TCM in Palliative and End of Life Care
An undeniable reality of working with cancer patients is that some patients will not survive their diagnosis. Chinese medicine and acupuncture has the ability to significantly improve the quality of life of terminal patients. Many barriers exist that block the use and acceptance of acupuncture as a tool for end of life care, including lack of awareness of the modality, funding and insurance coverage. In addition to the ability to treat side effects of medication and disease along with the pain associated with death, acupuncture helps reduce anxiety, stress and helps patients find peace in the dying process. As practitioners working with patients with potentially terminal diseases, it is critical to place focus on our ability to hold space for the healing process through death as it is for the healing process through the curing of disease.
An undeniable reality of working with cancer patients is that some patients will not survive their diagnosis. The role of Chinese medicine and acupuncture in palliative and end of life care is by no means as researched or studied as the care and treatment of disease and illnesses like cancer, but its role is powerful, impactful and has the ability to significantly improve the quality of life of terminal patients up until their transition. Many barriers exist that block the use and acceptance of acupuncture as a beneficial tool for end of life care, including lack of awareness of the modality, funding and insurance coverage. In addition to the ability to treat side effects of medication and disease along with the pain associated with death, acupuncture is an excellent modality to help patients reduce anxiety, stress and find peace in the dying process, to ultimately, die a good death. Inherent within acupuncture elemental theory is the process of the transition from birth to death and the cycle of life, associated emotional states and opportunity for healing. By deepening our understanding of the connection this medicine has with not only the physical body but the mind and spirit we have a unique opportunity to help our patients not only experience relief of pain and suffering, but also an impactful and meaningful transition. As practitioners of acupuncture and Chinese medicine working with patients with potentially terminal diseases, it is just as critical to place focus on our ability to hold space for the healing process through death as it is for the healing process through the curing of disease.
Barriers to End of Life Acupuncture Care
Acupuncture has become a common modality in the treatment of issues like orthopedic pain, and while the list of approved diagnoses for insurance coverage continues to grow, it is far behind the pace that is needed for acupuncture to truly serve the public in the way that is possible. In particular the role of acupuncture in palliative care settings like hospice is virtually non-existent in the United States, yet is an approved and utilized treatment in other countries like the UK. Acupuncture has been found to be effective in the hospice and palliative care setting for the treatment of dyspnea, nausea and vomiting, pain and xerostomia with statistically significant results favoring acupuncture for the treatment of these conditions.  Acupuncture is safe, has low rates of negative side effects and is a cost effective solution for management of common symptoms in palliative care. 
Another barrier to access in the United States may be the lack of awareness of the general public and medical providers. When surveyed, acupuncturists and medical providers alike agreed or somewhat agreed that acupuncture can help provide higher quality of life for hospice patients, however the specific conditions and knowledge of how acupuncture may help patients varied among respondents of this specific survey. This points to the lack of sufficient evidence to support the use of acupuncture specifically in a hospice type setting, although acupuncture is well documented in improved quality of life outcomes for many other conditions, the aspect of death care is grossly overlooked. [2, 3]
Quality of Life Improvements in Hospice Care
One of the most studied aspects of the use of acupuncture in end of life care is in symptom severity reduction. Symptoms commonly treated are pain, nausea, fatigue, depression, drowsiness, anxiety, appetite and dyspnea, however not limited to these symptoms listed. Acupuncture effectively reduced symptoms of pain, tiredness, nausea, depression, anxiety, and shortness of breath, and enhanced feelings of well-being.  More research is required to assess the long-term benefits and symptom reduction of acupuncture in a palliative care setting. 
While symptom reduction and improvement is important, this approach is still more analytical and western in practice, and the practice of being a provider of end of life care is much more nuanced, delicate and holistic than simply symptom reduction. A patient facing the end of their life has much more in their awareness than just the experience of physical pain or other symptoms, it is in this process that the acupuncturist has a very important opportunity to treat the person as a whole, truly seeing them in their experience and being witness to the transformation that is taking place. Acupuncturists who have worked in hospice care settings have described their practice with hospice patients as a “departure from how they treat patients in a typical practice context.”  The focus is not so much on the ‘treatment’ of disease or symptoms but on the support of the patient as a whole, providing comfort to the patient. These practitioners witness outcomes in psychological, social and spiritual experience regardless of the initial intent of the treatment. 
The Good Death
A relatively newly popularized concept is that of the ‘good death’ or ‘successfully dying.’ There isn’t an agreed upon definition of what specifically constitutes a good death, but the general intention of the concept is that one is free of unnecessary suffering and is able to transition on their own terms, i.e. in accordance with their wishes, which may also include completing unfinished business with others, last wishes, etc. Ultimately a good death is highly unique to the individual and cannot truly be generalized in any way.  Acupuncturists have an opportunity to help contribute to a patient’s successful death by ameliorating suffering and also in holding space, being fully present and without judgment; for the spiritual, mental and physical transition taking place.
