Respectful Insolence

The ethics of therapeutic touch

Lest I forget to mention this one, Randy Cohen, a.k.a. The Ethicist, answers a question. Here’s the question:

I work at a hospital where several nurses practice therapies like healing touch and therapeutic touch, said to adjust a patient’s energy field and thereby decrease pain and improve healing, although there is no significant evidence for this. If those nurses believe in these treatments, may they tell the patient they are effective? If the treatments provide merely a placebo effect, telling patients about this lack of evidence might undermine that benefit. Would that justify withholding the information? — name withheld, St. Louis

Think about how you would answer the question and then flip below the fold for the answer:

Something needs to be adjusted here, but it is the nurses’ behavior, not the patients’ energy fields. These nurses, however well intentioned, should not perform unproven therapies — if these are unproven; opinions differ passionately — on unwitting patients. To do so is to tell a kind of lie to patients, who reasonably assume that their care meets hospital standards. And while the placebo effect can be beneficial, that is insufficient reason to routinely deprive patients of pertinent facts. Patients cannot give informed consent if they lack honest information about their treatment.

That the nurses sincerely believe in the efficacy of their methods is of no account. People sincerely believe all sorts of things. My imaginary uncle Milt sets great store by the potions he whips up in the bathroom sink under a full moon in his underwear. It is evidence, not sincerity, that is wanted here. (Or, in the case of my uncle Milt, trousers.)

What the nurses could do is explain that their techniques are unproved and unendorsed by the hospital (if this is the case; hospitals vary), offering patients, in effect, the sort of supplemental treatment available outside the hospital. But this approach is not without risk. A therapy provided in the hospital by its staff carries a sense of official approval, no matter what disclaimers are offered. In any case, these nurses must alert their colleagues and hospital administrators about such things. Both groups need to know how patients are being treated if they are to do their jobs well.

Not bad for a mainstream media commentary. I would only add that I saw a comment on this article on a blog somewhere (sorry, I can’t remember which) questioning why a nurse could administer a “therapy” that wasn’t ordered by a doctor. The reason is that there are nursing diagnoses and treatments that do not necessarily require a physician’s order, usually diagnoses having to do with issues like skin integrity or preventing decubitus ulcers and other patient issues for which nursing care is incredibly important. Unfortunately, some of these nursing diagnoses allow for “interventions” such as therapeutic touch.

That, however, is too big a topic for here. It will have to be a topic for another post in the future.

Comments

  1. #1 Joe
    December 5, 2007

    That was interesting.

  2. #2 PalMD
    December 5, 2007

    This practice should be forbidden. I’ve seen it in my own hospitals in the past. Therapeutic touch is complete and utter bs.

  3. #3 Mary
    December 5, 2007

    I would be very unhappy if a nurse/anyone offered Therapeutic Touch to me or mine. However, I appreciate that some people feel so vulnerable in hospital (particularly in the UK) that they would be apprehensive about getting on the wrong side of someone by refusing to accept something that they offered and plainly believed in.

  4. #4 marks tails
    December 5, 2007

    beware of more questions like this since Oprah and Dr. Oz touted alternative medicine on The Oprah show this past Monday. I commented on it on my blog.

  5. #5 Andrew Taylor
    December 5, 2007

    Seems odd to me that he said “if [therapeutic touch is] unproven; opinions differ passionately” when clearly “it is evidence, not sincerity, that is wanted here”.

    Especially bearing in mind that therapeutic touch was disproven in a paper authored by an eleven year old girl. I mean, opinions that can be disproven by infants are not exactly “evidence”.

  6. #6 T. Bruce McNeely
    December 5, 2007

    If I were still admitting patients to hospital, I would have a standing order “No alternative interventions without clearance from me”.
    If I see it done on any of my family, there will be words.

  7. #7 Alan Johns, M.D.
    December 5, 2007

    I have no problem with one of my postop patients having a nurse talk with them softly and gently while giving them a pseudo massage. Just no conversation about a non-existent “energy field” or any other BS. Call it what it is, nurses talking with patients and showing concern while waving their hands around. My fear is that, if “theraputic touch” is called that and performed in a hospital setting, it could become reimbursable. With continuing Medicare cuts just around the corner, absolutely no one should pay for this nonsense. Free is OK, but i bet the nurses time could be better utilized.

  8. #8 Annie
    December 5, 2007

    Nurse administrator here:

    Therapeutic touch would have to be incorporated into recognized professional nursing policies and procedures in order to be performed. Those are supposed to be based on – get ready for it – evidence. I’m not in front of the journals of nursing research, so I can’t reference what’s current in the literature. Anyone with a decent EBSCO subscription to help out here? Nurses should not, and for the most part, do not, carry out interventions which are not formally assessed, evaluated and sanctioned by their employing entities – and they need to practice within the scope of practice as regulated by the appropriate state board of nursing licensing agency.

