Palliative Care and Use of Animal-Assisted Therapy


Dr. Suzanne Engelman
California Licensed Psychologist PSY7977
Board Certified in Biofeedback
Certified Thanatologist
Certified Animal Assisted Therapist

LOCATION:
30131 Town Center Drive
Suite # 268
Laguna Niguel, CA 92677

Office Phone:  (949) 460-4908 
FAX:  (949) 248-0421
Confidential email: srephd@hushmail.com

Suzanne R. Engelman, PHD, BCB, FT

St. Joseph Hospital, Orange, California

Published in OMEGA, Vol. 67(1-2) 63-67, 2013

Abstract

A growing body of research and clinical reports support the benefits of utilizing animal-assisted therapy (AAT) as a complementary, transdisciplinary treatment intervention in medical settings. However, fewer articles are found demonstrating AAT’s use in palliative care settings. This article is a study of the effects of AAT in palliative care situations, presenting one anecdotal clinical vignette. In this way, the efficacy of this technique in decreasing patient pain, thereby increasing patient quality of life, and lowering staff stress levels may be illustrated.

Background

Palliative care is described by the American Medical Association as a “therapy that focuses on decreasing pain and suffering by providing treatments for relief of symptoms along with comfort and support for patients of all ages” (Stevens, 2006).  The National Hospice and Palliative Care Organization indicates, “no specific therapy is excluded from consideration” (NHPCO, 2013).

*Editor’s Note: The content from this article is a result of the author’s attendance and participation in the ACE Project: Advocating for Clinical Excellence: A Transdisciplinary Palliative Care Education program supported by a grant from the National Cancer Institute of the National Institutes of Health under award number R25CA110454 (Shirley Otis-Green, Principal Investigator). We appreciate the OMEGA: Journal of Death and Dying for publishing this article as part of a dedicated special issue celebrating the achievements of the ACE Project participants. 2013, Baywood Publishing Co., Inc.ndoi: http://dx.doi.org/10.2190/OM.67.1-2.g

http://baywood.com OMEGA, Vol. 67(1-2) 63-67, 2013

Animal-assisted therapy (AAT) is a therapeutic modality which involves a patient, a highly trained animal, and a therapist with the goal of achieving a specific therapeutic outcome (Delta Society, 2011). AAT is a complementary health treatment modality which has gained wide-spread support in documenting cost-effective physiological, psychological, and emotional benefits across a variety of treatment settings including general hospitals (Diefenbeck, Bouffard,

Matukaitis, Hastings, & Coble, 2010; Horowitz, 2010), hospital critical care units, especially Cardiac ICUs where heart rate, blood pressure, respiratory rates, cortisol levels, epinephrine and norepinephrine levels, stress, depression, anxiety, and pain medication usage have all been shown to decrease (Cole, Galinski, Steers, & Kotlerman, 2007; DeCourcey, Russell, & Keister, 2010), and in nursing homes and hospice settings (Chinner & Dalziel, 1991; Geisler, 2004; Phear, 1996). 

Studies of the effect of AAT on patients in medical settings show reduced heart rates, respiration rates, and blood pressure, pupillary constriction, and increased peripheral skin temperature. These are all indicative of a relaxation response in which sympathetic nervous system activation is decreased and parasympathetic nervous system activation is stimulated (Braun, Stangler, Narveson, & Pettingell, 2009; Cole & Gawlinski, 2000). Thus, it appears that AAT may facilitate a relaxation response which, in and of itself, may reduce the affective and sensory components of some types of pain, resulting in a type of “hypnoanalgesia” (Patterson & Jensen, 2003).

Patterson and Jensen have concluded that hypnotic techniques for the relief of acute pain are superior to standard care, and often better than other recognized treatments for pain (APA, 2004). However, few studies are found that show the impact of AAT on the alleviation of “total” pain in palliative care settings. This may include physical aspects of pain, as well as suffering components such as emotional factors, loss issues, fear of death, and spiritual concerns (Gagnon, Bouchard, Landry, Belles-Isles, Fortier, & Fillion, 2004; Geisler, 2004; Horowitz, 2010; Skeath, Fine, & Berger, 2010).

