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The potential role of aromatherapy in palliative care

The potential role of aromatherapy in palliative care

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An essay for the 2011 Undergraduate Awards Competition by Ailish Beakey. Originally submitted for Natural Remedies, Complementary Medicine, Ectoparasiticides at Trinity College, Dublin, with lecturer Dr. Helen Sheridan in the category of Life Sciences
An essay for the 2011 Undergraduate Awards Competition by Ailish Beakey. Originally submitted for Natural Remedies, Complementary Medicine, Ectoparasiticides at Trinity College, Dublin, with lecturer Dr. Helen Sheridan in the category of Life Sciences

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Published by: Undergraduate Awards on Aug 29, 2012
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10/27/2013

 
The potential role of aromatherapy in palliative care
Introduction:
 The application of aromatherapy as a therapeutic aid in the treatment of palliative care patients has come under increased investigation
1, 2
in recent timesin lieu of the many positive outcomes attributed to the therapy in areas such asmental health
3
and sleep disorders
4, 5
. These positive outcomes have been far-ranging in terms of disease spectrum/specificity and indeed, in terms of the levelof success achieved. Nonetheless, the prudent association between observedpsychological and emotive disturbances in palliative care patients and thecurrent evidence base
 
for aromatherapy in alleviating the effects of disturbedmental health warrant scope for further investigation in this regard.
Discussion:
One of the more notable attributes currently associated with aromatherapy is thelack of concordance among practitioners regarding the quality, safety andcrucially, the efficacy of its application. This disaccord is the primary limitingfactor to its application in palliative care settings at present
6
.Aromatherapy can be defined as the use of essential oils to achieve therapeuticeffect. However, the interpretation of ‘therapeutic effect’ has been ambiguous todate. While history and much of the literature
3, 7
have concluded thataromatherapy has measurable psychological therapeutic benefit, there iscurrently little evidence to support a physiological based mechanism of action.However, it must be considered that this lack of evidence may stem singularlyfrom a general lack of high-quality, reproducible data in this area, oralternatively, may represent a perceived lack of viability for a physiologicallymediated mechanism of action. The latter seems more likely as evidenced bycurrent research focuses on psychological benefit and for numerous practicalreasons including the
route
through which the aromatherapy is delivered. There are only two well documented routes considered appropriate for the safeadministration of aromatherapy-inhaled and topical (typically through massage).Although it may be argued that essential oil molecules are of a size whichpermits their permeation through the skin surface and supporting tissue layersthrough to the bloodstream for carriage to a distant target, a simple extension of this logic would predict similar systemic implications for the individual deliveringthe aromatherapy massage which are simply not observed in practice, i.e. themasseuse does not experience the same (if any) effects as the patient indicatinga significant psychological basis for aromatherapy. Furthermore, manyaromatherapy studies
1, 4, 8, 9
in the palliative care setting have explored theeffects of aromatherapy massage rather than just aromatherapy alone. Thiscreates dispute about the actual source of the therapeutic benefit particularlywhere this is no control group included in the study design to affect a distinction.Wilkinson et al (1999)
8
suggest that an anxiolytic benefit is observed in palliativecare patients following massage alone and that addition of an aromatherapyagent like Roman chamomile oil may have a supplementary role. A later study by
 