One aspect that has improved outcomes in hospice settings with acupuncture is the communication around expectations or beliefs around the possibility of acupuncture to help patients in this end of life transition. The awareness generated for the patient around the holistic nature of health and well-being helped to contribute to a better death in patients who received the treatments.  It is in this bridge of the body, mind and spirit that the role of acupuncture can truly shine in the realm of the death transition.
Acupuncture and Elemental Transitions
Five Element Acupuncture theory is one of the more cohesive and holistic ways of viewing the death and dying process through the lens of Chinese medicine as compared to Traditional Chinese Medicine Zang Fu pattern diagnosis. The Five Element approach encompasses a wide array of the spiritual, emotional and physical experience of life and death, including much needed nuance and subtlety. While the typical modernized, point prescription focused model that is taught in most acupuncture schools and practiced in most allopathic clinical care settings can be beneficial to patients in the management of symptoms, it tends to overlook the complexities of the patient experience, especially spiritually and emotionally and may miss an opportunity for the support of spiritual and emotional health.
Transition of Time Among the Elements
By looking at the five elements we can have a deeper understanding of the transitions taking place and the mental, emotional and spiritual experience the patient may be having through the process of dying. These elements and transitions also apply to the ‘seasons’ of life, as we cycle through the element cycle numerous times throughout our lives.
When looking at cycles of time we first begin with the growth of the wood element connected to our early childhood and development. The carefree experience of adolescence relates to the fire element. The Earth element represents the periods of life where we experience a living death - the loss of a job, divorce, a shift within where we leave our old selves behind to step into who we are becoming. The metal element is connected with the process of dying, the autumn harvest where we have the opportunity to evaluate what is beneficial and leave behind what isn’t. The water element is the beginning and end of the elemental cycle, when there is death there is also rebirth, water represents the time of conception. 
The Elemental Emotions of Death
Each element has its associated emotions and we can look to these stages in order to help understand our patient’s experience and support them in the process. While there are plenty of indicated points for treatment and support of each emotional or spiritual state, it is most helpful to support the patient with presence, the cultivation of safety and compassion. When seeking specific points for treatment we can think about treating the associated element and looking to the more metaphorical point descriptions which we can intuit based on traditional descriptions and the names of the points. Understanding the emotional connections with the elements gives deep insight into the death and dying process and what is possible when healing of these elements takes place.
Water - Fear and Wisdom
The water element is associated with the emotion of fear and survival, in a healed and aligned system the water element’s virtue is wisdom. Fear of death and fear of the unknown are two aspects of the dying process that connect with the water element.  When water is not flowing smoothly it begins to stagnate and freeze, causing an excess or sticking of fear which can block healing and contribute to suffering. Wisdom as a virtue of the water element is an aspect of surrender, the surrender of our ego’s will to the will of the Tao. This is the healthy flow of water, where emotions like fear can arise, yet they aren’t grasped onto and allowed to continue to move and flow. This system is also connected with the collective unconscious, there is an inherent wisdom within the ebb and flow of the process of life and death. By healing the water element the patient can experience more free flow and less grasping with the experience of fear.
Wood - Anger and Forgiveness
The wood element’s associated emotion is anger, it may also be associated with the act of repressing one’s emotions, anger is the up and out motion of wood whereas the repression of emotions is the stunting of the growth of wood. In a healed and aligned system the virtues of wood are humanitarianism and passion. Anger is a common emotion in the process of death, and the act of repressing one’s emotions is also common as the act of experiencing such intense emotion can feel overwhelming. By working with the wood element we help to initiate the smooth flow of qi, the ‘free and easy wanderer,’ the release of anger and the movement of repressed emotions. Justice and injustice are also associated with the wood element, and it can be easy to see where the feeling of injustice can be experienced with the knowledge that one is dying. With the smoothly flowing wood qi in the system, forgiveness is now a possibility. Forgiveness is not the acknowledgement and dismissal that what happened was ok, but the release from the energy of the interaction. Forgiveness is an essential step in the death process, when reaching this place anger falls by the wayside and the essence of forgiveness is embodied, bringing a sense of peace and closure.
Metal - Grief and Release
The emotion of the metal element is grief, and it’s virtue is integrity. The function of the metal system is all about breathing in and then releasing, letting go and the actual process of death is a function of the metal element. A healed metal system allows the patient to fully release, to say goodbyes, to let go of any unfinished business and release the grief that is present through the process. Metal is associated with actual metal but also gemstones and crystals that lie beneath the earth, an aspect of the metal element is how we experience the richness of life, the luxuries and lavishness in our own unique way. In healing the metal element at the end of life it allows one to soften and be able to acknowledge the richness and worth of the life one has had.
