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American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference
2006年6月7－10日
美国明尼苏达州
June 7 - 10, 2006, St. Paul, Minnesota
Lessons of the Heart -- Cardiovascular Disease: A Mind, Body, and Spirit Approach
Veda Andrus, EdD, MSN, RN, HN-BC
Introduction: The Heart Speaks
Medical schools do a superb job of teaching about the physical heart: a 4-chambered, fist-size organ functioning as a mechanical pump beating an average of 72 beats per minute, more than 100,000 times each day. The conventional role of a cardiologist is that of a technical specialist who can, with a wide range of technologic equipment and professional acumen, diagnose and treat the physical issues of the heart.
As Mimi Guarneri, MD, FACC,[1] notes in her book The Heart Speaks: A Cardiologist Reveals the Secret Language of Healing:
No one spoke of the other layers of the heart that didn't appear on a stress test or electrocardiogram: the mental heart, affected by hostility, stress, and depression, the emotional heart that could be crushed by loss, the intelligent heart that has a nervous system of its own and communicates with the brain and other parts of the body. No one lectured about the spiritual heart that yearns for higher purpose, the universal heart that communicates with others, or the original heart that beats in the unborn fetus before the brain is formed.
Dr. Guarneri, Founder and Medical Director of Scripps Center for Integrative Medicine in La Jolla, California, and attending physician in cardiovascular disease at Scripps Clinic since 1995, provided an informative and inspiring keynote address.[2] Her presentation addressed foundational information about heart health, guidelines for maintaining a healthy heart, and an exploration of the deeper messages of the heart.
Foundational Information on Heart Health
Dr. Guarneri provided foundational information about heart health and cardiac disease to lay the groundwork for her presentation.
Risk factors for cardiac disease include:
Family history of heart disease;
Smoking;
Diet;
Cholesterol levels over 200 mg/dL;
Inflammatory processes;
Depression;
Stress;
Anxiety; and
Social isolation.
Statistics that opened her eyes to a deeper meaning of cardiac disease include:
80% of people with a heart attack will have the same cholesterol level as those who do not have a heart attack;
300,000 Americans die each year of poor diet, inactivity, and stress-related illnesses;
American children spend an average of 6 hours/day watching television or sitting at the computer; and
The rate of diabetes has increased multifold in Americans: 1958 (less than 2 million), 2000 (15 million), and 2025 (projected 23 million).
Dr. Guarneri, in reflecting on the factors influencing cardiovascular health, recognized that the heart is complex, and treating the heart required more than the insertion of stents and the use of statin drug therapy. She began to see that "behind every heart there is a story," and listening intently to her patient's words could provide deeper insight into their heart health. She recognized that "how we live our lives and, more importantly, whom we live our lives with" are critical factors that must be considered when looking at the big picture of a person's heart health. "Western medicine excels at crisis and acute care, and cardiologists are taught to treat only a piece of the person. They deliver therapies that would not get to the underlying factors of heart disease by treating only the symptoms."
Guidelines for Maintaining a Healthy Heart
Dr. Guarneri noted that heart disease was related to an inflammatory reaction that increased the potential for plaque formation and the capacity for the plaque to adhere to the walls of the arteries. She indicated a direct relationship between proper nutrition and heart health, noting that when patients ate within the following guidelines, there was a 70% reduction in cardiac disease:
Following an Indo-Mediterranean diet: high in fruits, beans, vegetables, whole grains, nuts, soy, and fish;
Using inflammation-reducing herbs: turmeric, ginger, and rosemary;
Drinking green tea;
Avoiding trans fats, partially hydrogenated oils, simple sugars, meat, and saturated fats;
Avoiding supersizing: being aware of the quantity of food ingested; and
Reducing intake of alcohol.
In addition to dietary recommendations, Dr. Guarneri recommends exercising 6 days/week and indicates that with this regimen, there may be a 50% reduction in heart disease, a reduction in blood pressure, an increase in high-density lipoproteins (HDLs), an overall improvement in the lipid profile, and a decrease in stress.
Deeper Messages of the Heart
When in medical school, Dr. Guarneri recalls learning not to "open Pandora's box" by asking patients leading questions, but she quickly added that "it is not until you ask the questions that you can really help someone." She said it was from her patients that she learned "much more than the physical aspects of the heart" and learned to listen for the deeper messages.
"Thought can become biology" grew to have meaning for her when she recognized that 75% to 90% of all patient visits to medical practitioners were related to stress-related disorders. She noted that these "disorders" included anger, anxiety, hostility, and depression, noting that anger is the most toxic emotion for the heart (increasing the rate of a heart attack 230%), and anxiety yields a 5% increase in sudden death. In her professional opinion, depression yields the worst cardiac outcomes.
