Above photo: Massage therapy is a natural fit for the comfort-oriented goals of hospice and palliative care. Studies cite improvements in pain and anxiety (Havyer, 2022; Polubinski and West, 2005; Cassileth and Vickers, 2004). (Photo by Candice White.)
This was the experience that launched my career in palliative massage therapy. The year was 1999. Unbeknownst to me, the World Health Organization had, in 1990, declared palliative care as the global standard and a basic human right, not just for people with cancer, but also those with heart failure, lung disease, dementia, kidney and liver disease, brain disorders, brain injuries, and motor neuron illnesses such as Parkinson’s and ALS.
Palliative medicine is care that addresses the relief of suffering for people with life-limiting disease. Unlike hospice, which is available during the last months of life after curative care has been discontinued, palliative care can be received alongside treatment to address common symptoms such as pain, anxiety, shortness of breath, fluid overload, constipation, nausea and vomiting. Based on the hospice model, palliative care is holistic. The client’s emotional and spiritual needs are deemed no less important than their physical needs.
Palliative medicine is not new.
Even in the U.S., which has lagged behind other countries, palliative care has been a recognized medical specialty since 2006. But the shape of palliative care is changing. What is new is the now-urgent demand for providers of various specialties, including massage therapists, to hone our knowledge and skills as primary providers of palliative care.
In response to the strain imposed by COVID-19 on our health care system, experts are calling for palliative care training to be integrated as a fundamental competency for all health care providers, rather than a specialty provided by a small few who can no longer meet the demand. As the pandemic continues to divert health care resources, and as palliative care expands to support people earlier in their disease trajectories, the number of clients who need these services is growing exponentially. Every client we see, every loved one, every person we know, will eventually need palliative care. You are likely already providing massage for some of them.
Palliative care is a vast discipline with endless opportunities for education. It takes time and practice to cultivate true mastery and ease around working with people who are seriously ill. But in a post-COVID-19 world where all our efforts are needed, we can commit to developing a broad understanding of the adaptations that may be required of us. Below are a few ideas.
Palliative massage training is ideal, but oncology massage classes are more widely available and offer excellent preparation. The field of oncology massage has yielded useful adaptations that can be applied to other illnesses, including a five-point scale to describe massage pressure1,2.
Palliative massage makes liberal use of the two lightest pressures on the scale, levels 1 and 2.
• Level 1 is described as “light lotioning,” the minimum pressure needed to spread lotion across the skin.
• Level-2 pressure is described as “heavy lotioning,” the slightly deeper pressure needed to rub lotion into the skin. There may be marginal displacement of superficial muscle with level-2 pressure, but no displacement of joints or deeper tissue.
Knowledge of this pressure scale should become universal in our profession, as a common framework and language for quantifying safe pressure for any situation.
Oncology massage training addresses additional issues that pertain to many other diseases, including knowledge of edema and lymphedema, risk of blood clots and bleeding, bone health, skin issues and infection control. Massage therapists with credible expertise in these topics must become our mentors as we develop more nuanced literacy in these essential subjects.
We must also look to clinical colleagues to expand our learning, developing personal alliances with palliative care doctors, nurses and others. Palliative care organizations and conferences are typically open to massage therapists, and we should avail ourselves of these opportunities to learn, network and affirm our affiliation with these interdisciplinary teams.
Supportive positioning for a client in the inpatient palliative care setting, using five pillows. A pain score can often be reduced with mindful propping before the massage even begins. Massage for this client can be provided from three sides of the bed to the head, neck, shoulders, arms, hands, legs and feet. (Photo by Candice White.)
Many clients in palliative care will require adaptive positioning and propping for safety and comfort. Therapists will need to think outside the box of prone and supine positioning on a massage table with a bolster under the knees. Prone positioning, in fact, will be inaccessible to many people with advanced illness. Proficiency in side-lying position (which I first learned in a prenatal massage class), semi-reclining position, forward-leaning position, and variations of these must be integrated into our standard repertoire.
Pillows of varied sizes and rolled bath towels, hand towels and washcloths can be used to provide support for the natural curves of the body and to cushion vulnerable areas. One valuable source of learning about positioning and propping is the field of restorative yoga. Oncology and elder massage trainings typically address this topic as well.
A rolled washcloth fills space between the client’s neck and the pillow below, conveying a sense of “nesting.” Good propping can communicate to the nervous system that it is safe to let go. (Photo by Candice White.)
