To put the patient in the best condition: integrating integrative therapies in critical care

What do critically ill patients need? After some 40 years of research in critical care it is remarkable how little we still know. Fulfilment of human needs is both the therapeutic and moral imperative of nursing. Since Nightingale's time, the assumption has been that by taking care of human needs, we ‘put the patient in the best condition for nature to act upon him’ (Nightingale, 1860). Our terminology has evolved but the intention is the same. Instead of ‘nature’ we now allude to innate homeostatic mechanisms, neuroimmuno-endocrine balance and metabolic equilibrium. The underlying idea remains the same: there is a healing potential within the person that we need to tap into. Minimizing external demands and stressors onto the system, that is allostatic load, buys time for homeostasis and healing. This is the basic principle of critical care. Organ support interventions, either pharmacological or technological, are mostly ‘supportive’ and non-curative, addressing symptoms, not pathogenic causes. When recovery occurs it can be viewed as a manifestation of innate processes that succeeded in restoring balance. The significance of balance in recovery has led to the patient-centred health care movement. Patient-centeredness has been suggested as an imperative, driving future critical care beyond its traditional boundaries (Cabrini et al., 2015). The notion of patient-centeredness has its roots in holistic health care (Epstein, 2000). The patients' perspective is central to this paradigm. Accordingly, patient-centred priorities for care include: respect, efficiency, patient involvement, time for care, exploring patient needs and communication (Jennings et al., 2005). However, little is known of critically ill patients' needs. We know that the majority of the critically ill experience sustained levels of pain, to the degree that their neural chemistry is chronically altered and pain may persist long after the intensive care unit (ICU) period (Papathanassoglou, 2014). We also know that stress is so unbearable that autonomic response and neurotransmission are dysregulated to the degree of psychosis (ICU delirium). This experience too can persist after discharge giving rise to post-traumatic stress symptomatology and anxiety disorders (Wade et al., 2015). The critical illness experience itself remains elusive. Most of what we know comes from qualitative studies. Themes such as ‘existential struggle’ (Palesjö et al., 2015), experiencing a state of chaos, fear, vulnerability (Granberg et al., 1998), transformations of perception and encountering death (Papathanassoglou and Patiraki, 2003) are prominent in patients' experience. It appears that by facing unprecedented levels of stress, patients struggle for hope and meaning. So what do patients need? Comfort from suffering; bodily, emotional and spiritual comfort? The need for comfort is not new. Since the inception of critical care, the need to comfort and protect patients from overwhelming stress has been clear. So we protected patients from the experience. We protected them from stress by sedatives and we were thankful when memory of illness was lost. We protected them from further stressors by isolating them, i.e. closed visitation. We protected them from further demands on their cardiovascular system, by avoiding mobility. We protected them from harming themselves when delirium kicked in, by pharmacologically or physically restraining them. We protected them from excessive anxiety that did not let them sustain effective breathing, by paralyzing them and taking control over their breathing. We did our best. Then we had to do our best to combat the side-effects of all these protective measures (benzodiazepines, propofol, opioids, immobility, neuromuscular blockers, isolation). For 40 years we searched, researched and suffered along in a quest of care and compassion, with one goal: to make them well. Finally, a new realization surfaced. There is nothing out there to protect them from, the enemy is within. In most cases critically ill patients succumb not to the initial insult that led them to the ICU, rather it is their own bodies' overwhelming inflammatory reaction that shuts down everything from organ systems to cell respiration. A whole-body toxic stress response, that manifests as uncontrolled inflammation. Cell damage and organ dysfunction can be fatal and we simply have no treatment for this (Fry, 2012). How can we stop this devastating cascade? We need help from the patients themselves. There is not much we can do to patients to make them better, we have to do things with them. We cannot heal them by pharmacological agents alone, it is they who are the agents of healing. Where does the potential for healing lie? As mundane as it may sound, the answer is likely within the mind–body balance. The central neural system, with all related circuitry, including the autonomic system, is the only higher order regulator that can prevent or shut the generalized inflammatory response down and salvage cells and organ systems (Papathanassoglou