What is palliative care?
Palliative care is a specialised medical approach for people living with chronic, life-threatening illnesses, which are often terminal. This type of care focuses on providing relief from the symptoms and stress of the illness. The goal is to improve the quality of life for both the patient and their family, who face challenges associated with the disease, whether physical, psychological, social, or spiritual [1, 2].
Most adults in need of palliative care have chronic diseases such as cardiovascular disease, cancer, chronic respiratory disease, AIDS, or diabetes. Many other conditions may also require palliative care, including kidney failure, Parkinson’s disease, neurological disorders, chronic liver disease, multiple sclerosis, rheumatoid arthritis, dementia, congenital anomalies, and drug-resistant tuberculosis [3, 4].
Palliative care can be provided in hospitals, nursing homes, palliative care clinics, or patients’ homes. A care team consists of specialised doctors and other healthcare providers, such as nurses, nutritionists, and chaplains. They work together to provide the best possible support [1–3].
What is alternative medicine?
Complementary and alternative medicine (CAM) is defined as “diagnosis, treatment and/or prevention that complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine” [5, 6].
Complementary and alternative healthcare and medical practices is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine [6, 7].
Nowadays, it is composed of 5 major groups: alternative medical systems, mind-body interventions, biologically based treatments, manipulative and body-based methods, and energy therapies. All methods that are not part of allopathic medicine are included in alternative medicine: prayer (45.2%), herbalism (18.9%), breathing meditation (11.6%), meditation (7.6%), chiropractic medicine (7.5%), yoga (5.1%), body work (5.0%), diet-based therapy (3.5%), progressive relaxation (3.0%), mega-vitamin therapy (2.8%), and visualisation (2.1%) [7, 8].
Popularity of alternative medicine
CAM has gained popularity among the general population, but its acceptance and use among medical specialists have been inconclusive. Over the past 2 decades, the use of CAM has greatly expanded in all modern societies and is expanding and growing more quickly than ever before in healthcare [8].
Worldwide alternative medicine has a different approach and popularity. For example, the 12-month prevalence of CAM provider use was 26.4% overall, with rates varying from below 10% in Bulgaria, Poland, and Slovenia to over 50% in mainland China, the Philippines, and the Republic of Korea. In terms of treatment satisfaction, over 80% of users reported being satisfied in Denmark, Slovenia, Spain, and Switzerland in Europe, as well as in Taiwan and the USA [9].
What role does alternative medicine play in palliative care?
Patients approaching the end of life can experience suffering physically, emotionally, socially, and spiritually. Palliative care patients seek additional symptom management interventions to complement their medical treatment. While conventional treatments, including pharmacological interventions, are essential in alleviating these symptoms, they may not always provide complete relief or may be accompanied by undesirable side effects.
As a result, there has been growing interest in exploring CAM practices as adjuncts to traditional care, aiming to provide holistic support to patients.
Some of the methods mentioned in our article, such as acupuncture, aromatherapy, hypnosis, and others, demonstrate reduction of pain and anxiety and improving mood by influencing the nervous system and triggering endorphin release.
Through this exploration, we aim to highlight how integrating alternative medicine with conventional therapies can improve patient care and contribute to a better quality of life for those in palliative care.
Aromatherapy
Aromatherapy is a complementary treatment that involves the use of essential oils derived from various plants, flowers, herbs, and fruits to promote physical, mental, and emotional well-being. This practice is grounded in the belief that the natural oils extracted from these plant sources possess therapeutic properties that can influence the body’s physiological and psychological processes. Aromatherapy is performed by inhaling, massaging, and bathing in essential oils extracted from aromatic plants.
Some studies show that aromatherapy improves sleep quality and reduces stress, pain, anxiety, depression, and fatigue in adults and elderly people.
When essential oil molecules are inhaled, they interact with olfactory receptors in the nasal cavity, triggering signal transmission via the olfactory nerve to the limbic system, and stimulate the brain to exert neurotransmitters (serotonin and dopamine), thereby further regulating mood [10, 11]. Lavender, rosemary, bergamot, eucalyptus, rose, lemon, and grapefruit oil have revealed autonomic nervous system activity modification via the inhalation route. Lavender oil has shown a sedative effect. Peppermint and coffee have shown a stimulating effect, as demonstrated by electroencephalogram [12].
