THE theory of “hospice” has been published for more than half a century. It has been promoted increasingly in medical systems of many countries. When disease becomes irreversible, the core conception as in hospice and palliative care is to relieve pain, maintain dignity and improve quality of life.1
Aromatherapy uses plant essence extracts from aromatic plants to cure, alter or improve the healing of body and mind. Plant-derived essential oils contain highly volatile compounds that can release physical and mental symptoms and improve quality of life for patient at the end of life, instead of healing the disease. As one of multiple therapeutic methods in palliative care, aromathe-rapy has been promoted and used widely in the United States, United Kingdom, Germany, Australia, Japan and some other countries. Its application in the treatment of various health conditions and its effectiveness of improving overall wellness can be traced from antiquity. In the current case, we report a cancer patient with multiple metastatic diseases from unknown primary tumor who was suffering from pain, nausea, lower limb edema and insomnia. Individualized aromatherapy was performed and significant relieves of his symptoms were observed. The patient passed away peacefully.
CASE DESCRIPTION
History, examines and diagnosis
A 32-year-old man was hospitalized due to diarrhea and stomachache for more than a year, lumbosacral pain for two months, as well as pitting edema in both lower extremities. In January 2017, diarrhea and weight loss occurred for no incentive. These conditions were improved through symptomatic treatment. In late December 2017, the patient begun to suffer from periumbilical and upper abdomen pain again, NRS 2-4 points, for no obvious incentive, accompanied with right waist ache radiating to the right inguinal region, NRS 7-8 points. The patient was diagnosed as kidney stone at local hospital, received extracorporeal lithotripsy, with somehow relief of suffering. In April 2018, the lumbosacral pain progressively aggravated, NRS 7-8 points, which had seriously influenced his positioning, like sitting or lying, daily activities and sleeping, accompanied with poor appetite, diarrhea, and lacking in strength; meanwhile, the urine output decreased to 500 mL/d, the pitting edema reoccurred in both lower extremities and extended to scrotum. So the patient was sent to our hospital for emergent treatment.
The serum creatinine elevated to 502umol/L, pancreatic function examination and routine urine test were both negative. The serum tumor markers examinations showed significantly increases of CA19-9 (17310.0 U/mL) and CA24-2 (>150 U/mL). The urinary ultrasonography(US) showed bilateral hydronephrosis with dilated left upper ureter, and diffuse lesions in double kidney, suggesting posterior renal obstruction. Imbedding D-J tube of the left side failed, and the right D-J tube imbedding was successful, with subsequently increased urine volume and relieves of lumbago and leg edema, and Creatinine fell to 258 μmol/L. Abdominal ultrasonography(US) showed multiple solid nodules in liver, hepatic portal vein thrombosis, spongiform degeneration, enlarged pancreas with abnormal echogenicity, and splenomegaly. PET-CT indicated peripancreatic, retroperitoneal and mesenteric multiple hypermetabolic lymph nodes; multiple hypermetabolic metastasis in the liver and in vertebral body, both lungs, accompanied by abdominal and pelvic effusion and pleural effusion. Liver biopsy of hepatic lesion demonstrated poorly differentiated adenocarcinoma. Thus, the diagnosis of metastatic poorly-differentiated adenocarcinoma was made, the primary lesion was unknown.
Clinical management
As patient’s general situation was poor, Zubrod-ECOG-WHO(ZPS) 3 points,2 it was difficult for the patient to tolerate chemotherapy. Radiotherapy was considered by his attending doctors at first, but due to the inconsistency between pain and location of the disease, radiotherapist did not use radiotherapy to him.
The patient was successively given oxycodone-acetaminophen tablets 1# tid, morphine sulfate controlled-release tablets 10 mg Q12h, oxycodone hydrochcoride controlled-release tablets 20 mg Q12h, and transdermal Fentanyl 8.4 mg for analgesia. Although the pain was relieved, the patient began severe dizziness, nausea and vomiting. The medication had to be adjusted. Dose of Oxycodone hydrochcoride controlled-release tablets was reduced to 10 mg Q12h, and transdermal Fentanyl 4.2 mg, with oxycodone-
acetaminophen tablets 1# PRN (Pro re nata). The pain symptom was slightly controlled, NRS was 5-7 points at appropriate body position and 8-10 points when changing the body positions. Patient still vomited 3-5 times per day due to tumor irritation and pain control medication.
