Open Journal of Gastroenterology, 2013, 3, 78-83 OJGas Published Online February 2013 (
Patient stress and satisfaction when allowed the presence of
an accompanying person during endoscopy
Jesse Lachter1,2, Benjamin Ephraim Bluen1
1Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
2Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel
Received 17 November 2012; revised 18 December 2012; accepted 24 December 2012
Introduction: Patients undergoing esophagogastro-
duodenoscopy (EGD) have variable stress and anxiety
and therefore commonly receive medications as seda-
tive-anxiolytics. These medications have small but
significant risks. To possibly make procedures safer
and to increase patient satisfaction, this study aimed
to measure the effects of allowing an accompanying
person (AP) to be present in the endoscopy suite dur-
ing EGD. Patients and Methods: Forty-two patients
were randomly divided into two groups who would
either be or not be offered to have an AP during en-
doscopy. Spielberger’s well-validated state and trait
anxiety evaluations were administered to patients
before and after EGD. APs also completed question-
naires as to their reactions after EGD. Results: 84.2%
of the patients after EGD recommended accompani-
ment. Patients who underwent EGD with an AP
tended (p < 0.06) to have decreased measurable anxi-
ety compared to patients who were not offered an AP.
The benefit was significant for persons with higher
levels of anxiety prior to EGD (p < 0.04). Patients
undergoing EGD for the first time had significantly
more anxiety than those with previous EGD experi-
ence (p < 0.034). There was no significant reduction
in sedative dosage when APs were present. Conclu-
sions: Offering to permit the presence of an accom-
panying person during EGD was often shown to im-
prove patient satisfaction and reduce anxiety.
Keywords: Endoscopy Escort; Sedation; Satisfaction
It is understandable for patients to experience some
stress preceding and during EGD. One appropriate way
to reduce this anxiety is to use sedatives. Such medica-
tion has been found to have minimal but occasionally
significant morbidity. However, based on a study in-
cluding over 320,000 endoscopies, more than half of the
major complications including mortality in endoscopic
procedures may be attributable to the medications used
Any intervention which may reduce anx iety, and t her eby
reduce the need for sedation, might therefore be hy-
pothesized to help reduce morbid ity and mortality. Anxi-
ety, which is not easily quantified, has been made ap-
proximately measureable using physiologic parameters
including heart rate, blood pressure and degree of sweat-
ing and by using validated questionnaires such as that of
Spielberger, which test both state and trait anxiety [2].
High anxiety levels have various adverse effects not only
in medical but also in daily situations, including negative
affective response, more prolonged and difficult recov-
eries, and increased need for pain and anxiolytic medica-
tion [3]. Furthermore, reducing anxiety may reduce medi -
cal phobia (disproportionate fears) which might other-
wise lead to avoidance of beneficial procedures [4]. This
is especially true for patients undergoing their first en-
doscopic exam [5]. When patients feel lack of control,
anxiety is increased. Reducing anxiety lessens the amount
of time and support resources needed for recovery, which
furthermore results in increased patient satisfaction and
adherence to medical plans.
While the patient is irrefutably the primary client, a
patient's surrounding environment includes significant
others who may have a profound impact on his or her
physical and mental health. The people who the patient
knows and trusts may influence adherence to medical
therapy. These “significant others” or APs may also be
seen as secondary clients. Including these APs in part of
any medical intervention such as EGD may help to
achieve successful outcomes by leveraging their pres-
ence and role to help reduce the stress and anxiety of the
patients undergoing endoscopy.
It is from the experience of the first author, having
visited endoscopy centers worldwide that allowing the
presence of an AP during EGD is quite rare in the United
States, Canada, and in Western Europe with a notable
J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83 79
exception to be in Chin a where such pr actice is common.
A questionnaire of 400 men and women ages 16 - 65
years old in England identified that the most important
factor in the examination was the attitude of the doctor;
allowing an AP during examinations was viewed by pa-
tients as a sign of respect [6]. Although the issues of
anxiety and sedatives have been addressed at length by
the American and European practice guidelines, they
have not related to the influence of allowing an AP dur-
ing EGD [7]. Therefore, two additional goals of this
study are to raise awareness of this option and to en-
courage further investigation to assess the impact of pa-
tients’ significant others in large-scale studies.
