Palliative Alchemy

1. Converting Fears into Healingcollaborative spiritual and complementary medicine care for the dying Joyce Greenberg, EAMPRev Shakur Sevigny Palliative Alchemy

2. Bios • Rev Shakur Sevigny is a Spiritual Care Provider with Kindred Hospice of Seattle.  He is ordained a Healing and Life Transitions Minister in the Inayati Sufi Spiritual Order.  He is also a graduate of the IM School of Healing Arts in New York City.  While in Portland, he was appointed Affiliate Instructor in the Department of Family Medicine in Palliative Care at Oregon Health Sciences University.  He has a B.A. In Religious Studies and has completed graduate Applied Theology coursework at Marylhurst University.  He has developed integrative medicine programs of several modalities at the Kindred Hospice programs of Portland and Seattle, including Acupuncture medicine. • Joyce Greenberg, EAMP, holds a Masters of Acupuncture from the Northwest Institute of Acupuncture and Oriental Medicine. She is a National Board Certified acupuncturist and has completed a chaplain residency through the Clinical Pastoral Education program at Harborview Medical Center in Seattle. Joyce served as the consulting acupuncturist and hospice chaplain for Kline Galland Nursing Home and Hospice. Currently, she is an acupuncture provider for Kindred Hospice. Her private practice in Seattle specializes in complementary health care, palliative acupuncture, and end-of-life care.   • No conflict of interest

3. How Kindred Hospice implemented Complementary Therapies • Cultural issue - began identifying patient need or request as unmet need (ex. COPD Pt requesting her L.Ac.) • Limited use of complementary therapies until success stories (aka positive outcomes) accumulated. • Discussion with Management team: complementary therapies expand palliation through increasing available modalities. • Support from medical director. • Management agreed to pay for services and later contracted with practitioners. Recognition that paying for a service results in better care 

4. Objectives • Learning Objective 1:  • Participants will learn concrete steps in how to establish and maintain a complementary program within the Medicare Conditions of Participation. • Learning Objective 2: • Upon completion of this session, participants will know how to make appropriate referrals for palliative acupuncture and related modalities for improved spiritual outcomes. • Learning Objective 3: • Upon completion of this session, participants will be able to give two examples of symptoms which can be co-treated by acupuncture and spiritual support providers collaboratively.

5. Healing Coming into relationship and harmony with body—mind complex amplifies a patient's sense of well-being and healingeven in the face fear and/or suffering. “God turns you from one feeling to another and teaches by means of opposites so you have two wings to fly not one.” Rumi Mind Body

6. Utilization of Acupuncture in Palliative Care • Most common utilization in Palliative Care • Pain (including neuropathic pain) • Chemo-induced nausea and vomiting • Fatigue  • Dry mouth (xerostomia) • Breathlessness (dyspnea) 

7. Research Summation of Research Findings • From  Leila Kozak PhD, Clinical Champion, OPCC&CT –IHCC/VACOhttps://www.va.gov/patientcenteredcare, Co-Director, Center for Integrative Palliative Care, Co-PI,Integrative Therapiesin Palliative Care Project, R41 NCIAffiliate Assistant Professor, Dept. of Family Medicine, UW School of Medicine, Seattle, WA • More than 1300 Randomized Controls Trials published on acupuncture and pain • Most suggest decrease pain, including neuropathic pain • Good evidence for chemo-induced nausea and vomiting • Smaller number of studies: positive effect on stress-related symptoms, depression, fatigue & Quality of Life • Few studies: decrease dyspnea and dry mouth  • Methodological issues: what constitutes good control group (sham acupuncture or sham needles) • Dose issues • Lic Acupuncturists: well organized profession, highly trained, lowest medical liability rate • Training in oncology expanding, oncology clinical guidelines available