In view of the portal vein thrombosis, the anticoagulant therapy with Low-Molecular-Weight Heparins Sodium injection 6000U q12h was conducted after consulting vascular surgery. Because obvious edema of both lower extremities, vascular US of both lower extremities was performed and venous thrombosis was eliminated. Consequently, the patient received supporting treatments including intake control, diuresis, supplementation of proteins, etc. However, there was no significant improvement of his symptoms. The patient complained lumbosacral pain, heaviness and swelling of the lower extremities, difficulty in moving body, which had seriously affected his daily activities and sleeping.
Aromatherapy
As the patient was in the terminal stage of cancer, and the family members hoped to alleviate the patient’s discomfort as much as possible and smoothly pass the terminal stage, palliative care specialist was invited for consultation. Considering the poor control effect of medication on the systemic symptoms, the patient was referred to aromatherapy group for better management of patient’s current symptoms.
The nurses in aromatherapy group carried out bedside assessment to the patient, and communicated with the patient and his family members to ensure patient and his families understand the disease with proper expectations on the prognosis. The therapeutic efficacy, performance, possible side effects of aromatherapy were explained thoroughly. The patient described the lumbosacral pain as the major suffering, hoped to alleviate the pain and reduce the dosage of painkillers through aromatherapy, as well as to improve the conditions of edema of lower extremities, nausea and sleep disorders. The existing problems and clinical managements of the patients are illustrated in Fig. 1. Based on patient’s major complaints, the pain, edema of both lower extremities, nausea and vomiting, we performed aromatherapy treatment with compound essential oils. The oil selection, compatibility, mechanism and performance for each symptom controlling were described in detail in Table 1. (video available at http://cmsj.cams.cn)
Figure 1.
Illustration of patients’ major complains, main symptoms, causing pathologies and clinical managements.
Effects feedback and scheme adjustment
Pain: The patient described that the pain at the area of massaging was relieved after the first time application, and the lumbosacral pain was reduced to 5-6 NRS points when move the body position and 3-4 NRS points at the appropriate body position, which was moderate pain. At the follow-up visit after 3 days application, the family member told us that the patient felt comfortable, and the coadministration of painkillers had basically controlled his pain, so that he was able to fall asleep easily. The NRS points of the patient fell to 3. This formula of aromatherapy was applied continuously to the patient during his terminal stage.
Edema of lower extremity: The patient’s thigh circumference (10 cm above patella) reduced slightly after 3 days application (Left: from 50 cm to 49 cm; right: from 49 cm to 48.5 cm). The family reported that, after daily massages several times, the patient felt better with the swelling of legs, accompanied with a better ability to move his legs. The patient continued to use this regimen.
Nausea and vomiting: We attempted to evaluate the effect on nausea and vomiting by scales of symptoms. Considering the self-rating scale has to be complete by patient himself, which was likely to induce or aggravate his nausea and vomiting behavior and cause his bad experience, we decided to just record patient’s frequency of nausea and vomiting per day by family’s observation. On the follow-up visit after using spray and sniffing rod for 3 days, the frequency of nausea was reduced to 3-5 times per day, and no vomiting at all. The patient expressed his desire for better sleeping, so after discussing with his family, we adjusted the spray formula, peppermint was replaced by true lavender.