Essential oils are also absorbed through the stratum corneum, the outermost layer of the skin, and can enter the bloodstream. Research has demonstrated that certain essential oils enhance skin permeability and improve local circulation [13]. A massage with lavender and geranium oils was also effective in reducing heart rate and blood pressure [12].
Aromatherapy has been shown to influence autonomic nervous system activity, particularly by enhancing parasympathetic tone, which is associated with relaxation and reduced physiological stress. Studies indicate that lavender oil inhalation, for example, increases parasympathetic modulation, leading to improved relaxation responses [14, 15].
Lavender, chamomile, bergamot, sweet orange, anise, geranium, and mountain pepper reduced depression in the elderly, restless patients, breast cancer patients, irritable bowel syndrome patients, mixed anxiety and depressive disorder, and residents in a long-term care unit. Peppermint, rosemary, grapefruit, and cinnamon oils improved vigilance, and lavender improved objective sleep quality [12].
Many palliative care patients suffer from nausea and vomiting, which are commonly experienced symptoms, and the aetiology is often multifactorial. The most common causes are impaired gastric emptying, medications, and constipation [16]. Most patients respond to antiemetics, but many patients require a trial of one or more antiemetics to achieve good symptom control. A retrospective analysis evaluated the use of lemon oil aromatherapy in managing nausea and vomiting in patients with advanced cancers. The study reported that 73% of the applications resulted in adequate relief of these symptoms, suggesting that lemon oil pads may be a feasible option for symptom control in this population [17, 18].
A systematic review assessed the impact of aromatherapy interventions on pain and anxiety in palliative care settings. The findings indicated that aromatherapy, particularly through massage, demonstrated significant efficacy in reducing pain and anxiety levels among patients. However, variations in intervention procedures and outcome measures necessitate cautious interpretation of these results [18–20].
While research supports the effectiveness of aromatherapy in symptom management, methodological inconsistencies across studies highlight the need for further investigation. Standardised approaches and more studies are essential to validate its efficacy for various symptoms in palliative care, ultimately enhancing its clinical applicability and integration into therapeutic practice.
Acupuncture
Acupuncture therapy has spread worldwide and has shown significant potential in health promotion and management of acute pain, which is why it could be used in palliative care, where patients very often struggle with complex pain, not only nociceptive but also neuropathic [21]. Chronic pain in cancer patients is dominated by a neuropathic component, even when accompanied by nociceptive pain. Neuropathic pain is the most difficult type of pain to treat in cancer patients and generally does not respond well to drug treatment.
There are various techniques of performing acupuncture, which can be modified to meet the specific needs of a patient. The most commonly practiced method is traditional needle acupuncture, which is a technique rooted in the principles of traditional East Asian medicine. A trained practitioner chooses a precise location on the body (acupoints) and inserts a thin needle. This method may be performed alone or enhanced with electrical stimulation or heat therapy [22].
Although acupuncture has been practiced for thousands of years, its mechanism in pain management is not fully understood. However, various studies and hypotheses have been proposed to elucidate the potential neurological pathways involved in its analgesic effects. One study from 2010 showed that insertion and manipulation of acupuncture needles resulted in a rise in levels of neurotransmitter adenosine. The binding of adenosine to peripheral and central A1 receptors exhibits an ani-nociceptive effect, leading to a reduction in inflammatory and neuropathic pain [23]. Other research suggests that acupuncture and electroacupuncture (EA) can lower the levels of substance P (SP), a molecule released during inflammation in the nervous system. By decreasing SP, the activity of sensory fibres connected to acupuncture points is reduced, leading to a decrease in pain signal transmission [24]. Moreover, multiple studies have revealed that acupoint stimulation can modulate serotonin and enkephalin (which modulate pain through opioid receptors distributed across the central and peripheral nervous systems) concentrations in both the brain and peripheral tissues. This mechanism may contribute to pain relief, given the well-established correlation between reduced serotonin levels and the development of pain or hyperalgesia [25]. There is increasing evidence from studies showing that serotonin receptors, particularly 5-HT1A and 5-HT1B, play a role in pain modulation. However, the exact contribution of other serotonin receptors to pain relief is still not fully understood. Additionally, some research suggests that the interaction between oestrogen and serotonin may influence pain perception, particularly through the activation of the 5-HT2A receptor, which seems to reduce pain when oestrogen levels are high [26].
