Unveiling the Nocebo Effect: Harnessing the Power of Positive Communication in Anaesthesia

On the anniversary of Portugal’s Carnation Revolution, a historic moment celebrated for its peaceful uprising, ESRA hosted a webinar that echoed the spirit of transformative change. Barbara Breebaart’s captivating presentation, “Unveiling the Nocebo Effect: Harnessing the Power of Positive Communication in Anaesthesia,” drew a poignant parallel to the ethos of that pivotal event.

In the pursuit of informed consent, the ethical maxim of “primum nihil nocere” (first, do no harm) often feels like navigating a labyrinth. Much like the revolutionaries who wielded flowers instead of violence, positive communication emerges as a revolutionary force in the medical world, dismantling the tyranny of fear and uncertainty.

The term ‘nocebo’ itself, derived from Latin, meaning ‘I will do harm,’ encapsulates this pervasive fear. At times, in our zeal to educate, we unwittingly inflict harm. However, as history has shown, change can be tranquil and affirming, and so can our communication.

Barbara Breebaart’s webinar illuminated how disregard and ignorance of nocebo effects can lead to unintended repercussions. She underscored that while comprehensive risk descriptions may seem beneficial, they can provoke distress and nonadherence in patients. The nocebo effect, fueled by negative expectations, can yield detrimental outcomes.

Prior to the webinar, participants were surveyed regarding their communication practices with patients through a series of questions. Following Barbara’s presentation, a subsequent poll was conducted on the same topic. It was enlightening to observe a notable shift in comprehension and perspective (refer to figure 1 for results) as the majority of participants selected all the correct answers from the new set!

During the Q&A session, participants delved deeper into the subject matter, seeking elucidation on various aspects:

What would be the best way of counselling a patient who strongly believes epidural causes backpain?
Dr Breebaart’s answer: This is a very good and relevant question. Existing beliefs and expectations influence experience to a great extent and exploring them can be done by the “ICE” principle. This means exploring Ideas, Concerns and Expectations. Knowing where these ideas come from allows reframing before the procedure takes place. If done properly patients might have more realistic expectations and positive communication can be used during the procedure.
Is there any different techniques of communication in pediatric patient group?
Dr Breebaart’s answer: Absolutely. First of all, since when parents are present we have a communication triangle. You might want to use positive communicaiton techniques towards the parents as well, as they are or often are very nervous themselves and tranfser this subconsiouslys to their children. Children have a magnificant imagination which creates a lot of opportunities. Depending on the age this is very variable and can go from soothing sounds and facial expressions to making the or table an aeroplane or to go to a safe place where the sky is the limit.
How can we handle litigation if something bad experienced which was not told earlier?
Dr Breebaart’s answer: Positive communication is a technique that is developed to use during invasive techniques to reframe this experience in the moment itself. In handling complications, provision of information is of uppermost importance. It is important that risk communication is correctly done when obtaining informed consent before a procedure takes place. For this there are several communication techniques avaliable that go beyond the scope of this topic. Anouncing risks and side effects does work as a nocebo and there is a lot of discussion on how we should adress this problem.
Which is best as per your practice? combined spinal epidural or epidural only?
Dr Breebaart’s answer: As far as technical performances, I do not have a personal preference. If you have a protocol that works and is clear for everybody either technique is effective. Communication during either one of these procedures requires the same principles. More important is active listening in order to adjust your communication to the patient rather than to the procedure to understand your patient specific needs.
If we used placebo instead of any analgesic is this bioethically correct?
Dr Breebaart’s answer: This question can be answered from different views. When we talk about pharmacoligal analgesics, placebo migh be used in research setting for which clear ethical legislation is available (ethical approval, informedconsent). However when we talk about placebo in and nocebo effects in communication there are only opinions and experiences. My own opnion is to leave the experience with the patient, which implies no nocebo but also no promises of “feeling noting”. Everybody is different and has a different pain threshold.
What if to say to the patient “it will stink a little bit’, it also gives an information.
Dr Breebaart’s answer: It absolutely does and your question is very correct. As mentioned above, every person is different and has different experiences. What might smell awful for one person might be a more neutral scent for another. I would prefer to say “you might smell somthing”, without deciding how this will be: I tend to avoid the word “a little bit” for the same reasons.
It is important to understand the why of nocebo and placebo. Both occur via language conditioning. Words in our language have come to elicit an emotional response. A negative word elicits negative emotional responses that make pain worse. Think about the words themselves.
Dr Breebaart’s answer: This is so true. Therefore it is important to realize that eventhough when we are trained in the avoidance of nocebo’s, we might subconiously use words or bodylanguage that is experienced as a nocebo by the patient. Learning to become conscious of bodylanguage can be very helpful here to detect any reactions that are not verbally expressed.

In embracing positive communication, we are not merely imparting knowledge; we are empowering, comforting, and fostering healing. Like the Carnation Revolution, it represents a tranquil yet formidable catalyst for change.