Simple, nonpharmacologic interventions to help patients cope with stress-related disorders that influence the heart include:
Guided imagery;
Meditation;
Exercise;
Yoga;
Support groups;
Healing Touch;
HeartMath techniques[3]; and
Adequate quality sleep.
In closure, Dr. Guarneri stated that from her perspective "the heart is not just a pump, but a home to the soul" and that she has "gone from putting in stents to spreading the word of love and compassion."
References
Guarneri M. The Heart Speaks: A Cardiologist Reveals the Secret Language of Healing. New York: Touchstone; 2006.
Guarneri M. Lessons of the heart -- cardiovascular disease: a mind, body, spirit approach. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
HeartMath. Available at: www.heartmath.com Accessed July 20, 2006.
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Holistic Healthcare Clinics: How Do They Work?
Veda Andrus, EdD, MSN, RN, HN-BC
Independent and Free-Standing Holistic Health Clinics
Three nationally recognized, independent (free-standing) holistic healthcare clinics were presented during a panel discussion, which was moderated by Guy Odishaw. Clinics included True North, Maine's Center for Functional Medicine and the Healing Arts, Falmouth, Maine; Seattle Healing Arts Center, Seattle, Washington; and Manakai O Malama Integrative Health Group and Rehabilitation Center, Honolulu, Hawaii. The intention of this panel was to share the experience and expertise that has been gained and the challenges that have been overcome in developing these models of care delivery.
True North, Maine's Center for Functional Medicine and the Healing Arts
Kathryn Landon-Malone, MSN, RN, CPNP, and Bethany Hays, MD, represented True North Center for Functional Medicine and the Healing Arts.[1] Ms. Landon-Malone began the session by sharing the process by which the True North Center began in 1997. In brief, the Center began as a vision of 3 nurses using the concept of "circle principles" that were brought forth by Christina Baldwin, in her book Calling the Circle.[2] This set of principles serves as the foundation of inclusion, recognizing that a successful venture can best manifest if the voice of each person is heard, included, and respected. Physicians and alternative practitioners joined the circle process with consensual decision making as the root of this process. The core essence of True North Center is based in "coming together as an intentional community of holistic healers" creating "reverent participatory relationships" that are patient-centered and focused on building community between practitioners and patients. As stated in the Mission Statement, "this unique integrative practice combines state-of-the-art conventional medicine with expert complementary care." True North Center opened its doors in 2002.
Dr. Hays outlined many of the operational details of True North Center. These include:
501(C)3 nonprofit status;
18 credentialed practitioners, including MDs, DOs, APRNs, NDs, acupuncturists, Rubenfeld practitioners, massage therapists, Shamanic healers, energy healers, and psychologists, who are sole proprietors contracted to provide services at True North;
Fee-for-service; over half of the patients are reimbursed if they have an out-of-network clause in their healthcare insurance;
Integrative practice with single patient record;
Ancillary services, including a supplement store;
Education: Pathfinder (newsletter), Tune-Up (email newsletter), True North Annual Conference, and Web site;
Research: outcome-based studies (both independent and in collaboration with other healthcare institutions); and
Patient care: "patient is at the center of the circle."
Dr. Hays clearly articulated the concept of "patient as the center of the circle" as "creating an integrative practice rather than an integrated practice." She pointed out the difference: Integrated involves different types of practitioners working together, perhaps under one roof, whereas integrative practice is when the practitioner puts the patient in the center of the circle and does what's needed.
In the experience of this group, the challenges of this type of practice include:
Overbuilt: empty rooms = no revenue;
Fund-raising difficulties: opened doors 4 months after September 11, 2001;
Employed practitioners = decreased productivity;
Ethical issue about ancillaries, eg, how profits from supplement store are used (profits, in this case, go to the 501[C]3);
Part-timers (time and energy spread thin); and
Marketing (not brought number of patients anticipated).
Recommendations include:
Use of circle process;
Starting with a small space and building;
Consider profit or nonprofit approach;
Deciding whether you want to be integrated or integrative;
Working on accessibility;
Creating a sense of safety and legitimacy (credentialing practitioners); and
Being prepared to "stay the course" 5-10 years: have funding available.
The healthcare practice of the True North, Maine's Center for Functional Medicine and the Healing Arts is an integrative, patient-centered, community-based model of care in which "patients and practitioners work together to determine the direction of the healing journey."