Table 1 Aromatherapy treatment plan: formula of compound essential oil, working mechanism and performing methods
| Symptom | Aromatherapy formula | Working mechanism | Method of application |
|---|---|---|---|
| Pain | 1. Saint John’s Wort 20 ml 2. Lavender 3 drops 3. Gaultheria 2 drops 4. Lemon eucalyptus 1 drop | •Saint John’s Wort can relieve musculoskeletal pain, and has the mood-stabilizing and anti-depression effect;3 •the linalyl acetate and linalool in true lavender have the effects of local anesthesia, anti-muscle spasm, and can also soothe anxiety and uneasiness;4,5 •the main composition of gaultheria is methyl salicylate, which has good analgesic and anti-spasm effects;5 •citronellal in lemon eucalyptus has the pain-relieving effect.6,7 | •Take 5 ml and smear it on the lumbosacral region of the patient and gently massage for 10 minutes. •Massage every 2 hours, •or give massage when the patient felt necessary. |
| Edema of lower extremity | 1. Sweet almond 30 ml 2. Grapefruit 4 drops 3. Cypress 3 drops 4. Vetiver 2 drops | •Sweet almond oil can lubricate, and it is suitable for massage; •grapefruit and cypress have the effect of improving fluid retardation, excessive body fluid, and eliminating edema;8 •the furocoumarin in grapefruit also has an anti-de- pressant effect; •vetiver has the effect of promoting blood circulation and deep relaxation; •grapefruit and herb can be used together to soothe patients’ mood and improve their sleep. | •Gently massage the lower extrem- ities from distal end to proximal end for purpose of good absorp- tion of the essential oil, instead of helping drainage.* •Changing gesture if patient felt tired or intolerable during perfor- mance. •massage for about 10 minutes, or till the patient fell asleep.# •Perform massage 2-4 times a day. |
| Nausea and vomiting | 1. 75% ethyl alcohol 50 ml 2. Bergamot 15 drops 3. Sweet orange 10 drops 4. Peppermint 5 drops | •Bergamot, sweet orange and peppermint essential oil can alleviate nausea and anxiety. •The combined use of three essential oils can prevent the maladaptation of a single essential oil due to its high concentration and single smell.9 | •Spray in patient’s room 4 times a day. •Put 10 drops of compound oil (Bergamot and Sweet orange) on the sniff stick for patient to smell when the symptoms were severe. |
*Video available as supplementary material. #Put compound oil in the palm and let the patient smell it before massaging; ask the patient about his feeling during the massage. Family members were taught to perform the massage. Instructions in operation and cautions of the massage were given. The massages were performed after eliminating venous thrombosis of lower extremities.
DISCUSSION
The word aromatherapy was first proposed by a French chemist Rene Morris Gedfose and applied to the wounded soldiers in the First World War. In the Second World War, a French military doctor Jean Vaughn applied aromatherapy to clinical medical practice. After Shirly Price published the book Aromatherapy for Health Professionals, it sparked the attention of the UK medical care community. Since then, the United States, France, the United Kingdom, Australia and many other countries have carried out many clinical researches on application of essential oils. More and more medical care providers accept that aromatherapy, as a complementary therapy, is beneficial to palliative patients. It relieves the patient’s anxiety and depression, alleviates pain, reduces the dose of drugs and the related adverse effects, thus bring physical and mental comfort and peace to suffering patient with improved quality of life.10.11
In recent years, aromatherapy has been used as a supplementary medical method clinically, especially in the fields of pain relief, emotional improvement, antibacterial and anti-inflammatory treatment and palliative care. It has many advantages, such as the improvement in the patient’s comfort level, little adverse reactions, and saving medical resources. 12 In this case, aromatherapy was used to treat various symptoms and uncomfortableness at the end of life, and good feedback was received. The patient was not tolerant to nausea and vomiting induced by painkillers, and the repeated nausea and vomiting made the patient to reject painkillers, thus aggravated the pessimistic mood of the patient. Aromatherapy had no gastrointestinal stimulation for its exogenous administration, so it was easier for the patient to accept; simultaneously, the synergy of different essential oils could not only ease the pain, but also relieve the anxiety and depression mood; the performance of massage with essential oil could increase the communication between the patient and his family members, thus make the patient feel being emotionally close to the family, and more willing to express his inner feelings, so as to relieve inner discomfort.
It was found that the effect of aromatherapy on edema was not as significant as that on pain, nausea and vomiting, suggesting that aromatherapy is more effective on subjective complains. Aromatherapy improves patient's wellbeing by local therapeutical effects of essential oil, as well as by relieving emotional stress such as anxiety and depression through engaged love and attention of caregivers, especially family members, while massaging. Patients can get a better personal experience that cannot be achieved by any other treatment measures.