Acupuncture activates central brain pathways, thereby inhibiting the abnormal reflex that contributes to neuropathic pain [27]. Extensive neuroimaging studies in humans have demonstrated that acupuncture modulates a widely distributed central neural network, with a significant portion functionally corresponding to nociceptive processing regions. Its results showed distinct temporal patterns of neural activity during acupuncture. Increased activation in the amygdala and pACC was observed during needling, followed by a gradual decline below baseline. Intermittent activations were seen in the PAG and hypothalamus, while sustained activity was noted in the anterior insula and prefrontal cortex. These findings suggest that acupuncture may induce long-lasting neural changes, potentially contributing to enduring effects in pain modulation [28].
Patients receiving palliative care or undergoing oncology treatment are particularly vulnerable to depression. A meta-analysis examining 24 studies on palliative care patients found that the prevalence of depression is 24.6%. However, other research suggests that the incidence may be much higher, with some studies reporting that up to 64% of these patients experience depressive symptoms [29]. Depression leads to significant emotional distress and suffering in patients, negatively impacting their quality of life and worsening the prognosis of the underlying condition. Depression can intensify the somatic symptoms of advanced terminal illness, particularly pain, and is often linked to reduced adherence to treatment, further worsening the patient’s condition [30]. As pharmacological treatments are often insufficient, it is beneficial to explore alternative approaches in addition to medication.
Chronic neuropathic pain is commonly used as the main animal model in studies exploring the link between chronic pain and depression or anxiety. Research suggests that electroacupuncture may help reduce depression or anxiety related to neuropathic pain, mainly by influencing certain molecular mechanisms and neuronal pathways [31]. A 2023 study conducted on rats demonstrated that electroacupuncture effectively alleviates behaviours associated with depression and anxiety. A widely used rat model of neuropathic pain involves chronic constriction injury (CCI) of the sciatic nerve. This injury caused behaviours resembling depression and anxiety, along with a reduction in the phosphorylation of the NMDA receptor subunit NR1 in the hippocampus. The study suggests that electroacupuncture may reduce depression and anxiety in rats with neuropathic pain, potentially by reversing the decrease in NR1 phosphorylation in the hippocampus [32].
Other findings demonstrate that electroacupuncture reduces mechanical allodynia – a condition where non-painful stimuli are perceived as painful – and improves emotional disturbances associated with neuropathic pain. These effects may be linked to the regulation of the dopamine system in the amygdala, which could play a key role in the therapeutic mechanism of electroacupuncture for neuropathic pain [33]. While acupuncture shows promising results in pain management, there are certain challenges in the research, including small sample sizes, high dropout rates, insufficient follow-up, and randomisation issues, which are common in other fields as well. Additionally, acupuncture studies face unique methodological challenges such as
placebo interventions, blinding, and powerful
placebo effects (often stronger than inactive pills). Despite these hurdles, acupuncture continues to demonstrate potential, and with further research addressing these issues, more precise and reliable results can be expected [34].
Music therapy
Another approach to managing pain is music therapy, a non-pharmacological method that is gaining increasing recognition. This section will introduce its role and potential benefits in pain treatment. A research paper from 2024 reviewed 16 different studies investigating the effects of music therapy on patient well-being and pain management. The findings from many of these studies indicated short-term improvements in symptoms and overall condition [35].
A study was conducted on adult cancer patients aged 12 years and older at a major tertiary care cancer institute in Sri Lanka, all of whom were experiencing baseline levels of pain. The intervention consisted of 30-minute sessions of classical music played daily in the morning. The study found significant improvements in pain, anxiety, and low mood, as well as objective parameters such as pupillary size and respiratory rate. No adverse effects were reported, even among participants who were not accustomed to listening to music. The only patient who continued to experience severe pain (10/10) did not show any improvement despite the intervention [36]. Another study from between 2009 and 2011 at University Hospitals Case Medical Center with 200 palliative care patients also assessed the impact of a single music therapy session on pain reduction. The music therapy group showed a significant decrease in pain compared to the standard care group. No significant differences were found in other measures such as comfort or emotional responses.
However, the music therapy group experienced a notable improvement in functional pain scores [37].
There are several theories about the impact of music on pain, suggesting that it can serve as a distraction, provide a sense of control, stimulate the release of endorphins to alleviate pain, and promote relaxation by slowing down breathing and heart rate [38].
