Preoperative communication between anaesthetists and patients with obesity regarding perioperative risks and weight management: a structured narrative review
Perioperative Medicine volume 9, Article number: 24 (2020)
Individuals with obesity frequently present for anaesthesia and surgery. Good communication during the preoperative consultation can optimise the provision of relevant health information and guide improvement of health status preoperatively.
We planned a systematic literature review to assess existing guidelines and evidence of effectiveness for how anaesthetists should communicate with patients who have obesity in the preoperative period about perioperative risks and weight management. Database searches used keywords related to perioperative weight loss conversations. We found no papers that directly addressed our aim. The literature identified as most relevant was analysed in the form of a narrative review.
The majority of suggestions for weight loss conversations came from primary care. Four primary themes potentially relevant to anaesthetists were identified: barriers to such conversations, communication tools, language and communication and specific recommendations. Identified barriers included lack of skills, training, poor remuneration, pessimism and time constraints for clinicians. Established discussion tools including the ‘5A’s’ approach (Assess, Advise, Agree, Assist, Arrange) and motivational interviewing may hold promise to improve preoperative conversations. The papers highlighted a need for empathetic language, including use of patient-specific language where possible.
There are currently no published guidelines for how anaesthetists could most effectively discuss weight in the perioperative period with patients who have obesity. Much of the literature for obesity communication is based on the primary care setting. The perioperative period may represent an increased time of receptiveness for patients. Guidelines for discussions about weight management and associated perioperative risk are suggested.
Obesity is an increasingly common problem in many countries (Twells et al., 2014) with many potential health implications in the perioperative period (Nightingale et al., 2015). Rates of obesity in surgical patients have been reported to vary between 35 and 70% depending on the type of surgery and can be twice the background rate of the general population (Mullen et al., 2009; AIHW, 2019; STARSurg-Collaborative, 2016; Hamlin et al., 2013; Freckelton et al., 2019; Harms et al., 2007). Preoperative problems include optimisation of concurrent medical conditions such as obstructive sleep apnoea (Chung et al., 1999; Abdullah & Chung, 2014). Intraoperative concerns include mechanical problems such as accurate blood pressure measurement, intravenous access and adequacy of ventilation (Chung et al., 1999; Abdullah & Chung, 2014). Postoperative complications include respiratory failure requiring prolonged endotracheal intubation and intensive care, myocardial infarction and cardiac arrest, wound infection, urinary tract infection, pulmonary embolism, renal failure, peripheral nerve injury and prolonged time in the post-anaesthesia care unit (PACU) with respiratory difficulties (Chung et al., 1999; Bamgbade et al., 2007; Chen et al., 2011; Merkow et al., 2009; Blouw et al., 2003).
Anaesthetists face many unique communication challenges with patients (Hool & Smith, 2009; Kopp & Shafer, 2000). Their contact together is usually brief and often time-pressured. Patients may be anxious, in pain, acutely unwell or affected by medications such as potent analgesics. The perioperative period is in itself a time of vulnerability for patients (Cousley, 2015). They are dealing with a health problem that may vary in severity and urgency, with uncertain outcomes, admission to hospital, multiple health care providers and the loss of control that occurs with anaesthesia and surgery. The necessity for a surgical procedure may be related to lifestyle factors such as smoking and obesity. All of these factors support the need for high-quality professional communication skills, which are rarely explicitly taught (Hool & Smith, 2009; Kopp & Shafer, 2000).
Preoperative consultation with an anaesthetist generally occurs either days or weeks before the day of surgery in a preoperative assessment clinic (PAC), or immediately prior to surgery on the day of admission. Both situations offer only a limited opportunity to address significant behaviour change prior to the planned procedure. The anaesthetist would ideally cover two related but separate issues with patients who have obesity: the risks associated with obesity in the perioperative period, and encouragement for weight loss (Nightingale et al., 2015; Chung et al., 1999; Abdullah & Chung, 2014; Bamgbade et al., 2007; Chen et al., 2011; Merkow et al., 2009; Blouw et al., 2003).
