Originally published in Massage & Bodywork magazine, February/March 2004.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.
Miranda was a dying woman who served as a challenge and inspiration for me in the last months of her life. My experiences with her marked the true beginning of my realization of the importance of energy work in hospice-based massage. Since Miranda's death, I have come to fully accept and integrate energy work into my practice and I now routinely use it alongside other manual modalities. Working with her was a privilege for me. The opportunity to witness the spiritual transformation within the sacred space surrounding a person dying is always an awesome gift, but to do so while companioning them over a period of five months is a miracle. It simply changed my entire perspective concerning why I do what I do.
Furthermore, to recognize the fact that I was the only male caregiver -- in a sea of social workers, nurses, physicians, nurses aides, etc. -- who she allowed in her presence, the only male that she did not fire or shun, humbles me.
I look back on this time as perhaps one of the most profound of my career. Of course, it made me nervous at times, afraid and bewildered. But, by simply not giving up on her in those moments when I lost my grip, great things happened.Patient Background
This case study spans a period of five months in the life of a young mother who accepted touch and energy to provide her with relief from pain and insomnia during her final months of life. It is an unusual case, primarily due to the intensity of the final sessions and use of reiki to resolve multidimensional pain.
Miranda was a 42-year-old, single mother of three. Her children ranged in age from 13 to 18 years, each with a different father. During Miranda's last six months of life, she sought adoption for her youngest child. Prior to her diagnosis, she worked as a waitress. A social worker later described her home environment and relationship with her children as highly dysfunctional.
In 1998, Miranda was treated for squamous cell anal carcinoma. She experienced a complete remission. However, in early 2002, she began to complain of severe pain in her upper right quadrant of her body. A massive hepatomegaly was found, practically replacing the left lobe of her liver.
Soon, Miranda began experiencing significant clinical depression with heightened anxiety. Her physician described her as emotionally fragile and withdrawn, with a substantial fear of dying. Miranda had terrible nightmares. A referral to hospice was made in June 2002, meaning she had less than six months to live. By September, it became difficult for her to remain at home, with her eldest child acting as her primary caregiver. At this time, her hospice team talked with her about moving to a residential hospice.
Miranda did move, but remained there for only approximately 60 hours, eventually discharging herself and returning home. While in residence, she found it unbearable to be around other people who were also dying. She identified a friend who would be willing to care for her, though upon her return home, she continued to accept hospice services. This arrangement did not last long, and once again it became imperative for Miranda to receive outside help. In October, she chose to return to the residential hospice.
Miranda was recognized by the staff as having changed drastically in physical appearance. Jaundice discolored her skin and ascites (accumulated fluid in the peritoneal cavity) made her appear nine months pregnant. Her nurse encouraged the use of music and massage therapies, especially for emotional support. Pain control was a significant challenge.
It soon became evident that Miranda did not trust men and had great difficulty opening up and relating to them in any way. Her affect was normally flat, and she disclosed little information to anyone, including her social worker, who indicated that she displayed little emotion during their sessions. It remained excruciatingly difficult to assess what Miranda was thinking or how she was reacting. Initially, she was quite reclusive, keeping the door to her room closed and rarely venturing out. Her primary complaints throughout her stay were of pain, nausea and insomnia.
My primary intention, as a massage therapist specializing in hospice, was to use massage, manual modalities and energy interventions as a natural and gentle complement to the traditional means of coping with the pain associated with terminal illness. Initial Sessions, September 2002
Upon her first admittance, Miranda was informed that both music and massage therapies would be available to her. Her nurse encouraged Miranda to utilize them, especially for her anxiety and emotional instability.
After having been in residence for approximately 15 hours, Miranda requested that the caregiving staff call me in from home. Upon arrival, I learned that her primary complaint was left axillary and shoulder pain. The staff reported Miranda had been crying throughout the day. She rated her pain at an 8 out of 10, and described it as a non-referring, chronic, throbbing nuisance. Three doses of Roxanol dispensed at 30-minute intervals prior to the massage did not influence the pain. She was crying throughout the assessment and was most comfortable in a right, sidelying position. Palpation revealed no significant muscular involvement.
Miranda received slow stroke back massage blended with digital kneading and palmar compression; friction; reiki to the crown, spinal column and left shoulder (focusing on the thalamus-pituitary gland neural pathway for bio-opioid release); brushing and holding.
