Concept Analysis: Therapeutic Touch and Pain Management in Palliative Care Patients, Case Study Example

Introduction

Pain is one of the most distressing accompaniments of injury and disease and particularly more so in patients afflicted with terminal diseases such as cancer. Although the phenomenon has been vanquished by the development of pain relieving drugs, they offer only temporary relief which is occasionally accompanied with undesirable side effects. Alternative and less invasive techniques of pain management therefore need to be employed in order to render permanent relief, either through psychotherapy or traditional systems of pain management such as massage, elimination of the cause and proper positioning of the afflicted organ. Such management techniques should be an essential component of palliative care practice, especially for patients in the recovery stages after being treated for chronic diseases, grievous injuries or any other disorder which involves acute or chronic pain as an essential component. Terminally ill patients such as those suffering from organ failures, cancer or immunodeficiency diseases need special palliative care over a long period in the clinical as well as domestic setting. The therapeutic touch in pain management involves both psychological and physical approaches which tend to alleviate if not eliminate pain in its totality.

Significance of Concept

With the increasing number of terminally ill patients due to the increased incidence of incurable diseases like cancer and AIDS, relieving the symptoms of pain is an essential component of daily nursing duties. The number of such patients has increased with the passage of time due to the adoption of sedentary lifestyles and excessive consumption of junk food in the developed countries. Health facilities have multiplied in numbers as well as become technologically equipped with modern systems of medicine to handle ill health. Better longevity in the human population has come with a rider due to the increase in the occurrence of lifestyle diseases such as Hypertension, Diabetes and cancer. The onus of providing relief to such patients lies with the healthcare providers who must be aware of the latest findings of research and use an evidence based mechanism for the application of therapeutic interventions. Alleviation of painful conditions in patients is an omnipresent phenomenon and needs to be handled with care.

Review of Literature and Definitions of Concept

Alternative therapies have existed all along the course of history and home made remedies have been used since time immemorial. Homeopathy, The Chinese Medicine System, Ayurveda, Reiki, etc. are alternative therapeutic systems of medicine developed in different regions of the world and have their basis in the unique socio-cultural environments but have not received total approval from the scientific community. However successful alternatives exist in such systems for the alleviation of a number of symptoms. The ‘Therapeutic Touch’ has been identified as an alternative and wholesome therapeutic system which derives from a mutual relationship between the sufferer and the healer. The most appropriate definition of the therapeutic touch has been attributed to Meehan which says that therapeutic touch therapy involves ‘a knowledgeable and purposive patterning of patient-environmental energy field process in which the nurse assumes a meditative form of awareness and uses his/her hands as a focus for the patterning of the mutual patient environmental energy field process’ (Green, 1998). Therapeutic touch involves a multi dimensional approach to healing pain and goes well beyond the generally accepted scientific principles of pain management, as explored and handled by a pharmacological approach. It almost has a spiritual as well as supernatural angle involved in its application and delivery which affect both the patient and the person delivering touch therapy in a parallel manner (Green, 1998). In patients who refuse to take pain medications due to the known adverse and side effects or in others in whom such interventions are contraindicated it has a definite and lasting role in nursing care. The concept was developed following the philosophy put forward by Rogers which conceptualized the individual existence of a person in harmony with the environment which are different entities but still in a constant state of energy exchange (Green, 1998).

Pain itself is looked at as not just a physiological aberration, but the result of a complex interaction between the patient’s psychological make-up and the precipitating causes necessitating the need for a broader therapeutic intervention. Sensory and affective components of pain are responsible for the actual manifestation (Piotrowski et al, 2003). The sensory component involves the interplay of neurohumoral mechanisms which convey the sensation from the locus to the brain where it is consciously perceived as extreme discomfort. Sensory qualities are expressed in terms of relationship to time, intensity, location, pressure and thermal gradients. The affective component of pain involves the emotional context in which the patient identifies pain as an unpleasant experience. Tension, fear and autonomic responses contribute to the unpleasantness of pain which vary in individual patients (Piotrowski et al, 2003).