8. Who Benefits from East Asian Modalities? • Patients and families from cultures that value traditional medicine (Chinese, Vietnamese, Russian, etc.) • Patients and families who are mood and consciousness altering medication resistant or opiod dependent • Patients - control of symptoms and management of breakout pain • Patients - enables coping through alleviation of symptom clusters and increased relaxation, awareness and sense of well-being • Patients – more open to referrals to spiritual care after treatments • Nonverbal patients (advance dementia, Alzheimer's, TBI, End stage patients) • Clinical staff on team • Caregivers

9. Benefits for Clinical Staff • Increases work satisfaction by improved patient outcomes • Relieves moral distress in clinicians when they feel stuck • Provides better opportunities to address complex issued such as trauma, PTSD and web of EOL symptoms (pain, lack of sleep, personal dignity concerns, etc.) • Help bridge communication about mind-body issues through physical assessment and diagnostics. • Clinician becomes part of whole person healing treatment plan - not just symptom management

10. From Kindred’s Medical Director • “The use of complementary medicine in our hospice care has been a unique and an effective adjunct in patient care. Our patients have benefitted with the use of additional modalities to treat a wide range of symptoms. Our clinicians have been able to address issues of ineffective control of symptoms that often do not respond to conventional medications. In discussion at IDG we are faced with patients who are suffering from incomplete pain control and a wide variety of psychological diagnoses. Our practitioners have been able to help patients who experience nociceptive and neuropathic pain poorly controlled with usual pain medications. Many patients have an element of emotional stress which contributes to pain perception. With these added tools in our treatment regimen we have been able to help patients with improved pain control and help them recognize the degree to which psychological issues can be a barrier to achieving the goals of integrated multifaceted care at the end of life. With the team of Joyce Greenberg and Shakur Sevigny we have an experienced duo of practitioners who can identify appropriate patients and provide a high level expertise. I feel very fortunate to learn from them about the use of these modalities and benefit from their talents. ” Marc Cordova MD, Kindred Hospice Medical Director

11. Caregiver Support Caregiver training and support for bedside comfort care Daughter of hospice patient said to us: “There is more than one kind of medicine, I know,  and we want to use everything we can for mom.  We want her to be relaxed to she can feel less pain and enjoy more of her time with her family.” 

12. WA State RCW 18.06.10 Definitions (1) "East Asian medicine" means a health care service utilizing East Asian medicine diagnosis and treatment to promote health and treat organic or functional disorders and includes the following:      (a) Acupuncture, including the use of acupuncture needles or lancets to directly and indirectly stimulate acupuncture points & meridians;      (b) Use of electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians;    (c) Moxibustion    (d) Acupressure    (e) Cupping    (f) Dermal friction technique    (g) Infra-red    (h) Sonopuncture (i) Laserpuncture     (j) Point injection therapy (aquapuncture)    (k) Dietary advice and health education based on East Asian medical theory, including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements     (l) Breathing, relaxation, and East Asian exercise techniques     (m) Qigong     (n) East Asian massage and Tui na, which is a method of East Asian bodywork, characterized by the kneading, pressing, rolling, shaking, and stretching of the body and does not include spinal manipulation     (o) Superficial heat and cold therapies.

13. Channels and Acupoints Mechanism of Action According to TCM, acupuncture points are located at specific areas along channels or meridians. Qi (energy) flows in this network of channels which connect different parts of the body and organs into a unified system.

14. Acupuncture • Single use sterile needles • Possible side effects: bruising, dizziness, bleeding, pain. • Have large selection of types of needles, techniques and treatment protocols to accomplish therapeutic goals. • Do not need to treat affected area. Can use distal points on channel or microsystems (ear, hand, scalp, body). • Acupuncture commonly used in combination with other modalities. Pain (Acute and Chronic), swelling, fatigue, constipation, depression, anxiety, insomnia, immune system support, Chemotherapy and Radiation side effects (pain, nausea, vomiting, hot flashes fatigue, dyspnea)

15. Electrical Stimulation Benefits of Electro-acupuncture • Stimulation of acupuncture points in combination with trigger points relaxes muscles, increases circulation, reduces inflammation, releases beta-endorphins. • Can provide instant symptomatic pain relief from muscles spasm, contracted muscles, stiff joints. • Average response is 24 -72 hours, results build with successive treatment. • Relief or reduction of pain can be permanent or last from few hours to days. • Chronic pain conditions require more treatments. • Hand held devices appropriate for bedside care.

