GUIDELINES FOR MASSAGE THERAPY IN THE HOSPICE INPATIENT ENVIRONMENT

January 2021 Update

Nearly eight months since we posted our original guidelines for massage therapists working in a world changed by COVID, we have all learned so much. Transmission has been found to be primarily via airborne droplets. PPE and testing are more available, and two vaccines have been approved and are slowly becoming available. But we’re far from out of the woods yet. The scope of the virus is still daunting, and the death toll is likely much higher even than reported. We’re taking care of a growing number of patients who, though they test negative for COVID at the time of death, are succumbing to problems caused by or worsened by previous COVID infection. We still have a long way to go in our battle against this disease.

The following guidelines have been updated by Final Touch Training in collaboration with hospice team members. Guidelines are based on practices which have now been used to conduct more than 700 massage sessions at a 24-bed hospice inpatient unit without a single case of patient-to-therapist or therapist-to-patient transmission. Of note, these same practices have also been implemented by a full-time massage therapist working with hospice patients in home environments, also without a single case of transmission. Based on the safety record of our practices, we have growing confidence that what we are doing is working. And we are happy to share our results with others.

The massage therapy program remains a well-established component of the comfort measures provided to our patients, considered as integral to the care plan as spiritual support, bathing, oral hygiene and clinical management of end-of-life symptoms. As such, massage therapy services have been universally supported by medical and administrative leadership at the IPU. Massage at the unit has in fact expanded this year, with the hiring of an additional part-time therapist. While the vaccine has been approved for us, we have not received it at the time of this writing.

Updated Modifications for Massage Therapy in the Hospice Inpatient Unit

• • The hospice inpatient unit continues to screen patients for COVID-19, and does not accept patients who test positive. We do have some home and facility patients who are COVID-positive at any given time, but such patients are not deemed appropriate for massage while known to be infectious.
  • Personnel, visitors and others entering the building are screened for symptoms and exposures, including a temperature check and use of hand sanitizer. Anyone with fever of 100 or above is denied entry to the hospice inpatient unit.
  • The hospice inpatient unit continues to allow up to two visitors per patient (up to four visitors when the patient is actively dying). Visitors must wear face masks in common areas and when staff are present in the patient room.
  • Due to the possibility of asymptomatic presentation, therapists and other personnel operate with an assumption that patients, visitors and they themselves may be positive for the virus.
  • Massage therapists and all personnel are provided with N-95 face masks which must be worn at all times during the work day. A clean N-95 is provided on a weekly basis.
  • Massage therapists and all personnel are provided with eye goggles which must be worn in the presence of patients or visitors.
  • Hands are washed thoroughly throughout the day per WHO Guidelines. Surfaces are wiped down by housekeeping personnel on a routine basis. Hand sanitizer is, of course, widely available on the unit.
  • Massage therapists continue to focus on what is carried into and out of the patient’s space, avoiding contamination of carried supplies and personal items.
  • We now have access to onsite testing. Personnel who test positive and those with known or high-risk exposures are required to follow standard self-quarantine practices. We have had very few personnel to test positive and 100% of those transmissions occurred in the community rather than at work.

 

Additional Guidelines

One of our therapists continues to wear aprons that tie at the neck and waist, which can be changed between patients to provide clean barrier protection. Aprons are removed at the end of each session, folding contaminated surfaces together and storing contaminated aprons in a separate bag from clean aprons. The aprons have pockets for carried supplies. Our second therapist wears scrubs, akin to the nursing staff.

One of our therapists wears gloves for every massage conducted at the inpatient unit. The other therapist wears gloves only when contact precautions are indicated.

Single-serve lotion containers are utilized to prevent contamination of a lotion bottle or holster that is carried between clients.  We have found that a 1-ounce “to go” container with a lid (available from restaurant supply companies) is adequate for one to two sessions of partial-body massage.  The container is discarded if all of the lotion is utilized in the session, or left behind with the patient or family if lotion is not completely utilized. To minimize risk of contamination, nothing else is carried into the patient’s room: no cell phones, no reading glasses, no paper, pens or other extraneous items.

The therapists use large reusable grocery-style bags with flat bottom and handles as portable containers for storage and transport of PPE and other supplies, one for clean PPE and the other for contaminated PPE (i.e. aprons).  Bags are washed at the end of the work day.  A spring-loaded clip is used to close and protect the contents of each bag during the work day.

If more than two visitors are present in a patient room, the therapist will return at a time when fewer visitors or no visitors are present (while visitors get lunch, for example).

Therapists continue to avoid unnecessary touching of environmental surfaces (light switches, tray tables and door handles).Therapists continue to avoid touching their faces, including eyes, nose, mouth and face mask, before, during and after the session.

Therapists conduct their charting and eat their lunches in an area of the IPU where social distancing can be practiced.

Self-Care for the Therapist

The measures described above continue to require time, energy, commitment, mental focus, and emotional stamina from the therapist, operating in a world shaken by this crisis.  Massage therapists in hospice care are accustomed to bearing witness to suffering, both the suffering of dying patients, and the suffering of the people who love them.  The COVID-19 pandemic complicates the dying process, adding additional stress and grief.  Massage therapists, like everyone else, are coping with their own losses, fears and life disruptions.

In recognition of these realities, therapists at the IPU are dedicated to the following self-care practices:

• • Working to adjust expectations regarding the number of massages they are able to provide in a day’s time, working more slowly and more methodically.
  • Not working excess hours.
  • Getting adequate rest and nutrition.
  • Maintaining safe practices at work and at home.
  • Mindful participation in enjoyable activities while not working.

 

Our administration has provided lunches and other gestures of appreciation for personnel involved in direct patient care.  Therapists and the other hospice team members have benefitted from this caring, supportive environment.  More than ever before, we are aware of our interdependent well-being.  Maintaining our own good health is paramount to protecting the health of those we care for and hold dear.