    The most pragmatic answer to the question as it was posed is to ascertain what is sanctioned, and whether the nurse involved was practicing per policy and scope of practice?

    It is also possible, although less likely, that the nurse and patient referenced were participating in nursing research, but in that case, that should have been known to the patient or the patient’s advocate/ guardian.

    Please don’t let this discussion devolve into one of blanket nurse bashing.

    However, for quick reference, there is an overview of a meta-analysis:

    Altern Ther Health Med. 1999 Nov;5(6):58-67.

    An integrative review and meta-analysis of therapeutic touch research.Winstead-Fry P, Kijek J.

    University of Vermont School of Nursing, Burlington, USA.

    OBJECTIVE: To perform an integrative research review and meta-analysis of therapeutic touch research. DATA SOURCES: Bibliography maintained by the Nurse Healers-Professional Associates International; MEDLINE, CINAHL, and Psylit databases; dissertations and master’s theses. STUDY SELECTION: Thirty-eight research articles were included in the analysis. All dissertations and research articles were analyzed. DATA EXTRACTION: Data on 32 substantive characteristics of the sample, the therapeutic touch procedure, and the article/dissertation were extracted following Moody’s method for an integrative research review. The meta-analysis used studies that reported means and standard deviations of the treatment and control groups. DATA SYNTHESIS: The research questions were as follows: (1) What are the substantive characteristics of the sample, the therapeutic touch practice, and the article/dissertation in research studies from 1975 to 1997? (2) What does the research demonstrate regarding the efficacy of therapeutic touch as an intervention? (3) Based on the results of the review and meta-analysis, what are the gaps, trends, and outcomes of the therapeutic touch research studies? CONCLUSIONS: The review demonstrated that there are many approaches to therapeutic touch research, samples are described incompletely, and the therapeutic touch practices vary in the studies. Most of the studies supported hypotheses regarding the efficacy of therapeutic touch, though a number had mixed or negative results. A meta-analysis was performed on 13 studies. The average effect size in these studies was .39, which is described as moderate. Gaps, trends, and outcomes were identified and discussed.

    I don’t find a current reference to therapeutic touch on the National Institute for Nursing Research website. I haven’t really seen much discussion about it nor use since the mid 1980s.

  9. #9 Amenhotep
    December 5, 2007

    I hope they are using robust infection control measures, such as aprons and gloves. Wouldn’t want the energy fields of those nasty MRSAs and C.Diffs getting adjusted into a state of hyper-virulence.

    The common thing between all these alternative therapies is that they are a pretend vehicle for the Nice Wee Chat. Niceweechatotherapy(TM) is a proven method for making people feel better whether they are ill or not. Why in the name of feck do we have to dress it up in “alternative” or “complementary” horseshit? Whether we’re nurses or doctors or physios or whatever, why don’t we just talk to our patients, smile a bit, be kind and caring, and employ the evidence-based principles of NWCT?

    It’s not as if it’s fricking rocket science.

    [Yes, I know most of us don't get time to scratch our arses, but I'm talking about the principle here]

  10. #10 PalMD
    December 5, 2007

    FYI Nursing Admin:
    http://www.quackwatch.org/01QuackeryRelatedTopics/tt.html
    http://en.wikipedia.org/wiki/Theosophical_Society
    http://www.therapeutic-touch.org/newsarticle.php?newsID=6
    L. Rosa, E. Rosa, L. Sarner and S. Barrett, A close look at therapeutic touch. JAMA 279 (1998), pp. 1004-1010. Conclusions.– Twenty-one experienced TT practitioners were unable to detect the investigator’s “energy field.” Their failure to substantiate TT’s most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.
    Tall FD. A close look at “A close look at therapeutic touch”. [Review] [17 refs] [Journal Article. Review] Nursing Outlook. 51(3):126-9, 2003 May-Jun
    Mentgen JL. Healing touch. [Review] [21 refs] [Journal Article. Review] Nursing Clinics of North America. 36(1):143-58, 2001 Mar. This article explores how nurses can use energetic principles and Healing Touch to enhance the healing of their patients, for their own personal healing and growth, for improving job satisfaction, and for identifying educational resources available for more intense study
    Krucoff MW. Crater SW. Gallup D. Blankenship JC. Cuffe M. Guarneri M. Krieger RA. Kshettry VR. Morris K. Oz M. Pichard A. Sketch MH Jr. Koenig HG. Mark D. Lee KL. Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study.[see comment]. [Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled Trial. Research Support, Non-U.S. Gov't] Lancet. 366(9481):211-7, 2005 Jul 16-22. The primary study endpoint in this 2×2 randomised trial was a composite of in-hospital major cardiovascular events, death, or readmission within the next 6 months. Neither prayer nor music, imagery, or touch produced any effect on this outcome.