Attempts have been undertaken to reduce stress by
various psychological preparations. Such preparations
for EGD have included provision of information (orally
and in pamphlets), modeling (seeing a videotape before
EGD), hypnosis and other relaxation techniques [8]. As
an unfortunate consequence of the modern healthcare
system and training centers, over-worked house officers
often either lack the time, the awareness, and/or the
overall ability to optimally manage va rious patient social
and behavioral concerns [9]. This further emphasizes the
value of psychological pr eparations and the presence of a
significant other during EGD as a low-cost method to
reduce anxiety and perhaps thus also to reduce associated
anesthesia-related morbidity.
The influence of psychological preparation for gastro-
scopy was investigated by Mahajam et al. in a study in-
volving pediatric patients with a mean age of 12.2 years
who underwent endoscopy. Studying a control group
having regular preparation vs. additional psychological
preparation including dolls of photography books simu-
lating EGD procedures demonstrated statistically sig-
nificant decreases in autonomic nervous system stimula-
tion and pro cedural anxiety. This led to decreased p aren-
tal anxiety and helped to strengthen doctor-patient rela-
tionships [10]. In a similar manner, the anxiety of a pa-
tient’s significant other may be decreased by pre-proce-
dural psychological preparation.
Individualization of approach and considering the ho-
listic approach to a patient as a part of a social network
that includes others is key to patient satisfaction. It is
important to realize that patients vary in terms of the
extent of worry over EGD. For example, younger pa-
tients have been shown to be most concerned about
EGD-related pain and procedural complications whereas
elderly patients were most concerned about potential
findings [5]. Also key is to identify specific groups of
patients who have a high risk of elevated anxiety levels
prior to procedures. Increased anxiety is a phenomenon
which has been shown to be particularly prevalent in
certain patient groups, notably younger patients and
those undergoing gastroenterological procedures for their
first time. Extra emphasis should be placed on helping
such individuals to relieve any excessive anxiety [6]. The
outlined anxiety may be reduced by the presence of an
AP may in turn allow the reduction or eliminatio n of the
use of anti-anxiety medications, most commonly benzo-
diazepines, which according to major studies are respon-
sible for the majority of the morbidity and mortality from
upper gastrointestinal endoscopy [1].
2. AIM
By having an accompanying person present in the endo-
scopy suite, persons who chose to have such an accom-
panying person present might become less anxious be-
fore and during the procedure. This study hypothesized
that measureable anxiety and satisfaction of patients and
APs within the medical encounter might be affected by
offering this option to patients.
Every patient was instructed to come for EGD with an
accompanying person, without explanation for such be-
ing given. This is standard operating procedure, because
anyone receiving sedation should be accompanied after-
wards. 42 outpatients were randomized to either have
offered to them the presence of an AP during the proce-
dure or not. With the help of a trained interviewer, every
patient prior to EGD underwent testing using the Spiel-
berger anxiety scales for state anxiety and situational
anxiety. The sedation used for these procedures was a
standard dosage of fentanyl 0.05 mg IV in addition to
midazolam titrated until considered sufficiently effective
(1 - 5 mg). No oral or topical spray anesthetic was used.
After EGD, the patients again completed a question-
naire measuring anxiety. Every patient had heart rate,
blood, pressure, and d egree of sweating no ted on ce at the
beginning and once at the end of the EGD. The accom-
panying persons also completed a questionnaire, includ-
ing scaled questions regarding satisfaction with the medi-
cal encounter and evaluation of their experience. Data
was analyzed using the Statistical Program for the Social
Sciences (SPSS) and by X2 analysis.
This study was approved in advance by the Helsinki
Committee (Institutional Review Board) of the Rambam
Healthcare Campus. The study was not funded and thus
there are no relevant disclosures.
Forty-two patients were selected with 23 controls and 19
subjects. The control group consisted of 56.5% (13/22)
male and 43.5% (10/23) female patients; the experimen-
tal group contained 47.4% male (9/19) and 52.6% (10/19)
female subjects. Patients were sampled from a variety of
Copyright © 2013 SciRes. OPEN ACCESS
J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83
Copyright © 2013 SciRes.
different ethnic backgrounds mostly including those from
Israeli, Russian, Romanian, and Ethiop ian heritages. APs
consisted of mostly spouses (34%), children (20%), or
fa mily memb er s ( 12% ).
After endoscopy, results from questionnaires filled out
by patients who underwent EGD with the presence of an
AP showed that 83% (16/19) of the experimental group
patients recommended that procedural accompaniment
be offered (see Table 1). Including the control group, a
total of nearly 59% of subjects requested to have APs
during EGD whereas 38% declined, and 3% of patients
were undecided, which likely reflects the high anxiety
rate in the pre-procedure waiting room and from EGD
itself. After EGD, 72.2% of APs recommended having
an AP present during EGD while 16.7% recommended
against the presence of an AP during the procedure while
11.1% were undecided (see Table 2).
