National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care

National Guidelines for the Use of Complementary Therapiesin Supportive and Palliative Care

Supported by

2 National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care

AcknowledgementsThe development of these guidelines would not have been possible without theinterest and collaboration of the large number of individuals who gave their timeand expertise to this project. In particular, we are indebted to the steering groupfor their contribution throughout the process. Three regional symposia, whichbrought together key people with experience of supportive and palliative care,informed the development of the guidelines. Our thanks go to the service userswho participated in the symposia and kept the project grounded; all theprofessionals who took time out from busy schedules to contribute to thesymposia; the experts who critiqued the drafts, and those who contributed toparticular chapters: Annie Hallett, Liz Hawkins, Dr. Jacqueline Filshie, Dr. HughMacPherson, David Simons; the wider consultative group and all who respondedto the consultation document. Thanks also to all at the National Council and theFoundation and for their work in producing these guidelines.

Eve RichardsonChief ExecutiveNational Council for Hospiceand Specialist Palliative Care Services

Michael FoxChief ExecutiveThe Prince of Wales’s Foundation for Integrated Health

May 2003

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Marianne Tavares

The Prince of Wales’s Foundation for Integrated Health

The National Council for Hospice and Specialist Palliative Care Services

Supported by Lloyds TSB Foundation for England and Wales

The Prince of Wales’s Foundation for Integrated HealthLondon, England

National Guidelines for the Use of Complementary Therapiesin Supportive and Palliative Care


National Guidelines for the Use of Complementary Therapies inSupportive and Palliative Care by Marianne Tavares

© The Prince of Wales’s Foundation for Integrated Health and theNational Council for Hospice and Specialist Palliative CareServices, 2003

ISBN 0 9539453 5 9

All rights are reserved. Apart from any fair dealing for thepurpose of private study, research, criticism or review, aspermitted under the Copyright, Designs and Patent Act 1988, nopart of this publication may be reproduced, stored ortransmitted, in any form or by any means, without priorpermission in writing of the publishers. Enquiries should beaddressed to:

The Prince of Wales’s Foundation for Integrated Health12 Chillingworth RoadLondon N7 8QJ020 7619 6140

www.fihealth.org.ukemail: [email protected]

DisclaimerWhile every effort has been made to provide accurateinformation, the publishers do not assume and hereby disclaimany liability to any party for loss or damage caused by errors inthese guidelines.

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Foreword by HRH The Prince of Wales

I am delighted to have the opportunity of introducing these National Guidelines for the Use of Complementary Therapies inSupportive and Palliative Care which have been developed by myFoundation for Integrated Health working in partnership with theNational Council for Hospice and Specialist Palliative Care Services.

Complementary therapies are becoming increasingly available topatients suffering from long-term or chronic illness as an integralpart of the palliative and supportive care that they receive inhospital wards, hospices, cancer support centres and at home.These guidelines will, I am sure, prove to be invaluable to managersand providers of these services and will, hopefully, give them theconfidence to extend the range of therapies that they provide.They are clear, concise and comprehensive and will go a long way towards ensuring that complementary therapies are deliveredsafely, effectively and appropriately and in a way that will bring themost benefit to patients.

Patients are increasingly demanding a more holistic approach to their treatment; an approach which takes into account theirphysical, mental and spiritual wellbeing. I look forward to the daywhen these healing therapies will become available to all those whowould benefit from them and I very much hope that these excellentguidelines will help carry this process forward.


Preface by Professor Mike Richards,National Cancer Director

A substantial number of cancer patients choose to receivecomplementary therapies alongside their mainstream cancertreatment. Individual patients frequently report that the use of acomplementary therapy has helped them. Despite this, it has beendifficult to generate convincing research evidence of the benefits ofthese therapies with respect to the amelioration of physical orpsychological symptoms. Because of this, decision makingregarding the provision of complementary therapy services remains complex both for commissioners and service providers.

There is broad agreement, however, that patients should have readyaccess to reliable information about complementary therapies andcomplementary therapy services. It is also important that whereservices are provided this is done in a way which protects patients'safety.

These guidelines address issues which are directly related to patientsafety in the provision of complementary therapy services, includingclinical governance, regulation and training of therapists and auditand evaluation. The guidelines will usefully complement theforthcoming NICE guidance on supportive and palliative care.

Professor M A Richards

May 2003

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The Patient’s PerspectiveWhy use complementary therapies in supportive and palliative care?

" For oft, when on my couch I lieIn vacant or in pensive mood,They flash upon that inward eyeWhich is the bliss of solitude…"

William Wordsworth (1770 – 1850)

"Marion’s massages were something to look forward to, somethingnice that happened in the daily round of unpleasantness. I was moreable to accept what was happening to me, more ready to deal with thetreatment, simply was in a better frame of mind to heal myself." (Izod 1996)

"It has meant that I no longer get tummy cramps and awful wind. I amable to go to the toilet once a day instead of feeling that I need to goseveral times a day." (Preece 2002)

"I am now sleeping through the night.""Headaches are almost gone or are coped with.""My energy levels are increased." (Wright et al 2002)

"When the healing started I began to calm a little. I realised this was mytime to receive… and that I was beginning to connect with my innerfeelings and acknowledge my emotions. After approximately foursessions I began to feel huge surges of energy, a high following thehealing. My healer made sure that I was grounded before I left and Ilearnt to direct and use this energy myself and to call upon it when Ineeded it.”(Penson 1998)

"It was wonderful, I completely forgot about everything that was beingdone to my body, and got lost in the gentle music and massage."

"I felt very good, the pain seemed to go out of my body. Massage diddefinitely help very much."(Corner et al 1995)


Contents Acknowledgements 2

Foreword by HRH The Prince of Wales 5

Preface by Professor Mike Richards, NationalCancer Director 6

The Patient’s Perspective 7

1. Executive Summary 10

2. Introduction 112.1 Background 112.2 The need for guidelines 112.3 Scope of the guidelines 122.4 Definition of terms 13

Service Development and Management

3. The Development of Complementary Therapy Services 143.1 Introduction 143.2 Initial development 143.3 Management and on-going development 153.4 Configuration of complementary therapy

teams 16

4. Clinical Governance 184.1 Introduction 184.2 Policies, procedures and standards 184.3 Supervision 184.4 Individual performance review 184.5 Education and training 194.6 Audit and evaluation 194.7 Research and development 194.8 Health and safety 20

5. Regulation and Training of ComplementaryTherapists 205.1 Introduction 205.2 Regulation 205.3 Training, qualifications and national

occupational standards 215.4 Choosing a therapist 22

6. Recruitment and Selection 236.1 Introduction 236.2 Regulation and training 236.3 Prior experience 236.4 Interview and assessment 236.5 Salary 246.6 Contract 246.7 Orientation and induction 24

7. Volunteer Therapists 257.1 Introduction 257.2 Recruitment and selection 257.3 Orientation and induction 267.4 Line management 267.5 Supervision and support 267.6 Code of practice 26

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7.7 Continuing relationship with patients and carers 26

7.8 Personnel policies 277.9 Health and safety 27

Practice Development

8. Professional and Ethical Issues 288.1 Introduction 288.2 Professional accountability 288.3 Consent 288.4 Confidentiality 29

9. Supervision 309.1 Introduction 309.2 Therapy specific supervision 309.3 Supervision as reflection on practice 309.4 Cost of supervision 31

10. Clinical Issues 3210.1 Introduction 3210.2 General contraindications and

precautions 3210.3 Issues which patients with cancer may be

facing 3210.4 Issues specific to patients with motor

neurone disease, Parkinson's disease & multiple sclerosis 34

11. Referral and Assessment 3511.1 Introduction 3511.2 Referral 3511.3 Assessment 3511.4 Treatment record 3611.5 Review of patient and treatment 36

12. Complementary Therapies 3712.1 Introduction 3712.2 Criteria for including therapies in these

guidelines 3712.3 Information provided about each therapy 3712.4 Methodology for reviewing the evidence

base 38

13. Touch Therapies 3913.1 Introduction 3913.2 Use of touch therapies in supportive and

palliative care 3913.3 Massage 4113.4 Aromatherapy 4213.5 Reflexology 45

14. Healing and Energy Therapies 4714.1 Introduction 4714.2 Use of healing and energy therapies in

supportive and palliative care 4714.3 Reiki 4714.4 Spiritual healing 4814.5 Therapeutic touch 49

15. Hypnosis and Hypnotherapy 5115.1 Brief description 5115.2 Evidence 5115.3 Use of hypnosis in supportive and

palliative care 5415.4 Regulation and training 54

16. Acupuncture 5616.1 Brief description 5616.2 Evidence base 5716.3 Use of acupuncture in supportive and


17. Homeopathy 6217.1 Brief description 6217.2 Evidence 6217.3 Use of homeopathy in supportive and


18. Guideline Development Process 6518.1 Steering group 6518.2 Gathering information and evidence 6518.3 Consultation and peer review 65

19. Appendices 67A. Configuration of Complementary Therapy

Teams 67B. Main Components of Clinical Governance 72C. Resources for Audit, Evaluation and

Research 73D. Evidence for Best Practice (databases) 74E. Working Groups for Developing Single

Regulatory Bodies, as at March 2003 (fortherapies in these guidelines) 76

F. Sample Job Description 79G. NCVO Good Practice Checklist 80H. Sample Volunteer Role Description 81I. Sample Referral Form 82J. Sample Key Worker’s Initial Assessment

form 84K. Sample Key Worker’s Review Assessment

form 85L. Sample Treatment Records 86M. Symposia Participants 88N. Wider Consultative Group 90O.Experts Consulted 91P. Glossary of Terms 92Q.Useful Resources 93

20. References 97


1 Executive Summary1.1 These guidelines bring together the differentissues and questions that organisations face whenconsidering the development of complementarytherapy services in supportive and palliative care.The guidelines have been written for the use ofmanagers and those responsible for developingcomplementary therapy services in both thestatutory and voluntary sectors, and for self-helpgroups. The focus is mainly on cancer, althoughinformation is also given about key clinical issues forpeople with motor neurone disease, Parkinson'sdisease and multiple sclerosis.

1.2 The term complementary therapies refers tothose therapies which are used alongsideconventional health care. Surveys show that over30% of people with cancer use complementarytherapies (Rees et al 2000, Lewith et al 2002). Mostprovision is in hospices (36%) and hospitals (31%),with up to 20% based in the voluntary sector (Kohn2003). The touch therapies, such as aromatherapy,massage and reflexology, are provided in over 90%of services; mind-body therapies, for examplerelaxation and visualisation, in over 80% and healingand energy work by about 45% of service providers(Kohn 2003).

1.3 The guidelines set out a range of issues to beconsidered when developing services; these comeunder two main headings:• service development and management• practice development

Service development includes clinical governance,the regulation and training of therapists, recruitmentand selection, and the management of volunteertherapists. Practice development considersprofessional and ethical issues, supervision, clinicalissues, referral and assessment, and the use of ninetherapies.

The guidelines provide additional advice forpractitioners on ethical issues, which include:• the importance of respecting the patient’s choice

in all areas of their care• the need for professionals to recognise and

respect the role and contribution of conventionalhealth care colleagues within supportive andpalliative care

• the importance of not making any claims forcomplementary therapy treatments

1.4 The nine therapies included are the touchtherapies of aromatherapy, massage andreflexology; the healing and energy therapies of reiki,spiritual healing and therapeutic touch; hypnosis andhypnotherapy; acupuncture; and homeopathy. For

each, the best available evidence is reviewed, andinformation is given about the conditions for whicheach therapy may be useful. Guidance is also givenon contraindications and precautions for the use ofthese therapies in supportive and palliative care.

1.5 The guidelines provide an outline of the currentsituation regarding the regulation, training andqualifications of therapists and gives usefulinformation about recruiting therapists. In addition,guidance is given on the position and recruitment ofvolunteer therapists.

1.6 Broad advice is given in relation to clinicalgovernance and the development of complementarytherapy services. Suggestions are made for thedifferent ways in which clinical governance could beimplemented.

1.7 A wide range of other complementary therapiesare used in supportive and palliative care, and it hasnot proved possible to include detailed informationabout all of them. Useful contact information isgiven in the appendices. The Macmillan Directory(2002) also provides valuable information onorganisations which offer therapies not included inthese guidelines.

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2 Introduction

2.1 Background

These guidelines bring together the different issuesand questions that organisations face whenconsidering the development of complementarytherapy services in supportive and palliative care.This introduction explains the need for nationalguidelines, outlines the scope of the guidelines andgives definitions for supportive and palliative care.

The use of complementary therapies following adiagnosis of cancer is a significant and growingphenomenon. One recent survey of 1023 womenwith breast cancer showed that 31.5% had consulteda complementary therapist since diagnosis (Rees etal 2000). Another survey showed that 32% (n=162)of those with cancer were receiving complementarytherapy treatments, whilst 49% of those notreceiving them would like to have complementarytherapy treatments (Lewith et al 2002).

A survey of the provision of complementarytherapies, conducted in 108 hospice and palliativecare units, showed that the most popular therapieswere massage (76 units), aromatherapy (73 units),and relaxation (71 units). (Wilkes 1992) Researchon access to complementary medicine via generalpractice (Thomas et al 2001) indicated that 39.5% ofgeneral practice partnerships in England providedaccess to some form of complementary therapy fortheir national health service patients.

The Directory of Complementary Therapy Services inUK Cancer Care produced by Macmillan CancerRelief (Macmillan 2002) shows widespread use ofcomplementary therapies in the UK. Most provisionis in hospices (36%) and hospitals (31%), with up to20% based in the voluntary sector (Kohn 2003). Ofthe 40 or more therapies offered (Macmillan 2002)those most commonly provided are the touchtherapies, such as aromatherapy, massage andreflexology, in over 90% of services, and mind-bodytherapies, for instance relaxation and visualisation, inover 80% of services (Kohn 2003). Healing andenergy work including reiki, spiritual healing andtherapeutic touch, are also widely available in 45% ofservices.

The impetus to develop national guidelines camefrom the National Council for Hospice and SpecialistPalliative Care Services and The Prince of Wales’sFoundation for Integrated Health. The project wasfunded by The Lloyds TSB Foundation for Englandand Wales.

In October 2001, a request was made to about 500providers of supportive and palliative care in the UK,

as listed in the 2001 Directory of Hospice and PalliativeCare Services, for local guidelines, policies,standards and protocols. Approximately 100 sets ofpolicies or standards (20%) were received, andabout another 20 organisations replied that policieswere being developed or reviewed. It is not knownwhether this response rate is an indication of lack ofpolicies despite the widespread use ofcomplementary therapies shown in the Macmillandirectory. It is known, however, that there are anincreasing number of enquiries to the NationalAssociation of Complementary Therapists inHospice and Palliative Care for guidance on thedevelopment of policies.

2.2 The need for national guidelines

Clinical governanceWhile the framework of clinical governance(Department of Health 1999) applies to NHSorganisations, it is becoming equally important forservices in the voluntary sector to be able todemonstrate to funders their determination tosafeguard quality of care. Complementary therapyservices are not exempt from the same scrutiny.Indeed, the process of safeguarding quality of carewithin complementary therapy services is likely toinspire confidence and encourage integration withconventional health care, as recommended by theHouse of Lords Report on complementary andalternative medicine (House of Lords 2000). Thepurpose of these national guidelines is to provideinformation and recommend activities which cancontribute to quality improvement, patient safety andimproved outcomes.

NICE guidance on supportive and palliative careComplementary therapies will be included as oneaspect of the forthcoming Guidance on ImprovingSupportive and Palliative Care for Adults with Cancer,which is being developed under the auspices of theNational Institute for Clinical Excellence (NICE), andcommissioned by the Department of Health. Thepurpose of the NICE guidance is to identify servicemodels most likely to lead to high quality care forpeople with cancer and their carers and it will make aseries of recommendations about service provision,planning and workforce development. It is due to bepublished towards the end of 2003.

These guidelines for the use of complementarytherapies in supportive and palliative care consider abroader range of issues within service development,for example recruitment, qualifications and training,supervision, referral and assessment. Also includedis a review of the evidence base for the use of thekey therapies in supportive and palliative care.


Evidence The focus of the government’s 10 year programmeto improve the NHS, as set out in the white paper,The new NHS, modern, dependable (DoH 1997), isprimarily on evidence-based integrated care, qualityassurance, clinical and cost effectiveness, andperformance management. Commissioners andservice providers call for evidence to support theuse of complementary therapies in palliative care.The factors which have hindered research into theeffectiveness of complementary therapies are well-documented (Penson 1998, Dunn et al 1995; Hobbs& Davies 1998), as are the difficulties of conductingresearch with people with a life-threatening conditionor advanced and progressive illness (Donnelly 2000,Karim 2000).

The emerging picture shows that the evidence baseis greater for some therapies than others.Professionals with a conventional medical orscientific background believe that in order forcomplementary therapies to be more widelyaccepted, it is important "that they have a criticalmass of scientifically-controlled evidence to supporttheir claims and that at the moment most therapieslack such evidence" (House of Lords 2000).Following the House of Lords report and thegovernment’s response, a framework for increasingresearch capacity in complementary and alternativemedicine is currently being developed by theDepartment of Health (seewww.doh.gov.uk/research). There is a need formore research from a variety of perspectives andmethodological approaches.

However, lack of evidence is not necessarilyevidence of a lack of effectiveness. It is clear fromnumerous surveys and service evaluations thatpatients value the use of complementary therapiesas an integral part of their care. It may be useful toremember that evidence based practice has beendescribed as the conscientious, explicit, andjudicious use of current best evidence in makingdecisions about the care of individual patients(Sackett 1996). Evidence based practice requirespractitioners to integrate the best external evidencewith individual clinical expertise and the patient’schoice (Sackett 1996).

These guidelines have been written, based on the bestavailable evidence, to facilitate the development ofservices and to encourage the integration ofcomplementary therapy services in supportive andpalliative care. Although such services are provided ina large and growing number of organisations, provisionremains patchy and without equality of access.

RegulationThe Prince of Wales’s Foundation for IntegratedHealth is working with eighteen different therapieswho are working towards more robust regulation,statutory or voluntary. However, the groups are

currently at different stages of development, whichmeans that standards of practice may vary, andpatients may be exposed to inconsistent,inappropriate or even poor quality care. Althoughmany excellent models of practice exist, the lack ofconsensus on standards not only causes confusionfor patients when considering a therapy or therapist,but also raises issues for health care providers whenit comes to recruitment. For example, whatconstitutes acceptable qualifications and registrationrequirements for the different therapies, and who toapproach for advice.

2.3 The scope of the guidelines

Who are the guidelines for?These guidelines are intended for the use ofmanagers and those responsible for developingcomplementary therapy services in organisationswhich provide supportive and palliative care.Supportive and palliative care is provided in a varietyof NHS and non-NHS settings, including hospices,hospitals, primary care, cancer support centres andself-help groups and it is expected that individualservice providers will develop local policies andprotocols appropriate for their organisation.

What do the guidelines cover?The purpose of the guidelines is to recommendgeneral principles of best practice, on which servicescan be developed. These cover the following areas: • Service development and management • Practice development

The variety of current operational models, and thedifferent combination of therapies provided inexisting services (Kohn 1999, Macmillan 2002) 1

show that services have been developed accordingto local resources and circumstances, including thevision, enthusiasm and commitment of keyindividuals. There are vital differences in services,depending on whether provision is in a non-clinicalsupport setting, for example, in the absence ofmedical or nursing staff, or a clinical hospice orhospital setting. Models, therefore, cannot beimported whole or unchanged and the guidelinesprovide examples of different configurations ofteams (see Appendix A). Various examples aresuggested for processes such as referral andassessment, induction, supervision and continuingprofessional development.

Particular attention is given to the role andrecruitment of volunteer therapists as this has beenshown to be an area of concern common to mostproviders currently utilising volunteer therapistswithin their service.

1 See also The Prince of Wales's Foundation for Integrated Health,2001 and The Prince of Wales’s Foundation for Integrated Health,2002

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Nine therapies have been included: acupuncture,aromatherapy, homeopathy, hypnosis andhypnotherapy, massage, reflexology, reiki, spiritualhealing and therapeutic touch. The choice of whichtherapies to include was based on a number ofcriteria (see Chapter 12). The information abouteach therapy includes a brief description, theevidence-base, how they are used in supportive andpalliative care, precautions and contraindications andappropriate qualifications. Information is also givenabout which organisations to contact for advice ontherapies less commonly used in palliative andsupportive care, such as Bowen technique andshiatsu.

Cancer and three neurological conditions (motorneurone disease, Parkinson’s disease and multiplesclerosis) are considered in relation to the use ofcomplementary therapies. Guidance is given aboutclinical issues that complementary therapists needto be aware of when treating patients with theseconditions. Information is also provided onorganisations to contact for advice on otherprogressive, life-limiting or life-threateningconditions, such as heart disease, respiratoryconditions and HIV/AIDS.

What is not covered?Ernst and Cassileth’s (1999) overview of the use ofunconventional cancer treatments indicates thatsuch treatments are used, but a distinction is madebetween alleged cures for cancer itself andpreventive and adjunctive measures. In thisdocument, the term complementary therapies refersto those therapies which are used alongsideconventional treatment. Alternative treatmentoptions intended to ‘cure’ cancer are not dealt within these guidelines.

As indicated, these guidelines are for the use ofmanagers and those responsible for developingcomplementary therapy services within the NHS andindependent sector, including cancer supportcentres and self-help groups. They are not designedfor use as a guide by, or for, patients and the public,nor as a teaching manual for the use of therapies insupportive and palliative care.

2.4 Definition of terms

Complementary therapiesThere are several published definitions of the termscomplementary medicine and complementarytherapy (British Medical Association 1993, RoyalCollege of Nursing 1993, Foundation for IntegratedMedicine, 1997). The United States NationalInstitute of Health, Office of Alternative Medicine,coined the term complementary and alternativemedicine to encompass both complementary andalternative approaches. This term includes a much

broader spectrum of medical and therapeuticapproaches to those used in supportive andpalliative care.

A distinction is sometimes made between the termscomplementary and alternative. Complementarytherapies is often used to describe treatmentsemployed alongside, or integrated with, orthodoxmedical treatment, while alternative therapies indicatesthose which are used instead, or independently, oforthodox medical treatment (BMA 1993).

In these guidelines, the term complementarytherapies refers to those therapies which are usedalongside conventional health care.

Palliative careThe following definition of palliative care, which isbased on the World Health Organisation’s definition(WHO 1990), and is inclusive of other progressiveand life-limiting conditions, has been developed bythe National Council for Hospice and SpecialistPalliative Care Services (NCHSPCS 2002). This isalso the definition proposed in the consultationdocument of the National Institute for ClinicalExcellence (NICE 2002), Guidance for CancerServices – Improving Supportive and Palliative Care forAdults with Cancer.

"Palliative care is the active holistic care of patientswith advanced, progressive illness. Management ofpain and other symptoms and provision ofpsychological, social and spiritual support isparamount. The goal of palliative care isachievement of the best quality of life for patientsand their families. Many aspects of palliative careare also applicable earlier in the course of the illnessin conjunction with other treatments." (National Council for Hospice and SpecialistPalliative Care Services 2002; NICE 2002).

The principles and aims of palliative care are to:• affirm life and regard dying as a natural process• provide relief from pain and other symptoms• integrate the psychological and spiritual aspects

of patient care• offer a support system to help patients live as

actively as possible until death• offer a support system to help the family cope

during the patient’s illness and in their ownbereavement(Aims of Palliative Care, National Council for Hospiceand Specialist Palliative Care Services 2002)

Supportive careThe concept of supportive care was highlighted inthe NHS cancer plan (Department of Health, 2000),when it was also acknowledged that supportive careshould be provided throughout patients’ and carers’cancer journey. At present the definition andprinciples of supportive care, as described in The


NHS Cancer Plan, relate only to cancer services.However, the principles of supportive care are seento be beneficial for other life-limiting or life-threatening conditions.

Supportive care encompasses nine services, ofwhich complementary therapies is one, that canempower cancer patients and their carers, enablethem to develop strategies for living with cancer andsupport them in the process. The following definitionwas developed by the National Council for Hospiceand Specialist Palliative Care Services (2002) and isalso proposed in the National Institute for ClinicalExcellence consultation document, Guidance onCancer Services – Improving Supportive and PalliativeCare for Adults with Cancer (2002).

"Supportive care is that which helps the patient andtheir family to cope with cancer and treatment of it –from pre-diagnosis, through the process of diagnosisand treatment, to cure, continuing illness or deathand into bereavement. It helps the patient tomaximise the benefits of treatment and to live aswell as possible with the effects of the disease. It isgiven equal priority alongside diagnosis andtreatment".

The National Council for Hospice and SpecialistPalliative Care Services (2002) suggests that thereis considerable overlap between supportive andpalliative care in terms of need, and that for the usualprofessional carers of the patient with cancer andtheir family, this may best be acknowledged byregarding the care they give as supportive/palliativecare. The patient’s usual professional carers rangefrom the primary care team to professionals withinspecialist palliative care services, as well as otherservice providers in the community, such as cancersupport centres and support groups.

The range of provider settings and their differingneeds and resources have shaped the developmentof these guidelines as broad principles of bestpractice on which decisions for developing servicescan be based. The range of issues considered in thefollowing chapters come under two main headings:service development and management and practicedevelopment.

3 Development ofcomplementarytherapy services

3.1 Introduction

This chapter draws on the experience of establishedservices, and considers the issues that areimportant in the initial stages of servicedevelopment, as well as in on-going developmentand management. Depending on the resources ofthe organisation and the needs of the modeladopted, a range of practitioners may provide thehands-on service and corresponding managementrequirements are suggested. A number of examplesare given of the ways in which teams are currentlyconfigured.

3.2 Initial development: starting up

The initial development of a complementary therapyservice is often dependent on the vision of one ormore individuals who are prepared to invest time andenergy to explore possibilities, and who have theskills to influence development and to take thingsforward (The Prince of Wales’s Foundation forIntegrated Health, 2002). What is feasible dependson the resources available, including the skills ofexisting staff, and the availability of funding, but alsoon what an organisation considers acceptablefunding for starting up a service.

The process of service development can be topdown or bottom up or may be an inclusive modelwhere planning and decision-making are shared fromthe onset. What seems to be important is thecreation of an environment that fosters a culture ofrespect, trust and awareness, which allows theservice to evolve and where dialogue and feedbackare welcomed (The Prince of Wales’s Foundation forIntegrated Health, 2002). There are many models ofservice; but the consensus is that it is advisable tostart ‘small, safe and simple’, and that patientcentredness, and the involvement of service usersfrom the beginning, are at the heart of servicedevelopment. Offering complementary therapies tocarers is also seen to be an integral part of caring forpatients. Extending the service to staff andvolunteers helps to promote the service, as well asprovide an element of staff support, which improvesworking lives.

Consideration needs to be given as to whetherpatients are required to pay for complementarytherapy treatment. Many complementary therapyservices in supportive and palliative care are free of

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charge; for others a cost is incurred, often based ona sliding scale.

Checklist of issues for consideration in starting aservice • Aims and objectives of the service• Clarity about approach: top-down, bottom up or

inclusive • Involvement of service users, patients and carers,

from the beginning• Employing a fundraiser• Funding:

therapistsequipmenttherapy space or room office space and administration

• Which therapies (see chapters 12-17) and at whatpoint they will be offered

• Accessibility and availability: number of sessionsfor patients or patients and carershow oftencultural and language issues

• Consider providing therapies to staff• Therapists:

possible configurations of team (see Appendix A)recruitment (see chapters 6-7)appropriate qualifications (see chapter 5)job or role description, person specification interview process

• Management should include a designated personto be responsible for overseeing development,and day-to-day management and practicalities(see Table 1 on page 17) including:

- promoting the availability of the service to -patients, carers and staff

- familiarising staff with the role ofcomplementary therapies

- induction, including, where relevant,familiarisation on working within conventionalhealth care setting

- supervision, appraisal and continuingprofessional development of therapists (seechapters 4 and 9)

- policy and protocols (see chapter 4)- referral criteria (see chapters 11 – 17)- assessment or screening for contraindications

(see chapter 11) - documentation- integration with existing services - health and safety measures (see chapter 4)- evaluation (see chapter 4)

Initial development: checklist of what works• involving everyone from the start• early development of policies, including date for

review• choice and flexibility in service provision• rigorous recruitment procedures• a well-developed referral system• assessment guidelines

• open days for staff in conventional medicine• providing therapies to staff• willingness to work within NHS and previous NHS

experience• funding a co-ordinator of complementary therapy

services• supervision• professionalism• volunteer training and induction programmes• sharing good practice• networking tools such as forums, journals, and

meetings

(The Prince of Wales’s Foundation for IntegratedHealth, 2002)

3.3 Management and ongoingdevelopment

There are many organisational approaches to on-going development, some of which are similar toinitial development. Commitment to a patient-centred approach cannot be assumed, and must beunderpinned by processes and facilitation whichencourage the participation of users at all levels.This challenge requires leadership, a willingness towork collaboratively and the skills to managechange.

Although clinical governance refers primarily to NHSorganisations (Department of Health 1999), fundersare likely to be looking for similar processes whichassure and improve quality in all organisations.Chapter 4 on clinical governance sets out in greaterdetail the activities that complementary therapyservices need to be engaged in.

Two key areas to be considered in on-goingdevelopment are audit and evaluation, and theintroduction of further therapies. Evaluation of aservice can result in the following decisions:a) maintenance of current level of service provision,

with simple improvementsb) development of a service that is ‘small, safe and

simple’ into one that is integrated and diverse.Integration can be achieved at different levels, forinstance within an organisation and/or in the localarea.

c) growth or expansion of the service

When considering the introduction of othertherapies, it is important to remember that the lackof evidence does not necessarily constituteevidence of a lack of effectiveness. Where theevidence-base is not strong, often for a variety ofreasons, the development of pilot projects, withinbuilt evaluation, would allow the introduction oftherapies which could be helpful to patients.


Checklist of ongoing development issuesGrowth or expansion of service• Increasing the number of therapies • Increasing the range of services, for instance

groups; classes; teaching therapy skills and self-management skills

• Increasing access, including outreach services tothose too ill to leave home; outreach clinicstargeting specific groups; bereaved relatives

• Increase in the establishment, such as moretherapists

• Maintain or increase fundingIntegration at different levels, within theorganisation and in local area• Involvement of local community and service users• Participation at team meetings such as

multidisciplinary team, centre team• Access to patient notes*• Shared documentation*• Teaching therapy skills to other members of the

clinical team*• Collaboration and good communication with all

involved using letters, telephone calls andmeetings

• Recognising the presence of, and relating in waysthat overcome, ignorance, prejudice, fear

• Familiarisation with and education in the role ofcomplementary therapies

• Publicity• Providing a seamless service within local cancer

services

Management and leadership• Representation at senior management level*• Review configuration of team• Clear lines of responsibility and accountability• On-going development of therapists, including

supervision and appraisal• Management of change as the service grows,

utilising team work and communication• Management and facilitation of user involvement• Risk management• Audit, evaluation and research• Funding

* in organisations where complementary therapies areoffered as part of a multidisciplinary clinical team

3.4 Configuration of complementarytherapy teams

The configurations of complementary therapy teamsare multiple and varied, as are the roles of individuals.Many organisations currently deliver a service byusing a combination of employed and volunteertherapists. In a clinical environment, some therapistsare also nurses who use complementary therapiesalongside their nursing role. Nurses and health careassistants are trained to use therapies in a limited

fashion, for instance simple massage of hands andfeet. Other members of the clinical team likedoctors, physiotherapists, occupational therapistsand social workers may have had additional training intherapies such as acupuncture or Reiki which theyincorporate with their primary role.

Services in non-clinical settings are not bound by thesame structures as those within the NHS andhospice environments. However, developmentneeds to take into account the absence of on-sitesupport of the clinical team. Cancer patients arealso likely to be at an earlier stage of their cancerjourney, and may have different needs, such assupport during chemotherapy and radiotherapyregimens.

Supportive and palliative care could enhance therehabilitation of patients with motor neuronedisease, Parkinson’s disease and multiple sclerosis.Complementary therapies are offered in anintegrated way to patients with these conditions,but mainly in hospice settings, and considerationneeds to be given as to how they can be providedmore widely.

Table 1 indicates the variety of practitioners whomay provide complementary therapies within anorganisation, and corresponding managementrequirements.

There are a variety of ways in which services can bedeveloped, depending on resources. What isimportant is that there are clear lines of accountabilityand responsibility. Some examples of establishedteams are shown in Appendix A.