Seattle Healing Arts Center
Hope Wechkin, MD, and Amy Hobson, ND, represented Seattle Healing Arts Center.[3] Founded in 1982 by Dr. Fernando Vega, Seattle Healing Arts Center is an association of independent practitioners, including medical doctors, naturopathic doctors, chiropractors, massage therapists, and acupuncturists. There is recognition among the practitioners, according to Dr. Hobson, that "collaborative medicine is best for the patient and also best for the practitioner, allowing them to learn and grow as providers and healers." Each practitioner is a sole proprietor who rents shared office space. A benefit of this structure is that practitioners are available from various medical disciplines to serve as "resident expert" and provide an avenue for patient referrals. Many allopathic students from the University of Washington School of Medicine and naturopathic students from Bastyr University, both in Seattle, Washington, have found their way to the Center that serves as a flagship for those who are interested in healing work.
Here is what has worked well at the Seattle Healing Arts Center:
Patients love this model of care, including accessibility to both conventional and alternative healthcare;
Insurance plans: Each practitioner has the flexibility to decide whether to accept insurance coverage and which insurance plans to include;
Practitioners love the model because they are there because they want to be (not just a job);
Hospital privileges at Seattle-based hospitals; and
Practitioners share call as "call groups."
Challenges include:
Confusion for patients because independent practitioners each have a separate patient chart; and
Variability in insurance plans: Each practitioner independently decides whether to accept insurance coverage and which insurance plans to include, which can be confusing for patients and challenging for collaboration among practitioners.
The Seattle Healing Arts Center cultivates a healthcare practice that their mission statement describes as an "association of independent health care practitioners in a collaborative environment," providing conventional and alternative medicine as the model of care.
Manakai O Malama Integrative Health Group and Rehabilitation Center
Ira Zunin, MD, MBA, Medical Director, and Michael Gardner, MBA, Director of Operations, represented Manakai O Malama Integrative Health Group and Rehabilitation Center.[4] Manakai O Malama ("Healing Spirit of the Ocean") is composed of a number of entities:
Integrative Healthcare Group and Rehabilitation Center -- healthcare center;
Kokua Integrative Healthcare Solutions -- practice management, administration;
Global Advisory Services -- consulting firm that has helped others establish successful integrative clinics, nationally and internationally;
ZEIR Integrative Solutions -- clinical research; and
Hawaii State Consortium for Integrative Healthcare -- research, education, clinical models, and Hawaiian affairs associated with integrative medicine.
Dr. Zunin and Mr. Gardner outlined the operational components of Manakai O Malama:
Opened in June 2002, it has had 80,000 healthcare visits over the past 4 years and has been profitable since the Center opened;
Services include primary care-integrative medicine (50% of practice), nutritional counseling, acupuncture, physical therapy, chiropractic, massage therapy, osteopathy, naturopathy, psychological counseling, and Hawaiian healing;
Practitioners are salaried employees of the Center with benefits;
Outpatient program: 12-week program for people with pain and depression, including group therapy, psychotherapy, cognitive-behavioral therapy, therapeutic movement, acupuncture, manual therapy, meditation, medication management, and pain education;
Approximately 20 healthcare providers;
Accepts both insurance and cash;
Electronic integrative medical records; and
Malama Fund: nonexempt nonprofit formed to care for the underserved.
Mr. Gardner identified the internal priorities for the Center:
Coordinated quality patient clinical care (foremost concern);
Patient healing experience, including physical and personal environment;
Staff care: balanced staff yields quality patient care;
Financial stability; and
Team building: inclusive of all practitioners and staff.
When asked how the newly opened Center was able to be immediately profitable, Dr. Zunin acknowledged an initial $100,000 loan and shared that the Center has focused on public relations (consistent TV spots, newspaper articles, and articles in professional periodicals) rather than print advertising, referrals from local practitioners, and word of mouth to grow a successful business. The Center is known for its high-quality integrative healthcare and fosters a team approach among its practitioners.
References
Landon-Malone K, Hays B. True North Center for Functional Medicine and the Healing Arts. Keynote Panel of the American Holistic Nurses Association-American Holistic Medical Association Conference 2006. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
Baldwin C. Calling the Circle: The First and Future Culture. New York: Bantam Books; 1998.
Wechkin H, Hobson A. Seattle Healing Arts Center. Keynote Panel of the American Holistic Nurses Association-American Holistic Medical Association Conference 2006. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
Zunin I, Gardner M, Manakai O. Malama Integrative Health Group and Rehabilitation Center. Keynote Panel of the American Holistic Nurses Association-American Holistic Medical Association Conference 2006. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
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Integrative Care in Hospital Settings
Marie M. Shanahan, RN, BSN, HN-BC
Making Integrative Care Work
Panel members came together at the joint American Holistic Nurses Association/American Holistic Medical Association Annual Conference to share the steps to successful program implementation of integrative care at their respective healthcare institutions.
