Manual lymph drainage (MLD) is a useful intervention employed in hospice and palliative care. It is comprised of the four Vodder strokes (stationary circles, pump technique, scoop stroke, and rotary technique) and is an exceptionally gentle experience for patients, while simultaneously being a functional clinical modality. It has the potential to effect a powerful change in the lives of hospice patients coping with various disease-related swellings.
Beyond decreased fluid retention, MLD has secondary benefits that include decreased pain, improved ambulation efficiency and respiratory effort, renewed socialization, assistance in the healing of situational depression, the soothing of anxiety, elevated body image, cessation of infectious portals, and engaging of trust in medical personnel.
The disease processes impacted by MLD that are discussed here are only a sampling of the many that may be aided. A few that are not mentioned—but that I have encountered—include the extension of MLD into palliative management of lymphedema due to lymph node dissection, radiation scarring, tumor obstruction, and deep vein thrombosis. Patients who have experienced MLD in other settings often marvel at the transformation that occurs psychologically and spiritually as the hospice therapist accompanies them on their journey using the hand, mind, and heart as a healing bridge beyond the physical world. This illustrates one of the profound differences between MLD delivered in a nonhospice setting and MLD provided by a hospice therapist who is sensitive to the many multidimensional issues patients encounter as they journey through the stages of release.
For those therapists seeking to employ MLD in hospice care, a word of advice: Acknowledge that adaptation and modification of every aspect of treatment will be a requirement. Hospice MLD is more than mobilizing fluid. MLD should be performed as a loving intervention that serves to accompany patients through the transition from this life to the next. Here are three case studies that depict the value of MLD in hospice care.
Patient 1
A 90-year-old female was recently placed in a skilled nursing facility. She presented with a terminal diagnosis of protein calorie malnutrition. She had a nonhealing gangrenous wound to the left foot, secondary to an injury sustained three months prior to her facility placement. The wound consisted of four sites, two proximal to the third toe and two proximal to the lateral malleolus, each weeping bloody lymphatic fluid. Her left lower extremity was edematous (abnormally swollen with fluid). Her personal physician recommended amputation of the leg, but the hospice physician believed that doing so would hasten her death: Either her heart would not survive the surgery or the emotional outcome of amputation would result in anguish. Otherwise, the patient was fairly strong for her age with tremendous motivation and a good appetite.
The massage therapist received permission to engage the patient in manual therapy after making a request during a team meeting. Team members stated it was the patient’s “last hope.” The goal was to prevent systemic infection through complete wound healing by (1) increasing tissue nutrition through support of blood and lymph circulation; (2) decreasing lymphatic fluid stagnation, thereby decreasing tissue toxicity; (3) stimulating cell production for repair; (4) stimulating and supporting immune function; and (5) increasing the patient’s sense of well-being.
MLD and energy work were initiated, supported by exemplary nursing care. The hospice aide was trained in Swedish massage techniques to be applied in conjunction with MLD on alternating days. Foot soaks were also provided. The patient was encouraged to ambulate in her wheelchair and to be as active as possible. The process was complicated by the discovery of a deep vein thrombosis in her left thigh approximately five weeks into therapy. Permission was obtained to continue energy work during the acute period, and therapy was continued once the acute period had passed.
After receiving a total of 28 MLD and 35 energy sessions—plus numerous Swedish massage sessions and foot soaks—she experienced complete wound healing. She was discharged from hospice and returned home with visiting nurse oversight.
Patient 2
An 80-year-old female had breast cancer with lung and liver metastasis. Secondary diagnoses included diabetes and congestive heart failure. Accompanying medical concerns were: left mastectomy with removal of 17 nodes; lymphedema of the left arm and edema of the lower extremities; and, most significantly, ascites (abnormal buildup of fluid in the abdomen) requiring paracentesis every 15 days with 4–5 liters removed each visit. Her weight fluctuated from a baseline of 125 pounds to 140–150 pounds, as the ascites worsened.
She was placed in a residential hospice just prior to therapy intake. The referral was made by the hospice registered nurse, who wanted to administer MLD to the patient’s left arm due to her complaints of swelling, discomfort, and decreased mobility.