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Practitioners

*Existing staff qualified in complementary

therapies to use them with patients on

their own caseload or team

*Existing staff who use therapy skills such

as simple massage or relaxation with

patients on their own caseload or team

Paid full-time, part-time, sessional or self-

employed or volunteer therapists

Volunteer therapy assistants

Complementary therapies coordinator,

who is also a provider

Management requirements

Designated individual to take responsibility for

• Developing policy, protocols and documentation

• Resources and equipment such as essential oils, and acupuncture needles

• Supervision


• Recruitment

• Training and supervising staff

• Developing policy and protocols

• Equipment such as essential oils


• Recruitment including job or role description

• Contract or written agreement

• Office and equipment

• Therapy room(s)

• Induction, supervision and training appropriate to the experience of the

therapist


• Equipment such as oils, sheets and towels, couch or acupuncture needles

• Coordinating practical issues such as referrals, working days and therapy space

• Supervision and appraisal


• Recruitment including role description

• Contract or written agreement

• Induction, training and supervision


• Equipment such as essential oils

• Co-ordinating practical issues, for example referrals, working days and

therapy space

• Supervision and appraisal

Designated individual to take management responsibility for:

• Recruiting the coordinator

• Contract of employment

• Office and equipment

• Identifying a therapy room or space

• Induction and supervision

• Priorities for service development

*Applies to clinical settings only; existing staff refers to members of the clinical team with conventional healthcare roles

Table 1 Setting up a service: practitioners and management requirements


4 Clinical governance

4.1 Introduction

Clinical governance is the framework through whichNHS organisations are accountable for continuouslyimproving the quality of their services andsafeguarding high standards of care, by creating anenvironment where excellence will flourish(Department of Health 1998). Although thisframework applies to NHS organisations, it is equallyimportant for services in the voluntary sector todemonstrate to funders and others theirdetermination to safeguard quality of care. Thischapter considers the importance of clinicalgovernance for complementary therapy services,within and outside of the NHS. The differentaspects of clinical governance addressed include thedevelopment of policies, supervision, appraisal,continuing professional development, auditevaluation and research, and risk management.

The white paper, The new NHS: Modern, Dependable(DoH 1997) and the consultation document A FirstClass Service: quality in the new NHS (DoH 1998) setout the government’s strategy for ensuring thatquality of care becomes the driving force for thedevelopment of health services in England. Centralto this is clinical governance. Voluntary sectorhospices are already very familiar with the conceptof quality improvement, and 48% have started toimplement clinical governance (NCHSPCS 2002a).The National Council for Hospice and SpecialistPalliative Care Services has provided guidance onhow the principles of clinical governance may beapplied to voluntary sector hospices (NCHSPCS2000), and how some hospices have interpretedclinical governance according to their own needs(NCHSPCS 2002a).

The principles of quality improvement apply equallyto complementary therapy services, and manyservices may already be pursuing qualityimprovement activities. The challenge posed by theduty of quality of care, in complementary therapies,is to review and transform the delivery of services sothat:• patients are included in planning and evaluation• there is written information for patients about the

different therapies provided, how they may help,how to access the service and complaintsprocedures

• decisions on choice of therapy and/or the aims oftreatment are based on the best availableevidence

• consistently better outcomes are produced forpatients

• there is a reduction in variations of access, so thatissues such as geographical location, needs of

housebound patients and promoting the servicewith minority groups are considered

• there is a collaborative style of leadership,systems awareness, teamwork and effectivecommunication

• there are clear procedures to enable staff toreport any concerns about colleagues’professional conduct or performance

The main components of clinical governance, asapplied in the NHS, are set out in Appendix B. Theactivities within the framework of clinical governancerecommended for complementary therapy servicesare described in the following sections.

4.2 Policies, procedures andstandards

These national guidelines have also been developedto form a reference point for the development oflocal policies, procedures and standards. Manyorganisations have already developed policies andprocedures. It may be useful for those developingpolicies to look at the policies and procedures ofother organisations, in order to choose the elementswhich most nearly meet local needs.

Policies are agreed rules that the organisationmakes to ensure safe and consistent practice, andto reduce risk. Policies clearly outline what staffneed to do, as well as limits, so that staff understandwhat is expected of them. When drawing up policiesthe place of professional judgement should beconsidered. (See also Chapter 8 on professional andethical issues)

Procedures describe how to do something, outliningin considerable detail the elements of good practicethat should be followed to achieve a quality result.

Standards are statements which distil elements ofgood practice, a measure against which quality canbe judged, so as to ensure that procedures havebeen followed. Standards often extract elements ofgood practice from procedures.

4.3 Supervision

This is addressed separately in Chapter 9 onsupervision.

4.4 Individual performance review orappraisal

Individual performance review or appraisal is astrategy that encourages professional and personaldevelopment and contributes to quality,

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improvement of services and the development of anorganisation. Many organisations have establishedprocedures for this process. When fully understoodand implemented, it is a two-way process, which canboth motivate and support staff. It is recommendedthat all organisations which employ therapistsdevelop a system for appraising or reviewingperformance.

4.5 Education and training

Continuing professional development (CPD) is arequirement for on-going registration of manycomplementary therapy professions, and has alsobeen identified as a quality improvement activitywithin clinical governance.

Education and training needs vary, depending onexisting skills and experience. The needs ofcomplementary therapy staff for specialist training towork in palliative care should be assessed andplanned for. Chapter 10 on clinical issues is aresource that can be used when considering theCPD needs of therapists working in supportive andpalliative care. Training in assessment,communication and counselling skills can alsoimprove quality of care. (See Chapter 9 onsupervision, and Chapter 11 on referral andassessment).

Several organisations offer comprehensiveprogrammes of training for complementarytherapists working in palliative care, parts of whichmay be accessible in independent modules.Courses are available in different parts of England,including Bristol, East Sussex, London, Manchester,and Rochdale.

4.6 Audit and evaluation

Clinical governance encourages an evaluationculture, which measures effectiveness in the form ofpatient outcomes. Audit of different aspects ofservice delivery, for example waiting times, uptake ofservice, responsiveness of service, missedappointments, cost and adverse events, can informplanning and delivery. However, the primary role ofaudit and evaluation of complementary therapyservices in supportive and palliative care is to seekthe views of patients, as well as measuringoutcomes, on a regular and systematic basis.

The difficulty of identifying a single tool whichcaptures the whole picture of how patients may bebenefitting from complementary therapies isrecognised and is an area for future research. Thefollowing section on research suggests a range ofmethodologies and other resources can be found inAppendix C.

4.7 Research and development

Clinical governance encourages participation in well-designed, relevant research and developmentactivities. Research is essential for the improvementand broadening of services and skills in all branchesof the health professions and palliative care (Franks& Ahmedzai 1995). However, the difficulties ofconducting research in complementary therapiesand supportive and palliative care are acknowledgedand include funding, ethical issues, high attritionrates and lack of research experience amongstcomplementary therapy practitioners. (House ofLords 2000; Westcombe et al in press)

The diversity of patients’ symptoms and experienceand the complex nature of complementary therapyinterventions provide a challenge. A singlemethodological approach is unlikely to provideevidence of the spectrum of potential benefits forpatients. A multifaceted approach is recommended,which is inclusive of:• Objective measures in relation to, for example,

sleep, nausea and vomiting, need for medication,use of other services, cost-effectiveness

• Subjective measures to assess pain, quality oflife, well-being, anxiety, depression

• Exploration of the patient’s experience andconcerns

If research, rather than evaluation of services, isundertaken it is important to take into account thedifficulties that may arise. These include attemptingto match sample populations, patients being atdifferent stages of illness and patients havingdifferent types of cancer. It is also important to beaware of the implications of conclusions that may bedrawn. In the absence of in-house expertise inresearch, it may be helpful to work with the localuniversity health research department.

Standardised and validated questionnaires and otheraudit tools which are used in cancer and palliativecare include:• Hospital Anxiety and Depression Scale (Zigmond

and Snaith 1983)• Rotterdam Symptom Checklist (De Haes et al

1990) • State-Trait Anxiety Inventory (Spielberger et al

1983)• Quality of life and symptom distress scale

(Holmes and Dickerson 1987)• Measure Your Medical Outcome Profile (Paterson

1996; Paterson & Britten 2000)• Measure Your Concerns and Well-Being

(Paterson et al 2002)

A number of databases can be used to search forpublished research on complementary therapies.The list compiled by Richardson (2001) can be seenin Appendix D.


4.8 Health and Safety

Organisational policies aimed at assessing andmanaging risks should be understood by allcomplementary therapists. In complementarytherapy services, issues for consideration includethe following:• Training in safe handling and moving • Risk assessment• Reporting of critical incidents which ensures that

adverse events are identified, investigated, andlessons are learned and applied

• Disposal of equipment, such as acupunctureneedles, and essential oil containers

• Storage of essential oils, acupuncture equipmentand homeopathic remedies

• Spillage of essential oils

5 Regulation andtraining ofcomplementarytherapists

5.1 Introduction

The training and qualification of therapists is a keyissue for managers. The Prince of Wales’sFoundation for Integrated Health is supporting anumber of therapies in their development of a morerobust system of regulation and accreditation oftraining for their professions. This chapter outlinesthe current position on regulation and training, andgives information which may be useful for theappointment of therapists.

5.2 Regulation: the current position

With the exception of osteopaths and chiropractors,who are regulated by law, (statute) mostcomplementary therapy practice is either voluntarilyself-regulated or is unregulated. In response to theHouse of Lords Report (2000), the governmentstrongly encouraged the representative bodieswithin each therapy to unite to form a single body forregulating their profession (Department of Health2001). This approach is considered to be in the bestinterests of patients and the wider public, as well aspotentially enhancing the status of individualprofessions. The acupuncture and herbal medicineprofessions have formed working groups to developproposals for statutory regulation. Someprofessions have well-developed voluntary self-regulatory structures and others are workingtowards that position.

Most of the therapies included in these guidelinesare working to achieve statutory or voluntary self-regulation and have formed working groups to makeproposals for the development of single regulatorybodies for their profession. The working groups arecurrently at different stages of development.However, they are likely to play an increasinglyimportant role in developing self-regulation, includingoverseeing standards of education and training.

All practitioners of complementary healthcare areadvised to register with an organisation that ensuresits members are properly qualified, insured topractise, and undertake continuing professionaldevelopment. Membership of a professionalorganisation represented on the working group fordeveloping a single regulatory body for theprofession is likely to assume increasing importance.

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A professional organisation should have:• High quality, clear information on its registrants

and what they offer• Membership requirements which include

competence to practise and insurance • Requirements for renewal of membership which

include continuing professional development• A code of conduct and practice• Complaints and disciplinary procedures• A system for involving members in decision-

making • Published annual accounts

Conventional healthcare professionalsStatutorily regulated health professionals such asdoctors, nurses and physiotherapists who wish topractise complementary therapies are bound by thecode of conduct of their profession. However, theyare advised to consult their regulatory body (egNursing and Midwifery Council), their professionalbody (eg Royal College of Nursing) and employer forguidance before incorporating complementarytherapies into their clinical practice. Organisationswhich offer healthcare within the NHS and theindependent sector are advised to develop localpolicies and protocols for the use of complementarytherapies.

The government’s response to the House of LordsSelect Committee report on complementary andalternative medicine recommended that eachstatutory regulatory body in the conventionalhealthcare professions, whose members makesignificant use of complementary therapies, shoulddevelop clear guidelines for members on both thecompetences and training required for the safe andeffective practice of the leading complementarytherapies. (Department of Health 2001)

The Chartered Society of Physiotherapists (CSP)have published an information paper onphysiotherapy and complementary medicine (CSP2002). Massage, as a manual therapy, remains acore skill of many chartered physiotherapists.Individual physiotherapists are increasinglyintegrating a range of complementary therapyapproaches into their own scope of practice, andthere are a number of clinical complementarytherapy interest groups recognised by the CSP.(www.csp.org.uk)

The Royal College of Nursing and the Nursing andMidwifery Council have issued guidelines on practicefor nurses thinking about some of the issues aroundcomplementary therapies (for example seewww.rcn.org.uk). Advice is given about• Indemnity insurance for practitioners using

complementary therapies• Product liability cover• Self-employed practitioners using complementary

therapies• Nurses who work as homeopaths• Choosing a complementary therapy course• Advertising• Homeopathic substances and herbal preparations

5.3 Training, qualifications andnational occupational standards

Courses in osteopathy and chiropractic, which arestatutorily regulated therapies, are standardised andaccredited by the regulatory bodies for each therapy.Many of the other complementary professions areworking towards common standards of educationand training and the accreditation of professionalcourses. The government has recommended thatany accreditation board is completely independent ofthe institutions being accredited. (Departmen ofHealth 2001).

For conventional healthcare practitioners, thegovernment supports the recommendation (Houseof Lords 2000) that the training of theseprofessionals should be to standards agreed withthe appropriate complementary therapy regulatorybody (Department of Health 2001). This may includethe development of standards which reflect bothtraining and practice at different levels.

Complementary therapy qualificationsA qualification may be• a diploma or other qualification awarded by a

private college or training institute• a nationally recognised qualification, such as a

diploma, from an awarding body that is regulatedby one of the four UK statutory regulatingauthorities. These are:

- for England, the Qualifications and CurriculumAuthority (QCA)

- for Wales, the Qualifications, Curriculum andAssessment Authority (ACCAC), except fornational vocational qualifications, which areregulated by the QCA

- for Scotland, the Scottish QualificationsAuthority (SQA)

- for Northern Ireland, the Council for theCurriculum, Examinations and Assessments(CCEA), except for post-19 externalqualifications which are regulated by the QCA.

• a degree, or sometimes a higher certificate ordiploma, from a university

For details of the external awarding bodies forcomplementary therapy qualifications currentlyregulated by the QCA please see the QCA websitewww.qca.org.uk


National occupational standards are statements ofcompetence, and are written to measureperformance outcomes. Competence may bedescribed as the ability to apply knowledge,understanding and skills in performing to thestandards required in employment. Nationaloccupational standards describe good practice, areused by providers of education and training to definelearning outcomes, and form a basis forqualifications.

National occupational standards are published by theQualifications and Curriculum Authority. At the timeof publication of these guidelines, standards havebeen published for aromatherapy, homeopathy,hypnotherapy and reflexology and are beingdeveloped for other therapies. For information onthe progress of national occupational standards forother therapies, contact Skills for Health, thenational training organisation for health(www.skillsforhealth.co.uk), which is contracted bythe Qualifications and Curriculum Authority todevelop and set standards.

5.4 Choosing a therapist:qualifications and regulation

Membership of a professional organisationrepresented on the working group developing asingle regulatory body for individual therapies islikely to assume increasing importance. Appendix Eprovides the following information about thetherapies included in these guidelines:• The working groups for the development of single

regulatory bodies for each therapy, with lists ofmember organisations (as at May 2003).

• The availability of national occupational standardsfor each therapy.

However, if therapists do not belong to one of theseorganisations the interview process will assumeparticular importance for verification of competence.This may include, for example, using competency-based questions or scenarios. Please see Chapter6.4 on interview and assessment.

It is in the interests of services and therapists thattherapists are registered with organisations that arerepresented on developing working groups if there isone for that therapy.

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6 Recruitment andSelection

6.1 Introduction

The purpose of this chapter is to provide informationthat will be useful when employing complementarytherapists. Key points to be considered include thecandidate’s prior experience in supportive andpalliative care, their experience of using the therapy,assessment of competence and other skills.Orientation and induction complete the recruitmentprocess. The qualification and regulation oftherapists is an area of particular concern toemployers and Chapter 5 is devoted to this subject.This chapter should be considered in conjunctionwith Chapter 7 on volunteer therapists.

6.2 Regulation and training

When considering the qualifications of therapistsreference should be made to Chapter 5 for thecurrent position on regulation and training.

6.3 Prior experience

It is reasonable to expect complementary therapycoordinators or team leaders and other therapistswho are paid, to have had education, training orexperience of working in supportive and palliativecare, and of using complementary therapies withpeople who are ill. Relevant experience would bedesirable for volunteer therapists but training andsupervision can be provided, if there is acomplementary therapy coordinator or team leader.(See Chapter 7 on volunteers)

6.4 Interview and assessment

The interview process is crucial in the recruitmentand selection of therapists, particularly since thereare at present variable standards of training in manytherapies. Patients emphasise the need for atherapist to be a ‘people person’ and have excellentinterpersonal and communication skills, as well asbeing appropriately qualified. (The Prince of Wales’sFoundation for Integrated Health 2002) It isadvisable to include a service user on the interviewpanel, as well as an experienced practitioner in thetherapy for which the candidate is being interviewed.Some organisations incorporate in the interview anassessment of the skills and strengths of thetherapist. For example, the applicant may berequired to give a short treatment to a member ofthe panel who takes the role of the patient.

Recruitment and selection: best practice key points a) Organisations should have a recruitment andselection policy that includes equal opportunities andwhich is communicated to all staff

b) Systems must be fair, consistent and valid

c) Recruitment and selection must take into accountthe needs of the individual as well as the needs ofthe organisation

d) All applications should be acknowledged wherepossible and treated confidentially

e) Recruitment advertisements should:• state briefly the requirements of the job and the

necessary and desirable criteria for job applicants• state the activities and working practices of the

organisation• state the job location, and application procedure• state the reward package, and job tenure• not make misleading claims or present misleading

information• never contain age barriers or age-related criteria

f) Job profiles and person specifications should:• outline roles and responsibilities• state the necessary and desirable criteria for

selection• be based on appropriate qualifications and

competencies, for example skills, aptitude,knowledge and experience

• specify the personal qualities relevant to the job,such as the ability to work as part of a team(See Appendix F for an example of a job descriptionfor a complementary therapy co-ordinator)

g) References• The recruitment policy should state clearly how

references will be used, at what stage of therecruitment process, and what kind of refereeswill be necessary. These rules should be appliedconsistently

• Recruiters should always use references to checkfactual information, such as qualifications

• Former employers should not be asked to supplya subjective opinion as to an applicant’s likelyfuture performance

h) Occupational health clearance and medicalexaminations• It is reasonable to require the completion of a

health questionnaire where good health is relevantto the job

• Public service organisations are obliged to obtainoccupational health clearance for a prospectiveemployee

i) Criminal Records Bureau• Clearance for new staff working with children and

vulnerable adults must be obtained from 1 April


2002 and for existing staff by April 2004(Department of Health 2000).

j) Interviews should:• always be conducted or supervised by trained

individuals• be structured to follow a previously agreed set of

questions mirroring the personal specifications orjob profile

• allow candidates the opportunity to ask questions

It is desirable to include on the interview panel aservice user and an experienced practitioner in thetherapy for which the candidate is being interviewed. (Chartered Institute of Personnel Development2002)

6.5 Salary

The payment of therapists varies widely. The salaryof team leaders or coordinators can vary from about£17,000 – £30,000 per annum. Posts which havebeen incorporated in the nursing budget are paidaccording to the nursing scale and can range fromgrade E – grade H. Self-employed therapists arepaid per session and this can vary from £10-£30 perhour.

Leadership roles include team leader, lecturer-practitioner, lecturer and consultant. It isrecommended that posts should be gradedaccording to the role expected of the post-holder.The job descriptions of therapists should becomparable to those of other members of the clinicalteam (if any) in terms of skills and responsibilitiesrequired and posts should be graded accordingly.

6.6 Contract

It is a legal requirement for employers to provideemployees with a contract stating the terms andconditions of employment. Self-employed therapistsshould also have a contract which states terms andconditions, including agreements regarding paymentwhen appointments are cancelled. It may beimportant to include ethical issues such asconfidentiality, not making claims about outcomesand not criticising or judging other healthprofessionals. (See Chapter 8 on professional andethical issues)

6.7 Orientation and induction

Therapists should receive the same orientation asthat provided for other members of the clinical team.The induction needs of therapists differ and shouldbe agreed and planned with the individual.Information on precautions to be taken whenproviding treatment in supportive and palliative carecan be found in Chapters 12-17 on the therapies, butthis should not be used in place of additionalspecialist training. Therapists should be introducedto all the policies and procedures of the organisation,including personnel and health and safety policies.

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7 Volunteer Therapists

7.1 Introduction

There are a number of organisations in supportiveand palliative care which depend on volunteertherapists. The use, recruitment and managementof volunteer therapists are issues which generatemuch debate (The Prince of Wales’s Foundation forIntegrated Health 2002). One of the key points inworking with volunteers is the principle ofreciprocity, which can often be overlooked in a busyworkplace. This chapter considers the issuesinvolved in managing volunteer therapists, such asrecruitment terminology, line management,supervision and support, and gives information onbest practice.

On the one hand best practice demands thedevelopment of a culture that values the contributionof volunteers. On the other hand, the managementof volunteer therapists is time consuming and has tobe balanced against the benefits. It is said of thevoluntary sector that "individuals and teams of paidstaff and volunteers are striving to accomplish anenormous amount with resources that are neversufficient" (Voluntary Sector National TrainingOrganisation 2002). This is true for all organisationsdelivering health care. Time and expertise,therefore, are at a premium and "volunteers are asource of risk or liability as well as a benefit".(Association of Chief Executives of VoluntaryOrganisations 1998)

A well-managed volunteer service can deliver benefitto the organisation and also to the volunteer in termsof personal satisfaction. The home office and theNational Council for Voluntary Organisations havedeveloped a code of good practice for volunteeringin general. (NCVO 2001) Some of the basic pointsare summarised in Appendix G. Supported by theDepartment of Education and Skills, the voluntarysector national training organisation is taking theNCVO Volunteering: Code of Good Practice forwardin a project to develop national occupationalstandards for managing volunteers. (VoluntarySector National Training Organisation 2002) Theproject is due for completion by September 2003,and information can be obtained from the VoluntarySector National Training Organisation websitewww.voluntarysectorskills.org.uk

One of the principles of volunteering is reciprocity:volunteers offer their contribution unwaged, butshould benefit in return. Benefits to volunteersinclude the establishment of a reciprocal relationshipin which the volunteer gains a sense of worthwhileachievement, experience and contacts; is taught theskills involved in the execution of their role, and is

included in the life of the organisation. It should berecognised that volunteer complementary therapistsare highly qualified individuals who are eitherfinancially in a position to give some of their timefreely and are motivated to do so, and/or want togain experience while building up a private practiceor waiting for paid employment opportunities.

The following key areas, which need to beconsidered in managing complementary therapyvolunteers, are addressed in this section:• Recruitment and selection• Orientation and induction• Line management• Supervision and support• Professional and ethical issues• Continuing relationships with patients and carers • Application of personnel policies• Health and safety

7.2 Recruitment and selection

QualificationsThe qualifications of volunteer therapists should beno less than those required of paid therapists (seeChapter 5 on regulation and training).

Role description and agreementIn order to be clear about the expectations of avolunteer therapist and encourage belonging withinthe organisation, it is suggested that volunteersshould receive a role description as part of therecruitment process. An example of a roledescription is found in Appendix H. However, therehas been increasing litigation in relation tovolunteering, following recent developments inemployment law. Role descriptions should be freeof any terms which can be construed as employmentterminology, such as job description, hours of work,probation, appraisal and obligations. It is alsoadvisable to be clear that there is no intention tocreate a legally binding relationship. For advice,organisations should contact their legal advisers, theCitizens Advice Bureau, the National Council forVoluntary Organisations, or the Employment LawHelp Line of Help the Hospices.

ProcessThe principles of best practice which apply to theemployment of paid therapists should be adhered toin the recruitment of volunteers (see Chapter 6 onrecruitment). For example, there should be aprocess through which qualifications, insurance andreferences are checked and an interview whichprovides the opportunity for judging the suitability oftherapists for working in supportive and palliativecare, and which could include an assessment ofskills. Public service organisations are obliged toobtain occupational health clearance for individuals.Clearance for working with children and vulnerable


adults, as an employee or volunteer of anyorganisation, must be obtained for new staff (paid orvolunteer) from 1 April 2002 and for existing staff byApril 2004 (Department of Health 2000).

AgreementsVolunteering agreements, including details of theplacement, should be confirmed in writing (VoluntarySector National Training Organisation 2002).However, as for the role description, it is importantto avoid any terms which could be construed asemployment terminology.

7.3 Orientation and induction

A volunteer therapist should receive a generalorientation to the organisation, and thecomplementary therapy service. Specific inductionneeds should be identified with the individual, andplanned for. Additional training may be required, forinstance in supportive and palliative care, the use ofthe specific therapy in supportive and palliative careor working in a conventional health care setting, anon-clinical environment or in a patient’s home.Organisations with volunteer therapists and/orwhose in-house expertise does not extend toteaching the use of complementary therapies inpalliative care should consider paying for shortcourses or study days provided by otherorganisations.

7.4 Line management

Volunteer therapists should be introduced to thestructure of the organisation so that they can seewhere they fit in. Line management responsibilitiesshould be clarified. Regular planned reviews can beused to identify supervision and support needs,assess satisfaction levels, reassess the availabilityof the volunteer versus the needs of the organisationto provide a service and clarify the time commitmentinvolved in managing volunteers.

7.5 Supervision and support

The expectation that volunteer therapists shouldparticipate in supervision can be difficult to fulfil.Volunteer therapists have been known to bemotivated to give their time freely to patients andcarers, but less keen to participate in supervision forthemselves. (The Prince of Wales’s Foundation forIntegrated Health 2002) Nevertheless, supervisioncould be provided in-house or the individual could beresponsible for their own therapy specificsupervision and reflective practice away from the

organisation (see Chapter 9 on supervision).Management supervision should be via thetherapist’s line manager within the organisation.

Support can be provided in a variety of other ways,for example informally, through network groups orpeer support, and through opportunities to receiveand exchange therapies. Supporting thedevelopment of volunteers’ knowledge, skills andcompetence can be done through participation in in-house study days, discussion groups, involvement inplanning and evaluation, and through innovativeprojects.

7.6 Code of practice

Volunteer therapists are bound by the code ofpractice of the professional organisation of whichthey are members. They should be accountable fortheir practice and behaviour in the same way thatpaid therapists are. Details are given in the separatesection on professional and ethical issues in Chapter8. In addition, organisations should have, ordevelop, their own policies on issues such asconfidentiality, consent, and the receipt of gifts.

7.7 Continuing relationships withpatients and carers

A contentious issue seems to be the continuation ofa professional relationship between the volunteertherapist and the patient or carer, once the personhas completed their treatment in the organisation(The Prince of Wales’s Foundation for IntegratedHealth 2002). Patients value continuity once theyhave established a relationship with a therapist, andfind the continuation of the professional relationshipa support for their illness journey.

Concerns regarding the continuation of treatment ina private capacity with the therapist include lack ofsupervision of the therapist in relation to thepatient’s changing clinical condition, issues ofaccountability, and legal and ethical issues where thepatient sees the continuation of treatment as acontinuation of the service provided by theorganisation. For example, a patient couldsubsequently involve the organisation in a complaintabout the treatment or therapist.

It is recommended that organisations consider thisissue and are clear about where they stand, and forthat position to be made clear to potential therapists.However, it is the patient’s right to negotiate whereand from whom they receive private treatment. Away forward may be that when such a situation

27

occurs, the patient should be clear that he/she isentering into a private contract with the therapist,and that this is unconnected with the organisation.

It is also recommended that organisations considercompiling a list of therapists in the local area withexperience of treating people with cancer and/orchronic illness. This list could be made available forpatients, although it would be important toemphasise that the list should not be interpreted asa recommendation of therapists by the organisation.

7.8 Personnel policies

Personnel policies which apply specifically tovolunteers, and other general policies that also applyto volunteers, should be easily accessible to thevolunteer. These policies should include: • Equal opportunities, diversity, and anti-

discriminatory statements• Complaints policy• Management of capability, skills and development• Staff support policies• Disciplinary and grievance policy• Bullying and harassment policyPolicies should provide volunteers with informationabout the organisation’s expectations and therequirements of their role. Details of support andprotection for the volunteer should be included.

7.9 Health and safety

Volunteer therapists should be familiarised with thehealth and safety policies of the organisation, andshould be included in annual safe handling andmoving training and fire training.


8 Professional andEthical Issues

8.1 Introduction

Although professional organisations that registercomplementary therapists should have codes ofpractice and ethics, the multitude of organisationsthat currently exist for many therapies results in asmany different codes and varying standards. Thischapter has adapted standards for professionalaccountability, consent and confidentiality from themedical, nursing and midwifery professions. It isrecommended that complementary therapyprofessionals working in supportive and palliativecare and who are not also a member of a statutorilyregulated profession, should follow these standards,in addition to those set by their own professionalorganisation.

Although these guidelines have drawn on thedocuments, Code of Professional Conduct (Nursingand Midwifery Council 2002a), Standards of Practice(General Medical Council 1998), Duties of a Doctor(General Medical Council 1998) and otherdocuments (Nursing and Midwifery Council 2002 b-e), it is emphasised that the adaptation of thesemedical and nursing standards does not in any wayimply that either the General Medical Council orNursing and Midwifery Council has responsibility forcomplementary practitioners. The regulation ofdoctors, nurses, midwives and health visitors isseparate from the ethical standards recommended inthese guidelines for complementary therapists.Moreover, the recommendation of the followingethical standards does not imply a similar level ofexpertise, training or regulation of non-statutorilyregulated complementary therapists.

8.2 Professional accountability

Ethical guidance aims to promote optimal standardsof care (Stone 2002). As a general rule, thecomplementary therapist shall act, at all times, insuch a manner as to:• safeguard and promote the interests and well-

being of clients• justify the trust and confidence of clients• uphold and enhance the good standing and

reputation of their complementary therapyprofession

• uphold and enhance the good standing of theorganisation in which they are providing a service

Complementary therapists are personallyaccountable for their practice, and in the exercise ofthat professional accountability, must :

• ensure that no action or omission on their part isdetrimental to the interests, condition or safety ofclients

• maintain and improve their professionalknowledge and competence

• recognise the limits of their professionalcompetence

• make no claims for their treatment which are notwholly true and justifiable

• communicate and provide information in a waythat clients can understand

• work in partnership with clients, foster theirindependence, and respect the treatment choicesthey make

• respond to patients’ need for care, irrespective ofgender, age, race, disability, sexuality, culture orreligious beliefs

• maintain professional boundaries and avoid anyabuse of their privileged relationship with clientsand of the privileged access allowed to the client’sperson, property or residence.

• protect all confidential information concerningclients obtained in the course of professionalpractice and make disclosures only with consent,or within the policy of confidentiality as practisedwithin the organisation, except where they canjustify disclosure in the wider public interest

• refuse any gift, favour or hospitality from clientscurrently in their care which might be interpretedas seeking to exert influence to obtain preferentialconsideration

• work in a collaborative and co-operative mannerwith the multidisciplinary team and others involvedin providing care

• recognise and respect the role and contribution ofcolleagues, within conventional medicine andother complementary therapy practitioners; forexample, when interacting with a client do notcriticise or question any other colleague’sapproach

• report to an appropriate person or authority anycircumstances which could jeopardise orcompromise safety or standards of practice,including the fitness of themselves or a colleagueto practice, while having regard to the physical,psychological and social effects on clients

• follow the employing organisation’s policies andprotocols

8.3 Consent

There are three over-riding professionalresponsibilities with regard to obtaining consent.The practitioner must:• act in the best interests of the client• ensure that the process of establishing consent is

transparent and demonstrates a clear level ofprofessional accountability

• record all discussions and decisions accurately

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Valid consent consists of three elements:• if the patient is unable to give consent

themselves, it is given by a competent person,who may be a person lawfully appointed on behalfof the patient

• it is informed• it is given voluntarily

Effective communication is the key to enablingclients to make informed decisions, and includesfinding out about the individual’s needs and priorities.Sufficient information should be provided, in a waythat the client can understand, and this includes anexplanation of any risks involved. Sufficient timeneeds to be set aside for this, so that the individualhas the time to consider and ask questions beforemaking a decision.

A client who is legally competent may give consentin writing, verbally or by co-operation. Someorganisations prefer to have written consent tocomplementary therapy treatment. Otherorganisations consider verbal consent, or consentby implication (by cooperating) to be sufficient. Thecomplementary therapist should follow the policy ofthe organisation with regard to written or verbalconsent. In the case of verbal consent therapistsshould record their discussion with the client at thetime of the assessment.

The scope of consent should be clear. For example,a client who consents to having reflexology, has notalso consented to receiving acupuncture. Thisshould also be made clear to the patient.

The policy of the organisation should be followed incases where the patient is semi-conscious orunconscious and unable to give consent. If a clientdeclines treatment at any particular time, this shouldbe respected and recorded.

When complementary therapies are provided in anorganisation where there is a medical team, forinstance within the NHS or a hospice in-patient unit,the patient’s doctor has the overall legalresponsibility for the patient’s care. A system forobtaining consent from the patient’s doctor for theuse of the different complementary therapies shouldbe agreed.

8.4 Confidentiality

The therapist should recognise and respect a client’sright to expect that information given in confidencewill be used only for the purpose for which it wasgiven, and will not be released to others without theirpermission.

The therapist is responsible for any decision torelease confidential information. If it is appropriate

to share information gained in the course of givingtreatment with other health and social workcolleagues, the therapist must ensure that as far asis reasonable, the information will be kept in strictprofessional confidence and used only for thepurpose for which it was given.

As it is impractical to obtain consent every timeinformation needs to be shared with others, thetherapist should ensure that the client understandsfrom the start that some information may be madeavailable to other members of the team involved inthe delivery of care. In some organisations this isknown as team confidentiality. The therapist shouldfollow the organisation’s policy on confidentiality.Disclosure of information, without consent andoutside of the team, may be made only where it canbe justified in the public interest, usually wheredisclosure is essential to protect the client orsomeone else from the risk of significant harm, orwhen the therapist is required by law or by order of acourt. Clients should be made aware of this.