OBJECTIVES

Utilizing a licensed psychologist and her small therapy dog, it was the objective of this study to observe the effects of AAT on palliative care patients’ pain levels in both in-patient and out-patient settings.

METHODS

Over the course of 1 year, patients (both in-patients and out-patients) were referred to the psychologist for interventions to assist them with pain management. Twenty patients were contacted and 19 agreed to AAT visits. The psychologist conducting the AAT had been a clinical psychologist for over 25 years, and had been teaming with the therapy dog for over 8 years. Lizzy, the therapy dog, used in this study was an 8-year-old white bischon friese, weighing about 13 pounds. She had been certified by the Delta Society for several years, along with the psychologist, to provide AAT as a team in “complex” (hospital) settings. The Delta Society is the flagship training group whose mission is “to advance human health and well being through positive interactions with animals” (Delta Society, 2011).

Narrative reports and observations were recorded by the psychologist in all 19 situations demonstrating the use of AAT. Observations of staff reactions to the therapy dog being on the floor were also made. Recordings were made by the psychologist through written records in the medical chart notes, as well as in separate psychotherapy notes. Following is a presentation of a clinical vignette which exemplifies the type of interventions used. Names and exact circumstances have been changed to preserve confidentiality.

Juan, a 51-year-old Hispanic man, was admitted to the hospital for renal failure and remained in the hospital for over 3 months. In the process of being evaluated with exploratory laparotomy, his kidney was removed. After surgery, he developed severe complications and unexplained pain that was inconsistently responsive to opiate medication. The palliative care physician referred him to the psychologist for evaluation of his depression and chronic pain syndrome.

During his many months in the hospital, Juan had barely moved while reclining in bed. Depressed and angry, Juan asked to be “left alone,” hanging a sign on his door

to “keep out” his nursing staff and friends alike. Not knowing how Juan would respond to the AAT, the rebuffed nursing staff stated “not to expect much.” Lizzy, the therapy dog, served as a stress relief valve for the caring, but frustrated, staff who petted and enjoyed her, while expressing concerns about Juan’s attitude.

The project team approached his room, knocked, and slowly entered. Juan immediately lit up when he saw Lizzy and reached down from his bed to pet her. In a subsequent meeting, he asked if Lizzy could jump up to be with him in his bed, which she did. Lizzy snuggled up against Juan’s abdomen in the place where it hurt.

Several minutes later, she left the abdominal area and jumped down off of the bed to the floor. As a result of Lizzy’s snuggling with Juan, he indicated the pain had subsided, saying “ it was like she took the pain with her!” During this visit, as we were leaving, Juan asked us to “take the ‘stay out’ sign down”!

RESULTS

This anecdotal study of 19 patients provided evidence that AAT can be an effective method for reducing pain in palliative care patients. The study did not utilize empirical measures; rather, phenomenological experiences were recorded in medical chart notes and records. Findings were based on patients’ self-reports, staff responses, and staff observations of Lizzy and me working with patients.

All 19 of the palliative care patients reported being pleased with the therapy dog encounters as expressed by comments like “I feel more relaxed now,” or “please come back,” “I really liked having Lizzy here,” “She’s like a breath of fresh air,” “She reminds me of my dog, and its like having a bit of home here in the hospital,” “My pain feels better,” and “My discomfort is less.”

None of the patients reported negative feelings or increases in pain with the therapy dog.

In at least five situations, the therapy dog’s proximity to the physical location of somatic pain in the palliative care patient’s body and then subsequently moving away, the patient reporting a reduction in pain symptoms, replicating the findings reported above, suggestive of a “hypnoanalgesia” phenomenon. With other patients, the presence of the therapy dog with patients appeared to reduce their pain as they “relaxed” into petting the animal and being distracted from their focus on pain sensations.

An unanticipated result of this study was that staff stress levels appeared to decrease as a result of interactions with the therapy dog. This was determined by the researcher noting that the therapy dog provided an opportunity for staff, administrative, nursing, and physicians alike, to take a break from their activities to be soothed and sometimes amused by the therapy dog in the midst of an otherwise serious, stressful, and fast-paced setting. With both patients and staff alike, it appeared that the therapy dog fostered relationship building.

