Managing Patient Expectations

Managing Patient Expectations

PEP Topic 
Chemotherapy-Induced Nausea and Vomiting
Description 

Managing patient expectations involves influencing the patient regarding the anticipation of symptom development or effectiveness of an intervention through education and discussion. This type of intervention is based on the idea that if patients expect to have a problem, they are more likely to do so, and if patients expect an intervention for symptoms to be effective, it is more likely to be effective. Education and discussion are pointed to diminish negative expectations. Managing patient expectations has been examined in patients with cancer for prevention and management of chemotherapy-induced nausea and vomiting (CINV).

Likely to Be Effective

Systematic Review/Meta-Analysis

Colagiuri, B., & Zachariae, R. (2010). Patient expectancy and post-chemotherapy nausea: A meta-analysis. Annals of Behavioral Medicine, 40, 3–14.

doi: 10.1007/s12160-010-9186-4
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Purpose:

To evaluate the relationship between patient expectations of postchemotherapy nausea and subsequent reports of nausea

Search Strategy:

Databases searched were MEDLINE, PsycINFO, and CINAHL.

Search keywords were expectancy, expectations, placebo effects or placebo responses with chemotherapy and nausea or emesis.

Studies were included if they

  • Measured patient expectation for post-chemotherapy nausea.
  • Reported occurrence, severity, or frequency of post-chemotherapy nausea.

Studies were excluded if they focused only on anticipatory nausea.

Literature Evaluated:

The authors independently coded the sample characteristics, the independent and dependent variables, and whether the study met the inclusion criteria for each study. Differences were discussed, and a final assessment negotiated for each study. A global effect size was calculated for each study. No formal scoring was used to assign a quality score to each study. Publication bias was addressed using the Egger test and calculations of failsafe.

Sample Characteristics:

  • The review consisted of 17 studies.
  • The average study sample size was 141 participants, ranging from 29–67, and totaling 1,497 patients.
  • Patients with breast cancer were most frequently studied.
  • Ten studies involved highly emetogenic chemotherapy (HEC), and four involved therapy with low emetogenic potential.

Results:

  • Patients who expected to experience nausea were almost twice as likely to experience postchemotherapy nausea (pooled effect size, Cohen’s d = 0.35, OR = 2.07, p < 0.0001).
  • No significant relationship was found among nausea frequency, severity, duration, or peak nausea level.
  • Findings differed based on the timing of measurement in the study. Larger effect sizes were seen in studies in which post-treatment nausea was assessed after multiple infusions compared to those in which nausea was assessed after the first infusion.
  • A slightly higher effect size was seen in studies that controlled for nausea history.

Conclusions:

This meta-analysis confirmed that nausea expectations and experience of post-chemotherapy nausea are positively correlated. The discussion also identified research methods, such as incorporating expectancy-based manipulations that consider the source of the patient’s expectations, actively investigating the possible moderators of the association between expectancy and post-chemotherapy nausea (e.g., age, anxiety), and measuring the expectancies before the first chemotherapy administration.

Limitations:

  • Methods and timing of nausea measurement varied among studies, which influenced effect sizes seen here.
  • No subgroup analysis was provided based on the level of emetogenic potential of the chemotherapy, which would be expected to influence actual symptom occurrence.
  • Forms for abstraction of data (no documented protocol) were not used and, therefore, not available for replication or expansion of the meta-analysis.

Nursing Implications:

Prechemotherapy assessment needs to include patient expectations regarding the experience of postchemotherapy nausea. If a patient expects that he or she will experience nausea, additional evidence-based interventions to minimize nausea should be used prior to and during chemotherapy administration.

Research Evidence Summaries

Roscoe, J.A., O’Neill, M., Jean-Pierre, P., Heckler, C.E., Kaptchuk, T.J., Bushunow, P., … Smith, B. (2010). An exploratory study on the effects of an expectancy manipulation on chemotherapy-related nausea. Journal of Pain and Symptom Management, 40, 379–390.

doi: 10.1016/j.jpainsymman.2009.12.024
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Study Purpose:

To test whether providing information about the expected efficacy of acupressure bands would enhance their effectiveness in reducing nausea

Intervention Characteristics/Basic Study Process:

  • Chemotherapy naïve patients completed baseline questionnaires then received acupressure wristbands.
  • Patients were randomized to the following groups.
    • 1: neutral handout and neutral compact disk (CD)
    • 2: acupressure-enhancing handout and neutral CD
    • 3: neutral handout and acupressure-enhancing CD
    • 4: acupressure-enhancing handout and acupressure-enhancing CD
  • Patients were instructed to use the acupressure wristband and CD as needed during chemotherapy to prevent or alleviate nausea.
  • Patients recorded antiemetic use, severity of nausea and vomiting, and wristband and CD usage in diaries.

Sample Characteristics:

  • The study consisted of 74 participants.
  • Mean age was 51.5 years with a range of 28–74.
  • All participants were female patients with breast cancer.
  • The majority of patients were White (93%), married (76%), had graduated from high school (99%), and had graduated or attended college (66%).
  • The majority of patients were receiving doxorubicin-based chemotherapy (82%). The remaining were receiving docetaxel combined with either cyclophosphamide or carboplatin.

Setting:

The study was conducted in a single outpatient setting. The location was not stated.

