JOHN DIXON ACUPUNCTURE

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Acupuncture in Palliative Care

Acupuncture and Complementary Therapies in Palliative Hospice Care 

A major part of complementary therapies in the UK is in hospices and providing palliative care. Complementary therapies encompass many kinds of therapies such as aromatherapy, reflexology, holistic massage and many others. Among these therapies, the practice of acupuncture is becoming increasingly popular in hospice care and in hospitals in the NHS.

Patients in hospice care may suffer from a variety of health conditions, but by far the most common conditions tend to be Chronic Obstructive Pulmonary Disease (COPD), Multiple Sclerosis (MS) and Cancer. Of which, cancer is the most predominant. Patients dying from cancer experience heavy symptom burden – in particular the physiological and psychological effects of pain, which at times can be severe.

Other Symptoms

Other common problems that people are affected by in palliative care are muscular skeletal pain, internal pain, breathing problems, nausea, oedema, vomiting, stress and anxiety. Family members and carers also suffer from stress, anxiety, grief and muscular pain especially if they have to lift the patient often. Stress and anxiety can also lead to sleeping problems, fatigue and depression.

Complementary therapies can help people deal with all these problems and I have treated many patients and carers for these problems. This is important because it takes the strain off other medical staff – doctors and nurses and it means less suffering for the patients and their carers, which in turn creates better wellbeing.

Who Definition of Palliative Care

For anyone working in palliative care, it is useful to know the World Health Organisation’s definition of Palliative Care:

 “Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”. (WHO)

The World Health Organisation (WHO) expands on this definition of what palliative care should encompass. In particular, palliative care should:

  • Provide relief from pain and other distressing symptoms.
  • Integrate the psychological and spiritual aspects of patient care.
  • Offer a support system to help the family cope during the patient’s illness and in their own bereavement.
  • Enhance quality of life.

Physical, Psychosocial & Spiritual,

According to this definition, one of the most important objectives of palliative care is in improving the quality of life and also the relief of suffering and pain – measure that can be achieved with medications. However, from this definition it is clear that pallitaiv care encompasses more than physical needs. It encompasses psychosocial and spiritual.

It is my experience that acupuncture and complementary therapies can help satisfy these objectives, especially the aim to “provide relief from pain and other distressing symptoms”. To back this up, clinical research and studies have been carried out which have shown the benefits of acupuncture in hospice care and cancer treatment especially for providing relief from pain and other distressing symptoms.

The Hospice Environment

Hospitals have a conveyer belt type operation. A patient gets a diagnosis and then is moved from one section to another, seeing one consultant than another. Undergoing treatment, tests, more treatment more tests. It is natural to feel a cog in a machine. Many hospitals run more like bureaucratic organisations than places of healing. Hospitals are in the business of cure (link). They want to fix you. And as long as they feel they have a chance, you will keep you in the system.

However, if the moment comes when a disease process is too advanced, terminal or incurable, than they may pass you on. A referral to a hospice may come. Not surprisingly, many people dont want a referral to a hosice. May people still hope they will recover and so a hospice referral is hard to deal with at first.

Misconceptions about hospices

Aside from the fact that we are all going to die… sometime. When considering hospices, there is a misconception that patients in hospices are in an immediate terminal condition. In the U.K. this is not true. People may be referred to hospices to recover after having operations or undergoing treatments but are then deemed to be incurable (with conventional medicine). The hospice can also serve as a drop in. Some patients will come in for a few weeks during the year and then return home. I have seen some patients return throughout the years.

Fortunately, hospices are much more pleasant places than hospitals. It is not necessarily the case, a person will die once they are referred to a hospice. I met people who had been referred to the hospice many years earlier and were still very much alive and relatively well when I left. People may get a referral but then can get refused or discharged by the hospice feels their condition is not terminal or fits their criteria. is

Warmer Environment

Hospices are usually brighter and more friendly places. The decoration will be warmer. Nurses and staff are much more relaxed and aim to make the patient experience far more comfortable than their counterparts in hospitals who are more concerned with running you through their programme.

Hospices may have private rooms or mixed wards depending on the size. Some may take in respite patients – a kind of holiday from home – for a few weeks. – Many hospices will have outpatient services. The more developed ones will provide community groups for people to join as well as offering seated acupuncture groups, free talks, tai chi lessons, yoga classes and even training courses to anyone who is interested.

