The word palliate comes from the Latin palliare, meaning to conceal, or to cover with a cloak.1 In the context of health care, a palliative approach is one that alleviates symptoms without curing disease. In a sense, all massage therapy is palliative care. Skilled touch cannot cure disease, but has significant potential to reduce distressing symptoms, including shortness of breath.
What Causes Shortness of Breath?
The medical term for shortness of breath is dyspnea, a common and extremely distressing symptom that can accompany many conditions, including primary lung cancer, cancers that metastasize to the lungs from elsewhere in the body, chronic obstructive pulmonary disease, pulmonary fibrosis, cystic fibrosis, amyotrophic lateral sclerosis (ALS) and long COVID.
Dyspnea can also occur in advanced diseases that cause fluid to collect in the torso, such as heart, renal or liver failure. Any end-stage disease can ultimately cause shortness of breath, as the body’s O2 and CO2 receptors begin to fail during the dying process.
Signs and Symptoms Relate to Dyspnea
The burdens of dyspnea are related to poor oxygenation, fluid overload, the labor of breathing and side effects of treatment. These are likely to result in at least several of the following:
• Coughing, wheezing
• Impaired sleep
• Fatigue that severely limits activity
• Frequent respiratory infections
• Pain in the accessory muscles, including the pectorals, scalenes, trapezius, intercostals and muscles of the arms
• Abdominal swelling (called ascites)
• Edema in the lower extremities
• Easy bruising, skin tears, slow wound healing
• Blue skin, lips, or fingertips, known as cyanosis
• Rounded or clubbed fingers and toes
• Change in appetite, weight loss
• Possible confusion from low oxygenation, also known as hypoxia
• Jitters or tremors during or immediately following breathing treatments
• Anxiety. Agitation
• Depression
Coughing in some cases is severe enough to result in rib fractures that may be asymptomatic or quite painful. Fatigue can be so extreme that the affected person is confined to a chair-to-bed existence. But it is the frightening nature of air hunger that is likely the most distressing aspect of dyspnea. End-stage patients may endure episodic breathing crises and related trips to the emergency room.2 There may be fear of a death that involves suffocation or drowning in secretions.
Medical Interventions
Given the profound symptom burden and related anxiety that clients with dyspnea experience, palliative care is ideal at an early stage of disease. Many palliative and hospice care teams include a respiratory therapist to assist with symptom management. Interventions are aimed at opening the airway, reducing inflammation, and managing excess fluid. Common strategies include:
• Corticosteroid medications, such as dexamethasone (Decadron) to dilate the bronchial tubes. Sometimes steroids are delivered in mist form through breathing treatments with a nebulizer. Side effects include insomnia, agitation, tremors, reduced immune function, easy bruising, and thinning skin with chronic use.
• Diuretics, such as furosemide (Lasix) can help reduce congestion, ascites, and edema. Potential side effects include gastrointestinal symptoms, low blood pressure, dizziness, and urinary frequency.
• Thoracentesis and paracentesis are procedures involving the use of a needle to drain fluids from the chest or abdomen. Though relief can be immediate, the fluid often returns quickly and increases in volume following attempts to remove it. For this reason, drains may be left in place permanently, creating a risk of infection.
• Palliative care often includes a small dose of an opioid, typically morphine, to reduce the sensation of air hunger. Side effects include altered sensation and sedation.
• Benzodiazepines are sometimes added to relieve anxiety related to shortness of breath, including diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax). Side effects include altered sensation and sedation.
• Supplemental oxygen is indispensable to some people, but less helpful to others. Interfaces range from a small nasal cannula (with flexible rubber prongs that rest inside the nostrils), to a nasal pillow (soft plugs that seal the nostrils), to a partial or full face mask (called BiPAP) that delivers pressurized air. Potential side effects include nasal dryness, skin irritation, and bruising at points of contact with tubing or mask. Some people on BiPAP experience claustrophobia.
Adapting Massage to Address Dyspnea
There are many nonmedical approaches to dyspnea that massage therapists can support. Cool room air and energy conservation (avoiding unnecessary exertion such as relocating for massage) are ways to reduce respiratory demands.
Patients are often taught the pursed breathing technique, which involves inhaling slowly through the nose for a count of two, then exhaling for a longer count through puckered lips, as if blowing out a candle.
