Hospices offer power of touch

Massage therapy provided in varied ways

Interest in complementary or alternative therapies is booming throughout the U.S. health care system, and massage or touch therapy seems to offer the most common avenue for many hospices to start exploring their role in this area. In a survey of Hospice Management Advisor readers earlier this year, they were asked to indicate whether they offered or planned to offer a number of complementary therapies; 44% said yes to massage/touch therapy. Massage programming is turning up more and more on the schedules of state and national hospice conferences, as well.

Hospices use massage therapy and other forms of therapeutic touch in a variety of ways. But they all face a number of basic questions, such as whether it is a covered service, whether it is written into the patient’s plan of care, and when it is indicated as an appropriate therapeutic modality for symptom management. Hospices also need to validate the credentials of massage professionals, train them in the hospice philosophy, and integrate them into the overall functioning of the hospice team.

The American Massage Therapy Association (AMTA) of Evanston, IL, defines massage as "manual soft tissue manipulation; includes causing movement and/or applying pressure to the body," with the aim of increasing health and wellness. Different types of massage include Swedish and deep tissue massage, Shiatsu and acupressure, and reflexology or massage of certain points on the hands or feet thought to correspond with other areas of the body. Other types of touch therapy include therapeutic or healing touch and Reiki — a form of hands-on healing involving energy channeling.

Massage as a complementary health therapy does more than just make people feel good; increasingly, it is being integrated into medical practices and covered by insurance plans. Hospices are using massage therapy as an adjunct to pain management, to help prevent decubitus ulcers, and to treat patients’ anxiety, agitation, insomnia, or isolation. Family caregivers also may be targeted for massage if their stress level is high.

How do hospices utilize massage?

At Boulder County Hospice in Boulder, CO, massage therapy volunteers have been employed since the late 1970s. Credentialed massage therapists go through a hospice volunteer training course to orient them to the hospice philosophy and are required to take a course titled "Comfort Touch for the Elderly and Ill," taught by Mary Kathleen Rose, CMT, a volunteer with the hospice since 1989 and currently its supervisor of massage therapy.

Comfort touch is a term Rose coined to describe her approach to touch therapy for the ill or elderly, which focuses on comfort, safety, and the use of slow, broad, gentle strokes — since the deep tissue work practiced in sports massage, for example, would be too painful for hospice patients. Massage therapists also must work on patients where they find them, without the benefit of a massage table.

"We view it as one more thing to add to hospice’s comfort package," explains Jackie Stipe, the Boulder hospice’s human resources coordinator. "We address it like any other volunteer going into the home to provide companionship or support, under the supervision of the nurse case manager. It complements what we already offer as far as palliative, comfort care and relaxation, and it’s immensely popular," Stipe says. The hospice also utilizes student interns nearing the end of their classroom training, and refers bereaved survivors to a list of local massage therapists. Currently it has 18 massage therapy volunteers or interns under Rose’s supervision, and about a third of its caseload receives the service.

"I hear patients say this is the brightest spot in their week — just knowing someone cares enough to touch them. They sometimes say, Nobody has ever touched me this way before,’" she adds. "The therapists tell us it feels so good to make such a difference in their patients’ lives."

FirstHealth of the Carolinas Hospice in Pine hurst, NC, also offers massage services to its patients. But if the therapy is considered an appropriate part of the interdisciplinary team’s plan of care and approved by the attending physician, the hospice will pay for it, under contract with a nearby fitness center run by its parent health system. "We let patients know we have complementary therapies. They may have an interest and ask us about the option, or we may feel they need it" and recommend it to them, explains hospice social worker Tina Markoff, CCSW. "We discuss it as a team, then we definitely put it in the treatment plan."

The North Carolina hospice also is developing a new pre-hospice program, emphasizing complementary therapies such as massage, yoga, Tai Chi, group therapy, and individual counseling, explains Options program coordinator Judy Fore. The program targets the problem of short length of stay in hospice by connecting with patients who have life-limiting illnesses before they are appropriate or ready for hospice care. "I think people need to start dealing with death and dying, grief, loss, and spirituality much sooner in the course of their illness," Fore says. "We hope to pull together a community of people sharing these common concerns."

The hospice at Kaiser Permanente HMO’s Walnut Creek, CA, medical center currently has three part-time massage therapists on staff, says hospice director Valerie Ghirardo, RN, MPA. They are part of its menu of ancillary services, including art and music therapy, which are offered to all hospice patients and paid with donated funds. "Most of our patients accept at least one ancillary therapy, and massage is very popular," Ghirardo says. "It’s just nice to have that touch. It means someone’s there to care for them, that they’re special."

The hospice also uses massage for pain control, for emotional isolation, and just to help patients relax. "When we get a physician order, we look at the frequency of massage visits and use a problem, intervention, goal, assessment approach on the plan of care. The massage therapist also does progress notes," she explains. "Massage therapists will tell you that they also do a fair amount of listening and counseling. When people are more relaxed, they tend to talk more. The therapists are very much part of the team — they come to team meetings and teach other staff about the benefits of massage."

Massage also is appropriate for family caregivers, who sometimes experience such great stress, anxiety, or exhaustion that it physically tightens them up, says Jan Sinn, LCSW, social worker at Hospice of Bloomington, IN. "What’s important about massage is it can often be provided when there’s little communication going on between the patient and caregiver. Teaching simple hand or foot massage can help such caregivers interact with their dying loved ones," Sinn observes. "It’s also an important provision of care when the patient is comatose or semi-comatose. The family finds it very rewarding to continue massaging the patient."

Other issues for massage programs

Although hospice directors with massage programs report that they are popular with patients and well accepted by physicians, there are potential problem areas. One of these, Markoff says, concerns the number of visits made by the massage therapist. "It’s important to make it clear to the family up front that massage is an not unlimited benefit," she says.

Another key question is how to pay for it, says Emil Zuberbueler, a registered massage therapist, administrative specialist with Family Hospice in Dallas, and allied therapies representative on the Arlington, VA-based National Hospice Organiza tion’s Council of Hospice Professionals. "If you just use volunteers as massage therapists, they should go through the hospice volunteer training," he says. "It is also important that they be appropriately credentialed in their state."

Pikes Peak Hospice in Colorado Springs, CO, offers a full complement of massage and touch therapies, says its CEO, Martha Barton, RN. "But when we embraced the process more than 4 years ago, we decided we would only do it if we saw it as an extension of symptom control" for patients with complex symptom management needs, not just because it feels good to the patient. "We take massage very seriously. We will pay for hours of direct services and management. We also use as many volunteers as we can," she says, adding that half of the agency’s current caseload benefits from the service.

"We just think it broadens our opportunity to achieve successful outcomes," Barton says. "As we’ve tightened up in so many areas, this is one of those programs I’m working very hard to hold onto. We really do see that it translates into patient comfort."

Zuberbueler believes that resistance to the idea of massage therapy by hospice professionals has largely evaporated in recent years. "Enough has been in the media about alternative therapies. The federal government has two different organizations set up to look at the issues. I don’t think many people today would say this is too far out. Ten years ago, yes. Then I would say I do massage therapy and they’d just laugh. That doesn’t happen anymore, even in Texas."