“How was your massage last week?”
“It was fine, good, actually. But honestly I would have liked it much harder. Can you go deeper today?”
My client was speaking to me from her bed. She had advanced pancreatic cancer. Her pain was deep and constant. She wanted relief, and she wanted heavy massage.
I’ve had this conversation many times. It’s a crossroads moment. My role, my compassion, my ethics all collide in my brain before settling. I breathe a bit before I respond.
Some would say, “Give her whatever she wants.”
Suppose this was your client. She is ill, nearing the end of her life. She is in constant pain. She just asked, perhaps begged, for deep pressure. What do you do?
Students have asked me what to do. Teachers have advised what to do. On Facebook, MTs tell each other what to do.
Kicking around in those discussions is this advice: “At end of life, give the client whatever they want.” Even if that involves heavy pressure. The reasoning goes like this: The client does not have much time left, so it’s time to do what they ask. The usual precautions must not apply in this circumstance.
No. Just no.
I appreciate the feeling that drives this advice. It is a call to ease suffering and pain in difficult circumstances. But “Give them whatever they want” is the wrong message.
This situation calls for more caution, not less. Care and caution are supremely important when working with people at end of life.
I feel strongly about this, for many different ethical, practical, and let’s-grow-up-as-a-profession reasons. Here are a few:
1. “The customer is always right” is not a moral imperative.
Although client-centered care is a good goal in massage therapy, it can sometimes border on the old cliche, “the customer is always right.” People pay their money and they make their choice, and it’s our role as helping professionals to respond to that choice.
When a client is hurting at end of life or during serious illness, we might feel obligated to provide whatever they want. Surely the level of pain trumps all the usual precautions. Surely the client knows best what she needs.
But we are not in the business of granting everyone’s wishes. Client satisfaction is only one of many considerations in our plan of care. And as popular as it is to believe that everyone knows what their body needs in every moment, there are plenty of examples of human behavior that suggest otherwise.
In this situation, one of our professional responsibilities is to zoom out and think carefully, and to question the view that this customer is always right. For reasons listed below, we may have to take on a strong leadership role, ensuring that more caution is used, not less.
In our professional role, the ultimate responsibility for a massage session lies with us, not with our clients.
2. In palliative care, we consider side effects.
“First, do no harm” does not square with “Throw out all precautions.”
Palliative care focuses on relief of pain, anxiety, nausea, and other problems. In these efforts, symptom-relief measures and dosages are carefully balanced against their side effects.
Too much massage can cause side effects, and for massage therapy to be truly part of palliative care, we need to consider dose and minimize those side effects. Here are just a few examples of how heavy-handed massage could make things worse, not better. (Find more good info at the end of this post.)*
• Bruising and pain. Deep or medium pressure could cause bruising, increased pain, anxiety about that pain, or reduced function. Liver compromise is only one factor at end of life can lead to easy bruising and bleeding.
• Blood clot risk. Many, many people at end of life are at elevated risk of DVT. About half of blood clots are asymptomatic—there is no sign of DVT it in the lower extremities where it often begins to form. This is truly chilling, as a massage therapists working with clients at end of life must take care with pressure and joint movement on the lower extremities, avoiding even the appearance of contacting deeper vessels. Why? Loosened, a blood clot can be dangerous or even fatal. Blood clots can also form in other places in people who are seriously ill, so massage therapists do well to educate themselves and consider the risks carefully in each client.
• Fluid balance. End of life conditions can cause precarious fluid balance problems, in the event of kidney, liver, or heart failure. Swelling can be present for a variety of reasons. Some have lymphedema or are at risk of it. Although it is tempting to go at the swollen tissues and try to ease swelling, incorrectly applied massage or heat could make things worse. In most cases, the massage therapist’s intent should be to leave things as they are, not to redistribute fluid from compartment to compartment.
• Bone integrity. In advanced cancer and other conditions, clients might have compromised bone integrity that is not obvious to an observer, and medium-pressure massage or strong joint movement could lead to fracture.
In my client, several of these factors were at play. There were multiple bone metastases and liver function compromise. Her DVT risk was elevated for several different reasons.
These factors are not necessarily intuitively obvious. They take some digging. I understood them from an initial intake of targeted health question, months of working with her, and my own follow-up research. I considered all of these things in my conservative approach.
Had I reacted only to the request for more pressure, and made a snap decision to comply with her wishes, I could easily have over-treated her with massage and caused discomfort or worse. The risk would be heightened if we had just met, and had no history of working together.
