Palliative care

Palliative care is the active holistic care of patients with advanced progressive illness, such as those with advanced cancer, end-stage renal disease, AIDS, and chronic obstructive pulmonary disorder (COPD)(WHO 2002). Management includes treatments for pain and other symptoms (e.g. fatigue, nausea and vomiting, breathlessness, anxiety, depression, vasomotor symptoms, xerostomia), as well as the provision of psychological, social and spiritual support (NICE 2004). Up to 457,000 people in the UK need good palliative care services every year but around 92,000 people are not being reached (Hughes-Hallett 2011).

The goal of palliative care is to achieve the best quality of life for patients and their families, and to provide a support system to help patients live as actively as possible until death (WHO 2002). Ideally, palliative care is applied early in the course of illness in conjunction with other therapies intended to prolong life (such as chemotherapy or radiation therapy), and investigation and management of distressing clinical complications (NCHPSCS 2002; DH 2000). Conventional treatments used in palliative care include drugs such as opioids, NSAIDs, antiemetics, corticosteroids, tranquillisers and laxatives; radio- and chemotherapy; and surgery (GP Notebook n.d.). People may be cared for in their own homes, hospices, care homes or hospitals (Hughes-Hallett 2011).

References

Department of Health. The NHS Cancer Plan: a plan for investment, a plan for reform. London: DoH. September 2000.

Hughes-Hallett T et al. Palliative care funding review. The right care and support for everyone. July 2011 [online]. Available: http://palliativecarefunding.org.uk/wp-content/uploads/2011/06/PCFRFinal%20Report.pdf

Palliative care. GP Notebook [online]. Accessed: 24 November 2011. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=1060438084

National Council for Hospice and Specialist Palliative Care Services. Definitions of Supportive and Palliative Care. Briefing paper 11. London: NCHSPCS. September 2002.

NICE 2004. Guidance on Cancer Services Improving Supportive and Palliative Care for Adults with Cancer http://www.nice.org.uk/nicemedia/live/10893/28816/28816.pdf

World Health Organization. National Cancer Control Programmes: policies and managerial guidelines. Geneva: WHO. 2002.

How acupuncture can help

Most research so far has focused on helping the side-effects of orthodox cancer treatments, and on relieving pain. First we consider those symptoms where there has been enough research to merit it being systematically reviewed.

Pain

Several randomised controlled trials (RCTs) have indicated that acupuncture may relieve pain in palliative settings and in addition it may reduce the need for cancer pain drugs (Lu 2008). One recent systematic review found (limited) evidence that acupuncture may provide long-term pain relief in patients with cancer (Paley 2011) and the most recent trials have strengthened the evidence (refer to the 'Acupuncture for Cancer Care' Fact Sheet, 2011).

Most research on acupuncture for chronic pain has been carried out in primary and secondary care with musculoskeletal conditions and headache, though also to some extent for visceral pain. Recent studies are demonstrating an effect over and above placebo (Hopton 2010). Palliative care patients, too, frequently suffer from non-cancer-specific pain and would be expected to benefit similarly from acupuncture.

Pain arising indirectly from cancer treatments may also be addressed with acupuncture, for example for chemotherapy- induced neuropathy (Donald 2011). Patients with HIV-associated neuropathic pain may also benefit (refer to the 'Acupuncture for Neuropathic Pain' Fact Sheet, 2012). Filshie (2003) reported that pain from cancer treatments is likely to respond better, and for longer, that that from the disease itself; nevertheless, there are still benefits possible for patients with late-stage cancer.

Dry mouth (xerostomia)

A systematic review found possible benefits with acupuncture for radiotherapy-induced xerostomia (O'Sullivan 2010). Not all the inter-group differences were significant but this is typical in trials comparing acupuncture with sham acupuncture, for the latter is commonly viewed as being an active treatment itself, not a placebo, and hence may underestimate the effects of the therapy (Lundeberg 2011; Sherman 2009; Paterson 2005).The RCTs to date are few in number and small in size. Although they have produced encouraging results, and are supported by observational studies (for example, Meidell 2009), larger trials are required to achieve more robust evidence. Acupuncture may also help with xerostomia dysphagia (swallowing difficulty) in late-stage palliative care (Filshie 2003).

Nausea and vomiting

Three systematic reviews found that moxibustion or acupuncture can help relieve chemotherapy-induced nausea and vomiting (Lee 2010; Chao 2009; Ezzo 2006), especially in acute situations, and even self-administered acupressure may be effective. There is little information on whether acupuncture is also effective for nausea and vomiting in advanced terminal care (unrelated to chemotherapy).

Breathlessness

Systematic reviews found low strength evidence that acupuncture/acupressure is helpful for breathlessness, with most of the studies on patients with COPD (Bausewein 2008). Semi-permanent indwelling needles have been used to prolong the effect and to give patients some control, by massaging them (Filshie 2003).

Hot flushes

The vasomotor symptoms brought on by chemotherapy treatment for breast and prostate cancer may be alleviated with acupuncture, though the evidence is not yet conclusive (Lee 2009a, 2009b; see Cancer Care Fact Sheet for details of more recent trials). Filshie (2005) provides details of the protocol used in a specialist UK cancer centre (which again includes self-treatment) together with positive audit results.

