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Complementary and alternative medicine in hospice care

A number of news outlets (e.g. Bloomberg Business Week, MSN.Com, US News, etc) have recently reported that use of complementary and alternative therapies (CAT) is widespread in hospice care facilities. This is based on a report from the Centers for Disease Control, Complementary and Alternative Therapies in Hospice: The National Home and Hospice Care Survey, Untied States, 2007. According to most news reports, about 42% of hospice care providers offer some kind of CAT.

I was initially inclined to find this a little worrisome. In my own field of veterinary medicine, advocates of alternative therapies are prominent among the organizers of the nascent hospice care movement. And while I am strongly supportive of better and more available veterinary hospice care, the involvement of CAM advocates raises the concern that animals at the end of their life might receive ineffective palliative care, or be denied the benefits of conventional treatments by some CAM providers, who often characterize “allopathic” treatments as “unnatural” and harmful.

In practice, I have seen this happen to patients with terminal diseases. I will never forget a Rottweiler dog I diagnosed with osteosarcoma, a very painful bone cancer, whose owner was convinced that homeopathy was adequate to control his pain and refused to use NSAIDs because of her conviction they were “toxic.” I have also seen my patients denied euthanasia even in the face of great suffering because so-called “animal communicators” claimed the pet was “not ready to leave” and had expressed a desire to remain with their owner as long as possible.

Perhaps these experiences have made me overly sensitive on this subject, but I saw these recent news reports and pictured people at the end of their lives being similarly denied effective palliative care or subjected to pointless therapies like homeopathy and “energy medicine,” or even more worrisome treatments like chiropractic or herbal remedies with real risks. However, a little digging into the details suggests that the headlines are a bit misleading, and these fears are probably unfounded.

As always, when trying to assess how popular alternative medical therapies are, the tricky issue arises of defining “alternative.” In this study, the authors referenced the MedlinePlus definition:

Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy and allied health professionals, such as registered nurses and physical therapists, practice. Alternative medicine means treatments that you use instead of standard ones. Complementary medicine means nonstandard treatments that you use along with standard ones. Examples of CAM therapies are acupuncture, chiropractic and herbal medicines.

Personally, I prefer Dr. Novella’s definition:

CAM is a political/ideological entity, not a scientific one. It is an artificial category created for the purpose of promoting a diverse set of dubious, untested, or fraudulent health practices. It is an excellent example of the (successful) use of language as a propaganda tool.

In any case, in order to measure the popularity of something, one has to define it in some way, and in the past assessments of how popular or widespread CAM use is have created misleading impressions due to dodgy definitions. For example, the 2007 National Health Interview Survey (discussed in detail here) reported 30% of Americans to be regular CAM users. A closer look at the details of the survey, however, showed that very little of this self-reported usage involved the application of the usual dubious CAM approaches (e.g. acupuncture, chiropractic, homeopathy, various herbal traditions, etc) to treat specific medical problems. Much of this supposed CAM usage involved the non-medical application of massage, yoga, tai chi, prayer, and so on to provide psychological comfort or facilitate relaxation.

Of course, if one argues that massage, yoga, or even prayer are effective in reducing the objective signs or disease, or even bringing about a cure, then one could argue these are forms of alternative medicine. But such methods are mostly employed to provide comfort and help patients cope with their illness, and as such they can be valuable and legitimate interventions. This does not make them medical therapies, however, alternative or otherwise.

The hospice care survey suffers from the same kind of problematic definition for “complementary and alternative.” According to the report’s technical notes, providers of hospice care were asked first to choose all the services they offered from a list, and “Complementary and Alternative Medicine (CAM)” was one of the choices. Those that indicated they offered CAM were then asked to indicate “Which of these complementary and alternative medicine therapies does this agency use?”

