With the aging of American “baby boomers,” our society has a critical need to develop more effective care for supporting people with chronic health conditions and especially at the end of life. As part of that effort, massage therapists need to be well trained to deal with the special needs of the frail elderly. For more on this see the CE course “Serving Older Adults,” by Ann Catlin, on page 111 of this issue.
One consequence of a nation with an increasingly large segment of frail elders will be a greater call for palliative care, which focuses on services that are oriented toward “caring” rather than “curing.”
One element of palliative care needs to be focused on making the end-of-life experience more comfortable for people who are dying, as well as for their families. Yet, because we live in a death-denying culture, many health professionals, as well as the general public, tend to regard death as a failure of the medical system rather than a natural stage of life. This denial is made easier by the fact that most people are completely removed from the death process, since their loved ones die in hospitals and nursing facilities rather than at home.
Despite our national tendency to avoid thinking of or planning for end-of-life care, the hospice movement has gained steady support over the last three decades since massage at end of life the first American hospice, Connecticut Hospice Inc., initiated in-home services in 1974. Since then, there has been steady growth of demand for these services, which are covered by Medicare as well as Medicaid in 46 states and the District of Columbia. The services covered by Medicare include medical care (i.e., services provided by doctors, nurses, physical and occupational, social work services) as well as medications and equipment needs (e.g., wheel chairs, catheters).
Since massage is not yet covered by Medicare, it is not generally available as part of hospice or other end-of-life care in hospitals. However, an increasing number of entities are developing programs to provide palliative care that includes massage to people who are chronically ill or dying. For example, the Planetree Alliance, which was founded in 1978 as a nonprofit organization of hospitals and other health care entities, focuses on providing patient-oriented services that include a 10-point list of components that combine conventional medical services with enhanced human interaction, architectural design, nutrition and forms of touch therapy.
Hospitals that are part of the Planetree Alliance—currently 100 in this country—must commit substantial financial resources ($20,000 to $30,000) and agree to operate within the Planetree guidelines.1
The Metta Institute is another entity that gives attention to improving the palliative care given to people at the end of life. The institute established its End-of-Life Care Practitioner Program in 2002, which is a year-long training to develop “midwives to the dying” and to create a national network of educators and advocates for people facing life-threatening illness. Metta also provides workshops, presentations and retreats to help individuals and institutions become more equipped to provide care to the dying.2
Touch and Energy Work at End of Life
All efforts to deal compassionately with people facing death must be sensitive to their physical, emotional and spiritual needs. Massage and energy work can bring relaxation, comfort and connection at a time when people are most likely to feel isolated and fearful. In addition to conventional massage, three other modalities—compassionate touch, reiki, and therapeutic touch—are increasingly being used to support people at the end of life.
Compassionate touch, which was developed by Dawn Nelson, is a modality that combines focused attention, intentional touch and sensitive massage with specialized communication skills.3 Reiki and healing touch are two energy-balancing approaches that seek to provide relaxation and comfort.4 Although little or no formal research currently exists on the effectiveness of these modalities at supporting people at the end of life, informal conversations with several clinicians working with people at end of life suggest that each of these modalities may contribute to greater relaxation, as well as physical and emotional comfort for people and their families at the end of life.
These three modalities have particular advantages in supporting people approaching death because they can be given to fully clothed recipients in varying levels of health who are in a variety of physical positions and can be taught relatively easily to caregivers.
Research on Massage at End of Life
To date, limited research is available about the use of massage at the end of life. In 2006, W. E. Lafferty et al. conducted a systematic review of the use of massage and mind-body modalities in improving the quality of life at the end of life.5 Of the 27 clinical trials reviewed, 26 showed significant improvements in a variety of symptoms such as emotional distress, nausea, comfort, anxiety and pain. The authors concluded that massage and mind-body modalities appear to offer support at the end of life. However, due to the substantial variation in methodologies used among the studies, more research is needed to assess the significance of the review findings and determine the value of these modalities for supporting people at the end of life.
Two small studies offer further insights into the potential use of massage at the end of life. In the first one, a group of researchers (A. Williams et al.) at Yale Prevention Research Center conducted a pilot randomized control trial in 2006 to assess the independent and interactive effects of Metta meditation and massage on quality of life in people with late-stage acquired immunodeficiency syndrome (AIDS).6 Fifty-eight patients were divided randomly into groups that used meditation, massage, combined meditation and massage or standard care. During the month-long intervention, the meditation group used a tape to lead themselves in meditation and the massage group were given 30-minute massages once per day for five days a week.
Although massage and meditation were independently associated with increased quality of care scores, the combination of meditation and massage had the greatest increase in quality of life measures. This raises questions about the relative value of using individual versus combined modalities for helping people at the end of life. The study clearly needs to be repeated with a larger sample of people and could also be explored with people dealing with other late-stage and life-threatening conditions.
The second small study worthy of mention was conducted by S. S. Meek in 1993 and used a quasi-experimental design, where the participants were not randomly selected, to assess the impact of slow stroke back massage (SSBM) on systolic and diastolic blood pressure, heart rate and skin temperature on 30 adults from two hospice home-care programs.7 SSBM is a slow, rhythmic stroking with the hands at a rate of 60 strokes a minute on two-inch wide areas on both sides of the spinous processes from the crown of the head to the sacral area, lasting for three minutes. The study results showed a significant decrease in the subjects’ systolic and diastolic blood pressure and an increase in their skin temperature. These changes lasted for at least a five-minute follow-up period, and were consistent with the conclusion that the subjects were more relaxed after receiving SSBM than they had been before it.
These study results suggest the need for further research using a larger sample of adults in hospice care and a longer follow-up period for assessing the impact of SSBM. In addition, we need to know if other types of massage that involve more time, larger areas of the body and/or in combination with other modalities, such as compassionate touch, meditation, reiki or therapeutic touch have a similar impact on blood pressure and skin temperature and on other measures of interest including quality of life, anxiety, and depression.
Although there is limited research at this time to substantiate the benefits of massage for helping people at the end of life, the research that does exist suggests potential value of massage for bringing comfort to people at this critical time of transition. Given the demographics of our population, all massage therapists should have some understanding of effective strategies for working with elderly and end-of-life clients. While we wait for more research on caring for the dying, we need to rely on massage therapists working with this population to provide us with valuable case reports about how to best use massage, alone and in combination with other modalities, for supporting people at the end of life.
- For more information about Planetree, visit www.planetree.com.
- See www.mettainstitute.org for more on the training program.
- See www.compassionate-touch.org for more information.
- For more information about reiki see: Piltch, C. “At ease: the restorative power of reiki can improve your health and practice.” mtj 2008;47(1):64-74. For more on therapeutic touch, visit www.therapeutictouch.org.
- Lafferty WE, Downey L, McCarty RL, et al. “Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation.” Complement Ther Med. 2006 Jun;14(2):100-12.
- Williams A, Selwyn PA, Liberti L, et al. "A randomized controlled trial of meditation and massage effects on quality of life in people with late-stage disease: a pilot study." J Palliat Med. 2005 Oct;8(5):939-952.
- Meek, SS. “Effects of slow stroke back massage on relaxation in hospice clients.” Image J Nurs. Sch. 1993;25(1):17-21.