Other symptoms

Several pilot RCTs have found acupuncture to benefit patients with chemotherapy-relatedfatigue (Lu 2008). Acupuncture has also provided an alternative method for managing fatigue in patients with end-stage renal disease (Tsay 2004). Two recent observational studies have provided positive preliminary findings for lymphoedema (Cassileth 2011; de Valois 2011). Also in cancer patients, recent trials have suggested benefit for insomnia and depression (Feng 2011). Filshie (2011) has reported a wide range of other applications, especially for side effects of radiotherapy.

HIV patients may find adjunctive acupuncture useful for gastrointestinal side-effects of anti-retroviral therapy (Chang 2011), for sleeplessness (Philips 2001) and forneuropathic pain (discussed above).

Holistic care

Most patients in palliative care do not present with single symptoms and it may be advantageous to address them globally (Filshie 2011; Lim 2011). Further, although symptom control may be the main focus palliative care also emphasises patient dignity, autonomy and self-efficacy (Kauffman 2008; Lu 2008). Broad holistic benefits, covering multiple physical and mental symptoms and self-empowerment outcomes are characteristic of acupuncture (Rugg 2011).

Reviews of the evidence for acupuncture in palliative care have concluded that it is a promising adjunctive therapy (and potentially cost-effective), though more research is needed, especially with non-cancer patients (Filshie 2011; Couillot 2008; Lu 2008; Standish 2008).

A number of observational pilot studies in advanced cancer and haemodialysis populations have demonstrated change over a wide range of symptoms, alongside improved quality of life (Dean-Clower 2010), safety (Kim 2011), user endorsement of the service (Johnstone 2002), and the capability to stay living at home through the terminal stages (Takahashi 2009). A small RCT of acupuncture compared to nurse-led care in patients with incurable cancer reported global benefits without significant side-effects or other tolerance issues (Lim 2011). Also, most symptom improvement was still evident 6 weeks after the end of treatment (though in practice, a regime of follow-on maintenance sessions would usually be advisable given the nature of the disease). For HIV patients with peripheral neuropathy RCT results indicated reduced attrition and mortality with acupuncture, though the effects on pain were inconclusive (Shiflett 2011).

For further details of cited research refer to the table below. For information about more of the individual trials, especially those published since the systematic reviews reported here, see the Cancer Care Fact Sheet. There is further information on the effects of acupuncture on symptoms associated with terminal illnesses in the Anxiety, Chronic Pain, COPD, Depression, Insomnia, Nausea and Vomiting, and Neuropathic Pain Fact Sheets.

Mechanisms

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically benefit symptoms associated with palliative care by:

  • Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the 'analytical' brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009)
  • Regulating neurotransmitters (or their modulators) and hormones such as serotonin, noradrenaline, dopamine, GABA, neuropeptide Y and ACTH; hence altering the brain's mood chemistry to help to combat negative affective states ( Cheng 2009; Zhou 2008;
  • Increasing the release of adenosine, which has antinociceptive properties (Goldman 2010)
  • Improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swellingStimulating production of endogenous opioids that affect the autonomic nervous system, promoting relaxation and reduced stress Arranz 2007)
  • Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003)
  • Reversing stress-induced changes in behaviour and biochemistry (Kim 2009)
  • Increasing levels of T lymphocyte subsets such as CD(3), CD(4), and CD(8), as well as Natural Killer cells (Zhao 2010)
  • Relieving nausea and vomiting via central opioid pathways (Tatewaki 2005), regulating gastric myo-electrical activity (Streitberger 2006), modulating the actions of the vagal nerve and autonomic nervous system (Huang 2005), and regulating vestibular activities in the cerebellum (Streitberger 2006)
  • Enhancing levels of vasoactive intestinal polypeptide and calcitonin gene-related peptide (O'Sullivan 2010), which may relieve xerostomia and hot flushes

Safety and adverse effects

Acupuncture may be used to treat the person, some of the symptoms of cancer, and the side-effects of conventional cancer treatments, but it is not used to address the cancer itself.

Acupuncture needling is contraindicated in any area of actual or potential spinal instability due to cancer, as it potentially increases the risk of cord compression or transaction; directly over a tumour itself or nodules or related sites, such as ascites; when there is severely disordered clotting function; into a lymphoedematous limb (but see Cassileth 2011 below); directly above a prosthesis; or over any intracranial deficits following neurosurgery. Indwelling needles should not be used in patients at risk of bacteraemia, for instance in valvular heart disease and immune-compromised patients with neutropenia (Filshie 2003). It should be noted that acupuncture palliation of symptoms could mask both cancer and disease progression. Although the safety record of oncology acupuncture is extremely good, additional patient eligibility guidelines are in place in some countries, especially to protect against the possibility of infection in immune-compromised individuals (Lu 2010).

Filshie, J. National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care. Acupuncture. The Prince of Wales's Foundation for Integrated Health; National Council for Hospice and Specialist Palliative Care Services. May 2003

Lu Weidong et al. Recent advances in oncology acupuncture and safety considerations I practice. Current Treatment Options in Oncology 2010;11(3-4):141-146

Additional Info

Terms and conditions:Terms and conditions The use of this fact sheet is for the use of British Acupuncture Council members and is subject to the strict conditions imposed by the British Acupuncture Council details of which can be found in the members area of its website www.acupuncture.org.uk.

Last modified on Tuesday, 12 March 2013 09:28


 

 

 

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