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Massage Today
November, 2010, Vol. 10, Issue 11

Hospice Massage: Ethical Considerations

By Ann Catlin, LMT, NCTMB, OTR

As a massage therapist, like other health care professionals, you are expected to adopt and uphold standards of practice that serve as "guiding principles" in scope of practice, client relationships, clinical decisions, and business practices.

If you choose to work in hospice you enter a complex field of service that exposes you to ethical issues and dilemmas unique to end-of-life care. Of course, the standards of practice for massage therapy apply, but you will also need to be familiar with the ethical principles and guidelines found in hospice care to have a foundation from which to act. Some principles act as guidelines but many are highly individual, steeped in your own personal moral compass, providing a touchstone in situations where you search for the "right thing to do".

As massage therapy takes its rightful place in hospice care it is possible, if not likely, that you will be exposed to some ethical dilemmas of modern-day health care. Medical treatments and technology have changed the way we die in our culture. For many patients, their families as well as the professional caregiver, the experience becomes laden with conflict and moral choice.

aged man - Copyright – Stock Photo / Register Mark Dr. Richard Fife,3 an ethicist, states: "In hospice care, staff members are constantly faced with the possibilities and realities of ethical dilemmas." He reports findings from a two-year study of ethical dilemmas faced by hospice staff. Some of the most common issues included:

  • Working with patients who have been admitted without a do-not-resuscitate (DNR) order.
  • Withdrawal or withholding of nutrition/hydration.
  • Patient autonomy versus patient safety and physical needs.
  • Conflicts with the patient's family or significant others.
  • Conflict over whether to follow a patient's wish to be discharged from a hospice unit when the staff member feels that the primary caregiver is incompetent to take care of the patient.
  • Pain medication and respiratory distress/consciousness. The question here being whether the pain is so great that it is necessary to adversely affect consciousness and cause some respiratory distress by the higher use of medications to suppress the pain. Is it better to control the pain or for the patient to be more alert?
  • Having to go into a neighborhood recognized as dangerous in order to provide home care for a patient.

Granted, as a massage therapist, you may not directly be involved in resolving these issues. But it's possible that you may be exposed to them. By anticipating these issues you will be more prepared and resilient when they do come up.

I will compare one area of standards of practice--the roles and boundaries as put forth by the National Certification Board for Therapeutic Massage & Bodywork6 and related ethical principle from the National Hospice and Palliative Care Organization (NHPCO)2 and how they impact day-to-day activities of providing massage services in hospice care.

Roles, Boundaries & Principle

Roles and boundaries: Adhere to ethical boundaries and perform the professional roles designed to protect both the client and the practitioner, and safeguard the therapeutic value of the relationship.

Related principle: Provide patients and their families with the highest possible level of quality end-of-life care and services, while maintaining professional boundaries that respect their rights and privacy.

Considerations for the massage therapist:

  1. Respect patient privacy and personal boundaries and do not enter into the patient's family life and affairs anyfurther than is required to meet the goals of the care plan. Becoming overly involved in family dynamics or trying to "help" in ways outside of your role actually weakens your ability to serve because you place yourself within the family dynamic.

  2. Respect cultural, ethnic, and religious beliefs of the patient and family and do not impose your own beliefs or values. We live in a multi-cultural society with diverse beliefs about death and dying, rituals, and approaches to caregiving. Remain open and sensitive to individual differences and see it as an opportunity to see things from a broader perspective.

  3. Recognize your influential position with the patient/family and do not exploit the relationship for personal or other gain. In your private practice you may offer products or other complementary approaches, for example nutritional supplements, essential oils or guided imagery techniques. When you are working within a health care organization you must be clear about what your scope of service is and utilize proper channels to get approval to offer a modality that falls outside of that scope. For example, you feel your patient would really benefit from an aromatherapy treatment or herbal supplement for symptom relief. It is not appropriate for you to introduce it to the patient or family. You must ask the members of the interdisciplinary team to consider its use and, most likely, the attending physician would need to approve it. This certainly is not the time to peddle your wares or solicit the patient's family or friends to make appointments for massage.

  4. Recognize and limit the impact of transference and counter-transference between the patient/family and yourself. This is when your professional and personal lives collide. We are all affected by subtle influences of our personal history and our emotional responses to it. Katz states: "If we can distinguish what belongs to us, what belongs to the patient, and what these responses might indicate about our interactions, our patients benefit in that we come to more deeply 'know' them without acting out our own issues."

  5. Avoid dual or multidimensional relationships that could impair professional judgment or result in exploitation of the patient/family or co-workers. It is difficult to blend personal and professional roles. It is best to let another skilled practitioner take the professional role for people you are close to.

  6. Acknowledge and respect the client's freedom of choice and right to refuse any part of the therapeutic session. Of course, your services are permission-based. It's important to recognize that a patient's situation and tolerance of massage or even touch may fluctuate.

Case example: I know of a massage therapist, "Kim", who was working as an independent contractor for a local hospice organization. She was asked by the hospice nurse to see a woman with advanced Parkinson's disease. The massage therapist saw the patient for weekly sessions. I learned that Kim had, in addition, been hired by the family as a personal care attendant and was essentially "on-call" to run errands, drive the patient to doctor's appointments and stay with her in the home when the family needed to be away. Kim complained to me that the hospice had let her go because they saw her actions as inappropriate. She also complained that the family was calling on her more and more and hadn't paid her in some time. She stated that she couldn't bring herself to discontinue her service because the patient "needs me so much".

Reflection question: What is the ethical dilemma here? What would have been an appropriate course of action for Kim?

Anyone who chooses to serve those in hospice care recognizes that it is a privilege to do this profound work. Caring for the dying through the medium of touch can be an experience that forever alters your worldview of death and dying. You will be forced to examine your thoughts, feelings and behavior in this profoundly personal, yet professional work. By accepting the responsibility to explore the personal nature and impact of end-of-life care you will be more equipped to uphold the highest ethical standards of your professional role. 


  1. Huff M, Murphy M. End-of-Life Care: A Manual for Social Work Students and Practitioners, 2008. Alexandria, VA: National Hospice and Palliative Care Organization (NHPCO).
  2. National Hospice and Palliative Care Organization Ethics Committee. Ethical Principles: Guidelines for Hospice and Palliative Care Clinical and Organizational Conduct, 2006.
  3. Fife R. Ethical Dilemmas in Hospice Care, pp. 207-20.
  4. Jennings B. Ethics in hospice care: Challenges to hospice values in a changing health care environment, 1997. Binghamton, NY: Haworth Press.
  5. Katz R. When Professionals Weep: Emotional and Counter Transference Responses in End of Life Care, 2006. New York: Routledge.
  6. National Certification Board for Therapeutic Massage and Bodywork (2008) Standards of Practice.

Click here for previous articles by Ann Catlin, LMT, NCTMB, OTR.


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