The goal of massage for a client at end of life is palliation. As such, massage therapists work within palliative care practices. No matter how you see yourself—as a health care practitioner, as a massage therapist who wants to be accepted as a health care practitioner, or as a provider of an entirely separate service—you are bound to the ethic of doing no harm.
3. This is not just between the therapist and the client.
By its nature, a massage session is private. What happens in the massage session may forever stay in the massage session, especially when a client is near the end of life. This reality might tempt a therapist to go with a client’s request and be less cautious. After all, no one else will know, right? The MT is responsible to only the client?
In my massage therapist role, the client is not the only one to whom I am accountable. There are others in the picture. Even after the client passes, I answer to the client’s family and health care team. If I have stepped out of the usual protocol and done harm, or even if it appears that I have done harm, I answer to everyone in that client’s circle of care.
Some of you might also be accountable to a supervisor, employer, or third-party payer. All of us are accountable to our profession, professional organizations, licensing boards, and providers of liability insurance. We are accountable to each other.
Clearly, there is plenty of accountability, and it extends well beyond the client-therapist relationship.
Suppose a massage therapist provided deep work that seemed to provide relief, but the client’s pain worsened in the hours afterward, possibly due to the injury of delicate structures. Suppose strokes in the wrong direction aggravated or precipitated lymphedema. Suppose a client became nauseated or developed flu like aches, which can follow even a medium pressure massage in a medically frail client. Such a massage can be too stimulating.
These are a few of the countless stories of heavy-handed massage. [And, my beloved research-y friends, I ask you to trust me on this, even without a body of research on adverse effects. Follow me around and listen to the stories I hear and see. Understand why I borrow the precautionary “suggestion of harm” rather than “proof of harm” to guide our work.]
Side effects of over-treatment might set in motion a cascade of medical interventions that are expensive, that no one wanted, and that cause great emotional pain and suffering to the client and client’s loved ones. At end of life, the stakes are especially high.
4. You cannot be sure that your intuition will guide you.
Some therapists rationalize a heavy-handed approach by offering intuition as an ultimate protector of the client. “I won’t hurt them if I follow my intuition.”
The role of intuition in decision making warrants a longer discussion and possibly a whole blog post in itself.
For now, I’ll note that intuition can be fallible. Neither you nor I are endowed with perfect intuition at every moment of our working lives.
My intuition easily fails me when I am short on sleep or food, or long on stress. I make poor decisions sometimes, even when I think I’m following my gut. And that’s just me; massage therapists have told me many stories of following their instincts. Even though I wasn’t there, even though things might have turned out fine, the decisions they describe often fly in the face of common sense, common health care practices, and even common practices in massage therapy.
If your client asks for more pressure and your intuition agrees, I hope there is more in the mix than those two messages. Even though intuition, by itself, is highly prized in massage therapy, intuition is best honored as part of a set of skills, not as a single compass. Nurses and doctors who successfully “go with their gut” typically have years of experience and a whole raft of skills to go with that intuition. Other factors such as good information, communication, and reasoning round out our clinical skills as massage therapists.
Take care not to glorify intuition or rely on it in isolation. A more fully formed clinical decision making process is necessary to get through tricky territory.
5. The MT’s comfort is as important as the client’s comfort
A client’s acute distress is compelling, and necessarily becomes a central focus. It often causes waves of distress in the loved ones surrounding the client. Such a scenario hits us deep in our hearts. We want to roll up our sleeves and go to work on that distress, seeing to as many needs as possible at the expense of our own. We want to do whatever it takes, and if it takes extreme pressure, then we want to provide it. It seems heartless to withhold it.
But it is possible, at once, to offer compassion and set limits. I can deny a request for heavier work without diminishing it.
As the therapist, I am in this picture, too. I have my own needs and responsibilities to honor. I need to sleep well at night, with as few misgivings and mistakes as possible to haunt me. With thousands of massage sessions ahead of me, I don’t have energy to squander on inner conflict or poor decisions. I need the peace of work done safely and well.
In fact, with clearly drawn lines around what I will do, I can step into my work with my fullest heart. My compassion comes easily. It comes through gentle hands rather than heavy ones.
Working gently works for me. I need to make it work for my client.
6. Heroics can be a rush, but don’t rush in.
Many forces come into play in compelling situations such as end of life care. Our old pains and fears about death, our pesky egos. Our history of watching people die, the times we could help and the times we could not. We come by our own pain honestly, but it confuses our decisions sometimes.
