Managing terminal restlessness, anxiety, and distress during the dying process with Yintang (EX-HN 3) point acupuncture or acupressure: a case series of 19 palliative care patients from a hospital in Germany

This is a case series report of 19 palliative care patients where 23 acupuncture sessions were performed which included Yintang (EX-HN 3) acupuncture or acupressure for the relief of terminal restlessness, anxiety or psychological distress present during the dying process. There was an observable relief from the restlessness, anxiety and distress both in sessions where only Yintang (EX-HN 3) point acupuncture or acupressure was performed (observed in 10 out of 11 sessions) as well as in sessions where Yintang (EX-HN 3) point acupuncture or acupressure was performed together with additional interventions, such as other points acupuncture, ear acupuncture or benzodiazepine treatment (observed in 10 out of 12 sessions). In total relief was observed in 20 out of 23 sessions (86.9%). A hypothesis that might worth further testing is whether Yintang (EX-HN 3) acupuncture or acupressure has an anxiolytic, tranquillising or sedative effect in dying patients. If confirmed this could be potentially useful in the fields of palliative care or disaster/triage medicine.


Introduction
Complementary and alternative medicine has been used in palliative medicine patients especially in cases where symptoms are inadequately controlled with conventional therapies. In many studies a short-term improvement of symptoms was shown [1]. Acupuncture is among the most researched complementary medicine therapies and its evidence base is quickly growing. As it is safe, acupuncture is increasingly recommended by many experts for the treatment of symptoms in oncology and palliative medicine [2]. Reaching a calm state can be achieved with the use of complementary medicine techniques including acupuncture [3]. On the other hand, the effect of acupuncture on psychological well-being of cancer patients has been reviewed only in two systematic reviews and no significant positive effect was identified [4]. There is a need for more research on the effects of acupuncture on the psychological state of palliative care patients.
One of the authors (AK) during her work in a major palliative care unit provided acupuncture treatment, for the management of anxiety, distress and other specific symptoms of terminally ill patients, complementary to standard palliative care. Quickly a pattern emerged where patients showed considerable relief from the anxiety and distress present during the dying process -often followed by falling asleep -after acupuncture or acupressure in Yintang (EX-HN 3) point. Additionally in many cases death occurred peacefully shortly thereafter, e.g within a few hours. A decision was made to collect and review all these cases. The aim was to document any findings which might help generate a new hypothesis for further testing. The objective of this case series was to identify the proportion of acupuncture or acupressure sessions during which improvement of terminal restlessness, anxiety and distress was observed, among the palliative medicine patients who were treated with acupuncture or acupressure in Yintang (EX-HN 3) point.

Methods
This is a case series report, a descriptive study based on the retrospective collection of anonymised data from patient files. From the patients admitted in the palliative medicine unit of the Nordwest hospital in Frankfurt am Main, Germany from July 2019 till June 2021, all 19 patients who received Yintang (EX-HN 3) point medical acupuncture or acupressure complementary to their standard medical treatment were included. In some of these patients, additional acupuncture points were used depending on their specific symptoms. Common medical acupuncture needles were used (B type with 0.20mm diameter and 15mm length) and each acupuncture session lasted approximately 20-30 minutes. In patients with bleeding diathesis or with an increased risk of bleeding, as judged by the doctor, acupressure was performed instead with a duration of approximately three minutes. All sessions were performed by the same medical doctor, an anaesthesiologist trained in medical acupuncture, who is one of the authors (AK). In all 19 patients Yintang (EX-HN 3) acupuncture or acupressure was performed for the treatment of terminal restlessness, anxiety or psychological distress present during the dying process. The outcomes were collected from the patient files, which in some cases included also patient feedback following the intervention, and direct observations captured by the doctor performing the session. In this case series improvement was defined as an observation of either the patient falling asleep during or shortly after the session, or of relief of patient´s anxiety and distress or of a temporary decrease of seizures (for the 3 cases where seizures were present). The acupuncture points that were used in the patients included in this case series are described in detail in Table 1 [5-8].

