Complementary and AlternativeMedicine in Palliative Care

Karen Washburn, MSW ACSWDirector of QLife/Palliative Care

Lee Memorial Health System

October 14, 2011

Objectives

Understand the medical evidenceregarding CAMUnderstand the role of CAM inpalliative careDevelop an understanding of thepotential for CAM in the future ofpalliative careExperience relaxation/guided imagery

WHAT is CAM?

Alternative Therapythe term used to describe any medicaltreatment or intervention that has not beensufficiently scientifically documented oridentified as safe and effective for a specificcondition.Alternative therapy encompasses a variety ofdisciplines including acupuncture, guidedimagery, chiropractic treatment, yoga,hypnosis, biofeedback, aromatherapy,relaxation, herbal remedies, massage andmany others.

WHAT is CAM?

CAM – Complementary andalternative medicine

Defining CAM is difficult, because the field is very broadand constantly changing.National Center for Complementary and AlternativeMedicine, National Institutes of Health(http://nccam.nih.gov) defines CAM as a group of diversemedical and health care systems, practices, and productsthat are not generally considered part of conventionalmedicine as practiced by holders of M.D. (medicaldoctor) or D.O. (doctor of osteopathy) degrees and bytheir allied health professionals.The boundaries between CAM and conventionalmedicine are not absolute, and specific CAM practicesmay, over time, become widely accepted.

WHAT is CAM?

Integrative MedicineMedical care that combines the verybest scientific medicine with evidence-based complementary therapiesIt combines conventional Westernmedicine with alternative orcomplementary treatments, such asherbal medicine, acupuncture, massage,biofeedback, yoga, and stress reductiontechniques -- all in the effort to treat thewhole person.

Why CAM?

1) patient dissatisfaction withconventional medical care2) a need for personal control3) philosophical congruence

Negotiating the Alternatives: How and Why People useAlternative Medicine.

Bonafede M, Chin NP; AcademyHealth. Abstr AcademyHealth Meet.2004; 21: abstract no. 1080. University of Rochester, School ofMedicine and Dentistry, Community and Preventive Medicine, Box644, 601 Elmwood Avenue, Rochester, NY 14642 Tel. (585) 273-2617 Fax

Who uses CAM?

Who uses CAM?

Who uses CAM?

Who uses CAM?

What is being used

What is being used

“The market for alternative medicine isvast and growing, ... This trend mustbe guided by scientific inquiry, clinicaljudgment, regulatory authority andshared decision-making.”David Eisenberg

Associate Professor of Medicine David M. Eisenberg is the Director of theDivision for Research and Education in Complementary and IntegrativeMedical Therapies and the Osher Institute at Harvard Medical School.

History

"Unconventional Medicine in the United States: Prevalence,Costs, and Patterns of Use” Eisenberg et al. NEJM Jan1993

The article contributed significantly to the recent explosion ofinterest in "alternative medicine" in the United States.The paper reports a telephone poll of 1539 people on their useof "unconventional" methods on the previous year.This has become one of the most frequently cited articles in thealternative medical literature

1993 NEJM report, the “Dietary Supplement Health andEducation Act (DSHEA)” freed the health food industry frommuch of the regulatory oversight of the FDABill Moyers' PBS series "Healing and the Mind," 1993

Techniques

Mind-Body TherapiesRelaxation/imagerySupportive group therapyAcupuncture/TENSChiropractic Treatment and MassageTherapeutic Touch and Reiki HealingNutritional SupplementsHerbal Remedies

“We found there were people doingacupuncture, meditation, naturopathyand other forms of alternative orcomplementary medicine ... but itwas being done in a disorganizedway.”

Albert Einstein

The Evidence

In 2000, The efficacy of a CAM modality wasevaluated in 21 studies of symptomatic adultpatients with incurable conditions

Acupuncture, TENS, supportive group therapy, self-hypnosis, and massage therapy may provide pain reliefin cancer pain or in dying patients.Relaxation/imagery can improve oral mucositis pain.Patients with severe chronic obstructive pulmonarydisease may benefit from the use of acupuncture,acupressure, and muscle relaxation with breathingretraining to relieve dyspnea.

“Complementary and alternative medicine in themanagement of pain, dyspnea, and nausea and vomitingnear the end of life. A systematic review.”

J Pain Symptom Manage. 2000 Nov;20(5):374-87

The Evidence

In 2006, Eighteen trials wereidentified with a total of 1,499 patients

Evaluating CAM interventions for cancerpainHypnosis, imagery, support groups,acupuncture, and healing touch seempromising, particularly in the short term

“Efficacy of complementary and alternative medicinetherapies in relieving cancer pain: a systematic review.”

J Clin Oncol. 2006 Dec 1;24(34):5457-64.

The Evidence

In 2008, Twenty-seven randomized controlled clinicaltrials of acupuncture were found that reported onconditions common to the hospice and palliative caresetting

dyspnea, nausea and vomiting, pain23 reported statistically significant results favoringacupuncture use for the conditions investigated.Acupuncture is safe and clinically cost-effective formanagement of common symptoms in palliative care andhospice patients.Acupuncture has potential as adjunctive care in palliativeand end-of-life care, and the evidence warrants itsinclusion in reimbursed palliative and end-of-life care inthe United States.

“Acupuncture is underutilized in hospice and palliative medicine”Am J Hosp Palliat Care. 2008 Aug-Sep;25(4):298-308. Epub 2008 Jun 6

Conclusions

Acupuncture, relaxation, massage, Hypnosis,imagery, support groups, acupuncture, andhealing touch have evidenceAcupuncture, TENS, supportive group therapy,self-hypnosis, and massage therapy mayprovide pain relief in cancer pain or in dyingpatients.Relaxation/imagery can improve oral mucositispain.Patients with severe chronic obstructivepulmonary disease may benefit from the use ofacupuncture, acupressure, and musclerelaxation with breathing retraining to relievedyspnea

Cultural influencescontributing to growth

Study of 1,000 Mexican Americansliving in Texas found approximately45% of them had used CAM(Martinez, 2009)82% of 153 Chinese Americanpatients accessing mental healthservices at community health centersin NYC reported current use ofcomplementary therapies (Fang andSchinke, 2007)Caribbean Island influence

Practice Issues

Know your community

Patient Assessment

Scope of Practice

Self-Care

Practitioner – heal thy self