After the evaluation, a decision was made to recommend assistance with the ascites component instead, thus possibly lessening the need for paracentesis, especially since this seemed to be of greater value due to the accompanying problems affecting the patient’s well-being: orthopnea (shortness of breath that occurs when lying flat); organ compression and related discomfort; diaphragmatic compression and shortness of breath; lymphatic fistulas (abnormal connection between two organs, such as blood vessels, intestines, or other hollow organs) and cellulitis (bacterial skin infection) of the left leg; ambulatory difficulties; and poor self-image. The patient also found it necessary to sleep in an upright position. The goals were to ease respiratory effort and decrease orthopnea, mobilize fluid to prevent infections and decrease occurrence of cysts/fistulas, decrease systemic discomfort, improve ambulation through weight control, improve self-image, and decrease the need for paracentesis.
After the evaluation, a paracentesis was conducted. During that procedure, a total of four liters was evacuated. Her weight was 140 pounds. Daily MLD sessions were initiated upon her return from the hospital. The next scheduled paracentesis was delayed an additional 14 days, due to the effectiveness of MLD in slowing down the fluid accumulation. When the next paracentesis was performed, only three liters were removed. Her weight was 133 pounds. The patient survived another two and a half months after this final paracentesis. A routine MLD schedule eliminated her need for further procedures. Her weight remained under 130 pounds. Other benefits included decreased need for optimal diuretic therapy, decreased orthopnea (she was able to lie at 30 degrees without discomfort and was able to finally sleep in her bed), decreased dyspnea, improved ambulation, controlled fluid weight gain, and elimination of cellulitis infections. She also began attending social meal times.
Patient 3
A 97-year-old male lived in a skilled nursing facility. He presented with a terminal diagnosis of congestive heart failure. Secondary diagnoses included chronic renal failure, diabetes, early Alzheimer’s disease, early Parkinson’s disease, and severe kyphosis (excessive outward curve of the spine). Prior to his hospice admission, he had experienced recurrent cellulitis due to longstanding edema in his lower extremities. Both legs were hardened by a significant fibrosis rubra. Recommended by his physician, therapy for this condition included high doses of diuretics and ACE bandages, which were worn throughout the day.
The patient spent most of his time in a wheelchair, as he was unable to lie in bed comfortably, sleeping upright in a recliner at night. The main concern was to address the lymphatic fistulas that repeatedly led to cellulitis and to provide the least restrictive intervention possible since the patient intensely disliked living with ACE bandages binding his legs.
Observation prior to therapy revealed brutalized tissues damaged by constant ACE bandaging. This resulted in a tourniquet-like appearance with tissue creases caused by an improper pressure gradient. The goals were to mobilize lymphatic fluid in order to decrease interstitial fluid stasis, eliminate occurrences of cellulitis, promote well-being, restore normal tissue volume appearance as appropriate with disease progression, and increase functional mobility.
With physician and hospice team approval, the following interventions were initiated: (1) The nursing staff were trained in short-stretch bandaging techniques, to be applied four days a week with a break of 2–3 hours each day; (2) restorative nursing was implemented, providing him with walking and range of motion; (3) the aides were encouraged to lotion massage the patient; (4) MLD was provided on a varying schedule, from twice a day, five days a week to three days a week, depending on his condition and need; and (5) Swedish massage and other modalities were provided as treatment for the kyphotic curve. Therapeutic effects were noticeable within two weeks. The relationship continued for five months. Thereafter, because of improvement, he was discharged from hospice.
The benefits observed by staff, family, and patient were: (1) significant decrease in the occurrence of lymphatic fistulas/cysts; (2) resolution of cellulitis infections; (3) increased energy level; (4) increased immune function; (5) decreased postural deficit; and (6) increased mobility. His physicians noted increased health and appearance of his legs, less edematous volume, a heightened vibrancy in well-being, and improved functioning, stating “MLD is clearly beneficial.”
