Part 2 of a series on end-of-life care
By Lynn Keegan, RN, PhD, HNC, FAAN
As discussed in part 1 of this series on end-of-life care, achieving a peaceful and comfortable death for patients must be a priority.1 Complementary and alternative (CAM) therapies could help in this regard. Specific imagery scripts, ritual exercises, massage therapy, and guided imagery are examples of CAM therapies available to support this mission. A patient with terminal illness and pain could receive not only medication for pain control, but also could be offered therapies such as blending breaths and co-meditation, healing touch, acupuncture/acupressure, or soothing aromatherapy. Toward the end of life (EOL), palliative care should generally increase in line with increasing symptoms and other problems.
Fortunately, there is increasing recognition of the importance of delivering high-quality symptomatic care and support near EOL.2 This article will examine the roles acupuncture and massage can play at this pivotal stage of life.
Acupuncture
Many practitioners and researchers recommend traditional Chinese medical therapies for the supportive care of cancer patients, and believe that the holistic approach of traditional Chinese medicine (TCM) may be integrated into conventional Western medicine to supplement the current biomedical model.3
Acupuncture use for cancer patients has been recommended by the American Cancer Society (ACS) for the treatment of cancer and treatment-related symptoms. Pain, nausea, breathlessness, vasomotor symptoms, and limb edema have all been found to respond to this treatment modality. In addition, the immunomodulatory effects of acupuncture, both via the release of pituitary beta-endorphin and ACTH, as well as the alleviation of patient stress through relief of symptoms, may be anti-carcinogenic.4
Studies support the belief that acupuncture is effective in pain relief in terminally ill patients. A French investigation in a pain-management unit examined the efficacy of auricular acupuncture in decreasing pain intensity in cancer patients.5 Treatment effectiveness was based on the absolute decrease in pain intensity measured two months after randomization of 90 patients using a visual analog scale (VAS). Pain intensity decreased by 36% at two months from baseline in the group receiving acupuncture; there was little change (2%) for patients receiving placebo (P < 0.0001).
A U.S. military hospital study of 123 patients with cancer or symptoms associated with cancer therapy offered acupuncture for potential palliation of their symptoms.6 A practice-outcome analysis was performed on patients receiving acupuncture therapy. Standard medical care was continued while patients were receiving acupuncture. Major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%), and nausea/loss of appetite (6%). Patients had a mean of five acupuncture visits (range 1-9). Most patients (60%) showed at least 30% improvement in their symptoms. About one-third of patients had no change in severity of symptoms.
Many men who undergo castration therapy for prostatic carcinoma have vasomotor symptoms that persist for years. Swedish researchers offered seven men with vasomotor symptoms due to castration therapy acupuncture treatment 30 minutes twice weekly for two weeks and once a week for 10 weeks.7 Effects on hot flashes were recorded in logbooks. Of the seven subjects, six completed at least 10 weeks of acupuncture therapy and all had a substantial decrease in the number of hot flashes (average 70% after 10 weeks). At three months after the last treatment, the number of hot flashes was 50% lower than before therapy.
British researchers explored the safety and efficacy of acupuncture in 20 patients who were breathless at rest and whose breathlessness was directly related to primary or secondary malignancy.8 Sternal and LI4 acupuncture points were used. Outcome measures included pulse, respiratory rate, oxygen saturation, and patient-rated VAS of breathlessness, pain, anxiety, and relaxation. At each time point the mean values of the variables were calculated and compared to their pretreatment levels. Fourteen patients (70%) reported marked symptomatic benefit from treatment; there were significant changes in VAS scores of breathlessness, relaxation, and anxiety at least up to six hours post-acupuncture (maximal response at 90 minutes). There was a significant reduction in respiratory rate, which was sustained for 90 minutes post-acupuncture (P < 0.02).
Massage
Massage is increasingly used to relieve symptoms in patients with cancer. Four American studies and two British studies document the effectiveness of massage therapy. The Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York conducted a trial with patients reporting symptom severity pre- and post-massage therapy using 0-10 rating scales of pain, fatigue, stress/anxiety, nausea, and depression.9 Changes in symptom scores and the modifying effects of patient status (inpatient or outpatient) and type of massage were analyzed. Over a three-year period, 1,290 patients were treated. Symptom scores were reduced by approximately 50%, even for patients reporting high baseline scores. Outpatients improved about 10% more than inpatients. Benefits persisted, with outpatients experiencing no return toward baseline scores throughout the 48-hour follow-up.
In a randomized, prospective, two-period, crossover intervention study, researchers tested the effects of therapeutic massage (MT) and healing touch (HT), in comparison to presence alone or standard care, in inducing relaxation and reducing symptoms in 230 subjects with cancer.10 MT and HT lowered blood pressure, respiratory rate (RR), and heart rate (HR). MT lowered anxiety and HT lowered fatigue, and both lowered total mood disturbance. Pain ratings were lower after MT and HT, with four-week nonsteroidal anti-inflammatory drug use less during MT. There were no effects on nausea. Presence reduced RR and HR but did not differ from standard care on any measure of pain, nausea, mood states, anxiety, or fatigue. The authors concluded that MT and HT are more effective than presence alone or standard care in reducing pain, mood disturbance, and fatigue in patients receiving cancer chemotherapy.
