European Journal of Cardiovascular Medicine

Cardiovascular disease (CVDs) is the leading cause of mortality worldwide. Approximately 17.9 million people die each year. Coronary Artery Disease (CAD) is a major cause of morbidity and mortality, worldwide. India had the highest burden. According to WHO it causes 3.7 million deaths in the South-East Asia Region (SEAR) and contributes to 38% of mortality before the age of 70 years1.

Coronary artery bypass grafting (CABG) is a recommended surgical treatment for CAD patients, whose condition has progressed to such an extent that it is no longer controlled with medical management. The number of CABG surgeries performed in India is increasing. It bypasses the blocked arteries. Its purpose is to bypass the blocked arteries and maintain a normal circulation to the heart. The quality of life and survival time can be improved by CABG surgery3.

Waiting for CABG surgery is crucial for patients with CAD progression during the waiting period, as these patients may experience adverse coronary incidents, such as persistent chest pain not relieved by medicine, heart attack, and even death4.In addition, patients have to cope with other symptoms, such as angina, dyspnoea, fatigue, and even side effects associated with medicines.

Long waiting lists because of the shortage of beds, operation theatres, funds required for the surgery, and sometimes the patients’/caregivers' own wish to postpone could be reasons for the long waiting time in patients undergoing CABG. When CAD patients are on the waiting list for a prolonged period their anxiety is extremely high.

Females experience higher anxiety than men 5. Patients feel more disturbed because of fear of surgery and uncertainty about life. 

Nurses are part of a team that enables patients to return to optimal health. Nurses must contribute to managing patient anxiety during the CABG waiting period because higher anxiety is associated with poor outcomes 7. Interventions to alleviate anxiety typically include information, education, communication, and support. Gradual preparation of patients and their families during waiting time helps decrease their anxiety related to surgery.

From a literature review, it was found that most published studies on patients with CAD awaiting CABG surgery have been conducted in developed countries. These Western studies do not apply to the Indian scenario because of differences in culture and perceptions of health and illness. Patients with CAD usually experience variable and inconsistent patterns of symptoms.

Patients awaiting CABG surgery should be routinely assessed for anxiety. Interventions should be introduced to avoid or alleviate anxiety, as patients who are depressed are vulnerable to more discomfort, longer hospital stays, readmissions, and poor quality of life during the postoperative period. When anxiety persists even after surgery, it can have deteriorating effects on psychological health. Proper support and education from credible authorities, such as nurses and doctors, and support systems from families, can help deal with uncertainties. Therefore, recognition of areas of improvement can be explored based on their lived experiences.

A phenomenological research design was used to explore the lived experiences of patients waiting for CABG surgery. This study was commenced at a tertiary care hospital in India. Patients who consented to participate, age between 18-75 year and both genders waiting for more than 3 months for CABG surgery were selected purposely. Data were obtained from the participants using a pre-validated, in-depth interview guide. The semi-structured interview guide comprised 30 open-ended questions. Each participant was provided a comfortable sitting environment.  Sociodemographic and clinical data were collected from the participants and interviews were conducted. The duration of each interview was–20-40 minutes. All interviews were recorded using an audio recorder.

This study provides a profound and detailed understanding of the life experiences of patients waiting for CABG surgery. Ethical clearance was obtained. Written consent was taken from each participant after the objectives and needs of the study were explained to them. Anonymity and confidentiality were also ensured.

Quantitative data was analyzed using descriptive statistics and for the qualitative data, Colaizzi`s steps were used for analysis. Data saturation was achieved after interviews with the 17 participants. Verbatim was transcribed from interviews. The transcribed verbatims were read and re-read, significant statements were underlined, and codes were extracted. All similar codes were combined, and a single theme was formed. The various issues highlighted under this theme were named as subthemes. The codes, themes, and subthemes were read and re-read to verify their appropriateness.

The information profile of the participants indicated that the mean age(years) ±SD of the participant was 60.47±7.64, with a range of 47-70 years. More than 50% were male. 88.2% were married and 11.8% were widows. 52.9% participants had primary level education and 5.9% were illiterate. 76.47% Of participants were either not working, housewives, or retired. More than 50 % of the participants lived in nuclear families. 41.2% were having a sedentary lifestyle. 88.2% Of the participants were to the NYHA class 2 category. 47.2% were in stage 2 hypertension. Seventy% of participants had other comorbidities, including hypertension.

This study aimed to explore and understand the life experiences of patients waiting for CABG surgery. The various themes generated were physical impact of the disease, psychological impact of the disease, aggravating factors/stressors of the disease, effect on daily routine, financial constraints and arrangement, impact on social and recreational activities, effect on family life, job, and income, and support system and coping strategies”. Figure 1.shows conceptual framework for CAD patient waiting for CABG surgery.

The physical impact of the disease

 All participants in the study had physical symptoms (chest pain, dyspnea syncope, palpitation, etc.), although the pattern of symptoms varied in every patient. These symptoms imposed physical limitations on the patients because they were not able to perform activities of daily living and were not able to fulfill their recreational activities and hobbies. McCormick et al. also reported that fatigue, dyspnea on exertion, and chest pain were the most frequent and distressing symptoms among patients ⁸. Another study showed that participants waiting for more than three months for surgery had a decrease in physical and social functioning in the perioperative period. A longer waiting time is directly associated with inability to work after surgery and more postoperative complications ^9.

