Hospice and Palliative Massage

Palliative massage may or may not be part of an entire hospice care program that the individual participates in. Hospice care is appropriate when the individual can no longer benefit from or decides not to participate in active treatment for their disease or condition. In the hospice setting, the palliative massage practitioner will be part of the hospice team, a group of people including physicians, nurses, home health aides, social workers and counselors, spiritual or pastoral counselors as well as myriad volunteers. Any member of the team can then refer an individual for a palliative massage session, not just the attending physician; and the referral can be either for relief from physical symptoms, emotional symptoms or spiritual needs.


The palliative massage practitioner can become an integral part of the hospice care team, working hand in hand with the doctors, nurses, social workers and any others who may be involved in end of life care. Each session is planned using the medical information, expressed interest of the client/patient, and the skills and abilities of the massage therapist, to enhance the client’s well-being and feelings of comfort and ease.


The massage practitioner working with hospice clients has to be able to deal with stressful and chaotic settings, work with clients hooked up to machines and tubes, in rooms where other people are coming and going. This contradicts the usual practice, where the therapist is in control of their therapeutic environment, creating the mood and scene they want for themselves. Therefore, being able to let go of preconceived notions about the ideal setup for a massage session is important for the palliative massage practitioner.


Some types of bodywork are not appropriate for hospice clients; massage that is calming and relaxing will probably be most beneficial to the client. Massage for these individuals can enhance their quality of life, self-esteem, and acceptance. Palliative massage can relieve tired, sore muscles, improve circulation and relaxation, and leave clients feeling soothed and rested. Remember that touch is important at all stages of the individual’s progression through their illness, even when they can’t communicate verbally. Clients in hospice may be traumatized from all the invasive procedures they’ve gone through, the emotional ups and downs, as well as the physical symptoms they are experiencing.


You may need to be flexible to accommodate the needs of a client in the hospice setting, providing a “walking massage,” for example, if someone cannot sit or lie still for any period of time, or even getting on the bed with them if that is the only way they can be reached.


Providing choice to clients on where and how they receive their massage is critical, because they have had most of their control stripped from them in dealing with their disease and their terminal diagnosis.


Code of ethics for palliative massage

One of the important differences between a palliative massage practitioner and any other massage practitioner is the necessity of facing one’s own attitudes and/or fears regarding death and dying.


Working with clients who are dying forces the palliative massage practitioner to confront these issues directly, even if they are disturbing or upsetting, to know one’s own limitations, and be able to assist clients in confronting their own fears of death of dying. One of the primary components of the Palliative Massage Code of Ethics is that the practitioner provides time and space to know and heal oneself.


A second, equally important component of the Palliative Massage Code of Ethics is confidentiality. The client’s right to privacy is paramount. Any information shared during a session, whether of a medical or non-medical nature, must be kept in the strictest confidence, with one exception: If something is disclosed during a session that another member of the hospice team needs to know, the palliative massage practitioner must disclose that information.


Examples of information that might need to be disclosed would be suicidal tendencies, any incidents of abuse or neglect, or a need for changes in pain medication.


Informed consent is necessary before the palliative massage practitioner can perform any massage services with a hospice client. This means that the individual has an opportunity to learn details of the treatment plan, including, for example, the role of massage in that plan, how the client will be draped during massage, and their right to terminate the session, should they feel uncomfortable in any way.


For individuals unable to give informed consent, such as those in advanced stages of Alzheimer’s disease, a primary caregiver, legal guardian, or other individual holding health care power of attorney, may give consent. The primary caregiver should be present during initial sessions to ensure that the client is comfortable and responds positively to the massage.


Respect for the client’s boundaries and sense of personal space is paramount in palliative massage. Clients who are terminally ill may have already experienced multiple invasive procedures over a period of time; they may be resistant to touch, even pleasant and soothing touch. For that reason, it is critically important to establish a rapport with the client, be aware of his or her established boundaries and personal space, and consider the client’s needs throughout the process. The right of refusal belongs both to the client and the practitioner; the client may choose to terminate a session at any time, for any reason.


The palliative massage therapist may also refuse to work with a particular client. If a practitioner is hesitant or reluctant to work with a particular client, it might affect the quality of care or treatment he or she receives.


