Archive for November, 2009

Recently I had the good fortune to attend a workshop called “Circle of Life: Hospice and Palliative Massage,” taught by Valerie Hartman. Valerie is both a nurse and a massage therapist, and she runs a complementary therapy program at a hospice in Philadelphia.

Although we covered many issues relating to hospice massage, I left the workshop with a deeper understanding of the role massage therapy can play within the interdisciplinary framework of hospice care.

Hospice practice, coupled with government regulations, require that patient care be provided by an interdisciplinary team of health care professionals. This team is comprised of physicians, nurses, health aides, social workers, and chaplains. The idea is to care for the patient (and family) on not just a medical level, but a psychological and spiritual level as well.

Introducing massage therapy into this context provides an opportunity to weave all three of these objectives together into one form of clinical practice. When we enter a patient’s room, we are working to relieve the fear-based component of his/her symptoms and create a sense of peace and well-being. We treat our patients on the medical, psychological, and spiritual levels at the same time.

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Watching people die, day after day, makes for a challenging job. When patients die of age-related conditions and I am able to use massage therapy to help make them comfortable, the job does not seem as hard. But working with young patients who have devastating illnesses can be overwhelming.

Most people who work in this field share a basic personality characteristic, in that we are all, at heart, caregivers. Working alongside others who are driven by the need to care for people inspires me on a daily basis. Sometimes that need can become unhealthy. This is when boundary maintenance counts the most.

Joe was a patient in his mid-30s with an aggressive cancer. His wife was pregnant with their second child. When I met him he was still conscious, but very weak, and spent his time in the hospital surrounded by family and friends. He was clearly going to die soon.

I entered the room and introduced myself, explaining that I was offering massages for family members. At first, no one wanted to take me up on it. Finally Matt, Joe’s brother-in-law, agreed. I brought him out of the room to a semi-private area and invited him to get into the massage chair. During the session he shared a little bit about his heartbreak at seeing Joe so sick. I felt my heart breaking along with his.

Matt helped me convince Joe’s mom and sister to come and get massages. His mom was stoic but his sister sobbed the entire time. As someone who has one, precious younger brother, I found myself identifying with her. I felt a deep terror creeping into me at the idea of facing the loss of my brother. At that point my boundaries began to strain and crack.

I went back into the room to offer Joe his own massage. At first he said he wasn’t up to it, because he thought it meant having to reposition himself and he was too tired to move. I explained that he could stay right where he was and I offered to just massage his feet. He agreed, and I got to work.

Throughout the session, Joe was watching TV and playing with his PDA. I’ve experienced this before with young patients who are dying: the need to stay plugged in and connected seems to be a way to cling to life. His mother came in and I showed her what I was doing. She told me that she also massaged Joe’s legs, and I encouraged her to do so whenever she could.

When I finished, I thanked Joe and his mom, and went about seeing a few other patients. I was getting ready to leave for the day when Joe’s wife arrived. I heard the nurse ask her if she wanted a massage, and she said she really needed it, but had to eat something first. I realized that I might end up having to stay late, and wrestled with my boundaries once more.

How, I wondered, could I take care of this woman and also take care of myself? I had an important meeting that afternoon and I couldn’t be late. I gave her 15 minutes, then went to check in. Although my instincts were calling me to put my own needs aside, I forced myself to let her know that I wanted to work with her but I had to leave soon. I was able to work with her and still leave with enough time to get to my meeting.

Most of the time I visit this inpatient hospice unit once a week, on Wednesdays. That week, however, I had scheduled time there on Friday to train one of my volunteer massage therapists. Because I had been so emotionally involved with his case the last time I was there, the first person I went to see was Joe.

Once again, he only wanted his legs and feet massaged. He told me that his mom and wife had also been massaging his feet and legs. He was still weak, and seemed more tired and anxious. His mother later told me that she had been up with him all night as he processed the information that his death was imminent. He was scared, she said, and she had tried to comfort him. I tried to imagine what that must have been like, and again my boundaries began to give way.

When I got home from work that night, I broke down in tears over a petty disagreement with my husband. I needed to show him, and to show myself, that this case had gotten to me, that the cumulative effect of so much death and dying sometimes overwhelmed me. It was the first time in nearly a year on the job that I had ever cried about it.

During the weekend I found myself thinking of Joe and his family from time to time, as much as I tried to let it go. When Monday came along I thought I might end up stopping by the inpatient unit to see them after spending the morning in the office. As the day went on, I tried to get clarity about the situation. Joe was being cared for by nurses, doctors, social workers, family, and friends. His mother and wife were massaging him. Did this family really need me, or did I need them? Was I planning to make a special trip because I needed to feel important, to prove my dedication to my work?

I confessed my ambivalence about the plan to my husband and told him I thought I might be setting bad boundaries. He said he agreed, and reminded me that I should try to treat all patients the same. In the end, I chose to stay at the office and finish the important program development work that I had set out to do that day.

I know that some cases will affect me more than others. I can’t control that. I can only observe my emotions, find a way to let them out, and try not to lose myself in the process.

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The International Journal of Behavioral Medicine recently published a study by Shamini Jain and Paul J. Mills that reviewed 88 clinical studies of energetic healing techniques such as Reiki, Therapeutic Touch, and laying on of hands. “Biofield therapies” is the preferred terminology used by the National Center for Complementary and Alternative Medicine, a branch of the National Institutes of Health.

As a massage therapist who values scientific inquiry, I found this article helpful. I have not studied any biofield therapy modalities and I am somewhat skeptical of them. I am also aware, in my clinical practice, of subtle forces that cannot be quantified in simple physiological terms. This means I have felt something that might be called “energy” in the course of performing massage therapy.

Jain and Mills have found strong evidence that biofield therapies can reduce pain for certain patients, and moderate evidence for reducing pain in others. They found moderate evidence for decreasing negative behaviors in dementia patients and moderate evidence for decreasing anxiety for people who are hospitalized. In other areas, the evidence was less clear, but the main conclusion of the article is that this is an area that merits further study.

I’ve come to the same basic conclusion myself: that it would probably benefit me to study at least one of these modalities so that I can make a more informed judgment about their usefulness.

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