Complementary and Alternative Medicine in Palliative Care - Literature review Example

?Is Complementary and Alternative Medicine Safe and Effective in Palliative Care? Table of Contents Table of Contents 1. Introduction 2 1 What ismeant by Complementary and Alternative Medicine? 2 1.1.1Types of Complementary and Alternative Medicine 2 1.1.2Herbal Medicine 3 1.2Palliative Care 4 1.2.1Terminal Cancer 4 1.3Measure of Safety and Effectiveness of Treatment in Palliative Care 5 1.4Literature Review 5 1.4.1 Search Strategy 9 1.4.2 Inclusion & Exclusion Criteria 10 1.5Summary 10 1.6References 10 1. Introduction 1.1 What is meant by Complementary and Alternative Medicine? Complementary and Alternative Medicine (CAM) can be difficult to define because of the way it encompasses several different areas and types of medicine which are constantly evolving. However, the general definition is that CAM is a group of products, services and practices that are not considered to be part of conventional or Western medicine (NCCAM, 2011). Whereas conventional medicine is practiced by registered, qualified doctors, nurses and other health professionals, conventional medicine is typically administered by those with less formal qualifications (Astin, 1998). It should be noted that the difference between conventional medicine and CAM is not distinct and certain CAM practices may become considered conventional over time (Micozzi, 2007). 1.1.1 Types of Complementary and Alternative Medicine There are many types of CAM. Most popular are dietary supplements, which include probiotics and non-vitamin natural products (NCCAM, 2011). These are generally consumed on a regular basis and are normally considered preventative rather than curative (Dalen, 1998), although this is not always the case. These dietary supplements are now so common that they can be purchased in almost any supermarket. Another important type of CAM is known as mind and body medicine. Like dietary supplements, these are used by many on a regular basis and are generally thought to be preventative (Dalen, 1998), although an increase in mind and body medicine after certain diagnoses is not uncommon (Astin, 1998). This group includes activities such as yoga and meditation, which can be carried out as an individual, and hypnotherapy and acupuncture which are generally carried out by someone specialising in the technique (Micozzi, 2007). Additionally, there are body-based practices that require some form of qualification to become recognized. This includes the highly controversial chiropractic medicine and massage therapy. These areas tend to be considered more mainstream forms of CAM and can be recommended by a practitioner of conventional medicines (Dalen, 1998). There are other forms of CAM, which include movement therapies (such as the Alexander technique), as well as healing therapy sessions by traditional healers, which have become popular in the last few decades (Dalen, 1998). Many of these types of CAM have origins in Eastern medicine and tend to focus on a holistic sense of healing for the patient. 1.1.2 Herbal Medicine Herbal medicine refers to a wide range of practices that fall under the CAM umbrella, but refers generally to the use of plant-derived products as medications (Astin, 1998). Many medications that are now used within conventional medicine have their roots in herbal medicine, with perhaps up to 122 commonly used medications having the same or similar formula as their traditional relative (Dalen, 1998), including opium, quinine and aspirin. Herbal medicine has roots in both Eastern and Western traditional medicines and is constantly evolving, and is one of the most popular types of CAM because of the low cost and easy attainment of the products (Bent, 2008). Products that come within the herbal medicine bracket can be bought in a number of high street stores and supermarkets, perhaps testimony to their popularity. 1.2 Palliative Care Palliative care refers to a set of medicines and treatments that are used for the prevention and relief of suffering in the patient, rather than for any curative reason (Twycross, 2003). This type of medicine is most commonly associated with patients suffering from a terminal illness, such as end-stage cancer, but is appropriate for anyone undergoing medical care. Palliative care in the U.K. is offered free through the NHS, which just illustrates the importance of providing palliative care to those in need. Unlike curative medicine, where the patient may be in danger if the treatment has not undergone clinical trial, many areas of palliative care have more freedom to use alternative medicine if there is no interaction with existing drug regimens (Twycross, 2003). 1.2.1 Terminal Cancer Terminal cancer is one of the most important areas for palliative care. For those suffering from terminal cancer, there are many ways in which they can receive the treatment. Charities such as Marie Curie Cancer Care offer palliative care treatment in a hospice or in the home, and many hospitals also offer various therapies to deal with the effects of chemotherapy and advancing cancer stages (Micozzi, 2007). Many terminal cancer patients also experiment with CAM for their palliative care either to replace or enhance conventional medicines (Twycross, 2003f). 