Chronic Refractory Angina

Patient centred treatment model

Counselling: Patient version

Refractory angina is a chronic pain syndrome that cannot be cured and the majority of patients have already come to terms with that by the time the diagnosis has been made. 
Once the diagnosis has been established it is essential for the the patient and their carers to reach agreement with their doctor on desirable and achievable treatment objectives. Once the aims of treatment are established a strategy can be developed that is tailored to the particular needs of the patient.

Treatment aims and the treatment contract

The primary aim of therapy is to maximise the patients quality of life by ameliorating the effects of the condition without jeopardising quantity of life. In other words patients want the longest happiest life possible. Once a diagnosis of chronic refractory angina is made there are a number of simple ways to increase the length of life. Broadly speaking these can be divided into things the doctor can do (i.e. prescribing tablets such as cholesterol lowering drugs, aspirin-like drugs and some special drugs for certain patients) and things the patient can do (i.e. take the drugs, avoid smokers, eat the right things and exercise regularly). Once that has been sorted out the rest is all about improving quality of life. 
The effect of angina on the ability of the patient and their family to enjoy their lives is tremendously variable. The reason for this is simple. Mostly it depends on the extent that the angina stops you doing what you want to do and everyone enjoys different things. On top of that angina is very sophisticated and uses all sorts of tricks to take the angina sufferer's quality of life. In some it will just cause nasty pain whenever they try to do something they enjoy "I used to love walking but the pain is so awful I have had to give up". In others angina will terrorise them into avoiding anything that might bring on a heart attack "I used to love bowling but a friend of mine died after a bowling match so I gave it up". Sometimes angina will ignore the patient and will use fear to trick the carers into stopping the patient from doing things "I used to love golf and I don't mind a bit of angina but my wife won't let me so I have had to give up".

In order to get to the bottom of how the angina is affecting them and how to best deal with it the patient and their loved ones need time and help to define how angina impairs their quality of life and what level of recovery would be acceptable. We work through all the options with the patient until we all agree to aim for a realistic target to be achieved within a year. We call this the treatment contract.

Treatment contract

A typical treatment contract might be an improvement from 30% quality of life to 70%, a holiday abroad and regular walks in the countryside but is entirely dependent on the particular needs of the patient. Once the improvements have been realised it is perfectly alright to renegotiate for an even greater improvement if the inherent disadvantages of the additional treatments that would be required are considered worthwhile. These are difficult concepts in the present medical system where patients have assumed an almost subsidiary role in a largely pathology or disease-centred treatment approach. How often have patients felt that their real reasons for coming to the doctor are being ignored whilst they are swept along on the conveyor belt of investigation and treatment only to find that they are still not sure that they are getting what they wanted in the first place? Once on the conveyor belt it becomes difficult to ask questions partly because of the prevailing view that "the doctor knows best" coupled with an understandable desire not to challenge medical authority. But how can the doctor know what the patient really wants unless she/he takes the trouble to ask? Unfortunately the system has generated an expectation that follow up patients can be dealt with in a five or ten minute consultation. One way around this is to request to be seen in the new patients clinic once a diagnosis of chronic refractory angina has been made. The general practitioner should be able to arrange this. It is no guarantee that the doctor will work with the patient and their carers to identify achievable aims and a sensible strategy but it is a start.

Anxiety, stress and angina
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