In Britain, aromatherapy massage is a commonly used complementary therapy, and is employed in cancer and palliative care largely to improve quality of life and reduce psychological distress. One systematic review investigated whether aromatherapy and/or massage decreases psychological morbidity, lessens symptom distress and/or improves the quality of life in patients with a diagnosis of cancer.11 Researchers searched all the primary databases for relevant articles of randomized controlled trials; controlled before and after studies; and interrupted time series studies of aromatherapy and/or massage for patients with cancer that measured changes in patient-reported levels of physical or psychological distress or quality of life using reliable and valid tools. The search strategy retrieved 1,322 references.
The most consistently found effect of massage or aromatherapy massage was on anxiety. Four trials (207 patients) measuring anxiety detected a reduction post-intervention, with benefits of 19-32% reported. Contradictory evidence exists as to any additional benefit on anxiety conferred by the addition of aromatherapy. The evidence for the impact of massage/aromatherapy on depression was variable. Of the three trials (120 patients) that assessed depression in cancer patients, only one found any significant improvements with therapy. Three studies (117 patients) found a reduction in pain following intervention, and two (71 patients) found a reduction in nausea. The conclusion was that massage and aromatherapy massage confer short-term benefits on psychological well-being, with the effect on anxiety supported by limited evidence. Effects on physical symptoms may also occur. Evidence is mixed as to whether aromatherapy enhances the effects of massage.
Another study compared the effects of four-week courses of aromatherapy massage and massage alone on physical and psychological symptoms in patients with advanced cancer.12 Forty-two patients were randomly allocated to receive weekly massages with lavender essential oil and an inert carrier oil (aromatherapy group), an inert carrier oil only (massage group), or no intervention. Outcome measures included a VAS of pain intensity, the Verran and Snyder-Halpern sleep scale, the Hospital Anxiety and Depression scale, and the Rotterdam Symptom Checklist. The investigators were unable to demonstrate any significant long-term benefits of aromatherapy or massage in terms of improving pain control, anxiety, or quality of life. However, sleep scores improved significantly in both the massage and the combined massage (aromatherapy and massage) groups. There also were statistically significant reductions in depression scores in the massage group. In this study of patients with advanced cancer, the addition of lavender essential oil did not appear to increase the beneficial effects of massage. The results suggest that patients with high levels of psychological distress respond best to massage therapy.
Thirty-six oncology inpatients participated in a follow-up pilot study investigating the effects of foot reflexology.13 Foot reflexology was found to have a positive immediate effect for patients with metastatic cancer who report pain, although there was no statistically significant effect at three hours after intervention or at 24 hours post-intervention.
A quasi-experimental nursing study examined the effects of therapeutic massage on perception of pain, subjective sleep quality, symptom distress, and anxiety in 41 patients in the oncology unit at a large urban medical center.14 Twenty participants received therapeutic massage and 21 received standard nursing care. The outcome variables were measured on admission and at the end of the first week with several psycho- logical instruments. Mean scores for pain, sleep quality, symptom distress, and anxiety improved from baseline for the subjects who received therapeutic massage; only anxiety improved from baseline for participants in the comparison group. Statistically significant responses were found for pain, symptom distress, and sleep. Sleep improved only slightly for the participants receiving massage, but it deteriorated significantly for those in the control group. The findings support the potential for massage as a therapeutic intervention for cancer patients receiving chemotherapy or radiation therapy.
Conclusion
While the majority of articles cited here address patients with cancer, relief of pain and anxiety is mandatory within any clinical scenario in which a patient suffers. The focus during end-of-life care should be equally spread over treatment, safety issues, and modalities that can enhance an individual’s quality of life. Health care professionals have an ethical and legal responsibility to be aware of, and knowledgeable about, any modality that might offer their patient relief from suffering, even if methodologically sound data are wanting.15 Despite the paucity of controlled trials, there are data to support the use of some CAM modalities in terminally ill patients.16
Recommendation
At end of life, uncontrolled pain is often a serious concern. For effective pain management, suitable pharmaceutical agents along with CAM therapies are indicated. In some instances, the CAM therapy alone may offer relief and/or a respite from distressing symptoms. Hypnosis, music, acupuncture, and massage are some of the CAM therapies that promote relaxation and relieve pain, and of these, acupuncture is the only "invasive" therapy. When used appropriately these therapies are safe and generally effective. A variety of symptoms such as pain, nausea, dyspnea, anxiety, or even loneliness should alert the health care provider to consider CAM therapies along with the traditional allopathic regime. Most mind/body therapies can be safely used in even the most earnest circumstances. There comes a time in EOL care when we can and should use all available therapies to make EOL a time of comfort and care.
Dr. Keegan is Director, Holistic Nursing Consultants, Port Angeles, WA.
References
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11. Fellowes D, et al. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Syst Rev 2004;(2):CD002287.
12. Soden K, et al. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med 2004;18:87-92.
13. Stephenson N, et al. The effect of foot reflexology on pain in patients with metastatic cancer. Appl Nurs Res 2003;16:284-286.
14. Smith MC, et al. Outcomes of therapeutic massage for hospitalized cancer patients. J Nurs Scholarsh 2002;34:257-262.
15. Sparber A. Complementary therapy in critical care settings: A review of surveys and implications for nurses. Crit Care Nurs Clin North Am 2003;15:305-312.
16. Pan CX, et al. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage 2000;20:374-387.
Keegan L. Complementary and alternative therapies and end-of-life care. Altern Med Alert 2005;8(3):32-35.
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