Music influences the central nervous system, triggering changes in endocrine, autonomic, and immune activity, which evoke a wide range of emotions. Its stress-reducing effects are linked to its impact on the hippocampal formation, which regulates the hypothalamus–pituitary–adrenal (HPA) axis – a key system in the body’s stress response. By lowering cortisol levels, music listening has been shown to reduce stress, which is a known factor in chronic pain development. Consequently, music can alleviate pain by mitigating stress, a phenomenon referred to as “audioanalgesia” [39]. In a 2013 article, Paszkiewicz-Mes mentioned a study on the impact of music therapy on postoperative pain, which showed that listening to personally preferred music reduced pain perception and the need for medication. Despite the benefits of a multimodal approach to pain management, non-pharmacological methods remain underutilised in medical practice [40].
Another article described a study on 12 healthy women that examined pain perception using thermal electrodes while listening to their favourite music or in silence. fMRI recorded brain, brainstem, and spinal cord activity. Pain intensity ratings were significantly lower during music exposure. Listening to music activated the limbic system, frontal areas, and auditory cortex. Researchers identified key structures involved in pain modulation, including the lateral prefrontal cortex and periaqueductal grey, rostral ventromedial medulla, and spinal grey matter. This activation pattern resembles that observed with pharmacological pain relief methods [41]. Music affects pain perception through various brain regions, networks, and neurotransmitters, including dopamine and oxytocin. It also can have analgesic effects by increasing the release of endorphins – peptide hormones produced in the central nervous system. Endorphins not only relieve pain but also induce feelings of well-being and euphoria. These interactions at receptor and synaptic levels contribute to the complexity of pain experience. Opioids, like -endorphin, influence not only nociception but also functions such as learning, memory, reward, social interactions, mood, and stress. PET studies show changes in µ-opioid receptor binding in chronic pain sufferers, indicating increased release of endogenous opioids. In peripheral nerve systems, opioid expression is altered in chronic pain and is inversely related to pain perception. Furthermore, immune cells can release opioid peptides that reduce nociceptive transmission. Music has been shown to activate these pathways, decreasing pain perception [42].
Despite many theories, most studies suggest that while music interventions may not directly influence physiological processes related to chronic pain, they can improve quality of life by increasing a sense of control, which plays a role in alleviating pain and enhancing overall well-being [43].
Hypnosis
Hypnosis has a 250-year history, marked by important advancements in psychotherapy, psychosomatics, and medicine, with the concept of imagination as a crucial component of hypnotic treatment first introduced in 1784. Contemporary hypnotherapy is based on the techniques developed by Milton H. Erickson, and while studies on medical hypnosis have shown effective outcomes, its widespread application in everyday medical practice is still constrained [44].
Hypnosis is a technique that combines suggestion, relaxation, and imagery to induce an altered state of consciousness to modify one’s subjective experiences, reactions, and behaviours in a given situation. Previous meta-analyses of clinical hypnosis have confirmed its effectiveness in addressing pain, anxiety, and well-being [45]. Various studies show that hypnosis can influence pain perception, with some indicating that suggestions to alter the emotional aspect of pain shift activity in the anterior cingulate cortex without affecting other pain-related regions. Conversely, other studies find that suggestions to change pain intensity affect activity in primary somatosensory areas, highlighting the ability of hypnosis to modulate pain processing [46]. One study evaluated the effects of hypnosis on pain and anxiety during the application of a capsaicin patch. Although hypnosis did not significantly reduce pain, it was shown to significantly lower anxiety compared to standard care. These findings highlight the potential of hypnosis as a non-invasive method to alleviate anxiety during painful procedures, which could be especially valuable for patients in palliative care who often face high levels of discomfort and distress [47]. In 2008, another study suggested that hypnosis could be an effective treatment for chronic widespread pain (CWP), which can affect patients with advanced diseases, such as cancer, and may also result from other conditions like degenerative joint diseases, neuropathies, or musculoskeletal problems. Following this, this pilot study evaluated a standardised hypnosis program in general practice. Sixteen patients were randomised into a treatment or control group, with 12 completing 10 weekly hypnosis sessions focused on relaxation, reducing muscle tension, and enhancing self- efficacy. The treatment group showed a significant reduction in symptoms, while the control group’s symptoms worsened. Improvements persisted one year later, suggesting that hypnosis may benefit pain management and quality of life in CWP patients [48].