At the conclusion of the session, Miranda was sleeping. I placed a referral to music therapy and asked the staff to notify me with Miranda's perspective of the session when she awoke.
The next day I received another call indicating Miranda was asking for my assistance. Upon my arrival, she said the previous day's session decreased her pain and aided her sleep. When she awoke, the pain level was tolerable; as the day progressed, it worsened. Her pain medications were increased, but they were making her gaseous. I noticed that her affect seemed brighter, but her depression was observable.
I provided her with a session using the same techniques as the day before, but in a different pattern. She once again fell asleep during the session and remained so for several hours thereafter.
Miranda discharged herself from the hospice the next day. Readmittance, October 2002, Attempt to Re-unify
Two days after Miranda's return, several attempts were made to reconnect with her. Most often, these attempts were of short duration and consisted mainly of female staff intervention on the behalf of the massage therapist. Miranda preferred to be alone. Silence and refusal continued in excess of one month.Breakthrough, December 2002Session 1:
On this day, a caregiver suggested massage to Miranda as a method to relieve her pain after she experienced a morning of agony. Surprisingly, Miranda accepted.
She complained of extreme pain in the upper right quadrant that was referring around to her back. She also continued to experience left shoulder pain. Her ascites was pronounced, and it was uncomfortable for her to lie on her left side. She displayed jaundice, cachexia (wasting away) and weakness, but was still able to ambulate and venture around the building. Miranda's pain was multidimensional: The physical was compounding her emotional, social and spiritual suffering.
Since she was in such turmoil, I decided upon a modality that I had minimally utilized in our first few sessions together -- reiki. The comforting nature of passive touch coupled with the awesome energy involved could be of great benefit. I explained to Miranda what I would be doing and with her approval, proceeded.
While performing a bio-opioid release on her parietal region, access to her thalamus-pituitary gland pathway required intense focus, more than I was able to perform. Eventually, my left hand broke through the barrier, but only briefly. I could visualize the region, but not on a cellular level. While at her shoulder, the opposite was true: A magnetic draw toward her heart was experienced. The first, in what was to become a striking series of visualizations later in our work together, occurred here. A thick wall, encasing her heart, was seen. I did not believe that the energy made a significant impact on this wall as it was quite old and strong. The other positions felt unsuccessful as well. Miranda offered no comment as to the outcome of the session.Session 2:
When she passed me in the hallway 11 days later, Miranda turned around and asked me to visit her that day. I decided to see her immediately.
I began attacking Miranda's pain on several levels and provided her with a session that integrated many modalities in a rhythmic interchange that was seamless and full of continuity. I was conscious not to overwhelm her system and developed a strategy to emphasize only crucial points. While she remained in a right fetal position, I performed reflexology to her liver, reiki directly to the liver region and to pain control centers, therapeutic touch, brushing, acupressure along her shoulder and cervical region, slow stroke back massage and light, highly repetitive Swedish to the left aspect of her back and shoulder.
Miranda allowed herself to fall asleep intermittently during the session.Session 3:
Three days later, Miranda asked for me to visit her once again, requesting massage for pain relief.
An energy assessment revealed the following: Cluttered static acting as a barrier surrounding her head; a void over her heart with cold darkness; and a liver region loaded with heaviness.
This session resembled the last in structure, but included a greater degree of Swedish massage. I was able to access her heart and began filling it with energy, but her brain remained difficult to penetrate, accepting very little.
For the first time, she said "thanks" when I left her room.Opening of Heart and Mind, December 2002-January 2003Session 1:
While I was studying clinical charts in the office, Miranda approached the doorway and secured my attention. She requested a session. I was stunned, as were my colleagues, by her behavior -- this was not the Miranda that came to us in late October. Several of the staff mentioned to me that they had witnessed her coming out of her room more, eating at the common dining table and entering the smoking porch to talk with fellow residents. Her appetite had increased and they noticed a decrease in her reliance upon pain meds.
I continued to use a blending of modalities in order to confront her pain on various levels. However, the reiki portion began taking precedence. This marked the first session during which intense visualizations occurred, guiding me in my work.
During the initial placement of my hands upon her head in order to secure the bio-opioid release centers, I began to experience a deep, meditative-like level of consciousness. I could see Miranda, twirling in a turbulent sea of air. She had a fearful expression on her face and was very confused. She was unable to stop her body from being tossed about in the wind. Later, while my hands were over her heart, I visualized something completely different. Miranda was clothed in light and appeared as an angel. Light was beginning to fill the space she was standing in, and she smiled at me. An angel approached her, took her hand and began walking with her toward a pinpoint of light in the distance.
