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Who Undergo Cardiac Surgery What Social Services Offer to Patients Who Undergo Cardiac Surgery ROBERTA E. PEAY, M.A.f M.S.W. techniques for diagnosis and treat¬ part of this staff, can do has been of specific SPECIALment of patients with rheumatic or con¬ interest to me, as I have provided social services genital heart disease have developed dramati- to this particular group of patients for the past cally over a relatively short time. No longer &y2 years. are many of these patients diagnosed solely by The Clinical Center of the National Institutes X-ray, the stethoscope, and the electrocardio¬ of Health, Public Health Service, is a 500-bed gram in their own communities. They are re¬ research hospital which serves seven separate ferred to large medical centers which frequently Institutes, one of which is the National Heart are far from their homes. There they meet Institute. The clinical investigations bf the many different people and have new and un- Cardiology and Surgical Branches of the Na¬ predictable experiences, including undergoing tional Heart Institute are primarily in the area a multiplicity of unfamiliar diagnostic tests and of diagnostic techniques for evaluating congen¬ procedures relative to their heart condition. ital and acquired heart defects and in surgical There is also, now, a much greater chance that techniques for treating these lesions. All a heart operation will be the treatment of patients are referred by their physicians and are choice. admitted on the basis of the research interest The sobering fact that the heart is the organ of the clinical investigators. There is no cost involved, and that an operation may be nec¬ to the patient for hospitalization or for services essary, increases the patient's and family's provided. Patients come from all parts of the anxiety.already engendered by leaving home, United States and from many foreign countries, by transportation problems, by possible family and they have varied economic, educational, disruption, by the degree of cardiac disability, racial, religious, and social backgrounds. and by economic hardship. The knowledge There are six social work positions in the Na¬ that diagnostic and surgical techniques are tional Heart Institute; one is that of social serv¬ available and are improving is helpful, but their ice program supervisor. To enable the same comparative newness can make the hospital ex¬ social worker to follow a patient throughout his perience for cardiac patients frightening as well hospital experience, two caseworkers are as¬ as hopeful. signed to the Cardiology and Surgical Branches. To help these patients get the most construc¬ This continuity of social service through a tive benefit from their experience is the re¬ particularly stressful experience is felt to be sponsibility of the whole staff of the hospital important. or medical center. What the social worker, as These two caseworkers carry full social serv¬ ice responsibility for their group of patients Miss Peay is with the Social Service Department of and therefore are an integral part of the clinical the Clinical Center, National Institutes of Health, programs of both the Cardiology and Surgical Public Health Service, at Bethesda, Md. Branches. They are as responsible for con- Vol. 78, No. 12, December 1963 1045 tributing their knowledge to the treatment of happening, the problems presented by patients the patient group as they are for assisting the and families, and the ways in which the social individual patient. The chiefs of the Cardi¬ worker can be helpful. ology and Surgical Branches are easily acces¬ sible to the social workers for discussion of First Days After Admission general and specific problems. The chief sur¬ geon, the chief cardiologist, and I collaborated When a patient, child or adult, arrives at the in writing pamphlets which are sent to parents Clinical Center, he frequently has come from a of children and adult patients prior to admis¬ distant place. He may be from another country sion to the diagnostic service of the Cardiology and may not even speak English. He may have Branch. These pamphlets are based on recogni¬ left his home and community for the first time tion by the Heart Institute staff that this is an in his life, and his social and educational experi¬ anxious period for patients, and they can be ences may have been very limited. He may be prepared in advance for certain general alone or accompanied by family members who procedures. may be dominating, controlling, anxious, or at The social workers participate in interdisci- times even hysterical. He may have little un¬ plinary preadmission and discharge planning derstanding of what to expect from the Clinical for certain groups of patients referred by State, Center staff. He brings his own particular wor¬ national, or Federal programs such as United ries about his heart condition and about what Mine Workers of America Welfare and Retire¬ the future has in store for him. He may be ment Fund, Bureau of Prisons, and Crippled deeply concerned about his family and their wel¬ Children's Programs. They also take part in fare during his absence, about the stability of the medical and nursing conferences and in his job, and about his status in his family and daily and weekly rounds. However, direct his community. He may have had no experi¬ social casework services to the individual patient ence or previous unhappy experiences with hos¬ and family are the major responsibility of these pitals and medical care. two social workers. Some patients may be unable to ask questions Approximately 500 patients, from infants to or unable to express or show fear in order to pro¬ the elderly, were admitted to the cardiac diag¬ tect their families or themselves, and some may nostic and surgical services in 1961. Usually maintain such control of their feelings that they from 7 to 13 patients are admitted weekly, and are immobilized. There are hostile, demanding, children and adults are placed in the same nurs¬ vociferous, unit-disrupting patients, and there ing unit where they remain from 4 or 5 days to are the compliant, dependent, quiet, "good" a month or longer. These patients can be criti¬ patients. cally ill or relatively asymptomatic. The Neither the child nor his parents may have Cardiology Branch has 18 beds in one nursing anticipated separation at night, and this can be unit and the Surgical Branch has 14 beds in an¬ their first unhappy experience. The parents other unit on another floor. may be unable to explain this necessity or to From 35 to 50 percent of the patients are tell the child that he is going to have tests and under 16 years of age, and are usually accom- injections. Some children are terrified of sepa¬ panied by one or both parents. Frequently ration from their parents even briefly, and there family members also accompany the adult are those children who cannot show any kind of patients. At times parents or spouses require weakness like tears because they will incur the the most constructive social casework services if anger of their parents. The social worker de¬ the patient is to get the fullest benefit from his termines the reason for these kinds of behavior medical and surgical care. and effects modification or change, if possible. Certain periods during hospitalization for Most patients and families have some fears or diagnostic evaluation and for surgery are likely anxieties when they arrive, varying from what to be more stressful for patients and their fami¬ we consider minimal to near panic; these emo- lies than others. These will be described as tions can also vary in terms of the situation at clearly as possible in relation to what might be a given time. In this initial period the social 1046 Public Health Reports worker assesses the extent and nature of the pa- child, may mean punishment. There may be tient's anxiety and needs. Her task is to elimi- acquiescence to authority without understand- nate, if possible, misunderstandings or unreal- ing or ability to question. istic expectations or fears, to clarify some Although other factors may contribute to the medical recommendations or explanations, to anxiety of patients and families at this time, relieve immediate economic and other external concern about what the catheterization will re- pressures, if possible, and give supportive case- veal is a primary source of anxiety. This is work help. It is important to recognize with the test which will show more specifically the the patient that everybody is scared and that kind and degree of heart disease and determiine these feelings are natural, to assure him that he whether or not surgery is indicated. The time will have help as needed-that he is not alone during the catheterization can be particularly with his troubles. When the initial supportive upsetting for the parents and family members relationship and the assessment of the patient's who are waiting for the patient to return and needs, strengths, and weaknesses are shared also for the results of the test, particularly if with the medical and nursing staff, the staff's it lasts longer than they expected or if there care of the patient enables him to react more appear to be complications after the patient re- constructively to the procedures and recommen- turns to his room. Some patients need to be dations of the diagnostic period. put in oxygen tents or have intravenous feed- ings; some are hooked up to EKG machines or Diagnostic Period blood pressure cuffs. The level of anxiety in the family or patient sometimes prevents their All patients have routine X-rays, electro- understanding factual explanations and reas- cardiograms, phonocardiograms, and blood surances from the physician and nurse. The tests.
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