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Mary
Introduction
Mary
is a 65-year-old woman living in a Nursing Home for elderly people.
She was diagnosed with Multiple Sclerosis about 15 years ago, recently
moving into a nursing home from a residential home as mobility and self-care
became increasingly more difficult. She
refers to her diagnosis as her ‘nerves’ and understands and accepts the
prognosis of further gradual deterioration.
Mary
had been a widow for a long time, her husband dying when he was young.
She has a married daughter living nearby and 3 grandchildren.
She has other friends living nearby in the Residential Home where she
used to live. She also gets regular
visits and phone calls from her family. She
walks with the aid of a walking frame but has been finding it more and more
difficult recently. Her increasing
disabilities have also affected her self-confidence and she now will only
attempt short walks to and from her room to the lounge and dining areas of the
home but would usually have to use a wheelchair.
Mary
has particular routines she likes to adhere to, everything must be done in the
right order and everything has to be in the right place as if she is drawing
comfort from the set routines and safety from predictability.
I found this amusing to observe but was soon drawn into using her
routines as part of my treatment.
Mary
impressed me with her attitude to her life and eventual death, she was keen to
maintain her mobility as long as possible and thought that aromatherapy and
massage would help her achieve this. She
had experienced massage as part of intensive physiotherapy after a road accident
several years ago and remembered it helping both emotionally and physically.
Mary
was a selfless individual who took on the problems of the people whose lives she
shared. She was also a deeply
religious person drawing great strength from her beliefs. She saw the good in everyone and was continually grateful for
the things she had achieved in life and the achievements of her family and
friends.
The Consultation
Mary has been diagnosed with Multiple sclerosis and angina. For the angina she has been prescribed glyceryl trinitrate, a fast acting drug to combat the first signs of an attack and propranalol to reduce the heart rate and block noradrenaline secretion. She suffers from frequent attacks of bronchitis and finds breathing difficult at times. She likes to sleep propped up by several pillows at night and uses olbas oil on her nightdress to help her breath more easily.
Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system in which parts of the insulation to nerve fibres (myelin) is gradually destroyed, affecting the function of the nerves involved. The brain and spinal cord are also systematically affected leading to symptoms of vision disturbances, tremor of the hands, weakness of the extremities, sensory changes such as numbness, tingling, or pain, slurring of speech, and loss of control over the urinary and anal muscles (Martin 1994, p424). Tingling, itching and pain in Mary’s hands, legs and feet was a particular problem, and her speech was noticeably slurred and often difficult to understand. Mary often complained of excessive itching in her legs for which she had been prescribed a hydrocortisone cream, which is a topical steroid – as a result, the skin on her legs had become very thin, discoloured and fragile. She has taken oral steroids in the past and shows the characteristic moon face associated with long term steroid use.
She said she often felt disorientated when walking and this has affected her confidence using her walking frame.
Mary’s type of multiple sclerosis had been diagnosed 15 years ago and was thought benign for many years. It had now developed into the more chronic relapsing-remission type, affecting her periodically when new symptoms would occur, particularly after infections and illness. While some of the symptoms of MS are controlled by conventional medication, there is much evidence suggesting the benefits of a more holistic approach, particularly relating to stress, diet, and helping to boost the immune system. Mary’s daughter had researched various approaches available for treating MS and was supplying her with linoleic acid supplements (Effamol), which Mary took daily.
Linoleic
acid is an essential component in building nerve tissue, particularly in myelin
sheath formation: the insulation material for nerve tissue.
Myelin is a protective sheath surrounding all the nerve fibres in the
brain and spinal cord. It works like insulating cable, helping to conduct
electrical impulses between the brain or spinal cord and the rest of the body,
and preventing them from being short-circuited.
When myelin is healthy and functioning properly, electrical impulses get
through quickly and efficiently allowing for easy and co-ordinated movement.
When myelin is damaged, messages are slower, distorted, or non-existent and do
not get through properly (Multiple Sclerosis Society). This causes many of the
symptoms of MS. Although I had not treated anyone with MS as an
aromatherapist, I had treated several patients with the disease as a practicing
Nurse. I was also familiar the
benefits of linoleic acid therapy to encouraging myelin sheath formation in
people with autism and attention deficit disorder, as myelin inefficiency is
thought to be one of the contributory organic causes of both disorders (Crawford
1997).
