Introduction

Palliative care is an approach that aims to improve the quality of life of patients and their families in the face of life-threatening illnesses. This care is provided by a multidisciplinary team and involves the control of pain and other physical symptoms, as well as psychological, social, and spiritual support. The World Health Organization (WHO) defines the term palliative care as “Care provided by a multidisciplinary team, which aims to improve the quality of life of patients and their families in the face of life-threatening illnesses, through the prevention and relief of suffering, and the early identification, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems”.¹⁾ This multidisciplinary approach, focused on patients with advanced or terminal illness and their families, aims to promote quality of life and the relief of suffering, while respecting values and beliefs. ²

In Brazil, the publication of GM/MS Ordinance number 3,681, dated May 7, 2024, established the National Palliative Care Policy (NPCP) within the Unified Health System (UHS), by amending GM/MS Consolidation Ordinance number 2, dated September 28, 2017. This standard defines palliative care as “health actions and services for the relief of pain, suffering, and other clinical manifestations in people facing illnesses or other health conditions that threaten or limit the continuity of life”.³ The policy recommends the early initiation of this care, ensuring the fundamental principles of the NPCP, aimed at promoting dignity, comfort, and quality of life.

In this context, Integrative and Complementary Health Practices (ICPs) are therapeutic strategies that promote expanded and humanized care, based on a holistic approach to the health-disease process. Acupuncture and traditional Chinese medicine, including auriculotherapy, have been present since the creation of the National Policy on Integrative and Complementary Practices (NPICP), instituted by Ministerial Ordinances number 971, of May 3, 2006, and number 1,600, of July 17, 2006. These guidelines value the therapeutic bond and promote the integration of human beings with the environment and society, stimulating self-care and broadening the perception of the health-disease process.⁴

The use of ICPs has expanded worldwide, especially among cancer patients, whose coping with the disease often involves complex physical and emotional symptoms, such as pain, anxiety, depression, nausea, fatigue, insomnia, and anorexia. Many of these conditions can be managed non-pharmacologically, with fewer adverse effects and greater comfort, making these practices a promising therapeutic alternative to improve the quality of life of patients in palliative care. ^5,6

Currently, the SUS recognizes 29 integrative and complementary practices, such as acupuncture, auriculotherapy, homeopathy, aromatherapy, flower essences, and Reiki, among others.⁴ The possibility of these therapies being applied by professionals from different areas demonstrates their breadth and accessibility in the public health system. In the palliative care setting, it is urgent to understand which of these practices are being used effectively, considering both public policy guidelines and the therapeutic potential of these interventions in the face of the clinical complexity of patients with no prospect of recovery.

Scientific literature has demonstrated the beneficial effects of Integrative and Complementary Therapies in the relief of clinical manifestations in palliative care. The systematic review conducted by Lopes-Junior et al. (2020), for example, demonstrated positive results with the use of massage therapy, progressive relaxation, and guided imagery in the management of cancer pain.⁶

Other integrative reviews point to the frequent use of acupuncture, auriculotherapy, aromatherapy, reflexology, music therapy, and animal-assisted therapies in the management of symptoms such as anxiety, pain, and depression, promoting relaxation and strengthening the bonds between the patient, family, and the healthcare team.^5,7

Given this scenario, the need for a comprehensive integrative review is justified, which would systematize the available evidence and identify the most commonly used Integrative and Complementary Therapies in palliative cancer care, in addition to understanding their impact on patients’ quality of life.

The scarcity of comprehensive syntheses on the topic reinforces the importance of organizing the knowledge produced to date, helping to guide clinical practices and public policies aligned with a comprehensive, evidence-based care model.

Thus, this study aims to identify, through an integrative review of the scientific literature, publications related to complementary practices within palliative cancer care, focusing on the analysis of their positive impacts on the quality of life of these patients.

Methodology

This is an integrative review, using the six stages proposed by Mendes, Silveira, and Galvão:⁸ topic identification and selection of the research question; establishment of inclusion and exclusion criteria; the information to be extracted from the studies and their categorization, using a database with content categorized; study evaluation; interpretation and discussion of the results; and presentation of the integrative review and its outcomes.

To prepare the research question for this integrative review, the PICO strategy, an acronym for Population, Intervention, Comparison, and Outcome (Outcomes), was used. This strategy contributes to the definition and investigation, facilitating the selection of descriptors and keywords for database searches. In this context, Population (P) refers to cancer patients in palliative care; Intervention (I) corresponds to the application of complementary therapies in this group; Comparison (C) is not applicable and the outcome (O) relates to the benefits provided by these therapies, such as improved quality of life, symptom relief, and overall well-being. Thus, the guiding research question was: “What are the benefits of using complementary therapies in cancer patients in palliative care?”