As the issue of specific communication between anaesthetists and patients with obesity has been rarely considered, a survey was performed by the Australian and New Zealand College of Anaesthetists (ANZCA) to uncover attitudes and practices related to perioperative communication with these patients. The results of this survey showed that many anaesthetists find it difficult to communicate with patients with obesity about their weight (Hinks, 2015). Approximately two-thirds of the 800 respondents indicated that obesity was the most common co-morbid condition they encounter and the same proportion noted that they had anaesthetised at least one obese patient on their most recent clinical day. The survey found almost universal agreement that obesity increases both perioperative and lifetime risks for patients. However, respondents indicated uncertainty in knowing how best to approach the problem, with concerns about not wanting to cause hurt or offence with chosen language, changing societal norms regarding the increasing prevalence and normalisation of obesity and low patient health literacy regarding obesity and its implications for anaesthesia and surgery.
The lack of specific advice available for anaesthetists with regards to weight loss counselling represents a gap in current literature. Anaesthetists desire guidance on this important and frequent presentation; however, there are no recommended guidelines available. Our aim was to perform a literature review to uncover guidelines as to how anaesthetists should most effectively conduct preoperative conversations with obese patients to include both perioperative risks and weight loss management.
The methodology was planned as a systematic literature review. The question for the review was: How can anaesthetists best conduct preoperative conversations regarding perioperative risk and weight loss with patients who have obesity? Formal searches of Ovid MEDLINE® were performed in February 2016 by professional librarians from two institutions (ANZCA and the Illawarra Shoalhaven Local Health District). After finding no relevant literature from the original searches, we repeated the search using expanded search terms in May 2016 (see Table 1 below). Searches were restricted to the English language and covered the period from 2006 to May 2016. The grey literature was not included. Search terms were used both individually and in combination.
No studies directly addressing the study question were found. Therefore, a narrative review of the closest related papers was performed based on thematic analysis associated with the research question. We reviewed papers that dealt with the fields of communication between anaesthetists and patients in any situation, between surgeons and patients relating to obesity in any way, any type of perioperative communication and weight loss or management conversations between any health professionals and patients. Literature regarding other patient counselling circumstances such as smoking cessation and drug addiction was also considered if thought to be potentially relevant to a preoperative consultation situation. Abstracts and references from relevant papers were manually searched and papers were added to the evaluation list if they were deemed likely to add value to the study question. This search was conducted by one investigator (AH) and clarified in discussion with a second investigator (NAS) until agreement on papers to be included was reached. Literature regarding other patient counselling circumstances such as smoking cessation and drug addiction was also considered if thought to be potentially relevant to a preoperative consultation situation.
A thematic analysis approach was used. After reviewing the literature base broadly, eight draft themes were agreed upon by the authors. Review was undertaken of each full text paper categorising and coding the content that related to these themes in Microsoft Excel. Following initial review, it was agreed by the authors to collapse the number of themes to four, with the inclusion of subthemes. An obesity physician and a medical communication expert independently reviewed the final collection of themes and no changes were made. Papers were included in the review if they contributed to the selected themes. Due to the varied source and nature of the reviewed publications, and the exploratory nature of the investigation, we did not undertake a formal critical evaluation of the quality of evidence.
One hundred and eighty-five papers were originally identified. A total of 116 papers were selected for review, with 95 papers able to provide input to the research question (Fig. 1). These 93 papers came from diverse healthcare backgrounds including primary care (49), communication (18), paediatrics (seven), anaesthesia and perioperative management (six), internal medicine (five), obstetrics (four), dietetics (two), surgical management (one) and allied health (one). The majority of papers relating to weight loss discussions were drawn from primary care and communication literature, with the anaesthesia and perioperative medicine papers relating to general pre-anaesthetic communication rather than specifics of weight counselling in these areas.