Mary
is incontinent and often has accidents when trying to stand after sitting for a
while. She wears a continence pad
during the day and sleeps with a plastic draw sheet under her bedding at night.
She takes an interest in alternative and complementary therapies and has
recently tried reflexology. Her
bedtime routine takes a long time as everything has to be done just right –
this has become a source of exasperation to staff who might be in a hurry and
cannot see the need for her to feel safe and in control.
I
told Mary that I could not cure her Multiple sclerosis but I could certainly
help the circulation in her limbs to help alleviate some of the tingling,
improve skin quality, and help with any aches and pains she occasionally
experienced. Mary told me that she
often has a ‘down’ feeling before she goes to bed at night, so I told her
that I could plan my visits for this time which would help to leave her feeling
comfortable and relaxed, and more positive before going to sleep.
I
took a detailed consultation but needed to go away and research more on the use
of oils and massage with multiple sclerosis.
An evaluation of research.
There
is little to find regarding the use of essential oils specifically with MS
although more information is available about diet and lifestyle.
As
a dietary supplement, linoeilic acid is frequently mentioned in research
articles as having a positive effect on the formation of myelin (Earle 1994,
p55; Multiple Sclerosis Society no date). Linoelic
acids cannot be made by the body and have to be taken in by diet.
Rich sources of linoleic acid include evening primrose, corn oil,
safflower, sesame, soya and sunflower oil (Capadose 1991, p139) but would have
to be ingested orally to be of any benefit as their molecular weight is too
large to be absorbed through the skin (Smith 2000).
Mary has been taking ‘Effamol’ daily as a linoleic acid supplement
– Effamol is a brand preparation high in essential and gamma linoleic acids
marketed for pre-menstrual and menopausal symptoms, and to help neural activity
and concentration in people with dyslexia, attention deficit disorder and
autism. Also regarded useful in the management of MS are vitamin B12,
zinc and folic acid, all-important in maintaining a healthy nervous system.
Price et al. 99 refers to studies in MS by Donald 1996 who used Rosemary (Rosemarinus officinalis) to help boost the immune system, alleviate muscle fatigue, and stimulate circulation and memory; Mutch (1997) using essential oils to help sleep, and muscle tension and spasm; and Hulmston (1995) addressing pain. Sandalwood (Santalum album), Geranium (Pelargonium graveolens) and Lemongrass (Cymbopogon citratus) are also cited as being common to all 3 trials (Price et al. 99, p167). Lunny (1997) suggests using essential oils for their relaxing but uplifting and soothing properties, and oils high in esters and aldehydes for their immuno-stimulating properties (Lunny 1997, no page no.). Essential oils high in esters and aldehydes would not include Rosemary or Sandalwood, but would include Geranium; Lemongrass; Eucalyptus (citriodora); Roman chamomile (nobile); Petitgrain bigarade (Citrus aurantium); Bergamot (Citrus bergamia); Everlasting (Helichrysum angustifolium); Lavender (Lavendula angustifolia); Lavendin (Lavandula); Melissa (Melissa Officinalis); Clary sage (Salvia sclarea); and Clove bud (Syzygium aromaticum).
There are also suggestions that addressing candida infection can also help to improve the symptoms of MS (Toohey et al. 1997 p9). Essential oils reported effective against candida are the anti-fungal oils such as Cinnamon bark (Cinamomum verum); Eucalyptus (Globulus); Fennel (Foeniculum vulgare); Lavender (Angustifolia); Tea tree (Melaleuca alternifolia); Cajaput (Melaleuca leucadendron); Pine (Pinus sylvestris); Winter savory (Satureia montana); Clove bud (Syzygium aromaticum); Spanish marjoram (Thymus mastichina); and Thyme (Vulgaris) (Price et al. 99, p73). Other immuno-stimulating oils are reported to be Frankincense (Boswellia carteri); Lemon (Citrus limon); Niaouli (Melaleuca viridiflora); Patchouli (Pogostemon patchouli); and Vetiver (Vetiveria zizanioides) (Price et al. 99, p354-356).
