Prehabilitation and paternalism

As many of you may know, I have been involved in a project where we train our patients physically and psychologically before their cancer surgery. The project (which I described a couple of years ago in a blog post here) has won many awards, has reduced our length of stay by about 25% and reduced our postoperative complication rate by a staggering 60%. Not only that, but the complications our patients get are now less severe, so fewer of them need to be admitted to the intensive care unit.

What has really impressed me, however is how much more motivated our patients are. They are psychologically much more prepared for the operation – one of the most invasive and extensive that we perform – understanding it better and understanding the hard work they themselves have to put in. This month I had a patient who successfully stopped smoking at the first consultation, and by the time she came to surgery her sheer will to succeed was obvious.

In this week’s BMJ I read an editorial by Giles and Cummins on prehabilitation, discussing particularly its negative aspects. Some of the problems they suggested puzzled me, especially having seen how the patients I’ve treated responded.

Maybe I’ve misunderstood the message that it’s trying to convey, but I find the suggestion that patients may be too upset by their cancer diagnosis to engage in lifestyle modification and pre-habilitation insulting and patronising to our patients, as is the statement that our patients can’t process the additional information because they’re getting information overload already.

So are they really saying that because our patients have just been told they have cancer and need treatment they’re going to be too upset for us to be able to help them stop smoking and increase their exercise levels? In my experience the time of a cancer diagnosis is an immensely valuable moment when people re-assess their life and are very open to lifestyle modifications. To deny our patients this opportunity because they may be “upset” would be do do wrong by them. Our patients love the pre-habilitation programme we provide for them, and one of the points they always mention is how it gives them a chance to be active participants in their care rather than passive recipients.

Further down the article the authors caution against pre-habilitation for lower social class patients as they may be more resistant to interventions such as stopping smoking. I found this bizarre, as in our experience the high success we have in getting our patients to engage in our pre-hab programme is not dependent on social class, and in fact those patients stand to gain more benefit from the programme than better informed health conscious patients who will probably be quite fit to begin with.

The paternalistic tone in the article is something I thought we had left behind in the 1980’s, and I think it’s really important we don’t reinforce the stigma of cancer where we have to protect them from information or additional resources as they may be upset about their diagnosis. It is a difficult time for them, and the structure of a pre-habilitation programme is an immensely positive addition where our patients feel cared for, guided through the programme, and…yes…even loved.