Projecting Optimism: Creating Positive Outcomes

RobbiRN, RN

Mr. Aldred is relatively calm as I start an IV and draw some blood for his labs. His chest pain started two hours ago while he was watching TV, eating some chips, and drinking a diet coke. There had been no unusual stress, no new sources of anxiety, or any other precipitating factors. It was a day like any other day. He is a sixty-three-year-old nonsmoker in generally good health. He exercises regularly, and his only medication is Norvasc for mild hypertension. Ten minutes into his ER visit, he's still optimistic that he's wasting his time getting checked out to make his wife happy. But everything changes with one sentence.

Dr. Benson stands at the foot of the bed. Glancing up from the EKG in his hands, he looks Mr. Aldred in the eye and announces: "You're having a heart attack." In seconds, Mr. Aldred's face turns pale, his head slumps to the right, and he becomes unresponsive. The monitor alarms signal a lethal arrhythmia. Ventricular tachycardia has replaced Mr. Aldred's normal sinus rhythm. He has no pulse.

Dr. Benson calls for other staff to help before starting CPR as I tear open a pack of defibrillator pads, place them on Mr. Aldred's chest, and charge the unit. The first shock at 200 joules converts Mr. Aldred back into a sinus rhythm.

Stop here. Ask yourself what really happened in those crucial minutes? I'm convinced that the V-Tach was no coincidence. In twenty-four years of ER nursing, I have seen this same scenario play out on three separate occasions. The doctor announces: "You're having a heart attack." And the patient's brain responds, "Well, if I'm dying, I'm going to get on with it." The body does what the brain tells it to do, and, presto, the patient goes into V-Tach. Without immediate defibrillation, the patient dies.

Subconsciously and consciously, the brain continually directs physical functions. You dream that you're being chased by a ferocious lion. He slaps you to the ground with one massive paw and towers over you, roaring and slobbering as his open mouth comes closer to your face. You wake up in a cold sweat with your heart racing and your blood pressure through the roof. You were sleeping peacefully for hours before the terrifying thoughts disrupted your stable physical state, jolting your cardiovascular system into overdrive. Your own imagination drove the entire episode.

Imagine that you are stressed about being passed over for a promotion. You've been stewing over the news for hours. But you meet a good friend for lunch who creates a lighthearted distraction from your disgruntled musings. She tells you a story about her new puppy refusing to come in from his playtime in the backyard. She animatedly describes his playful antics as he repeatedly dodged when she lunged for him. After watching her clumsy, failed attempts to catch the puppy, her old dog decided to help out. He chased down the puppy and held him until she got there to pick him up. The story is amusing. You laugh. Endorphins flood your system. Your blood pressure drops, the acid in your stomach eases, and your pulse slows. Your distracted brain has calmed.

All day, every day, the brain tells the body what to do. Short of deep sedation, there is no avoiding its directive energy. As caregivers, we need that energy on our side. There are two essential ways we can harness the massive power of our patients' thoughts:

First, we need to confront and refute our patients' own predisposition to failure. For example, I come in to start an IV, and a patient says, "You get one stick, and then you better go get someone who knows what they're doing." Obviously, he expects failure. I just smile at him while shaking my head with a mild scolding effect. I'm calm, playful, and look him straight in the eye. "Really? Is that really how you want to do this? So, are you saying that if I happen to miss for the first time in six months, you want me to go get the new girl down the hall to try next? It that really what you want to do?"

Most patients back down at this point. But I really want them to believe, and I go to great lengths to generate confidence before we even start. If they grab the rail with their free hand, tense up, or breathe fast, I just stop to talk them down. "When you do that, your blood pressure goes up and your veins spasm down. I need you to calm down, go to your happy place, and expect this is going to go well. You said no one ever gets you on the first try. I told you that I plan to do it. One of us is going to get to say 'I told you so' in few seconds. You'd better hope it's me." Or I might tease them with something like, "Remember, even Jesus couldn't do miracles surrounded by unbelief. I need you in this." IV's are like baseball. Sure, we are going to miss occasionally, but it goes better when we both expect to hit.

The patient says, "I can't quit smoking. I've tried everything." We can grant the difficulty without validating the failure. One possible response: "You're right, it can be really hard. But in reality, you can't just quit anything. Any behavior has to be replaced. How do you stop sitting? You stand up, right? You don't quit smoking; you replace it with something better and crowd it out of your life. You like to dance? Dance more; smoke less." The conversation can go on from there. The point is, we replace a vision of failure with a vision of possibilities.

I bring liquid Tylenol for a fever, and Mom states that her three-year-old "won't take that. She's going to spit it out." I confront this outright. "Well, maybe that's what she's done in the past, but she's getting to be a big girl now, and she can swallow this." Then I get down, look the child in the eye and say, "Here, in the hospital, you have to take your medicine. It's better if you swallow it yourself. I know you can do it." Then I turn back to Mom and say, "Here, we always have to find a way to make it happen. We can put it in her bottom if she won't swallow it." Sometimes the child just takes the Tylenol. Sometimes it still turns into a knock-down drag-out battle that we ultimately win. Of all patients, children will attempt to fulfill prophecies of failure. The negative images have to be replaced with an expectation of compliance.

Be honest. Be realistic. Say what works for you, but find a way to get patients to expect or hope for success. There is nothing to gain from accepting and validating their anticipation of failure.

Second, and maybe more crucial, we need to avoid creating negative energy that patients didn't bring with them. Invoking positive probabilities is always fair game: "We are going to check you out carefully, but the vast majority of patients who come in with dizziness are not having a stroke or any serious medical emergency. After a complete evaluation, we most often get normal labs, a normal CT, and the patient goes home with some medication for dizziness. It usually isn't serious." This projection is honest and accurate. Would you rather hear, "You might be having a stroke"? Why fuel fear, especially if the odds of a lesser problem are heavily stacked in the patient's favor?

When we suspect the worst, it is still reasonable to project the best and focus the conversation on the things that are okay. "I agree your symptoms are concerning, but the good news is that you're here, your vital signs are great--in fact your blood pressure is better than mine--and you got here in time for us to investigate this carefully." We can address concrete findings as they emerge.

Even when we confirm the worst, we can be accurate without projecting a bad outcome or using words that cause a patient to expect one. For example, instead of saying, "You're having a heart attack," the doctor could say, "The EKG shows that part of your heart isn't getting enough oxygen. We are going to do what we can to correct that situation to avoid any lasting damage to your heart muscle." Both statements are accurate. But the first suggests an impending death while the second creates the expectation for a positive outcome.

When Mr. Aldred stabilized after we shocked him back into a sinus rhythm, he asked what happened. I told him, "You passed out when your heart went into a fast rhythm, and we had to shock you to fix it. It's normal now, everything looks great on the monitor. I guess this wasn't your time. We're still going to transfer you to the cardiac unit and keep an eye on you for a while."

He said, "Well, maybe it was a good thing I came in today, right?"

"Absolutely. So what do you do for fun when you're not hanging out at the hospital?"

Moment by moment, our patients' own thoughts will move them toward healing or away from it. Their lives are in our hands--and our words. What we say, and how we say it, changes outcomes. We have everything to gain from projecting optimism.

Projecting Optimism: Creating Positive Outcomes

About RobbiRN, RN

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