With regard to disclosure of information where thereis an issue of child protection, the therapist shouldact at all times in accordance with national and localpolicies.


9 Supervision

9.1 Introduction

Supervision is understood to be central to theprocess of learning before expansion of the scope ofpractice and a means of encouraging assessment,analytical and reflective skills. (Department of Health1993) There are different interpretations of theterms supervision and clinical supervision. Thischapter describes supervision which is specific tothe practice of the particular therapy and that whichfacilitates reflection on practice. Suggestions aremade about the different ways in which supervisioncan be organised, but managers and therapists needto be clear about how the cost of supervision will bemet.

As a formal process of professional support andlearning, supervision:• enables individual practitioners to develop

knowledge and skills to help them meet newchallenges, find ways of meeting needs andremain receptive to change through thedevelopment of practice

• provides support for those working in stressfuland distressing situations

• maintains high standards of safe and effectivecare (Department of Health 1993; NHS Executive1994)

The benefits of supervision have been reported indifferent studies (Bowles & Young 1999; Cullverwell& Green 1998), but the evidence to supportsupervision for complementary therapies is currentlylargely anecdotal or derived from a small number ofstudies. (Mackereth 2001)

Whilst supervision is also considered to be aneffective risk management tool (Tingle 1995), for itto be welcomed and effective it must also be viewedas useful, safe and appropriate to the supervisee’spractice. (Mackereth1997) Within complementarytherapies, depending on the therapy practised andthe structure of provision of supervision within anorganisation, supervision can be further sub-dividedinto the provision of therapy specific supervision andreflective practice, although in some situations thisdistinction is not made.

9.2 Therapy specific supervision

Therapy specific supervision is supervision in theuse of a particular therapy in the context ofsupportive and palliative care. This can also beunderstood as an exchange between practisingprofessionals to enable the development of

professional skills. (Faugier and Butterworth 1994)The depth of supervision depends on the therapist’sexperience of practising the therapy, of working withpatients, and of using the therapy within supportiveand palliative care. It is suggested that organisationsshould assess the therapist’s experience andexpertise in the interviewing process, agree the levelof supervision required and agree who will providethis. If the organisation is unable to provide therapyspecific supervision, for instance, for anacupuncturist, it may be that the therapist will needto find an external supervisor. Some employersspecify that self employed therapists are responsiblefor their own therapy specific supervision.

9.3 Supervision as reflection onpractice

PurposeThe purpose of providing time, space and asupportive relationship that enables practitioners toreflect on their own practice is two-fold. Firstly, themotives for working in the helping or caringprofessions are not clear and simple, and the role ofhelper carries with it certain expectations. (Hawkinsand Shohet 1989) Supervision can improve patientcare by distinguishing personal from professionalissues, thus enabling the focus to remain on thepatient, while supporting practitioners in work thatcan be challenging and emotionally demanding.Other benefits include an increase in confidence,and the avoidance of burnout. (Hallberg et al 1994)Developing clear supervision contracts, andensuring that supervisors also receive supervisionfor their role, can contribute to clarifying theboundaries within supervision. (Mackereth 2001)

Secondly, the provision of supervisionacknowledges and celebrates the potency intherapeutic work. (Mackereth 1997) Emotional andphysical responses to complementary therapytreatments can happen. The practitioner’s skills andsupport, and issues of boundaries to practice needto be considered in order to effectively manage anyemotional and physical responses. (Mackereth1999) Complementary therapists usually seepatients on a one to one basis, and additionaltraining in communication skills may increase theirconfidence when relating to patients in challengingsituations. Studies have shown that communicationskills can be taught, (cited in Heaven & Maguire1997) and there is growing evidence to supporteffective models for training in communication skills.(National Institute for Clinical Excellence 2002)

Training in communication skillsTraining programmes in communication skills thatlead to positive outcomes should: • include cognitive, behavioural and emotional

aspects of communication and focus on the

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acquisition of specific skills and/or strategies fordealing with specific situations

• use a combination of didactic and experientialmethods, including role play, group work anddiscussion

• be learner centred• provide a safe environment for the development

of skills, reflection and self-awareness• have defined and measurable core competencies• be led by professionals who are trained and

understand issues relevant to the clinical context• provide constructive feedback

(National Institute for Clinical Excellence 2002)

The following are examples of communication skillstraining currently available:• Cancer Research UK, Psychological Medicine

Group, Stanley House, Christie Hospital NHSTrust, Wilmslow Road, Manchester M20 4BX.Tel: 0161 446 3679. Facilitated by ProfessorPeter Maguire and team

• Help the Hospices, Hospice House, 34-44Britannia Street, London WC1X 9JG. Tel: 0207520 8200. Facilitated by Dr. Susie Wilkinsonand Anita Roberts

• St. Ann’s Hospice, Institute for Learning andDevelopment, St. Ann’s Road North, HealdGreen, Cheadle, Cheshire SK8 3SZ. Tel: 0161437 8136. Contact Christine Lawther, Head ofthe Institute for Learning and Development

The culture of supervisionApart from the social work and counsellingprofessions, the culture of supervision within thehelping professions is not strong. Indeed, the needfor supervision has often been regarded negatively,as an acknowledgement of weakness. However,one of the implications of the introduction of clinicalgovernance is the need to create an environment forlife-long learning, in which excellence will flourish.Within this culture, the understanding of the value ofsupervision is growing, although it is still early days.The issues that need to be considered are:• a general lack of experience of the supervision

process in the helping professions, both ofsupervisees and supervisors

• the provision of supervision to therapists workingin diverse settings and circumstances, such asself-employed, sessional, part-time, volunteers,hospitals, cancer support groups, self-help groups

• a general reluctance by professionals to engage inthe supervision process for a variety of reasons,some of which are personal, financial orprofessional, not least a lack of understanding ofthe value of supervision

• management support for developing supervision.

The organisation of supervisionAs there is no statutory requirement for supervision,the challenge to introducing this supportive andprofessional development strategy demands flexible

models that meet local needs, training andeducation, and the building of relationships which arehelpful for sustaining and developing practice. Thereare different ways in which supervision has beendeveloped for complementary therapists insupportive and palliative care settings.• Individual, with supervisor from the same or

different profession• Small group supervision, with supervisor during

work time or in the evening• Peer supervision, individual or group• Complementary therapies coordinator supervises

own team• Non-management supervision, such as external

supervisor, supervisor from another clinicalspeciality, complementary therapies coordinatorfrom another centre, perhaps on a mutualexchange basis

• List of supervisors from which the therapist canchoose

• Commitment to regular supervision, with agreedcontract

9.4 Cost of supervision

The cost of supervision may not be an issue foremployees who receive in house supervision duringwork time, but for volunteer and self employedtherapists the time and cost involved needs to beconsidered. Organisations need to be clear withinthe recruitment process about expectations for theself employed or volunteer therapist to participate insupervision, and about who will meet the costsinvolved. The sessional payment for self employedtherapists could include an element for participationin supervision. Volunteer therapists may considersupervision as part of their support and learningprocess. Although the process of supervisioncontributes to quality care, it is against the basicprinciple of supervision to coerce anyone toparticipate. Ultimately it is dependent on thecreativity and flexibility of provision, as well as thevalue placed on supervision by therapists.


10 Clinical Issues

10.1 Introduction

The purpose of this chapter is to give an indication ofwhat therapists can reasonably be expected toknow, and the clinical issues in supportive andpalliative care of which therapists need to be aware,although there is less emphasis given to neurologicalconditions than for cancer. These clinical issues fallunder three main headings:• general contraindications and precautions• issues which patients with cancer may be facing• issues specific to patients with motor neurone

disease, Parkinson's disease and multiple sclerosis

10.2 General contraindications andprecautions

Therapists trained to the standard required forregistration with professional complementarytherapy bodies should be knowledgeable about thegeneral contraindications and precautions for thetherapy they practise. However, in order to be ableto assess the patient prior to treatment, thetherapist will need access to the person’s medicalnotes or information about the patient’s medicalcondition(s) and current medication. The latter canbe obtained from the patient or via referral forms(See Chapter 11 on referral and assessment andAppendix I).

Staff in conventional healthcare who are nottherapists will need familiarisation, guidance ortraining on:• when, and when not, to refer patients for

complementary therapies.• how to communicate with patients about

complementary therapies, so as not to raise falsehopes.

10.3 Issues which patients with cancermay be facing

Complementary therapists will need induction andtraining on the issues which cancer patients may befacing and how these could impact oncomplementary therapy treatment. The areas fortraining will depend on the therapist’s experience andbackground. Therapists should have a basicunderstanding of the conventional treatmentspatients are likely to receive, how the treatmentswork and what they are trying to achieve, in order toavoid making uninformed or insensitive commentsabout the treatment, which can be confusing anddistressing for the patient. Therapists need to know

that patients respond as individuals, that theperson’s condition will fluctuate, and that they mayexperience different problems and/or emotions atdifferent times. Following are some examples ofissues which patients with cancer may be facing.

A. Issues pre and post diagnosisPhysical• Symptoms depending on the site of the cancer,

for example pain or change in body functions• Symptoms relating to side effects of treatment

Psycho-spiritual• Waiting for results• Shock, numbness, fear, anxiety, anger, ‘why me?’• Denial• Living with uncertainty: many aspects of the

future, inability to plan; ‘how do I cope?’• Fears about untouchability and infectivity • Low self-esteem

Treatment options• Surgery• Radiotherapy• Chemotherapy• Hormonal treatment• Novel therapies, multimodal therapy, etc.• Clinical trials

Social• In relation to job, family and other relationships• Isolation, ‘who can I talk to?’, ‘where can I get help?’

B. Issues relating to treatmentIssues which may be common to all patients includewaiting for results and altered body image.Surgery• Anticipatory fears• Recovery and convalescence – care needs,

wounds, pain and discomfort• Colostomy and other stoma bags

Chemotherapy• Fatigue• Discomfort and feeling unwell generally• Nausea and vomiting• Hair loss• Sore mouth and mouth ulcers• Effects of neutropenia: greater risk of infection,

for example, thrush• Possibility of blood clotting impairment during

cycles of chemotherapy• Diarrhoea• Altered sensations in extremities• Altered taste

See Chapters 12-17 about therapies

Radiotherapy• Fatigue• Discomfort

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• Change in body functions, depending onradiotherapy sites

• Skin sensitivities• Nausea and vomiting• Mouth soreness and swallowing difficulties (head

and neck treatment)See Chapters 12-17 about therapies

Hormonal treatment• Side effects, such as hot flushes

Systemic steroids• Thin skin• Weakness of thigh and upper arm muscles• Sleep disturbance• Altered behaviour or personality

C. Issues of patients with advanced cancerIt is important to remember that patients have gooddays too!Physical• Fatigue: their system may be unable to cope with

vigorous treatment• Pain, cancer and non-cancer related• Increased incidence of undiagnosed deep vein

thrombosis as immobility increases• Discomfort, general and specific areas• Reduced function of organs or systems leading

to, for example, oedema or skin breakdown• Pathological fractures, if there are bony

metastases, or multiple secondaries• Confusion or disorientation, if there are brain

tumours• Condition can fluctuate greatly

Emotional• Anxiety, fear, panic attacks• Low mood, clinical depression• Anger, irritation, frustration• Denial• Altered body image• Moods can fluctuate

Spiritual• Guilt• Hopelessness, loss of meaning, faith• When all active treatment has been discontinued,

and the patient is aware that they are dying

Social• Plans in relation to family, will, funeral• Change in personality• Family dynamics, relationships, problems• Need for care and support• Carer’s needs• Financial

Death• A patient may die while a therapist is with them

(rare)

D. Therapists need to know what could happen to apatient during a treatment session, albeit rarelyInstructions on what to do in the event of thefollowing:• Seizure or epileptic fit, usually associated with

brain tumours • Haemorrhage (rare), could be from the stomach

via the mouth, the lungs via coughing or via therectum

• Breathlessness• Vomiting• Pain• Pathological fracture (rare), usually associated

with bony metastases

E. Other important clinical issuesDeep vein thrombosis (DVT)• a patient with recent or current DVT should not

receive massage to the affected limb. • a gentle treatment is indicated for patients with

advanced cancer as there is a known highincidence of undiagnosed DVT in hospice patientsand those with increasing immobility

Cord compression• recent loss of skin sensation and/or muscle

power in the lower limbs which could indicatecompression of the spinal cord

Intestinal obstruction• abdominal massage and other treatments that

attempt to treat constipation should be avoidedunless it is known that the patient is not sufferingfrom intestinal obstruction

Any change in condition• the importance of the interprofessional

communication role that therapists can have • who to notify/inform about the patient’s change in

condition (if relevant)• what discussion to have with patients who report

a change in condition and what advice to give


Table 2 Clinical issues in motor neurone disease (MND), Parkinson’s disease (PD) and multiple sclerosis (MS)

(The presence of the following signs and symptoms depends on the severity of the patient’s condition)

Clinical issue MND PD MS How this may influence treatment and

relationship

Level of function impaired √ √ on/off √ Check with patient, family or nursing staff

Moving and handling needs √ √ √ Assess, check with patient, family or nursing staff and preferences

Joint problems or contractures √ √ May affect moving and handling, check with staff

Breathing problems √ Check with patient, family or staff and position as required

Speech impairment √ √ √ Communication

Dribbling of saliva √ √ √ Assistance with wiping the saliva

Difficulty swallowing √ √ on/off √Choking attacks √ √ on/off √ Assist patient and keep calm, summon help as

needed

Tremor √ Gentle treatment

Rigidity √ Gentle treatment

Spasms, rigidity and pain √ √ Gentle treatment

Massage can provoke or increase spasm

Pain √ √ √ Gentle treatment

Neuropathic

Bradykinesia (slowness) √ Allow time to relate at the patient’s pace

Fatigue √ √ Gentle treatment

Oedema in limbs √ √Incidence of DVT in advanced √ √ √ Check with staffdisease (depends on level of immobility)

Urinary catheter √ √PEG feed (feeding tube in abdomen) √ √

Treatment - know what the patient can tolerate, otherwise give only gentle treatments

10.4 Issues specific to patients withmotor neurone disease, Parkinson'sdisease or multiple sclerosis

Complementary therapists should be familiarised withthe clinical issues with which they may be faced whentreating a person with motor neurone disease (MND),Parkinson’s disease (PD), and multiple sclerosis (MS)and should be aware of the patient’s special needs.The clinical issues that need to be considered includethose in Table 2. Further advice and information onneurological diseases can be obtained from:• The National Hospital for Neurology and

Neurosurgery• Motor Neurone Disease Association• Multiple Sclerosis Society• Parkinson's Disease Society• The department of neurology in local NHS

hospital trusts

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11 Referral andAssessment

11.1 Introduction

The referral of patients for complementary therapytreatment relies on a number of factors, including theavailability of information for patients, carers andprofessional staff, healthcare professionals’knowledge of complementary therapies and theresources available within a service. Patients shouldbe given information on the availability ofcomplementary therapy services, and how to accessthem. (NICE 2002) Assessment of patients prior totreatment also takes different forms and isdependent on a number of factors. This chapteroutlines the reasons for which a patient may bereferred, the different ways a patient may bereferred and assessed, and the documentationinvolved.

11.2 Referral

It is recommended that patients and carers are ableto self refer for assessment for complementarytherapies. The different routes of referrals are asfollows:• self referral or introduction• by a family member• by a health professional

Referral criteria are useful in organisations wherehealth professionals make referrals forcomplementary therapy treatment, and whereresponsibility for the patient’s care is ultimately theresponsibility of the medical team. In theseorganisations, there will also need to be a system toensure consent for treatment is obtained or agreedby the relevant medical practitioner. The evidence inthe chapters on individual therapies suggests thatpossible reasons for referral include the following:

• For relaxation• To improve quality of life through comfort, well

being, support• Tension, stress• Anxiety, fear, panic attacks• Low mood, depression• Pain• Musculoskeletal problems• Breathlessness• Nausea and vomiting• Constipation• Hot flushes• Sleeplessness• Fatigue• Body image changes

Patients and carers should be given information leafletsabout the different therapies available either within theorganisation, or in the local area, in order to facilitateself referral. It is also recommended that professionalsare familiarised or trained to routinely discuss theopportunity for complementary therapy treatments withpatients and carers. Ideally, patient referrals fromprofessionals should be accompanied by a referralform, which should give the following information:

• Name and date of birth • Contact information• Diagnosis: primary and/or secondary cancer

sites, Parkinson’s disease, multiple sclerosis,motor neurone disease, and year(s) of diagnosis

• Other medical diagnosis• Current medication• Details of current chemotherapy treatment (if any)

for cancer patients• Details of current or recent radiotherapy (if any)

for cancer patients• Patient’s awareness of diagnosis and prognosis• Reasons for referral• Physical symptoms, eg pain, nausea/vomiting,

open wounds/lesions, breathlessness,sleeplessness, lymphoedema, DVT

• Other relevant/useful information

An example of a referral form can be seen inAppendix I. However, forms should not inhibitreferrals and it may be more appropriate, especiallyin some circumstances where medical notes areavailable to the therapist, that the referral is verbal.Where a patient or carer self refers in a non clinicalenvironment, there may not be a referral form, and itis incumbent on the assessor and/or therapist toscreen for contraindications or perform a fullassessment.

11.3 Assessment

The world of complementary therapy can bedaunting and an unknown quantity for patients forwhom it is new. Patients need to have anexplanation (in lay terms) of what the therapies are,what they mean, what is involved in the treatmentand what outcome can be hoped for. Leaflets maybe available, but should not take the place ofdiscussion, wherever this is possible.

Depending on the setting in which the therapy isprovided, the time available and/or the skills of thepractitioner, the level of assessment will range fromscreening for contraindications to a full assessment.Assessment requires the recognition or knowledgeof contraindications, change of circumstances andindications of when to discontinue therapy.Contraindications and precautions for use ofindividual therapies in palliative care can be found inchapters 13-17.


ScreeningSome organisations may decide on a model ofservice provision in which patients are screened forcontraindications. When complementary therapytreatment, usually the touch therapies, is provided insome environments, it may be appropriate for thetherapist to carry out a screening forcontraindications, rather than a full assessment.These environments include:• an outpatient environment where the patient may

be awaiting or receiving chemotherapy in a roomshared with other patients

• an inpatient setting where the room is shared withother patients

Full assessmentFull assessment includes assessment of physicalsymptoms, as well as psychological, emotional,social and spiritual factors which have an impact onthe patient’s life. This form of assessment is likely toelicit information that informs the treatment, butmust also be received in a responsible manner (seeChapter 9 on supervision). At some centres, it isthe complementary therapy coordinator or teamleader who conducts the full assessment. Thefollowing issues should be considered prior to a fullassessment:• In an environment where other members of the

multidisciplinary team may have carried out a fullassessment, the patient’s notes should beavailable to the therapist, in order to avoidduplication. Similarly, a summary of assessmentsand treatments prescribed, for instance byhomeopaths and acupuncturists, should beavailable for other members of themultidisciplinary team. In service settings wherethe patient’s medical notes are not usuallyavailable, the assessor will be able to completetheir own assessment.

• The therapist should have had training whichenables them to appropriately support the patientthrough any distressing emotions, withoutdistancing themselves (Heaven & Maguire1997:A12; Maguire et al 1993)

• The therapist should be aware of other avenues ofsupport to which the patient can be referred

• Supervision should be available to the therapist(refer to Chapter 9 on supervision)

Key worker assessmentAt some centres which offer a wide range oftherapies, it may be that designated key workers,who follow the patient’s pathway of care through theorganisation and who have had specialistassessment training, perform the assessment anddecide (with the patient) on the most appropriatecourse of therapy. In this case:• The assessment, or a summary, should be

available to all the therapists who will be treatingthe patient.

• The therapist should then make the appropriate

assessment for the therapy provided.Examples of key worker assessment forms canbe found in Appendices J and K.

Communication skillsCommunication skills are key to the delivery ofeffective supportive and palliative care services.(NICE 2002) Specialist assessment andcommunication skills training is available, and thecomponents of courses which lead to positiveoutcomes have been identified by NICE (2002) (seeChapter 9.3) Courses currently available includetraining with: • Prof. Peter Maguire and team, Psychological

Medicine Group, Christie Hospital NHS Trust,Wilmslow Road, Manchester M20 4BX. Tel. 0161446 3679

• Help the Hospices, Hospice House, 34-44Britannia Street, London WC1X 9JG. Tel. 0207520 8200

• St. Ann’s Hospice, Institute for Learning andDevelopment, St. Ann’s Road North, HealdGreen, Cheadle, Cheshire SK8 3SZ. Tel. 0161437 8136. Contact Christine Lawther, Head of theInstitute for Education and Development

11.4 Treatment record

Documentation of treatment is an essential elementof ethical practice. The following are basic rules fordocumentation:• Patient’s name and date of birth/hospital/hospice

number should be on each page• Each entry should be signed and dated.

Signatures should be identifiable, or a separaterecord kept to match signatures to individualpractitioners.

• The record of treatment should be written legibly• Entries should be made in ink which allows the

document to be legible when photocopiedExamples of treatment records can be seen inAppendix L.

11.5 Review of patient and treatment

Different models of practice exist, depending on theorganisation and the configuration of thecomplementary therapy team (see Chapter 3 andAppendix A). With the exception of one-offtreatments, it is recommended that there should bea review with the patient, in order to shape and planfurther treatments. Reviews may be incorporatedinto a treatment session, but there should also beperiodic reviews with a patient to establish • Patients’ views and level of satisfaction• The effects, if any, of treatment• The possibility of treatment with a different

therapy

37

There is advantage in the on-going review beingundertaken by a professional other than thetherapist(s), but it is important that this person istrained in assessment/review and familiar withcomplementary therapies. Appendices K and L(i)are examples of practices which incorporate areview of treatment.

12 ComplementaryTherapies

12.1 Introduction

This chapter outlines the criteria used fordetermining the choice of the nine therapies includedin the guidelines, the information contained in thechapters which follow on the individual therapies andthe methodology used to search for the evidence foreach therapy. There are a number of other therapieswhich are used in supportive and palliative care(Macmillan 2002), but it was not within theresources of this project to include them all.

12.2 Criteria for inclusion of therapiesin these guidelines

The choice of which therapies to include was guidedby: a. How commonly the therapy is provided in

supportive and palliative care servicesb. Which therapies are used by conventional medical

practitioners and other professionalsc. The existence of professional bodies and

regulation for the therapy

Where there are significant similarities for use withinsupportive and palliative care, the therapies havebeen grouped, and the nine therapies are:• touch therapies: aromatherapy, massage and

reflexology • healing/energy therapies: reiki, spiritual healing

and therapeutic touch • hypnosis/hypnotherapy• acupuncture • homeopathy

12.3 Information provided about eachtherapy

A brief description of the therapy is followed byinformation about the evidence base and guidancefor the use of the therapy in supportive and palliativecare, including conditions for which the therapiesmay be helpful and contraindications andprecautions. Also included is information about theregulation and training of practitioners in thattherapy. (See also Chapter 5)


12.4 Methodology for reviewing theevidence base

The evidence base for complementary therapies is asignificant consideration for managers and clinicians,as well as commissioners and providers of care.However, there is often a misunderstanding ofevidence based practice. Evidence based care isdescribed as the conscientious, explicit, andjudicious use of current best evidence in makingdecisions about the care of individual patients.(Sackett 1996) It requires practitioners to integratethe best external evidence with their own clinicalexpertise and the patient’s choice (Sackett 1996).

It is with the above understanding of evidence basedpractice that these guidelines have been written. Itis advisable that the information given about the ninetherapies is integrated with the individualpractitioner’s clinical expertise in deciding whetherand how it is appropriate for the patient’s clinicalstate, predicament, and preferences, and whetherand how it should be applied.

The search for evidence on the use of the differenttherapies in palliative care was via the followingdatabases: AMED, BNI, RCN Journals, CINAHL,CISCOM, Medline, PubMed and the databases atthe King’s Fund. The terms used in the search were:(acupuncture or aromatherapy or massage orreflexology or homeopathy or homoeopathy oracupressure or hypnotherapy or healing ortherapeutic touch or reiki) and (pain or anxiety ordepression or well-being or well being orconstipation or nausea or vomiting or sleep orsymptom control or quality of life or self-esteem orself esteem or confidence or mood* orbreathlessness or dyspnoea or dyspnea or fatigue orspiritual distress or support or pleasure) and (end oflife or palliative care or terminal or hospice orsupportive or oncology or cancer or neoplasm orchemotherapy or radiotherapy) and (clinical or trial*or controlled or randomised or non-randomised orsystematic review* or qualitative or study orresearch or project or audit or evaluation or pilot orpatient* survey* or consumer choice).

The purpose of the above was to search forevidence on how the therapies may be useful incancer and palliative care. It was not the intention ofthe project, nor within its scope, to conduct asystematic review of evidence and this was notperformed. Evidence was also identified throughcollaboration with colleagues in the different fieldsand the sharing of information.

The available literature was sorted and reviewedaccording to the following categories whereverpossible and a summary is provided of symptomsand conditions with which the therapy may be usefulin supportive and palliative care.

• Evidence derived from randomised controlledtrials or reviews of randomised trials

• Evidence from prospective studies with acomparison group (non-randomised controlledstudy or observational studies)

• Comparison groups, calculation of sample sizeand accurate, standard definition of outcomevariables

• Cross-sectional studies• Professional consensus

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13 Touch Therapies

13.1 Introduction

This chapter gives guidance on the use of the threetouch therapies most commonly provided withinsupportive and palliative care: massage,aromatherapy, and reflexology. These therapieshave been grouped together because the conditionsin which they may be helpful, and the precautions fortheir use, are similar. Information is included onwhether massage spreads cancer, as this seems tobe a question that is frequently raised. The controlof infection is an issue for all therapies, butparticularly so for the touch therapies; the principlesof universal infection control are outlined.

13.2 Use of touch therapies insupportive and palliative care

The areas common to massage, aromatherapy andreflexology are described first, followed separatelyby descriptions of and the evidence base for eachtherapy.

When touch therapies may be helpful The best available evidence suggests that massage,aromatherapy and reflexology may be useful in thefollowing ways:

• To promote relaxation (Ferrell-Torry & Glick 1992,Dossey et al 1995, Corner et al 1995, Van de Riet1999, Byass 1999, Hodgson 2000, Wilkie et al2000, Manasse 2001, Hadfield 2001, Grealish2002, Gambles, Crooke & Wilkinson 2002)

• To alleviate anxiety (Ferrell-Torry & Glick 1992,Corner et al 1995, Wilkinson et al 1999, Byass1999, Stephenson et al 1999, Hills & Taylor 2001,Gambles, Crooke & Wilkinson 2002)

• To reduce depression (Wilkinson 1995, Field1998, Hills & Taylor 2001, Jorm et al 2002)

• To reduce pain (Ferrell-Torry & Glick 1992, Smithet al 1994, Wilkinson 1995, Field 1998, Byass1999, Van der Riet 1999, Wilkie et al 2000,Grealish et al 2002)

• To reduce nausea (Grealish et al 2002)• To alleviate symptoms, such as breathlessness,

constipation, diarrhoea, pain, nausea, fatigue,poor appetite (for reflexology: Hodgson 2000,Hills & Taylor 2001)

• To alleviate side effects of chemotherapy (forreflexology: Hills & Taylor 2001)

• To improve sleep pattern (Hills & Taylor 2001)• To reduce stress and tension (Garnett 1994,

Wilkinson 1995, Dossey et al 1995, Micozzi1996)

• To reduce psychological distress/provide

emotional support (Trousdall 1996, Kite, Maheret al 1998, Hodgson 2000, Hills & Taylor 2001)

• To improve well-being and quality of life(Wilkinson 1995, Wilkie et al 2000, Hodgson2000, Hills & Taylor 2001, Billhult & Dahlberg2001)

• To live with an altered body image (Bredin1999,Van der Riet 1999)

Does massage spread cancer?This is a question that is frequently raised and anarea where there is some confusion. Gentlemassage can be given to areas of the body notaffected by cancer. Some oncologists andradiotherapists have stated that there is no evidencethat massage increases the spread of lymphoma orindeed leukaemia cells, and that cancer is not acontraindication to receiving gentle massage (Sikora1991, cited McNamarra 1999). MacDonald (1999)describes how cancer spreads, directly andindirectly. Cancer spreads even while patients areresting and inactive, for instance sleeping or justsitting. Gentle massage does not increase vascularor lymphatic circulation any more than the activitiesof daily living, such as exercise, shopping, taking awarm bath (MacDonald 1999).

Massage therapists are advised to be cautious overtumour sites, because any mechanical force on thetumour may contribute to the pressure alreadytaking place due to the uncontrolled growth of thecancer, and may influence spread. Deep massage toany part of the body is not advisable for those withactive cancer, in order to avoid trauma and activationof the immune response (MacDonald 1999). It isalso advisable for therapists to work within theboundaries of current contraindications andprecautions for supportive and palliative care.

General contraindicationsMassage therapists, aromatherapists andreflexologists are trained to assess and screen forconditions in which treatment is contraindicated forany individual, for instance when the person ispyrexial.

PrecautionsTherapists with limited experience will need furthertraining and/or supervision (see Chapter 9 onsupervision) from therapists experienced in the useof the therapy in supportive and palliative care.Clinical issues to be considered for people withmotor neurone disease, Parkinson’s disease andmultiple sclerosis are addressed in Chapter 10. Thefollowing guidelines on the use of aromatherapy,massage and reflexology in cancer care form ageneral consensus amongst complementary therapypractitioners in cancer and palliative care(McNamarra 1999, Hodkinson & Williams 2002), andshould be included in induction and training, asneeded.


a) Aromatherapy and massage• Avoid using any pressure directly on the area of

the cancer • Avoid pressure work with patients who are taking

anti-coagulation medication or who have a lowplatelet count. What is considered a low plateletcount varies; some haematologists advise thatpatients with a platelet count of 50,000 or less arenot treated with massage or aromatherapy.

• Be aware of the risks of massaging patients withareas of petechiae (pinprick bruising is anindicator of very low platelet count). Use gentlestroking or light, holding touch only, unlessworking in a specialist area and in consultationwith the medical team.

• Avoid a limb or foot with suspected or recentlydiagnosed deep vein thrombosis. Check withclinical team, be aware of signs and symptoms ofdeep vein thrombosis.

• Be aware that patients with advanced cancer orseverely impaired mobility are more susceptible tolow grade, undiagnosed and asymptomatic deepvein thrombosis (Johnson et al 1999); use gentlemassage only

• Avoid areas of bony metastases, and use gentlestroking or light, holding touch only

• Only treat lymphoedematous limbs or areas ifworking in conjunction with a lymphoedemaspecialist nurse or physiotherapist. In theabsence of specialists, refer to local policy oravoid working the area or limb.

• Avoid massaging over ascites (fluid retention inthe abdomen) and use gentle stroking or lightholding touch only

• Avoid stoma sites, dressings, catheters andTENS machines.

• Be aware that patients have a lowered immunefunction and are more susceptible to infection

• Be aware that the skin can be sensitive, and/orpaper thin due to medication and treatment,especially in elderly or cachectic patients. Usegentle touch only.

• Be aware of other clinical issues (See Chapter10)

• RadiotherapyBe aware of possible side effects, such asfatigue, soreness of skin, digestive disturbanceAvoid the entry and exit sites during and for 3-6weeks following radiotherapy; check withpatient and assess whether the skin is stillsensitive, tender or soreEncourage the patient to seek advice from theradiotherapy department regarding the use ofgels and creams

• ChemotherapyBe aware of possible side effects ofchemotherapy on the whole person, forinstance extreme fatigue, lowered immunefunction and increased risk of infection,increased risk of bruising, dryness or peeling ofskin, digestive disturbance, nausea, altered

sensation in extremities, hair loss, alteredbehaviour or personality, skin sensitive to touch Be aware that patients could have altered smellpreferencesConsider using gentle massage only, as thepatient may not be able to cope with evenmoderately energising or vigorous treatment

• Modify pressure and adapt approach and durationof session to take account of the patient’spreference, and also the physical, emotional andenergetic condition of the patient. For instanceuse gentle stroking or light touch if the patient isvery tired, unwell or emotionally labile. Be guidedby the patient’s body language and clinical issues(see Chapter 10).

• Consider massaging part of the body only and inshorter sessions.

• Use of essential oils is addressed separately inthe section on aromatherapy (13.4).

• Aromatherapy via vapourisersBe aware of respiratory conditions such asasthmaBe aware when used in a room where there areother patients or individuals with respiratoryconditions, or different smell preferences orallergiesUse electric vapourisers in the presence ofoxygenUse burners with caution: follow the health andsafety policy of the organisation with regards torisk of fire if using aromatherapy burners, forinstance patients should not be left on theirown at any time when a burner is used andburners should not be left unattended.

b) Reflexology• Avoid a limb or foot with suspected deep vein

thrombosis and avoid varicose veins.• Be aware of any tender areas on the foot or hand

that relate to new surgical wounds.• Only treat lymphoedematous limbs or areas, if

working in conjunction with a lymphoedemaspecialist. In the absence of a specialist, refer tolocal policy or avoid working the area or limb.