Three hospitals with well-established programs of integrative medicine and holistic nursing discussed their journey toward integrative care during a keynote panel. The panel, which was moderated by Robert Christianson, included nurse and physician representatives from the Institute for Health and Healing (IHH), Abbott Northwestern Hospital, Minneapolis, Minnesota; Cancer Treatment Centers of America (CTCA), Zion, Illinois; and Woodwinds Hospital, Woodbury, Minnesota.[1]
IHH, Abbott Northwestern Hospital
Lori Knutson, RN, HN-BC, Director of the Institute for Health and Healing (IHH), and Bill Manahan, MD, Integrative Medicine Consultant, gave an overview of the IHH program.
Abbott Northwestern Hospital is licensed for 650 beds and employs 5000 people, including 2000 nurses. It is 1 of 11 hospitals within the Allina Healthcare System, and it serves over 200,000 people yearly in the Twin Cities area. Incorporating integrative care in such a large facility required sensitivity to the existing culture and alignment with the system mission and vision. With support from senior leadership, IHH at Abbott Northwestern Hospital is viewed as the beta site for the system to bring the services throughout the Allina organization.
The IHH began in 2001 after Penny George, philanthropist, began her own healing journey at the hospital. The experience inspired her to envision a center that could transform healthcare with the art of caring and the science of healing in order to optimize care for the whole person. With the support of her husband Bill and another generous donor, Roberta Mann-Benson, the IHH was created.
Ms. Knutson emphasized the 4 main focus areas of the IHH: education, research, and inpatient-outpatient services. She noted that education has to have a comprehensive approach and include healthcare professionals, senior management, and philanthropists; patients and families; and the community. Research at the IHH focuses on clinical trials, quality measures, and establishing the business model for integrative care. Inpatient services consist of acupuncture, aromatherapy, energy field therapy, guided imagery, massage therapy, reflexology, relaxation therapy, and music therapy. Outpatients can access similar service with the addition of wellness psychology and a personal healing coach.
Inpatient services have succeeded in part due to strategic planning and physician champions. To increase visibility, Ms. Knutson placed "integrative care teams," consisting of integrative medicine nurse clinicians, massage therapists, and acupuncturists in every service area, with the exception of behavioral medicine. With the assistance of Dr. Manahan, IHH established a physician advisory board, with MD representatives from all service areas. These 2 strategies have resulted in the steady growth of patient visits, currently at 1500 monthly. Referrals can come from patients or healthcare professionals. A physician's order is required for acupuncture only.
Cancer Treatment Centers of America
Timothy Birdsall, ND, Vice President of Integrative Medicine, and Margaret Snittjer, RN, APN, MSN, presented integrative care at the Cancer Treatment Centers of America (CTCA).
Ms. Snittjer noted that the approach to treatment at CTCA has included integrative care since its inception 18 years ago. At the time when CTCA was founded, integrative care was incorporated into their patient-centered philosophy. When beginning an integrative model of care, she recommended that frequent communication be established so that integrative care can be consistently valued throughout the institution. The CTCA model of care is successful because of the organization's commitment to education for patients and families and among professionals.
Dr. Birdsall illustrated the importance of tailoring integrative care to the patient's specific needs through thorough and attentive assessment. Citing a recent study conducted at CTCA with 227 new patients, Dr. Birdsall noted that 75% of patients had used 1 or more dietary supplements within the last 30 days: Twenty-five percent of that group were using dietary supplements that were potentially contraindicated while receiving chemotherapy, and 50% had not consulted with a healthcare professional with regard to dietary supplements, but were self-medicating.[2]
The CTCA model requires collaboration between professionals prior to making contact with the patient, so that the patient is truly at the center of care. All disciplines are part of the patient's care team, and team meetings are held 3 times per week. In addition, comfort rounds, which differ from pain management and palliative care, are held with patients twice weekly. The nutrition department is staffed to assess each patient at every visit and provide nutritional education and support. Patients are offered yoga, tai chi, massage, and fitness options, including Motion for Life, a proactive program to help oncology patients remain active during treatment. Naturopathic physicians offer a wide array of botanical, homeopathic, and vitamin and mineral supplements to support patients during the course of treatment. Pastoral care at CTCA is dedicated to helping patients explore their spiritual journey while experiencing cancer.
Woodwinds Hospital HealthEast Care System
Craig Svenson, Medical Director, and Valerie Lincoln, PhD, RN, AHN-BC, presented the Woodwinds Hospital journey toward integrative care.