Therapists whose practices include home visits are urged to embrace alternatives to a massage table. Palliative care clients quickly learn that massage can feel just as good in a recliner or hospital bed as it does on a table. It will likely take massage therapists a little longer to learn to adapt their work accordingly, but it can be done with practice. Advantages include no setup or takedown time, no sheets to launder, and the fact that the client can fall asleep without being disturbed at the conclusion of the session.
A portable stool can be a useful tool for sessions in homes or facilities. Sitting to work, or raising the height of our clients to meet our hands, will curtail the use of the therapist’s body weight to achieve deep pressure, which is an absolute contraindication for palliative clients.
Therapists must, in fact, be willing to rethink every approach they learned in massage school. An example is the industry standard of a 60-minute massage session, which is often too much for a client in palliative care. The rigors of advanced disease and treatment might indicate a 45- or 50-minute session; clients with severe symptoms might tolerate 20 minutes or less.
Massage therapists at MD Anderson Cancer Center in Houston have observed that a 20-minute massage is adequate to achieve relaxation and satisfaction in most of their patients.3
Another skill for therapists to develop is the ability to work over clothing. While the application of an emollient lotion or cream is of great value to the distressed skin that often accompanies advanced disease, clients who are ill may be unable to dress or undress themselves, or they may be able to do these things but only with great effort.
One option for working over cloth is to use a double-sided piece of silk, which allows the hands to slide over fabric. A silk pillowcase can be adapted for this purpose. (Photo by Candice White.)
When the client’s energy is impaired, it may be preferable for palliative massage to be applied with lotion on accessible areas of skin, but otherwise with dry hands over the client’s clothing or gown. Massage can even be applied over or under a blanket if the client is cold.
Soft modalities such as Reiki, therapeutic touch, craniosacral therapy and aromatherapy are great additions to the therapist’s palliative tool kit, though almost any modality can be adapted for this work.
Palliative massage requires lighter pressure, slowing down and listening deeply. Holds are extremely calming, especially when the client has severe symptoms. Cradling the client’s head, holding the hand and shoulder, or cupping the heart with one hand on top of the body and the other hand underneath can provide the comforting sensation of being cradled.
The most important and perhaps the most difficult adaptation that therapists are required to make for palliative clients is to let go of the need to “fix” them. Palliative care requires us to surrender our ambitions and relax into simply being with another person. It is impossible to overstate the healing nature of this approach. Training, preparation and informed judgment are vital for professionals working with vulnerable people. But our expertise is always secondary to our humanity. Every client deserves to be seen as a whole person, rather than the sum of their broken parts.
While it is important for us to know how to adapt our massage techniques according to the needs of each palliative care client, much of this work is less about technique and more about caring connection. (Photo courtesy of Cindy Spence.)
It is not surprising that palliative care clients and their loved ones often embody highly activated nervous systems. The most caring thing we can do for them, and for ourselves, is to cultivate practices to stabilize our own nervous systems. Bringing our attention to the inhalation and exhalation, even briefly, may calm an unsettled mind and body, which can then serve to settle the mind and body of the person we are touching.
Any grounding practice—including prayer, a mantra, use of a protective talisman, or other contemplative ritual—can be helpful. Calm presence in the face of anxiety and fear may, in fact, be the biggest gift we have to offer our clients.
There has never been a more important time for massage therapists to offer our services to the world, a world which is demanding a more robust skill set. All of us have an opportunity to join hands with our health care colleagues across disciplines to make palliative care the new standard.
This article was adapted from “Palliative Touch: Massage for People at the End of Life,” by Cindy Spence. Copyright © Handspring Publishing 2023; reproduced with permission.
1. MacDonald G. Medicine Hands: Massage Therapy for People with Cancer. 2014. Third Ed. Findhorn, Scotland: Findhorn Press.
2. Walton T. Medical Conditions and Massage Therapy: a Decision Tree Approach. 2011. Baltimore: Lippincott Williams & Wilkins.
3. Walton T. “A healthy dose of hospital-based massage therapy.” 2013. Accessed July 2022: tracywalton.com/a-healthy-dose-of-massage-in-hospital-based-massage-therapy.
Cindy Spence 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.
