By Walter E. Jacobson, MD
HEARTS & MINDS
A friend of mine has a close relative who recently suffered a heart attack, and then underwent Cardiac Artery Bypass Graft surgery. My friend indicated that her relative received excellent medical and surgical care.
However, although procedures and medications were sufficiently explained, the psychological aspects of life after bypass surgery were not, such that her relative and all the family members were not prepared for what happened.
It is not uncommon for there to be a one or two day period immediately after bypass surgery where the patient feels upbeat, encouraged, and optimistic. This is followed, however, by a severe emotional letdown phase that can last several days to several weeks, perhaps even six weeks or longer.
During this letdown phase, the patient is depressed, discouraged, demoralized. There can be severe mood swings, irritability and anxiety. There can be cognitive decline as well, with attention and concentration difficulties and memory deficits.
The letdown phase is believed to be due to the intense stress of having been in an unfamiliar, traumatic and somewhat nightmarish environment (better known as the Open Heart Recovery Intensive Care Unit), as well as being dosed with so many powerful medications. But I believe there’s more to it than that.
The first day or two after bypass surgery is the “honeymoon period.” The patient has survived. It’s an exhilarating experience to get a new lease on life. There is joy, there is hope.
But after the first day or two, as the adrenaline rush of being alive and getting a second chance calms down, reality sets in, and now fear of the future, fear of the unknown takes center stage. The patient’s mind now gets hammered with the realization that all the stress he and his family have been under up to now is only the beginning. Now there are a whole new set of catastrophic concerns.
“Am I really going to be all better? Will I really be able to do everything I used to do? What if I get chest pains? What if I can’t concentrate and can’t remember things? Will I still be expected to be back at work in six weeks? What if I go back to work and can’t cut it? What if they force me into early retirement? How will we manage? How will it affect my family? Will my wife have to work? Will my kids still look up to me? Will my wife still look up to me? What if I’m too scared of having a heart attack to have sex? What will that do to the marriage? Will my wife have an affair? What if she leaves me?”
Before bypass surgery, the concerns were all about survival, life versus death. After surgery, after survival has been achieved, at least for the time being, the patient is flooded with, “Now what?!” The “Now what?!” can be very frightening, overwhelming and demoralizing, particularly as the patient imagines the worst possible scenarios and outcomes, and then terrorizes himself over them. “Now what?!” turns into “I can’t do it! It’s too much!”
It is catastrophic thinking of this nature that needs to be discouraged. The patient needs to be reassured that what he’s feeling is normal, it’s natural, and it will pass. He needs to be reassured that as he recovers, he will be well-counseled, and all his concerns will be addressed and worked through.
The patient needs to be encouraged to maintain a positive attitude, and to look towards returning to normal function, to not assume the worst will happen, to take one day at a time.
The patient is encouraged to engage in counseling immediately after surgery. Family counseling and marital counseling are options. A post-bypass surgery support group could be extremely helpful.