• Avoid areas corresponding to colonic stimulationif there are any symptoms or risk of intestinalobstruction due to causes other thanconstipation.

• Adjust pressure for patients with a low plateletcount, taking note of any existing bruising andskin viability. What is considered a low plateletcount varies; some haematologists advise thatpatients with a platelet count of 50,000 or less arenot treated with reflexology.

• Be aware that peripheral sensation may be affectedby a person’s psychological state, or medication,such as steroids, opioids or chemotherapy.

• Be aware that peripheral neuropathy may be asymptom of diseases such as multiple sclerosisand certain tumours, although diabetes is themost common cause of peripheral neuropathy.

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• Palpate gently and sensitively over the reflexesrelating to tumour site(s)

• Assess the condition of the reflexes and adapttreatment accordingly so that the feet are notoverstimulated in any way, especially in patientswith altered peripheral sensation or peripheralneuropathy

• Establish a working pressure that is comfortablefor the patient at all times, and tailor treatment toavoid strong reactions

• Use fragrance free talcum powder or appropriatecream if the skin is very dry

Teaching carers/patientsIt may be helpful to the patient and/or their carers forthe therapist to teach them basic massage skills,with or without essential oils.

Side effects and adverse effects Complementary therapists should discuss possibleside effects which should not be a cause for concernwith patients, for instance that they may feel drowsyfollowing treatment and want to sleep. Possiblereactions to essential oils are addressed in thesection on aromatherapy (see 13.4).

Infection controlUniversal infection control procedures are precautionsto be followed at all times to prevent the spread ofinfection, as it is not always possible to identify peoplewho may spread infection to others. All blood andbody fluids are potentially infectious and precautionsare necessary to prevent exposure to them.(Department of Health 1996, Mallett & Dougherty2000) These routine procedures should be familiar totherapists with a conventional healthcare qualificationbut may not be familiar to others.• Complementary therapists should follow good basic

hygiene practices at all times including thoroughhand washing before and after treating a patient.

• If the therapist has any grazes, cuts or any woundin the hands, these areas should be covered witha waterproof dressing. Under health and safetylegislation, such dressings must always beavailable in the first aid box. (Department ofHealth 1996)

• Therapists with any skin condition on their handsthat cannot be covered with a waterproofdressing should seek medical advice andclearance prior to providing hands-on therapies.

• Should the therapist need to deal with spillages ofblood, vomit, urine or excreta, a disposable apronand gloves should be worn.

• Methicillin Resistant Staphylococcus Aureus(MRSA) is addressed specifically in theseguidelines because of the widespread concernand lack of knowledge on this issue.(i) The prevention of spread of MRSA between

patients is very much dependent on the properunderstanding and practice of universalinfection control procedures.

(ii) The single most important practice is properhand hygiene, before and after attending to thepatient. If the patient is isolated in an inpatientunit, there may be additional procedures onleaving the room, such as using an alcoholic orbactericidal hand rub in addition to handwashing procedures inside the room.

(iii) Some organisations with inpatients requiretherapists to wear gloves and others do not.Therapists will need to check.

(iv) When treating a patient with MRSA in anenvironment where there are other patients thetherapist may be treating, it is generally advisedthat an apron is worn.

• Training and guidance on infection control shouldbe considered within the induction programme fornew therapists.

Regulation and training of therapistsTraining in massage, aromatherapy and reflexology iscurrently available in a large number of schools andinstitutions, privately as well as in community andfurther education colleges and universities. Coursesvary in length, depth and quality. A guide tochoosing complementary therapy courses ispublished by The Prince of Wales’s Foundation forIntegrated Health (Williams 2003).

For further information please see Chapter 5 onregulation and training, Chapter 6 about recruitmentand selection and Chapter 7 on volunteers.

13.3 Massage

Brief descriptionMassage is a generic term for a variety of techniquesthat involve touching, pressing, kneading, andmanipulation of the soft tissues of the body fortherapeutic purposes (Calvert 1992; Jackson 1993).There are a number of types of massage, (Russell1994) for example Swedish, Thai, Ayurvedic, remedial,and sports massage. The precise method depends onthe culture from which the technique originated, andthe philosophy on which it is based. Individualpractitioners are likely to have developed a particularstyle, based on their skills, interest, philosophy andexperience with different client groups.

Massage therapy in supportive and palliative carerefers to therapeutic massage, in which touch isconsidered to be an independent channel ofcommunication. (Weiss 1979, Westland 1993,McNamara 1999) The essence of the therapeuticprocess is embodied in the concepts of skilful touch,(Juhan 1987) and essential touch. (Smith 1990)

In cancer care, Simonton (1991, cited McNamarra1999:21) indicates that "good therapeutic massage


is massage done by a well-trained massage therapistwho is sensitive to the problems of massagingpeople with cancer, and is comfortable dealing withpeople who are seriously ill." Therapeutic massageconsists of gentle rhythmical touch, with movementsvaried to suit individual needs and with a clear startand finish to the session. (McNamara 1999)

The recognition that touch and massage can havetherapeutic value dates back to the Yellow Emperor’sClassic of Internal Medicine (about 250 BC), Sanskrittexts, Homer’s Odyssey, Hippocrates andAsclepiades, Galen in the Middle Ages, andParacelsus in the 15-16th centuries. There is a vastamount of anecdotal as well as research evidencewhich suggests that massage therapy has thepotential to produce physiological and psychologicalbenefits for palliative care patients (cited Wilkie et al2000). There are many theories about how massageworks; see for instance Juhan 1987 and McNamara1999.

Evidence baseIn cancer care, the scientific evidence relies on anumber of studies, mainly based on small numbers.Corner et al’s (1995) quasi-experimental study with52 cancer patients over 8 weeks found thatmassage had a significant effect on anxiety, assistedrelaxation and reduced physical and emotionalsymptoms. Wilkie et al (2000) carried out arandomised controlled pilot study with 29 patients toevaluate the effects of massage on pain intensity,analgesics and quality of life of cancer patients. Thestudy confirmed the findings of other studies, thatthe use of massage to modify anxiety and theperception of cancer pain is effective in the short-term. (Ferrell-Torry & Glick 1992; Meek 1993,Weinrich & Weinrich 1990)

The results from Wilkinson et al’s (1999) study with103 cancer patients, randomised to receivemassage or aromatherapy, suggest that massage,either with or without an essential oil, is beneficial forreducing anxiety levels in patients with advancedcancer. Grealish et al (2000) measured the shortterm effects of foot massage on pain, nausea andrelaxation in 87 hospitalised cancer patients, using aquasi-experimental research design. Foot massagewas found to have a significant immediate effect onreducing pain and nausea, and encouragingrelaxation.

Pan et al’s (2000) systematic review ofcomplementary and alternative medicine in themanagement of pain, dyspnoea and nausea andvomiting near the end of life concludes that, amongstother therapies, massage may provide pain relief.

A Cochrane Review taking forward the work of Cooke& Ernst (2000) is in process, to review the use ofaromatherapy and massage for symptom relief in

patients with cancer. The objective is to assess theevidence for the effectiveness of aromatherapy and/ormassage in improving physical and psychological well-being in patients with cancer. (Fellowes, Barnes &Wilkinson 2003) 1323 references were retrieved.Nine met the inclusion criteria and a further two are stillunder consideration. The nine that met the inclusioncriteria included references representing sevenstudies, all of which were randomised controlled trials.Assimilation of results from the seven trials, andconsideration of two new studies is ongoing. Initialtrends suggest that massage confers some short-termbenefits over no massage, and aromatherapymassage confers some additional benefit whencompared with non-aromatherapy massage. Studieshave measured changes in a range of physical andpsychological symptoms, and in quality of lifemeasures, but sample sizes were small and in mostcases follow-up times were short.

Billhult and Dahlberg’s (2001) phenomenologicalresearch on eight female cancer patients’ experienceof massage on 10 consecutive days, describes theexperience of ‘meaningful relief’. The relief wasmeaningful for a number of reasons: it offered relieffrom suffering, an experience of being able to ‘feelgood’ in spite of the cancer and its treatment, feeling‘special’, empowerment and autonomy, and themassage contributed to the development of apositive relationship with the therapist.

Bredin (1999) conducted a qualitative study of threewomen’s experience of therapeutic massagefollowing mastectomy and body image problems.She concluded that therapeutic massage, combinedwith listening to the women’s experiences, couldhelp with certain aspects of adjustment to havinghad a mastectomy.

Audits and evaluations of service and interviewsshow that patients feel they benefit from massage(for example Bell 1999; Billhult & Dahlberg 2001;Byass 1999; Wilkinson 1995). Patients seektherapies to enhance hope, (Downer et al 1994) aswell as to reduce anxiety, stress and pain. Theevidence of use clearly shows that massage is oneof most widely-used therapies in supportive andpalliative care (Wilkes 1992; Ernst 1997; Coss 1998;Bell 1999; Foundation for Integrated Medicine,2001; Lewith et al 2001; MacMillan 2002).

It may be concluded that massage is an acceptableintervention with cancer patients.

13.4 Aromatherapy

Brief descriptionAromatherapy is the systematic use of essential oilsin treatments to improve physical and emotional

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well-being. (National Occupational Standards forAromatherapy, Healthwork UK 2002) Many plantspecies contain essential oils, highly fragrant andflammable essences, which evaporate quickly andwhich are extracted from plants by a distillationprocess. (Tisserand 1988) Aromatherapists in theU.K. are trained to use essential oils topically andthrough inhalation. (Buckle 1997) Essential oils areapplied in a variety of ways, which include massage,vapourisers, baths, creams and lotions, andcompresses, and are absorbed through the skin,diluted in a vegetable carrier oil or by inhalation.

Essential oils have been used in many culturesthroughout history. Aromatherapy as we now knowit, owes its development and name to Rene-MauriceGattefosse, a French chemist, who was impressedby the healing powers of lavender essential oil onburns and began to study the healing powers ofessential oils in the early 20th century. Elsewhere inthe European Union essential oils can be taken orallywhen prescribed by medical doctors and medicalherbalists trained in their use.

The therapeutic effect of aromatherapy results froma combination of the physiological effects of the oilsand the relaxation of massage. As the fragrance ofthe oils also stimulates the sense of smell, whichelicits certain emotions, the limbic system of themidbrain, which is concerned with emotional as wellas visceral function, may be involved in the releaseof hormones which influence mood. (Kohn 1999)

Evidence baseAs massage is the most widely used medium forapplying essentials oils in palliative care, theevidence for massage therapy (see 13.3) should beconsidered with this section .

Cooke & Ernst (2000) undertook a systematicreview of the use of essential oils and aromatherapymassage in reducing anxiety for patients in a healthcare setting. Six trials met the inclusion criteria.Three studies were conducted in cancer andpalliative care, evaluating the use of aromatherapyand essential oils with massage for reduction ofanxiety and symptom scores, and increase in well-being and quality of life. (Corner et al 1995;Wilkinson 1995; Wilkinson et al 1999) The results ofthe studies suggest that aromatherapy massage canbe helpful for anxiety reduction in the short term.

However Cooke & Ernst (2000) concluded that thetrials were comprised of small samples and lackedmethodological rigour. There was no differentiationbetween the effects of any transdermal absorption,the effects of smell and the influence ofpsychological factors. The methodologies wereconsidered "sufficiently flawed to prevent firmconclusions from being drawn". However, it wasacknowledged that a double-blind design to compare

aromatherapy treatments is probably impossible toachieve. In view of the above, and the increasingpopularity of aromatherapy, it was recommendedthat national guidelines on the use of aromatherapy(and other complementary therapies) within thehealth service should be developed.

Corner et al’s (1995) quasi-experimental study with52 cancer patients, compared the effect of an eightweek course of massage, with or without a blend ofessential oils, on patients undergoing cancertreatment. Patients were randomised into one oftwo treatment groups, with a control group ofpatients who were unable to attend for massage.Patients were interviewed before the study beganand at eight weeks following completion, andoutcome measures included the Hospital Anxietyand Depression scale (Zigmond and Snaith 1983)and a quality of life and symptom distress scale(Holmes and Dickerson 1987). The results suggestthat massage has an effect on anxiety, and this wasfound to be greater where essential oils were used.Massage also assisted relaxation and significantlyimproved emotional symptoms, in particularconcentration, mood and feelings about appearanceand the future. Massage with essential oils showedoverall improvement in pain, mobility, tiredness,function and ability to return to paid employment.

Wilkinson et al (1999) researched the effectivenessof massage and aromatherapy massage in improvingthe quality of life of patients with advanced cancer,and patients’ perception of the value ofaromatherapy massage in improving their quality oflife. Patients were randomly allocated to one of twotreatment groups, and received a course of three fullbody massages, with or without the essential oilRoman camomile. Outcome measurementsincluded the Rotterdam Symptom Checklist (DeHaes et al 1990), the State-Trait Anxiety Inventory(Spielberger et al 1983), and a semi-structuredquestionnaire completed 2 weeks after the lasttreatment to explore patients’ perceptions of thetreatment. Both the preliminary study with 51patients (Wilkinson 1995) and the final results with103 patients (Wilkinson et al 1999) showed animprovement in quality of life in both groups, withstatistical significance in the aromatherapy group.The results also showed a significant reduction inanxiety in both groups, although the effect wastransient. Comparison of results between the twogroups suggests that massage with essential oilenhances the effects of massage, and improvesphysical and psychological symptoms, as well asoverall quality of life. From the patients’ perception,massage or aromatherapy is beneficial in reducinganxiety, tension, pain and depression.

A study not included in the Cooke & Ernst (2000)review was a randomised controlled pilot study(Manderson, Weller, Wilcock, Ernst et al 2001)


which assessed the effect of aromatherapy massagein palliative day care. Forty-six patients wererandomised to receive day care alone or day careplus weekly aromatherapy massage for four weeks,using a standardised blend of oils. Outcomemeasures included the centre’s own questionnaireswhich rated quality of life, physical symptoms andpatient satisfaction. The scale Profile of MoodStates (POMS) was also used. All patients weresatisfied with aromatherapy massage and wanted tocontinue with treatment. There was improvement inall measures in both groups but there was nostatistically significant difference between thegroups. Due to the high attrition rate, it wasrecommended that multi-centre trials werenecessary for studies of sufficient power.

A multi-centre randomised controlled trial(Wilkinson, Ramirez, Maher, Sun, et al 1999) toevaluate the use of aromatherapy massage inimproving psychological distress and othercomponents of quality of life in patients with cancerhas been designed in line with Cooke & Ernst’s(2000) recommendations. The inclusion criterionwas patients with cancer who were psychologicallydistressed, assessed by a structured psychiatricinterview as experiencing depression and/orgeneralised anxiety disorder. Results of this studywill be reported in early 2003.

A Cochrane Review to take forward the work ofCooke & Ernst (2000) is in process. The use ofaromatherapy and massage for symptom relief inpatients with cancer is being reviewed, with theobjective of assessing the evidence for theeffectiveness of aromatherapy and/or massage inimproving physical and psychological well-being inpatients with cancer (Fellowes, Barnes & Wilkinson2003). 1323 references were retrieved. Nine metthe inclusion criteria and a further two are still underconsideration. The nine that met the inclusion criteriaincluded references representing seven studies, allof which were randomised controlled trials.Assimilation of results from the seven trials, andconsideration of two new studies is ongoing. Initialtrends suggest that massage confers some short-term benefits over no massage, and aromatherapymassage confers some additional benefit whencompared with non-aromatherapy massage. Studiesmeasured changes in a range of physical andpsychological symptoms, and in quality of lifemeasures, but sample sizes were small and in mostcases follow-up times were short.

There are a number of service evaluations and auditson the use of aromatherapy massage in cancer care.(eg Evans 1995; Kite, Maher et al 1998; de Valois &Clarke 2001, Hills & Taylor 2001; Hadfield 2001)The findings are similar to those of theabovementioned trials, showing improvement inpsychological symptoms such as anxiety,

depression, tension, stress, emotions such as fear,anger, guilt, as well as physical symptoms includingpain. From the patients’ perception, relaxation andreduced tension are most commonly identifiedbenefits.

Despite the lack of scientific evidence on the effectsof aromatherapy, it remains one of the most widelyused therapies in supportive and palliative care.(Foundation for Integrated Medicine, 2001; Manasse2001, Lewith et al 2002, Macmillan 2002) From thepatients’ perspective, the service evaluations andaudits also support perceived effectiveness andsatisfaction. (Dunwoody, Smyth & Davidson 2002)

Essential oilsIn the absence of scientific data, the followingguidelines form a general consensus amongstaromatherapists working in palliative care (eg Buckle1997; Price & Price 1995; Foundation for IntegratedMedicine 2001).

There is a difference in opinion regarding the need torecommend oils which are considered safe andthose to be avoided or used with precaution incertain conditions, such as with oestrogen sensitivecancers, patients with reduced kidney function andhypertension. There is no definitive evidence tosupport the range of opinions, and it isrecommended that professionals refer to the work ofTisserand and Balacs (1995) Essential Oil Safety, andto experienced aromatherapists working insupportive and palliative care.

a) The decision to use essential oils • The decision to use and mix essential oils should

only be made by aromatherapists who areregistered with an appropriate professional body(see Chapter 5 and Appendix E).

• Essential oils should only be used and mixed byaromatherapists following an assessment of thepatient or screening for contraindications

• Develop a protocol for the safe use of a range ofessential oils by other members of the clinicalteam in situations such as use with vapourisers

• Massage therapists, practitioners of simplemassage or carers who have been shown how tomassage the patient should use blends made byaromatherapists for the individual patient

b) Blending and strength of oils• It is the general consensus within aromatherapy

education and training that a 1% dilution (or less)is used in massage with children and adults inpoor health.

• For the use of essential oils in the bath, it issuggested that the oils should be diluted in a non-oil-based medium (to 1% or less). Oils should notbe added undiluted to bath water as they maycause irritation if the patient has sensitive skin. Inparticular, patients undergoing or having recently

45

undergone radiotherapy or chemotherapy mayhave hypersensitive skin.

c) Buying oils• Essential oils should be purchased from suppliers

who provide a safety data sheet for each oilpurchased (CHIP 1994; COSHH 1994; Buckle1997), including a GLC readout of constituents ofthe oil.

• There are numerous suppliers of essential oils andthe importance of using pure essential oils isstressed in the training of aromatherapists.

• It is suggested that organisations purchaseessential oils from suppliers recommended byaromatherapists who provide a service within theorganisation.

d) Storage and packagingUndiluted essential oils should be stored andpackaged as follows. (Buckle 1997; Price & Price1995; Tisserand & Balacs 1995)• In a locked container at all times, away from naked

flames, food or drink • Oxidation changes the chemical composition of

essential oils, and the process is speeded up byheat and light. Undiluted essential oils should be: (i) packaged in blue or amber glass bottles, away

from direct sunlight(ii) packaged in glass bottles containing integral

droppers of UK standard (20 drops per ml). (iii) stored in a cool environment

• The bottle should indicate a packaged or use by date.

e) Accidents with essential oils (Buckle 1997:102)• Skin reaction to undiluted essential oil

Dilute with carrier oil (to dilute), then wash thearea with unperfumed soap and water and dry.Keep the bottle to show content, and seekmedical assistance

• Undiluted essential oil splashed in the eyeIrrigate the eye with milk or carrier oil (to dilute),and then with water. Keep the bottle to showcontent, and seek medical assistance

• Ingestion of more than 5 mls of essential oil (to betreated as poisons)Give milk to drink, keep the bottle to showcontent and seek medical assistance.

• Essential oil bottle broken and oil is spiltGloves should be worn to prevent the skinbecoming contaminated with the undilutedessential oil. Soak up the liquid with paper toweland collect the glass. Dispose of glass in thesharps container in a clinical environment, or wrapin layers of paper and dispose in securedpolythene bag in other settings

f) DisposalEmpty bottles should be disposed of in a sharpscontainer in a clinical environment, or wrapped inlayers of paper and disposed of in a securedpolythene bag in other settings

13.5 Reflexology

Brief descriptionReflexology is based on the principle that there arereflex areas in the feet and hands which correspondto all of the glands, organs and parts of the body(National Occupational Standards for Reflexology,Healthwork UK 2002). The purpose of thesystematic application of pressure, using the thumband fingers, to specific reflex points on the feet orhands is to release congestion, promote the flow ofenergy and promote homeostasis.

Different types of foot treatment have been used invarious cultures including India, Egypt and Chinasince ancient times. In the west, reflexologydeveloped in the 20th century through thediscoveries of the American ear, nose and throatspecialist, William Fitzgerald, and was further refinedby massage therapist, Eunice Ingham. Doreen Baylybrought the treatment to Europe and established thefirst school of reflexology in the UK. Reflexology,reflex zone therapy or reflexotherapy are all termsthat refer to the current use of the treatment, andare associated with developments by individualssuch as Hanne Marquardt, Froneberg, and PatMorrell. (Tiran 2002)

The language of reflexology is not easily understoodby people with conventional western medicaltraining. Within conventional health care, reflexologymay be more easily understood as a sophisticatedsystem of touch. (Tiran 2002) Techniques includethe application of pressure to all areas of the feet orhands that relate to a map of the whole body.Reflexologists claim to feel areas which have analtered granular texture at specific points in the foot,indicative of imbalance, weakness or disease of thecorresponding body part and then massage theseand other related areas.

Reflexologists do not diagnose specific medicalproblems, but aim to treat the individual, with a viewto alleviating physical and emotional symptoms.(Lynn 1996, National Occupational Standards forReflexology, Healthwork UK 2002).

Evidence base A randomised controlled study of reflexologytreatments for 35 women with premenstrualsyndrome during an eight week period showed adecrease in premenstrual signs and symptoms(including anxiety), significantly more in theintervention group than in the placebo group.(Oleson & Flocco 1993)

Stephenson et al (2000) completed a quasi-experimental crossover study on the effects of footreflexology on anxiety and pain in 23 patients withbreast or lung cancer. A Visual Analogue Scale(Cline, Herman, Shaw & Morton 1992) was used to


measure anxiety, and the Short-Form McGill PainQuestionnaire (Melzack 1987) to measure pain. Thestudy reported a significant decrease in anxiety; theeffects on pain reduction were less clear.

Foot massage was used as a nursing intervention ina quasi-experimental study with 87 patientshospitalised with cancer. (Grealish et al 2000)Patients were randomly assigned to one of threefactor control groups and heart rate was monitored.Visual analogue scales were used to measure selfreports of pain, nausea and vomiting, and relaxation.Their findings showed that foot massage has asignificant immediate effect on pain, nausea andrelaxation.

Hodgson’s (2000) study compared the effects of acourse of three real or placebo reflexologytreatments on the quality of life of 11 patients withcancer. The outcome measures included theHolmes and Dickerson (1987) quality of life scale,modified to incorporate an open-ended question forpatients’ comments. There was statisticalsignificance in the difference in improvement inquality of life between the two groups. All thepatients in the reflexology group reported animprovement. However, improvement in breathingwas the only individual symptom with a statisticallysignificant result. The patients’ perception, in bothgroups, was that it was relaxing, calming andcomforting.

A Cochrane systematic review on the use ofreflexology for symptom relief in patients with canceris nearing completion. (Fellows, Gambles, Lockhart-Wood, Wilkinson 2003) The objective of this reviewis to assess the evidence for the effectiveness ofreflexology in improving physical and psychologicalwellbeing in patients with cancer. 312 referenceswere retrieved; only three met the inclusion criteria.The three references represented two randomisedcontrolled trials, both of which have been mentionedabove.

Both trials found some positive effects forreflexology. Hodgson (2000) found significantdifferences between groups for overall scores andfor breathing, with greater benefits in the reflexologygroup. In the Stephenson (2000) crossover trial,anxiety scores were significantly lower afterreflexology than after control. Significantimprovements in pain scores were found afterreflexology and after control. However, theCochrane review concludes that methodologicalproblems occurred for both trials. Sample sizeswere small, and follow up was very limited.Possibility for bias occurred in both studies and nocomparisons were possible to determine if repeatedtreatments confer additional benefits. In addition,neither study sought to record adverse effects so itis not possible to know if any exist.

Audit and evaluation of services similarly identifyrelaxation, relief from tension and anxiety, andimproved well-being as the primary benefits ofreflexology in palliative care. (Hills & Taylor 200l;Milligan et al 2002; Gambles, Crooke and Wilkinson2002)

There is much anecdotal literature which similarlysupports the use of reflexology in cancer care forrelaxation, wellbeing and stress relief. (Gillard 1995;Stephenson 1996; Botting 1997; Joyce &Richardson 1997; Tanner 2000; Hodkinson 2000).Despite the lack of scientific evidence, surveys ofpatient use reveal that reflexology is one of the mostwidely used therapies in cancer care. (Oneschuk etal 2000; Lewith et al 2001; Foundation forIntegratedMedicine 2001; Manasse 2000;Macmillan 2002; Gambles, Crooke & Wilkinson2002)

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14 Healing and energytherapies

14.1 Introduction

The term healing is from the Saxon root Haelen,meaning to make whole and is not seen as a desireto cure or as an attachment to a particular outcome.(Hallett 2002) The term subtle energy techniques isalso used in the context of healing. (MacDonald1999) There are a number of energy therapies andthis chapter focuses on the use of reiki, therapeutictouch and spiritual healing as the mostly widely usedin palliative care. (Macmillan 2002) The conditions inwhich these therapies may be helpful, and theprecautions for their use are outlined, followed bydescriptions, the evidence base and training for eachtherapy.

14.2 The use of healing and energytherapies in supportive and palliativecare

The conditions for which reiki, spiritual healing andtherapeutic touch may be useful are similar, as arethe precautions for the use of these therapies insupportive and palliative care.

When healing and energy therapies may be usefulThe best available evidence suggests that reiki,spiritual healing or therapeutic touch may be usefulin the following ways:

• To contribute to pain relief (Keller & Bzdek 1986,Gordon et al 1998, Neate & Neate 2001, Benor2001, Hills & Taylor 2002)

• To promote relaxation (Krieger et al 1979, Heidt1981, Quinn 1982, Wardell & Engerretson 2001,Neate & Neate 2001)

• To improve sleep pattern (Braun et al 1986, Hills& Taylor 2003)

• To reduce tension, stress and anxiety (Heidt1981, Quinn 1982, Olsen 1992, Hallett 1996,Neate & Neate 2001, Wardell & Engerretson2001, Hills & Taylor 2003)

• To provide emotional and/or spiritual support(Hallett 1996, Hallett 2000, Neate & Neate 2001,Benor 2001, Hills & Taylor 2002)

• To contribute to a sense of well being (Hallett1996, Hallett 2000, Neate & Neate 2001, Hills &Taylor 2002)

• To reduce side effects of chemotherapy andradiotherapy (Neate & Neate 2001)

• To support the patient in the dying process(Neate & Neate 2001)

General contraindications and precautionsThere are no specific contraindications, but there aresome precautions for the use of healing insupportive and palliative care:• Give healing treatment only in response to a

request from the patient or carer and followingconsent from the patient.

• Be aware that the patient may misunderstand theword healing to mean cure; emphasise healingmay be physical, psychological, emotional orspiritual, but discuss possible benefits in a waythat does not raise false hopes. Emphasise thatthere is no religious association.

• Be sensitive to the needs of the patient, and givehealing in a position that is comfortable for thepatient, rather than the customary positions ofsitting in a chair or lying flat on a couch.

• Use with sensitivity with patients and carers who,because of their personal history, diseaseprogression or medication, may have an alteredperception of reality, either emotionally ormentally.

• Be aware that the relaxation response can act asa releasing mechanism, which can sometimesgenerate strong emotions. It is important thatpractitioners should be aware of this, and be ableto allow and contain strong emotions. Spiritualhealers who are undergoing training are known asprobationary healers and normally practise healingwhen a fully qualified healer is available for advice.

• Ensure that sessions are not overlong; anexperienced practitioner can generally recognizewhen healing is completed in a particular session.

Teaching carers and patientsReiki is a healing therapy that patient and carers canlearn from a reiki master for self treatment and touse with family and friends.

Infection controlRefer to Chapter 13.2.

Regulation and TrainingFor information on the regulation of therapists, referto Chapter 5. There is information on levels oftraining for the three healing therapies in thefollowing sections on the individual healing therapies.

14.3 Reiki

Brief descriptionReiki is a method of healing that was rediscoveredby Dr Mikao Usui in Japan in the 1800s. Central tothis system of healing is the concept that an energyflow exists within living beings which supports life byhelping to maintain homeostasis. This energy isknown as Ki. When Ki is diminished ill health canarise. The other important concept is that Ki can bechannelled from its originating source by a reikipractitioner and passed on to a recipient. The


original source may be referred to as the universalsource, which in Japanese is Rei, hence the namereiki. The main aim of reiki is to bring about balancein mind, body and spirit to improve well-being. Thereare no religious connotations within reiki, thereforeno belief system is necessary to practise or receivethis method of healing.

Reiki was primarily developed as a system forhealing oneself, as well as being used to help others,therefore practitioners are encouraged to practiseself-healing on a regular basis. A reiki treatment, foroneself or another, involves the practitioner placinghis/her hands either on, or just above, certain pointson the body. The recipient may sit or lie and remainsfully clothed. Reiki can also be used as a method ofdistant healing during which the practitioner worksusing visualization techniques. With both methodsrecipient consent is of paramount importance. R eikienergy is channelled for the ‘greatest and highestgood’ of the recipient, and is understood to flow inresponse to the needs of the recipient. Recipientsoften report a feeling of deep relaxation during andfollowing the therapy.

Evidence baseAlthough there is some emerging evidencesupporting the claims of both spiritual healing andtherapeutic touch, the evidence for reiki to date isvery small. The search for evidence did not find anystudies carried out in supportive and palliative care.

Wardell & Engerretson’s (2001) study examined thebiological correlates of reiki healing. Twenty threehealthy subjects received reiki lasting thirty minutes.The biological markers related to stress reductionresponse were measured pre and post reiki. Thesemarkers included breathing rate, pulse rate, bloodpressure and salivary immunoglobulin levels.Significant biochemical and physiological changes inthe direction of relaxation were noted. Althoughacknowledged as small, this study suggests thatreiki would be a useful intervention for relaxationwhich warrants further study.

Despite lack of scientific evidence on the effects ofreiki, anecdotal evidence suggests that reiki canassist in the care of patients in supportive andpalliative care.

TrainingThere are differing styles of reiki available today,which means that the number of levels of training willvary from one style to another. It is generallyaccepted that level 1 is mostly for personal use andfor use in an informal way with friends and family.Practitioners of reiki in supportive and palliative careshould be trained to practitioner level 2. There isalso the master/teacher level which some approachas level 3, while others divide master level intomaster practitioner level 3, and master teacher level

4. At present, the standards of courses vary greatly.The UK Reiki Federation is currently laying thefoundations for a core curriculum, and informationcan be found on their website: www.reikifed.co.uk.Other reiki organisations are in the process of beingconsulted on how best to carry the accreditationprocess forward.

Practitioners of reiki in supportive and palliative careshould have transferable skills, relevant experience,or receive additional training in order to be able todecide on the suitability of reiki for use on vulnerableadults who are seriously or chronically ill, and takethe necessary precautions. Refer tocontraindications and precautions mentioned in 14.2.

14.4 Spiritual healing

Brief descriptionSpiritual Healing is an ancient therapy which hasbeen used throughout recorded history. Pythagoras(6 BC) considered healing to be the noblest of hispursuits and integrated it into his considerations ofethics: mind and soul. (Benor 2001) Spiritualhealing, often referred to simply as healing, is aprocess that promotes better health, through thechannelling of healing energies through the healer tothe patient. (National Federation of Spiritual Healers1998) Healing is said to quicken the body’s naturalhealing processes on all levels. (Neate and Neate2001) It is a supportive approach which may involvelight touch or no touch at all, depending on therecipient’s condition and wishes.

Healers view human life as four-dimensional,comprising body, emotions, mind and spirit. Theyare drawn to the work because of their interest in thespiritual dimension of life, and because they find theycan transmit healing energy. Healers draw upon thefiner energies of the universe, and they may or maynot follow a particular religion. Many healers mayembrace a spiritual understanding based onunconditional love. (Neate and Neate 2001)

Healing is becoming accepted as a valid and credibletherapy, offered in some medical centres as acomplement to conventional medical treatment(BMA 1993). Healers do not usually relate to thedisease entities of conventional medicine, but aim tohelp the patient in more general terms, for exampleby increasing well-being. (Ernst 2001) The healerprovides time for the patient to discuss problems, inorder to gain some understanding of them;subsequently the patient may be asked to lie or sitdown for treatment. (Ernst 2001)

Evidence base At the moment there is a paucity of clinical trials tosupport the efficacy of spiritual healing. Benor(2001) writes about the scientific validation of

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healing, giving brief descriptions of 191 controlledstudies across a broad range of conditions andorganisms. Over 50% of the trials are said to resultin a significant outcome in favour of healing.However, Benor himself points out themethodological flaws, and his interpretation of theevidence is unconventional. (Abbott 2002) Otherauthors reporting on the same trials conclude thatthe findings cannot be relied upon to draw firmconclusions about the efficacy or inefficacy ofhealing. (Abbot 2000)

Despite the lack of evidence, spiritual healingremains a popular therapy in supportive and palliativecare. (Macmillan 2002)

TrainingTraining for spiritual healers is currently provided bymany professional organisations and usually takesabout two years. This period involves attendance atformal training courses, supervised healing practiceand documented records of ongoing personaldevelopment. During the training period healers areknown as probationary healers, student healers ortrainees. The development of standards of goodpractice, by UK Healers, along the lines of thenational occupational standards for complementarytherapies, is underway. Probationary, student ortrainee healers are assessed by a panel prior toacceptance for registration with a regulatory body.