16. Moxibustion Benefits of Moxibustion • Improves blood circulation • Eases muscular tension & stiffness, arthritis, muscular pain and neuralgias. • Dispels cold from channels • Increases energy • Increases immunity & resistance Indirect Moxa Tiger Warmer Direct Moxa

17. Heat & Cold Therapies Fomentek Bag • Comfortable • Safe (110-113 F) • Easy to apply

18. Manual Therapies Gua Sha is a method that involves increasing circulation at the surface of the skin by means of "scraping" the skin vigorously with a blunt edged object. Cupping increases blood flow and loosens fascia. Indicated for these conditions: Headaches, Neck, shoulder, back pain, jaw pain, leg pain, shortness of breath, colds, sinus congestion

19. Acupressure Benefits of Acupressure • Stimulates Blood Flow • Stimulates endocrine gland function • Stimulates lymph and venous drainage • Releases waste products from musculature • Helps achieve mental relaxation as well as physiological peace • Reduces pain

20. Acupressure Treatments • Channel Location • Identify points with blockage • Apply pressure • What to avoid

21. Reflexology of Feet Locate reflex zones which correspond to body areas Treat tender and congested areas Amount of pressure

22. Reflexology of Ears Locate auricular points which correspond to body areas. Areas to concentrate on. Applying pressure to areas on ears Application of essential oils on ears for calming spirit

23. Essential Oils Clinical Aromatherapy from TCM Perspective Therapeutic applications for psycho-emotional issues: stress, agitation, depression, anxiety, tension, grief. Physical symptoms: pain, nausea, respiratory issues, itching, bruising, fatigue, sleep issues. Applications: • Applied on acupuncture points • Used with other modalities like acupressure and dermal friction. • 1-3 drops placed on cotton ball for inhalation • Sprayed in room • Custom blends, specific for caregiver and patient’s conditions & contra-indications. • Utilized as ritual anointing for transition

24. Qigong Qigong Instruction empowering, relaxing, therapeutic • Simple breathing • Movement Exercises • Seated Meditations

25. Qigong External Qigong Therapy • Circulates Qi • Clears blockages • Restores Qi flow

26. Breathing/Relaxation “However strenuous the times be, we need to relax so as to gain insight into the reservoirs of feeling and dream which make us what we are” Helen Keller Skills Based Practices Letting Go • Mindfulness Practices • Guided Meditations • Breath Awareness

27. Sonopuncture - tuning forks Benefits of Sonopuncture Stress reduction Relaxation Energy enhancement Inner expansiveness “Wow, this is so soothing!”

28. http://www.professionalchaplains.org/files/resources/reading_room/complementary_spiritual_practices.pdfhttp://www.professionalchaplains.org/files/resources/reading_room/complementary_spiritual_practices.pdf

29. What is coming forward to be healed at this stage of life? What domain? • Somatic • Emotional • Mental • Relational • Spiritual/existential • Situational

30. Spiritual Suffering Scale Spiritual pain is defined here as emotional distress due to spiritual and religious issues. Spiritual issues that may result in emotional distress include: ·theological and belief issues, such as: -inability to participate in usual religious practices -a belief that God is punitive -incongruence between experience and beliefs -troubling beliefs about dying, death, or afterlife ·existential and meaning issues, such as: -loss of a sense of meaning, loss of role which gave meaning -loss of a sense of hope; letting go, and grief, and anger -loss of a sense of dignity, or loneliness ·relationship issues, such as: -difficulties in relationship with God, or sense of God’s absence or failure, or sense of a need for forgiveness -difficulties in relationship with loved one, or broken relationships, or sense of need to forgive or be forgiven, or need to let go of expectations -negative sense of self-value, or feelings of guilt or regret in life lived