The four final themes with subthemes are presented in Table 2. More than one theme was present in most papers. The most common theme related to the barriers to conversations between patients with obesity and health care providers, with 59 of the 93 papers (63%) making reference to barriers. Lack of training (in 45%) and the perception of insufficient time (in 44%) within a consultation were the most commonly found barrier sub-themes.
Motivational interviewing (in 20%) and the 5 A’s (Assess, Advise, Agree, Assist, Arrange) (in 18%) were the most commonly identified communication tools, with less frequent references to a similar tool, the 4 E’s (engage, empathise, educate, enlist), and written materials. Multiple papers made reference to the terminology recommended when engaging in weight loss conversations. ‘Weight’ was the preferred term for conversations, with ‘fatness’ the least preferred term (Dutton et al., 2010). Patients desired an empathetic approach from their doctor, with patient-centred communication considered of higher value than generic weight loss advice (Huang et al., 2004).
The most common subtheme regarding specific recommendations for weight loss conversations was for physicians to be specifically trained in how to discuss weight with patients with obesity (in 19%). Availability of clear referral pathways to manage obesity was also mentioned (in 10%): this ties in with the ‘assist’ and ‘arrange’ elements of the 5 A’s.
Table 3 provides more detailed information on the papers’ specific contributions to the themes. Although 93 papers provided information, many of these papers contained repeated thematic material; therefore, only the most relevant have been included to provide a summary. Fifty-two quotations from 36 papers are presented in Table 3 that were deemed by the authors to be representative of the themes and subthemes associated with weight loss conversations. This is not an exhaustive list of all thematic data collected during the analysis of the literature; however, the table represents the most salient points relating to our research question.
An additional theme relating to obesity-related conversations in special groups such as paediatrics, obstetrics and different cultures, ages or gender was explored but not found to add to the specific study question. These data are not reported.
Barriers to conversations
The most common theme from the literature concerned the perceived existence of multiple barriers to healthcare professionals having conversations with patients about their obesity. This theme was further stratified into several specific barriers, with one paper ranking the barriers according to physician feedback (Table 4) (Huang et al., 2004). The overarching premises surrounding this theme related to either lack of skills, training and time, and a perceived futility of such conversations. A recent paper described the effectiveness of a 7.5-h communication-training program for improving physicians’ communication self-efficacy, attitudes and behaviours (Saslaw et al., 2017). This paper stated that there are benefits of brief communication skills training to both physician and patient satisfaction (Saslaw et al., 2017). Despite the recognised barrier of time constraints, the evidence for success of brief interventions in smoking cessation is encouraging for weight loss (Stead et al., 2013). The premise of the efficacy of the brief weight loss intervention coincides with the concept of the ‘teachable moment’, which is discussed further in specific recommendations below.
Although none of the reviewed articles related directly to preoperative anaesthesia consultations, these barriers appeared to be relevant enough to be applicable and potentially useful to this situation.
Specific communication tools were examined or explained in many of the papers. These included specific guidelines such as the 5A’s and the 4E’s frameworks that provide a structured approach, as well as more broad reference to communication methods such as use of motivational interviewing (MI) and use of written materials given to patients. Description of the use of these tools mainly emerged from primary care, with a focus on evidence-based practice in overweight/obesity conversations. The 5A’s and MI were the most commonly reported communication tools: these have previously been used with success in addressing smoking cessation (Fiore et al., 2008; Pollak et al., 2010). The difference between smoking cessation and dietary advice was highlighted by Phillips et al: ‘Success for smoking is measured as an absolute (smoking cessation), but success for healthy eating traverses along a continuum, measured by various factors (such as weight loss, and reduced cholesterol level)’ (Phillips et al., 2012). Likewise, Jebb et al. noted that unlike smoking cessation, campaign messages of ‘Stop Smoking’, the messages to obese patients are much more complex as cessation of eating is not an appropriate intervention (Jebb et al., 2003).