Faced with our internal discomfort, we hurry to do something about it. The impulse to give in to a client’s request may arise from our own reaction to our own discomfort. It’s hard to tolerate someone else’s pain and suffering, much less our own pain that bubbles up, so we act quickly to relieve it.
Why else would we hurry? I like to think of myself as someone who can fix problems. (Someone left the door open and let my ego out!) To serve this image of myself, I might be more likely to rush to solutions, bypass the usual precautions, and give deep pressure to someone asking for deep pressure. In a hurry, my judgment can be compromised.
But the client needs help, not heroics. We are practicing massage therapy, not emergency medicine. It’s good to keep some impulses in check. Most situations allow us some time to consider what to do.
The best massage approach includes a thinking pause. Consider tissue stability, and all the factors that might compromise it in certain areas. Think through which organs are under-performing, and how that affects the rest of the body.
And in the off hours? Spend some time in reflection, healing the pain and fear that can interfere with good judgment. Read about end of life, explore the depths. Take part in a hospice volunteer training. Start or join an ongoing conversation about death. Get some help, and get cozier with the reality of where we are all headed, and what we need to heal ourselves along the way.
7. In palliative care, we also work as part of a professional team.
At its best, palliative care is provided by a team of experienced professionals who follow standard practices in symptom relief. Health care providers increase or decrease a dose as carefully as possible. Patient care is layered. Multiple factors are considered.
This is not a time to go rogue. Instead of taking matters into our own hands, instead of riding cowboy-style into a solo effort, massage therapists need to assume a role as part of a team.
It is time to respect the work of the team, and integrate massage therapy as seamlessly as possible into the care of the patient.
How does this look in action? Gentle work. Risk under-treating rather than over-treating. Follow-up and monitor results where possible.
And make good referrals. Ask questions. If an appropriately gentle massage does not help, or even if it does: “This might be a good time to call your doctor and talk with them about the pain.” “When does the hospice nurse visit?” “How about asking your team for more help with this?”
Act as part of a team even if the team doesn’t think you are part of a team. And if there is no team, ask and refer. “Who is helping you with this?” “I have the sense that this could be made a lot easier on you and your family. Who can we call?”
Playing our part in end of life care
When we remember to first, do no harm, to consider dose, intensity, and side effects, we can avoid the pitfalls of over-treatment. With checks on the impulse to overdo it, we can be more helpful.
By using a set of clinical skills, rather than relying on intuition alone, our work is both fully-formed and well-informed.
By honoring our own needs and those of everyone else to whom we are accountable, we take our place in the circle of care.
Massage therapy is poised gain real traction in the world of pain control, supportive care, and end of life. If we go in with a healthy dose of humility rather than an inflated sense of our skills, we will build more bridges and help more people. As team players, we can be more effective. When we learn to communicate with clients and care providers about all of this, we take leadership.
With care and thought, our role in end of life care will earn greater recognition.
How I said “No.”
After the client’s request for more pressure, I sat down beside her. I breathed, and looked her in the eye. I told her I had a good sense of her request and the need she was expressing, and I wanted to address her pain as well as I possibly could.
I listened. I asked her to describe her symptoms more fully, and to point to areas of discomfort. I listened carefully and asked questions. This time, I said, we would pay more attention to the areas of pain.
Then I reviewed the tools I had at hand and told her, from experience, that I thought these measures could help: Setting up comfortable and supportive bolstering. Gently working at tension and stiffness in her muscles. Occasionally asking her to “breathe into the place under my hands.” Long, quiet strokes. Simple, still hands holding the tissues.
My client agreed with the plan a bit halfheartedly, but she said she understood, and I went to work.
An hour later I packed up quietly, in case she was asleep. As I tiptoed out, she called out sleepily to thank me. She had found some relief.
She felt better, and so did I.
*None of the examples, above, provides a full discussion of the signs, symptoms, risks, or possible scenarios to consider at end of life. There is much more to DVT, hepatic failure, bruising, and cancer with bone involvement. Further understanding is essential for MTs working with medical compromised clients. Resources are below, but more are out there, and a MT provides the safest, best care to clients at end of life after a good dredge of the literature and a good face to face training.
Great blogs and trainings on massage at end of life, massage for people who are aging, and massage during serious illness.
- Cates, Lauren. Lighthold: Massage Therapy and End of Life Care
- Puszko, Sharon. Day-Break Geriatric Massage Institute
- Smith, Irene. Everflowing
MacDonald, Gayle. Medicine Hands: Massage Therapy for People with Cancer (3rd ed). Forres, Scotland, Findhorn Press, 2014.