Apart from using the anti fungal/viral/bacterial action of essential oils to help boost the immune system, I wanted to select oils to help stimulate the immune system by suppressing hormones such as adrenalin and cortisol (hydrocortisone), which are released through long term stress, having the effect of inhibiting the body’s immune responses (Borysenko 99, p14). Unfortunately, Mary’s long-term use of steroids has also had the affect of further suppressing her immune system by acting as a synthetic cortisone (Henry 1995, p141). Oils to avoid would be the adrenal and cortisone stimulating oils such as rosemary and thyme (vulgaris) which reportedly stimulate the adrenal glands; and oils which stimulate the anterior pituitary gland, also involved in stimulating the adrenal glands (Bitter orange: Price et al. 1999, p80).
The mechanisms which
form the body’s immune responses, are very complex involving the interactivity
of many different hormones. Adrenalin
and hydrocortisone are produced in the adrenal cortex of the kidneys and are
produced as a response to pain, cold, fear and stress.
The effect of these hormones being released into the body quickens
metabolism, produces heat, supplies instant energy (the fight or flight
response) but at the cost of suppressing other body functions such as the immune
system and digestion. Long-term
stress results in prologues excessive secretion of cortisol in particular, which
has the long-term affect of immune mechanism suppression resulting in frequent
infections and illness. As MS is
generally regarded as an auto-immune disease (Multiple sclerosis Society- no
date), Mary would be locked in a cycle of chronic disease producing long-term
stress, which in turn inhibits the body’s ability to fight the disease,
further exacerbated by the long term use of immune-suppressing corticosteroid
medication. Massage is an ideal
medium to alleviate stress and anxiety - it is well known that massage can
enhance mood, promote relaxation and the feeling of well being.
(Graydon et al. 1997, p27-28 reviews all the supporting literature as
well as using massage in a trial to positively enhance mood states in people
with MS). There much more
information available on the positive general benefits of massage to alleviate
general stress and anxiety (Diego
et al. 1998, p217-224; Cannard 1996, p38-40; McKechnie et al. 1983, p125-129;
Frazer et al. 1993, p238-245; Meek 1993, p17-21) in order to make massage a
worthwhile intervention for people suffering from the stress of any chronic
disease including MS.
After
researching the information available, I decided that the best way to treat Mary
would be to select oils to help boost her immune system and offer massage
treatment to help lower the stress and anxiety surrounding her illness.
The effect of lowering long term stress and anxiety would help to
suppress adrenalin and hydrocortisone secretion, which in turn should enable
more efficient immune responses to help combat the spread of her disease.
An important part of treating long-term stress would be to try to address
immediate emotional and physical needs as well as promoting comfort and
relaxation. I would also wanted to
see if I could help alleviate the tingling and itching sensations experienced
which I suspected were not flammatory or allergic responses but due to the
neural myelin sheath damage as a result of her MS.
Treatment 1
Mary
complained of several aches and pains particularly in her neck and shoulders as
well as a greater concern about the degenerative effects of her MS and how I
could help. As I had not yet had
the opportunity to research ways of effective treatment in detail, I offered her
a back and neck massage to address her immediate physical discomfort as well as
relaxing and sedating oils with immune-stimulating properties. I selected mandarin for its sedating but immune-stimulating
properties) Price et al. 1999, p354 and 322); marjoram (sweet), also for its
sedating and relaxing properties but also for its effect on muscular and
arthritic pain as well as a neurotonic (Price et al. 1999, p337); and myrrh for
its sedating and immune-stimulating action, and to balance the blend.
I massaged Mary’s back, neck and shoulders while she sat in her
wheelchair. The top half of the
backrest folded down to allow me easy access to her upper back and shoulders.
During the massage she kept saying that it felt ‘wonderful’ and at
one time dozed off to sleep. After
the massage, Mary took me through her bedtime routine which included all her
pillows and bedding being folded just right, her radio on the right channel,
tissues, magazines and telephone all with their appropriate place on her bedside
table. I left her feeling comfortable but the bedtime routine had
taken nearly as long as the treatment. I
decided that it would not be fair to Mary to include her bedtime routine into
the price of her treatment so I made arrangements in the diary for staff to get
her ready for bed before her next treatment.
