Finding a place for alternative therapies
Providers should understand, provide them
Holistic, alternative, unconventional, or complementary therapies by whatever name, the varieties of approaches to personal health and self-healing outside of conventional Western medicine are a huge and growing trend in the American health care system. As many as a third of health care consumers turn to these alternatives each year.
No longer confined to the frontiers of the counterculture, holistic alternatives are now practiced coast to coast. HIV patients, who until recently stood to derive little lasting benefit from medical care, have opened the door to a wide range of alternatives. Meanwhile, in Florida, the elderly are becoming increasingly sophisticated and vocal about complementary therapies.
Hospice, with its origins as consumer-driven care, will be called on to respond to the growing public interest in this area. For some providers, this will require self-education, nonjudgmental inquiries into patient preferences, and creative ways to harmonize hospice interventions with the alternative therapies many patients are already using. Others may wish to join the holistic movement, offering their patients a wide range of complementary therapies. This might be done with professional volunteers, professional hospice staff who have additional skills in complementary therapies, or even certified alternative practitioners who are paid for their contributions to the hospice menu of comfort-oriented care.
Complementary therapies in hospice run the gamut from medically recognized disciplines such as art, music, and recreation therapies, which have small but acknowledged roles in conventional care, to varieties of nontraditional approaches outside of the medical system although this distinction is fading. The latter include various kinds of body work, massage, and therapeutic touch; disciplines incorporated from other cultures, such as Chinese acupuncture; and other nonconventional fields, such as naturopathy, homeopathy, energy field work, biofeedback, herbal medicine, and even aroma therapy.
"The biggest problem is to define what you mean by alternative," says Susan Mann, RN, CRNH, vice president for medical and nursing services at Hospice Inc. in Wichita, KS, and president of the Hospice Nurses Association based in Pittsburgh. "It’s a coming thing. We have people on our own staff who are taking some of these things," she says.
The Association of Kansas Hospices (AKH) last year held its annual meeting at the Center for Human Functioning International, a holistic institute in Wichita, exposing the state’s hospices to a variety of alternative approaches. "I think hospice people do want to offer any kind of therapy that is truly helpful to their patients," says AKH executive director Donna Bales. "Hospices have always been willing to offer treatment outside of the mainstream."
Explore the options
"There are lots of different [ideas being tried]," adds Lisa Johnson, RN, CRNH, office director for Hospice of the Bluegrass in Lexington, KY. "We have practitioners on staff, including myself, and we will offer those therapies as part of hospice care," explains Johnson, who practices therapeutic touch. "I think we have a pretty liberal broad view working in hospice more toward healing and wholeness than just scientific medicine. Alternative therapies, as I understand them, are also about healing not curing. What we do in hospice is to help people become whole the best they can be in their situation. I think hospice is also about respecting people’s personal preferences," she says.
Emil Zuberbueler, BS, a registered massage therapist and administrative specialist with Family Hospice in Dallas, leads the Allied Therapies Section of the Arlington, VA-based National Hospice Organization (NHO) Council of Hospice Professionals. This section currently has 55 members from diverse backgrounds and disciplines. Five of them will be part of a group presentation on complementary therapies at NHO’s Annual Meeting in Atlanta in October, highlighting massage, art, music, occupational, and recreational therapies.
"Medicare doesn’t reimburse for those therapies separately, and a lot of hospices aren’t willing to go into their per diem to pay for them. That’s what we’re working on greater recognition for the allied therapies," says Zuberbueler, who began as a volunteer massage therapist with Family Hospice. Later, a line item for "therapy" in the hospice’s budget paid his salary as a massage therapist, although when that line item was cut from the budget, he became an administrative specialist for the agency instead.
"When I first started in massage, it was the first year that Texas had a massage therapy law. When you said massage,’ everybody giggled. Now most people say, Right here. I need a massage right here,’" he says. "Attitudes have shifted tremendously even in Texas, which is pretty conservative. The same thing is happening in hospice. More and more, the public is demanding it."
