedure

(65

[82%

January

1 1992

Table

-

3

Methods

of Relaxation Cancer

Patients

Used during

with

by CT

knowing (n = 6).

of Relaxation*

Following Mediating Praying Taking

Patients

instructions or visualizing

As the radiobogic

44(56) 35(44)

before-

hand

4 (5)

Note.-Numbers

in parentheses

are percent-

radiology

ages. * Patients responses.

could

select

Table 4 Patient Responses:

Radiologist Your

choices

from

suggested

Do You Want

the

to Give You the Results

of

CT Scan? No. of Patients Responding

Response If the results (n

Want

are normal

79)

=

radiologist

to give

results

55(70)

Do not want radiologist give results

to 19 (24)

No response

If the results (n

Want

5 (6)

are abnormal

79)

=

radiologist

to give

results

40 (51)

Want radiologist to give results only if asked Do not want radiologist to give results No response Note-Numbers ages.

in parentheses

15(19) 17(22) 7(9) are percent-

the same day; seven [9%], the day after; and 15 [19%], after several days) and in person (n = 60 [76%]). Twenty-three patients (29%) had initially received results of their CT examinations from the diagnostic radiologist; asked the

12 patients radiologist

had specifically to give them

results. Table 4 shows the responses of patients when asked whether they wished radiologists to initially tell them results if the results were nonmab or abnormal. Twenty-nine (37%) of the patients recalled that the radiologist had talked with them about their most recent CT scan or procedure, and 52 (66%)

recalled

that

the

available

technologic procedures

complexity has grown,

of the

emotional reactions of patients to these procedures have become more prominent, and interaction between patients and the staff of diagnostic

33(42) medication

was

DISCUSSION

No. of Method

support

technologist

had done so. When asked how interaction with the radiologist and technobogist was helpful, the most common responses were (a) in knowing what to expect (n = 19), (b) in understanding the procedure (n = 16), and (c) in addressing specific fears or

units

has

become

more

im-

portant (8). This report supplies furthen information about several aspects of the experience of cancer patients with CT scanning. This information may be useful to the staff of diagnostic radiology departments interested in anticipating the needs of their patients. Like the smaller number of patients surveyed by Monics et al (3) after undengoing a variety of radiobogic procedunes at a teaching hospital, patients in this sample were more concerned with explanations of procedunes and results, and with factors affecting their physical comfort, than with the competency of the staff or their own convenience. Perhaps this is because

they

assumed

competence

and the procedure was relatively efficient. Some patient comments about unusually uncomfortable examinations

at various

hospitals,

however,

indicated some question in their minds about the consideration and competence of the staff involved. The observation that two-thirds of patients with cancer undergoing CT were accompanied by a family memben or a friend should be taken into consideration in the design of CT waiting areas, especially with regard to size. Patients, family, and friends all found themselves mutually supportive, and many developed ongoing supportive relationships with staff during repeated visits. Separation of well from very sick patients was also considered important by several patients in the study. Since most of the patients had undengone intravenous administration of contrast material only during prior CT examinations outside our institution, conclusions based on this small set of responses are limited. Whether the major source of great discomfort was the explanation or consent pmocedune, the contrast material, on the yenipunctune was not determined. The reflections of patients regarding intnavenous contrast material administralion, however, suggest that it is an uncomfortable experience for a significant number of cancer patients and that these fears and reactions should

be addressed when offering support to the patient. For these patients with cancer, the major source of anxiety was cleanly the outcome of the CT examination. This is probably because most of these patients had undergone three prior CT examinations and understood their disease and the implications of the results of the scanning. The CT technology

itself,

while

a source

of

concern on curiosity at the initial examination, was not a significant source of anxiety during subsequent examinations. Recognition of cancerrebated fears may help the staff of diagnostic radiology units in relieving this anxiety; Dunphy (9), in his classic address, and Holland and Rowland (10), in reviewing methods of emotional support for cancer patients, emphasize the importance of personal physician

contact

and

the

demonstra-

tion of interest and empathy during technical procedures. Diagnostic radiobogists and technologists have excelbent opportunities to provide such emotional support to cancer patients during imaging performed at the criticab times of diagnosis, staging, mesponse assessment, and follow-up of malignancy. The frequent employment of such techniques as meditation and visualization during CT by patients in this study bends support to their usefulness to cancer patients anxiety, as well as other

in relieving symptoms

such as nausea, pain, and insomnia (11). This is consistent with the report of Quirk et ab (12), which showed that relaxation exercises were more effective than the provision of information alone in preventing anxiety during MR imaging. Prayer was used by a substantial number (n = 33 [42%]) of the patients interviewed. Studies have indicated that a person’s faith, religion, and/or spirituality can be a vital support in times of medical crisis (13-15). The diagnostic radiology staff as well as the hospital staff can provide an envinonment that nurtures this source of support before, during, and after CT. For patients interested in talking about their faith, listening and mesponding to the patients can build trust in the staff-patient relationship. Material that invites reflection in the waiting room can convey that prayer is a respected