Treatment 2
Mary
had been looking forward to her treatment.
She asked if I could massage her back and legs because they were feeling
particularly uncomfortable. She had
been experiencing numbness in her legs and wanted me to use Evening primrose
because she had read that it was good for treating MS. I explained to her that
while Evening primrose taken orally could help with the insulation of nerve
fibres due to its linoleic and essential fatty acid contents, the molecules were
too large for it to be absorbed into the body through massage.
I pointed out that she was already getting a good source of linoleic acid
from the Effamol supplements she took daily.
However, recognising the powerful effect of emotional healing, I said I
could use evening primrose as a carrier as it could also help with skincare
(Earle 1994, p29).
I
had already asked staff if Mary could be made ready for bed before the treatment
so she could go straight to sleep after the session. I also didn’t want the beneficial effects of treatment to
be negated by Mary subsequently having to go through a frustrating bedtime
routine with staff who may have been in a hurry to get her ready.
I timed my visit for 9 pm as she said she likes to listen to the radio at
10 pm to get off to sleep.
Mary
said she had had a few ‘bad’ nights recently so I selected sedating and
relaxing oils as well as those to help boost the immune system.
I selected sweet marjoram again for its relaxing properties as well as
working against candida which has been associated with MS (Toohey et al. 1997,
p9); Roman chamomile for its calming, relaxing and sedative properties, also
being high in esters (75-80% according to price et al. 1999, p316), and for its
anti-inflammatory and skin soothing properties (Bartram 1995, p106); With Myrrh
for its relaxing and immune-stimulating actions (Price et al. 1999, p354 and
322). As a carrier I had decided to
use one part evening primrose (client preference) with one part calendula for
its anti-inflammatory effect and skin strengthening properties (Price et al.
1999, p230) for the weak and thin skin on her legs, with four parts grape seed
to make the blend a more suitable consistency for massage.
Mary
was not able to lie on her front in order for me to massage her back and I
didn’t want her to have to go through the effort of getting in and out of bed
to sit in her wheel chair. So in
order to access her back I asked her to sit on the bed with her feet on the
floor – I placed her bedside table in front of her and stacked several
pillows. I covered the pillows in a
towel and asked her to lean forward over the pillows.
This offered her a comfortable supported position while I had access to
her back by standing to the side. I
divided the massage time into equal halves first massaging her left side, and
then moving over to her right side.
After
the back massage Mary was able to easily slide back into bed.
I raised her legs slightly with pillows to help blood circulation and
lymphatic drainage of the feet and lower leg, while finishing off with leg and
foot massage.
I
needed to be careful massaging Mary’s legs due to the thinness of her skin,
however, I was able to use light frictional movements on her feet where the skin
was more robust, which helped to increase the surface circulation and alleviate
some of the tingling. She told me
she had not had so much relief in years and found the foot massage particularly
soothing.
Treatment 3
The staff told me that
Mary had been uplifted by her last treatment and had been telling everyone how
good she felt. I thought it was
important to build on the emotional success and used the same blend as before.
Mary wanted me to massage her back again then to finish off with her legs
and feet. She was still
experiencing numbness and tingling sensations in her legs and feet and said that
at times it affected her face and lips, making it difficult to talk properly.
I offered a face and neck massage but she declined, preferring to have
the same treatment as before. I
used the same position and massage techniques as for treatment 2 but spent a lot
more time on her feet, something she found very relaxing.
Mary told me that the leg massage did offer temporary relief from the
tingling sensations she experiences due to neural damage.
In order to evaluate the effectiveness more accurately, I asked Mary to
help assess if the massage with oils was working by remembering how long she
experienced relief from the tingling sensations after each treatment.
Treatment 4
To help evaluate the last treatment, Mary told me that the tingling had not returned before she fell asleep that night, but had woken her up as usual in the early hours of the morning.