How MLD Helps
The principal reasons for employment of MLD in the hospice environment are to:
• Assist with negative self-image issues
• Decrease pain or discomfort, especially pain or discomfort related to distension, compression, or pressure—including sternal discomfort due to diaphragmatic compression (primarily from ascites)
• Enhance multidimensional comfort and psychosocial/emotional well-being
• Make ambulation, transfers, or positioning easier
• Provide ease of respiratory effort or dyspnea (from ascites or other weight increase)
• Provide infection control (weeping lymphatic fistulas or cellulitis resolution)
• Provide management of lymphedema
• Provide paracentesis support or eliminate the need for paracentesis
• Provide wound care
Compression Issues
Normally in the management of various swellings, compression therapy is provided to patients as standard practice. This typically occurs through the use of short-stretch bandages. These are eventually replaced by compression garments or other materials that are worn daily for life. In hospice, unless otherwise directed by the physician, desired by the patient, or deemed appropriate by the therapist, the practice of bandaging is discarded or significantly altered. For instance, Tubigrips, while not as effective as short-stretch bandages, are a compromise in many cases. This is a complex subject and worthy of discussion in a separate article. Here are a few considerations:
• Most hospice patients do not have the strength to manage the weight, bulk, and binding quality of compression. These not only impact their mobility and comfort, but also negatively influence their quality of life. It can often mean the difference between participating in a social outing with friends or staying in bed because of the effort involved. Or worse—especially with a confused patient—it can be the precipitating and contributing factor in falls. A practitioner should have a “least restrictive environment” mentality when deciding on the use of compression.
• The comorbidities encountered in most patients warrant adaptation. When presented with frail skin, altered sensation or paralysis, hypertension, frequent infections, cardiac edema, diabetes, peripheral vascular disease, congestive heart failure, or metastatic processes, the wisdom of applying bandaging is tenuous.
• Compression adds to the discomfort of dying and is always discontinued when a patient is nearing terminal decline.
• When a patient lives in a skilled nursing facility and reliance on staff can be a helpful benefit to the therapist, the maintenance and application of bandaging by staff is often a practice in futility. Often, bandaging is lost, soiled beyond ability to reuse, discarded onto the floor, or consistently imperfectly applied. Even with conscientious training and consistent oversight, problems inevitably arise, requiring the practitioner to either abandon bandaging or be responsible for the total effort of reapplication.
Therefore, it is wise to examine the case in detail. If the patient presents a significant need for compression, it is best to perform all sessions without reliance on facility staff or colleagues. Use compression primarily only for severe cases of lymphatic fistula formation (draining/weeping legs).
Intake Considerations
In standard hospice practice, MLD is not offered to every candidate referred by medical personnel for lymphedema or edema management. Every hospice patient poses complex multidimensional issues that often exacerbate or influence, in some manner, the task at hand—especially given the wide range of diseases and comorbidities that are encountered. For instance, engaging a patient in MLD who clearly has days or weeks to live may not be wise given the tactile invasiveness of the procedure. Patients experiencing psychological fluctuations may find touch too stimulating or escalation of their condition could arise due to misinterpretation. Even the living conditions surrounding a patient could warrant refusal to treat if the patient had been a victim of physical or sexual abuse psychologically active with previous or current counseling.
Prior to performing an intake, there are a few requirements that should be garnered from the medical record: The patient should have reasonable function of the kidneys, heart, and lungs; the patient should have the ability to tolerate the invasiveness of the procedure, with regard to frequency and duration of treatments; the patient should have the ability to assume variations in position (no hospice patient is ever requested to lie prone—the practitioner must adapt); the patient should have no communicable skin disorders; the patient should have the ability to engage in ambulation or limited movement through the day, even if only simple range of motion; and the patient should be reasonably outside the near-actively dying stage (best approximation).
Conclusion
Of the three case studies presented, it may seem remarkable that two of the people were discharged. Hospice is not normally thought of as an experience in which one finds stabilization, rehabilitation, or improvement, let alone survivorship. Occasionally, due to the focus on providing multidimensional care and the extension of a heightened level of attention, patients will blossom in one or several ways, thus impacting their quality of life in every realm (mental, social, emotional, physical, and spiritual).
As with all things, there are complexities involved that make this quite difficult for every patient. The typical end result is a journey in which growth and maturity results, pain is subsided, and an easeful transition from this life into the next is attained.
As attested to, hospice patients can benefit greatly from touch. All of the patients in these case reports eventually died of their primary diagnosis but, because of the power inherent in the technique and the focus on serving with a heart that encapsulated the totality of a person’s life experience—not just their physical dimension—the quality and quantity of their life was improved. What gifts were bestowed upon them during this period is often beyond our awareness. The therapist’s life journey, though, is enriched beyond words.