et al., 2010). Mind–body interactions have traditionally been considered within the realm of complementary/alternative medicine (CAM). The increasing worldwide use of CAM is well documented, ranging from 30% to 80% of the general population (Vohra et al., 2005; Shirwaikar et al., 2013). Although there are no data with regard to critically ill patients' preferences for CAM, it is conceivable that with the widespread use of CAM in the general population, requests for CAM among critically ill patients will increase. A survey of critically ill nurses in the USA has identified that patients and families commonly request some CAM modality (Tracy et al., 2005); conversely, results of an Australian survey showed less common requests for CAM (Cooke et al., 2012). While current results are mixed, the evidence is clear that CAM is an increasingly popular health care choice. For clarity a few definitions are needed. CAM generally connotes health care approaches developed outside of mainstream Western, or conventional, medicine (NCCIH, 2015). CAM therapies can be classified as: (a) whole medical systems (e.g. Ayurveda, Homoeopathic Medicine); (b) mind-body medicine (e.g. meditation, guided imagery, music therapy); (c) art therapies (e.g. dance, painting); (d) biologically based practices (e.g. herbs, dietary supplements); (e); manipulative practices (e.g. chiropractic, osteopathic manipulation); (f) body-based practices (e.g. massage, rolfing); (g) bio-field therapies (e.g. Qi Gong, Reiki, therapeutic touch) and (h) bio-electromagnetic-based therapies (pulsed fields, magnetic fields and current fields). This editorial focuses mainly on mind-body, body-based and bio-field therapy approaches as these are more readily implemented in critical care, they can be integrated in nurses' role and they do not require additional equipment. Recently, a new terminology emerged which reflects opportunity for expansion of paradigms. Integrative therapy (or medicine) (IT) emphasizes healing of the whole person by taking into account biological, psychosocial and spiritual dimensions, drawing on both conventional and complementary approaches (NCCIH, 2015). IT encompasses a broader paradigm which is patient-centred and oriented to healing; it is not just the combination of complementary and alternative approaches (Maizes et al., 2009). Based on the increasing wide-spread use of CAM approaches, reports of their merits and efficacy to date, efforts in various fields of health care have focused on developing guidelines and establishing frameworks for successful integration of IT approaches into practice (Singer and Adams, 2014). Integrative health care programs and centres are also increasing (Coulter et al., 2010). Among the earliest attempts, the American College of Cardiology has developed an expert consensus on Complementary and Integrative Medicine (Vogel et al., 2005); however, most attempts to date involve primary health (Shirwaikar et al., 2013), oncology care (Frenkel et al., 2015) and chronic pain management (Tan and Jensen, 2007). Why critical care hasn't caught up with developments in integrative therapy approaches? Can this be due to a lack of evidence? Although a review is beyond the scope of this discussion, accumulating evidence supports the efficacy of a range of integrative approaches on critical illness outcomes. Approaches such as relaxation, guided imagery, massage and music therapy appear to impact on a number of outcomes in critical illness. Overall, favourable effects of integrative interventions compared with standard care alone have been documented. Outcomes are compelling and include decreased pain ratings, systolic blood pressure and heart rate, sedative and analgesic drug intake, patients' anxiety, length of stay, duration of mechanical ventilation and improvements in weaning, sleep quality, patient satisfaction with care and cost of care (Casida and Lemanski, 2010; Lee and Higgins, 2010; Papathanassoglou, 2010; Bradt and Dileo, 2014). However, some methodological limitations are common in this body of evidence; small sample sizes, ambiguity with regard to the underlying theoretical framework and mechanisms of action, and overall limited use of sham interventions. Nonetheless, although the typical gold standard randomized controlled trial design is the mainstay for adopting new evidence-based interventions, to prove efficacy over placebo effects, this design may be in opposition with fundamental principles of IT. In IT, the combined effect of therapeutic intentions and a person's faith, cognitive and emotional response to treatment, that is the placebo effect, is not to be discarded as a confounder but rather to be harnessed as an effector of healing. More work is needed not only to clarify the efficacy of IT interventions in critical care but also to standardize research methodologies commensurate with the integrative framework. On the other hand, this is not a sufficient reason for the reluctance of implementing IT in critical care. Indeed, many current conventional practices – coronary bypass surgery, percutaneous coronary interventions and pulmonary artery