Integrative Healthcare: Caring for the Whole Patient

Gwen Wyatt, PhD, RN, FAAN

Gwen Wyatt, PhD, RN, FAAN

More people than ever are using complementary and integrative therapies (CIT) to manage their illnesses in addition to conventional treatments. A study published in 2011 found that about 53% of American adults used CIT at some point in their lifetime, and 42% said they used it within the past year. People with cancer reported even higher use: 65% of cancer survivors used CIT at some point, and 43% used it within the past year.¹

The five modalities of complementary therapies include mind-body, manipulative and body-based, biologically-based, energy, and alternative medical systems. According to Gwen Wyatt, PhD, RN, FAAN, the most common types of CIT oncology nurses hear about from their patients are those of the mind-body modality. These therapies, such as meditation, mindfulness, and yoga, are often helpful for the patient and have very low risk, Wyatt, a professor at the College of Nursing at Michigan State University in East Lansing, explained. Manipulative and body-based therapies, such as reflexology and acupressure, are also considered fairly low risk, Wyatt noted. “We have increasing evidence of their efficacy,” but, she added, assessments should be made regarding how appropriate each therapy would be for individual patients.

When speaking with patients about possible therapies, nurses must weigh the potential benefits versus the potential risks. For example, while yoga may help a patient with relaxation or flexibility, a deep tissue massage could be harmful if that patient had low platelets.

From the patients’ perspective, their preference for mind-body modalities is likely because these therapies are noninvasive, Rebecca Lehto, PhD, RN, said. “They don’t involve ingesting substances, such as herbs, vitamins, or supplements, and they don’t involve needles.” In addition, if the patients are receiving treatment at a cancer center that offers integrative healthcare or has an integrative health department, these are the types of therapies predominantly offered. In addition to supporting oncology patients, many of these departments are also involved in CIT clinical research.

Mind—body therapies such as meditation are very portable. As the patients learn the techniques and how to use them, they can be practiced while sitting in treatment waiting rooms, for example, Lehto explained. “Patients can experience real benefits over time.” Lehto is an associate professor at the College of Nursing at Michigan State.

Identifying the Patients’ Therapy Goals

Patients often depend on their nurses for information about available treatments and therapies, including complementary therapies. This fits in well with the nursing focus on a holistic approach to patient care, Lehto said.

“We want to integrate the whole person into nursing care. One thing about integrative modalities is that they’re framed to address quality-of-life issues and perhaps improve emotional symptoms that a patient might be experiencing, as well as to potentially impact patient function,” she continued. “These kinds of parameters are so essential to a patient’s well-being, as well as for personal empowerment.” Just as not all patients receive the same medical treatment, their approaches to and needs for complementary therapies differ. By discussing the issues with their patients, nurses can determine what types of therapies might be of benefit to them.

To start, it’s vital to determine if their patients’ goals are realistic. “If they’re looking for something that is going to cure their cancer, we don’t have any complementary therapies that have shown the same type of efficacy as conventional treatment,” Lynda G. Balneaves, PhD, RN, said.

Rebecca Lehto, PhD, RN

Rebecca Lehto, PhD, RN

Are they looking for relief of physical issues, such as fatigue, nausea, or pain? Or are they trying to deal with depression or anxiety? Or both? Determining if they have used complementary therapies in the past and the outcome is also helpful. Balneaves is the Director for the Center for Integrative Medicine at the University of Toronto in Canada.

Balneaves also pointed out that a difficulty faced by many nurses is finding the time to speak to their patients about these issues. “To me, the biggest challenge is time, and for nurses, being able to find time in their busy practices to actually sit down with the patients and ask them about their beliefs and values, and what they’re most interested in learning about.”

Finding the Right Resources

When asked for referrals, nurses may find themselves unsure of how to proceed, particularly if they work in smaller communities with limited resources.

“When I consult with health agencies, I encourage them to do an investigation of the local practitioners and to have a list within the facility of the ones who have been checked out in terms of their credentials and their ability to work with patients with various conditions,” Wyatt said.

“I’m always looking for those that are sensitive to cancer diagnosis, because some work only with patients who have arthritis, for example. So you have to have practitioners who are familiar with patients who have the diagnosis, and who have certification or a license if it is available in that therapy. These are the types of things that need to be considered.”

Unfortunately, this type of information is not always available. “It’s time-consuming and expensive to do a full community assessment of which therapists and practitioners in the community are really providing the services that they market, and that they are qualified to provide the services,” Wyatt acknowledged.

There is a good bit of information on integrative health available online, as several websites are dedicated to the topic. However, it’s vital that nurses know which sites are safe for their patients and which should be avoided.

Websites like the National Center for Complementary and Integrative Health and the Complementary and Integrative Medicine section of MedlinePlus, which are federal government sites, are safe sites for patients to explore, as are major hospital and healthcare system sites.