Maintaining professional boundaries is the next piece of the Palliative Massage Code of Ethics. Acceptable activities to perform during a palliative massage session include adjusting pillows, responding to requests for personal items, requests for water or something to drink, listening, holding a hand, and comforting a caregiver.


Activities that are never acceptable are lifting and transferring a client, bathing a client, changing his/her undergarments, dispensing medication, engaging in any conduct which could be deemed sexually harassing or intimidating, or referring to a client in an inappropriately familiar way.


Record-keeping is a necessary part of the palliative massage practitioner’s duties. Keep careful notes on the time and date of each session, who was present, the observed condition of the client both before and after the session, and any comments or questions from 7 the client regarding the session, or any other information that might be useful in evaluating the effectiveness of the massage program or hospice care.


Palliative massage practitioners also recognize that a diagnosis of terminal illness impacts more than just the client — the family also suffers. Primary caregivers can also benefit from massage, allowing them to ease some of the stress they experience. An excellent way to integrate massage into the relationship between the caregiver and their loved one is to teach the caregiver some simple massage techniques that they themselves can perform on their loved one. This allows the caregiver to be involved in a positive aspect of caring for their loved one, along with the many mundane tasks that are usually the responsibility of caregivers.


A third group that can benefit from palliative massage are members of the hospice team. Dealing with death and dying can be extremely stressful and draining for staff members. Massage can nurture hospice workers, helping them continue with their critically important work. Even a 15-minute chair massage can significantly improve one’s outlook.


The palliative massage environment

Each practitioner must develop his or her own way to prepare for a palliative massage session. This may be a process of confronting, to some degree, your own fears about death and dying. Many palliative massage therapists fi nd that an awareness of their own mortality and an understanding that death is a natural part of the life cycle are important to their preparation. Some practitioners take a few moments, before a session, to meditate, reflect, or pray, feeling this helps give them the mental and spiritual focus needed to provide maximum benefit to the client.


Clients who have been poked, prodded, or otherwise handled poorly by caregivers over a period of months or years are likely to have concerns or fears about being touched in any way. Spend some time to get to know the client, to understand something about him or her, why they are interested in massage, and what they would like to get out of the treatment.


Then work together to develop a safe, effective, and meaningful massage treatment plan. The practitioner should clarify any questions he or she has about the client’s stage of illness, the progression of the disease, and any special needs or limitations that would be useful information in creating a treatment plan.


Effective palliative massage requires a proper external, as well as internal, environment. The ambiance should be relaxing, comforting, and supportive. Keep the voice soft and concerned, communicating your empathy and sincere desire for the client’s well-being. Make a conscious effort to be mentally and spiritually, as well as physically, present in the session.


Deep breathing exercises can be beneficial for both the client and the practitioner, helping to release tension and bring focus to the present moment. Active listening and good verbal and nonverbal communication skills, in addition to technical proficiency, are important parts of the treatment in palliative massage. People nearing death can become extremely emotionally vulnerable. Massage can help clients release their emotional burdens they may need to cry or discuss their fears.


Use a bed or a chair, depending on your client’s condition and preference. The bed should be at a height where the practitioner can comfortably keep the knees soft, and touch the bent knuckles to the bed. Use clean sheets, large towels, or blankets to drape the client.


Lubricants like oil, cream, and powder can make the massage more comfortable for elderly clients, who may have fragile skin. Music, soft lighting, and aromatherapy can be used to enhance the ambiance, making it more relaxing and pleasurable, and increasing the benefits of massage.


Position the client as comfortably as possible during the session.


Paralysis, amputations, skin sensitivity, decubitus ulcers, and breathing difficulties can be obstacles to client safety and comfort. Prone positioning is often not possible, but extra pillows can be used to keep the client comfortable and help him/her get the maximum benefit possible from massage.


To end a palliative massage session, allow the client to lie quietly and integrate the benefi ts received. You may want to ask them how they are feeling now, or if there has been any change in their condition during the massage, or ask if they have any questions for you regarding the massage. Some practitioners consider silent meditation or hand-holding effective integrating techniques for ending the palliative massage session. Some clients prefer to talk or share their feelings after a massage; others are silent. Let your client guide the closure; never pressure them to pray or hand-hold, if it is not in their character.