Here is the list:

  1. Acupuncture
  2. Aromatherapy
  3. Art therapy
  4. Guided imagery or relaxation
  5. Massage
  6. Music therapy
  7. Pet therapy
  8. Supportive group therapy
  9. Therapeutic touch (a westernized version of reiki)
  10. TENS (Transcutaneous Electrical Nerve Stimulation)
  11. Other

Personally, I see little on this list that I would classify as CAM. Acupuncture, certainly, along with therapeutic touch (like reiki) and aromatherapy. But most of the rest, unless specifically marketed as treatments for disease, seem more like benign, pleasurable activities designed to provide comfort, relaxation, and enjoyable stimulation. As a veterinarian, I work with a lot of pet therapy dogs, and I have yet to run across a handler of one who thought they were practicing alternative medicine! (Though I suppose there might be some such folks out there). And TENS is a perfectly conventional intervention, often somewhat disingenuously confused with acupuncture.

The most popular of the “true” CAM therapies offered was therapeutic touch, available at 48.3% of facilities. Aromatherapy was offered by 39.7% of hospice providers. I cannot even find a number for acupuncture in the report. And by far the most popular “alternative” therapies offered were massage (71.7%), group therapy (69%), music therapy (62.2%), and pet therapy (58.6%).

The report also indicates that only 8.6% of patients discharged from a hospice facility that offered CATs actually received one of these therapies. So even under such a loose definition of alternative, there is no evidence that large numbers of hospice patients are receiving alternative medical treatments.

It wouldn’t surprise me if we begin to see advocates of alternative medicine proclaiming that this report shows CAM is widely available, popular, and even indispensible in hospice care. The 2007 National Health Interview Survey results were frequently used this way to create the impression that CAM is becoming mainstream and that resistance to it is the province of extremists and ultimately futile. The details of both surveys, however, indicate that even with aggressive expansion of the definition of CAM to include conventional therapies such as TENS and non-medical interventions like pet therapy, CAM is not truly as popular ubiquitous as its proponents claim.

There is little objectionable from a science-based medicine perspective in most of the therapies hospice care providers are offering, according to this study. I enjoy a good massage, relaxing music, and the company of a friendly dog as much as anyone. And those elements that are truly nonsense, such as therapeutic touch and aromatherapy, are unlikely to do harm or replace appropriate conventional therapies, and they seem in any case not to be especially popular with patients even when they are available. So regardless of what PR use is made of this study, it does not suggest that human hospice care is becoming predominantly the domain of CAM providers, as I might have feared. I only hope the same will be true of veterinary hospice care as that becomes, hopefully, more commonplace.

Posted in: Cancer, Science and Medicine

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20 thoughts on “Complementary and alternative medicine in hospice care

  1. Harriet Hall says:

    In our local cancer center, I saw a poster offering various modalities of “comfort care” to cancer patients. I like that concept. It makes no claims of medical efficacy.

  2. Zetetic says:

    Yes – My long term observation is that hospice services are rife with “alties” and therapeutic touchers in particular. My wife and I cared for of my ailing mother in law in our home and when hospice care became part of the process, some strange things happened. I observed an RN waving her hands and chanting over my MIL and knew immediately what was going on. My MIL didn’t say anything at the time but after the RN left, she proclaimed “If I had wanted a priest, I would have asked for one!” She also requested that the RN not visit again!

  3. Scott says:

    The bit on pet therapy made me think a bit. I find that friendly dogs can actually cause pain.

    One such canine of my acquaintance is large, very friendly, and very excitable. Interaction with her tends to result in pain in the gluteus maximus, due to high-velocity encounters with floorboards.

  4. @Scott

    Therapy dogs are pretty rigorously screened, both for behavior and infectious/parasitic disease risk. Really rambunctious dogs, even if well-intentioned, generally don’t pass the screening process.

  5. Scott says:

    Yeah, I expected that was probably the case. But I think it’s an amusing tidbit anyway.

  6. Even aromatherapy might just be considered a form of relaxation , depending on how it is promoted and used and what benefits are being claimed. (especially by those who don’t really understand what it is claimed to be useful for). Massage feels good, classical music sounds nice, and mint or roses smell nice as well.

    Many CAM modalities are their own starter-woo. The basic premises that a massage feels good, good music is enjoyable to listen to, or fresh flowers smell nice are acceptable enough, but when more than that is claimed, you’re usually headed down the rabbit hole of woo.