Sitting upright or leaning forward expands the diaphragm, which decreases the work of breathing. Therapists should be sensitive to the needs of clients on a diuretic who may need quick access to a toilet or bedpan during the session.
A summary of these and other recommendations appear below:
• Patients with respiratory distress will be unable to lie flat. A comfortable chair, recliner, or hospital bed with the head raised will likely be most comfortable. If a massage table is used, pillows can be placed under the fitted sheet to elevate the client’s upper body. Every body part should be supported for maximum relaxation.
• Patients often prefer cool, circulating air and to be uncovered. A small fan directed at the face triggers O2 receptors in the forehead and cheeks.
• Assist clients to conserve energy according to activities that cause shortness of breath. This may include working on the client wherever found and reducing conversation during the session.
• Therapists should develop proficiency in the five-point pressure scale from the field of oncology massage.3,4 Level-2 pressure, described as heavy lotioning or the amount of pressure required to rub lotion into the skin, is usually well tolerated by clients with dyspnea. Level-1 pressure, light lotioning, or the minimum pressure needed to spread lotion across the skin, is indicated for clients with easy bruising.
• Level-1 and level-2 massage can provide relief to accessory muscles that are working overtime in the dyspneic client, including the pectoralis major and minor, latissimus dorsi, serratus anterior and posterior, scalenes, sternocleidomastoid and intercostals.
• Strokes toward the heart will support venous return, but the intent is to provide comfort, not to move fluid. Any client who cannot lie flat due to dyspnea is a poor candidate for manual lymphatic drainage.
• For O2-dependent patients, gentle fingertip massage around the head, face and neck can provide relief from mask, straps and O2 tubing. A water-based gel can soothe dry nasal passages.
• Some patients are helped by gentle tapotement (light taps with the fingertips, no greater than level-2 pressure) applied over the posterior lungs.
• Reflex points for the lungs are located in the ball of the foot and at the base of the fingers. Static or circular pressure to these areas can be comforting.
• Use of noise-cancelling ear buds with preferred music can be a way for clients to escape the sound of the oxygen machine. This can be especially nice during a massage.
• Therapists should be aware that people with dyspnea are often at increased risk of falls. Patient transfers, the height of the hospital bed, and bedrails (if used) should be monitored accordingly.
• Use caution not to step on or pull O2 tubing.
• People on supplemental oxygen should not smoke or allow anyone near them to smoke, including e-cigarettes and vape pens. O2 canisters should remain ten feet away from open flames and five feet from electrical appliances that could produce a spark.
• Oil-based lotions and balms are used in many palliative care environments for their lubricating properties and superior function as a moisture barrier. These products do not present a fire hazard so long as no flame or spark is introduced.
• Avoid sites with indwelling drainage tubes, if present, due to risk of infection.
Benefits to the Palliative Client
Palliative care is, by definition, a team endeavor provided by an interdisciplinary group of professionals whose combined experience is aimed at optimizing the physical, mental, emotional and spiritual well-being of the affected individual. Massage therapists have valuable contributions to make as members of the care team to address dyspnea and other symptoms of disease.
Any intervention that reduces anxiety, including massage, will have a beneficial impact on the palliative client.
Footnotes
1. Moore R, 2017. “Strengthening the presence of massage therapy in palliative care.” Massage & Myotherapy Journal. 2017; [e-journal] (1), pp.14-19.
2. Ross J, Sanchez-Reilly S, 2018. Hospice criteria card.
3. MacDonald G. Medicine Hands: Massage Therapy for People with Cancer. 3rd ed. 2014. Findhorn, Scotland: Findhorn Press.
4. Walton T. Medical Conditions and Massage Therapy: a Decision Tree Approach. 2011. Baltimore: Lippincott Williams & Wilkins.
This article was excerpted by permission from “Palliative Touch: Massage for People at the End of Life.” Copyright © Handspring Publishing 2023. Reprinted with permission. This article may not be reproduced for any other use without permission.
About the Author
Cindy Spence, MPH, LMT, has been a massage therapist specializing in palliative care since 1999, after her father-in-law’s dying wish for gentle touch inspired her to attend massage school. With her teaching partner, Susan Gee, Cindy offers a 20-hour CE class, Clinical Skills for End-of-Life Massage, for massage therapists, nurses and other health care professionals.