Results
Our sample of palliative care patients included 14 patients with advanced stage cancer, 3 patients with haematological malignancies (one chronic myelomonocytic leucemia/CML with myelodysplastic syndrome/MDS, and two cases of acute myeloid leucemia /AML), 1 patient with subarachnoid haemorrhage (SAH) and 1 patient with chronic kidney disease and hepatic cirrhosis. These 19 patients had received in total 23 acupuncture or acupressure sessions in which Yintang (EX-HN 3) point acupuncture or acupressure was included (  (Table 3).
In total in 20 out of the 23 acupuncture or acupressure sessions (86.9%) in which Yintang (EX-HN 3) point was included there was an observed improvement of the patient´s terminal restlessness, anxiety or psychological distress, meaning that the patient fell asleep or the anxiety and distress was relieved or the seizures temporarily decreased. For 3 out of the 23 sessions the data captured in file were not enough to confirm an observed improvement (patients 13, 9 and the second session of patient 2). Improvement was observed in 6 out of the 7 sessions (85.7%) where only Yintang (EX-HN 3) point acupuncture was performed and in 4 out of 4 sessions (100%) where only Yintang (EX-HN 3) point acupressure was performed. Concerning the sessions where Yintang (EX-HN 3) point acupuncture or acupressure was performed together with additional interventions (such as acupuncture in additional acupuncture points, ear acupuncture, or benzodiazepine treatment) there was an observed improvement in 10 out of 12 sessions (83.3%). If we consider exclusively the sessions where only acupuncture or acupressure at Yintang (EX-HN 3) point was done, there was an observable relief from the terminal restlessness, anxiety and distress during the dying process in 10 out of the 11 sessions (90.9%) performed (Table 4).

Discussion
Acupuncture has been used in cancer and palliative care patients for the management of symptoms related to the disease itself (pain, fatigue, dyspnoea, anxiety) or its treatment (nausea, vomiting) and can improve the severity of breathlessness in patients with cancer or COPD [9,10]. Anxiety is a condition often present in terminally ill patients and periods of fear and distress are observed as death approaches [11,12]. Yintang (EX-HN 3) point acupuncture or acupressure was shown before to decrease the anxiety levels preoperatively in patients waiting for neurosurgery or gastrointestinal tract surgery [13,14]. There is also a case report of successful management of restlessness and agitation in a three months old paediatric patient with acupuncture sessions which included -among others -Yintang (EX-HN 3) and Shen Men (ear) points. Subsequently sedative medications were discontinued [15]. Nevertheless to our knowledge this is the first report on the use of Yintang (EX-HN 3) point acupuncture or acupressure for the management of terminal restlessness, anxiety and distress in dying palliative care patients. In our sample of patients in 12 out of 23 sessions many different interventions were used together with acupuncture or acupressure in Yintang (EX-HN) point which makes evaluation of their outcomes more difficult. On the other hand, in 11 sessions only acupuncture or acupressure at Yintang (EX-HN 3) point was done and in 10 of them (90.9%) there was an observable relief from the anxiety and distress present during the dying process. As a result, the hypothesis whether Yintang (EX-HN 3) acupuncture or acupressure has an anxiolytic or sedative effect in dying patients might worth further testing. The location of Yintang (EX-HN 3) can be easily identified and can be used with minimal equipment and training, also by medical and paramedical staff not specialized in acupuncture. Such an intervention could be a cost effective one to further explore and consider in the field of palliative medicine, as well as in situations where access to palliative care services is restricted or non-existent (e.g. limited resources settings, remote geographical locations, disaster related triage situations).
Limitations: being a case series, there are many limitations in this study and no causal inferences can be made. There is no control group to compare the outcomes and the study is based on retrospective collection of data which can lead to bias due to insufficient records. Furthermore, only a small sample of patients is included in this series so it is prone to selection and measurement bias. On the other hand, a case series might have high external validity and relevance as the patients included are more diverse and more representative of the routine clinical practice [16].

Conclusion
In our series of palliative care patients, relief from terminal restlessness, anxiety and distress present during the dying process was observed in 20 out of 23 sessions (86.9%) where acupuncture or acupressure at Yintang (EX-HN 3) point was performed alone or with additional interventions. A hypothesis that might worth testing in further studies is whether Yintang (EX-HN 3) point acupuncture or acupressure has an anxiolytic, tranquillizing or sedative effect in dying patients. If confirmed this could be potentially useful in the fields of palliative care, disaster and triage medicine.

Yintang (EX-HN 3)
On the anterior midline between the eyebrows. Psychological/ mental restlessness Pericardium 6 (PC 6) Anterior aspect of forearm, three fingers proximally from the base of the palm between the two tendons.

Nausea, vomiting
Spleen 9 (SP 9) In the depression at the interior border of the medial epicondyle of the tibia.