Purpose The aim of the present work was to evaluate the availability of acupuncture in UK hospices and specialist palliative care services and to identify any barriers to the use of acupuncture in these settings, to determine the characteristics of available acupuncture services and of practitioners providing acupuncture, and to determine awareness of the evidence base for the use of acupuncture in palliative care.
Methods An online questionnaire with an invitation to participate was circulated by email to 263 hospices and specialist palliative care services in the UK.
Results A response rate of 54% was obtained. Acupuncture was provided by 59% of services that responded. In general, small numbers of patients receive acupuncture as part of their palliative care treatment as inpatients, day patients or outpatients. Most practitioners were regulated health professionals who had received a Western-style training in acupuncture and used a Western-style medical acupuncture approach. Where acupuncture was not available the commonest reason given was the lack of a suitable practitioner. Most agreed that if funding and a suitable practitioner were available, acupuncture would be a useful addition to their service. The level of awareness of specific types of evidence supporting the use of acupuncture in palliative care was low, but most respondents were aware that some evidence existed.
Conclusions There is a need to increase training in acupuncture for healthcare professionals working in palliative care. There is also a need to raise awareness of the potential benefits to patients and the evidence base supporting the use of acupuncture in palliative care.
- Palliative Care
- Pain Management
- Complementary Medicine
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Acupuncture can be used for pain and control of other symptoms in palliative care.1 ,2 A number of studies have investigated the availability of acupuncture in hospices, palliative care and oncology services in Europe and the USA3–7 (see web only appendix 1) but it is not known how many palliative care units in the UK provide an acupuncture service.
The use of acupuncture in this context is supported by an evidence base8–52 (outlined in web only appendix 2). There is evidence to support the use of acupuncture in patients in palliative care for a range of symptoms including pain,8–19 nausea and vomiting,20–27 dyspnoea,28–30 xerostomia,31–37 hot flushes,38–44 fatigue45 ,46 and detrusor instability.47 ,48 There is also limited (anecdotal) evidence for use of acupuncture in a variety of other conditions such as anxiety, skin ulcer healing, intractable hiccough, dysphagia, radiation rectitis and uraemic pruritus.1
The primary aims of this study were to evaluate the availability of acupuncture in UK hospices and specialist palliative care services and to identify any barriers to the use of acupuncture in these settings.
The objectives of the project were to determine: availability of acupuncture in UK palliative care services, characteristics of available acupuncture services, characteristics of practitioners providing acupuncture, reasons why acupuncture may not be available and awareness of evidence base for the use of acupuncture in palliative care.
An online questionnaire was designed using the website Survey Monkey53 (see web only appendix 3). This was piloted by asking local colleagues to complete the survey and to comment on clarity of questions and ease of completion. Modifications were made to the wording of some of the questions following the pilot. A list of email addresses of adult inpatient units and day care services was obtained from Help the Hospices, who hold an online searchable database of specialist palliative care services in the UK, which is publicly available.
An introductory email was sent to lead clinicians in each palliative care service describing the project. This was an opportunity to test the validity of the email addresses and also gave the option for the recipient to suggest a more appropriate contact or to opt out of the survey if they wished. A number of emails were undeliverable and were updated by checking the website of the service or by telephone.
An invitation to participate in the survey was then sent by email to the updated mailing list. This contained a hyperlink to the online questionnaire and an alternative hyperlink to opt out. Two subsequent reminder emails were sent to non-responders and the survey was closed after 4 weeks.
The survey was split into six sections (see web only appendix 3). These were: (1) description of palliative care service, (2) complementary therapies available, (3) acupuncture service available, (4) reasons why acupuncture not available, (5) awareness of evidence base for the use of acupuncture in palliative care and (6) additional comments.
A total of 263 email invitations were sent out with a link to the online survey. In all, 13 recipients opted out of the survey, 141 responded and 105 did not respond. The response rate was 54%. Of the 141 respondents 126 (89%) completed the survey and 15 partially completed the survey.
The survey was completed by a consultant or other doctor in 48% of cases, a nurse or nurse manager in 25%, a therapist in 26% and a secretary or administrator in 1%.
Description of palliative care services
Most units who responded were in England (72%) with smaller proportions in Scotland (17%), Wales (9%) and Northern Ireland (2%). Nearly all services offered inpatient beds (86%), day care (89%), outpatients (84%) and most offered home visiting by doctor or specialist nurse (72%). The average number of inpatient beds was 13, and the average number of day care places per week was 50. On average there were three medical clinics per week, five nurse/physiotherapist-led clinics per week, five complementary therapy clinics per week and one acupuncture clinic per week.
Complementary therapies available
Complementary therapies were provided by 91% of units. Most was offered to day patients (93%) and inpatients (85%) but they were also available to outpatients (65%), patients at home (36%) and patients in care homes (15%). The commonest therapies available were aromatherapy (92%), reflexology (86%), Reiki (66%) and Indian head massage (61%).
Acupuncture service available
The number of respondents who answered that acupuncture was available in their unit was 76. This represented 59% of the 129 people who answered the question. Where acupuncture was provided this was available to inpatients (85%), day patients (84%) and outpatients (80%). A smaller proportion of services provided acupuncture to patients at home (26%) and in care homes (15%).
