While well-intentioned, many of these 'therapeutic alternatives' do patients a disservice by not giving them accurate information on what to expect, i.e. what is normal.
For example, not warning a patient that propofol injection can often sting, risks the arguably greater harm of them thinking something has gone wrong when they feel the pain on injection.
As with most things in life, finding a balance between the two is key.
We "have the power of life and death on our tongues." Language matters, tone matters, especially in the pediatric arena. I’ve witnessed a colleague go straight to the fear tactic of "If you don't take this (PO midazolam), you'll have to get a shot (IM Ketmaine)!" This did nothing but create a more negative environment in already anxious child. I'm an absolute advocate for reframing language when communicating with patients and parents.
There have been several instances in my career where I've been called into pre op to see a child who is anxious, tearful and refusing to take pre med. It's amazing how limitng the stimulation, a calm approach, a soft steady tone can open the door to changing the child's (and the parents') entire demeanor. We can then do some distractive techniques and imaginary play. The child suddenly has a peaked interest. The tears turn into smiles and laughter. The patient is cooperative and more at ease. In some instances we can skip the need for pre med altogether.
Another nocebo example I've seen is in PACU. The nurses will ask as the child is awakening "Are you hurting? Are you in pain?" It always bothered me to use the word "pain" as the patient is just coming to. Instead, I recite how well the patient did during surgery and that it's already done. I asses the need for additional analgesia by asking "Are you comfortable or would you like to be more comfortable?" I try to avoid the word "pain" initially.
In the world of pharmaceuticals placebo and nocebo are fascinating phenomena. Did you know that when valproate was in Phase III testing by J&J there was no difference in seizure suppression between valproate and placebo? That is, not until about 3 months, at which time there was divergence. How can placebo suppress epilepsy? IDK, but it does.
Similarly, if you look at the side effect profile in the PDR for any drug, ANY drug, you'll see that placebos always result in side effects in 1-5% of the population: you name it -- nausea, vomiting, headache, rash, weakness, constipation...this is the nocebo response in real life.
So I fully agree that telling people that something is going to hurt a little will make it hurt for many people.
Regarding discussions of risk pre-anesthesia, is there a parent alive who doesn't know that anesthesia can kill their child? So why bring it up? In 30 years of expert witnessing for both plaintiffs and defense, I've never seen or heard of a case being decided for the plaintiff because the informed consent was not complete or comprehensive. It's always something plaintiff attorneys throw into the litany of charges, but never something that decides an outcome.
While well-intentioned, many of these 'therapeutic alternatives' do patients a disservice by not giving them accurate information on what to expect, i.e. what is normal.
For example, not warning a patient that propofol injection can often sting, risks the arguably greater harm of them thinking something has gone wrong when they feel the pain on injection.
As with most things in life, finding a balance between the two is key.
We "have the power of life and death on our tongues." Language matters, tone matters, especially in the pediatric arena. I’ve witnessed a colleague go straight to the fear tactic of "If you don't take this (PO midazolam), you'll have to get a shot (IM Ketmaine)!" This did nothing but create a more negative environment in already anxious child. I'm an absolute advocate for reframing language when communicating with patients and parents.
There have been several instances in my career where I've been called into pre op to see a child who is anxious, tearful and refusing to take pre med. It's amazing how limitng the stimulation, a calm approach, a soft steady tone can open the door to changing the child's (and the parents') entire demeanor. We can then do some distractive techniques and imaginary play. The child suddenly has a peaked interest. The tears turn into smiles and laughter. The patient is cooperative and more at ease. In some instances we can skip the need for pre med altogether.
Another nocebo example I've seen is in PACU. The nurses will ask as the child is awakening "Are you hurting? Are you in pain?" It always bothered me to use the word "pain" as the patient is just coming to. Instead, I recite how well the patient did during surgery and that it's already done. I asses the need for additional analgesia by asking "Are you comfortable or would you like to be more comfortable?" I try to avoid the word "pain" initially.
Thanks for sharing the article!
In the world of pharmaceuticals placebo and nocebo are fascinating phenomena. Did you know that when valproate was in Phase III testing by J&J there was no difference in seizure suppression between valproate and placebo? That is, not until about 3 months, at which time there was divergence. How can placebo suppress epilepsy? IDK, but it does.
Similarly, if you look at the side effect profile in the PDR for any drug, ANY drug, you'll see that placebos always result in side effects in 1-5% of the population: you name it -- nausea, vomiting, headache, rash, weakness, constipation...this is the nocebo response in real life.
So I fully agree that telling people that something is going to hurt a little will make it hurt for many people.
Regarding discussions of risk pre-anesthesia, is there a parent alive who doesn't know that anesthesia can kill their child? So why bring it up? In 30 years of expert witnessing for both plaintiffs and defense, I've never seen or heard of a case being decided for the plaintiff because the informed consent was not complete or comprehensive. It's always something plaintiff attorneys throw into the litany of charges, but never something that decides an outcome.