14.5 Therapeutic touch

Brief descriptionTherapeutic touch emerged in the 1970s, introducedinto mainstream nursing education by Dr. DoloresKrieger, then professor of nursing at New YorkUniversity. Krieger had experienced the laying on ofhands and was convinced that this was a naturalpotential inherent in everyone, which could berealised if the intention to help or heal was present.Therapeutic touch is without religious association,has been studied and researched within a healthcareframework, and has been introduced into nursingprogrammes in the USA at masters and doctoratelevels. It has been taught at degree level in the UKfor the last ten years.

Therapeutic touch has been considered as acontemporary interpretation of several ancienthealing practices. Whilst honouring and respectingthe influence of other traditions, it is within aframework which uses the insight of modernquantum physics that therapeutic touch is described.(Chopra 1989, Rogers 1983) It has also beendescribed as an attempt to focus completely on thewell-being of the patient in an act of unconditionallove and compassion. (Quinn & Strelkkaukas 1993)This is not seen as a desire to cure or an attachmentto a particular outcome.

Therapeutic touch is not regarded as involvingchannelling of energy or an energy exchange but asa mutual process, a healing meditation. It has beensuggested that undergoing this process with apractitioner who is ‘centred’ (in a calm, alert andopen state of consciousness with a clear sense ofoneself and being connected to the holistic nature ofhealing, Sayre Adams & Wright 2001) brings about achange with the practitioner acting as a template tofacilitate this change towards wholeness. (Quinn1992)

During a treatment, the practitioner’s hands aremoved in a rhythmic, downward movement, a shortdistance away from the body of the client, starting atthe head and working towards the feet. During thisprocess the practitioner makes an assessment andmay become aware of some imbalances in what isdescribed (not without controversy) as the energyfield. The practitioner then works towards ‘clearing’these areas and promoting a sense of harmony andwholeness. Clients usually experience a deeprelaxation response and anecdotal evidencesuggests that they can become clearer aboutproblems they are facing and feel less anxiousgenerally.

Evidence baseThe following are studies relevant to palliative careand which provide evidence on the efficacy oftherapeutic touch. A full overview and analysis canbe found in the text by Sayre Adams & Wright(2001).

a) Relaxation ResponseKrieger et al’s (1979) study demonstrated a deeprelaxation response being present in clientsreceiving therapeutic touch. This was verified byECG, EEG and electro–oculo graphic responses.Electro–myographic, hand temperature and galvanicskin responses were also recorded. Interestingly,the EEG of the practitioner demonstrated apredominant amount of fast synchronous betaactivity, demonstrating intense concentration.Patients showed a high amount of alpha activity,which indicates a deep state of relaxation. This wasa small study and has some flaws in its design.However, its findings are not without significance.

In Heidt’s (1981) study ninety hospitalisedcardiovascular patients were randomised into threegroups. One group received therapeutic touch forfive minutes, another group (control) received casualtouch and the third had a nurse who talked to themfor the five minutes test time. Pre and post testanxiety was assessed using the State-Trait 2 AnxietyInventory (Spielberger 1983), a self-evaluation tool.The experimental group was found to have astatistically significant greater reduction in state

2 State anxiety can be described as stress /anxiety felt at the time,and trait anxiety as stress/anxiety felt ‘normally’


anxiety scores than the other two groups. Acriticism of this study is that the experimental groupwere aware that they were having therapeutic touchand therefore the placebo effect cannot be ruled out.

Quinn’s (1982) sixty hospitalised patients withcardio- vascular conditions were randomly assignedto two groups. One group received a mimictreatment from three nurses with no knowledge oftherapeutic touch, the other received therapeutictouch. Both treatments lasted for five minutes.Quinn’s hypothesis that the therapeutic touch groupwould have a greater reduction in post test-traitanxiety scores (using the Spielberger State-TraitAnxiety Inventory 1983) was supported. This resultalso indicated that therapeutic touch involves anenergy interaction, but the study does not attempt todraw conclusions as to defining its exact nature.

Quinn (1989 b) replicated the above study, withthirty-eight women and one hundred & fifteen men,all awaiting open heart surgery the following day,who were treated with either mimic therapeutictouch or therapeutic touch. The same assessment,using the State-Trait Anxiety Inventory, was used aspreviously. Blood pressure and heart rate wererecorded pre and post test using separate analysesof co variance. Although no significant differenceswere recorded between the two groups, all post testmeasures did improve.

It must be noted that, where as in the 1982 studymimic therapeutic touch was given by nurses with noknowledge of therapeutic touch, in this studytherapeutic touch and mimic therapeutic touch weregiven by therapeutic touch practitioners. Thereforeit is possible that this influenced the small differentialbetween groups. Similarly the shortness of length ofthe treatment has been questioned.

Olsen’s (1992) study took place in the two monthsfollowing hurricane Hugo in the United States. Aconvenience sample of twenty three volunteers, whohad all experienced personal stress was used. Arepeated session design was used with datacollected before during and after each session.Physiological measurements such as blood pressureand skin temperature were included. Thepsychological variables were state anxiety and traitanxiety. These were tested by two visual analoguequestionnaires. The findings showed that meanstate anxiety scores decreased significantly after thetherapeutic touch sessions, but that trait anxietyscores remained similar pre and post test.Physiological outcomes indicated a trend towardsrelaxation but these were not statistically significant.

b) PainUsing a sample of sixty people, one group wastreated with mimic therapeutic touch and the otherwith therapeutic touch. (Keller & Bzdek 1986) The

hypothesis was that the therapeutic touch groupwould experience greater relief from headache andthat this would persist for four hours post treatment.The research design was rigorous and appropriateassessment tools were used. The hypothesis wassupported, with statistically significant results.

This was a single, randomised control trial todetermine the effect of therapeutic touch onosteoarthritis of the knee. (Gordon et al 1998). Thiswas a small sample of twenty five, but significantdifferences were found in improvement in functionand pain for those who received therapeutic touch.

In addition to supporting the hypothesis relating topain, these studies also support the hypothesis thatthere is an energy interaction occurring duringtherapeutic touch.

c) SleepUsing the Sleep Quality questionnaire as a measure,it was found that five out of six elderly subjects had abetter quality of sleep during nights whentherapeutic touch had been administered to them atbedtime. (Braun et al 1986)

d) Audit & evaluation of serviceIn Hallett’s (1996) survey with oncology patients,following therapeutic touch: • 75% said they were coping better (20% were

coping the same)• 70% reported feeling less anxious• 47.5% felt happier• 75% felt more peaceful and calm

Other responses included coping better withchemotherapy and radiotherapy (32.5%) 40%reported feeling more in control and 37.5% felttherapeutic touch had helped them to adjust to theirdiagnosis. A similar survey was conducted (Hallett2000) and findings were very similar.

In summary, both research and anecdotal evidenceindicate that therapeutic touch is helpful from aquality of life perspective and, for some, can beperceived as a deep and meaningful experience.

TrainingTraining in therapeutic touch is available at twolevels. A two day introductory course introduceshealth care professionals to the main principles oftherapeutic touch and is a pre-requisite to the full,advanced practitioner training. The course thatleads to full, advanced practitioner status takes eightmonths and can be undertaken as an independentmodule or as a module within the degree for healthcare studies. Currently the only practitioner trainingcourse is in Lancaster, validated by St. Martin’sCollege, University of Lancaster. Information ontraining can be obtained from the website of TheSacred Space Foundation, www.sacredspace.org.uk

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15 Hypnosis andHypnotherapy

15.1 Brief description

Hypnosis has been described as a psychologicalstate in which certain human capacities areheightened while others fade into the background.During hypnosis a person’s critical faculty or logicalmind is suspended or diminished, leading to anincrease in the probability of the acceptance oftherapeutic interventions. (Hawkins 1994, cited inLiossi and Mystakidou 1996) The term hypnosisdenotes an interaction between one person, thehypnotist, and another person or people, the subjector subjects. (Heap et al 2001) In this interaction thehypnotist attempts to influence the subject’sperceptions, feelings, thinking and behaviour byasking them to concentrate on ideas and images thatmay evoke the intended effects. There arenumerous theories but no universally acceptedmechanism to explain all the phenomena ofhypnosis.

Trance is ". .a waking state of awareness in which aperson’s attention is detached from his or herimmediate environment and is absorbed by innerexperiences such as feelings, cognition andimagery". (Heap 1996) Suggestion is the purposefuluse of the phenomenon of trance and is at the heartof hypnosis. (Zahourek 2001)

Trance or change in the state of mind is akin tointense or focused concentration or attention, astate which may be induced by techniques such asdeep relaxation routines, visualisation, imagery,guided imagery, autogenic training, neurolinguisticprogramming and meditation, as well as othersituations such as music festivals, religiousceremonies and sporting events. (Finlay and Jones1996, Owens 2002)

In hypnosis the imagination, rather than the intellect,is active. (Taylor 2002) Hypnosis is a valuable toolwhich involves interaction between body and mind,using the mind to affect therapeutic change, and canbe instrumental in engendering coping strategies,helping people to connect with their inner being andactivate innate healing forces. (Spiegel and Moore1997, Owens 2002)

In a consultation, the clinician, by the use of rapportbuilding and communication skills, establishes theneeds of the patient and endeavours to remove anydoubts, fears and misconceptions they may haveabout hypnosis. Close empathic rapport is the firststage of the hypnotic process, and is generallyfollowed by induction, following which the patient is

guided into a state of deep relaxation. Within thisstate communication is retained, and specificsuggestions geared to that person’s presentingconcerns are made. The benefits, and growth of thepatient’s autonomy, are reinforced by self hypnosistechniques and by post hypnotic suggestions,through which the patient goes through the hypnoticprocedures on their own.

Whilst it is recognised that relaxation is a core skillfor occupational therapists, and physiotherapists usesome relaxation techniques, increasingly physicians,nurses and allied health professionals are usingrelaxation and visualisation and other forms ofguided imagery, frequently within a group format, inthe field of supportive and palliative care. (Walker1992; Cayrou and Dolbeault 1997) Within thiscontext, a question not infrequently raised bypractitioners of hypnosis is ‘are these conventionalhealthcare practitioners in fact using hypnosis?’ It isadvisable that practitioners who use hypnotictechniques, such as relaxation, visualisation andguided imagery within their field of work should havereceived formal instruction and training and becognisant of the contraindications and precautionsdescribed later in this chapter.

15.2 Evidence

As an adjunct to more conventional forms ofpsychotherapyThere is substantial evidence that hypnosis can be avaluable adjunct to more conventional forms ofpsychotherapy. The following are some examples.

Kirsch et al (1995) carried out a meta-analysis on 18studies in which cognitive-behavioural therapy wascompared with the same therapy supplemented byhypnosis. The results indicated that the addition ofhypnosis substantially enhanced treatment outcome,so that the average client receiving cognitive-behavioural hypnotherapy showed greaterimprovement than at least 70% of clients receivingnon-hypnotic treatment.

Similarly, Schoenberger (2000) writes of the growingbody of research evaluating the use of hypnosis withcognitive-behavioural techniques in the treatment ofpsychological disorders. Overall, studiesdemonstrate a substantial benefit from the additionof hypnosis.

Lynn S J et al, (2000) summarised the evidence forthe effectiveness of hypnosis as an empiricallysupported clinical intervention. Indications are, thatas a whole, the clinical research to date generallysubstantiates the claim that hypnotic procedures canameliorate some psychological and medicalconditions.


Bejenke (2000) writes of the benefits of earlyintervention with cancer patients in a study basedupon fifteen years of clinical practice. The use ofhypnosis, including imagery andpsychoneuroimmunological modalities, as apreparation for surgery, chemotherapy, radiation andbone marrow transplantation can reduce physicalsuffering and treatment side effects, and facilitatepatient management.

Trijsburg et al (1992) reviews twenty-two studies onthe effects of psychological treatment on cancerpatients. Behavioural interventions and hypnosiswere effective with respect to specific symptomssuch as anxiety, pain, nausea, and vomiting.

Levitan (1992) describes a number of specificapplications of hypnosis within cancer care.Hypnosis has unique advantages for patients,including improvement of self-esteem, involvementin self-care, return of locus of control, lack ofunpleasant side effects and continued efficacy.

Stetter et al (2002) carried out a meta-analysis toevaluate the clinical effectiveness of autogenictraining. Seventy-three controlled outcome studieswere found (published 1952-99). Sixty studies (35randomized controlled trials) qualified for inclusion inthe meta-analysis.

In the context of cancer managementTypically a person having cancer may encounter aseries of ‘pulses’ of need for intervention as thedisease and its treatment follow their course. Majorconcerns of the patient may be in relation tophysical, psychological, emotional or spiritualdistress. Interventions in the management ofcancer, typically surgery, chemotherapy andradiotherapy, can be unpleasant, and will oftenbecome central to a patient’s fears, anxieties andconcerns, and may be addressed using hypnosis.

Certain concerns are not limited specifically to thecancer experience, but may be of a more generalnature, for example panic attacks and needle phobia,and this will be evident in the references cited. Thissection attempts to identify the value of hypnosis inthe management of some of the many crises occurringwithin the cancer journey. See Walker 1992.

a) Emotional response to cancerSpiegel (1990) states that patient resources forcoping with breast cancer can be enhanced byattention to cognitive, affective, psychosomatic andsocial components of the illness. Systematicstudies of such treatment interventions have shownfavourable results, including significant reductions inmood disturbance and pain.

Walker et al (1999) examined the relationshipbetween stress and response to chemotherapy.

They stated that the diagnosis and treatment ofbreast cancer are stressful, and stress may beassociated with a poorer response to chemotherapy.There is a need, therefore, to develop and evaluateinterventions that might enhance quality of life and,possibly, improve treatment response. The effectsof relaxation combined with guided imagery(visualising host defences destroying tumour cells)on quality of life and response to primarychemotherapy, to date, have not been adequatelyevaluated.

Ninety-six women with newly diagnosed large orlocally advanced breast cancer took part in aprospective, randomized controlled trial. Ashypothesised, patients in the experimental groupwere more relaxed and easy going during the study,according to the Mood Rating Scale. (Anderson et al2000) Quality of life was better in the experimentalgroup, as assessed using the Global Self-assessment (Walker et al 1999) and RotterdamSymptom Checklist. (De Haes et al 1990) Theintervention also reduced emotional suppression, asmeasured by the Courtauld Emotional Control Scale(Watson and Greer 1983). The incidence of clinicallysignificant mood disturbance was very low and theincidence in the two groups was similar. Finally,although the groups did not differ for clinical orpathological response to chemotherapy, imageryratings were correlated with clinical response.These simple, inexpensive and beneficialinterventions should be offered to patients wishingto improve quality of life during primarychemotherapy.

b) Adjunctive to surgery Montgomery et al, (2002) carried out a meta-analytical review of studies using hypnosis withsurgical patients. The results indicated that patientsin hypnosis treatment groups had better clinicaloutcomes than 89% of patients in control groups.These data strongly support the use of hypnosis withsurgical patients.

c) Chemotherapy related nausea and vomitingMarchioro et al (2000) reported on 16 consecutiveadult cancer patients affected by chemotherapyinduced anticipatory nausea and vomiting who hadreceived at least four treatment cycles. Theexperience highlights the potential value of hypnosisin the management of anticipatory nausea andvomiting.

Jacknow et al (1994) studied the effectiveness ofhypnosis for decreasing antiemetic medicationusage and treatment of chemotherapy relatednausea and vomiting in children with cancer. Resultssuggest self-hypnosis is effective for decreasingantiemetic medication usage and for reducinganticipatory nausea during chemotherapy.

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Burish T G et al (1983) report that some adverseside effects of cancer chemotherapy are attributedto the pharmacologic properties of the anti-neoplastic drugs, while others appear to beconditioned or learned. The literature suggests thatbehavioural relaxation techniques can significantlyalleviate some conditioned side effects ofchemotherapy including nausea, vomiting andnegative emotions such as anxiety and depression.These behavioural procedures are generallyinexpensive, easily learned, and have few if anynegative side effects.

Walker et al (1988) describe a promisingpsychological treatment for ameliorating the sideeffects of cytotoxic chemotherapy used in cancertreatment. It is brief, does not require the therapistto be present immediately before or duringchemotherapy, and does not need to be carried outin the same clinical area as the chemotherapy.Fourteen patients, all of whom had severe sideeffects, took part in an open clinical trial. Allpatients, including two who had previously refusedfurther chemotherapy, completed their prescribedcourse of chemotherapy. In a number of patients,impressive improvements were observed inconditioned nausea and vomiting, pharmacologicalnausea and vomiting and other symptoms.

In a study by Zeltzer L et al (1984) fifty-one children6-17 years of age rated the severity of nausea,vomiting, and the extent to which chemotherapybothered them during each course of chemotherapy.The data indicate that chemotherapy related nauseaand emesis in children can be reduced withbehavioural intervention and that reductions aremaintained after intervention has been discontinued.See also Walker et al 1990.

d) Scanning and radiotherapy proceduresFriday et al (1990) reported on the use of hypnosisas an intervention in MRI procedure. Medicalhypnosis has been an effective intervention in tenpatients, permitting completion of their diagnosticprocedure. See also Steggles 1999.

e) Pain Syrjala K L et al (1995) compared oral mucositis painlevels in four groups of cancer patients receivingbone marrow transplants. From results obtained theconclusion is that relaxation and imagery trainingreduces cancer treatment related pain. The resultsfrom other studies also indicate that pain in cancercare responds well to hypnosis.

Spiegel & Bloom (1983) studied the pain and mooddisturbance of 54 women with metastatic carcinoma ofthe breast over the course of one year. Those whowere offered the self-hypnosis training as well as grouptherapy fared best in controlling the pain sensation.Pain frequency and duration were not affected.

f) In advanced cancer Liossi & White (2001) carried out research toevaluate the efficacy of clinical hypnosis in theenhancement of quality of life of patients with far-advanced cancer. The study concluded thathypnosis is effective in the enhancement of quality oflife in terminally ill cancer patients.

g) Immune responseLynn et al (2000) report the results of an 18-monthstudy of immune system and psychological changesin stage 1 breast cancer patients provided withrelaxation, guided imagery, and biofeedback training.The results show that behavioural interventions canbe correlated with immune system measures,thereby replicating the results of an earlier pilot study.

Spiegel & Moore (1997) report on a 10-year follow-up of a randomized trial involving 86 women withcancer which showed that a year of weeklysupportive, expressive group therapy significantlyincreased survival duration and time from recurrenceto death.

Johnson et al (1996) carried out a study with theaims of evaluating the psychological andimmunological effects of 3 weeks' relaxationpractice; investigating the effects of relaxationtraining and hypnosis on the modulation of theimmune response to an experimental stressor; andrelating changes to hypnotic susceptibility. Aconclusion was that hypnotisability may be animportant moderator of thepsychoneuroimmunological response to relaxationtraining and exposure to acute stress.

Walker (1998) states that in recent years it hasbecome increasingly clear that the diagnosis andtreatment of cancer are stressful experiences. Notsurprisingly, therefore, high levels of psychiatricmorbidity and psychological distress have beenreported. (Derogatis et al 1983) There is nowevidence, however, from prospective, randomizedcontrolled trials that psychological interventions canenhance the quality of life of patients with cancer(see Meyer and Mark, 1995 for a meta-analysis). Inaddition, psychological interventions, includinghypnosis, can modulate the immune response in away that might be relevant to the progression ofmalignant disease. (Walker and Eremin, 1995) Seealso Walker (1992)

In summary, a large body of evidence exists for theuse of clinical hypnosis and hypnosis may be usefulin supportive and palliative care for in the followingways:

• To enhance the immune response (Walker 1992,Walker & Eremin 1995, Johnson et al 1996,Spiegel & Moore 1997, Walker 1988, Lynn et al2000)


• As an adjunct to more conventional forms ofpsychotherapy (Levitan 1992, Kirsch et al 1995,Schoenberger 2000, Lynn et al 2000, Bejenke2000)

• To enhance coping ability (Walker 1992, Levitan1992, Walker 1999)

• To enhance recovery from surgery (Montgomeryet al 2002)

• To reduce chemotherapy-related nausea andvomiting (Burish et al 1983, Walker 1988, Walker1992, Jacknow et al 1994, Marchioro et al 2000)

• To increase tolerance of scanning andradiotherapy procedures (Friday et al 1990,Walker 1992, Steggles 1999)

• To reduce pain (Syrjala et al 1995, Spiegel &Bloom 1983, Trijsburg et al 1992)

• In mood disturbance and emotional andpsychological distress (Spiegel 1990, Walker1992, Lynn et al 2000)

• To enhance quality of life (Levitan 1992, Walker1999)

• To reduce anxiety and depression (Trijsburg et al1992, Burish et al 1983)

15.3 Use of hypnosis in supportive andpalliative care

Contraindications• Psychiatric status: where any psychiatric

condition exists which may lead to unpredictablebehaviour and responses, hypnosis iscontraindicated.

• Emotional status: depression is often aconcomitant of cancer. Effective treatment ofdepression in cancer patients results in betterpatient adjustment, reduced symptoms, reducedcost of care, and may influence disease course(Spiegel 1996). When using hypnosis, the lack ofclinical expertise specifically in working with thedepressed person may only serve to compoundtheir problem.

Precautions• Be aware of inexpert use. Clinicians should not

work outside their own areas of training andcompetence. Stanley et al (1998) state thatincreasingly there is developing a conviction thatthe hypnotic state or process itself poses noinherent dangers for patients but that its inexpertuse may. The solution to prevent potential patientharm is to ensure that all clinicians of whateverdiscipline have adequate and appropriate clinicaltraining prior to being allowed to practise.

"With….real authorities, agreement is almostunanimous that dangers (of hypnosis) are minimaland can be avoided. In some instances therehave been bad results, but they have comebecause of personality difficulties of the hypnotist,authoritative, coercive use of hypnosis, or lack of

knowledge. Patients will protect themselves fromharm when the therapist shows respect for theirability to do so" (Cheek & Le Cron 1968).

• Explain to the patient the likely process of thehypnotic intervention, to remove any doubts andfears, and to obtain the approval and consent ofthe patient.

• Be aware of the legal implications of working witha patient who is in a state of hyper-suggestibility,and who, generally, will have their eyes closed.

• Be aware that abreaction, a (possibly powerful)emotional response to recalled images andfeelings, may be triggered in hypnosis. This isparticularly likely where the patient is alreadyunder considerable emotional pressure. Theclinician should be trained and competent in usingskills to protect and work with the patient, and tore-orientate the patient following an abreaction.

• Remove any suggestion other than thoseintended to be post hypnotic, before ‘alerting’ apatient. For example, if anaesthesia had beenproduced it is important to terminate it. (Cheek &Le Cron 1968)

• Ensure post hypnotic suggestions are time andsituation specific.

• Ensure the patient is brought out of the hypnoticstate gradually.

• Ensure the patient is fully awake and alert beforeconcluding the session.


Chapter 5 should be referred to for the current positionon regulation and training of complementary therapyprofessions. The regulation of hypnotherapists under asingle regulatory body is at an early stage and aworking group that is inclusive of all the differentorganisations and facilitated by an independent chair,has not been agreed. Further information can beobtained from The Prince of Wales’s Foundation forIntegrated Health www.fihealth.org.uk

RegulationBritish Society of Medical and Dental Hypnosis andits branches, and The British Society of Experimentaland Clinical Hypnosis are the two professionalorganisations in the UK whose members practisehypnosis integrated with the professional’s primaryconventional health care role. Members areanswerable to, and follow the codes of ethics,conduct, etc of their relevant regulatory body, forinstance the General Medical Council, or Nursingand Midwifery Council.

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Members of the British Society of Medical andDental Hypnosis are encouraged to work towardsaccreditation, and accredited members are listed onthe Society referral register. Details can be obtainedfrom the national office.

Hypnotherapists who are also psychotherapists areregistered with the United Kingdom Council forPsychotherapists. Information can be obtained bywriting to the United Kingdom Council forPsychotherapists email:[email protected]

There are a large number of professionalorganisations that register hypnotherapists whohave trained with organisations other than the BritishSociety of Medical and Dental Hypnosis. The UKConfederation of Hypnotherapy Organisations is theumbrella body for a number of organisations, seewww.ukcho.org. There are also hypnotherapyorganisations who are not members of UKCHO.

TrainingThe British Society of Medical and Dental Hypnosisis a national and federal organisation which offerstraining in hypnosis to professionals with aconventional health care qualification who areemployed in a substantive post with the NHS.Training is at basic, intermediate and advanced levelsand members are encouraged to pursue trainingtowards accreditation by the British Society ofMedical and Dental Hypnosis. The core curriculumis set at national level and training is organised atbranch level. In order to maintain consistentstandards, a selection of branch level courses areattended annually by observers from other branches.Details of training courses can be obtained from theBritish Society of Medical and Dental Hypnosisnational office. Tel/fax: 07000 560309, email:[email protected] Website: www.bsmdh.org

The British Society of Medical and Dental Hypnosisview hypnosis as an additional skill or tool forprofessionals with a conventional health carequalification, to be used alongside their primary roleas a doctor, dentist or nurse and within the expertiseof their primary qualification. From the perspectiveof the British Society of Medical and DentalHypnosis, the ethics and clinical responsibility thatcome with working with a person in a hypnotisedstate are such that those practising hypnosis shouldalready have a primary professional relationship withthe patient, be able to accept clinical responsibilityfor their actions, and have indemnity cover. Somemembers of the Society go for further training inpsychotherapy or hypnotherapy.

The British Society of Experimental and ClinicalHypnosis works closely with the British Society ofMedical and Dental Hypnosis and offers somecourses, but does not accredit practitioners.

Although open to other professionals, membershipcomprises mainly psychologists who may or may notbe trained in hypnosis.

The Department of Hypnosis at University CollegeLondon offers training to appropriate conventionalhealth care practitioners to diploma and MSc level inclinical and applied hypnosis. Contact Dr. DavidOakley at [email protected]. Graduates are eligiblefor membership of The British Society of Medicaland Dental Hypnosis or The British Society ofExperimental and Clinical Hypnosis, and also toapply for accreditation. Glasgow CaledonianUniversity has introduced a diploma course this year.

Apart from the British Society of Medical and DentalHypnosis, hypnotherapists also train at a largenumber of other establishments and professionalorganisations. The level of training varies, and thereis at present no agreed standard or core curriculum.The second edition of national occupationalstandards for hypnotherapy is currently beingdeveloped. These are the minimum agreedstandards to which practitioners should be able towork.


16 Acupuncture


Acupuncture is a word derived from the Latin acus,needle and pungere, to pierce. It is a therapeutictechnique that involves the insertion of fine needlesinto the skin and underlying tissues at specificpoints, for therapeutic or preventative purposes.(Ernst 2001) The origins of acupuncture go back atleast 2,000 years in China (Ma 1992).Anthropologists and medical historians havedescribed many ways in which sensory modulationhas been used for therapeutic purposes over theyears in different cultures (Melzack 1994). Indeed,Ötzi, the European Ice Man, discovered in the Alpsin 1991 and dated 5,200 years old, had numeroustattoos on his body over areas which correspondedto areas of arthritis on imaging. (Dorfer 1999) Thelocations and asymmetry of the tattoos on the bodysuggests that they were not ornamental and manywere at sites commonly used for acupuncturetreatment, so it was concluded that theyrepresented a therapeutic technique.

Traditional acupuncture is used to treat a widevariety of disorders. For many traditionalacupuncturists, acupuncture is practised as part ofTraditional Chinese Medicine. In Traditional ChineseMedicine a fundamental concept is qi (pronouncedchee), which is usually translated as ‘energy’.(Vickers and Zollmann 1999; Ernst 2001) The rootsof the concept qi, and many of the most importanttraditional acupuncture concepts, are at the veryheart of Chinese culture. Qi is associated with theimage of a warm hearth, a full stomach, and a senseof well-being. (Birch and Felt 1999) A person’s qi, orenergy, is present at birth and circulates throughoutthe body maintaining its physiological functions.When qi is fully dissipated death occurs. The majorpathways for its circulation are the meridians orchannels that form a continuous network throughoutthe body. Another basic concept of health is thebalancing of two opposites, yin and yang. By carefulobservation of the symptoms of someone who is ill,a practitioner can determine the nature of thedisturbances in the flow of energy, and of thedisharmony to the normal balance of yin and yang.

Practitioners who solely use the traditional,energetic concept of acupuncture will insert needlesat acupuncture points for which credibility has beenestablished empirically. The aim of this approach isdescribed in terms of correcting the body’s energyflow and restoration of balance. Traditionalacupuncturists base their diagnosis on a carefuldiscussion with the patient, which may take intoaccount more than obvious signs and symptoms. Intheir overall diagnosis, they often incorporate a

sophisticated pulse and tongue diagnosis in order toidentify the underlying patterns of disharmony whichwill guide treatment. (Lu and Needham 1980;Kaptchuk 2000) Acupressure uses similar principlesbut without needles; it can be administered with localfinger pressure or pressure bands.

Many western medical acupuncturists undertakeinitial extensive training in traditional acupuncturetechniques. However neurophysiological andneuropharmacological advances in the study ofacupuncture have caused them to challenge thecredibility of the traditional energetic diagnosticapproach. Recent neuropharmacological andneurophysiological advances have givenacupuncture an additional scientific basis and farmore clinical acceptability for sceptical opponents ofthe subject. For example, acupuncture’s actions areblocked by pre-treatment with injection of localanaesthetic. (Chiang, et al, 1973; Research Groupof Acupuncture Anaesthesia, 1973; Dundee andGhaly, 1991) It releases b-endorphins (Sjolund et al,1977; Clement-Jones et al, 1980), met-enkephalinand dynorphins, which work on MOR, DOR andKOR (mu, delta, and kappa) opioid receptors. (Hanand Terenius 1982; Han et al, 1991) Oxytocin, whichis anxiolytic and analgesic, is released. (Uvnas-Moberg et al, 1993) This in turn releases serotoninwhich has both analgesic and mood enhancingproperties (Han and Terenius, 1982). It haswidespread autonomic effects (Ernst and Lee, 1985;Lundeberg 1999) and releases endogenoussteroids. (Roth et al, 1997) Acupuncture is thoughtto up-regulate endogenous opioid gene production(Guo et al, 1996) which explains why top-ups arerequired, in part to maintain the gene expression in a‘switched on’ mode. (Zieglgänsberger 2002,personal communication)

Many theories have been put forward regarding theanatomical or physiological basis of acupuncture pointsand meridians. For example, functional magneticresonance imaging (fMRI) has been used to detectactivity in the visual and auditory lobes of the brainduring needling of distal acupuncture points on the legand foot, the locations being based on traditionalacupuncture practice for the treatment of eye andear dysfunctions. (Cho et al 1998, Cho et al 1999)

Many neurophysiological mechanisms are describedin further detail by Bowsher (1998), Pomeranz(2001), White (1999), Lundeberg (1999), and Filshieand Thompson (in press). There is a 71% overlapbetween acupuncture and trigger points. (Melzack,Stillwell and Fox, 1977) Trigger point acupuncture isparticularly effective for myofascial musculoskeletalpain (Baldry, 2001). The meridian pathwaysfrequently coincide with the referral pattern of triggerpoints. (Filshie and Cummings, 1999) Thediagnostic reliability of the pulse diagnosis has beenquestioned. (Vincent, 1992)

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Within the broad rubric of traditional acupuncture,there is considerable diversity in styles, for example,Chinese, Korean, Vietnamese and Japaneseacupuncture, plus Chinese and Frenchauriculoacupuncture or ear acupuncture. Manywestern medical acupuncturists often take a morepragmatic approach to treatment and use an eclecticmix of treatments, traditional and western medicalapproaches and many use microsystemacupuncture, for example ear acupuncture orauriculotherapy. Some have even simplified thetreatment approach further, leaving the complexenergetic approach to its historical context only.(Mann, 2000; Campbell, 2001; Baldry, 2001)

Acupuncture is currently performed in over 84% ofpain clinics (Woollam and Jackson, 1998; CSAG,2000). Twenty-one per cent of GP practices offeraccess to acupuncture. (Thomas 2001) Westernmedical acupuncture treatment is not restricted topain treatment alone and is used for treatment ofmultiple problems including respiratory problems,gastro-intestinal symptoms, cardiac, neurologicaland gynaecological conditions. (Filshie and White,1998) Western medical acupuncturists use amixture of segmental points appropriate to thedisordered segment, for example T1 and T2 whenthe intercostobrachial nerve is damaged in axillarydissection, trigger points, tender points, plusselected ‘strong’ traditional points which have beencommonly used, many of which, for example LI4, areknown to increase the pain threshold. (Brockhausand Elger, 1990)

Western medical acupuncture is used following anorthodox diagnosis based on conventional historytaking, examination and special investigations(Filshie and Thompson, in press). Traditionalacupuncturists are trained in basic sciences andhave some degree of training in conventionalmedicine to a level which enables them to recognisesymptoms of a more serious nature or red flags.Where appropriate, they ensure that patients arereferred to their GP or oncologist for furtherinvestigations. This is important as an energeticdiagnosis alone is potentially dangerous in certaincircumstances. (Filshie, 2001) As a result of this,specific training courses have been developed in theUK for palliative care physicians and other medicalpractitioners who wish to treat palliative carepatients as have acupuncture courses to familiariseother doctors and acupuncture practitioners whowork with cancer patients (see 16.4).