Acupuncture in Hospices

Acupuncture treatment in a hospice setting is more than just pin-sticking. Listening and counselling skills become essential and more developed. Often the session with a client becomes a much needed ‘time out’ for the patient – a chance to de-stress and release some tension.

Acupuncture usually sits within the supportive care radar. These are the non-medical modalities, which includes physiotherapy, occupational therapy, counselling, arts and various other things. Acupuncture is growing in recognition and popularity not just in the private market but also in hospital and hospice care. There is also an increasing number of scientific studies being carried out to show the benefits of acupuncture for the symptoms of palliative care or cancer treatment.

Clinical Research and Studies

In one study in the American Journal of Hospice and Palliative Medicine, – ‘Acupuncture is underutilized in hospice and palliative medicine (2008)’, research showed that acupuncture was more established in the UK than in the USA. Researchers studied 27 randomized trials of acupuncture and found that in 23 of these trials; acupuncture was effective for treatment of dyspnoea, nausea, vomiting, pain and xerostomia. They also found it safe and cost effective and good value for palliative and hospice care.

Acupuncture for nausea and vomiting

In the Pub-Med Journal – ‘Acupuncture: role in comprehensive cancer care–a primer for the oncologist and review of the literature (2005), a review of acupuncture in cancer care was carried out. According to this review of studies, it was found that acupuncture significantly reduced vomiting episodes for patients receiving chemotherapy. Acupuncture was also observed by several researchers to be just as effective as or more effective than antidepressants.

Acupuncture for physical symptoms and quality of life

From another Pub-Med paper – ‘Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients (2010).’ A trial was carried out to study acupuncture treatment on patients with ovarian or breast cancer. In this pilot study, patients with advanced ovarian or breast cancer received 12 acupuncture sessions over 8 weeks with a follow-up after 12 weeks.

Among all 32 assessed patients, there was self-improvement reported immediately following treatment in levels of anxiety, fatigue, pain, and depression. Psychological distress, life satisfaction, and mood states also showed improved scores during treatment with some of these benefits still being sustained after 12 weeks. This improvement in psychological distress and life satisfaction seems to indicate that acupuncture can satisfy the WHO definition of palliative care – that treatment should integrate the psychological and spiritual aspects of patient care.

Acupuncture for breathlessness

Studies on breathlessness also showed that acupuncture had a significant positive effect on chronic obstructive pulmonary disease. Patients with hot flushes due to hormonal imbalance may also benefit from the use of acupuncture. One pilot study also showed an improvement of chronic post chemotherapy fatigue following acupuncture treatment.

Acupuncture and WHO recommendations

The WHO definition recommends that palliative care should ‘offer a support system to help the family cope during the patient’s illness and in their own bereavement’. Acupuncture is one such support system that can help the family cope during the patient’s illness and in their own bereavement. Acupuncture and other complementary therapies can be offered to family members and their carers and can help improve the quality of their life and help with stress. It is often the case that the family member is also the carer which means they must go through the difficulty of seeing a loved one suffer but must also hold themselves together to look after their family member which includes things like dressing, preparing food, lifting them up and transporting them as well as other duties.

Acupuncture and supporting family members

There are several ways that acupuncture can also support the family members of a palliative care patient. Sessions with a carer or family member provides a much needed quiet time and the opportunity to take some guilt-free ‘me-time’ for a change. Family members and carers may also have their own health problems and acupuncture provides the opportunity to address these problems and alleviate their own suffering. For example, a common problem for a family member/carer is back pain. This can be caused or exacerbated by lifting their sick family member. From treating family members and carers I have found that acupuncture is especially helpful for dealing with stress, anxiety and sleep problems. Acupuncture sessions also provides a reflective space for carers and family members. As well as some additional space to talk freely or even cry.

Cancer

From my experience of both volunteering and working in a hospice, I found that 80% of the patients you will see will be patients with a form of cancer. You will encounter all sorts of cancers – lung, brain, liver, kidney, metastasised, primary and secondary cancers. Conventional treatments are mostly focused on chemotherapy, (drugs to destroy cancer cells), Immunotherapy (drugs to enhance aspect of the body’s own immune system), radiotherapy (application of radiation to tumours directly to shrink them) and surgery (to remove the tumour and associated lymph nodes). All of these treatments carry side effects and other symptoms ranging from mild to extreme.

In a palliative care setting, these treatments will still be used and adapted in order to shrink any tumour if it can improve symptoms or quality of life. For example, a tumour on the spine can cause severe back pain by impinging on the nerves. Radiation on the tumour may cause it to shrink and reduce the pain.