The news was not good. The cancer was widespread. All my father-in-law asked of me was to locate a therapist who could provide massage for him. It sounded so simple. But it was not. Phone call after phone call, I was told no. No because he was “too sick.” No because “massage is contraindicated for people with cancer.” No because “that’s not the kind of massage I do.”
This was the experience that launched my career in palliative massage therapy. The year was 1999. Unbeknownst to me, the World Health Organization had, in 1990, declared palliative care as the global standard and a basic human right, not just for people with cancer, but also those with heart failure, lung disease, dementia, kidney and liver disease, brain disorders, brain injuries, and motor neuron illnesses such as Parkinson’s and ALS.
Palliative medicine is care that addresses the relief of suffering for people with life-limiting disease. Unlike hospice, which is available during the last months of life after curative care has been discontinued, palliative care can be received alongside treatment to address common symptoms such as pain, anxiety, shortness of breath, fluid overload, constipation, nausea and vomiting. Based on the hospice model, palliative care is holistic. The client’s emotional and spiritual needs are deemed no less important than their physical needs.
Palliative medicine is not new.
Even in the U.S., which has lagged behind other countries, palliative care has been a recognized medical specialty since 2006. But the shape of palliative care is changing. What is new is the now-urgent demand for providers of various specialties, including massage therapists, to hone our knowledge and skills as primary providers of palliative care.
In response to the strain imposed by COVID-19 on our health care system, experts are calling for palliative care training to be integrated as a fundamental competency for all health care providers, rather than a specialty provided by a small few who can no longer meet the demand. As the pandemic continues to divert health care resources, and as palliative care expands to support people earlier in their disease trajectories, the number of clients who need these services is growing exponentially. Every client we see, every loved one, every person we know, will eventually need palliative care. You are likely already providing massage for some of them.
What Can We Do?
Palliative care is a vast discipline with endless opportunities for education. It takes time and practice to cultivate true mastery and ease around working with people who are seriously ill. But in a post-COVID-19 world where all our efforts are needed, we can commit to developing a broad understanding of the adaptations that may be required of us. Below are a few ideas.
• Pick your next CEs with palliative care in mind.
Palliative massage training is ideal, but oncology massage classes are more widely available and offer excellent preparation. The field of oncology massage has yielded useful adaptations that can be applied to other illnesses, including a five-point scale to describe massage pressure1,2.
Palliative massage makes liberal use of the two lightest pressures on the scale, levels 1 and 2.
• Level 1 is described as “light lotioning,” the minimum pressure needed to spread lotion across the skin.
• Level-2 pressure is described as “heavy lotioning,” the slightly deeper pressure needed to rub lotion into the skin. There may be marginal displacement of superficial muscle with level-2 pressure, but no displacement of joints or deeper tissue.
Knowledge of this pressure scale should become universal in our profession, as a common framework and language for quantifying safe pressure for any situation.
Oncology massage training addresses additional issues that pertain to many other diseases, including knowledge of edema and lymphedema, risk of blood clots and bleeding, bone health, skin issues and infection control. Massage therapists with credible expertise in these topics must become our mentors as we develop more nuanced literacy in these essential subjects.
We must also look to clinical colleagues to expand our learning, developing personal alliances with palliative care doctors, nurses and others. Palliative care organizations and conferences are typically open to massage therapists, and we should avail ourselves of these opportunities to learn, network and affirm our affiliation with these interdisciplinary teams.
Supportive positioning for a client in the inpatient palliative care setting, using five pillows. A pain score can often be reduced with mindful propping before the massage even begins. Massage for this client can be provided from three sides of the bed to the head, neck, shoulders, arms, hands, legs and feet. (Photo by Candice White.)
• Approach positioning and propping with creativity.
Many clients in palliative care will require adaptive positioning and propping for safety and comfort. Therapists will need to think outside the box of prone and supine positioning on a massage table with a bolster under the knees. Prone positioning, in fact, will be inaccessible to many people with advanced illness. Proficiency in side-lying position (which I first learned in a prenatal massage class), semi-reclining position, forward-leaning position, and variations of these must be integrated into our standard repertoire.
Pillows of varied sizes and rolled bath towels, hand towels and washcloths can be used to provide support for the natural curves of the body and to cushion vulnerable areas. One valuable source of learning about positioning and propping is the field of restorative yoga. Oncology and elder massage trainings typically address this topic as well.
A rolled washcloth fills space between the client’s neck and the pillow below, conveying a sense of “nesting.” Good propping can communicate to the nervous system that it is safe to let go. (Photo by Candice White.)