In palliative care, acupuncture is used alongsideconventional medical treatment and has anincreasing supportive role for pain and symptommanagement. (Filshie; 2001; Wong et al; 2001)Some practitioners advocate its use to enhancepsycho-spiritual well-being. (Aung, 1994; Wong et al,2001) Filshie and Thompson (2000) are more

circumspect, though they acknowledge thatpsychoneuroimmunomodulation can go part way toexplain how acupuncture works on the body and themind.

16.2 Evidence base

Significant positive evidence is now availablebased on systematic reviews and meta-analysesfor the use of acupuncture for the control ofnausea and vomiting (Vickers, 1996),postoperative nausea and vomiting (Lee and Done,1999), experimental pain (White, 1999), dentalpain (Ernst and Pitler, 1998), headache (Melchart,1999) and fibromyalgia (Berman, 1999).Acupuncture treatment for back pain is somewhatmore controversial with a positive review (Ernstand White, 1998), a negative review (Smith, 2000)and a rather neutral review (Van Tulder, 2000).Cummings (2000) has critically appraised theseanomalies. Inconclusive evidence exists forstroke, asthma and neck pain and negativeevidence for weight loss and smoking cessation(Ernst, 1999), though the results for this arecomparable to the success of nicotine patches.

Based partly on Vickers’ (1996) data on acupuncturefor nausea and vomiting, the National Institutes ofHealth Consensus Statement on Acupuncture (NIH,1997) recommended acceptance of acupuncture asa useful clinical modality of treatment.

Acupuncture has been used to treat acutepostoperative pain in cancer patients and alsochronic or intractable pain associated with thecancer or its various treatments, for examplesurgery and radiotherapy. It is also used for non-painsymptoms such as nausea and vomiting, dyspnoea,xerostomia and many other troublesome problems inpalliative care.

The results of clinical trials of acupuncture for painunrelated to cancer have often been conflicting, withinconclusive results based on heterogeneous dataand greatly flawed methodology (Patel, 1989; TerRiet, 1990). This is hardly surprising, as trialmethodology for acupuncture studies is particularlycomplex (White, 2002). Though randomisation ispossible, suitable ‘blinding’ of patients isproblematic, as is the provision of a credibleneedleless placebo (White, 2001). However,depending on the research questions asked, it ispossible to use an alternative non-acupuncturegroup for comparison. A more recent pain review byEzzo et al (2000) was similarly inconclusive butshowed some superiority of acupuncture treatmentcompared with untreated patients, anddemonstrated a greater effect for invasive comparedto non-invasive controls.


Acute postoperative pain and symptom controlAcupuncture reduced per and post operativeanalgesic requirements in a randomised controlledtrial of 250 patients undergoing major abdominalsurgery for cancer (Poulain, 1997). Intradermalneedles sited pre-operatively and remaining postoperatively reduced post operative analgesicrequirements in a study involving 191 patients havingupper and lower gastrointestinal surgery. (Kotani etal, 2001) It also caused less pain and increasedmobility in the post operative period for patientsundergoing axillary dissection for breast cancer. (Heet al, 1999) Acupuncture as an alternative toanaesthesia is risky, but as an adjunct can be veryefficacious in reducing per and postoperativeanalgesic requirements.

Chronic cancer and cancer treatment related painAcupuncture has been used quite extensively forcontrol of chronic and treatment-related cancer pain.However, the majority of work relies onobservational reports, audits and case series todate. It is notoriously difficult to recruit patients toclinical trials in palliative care (Faithful, 1996) andacupuncture is no exception. There is a high attritionrate for conventional studies (Kirkham, 1997), letalone studies in complementary medicine.

In summaries of two extensive audits (Filshie andRedman, 1985; Filshie, 1990), acupuncture wasfound to improve pain control and reduce analgesicrequirements in patients who had failed to respondto conventional treatment, though top-ups werelikely to be more frequent than with non-cancerpatients. An increase in mobility often accompaniedpain reduction.

Patients with cancer treatment related pains such aspost-surgical syndromes or post-irradiation like painrespond better than patients with extensive disease.The more advanced the disease, the shorter theresponse to treatment. Any tolerance to treatmentwas often an indication for tumour recurrence andhence a warning to check on the cancer status of thepatients. Leng (1999) showed similar results in ahospice-based audit. Pain control in abdominalcancer was also achieved for at least one month in acase series of patients with mild or moderate painand 72% with severe pain. (Xu, Liu and Li, 1995)Wen (1977) gave several electroacupuncturetreatments per day and then steadily reduced thenumber of treatments per day on patients whoresponded with uncontrolled pain. Percutaneouselectrical nerve stimulation (PENS) is reported as anovel treatment but appears to beelectroacupuncture with a new name. One reportshowed pain, secondary to bony metastases, to beimproved in two out of three patients (Ahmed, 1998).

Aung (1994) combined acupuncture with Qi Gongand breathing exercises and meditation in his case

series. A recent audit by Johnstone et al (2002)showed success for a range of symptoms includingpain: 86% of patients considered it ‘very important’to continue to provide an acupuncture service. Anaudit on patients with breast cancer related painshowed an improvement of depression scores inaddition to improvement in pain, distress andinterference with lifestyle. (Filshie et al, 1997)Maintenance of relief is often problematic in cancerpatients and two studies showed the short-termimprovement in pain control using semipermanentindwelling needles in the ear, auriculoacupuncture.The former included five patients with motor neuronedisease. (Dillon and Lucas, 1999; Alimi, 2000)

Nausea and vomitingNumerous randomised controlled trials (RCTs) havebeen performed using mostly the traditional pointPC6 with a variety of stimuli to reduce chemotherapyinduced nausea and vomiting. The impact ofuncontrolled nausea and vomiting may be significantand may even lead to patients abandoningchemotherapy due to the negative impact on qualityof life. Prevention is more successful than treatmentonce it develops. Acupuncture, electroacupuncture,acupressure or transcutaneous electrical nervestimulation (TENS) were all compared with a controltreatment. Seven out of eight studies were positive(Dundee et al, 1987; Stannard, 1989; McMillan et al,1991; Price et al, 1991; Dibble et al, 2000; Shen etal, 2000; Roscoe et al, 2002). Roscoe et al (2002),the negative study, used electrical stimulation atPC6 but did not stipulate the exact electricalparameters used and may have been different fromthose by the late John Dundee and ChristineMcMillan (1991) found to give optimal effect.

Andrew Vickers (1996) performed the firstsystematic review on acupuncture for nausea andvomiting and reviewed acupuncture for nausea andvomiting associated with surgery, cancerchemotherapy and morning sickness. The reviewconcluded that, although the studies were notmethodologically perfect, PC6 acupuncture seemsto be an effective antiemetic technique, thoughsomewhat less effective in some of the trialsreviewed when administered under anaesthesia.

Numerous other subsequent reviews have come tosimilar conclusions. (Mayer, 2000; Jacobson,Workman and Kronenberg, 2000; Pan, 2000; Wong,Sagar and Sagar, 2001) However, a preliminaryanalysis of the Cochrane review (Richardson et al,2001) examining the effectiveness of acupuncturefor chemotherapy induced nausea and vomitingfound that the stimulation of PC6 acupoint reducedvomiting during chemotherapy, but the effectappears to be short-term only. The challengeremains to compare adequately powered randomcontrolled trials with newer antiemetics such as the5HT-3 antagonist ondansetron.

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Nausea and vomiting in advanced terminal care isconsiderably more complex and may be due to oneor many of the following causes: gastrointestinalproblems including intestinal obstruction; drugs, forexample strong opioids like morphine; metaboliccauses including hypercalcaemia and renal failure;brain metastases; or dehydration. The cause of thenausea and vomiting needs identifying by orthodoxmedical diagnosis and clinical tests as appropriateand acupuncture may or may not be indicated. Ifacupuncture is found to be of potential value, havingexcluded serious causes, points with knownphysiological effects such as ST36 (Tougas et al,1992) or CV12 or ST25 may need to be added ifreversible gastrointestinal dysfunction is contributingto the nausea and vomiting.

Shortness of breathIn a single-blind random controlled trial on 24patients with chronic obstructive pulmonary disease(COPD) and disabling shortness of breath, patientshad significant benefit in subjective breathlessnesswith the use of traditional acupuncture comparedwith sham, and had an increased 6-minute walkingdistance, though objective measures wereunchanged (Jobst et al, 1986). In a further single-blind, randomised crossover study, 31 patients withsevere COPD were taught to practice acupressuredaily for 6 weeks, then sham acupressure for afurther 6 weeks. Dyspnoea, as measured by a visualanalogue scale, was significantly less with realacupressure (Maa et al 1997). Ernst’s (2001) reviewconcluded that, despite the paucity of trials, there isdata to support the use of acupuncture andacupressure to relieve dyspnoea towards the end oflife for patients with severe chronic obstructivepulmonary disease.

A pilot study of 20 patients (Filshie et al, 1996) withcancer related breathlessness at rest, who weretreated with acupuncture at points on the upper 5cms of the sternum and LI 4 for 10 minutes, foundthat 70% of patients reported a marked symptomaticimprovement; there were significant improvement invisual analogue scores of breathlessness, relaxationand anxiety that peaked at 90 minutes and lasted upto 6 hours. Respiratory rate also significantlydecreased. Semipermanent indwelling needles wereused to prolong the effect. These can remain inplace covered by a clear plastic dressing for up tofour weeks at a time to give patients immediatecontrol by massaging them in the event of a panicattack or prior to any, even trivial exercise. (Filshieand Thompson, in press)

XerostomiaAcupuncture has been shown to improve theunpleasant symptoms of xerostomia due to a varietyof causes. Blom and Dawidson’s team haveperformed many studies, including an RCT on 38patients with xerostomia following radiotherapy that

showed both classical and superficial acupuncture toincrease salivary flow (Blom et al, 1996). In anotherstudy, 50% of patients with xerostomia, who wererefractory to pilocarpine, were also helped.(Johnstone et al, 2001) Lundeberg has describedmany of the physiological principles by which it isknown to work (Lundeberg, 1999). Acupuncture hasalso helped patients in late stage palliative care forxerostomia dysphagia and articulation problems.(Rydholm and Strang, 1999)

Cancer-related hot flushesAcupuncture has been found to be helpful for hotflushes due to the natural climacteric. (Wyon et al,1994). Acupuncture can reduce the hot flushesassociated with hormone manipulation in breastcancer care following tamoxifen (Cumins et al,2000). Semipermanent needles inserted in SP6 canhelp to maintain the effect in patients who fail torespond to a short course of weekly treatments(Towlerton et al, 1999). Acupuncture has alsohelped patients with prostate cancer undergoinghormone treatment. (Hammar, 1999)

Anxiety and depressionThe use of indwelling anxiety, sickness anddyspnoea (ASAD) points on the upper 5 cms of thesternum has been found to be useful for anxiety aswell as dyspnoea and in some cases nausea, thoughnot formally tested. (Filshie and Thompson, in press)Patients can stimulate the semipermanent needlescovered by a clear plastic dressing by gentlymassaging over the needles when they areparticularly anxious, and this can have a rapidcalming effect in responders. Though acupuncturehas been found to be equally as helpful as tricyclicdrugs, (Ernst et al, 1998) there are also many newerdrugs which are reliable for the treatment ofdepression in this group of patients. Patientsattending for physical complaints have oftenexperienced marked changes to their emotional andmental states (Gould & MacPherson 2001),supporting claims of a lift in mood occurringconcurrently with a course of acupuncturetreatment.

People with HIV/AIDSForty-eight per cent of 1016 patients with AIDS usedacupuncture to treat their symptoms (Green et al,1999). Though acupuncture has been found helpfulfor sleep disturbance (Philips and Skelton 2001), alarge random controlled trial comparing acupuncturewith amitriptyline and placebo failed to show anybenefit of acupuncture over the other treatments forpain of peripheral neuropathy. (Shlay et al, 1998)

MiscellaneousPatients with cancer often present with non-cancerrelated symptoms. A prospective and descriptivestudy with 291 acupuncture patients showed areduction in symptoms, such as musculoskeletal,


respiratory, psychological, and neurological, in themajority of patients. (Chapman, Norton andPaterson 2001) The outcome measure used wasthe Measure Yourself Medical Outcome Profilequestionnaire.

Acupuncture has been found to be helpful for avariety of vascular problems including angina andischaemic skin flaps, (Lundeberg, 1999) and evenradionecrotic ulcers have been healed, whichclassically do not heal (Filshie, 1988). Acupuncturehas also helped intractable hiccup, (Yan 1988)dysphagia due to oesophageal obstruction, (Feng,1984) radiation rectitis (Zhang, 1987) and uraemicpruritis (Duo, 1987).

In summary, current evidence supports the use ofacupuncture and acupressure in palliative care forchemotherapy induced and post operative nauseaand vomiting with high level evidence emerging foracute pain and xerostomia. Despite the limitedscientific evidence, there is data to support the useof acupuncture for other symptoms, and it may beuseful in supportive and palliative care for thefollowing conditions.

• Chemotherapy-induced and post-operativenausea and vomiting (Dundee et al, 1987;Stannard, 1989; McMillan et al, 1991; Price et al,1991; Dibble et al, 200; Shen et al, 2000; Aglietti,1990; Roscoe et al, 2002. Reviews: Vickers,1996, Richardson et al, 2001. Postoperativenausea and vomiting: Lee and Done, 1999)

• Pain relief (Acute pain: Poulain, 1997; Kotani,2001; He et al, 1999. Chronic pain: Wen, 1977;Filshie and Redman, 1985; Filshie, 1990; Aung,1994; Thompson and Filshie, in press; Xu, Liu andLi, 1995; Filshie et al 1997; Dillon and Lucas,1999; Leng, 1999; Filshie, 2000; Johnstone et al,2002; Alimi et al, 2000)

• Non-cancer related pain: musculoskeletal(Baldry, 2001); dental pain (Ernst & Pittler 1998);headache (Melchart, Linde & Fisher 1999);experimental pain (White, 1999) fibromyalgia(Berman, 1999)

• Breathlessness, including severe COPD and useof indwelling semi-permanent needles (Jobst etal 1986; Filshie et al 1996; Maa et al 1997; Ernst2001; Filshie and Thompson, in press)

• Xerostomia (dry mouth) (Blom et al 1992; Blomet al 1993; Talal et al 1992; Blom, 1996; Blom &Lundberg 2000; Johnstone et al 2002)

• Radiation induced rectitis (Zhang 1987)• Hiccups (Yan, 1988)• Hot flushes, including semi-permanent

indwelling needles (Wyon, 1998; Towlerton,Filshie et al 1999; Hammar, 1999; Cumins, 2000;Johnstone et al 2002)

• Angina (Richter et al 1991; Ballegaard et al, 1995)• AIDS (Philips and Skelton, 2001)

16.3 Use of acupuncture in supportiveand palliative care

Contraindications• Avoid any area of actual or potential spinal

instability due to cancer. It potentially increasesthe risk of cord compression or transection

• Avoid inserting needles directly over the tumouritself or nodules or related sites, such as ascites

• Do not use acupuncture in severely disorderedclotting function

• Avoid indwelling needles with patients at risk ofbacteraemia, for instance in valvular heart diseaseand immunocompromised patients withneutropenia

• Avoid needling a lymphoedematous limb• Avoid needling directly above a prosthesis• Avoid needling over any intracranial deficits

following neurosurgery

Precautions • Only use sterile, single-use disposable needles• Take particular care when needling over the

ribcage and the domes of the pleura, especially incachectic patients and the hyperinflated chests ofpatients with chronic obstructive pulmonarydisease

• To reduce the risk of pneumothorax, paravertebralneedling or needles to the top of the sternum areuseful alternatives

• Avoid the arm on the side of mastectomy and/oraxillary lymph gland dissection

• Be aware that if tolerance occurs, it mayrepresent progressive disease and fullinvestigation of tumour status may be required

• Caution with indwelling semipermanent needles inany strong reactor to acupuncture

• Be aware that patients may be undergoingchemotherapy, radiotherapy or hormonaltreatments (refer to Chapter 10, Clinical Issues)

• Be aware that patients may be particularlyfatigued and are living with a chronic/life-threatening illness (see Section 10, ClinicalIssues)

• Be aware that acupuncture can mask both cancerand disease progression

• Use acupuncture with caution where the patient’sbehaviour is unpredictable

Additionally, any advice about offering acupunctureas an alternative to conventional treatment or overoptimism about the potential for helping any patientis clearly inappropriate. In cases where patients areangry or in denial about their illness, practitioners willneed to be especially sensitive and skilful. (Filshie,2001)

SafetyIn the hands of appropriately qualified healthprofessionals, acupuncture seems safe (Vincent,

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2001). Professional bodies that registerpractitioners of acupuncture issue clinical standardsand guidelines for safe practice. In addition,practitioners should be familiar with recentpublications on safety issues (Filshie 2001;MacPherson et al 2001; White et al 2001; Peukerand Gronemeyer 2001, Walsh 2001, Hoffman2001). In particular, the article by Filshie (2001),which outlines specific problems of acupuncture incancer patients, is recommended reading. For easeof reference, these articles can be downloaded fromthe website of the British Medical AcupunctureSociety www.medical-acupuncture.co.uk

a) Serious adverse effectsSerious adverse effects are well recognised butrare, and Peuker and Gronemeyer (2001) reviewedrare but serious complications of acupunctureincluding:• Delayed or missed diagnosis of the condition

treated. Acupuncture can mask both cancer anddisease progression (Filshie 2001)

• Trauma to tissues and organs• Pneumothorax. This is a particular hazard in

patients with thin chest walls, and cachecticpatients will therefore be at particular risk.

• Bacterial and viral infections, hepatitis B, C andHIV. (Walsh 2001) The introduction of infectionthrough bacteraemia, septicaemia inimmunocompromised patients, and endocarditisin patients with heart valve lesions. Using singleuse disposable needles has dramatically reducedthe risk of spread of hepatitis B and C infections.

b) Mild reactions Relatively mild reactions to treatment are common.Two recent large prospective surveys of adverseevents associated with acupuncture, involving a totalof 66,000 patients, showed a low incidence ofsignificant minor adverse events, 13 per 10,000 orless, though the number of cancer patients treated inthe samples was unspecified. (White et al, 2001;MacPherson et al, 2001)• Bleeding (3%) and pain at the site of needling

(1%) are common local reactions. In a varyingproportion of cases (1% to 3%) symptoms maybe aggravated. This seems to make littledifference to the eventual recovery of the patient.

• Generalised reactions after treatment also occur,ranging from a pleasant drowsiness to disablingweakness and lethargy. Patients may alsooccasionally react severely during the treatment,with events such as fainting. Cancer patients areoften more sensitive to acupuncture than otherpatients and many become excessively drowsyduring treatment. It is advisable to have nursingassistance present, or assistance immediatelyavailable.

• Symptoms such as headache, nausea andvomiting, and dizziness can occur.

Patients are often cachectic and they should begiven superficial needling with the greatest of careespecially over the chest wall. It is unsafe to useacupuncture without a reasonably full knowledge ofthe clinical stage of the disease and the currentstatus of orthodox therapy. (Filshie, 2001)


Western medical acupuncture training is providedlargely by the British Medical Acupuncture Society(BMAS) with a formal accreditation andreaccreditation process. Physiotherapists andnurses are trained on courses recognised by theAcupuncture Association of CharteredPhysiotherapists, or the British Academy of WesternAcupuncture. The British Medical AcupunctureSociety offers specific foundation courses fordoctors wanting to practise acupuncture in palliativecare, and a supplementary one day course is alsoavailable for all practitioners who use acupuncture inpalliative care.

Traditional acupuncturists, who may or may not bephysicians, have undertaken a three year trainingcourse (or equivalent) accredited by the BritishAcupuncture Accreditation Board and are membersof the professional body, the British AcupunctureCouncil. Traditional acupuncturists who have trainedin other countries or on other courses can apply tothe British Acupuncture Council admissionscommittee for validation of their qualification andpractice in order to be eligible for registration withthe British Acupuncture Council.

For information on regulation and nationaloccupational standards, see Chapter 5 on regulationand training.


17 Homeopathy


The word homeopathy comes from Greek andmeans similar suffering. It is the treatment of illnessby using medication (known as remedies) prescribedaccording to the principle that ‘like cures like’. Thatis to say, the patient is prescribed a remedy which,from experiment and experience, is known toproduce very similar symptoms, when proved(tested) in healthy people, to the symptoms fromwhich the patient is suffering.

The remedies used are derived from plant, animaland mineral sources which, through a process ofserial dilution and agitation (succussion), arerendered dilute. (Lewith & Kenyon 2001; Thompson& Reilly 2002a) Homeopathy is not necessarily freeof side effects, but a comprehensive search of theliterature shows these to be rare, mild and transient.(Dantas & Rampes 2000) It is not possible tooverdose on homeopathic medicines, in the usualunderstanding of the word, but taking more than oneneeds over a prolonged period can result in aproving of the remedy, which means that one startsto feel and exhibit the symptoms the remedy ismeant to cure or relieve. These symptoms resolvewhen the remedy is stopped or changed to a moreappropriate one.

There are different approaches to the practice ofhomeopathy. In the classical approach, one remedyis prescribed at a time, based on a match of one ofthe known remedy pictures to the patient’s wholesymptom picture, including the symptoms of theirpresenting or diagnosed complaint. Pluralisthomeopathy involves the prescription of severalsingle remedies at a time or close together, often inalternation, according to the practitioner’s perceptionof different facets of the patient’s condition thatneed to be treated. Complex homeopathy involvesthe use of fixed combinations of several remedies insingle dose forms prescribed according to theconventional diagnosis of the patient’s presentingcondition. Some practitioners will use just one ofthese approaches while others may use acombination of them.

Homeopathy is practised by statutorily registeredhealth care professionals, who have completedpostgraduate studies in homeopathy and by otherprofessional homeopaths. For many of the lattergroup, homeopathy is a second career, and they willoften have other professional skills and expertise.The former group includes doctors, dentists, nursesand pharmacists who use their clinical judgement,within the clinical context in which they work, todetermine the extent to which homeopathy is

relevant to their patients; their training to usehomeopathy builds on their primary professionaltraining and expertise, and affiliation is to theirprimary profession. (National Occupational Standardsfor Homeopathy, Healthwork UK 2000)

17.2 Evidence

There have been several meta-analyses andsystematic reviews of the use of homeopathy fordifferent conditions, which show a positive trend,that homeopathy appears to be more effective thanplacebo (Kleijnen et al 1991; Linde, Melchart et al1997; Linde & Melchart 1998, Cucherat, Boissel etal 2000). However, the conclusion is that theevidence is not sufficiently convincing for any onecondition because of methodological shortcomingsand inconsistencies, as well as some publicationbias. The conclusion is that there is a need for moretrials of greater methodological quality. It is also notknown whether homeopathy is better than otherstandard treatments (as opposed to placebo), andfor what conditions homeopathy is most effective.(RLHH 1999; Lewith & Kenyon 2001)

It was also recommended that homeopaths shouldcritically evaluate their performance and personalexperiences in well-planned case series andobservational studies as clinical trials seemed torarely reflect what happens in everyday practice.Homeopathic consultations, the review of cases andprescribing of remedies, involves consideration ofthe person as a whole and is highly individualised;this approach does not necessarily lend itself toclinical research.

Ernst’s (1999) systematic review of trials of classicalhomeopathy versus conventional medications foradults and children with rheumatoid arthritis,proctocolitis, irritable bowel disease, malaria, otitismedia or tonsillitis, found that the few comparativeclinical trials of homeopathy contain seriousmethodological flaws. He concludes that the valueof homeopathy compared to allopathic medication isunknown. However, Ernst’s (2001) overview ofexemplary studies and available systematic reviewsof complementary therapies in palliative careconcluded that, although the evidence is notcompelling for any of the therapies, promisingresults exist for some treatments, includinghomeopathy.

Since the above reviews were published, there havebeen other randomised controlled trials. A doubleblind randomised controlled trial on the efficacy ofhomeopathic treatment for skin reactions duringradiotherapy following surgery for breast cancerinvolved 65 women. (Balzarini, Felisi & De Canno2000) The results suggested that the homeopathiccomplex was superior to a placebo in minimising the

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dermatological adverse effects of radiotherapy.Plans for a Cochrane review of homeopathy forcancer is underway. (Kassab et al 2003)

Oberbaum (1998) described the use of ahomeopathic complex preparation in chemotherapyinduced stomatitis in an uncontrolled study with 27patients, and found a reduction in the duration ofsymptoms in the treated group. This study wasfollowed by a randomised, double blind controlledtrial of the homeopathic medication TRAUMEEL S3 inthe treatment of chemotherapy induced stomatitis in32 children undergoing stem cell transplant.(Oberbaum et al 2001) Stomatitis scores wereevaluated according to the World HealthOrganisation grading system for mucositis. Resultsindicated that TRAUMEEL S may reduce significantlythe severity and duration of chemotherapy inducedstomatitis in children undergoing bone marrowtransplantation. The results of this study are beingtaken forward in a multi-centre trial on the use ofTRAUMEEL S in adults undergoing bone marrowtransplant. (Thompson 2002)

There are a number of outcome based observationalstudies which support the use of homeopathy incancer care for psychological distress, includinganxiety and depression (Clover, Fisher et al 1995),pain (Vozianov & Simeonova 1997, cited Thompson1999), symptom control and its impact on mooddisturbance and quality of life (Thompson & Reilly2002a; Thompson & Reilly 2000b). A double blindrandomised placebo-controlled trial of homeopathyin the management of menopausal symptoms inbreast cancer survivors followed the above pilotstudy (Thompson & Reilly 2002b) and a paper on thestudy awaits publication. (Thompson 2003)

Good quality observational studies in variousconditions including upper respiratory tractinfections (Riley, Fisher et al 2001; Frei andThurneysen 2001a), attention deficit hyperactivitydisorder (Frei and Thurneysen 2001b), and headache(Muscari, Tomaioli et al 2001) consistently givepositive results.

Case studies describe the effectiveness ofhomeopathy for various symptoms. These includethe value of intrathecal baclofen and homeopathy forthe treatment of painful muscle spasms associatedwith malignant spinal cord compression (Thompson

& Hicks 1998), and the use of homeopathicremedies for a patient with advanced cancer of theliver, spleen and gall bladder. (Every 1999)

Surveys of patient satisfaction and effectivenessfrom the patient’s perspective of homeopathy usedwithin a package of care showed high levels ofsatisfaction (Reilly 1995; Sharples & Van Haselen1998; GHH 1998; Spene 1999 cited Boyd 2002;Ward 1994; Christie & Ward 1996). The surveysalso showed a reduction in the use of conventionalmedication, an improvement in the presentingcomplaint, overall ability to cope and well-being,fewer appointments with the general practitioner,outpatients and admissions to other hospitals.

In summary, the evidence for the clinicaleffectiveness of homeopathy is mixed (Lewith &Kenyon 2001), and scientific research intohomeopathy in the cancer setting is in its infancy(Thompson & Reilly 2002). Nevertheless,homeopathy is used by cancer patients (Downer etal 1994) and there is evidence that patients find theapproach helpful. Homeopathy is available on theNHS, mainly through the five homeopathic hospitalsin London, Bristol, Glasgow, Liverpool and TunbridgeWells. Although more detailed clinical research isrequired, the best available evidence suggests thatthere is some basis for prescribing homeopathicremedies in the following circumstances:

• Fatigue (Thompson & Reilly 2002a and b)• Hot flushes (Thompson & Reilly 2002a and b)• Pain, including joint pain and muscle spasm

(Clover, Fisher et al 1995; Vozianov & Simeonova1997; Thompson & Hicks 1998; Thompson &Reilly 2002a)

• Anxiety and stress (Clover, Fisher et al1995;Thompson & Reilly 2002a and b)

• Depression (Thompson & Reilly 2002a and b)• Quality of life, including mood disturbance

(Clover, Fisher, et al 1995; Thompson & Reilly2002 and b)

• Radiotherapy and skin reactions (Balzarini, Felisi& De Canno 2000)

• Post-surgery ileus (Barnes, Resch & Ernst 1997)

3 TRAUMEEL S is a homeopathic complex remedy that has beensold over the counter in pharmacies in Germany, Austria andSwitzerland for over 50 years. It contains extracts from thefollowing plants and minerals, all of them highly diluted (10-1 – 10-9of the stem solution): Arnica montana, Calendula officinalis, Achilleamillefolium, Matricaria chamomilla, Symphytum officinale, Atropabelladonna, Aconitum napellus, Bellis perennis, Hypericumperforatum, Echinacea angustifolia, Echinacea purpurea, Hamamelisvirginica, Mercurius solubilis and Hepar sulfuris. Information fromthe manufacturer indicates that TRAUMEEL S is used normally totreat trauma, inflammation and degenerative processes.


17.3 The use of homeopathy insupportive and palliative care

Precautions (Scrine 2002; Thompson & Reilly 2002a;Fisher 2003)The reviews of the safety of homeopathy concludethat the main risks are indirect rather than direct,that is they relate to practitioners, not the medicines. • Be aware that aggravation of symptoms at the

start of treatment is unusual in palliative care, isusually short-term and falls away gradually.

• Be aware of aggravation of symptoms followingrepeated doses of a remedy. Homeopaths willusually stop the remedy or decrease thefrequency of administration, which should beaccompanied by an overall improvement in well-being within a couple of weeks.

• Be aware that a return of old symptoms is thoughtto be a response of the body’s self-healingmechanism. In the process of positive change,previous trauma is revisited briefly before anoverall improvement is experienced

• Be aware that new symptoms may mean that theremedy does not match the patient's symptomsand needs to be changed. This can also occur ifthe correct remedy is chosen but is given toofrequently, or if the patient has a history ofsensitivity to other medication. When the remedyis stopped, symptoms should cease.

• Be aware of possible effects on symptom controland conventional medication. If homeopathicremedies reduce pain or improve othersymptoms, the dose of allopathic medication mayneed to be reviewed. Otherwise, the clinicalexperience of homeopaths is that homeopathicremedies are unlikely to interact with allopathicmedication in the usual chemical understanding ofthe term.

• Be aware of practitioners’ lack of understandingof disease process and treatment

• Be aware of practitioners’ lack of awareness ofthe bounds of their own competence


TrainingStatutorily regulated health care professionalsmostly undertake their post-graduate homeopathystudies with the Faculty of Homeopathy. There are anumber of private and university educatedhomeopaths who are voluntarily self-regulated. TheCouncil of Organisations Registering Homeopaths(CORH) consists of organisations that registerhomeopaths. The Faculty of Homeopathy and theCouncil of Organisations Registering Homeopathsagree that education and training should enable allhomeopaths who practise independently, to practiseat the level of the national occupational standards forhomeopathy (Healthwork UK 2000).

At the Faculty of Homeopathy, there is a structuredthree level training pathway for medical homeopaths,to licentiate (one year introductory, LFHom),membership (after 4-5 years, MFHom), andspecialist register level (a further 2-3 years). Thedifferent levels of training qualify doctors for differentlevels of practice. The completion of themembership level training certifies a doctor’scompetence to use homeopathy in a wide range ofclinical situations in primary care or on referral, withthe support of specialist colleagues. A further twoyears’ specialist training qualifies a doctor forindependent specialist practice in the community orwithin a medical speciality. The diploma level is fordentists and pharmacists (DFHom).

For other professional homeopaths education andtraining is delivered either through three year full-time or four year part-time courses in privateeducational institutions or through university baseddegree courses. The University of Westminster andUniversity of Central Lancashire currently offer threeyear full-time BSc (Hons) degree courses ofeducation and training in homeopathy.

Licence to practiseStatutorily regulated health care practitioners whopractise homeopathy carry a statutory licence topractise by virtue of their registration with theirrelevant regulatory body.

Other professional homeopaths are granteddiplomas or university degrees together with alicence to practise by their educationalestablishment once they have successfullycompleted the course. Although the licence topractise is not a legal requirement and does not haveany legal status, the courses accepted by theprofessional bodies define the terms on which alicence to practise can be awarded to students.They further stipulate the terms on which candidatescan proceed to a register.

RegulationInformation on the regulation of homeopaths can befound in Chapter 5 on regulation and training.

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18 Guidelinedevelopment process

18.1 Steering group

The steering group for the project was drawn frommajor stakeholding organisations and professionalswithin palliative care, service users andrepresentatives from a range of service deliveryorganisations.