Well-being and safety during palliative massage

The palliative massage practitioner is concerned not only with the safety and well-being of the client, but his/her own, as well. Monitor your own emotional health for signs of stress, and maintain a healthy balance in your life by recognizing your own limitations and strengths, building support networks for yourself, and developing strategies for dealing with grief and loss; all are necessary to your emotional health.


The way a practitioner dresses, his/her personal health, hygiene, tone of voice, body language, and overall manner are all factors influencing the quality of the session. Dressing comfortably, as well as professionally, is important; neat, well-cared for clothing that allows the practitioner to move and interact easily enhances the professional image.


Appropriate body dynamics and positioning during treatment minimize the possibility of injury on the job, the most common of which are tenosynovitis, infl ammation of the tendon sheath, which results from repetitive strain, and carpal tunnel syndrome, a swelling of the sheath around the tendons in the wrist, causing weakness, pain and tingling in the thumb and the hand. Maintain a proper center of gravity, with correct breathing and positioning of the arms. Stand in a slight forward lunge, with soft knees, and your hips aligned with the area you are massaging. Leaning and bending stress the lower back, and should be avoided.


Proper diet, exercise and sleep, as well as good hygiene, are crucial components of safety in palliative massage. Maintain clean skin, hair and clothing, wash hands frequently with antibacterial soap and water to preventing the spread of germs and infection. Universal precautions other than handwashing, such as wearing gloves, mask and/or gown are sometimes appropriate, depending on the client’s condition at the time.


The practitioner must maintain good personal health, and be well-rested, healthy, and energetic during the session to provide the most effective, caring treatment of clients. Remember that palliative massage practitioners risk their clients’ health as well as their own if they choose to work with a cold, fl u or other illness.


Terminal illness and palliative massage

The World Health Organization defines palliative care as that which focuses on the comfort of terminally ill patients. Palliative massage is reflective of our culture’s growing acceptance of alternative methods to treat the body and mind, since it is focused not on a “cure” but purely on comforting and easing the whole person as they make the transition from life into death.


Palliative care attempts to minimize or eliminate emotional and physical pain or distress, emphasize the individual’s dignity and quality of life, and provide bereavement care for families. On a purely physical level, palliative massage is critical in preventing pressure sores, ulcerations that are likely to occur in people who are unable to leave their beds or wheelchairs for long periods of time.


They commonly occur on bony areas like the tailbone, buttocks,ankles, heels, elbows and shoulders, areas that are in direct contact with the mattress or the wheelchair.


More than other types of massage, palliative massage demands sensitive, perceptive, and gentle interpersonal skills as well as a personal assessment of one’s own attitudes regarding death and dying. Denial regarding the diagnosis, fear of illness and death, frustration with the state of medical care, mood swings, depression, and suicidal tendencies — all are commonly associated with the powerful emotions experienced by individuals with terminal illness.


Palliative massage can help a person come to terms with these feelings, and even to find acceptance and peace.
Palliative massage can assist the client in dealing with the tumultuous feelings experienced with a diagnosis of terminal illness, helping them to cope with the physical or mental limitations imposed by the disease or level of disability, and confront or manage their anxiety regarding loved ones who must cope with the illness and death of a person close to them. Case studies show that palliative massage provides a nurturing environment, beneficial to stabilizing moods, easing depression, and allowing people to live the rest of their lives more fully, as it allows clients to confront their deepest fears about death and dying, leaving them with a sense of peace and comfort. Palliative massage can ease depression, anger, anxiety, and loneliness for those with terminal illness, as well as their family members and dear friends who are caregivers.


Palliative massage has been shown to be especially beneficial to those with no family or few visitors, easing the client’s loneliness, fear, and anxiety, and extending warmth, affection, and care through the power of touch. Clients may have lost friends and other important people from their lives over the years; they may be unable to speak frankly with the individuals who currently surround them. Palliative massage can help bridge that gap, providing a human connection, easing stress and comforting the individual as he or she approaches death.


Palliative massage uses a lighter touch than most massage. Its purpose is to encourage relaxation and ease tension , so light, soothing strokes, and a comforting touch is required. The relaxation response elicited from this type of massage enables the client to approach death with less fear and anxiety, feelings that often accompany a diagnosis of terminal illness.