31. SPIRITUAL SUFFERING LEVELS 0.No end-of-life issues causing spiritual distress. This is for patient who has no life regrets and no family issues and is ready for death. 1.Patient puts little focus on life events which are possible sources of minimal spiritual distress during end-of-life, and most focus on issues of well-being. No recent losses; no regrets. 2.Patient puts some focus on spiritual/religious issues in their lives which cause distress, but does not acknowledge distress; puts focus on drawing from sources of spiritual well-being and coping. 3.Patient expresses minimal spiritual distress from life issues, but more focus on issues of well-being. 4.Moderate distress from issues noted. Patient acknowledges the distress, but continues to also focus on sources of well-being. 5.Moderate distress from issues noted, with less focus on sources of well-being. 6.Moderate suffering from issues noted, dominating the patient’s focus. Patient either unable to draw from sources of spiritual well-being or has not identified sources. 7.Severe suffering from issues noted. Patient still able to draw from sources of well-being. 8.Severe suffering from one or more issues noted. Patient having difficulty drawing from sources of well-being. 9.Severe suffering from one or more issues noted. Patient unable to find relief through humor or distraction, with little or no ability to draw from sources of well-being. 10.Severe, unbearable suffering from one or more issues noted. Loss of hope; utter despair.

32. Case Studies

33. Meditation, Music, Silence, Reflexology Ken - CHF. Also craniotomy for Meningioma and vascular dementia. PPS 40 with weight loss - has had no religious preference but has been describing periods of conscious meditation during periods of deep relaxation and during his Music Thananatology vigils. Referral for help with relaxation and comfort following SCC observation of daughter massaging Kim’s shoulders and back. Spiritual Suffering Scale 0: No end-of-life issues causing spiritual distress. This is for patient who has no life regrets and no family issues and is ready for death.

34. prayer and religious support, acupuncture and caregiver support Tran - Vietnamese woman - young family with 6 yo child w/ esophageal cancer. Immigrant family, relatively isolated from family in Vietnam except for Mother-in-Law who lives in the home. She is muted from her cancer and has a frequent sullen look. Religion is Cao Daism. Referral for: Neck pain, caregiver support and culturally relevant medicine Spiritual Suffering Scale 9: Severe suffering from one or more issues noted. Patient unable to find relief through humor or distraction, with little or no ability to draw from sources of well-being.

35. palpation, body work, visualization Deb - an 89 yo female with Alzheimer’s Dx. Additional Dx include behavioral disturbances. She resides in a memory care unit and weighs 90 lbs. PPS is 40. She was a lifelong Catholic but her faith practice has come to mean little to her as her cognition has deteriorated. Referral for: Pain and axiety Spiritual Suffering Scale 1: Patient puts little focus on life events which are possible sources of minimal spiritual distress during end-of-life, and most focus on issues of well-being. No recent losses; no regrets.

36. Aromatherapy, Visualization, Pastoral grief counseling, mystical poetry and music Don -70 yo with Prostate CA with bone mets, severe pain with pain pump requiring frequent titration, Anxiety Dx, Major Depressive Disorder, Insomnia. Family dog recently died, exacerbating financial distress due to final disposition costs. Referral for aromatherapy Spiritual Suffering Scale 4: Moderate distress from issues noted. Patient acknowledges the distress, but continues to also focus on sources of well-being.

37. Heat, Acupuncture, Qigong, Catholic prayer Sergio - a 78 yo filipino male with DX - Advanced Lung Cancer Referral for: Chest pain. Spiritual Suffering Scale 1: Patient expresses minimal spiritual distress from life issues, but more focus on issues of well-being.

38. acupuncture, music therapy, prayer, sacred story narrative work Jan is a 99 yo with CHF with a PPS of 50 and progressive weakness and activity intolerance. Pain medication increasing with comfort needs in shoulder, elbow and leg. Increasing sleep needs but with noted insomnia at night due to sleep disturbance from hearing sounds, music, voices, and being touched. She is afraid of dying and asks that she not be alone during her dying time. Referral for: sleep disturbance and elbow pain and with assistance for for related to possible ‘musical ear syndrome’ Spiritual Suffering Scale: 5: Moderate distress from issues noted, with less focus on sources of well-being.