Earth - Worry and Connection
Sympathy, worry and shame are the emotions connected to the Earth element and in a healed system the virtue is empathy. This is the element that helps one to feel at home, connected to others and feel seen and heard. Earth is the universal mother energy, and the experience of feeling alone or disconnected from others during death would be a sign of imbalance within the earth element. As the earth element heals one is able to experience gratitude for all that they have received, feel grounded and connected, to others and to the process of life itself. Healing the earth element at the time of death allows for peace and the sense of completion.
Fire - Joy and the Journey Home
Finally, the element of fire, our joy and the seat of the Shen, our spirit that connects us to the all that is, God, source, the Tao, the universal consciousness. The virtue of the fire element is compassion and connection, it is the experience of having an open heart and an openness to all that is available. The Shen is one aspect of the spirit that continues on beyond the death of the physical body and when one has a strong connection to it, this can help to carry us over the transition of death with a soft and joyful release. This is the experience of ‘going home’ that is often spoken of, the open heartedness and peace that one already knows and remembers where they are moving on to next. Generally, when the patient has worked through the emotional states of the previous elements, the connection with the Shen is simple and easy as the creation of a calm and emotionally pleasant home for the Shen has been created. Vulnerability is another aspect of fire emotions, and this is present during this time of transition where one can open to allowing themself to be truly seen by family and friends during this important time. The experience of the soft joy of the good death is a completion of the element cycle and one of the most complete and full expressions of the element of fire, flaming softly into the ethers.
Hospice and palliative end of life care is certainly a unique and highly specialized field of work, and acupuncturists should not shy away from the opportunity to support patients through this transition if they feel called to do so. While the modern medical system of the United States falls short on the inclusion of acupuncture in the care of terminal and end of life patients it should not discourage acupuncturists from moving forward with outreach and collaboration with other deathcare providers. Diving into the nuanced, holistic and multi-faceted elemental theories in the practice of acupuncture and Chinese medicine will give acupuncturists a deeper understanding of the mind, body, spirit connection and a heightened awareness as to how to approach their practice in deathcare should they be called into this work. Death, like birth is a beautiful and important experience yet is often shied away from due to fear, the unknown or hesitation. Opening as a practitioner to all opportunities to support patients, even when those areas of life trigger fears can be as powerful of a healing and transformational experience for the practitioner as it is the patient. Healing does not require a disease or symptom to be cured, diminished or removed; it is simply the transformation of energy and consciousness from one state to another no matter how big or small. In understanding this fundamental principle of the art of healing, support for the terminally ill can be implemented into practice and create an incredibly supportive environment for patients.
- Standish LJ, Kozak L, Congdon S. Acupuncture is underutilized in hospice and palliative medicine. Am J Hosp Palliat Care. 2008 Aug-Sep;25(4):298-308. doi: 10.1177/1049909108315916. Epub 2008 Jun 6. PMID: 18539767.
- Luh C, Eckstrom E. Perceptions That Influence Acupuncture Use in Hospice Settings: Results of a State-Wide Survey Study. J Altern Complement Med. 2021 Sep;27(9):760-770. doi: 10.1089/acm.2021.0028. Epub 2021 Jun 15. PMID: 34129378.
- Leng G. Use of acupuncture in hospices and palliative care services in the UK. Acupunct Med. 2013 Mar;31(1):16-22. doi: 10.1136/acupmed-2012-010230. Epub 2012 Oct 26. PMID: 23103882.
- Romeo MJ, Parton B, Russo RA, Hays LS, Conboy L. Acupuncture to Treat the Symptoms of Patients in a Palliative Care Setting. Explore (NY). 2015 Sep-Oct;11(5):357-62. doi: 10.1016/j.explore.2015.06.001. Epub 2015 Jul 2. PMID: 26254221.
- Kaufman K, Salkeld EJ. Home hospice acupuncture: a preliminary report of treatment delivery and outcomes. Perm J. 2008 Winter;12(1):23-6. doi: 10.7812/tpp/07-124. PMID: 21369508; PMCID: PMC3042334.
- Meier EA, Gallegos JV, Thomas LP, Depp CA, Irwin SA, Jeste DV. Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue. Am J Geriatr Psychiatry. 2016;24(4):261-271. doi:10.1016/j.jagp.2016.01.135
- McPhail P, Sandhu H, Dale J, Stewart-Brown S. Acupuncture in hospice settings: A qualitative exploration of patients' experiences. Eur J Cancer Care (Engl). 2018 Mar;27(2):e12802. doi: 10.1111/ecc.12802. Epub 2018 Jan 11. PMID: 29323766.
- Bittel, E. Understanding the Stages of Dying - From a Five Element Perspective. Spirit In Transition Website. https://spiritsintransition.org/wp-content/uploads/2017/11/Stages_of_Dying_2nd_vet_hospice_sympos.pdf (Accessed February 19, 2022)
- Phuky, R MD. Five Element Acupuncture For Terminal Patients: A Powerful Intervention For Dying Well. Five Element Training Website http://www.fiveelementtraining.com/article_3.html (Accessed February 19, 2022)