The Utilization of Aromatherapy in Hospice Settings

hospice care, aromatherapy, essential oils, aromatherapy certification, essential oil classes

     Hospice is a Medicare, Medicaid (Medi-cal) or private insurance benefit that is available upon the written order of a licensed physician. A licensed physician will recommend that an individual consider hospice services due to an illness that is terminal; a terminal illness whereby there is no additional treatment that will cure the disease or illness. In addition, the individual decides that they no longer want to seek aggressive treatment, but instead they want to seek care that will provide comfort in their last months, weeks or days of life. When hospice becomes a part of a patient’s plan of care and per the Medicare guidelines, the patient is expected to die within 6 months if the terminal diagnosis runs its normal course.  When an individual and/or family elect to utilize hospice services it is very common and expected that the patient and family will experience an array of physical, emotional, mental and spiritual “ups and downs”. As a result, hospice services are available 24 hours a day, 7 days a week and to meet the needs of the physical, emotional, mental and spiritual “ups and downs” experienced by patients and their families, hospice offers the professional services and care from registered and vocational nurses, medical social workers, chaplains, volunteers, bereavement coordinators and health aids (for bathing/grooming tasks); disciplines working together and under the supervision of a medical director and per the patients plan of care that has been implemented the interdisciplinary team (that includes the patient and family). Each discipline contributes to a holistic approach in servicing families and helping each individual (patient and family) cope as best as can be expected under the circumstances while offering great support. 

Although hospice care was originally created for those with cancer, it is now common that hospice care includes terminal illness such as Alzheimer’s, dementia, AIDS, lung disease, heart disease, calorie malnutrition, end stage diabetes, ALS, liver disease, renal failure, stroke and more. The focus and goal of hospice services is to provide a quality of life to patients and their families to include comfort when it is most important.  Implementing aromatherapy as a complimentary modality can help achieve this focus and goal.

What is aromatherapy?

     The English word ‘aromatherapy’ is derived from the French word ‘aromatherapie’ which was first coined by the French chemist Gattefosse in the 1930’s (The Complete Guide to Aromatherapy, Battaglia, 2003). Aromatherapy is the extraction of essential oils via aromatic plants that help promote therapeutic benefits to one’s mental, physical and emotional balance and well-being. There is evidence that over some 4,000 years ago, the Ancient Sumerians made use of scented herbs such as cypress and myrrh, while in the 1870’s, George Ebers discovered a 21-metre (70-foot) scroll of papyrus that listed over 850 Ancient Egyptian botanical remedies dating from about 1500 BC. (Mojay, Gabriel “Aromatherapy for Healing the Spirit”, 1997).  

     Essential oils are comprised of varying chemical families and constituents that include Monoterpenes, Sesquiterpenes, Monoterpenols, Sesquiterpenols, Esters, Oxides, Phenols, Ketones, Ethers and Aldehydes. Each of these chemical families and their constituents offer an array of therapeutic benefits such as helping with pain, respiratory distress, depression, anxiety, grief and bereavement, insomnia, nausea, behavioral disorders, infections, wounds and more. When essential oils are used in a safe manner based upon their chemical benefits, essential oils can be of great help in promoting homeostasis. 

     Essential oils are central to Aromatherapy and the therapeutic benefits the oils and chemical properties offer and provide. But equally important is how the essential oils are applied and/or absorbed into the body. One of the fastest and most effective ways for individuals to benefit from aromatic, therapeutic properties is via the olfactory system via inhalation.  However, applying essential oils on the skin with a fat-soluble compound is just as effective (Rhind, Jennifer “Essential Oils: A Handbook for Aromatherapy Practice”, 2012).

     Implementing aromatherapy into hospice can be of great benefit when offering a holistic approach and treating the mind, spirit and body to patients and their caregivers.  In fact, according to “National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care”, 2003, The Directory of Complementary Therapy Services in UK Cancer Care produced by Mcmillan Cancer Relief showed a widespread use of complimentary therapies among hospices and hospitals with massage (76 units and aromatherapy (73 units) were the most popular therapies (pg. 11). 

Aromatherapy Interventions in Hospice Care

     As I have worked in hospice for nearly 10 years as a medical social worker I have observed common characteristics among the death and dying. Some of these characteristics include, but not limited to physical distress: pain, insomnia/fatigue, feelings of nausea/vomiting, shortness of breath and skin problems (wounds, dry skin, thin skin, bruising); psychological distress: grief (shock, bargaining), anxiety, fear, helplessness, anger, guilt, depression, frustration/agitation, increased feelings of worry and/or concern for others and hopelessness; and spiritual distress: fear of the afterlife, guilt, unresolved grief, the desire to want to be baptized and forgiveness.  For the purposes of this research paper, I will focus on physical and psychological distress.