Within a palliative care setting, assessment of pain requires the use of pain measurement tools (PMTs) which involve the use of visual analogue scales, numerical rating scales and verbal rating scales in order to arrive at a proper evidence based decision about its occurrence and intensity (Caraceni et al, 2002). A judicious use of all the scales is required in order to develop a therapeutic approach in palliative care, especially in children and older patients whose cognitive ability may have been compromised enough not to elicit appropriate responses to the measurement techniques employed to assess pain (Caraceni et al, 2002). Providing effective relief with minimal side effects to patients of different age groups with diverse precipitating factors should be the endeavor of the healthcare professional by deciding the optimal therapeutic strategies and putting them into application by overcoming any obstacles in their implementation (Caraceni et al, 2002). The success of a wholesome approach while handling acute postoperative pain has been studied and found to be more effective in patients receiving massage as an adjunctive therapy in a clinical trial (Piotrowski et al, 2003). Three separate nursing interventions viz. massage, focused attention and routine care were used in a prospective study on 202 male patients who had undergone major surgery. Although the use of the recommended opioid analgesics was made in all the three groups, incorporating massage as an adjunctive therapy was significantly more effective in accelerating the rate of decline of unpleasantness and postoperative pain as well as successful to some degree in reducing pain intensity (Piotrowski et al, 2003). The role of complimentary methods in palliative care is exemplified in another study where touch therapy was used in its direct literal perception as healing by gentle touch in terminally ill cancer patients (Weze et al, 2004). Pre and post treatment changes in physical and psychological functioning were evaluated in 35 cancer patients over a time span of six years (Weze et al, 2004). Complimentary techniques used in the study involved one hour healing sessions spread over a total span of 4-6 weeks in which a standard protocol of non invasive touching of the head, chest, arms, legs and feet was followed while the patient rested in supine position (Weze et al, 2004). A single session took 40 minutes and also involved informal conversation between the patient and the administrator of the therapeutic intervention. Concentration, meditation and contemplative prayer were the other essential components of therapy which culminated with a ten minutes resting period (Weze et al, 2004). Pre and post treatment questionnaire data analysis from the patients revealed a high degree of satisfaction in the included subjects as well as definite positive results of the adjunctive therapy. Effective pain management therefore involves the use of more than a single therapeutic modality which has been acknowledged by the experts in the field. In a systematic review of randomized controlled trials of massage and touch therapies, it was shown that complimentary and alternative techniques such as massage and mind-body therapy were significantly better in removing anxiety, depression, nausea and pain and increased the overall comfort level of the patients near the end of their lives (Lafferty et al, 2006).

The necessity of proficiency among the physicians and mid-level practitioners in the recognition of pain management in a long term care setting has been highlighted in the recommendations made for such personnel (Winn & Dentino, 2004). According to the recommendations a holistic approach should be adopted by the healthcare professionals by taking care of the physical, emotional, social and spiritual aspects of the residents’ psyche (Winn & Dentino, 2004). The process must involve repeated evaluation of chronic pain as a routine measure for all patients and treated aggressively when an incidence is encountered. Regular monitoring should be an essential feature for evaluating the success of therapeutic interventions undertaken in this regard (Winn & Dentino, 2004). Any negligence or deficiency can result in myriad situations where the patients might experience physical de-conditioning, gait disturbances, falls, slower rehabilitation, multiple drug use, cognitive disorders, malnutrition, sleep disturbances, decreases socialization as well as enforcing unnecessary burden on hospitalization expenses (Winn & Dentino, 2004). The sequels of all these undesirable experiences usually are rise in morbidity, premature decline in patients, increased dependence on healthcare staff, loss of well being and dignity which might result in premature death (Winn & Dentino, 2004).The pharmacologic approach of handling pain is the mainstay of treatment but the drug use and dosage should be after proper selection, taking into account the degree and nature of pain. The dosage should be modified according to individual requirements as determined by the existence of co-morbidities and tolerance levels in individual patients. The holistic approach uses non-pharmacologic measures as well which include a combination of physical, nonphysical and behavioral therapies. The physical component includes measures such as application of heat pads or cold bandages, massage and muscle stretching, trans-cutaneous nerve stimulation, chiropractic/osteopathic manipulations, acupuncture/acupressure and magnetotherapy (Winn & Dentino, 2004). The nonphysical components for alleviating pain are more abstract in nature and have been enlisted by the authors as spiritual meditation, prayer, aromatherapy, music and other such activities which serve to divert the attention of the sufferer from the pain focus by enhancing tolerance (Winn & Dentino, 2004).