Most services (73%) provided acupuncture when patients attended for other services, only a minority had a dedicated acupuncture clinic (23%). The numbers of patients receiving acupuncture in a typical week was small; the majority of services (80%) treated up to six patients per week. A few services (17%) treated 10 or more patients per week; of these, 82% offered a regular acupuncture clinic.
In all, 27 (37%) respondents had carried out audits or evaluations of their acupuncture service.
The number of individual practitioners providing acupuncture in each unit varied between 1 and 10, with an average of 1.7 per unit. Most of these practitioners were physiotherapists and doctors; other practitioners were nurses, professional acupuncturists and therapists (figure 1). These practitioners had received training in acupuncture from the British Medical Acupuncture Society (BMAS), the Acupuncture Association of Chartered Physiotherapists (AACP), a Traditional Chinese Medicine Course or a University degree (figure 2).
The number of years of experience in acupuncture was given as 0–2 years in 9%, 2–5 years in 38%, 5–10 years in 26%, 10–20 years in 26% and more than 20 years in 2%. Most practitioners had received training in acupuncture through the BMAS (43%) or the AACP acupuncture course (32%). A smaller number had undertaken a Traditional Chinese Medicine (TCM) course in the UK (12%) or in China (1%); 7% had undertaken a degree course. Some commented that they had undertaken more than one type of course. Most practitioners (83%) were employed by their organisation to provide acupuncture as part of their role for example, as a doctor or physiotherapist, 4% were employed specifically to provide acupuncture and 13% were unpaid volunteers.
The type of acupuncture provided was described as Western medical acupuncture (82%), trigger point dry needling (35%), traditional Chinese acupuncture (32%) and type not known in 8%. Some services offered more than one type of acupuncture.
Reasons why acupuncture was not available
Where acupuncture was not available the commonest reason given was the lack of a suitable practitioner (74%) and 13% thought there was a lack of training available (figure 3). Less common reasons given were financial constraints (30%) and time constraints (21%). None of the respondents felt that acupuncture was not appropriate for patients in palliative care or that there was a risk of adverse events. A small number felt there was no demand from patients or that there was a lack of a suitable governance structure in their organisation. Only one respondent felt that there was a lack of evidence base to support the use of acupuncture.
The 53 respondents who indicated that they did not have an acupuncture service available were asked how much they agreed with the following statement: ‘If funding and a suitable practitioner were available, acupuncture would be a useful addition to our service’. All 53 respondents answered this question and 73% of these agreed or strongly agreed with the statement (see table 1). Reasons given for a positive answer were mostly that they had had good previous experience with acupuncture or that they generally felt that acupuncture could be useful without giving a specific reason. A few mentioned the evidence base for acupuncture or patient demand for acupuncture. Negative reasons given were lack of experience/training, poor efficacy and lack of demand from patients. Several respondents stated that they would like more information or discussion before being able to decide.
Awareness of evidence for the use of acupuncture in palliative care
All respondents were asked how much they agreed with the following statement: ‘The lack of evidence in support of acupuncture prevents greater use of acupuncture in our palliative care service’. Just over half (51%) of respondents disagreed or strongly disagreed with this statement. A minority (26%) agreed or strongly agreed (see table 2). A number of respondents commented that they felt there was plenty of evidence to support its use, though some felt more was needed. Several respondents referred to anecdotal evidence and clinical observation that supported their own use of acupuncture. Several respondents made the point that other established treatments used in palliative care lack rigorous evidence and may be much less safe than acupuncture.
Respondents were aware of various types of evidence regarding the use of acupuncture in palliative care. This included UK National Institute for Health and Clinical Excellence (NICE) guidelines (37.9%), Cochrane reviews (33%), other systematic reviews (23%), randomised controlled trials (RCTs) (47%), case series/cohort studies (47%), basic science for example, neurophysiological studies (31%). A total of 24% were not aware of any evidence.
The most frequent comments restated that acupuncture was not available in their service either due to lack of a trained practitioner or lack of resources (financial/time/space). A number of respondents quoted good success with acupuncture in their practice. Some felt that it was a service they would like to develop or find more about, some were in the process of developing a service. One respondent felt strongly that acupuncture should be thought of as a clinical treatment rather than a complementary therapy.
Despite the high response rate to this survey it remains difficult to estimate the availability of acupuncture in hospices and palliative care services in the UK. Acupuncture was available in 76 (59%) of those who answered the question ‘Is acupuncture available in your hospice/special palliative care unit?’ However this is only 29% of the 263 units who were sent emails. It may be that clinicians with an interest in acupuncture would be more likely to answer the survey, which may introduce a potential bias in interpretation of the results. However there were also 53 respondents who did not have an acupuncture service and who were happy to give reasons why this was.
Acupuncture was available to patients in palliative care in a variety of care settings. In most cases acupuncture was used in the context of an existing palliative care service rather than a dedicated acupuncture service. In general small numbers of patients were treated but the services that treated the most patients used dedicated acupuncture clinics. It may be that this represents a more cost-efficient and time-efficient use of resources, which enables more patients to benefit.