However, Mary wanted me to continue treating her as before because she was convinced it was working. She certainly seemed in a much more positive mood emotionally. Although not wanting to upset the good results of treatment so far, I was a little concerned that Mary had latched onto another ‘routine’ that we would not allow deviation without causing anxiety. To overcome this, I suggested always trying something new at the start of each session, then finishing with the familiar routine of back, neck, shoulder and leg massage to help her settle before bedtime. She agreed to this so I suggested starting the session with a hand and arm massage.
Mary decided that she
wanted me to use a jar of body lotion with Evening primrose oil and lemon that
her daughter had bought her – I saw no reason not to use the lotion for her
hands and arms, recognising the importance of client preference and the placebo
effect of her belief that the Evening primrose would ‘do her good’. After massaging Mary’s hands and arms with her body lotion,
I massaged her back, neck and shoulders, paying particular attention to the
tension in her neck muscles and lower back, which she said had been aching.
I then finished by massaging her legs and feet using fast stroking
movements where skin was thin, with deeper frictional massage to encourage
circulation on the thicker layers of skin on her feet, finishing with a more
relaxing light effleurage movement.
Treatment 5
When I arrived for Mary’s treatment staff told me she had been suffering from bouts of feeling very ill over the last few days. When I saw her she was visibly pale and her speech was slurred and difficult to understand. She was complaining of tingling in her hands and legs and had been in bed all day. However, she did seem very pleased to see me and wanted to know all about what my children had been doing since my last visit.
Staff told me that the Doctor did not think she had suffered a stroke but had picked up a viral infection, which had caused a relapse of her MS symptoms. Mary told me that she thinks it all started when she had sat out for too long in the sun 3 days ago.
I could remember collecting some literature about hot baths being used in the middle of the last century as a diagnostic test to aggravate the neurological signs associated with MS in order to help diagnose the condition (Berger et al. 1983, p1751-1753). If prolonged heat exposure from bath water could exacerbate the symptoms of MS, so too could prolong exposure to other sources of heat. I mentioned this to the Home manager and she agreed that some of Mary’s relapses could be related to heat, as she would often find sunbathing or the warm lounge intolerable. She also agreed to mention it to Mary’s GP and look into issues such as bathing, ventilation and temperature control in her room.
Mary did not want a ‘proper’ massage but wanted me to stay and massage her hands. I used 1 drop of Sage essential oil with 1 drop of Petitgrain in 6 mls of sunflower oil. Sage is reported to be antiviral (including candida), analgesic, relaxing as well as a neurotonic and expectorant (Price 1998, p278-280) and seemed an obvious choice although it has to be used in high dilution (Price et al. 1999, p243). I hoped that the gentle mucolytic and expectorant action would help Mary breath more comfortably during the night. I chose Petitgrain for its calming and sedative properties as well as being generally an anti-infectious agent (Price et al. 1999, p320). I also applied a solution of Witch hazel (Hamamelidis virginiana) to her arms and legs with a cotton pad. Witch hazel has anti-inflammatory and cooling properties and is particularly suitable for treating skin fragility associated with topical steroid treatment (Bartram 1995, p455-456). On exposure to the air, the evaporation caused cooling which Mary found comforting and a distraction from the tingling sensations in her hands and legs.
I spent an hour with Mary helping to make her more comfortable and considered that being there for emotional support was the priority for treatment on this occasion. During the session, Mary’s conversation turned to thoughts of dying, which I listened to and tried to offer her some comfort through my replies and the physical touch of the massage. I also thought that with hindsight perhaps I should have selected more appropriate oils to address her depression and melancholy (such as frankincense, Rosewood, Lavender, Melissa), which had not really manifested itself until towards the end of the session.
I left Mary with a few
drops of Frankincense on her pillow. Frankincense
is not only antidepressive and can address melancholy (Price et al. 1999,
p152-153), but is also helps to stimulate the immune system and would act as an
expectorant and anticatarrhal agent (Price et al. 1999, p315), hopefully to let
Mary sleep more easily that night.