Dr. Svenson described the planning process for Woodwinds Hospital, a 78-bed hospital, as one that began with clear intention and solid leadership from the HealthEast Board of Directors and President. Integrative care was foundational to the design of the healthcare model at Woodwinds Hospital, which opened in 2000 after 3 years of planning. The steering committee identified the vision, values, and guiding principles that would form the culture, work environment, and health services offered by the hospital. He credits the combination of organizational, community, medical, and nursing leadership as the foundation for Woodwinds' success.
Selected modalities, such as healing music, use of essential oils, energy-based healing, acupressure, massage, and guided imagery, were built into the holistic nursing care model to facilitate the staff nurses' ability to offer integrated care directly at the bedside. Acupuncture and certified massage are offered through referral. Woodwinds has a robust volunteer service that serves 80-100 patients per month.
Medical staff support has grown consistently because patient concerns related to pain, nausea, and anxiety have been very successfully addressed through the integrative modalities.
Dr. Lincoln emphasized the importance of caregivers' healing intentions and presence as being critical components of the environment for care. She noted that employees must demonstrate a congruence with philosophy of care at Woodwinds, and the integrative model is as much "who we are at the essence and core of our being" as is any of the modalities or services offered.
The panel presentation concluded with a 30-minute question and answer period. Recommendations to audience members included:
Use pilot studies as a means of getting integrative care started in hospital settings;
"Fly under the radar" initially to enhance early success while deflecting potential critics;
Seek out physician champions when possible; and
Try multiple approaches to integration, paying careful attention to organizational culture and mission.
References
Knutson L, Manahan B, Birdsall T, Snittjer M, Svenson C, Lincoln V. Keynote panel. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
Gupta D, Lis CG, Birdsall TC, Grutsch JF. The use of dietary supplements in a community hospital comprehensive cancer center: implications for conventional cancer care. Support Cancer Care. 2005;13:912-919.
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Hospital-Based Integrative Health Clinics: Successful Models
Jeanne I. Crawford, MA, MPH American Holistic Nurses Association
The lead article in the November 1998 JAMA issue found that more than 42% of surveyed adults used complementary therapies, and that there were approximately 629 million visits to alternative practitioners in 1997, exceeding the total visits to primary care physicians.[1]
Integrative Health, the integration of complementary and alternative (CAM) approaches with conventional medicine, is a reality in America, a fact borne out by a Harvard University, Boston, Massachusetts, study[2] that noted that 79% of study respondents preferred integrative medicine to either allopathic or alternative medicine alone. That preference, which was detailed in this 1993 study, was signified by the fact that 1 in 3 Americans used alternative therapies ranging from aromatherapy to biofeedback.
In another article, Lawrence Snyderman and Andrew Weil[3] reported that Americans are now spending more on integrative approaches to healthcare than on traditional Western approaches, a fact that has made mainstream healthcare providers take note. This desire for integrative health regimens has been heard loud and clear in the world of healthcare, and motivated by increasing patient requests and the changing economies of healthcare, many hospitals, from New York to California, are now offering integrative therapeutic approaches.
However, not all hospital administrators and staff members welcome integrative centers, and insurance funding for many alternative therapies is still only minimally available. Given these realities, representatives of 3 hospital-based integrative health programs, The Institute for Health and Healing at the California Pacific Medical Center in San Francisco, California; Hennepin Faculty Associates (part of Hennepin County Medical Associates) in Minneapolis, Minnesota; and Scripps Center for Integrative Medicine in La Jolla, California, presented information about the development, evolution, and reasons for the success of their programs.
Each presenter emphasized the need for firm acceptance within the hospital setting as well as solid, long-term financial planning for a program to survive. Each center has taken a somewhat different approach to long-term stability while offering exemplary integrative healthcare for patients.
William B. Stewart, MD, Medical Director and Co-Founder of the Institute for Health & Healing, and Terry Tellep, RN, MS, CNS, Clinical Nurse Specialist in the Health & Healing Clinic, presented information about the rewards and challenges of developing an integrative health center within a large medical center.[4] The Institute, which sees 45,000 individual clients per year, initially was funded by philanthropic groups, but is now primarily funded by patient fees. The keys to survival, according to Dr. Stewart and Ms. Tellep, are setting long-term financial goals, playing by hospital rules, involving skeptics, and integrating all disciplines.
Patricia Culliton, MA, Director and Founder of the Hennepin Center, took a slightly different path to success and now has 1500 patient visits per month.[4] Started as a center for addictions, Hennepin receives no philanthropic support and relies on patient fees and research support. Hennepin emphasizes the need for research in CAM therapies and collects outcomes data on many of the therapeutic approaches used at the Center.