39. forgiveness work, spiritual direction, Music Thanatology, surrender through relaxation D is a 65 yo male with Prostate Cancer with mets and CHF (NYHA Class IV), COPD with history of MI’s. PPS 60. Has frequent chest pain, elbow, stomach, groin pain . Hesitant to add pain medications for increasing pain as remaining highly conscious and mobile are significant goals for him. He is afraid that his family will not care for him well if he becomes disabled. Referral for: groin pain, elbow pain and anxiety Spiritual Suffering Scale 8: Severe suffering from one or more issues noted. Patient having difficulty drawing from sources of well-being.

40. Visualization, acupuncture, counseling support Billy - 77 yo male with chronic respiratory failure with hypoxia, emphysema, asthma. On continuous oxygen, steroids and bronchodilators with poor symptom relief. Refused to fill out POLST. Referral for: Anxiety, SOB Spiritual Suffering Scale 5: Moderate distress from issues noted, with less focus on sources of well-being.

41. Acupressure, aromatherapy Ben - 82 yo male with CHF and uncontrolled Diabetes. PPS 30. Oxygen dependant. Has pressure wounds on sacrum. Has pain from neck fracture. Having increasing confusion, hallucinations. Referral for: Bilateral Neck pain Spiritual Suffering Scale 4: Moderate distress from issues noted. Patient acknowledges the distress, but continues to also focus on sources of well-being.

42. Pastoral counseling, family discussion for grief support, video education Patricia H. - 86 yo with recent Dx of Gioblastoma. Oncologist Surgeon gave a 2-month Px. Also has Parkinson’s Dx and a seizure disorder plus Adult Failure to Thrive. Upon admission, was ambulatory with 1-person assist. Pastor was called to support her with question: “how do I get ready?” but was unable to address this question. Referral for: Spiritual Suffering Scale: 4: Moderate distress from issues noted. Patient acknowledges the distress, but continues to also focus on sources of well-being.

43. Acupuncture, aromatherapy, caregiver support, pastoral counseling Ed - 63 yo with COPD and obstructive sleep apnea. Uses Bipap and morphine for comfort. PPS 40. DNR POLST with Comfort Measures Only. Referral for: Stomach pain, leg pain, anxiety Spiritual Suffering Scale 6: Moderate suffering from issues noted, dominating the patient’s focus. Patient either unable to draw from sources of spiritual well-being or has not identified sources.

44. Acupuncture, heat, reflexology Brian - a frail, cachectic 56 yo Veteran with Dx of malignant Neoplasm of Esophagus with mets and Protein-Calorie Malnutrition. Frequent severe SOB which is relieved through morphine elixir and nebulizer treatments. Has been having steadily increasing pain. Patient-centered goal of physical independence, eg, to be able to continue to gather wood for his wood stove. Referral for: neck and shoulder pain Spiritual Suffering Scale: 3: Patient expresses minimal spiritual distress from life issues, but more focus on issues of well-being.

45. Staff Education •  Educate staff on goal and outcome-oriented documentation needs for EMR • Educate Management and staff ongoing for most appropriate use of East Asian Medicine based on symptoms and stage • Integration of Complementary Practice into the IDG meeting • Demonstration on staff of East Asian Modalities.

46. Documentation • Integrated therapies and the Electronic Medical Record • Referral Protocols: Creation of Standard Operating Procedure • Best accomplished if monitored by a point person • Requires buy-in of team for accurate documentation and billing • Use of referral forms to assist staff capture requested information of the contracted integrated staff personnel • Use of Medical Orders to help track referrals and frequencies along Benefit Periods

47. Trigger Question Think of a time when treating a patient’s physical condition lead them unexpectedly to have a spiritual insight into their situation or other spiritual healing.