Physical Distress

     The utmost goal of hospice is to achieve comfort for the patient; comfort that aids in managed pain, decreased insomnia/fatigue, feelings of nausea/vomiting and shortness of breath. The use of a variety Western medications are incorporated into the patient’s plan of care for managed pain and includes Acetaminophen (Tylenol) and Norco to more effective pain relief of MS Contin, Morphine and the use of a Fentanyl Patch.  In addition to managing pain, hospice professionals also want to manage physical distress associated with insomnia/fatigue (typical medications include Trazodone, Lorazepam), nausea/vomiting ( typical medication includes Compazine) and shortness of breath (typical medications include Morphine, Albuterol, Oxygen) ~ all which cause patients to have feelings of distress. The table below lists just a few essential oils that would help in providing comfort and balance for the various symptoms of physical distress, including the chemical constituent and therapeutic property (Institute of Holistic Phyto-Aromatherapy, 2017):

     

Essential Oil Chemical Constituent Therapeutic Property
  • Sweet Marjoram (Origanum majorana)
  • Monoterpene/Monoterpenol
  • Calming to the nervous system, analgesic for aching muscles, antispasmodic, stomachic
  • Juniper Berry (Juniperus communis)
  • Monoterpene
  • Helpful for painful joints and insomnia, anti-spasmodic, stomachic, nervous system
  • Roman Chamomile (Anthemis nobilis)
  • Ester
  • Sedative, anti-inflammatory, analgesic, stomachic
  • Lavender (Lavandulal angustifolia)
  • Ester
  • Analgesic, sedative, calming, anti-inflammatory
  • Neroli (Citrus aurantium var. amara)
  • Monoterpene/Monoterpenol
  • Antispasmodic, sedative, digestive system
  • Birch (Betula lenta)
  • Ester
  • Analgesic, muscle pain (caution with blood thinning medications)
  • Kunzea (Kunzea ambigua)
  • Monoterpene
  • Analgesic, calming to CNS
  • Plai, Wild (Zingiber cassumunar)
  • Monoterpene/Monoterpenol
  • Analgesic, anti-inflammatory, extended pain relief (for up to 12 hours)
  • Inula (Inula graveolens)
  • Sesquiterpene
  • Analgesic, anti-inflammatory, antispasmodic, respiratory system

     Over the years, I have observed patients and families use the Western medications, at times, with reluctance, but know no other alternative to obtain the desired quality of life. The verbalized reluctance is typically due to the side effects of increased drowsiness, lethargy, disorientation, loss of appetite, increased constipation and their belief that using the more effective pain medications, such as Morphine, will speed up the dying process.  As a result, when patients and families have reservations, but still want comfort from the physical distressors, the implementation of Aromatherapy and essential oils would offer a great alternative and modality to the patient’s plan of care.  

     When patients exhibit signs and symptoms of unmanaged pain, insomnia and other physical distress, I have observed that such physical distress directly affects psychological characteristics of patients. According to Price and Price (2012), Twycross and Lack (1984), the perception of pain is exacerbated by the patient’s mood and moral.  

Psychological Distress

     Hospice patients and their families, often experience psychological distress that includes anxiety, anger, depression, worry/concern, frustration, feelings of hopelessness, forgetfulness, confusion and  disorientation, especially when combined with the side effects of taking Western medications.  The chart below illustrates the biopsychosocial model of pain and consequences on the quality of life during a patient’s time of coping with their terminal illness.

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     The use of a variety of Western medications that are commonly used in hospice to help patients decrease their feelings of anxiety, depression, anger, feelings of hopelessness, worry and concern are Ativan and Lorazepam (anxiety, nervousness, concern worry) and Risperidone and Prozac (depression, worry, anger). Once a hospice patient’s pain and psychological distress is managed, the hospice patient begins to experience homeostasis and quality of life during the final months, weeks or days of their life.  Of course, just like there are side effects of Western pain medications, there are also side effects of medications for psychological distress. Again, this is where hospice professionals have an opportunity to offer alternative, complimentary therapies to assist with psychological distress while minimizing the side effects of Western medications. The table below lists a few essential oils that can aid in the psychological distressors mentioned above (Institute of Holistic Phyto-Aromatherapy, 2017); (Aromatherapy for Health Professionals, 2012):