The psychological concern during the waiting time

 More than half of the participants reported fear and anxiety related to surgery, pain, and heart attack. They were concerned about the self-health and future of their family members during hospitalization. Some patients were tensed because of frequent hospital visits and delays in surgery. Disease and impending surgery can lead to psychological reactions in patients. The current study showed that participants were worried about their family members looking after their children when they were hospitalized for surgery. One participant said,’ There is a concern that who is going to work in the house, there is no one to work, now operation will be done and there will be no one in the house as well, there are boys, boys are worried about their work all the time. Look, my heart is receding and shivering, I cannot even hear it.” Some were concerned about the delay in surgery, why they are not getting dates for surgery, and during this waiting time, their illness can progress, and health conditions may deteriorate further. Therefore, they feared heart attack and death. They were from distant places, so they were worried that something would happen on the way they managed. One participant said, “Earlier I used to think that if there is no surgery, then it is good. I was afraid of coming to hospital, I have to visit frequently so I used to get afraid of surgery.” As the patients waiting list for surgery is long, they had to come for frequent follow-ups, which was also one of the reasons for their tension. Waiting time provides abundant time for patients to think about their illness and surgery, which invokes anxiety. The patients are also worried about their self-health due to weakness and weight loss. In the current study, the participants who had fears related to pain while performing household activities, surgery, and heart attack were women. One participant said, “I am little afraid of my pain and I worry if there will be any problem. Other said, “Yes, there is complete fear of operation, there is very little chance that I will get operated.” A Similar study reported that, during CABG surgery, 50 % of the patients experienced mild fear and anxiety. Some had high fear levels, but very few had high anxiety levels. Most of the patients who expressed fear were women ^10.

Factors/Stressors of the disease

These factors may enhance the disease progression. Two participants reported that the death of their loved one significantly affected them and continued stress regarding this issue aggravated their symptoms. One participant said, “Since my brother is dead, it has happened even a year ago, it has become more than that”. A similar study showed that grief over the demise of a loved one significantly increases the risk of myocardial infarction. This impact may be greater among individuals who have previously had risk factors for cardiac diseases ¹¹. One participant reported that her overthinking of life issues was the main cause of her problems. Another participant was claustrophobic. Therefore, being in a closed space exaggerates patient anxiety. Some participants reported problems with heavy meals and decreased bowel and bladder movement. The patients received relief after going to the washroom. “I feel breathlessness when I eat a heavy meal. We know that the man can survive on food only, but when the intake of food has been reduced, he will not be able to work. Earlier he used to eat food very well.”

Effect on daily routine

The disease affects patients’ sleeping, eating, walking habits, and performing activities of daily living. During the waiting period for surgery, the patient’s sleep was disturbed due to chest pain and dyspnea. Sometimes, they were unable to sleep at all, and if they slept, it was interrupted. Therefore, the patients were not able to sleep after that, and they were not able to wake up early in the morning.

One participant said, “Earlier, I was not able to sleep, when I sleep, I had breathlessness so I used to sit up whole of the night, my wife says that why do you keep sitting, I said, you don’t know what my problem is” So, due to that whole routine was disturbed. Others said, “I Cannot Walk, standing, and doing something is not possible.”  A similar study also reported that CAD patients were slow and more strained in performing activities of daily living ¹².

Financial constraints and arrangements

As disease and forthcoming surgery require finances, patients must arrange money for the surgery. If the patient is the only earning person in the family, and during the worsening of symptoms, the patient is not able to work, there is no source of income. Thus, a financial crisis emerged. If another member of the family is a supporting person, he must accompany the patient as well as go on her job; thus, it increases the burden on that person, and sometimes that person may have to leave the job and thus further add to the financial crisis. One participant said, “I could not go to my work and was not able to earn money due to that, that has caused problems for my family’s stability, burden came on children. My source of income has also gone, status was not well. Children earn INR 5000/month from a private job; from that how can status get well.” Therefore, a person must arrange the finances for surgery. Few have to borrow money from their relatives or friends. Some of the patients enrolled in the “Ayushman Bharat scheme” received financial support from the government. One participant said “It has affected a lot as there is not enough money, it is due to the God`s grace that the Prime Minister has run a scheme, my name has come in it, then I came here and asked if the card (Ayushman Bharat) is considered here, then they said yes.” The Ayushman Bharat Scheme was launched in September 2018 by the Ministry of Health and Family Welfare of India. Under this condition, the treatment is free, as it provides the poor with an annual insurance cover of INR 5 lakhs per family every year. It also has packages for CABG surgery, which cost approximately INR 1.5 lakh (National-health-protection-mission,2018). Chauhan and Mukherjee showed that the annual out-of-pocket expenditure was higher for in-hospital and outpatient treatment. Rich people can spend more to get their treatment done, but people with low socioeconomic status borrow, or sometimes they have to sell their assets ¹³. In the current study, one participant said, “We will borrow from people and what to do, we don’t have money, so, due to helplessness we have to ask for money from friends, for treatment.”