My immediate impression while experiencing these two images led me to believe that Miranda was experiencing a rift between her heart and mind and was in need of healing so that the two could be as one. I provided her with the initial treatment to connect her heart energy with her mind, using a connective hand position to shift energy from the heart center to the crown.
Miranda was sleeping peacefully at the conclusion of our session.Session 2:
Miranda requested this session. I was advised that her insomnia continued to be problematic and that her ascites was increasing.
The session was a variation of the usual treatment. I initiated a lotioned cervical massage that, up to this time, I had not felt comfortable applying due to the intimacy of contact that it connotes. Miranda accepted it.
During the energy portion of the session, I was again able to visualize her status mentally and found that she had progressed. She was sitting in a chair solemnly, and light was beginning to shine down upon her. Miranda enabled me to further the process of healing and I found the treatment successful.
While in session, Miranda fell into a deep sleep. So as not to disturb her, I remained by her side once I was finished, offering prayer and therapeutic presence. Session 3:
This remarkable session occurred 10 days later. Upon my arrival to work, Miranda caught me as I entered the house and requested a session.
I began by brushing through her energy field, mainly in order to prepare it for alteration and infusion. Thereafter, I provided her with full body stroking, with much repetition, in order to calm her on a more profound physical level and to prepare her for touch. Once complete, I slowly transformed that into slow stroke back massage. At this point, I considered her ready for reiki.
Placing one hand directly over her crown and the other upon the side of her head and face, I felt an immediate connection. I was amazed to meet Miranda in a field, dancing joyfully, the atmosphere surrounding her filled with a white glowing light. She spoke to me, telling me she was happy deep within and ready for what may lie ahead. With this information, I thought that the best I could do was offer her energy to support her in the journey. Soon thereafter, I witnessed sparkles of golden snowflakes showering down upon her. She lifted her arms in response to these and danced among them. I then disengaged and assessed her heart.
I was amazed to find nothing there. It was peaceful. I continued the session by giving Miranda Swedish massage, very lightly, upon her left shoulder where she had complained of pain in the past. It was gentle, slow and compassionate. Then, I proceeded to her feet where I initiated a long session of lotioned anti-anxiety massage to induce sleep. I also incorporated reflexology. At the point that I felt the session was virtually complete, I again engaged her in reiki, but at the feet. My visualization here confirmed previous findings -- the area where her heart center should have been was gone and her mind was joyful. I centered the energy physically to initiate release of bio-opioids, shield the liver and decrease pain stimulus transmission through the spinal cord.
At the end of the session, Miranda was sleeping soundly, deeply. I blanketed her and left the room.Session 4:
Upon arrival, the caregiver informed me that Miranda had been experiencing severe pain since approximately 7 p.m. the day before. Many medications had been given with limited results. Miranda sought out massage.
She informed me that her pain was centered in her abdomen, radiating around to her low back. I assisted in positioning her on her right side and began the treatment, which included digital pressure, palmar kneading, reflexology, manual lymph drainage (this mainly for its pain-reducing qualities) and reiki.
During the reiki sequence, I was stunned by another interesting visualization. Miranda was walking hand in hand with an angel toward a distant light. I felt something was wrong, however. Miranda did not seem as happy as she had been the day before. A black ring surrounded the light and the angel glowed with light in an odd manner; it did not seem to be coming from within him, but around him. With further concentration, and intense focus, I saw that the light was coming from the ground. The angel had a black face hiding under light and its body was dark under the garments. I quickly prayed that the bond between Miranda and this false angel be broken and shielded her with reiki energy. I asked for light to surround me, as well. With much help, the angel returned to the ground and the hole was sealed, with Miranda left alone, frightened. I again shielded her with light and instructed her to find the white light, to trust only her guardian angel. I did not have the strength to do any more, so I ended the session. Miranda was in a deep sleep when I finished, so I left her quietly.
Later that day, I was advised that Miranda had fallen, striking her head against a chair. She suffered a laceration that did not require stitches.Final Sessions, January 2003Session 1:
Two days after her injury, Miranda was very weak. She required assistance in all activities and began to accept aide to do so for the very first time. Our relationship progressed to the level where she desired to see me whenever I was available.