Despite the differences between weight management and smoking cessation, the shared underlying concept of these tools is to move patients through the change cycle towards self-motivated behaviour change (Jay et al., 2010a; Schwartz, 2010). While both MI and the 5A’s are described as effective tools in weight loss conversations (Gudzune et al., 2012), the simplicity of the 5A’s may make it more appropriate for preoperative use. The 5A’s was initially designed for smoking cessation (Manley et al., 1992) but there is clinical evidence for its use in weight management (Jay et al., 2010a; Alexander et al., 2011). A modified version of the 5A’s framework has been proposed for Canadian family physicians in the primary care setting (Vallis et al., 2013). The primary aim of the recommendations is for the physician to initiate sensitive conversations with the patient, to help empower patients to pursue their own weight loss goals and endeavours (Vallis et al., 2013). The 5A’s is also utilised in the Australian Government Department of Health National Health and Medical Research Council guidelines for management of overweight/obesity in primary care (NHMRC, 2013). These examples demonstrate the potential simplicity that could be utilised in the preoperative consultation. A communication tool that is relatively straightforward to teach and learn will also be important for the design and implementation of physician training programmes. A potential challenge to the implementation of the 5A’s in the preoperative period is that ‘assist’ and ‘arrange’ are the most important aspects (Alexander et al., 2011), but may be difficult to accomplish with the limited time frame and competing priorities of the preoperative consultation (Kopp & Shafer, 2000). A clear referral structure would help anaesthetists provide the most effective weight loss guidance for patients, and could include established pathways for referral to an exercise physiologist, dietician, psychologist, dedicated public health weight loss programmes or back to the primary care physician.
Language and communication
Several papers made reference to the specific language used in weight loss conversations. Some papers considered the broader concept of empathy, noting that patients wanted their physicians to be empathetic when holding weight loss conversations (Chugh et al., 2013; Farnesi et al., 2012). In terms of more specific communication language, papers identified particular terminology to use, and terminology to avoid, when describing the condition of overweight/obesity with patients (Dutton et al., 2010; Gray et al., 2011). Preferred terminology was partially dependent on patient demographics (Farnesi et al., 2012; Gray et al., 2011; Raaff et al., 2014), making it difficult to provide broad, definitive instructions for future guidelines. However, some terms were noted in multiple papers to be undesirable when discussing overweight/obesity with patients, such as ‘fat’, ‘fatness’, ‘obese’ and ‘obesity’ (Dutton et al., 2010; Mikhailovich & Morrison, 2007; Gordon & Black, 2016; Tailor & Ogden, 2009). Multiple papers reported ‘weight’ to be the most favourable term (Dutton et al., 2010; Mikhailovich & Morrison, 2007). Communication should also be patient-centred, and specifically tailored to the individual (Chugh et al., 2013; Greiner et al., 2008). Patients derive less meaning from generalised weight loss information (Chugh et al., 2013; Greiner et al., 2008). A simple acknowledgement of a patient’s overweight status has been associated with increased desire and attempts to lose weight (Post et al., 2011). This holds parallels with the so-called teachable moment of smoking cessation (Gritz et al., 2006), and may hold promise for discussions about weight in the preoperative period. The ‘teachable moment’ relates to the interaction between patient and healthcare provider at a time when a patient may be particularly receptive to heath information. This can occur in situations that involve increased perceptions of risk, adverse outcomes, emotional situations or that involve a re-definition of self (McBride et al., 2008). Examples include times of a diagnosis of cancer, pregnancy, an upcoming operation or major illness. This concept has been widely used in smoking cessation and has been described in the management of obesity (Phelan, 2010). Patients expect to receive health information and counselling whenever they interact with health care professionals, and a lack of this may be perceived as an affirmation of poor health practices (Pool et al., 2014). The perioperative period represents an opportunity to utilise this expectation as a ‘teachable moment’ (Wynter-Blyth & Moorthy, 2017). Assessment prior to an operation could be considered to be a time of ‘openness’ to healthcare information from several perspectives, and thus the preoperative anaesthetic assessment could be utilised to present obesity management information in an effective manner.