Statistical analysis demonstrated that patients under-
going EGD for the first time had higher state anxiety
than those who had previous endoscopy experience (p <
0.034). This was accomplished by comparing the state
anxiety X2 values. These were determined to be 2.86 for
patients who underwent EGD for the first time and 2.16
for patients who had undergone prior EGD. Further analy-
sis of state anxiety revealed that patients who underwent
EGD with an accompanying person tended (trend p <
0.06) to have a lessening of state anxiety as compared to
those who underwent EGD alone, with average state
anxiety scores of controls being 2.30 vs. 2.42 of the ex-
perimental group. This also brought about a trend to in-
creased patient satisfaction after the procedure, although
this was not found to be statistically significant. The
benefit of having an AP was greatest (and statistically
significant p < 0.05) for the subgroup of patients with the
highest initial state anxiety. The overall patient and phy-
sician experience was summarized in the artwork in the
accompanying Figures 1 and 2.
There were no statistically significan t differences not ed
in the change of heart rate, sweating, or blood pressure
between the two groups. Also, there was no reduction in
the dose of any of the sedatives or analgesics used amongst
the patients when allowed th e presence of an AP.
Allowing the presence of an accompanying person dur-
ing EGD came to be considered for research after many
patients and their family members requested this sponta-
neously, and was based on the commonly observed ob-
vious anxiety of many patients before EGD. After occa-
sionally acceding to requests for the presence of an ac-
companying person, some endoscopists found that there
was negligible if any interference in the procedure, al-
though it should be noted that other endoscopists may
feel uncomfortable with allowing the presence of an ac-
company i n g p erson during endosco py.
Patients with high anxiety prior to EGD appeared to
benefit from the presence of an AP during the procedure.
84% of experimental group patients and 72.2% of APs
recommended for having accompaniment of a significant
other during upper endoscopy (see Tables 1 and 2). The
most profound benefit was seen in patients with an ele-
vated pre-test anxiety who demonstrated a statistically
significant decrease (p < 0.05) in anxiety as compared to
the same patient category without an AP. Although the
optimal treatment for every patient’s emotional status
must be individualized, it appears that highly anxious
patients benefit the most from an AP during EGD. An-
other group of patients that may benefit from an AP dur-
ing EGD are those undergoing EGD for the first time. As
might reasonably have been expected, this group dis-
played statistically significant (p < 0.034) higher levels
of anxiety than those who had previously underwent
EGD. Patients and physicians alike expressed increased
satisfaction from EGD likely due to the anxiety reduction
most prominent in patients with high pre-procedural
anxiety (see Figures 1 and 2).
In another high-anxiety setting in which the presence
of APs was assessed was the emergency department. In
evaluating AP satisfaction in the high -anxiety emergency
department setting, 63.2% of APs to be very satisfied,
28.2% slightly satisfied, and the remainder of APs being
unsatisfied. It was also noted that these significant others
also served to highlight the feeling of isolation of the
patients in which they accompanied [11]. There, it was
Table 1. Did patients undergoing EGD recommend having a significant other present?
Patient desire for escort Number of patients-experim ental
group Percent (%)Number of patients-control
group Percent (%) Total Percent (%)
Yes 16 84.2 4 26.7 20 58.8
No 3 15.9 10 66.7 13 38.2
Undecided 0 0 1 6.7 1 2.9
Displayed in this chart are the recommendations of control and experimental group patients in regards to the presence of an AP during upper endoscopy. A key
observation is that 84% of experimental group patients recommend having a significant other (AP) prese nt during the procedure.
J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83 81
Table 2. Recommendations of significant others after being
present during EGD.
For/against accompaniment Frequency Percent (%)
For 13 72.2
Against 3 16.7
Undecided 2 11.1
Total 18 100.0
Listed in the table ar e the reco mmendatio ns of APs af ter EGD. Greater than
72% of APs advocated for accompaniment of a significant other during
Figure 1. Illustrates how high-anxiety states of pa-
tients may affect EGD. Not only do the changes
in heart rate and blood pressure affect the patient,
but they also have deleterious consequences on
the operating endoscopist that together may in-
crease the overall complication rate.