Phase of Care and Clinical Applications:

All patients were in active treatment.

Study Design:

This was a double-blind, four-arm, randomized, clinical intervention study.

Measurement Instruments/Methods:

  • Patients reported their experiences in diaries.
  • A nausea tool developed by Burish and Carey was used to measured nausea and vomiting on a 7-point Likert-type scale. No reliability or validity information was provided.
  • Patients rated nausea expectancy on a 5-point Likert-type scale.
  • Patients rated wristband effectiveness expectancy on a 5-point Likert-type scale.
  • A study data questionnaire was used to gather demographic and clinical information.
  • A feedback questionnaire evaluated the use of and recommendations for the acupressure wristband and CD.

Results:

  • Results indicated that 15% of the sample experienced vomiting.
  • The interaction of high-versus-low levels of nausea expectancy and neutral-versus-enhanced intervention showed a statistically significant difference for peak nausea (p = 0.030) but not for average nausea (p = 0.084).
  • Patients who received the neutral materials took more antiemetic than patients who received the acupressure enhancing materials (p = 0.003).
  • Expected nausea correlated with average nausea (p = 0.014) and peak nausea (p = 0.002).

Conclusions:

Patients with enhanced information required less antiemetics and had less nausea than patients with neutral information. Managing expectations may facilitate chemotherapy-induced nausea and vomiting (CINV) management.

Limitations:

  • The sample size was small with fewer than 100 patients.
  • Differences in the types of chemotherapy and antiemetic medications and providers' discussion about nausea could have affected the study outcomes.
  • The placebo effect of nausea intervention could have modified patients' expectations and response to the treatment.

Nursing Implications:

This study illustrates the need for nurses to assess and be aware of patient’s nausea expectations during chemotherapy. Patients with high expectations may benefit from information or discussion of the expected benefits of interventions on reducing nausea.

Shelke, A.R., Roscoe, J.A., Morrow, G.R., Colman, L.K., Banerjee, T.K., & Kirshner, J.J. (2008). Effect of a nausea expectancy manipulation on chemotherapy-induced nausea: A University of Rochester Cancer Center Community Clinical Oncology Program study. Journal of Pain and Symptom Management, 35, 381–387.

doi: 10.1016/j.jpainsymman.2007.05.008
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Study Purpose:

To evaluate the effectiveness of educational interventions in reducing patients’ nausea expectations by dispelling misconceptions about chemotherapy-induced nausea and vomiting (CINV) and building confidence in antiemetic regimens

Intervention Characteristics/Basic Study Process:

Patients were randomized one of two arms. Both arms received the same educational materials except that arm 2 patients received an additional handout emphasizing the benefits and effectiveness of ondansetron in the control of nausea and vomiting. Both arms received a standardized antiemetic regimen including ondansetron and dexamethasone on day one. Nausea and vomiting were measured in a patient-reported diary from day one to day four following chemotherapy treatment.

Sample Characteristics:

  • The study consisted of 322 patients who were chemotherapy-naïve.
  • The mean age in arm 1 (control group) was 57.8 years (SD = 13.4 years, n = 163). The mean age in arm 2 (intervention group) was 57.4 years (SD = 12.1 years, n = 59).
  • The majority of the patients were female (73%).
  • Diagnoses were not reported.
  • In arm 1, 52.1% of patients were receiving adriamycin, 34.4% were receiving carboplatin, and 13.5% were receiving cisplatin. In arm 2, 52.8% of patients were receiving adriamycin, 31.4% were receiving carboplatin, and 15.7% were receiving cisplatin.

Setting:

The study was conducted at 18 medical oncology practices (all Community Clinical Oncology Programs [CCOPs]) across the United States.

Phase of Care and Clinical Applications:

All patients were in active treatment.

Study Design:

This was a randomized, multicenter, clinical trial.

Measurement Instruments/Methods:

  • Expectation of nausea was measured using a five-point Likert-type scale anchored at one end by “1” = I am certain I WILL NOT have nausea” and the other end “5” = I am certain I WILL have nausea.
  • Patients measured nausea and emesis four times a day and recorded their experiences in report diaries.
  • Assessments were documented from the treatment day until the fourth day following the chemotherapy treatment.
  • Nausea severity was assessed on a 7-point rating scale.

Results:

  • No significant difference was found between groups in frequency or severity of nausea.
  • Approximately 76% reported no nausea, and approximately 25% experienced or average nausea.
  • A significant reduction in nausea expectancy was seen in the intervention group as compared to the control group (p = 0.024).

Conclusions:

Although the expectancy manipulation reduced patients’ reported expectations for the development of nausea, the occurrence of nausea was not reduced. Changing nausea expectancies did not affect the occurrence of nausea.

Limitations:

  • The expectancy manipulation in this study may not have been strong enough. The educational intervention was a one-page handout with basic statements.
  • Use of a reliability and validity expectancy measurement tool was not documented.
  • Past experiences of nausea and vomiting (motion or morning sickness) or the influence of past exposures to family or friends undergoing chemotherapy, which may have influenced chemotherapy-related nausea, was not considered.

Nursing Implications:

Educational interventions to increase awareness of nausea prior to first chemotherapy administration may reduce patients’ expectations for subsequent CINV. However, these interventions may not reduce actual nausea severity or occurrence.


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