Walton, Tracy. Selling Gentle Massage to Clients with Cancer. Massage Today, 14(2). February 2014.
Corey Marggraf says
Very well said Tracy.
It is a hard decision with conflicting emotions for the MT but in the end we MUST do what is BEST for the client and the client is NOT always right. We as MTs are trained to perform a job of Wellness and clients come to us because they trust us so we NEED to make the right decisions on their treatments. As hard as it may be light touch at the end of their existence is what is best!
Tracy Walton says
I like using the term wellness at end of life, Corey. Thank you.
Julie Goodwin says
This is so powerful; a must-read for all practitioners! As trained professionals, we must work with our clients by focusing on therapeutic intentions and treatment goals, understanding that when a client uses the term “deep” they may not be using it as we would. It’s quite possible that by asking for deep work, a client is asking for thorough, specific work (which may not be contraindicated) but lacks the vocabulary to be more precise. It empowers the client when we discuss what we CAN do, rather than what is contraindicated. Too often, we fail to value the power and depth of stillness. Thank you for this thoughtful piece.
Tracy Walton says
Julie, it is indeed important to focus on what we can do. Thank you for that reminder.
Lee Blank says
Love everything you said here. As someone who has done this end of life work for 16 years and studied Lomi Lomi I’ve found that connection to the bone between humans can feel like deep work when it is not. Occipital holding and reflexology on plantar surfaces (in ambulatory patients) often satisfies (and gates the pain) so that a client gets real respite. From haven taken your great trainings I can navigate these conversations with more ease.
Tracy Walton says
Lee, it has always made me happy that you are out there doing this work. And thank you for those suggestions.
Lee Blank says
That should say having taken 🙂
Julie Guard says
Thank you Tracy. I have been a massage therapist with Hospice for 7 years now. I often get requests for deeper work, and at times have had my hospice clients get upset with me for not working deeper. I tell them I am there to make them feel better and working deeper would in fact, make them feel worse. Even with light touch and a short first session they can feel the effects the next day, just like anyone receiving a massage.
I love my job and being able to bring massage to those at end of life. I have learned so much from my experiences and met people of all walks of life that I otherwise would never have came into contact with.
Tracy Walton says
Julie, thank you for your notes from the field. It’s true, requests for deep work are frequent and we need to manage those requests with compassion. So glad you are loving your work.
Pam Soule says
Tracy, so loved this piece! Always great to be reminded of Do No Harm.
Three small words that lend to PEACE for both client and practitioner. Three small words to help us stay connected and focused as a PROFESSION, and three small words that will help, overall, more PEOPLE to receive oncology massage.
Tracy Walton says
Yes, the simplicity is beautiful, right?
This speaks to me right now! Just thanks!
Tracy Walton says
Glad for the resonance, Jennifer!
Jessie Bernstein says
Yes, everything about this. I have these conversations so often in my practice, especially with an increase in the variety of oncology clients, and different stages of treatment, or end of life support. When I have the conversations with the HCPs, they usually get it after we really dive deep, and the respect is in an abundance with truly taking the time to explain why we do the work the way we do it. I’ll be saving this and sharing with my contacts. Thank you, Tracy.
Tracy Walton says
So glad your conversations about this are fruitful, Jessie!
Barbara Coughlin-Martin says
Thank you for speaking with reason and compassion, Tracy. In my experience patients (and their families, loved ones) who request strong pressure that is contraindicated will accept gentle bodywork if it’s offered respectfully with concern for their best interests, and find nurturing presence to be more relieving and deeply affecting than they could have imagined.
Jayne H says
Excellent points. As i perform hospice massage, i have to realize that patients sometimes think that “if it ain’t deep tissue, it’s weird, or just fluff.” It is my opportunity to help educate patient and family, when they think that a deep massage will help.
For some people i think it is a matter of not beingable to relax when they are being touched in a therapeutic manner. Being so close to someone near the end of their lives is a sacred space. I try to educate them as to what the strokes are like, always letting the patient know that we can stop at any time.
MT’s working with EOL patients will read their work so beautifully detailed here. A great refresher for those on palliative care. Thank you Tracy.
Tracy Walton says
You should know, Chandrika…:)
michael koplen says
Excellent article and advice all around!