Because aromatherapy is completed with the joint efforts of doctors, nurses, family members and patients, patients’ trust and dependence on medical staff has been improved, and patients are willing to express their wishes and feelings, fully at ease to discuss the possible deaths, and live through the denial period in a stable and smooth manner. On the other hand, the evasive attitude of traditional Chinese families towards death usually make patients lose the last chance of communication with their family, while the aromatic therapy process can provide an effective oppotunity for family members to communicate with patients, express their feelings to each other. In this way, aromatherapy improve the accompanying quality of family members, enhance the intimacy between family members and the patient, and help family members live through the pains of losing the loved ones more calmly.
Currently, benefits of aromatherapy in the patient care have been recognized, and there have been many relevant studies. However, most of studies and practices lack individualization. When carrying out aromatherapy for patients, it is necessary to make whole consideration from all aspects of a patient, such as his/her all relationships, the whole environment, and the whole-body condition, etc., which requires the expertise of aromatherapy professionals. Some clinicians and nurses do not familiar enough with aromatherapy, some even take an unacceptable attitude to it. It is important for aromatherapy practitioners with expertise to lecture in medical staff on relevant knowledge of aromatherapy, and apply aromatherapy clinically in patient care, so that its clinical value and benefits can be well recognized.
At present, aromatherapy care in many other countries has been adopted in the medical care system and can be charged as a medical service, while most of essential oil products we use are purchased by nurses at their own expense. In Chinese Taiwan, the essential oil products are free for patients and in self-help by the essential oil manufacturers, or, donated by the families of deceased patient. It is necessary for the mainland China to find a suitable payment model to provide sustainability of aromatherapy service for patients who are truly in need of it. In addition, “palliative medicine” is a systematic approach to support patients and families with life-threatening illnesses. Therefore, aromatherapy can also be used in caring for family members of terminal patients in future.
Constent
Writen informed consent was acquired from the family member of the patient reported in this article.
Statement of conflict of interest
The authors declared no conflict of interests.
参考文献
Overview of palliative care
Toxicity and response criteria of the Eastern Cooperative Oncology Group
A comparative study about efficiency of St. John’s wort extract in the treatment of female patients with involutional depression
Linalyl acetate as a major ingredient of lavender essential oil relaxes the rabbit vascular smooth muscle through dephosphorylation of myosin light chain
In a preliminary experiment, we found that lavender essential oil relaxes vascular smooth muscle. Thus, the present experiments were designed to investigate the relaxation mechanism of linalyl acetate as the major ingredient of lavender essential oil in rabbit carotid artery specimens. Linalyl acetate produced sustained and progressive relaxation during the contraction caused by phenylephrine. The relaxation effect of linalyl acetate at a concentration near the EC50 was partially but significantly attenuated by nitroarginine as an inhibitor of nitric oxide synthase, 1H-[1,2,4]oxadiazolo[4,3-a] quinoxaline-1-one as an inhibitor of guanylyl cyclase, or by the denudation of endothelial cells. In specimens without endothelium, the phenylephrine-induced contraction and phosphorylation of myosin light chain (MLC) were significantly attenuated after the pretreatment with linalyl acetate. The relaxation caused by linalyl acetate in the endothelium-denuded specimens was clearly inhibited by calyculin A as an inhibitor of MLC phosphatase, although not by ML-9 as an inhibitor of MLC kinase. Furthermore, suppression of the phenylephrine-induced contraction and MLC phosphorylation with linalyl acetate was canceled by the pretreatment with calyculin A. These results suggest that linalyl acetate relaxes the vascular smooth muscle through partially activation of nitric oxide/cyclic guanosine monophosphate pathway, and partially MLC dephosphorylation via activating MLC phosphatase.