Attitudes to cancer

Cancer can be a devastating disease. Though certain types of cancers have better outcome measures with conventional medicine treatments. Bowel cancer and breast cancer, if caught early, has a greater survival rate than prostate cancer or if a cancer has metastasised. Nonetheless, there seems to be a universal fear of cancer. The diagnosis of cancer comes as a great shock to the patient and their family. Despite millions being pored into the ‘war on cancer’, overall cancer rates remain the same. And if fact, the rates are increasing for certain types of cancer such as childhood leukaemia.

Causes of Cancer

Western science has shown us that cancer has multifactorial causes – a combination of different things.

According to Cancer Research UK, Some of the factors that increase the chance of cancer are:

  • Carcinogens – cancer causing substances like tobacco smoke. Also there are some indicators that diet may be a cause of cancer – particularly an excess of red or processed meat.
  • Age seems to make us more susceptible. For example, a large percentage of the elderly patients in St Joseph’s hospice – particular in their 80s or 90s tend to suffer from certain types of cancer. This may indicate that resistance to disease is reduced and there is an increased susceptibility to cancer with increasing age.
  • Some genetic factors, for example the BRCA1 and BRCA2 genes have a higher correlation with breast cancer.
  • An impaired immune system – caused by AIDS, HIV or people who have had organ transplant and have to take drugs to suppress their immune systems
  • Also some viruses may lead to certain cancers. For example, the human papilloma virus (HPV) is linked to cervical cancer. Hepatitis B & C has links to Liver cancer. The Epstein Barr virus has links to Lymphomas.
  • Even some bacterial infections may lead to cancer. Research shows a connection between helicobacter pylori infection and stomach cancer.
  • Environmental factors. For example, excess exposure to the sun may cause skin melanomas.

Traditional Oriental Medicine Theories & Cancer

Traditional Chinese and Japanese medicine have a different set of theories and model of medicine compared to Modern Western medicine. Traditional Oriental medicine is around 3-5000 years old. It has a relation to traditional Taoist medicine and has a unique way of understanding the human body, nature and the universe. Traditional Oriental Medicine is based on concepts such as the flow of Ki energy or Qi. The Channel (or Meridian) system of energy, the balance of Yin and Yang in the body. Causes of disharmonies in the body can be caused by an imbalance of any of the above – stagnant flow of Ki energy, or weakness of the organs, imbalance of the channel flow. However, other causes can be due to an imbalance of the emotions, in particular anger, grief, worry, fear and joy. Also, certain pathogenic factors such as heat, damp, cold, wind and phlegm are seen as causes of disease.

A different model of medicine

To the modern mind, understand that these theories were first formulated thousands of years ago and are related to Taoism. It is a simplistic way of describing nature and the human body in a way that made sense. To apply these concepts to our modern understand of the human body and disease it helps to look more carefully. For example, the pathogenic factor of heat has an immediate recognised as referring to ‘inflammation’ – the disease process where tissues of the body become inflamed. Also as regards, the emotions, it is recognised that anger raises blood pressure.  These are simple example.

Cancer and Stagnant Qi

In Traditional Chinese Medicine, cancer may be seen as an accumulation of phlegm or damp. There may also be Spleen and Stomach deficiency and the non-transforming and transporting of fluids and food. There is almost definitely a form of Liver Qi stagnation. Also some internal heat or fire which can come about from withheld emotions. I suspect the involvement of strong emotional factors either in the present or the past.

The pathogenic factor which is called ‘Phlegm’ is a way of describing a condensed form of tissue, mass or lump. Phlegm can manifest in different ways in the body. For example, it can refer to a benign growth like a fibroid or a polyp. Or it can refer to a malignant growth like a tumour. The presence of phlegm comes about from an imbalance of different organ disharmonies and pathogenic influences often all together. This is why it is difficult to pinpoint an exact cause of cancer.

As there are many types of cancer – it is worth looking to the area that is affected. For example, if it is lung cancer, consider firstly of course obvious environmental factors like whether the person is a long-term smoker or if there has been asbestos exposure. These could be considered to be the external pathogen. After that, it may be worth considering if there has been an excess of unresolved or buried grief in the past which is the emotion related to the Lung and metal element. Also consider the whole life and medical history.

