This article presents the collaborative effort of two complementary and integrative medicine (CIM) professionals caring for three patients with cancer. The challenges facing the integration of CIM in an oncology setting are addressed, and the collaboration between the two CIM practitioners is discussed. The effect of the combined approach was synergistic, empowering the patients and the CIM practitioners, reducing symptom burdens, and improving quality of life and function.
AT A GLANCE
- Nurses should consider taking a collaborative approach to providing integrative care and include nonmedical practitioners.
- Integrative palliative care can reduce the treatment burden of patients with cancer.
- Nurses can enrich the dialogue of treatment, addressing patients’ needs in supportive cancer care.
Edith, a 27-year-old, had recurrent invasive ductal carcinoma of the breast, which metastasized to the chest wall, skin, lung, and bones. Her oncology nurse referred her to the complementary and integrative medicine (CIM) service, which is located in a conventional oncology department. Edith complained of many concerns related to quality of life (QOL), such as fatigue with a feeling of heaviness, generalized pain with reduced sensation in both legs, constipation, disturbed taste sensation, mouth sores, insomnia, and facial swelling, which prevented her from going out with friends. She hoped that the CIM program would empower her and help with her physical functioning. She said, “I feel that I alone must bear the burden of the disease on my shoulders, so as not to ‘break’ those around me; I am the responsible adult at home.”
Martha, a 59-year-old author with metastatic colon cancer, had “persistent thoughts about dying” and a sense of “disconnectedness from the Spring of Creation.” She suffered from painful ulcerating subcutaneous metastases and was scheduled for home hospice care.
Dora, a 79-year-old widow with recurrent metastatic breast cancer, suffered from chemotherapy-induced peripheral neuropathy with an abnormal sense of touch of the lower limbs and left shoulder and temporomandibular joint pain, limiting her ability to chew. She suffered from a disturbed sense of taste, decreased appetite, nausea, weight loss, and fatigue, and looked forward to dying to end her suffering. She stated, “I do not find any purpose in life.” However, after her treatment had been changed (from paclitaxel [Taxol®] to docetaxel [Taxotere®]), her symptoms decreased and her QOL improved, as did her perception about living. “At present, I do not really want to die,” she said.
The Integrative Setting
Patients are referred by oncologists, oncology nurses, and psycho-oncologists, and undergo a consultation by an integrative physician (IP) dually trained in CIM and supportive cancer care. IP consultations and CIM treatments are provided free of charge to patients undergoing chemotherapy. The IP addresses expectations and QOL-related concerns, and designs CIM treatment plans with patients. The treatment plan and goals are sent to the referring oncology care provider and to the patient’s primary care physician (Ben-Arye, Israely, Baruch, & Dagash, 2014). CIM treatments are provided weekly by a multidisciplinary team of four IPs, two nurses, three paramedical practitioners (i.e., a psycho-oncologist, a clinical dietitian, and an occupational therapist), and seven nonmedical practitioners (i.e., spiritual care providers, a music therapist, acupuncturists, and a manual and movement therapist). All CIM practitioners are trained in supportive cancer care.
Complementary and Integrative Medicine Practitioners
Two of the current authors, Katz and Wolf, are CIM practitioners who work at the CIM service. Katz, a RN with a master’s degree in public administration, works in a specialized wound-care clinic. She has extensive training in traditional Chinese medicine and joined the service as part of a pilot project examining the integration of CIM-trained RNs in supportive cancer care. She incorporates CIM treatments, such as acupuncture and herbal and nutritional counseling, into her care and uses her skills in wound care when needed.
Wolf, a CIM practitioner, has degrees in geography and history but left her job in the film industry at age 26 years, following a stroke. She began to study complementary medicine, focusing on natural medicine and cranial osteopathy, as well as the Paula and Feldenkrais methods, manual therapies originating in Israel during the 1950s and 1960s. Katz and Wolf bring different and varied backgrounds, as well as paradigms of care, to the management of patients undergoing chemotherapy.
During a staff meeting, Katz and Wolf discussed the biologic, psychological, social, cultural, and spiritual challenges of and treatment options for their patients. The two often have different opinions, although they agreed that Edith, Martha, and Dora required interventions to address their physical pain and emotional distress (see Table 1). Katz preferred to focus on concerns and treatment goals that had been discussed during the IP consultation, primarily insomnia (Edith), wound care (Edith and Martha), and difficulty chewing and impaired physical functioning (Dora).