Tracy Walton says
Annie Merlino says
This was really great to read. Im am very new into OM Massage and can really appreciate end of life care and the need for the light pressure it really does make sense, however I would like to ask a question, I am starting to get post cancer clients who, are either months or years post their cancer diagnosis who are asking why they can’t have deeper pressure. I do understand the lymph nodes and why direction is important, however Im wanting to understand why deeper pressure can’t be used in accordance with the rules of OM massage on clients who are out doing heavy sports, boat racing, tennis, etc etc. Im going to be really vulnerable here and share what goes on in my mind..Wouldnt they apply more pressure just by applying their own moisturiser or scrubbing themselves in the shower?? In saying that I do only do the light work for all the reasons discussed above as I would not risk the well being of the client. but I really want to understand…
Tracy Walton says
Thank you, Annie, your question is a good one. End of life aside, you’re talking about people posttreatment whose bodies are high functioning. I’m recalling our “Activity and Energy Principle” from the course and from my book that says, exercise tolerance can be used to help predict massage tolerance. So overall strength of massage can be scaled to the client’s level of function/athletics. That speaks to the overall strength of the massage. That said, remember that late effects of cancer treatment, including on an at-risk quadrant from lymph node removal, an area of radiation (playing out in skin fragility and bone thinning), still require local or site-specific precautions. Mostly in the area of joint movement, stroke direction, and especially pressure. These are often lifelong concerns because late effects manifest years or decades later. There is a difference between someone participating volitionally in sports that might challenge those tissues, and a massage therapist imposing that challenge. Does that make more sense?
Ed Connor says
Ah,Tracy, eloquent, informative, beautiful and encouraging. Exactly what I expect from a Tracy Walton piece! Thank you for continuing to guide us to keep that space between our hands sacred.
Tracy Walton says
I miss you, Ed humanitarian Connor. 🙂
Carole Osborne says
Although I mostly work with clients who are in beginning-of-life situations, i.e. pregnancy, and postpartum, the ethical concerns you so eloquently and practically present are at play for me too. Pregnant clients on bedrest, in particular, can want deeper pressure than what safety considerations would require. One way I have managed these requests is to ask the client to take my hands deeper into their body and awareness or “draw me into where it hurts.” This doesn’t mean that I add more pressure; it means that I focus my pressure more precisely and with collaboration from the client. Thanks, once again, for a very useful article, Tracy.
Tracy Walton says
I love that, “draw me in to where it hurts.” Thanks!
Cindy Spence says
Tracy, thank you for this lovely piece! At Final Touch Training where we teach end-of-life massage, we urge therapists to provide sessions that are “shorter, slower, softer.” In my many years of hospice massage, I have never regretted using lighter pressure, whereas I have regretted on two occasions using pressure that caused later discomfort. Make the pressure lighter and the presence deeper. Deep presence is often what the client wants, not deep pressure.
One other point is that people in end-of-life care are often on medications which impair sensation and/or communication. Client feedback regarding pressure may be unreliable and it is up to us as therapists to safeguard our clients when this is the case. The “inching forward” premise that applies to oncology massage may not apply to end-of-life massage, due to the constant change of progressive decline.
Tracy Walton says
These are great points, thank you! Yes, I would add the sensation/feedback point and the different paradigm re: inching forward. I love that: deep presence not deep pressure.
Love the words that clients want more presence in this stage instead of more pressure.
Tracy Walton says
Agreed. Presence, not pressure.
Thank you all! What blessings and thoughtfulness from this article and conversation stimulated by it.
Blessings, peace and love.
Tracy Walton says
Joanne Duncan says
Excellent advice, Thank you Tracy. Your insight reminds me that we are body, soul, mind, and spirit. I am wondering if part of the pain a client is experiencing towards the end of life is comming from fear of there body shutting down and the pain that comes with it. The body does have it’s bio programing way of shutting down, it’s like the body know’s how to die but our mind, soul and spirit are still highly attached. I’m thinking working with there pain issue as an ensemble concept. So when it comes to the massage pressure to the body, less is more. Am I out to lunch on this or somewhere in the ball park?
Tracy Walton says
Joanne: I think we’re holistic beings, and it’s tough to separate out all the pieces or explain each one, right? So I join you in the mystery of it all. I do think much pain at end of life has clear physiological/pathological explanations. Bone mets cause hard, deep pain whether they are present at end of life or much earlier on. Masses pressing on nerves hurt. These are a couple of examples. What we also know is that poor sleep and anxiety worsen pain, and massage may help by easing those. So I operate off a simpler, easier to explain model. But we end up at the same place, which is working gently, which is well-received. Thank you for your thoughts!