This is where conventional medicine fails. It sees the problem but fails to consider the whole tapestry of a patient’s life. What was happening in a persons lfe for the five years before that tuour appeared? What was their work like? What was their lifestyle like/their diet? Did they go thorugh any painful experiences – divorce, bereavement? What was their childhood like? Have there been any significant hurts or painful experiences in their life. To give an example, I knew one woman with cancer who grew up during a time of civil war in her country. From speaking to her, I came to realise that she had gone trough some extremely painful experiences in her youth and which I felt still impacted on her later in life. Tough, this does not necessarily mean this is the cause of her cancer – from a Traditional Oriental medicine point of view, the emotions this lady felt, would have had an impact on her health.

Channel flow and disease location

I have treated several women with breast cancer and have found that treating the Jueyin channel (Pericardium and Liver) is effective in relaxing the mental state as well as helping with symptoms. It seems to help open up and release past issues – hurt and anger that was especially strong before the cancer appeared. The Pericardium channel also flows through the breast area and is strongly influenced by emotions. From an Oriental perspective and from my own experience, I feel that the concept of ‘Liver qi stagnation’ as used in TCM theory has some relevance. If applying a five elements point of view, emotional stress leads to excessive Liver energy which overacts on the Spleen and Stomach hindering its transforming functions and causing phlegm.

Cancer and Stagnant Energy

Whichever way you look at it, cancer is an indicator of stagnant energy which has accumulated and solidified. It probably involves the disharmony of several organs and channels. The answer is never straightforward especially if there are other disease processes and disharmonies occurring.

With some of the people I have seen, there is some history of strong emotional stress which have been repressed. Sometimes, there is overwork in a stressful living and work environment. It can be a difficult childhood or bad relationship or bullying at school. Either way, the energy is heated up internally and then repressed causing an internal imbalance. Although, these are just my own thoughts, I have come to appreciate how important it is for us to remove stress and deep emotional hurts from ourselves in any way possible whether it is regular gym exercise, yoga, tai chi, adventure sports, shopping, drinking and talking openly with close friends, counselling, or even setting up illicit fight clubs in order to burn off all that stuck internal heat. It’s better out than in.

Stress

It is well known that stress can have a harmful effect on the body. There is no clear correlation between stress and cancer, however, we do know that stress weakens the immune system. If the immune system is impeded, it will not be able to do its as effectively to target and destroy its own cancer cells.

The consideration of stress, is that it will be a major issue for a patient as well as their family and carers. it is stressful dealing with a life-changing disease. It is stressful dealing with the side effects of medication. With fighting disease, one needs to be a ‘unstressed’ as possible. This is one of the advantages of acupuncture. Acupuncture treatment can help to calm and relax the body. By inserting needles, the body’s musculature and fascia layers are released. Stress is released. This can help with sleep and relaxation.

The Muddy Pond

As an acupuncturist in the hospice, the primary role is in relieving suffering. Although I may suspect that some patients may hold strong emotional hurts within themselves, it does no good to bring these up or to try to open the patient up to this. To do so may cause more suffering. Stirring up a muddy pond only makes the pond worse until it settles down again – but the mud is still there. If you saw the hospice patient five or ten years earlier, maybe you could remove the mud, but in the hospice after they have a serious illness, it is no longer the time to remove it.

Some things should be left well alone – until the next life perhaps – especially for the older patients and those in a more diseased state. However, for some of the younger patients, if they seem to want to open up more – indicated by crying during the treatment and by them openly volunteering information about their life, then the acupuncturist can become the facilitator to this process by letting them open up and let it out.

Conclusion

Acupuncture does have a place in palliative and hospice care. I have worked in situations where it has been used extensively and successful to help patients deal with symptoms as well as reduce stress. There is a small yet significant number of studies to show the benefits of acupuncture in palliative care and cancer care. More importantly, it provides a non-drug approach to symptom relief. This is important because rightly-so, patients are probably sick of taking any more medications. They are tired of being run through the medical mill only to still up on the ‘dying’ list.

A lot of people are also requesting more ‘natural’ methods as part of their care. Standard medicine cannot offer anything like this and so, doctors and nurses will start to consider alternatives. Acupuncture along with other complementary therapies stands in a good place to fulfil this need. I hope that acupuncture and other complementary therapies can become more widely utilises n palliative and hospice care in the years to come.

In my next article, I will discuss how acupuncturists should consider volunteering in palliative care as a way to increase their skill, knowledge and experience.