Katz recommended that Edith receive conventional wound care in conjunction with CIM treatments. Katz used silver-sulfadiazine bandages to debride the ulcerated skin lesions, while providing acupuncture and other CIM modalities. Later, Katz became Martha’s case manager when she began home hospice care.
Wolf’s approach to healing provides the CIM team with a different paradigm of care, combining her knowledge and experience while providing a unique perspective on patients’ concerns that need to be addressed. Her integration of the Paula and Feldenkrais methods with movement therapies was important to Edith, who expressed a need for physical touch to relieve pain. Dora and Martha reported a reduction in symptoms following their session with Wolf, which addressed symptoms like feelings of stiffness, while also providing an environment of “spiritual healing.” Wolf was also able to help Edith and Martha talk about their emotional concerns. All women felt that Wolf had given them the tools and exercises with which they could cope with toxicities related to chemotherapy and cancer-related symptoms.
The Need for Dually Trained Practitioners
Katz and Wolf believe that two are better than one. Their collaboration had a significant impact on the treatment of Edith, Martha, and Dora, all of whom were suffering physically, emotionally, and spiritually. The treatment goals were both pragmatic and tangible (e.g., pain management), and the patients reported improved QOL and functioning, in a manner that was more synergistic than additive.
Concepts dominating traditional approaches to medicine, such as yin and yang, suggest that two opposing qualities may complement each other. Wolf and Katz were required to “translate” their vocabulary of care when discussing their treatment strategies. Both therapists described their counterpart’s contribution as a “broadening of outlook,” as was apparent in their treatment of the three patients (see Table 2).
Edith experienced the collaborative approach as a three-way “reflective mirror,” representing herself and her two CIM practitioners. This approach helped her overcome the difficulty of accepting the idea that emotional and spiritual concerns are valid and important outcomes. Wolf taught Edith breathing exercises, which helped her during her final days. Katz and Wolf accompanied her as case managers at the end of her life.
Martha had been hesitant about using CIM; acupuncture and mind–body therapies challenged her understanding of medical care. However, the collaboration between Katz and Wolf, created an environment of trust and safety, enabling her to address her sense of disconnectedness. The therapeutic process addressed body, mind, and spirit. She experienced relief from her painful ulcerating skin lesions and also got to explore beyond the physical symptoms.
Dora’s journey had more of a physical nature, and the CIM treatments addressed the symptoms of pain, stiffness, disturbed taste sensation, decreased appetite, and constipation, which had not responded to other therapeutic options, either conventional or complementary. The collaborative efforts of Katz and Wolf provided Dora with significant relief, and they offered step-by-step guidance on the bridge toward healing.
Addressing patients’ symptom burden in collaboration with other healthcare professionals is an important aspect of oncology care; it can support professionals reporting compassion fatigue and promote professional growth (Back, Deignan, & Potter, 2014). As “wounded healers” (Hankir & Zaman, 2013), healthcare professionals need to enrich their dialogue on treatment, sharing their understanding of patient needs while trying to fill the half-empty therapeutic “glass.” In this way, oncology providers can help soften the difficult challenges of cancer care and enhance compassion.
Implications for Nursing
Oncology nurses can be trained in CIM, enhancing the supportive care services provided in their workplace and creating a dialogue and mutual understanding with nonmedical CIM practitioners to promote patient health and well-being.
Collaboration of conventional CIM practitioners (e.g., integrative nurses) with nonmedical CIM practitioners can result in a synergy that better addresses patients’ biologic, physical, emotional, and spiritual concerns in supportive cancer care settings.
About the Author(s)
Eran Ben-Arye, MD, is the director of the Integrative Oncology Program, Yifat Katz, RN, MA, is an RN, and Daphna Wolf, DCO, is an integrative practitioner, all at the Lin Medical Center of Clalit Health Services in Haifa; and Noah Samuels, MD, is the medical director of the Tal Center for Integrative Oncology at the Sheba Medical Center in Tel Hashomer, all in Israel. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Ben-Arye can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
Back, A.L., Deignan, P.F., & Potter, P.A. (2014). Compassion, compassion fatigue, and burnout: Key insights for oncology professionals. American Society of Clinical Oncology Educational Book, 34, E454–E459.
Ben-Arye, E., Israely, P., Baruch, E., & Dagash, J. (2014). Integrating family medicine and complementary medicine in cancer care: A cross-cultural perspective. Patient Education and Counseling, 97, 135–139.
Hankir, A., & Zaman, R. (2013). Jung’s archetype, “the wounded healer,” mental illness in the medical profession and the role of the health humanities in psychiatry. BMJ Case Reports, 2013, bcr2013009990. doi:10.1136/bcr-2013-009990