catheterization (IOM, 2005) became accepted treatment before they were subjected to the scrutiny of controlled clinical trials. So how are IT approaches different? The key in understanding the differences lies with Hill's (1965) traditional criteria of causation, which permeate scientific reasoning in health and biological sciences. The criterion of ‘coherence’ dictates that an association (or treatment) should be compatible with existing theory and knowledge. Is there existing theory and knowledge to support IT approaches in critical care? IT approaches such as relaxation, guided imagery, massage and music therapy have been shown to alleviate stress and increase parasympathetic (PNS) activity (Oke and Tracey, 2009). Seminal work in animal models of critical illness illustrates that stimulation of PNS and release of acetylcholine (ACh) suppresses production of pro-inflammatory cytokines and may reduce systemic inflammation and decrease fatality, via activation of the cholinergic anti-inflammatory pathway (Oke and Tracey, 2008). Additionally, advances in complexity theory provide a theoretical framework for the effect of IT interventions in critical care (Papathanassoglou et al., 2008; Seely and Macklem, 2012). Thus lack of ‘existing theory and knowledge’ is not a barrier for the integration of such approaches; lack of conventional theory is. Therefore, in order to generate more evidence and gain acceptance from clinicians and health care systems, IT approaches can no longer remain in the periphery of conventional care. Continuing to challenge orthodoxy is not an effective route for achieving recognition. Rather, we need to expand orthodoxy and this can only be achieved through integration. For example, in neonatal critical care, through such integration efforts, a number of interventions such as kangaroo care, touch and music therapy, that had previously been considered as complementary, are now regarded as standard care (Mark and Barton, 2001). A number of approaches to integrating IT can inform efforts in critical care. The Program on Integrative Medicine, University of North Carolina, has identified seven models (Mann et al., 2004), the most common, but probably less effective, being that of the ‘informed clinician’. In this model clinicians become knowledgeable of IT approaches and they can therefore inform patients and families. The ‘informed networking clinician’ is the second suggested model and builds on the first approach adding informal referral networks with CAM practitioners, for example, when a critical care clinician refers patients to specialists for specific problems, such as persistent pain. The third model is described as ‘CAM-trained clinician’. For instance, critical care nurses who have acquired specific training in CAM modalities can administer CAM treatments to patients. The fourth model focuses on ‘multidisciplinary integrative practice’ and applies more to primary health care settings. Within the fifth model, ‘interdisciplinary integrative care group’, IT specialists are integral members of the critical care team. An advantage of this model is the interdisciplinary integrative perspective which results in comprehensive care planning. The sixth model involves ‘hospital-based integration’ and it incorporates conventional and CAM services in one hospital. To date, several hospitals and medical centres have implemented this approach in order to expand patient-care options and to improve patient satisfaction (IOM, 2005, p. 209). Lastly the ‘Integrative medicine in an academic medical centre’ model combines research, teaching and practice of IT and it is probably the most effective model for expansion of the current critical care paradigm. This model has found support within the academic community. For example, the Academic Consortium for Integrative Medicine & Health (The Consortium, 2016) was formed to advance research and practice of integrative health care within academic institutions. This model is important for future IT integration efforts in critical care, since lack of training and knowledge have been identified as major barriers to the introduction of IT approaches in critical care (Tracy et al., 2005; Cooke et al., 2012). In conclusion, integrative therapies can be a low-risk patient-centred approach for improving patient outcomes in critical care. The present state-of-the-art is not devoid either of evidence or theoretical framework to support these approaches, and multiple models can inform integration efforts. It, therefore, appears that critical care is in the verge of a paradigm shift. Critical care nurses must play a major role in facilitating this expansion, since many of these therapies, touch, massage, imagery and presence, have been taught and practiced by nurses for years and are commensurate with the holistic principle of nursing. If critical care abides to the laws of complex systems, even small subtle action is expected to bring about big unpredictable changes. So let us keep on listening to patients' needs and see how this can shape the future of critical care.

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