1.3 Measure of Safety and Effectiveness of Treatment in Palliative Care One of the more general measures of the safety of palliative care are patient reporting methods, which involves the patient reporting any adverse effects to hospital administration who can then report upon the likelihood of danger from that particular method (Leape, 2002, Truog et al, 2008). Generally, the physical treatments have a high safety value, and herbal medicines must only be used if there is no reported adverse effect with the existing treatment (Truog et al, 2008) The measures of effective are more vague, since many palliative care treatments are used without extensive clinical trials (Granada-Cameron et al, 2008), but where investigation has been conducted many palliative care treatments have significantly improved the quality of life of at least 70% of patients (Zimmermann et al, 2008). 1.4 Literature Review There have been many attempts to assess the effectiveness of palliative care in relieving the symptoms of end-stage cancer patients, many of which have shown that herbal and alternative medicines have a positive effect on the quality-of-life of these patients and perhaps should be used more within the realm of conventional medicine. The work of Engdal et al (2007) investigated the use of herbal medicine in palliative care amongst various cancer patients in Norway. The study had 112 participants, all of whom were undergoing chemotherapy for various types of cancer, and investigated both palliative and curative patients. It was shown that the palliative care patients were equally likely to use herbal medicine (a 38% prevalence) but far more likely to use garlic as a herbal remedy, reinforcing the fact that these medicines can be seen as a ‘last-resort’ and are less likely to be used when adverse effects of contraindications The research by Engdal et al (2007) was based upon a questionnaire, which has obvious limitations in that it does not necessarily provide accurate, truthful information. Additionally, whilst the wide inclusion criteria does allow for a variety of different chemotherapies and herbal medicines, this means that the specific effectiveness and safety of the treatments is not addressed. However, despite these limitations it does provide information about how palliative and curative cancer patients use herbal medicines and the different intent; curative patients were using the herbal medicines to combat the side-effects of chemotherapy. During the trial, only one adverse effect was reported and this was from injecting mistletoe at twice the usual dose. However, the research also suggests that as there are serious side-effects from chemotherapy and symptoms of end-stage cancer, these could be masking adverse effects from the herbal medicines. An Australian study by Correa-Velez et al (2003) was designed to investigate the difference between quality of life measures in terminal cancer patients who used CAM and those who did not. The study investigated 111 patients from 18 different hospitals with advanced cancers, all of whom had 3-18 months to live. These patients were investigated every 4-6 weeks until data gathering was no longer possible due to concerns from their illness. Quality of life was assessed on three main areas; physical symptoms (severity, frequency and distress caused), psychological symptoms (measuring psychological distress and self-perceived well-being scales) and social factors (the satisfaction with conventional medicine). Amongst the 111 participants, 32% were using some form of CAM, with almost half of these seeing an alternative practitioner, which was similar to that found in previous studies. What is perhaps most interesting about the work of Correa-Velez et al (2003) is that CAM users showed significantly lower quality of life based on the measures outlined above. Generally, CAM users suggested that they had a lower subjective well-being than conventional medicine only users, and they also reported more pain and physical symptoms. There was a high level of anxiety amongst CAM users. However, this does not necessarily mean that the CAM is causing these low quality of life scores; it could be that the lower quality of life perception is driving many patients to seek out alternatives to conventional medicine. There are limitations with the study, as it involved a higher number of younger participants than in the general population, as well as general sampling issues. However, the results do suggest some interesting links between quality of life and the use of alternative medicines. There are also studies on how effective certain types of herbal and alternative medicines are for end-stage cancer patients, such as that on the effects of Sun Ginseng by Kim et al (2006). Ginseng is one of the most popular herbal medicines and is often used as a palliative treatment in a variety of patients. In this research, 53 patients were part of a 12 week trial, in which they were assigned either a 2000mg dose of Sun Ginseng or a placebo. These patients were randomly assigned to each group and had either a gynaecological cancer, a hepatobiliary cancer or other cancer. The patients were analysed on their quality of life using two previously designed and tested standards. The results suggested that Sun Ginseng did have a positive effect on the quality of life of these patients, as they reported slightly higher quality of life scores than those on the placebo. This suggests that this type of herbal medicine is not just comforting to these patients but could be having a real physiological effect. There are several limiting factors of this research, especially as it is limited to mainly gynaecological and hepatobiliary cancer patients, and thus the results cannot be generalized. Additionally, there is