    Really what matters is, are the treatments and/or therapy based on quality scientific evidence of safety and effectiveness? If yes, it’s medicine, even if it’s outside of mainstream, common practice. If no, it’s not medicine, though many would label it as CAM.

  7. pmoran says:

    My usual, boring, recurring caution regarding the premature dismissal of acupuncture as an adjunct in the treatment of cancer pain.

    We can be confident that it doesn’t work as TCM traditionalists claim. What we don’t yet know for sure as whether it can or cannot reduce the need for opiates in cancer patients via placebo, distraction, counterirritant or other non-specific nurturing effects. Some well-designed studies are needed.

    This could have a significant effect on their quality of life.

    I personally expect any such effects will be modest, if preent at all. I merely point out that nearly every “negative” study on acupuncture is testing whether specific features of the acupuncture ritual are necessary, rather than whether it can have clinically useful effects via these other well-known mechanisms.

    I have no desire to be one of those saying “I told you so” if well-designed studies do suggest significant benefit for some patients and SBM adherents have to explain why they once so strongly opposed its use.

  8. @pmoran,

    As much as I don’t anticipate any quality evidence that there’s anything to acupuncture beyond an elaborate placebo, I usually qualify my position by saying I am comfortable throwing out any traditional or new age understanding of acupuncture based on the best controlled and blinded studies that show it neither matters where you needle, nor if you needle rather than just poke with toothpicks. This pretty much leaves out some generalized effects that don’t require invasive needling or just a powerful placebo response. I lean towards the latter.

    Any claim of effect or mechanism would need to be consistent with the results of the better studies. For instance, the study/studies that show some temporary effects on pain perception in mice with needling in non-traditional, localized points needs to be reconciled with the evidence that needling is no more effective than poking.

  9. …and of course, localized needling in non-traditional points for non lasting relief of pain perception is not really acupuncture, but the study has been touted as both proof that acupuncture works and proof of it’s mechanism of action.

  10. Actually, I’m pretty sure that my dog has healing powers. Only, she is very wise, for having such a little brain, and understands that curing terminal illness with her spiritual abilities would upset the balance of nature.

    So, she just contents herself with laying on my chest when I have a miserable cold, which miraculously makes me feel much better than any OTC cold medicine (sort of like a soulful hot water bottle).

    More to the point, my MIL volunteers at the local hospice. She often makes small bouquets from her garden for the patients. Is that herbalism? Sometimes she helps put on social teas for the local assisted living center, if they have green tea is that Chinese medicine?

    Sometimes I hate surveys. They always start out sounding objective, but the “magic” is in the way they ask they questions.

  11. BillyJoe says:

    “Really what matters is, are the treatments and/or therapy based on quality scientific evidence of safety and effectiveness? If yes, it’s medicine, even if it’s outside of mainstream, common practice. If no, it’s not medicine, though many would label it as CAM.”

    There should be only two categories:
    - science based medicine
    - unscientific nostrums and practises

  12. BillyJoe says:

    pmoran,

    I’m not really sure what you are trying to say so perhaps your responses to the following might illuminate:

    “My usual, boring, recurring caution regarding the premature dismissal of acupuncture as an adjunct in the treatment of cancer pain.”

    You are too cautious.
    Acupuncture does not work.
    Placebo does.

    http://www.youtube.com/watch?v=O1Q3jZw4FGs

    “We can be confident that it doesn’t work as TCM traditionalists claim. What we don’t yet know for sure as whether it can or cannot reduce the need for opiates in cancer patients via placebo, distraction, counterirritant or other non-specific nurturing effects. Some well-designed studies are needed.”

    They’ve been done.
    Acupuncture does not work.
    Placebo does.

    “…nearly every “negative” study on acupuncture is testing whether specific features of the acupuncture ritual are necessary, rather than whether it can have clinically useful effects via these other well-known mechanisms.”

    You mean, like the mechanisms of the placebo effect?