Several studies have been conducted to explore the mechanisms behind the effectiveness of hypnosis in treating chronic pain. Many studies have shown that hypnosis impacts multiple brain areas involved in pain processing, including the insula, prefrontal cortex, thalamus, sensory cortices, and cingulate cortex, as well as influencing pain processing at the spinal cord level. This suggests hypnosis affects various regions of the nervous system rather than relying on a single mechanism [49]. Hypnotic analgesia has been shown to decrease brain activity in regions involved in pain perception, such as the thalamus, striatum, and anterior cingulate cortex. This reduction in cortical activity is accompanied by a decrease in tension, anxiety, and emotional responses to pain. Studies suggest that the analgesic effects of hypnosis are linked to modulation of cortical areas, particularly the anterior cingulate cortex, which plays a key role in pain processing. Additionally, hypnotic induction increases activity in the orbitofrontal regions, especially in the left hemisphere, highlighting the complex neural mechanisms underlying hypnotic analgesia [50]. A paper by Faymonville et al. [51] on hypnosis pointed to their previous study demonstrated that hypnosis reduces both the sensory and affective components of pain through the activation of the midcingulate cortex (ACC). This study indicated that pain reduction during hypnosis is not dependent on opioid receptors, as the analgesic effect remains unchanged following the administration of naloxone. Also, increased connectivity of the ACC with areas responsible for autonomic responses, such as the thalamus and brainstem, may explain the altered pain response, including reduced autonomic activity and defensive reactions in patients undergoing hypnosis, which influences the analgesic effects during surgical procedures [51].
Mindfulness and meditation
Meditation, rooted in ancient spiritual practices, has evolved into a widely accepted therapeutic technique in modern healthcare. Through mindfulness, focused breathing, and mental visualisation, meditation encourages relaxation, emotional regulation, and enhanced self-awareness.
In study performed in 2008 by Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK and Department of Patient and Family Support Services, CancerCare Manitoba, Winnipeg, MB, patients undertook 90-minute weekly restorative Iyengar yoga classes with a follow-up after the 16th week.
After 16 weeks the participants noted improvement in their quality of life and psychological well-being. Participants reported improved physical strength, tension relief, and a sense of rejuvenation despite fatigue. They also highlighted yoga’s ability to promote relaxation, enhance focus, and reduce anxiety. Importantly, the individualised guidance and supportive props in Iyengar yoga allowed patients to perform poses correctly, boosting their confidence and empowering them with a stronger sense of control over their well-being. This empowerment, combined with a focus on self-care, was linked to improved resilience and better coping strategies during treatment.
Patients found mutual social support to be a valuable aspect of the program. Connecting with others who had experienced cancer provided them with emotional understanding that friends and family often could not offer. This sense of shared experience fostered comfort and helped individuals integrate their cancer journey into their daily lives. One participant described how being part of a group of peers brought acceptance of physical changes, such as scars, and allowed her to embrace cancer as part of her reality [52].
Another study, performed at Children’s Hospitals and Clinics of Minnesota, addressed the impact of yoga on paediatric cancer patients and their caregivers. After taking part in the study, the participants also noted improvement in their mood and overall wellness. The youngest participants observed that yoga classes “made them feel good and relaxed”. Adolescents also reported being calmer after the sessions. It is important to note that these sessions benefited not only the patients but also their caregivers, who serve as a vital support system for young patients and play a crucial role in their treatment [53].
Overall mild yoga and meditation can be a useful tool for the patients, letting them feel more empowered and helping them find internal strength in sickness, to feel less frightened facing the treatment and the symptoms. It also helps in building a strong supportive community among the patients, which is also an important factor in palliative care, helping them feel less alone.
Summary
The integration of alternative therapies in palliative care has gained increasing attention as healthcare providers seek holistic approaches to improve patients’ quality of life. Various complementary methods such as aromatherapy, music therapy, and acupuncture have shown promise in managing pain and enhancing emotional well-being in individuals with terminal illnesses.
These alternative therapies align with the holistic approach in palliative care, addressing not only physical symptoms but also the emotional, social, and spiritual dimensions of patient well-being. By incorporating such methods alongside standard medical practices, healthcare professionals can create a more comprehensive care strategy tailored to the diverse needs of patients and their families.
As research continues to expand, these complementary techniques are gaining recognition as valuable tools in improving comfort and enhancing the overall palliative care experience. Integrating alternative therapies into clinical practice holds significant potential for fostering greater dignity, peace, and quality of life for patients in their final stages.
Disclosures
- Institutional review board statement: Not applicable.
- Assistance with the article: None.
- Financial support and sponsorship: None.
- Conflicts of interest: None.
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