Michael Fox, (joint chair) Chief Executive, The Princeof Wales’s Foundation for Integrated Health

Eve Richardson, (joint chair) Chief Executive,National Council for Hospice and Specialist PalliativeCare Services

Marianne Tavares, Project Manager, ComplementaryTherapies in Palliative Care, The Prince of Wales’sFoundation for Integrated Health

Judy Abbott, service user, Sheffield

Angela Avis MBE,Chair, Complementary TherapiesForum, Royal College of Nursing; Lecturer, OxfordBrookes University

Ann Carter, Complementary Therapy Co-ordinator, St. Ann’s Hospice, Manchester

Liz Hawkins, Complementary Therapy Co-ordinator,St. Christopher’s Hospice (until Sept 2002);Lecturer, University of Westminster;Complementary Therapy Practitioner, Harley StreetClinic

Jean Hindmarch, Head of Education, Training andAwards, Help the Hospices

Dr. Jenny Kitchen, Consultant in Palliative Medicine,The Shropshire and Mid Wales Hospice, (until July2002), St. Peter’s Hospice, Bristol (from July 2002)

Dr. Michelle Kohn, Complementary TherapiesMedical Adviser, Macmillan Cancer Relief

Peter Mackereth, Lecturer/Practitioner inComplementary Therapies (from March 2002),Christie Hospital NHS Trust, Manchester; Lecturer,Salford University

Freda Magee, Chair, (from June 2002) NationalAssociation of Complementary Therapists inHospice and Palliative Care

Dr. Andrew Manasse, Clinical Lead, The CavendishCentre for Cancer Care, Sheffield

John Pickett, service user, London

Jan Wilkinson, Vice Chair, (until June 2002) NationalAssociation of Complementary Therapists inHospice and Palliative Care

Dr. Susie Wilkinson, Head of Caring ServicesResearch, Marie Curie Palliative Care RND Unit;Senior Lecturer, Department of Oncology, RoyalFree University College Medical School

18.2 Gathering information andevidence

Existing guidelines, policies and standards500 organisations, as listed in the Directory ofHospice and Palliative Care Services, 2001, wereapproached for their existing guidelines, policies andstandards with regard to complementary therapies.Policies were received from about 100organisations. Another 20 replied that they eitherdid not offer complementary therapies, or werecurrently developing or updating their policies.

The most widely provided therapies, and issuesaddressed in local policies were identified from thesets of guidelines received. Using the informationprovided, a draft outline of the national guidelineswas drawn up, and sent to the wider consultativegroup for the project.

Consulting professional organisations forcomplementary therapiesThe professional organisations for massage,aromatherapy, reflexology, acupuncture,homeopathy, hypnotherapy, and healing were invitedto contribute to the development process. Contactswere identified through the regulation programme ofThe Prince of Wales’s Foundation for IntegratedHealth, and the following information was requested:• Brief description• Evidence base, especially for palliative care• How patients can benefit from use of the therapy

in palliative care• General contraindications and precautions for the

therapy• Specific contraindications and precautions for

using the therapy in palliative care• Modification of approach in palliative care• Other issues for consideration• Practitioner training and qualification, regulatory

bodies

18.3 Consultation and peer review

SymposiaThree symposia were held in London, Bristol andManchester, involving about 100 service users and


professionals with responsibility for developingcomplementary therapy services. Services userswere approached via Cancerlink, and professionalswere invited from a range of providers includinghospitals, hospices, and cancer support centres indifferent parts of England and Wales. Theexperience of service providers ranged from those inthe early stages of developing complementarytherapy services to centres of excellence. AppendixM gives the list of participants in the three symposia.The symposia identified important areas for inclusionin the guidelines.

Experts Drafts of the relevant sections were sent to differentexperts and experienced practitioners of the therapywithin supportive and palliative care (see AppendixO). Some experts contributed to the writing of thedrafts.

National consultationThe national consultation process for the draftdocument was as follows: • Publication of the draft document on the websites

of The Prince of Wales’s Foundation for IntegratedHealth www.fihealth.org.uk and the NationalCouncil for Hospice and Specialist Palliative CareServices www.hospice-spc-council.org.uk

• Distribution of the document to the participants ofthe symposia (Appendix M), the professionalbodies for the therapies included in the guidelines,the wider consultative group (Appendix N), the listof experts (Appendix O), and as requested.

External EvaluationThere will be a process for evaluating the usefulnessof the guidelines following publication, led byProfessor Jessica Corner. The guidelines will bedisseminated to palliative care organisations fromwhom feedback is also welcomed.

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19 AppendicesAppendix AConfiguration of Complementary Therapy Teams: Models of Service Provision

A 1 Cancer Support CentreThe Cavendish Centre for Cancer Care, Sheffield

Founded in 1992; charitable organisation, offering assessment, support and a range of complementary therapiesto patients at all stages of disease, integrated with their NHS care. Services are patient centred and patient led,include children and carers, and are free of charge. Patients self refer, and are seen usually within 5 workingdays. Patient care is audited using an established outcome measure.

Director

Clinical lead, currently a doctor (this roleis changing - there is currentlyconsiderable overlap with the newtherapy services manager’s role)

Therapy services manager(This is a new post; there is considerableoverlap with the existing clinical lead rolewhich is changing)

Assessors/key workers

Complementary therapists, all self-employed

Fundraiser

Office manager, a key post within theorganisation

Receptionists, a very important firstcontact point

• Overall responsibility for: all aspects of the centre’s activity; the running of thecentre; forward planning

• Heads the management team and is accountable to the trustees

• On management team• Oversees research, issues related to provision of therapy, relationship with

NHS professionals especially medical profession, teaching• Answers therapy related questions from the public

• On management team• Assessment, co-ordination and management of clinical services• Responsible for service development• Provision of support for clinical staff• Ensures effective communication between clinical staff• Teaching and developing links with other health care professionals working in

cancer care

• Provide a key role in the process; overall responsibility for the patient’spathway through the centre; close relationship with therapists

• Assess patient/carer needs and decide most appropriate therapy, with client • Communicate routinely with all healthcare professionals involved with the

patient/carer• Review client following course of therapy, carried out by same assessor who

originally assessed the client• Manage outcome evaluation• Involved in running carer and bereavement groups

• Provide time limited courses of therapy: acupuncture, aromatherapy, arttherapy, counselling, healing, homeopathy, hypnotherapy, massage,reflexology, relaxation/visualisation, shiatsu and herbal medicine

• Some take part in running groups• Responsible for own therapy specific professional support and for continuing

professional development• Have own professional indemnity

• On management team• Responsible for all aspects of fundraising• Accountable to director

• Member of management team• Manages general office and reception – responsible for smooth running and

appearance of Centre• Manages all financial transactions for the Centre

• Receive all incoming calls from patients• Welcome people who drop in, and patients coming for appointments,

including offering refreshments• Introduce the Centre to patients, give information• Make appointments


Volunteer development manager

Volunteers (do not provide therapy)

Complementary therapy team leader,permanent contract (nursing budget)

Deputy team leader, permanent contract(nursing budget)

Complementary therapists, permanentcontracts (nursing budget)

Complementary therapists, self-employedhonorary contracts (oncology budget andother funds)

Nurses and health care assistants with aqualification in massage or reflexology,who have undergone training with thecomplementary therapy team, and whoare allocated time by their ward manager

Student massage therapists, (placements)undergraduates and post-graduates

Rehabilitation centre manager

Nurse consultant in cancer care(Rehabilitation)

• Recruits, trains, manages, supports and retains 60 volunteers• Develops volunteer projects, teams and individuals• Member of management team• Represents centre at forums/arenas related to volunteers through the city

• Many different activities: charity shop, fundraising events, reception and officesupport, website design, editing internal and external newsletters, organisingand distributing information and newsletters, speaking to community groups

• Responsible for service development, including development of policy andprotocols, documentation, evaluation of service

• Manages the service, including recruitment, referral and appointments system• Manages therapy team, and provides supervision• Provides therapies• Contributes to the in-house education and training of staff with cancer

services• Provides supervision for massage students doing clinical placements at both

hospitals

• Provide aromatherapy, massage, reflexology, relaxation, visualisation and arttherapy

• Provide aromatherapy, reflexology and massage

• Provide massage and reflexology within their working week to treat patients on their ward

• Provide massage, mainly feet and hands

• Provides overall strategic direction and management• Responsible for resource allocation• Responsible for co-ordination of service within rehabilitation

Function with respect to complementary therapies:• Overall responsibility for service development, standard setting, audit, policy

development and research• Works with complementary therapy team leader and other health care

professionals to develop services collaboratively

A 2 Hospital Complementary Therapy Team

Hammersmith Hospitals NHS Trust, Cancer Services Complementary Therapy Team, LondonThe service operates across the two sites of Charing Cross and Hammersmith Hospitals, within cancer services– outpatients and inpatients receiving treatment, eg radiotherapy chemotherapy and symptom control. There isalso staff massage

A 3 Hospital Rehabilitation Team

The Royal Marsden Hospital, London and SuttonFor cancer services, inpatients and outpatients in rehabilitation unit and wards

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Complementary therapy team leader

Complementary therapists

Nurses

NB Additionally, acupuncture is providedon both hospital sites and given byconsultant anaesthetists for pain andsymptom control in a multidisciplinarysetting.

Director of complementary cancerservices

Homeopathic physicians

Nurse and therapies manager

Nurse therapists

Access to state registered dietician

Access to autogenic trainers

• Provides massage and aromatherapy• Manages other therapists• Works with nurse consultant to develop policies, training and documentation

• Provide massage and aromatherapy

• Use therapy skills alongside nursing role with inpatients, following in-housetraining

• Overall responsibility for service development, research and audit• Screens all new referrals letters and directs to appropriate doctor/clinic• Provides homeopathy, Iscador, acupuncture on outpatient, daycare or

inpatient basis• Provides education to healthcare professionals on complementary medicine

for cancer

• Provide homeopathy, Iscador and acupuncture on an outpatient basis

• Responsibility for developing nurse therapists• Oversees delivery and audit of nurse therapies• Clinical supervision• Teaches autogenic training, relaxation, lifestyle management• Provides aromatherapy massage and reflexology

• Provide aromatherapy massage, reflexology, shiatsu, reiki, relaxation and TCMacupuncture

• Dietary review and appropriate, sensible nutritional advice

• For relief of stress and anxiety

A 4 NHS Specialist Complementary Medicine Hospital

The Royal London Homoeopathic Hospital, part of University College London Hospitals NHS TrustProvides packages of a range of complementary medicine therapies for various conditions. Complementarycancer care is one of the larger services.

• Founded in 1849 and part of the NHS since its inception.• Takes referrals from all over England and Wales (mostly London and SE England) from GPs or

hospital/hospice specialists.• Cancer treatments are offered on an outpatient, daycare or inpatient basis and include homoeopathy, Iscador,

acupuncture, aromatherapy massage, reflexology, reiki, shiatsu, relaxation and visualisation.• All homeopaths and therapists are statutorily regulated healthcare professionals with additional training in

complementary medicine.• Cross referral to other RLHH services, not mentioned below, as required.• Treatments are designed to complement conventional cancer care with ongoing liaison between RLHH and

the patient’s healthcare professionals.


Complementary therapies coordinator,permanent contract (within budget forallied health professionals)

Complementary therapists (self-employed)

Volunteer complementary therapists

Other members of clinical team(nurses, health care assistants, socialworker, chaplains)

Access to occupational therapist,physiotherapist

Access to social worker team

Access to other members ofmultidisciplinary team

Complementary therapy co-ordinator(Part time 22.5 hours per week )

On the hospice sites, any health careprofessional may refer a patient/carer forcomplementary therapy.

Key workers (professional backgroundsof nursing, at rehabilitation unit only)

Complementary therapists may be:• self employed on a sessional basis• nurses on either hospice site• other health care professionals e.g

doctors, physiotherapists with anappropriate qualification

• Responsible for service development, including development of policy andprotocols, documentation, evaluation of service

• Manages the service, including recruitment, referral and appointmentssystem, equipment

• Manages other therapists and provides supervision• Provides massage, aromatherapy and reiki• Provides training for therapy assistants

• Provide massage, aromatherapy and reiki • Supports therapy assistants

• Provide massage, aromatherapy, reiki and acupuncture

• Use therapy skills following suitable training (some in-house, some external)eg simple massage and reiki

• For assessment and therapy/aids as required

• For counselling

• For review and to integrate care

• Has responsibility for the co-ordination and development of theComplementary Therapy Service across the three sites.

• Assesses patient needs, agrees goals and decides with the patient a plan ofaction. Patient choice is from a wide range of services of whichcomplementary therapy is just one.The number of sessions is agreed with the patient, up to four sessions initially.Review takes place at end of the agreed number of sessions

• On each of the hospice sites therapists offer: aromatherapy, reflexology andreiki and Indian head massage.

• The benefits of essential oils and bases in wound care are being explored onthe two hospice sites

• Hypnotherapy and neurolinguistic programming is also used as part of therole of the psychological support nurse

• At the Neil Cliffe Cancer Care Centre acupuncture, craniosacral therapy,homeopathy and therapeutic massage are also offered in addition toaromatherapy, reflexology and reiki.

A 5 Hospice Complementary Therapies Service

St. Gemma’s Hospice, Leeds

Specialist palliative care unit, inpatient unit with 32 beds, day hospice, community team. For inpatients,outpatients, day hospice patients, carers and staff

A 6 Multi-site Hospice and Cancer Support Centre

For inpatients, outpatients, day hospice patientsSt. Ann’s Hospice, incorporating Neil Cliffe Cancer Care Centre (rehab unit) and sites at Heald Green and LittleHulton in Greater Manchester

Complementary therapy is regarded as core business and has an integral role to play in the care of patients andtheir carers. The service is well-established and offers a variety of approaches to help with the relief of stress,anxiety and tension.

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Health care professionals, mainly nursesand care assistants

Chair

Secretary

Treasurer

Publicity coordinator

Volunteer coordinator

Care coordinator

• A special clinic also combines the skills of a physiotherapist and anaromatherapist to help patients who mainly experience problems associatedwith breast cancer.

• The Neil Cliffe Centre also hosts a "Stress Busters" service which offerstherapies to staff and the public one evening per week.

• Use hands on therapeutic skills following house training for the "HEARTS"process. This approach was devised to extend the therapeutic use of touch fortherapists and health care professionals. In house training is given to acquirethe skills.

• Chairs monthly committee meetings• Deals with condolence letters• Purchases, then sells to the group vitamins and minerals as recommended by

the Bristol Cancer Help Centre

• Responsible for minutes of committee meetings, and other correspondence• Does a great deal of typing and photocopying, and orders stationery• Updates members and non-members mailing list• Organises distribution of information, including the programme of events, to

members• Compiles and contacts people taking part in the group programme• A telephone contact for people seeking support and information

• Oversees expenditure• Responsible for accounts and banking• Issues cheques• Arranges annual audit

• Assists secretary, especially with photocopying• Distributes leaflets and other information in hospitals, surgeries, clinics and

other public places• Collates a data bank of contacts re information• Organises information in the press• Assists with fundraising events

• Organises training for volunteers and therapists (weekend training workshopsand external supervision sessions are held regularly for volunteers)

• Organises volunteer and therapist meetings• Liaises with care co-ordinator regarding home/hospital visits• Compiles and distributes a therapist rota

• Identifies those members of the group who need particular support and help. • Discusses issues involved with the committee, and oversees actions to be

taken by the committee• Collates information regarding attendance• One of three telephone contacts for people seeking support and information

A 7 Self-Help Group

Northumberland Cancer Support Group (affiliated to Bristol Cancer Help Centre)

Founded in 1986; a committee of volunteers runs the group. The committee works as a team: many tasksoverlap; annual planning and review session; varied programme of activities, including discussion nights, funnights, gentle yoga, circle dancing, guest speakers, complementary therapies, social events; whole group meetsweekly on Tuesday evenings

Complementary therapies are offered free-of-charge at weekly meetings, at home and in hospital. Priority isgiven to members in greatest need


Librarian

Fundraising coordinators (2)

Complementary therapists(all volunteers, qualified and insured)

• Arranges home and hospital visits by volunteers and therapists• Active in all fundraising events

• Organises the running of the library• Reviews and updates the books, cassettes and videos in the library• Deals with the purchase of new stock• Supervises the training of library assistants• Supervises the library rota

• Organise fundraising events• Delegate jobs to committee and group members• Deal with publicity regarding events• Apply for grants and donations

• Provide gentle massage, reflexology, reiki, Indian head massage, shiatsu,aromatherapy, counselling

• Provide treatment at weekly meetings, at home and in hospitals

Appendix BMain components of clinicalgovernance (Department of Health1999)

1. Clear lines of responsibility and accountability

for the overall quality of clinical care

This is achieved through formally designatedindividuals, as well as regular and annual reports.

2. A comprehensive programme of quality

improvement activities which includes:

• Full participation in audit programmes• Full participation in the national confidential

enquiries• Evidence-based practice which is supported and

applied routinely in everyday practice• Ensuring the clinical standards of national service

frameworks and NICE recommendations areimplemented

• Workforce planning and development such asrecruitment and retention of appropriately trainedworkforce is fully integrated within the NHSorganisation’s service planning

• Continuing professional development:programmes aimed at meeting the developmentneeds of individual health professionals and theservice needs of the organisation are in place andsupported locally

• Appropriate safeguards to govern access to andstorage of confidential patient information asrecommended in the Caldicott Report on Reviewof Patient-Identifiable Information

• Effective monitoring of clinical care with highquality systems for clinical record keeping and the

collection of relevant information• Processes for assuring the quality of clinical care

are in place and integrated with the qualityprogramme for the organisation as a whole

• Participation in well-designed relevant researchand development activity is encouraged andsupported as something which can contribute tothe development of an ‘evaluation culture’.

3. Clear policies aimed at managing risks:

• Controls assurance which promote selfassessment to identify and manage risks

• Clinical risk systematically assessed withprogrammes in place to reduce risk

4. Procedures for all professional groups to

identify and remedy poor performance, for

example:

• Critical incident reporting ensures that adverseevents are identified, openly investigated, lessonsare learned and promptly applied

• Complaints procedures, accessible to patientsand their families and fair to staff. Lessons arelearned and recurrence of similar problemsavoided

• Professional performance procedures which takeeffect at an early stage before patients areharmed and which help the individual to improvetheir performance whenever possible, are in placeand understood by all staff

• Staff supported in their duty to report anyconcerns about colleagues’ professional conductand performance, with clear statements on whatis expected of all staff. Clear procedures forreporting concerns so that early action can betaken to remedy the situation

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Appendix CResources for conducting audit,evaluation and research

Books

Bowling A. Measuring Health: a review of quality of lifemeasurement scales. 2nd edition. Open UniversityPress, Buckingham, 1997

Lewith G, Jonas WB, Walach H. (editors). ClinicalResearch in Complementary Therapies: principles,problems and solutions. Churchill Livingstone,London 2002

Advice and information

Lesley Foulkes (re: the Practice Based HealthOutcome Measure)Newcastle Homeopathic PracticeThe Light House18 Water StreetNewcastleStaffordshire ST5 1JQTel. 01782 633759Email: [email protected]

On MYCAW and MYMOP questionnaires (seePaterson 2000 and Paterson 2002)Dr. Charlotte Paterson MRC Health Services Research CollaborationDepartment of Social Medicine, University of BristolCanynge HallWhiteladies RoadBristol BS8 2PREmail: [email protected]

Dr. Kate Thomas Senior Lecturer in Health Services Research;Deputy Director, Medical Care Research UnitScHARRUniversity of SheffieldRegent Court30 Regent StreetSheffield S1 4DATel. 0114 222 0753 /0114 222 5202Email [email protected]

Dr. E.A. ThompsonChair: Regional Complementary Therapy ResearchGroupConsultant Homeopathic Physician and HonorarySenior Lecturer in Palliative CareBristol Homeopathic HospitalCotham HillBristol BS6 6JUTel. 0117 973 1231Fax 0117 923 8759Email: [email protected]

Dr. Susie WilkinsonHead of Caring Services Research, Senior LecturerMarie Curie Palliative Care R&D UnitDepartment of OncologyRoyal Free University College Medical SchoolRoyal Free CampusRowland Hill StreetLondon NW3 2PFEmail: [email protected]

Health services research units: Contact school of health care studies of nearestuniversity

The Cavendish Centre for Cancer Care27 Wilkinson StreetSheffieldSouth Yorkshire S10 2GBTel. 0114 278 4600Email: [email protected]

National Association of ComplementaryTherapists in Hospice and Palliative Care29 King’s RoadBerkhamstedHerts HP4 3BHTel. 01442 874226Email: [email protected]

The Prince of Wales’s Foundation for IntegratedHealth12 Chillingworth RoadLondon N7 8QJTel. 020 7619 6140Fax 020 7700 8434Email: [email protected]: www.fihealth.org.uk

The Research Council for ComplementaryMedicine27a Devonshire StreetLondon W1G 6PNTel. 020 7935 7499Fax. 020 7935 2460Email: [email protected]: www.rccm.org.uk For good basic information on research and clinicalaudit


Appendix DEvidence for best practice (Richardson 2001)

Important electronic databases that include articlesand research information on complementarytherapies

AMED (Alternative and Allied Medicine Database)Database established in 1985 by the British Library’sMedical Information Centre. Total of 65,000references. Scans 400 journals for references tocomplementary therapy. Also contains referencesfor physiotherapy, occupational therapy,rehabilitation and podiatry. Updated monthly.Access by licence only, usually available in NHSlibraries

CAM on PubMed (Medline)Developed jointly by NIH Centre for Complementaryand Alternative Medicine and the National Library ofMedicine.www.nlm.nih.gov/nccam/camonpubmed.html

CISCOM (The Centralised Information Service forComplementary Medicine)Specialist information service based on a databaseproduced by the Research Council forComplementary Medicine. Contains around 70,000references. Combines data from a wide range ofsources including in house citation tracking. Aspecialist thesaurus is currently being developed.Specialises in clinical trials. Also holds references tosociological and psychological studies.www.rccm.org.uk

Complementary Medicine Programme DatabaseA programme that facilitates systematic reviews andevaluation. Includes the complementary andalternative medicine and pain database (CAMPAIN)www.compmed.ummc.umaryland.edu/default.htm

HerbMedHerbal database that provides hyperlinked access tothe scientific data underlying the use of herbs. Anevidence based information resource forprofessionals, researchers and general public.Contains 125 evidence based reviews of herbaltherapies.www.herbmed.org/

Hom-Inform information serviceContains 17,000 references based on contents ofFaculty of Homoeopathy library based at GlasgowHomoeopathic Hospitalhominform.soutron.com/homqbe1.asp

BNI (British Nursing Index)Has a nursing focus but with some complementarytherapy references. Access by licence only, usuallyavailable in NHS libraries

Cinahl (Cumulative Index to Nursing and AlliedHealth Literature)Records of literature on all aspects of nursing andallied health disciplines, includes somecomplementary therapy references. Access bylicence only, usually available in NHS libraries

NHS Centre for Reviews and DisseminationIncludes the DARE database, economic evaluationdatabase and health technology programme reports.www.york.ac.uk/inst/crd

OMNI gatewayProvides free access to a searchable catalogue ofinternet sites covering health and medicine, includingcomplementary medicinehttp://omni.ac.uk

Cochrane ReviewsExamples of published reviews:

Acupuncture for chronic asthmawww.update-software.com/abstracts/ab000008.htm

Acupuncture for induction of labourwww.update-software.com/abstracts/ab001218.htm

Alexander technique for chronic asthma www.update-software.com/abstracts/ab000995.htm

Massage for promoting growth and development ofpre-term and low birth-weight babieswww.update-software.com/abstracts/ab000390.htm

Massage for low back painwww.update-software.com/abstracts/ab001929.htm

St. John’s Wort for depressionwww.update-software.com/abstracts/ab000448.htm

Yoga for epilepsywww.update-software.com/abstracts/ab001524.htm

Examples of reviews in progress:Complementary therapies for acneGingko biloba in intermittent claudicationMassage and aromatherapy for symptom relief inpatients with cancerMind body therapy for fibromyalgiaReflexology for symptom relief in patients withcancerStress management for coronary heart diseaseTherapeutic touch in wound healing

75

Information details:Cochrane LibraryThe Cochrane Library contains over 5000 reports ofrandomised controlled trials and over 60 systematicreviews on complementary therapies (subscriptionrequired).www.cochranelibrary.com/enter/

RCCM (Research Council for ComplementaryMedicine) websiteAbstracts of the Cochrane Reviews ofcomplementary therapy available on the RCCMwebsite.www.rccm.org.uk/cochrane.htm

Cochrane Complementary and Alternative MedicineFieldRegistry of randomised controlled trials, located atthe University of Maryland Complementary MedicineProgrammewww.compmed.ummc.umaryland.edu/Compmed/Cochrane/Cochrane.htm


Appendix EWorking groups developing single regulatory bodies, for the therapies included inthese guidelines

Acupuncture

Working group Members of working group Development of national

occupational standards

(NOS)

Acupuncture Regulatory • Acupuncture Association of Chartered Agreed to develop NOS

Working Group Physiotherapists (AACP)

• British Academy of Western Acupuncture (BAWA)

• British Acupuncture Council (BAcC)

• British Medical Acupuncture Society (BMAS)

The Acupuncture Regulatory Working Group is working to develop recommendations for the statutory regulationof acupuncture in England, and its report is expected by July 2003. Acupuncture organisations not representedon the working group will be included in the consultation process. The Acupuncture Regulatory Working Groupis supported by the Department of Health and The Prince of Wales’s Foundation for Integrated Health. See alsoChapter 16 for further information about the training of acupuncturists.

Aromatherapy



Aromatherapy • Aromatherapy Organisations Council (AOC*) Completed and published

Regulation Working Group • International Federation of Professional Aromatherapists (IFPA)

• Institute of Complementary Medicine (ICM/BRCP)

• British Complementary Medicine Association (BCMA)

• The Aromatherapists Society (AS)

• Professional Association of Clinical Therapists (PACT –

part of Federation of Holistic Therapists)

* Members of AOC

Aromatherapy & Allied Practitioner’s Association (AAPA)

Association of Holistic Therapies Intl (AHPI)

Association of Medical Aromatherapists (AMA)

Association of Natural Medicine (ANM)

Association of Physical & Natural Therapists (APNT)

English Societe de L’Institute Pierre Franchome (ESIPF)

Intl Holistic Aromatherapy Foundations (IHA)

International Federation of Aromatherapists (IFA)

International Guild of Professional Practitioners

Renbardou Institute (RI)

77

Homeopathy



Council of Organisations • Alliance of Registered Homeopaths (ARH) Completed and published

Registering Homeopaths • Assoc. of Natural Medicine

(CORH) • Institute of Complementary Medicine (ICM/BRCP)

• Complementary Medical Association (CMA)

• Fellowship of Homeopaths (FoH)

• Homeopathic Medical Association (HMA)

• International Guild of Professional Practitioners

• Intl Register of Consultant Herbalists (IRCH)

• Society of Homeopaths (SoH)

Statutorily regulated health care professionals who practise homeopathy can become members of the Faculty ofHomeopathy. However, the Faculty is not a regulatory body, and these professionals are regulated by theregulatory body for their relevant profession. The Faculty of Homeopathy was involved in the development ofnational occupational standards for homeopathy. For information on the training of homeopaths, refer toChapter 17 on homeopathy.

Hypnosis and hypnotherapy



Has not been agreed N/A 1st edition completed and

published;

2nd edition in progress

Professionals with a conventional health care qualification are trained to use hypnosis by the British Society ofMedical and Dental Hypnosis, the British Society of Experimental and Clinical Hypnosis, and some universitydepartments. Psychotherapists trained in hypnotherapy are registered with the United Kingdom Council forPsychotherapists.

Apart from the above, hypnotherapists are trained at a large number of other establishments. The level oftraining is varied and there is currently no agreed standard or core curriculum. For further information, refer toChapter 15 on hypnosis and hypnotherapy.

Massage Therapy



General Council for • Fellowship of Sports Masseurs and Therapists (FSMT) Draft in consultation, to be

Massage Therapy (GCMT) • International Guild of Professional Practitioners published in 2003

• London & Counties Society of Physiologists (LCSP)

• Massage Therapy Institute of Great Britain (MTIGB)

• Massage Training Institute (MTI)

• Scottish Massage Therapists Organisation (SMTO)*

*Professional Association of Clinical Therapists (PACT, part of Federation of Holistic

Therapists) have applied to join this working group.

Massage, as a manual therapy, is integral to the training of chartered physiotherapists. The Association ofChartered Physiotherapists in Massage can be contacted for further information www.csp.org.uk


Reiki


occupational standards (NOS)

UK Reiki Federation (UKRF) The UKRF is making initial contact with a number of UKRF have applied to develop

organisations to widen its remit. These include: NOS in the near future and have

• The Reiki Association been involved in developing

• UK Reiki Alliance generic template for NOS in

• International Guild of Professional Practitioners complementary therapies

• Institute of Complementary Medicine (ICM/BRCP)

• British Complementary Medicine Association (BCMA)

Reflexology



Reflexology Forum • Association of Reflexologists (AOR) Completed and published

• British Reflexology Association (BRA)

• Centre for Clinical Reflexology (CCR)

• International Federation of Reflexologists (IFR)

• International Guild of Professional Practitioners

• International Institute of Reflexology (IIR)

• Reflexologists Society (RS)

• Reflexology Practitioners Association (RPA)

• Scottish Institute of Reflexology (SIR)

• Professional Association of Clinical Therapists (PACT, part

of Federation of Holistic Therapists)

The Association of Chartered Physiotherapists in Reflex Therapy can be contacted for further information on theuse of reflexology by chartered physiotherapists within their scope of practice www.csp.org.uk

Spiritual Healing


occupational standards (NOS)

UK Healers • The Spiritualists National Union (SNU) UK Healers have

• The British Alliance of Healing Associations (BAHA) applied to develop NOS in the

• The World Federation of Healing (WFH) near future and have been

• The School of Insight and Intuitions (School of Insight) involved in developing a generic

• Greater World Christian Spiritualist Associations template for NOS in

(Greater World) complementary therapies

• White Rose Foundation (White Rose)

• Holistic Healers Association (Holistic Healers)

• White Eagle Lodge

• United Spiritualists

• National Federation of Spiritual Healers (NFSH)

• Northern Healers Forum (NHF)

• Confederation of Healing Organisations(CHO)

• Association of Therapeutic Healers (ATH)

79

Therapeutic touch



N/A N/A N/A

Training courses for therapeutic touch, at practitioner level, are currently available in Lancaster, validated by St.Martin’s College, University of Lancaster. Practitioners of therapeutic touch are currently registered with theBritish Association of Therapeutic Touch (BATT). For further information, refer to Chapter 14.5 on TherapeuticTouch, and visit the website www.sacredspace.org.uk

Appendix FSample job description forcomplementary therapies coordinator(used with permission of St. Gemma’s Hospice,Leeds)

Job DescriptionPost: Complementary Therapies Co-ordinatorAccountable to: Chief Executive and Director of

Nursing

Responsible to: Deputy Director of Nursing and Allied Health Professionals

St. Gemma’s Hospice provides specialist palliativecare to the population of Leeds and surroundingareas. The hospice has a large in-patient unit of 32beds, a day hospice, hospice community team, out-patient service, education and conference centre, anda bereavement service.

Primary Aim of RoleThe Complementary Therapies Co-ordinator leads thedevelopment of complementary therapies and has apivotal role in managing the provision ofcomplementary therapies to inpatients, outpatients,day hospice and community patients, carers and staff.

• To communicate and work closely with all staffgroups, particularly ward, day hospice andcommunity teams.

• To be responsible for recruiting, managing anddeveloping a team of qualified volunteercomplementary therapists to work in palliative care.

• To identify needs in relation to the development ofcomplementary therapies, and co-ordinate theintroduction of other therapies.

• To collaborate with the Education Department, inparticular the training and development ofcomplementary therapy helpers.

• To address issues of quality, training, audit,research and development in complementarytherapies.

Main Responsibilities1 Clinical1.1 Ensure the efficient and effective system for

referral is maintained and developed.1.2 Ensure comprehensive holistic assessment of

patients for complementary therapies treatment,and evaluation of interventions.

1.3 Provide hands-on complementary therapies.1.4 Contribute to the development and

implementation of effective mechanisms forcommunicating information concerning patientcare including the completion of accurate andcomprehensive written records.

1.5 Prioritise and co-ordinate workload ofcomplementary therapies team according to theneeds of patients/carers and skills of therapists.

1.6 Provide clinical supervision to complementarytherapies team and helpers.

1.7 Advise, support and involve family and carers inproviding simple massage following assessmentof need.

1.8 Ensure the efficient control, supply and storage ofcomplementary therapy resources, eg oils, tapes,equipment, needles

1.9 Ensure there is an effective system for the supplyof clean laundry.

1.10 Comply with the requirements of ProfessionalCode of Conduct and Practice.

1.11 Ensure practice in complementary therapy isevidence-based and encourage the use ofresearch in further development of clinicalpractice.

2 Management and Development2.1 Lead the development of policies and procedures

for complementary therapies, and participate inthe development of the hospice quality assuranceprogramme.