The practitioner carrying out acupuncture in most cases was a registered healthcare professional such as a physiotherapist, doctor or nurse. Most had received a Western-style training in acupuncture and used a Western medical acupuncture54 or trigger point needling approach.
The commonest reason for acupuncture not being available was lack of a suitable practitioner. Most respondents agreed that acupuncture would be a useful addition to the service if funding and a suitable practitioner were available. This highlights the need for training in acupuncture to be made available to healthcare professionals. Some respondents were not aware that training in acupuncture was available. Time and financial constraints were also prominent reasons given for not providing acupuncture however an argument can be made for allocation of resources to the benefit of patients based on a convincing evidence base.
A significant minority of respondents felt that there was a lack of evidence, which prevented the use of acupuncture within palliative care. However, the majority did not agree with this and referred to published and anecdotal evidence that supported its use. Many centres had audited their own practice, which is a useful component of the clinical governance and development of a service. The level of awareness of specific types of evidence was low but most respondents were aware that some evidence existed.
Two literature reviews summarise the evidence for the use of acupuncture for a range of symptoms in palliative care.1 ,2 One of these found 27 RCTs reporting statistically significant results favouring acupuncture or related therapy.2
One RCT showed a significant reduction in pain scores in patients with cancer treated with auriculotherapy.8 There are also a number of cohort studies, case series and audits illustrating the beneficial use of acupuncture for pain in patients with cancer and patients in palliative care.9–19
Two Cochrane reviews and one other systematic review report positive conclusions regarding the use of acupuncture for nausea and vomiting associated with chemotherapy, pregnancy, or surgery.20–22 In addition there are two positive RCTs showing significant benefit from acupuncture for patients with nausea and vomiting due to chemotherapy23 ,24 and two cohort studies reporting benefit from acupuncture in patients in palliative care with nausea and vomiting.25 ,26 The studies used a variety of types of stimulation of the point PC6 with manual acupuncture, electroacupuncture and acupressure.
Two RCTs show significant improvement in objective and subjective measures of breathlessness in patients with end-stage chronic obstructive pulmonary disease following acupuncture.28 ,29 Two RCTs and a number of cohort studies support the use of acupuncture for radiation-induced xerostomia in patients with head and neck tumours.31–37
Three RCTs show significant improvement in hot flushes due to tamoxifen following acupuncture.38–40 There are also several cohort studies including two where acupuncture was used for the alleviation of flushes in me treated with androgen ablation therapy.41–44
One RCT and one cohort study show an improvement in cancer-related fatigue after chemotherapy with acupuncture and acupressure.45 ,46 Two positive RCTs show a significant improvement in irritative bladder symptoms with acupuncture although the patients treated were not patients in palliative care.47 ,48
There is growing interest in the use of acupuncture for chemotherapy induced peripheral neuropathy. This is a common and distressing problem that can be intractable and difficult to treat conventionally. One cohort study showed improvement in symptoms in 82% and a controlled trial showed improved nerve conduction studies following acupuncture.49 ,50
Acupuncture is available in 30% to 60% of hospices and specialist palliative care services in the UK. In most cases Western medical acupuncture is provided either within an existing palliative care service or in a dedicated acupuncture clinic. Acupuncture is mostly provided by regulated healthcare professionals.
Hospital palliative care and oncology services were not included in this study but may be suitable for a future study with some modification of the questionnaire. The same methodology could also be applied to other settings such as pain clinics, women's health, physiotherapy services and General Practice.
It may help to address some of the issues raised by this study to increase the availability of training in acupuncture for healthcare professionals working in palliative care. There is also a need to raise awareness of the potential benefits to patients and the evidence base supporting the use of acupuncture in palliative care. It would be beneficial to include such education in the undergraduate curriculums of medical, physiotherapy and nursing students and to encourage students with a particular interest to undergo training in acupuncture.
The BMAS runs training courses in acupuncture for regulated health professionals and has a regular Palliative Care Supplementary Day, in which the application of acupuncture to symptom management in patients in palliative care is discussed.55 It is recognised that acupuncture is an underused treatment modality in palliative care2 and it may be possible to address this deficiency by the provision of training.
Improved availability of acupuncture would be of benefit to patients in palliative care in providing an additional, non-pharmacological option for the management of pain and other symptoms.
141 out of 263 UK hospices responded to a survey about their use of acupuncture.
Acupuncture was unavailable in 41%, but most would provide it if a practitioner were available.
Most thought there was adequate evidence to support the use of acupuncture.
Review history and Supplementary material
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
Contributors GL fulfils the BMJ group criteria of authorship as stated on http://www.bmj.com/about-bmj/resources-authors/article-submission/authorship-contributorship.
Funding A research grant of £200 was kindly provided by BMAS to cover the cost of Survey-Monkey registration. Secretarial and administration support was provided by the Hospice of the Good Shepherd, Chester.
Competing interests GL is a member and Trustee of BMAS.
Ethics approval The chair of the local Ethics Committee was approached and confirmed that submission for ethics approval was not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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