Nurses may want to suggest to their patients that they download a workbook made available through the National Cancer Institute: Talking about Complementary and Alternative Medicine with Health Care Providers: A Workbook and Tips. This workbook contains documents that your patients can use to keep track of their CIT use and their providers, as well as their conventional medical therapy. There is also a glossary and cancer CIT resources. The workbook reviews types of questions patients should ask their healthcare providers and gives the reader other resources. A document like this can give nurses and patients a foundation on which to base their discussions.

Lynda G. Balneaves, PhD, RN

Lynda G. Balneaves, PhD, RN

No Secrets

There is some secrecy involved in CIT use on behalf of many oncology patients. A 2012 study looked at 305 patients who were receiving radiation therapy. A total of 43.6% of the study participants reported using CIT, but only 12.1% of the patients said that they had discussed their CIT use with their radiation oncologist, and only 11.1% mentioned it to their medical oncologist.²

Nurses must support disclosure, Balneaves said. “Nurses are in a really great position of trust. Patients will often open up to us, so we have to make sure that we don’t shut down that dialogue. It’s important that we start acknowledging complementary therapies as a reality in many patients’ lives and ensuring that we’re considering their whole care plan.”

Wyatt said that the best thing is to be straightforward with the patients who are reluctant to discuss CIT use with their physician. “Some of the therapies can actually interfere with the medical treatments. So if the medical practitioner understands what else the patients are doing, then they can adjust or give them advice so that the patients can see that it’s to their advantage to inform their health providers of what they’re doing.”

It is for this reason that nursing assessments of oncology patients should include more than the standard overview. “We have to get to the point that the assessments we do on patients when they come into the clinic are not just about blood pressure and pulse, but also about what therapies they are using,” Wyatt said. If such discussions become part of the regular routine, patients may feel more comfortable talking about CIT.

Keeping up to date on CIT research is another part of working with oncology patients. There are several resources online for nurses that review the use of integrative therapies in supportive care. In 2014, the Journal of the National Cancer Institute published clinical practice guidelines regarding integrative therapy for patients who have breast cancer.³ While the researchers concluded that more well-designed controlled trials were needed regarding CIT and its benefits, they found that therapies such as meditation, yoga, and massage, were appropriate for patients who were seeking to manage stress, anxiety, depression, and fatigue.

A year earlier, the American College of Chest Physicians published evidence-based clinical practice guidelines on complementary therapies and lung cancer.4 The researchers also concluded that certain types of complementary therapies, such as acupuncture, mind-body therapies, exercise, and massage, should be integrated with standard oncology care, and that such therapies could help patients manage symptoms such as anxiety, mood disturbances, pain, quality of life, and treatment-related side effects.

Nurses are also encouraged to do their own research to match their patients’ requests and interests. The NCI has a database, where nurses can find links to sites for research articles on CIT in scientific journals, the Cochrane Library, a directory of health organizations and research resources, and information on ongoing clinical trials. The site also has a link to CIT therapies, from A to Z, which offers an exhaustive list of therapies, some which nurses may never have heard of.

Breaking Down the Barriers

Barriers to use of integrative medicine among some healthcare professionals persist, however.

Wyatt encourages nurses to have an open mind to complementary therapies. “There are oftentimes barriers to professional thinking about complementary therapies, because they are not all well integrated into nursing programs, and certainly not into all medical programs,” she said.

“There always tends to be a bit of fear around something that people don’t understand well. I would encourage nurses to really enjoy the literature that’s out there and available about evidence-based practice in the area of complementary therapies, so they become better informed themselves and they can better answer their patients’ questions.”

Resources for Practitioners

National Center for Complementary and Integrative Health

nccih.nih.gov/health/integrative-health

Medline Plus: Complementary and Integrative Medicine

http://1.usa.gov/1NYaJnV

Office of Cancer Complementary and Alternative Medicine (OCCAM)

• Talking About CAM…A Workbook and Tips https://cam.cancer.gov/health_information/talking_about_cam.htm

• OCCAM Databases https://cam.cancer.gov

• CAM Therapies: A-Z https://cam.cancer.gov/health_information/cam_therapies_a-z.htm

Marijke Vroomen Durning, RN, is a freelance writer who specializes in patient education, and health and wellness topics.

REFERENCES

1. Mao JJ, Palmer CS, Healy KE, et al. Complementary and alternative medicine use among cancer survivors: a population-based study. J Cancer Surviv. 2011;5(1):8-17.

2. Ge J, Fishman J, Vapiwala N, et al. Patient-physician communication about complementary and alternative medicine in a radiation oncology setting. Int J Radiat Oncol Biol Phys. 2013;85(1):e1—e6.

3. Greenlee H, Balneaves L, Carlson LE, et al. Clinical practice guide- lines on the use of integrative therapies as supportive care in patients treated for breast cancer. J Natl Cancer Inst Monogr. 2014;(50):346- 358.

4. Deng GE, Rausch SM, Jones LW, et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer. Chest. 2013;143(suppl 5):e420S-e436S.