Treatment 6
When I arrived, staff told me that Mary was still suffering from the affects of a viral infection and a significant relapse of her MS, however, despite feeling very ill and nauseous, she had not wanted to cancel my visit. She had been bedridden for the last 3 weeks and the staff were now using a hoist to help manoeuvre her for care and hygiene. To Mary, using the hoist signified the end of her mobility and independence. She confided in me that she felt a loss of dignity being transported from commode to the bathroom along a busy corridor by staff that were very caring, but probably not aware of the emotional consequences of finally submitting to losing the ability to move unaided.
I offered Mary a hand massage, which is all she could tolerate at first using a 1% dilution of peppermint for its antiemetic and soothing properties (Lawless 1999, p132; Price 1998, p268). I have always found peppermint particularly effective in treating nausea and it also has the added advantage of being analgesic, anti-infectious and a neuro-tonic (Price 1998, p268). Its expectorant properties would also help Mary to breath more easily during the night. She then asked me if I could use Witch hazel on her legs and feet because she had found it particularly refreshing. While doing her feet I noticed that the skin was very dry and flaking so I used Calendula on a cotton pad to moisturise the soles of her feet and between her toes. Afterwards I applied a 5% solution of Tea tree in Witch hazel between her toes with a cotton pad to treat cracked skin and early signs of a tinea pedis infection. Tea tree has been proved particularly affective against tinea pedis (Athletes foot) (Bartram 1995, p42; Olsen 2000 – no date).
I finished off by
combing her hair, which had become neglected over the past few days.
By offering a little attention to her personal care, I hoped that I could
leave Mary feeling tidy, clean, relaxed and comfortable to help boost her
self-esteem and feeling of well being. At
her request, I put a few drops of Frankincense on her pillow before I left.
I recognised that Mary sought comfort from the routine of the previous
visits, wanted to feel valued, and needed someone to be with her to share her
thoughts and help pass the time. I
also recognised now that Mary’s treatment was palliative in nature - my main
aim being to offer her comfort in what ever form, and let her identify her own
needs for treatment in order to help her feel more in control.
I also wanted to support her emotionally and hoped that I had achieved
this.
I continued to visit
Mary for 3 more treatments and was able to sit with her and massage her hands to
indicate that someone was there who cared.
She died in November after being transferred to a Hospice for the last 2
weeks of her life.
Conclusion
Mary
enjoyed looking forward to her treatments because they offered an opportunity
for attention not always possible in a busy care home environment.
She was one of those rare individuals who touches your life and leaves
you thinking how grateful you are to have met her.
Even when feeling ill, she was always pleased to see her friends and took
great delight in catching up on the news from all the people who were part of
her life.
I
learnt to adapt the massage sequence to suit someone who is not able to use a
massage table or lie on their front properly.
I also learned to think ahead and prepare the work area beforehand to
allow access to both sides of the bed and both sides of the client.
Treating
Mary also taught me that it takes time to assess the real needs of a client,
particularly when dealing with people on such an intense emotional level.
With monthly visits it can take well into the treatment session before
the real emotional needs of the client are realised, often making the original
treatment plan insignificant. In
order to address this, one needs to be flexible and adapt the treatment
appropriately.
I
also learned how difficult it is to realistically evaluate treatment - in many
circumstances success cannot be measured by objective criteria due to the very
nature of having to address emotional as well as physical needs.
It is also very difficult when working in Nursing homes to attempt to
evaluate treatment due to the length of time between each treatment due to
client preference or the ability to afford regular treatments - the clients may
experience short term relief, but staff and client are not be able to remember
by the time of your next visit. I
did try to get Mary to help evaluate her own treatment, but this was superseded
by her changing physical and emotional needs requiring a different approach to
intervention.
I
was pleased that I was able to show respect for Mary’s dignity and hope that
it contributed to her comfort and spiritual needs at such a difficult time.
I also hope that it was an example to staff who, due to the nature of
their job, can become desensitised to such issues.
When
working with Mary, the priorities for treatment changed from trying to help
alleviate her symptoms to helping her die more comfortably. At the beginning I was keen to address the symptoms of her MS
until her emotional needs and the process of dying became more important.
Eventually her emotional needs were best addressed by being there rather
than trying to intervene with essential oils and massage.
I hope that Mary’s case study illustrates the role aromatherapy can
play in helping to support the emotional needs of a client during the process of
palliative care.