Local anaesthetic activity of the essential oil of lavandula angustifolia
In this work we studied the local anaesthetic activity of the essential oil obtained from LAVANDULA ANGUSTIFOLIA Mill., a medicinal plant traditionally used as an antispasmodic. We compared its activity to the essential oils obtained from two citrus fruits, CITRUS RETICULATA Blanco and CITRUS LIMON (L.) Burm. f., which have no medical uses. Biological tests were also performed on the major pure components of L. ANGUSTIFOLIA Mill. essential oil: linalol and linalyl acetate as determined by GC and confirmed by GC-MS. Anaesthetic activity was evaluated IN VIVO in the rabbit conjunctival reflex test, and IN VITRO in a rat phrenic nerve-hemidiaphragm preparation. The essential oil of L. ANGUSTIFOLIA, linalyl acetate and linalol (0.01 - 10 g/ml) but not the oils of CITRUS RETICULATA and CITRUS LIMON were able to drastically reduce, in a dose-dependent manner, the electrically evoked contractions of rat phrenic-hemidiaphragm. In the rabbit conjunctival reflex test treatment with a solution of essential oil of L. ANGUSTIFOLIA, as well as linalyl acetate and linalol (30 - 2500 g/ml administered in the conjunctival sac) allow a dose-dependent increase in the number of stimuli necessary to provoke the reflex, thus confirming IN VIVO the local anaesthetic activity observed IN VITRO .
Phytochemical composition of Cymbopogon citratus and Eucalyptus citriodora essential oils and their anti-inflammatory and analgesic properties on Wistar rats
Cymbopogon citratus and Eucalyptus citriodora are widely used herbs/plants as a source of ethnomedicines in tropical regions of the world. In this work, we studied the anti-inflammatory and gastroprotective effects of C. citratus and E. citriodora essential oils on formol-induced edema, and acetic acid induced abdominal cramps in Wistar rats. To fully understand the chemically induced anti-inflammatory properties of these plants, we first analyzed the chemical composition of the essential oils. A total of 16 chemical constituents accounting for 93.69 % of the oil, were identified in C. citratus among which, Geranial (27.04 %), neral (19.93 %) and myrcene (27.04 %) were the major constituents. For E. citriodora, 19 compounds representing 97.2 % of the extracted oil were identified. The dominant compound of E. citriodora essential oil was citronellal (83.50 %). In vivo analysis and histological assay showed that the two essential oils displayed significant dose dependent edema inhibition effect over time. They displayed strong analgesic and antipyretic properties similar to that induced by 50 mg/kg of acetylsalicylate of lysine. However, the E. citriodora essential oil was more effective than that of C. citratus. We identified significant numbers of aldehyde molecules in both essential oils mediating antioxidant activity that may contribute to the anti-inflammatory effects observed on the rats. Altogether, this work demonstrates the anti-inflammatory property of C. citratus and E. citriodora suggesting their potential role as adjuvant therapeutic alternatives in dealing with inflammatory-related diseases.
Antinociceptive effect of methyleugenol on formalin-induced hyperalgesia in mice
The effects of methyleugenol, an essential oil isolated from Asiasari radix, on antinociception were examined using the formalin test in mice. Oral administration of 10 mg/kg methyleugenol significantly decreased the duration of licking and biting behavior in the second phase without affecting that of the first phase, as did diclofenac, a non-steroidal anti-inflammatory drug. Methyleugenol also inhibited pain-related behaviors induced by intrathecal injection of N-methyl- d-aspartic acid (NMDA), while diclofenac did not affect these behaviors. These effects of methyleugenol were suppressed by bicuculline, a -aminobutyric acid A (GABA A) antagonist. Muscimol, a GABA A agonist, displays the same action as methyleugenol with respect to the formalin test and NMDA-induced behaviors. Methyleugenol did not affect cyclooxygenase-1 and -2 activities. These results suggest that the antinociceptive effect of methyleugenol on the second phase of formalin-induced pain may be due to the inhibition of NMDA receptor-mediated hyperalgesia via GABA A receptors.