Essential Oil Chemical Constituent Therapeutic Purpose
  • Roman Chamomile
  • Ester
  • Calming to CNS, recommended for anxiety, stress, depression
  • Elemi (Canarium luzonicum)
  • Monoterpene
  • Meditative, calming, energizing
  • Ylang Ylang (Cananga odorata)
  • Sesquiterpene
  • Ideal for treating nervous depression, feelings of anger, frustration, sedative
  • Neroli (Citrus aurantium var amara)
  • Monoterpenol
  • Mandarin (Citrus reticulate var mandarin)
  • Monoterpene
  • Uplifting, anti-depressant, anti-anxiety, sedative
  • Rose Otto (Rosa damascene)
  • Monoterpenol
  • Anti-depressant, calming to CNS, soothing anger, fear and anxiety
  • Frankincense (Boswellia carteri)
  • Monoterpene
  • Relieves nervous disorders such as anxiety
  • Lavender (Lavandula angustifolia)
  • Ester
  • Anti-depressant, CNS desative, reduces nervous disorders, relieves anxiety

     In addition to the above psychological distress, patients may exhibit, what is known as “terminal agitation”.  Symptoms of terminal agitation include that of increased anxiety, agitation, yelling and/or striking out, delirium behavior and restlessness/insomnia. This is a very difficult time, not only for the patient who is psychologically and physically uncomfortable, but also for the caregiver, who is, most likely sleep deprived, stressed, anxious and tearful. According to Today’s Geriatric Medicine (Weihbrecht, Linda), essential oils that will assist with reducing terminal agitation includes Lavender (Lavandula angustifolia), Sandalwood (Santalum album) and Frankincense (Boswellia carterii). It may be a good idea to use a diffuser in this case so that the caregiver can benefit from the oils as well. 

aromatherapy diffuser, hospice care, aromatherapy certification, essential oil classes

Evidence Based Research

     Many healthcare institutions are utilizing aromatherapy and essential oils into their daily practice of services. Studies show that essential oils relieve stress and anxiety for patients and caregivers/staff and essential oils can reduce pain and facilitate sleep among patients. According to an Aromatherapy Prescription Blends audit, conducted from April 2009-December 2009 by the NHS Community Health and among patients receiving cancer care, palliative and end-of-life care, 58% of patients indicated that they had good relief from the use of essential oil blends that targeted issues with sleeping, dry skin, bone and joint pain, pruitus/itching and anxiety, while 33% of patients indicated that they had partial relief from the use of essential oils that targeted issues with sleeping, bone and joint pain, sweats/flushes and anxiety. Nine percent of patients indicated no relief from the use of essential oils.  Overall, 91% of all patients had some relief of symptoms from the treatment of aromatherapy essential oils blends (Price and Price, 2012). 

     Another evaluation/audit of the use of aromatherapy combined with massage, showed improvement in psychological symptoms such as anxiety, depression, tension, stress and emotions such as fear, anger, guilt, along with physical symptoms of pain (National Guidelines for the Use of Complimentary Therapies in Supportive and Palliative Care, pg. 44). 

     In a review of six studies—including two randomized controlled trials, which together included a total of 387 participants—aromatherapy, administered by way of a 30-to-60-minute massage, was found to have positive effects on mood in people with depression, people with cancer-related depression, and mothers with postpartum depression. Oils used in these studies included lavender, chamomile and a blend of sweet orange, geranium, and basil (Using Essential Oils to Enhance Nursing Practice and for Self-Care, pg. 45). 

     Although there continues to be a lack of scientific evidence on the effects of aromatherapy and its use among patients in hospice care there is a consensus among aromatherapists that the use of essential oils are effective and patients are satisfied with the outcome of its use (National Guidelines for the Use of Complimentary Therapies in Supportive and Palliative Care, pg. 44). 

Tools and Safety of Essential Oil Use

     Although the use of Aromatherapy and essential oils show positive outcomes among patients and caregivers, it is important that agencies who offer this complementary therapy have policies and procedures in place, offer training to their professional staff that will be educating families and patients on the administration of essential oils, have proper storage and handling of essential oils and have proper consultation forms, evaluation, assessment and audit tools to determine the effectiveness of essential oils in their practices. 

     According to The National Association for Holistic Aromatherapy (NAHA) there are six, emphasized factors that influence the safety of an essential oil: quality, chemical composition, method of application, dosage (or dilution), integrity of skin, and age of the client.  NAHA provides these 12 safety guidelines (Using Essential Oils to Enhance Nursing Practice and for Self-Care, pg. 47): 

• Keep oils away from children and pets. 

• Avoid sunlight and tanning booths for 24 hours after using a photosensitizing essential oil. 

• Avoid prolonged use of the same essential oil (such as exposures of an hour or more to high levels of its vapor, repeated topical application to the same site, and repeated use over several weeks). 

• Research any oil before using it on yourself or a patient. 