Figure 2. Conveys the potential benefits of
having an AP present during EGD. Due to the
APs influence, a now-calmer patient and a
more comfortable performing endoscopist may
result in reduced procedural and anesthesia-
related complications while increasing patient
demonstrated that a lower anxiety level of APs correlated
with increased satisfaction upon leaving the department
The concept of having one’s significant other present
has been applied to obstetric wards as well. While per-
sonal preference may play a role, local experi ence s h o w ed
that after several birthing centers allowed for accompa-
nying persons during delivery, increased patient demand
strongly encouraged allowing the presence of additional
people in the delivery room amongst staff who otherwise
would have preferred not to make such an allowance.
This includes an AP present during forms of birth in-
cluding assisted deliveries and Cesarean sections [13]. In
regards to OB-GYN practice, it was demonstrated by
Afaneh et al. that although a majority of patients (65%)
felt no need for an AP, a small but significant group of
patients requested accompaniment regardless of the gen-
der of the examiner. Therefore, patients should be of-
fered the option of having an AP with their opinion re-
spected and documented [14]. One can perceive addi-
tional settings and procedu res includ ing EGD that lead to
high-anxiety states in which persons might come to feel
entitled to have an accompanying person present.
In reducing patient stress and anxiety, it has been
thought that this may lead to a reduction in the amount of
anesthesia administered prior to and during EGD, thus
improving procedural safety. As sedatives are more lib-
erally administered in modern medicine, a much larger
sample study population is needed to correlate respective
sedative doses with their associated levels of anxiety. A
potential alternative to this study would be to include a
group of patients with an AP who would not receive any
anesthesia which would then be compared to the other
study groups. However, this would be a drastic change as
compared to administering a half-dose of midazolam and
then measuring whether this dose-reduction would lead
to equivalent patient satisfaction and anxiety reduction.
As the safety profile of the administered sedatives is
quite good [15], power analysis suggests that a very larg e
sample population is necessary to demonstrate potential
benefits. This study was designed more of a “proof of
concept” in that patients’ significant others decrease anx i-
ety instead of directly addressing the quantity of seda-
tives required to achieve equivalent results. Nevertheless,
the presence of an AP decreasing patient anxiety and
increasing procedural satisfaction are important areas of
interest in gastroenterological procedures. In the emerg-
ing era of emphasis placed on quality indicators, such
cost-effective improvements by a patient’s significant
other may be proven in larger follow-up studies to aug-
ment procedural efficiency and lessen EGD-related com-
The present results were similar compared to a study
by Shapiro and Tamir, who used non-validated qualita-
Copyright © 2013 SciRes. OPEN ACCESS
J. Lachter, B. E. Bluen / Open Journal of Gastroenterology 3 (2013) 78-83
tive comparisons of anxiety and fearfulness [16]. The
present study utilized th e Spielberger state and trait anxi-
ety scores as quantitative indices, which have been vali-
dated in Hebrew and are widely used as benchmarks,
were employed for a rigorous and generalizable assess-
ment of anxiety [2]. In addition, the biological parame-
ters of anxiety, heart rate blood pressure and sweating
were also assessed. Both genders were evaluated equally
as well as patients from diverse cultural backgrounds. As
the reduction in anxiety particularly in high-anxiety pa-
tients was demonstrated to be similar in principle to the
reduction in anxiety of having an AP present during a
birthing procedure it may be offered to selected indi-
viduals as a low-cost therapy that may reduce overall
anesthesia-related complications and strengthen patient
adherence for future beneficial procedures.
The potential drawbacks of allowing an AP, such as
taking phone calls or interfering with the procedure were
not seen. It has been subsequent experience that only
rarely must an endoscopist ask an AP to leave the room
due to circumstances such as AP discomfort or AP de-
flecting of attention from the patient.
This is a single center small sample size study, which
involves one cu lture of people. Only a much larger stud y
could be expected to show reduction of the major anes-
thesia-related side effects because they are uncommon.
However, the culture is very diverse, and these numbers,
while small already point to significant benefits which
accrue to centers which allow the presence of an AP.
Offering to allow an accompanying person to be present
during EGD tended to:
1) Reduce patient anxiety, especially for high-anxiety
patients and first-timers.
2) Increase patient and family satisfaction with the
endoscopy encounter.
The authors wish to acknowledge the contributions to this study of Dr.
Hadas Wiseman, Psychologist at Haifa University, Israel, and to Dov
Shperling Shemer, for the artwork which he drew and donated to ac-
company this article to tell its message in a pleasant, memorable, and
lighthearted way.
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