    “I have no desire to be one of those saying “I told you so” if well-designed studies do suggest significant benefit for some patients and SBM adherents have to explain why they once so strongly opposed its use.”

    No one denies the very real effect that the placebo provides in the relief of subjective symptoms such as pain.

  13. WilliamLawrenceUtridge says:

    If acupuncture does work, it almost certainly doesn’t work as the ancient practice described it (i.e. manipulation of qi) and that bit of pseudomagical thinking is what needs to have a bullet put in its head. I’ve been arguing about acupuncture on wikipedia for months, if not years now, on whether it is pseudoscience. The best contention I can see is that the Traditional Chinese Medicine part of acupuncture is clearly prescientific nonsense and possibly harmful, but jamming needles into people might work for pain and nausea. Keep those needles away from organs and arteries and frankly, I don’t have a problem with it. Claim it can do anything but treat pain or nausea, and I do. If you want your needle to do something other than treat pain or nausea, you should use a hypodermic needle with actual medicine in it.

    As always, the larger problem is the corrosive effect the nonsense has on science and scientific awareness at the general level, rather than the question about whether the modality works or if it should be investigated.

  14. @WilliamLawrenceUtridge,

    But quality studies show that the needling is not needed either. If poking with toothpicks is just as effective as needling, you’re left with either that poking has a clinical effect beyond placebo (and the needling is not needed), or acupuncture is only placebo. The more we do quality studies of acupuncture the more we push back the boundary of any significance beyond placebo.

    The plausibility of acupuncture shrinks under controlled examination because now we are left with the plausibility that poking with toothpicks is a clinically significant treatment. Most of the proposed mechanisms whereby acupuncture might work (if it did work) go out the window when you try to explain how poking with toothpicks might work.

  15. tmac57 says:

    Karl-

    Most of the proposed mechanisms whereby acupuncture might work (if it did work) go out the window when you try to explain how poking with toothpicks might work.

    Maybe Dale Darlin can explain it for you:

    http://www.xtranormal.com/watch/8213859/

  16. BillyJoe says:

    The last four posters are pretty much on the same page:

    Cheap home-based acupuncture:
    Get a tooth pick and poke your skin anywhere you like.

  17. BillyJoe says:

    WLU,

    “Keep those needles away from organs and arteries and frankly, I don’t have a problem with it. ”

    “As always, the larger problem is the corrosive effect the nonsense has on science and scientific awareness at the general level”

    So do you, or do you not, have a problem with it?

  18. This is veering of topic, but regarding the acupuncture debate. I don’t think there have been any posts on dry needling.

    My BIL recently had a physical therapist preform this for a sports related tendon (or muscle, not sure) injury.

    Something like acupuncture needles were inserted into the area and then moved about. My BIL said it hurt like heck, but his injury did start improving after. Of course hard to tell from the anecdote, particularly since the physical therapist was doing other therapies as well. This is what wikipedia has to say about dry needling.

    “Dry needling is the use of a solid needle for therapy of muscle pain, sometimes also known as intramuscular stimulation.[1] Dry needling contrasts with the use of a hollow hypodermic needle to inject substances such as saline solution, botox or corticosteroids to the same point. Such use of a solid needle has been found to be as effective as injection of substances in such cases as relief of pain in muscles and connective tissue. Analgesia produced by needling a pain spot has been called the needle effect.[2] Acupuncture and dry needling techniques may be similar, but their rationale and use in treatment are quite different.”

    I’d be interested in seeing a SBM review of this therapy.

  19. pmoran says:

    “—– don’t yet know for sure as whether it (acupuncture) can or cannot reduce the need for opiates in cancer patients via placebo, distraction, counterirritant or other non-specific nurturing effects. Some well-designed studies are needed.”

    They’ve been done.
    =========================================
    They haven’t. I know of no good studies looking at this specific question, especially in a manner that is reasonably enabling of expectancy (placebo) and other non-specific influences, rather than .

    We cannot have a rational, fully evidence-based, compassionate, stance on acupuncture use until this kind of question is adequately addressed.

  20. pmoran says:

    –That should be “— rather than discouraging them”, of course..

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