an aspect of subjectivity to the GHQ-12 questionnaire, which is one of the measures of quality of life used here. There is also some evidence to suggest that Sun Ginseng might have an adverse effect on some medications and cancers (Micozzi, 2007) and thus further research should be conducted before relying on the results of this test. However, it is one of the few reliable double-blind controlled trials based around the effects of herbal medicine and thus gives a substantial amount of evidence in favour of using CAM in some cases of terminal cancer and palliative care. A final study that fit the inclusion criteria was by Tian et al (2010). This paper was a randomized controlled pilot trial on the use of Feiji Recipe on the quality of life of non-small cell lung cancer patients. The study had 60 participants in cancer stages IIIb-IV and each of these were likely to survive for at least three months from the start of the study. The participants were divided into three groups, one using only Feiji Recipe, one using a mixture of Feiji Recipe and chemotherapy, and chemotherapy only. The quality of life of these patients was assessed using quality of life questionnaires that aimed to examine a variety of areas. Interestingly, the patients using chemotherapy only had higher functional scores in areas such as emotional, social and financial status. There was no difference between the groups on psychological or cognitive functions in pain or insomnia. What is perhaps most interesting is that the use of Feiji Recipe alone as well as the mixed group both produced higher quality of life scores and could improve the longevity of these terminal patients. This is interesting as it has long been assumed that chemotherapy is one of the most appropriate ways to extend terminal patient life span (Micozzi, 2007) and this study suggests that some CAM herbal medicines may be almost as effective without the side-effects. As with many of the other studies, there are problems with the questionnaire as a method of surveying these patients as it relies on self-reporting which may not be accurate. However, it does suggest that there is room for investigation into traditional Chinese medicines and perhaps beyond this realm. 1.4.1 Search Strategy Databases: PubMed, MEDLINE Keyword Search: ‘quality of life’ AND ‘palliative care’ AND ‘terminal cancer’ OR ‘cancer’ 1.4.2 Inclusion & Exclusion Criteria To be included in the literature review, the article had to discuss the effects on the quality of life of palliative care on terminally ill cancer patients. The study had to include at least fifty participants who did not have any financial involvement in the trial itself. 1.5 Summary Throughout the literature, there are a variety of efforts to substantiate the effects of CAM and herbal medicines on the quality of life of end-stage cancer patients. Many of these have suggested that certain herbal medicines and physical treatments have a palliative effect on both the symptoms of terminal cancer and the side-effects of chemotherapy. However, in some cases CAM can be associated with a detrimental effect on the quality of life in some patients, although it is not clear whether this is causal. More research should be conducted on the effects of specific types of CAM and how they can be used in palliative care, particularly double-blind controlled trials. 1.6 References Astin, J.A., 1998. Why patients use alternative medicine. JAMA: the journal of the American Medical Association, 279(19), p.1548. Bent, S., 2008. Herbal medicine in the United States: review of efficacy, safety, and regulation. Journal of general internal medicine, 23(6), pp.854–859. Correa-Velez, I. et al., 2003. Use of complementary and alternative medicine and quality of life: changes at the end of life. Palliative Medicine, 17(8), pp.695 -703. Dalen, J.E., 1998. “ Conventional” and“ unconventional” medicine: Can they be integrated? Archives of internal medicine, 158(20), p.2179. Engdal, S. et al., 2008. Herbal use among cancer patients during palliative or curative chemotherapy treatment in Norway. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 16(7), pp.763-769. Granda-Cameron, C. et al., 2008. Measuring patient-oriented outcomes in palliative care: functionality and quality of life. Clinical Journal of Oncology Nursing, 12(1), pp.65–77. Kim, J.-H., Park, C.Y. & Lee, S.-J., 2006. Effects of sun ginseng on subjective quality of life in cancer patients: a double-blind, placebo-controlled pilot trial. Journal of Clinical Pharmacy and Therapeutics, 31(4), pp.331-334. Leape, L.L., 2002. Reporting of adverse events. New England Journal of Medicine, 347(20), pp.1633–1638. Micozzi, M.S., 2007. Complementary and integrative medicine in cancer care and prevention: foundation and evidence-based interventions, Springer Publishing Company. NCCAM, 2011. What Is Complementary and Alternative Medicine? [NCCAM CAM Basics]. Available at: http://nccam.nih.gov/health/whatiscam/ [Accessed January 8, 2012]. Tian, J.-H. et al., 2010. A randomized controlled pilot trial of “Feiji Recipe” on quality of life of non-small cell lung cancer patients. The American Journal of Chinese Medicine, 38(1), pp.15-25. Truog, R.D. et al., 2008. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine. Critical care medicine, 36(3), p.953. Twycross, R.G., 2003. Introducing palliative care, Radcliffe Publishing. Zimmermann, C. et al., 2008. Effectiveness of Specialized Palliative Care. JAMA: The Journal of the American Medical Association, 299(14), p.1698. Read More