option

(16,17),

and

in-

formation about the hospital pastoral cane department and how to contact chaplain emphasizes the availability of ongoing spiritual support. In addition to ensuring competent, considerate, and emotionally sensitive

a

treatment

of patients

using

their

facil-

ities, radiologists face the challenge of handling the results of their examinalions with patients. Published debate between

advocates

of the

rights

of

patients to answers and those of the traditional robe of radiologists as consultants to treating physicians has centered on the optimal handling of the reactions of patients to learning adverse results (whether directly from the radiologist on by inference from his or her unwillingness to provide them) (5,7). While most patients in this study were satisfied with the way they learned the results (promptly and in person from their oncologist, for the most pant)-and several clearly did not want to receive abnonmal results from the radiologist-it is noteworthy that a substantial number (n = 23 [29%]) did learn the results from the diagnostic radiologist and an even greater number (n = 55 [70%]) said they would like to do so. None complained of being offered on mefused results against their wishes. One explanation for this finding may be that patients in this setting were familiar with the close communicalion practiced between oncobogists and radiology staff and saw both groups as interested in providing them promptly with results. The obsenvation that 30% (n = 24) thought their oncologist interpreted the scans and 1 1 % (n = 9) were uncertain who interpreted

their

scans

bends

decided patients

to tell some their results.

Although

and

information

not about

other

2.

CT

scanning could be made available in a written form (such as a booklet), patients believed interaction with the technologists gist was most

about the technology and results of the examination. Given the frequency with which patients used relaxation techniques and prayer and harbored distinct preferences for how they learn results, the initial encounten with patients could include an introduction to any emotional and neligious support available, including relaxation training and some discussion of how results are communicated. Attention to fear or curiosity regarding the CT technology itself is important during the initial examinalion, but is of much less value subsequently. We believe that the patient responses in these interviews demonstrate that the optimal cane of cancer patients undergoing CT goes beyond technical to emotional and spiritual support. Finally, this study demonstrates the feasibility

of patient

satisfaction

sun-

veys including open-ended questions as a means of identifying and subsequently addressing areas for improvement in patient care specific to imaging technologies in diagnostic radiobogy departments. #{149}

indirect

support to this conclusion, but also suggests confusion oven the perceived clinical role of diagnostic radiologists, even among experienced patients. No information is available from this study about how the radiology staff

N 3.

4.

and diagnostic nadiobohelpful in allaying anxi-

ety

5.

6.

7.

We are indebted to Mary BSN, Anita Mulcahy, MSW, and MSW, for their help in interview-

ing patients and to Arlen Brown, RT, and the CT technologists of the Dana-Farber Cancer Institute for their help in making this study possible.

EnglJ

Med 1989;

K. Emotional disresonance imaging. 320:467-468.

Monics KJ, Tarico VS. Smith WL, et al. Critical analysis of radiologist-patient interaction. Radiology 1987; 167:565-567. Smith WL, Altmaier EM, Ross RR, et a!. Patient expectations of radiology in noninteractive encounters. Radiology 1989; 172: 275-276. Schreiber MH, Winslade WJ. Rights, roles, and relationships in radiology. Radiology 1987; 163:269-270. Jackson Fl. Rights, roles, and relationships in radiology (letter). Radiology 1987; 165:286. Hopper KD. Rights. roles, and relationships in radiology (letter). Radiology 1987; 165:286-287.

8.

9.

10. 11.

12.

13.

14.

15.

i6. Acknowledgments: Kathleen Barr, Elizabeth Roy,

Flaherty JA, Hoskinson tress during magnetic

17.

Weinreb JC, Masavilla KR, Peshock R, Payne J. Magnetic resonance imaging: improving patient tolerance and safety. AIR 1984; 143:1285-1287. Dunphy JE. On caring for the patient with cancer. N EnglJ Med 1976; 295:313319. Holland JC, Rowland J, eds. Handbook of psycho-oncology. New York: Oxford, 1989. Massie MJ, Holland JC, Straker N. Psychotherapeutic interventions. In: Holland JC, Rowland J, eds. Handbook of psychooncology. New York: Oxford, 1989; 455469. Quirk ME, Letendre AJ, CioHone RA, Lingley JF. Evaluation of three interventions to reduce anxiety during MR imaging. Radiology 1989; 173:759-762. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306: 639-645. Numbers RJ. Caring and curing: health and medicine in the religious traditions. New York: MacMillan, 1986. Peteet JR. Religious issues presented by patients seen in psychiatric consultation. Psychosocial Oncol 1985; 3:53-66. Pangrozzi A. Wanting to pray in time of sickness. In: Care notes. St Meinrad, Ind: Abbey, 1989. Rizzobi P. Going through hardship, growing through prayer. In: Care notes. St Meinrad, md: Abbey, 1988.

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102

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SC, Redd and

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(letter).

WH,Jacobsen

PB, et al.

during

magnetic resoLancet 1988; 2:512.

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1992