The Hennepin Clinic is the first alternative medicine clinic to open in a Western healthcare organization, and was the first clinic in the United States to train medical doctors in alternative medicine through a postdoctoral fellowship program. It is also the site of America's first residency program (family medicine) with a focus on CAM medicine and the first hospital-based alternative health clinic to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The Scripps Center, directed by Dr. Mimi Guarneri, MD, and Rauni Prittnen King, RN, BSN, HNC, CHTP/I, Director of Programs and Planning, has taken yet another approach.[4] Dr. Guarneri, saying that "we cannot live on philanthropy alone," has made the Scripps Center, in addition to being a center for integrative approaches, home to a comprehensive, high-technology diagnostic center. Located at the Scripps Center is the Dickinson and Gooding Early Detection Center, home to the most advanced positron emission tomographic (PET) and computed tomographic (CT) hybrid scanners in Southern California.
Most importantly, all 3 programs have also been able to integrate Western approaches with CAM approaches, have multidisciplinary staff, and offer various alternative therapies, including acupuncture, biofeedback, massage, hypnosis and guided imagery, and yoga. All have educational components and have or work with an herbal pharmacy. All 3 have focused not only on the complementary/alternative aspects of healthcare but on the integration of care -- the successful marriage of allopathic healthcare with complementary therapies.
References
Eisenberg DM, Davis RB, Etner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA. 1998;280:1569-1575.
Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-252.
Snyderman R, Weil AT. Bringling medicine back to its roots. Arch Intern Med. 2002;162:395-397.
Culliton P, Guarneri M, Hall K. Hospital based clinics. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
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Integration of Complementary and Alternative Therapies in Geriatric Care
Charlotte Eliopoulos, RN, MPH, ND, PhD
What Does Complementary and Alternative Medicine Offer Older Adults?
Complementary and alternative medicine (CAM) has caught the attention of many older adults and their caregivers, and for good reason. CAM often offers gentler and safer approaches to addressing common health conditions of seniors, a significant concern when the challenges of medication use in older adults are considered. CAM practitioners are likely to encourage good health practices to strengthen the body's defenses and healing abilities, which offer benefits beyond symptom management.
The unique composition of body, mind, and spirit guides CAM and promotes care that is individualized. In an era of abbreviated office visits and hospital stays, CAM practitioners provide older adults with the time and attention that they need. Also important to geriatric care, CAM emphasizes self-care and empowers older individuals with the knowledge, skills, and encouragement that support it.
Risks for CAM
Although they have many benefits as complements or alternatives to conventional therapies, CAM products and services are not without their risks to older adults. For example, improper use of herbal remedies can create a host of problems for older persons, who may have different responses to these products when compared with younger adults. It would not be unusual for older clients to be unaware of the adverse effects of herbs or herb-drug and herb-herb interactions. For example, older adults have a higher risk of developing serotonin syndrome when taking the common alternative herbal antidepressant St. John's wort. The symptoms of this syndrome (eg, fever) can be mistaken for an infection, leading to the adverse reaction being missed or mistreated. A serious adverse effect from the popular tonic ginseng is Stevens-Johnson syndrome, which can cause the skin to peel off. Ginkgo biloba and several other popular herbs that are used by the older population have anticoagulant effects.
Likewise, some "hands-on" therapies pose a unique risk to seniors if age-related differences are not considered, as may be the case with chiropractic therapies. Older bones are more brittle than younger ones and can fracture under stress. As an example, although this wouldn't be a concern for younger adults, tissue fragility and reduced muscle mass warrant special consideration when massaging older adults to avoid injury.
Not all risks relate to physical complications. Older adults tend to have long faith traditions that have significant meaning for them. A CAM therapy that conflicts with one's faith can result in spiritual distress. For example, a Christian who believes that Jesus Christ is the source of all healing and the highest spiritual power can react negatively to energy healing that calls on a universal power or other spirits.
CAM and Patient Assessment
It is important to ask clients about the use of CAM during every assessment. Keep in mind that some clients may not think of the supplements they're using or the magnetic mattress that they're sleeping on as CAM, so specific questions must be asked: For example, "what other types of things do you do for your health?" "Are you seeing an acupuncturist, chiropractor, or other type of practitioner?"
Obtain a full history before recommending CAM. Although the client may be seeking your advice for CAM recommendations for joint pain, he or she also may be treated for a psychiatric problem that could influence your recommendations. Keep in mind that poor memory and the stress of being in a practitioner's office or hospital could cause older persons to omit essential pieces of health history, so make an extra effort to ask many questions that could trigger recall.