This session was significant for the provision of a lotioned back, shoulder, neck and foot massage -- a big step in trust and openness for Miranda. Reiki was provided to her heart and mind. I had great difficulty connecting with her mind, but with the calling of her name, she appeared in two ways: Sitting in a chair and floating above a field. She was resistive to accepting energy, fearful of trusting and hesitant. Her heart was distant and required intense concentration. Once connected, I saw only light in an open space. I focused on providing strength, healing and balance to these areas.Session 2:
Miranda's hospice nurse stated that Miranda would likely develop terminal restlessness. I found her pain controlled much better than in weeks past. She informed me that sleeping was easier and that her pain level was lower.
I provided her with our usual session, although modified to her tissue loss. The reiki session was difficult. At the level of her heart, there was a blinding light that was incredibly intense and almost impossible for me to look into. I made out Miranda's form within this light, heading deeper into it and away from me. She stopped her movement to listen to me. I asked her not to go until she had connected this heart energy with her mind -- to use this light as a way to resolve her problems in this life. It was quite difficult to counsel her, as she was being drawn away from me by a force that was overwhelming. I finally had to release from it because it was too difficult to stay within it -- too much energy and heat. At the level of her head, I found her swirling in turbulence. She would not connect with me. I had to become very firm and insistent and finally she stopped and listened to me. I felt unsuccessful and weary. I concluded the session by diverting heart energy to her mind.Session 3:
Two days prior to this session, Miranda informed the staff that she was afraid to die. Even though she was close to death, Miranda continued to care for herself. The staff witnessed increased congestion and apnea. Restlessness became increasingly evident. Miranda experienced difficulty finding a comfortable position. It was time to discontinue all modalities except those based in energy and passive touch. I worked only at the level of her mind, to give her most troublesome area a final try.
With much perseverance, I was able to visualize Miranda. She was in a column of intense, concentrated light heading upward. She was being drawn through it, much as a piece of metal toward a magnet. Within this column there were wonderful colors -- primarily rose and white with sparkles of yellow and orange. The atmosphere within this column was quite thick, almost like a gel, and very warm. After a few moments, I realized I was actually inside of this as well, not observing her from without. At this time, I felt pulled up along with her and began to hear bells and faint singing -- it was beautiful, but without a tune really, and it was faint as if far in the distance. At this point, I attempted to speak to Miranda, but immediately received the sensation it was unnecessary to do so and also that I did not belong there, so I allowed myself to disengage. I witnessed Miranda floating away within it, higher and higher. I was so glad that she finally allowed her heart energy to resolve her mental struggle.Session 4:
Three days later, Miranda was actively dying. At the request of the staff, I approached Miranda to offer comfort through touch.
Initially, Miranda displayed only slight signs of terminal restlessness. After a reiki session to her feet, she was extremely calm with no visible attempts at movement of any kind.
I engaged her in a format that I usually reserve for the final days of life: The Hand/Heart Connection (HHC). After conducting an assessment, and finding a significantly weak human energy field with no energy at all palpated from the heart to the feet, I knew from experience that her time was near. I did not try to do visualization, for I did not wish to interfere with her natural process (it is thought that the spirit leaves through the head and to interfere with it at this time would be unnecessarily binding). So, with this in mind, I offered her support through the HHC, focusing on energy for peace, love and healing. It was at this time that I bid her farewell, thanked her for allowing me into her life and let her know that she was loved.
Miranda died later that day.The Lessons
Since these experiences with Miranda, I have found reiki to be an extremely effective modality for use within the hospice population. Combined with standard massage therapy modalities and manual therapies, it is an excellent choice for those suffering with anxiety and other issues surrounding death and dying. I have found few contraindications to its use and encourage its application especially with people who are difficult to engage otherwise. The visualizations experienced in this study were deeper than I had experienced previously and are not typical of all reiki interventions that I conduct. With excellent nursing, caregiving, social work and music therapy interventions, Miranda also used massage and reiki as an appropriate tool to assist her in overcoming her fears, anger and loneliness. John Mramor, MA, LMT, CMLDT, CR, NCTMB, is the massage therapist for the hospice division of the Visiting Nurse Association in Cleveland, Ohio. He is also the staff massage therapist for Malachi House, a non-profit residential facility for people who are indigent or without an available caregiver and with six months or less to live. He co-authored, along with his wife, Karla, the grant proposal that won Malachi House a three-year start-up grant from The Cleveland Foundation, with which he created the therapy program. Mramor is certified in both manual lymph drainage and reflexology, and is a member of various hospice organizations.