Soden et al (2004)
4
concluded that massage with lavender did not provide anymental health benefit surplus to massage alone. These results further disputethe notion that topical application of aromatherapy results in a system effect(s).Nonetheless there is reasonable argument for a local effect when appliedtopically, e.g. lavender for the treatment of dry skin conditions. However, this isdependent upon the physical properties of the drug rather than anypharmacological action. The alternative route for therapy is via inhalation. It is widely considered thatthere exists a link between olfactory stimulation and emotive response. With thisin mind, it has been investigated
10
whether or not aromatherapy could be used topsychologically condition a patient to achieve a desired behaviour or emotiveresponse. This would potentially have a very useful application in the palliativecare setting where negative emotion can be difficult to overcome as a result of poor prognosis prospects. However, while it is not yet clear if this could beadapted, there also exists mixed evidence as to the anxiolytic role for inhaledaromatherapy when used in palliative care
11, 12
with individuals seemingly at riskof being influenced by the notion of the therapy rather than the therapy itself 
13
.Nonetheless, it may be postulated that inhaled essential oil molecules bind tocilia in the nose and stimulate sensory receptors which then stimulate anemotive and/ or psychological response. Although it is theoretically possible thatphysiological mechanisms may be triggered as a result of the psychologicalstimulation, the observed effects of current exposure to aromatherapy
12
suggestthat it is unlikely to occur to the extent that it results in demonstrablephysiological improvement. This reinforces the argument for a complementaryand supplementary role only for aromatherapy in the treatment of any patientregardless of prognosis.Some studies
8, 12
and reviews
14
have indicated evidence to support physicalsymptom improvement following aromatherapy treatment among palliative carepatients but the degree of benefit has been unclear due to the fact it is often notmeasurable and often self-reported, e.g. pain reduction, whereas the evidence insupport of psychological improvement has been much better preserved
4, 11
. There is scope for the argument therefore that it is more likely that physiologicalimprovements in palliative care patients are observed secondary topsychological improvement whereby an improvement in the patient’s mentalityhas better equipped them in approaching and tackling their condition. This issupported by considering the role of stress in precipitating or exacerbatingphysiological dysfunction and/ or disease states in general. Where the stresstriggers have been controlled or avoided, more favourable outcomes for thepatient have resulted
15
. However, when considered in the context oaromatherapy, the mild anxiolytic actions observed for oils like lavender orcedarwood cannot be considered to equate to a cure or even symptom specificrelief. Rather, aromatherapy can be considered to offer an alleviation of emotiveburden which may prevent or limit physiological manifestations of the stressor. The evidence described therefore suggests a particular niche application foraromatherapy among palliative care patients where there exists psychological
 
and emotive disturbance often secondary to a disease state. The desiredoutcome from aromatherapy treatment with this patient group is centred on theimprovement of the patient’s quality of life through seeking to reduce anxiety,stress and other negative affections. Research
16
has indicated that the majorityof palliative care patients are trying to, or have already, established acceptanceof their prognosis and so present as ideal candidates for aromatherapyapplication with a view to alleviation of emotional burden. According to the WHOAtlas for Traditional, Complementary and Alternative Medicine (2005)
14
, patientsin the U.K. and Northern Ireland ‘’generally appeared to have their expectationsmet’’ following CAM therapy. Most patients also complained of a lack of CAMsessions and that those which were offered were too brief in duration. This iscertainly something supported elsewhere in the literature whereby the anxiolyticeffects of aromatherapy are described as being effective only in the short-termthereby suggesting a need for frequent application if prolonged benefit is to beachieved. Soden et al (2004)
4
and Wilkinson et al (2007)
1
investigated the long-term benefits of aromatherapy treatment for palliative care cancer patients andconcluded that no psychological clinical benefit was observed beyond amaximum of two weeks following a single application of aromatherapy. It wasalso observed
1, 4, 8
that aromatherapy is most useful for the treatment of thosemental health conditions which have an anxiety-related component, e.g. certainsleep disorders, stress and certain mild forms of anxiety itself. To this end,aromatherapy was introduced
5
for use on patients with problems of stress in theCoronary Care Unit of Tullamore General Hospital in light of the positive effects ithad demonstrated on sleep patterns of these patients with the added advantageof an associated reduction in the need for night-time sedation.More recent articles have suggested that jasmine oil may be an effectivesubstitute for Valium® suggesting a more potent anxiolytic effect foraromatherapy agents than previously thought. A study conducted by Ruhr-Universitaet Bochum (2010)
17
found that jasmine had GABA receptor modulatoryactivity and therefore, a potential pharmacologically derived mechanism of action for the treatment of more severe anxiolytic conditions. However, nofurther studies have yet been elucidated to support this theory. Indeed,controlled studies are difficult to achieve in any case. The degree of subjectivityinvolved in self-assessment of psychological status/ improvement and thedifficulty in conducting a double blind trial using a recognisable vapour likelavender make the introduction of bias very easy. The vulnerable nature of palliative care patients also merits consideration in thatsome patients will expect cures from aromatherapy exposure. In these instances,responsible ethical practice should be applied and it should be considered thatsuch patients are unlikely to benefit from the treatment.
Conclusion:
 The evidence base for the use of aromatherapy in palliative care is expandingboth in terms of quality and quantity. The suspected intricate nature of amechanism of action not yet amicably defined undoubtedly renders it difficult to

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