Instruct clients in the proper use, precautions, and adverse effects of the CAM therapies that are recommended and used. Like other adults, seniors often gather advice from peers, the Internet, or sources who may offer partial or even erroneous information. Assist clients to weigh the advantages and disadvantages of conventional against CAM therapies. There are times when medications are safer, less costly, and more appropriate than herbs and other CAM therapies. Also, guide clients in locating competent, credentialed practitioners.
Navigating the healthcare system can be a challenge even for those not of advanced age with multiple health conditions. CAM has the potential for many beneficial uses in the older population, but it is not without risks. Professionals can offer considerable assistance to older adults by assisting them to use CAM wisely and appropriately.
Suggested Reading
Carlson LK Reimbursement of complementary and alternative medicine by managed care and insurance providers. Alternative Ther Health Med. 2002;8:38-49.
Decker G. An Introduction to Complementary and Alternative Therapies. Pittsburgh: Oncology Nursing Press, Inc.; 1999.
Dillard J, Ziporyn T. Alternative Medicine for Dummies. New York: IDG Books Worldwide, Inc.; 1998.
Earthlink, Inc. Alternative Healthcare: Is It the Right Alternative for You? Blink. 2000;June/July:27.
Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the US: prevalence, costs and patterns of use. N Engl J Med. 1993;328:246-252.
Fontaine KL. Healing Practices: Alternative Therapies for Nursing. Upper Saddle River, NJ: Prentice Hall; 2000.
Freeman L. Mosby's Complementary and Alternative Medicine: A Research-Based Approach. St. Louis: Mosby; 2004.
Huebscher R, Shuler PA. Natural, Alternative, and Complementary Health Care Practices. St. Louis: Mosby; 2004.
Kirskey KM, Goodroad BK, Kemppainen JK, et al. Complementary therapy use in persons with HIV/AIDS. J Holistic Nurs. 2002;20:250-263.
Krohn J, Taylor FA. Finding the Right Treatment. Modern and Alternative Medicine: A Comprehensive Reference Guide That Will Help You Get the Best of Both Worlds. Point Roberts, Wash: Hartley & Marks Publishers; 2002.
McCaleb RS, Leigh E, Morien K. The Encyclopedia of Popular Herbs: Your Complete Guide to the Leading Medicinal Plants. Roseville, Calif: Prima Publishing; 2000.
McGovern K, Lockhart A, Malay P, et al., eds. Nurse's Handbook of Alternative and Complementary Therapies. 2nd ed. Philadephia: Lippincott Williams & Wilkins; 2003.
Morrison J. The Book of Ayurveda: A Holistic Approach to Health and Longevity. New York: Fireside; 1995.
Olshansky E. Integrated Women's Health: Holistic Approaches for Comprehensive Care. Gaithersburg, Md: Aspen Publications; 2000.
Skinner SE. An Introduction to Homeopathic Medicine in Primary Care. Gaithersburg, Md: Aspen Publishers, Inc; 2001.
Smith DW, Arnstein P, Rosa KC, Wells-Felderman C. Effects of integrating therapeutic touch into a cognitive behavioral pain treatment program. J Holistic Nurs. 2002;20:367-387.
Stephenson NLN, Dalton J. Using reflexology for pain management. J Holistic Nurs. 2003;21:179-191.
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Illuminating Heart: The Alchemy and Artistry of Unitary Healing
Marie M. Shanahan, RN, BSN, HN-BC
Calling for a New View of Healing
In our despair, against our will, comes wisdom through the grace of God.
Escalus
When a person is in despair, when it pervades his or her existence and becomes the lens for viewing life experience, what can healthcare practitioners offer that has meaning and the potential for a hopeful future? To be with a person experiencing despair is to see a human being who appears to be "broken" or "coming apart" in body, mind, and spirit. It is within the patient's experience of deep suffering that practitioners have the responsibility to reflect the individual's wholeness, through words and actions, so that the person may understand and embrace life beyond despair.
In a presentation mixing personal story and lessons from practice, with a moving montage of music and visual art, W. Richard Cowling, III, RN, PhD, Professor and Director of the PhD in Nursing Program at the University of North Carolina, Greensboro, and Editor of the Journal of Holistic Nursing, delivered a keynote presentation entitled "Illuminating Heart: The Alchemy and Artistry of Unitary Healing.[1]"
Dr. Cowling, well regarded as a Rogerian scholar, is also a nurse-scientist who has developed a research and practice framework known as unitary appreciative inquiry. This framework is informed by his extensive study of Martha Rogers' nursing theory "Science of Unitary Human Beings." He is certified as an advanced practice nurse in adult psychiatric mental health, and his research has focused on despair that is related to depression, loss, grief, childhood abuse, addictions, and chronic and life-threatening illnesses. He maintains a long-standing counseling practice in addition to his academic duties.