DISCUSSION

With patients, the therapy dog appeared to “lighten the atmosphere” and bring a “bit of home” and “normalcy” to the healing environment of the hospital room; pain was often times reduced and affect was improved in patients. The phenomenon of hypnoanalgesia discussed in this study offers a viable modality of reducing pain without the side effects of medication, and could benefit from empirical study. Unexpectedly, with medical staff, stress appeared to be reduced as well with the use of AAT.

IMPLICATIONS FOR PRACTICE

Utilizing AAT in the palliative care setting holds great promise in reducing patients’ pain, suffering, increasing their quality of life, as well as reducing the stress of palliative care staff. Complementary, transdisciplinary interventions such as AAT could benefit by both further empirical research with larger numbers of patients and more precise clinical documentation in palliative care situations, and thereby may enhance our abilities to reduce total pain symptoms, with minimal side effects and decreases in medication usage and cost.

Suzanne R. Engelman, PhD., (suzyengelm@aol.com) is a licensed psychologist with a private practice in Laguna Nigel.

REFERENCES

American Psychological Association (APA). (2004). Hypnosis for the relief and control of pain. Retrieved from http://www.apa.org/research/action/hypnosis.aspx

Braun, C., Stangler, T., Narveson, J., & Pettingell, S. (2009). Animal-assisted therapy as a pain relief intervention for children. Complementary Therapies in Clinical Practice, 15, 105-109.

Chinner, T., & Dalziel, F. (1991). An exploratory study on the viability and efficacy of a pet-facilitated therapy project with a hospice. Journal of Palliative Care, 7(4), 13-20.

Cole, K., & Gawlinski, A. (2000). Animal assisted therapy: The human-animal bond. American Association of Critical Care Nurses Clinical Issues, 11, 139-149.

Cole, K., Gawlinski, A., Steers, N., & Kotlerman, J. (2007). Animal assisted therapy in patients hospitalized with heart failure. American Journal of Critical Care, 16, 575-585.

DeCourcey, M., Russell, A., & Keister, K. (2010). Animal-assisted therapy: Evaluation and implementation of a complementary therapy to improve the psychological and physiological health of critically ill patients. Dimensions of Critical Care Nursing, 29(5), 211-214.

Delta Society. (2011). What are animal assisted therapy and activities? Retrieved from http://www.deltasociety.org/Document.Doc?id=10 Diefenbeck, C., Bouffard, L., Matukaitis, J., Hastings, H., & Coble, S. (2010). Healing paws: Animal-assisted therapy in acute care. Nursing Critical Care, 5(4), 34-39.

Gagnon, J., Bouchard, F., Landry, M., Belles-Isles M., Fortier, M., & Fillion, L. (2004). Implementing a hospital-based animal therapy program for children with cancer:

A descriptive study. Canadian Oncology Nursing Journal, 14(4), 217-222. Geisler, A. (2004). Companion animals in palliative care: Stories from the bedside.

American Journal of Hospice & Palliative Medicine, 21(4), 379-383 Horowitz, S. (2010). Animal-assisted therapy for inpatients. Alternative and Complementary Therapies, 16(6), 339-343.

National Hospice and Palliative Care Organization (NHPCO). (2012). What is hospice and palliative care? Retrieved February 2013 from http://www.nhpco.org/resources/palliative care

Patterson, D., & Jensen, M. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129, 295-521.

Phear, D. (1996). A study of animal companionship in a day hospice. Palliative Medicine,10(4), 336-338.

Skeath, P., Fine, A., & Berger, A. (2010). Increasing the effectiveness of palliative care through integrative modalities. In A. Fine (Ed.), Handbook on animal assisted therapy (pp. 301-327). San Diego, CA: Academic Press.

Stevens, L. (2006). Palliative care. Journal of the American Medical Association, 296(11),

1428. doi: 10.1001/jama.296.11.1428

e-mail: suzyengelm@aol.com