What Is the Evidence for Integrative and Alternative Therapies in Palliative Care?

Introduction and Scope of the Problem

Integrative medicine refers to a group of interventions that are used in conjunction with conventional therapies and that emphasize a patient-centered, holistic approach to care of the individual. Initially the term “complementary and alternative therapy” (CAM) was used, with the distinction being that alternative therapy was substituted for traditional Western medicine. Complementary and integrative medicine (CIM) is generally classified into categories of natural products, including vitamins and herbal supplements, mind-body practices, and complementary approaches, such as Ayurvedic medicine or traditional Chinese medicine.

According to the 2012 National Health Interview Survey, about one-third of American adults report the use of some form of integrative health practice, especially mind-body approaches such as deep breathing, chiropractic, massage, and yoga. Notably, the use of yoga has increased from an estimated 9.5% of respondents in 2012 to 14.3% in the 2017 survey. In addition, data from the 2012 Physician Induction Survey from the National Ambulatory Medical Care Survey indicated that 53.9% of physicians had recommended at least one complementary therapy to a patient in the past 12 months.

The use of integrative approaches by hospice care providers had been estimated to be over 40% based on the 2007 National Home and Hospice Care Survey. Massage and music therapy were among the most common interventions that hospice patients received. Given the focus on improving the whole person’s well-being, the use of integrative approaches has likely grown over the past 15 years in the hospice and palliative care settings. The Hospice and Palliative Care Nurses Association issued a position statement emphasizing key points about the use of integrative therapies including assisting patients in making informed decisions and the need to use appropriately licensed or certified integrative health services.

Despite the widespread use of integrative health practices in the hospice and palliative care settings, high-quality evidence of their efficacy remains limited. Case series, observational studies, small uncontrolled clinical trials, and systematic reviews continue to serve as the evidence base, and this should be recognized when considering the potential use of many of these practices.

Summary of Evidence Regarding Treatment Recommendations

A literature search was conducted to identify higher quality evidence of CAM in the palliative/hospice setting between January 1999 and May 2016; the dates were chosen originally to build on an earlier publication. Terminology including “palliative care,” “hospice care,” “complementary therapy,” and specific symptoms were used in searching Embase, CINAHL, PsycINFO, and MEDLINE databases. Studies were screened and scored by independent reviewers using the Jadad scale and included studies that had a score of at least 3. Further details of the search methods are found in the 2018 systematic review. For this chapter, an identical search was conducted for studies published between 2016 and 2020. Four new studies ( Table 78.1 ) were included along with 17 studies from the original systematic review and serve as the basis for this chapter. No studies evaluated natural products.

Breathing

Few studies have evaluated breathing therapy on breathlessness in the hospice and palliative care settings. A 4-week study of 124 patients with an intrathoracic malignancy assessed the effects of one or three sessions on breathing techniques on breathlessness. Participants received training on breathing management techniques from a physiotherapist and were provided with materials to reinforce the training. All patients received at least one session of breathing therapy while some participants received three sessions. The improvement in breathlessness was similar between participants receiving one versus three sessions as demonstrated by reductions in the “worst breathlessness” numerical rating scale scores in both arms. Based on the findings, receipt of at least one session provided some benefit in these patients.

In general, breathing management techniques produce no harmful effects. Patients who are in active respiratory stress may not be appropriate candidates, and the therapy should be conducted as a means of improving patients’ baseline breathing.