Integrative Palliative Care: An Emerging Field in Palliative Medicine

Updated | By Brieze Bell, MD

Explore how evidence-based integrative medicine therapies and palliative care intersect to expand the healing toolkit for patients with serious illness.

Integrative Palliative Care: An Emerging Field in Palliative Medicine

Integrative medicine is a holistic approach to healing that emphasizes whole-person care, combining the best of biomedicine with evidence-based, complementary therapies to help individuals optimize their health and wellbeing. Integrative medicine use is common among people with serious illness in the U.S. and can take many forms, including use of supplements, mindfulness practices, or complementary therapies such as acupuncture or massage. Surveys have found that up to 33% of cancer patients have used integrative medicine in the past year, and up to 60% percent of hospice agencies offer it to those approaching end of life (EOL).[1] Yet patients often neglect to disclose integrative medicine use to their health care teams, and providers cite a lack of time and knowledge to properly advise patients on safe and appropriate use of these therapies.[2]

Integrative palliative care is an emerging field within the specialty of palliative medicine that aims to embrace these shared principles and expand the healing toolkit available to our patients with serious illness by incorporating safe, evidence-based integrative therapies into their care.

The fields of integrative medicine and palliative care are closely aligned in their emphases on whole-person, interdisciplinary care with an aim to optimize quality of life at any stage in a person’s health journey.[3] Integrative palliative care is an emerging field within the specialty of palliative medicine that aims to embrace these shared principles and expand the healing toolkit available to our patients with serious illness by incorporating safe, evidence-based integrative therapies into their care.[4]

Integrative Palliative Care Looks Beyond the Opioid Prescription for Pain Management

Effectively managing pain for seriously ill patients is a challenge as old as the practice of medicine itself. Remarkable advances in medical technology have led to improved life expectancy for people living with many serious diseases. Despite this, our field has historically focused on a relatively small arsenal of symptom management therapies for this patient population. While opioids and other controlled substances play a critical role in our ability to optimize wellbeing for palliative care patients, their use comes with substantial risks that disproportionately impact low-income communities and communities of color.[5][6][7]

Many patients are seeking other options to manage their pain, particularly in the setting of the U.S. opioid epidemic. Substantial evidence supports the use of several integrative medicine therapies for cancer-related and non-cancer pain management, including acupuncture, mindfulness practices, massage therapy, music therapy, and forms of energy medicine such as Reiki or healing touch.[8][9][10][11][12] Acupuncture is particularly helpful for the treatment of cancer pain and neuropathic pain. In locations where it is legal, safe, and appropriate, use of cannabis can also be an important adjunctive therapy for pain management.[13][14] An anti-inflammatory dietary pattern has been shown to attenuate chronic pain by mitigating oxidative stress.[15] Studies suggest that incorporating integrative medicine therapies into cancer pain regimens is often an effective strategy to reduce total opioid use.[16] Patients also deeply value these therapies and cite improvements in quality of life when using them.[17]

Taking an Integrative Approach to Other Widespread Symptoms

Fatigue is a common symptom associated with many serious illnesses that responds well to an integrative palliative care approach.[18] Low-dose stimulants may be an appropriate therapy for a subset of our patients, but identifying the right population for this approach can be challenging, and comorbid conditions such as coronary artery disease can increase risks associated with their use. Acupuncture is an evidence-based treatment for cancer-related fatigue.[19] A recent systematic review and meta-analysis showed that regular exercise improved quality of life, fatigue, insomnia, physical function, social function, and dys­pnea among patients with advanced cancer.[20][21] Finding the right duration and intensity of exercise can be tricky for individuals with advanced illness and limited functional status. The good news is that low-intensity activities like walking, Tai Chi, Qigong, and yoga have shown significant benefit for alleviating cancer-related fatigue. An anti-inflammatory diet rich in omega-3 fatty acids (from foods like fish, nuts, flaxseed, vegetable oils, and leafy greens) can reduce the risk of anorexia-cachexia syndrome and improve fatigue among cancer patients.[22] Massage therapy with or without aromatherapy is also associated with decreased fatigue and improved sleep quality in the setting of cancer.[23]

Postoperative and chemotherapy-induced nausea responds well to cannabis and to particular supplements, including ginger.[14][24] Acupuncture or acupressure are helpful adjunctive therapies for managing this symptom as well, but should be used with caution in patients with thrombocytopenia or neutropenia.

Many people living with serious illnesses struggle with anxiety, depression, and/or existential distress, particularly as they near the end of life. Mindfulness interventions such as meditation, guided imagery, deep breathing, and Mindfulness-Based Stress Reduction (MBSR) have been shown to reduce mood distress in seriously ill individuals.[25][26] Music therapy and energy medicine also offer mood-boosting benefits.[27] Gentle movement therapies, including those described above alleviate anxiety and depression as well.[28][29][30]

Cautions and Concerns to Keep in Mind

It’s important to note that integrative palliative care does not endorse a rejection of gold-standard biomedical symptom management therapies, but rather advocates for a broader range of treatment options for the common challenges our patients experience, with the goal of optimizing their wellbeing. Many individuals interested in taking an integrative approach to their health may conflate integrative medicine with the use of supplements. While there is a role for the judicious use of certain botanicals and supplements in integrative palliative care, polyneutraceutical use—like polypharmacy—tends to have significant associated risks and limited benefits, particularly for those approaching the end of life.[31][32] Anytime a new supplement is being considered, one should discuss this recommendation with other providers on the team and perform a medication-supplement interaction check (using a platform such as Micromedex) to ensure it is a safe and effective intervention.