Application study on aromatherapy in chemotherapy-induced nausea and vomiting in children with high-risk neuroblastoma
Objective:To explore the effect of aromatherapy on chemotherapy-induced nausea and vomiting(CINV)in children with high-risk neuroblastoma(NB).Methods:From November 2015 to July 2016,patients with high-risk NB were treated with high-dose drugs chemotherapy in Blood Tumor Center of Beijing Children's Hospital They were selected as the research objects.The chemotherapy regimen included CAV regimen(cyclophosphamide+adriamycin+vincristine)and CVP regimen(cisplatin+etoposide).The self-contrast was used,and according to the random number table,a ill child using the same chemotherapy program was taken as the experimental group and control group respectively before and after.The patients in experimental group were given aromatherapy on the basis of antiemetic drugs,while the patients in control group were given only antiemetic drugs and the intervention last for 5days.The Chinese version of Index of Nausea Vomiting Retching scale was used to assess the occurrence frequency,experience time and the severity of three symptoms including nausea,vomiting,and vomiturition of the two groups of children.The vomiting self-assessment results and acceptable degree of aromatherapy were assessed after intervention.Results:A total of 39 cases were included in this study.A total of 76 cases/times of chemotherapy.There were 72 effective cases/times,36 cases/times of the experimental group,36 cases/times of the control group,46 cases/times of the CAV program,and 26 cases/times of the CVP program.The children's experience time,occurrence frequency,and severity of CINV were gradually increased,and reached the peak on the third day to the fourth day after chemotherapy,while the symptoms in experimental group was less than those in control group(except the intraday).The experience time,occurrence frequency,and severity of nausea,vomiting and vomiturition symptoms in experimental group were less than those in control group,in which there was the statistical significant difference in severity(P0.05).During the period of CAV regimen,there was no significant difference in CINV between the two groups(P0.05).During the period of CVP regimen,the experience time and occurrence frequency of nausea in experimental group were less than those in control group(P0.05).The severity of vomiting on the third day to the fifth day was lower than that in control group(P0.05).The experience time and severity of vomiturition on the third day to the fifth day were lower than that in control group(P0.05).In parental self-assessment results,5 cases/times(13.9%)with aromatherapy after nausea and vomiting improved significantly,25 cases/times(69.4%)improved,4 cases/times(11.1%)did not change,2 cases/times(5.6%)felt worse.In the acceptance degree of parents,19 cases/times(52.8%)believed that aromatherapy was very simple,17 cases/times(47.2%)believed it was simple,9 cases/times(25.0%)were very satisfied with the aromatherapy,22 cases/times(61.1%)were satisfied,4 cases/times(11.1%)thought it was ok,1 case//time was not satisfied,8 cases/times(22.2%)were very likely to continue to use,20 cases/times(55.6%)hoped to use continually,7 cases/times(19.4%)thought it was ok,1 case/time(2.8%)did not want to continue to use.There was no allergic reaction in the experimental group.Conclusions:CINV in children with high-risk NB has the highest and most serious incidence,especially delayed nausea and vomiting on the intraday to the first day after the end of chemotherapy.Aromatherapy could relieve the severity of nausea and vomiting in high-risk NB patients,especially reduce the experience time and severity of vomiturition and severity of vomiting during the period of CVP regimen on the third day to the fifth day.It was acceptable for parents and older ill children.
Application of aromatic therapy in patients with advanced cancer pain nursing
Evaluating the effectiveness of aromatherapy in reducing levels of anxiety in palliative care patients: Results of a pilot study
Results of the pilot study of the four counties randomised controlled trial to evaluate the effectiveness of aromatherapy massage with 1% The aims of the pilot study were to evaluate the effectiveness of aromatherapy in reducing anxiety in patients receiving palliative care in four counties. The primary end points of the research were to report a statistically significant difference in anxiety scores between experimental group (B) and comparison groups (A and C) and to influence the integration of aromatherapy into all aspects of palliative care. The limited data of the pilot study (=34) tested the logistics of the research, particularly the 25% attrition rate and the robustness of the data collection tools. The results were not substantial enough to generate coherent statistics. Therefore no assumptions could be drawn from these results due to the inconsistencies that were bound to occur in such a small sample. However, the results do seem to support the notion that Sandalwood oil is effective in reducing anxiety.
Application of aromatic therapy in clinical nursing work
It analyzed the application of aromatic therapy in clinical nursing work,and mainly expounded the influ influence of aromatherapy on treatment in aspects of mood,pain,high blood pressure,anti-bacterial anti-inflammatory,cancer and women's health,and introduced mechanism,the main treatment methods and related considerations of aromatherapy.