Model, Borderline& Contrary Case Studies

Model Case

A clear cut case of the successful use of touch therapy concept is that of Sarah (pseudonym), a 38 year old woman who refused hormonal therapy with Danazol (a testosterone substitute) for her condition which was diagnosed as endometriosis (Green, 1998). The reasons for her refusal were the side effects associated with this particular drug which include weight gain, amenorrhea and loss of libido (Green, 1998). Pain was an essential component of her disorder which increased her anxiety levels as well marred her QOL (Quality of life). Her usual treatment for pain involved the use of analgesic drugs. As an experiment Sarah opted for touch therapy sessions as an alternative mode for pain relief and to her surprise she was able to tolerate and later get completely cured from pain which she explained as a weird spiritual experience, although the administrator of touch therapy was not directly touching her. Sarah’s simple case is therefore a precise example for a model case where alternative therapy had resulted in a complete cure.

Borderline Case

A borderline case where an alternative approach is indicated but has not been used is that of a 54 year old woman who has been treated for pancreatic carcinoma which has metastasized to other parts of her body including bones (Hammes & Cain, 1994). There has been no response to chemotherapy and has been administered radiation therapy. Currently she is receiving hospice care at home which includes the use of morphine for pain which is exacerbated when she is repositioned in the bed. She asks for an increase in the dosage for pain. Her case is a borderline one as what is best for her has to be decided by the attending nursing staff taking into consideration the dangers of over-dosage with morphine. Alternative therapy is recommended in her case to ease her pain along with appropriate use of drugs.

Contrary Case

A contrary case can be that of any acute sports injury which is amenable to treatment by local dressing, hot and cold fomentation and administration of a general anti inflammatory analgesic drug such as aspirin. Although psychological aspects may be involved in very young or old patients, such cases usually heal spontaneously without the need for specialized interventions.

Summary

The numerous trials in recent years provide definite proof of better pain management with alternative and complimentary techniques, although the pharmacological intervention remains the primary mode of pain control. There is a definite physiological process behind the initiation of pain which is an indicator of disorder within an organ and which stimulates the sufferer to seek medical assistance. As the basis of human perception of pain is an intricate blend of physical and psychological experience, modalities to address both are necessary for optimum treatment, especially during palliative care of elderly patients with terminal disease. The administration of alternative modes of treatment need close cooperation between the patient and the healthcare provider which result in mutual benefit and better outcomes.

References

Caraceni, A., Cherny, N., Fainsinger, R. et al. (2002). Pain Measurement Tools and Methods in Clinical Research in Palliative Care: Recommendations of an Expert Working Group of the European Association of Palliative Care, Journal of Pain and Symptom Management, Vol. 23 No. 3

Green, C. A. (1998). Reflection of a Therapeutic Touch experience: Case Study 2, Complementary Therapies in Nursing & Midwifery Vol. 4, 17-21

Hammes, B.J. & Cain, J.M. (1994). The Ethics of Pain Management for Cancer Patients: Case Studies and Analysis, Journal of Pain and Symptom Management, Vol. 9, No. 3, 166-170

Lafferty, W.E., Downey, L., McCarty, R.L. et al. (2006). Evaluating CAM treatment at the end of life: A review of clinical trials for massage and meditation, Complementary Therapies in Medicine, Vol. 14, 100-112

Piotrowski, M.M., Paterson, C., Mitchinson, A. et al. (2003). Massage as Adjuvant Therapy in the Management of Acute Postoperative Pain: A Preliminary Study in Men, J. Am. Coll. Surg., Vol.197, 1037-1046

Weze, C., Leathard, H.L., Grange, J. et al. (2004). Evaluation of healing by gentle touch in 35 clients with cancer, European Journal of Oncology Nursing, Vol. 8, 40–49

Winn, A.S. & Dentino, A.N. (2004). Effective Pain Management in the Long-Term Care Setting, J Am. Med. Dir. Assoc., Vol. 5, 342–352