Dr. Cowling acknowledged the many lessons that he has learned from working with female survivors of child abuse: "They taught me courage. They turned despair into deep compassion and empathy... I am changed as a person and a nurse-scientist."
The journey of healing for these women incorporated a shared practitioner and patient view in which the individual is seen as the source of expertise, knowledge, and power relevant to their own experience. This is one of the central components of unitary healing. According to Dr. Cowling, personal experience and personal knowing are "important resources for enlightened forms of scholarship that include research and practice."
Dr. Cowling noted the need for unitary healing in contrast to the prevailing approaches to despair in our traditional medical system. The current medical model emphasizes a fragmented approach to the human experience, fortified by an overreliance on hyperspecialization and the default position of prescribing medication when dealing with intense emotional experiences. Although these approaches may have benefits, many people yearn to understand their conditions within the broader context of human life -- both their individual experience and the collective.
Practitioners may separate the person from their experience and focus on the presenting problem, translating patients' descriptions of daily life experiences into professional language that is pathology-based, and thereby perpetuating a system that "clincializes" and "medicalizes" human experience. A woman's despair over child abuse becomes clinical depression with posttraumatic stress disorder. However, lost in that approach is an opportunity to see despair as an opening for a life-changing and life-affirming transformational experience.
Unitary Healing
Holding open the gateway for transformation is achieved through the practice of unitary healing. Unitary healing places wholeness as the central focus for our professional work. It calls for an expanded view of health and healing that recognizes the wholeness of a person's life experiences as being integral with their expressions of physical, emotional, and spiritual health.
Dr. Cowling points out that studying the life patterning of the person, including physical-physiologic, mental, emotional, spiritual, mystical, social, and cultural, is key to understanding their expressions of illness or distress and the interrelatedness of their life experiences. He guides us to seek the expressions of a person's life patterning by consciously and reverently placing attention on the stories, wisdom, meaning, and sacredness emanating from the heart. By paying attention to the stories from the heart, a picture of the unique life patterning comes into view. Dr. Cowling refers to this as the "ensemble of a person's patterns" that are rich in information, not accounted for in clinically measurable data.
Illustrating his point, he described a participatory experience in his counseling practice with women experiencing despair from childhood abuse. Using music and pictures, he created an individual representation of his clients' healing journey and asked for their participation in correcting and/or evolving the presentations. This unique approach created the space for women to have their voices heard and their experiences validated. He described their responses as the ability to move with and through the dark emotions with a greater appreciation and expansion of their lives.
The 4 Forces of Unitary Healing
Insight into the practice of unitary healing can be gained by understanding the 4 forces of unitary healing and their application in practice:
The force of wholeness: A view of humans as essentially and inherently whole. Wholeness is not a goal; it is a given.
The force of appreciation: The practitioner has great reverence for life and is drawn to inquire beyond the superficial to understand the underlying patterning of an individual or group.
The force of participation: Facilitated by practitioners, participation helps people discover new choices for behavior, feelings, and thoughts that maximize the potential for desired changes.
The force of manifestation: The culmination of the 3 previous forces, manifestation is the grounding process of perception, reflection, and expression of feeling, thoughts, and actions. Power is mobilized to support efforts and practices that enhance well-being and the quality of life.
Illuminating One's Own Heart: The Promise of Unitary Healing
Dr. Cowling shared how powerful unitary healing is in his own life. As he prepared for a surgical event, he was mindful of the fear that he felt. During an early diagnostic procedure, the fear was compounded when a technician left him alone to find a physician "who just has to see this." Alone in a cold examination room, Cowling was understandably anxious, and the long waiting time only exacerbated his fears. Wanting to replace his fear with confidence in a positive surgical outcome, he activated the unitary healing options that were available to him. He used a guided imagery script created for him by a trusted colleague; he visited a Reiki practitioner who listened with care to his heart; and he engaged in deep reflection of his own life story. From these choices, he became aware of life patterning that offered him a transformative process, with the surgery providing the catalyst. The fear lifted and he was peaceful as he entered surgery.
In closing, Dr. Cowling called upon healthcare professionals to strive for a healthcare system that "allows us the time and resources to deal with people's lives and the depth of their experiences, to participate in new understandings and help them manifest the life that illuminates their hearts."
Reference
Cowling WR. Illuminating heart: the alchemy and artistry of unitary healing. Program and abstracts of the American Holistic Nurses Association (AHNA)/American Holistic Medical Association (AHMA) Annual Conference; June 7-10, 2006; St. Paul, Minnesota.
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