2.2 Manage and develop a team of volunteer


complementary therapists.2.3 Recruit volunteer complementary therapists in

accordance with agreed standards.2.4 Manage the introduction of other

complementary therapies.2.5 Explore the further development of

complementary therapies, eg a service topatients in their homes; the use of essential oilsin wound care

2.5.1 Collect and collate statistical data as requiredby the Hospice Management Team.

2.7 Liaise and collaborate with other complementarytherapists in palliative care

3 Education 3.1 Educate the multidisciplinary team on the role of

available complementary therapies to enableteam members to make referrals.

3.2 Participate in staff induction and educationprogrammes.

3.3 Provide support, teaching and advice to clinicalstaff on complementary therapies.

3.4 Lead and develop the Simple Massage Coursefor nurses and health care assistants.

3.5 Organise training for volunteers in palliative careand the use of complementary therapies inpalliative care

3.6 Be aware of current developments in palliativecare and the implications on clinical practice.

4 General4.1 Ensure the welfare and safety of patients, carers,

staff and volunteers within the hospice.4.2 The Hospice expects staff to demonstrate a

commitment to their own development, to takeadvantage of education and trainingopportunities and develop their professionalcompetence.

4.3 All employees are required to abide by theHealth & Safety at Work Act and the Hospicehealth and safety policies.

4.4 All employees are required to attend a firelecture annually.

4.5 All employees are required to respectconfidentiality applying to all Hospice areas.

4.6 St. Gemma’s is a no-smoking area for staff.4.7 Undertake activities from time to time,

representing the Hospice to outside groups orthe general public.

This job description is not exhaustive. It will besubject to periodic review and may be amendedfollowing discussion between the postholder andemployer.

Appendix GGood practice checklist for generalvolunteers (NCVO 2001)

1. Prior to recruitment, be clear about why youwant/need a volunteer;

2. Provide the volunteer with a clear role/taskdescription, identifying anticipated requirement/sof the organisation;

3. Provide the volunteer with an initial induction andtraining programme;

4. Provide the volunteer with appropriate linemanagement;

5. Add volunteers to organisation charts. Encouragevolunteers to participate in the organisation’swider decision-making process;

6. Monitor and acknowledge the contribution thatvolunteers make to the organisation, to the widerpublic, to funders and to other volunteers;

7. Ask the volunteer what they seek from theirplacement and share with the volunteer what youwant. Remember that any placement should beby mutual consent;

8. Always offer to reimburse out of pocketexpenses. These normally include travel andlunch. Where a placement is away from home,this might also include accommodation and asubsistence allowance;

9. Ensure that health and safety standards are inplace and applied equally to all employees (andvolunteers). Insurance policies should beextended to cover volunteers;

10. Provide opportunities for volunteers to acquireor develop new or existing skills and assistvolunteers who want to gain accreditationtowards recognised qualifications;

11. Volunteers should not be recruited to fill theplace of paid staff. This could be perceived asexploitation of the volunteer and deprival ofsomeone’s livelihood

12. Ensure that the work and contribution of thevolunteer adds quality and value to theorganisation’s aims and objectives;

13. Ensure that Equal Opportunities and/or diversitypolicies are in place and applied equally tovolunteers. Examine the organisation’s ways ofworking for anything that may pose a barrier forsome members;

14. Encourage and promote a diverse range ofemployees at all levels. This will help volunteersfrom different ethnic groups, ages, disabilities, etcto feel welcome;

15. In order to attract volunteers from groups thatthe organisation has previously failed to reach, itmay be helpful to approach those groups/peopledirectly to establish what would makevolunteering with the organisation more appealingto them.

81

Appendix HSample role description for volunteertherapistUsed with permission of St. Gemma’s Hospice,Leeds

COMPLEMENTARY THERAPIES SERVICEROLE DESCRIPTION

Role: Volunteer Complementary Therapist

Accountable to: Head of Personnel / VolunteersResponsible to: Complementary Therapies

Co-ordinator

Overall objectiveTo provide a service as a member of theComplementary Therapies Team and practice thetherapy which has been agreed, in accordance withthe policies of St. Gemma’s Hospice. The volunteertherapist will also follow the Guidelines for Practicefor volunteer therapists.

Main responsibilitiesKnowledge1. Be able to demonstrate a sound understanding of

complementary therapies, in particular the therapyfor which they are qualified to practice.

2. Be committed to develop skills and knowledgerelated to the care of patients with active,progressive and advanced disease.

Practice1. Provide a holistic approach to patients and their

carers, in collaboration with the other members ofthe multidisciplinary team, in order to ensure theprovision of the highest quality of care.

2. Be competent in therapeutic massage,aromatherapy, reiki or acupuncture

3. Be aware of the patient’s diagnoses, treatment,care and current condition.

4. Be aware of contraindications or precautions inrelation to the therapy they practice, and be ableto adapt a treatment accordingly.

5. Complete the required documentation.6. Provide feedback, including any adverse effects,

to the patient’s Team Nurse and theComplementary Therapies Co-ordinator.

7. Participate in 6-8 weekly group clinical supervisionwith the Complementary Therapies Co-ordinator.

8. Follow the Guidelines for Practice for Volunteers,general and specific to complementary therapies.

9. Follow the Complementary Therapies Policy.

General1. Respect the confidentiality of any information held

in relation to past or present patients, staff andadministration of the hospice.

2. Volunteers are required to abide by (theorganisation’s) Health & Safety policies.

3. Attend a fire lecture, and moving and handingtraining annually.

4. (The organisation) is a no-smoking area for staffand volunteers.

May 2002


Appendix IExample of referral form (Used with permission of St. Gemma’s Hospice, Leeds)

Referral Form for Complementary TherapiesMassage, Aromatherapy, Reiki, Acupuncture

Name of referrer: Date : Designation: Location/base:

Name of patientDate of BirthNext of kin Significant others:

Inpatient h Ward: Date of admission:Day Hospice h Attends on:Outpatient h Patient’s tel. no:

Priority: High h Medium h Low h

Brief Medical DetailsDiagnosis Date:Secondaries Date:Recently received/receiving chemotherapy? YES / NO When? Next dose/course due:

Recently received/receiving radiotherapy? YES / NO When? Next Rx due:Site:

Current medication

Other medical diagnosis

Is the patient aware of:Diagnosis YES / NO Prognosis YES / NOAny other insight into illness:

Reasons for referral:Anxiety h Low Mood / Depression h Diarrhoea h Constipation hN & V h Pain h Breathlessness h Discomfort h Support & Well-being hRelaxation h Fatigue h Stress h Wound care h Distressing odours hProblems with: Sleeping h Body image h Coping h

Main concerns:

83

Patients referred for acupuncture (must be completed by Day Hospice Team)

This patient has been screened for contraindications to acupuncture in palliative care by

Dr Date:

Referrer to sign:

OTHER USEFUL INFORMATION

PHYSICAL PROBLEMS

PAIN COMMENTSWhere?Specific/non specificSeverity

SKINItching h

Dry h

Sensitive h

Bruising h

Lesions h

MOBILITYNo. to transfer h

Fractures h

Falls h

BREATHINGCough h

Dyspnoea h

Asthma h

NEUROLOGICALHeadaches h

Dizziness h

Epilepsy h

Spinal metastases h

CIRCULATION COMMENTSHeart condition h

Thrombosis/clotting disorders h

High / Low BP h

Lymphoedema h

Oedema h

ANYColostomy/ileostomy h

Prostheses h

Catheter h

Drains h

Dressings h

Pressure sores/wounds hInfections h

RECENT SURGERY h

RECENT INJURIES h

KNOWN ALLERGIES h

DIGESTIVEAppetite h

Weight loss h

Nausea / vomiting h

Constipation h

Diarrhoea h

OTHER Diabetes h

Urinary problems h


Appendix JSample Key Worker Initial Assessment Form (condensed)Used with permission of the Cavendish Centre, Sheffield

THE CAVENDISH CENTRE / PATIENT: INITIAL ASSESSMENT

Patient’s Name: Assessor:D.o.B: Date:Diagnosis: Stage of illness (code):

HOPES and EXPECTATIONS of coming to the Centre:

CURRENT SITUATION:

Medical History (summarised):

Patient’s view of the future:

Current Drug and other therapies:

FAMILY / SOCIAL SITUATION including SUPPORT e.g. Day Care, Macmillan Nurse:CONCERNS:

ASSESSORS SUMMARY:

MYCAW COMPLETED? YES h NO h If not, why not?THERAPY: THERAPIST:Reasons for choices:

PERMISSION TO WRITE LETTERS TO: YES h NO h1)2)3)4)5)

RELAXATION GROUP:Action:ALSO CONSIDER: - Relaxation tape

- ‘Friendly faces’- Harold Miller Day Care Unit

INFORMATION LEAFLET GIVEN? YES h NO hPATIENT DONATION PACK GIVEN? YES h NO h

85

Appendix KSample Key Worker Review Assessment Form (condensed) Used with permission of the Cavendish Centre, Sheffield

THE CAVENDISH CENTRE / PATIENT: REVIEW ASSESSMENT

Patient’s Name: Assessor:Date: Therapist:Therapy received: No. of sessions:

Current situation:

Patient’s description of specific effects of therapy and their perception of any changes which have taken placeand why:(Use patient’s own words if possible)

Expectations* met?

Presenting concern(s)* met?

*As noted at initial assessment.

New Concerns:

What might we have done differently?

Are there any other resources which you would like to see us offer?

Patient Donation pack given? YES h NO h

Assessor’s Comments:

Interested in Relaxation Class? YES h NO hAction:Permission to write? YES h NO hLetters to:

Further therapy privately? YES h NO h POSSIBLY hMYCAW completed? YES h NO hIf not why not?


Appendix L (i)Example of Treatment Record (condensed)Used with permission of St. Gemma’s Hospice, Leeds

COMPLEMENTARY THERAPIES RECORD (for the touch therapies)

Name

Date: Therapist:

Review before Treatment

Oils used (if any)

Treatment and observations during treatment

Review after Treatment

Date: Therapist:

Review before Treatment

Oils used (if any)

Treatment and observations during treatment

Review after Treatment

87

Appendix L (ii )Example of Massage Treatment Record (condensed)Used with permission of The Royal Marsden Hospital

The Royal Marsden Hospital: Therapeutic Massage Assessment/Treatment Form

Name Hospital No. NHS PP OP DC IP

Ward:Address Consultant

DoB (age)

Tel No

Referral received Referred byReason for referral Date of first contactDiagnosis

Medical InformationSurgeryChemotherapyRadiotherapyOtherAllergies

Social HistoryProblem listTreatment plan

Referral to other members of the MDTTherapist’s name: Therapist’s signature:

Name: Hospital No:

Date Treatment No OP DC IP Ward: Duration MusicBase oil Essential oils No drops Treatment given / positioning

Therapist’s signature:

Date Treatment No OP DC IP Ward: Duration MusicBase oil Essential oils No drops Treatment given / positioning

Therapist’s signature:


Appendix MParticipants at the three symposia

Judy Abbott Service User, SheffieldDr Julian Abel Weston Hospicecare, Weston-super-MareAngela Avis MBE RCN Complementary Therapies ForumJane Bailey Salisbury HospiceJill Bailey Trafford MacMillan CentreElizabeth Baines CancerCare DorsetAnn Barnes Arthur Rank House, CambridgeMarlene Barry Springhill Hospice, RochdaleMaggie Brain Hospice in the Weald, Tunbridge WellsVeronica Bratt The Primrose Hospice and Cancer Help Centre, BromsgroveJeremy Browne Service User, HampshireNadia Brydon The Haven Trust, LondonStella Carmichael Newcastle Health Action ZoneAngela Chisholm Arthur Rank House, CambridgeAnn Carter St. Ann's Hospice, ManchesterHelen Cooke Bristol Cancer Help CentreAnna Craven Service User, North YorkshireSara Crisell Service User, EssexPeter Cross Service User, CumbriaLilibet Czyzewska Service User, BradfordDr Rosy Daniel Healthy BristolTricia Darnell The Prince of Wales's Foundation for Integrated HealthBeverley de Valois North Middlesex University Hospital NHS TrustTony Dougan Cancer Care (North Lancs and South Lakes)Diana Dunrossil The Prince of Wales's Foundation for Integrated HealthNorman Dunsby Willowbrook Hospice, PrescotJeannie Dyer Royal Marsden Hospital, LondonCarole Farah Service User, SwanseaGwyn Featonby Butterwick Hospice Care, Stockton-on-TeesFrances Fewell Anglia Polytechnic UniversityPauline Galloway Teeside Hospice Care FoundationTerry Gentry Service User, MiddlesbroughTina Glynn St. George’s Healthcare NHS Trust, LondonRoma Grant National Council for Hospice and Specialist Palliative Care ServicesRussell Hart-Davies South Leeds PCTBetty Heslop Service User, NorthumberlandDione Hills The Prince of Wales's Foundation for Integrated HealthSally Hughes The Prince of Wales's Foundation for Integrated HealthPat Hunter The Peace Hospice, WatfordSandra Hurd University Hospital of Leicester NHS TrustPamela Jack The Prince of Wales’s Foundation for Integrated HealthVal Jarvis Beechwood Cancer Care Centre, StockportRichard Kane North Devon Hospice

89

Dr Jenny Kitchen The Shropshire and Mid Wales HospiceDorothy Lambeth Robert Ogden MacMillan Centre, LeedsDr Richard Lamerton Hospice of the Valleys, TredegarWendy Leach Mount Edgcumbe Hospice, CornwallDr. Graham Leng Hospice of the Good Shepherd, ChesterGina Long South Leeds PCTKaren Loxton Richard Dimbleby Cancer Information & Support Service, LondonPeter Mackereth Christie Hospital NHS Trust, ManchesterDr. Andrew Manasse The Cavendish Centre for Cancer Care, SheffieldPatricia McDermott Edenhall Marie Curie Centre, LondonDeirdre McGuigan Bristol Children's HospitalLouise Meadan Marie Curie Centre Holme Tower, Vale of GlamorganDr. Alison Morrison Ardgowan Hospice, ScotlandLibby Mytton The Primrose Hospice and Cancer Help Centre, BromsgroveKate Nadkarni Bradford Cancer Support Gillian Peace The Cavendish Centre for Cancer Care, SheffieldLev Pedro Immune Development Trust, LondonMargot Pinder The Prince of Wales's Foundation for Integrated HealthHoward Plummer Sandville Court Self Help Centre, BridgendGwyneth Poacher Sandville Court Self Help Centre, BridgendJudith Powell Wakefield Hospice, West YorkshireNoel Ratcliffe The Peace Hospice, WatfordDr. Dai Roberts St. Ann's Hospice, ManchesterRobert Ross Service User, OxfordSerena Scrine St. Luke’s Hospice, PlymouthSue Smith Mustard Tree Macmillan Centre, PlymouthDawn Solomon Newcastle PCTDr Dingle Spence St. Peter’s Hospice, BristolJacqui Stringer Christie Hospital NHS Trust, ManchesterJackie Syrett Dove House Hospice, HullDavid Tapper St. David’s Foundation, NewportElizabeth Taylor Holistic Resources, LancashireGillian Thomas Edenhall Marie Curie Centre, LondonDr Elizabeth Thompson Bristol Homeopathic HospitalDr. Elizabeth Thompson St. Margaret’s Somerset HospiceAnna Thomson The Prince of Wales's Foundation for Integrated HealthChris Walker Service User, NorthumberlandMina West Cherry Lodge Cancer Care, BarnetDr Susie Wilkinson Marie Curie Palliative Care R&D Unit, Royal Free University College Hospital, LondonJane Wilkinson School of Integrated Health Care, University of WestminsterLorraine Williams The Prince of Wales's Foundation for Integrated HealthMaureen Williams Nursing and Midwifery CouncilAndrew Wilson Marie Curie Centre Holme Tower, Vale of GlamorganCatherine Wood Dove House Hospice, HullYvonne Young Service User, Swansea


Appendix NWider consultative group

Lucy Bell Charing Cross and Hammersmith HospitalsJo Bray H.O.P.E.Gordon Brown Department of HealthAnne Cawthorn University of ManchesterVal Chiesa The Peace HospiceProf. S.J. Closs University of LeedsProf. Jessica Corner University of SouthamptonDr. Michael Dixon NHS AllianceDr. Peter Fisher Royal London Homeopathic HospitalHelen Frances St. Luke’s Hospice, PlymouthSharon Haffenden MS SocietySue Hawkett Department of HealthProf. Irene Higginson King’s College LondonCaroline Hoffman Royal Marsden HospitalWendy Hoy Macmillan Butterfly Centre, EpsomDr. Sosie Kassab Royal London Homeopathic HospitalSteve Kirk St. Gemma’s Hospice, LeedsGillian Leng NICERosemary Lucey The Lynda Jackson Macmillan CentreJo Luthert Supportive & Palliative Care GuidanceDr. David McGavin Blackthorn Medical Centre and TrustHeidi MacLeod MND AssociationLynne Morrison CancerlinkDr. Charlotte Paterson Warwick House Medical CentreHelen Press Sue Ryder CareProf. Alison Richardson King’s College LondonDiane Robinson St. Catherine’s Hospice, ScarboroughSheila Scott Parkinson's Disease SocietyDr. Maire Shelly South Manchester University Hospitals NHS TrustPeter Smith National Association of Primary CareElaine Stevens RCN Palliative Nursing GroupMargaret Stevenson Scottish Partnership AgencyPeter Tebbit National Council for Hospice and Specialist Palliative Care ServicesPat Turton Bristol Cancer Help CentreDebbie Veel St. Michael’s Hospice, Basingstoke

Aromatherapy Regulatory Working GroupReflexology ForumGeneral Council for Massage TherapyCouncil of Organisations Registering HomeopathsThe Faculty of HomoeopathyAcupuncture Association of Chartered PhysiotherapistsBritish Medical Acupuncture SocietyBritish Academy of Western AcupunctureBritish Acupuncture CouncilBritish Society of Medical and Dental HypnosisUK Confederation of Hypnotherapy OrganisationsUK Reiki FederationBritish Association of Therapeutic TouchUK Healers

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Appendix OExperts consulted

Dr. Julian Abel Weston HospicecareRosie Anderson UK Reiki FederationEileen Aspinall St. Gemma’s Hospice, LeedsJill Bailey ACPOPCLucy Bell Charing Cross HospitalMaggie Brain Hospice in the Weald, Tunbridge WellsAngie Buxton University College Hospital, LondonAnn Carter St. Ann’s Hospice, ManchesterElaine Charlesworth University College Hospital, LondonDr. Raj Chopra Christie Hospital NHS TrustSara Crisell Service UserPeter Cross Service UserJeannie Dyer Royal Marsden HospitalDr. Jacqueline Filshie Royal Marsden HospitalDavid Franchi-Christopher General Medical CouncilStephen Gordon Society of HomeopathsProf. John Gruzelier Imperial College London UniversitySharon Haffenden MS SocietyAnnie Hallett Ipswich Hospital NHS TrustSarah Hart Royal Marsden HospitalLiz Hawkins Univ. of Westminster; Harley Street ClinicBetty Heslop Northumberland Cancer Support GroupVal Hopwood Acupuncture Assoc. of Chartered PhysiotherapistsDr. Sosie Kassab Royal London Homeopathic HospitalDr. Jenny Kitchen St. Peter’s Hospice, BristolDr. Michelle Kohn Macmillan Cancer ReliefLyn Lamont Northern Ireland Cancer Centre, BelfastDr. Graham Leng Hospice of the Good Shepherd, ChesterProf. Malcolm McIlmurray Royal Lancaster InfirmaryPeter Mackereth Christie Hospital NHS Trust, ManchesterDr. Hugh MacPherson Northern College of AcupunctureDr. Andrew Manasse The Cavendish Centre for Cancer CareGill McCall St. Thomas’ HospitalDr. McIllmurray Royal Lancaster InfirmaryHeidi MacLeod MND AssociationDr. David Oakley University College HospitalJacky Owens University College HospitalBrenda Peace UK Healers Jean Sayre-Adams Sacred Space FoundationSheila Scott Parkinson's Disease SocietySerena Scrine St. Luke’s Hospice, PlymouthLinda Shuttleworth St. Gemma’s Hospice, LeedsDavid Simons The Cavendish Centre for Cancer CareDr. Mike Stockton St. Gemma’s Hospice, LeedsJacqui Stringer Christie Hospital NHS Trust, ManchesterPeter Tebbit NCHSPCSGill Thomas Trinity Hospice, LondonDr. Elizabeth Thompson Bristol Homeopathic HospitalProf. Alan Thompson Nat. Hospital for Neurology & Neurosurgery Celia Tudor-Evans College of Traditional AcupunctureProf. Leslie Walker University of HullJoyce West Aromatherapy Organisations CouncilFrank Westell General Council for Massage TherapyDr. Susie Wilkinson Marie Curie Palliative Care R&D UnitJulia Williams University College HospitalMaureen Williams Nursing and Midwifery CouncilDr. Ann Williamson Brtish Society for Medical and Dental HypnosisProf. Steve Wright Sacred Space Foundation


Reflexology ForumAromatherapy Regulatory Working GroupGeneral Council for Massage TherapyCouncil of Organisations Registering HomeopathsBritish Acupuncture CouncilAcupuncture Association of Chartered PhysiotherapistsBritish Academy of Western AcupunctureBritish Medical Acupuncture SocietyBritish Society for Medical and Dental HypnosisBritish Association of Therapeutic TouchUK Reiki FederationUK Healers

Appendix PGlossary of terms

ACPOPC Association of Chartered Physiotherapists in Oncology and Palliative Care

CT Complementary therapy / therapies

Clients This term is used interchangeably with patients

Clinical services/setting/team This term is used to refer to services provided within a multidisciplinary

conventional health care team

DoH Department of Health

GMC General Medical Council

HOPE HIV/AIDS, Oncology and Palliative Care Education, British Association of

Occupational Therapists, specialist group

NACTHPC National Association of Complementary Therapists in Hospice and

Palliative Care

NCHSPCS National Council for Hospice and Specialist Palliative Care Services

www.hospice-spc-council.org.uk

NHS National Health Service

NICE National Institute for Clinical Excellence www.nice.org.uk

NMC Nursing and Midwifery Council

Non-clinical services This term is used to refer to services provided in settings without a

/setting/team multidisciplinary conventional healthcare team.

Patients This term is used interchangeably with ‘clients’

S & PC Supportive and palliative Care

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Appendix QUseful resources

1. Palliative care

Association of Chartered Physiotherapists inOncology and Palliative CareKatherine Malhotra, Secretary of MembershipPhysiotherapy DepartmentRoyal Marsden HospitalFulham RoadLondon, SW3 6JJ Email: [email protected]: www.acpopc.org.uk

British Heart FoundationHead Office14 Fitzhardinge StreetLondon, W1H 6DHTel: 020 7935 0185Fax: 020 7486 5820Email: [email protected]: www.bhf.org.uk

British Lung Foundation Head Office78 Hatton Garden London, EC1N 8LD Tel: 020 7831 5831 Email: [email protected] Website: www.britishlungfoundation.org.uk

Help the HospicesHospice House34-44 Britannia StreetLondon, WC1X 9JGTel: 020 7520 8200Fax: 020 7278 1021Email: [email protected]: www.helpthehospices.org.uk

Macmillan Cancer Relief89 Albert EmbankmentLondon, SE1 7UQTel: 020 7840 7840 Fax: 020 7840 7841Email: [email protected] Website: www.macmillan.org.uk

Marie Curie Cancer CareWebsite: www.mariecurie.org.uk For all general enquiries, please [email protected] or you can write to their headoffices in England, Scotland, Wales and NorthernIreland:

Marie Curie Cancer Care England89 Albert EmbankmentLondon, SE1 7TPTel: 020 7599 7777

Marie Curie Cancer Care Northern Ireland60 Knock RoadBelfast, BT5 6LQTel. 028 9088 2060

Marie Curie Cancer Care Scotland29 Albany StreetEdinburgh, EH1 3QNTel. 0131 456 3700

Marie Curie Cancer Care WalesRaglan Chambers63 Frogmore StreetAbergavenny,Monmouthshire NP7 5ANTel: 0187 330 3000

National Council for Hospice and Specialist PalliativeCare Services1st Floor34-44 Britannia StreetLondon, WC1X 9JGTel: 020 7520 8299Fax: 020 7520 8298Website: www.hospice-spc-council.org.uk

Occupational Therapists - HOPEChair: Jill Cooper, Head Occupational Therapist,Royal Marsden HospitalLilac CottagePlumpton LanePlumpton GreenNr LewesEast Sussex, BN7 3AHTel: 020 7808 2830Email: [email protected]

Royal College of Nursing, Complementary TherapiesForumChair, Mrs Angela Avis MBELecturerOxford Brookes UniversitySchool of Health CareDorset HouseLondon RoadOxford, OX3 7PETel: 01865 485291Email: [email protected]

Terrence Higgins TrustNational Office52-54 Grays Inn RoadLondon, WC1X 8JUTel: 020 7831 0330Fax: 020 7242 0121Email: [email protected]: www.tht.org.uk


2. Complementary therapies

Acupuncture Association of CharteredPhysiotherapistsSecretariat, Vibeke DawsonMere Complementary Practice Castle Street, Mere Wiltshire, BA12 6JETel: 01747 861151 Fax: 01747 861717Email: [email protected]: www.aacp.uk.com

Aromatherapy Regulatory Working PartyGeoffrey LawlerIndependent ChairThe Public Affairs Company21 Otley RoadLeeds, LS6 3AA

Association of Chartered Physiotherapists in ReflexTherapyAlison Stain3 Whichcote AvenueMeriden, CoventryWest Midlands CV7 7LR

Association of Chartered PhysiotherapistsInterested in MassageTessa Campbell9 Woodfield DriveWinchesterHampshireSO22 5PY

Bowen techniqueThe Bowen ForumWebsite: www.bowen4health.co.uk

Bristol Homeopathic HospitalDr. E.A. Thompson Consultant Homeopathic Physician andHonorary Senior Lecturer in Palliative CareCotham HillBristol BS6 6JUTel: 0117 973 1231Fax: .0117 923 8759Email: [email protected]

British Academy of Western AcupunctureTel: 0151 343 9168Fax: 0151 343 9168Email: [email protected] Website: www.bawa-acupuncture.org.uk

British Acupuncture Council63 Jeddo RoadLondon, W12 9HQ Tel: 020 8735 0400Email: [email protected]: www.acupuncture.org.uk

British Association of Therapeutic Touch c/o David Lewis3 Union StreetCarmathenCarms.SA31 3DETel. 01267 232715Email: [email protected]: www.ttouch.org.uk

British Medical Acupuncture SocietyThe Administrator12 Marbury HouseHigher WhitleyWarringtonCheshire, WA4 4QW. Tel: 01925 730727Fax: 01925 730492, Email: [email protected] Website: www.medical-acupuncture.co.uk

British Society of Medical and Dental HypnosisMrs Angela Morris National Office Secretary 28 Dale Park GardensCookridge Leeds, LS16 7PTTel/Fax: 07000 560309E-mail: [email protected] Website: www.bsmdh.org

Council of Organisations Registering HomeopathsPeter MitchellTreasurer11 Wingle Tye RoadBurgess HillWest Sussex, RH15 9HR01273 878777Email: [email protected]

Craniosacral therapyThe Cranial ForumWebsite: www.cranio.org.uk

The Faculty of Homeopathy15 Clerkenwell CloseLondon, EC1R 0AATel: 020 7566 7800.Fax: 020 7566 7815Website: www.trusthomeopathy.org

General Council for Massage Therapy46 Millmead Way Hertford SG14 3YH Tel: 01992 537637Email: [email protected] Website: www.gcmt-uk.org

95

The Prince of Wales’s Foundation for IntegratedHealth12 Chillingworth RoadLondon, N7 8QJTel: 020 7619 6146Fax: 020 7700 8434Email: [email protected]: www.fihealth.org.uk

Reflexology ForumPO Box 2367South CroydonSurrey, CR2 7ZETel: 0800 037 0130Email: [email protected]

ShiatsuThe General Shiatsu CouncilGlebe CottageHolywell RoadCastle BythamGrantham, NG33 4SLEmail: [email protected]

UK Confederation of Hypnotherapy OrganisationsSuite 401302 Regent StreetLondon, W1R 6HHTel/Fax: 0800 952 0560 E-mail: [email protected] Website: www.ukcho.org.uk

UK HealersChris Denton SecretaryPO Box 4137London, W1A 5FETel: 01943 468476 Email: [email protected]: www.ukhealers.info

UK Reiki FederationPO Box 1785Andover, SP11 OWBTel: 01264 773774Email: [email protected] Website: www.reikifed.co.uk

3. Complementary therapies in supportive andpalliative care

Bristol Homeopathic HospitalDr. E.A. ThompsonConsultant Homeopathic Physician andHonorary Senior Lecturer in Palliative CareBristol Homeopathic HospitalCotham HillBristol BS6 6JUTel. 0117 973 1231Email: [email protected]

Complementary Therapies in Practice (London andsouth east)Karen Loxton, Complementary Therapy Co-ordinatorRichard Dimbleby Cancer Information and SupportServiceSt. Thomas’ HospitalLambeth Palace RoadLondon, SE1 7EH Tel: 020 7928 9292 Extn. 6012Email: [email protected]

Hammersmith Hospitals NHS Trust Lucy Bell, Complementary Therapy Team LeaderClinic 8, Outpatients Department1st FloorCharing Cross Hospital,Fulham Palace RoadLondon W6 8RFTel. 020 8383 0463Email: [email protected]

The Cavendish Centre for Cancer Care27 Wilkinson StreetSheffieldSouth Yorkshire S10 2GBTel. 0114 278 4600E mail: [email protected]

Macmillan Cancer ReliefDr. Michelle KohnComplementary Therapies Medical AdviserMacmillan Cancer Relief89 Albert EmbankmentLondon SE1 7UQE mail: [email protected]

National Association of Complementary Therapistsin Hospice and Palliative CareChair, Freda Magee29 King’s RoadBerkhamstedHerts, HP4 3BHTel: 01442 874226 Email: [email protected]

Royal London Homeopathic Hospital Dr. Sosie KassabDirector of Complementary Cancer ServicesRoyal London Homeopathic HospitalGreenwell StreetLondon, W1W 5BP Email: [email protected]

Royal Marsden HospitalDr. Jacqueline FilshieConsultant in Anaesthesia and Pain ManagementThe Royal Marsden HospitalDowns RoadSuttonSurrey, SM2 5PTEmail: [email protected]


Caroline HoffmanNurse Consultant in Cancer Care (Rehabilitation)The Markus CentreThe Royal Marsden HospitalFulham RoadLondon, SW3 6JJEmail: [email protected]

Salford University/Christie Hospital NHS TrustPeter MackerethLecturer/PractitionerRehabilitation CentreChristie Hospital NHS TrustWilmslow RoadWithingtonManchester, M20 4BXTel. 0161 446 3795Email: [email protected]

St. Ann’s HospiceAnn CarterComplementary Therapy Co-ordinatorNeil Cliffe Cancer CentreWythenshawe HospitalSouthmoor RoadManchester, M23 9LTTel. 0161 291 2913Email: [email protected]

St. Gemma’s HospiceMarianne TavaresComplementary Therapies Co-ordinator329 Harrogate RoadLeeds, LS17 6QDTel. 0113 218 5567Email: [email protected]

4. Websites referred to in these guidelines

British Medical Acupuncture Society www.medical-acupuncture.co.uk

British Society for Medical and Dental Hypnosiswww.bsmdh.org

National Council for Hospice and Specialist PalliativeCare Services www.hospice-spc-council.org.uk

Skills for Health www.skillsforhealth.org

The Chartered Society of Physiotherapistswww.csp.org.uk

The Prince of Wales’s Foundation for IntegratedHealth www.fihealth.org.uk

The Royal College of Nursing www.rcn.org.uk

The Sacred Space Foundationwww.sacredspace.org.uk

The UK Confederation of HypnotherapyOrganisations www.ukcho.org

UK Reiki Federation www.reikifed.co.uk

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National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care

The use of complementary therapies following a diagnosis of cancer is a significant and growingphenomenon and a substantial and increasing number of supportive and palliative care services in theUK are offering complementary therapies to patients and carers. These national guidelines have beendrawn up for the use of managers, health professionals and others responsible for the development ofcomplementary therapy services in supportive and palliative care with the aims of encouraging goodpractice and enabling the development of high quality services.

The development of these guidelines has been a joint project between the National Council forHospice and Specialist Palliative Care Services and The Prince of Wales's Foundation for IntegratedHealth and the work has been funded by Lloyds TSB Foundation for England and Wales.

Based on the best available evidence, the guidelines bring together the different issues and questionsthat organisations face when considering the development of complementary therapy services insupportive and palliative care. The focus is mainly on cancer, although information is also given aboutkey clinical issues for people with motor neurone disease, Parkinson's disease and multiple sclerosis.

With a foreword by HRH The Prince of Wales and a preface from Professor Mike Richards, NationalCancer Director, these guidelines are intended to provide a basis for organisations to develop their ownpolicies, procedures and protocols based on good practice, which are appropriate for local needs.

Marianne Tavares is Complementary Therapies Coordinator at St Gemma's Hospice in Leeds.

Documents

National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care