The articles gave suggestions on how to overcome the identified barriers and incorporate effective language and tools in weight loss conversations. In recognising that most anaesthetists are not trained in providing detailed overweight/obesity advice and are uncertain and even uncomfortable in doing so, the establishment of well-defined referral pathways to dieticians or other specialists was an important recommendation (Vallis et al., 2013; Eley & Eley, 2009; Baron, 2011). This is particularly relevant for anaesthetists as they do not have an ongoing relationship with patients over time. Multiple articles highlighted the need for specific training of physicians, primarily around conversational techniques (Eggly et al., 2003; Ashby et al., 2012).
We found several recommendations that may be usefully considered as guidelines for preoperative weight loss discussions. These include acknowledgement of overweight/obesity in the initial consultation (Ahn et al., 2012), use of specific tools and checklists to open the discussion and assess the position of the patient on the change cycle (5As, MI) (Ahn et al., 2012), patients completing a short form on diet and exercise prior to the consultation (Ahn et al., 2012) and discussion of increased risks of obesity with reference to the specific planned surgery (Astin & Hardy, 2015). There should also be a limit on the overall amount of information provided to the patient, focussing on key messages, as patients have limited capacity to integrate a large amount of information in the preoperative setting (Sandberg et al., 2008). Training anaesthetists in these specific communication skills will be important. The support of pre-arranged consultation and referral pathways is particularly relevant in an anaesthesia preadmission setting. With clear referral pathways, patients can be followed through the change cycle by their primary care physician or allied health professional, with the goal of long-term, sustained weight loss.
There are several limitations to this review. There was a lack of directly pertinent research to the field of anaesthesia, which made compilation of practice recommendations for the field of anaesthesia challenging. However, this is also indicative that this is truly novel research, and the first work to suggest guidance for practice, and these suggestions can now be tested or clinically implemented for future investigations. A further limitation was the heterogenous nature of the sources utilised for the narrative review. This did enable a broad range of sources from which to draw recommendations, which may not have been possible if the source material was more homogenous. The review was also initially planned as a systematic review, which would have provided a high level of evidence than the performed narrative review. There was a lack of high-quality quantitative studies to include; therefore, the majority of the information incorporated in this review is qualitative in nature.
To summarise the main messages from this narrative review, we propose the following practice points that may be helpful for anaesthetists in preoperative consultations with patients with obesity.
Practice points to consider
Train anaesthetists and other perioperative medicine practitioners in obesity specific communication skills, including use of empathetic language
Patients can receive information about the effects of obesity on anaesthesia and surgery, and complete a short form on diet and exercise, prior to their preoperative review.
Start the conversation by acknowledging patient obesity using an empathetic approach: ‘I am concerned about your unhealthy weight’ or ‘Are you OK if we talk about your weight?’
Use a formal communication tool such as the 5A’s to help structure the discussion and assess the position of the patient on the change cycle (Table 5).
Discuss the increased risks of obesity with reference to the specific patient and planned surgery.
Communication should be patient-centred and specifically tailored to the individual.
Have pre-arranged consultation and referral pathways for ongoing care.
Provide written materials and/or web-links for online support and reliable information for patients to take away.
There is no existing literature to directly guide anaesthetists in conducting effective preoperative communications with patients who have obesity. Some potential guidelines and considerations for having these discussions in an effective and empathetic manner are proposed. Further research is required to provide evidence-based recommendations for this increasingly important issue.
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The authors thank Robyn Woodward-Kron, PhD, Associate Professor of Healthcare Communication, Melbourne Medical School, The University of Melbourne, Melbourne, Australia—advice on language, proofreading and editing. Dr. Nic Kormas, Senior Staff Specialist, Department of Endocrinology, Concord Repatriation General, Camden and Campbelltown Hospitals—input on themes, proofreading.
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Hodsdon, A., Smith, N.A. & Story, D.A. Preoperative communication between anaesthetists and patients with obesity regarding perioperative risks and weight management: a structured narrative review. Perioper Med 9, 24 (2020). https://doi.org/10.1186/s13741-020-00154-4