Impact on social and recreational activities

Physical limitations due to the disease have an impact on social and recreational activities, as patients do not visit relatives or attend social gatherings because of dietary restrictions. Some restrictions are imposed by family members as they worry about the health of the patient.

Underwood et al. reported in their study that longer waiting times affect social and recreational activities, work, and family relationships ^14. 

Similarly, in the current study, one participant said,’ Yes, it has affected, I cannot sing the song, as it happens in a function, just go and come back, do not eat anything, just handover gift and come back. I visit the village a bit, but not able to go to relatives.”

Effect on family life, job and income

Family is the central unit of the patient. If the patient is in a problem, the entire family is disturbed, which is supported by the current study. The family must bear financial crisis and other concerns. Sometimes, children have to discontinue their study, and even loss of job of patient/family members due to frequent visits to the hospital has an impact on the family. Another study also stated that, during waiting time, spouses were more uncertain about the patient ¹⁵.  One of the participants in the current study said “My daughter is doing physiotherapy course. Now she is worried about her father, both daughters of mine always think about me. It makes a difference, and my wife gets upset even before them.”

The current study’s findings showed that the inability to work due to the disease makes it difficult for patients to return to their jobs. Therefore, patients are required to leave their jobs. Because surgery patients have to leave their jobs, they are worried about their absenteeism. When they are unable to work, their income sources are lost. As one participant said, “There is no job, it is a private job. Their father used to work in some foreign country, where he had attack 8-9 years ago. Their grandfather's work is also not going well. Destiny is not in our favor. What to do. When illness is there, we have to get it treated in any way.” On the other hand, family members must accompany patients to the hospital; hence, their jobs are also disturbed. One participant said,’ No, there is no difference in the family, it is just that my boy has to come with me by doing this, he does not do any job, he used to do a private job (computer work). Then his boss said to him to see about the operation, he fired him.”

Support system

During the waiting period for surgery, patients have many concerns, such as physical, psychological, social, and financial concerns. Therefore, support during this period is essential. Family support, support from relatives and friends, and support and information from healthcare providers are also important. Many patients have faith in government schemes for their financial support. One participant said “Support, just like that (with a laugh) you know how it at home is nowadays, there is the only the family of the person who supports”. One study reported that during the waiting period for surgery, those who had less family support were more depressed than those with more support ^16. All participants in the current study highlighted the role of their family during the disease. One participant said “I am going with the courage of children. I am not afraid because of the enthusiasm of children, do not get panic even with the operation, it is ok, will get the operation done. Children say do not take tension about the money, just get yourself treated. Everything has to be seen for children.” Only one participant expressed a lack of support, saying, “Sometimes I think we feel a bit like a burden on them”. A systematic review has shown that survivors of myocardial infarction find it difficult to change their lifestyle and require constant support to enforcing modifications ¹⁷

Coping strategies

In the current study, adapting to stress due to forthcoming surgery, patients adopted various coping strategies or diversional techniques. They were engaged in recreational activities and spirituality. One participant said, “I read a holly book, and it gets well.” Others said, “It has to be spent whatever the time is. I talk around and go to the gurudwara(temple).”  Spirituality acts as a therapy that helps build self-esteem and optimism and provides meaning and purpose in life. It also acts as a meditation that helps the patient remain calm and peaceful and gain stability in the situation. One participant said, ‘I’m just taking medicines. My children look after me. I do little work in the kitchen. Keeps playing with the children”. Therefore, it was concluded that a support system is very important for coping with various concerns during the waiting period.

Waiting for a major surgery (CABG) is the most crucial time for patients. It significantly impacts all aspects of the life of patients, as it provides abundant time to think about various concerns during waiting times. Uncertainty regarding the date of surgery and prognosis prevails throughout the waiting period. During the waiting time, patients are concerned about the deterioration of their health and a sudden cardiac event such as a heart attack. Hence, support and education played important roles during this time. It helps patients to modify their lifestyles, adopt various coping strategies, and gain control over the situation. Hence, these patients’ lived experiences are complex and intricate, and understanding their feelings and concerns is important for decreasing their fear and anxiety. It also suggests the need for and importance of cardiac rehabilitation programs that include exercise, information about the disease, diet, lifestyle modifications, and psychological support. The study concludes that during this time, patients have various unique informational needs regarding illness and surgery.

Waiting during CABG significantly affects all aspects of a patient’s life. To understand the experiences of these patients, considerations must be taken from an individual point of view. Long waiting lists because of the shortage of beds, operation theatres, funds required for the surgery, and sometimes the patients’/caregivers' own wish to postpone could be reasons for the long waiting time. A delay in surgery leads to stress and uncertainty as it provides more time for patients to reflect, grieve, and anticipate threats. The patients manifested mixed feelings toward the surgery. Ambivalence has also been observed in these patients. During this period, patients have various unique informational needs regarding their illness and surgery.

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