  11. #11 DLC
    December 5, 2007

    For Annie:
    Last month Orac came up with this:
    http://scienceblogs.com/insolence/2007/11/the_woo_aggregator.php
    While not a listing of nursing schools, it’s a depressing list
    of academic medical centers that include some level of woo
    in their curricula.
    This is equivalent to teaching Hoagland’s “Alternative Physics” (term used loosely) in major engineering schools.

  12. #12 jen_m
    December 5, 2007

    As I noted there, I went through nursing training at one of those schools without ever being exposed to the idea of therapeutic touch, although I heard a lot about nursing theory and theoretical frameworks.

    I did a quick search for “therapeutic touch” in the nursing journals subset of PubMed, limited to English language, by date.

    1/1/70 – 12/31/79 6 citations
    1/1/80 – 12/31/89 35 citations
    1/1/90 – 12/31/99 180 citations
    1/1/00 – 12/31/07 153 citations

    I did the same thing for “urinary catheterization”, which is pretty much a staple of nursing care, and which I studied for many hours in nursing school.

    1/1/70 – 12/31/79 67 citations
    1/1/80 – 12/31/89 228 citations
    1/1/90 – 12/31/99 330 citations
    1/1/00 – 12/31/07 310 citations

    I concluded that the gradual rise in both topics is probably partly attributable to the growth of the nursing journals category: the same search for “nursing” got

    1/1/70 – 12/31/79 24,083 citations
    1/1/80 – 12/31/89 50,950 citations
    1/1/90 – 12/31/99 89,788 citations
    1/1/00 – 12/31/07 68,344 citations

    When I limited the most recent search to “MeSH Major Topic”, I got 113 hits for therapeutic touch, and 229 for urinary catheterization.

    So TT is probably discussed in the nursing literature disproportionate to its credibility or its importance. But it’s not the center of the nursing universe or nursing theory.

  13. #13 daedalus2u
    December 5, 2007

    The problem with niceweechatotherapy is that it is not billable. If is it not billable, it is not doable in these times of squeezing every last penny out of health care costs. It doesn’t matter if the patient gets better faster and hospital stays are shorter; saving every penny is what matters, even if it costs pounds, or even lives.

  14. #14 Emily
    December 5, 2007

    As a nurse who has spent much time reading the research about TT and HT (which I think is replacing TT in prominence), I can tell you the research is just like that of most other complementary therapies that have no plausible basis. Most of the research is very poorly done and in the instances where HT or TT demonstrate some kind of positive result there are usually multiple flaws in the study.
    The most discouraging thing to me is that NANDA (the North American Nursing Diagnosis Assoc.) actually has a nursing diagnosis ‘Energy Field Disturbance’. The TT/HT practitioners use this as a basis for claiming this is ‘accepted nursing practice’.

  15. #15 Ahistoricality
    December 5, 2007

    That’s the first time I’ve read a Randy Cohen answer that I thought he got right. He’s a pretty lousy ethicist, frankly: I was expecting to find a disaster under the fold, followed by a healthy demolition.

  16. #16 Ex-drone
    December 5, 2007

    Sadly, I note that NIH’s center of woo, NCCAM, calls this field Energy Medicine. Apparently, no claim-based therapy is too implausible to be in this field.

  17. #17 Alan Kellogg
    December 5, 2007

    Touch can be very therauputic, but you have to actually touch. :)

  18. #18 Annie
    December 6, 2007

    Thanks for all of the information. Brought me back to my HS physics project: Kirlian photography (auras, man – like far out). ;*)

  19. #19 bob koepp
    December 6, 2007

    I figure is just a matter of time, in the litigious USofA, until some TT practitioner is sued for damaging the energy field of some enterprising patient. If a patient saying “I feel better” counts as evidence of benefit, surely a patient saying “I’m suffering terribly” must be evidence of harm. Hosptials, which are run by Risk Management departments, would stop allowing this nonsense on their premises very, very quickly.

  20. #20 Luna_the_cat
    December 9, 2007

    One of the studies I was most impressed by — ever — was the Emily Rosa one, but that was not least because of the experimenter.

  21. #21 mollyrn
    January 10, 2008

    As a professional nurse I feel that we must distance ourselves from practices which are not researched well and that can be perceived as “quackery”. We need to develop sound nursing research and promote ourselves as an autonomous, science driven profession.