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Massage in Hospice Care
Geriatric Massage

By Dietrich W. Miesler, MA, CMT

Originally published in Massage Bodywork magazine, August/September 1999.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.



What is the reason for the establishment of hospices?
The idea of the hospice for the terminally ill comes from England. The main purpose was to make heavily sedating drugs (referred to as pain cocktails), including so-called "illegal" drugs, available in necessary dosages and combinations to keep these terminal patients pain-free. As the patients have been given up on medically, every action, though medically supervised, serves to make the patient live as comfortable as possible. In simpler terms, hospice care is no longer directed toward healing, but to making life bearable.

The British concept was accepted by the American health care system and one of the first American hospices was founded by Kaiser Permanente. The first thing Kaiser had to do to make the concept palatable to the American health care system was to eliminate the illegal substances from the pain cocktails. The humanitarian aspects of the original hospice concept was maintained and to this day, the Kaiser Permanente hospice has remained a model institute. A concept incorporated into some institutional hospice programs is that after working in the hospice department for one year, a nurse will rotate to a neonatal department for a short time. It was found that this juxtaposition of caring for those people whose life cycle was coming to an end and caring for the equally fragile newborn had an ameliorating, emotional effect to counteract the stress buildup caused by the constant exposure to all the suffering in the hospice department.

What is the modern hospice like?
A hospice is a shelter for travelers....at least according to Webster's New World Dictionary. This term apparently came into use for institutions for the terminally ill with the lyrical intent of lending grace to a grim stage of a human's journey through life as that journey approaches death or transitions into the next realm, depending on the philosophical conviction of the dying person and their families.

Taber's Cyclopedic Medical Dictionary has a more clear definition: "An interdisciplinary program of palliative care and support services that address the physical, spiritual, social and economic needs of terminally ill patients and their families."

How can massage help in hospice care?
Massage is one of those curious human interactions which differ in their effect, depending on the intent with which they are performed and received. The reason why touch is so powerful is based on the recognition that tactile experiences are the first sensations which greet us at birth. They are also the last perceptions to leave us when we die. Touch has been known to create a rise in blood pressure of people in a deep coma and to penetrate the nonverbal state of late stage Alzheimer's patients who, suddenly during a massage, may blurt out a sentence like, "Oh, this feels good," only to return immediately into their silent world. By the same token, touch can penetrate the semi-comatose state produced by a painkiller and give the treatment a modicum of human contact. In fact, patients sometimes reduce their demand for drugs when massage is an integral part of the treatment protocol.

What type of massage would you use in hospice care?
With these patients, you would emphasize geriatric massage techniques which are directed toward the amelioration of pain, rather than the vigorous approaches of deep tissue work or acupressure.

Do the techniques require a trained therapist?
Once the best approach has been established by an experienced massage therapist, it is very much in the interest of the family members to be trained to participate in the physical care of the patient. The techniques are not difficult to master and can be executed by lay people. This would of course be a great enhancement to the social aspect of the visits, allowing family members an opportunity to touch their ailing loved ones and possibly offer them some relief. Having family involved in the bodywork of a hospice patient would also lead to considerable financial savings, but more importantly, the schedule of therapeutic touch could be enhanced if there are several family members to take turns and share the task. In fact, male teenagers and young men who often feel awkward on occasions such as patient visits, especially like the fact that they have a purpose, sometimes even a compelling reason, to visit ailing grandma or dad, and it could make a big difference in their whole outlook on life. Even more importantly for the patient, these visits may be the closest they have been to that teenager in years and may help bring about a closure.

Sometimes the outcome defies expectations
When the Sequoias in the San Francisco Bay area began to develop their upscale senior housing concept, they based the financial calculations on the prevailing longevity statistics to establish a formula for sales prices for condo-type units with a lifelong service guarantee. They found to their surprise that the inhabitants "refused to die" when it was their actuarial duty. Tenants lived up to 10 years past their life expectancy which upset the financial applecart terribly. The reason, of course, was clear. They lived in beautiful surroundings with everything taken care of - this provided the emotional boost these tenants needed to want to stay alive.

A similar situation can happen in a well-run hospice program. I've seen people, who had at best four weeks left to live, hang on for months and months. Remissions are rampant and reversals are not uncommon. This shows that with proper care, the absence of worries and having a handle on the often vicious pain, the patient's innate will to live can be "recharged." As is common, the typical hospice - not being set up for extended stays - has to send those patients in remission home again. Therefore, it is important for families to continue care at the same rate as was received during the hospice stay. If massage is part of the treatment protocol, it is important to continue that care at the same level too.

While you can not expect any great changes or improvement in the general health condition of the client, the physical presence of a close relative or at least a loving friend can be incentive enough to continue the treatment. However, this should not preclude hoping for a miraculous breakthrough, and do not think last minute reprieves have not happened.

Guided by the patient's and doctor's permission, common sense and determination, or sometimes just pure curiosity, a therapist can plod along and, voil, in the end save a doomed leg. It can be done. Depending on the type of ailment the patient is suffering from, you may even discover an approach which works with other patients too.

There are some remissions that I was personally involved in. The most impressive is a story I've told here before, but which warrants repeating. I was working with a 79-year-old male patient whose legs had been scheduled for a bilateral amputation above the knee. With permission from the patient's physician, I began massaging him 20 minutes, three times a week for an indeterminate duration. The legs improved within 10 weeks to the point that the amputation was postponed and after eight months, cancelled. As the gentleman lived another three years with the use of his own legs and because it is impossible for a person of such advanced age to learn the use of two artificial legs above the knee, it can be claimed that the massage prolonged his life by at least two years. His life might have been saved by amputation, but at a terrible price for the patient and his whole family, and atrocious pain, even phantom pain, for the patient the rest of his days.

Author's Note
The Day-Break Geriatric Massage approach is a recently developed massage modality. It has only been practiced for about 20 years and has only been taught systematically since 1991. Yet, it has proven its value and it fills the need for a new approach to the special requirements of the ailing and the elderly, thus it became a favorite of many mature massage therapists who want to make a difference in their clients' lives. That many of the therapists who study with Day-Break are nurses who attend our workshops at the recommendation of other nurses who became familiar with Day-Break's work via this medium, makes us very proud. Geriatric Massage is an ideal modality to be included in hospice settings as the perfect partner in an interdisciplinary program of palliative care and support services which address the physical, spiritual, social and economic needs of terminally ill patients and their families.

Dietrich W. Miesler, M.A., C.M.T. is the founder and director of the Day-Break Geriatric Massage Project, P.O. Box 1815, Sebastopol, CA 95473; phone 707/829-2798; fax 707/829-2799; e-mail at daybreak@monitor.net. Find out more about Day-Break at www.daybreak-massage.com.






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