Therapists whose practices include home visits are urged to embrace alternatives to a massage table. Palliative care clients quickly learn that massage can feel just as good in a recliner or hospital bed as it does on a table. It will likely take massage therapists a little longer to learn to adapt their work accordingly, but it can be done with practice. Advantages include no setup or takedown time, no sheets to launder, and the fact that the client can fall asleep without being disturbed at the conclusion of the session.
A portable stool can be a useful tool for sessions in homes or facilities. Sitting to work, or raising the height of our clients to meet our hands, will curtail the use of the therapist’s body weight to achieve deep pressure, which is an absolute contraindication for palliative clients.
• Be flexible.
Therapists must, in fact, be willing to rethink every approach they learned in massage school. An example is the industry standard of a 60-minute massage session, which is often too much for a client in palliative care. The rigors of advanced disease and treatment might indicate a 45- or 50-minute session; clients with severe symptoms might tolerate 20 minutes or less.
Massage therapists at MD Anderson Cancer Center in Houston have observed that a 20-minute massage is adequate to achieve relaxation and satisfaction in most of their patients.3
Another skill for therapists to develop is the ability to work over clothing. While the application of an emollient lotion or cream is of great value to the distressed skin that often accompanies advanced disease, clients who are ill may be unable to dress or undress themselves, or they may be able to do these things but only with great effort.
One option for working over cloth is to use a double-sided piece of silk, which allows the hands to slide over fabric. A silk pillowcase can be adapted for this purpose. (Photo by Candice White.)
When the client’s energy is impaired, it may be preferable for palliative massage to be applied with lotion on accessible areas of skin, but otherwise with dry hands over the client’s clothing or gown. Massage can even be applied over or under a blanket if the client is cold.
• Add some soft skills to your toolbox.
Soft modalities such as Reiki, therapeutic touch, craniosacral therapy and aromatherapy are great additions to the therapist’s palliative tool kit, though almost any modality can be adapted for this work.
Palliative massage requires lighter pressure, slowing down and listening deeply. Holds are extremely calming, especially when the client has severe symptoms. Cradling the client’s head, holding the hand and shoulder, or cupping the heart with one hand on top of the body and the other hand underneath can provide the comforting sensation of being cradled.
The most important and perhaps the most difficult adaptation that therapists are required to make for palliative clients is to let go of the need to “fix” them. Palliative care requires us to surrender our ambitions and relax into simply being with another person. It is impossible to overstate the healing nature of this approach. Training, preparation and informed judgment are vital for professionals working with vulnerable people. But our expertise is always secondary to our humanity. Every client deserves to be seen as a whole person, rather than the sum of their broken parts.
While it is important for us to know how to adapt our massage techniques according to the needs of each palliative care client, much of this work is less about technique and more about caring connection. (Photo courtesy of Cindy Spence.)
• Learn to calm your own nervous system.
It is not surprising that palliative care clients and their loved ones often embody highly activated nervous systems. The most caring thing we can do for them, and for ourselves, is to cultivate practices to stabilize our own nervous systems. Bringing our attention to the inhalation and exhalation, even briefly, may calm an unsettled mind and body, which can then serve to settle the mind and body of the person we are touching.
Any grounding practice—including prayer, a mantra, use of a protective talisman, or other contemplative ritual—can be helpful. Calm presence in the face of anxiety and fear may, in fact, be the biggest gift we have to offer our clients.
There has never been a more important time for massage therapists to offer our services to the world, a world which is demanding a more robust skill set. All of us have an opportunity to join hands with our health care colleagues across disciplines to make palliative care the new standard.
This article was adapted from “Palliative Touch: Massage for People at the End of Life,” by Cindy Spence. Copyright © Handspring Publishing 2023; reproduced with permission.
Footnotes
1. MacDonald G. Medicine Hands: Massage Therapy for People with Cancer. 2014. Third Ed. Findhorn, Scotland: Findhorn Press.
2. Walton T. Medical Conditions and Massage Therapy: a Decision Tree Approach. 2011. Baltimore: Lippincott Williams & Wilkins.
3. Walton T. “A healthy dose of hospital-based massage therapy.” 2013. Accessed July 2022: tracywalton.com/a-healthy-dose-of-massage-in-hospital-based-massage-therapy.
About the Author
Cindy Spence 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.
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