Alternative therapies more accepted
Meanwhile, insurance companies are paying more attention to alternative therapies, while more therapy training schools are accredited and more of the alternative disciplines are being recognized through certification or state licensing standards. Research has been slow in catching up, but it is no longer accurate to say that the alternatives have not been scientifically studied as a Medline medical literature search will quickly demonstrate. A federal Office of Alternative Medicine has also been established, and a number of medical journals are devoted to alternative and holistic therapies.
"It’s a way of life here in Santa Cruz," says JoAnn Siemsen, MPA, executive director of Hospice Caring Project of Santa Cruz County in Aptos, CA. "We have challenged ourselves to be comfortable in all arenas. We mostly see patients who are doing something of everything. We’ve tried to learn about local physicians who are open to this approach for their patients. We also bring in practitioners to support our staff with seated massages, and we have volunteers who may do some of these things. But we haven’t directly recruited massage therapists on our staff," Siemsen says.
"We also look at credentials in any area, and we have a list of referrals [to various modalities], in case patients ask. We look at pain management very holistically as well," drawing on a variety of auxiliary pain therapies. "At the same time, our agency’s practice is still pretty conservative because we’re mostly taking care of older people," she says.
"Doctors are being told that people want these [options]. Medicine is coming to realize it had better put resources into what people want," says David E. Weissman, MD, director of the Palliative Care Program at the Medical College of Wisconsin in Milwaukee and a hospice medical director. "Does American medicine think it’s worthwhile? Well, there have been no controlled clinical trials on most of this stuff. Do individual patients find benefit? Absolutely! Should we pay for them? I’m not so sure, unless hospice personnel feel it’s an important adjunct. I refer my patients for acupuncture. My nurse does therapeutic touch. I say great go for it," Weissman says.
How can hospices get involved?
The growing focus on alternative therapies raises a number of important issues for hospices. First of all, they will be challenged to respect and support patients’ choices for modalities that may seem unscientific as long as these do not appear to be harming the patient. Being able to make such distinctions requires self-education by the hospice team, both from reviewing the literature and investigating modalities firsthand. Cross-cultural issues relating to the use of folk or traditional remedies also require education.
"There are a variety of beliefs about what’s helpful," says Jane Lesher, RN, MSN, CRNH, corporate director of clinical services for Hospice Associates of America and Heart of America Hospice in Kansas City, MO. "I preach the Star Trek prime directive not imposing our beliefs or values on patients and families."
Hospices need to practice a nonjudgmental stance if they hope to encourage patients to tell them which alternative therapies are being pursued. This information is vital if the team is to meld its interventions with those alternatives. It may be helpful for team planning to draw in community alternative practitioners, to make them aware of what the hospice team is doing, and to encourage them to share their observations, even checking the qualifications of holistic therapists although that will also raise risk management issues for the hospice.
The next question is what the hospice is willing to cover out of its per diem. "The rub for us is: Are we going to pay for it?" Mann says. "We are a medical service and physician-directed," she explains, adding that coverage decisions should not be based on cost but instead on whether the service is viewed as part of the plan of care.
"At the same time, there is a need for hospice to address the issue: Is this more of a psychosocial need for the patient to continue seeking a cure? The question goes back to what symptom are we trying to relieve with this therapy?" It would make sense for the hospice to cover acupuncture, for example, since that has recognized value for pain relief, Mann says. Recent Operation Restore Trust audits of hospices in California suggest that some regulators may want to make hospice financially responsible for any therapies deemed appropriate, necessary, or likely to contribute to the patient’s comfort.
"We need to be sure that we’re doing our jobs as hospice providers and respecting the patient’s right to choose. It can be a delicate balance," Zuberbueler concludes. "It’s not our place to say what they can or can’t do but it is our responsibility to know about it and to do what we can to monitor and support it. There is growing awareness in this area, but we’ve still got a long way to go for hospice people to know that this stuff is available, not off the wall, not voodoo."
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