Expanding Access and Training

Integrative palliative care offers an opportunity to dramatically expand our palliative care healing toolkit, and to more closely align with the lifestyle-based therapies that many patients desire in an era in which they are living longer (and often better) with serious illnesses than ever before. In addition to inadequate knowledge about integrative therapies, many providers cite excessive cost as a barrier to introducing integrative medicine therapies to their patients. Cost for some of these services can indeed be prohibitive. Many integrative palliative care therapies, including mindfulness practices, movement therapies, and music therapy, however, are low-cost or free. Others, including acupuncture, psychotherapy services, and diet-based interventions are increasingly covered by insurance or offset by philanthropic funds. Nonetheless, inequitable access to integrative palliative care is a major concern that parallels access challenges to specialty palliative care more broadly.[33][34] Addressing this is a major area of growth for our specialty.

Integrative palliative care offers an opportunity to dramatically expand our palliative care healing toolkit, and to more closely align with the lifestyle-based therapies that many patients desire in an era in which they are living longer (and often better) with serious illnesses than ever before.

There is currently an unmet need to train palliative care providers in the appropriate use of integrative palliative care to integrate this expanded healing toolkit into the gold-standard care that we provide to our patients with serious illness. Doing so will be a key to broadening access to these services that have historically been reserved for those with ample wealth and health literacy.

To learn more about incorporating evidence-based integrative medicine tools into the treatment of individuals with serious illness, explore the following resources, as well as the articles cited below:

Citations

  1. ↩ a Harte J, Leahy H, McCarthy J, O’Brien T. Exploring patients’ interest in complementary therapies in a specialist palliative care unit. Int J Palliat Nurs. 2019;25(3):108-110. doi:10.12968/ijpn.2019.25.3.108
  2. ↩ a Hsiao AF, Ryan GW, Hays RD, Coulter ID, Andersen RM, Wenger NS. Variations in provider conceptions of integrative medicine. Soc Sci Med. 2006;62(12):2973-2987. doi:10.1016/j.socscimed.2005.11.056
  3. ↩ a Adler SR, Marchand LR, Heap N. Integrative Palliative Care: Enhancing the Natural Synergy Between Integrative Health and Palliative Medicine. J Altern Complement Med N Y N. 2019;25(3):257-259. doi:10.1089/acm.2019.29063.sra
  4. ↩ a Chiaramonte DR, Adler SR. Integrative Palliative Care: A New Transformative Field to Alleviate Suffering. J Altern Complement Med. 2020;26(9):761-765. doi:10.1089/acm.2020.0366
  5. ↩ a Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. StatPearls Publishing; 2022. Accessed February 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK553166/
  6. ↩ a Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data. Published February 9, 2023. Accessed February 26, 2023. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
  7. ↩ a Larochelle MR, Slavova S, Root ED, et al. Disparities in Opioid Overdose Death Trends by Race/Ethnicity, 2018–2019, From the HEALing Communities Study. Am J Public Health. 2021;111(10):1851-1854. doi:10.2105/AJPH.2021.306431
  8. ↩ a Yang J, Wahner-Roedler DL, Zhou X, et al. Acupuncture for palliative cancer pain management: systematic review. BMJ Support Palliat Care. 2021;11(3):264-270. doi:10.1136/bmjspcare-2020-002638
  9. ↩ a Shin ES, Seo KH, Lee SH, et al. Massage with or without aromatherapy for symptom relief in people with cancer. Cochrane Database Syst Rev. 2016;(6):CD009873. doi:10.1002/14651858.CD009873.pub3
  10. ↩ a Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57(1):35-43. doi:10.1016/S0022-3999(03)00573-7
  11. ↩ a Henneghan AM, Schnyer RN. Biofield therapies for symptom management in palliative and end-of-life care. Am J Hosp Palliat Care. 2015;32(1):90-100. doi:10.1177/1049909113509400
  12. ↩ a Gao Y, Wei Y, Yang W, et al. The Effectiveness of Music Therapy for Terminally Ill Patients: A Meta-Analysis and Systematic Review. J Pain Symptom Manage. 2019;57(2):319-329. doi:10.1016/j.jpainsymman.2018.10.504
  13. ↩ a Briscoe J, Kamal AH, Casarett DJ. Top Ten Tips Palliative Care Clinicians Should Know About Medical Cannabis. J Palliat Med. 2019;22(3):319-325. doi:10.1089/jpm.2018.0641
  14. ↩ a b Doppen M, Kung S, Maijers I, et al. Cannabis in Palliative Care: A Systematic Review of Current Evidence. J Pain Symptom Manage. 2022;64(5):e260-e284. doi:10.1016/j.jpainsymman.2022.06.002
  15. ↩ a Brain K, Burrows TL, Bruggink L, et al. Diet and Chronic Non-Cancer Pain: The State of the Art and Future Directions. J Clin Med. 2021;10(21):5203. doi:10.3390/jcm10215203
  16. ↩ a Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute’s Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. J Natl Cancer Inst Monogr. 2017;2017(52):lgx005. doi:10.1093/jncimonographs/lgx005
  17. ↩ a Cronfalk BS, Strang P, Ternestedt BM, Friedrichsen M. The existential experiences of receiving soft tissue massage in palliative home care—an intervention. Support Care Cancer. 2009;17(9):1203-1211. doi:10.1007/s00520-008-0575-1
  18. ↩ a Treat Fatigue in Patients with Serious Illness | Palliative in Practice. Published March 6, 2023. Accessed March 10, 2023. https://www.capc.org/blog/how-to-identify-and-treat-fatigue-in-our-patients-with-serious-illness/
  19. ↩ a Birch S, Lee MS, Alraek T, Kim TH. Evidence, safety and recommendations for when to use acupuncture for treating cancer related symptoms: a narrative review. Integr Med Res. 2019;8(3):160-166. doi:10.1016/j.imr.2019.05.002
  20. ↩ a Chen YJ, Li XX, Ma HK, et al. Exercise Training for Improving Patient-Reported Outcomes in Patients With Advanced-Stage Cancer: A Systematic Review and Meta-Analysis. J Pain Symptom Manage. 2020;59(3):734-749.e10. doi:10.1016/j.jpainsymman.2019.09.010
  21. ↩ a Nadler MB, Desnoyers A, Langelier DM, Amir E. The Effect of Exercise on Quality of Life, Fatigue, Physical Function, and Safety in Advanced Solid Tumor Cancers: A Meta-analysis of Randomized Control Trials. J Pain Symptom Manage. 2019;58(5):899-908.e7. doi:10.1016/j.jpainsymman.2019.07.005
  22. ↩ a Alfano CM, Imayama I, Neuhouser ML, et al. Fatigue, Inflammation, and ω-3 and ω-6 Fatty Acid Intake Among Breast Cancer Survivors. J Clin Oncol. 2012;30(12):1280-1287. doi:10.1200/JCO.2011.36.4109
  23. ↩ a Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Syst Rev. 2004;(2):CD002287. doi:10.1002/14651858.CD002287.pub2
  24. ↩ a Marx WM, Teleni L, McCarthy AL, et al. Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review. Nutr Rev. 2013;71(4):245-254. doi:10.1111/nure.12016
  25. ↩ a Shennan C, Payne S, Fenlon D. What is the evidence for the use of mindfulness-based interventions in cancer care? A review: Evidence for the use of mindfulness-based interventions. Psychooncology. 2011;20(7):681-697. doi:10.1002/pon.1819
  26. ↩ a Smith JE, Richardson J, Hoffman C, Pilkington K. Mindfulness-Based Stress Reduction as supportive therapy in cancer care: systematic review. J Adv Nurs. 2005;52(3):315-327. doi:10.1111/j.1365-2648.2005.03592.x
  27. ↩ a Vitale A. An integrative review of Reiki touch therapy research. Holist Nurs Pract. 2007;21(4):167-179; quiz 180-181. doi:10.1097/01.HNP.0000280927.83506.f6
  28. ↩ a Wayne PM, Lee MS, Novakowski J, et al. Tai Chi and Qigong for cancer-related symptoms and quality of life: a systematic review and meta-analysis. J Cancer Surviv Res Pract. 2018;12(2):256-267. doi:10.1007/s11764-017-0665-5
  29. ↩ a Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;1(1):CD010802. doi:10.1002/14651858.CD010802.pub2
  30. ↩ a Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of exercise interventions for people with Parkinson’s disease: a systematic review and meta-analysis. Mov Disord Off J Mov Disord Soc. 2008;23(5):631-640. doi:10.1002/mds.21922
  31. ↩ a Frenkel M, Abrams DI, Ladas EJ, et al. Integrating dietary supplements into cancer care. Integr Cancer Ther. 2013;12(5):369-384. doi:10.1177/1534735412473642
  32. ↩ a Sancar F. Oversight of Supplements. JAMA. 2019;321(11):1042. doi:10.1001/jama.2019.1937
  33. ↩ a Saper R. Integrative Medicine and Health Disparities. Glob Adv Health Med. 2016;5(1):5-8. doi:10.7453/gahmj.2015.133
  34. ↩ a Chao MT, Adler SR. Integrative Medicine and the Imperative for Health Justice. J Altern Complement Med N Y N. 2018;24(2):101-103. doi:10.1089/acm.2017.29042.mtc

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