• Do not use undiluted oils (those not mixed with a carrier substance) on the skin unless specifically indicated. 

• If you suspect an allergy or sensitivity, perform a skin patch test. 

• Know the safety data on any essential oil you use. 

• Use caution when administering essential oil therapy to women who are pregnant or trying to become pregnant. 

• Avoid contact between essential oils and the eyes. 

• Keep all essential oils away from open flames. 

• Ensure adequate ventilation when using essential oils. 

• Do not use essential oils internally unless properly trained in such use. 

Variations of these guidelines are found throughout aromatherapy literature and serve as a safety 

framework for essential oil use. 

Conclusion

hospice care, aromatherapy, essential oils, aromatherapy certification, essential oil classes

     According to the National Hospice and Palliative Care Organization, 2016 Edition, 1,381,182 Medicare beneficiaries were enrolled in hospice care for one day or more in 2015. This included patients who died while enrolled in hospice, were enrolled in hospice in 2014 and continued to receive care in 2015 and left hospice care alive during 2015 (live discharges).  Additionally, of all Medicare decedents in 2015, 46% received one day or more of hospice care and were enrolled in hospice at the time of death.  

     Aromatherapy, which dates back to 1500 BC, has reentered into the healthcare system and many healthcare organizations, agencies and facilities are creating modalities that allow use of complementary therapies that includes the use of Aromatherapy and essential oils. As this trend continues to grow, thus, be widely accepted, certified aromatherapists and practitioners have an opportunity to contribute to the scientific research that will lend to evidence based outcomes. 

     Implementing aromatherapy into hospice care builds upon the holistic approach as defined by hospice and gives patients and their families an alternative to their end-of-life experience while building upon the quality of life for these patients. 

Kim Lineberger MSW, CPA

aromatherapy certification, certified aromatherapist, essential oil classes

Kim Lineberger has been a practicing Social Worker for over 20 years, earning her MSW in 1998. During this time, Kim has worked in an array of environments ranging from mental health, foster youth and adoptions, battered women, real estate and most recently, for the past 10 years, in the health care industry of hospice. For over 20 years Kim has had the pleasure of providing counseling services to hundreds of individuals, children and families, helping each to identify self-empowerment tools to be the best that they can be, emotionally, physically and mentally. Kim was first introduced to essential oils 9 years ago while working with an agency that offered complimentary aromacare to their patients. Not only did Kim notice the positive effects that essential oils had on her patients and family’s emotional well-being, Kim also noticed the positive effect essential oils had with her personally as related to minor headaches. In 2017, Kim decided to enroll in the Institute of Holistic Phyto-Aromatherapy to learn about the CHEMISTRY of essential oils and how to SAFELY use essential oils as Kim wanted to know “what “ makes a particular oil therapeutically effective.  Kim, now a Certified Professional Aromatherapist will continue her education in pursuing studies to be a Registered Aromatherapist while continuing with her passion of helping and empowering others achieve emotional homeostasis, balance, and well-being with the use of essential oils.  

 

References:

  1. American Journal of Nursing, February 2016: Vol. 116, No. 2. Allard, Melissa: Using Essential Oils to Enhance Nursing Practice and for Self-Care, pg. 45 & 47.
  2. Battaglia, Salvatore: The Complete Guide to Aromatherapy, 2nd Edition, 2003, pg. 4.
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935027/figure/f1-jpr-9-457/, February 11, 2018.
  4. Institute of Holistic Phyto-Aromatherapy, 2017, monographs and list of essential oils.
  5. Mojay, Gabriel: Aromatherapy for Healing the Spirit, 1997, pg. 9.
  6. National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care, 2003, pgs. 11 & 44.
  7. National Hospice Palliative Care Organization (NHPCO) Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, September 2017, pg. 3.
  8. Price, Shirley and Price, Len: Aromatherapy for Health Professionals, 4th Edition 2012, pgs 273-284.
  9. Rhind, Jennifer Peace: Essential Oils-A Handbook for Aromatherapy Practice, 2nd Edition, 2012.
  10. Stillpoint Aromatics: https://www.stillpointaromatics.com/elemi-Canarium-luzonicum-essential-oil-aromatherapy, February 11, 2018
  11. Stillpoint Aromatics: https://www.stillpointaromatics.com/red-mandarin-Citrus-reticulata-var-mandarin-essential-oil, February 11, 2019
  12. Stillpoint Aromatics: https://www.stillpointaromatics.com/neroli-Citrus-aurantium-var-amara-essential-oil-aromatherapy?keyword=neroli, February 11, 2018
  13. Today’s Geriatric Medicine: Clinical Aromatherapy, Vol. 7 No 4, Weihbrecht, Linda, pg 4.