Of the countless painful decisions surrounding a loved one's end-of-life care, among the trickiest is how to provide physical comfort in a way that also provides a dignified ending.
"For end of life, the opioids are very important for pain management, but they do leave people very sedated," says researcher and physician Josephine Briggs, who heads the National Institutes of Health's National Center for Complementary and Alternative Medicine. "Some people are looking for adjuncts to help with that."
Increasingly, those adjuncts include acupuncture, massage and other complementary therapies.
"We're seeing increased interest in complementary approaches in hospice settings," Briggs says, "and recognition by patients and caregivers that some of these approaches may be helpful in this stage of life."
A comprehensive survey by the Centers for Disease Control and Prevention in 2007 found that 41 percent of hospice care centers offered complementary and alternative therapies (CAT), had a CAT provider on staff or under contract, or both.
"It's certainly been gaining momentum in the past four of five years," says Dr. Porter Storey, executive vice president of the American Academy of Hospice and Palliative Medicine.
"There are patients who are not getting adequate relief from usual medications," Storey says. "Sometimes it's people who don't tolerate medicine well or get bad side effects and still have the pain or nausea. And sometimes it's people who value mental clarity so much they would rather have the symptoms than any kind of drowsiness.
"We try really hard to make sure whatever we're doing matches the patient's goals and desires and is most likely to provide the most relief with the fewest side effects."
Acupuncture proves particularly helpful with nausea, Briggs says.
"The affects of acupuncture on nausea are quite well-documented," she says. "If you've experienced something that made you sick to your stomach and you have smells or a place that reminds you of that experience, the nausea feeling can come back. Nausea of expectation is a real phenomenon, so some people are left with nausea or vomiting from chemotherapy or even (anticipating) chemotherapy, and there is very strong, very rigorous data showing that acupuncture tends to break that cycle."
Acupuncture may also help with proper digestion, a process with which morphine and other pain medications can interfere.
Grainne McKeown, a licensed acupuncture therapist, worked in a Nepalese clinic before opening her own practice in Chicago. She says she used acupuncture to help patients relieve constipation and vomiting.
"I treated a woman who was in the late stages of HIV who had so much vomiting and nausea and kept getting skinnier and skinnier," McKeown says. "They would give her morphine for her pain, which made her constipated. I was able to give her acupuncture, and she was able to have regular bowel movements and help her digestion, which makes a huge difference at that stage of life where the whole goal is just to keep someone comfortable."
With a little training, some alternative therapies can be administered by a patient's family members,
"Something that's very helpful in many families is to incorporate some massage therapies," Briggs says. "A massage therapist can help the family members learn some skills that involve touch that can help achieve relaxation and make the dying patient more comfortable."
She emphasizes the need for narcotics, particularly for pain management. ("I would be very worried about suggesting people should avoid proper pain management — the opioids, morphine, fentanyl.") But she encourages families to ask their physicians about incorporating alternative therapies to work alongside conventional approaches.
"I think turning to your hospice and asking for information about massage, music therapy and guided imagery is important and can really help caregivers as well as patients," Briggs says.
Guided imagery is a system of directing your thoughts and imagination toward a state of relaxation or focus. WebMD cites a common example: "Imagine an orange or a lemon in great detail — the smell, the color, the texture of the peel. Continue to imagine the smell of the lemon, and then see yourself taking a bite of the lemon and feel the juice squirting into your mouth. Many people salivate when they do this. This exercise demonstrates how your body can respond to what you are imagining."
"One of the good things about many of the complementary approaches is they're generally so benign that people can use them at any time, and they're one of the few things we can recommend to family members who are not under our care," Storey says. "Oftentimes the wife of a patient who is anxious or distressed can download some guided imagery files or listen to some meditative music and actually feel a lot better."
The availability of complementary and alternative approaches varies widely from facility to facility and region to region, and hospices are more likely to offer the therapies than hospitals.
A 2011 survey conducted by the American Hospital Association found that 42 percent of U.S. hospitals offer one or more CAT services, including acupuncture, homeopathy, massage therapy and herbal medicine. That statistic is up from 37 percent of hospitals in 2007.
But if you're caring for a patient at a hospital without CAT staffing on site, your options are likely slim.
"Hospitals tightly control who practices there with very restrictive credentialing requirements," Storey says. "This may limit their liability for mishaps, but it severely restricts access to complementary and alternative medicine therapies. Even if you wanted to pay privately for a complementary or alternative therapy you would likely not be able to get it in a (restrictive) hospital."
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"Hospitals can get narrowly focused on surgery and intensive care, as they should," he says. "But it's good for families to know what's available and ask for additional help, particularly in areas where we know alternative therapies are most effective."
And if families don't get anywhere in the hospital, they can consult with their dying loved one's doctor about a possible transition to hospice.
The mind-body connection, after all, is a critical one to honor at the end of life.
"There's so much anxiety, fear of what's coming next, possibly regrets about your life," McKeown says. "Anything that helps your body, not just for one hour, but to keep your mind and body in the present and accept what's to come can really help people face those final days with more strength and peace and calm."