The database search was conducted from July to September 2024, using the following databases: PubMed (National Library of Medicine of the United States), Scopus, and SciELO. The search strategies are presented in Table 1 . . . .

Table 1: Sources and search strategies 

For this integrative review, articles that simultaneously addressed the topics of Palliative Oncology Care and interventions with other ICPs, in addition to auriculotherapy, auricular acupuncture, and/or acupuncture, published in Portuguese, Spanish, or English, were included. Only studies with a population comprised of adults aged 18 years or older were considered. Not all studies specified gender distribution, and it was not possible to determine the predominance of female or male participants. Regarding methodological designs, studies with different approaches were included, without distinction or preference by type of method, as long as they were aligned with the research objective.

Studies that dealt exclusively with palliative care or only with auriculotherapy or acupuncture, with no association between these approaches, were excluded. Studies that used different interventions, such as electroacupuncture or other techniques that did not directly involve auriculotherapy or acupuncture in the context of palliative care, were also excluded.

Considering the established inclusion and exclusion criteria, it was decided not to apply specific checklists to assess the methodological quality and/or level of evidence of the selected studies. Likewise, it was decided not to establish a timeframe for the search, so as not to restrict or limit the scope of the findings. The main objective of these methodological decisions was to allow the inclusion of the largest possible number of relevant publications on the topic, favoring a broader and more in-depth analysis of Integrative and Complementary Practices (ICPs) in the context of palliative oncology care, and contributing to the construction of a consistent theoretical framework for the review.

In this review, 972 articles were obtained between abstracts and titles, in the following databases: SciELO (n = 131), Scopus (n = 706), PubMed (n = 135), resulting in 168 articles after eliminating ineligible and duplicate studies. Other 87 scientific articles were excluded after reading titles and abstracts, 46 because they were not related to the topic of the work, 41 because they did not answer the question of the work, leaving 81 complete articles for the evaluation of the inclusion criteria. Fifteen articles were selected to compose the sample because they met the previously established inclusion criteria. Some articles (54) were discarded because they could not be accessed in their entirety, leaving 27 articles. Of these 27, 23 articles were selected to compose the sample, of which 9 were excluded for not meeting the inclusion criteria, leaving 14 articles that met the previously established criteria. The publications and titles were organized in a PRISMA flowchart, and the contents were extracted using Microsoft Excel as follows: articles, reference, and journal, type of research (quantitative/qualitative), methodological design, and use of other techniques, study challenges, and main results.

The thematic analysis technique seeks both to confirm previously established statements and to reveal what lies behind the expressed content, going beyond the appearance of what is being communicated. Its objective is to segment the discourse through systematic procedures, aiding in the categorization of analyses to understand the meaning of the messages in a deeper way, going beyond a common and superficial reading. ⁶⁾f2

Figure 1: PRISMA Flowchart. 

Results

Most studies had a quantitative approach, and only one study was classified as mixed methods (quali-quanti). Among the methodological designs identified, systematic reviews (n = 8) stood out, followed by integrative reviews, cross-sectional studies, experience reports, semi-randomized studies, original articles, and short communications. This methodological diversity allowed for a more comprehensive and plural analysis of the available evidence, contributing to an understanding of the different approaches related to the use of auriculotherapy and other integrative and complementary practices in the context of palliative cancer care.

Acupuncture and auriculotherapy were the most frequently mentioned integrative practices in the analyzed studies, with promising results in the management of clinical manifestations such as cancer pain, anxiety, depression, fatigue, and chemotherapy-induced nausea and vomiting. ^10,11

Massage therapy and aromatherapy appeared in six studies, also with positive evidence, especially in the control of associated symptoms such as pain, anxiety, worry, and dyspnea. ^3,7,9,12-14

Other practices such as homeopathy, Reiki, music therapy, and reflexology were mentioned in four studies, noting benefits in relieving various complaints, such as pain, hypertension, anxiety, and vomiting. ^1,3,12,14

Finally, the use of essential oils, animal-assisted therapies, and integrative complementary medicine were mentioned in isolation in one study each. Even so, these interventions have demonstrated positive effects in the care of cancer patients in a palliative context. ^12,15,16)Table 2 . . shows the main results for each reference.

Table 2: Integrative and Complementary Practices (ICPs) and results 

Discussion

This integrative review identified the most frequently applied Integrative and Complementary Health Practices (ICPs) in the context of palliative oncology care, such as acupuncture, aromatherapy, Reiki, music therapy, and therapeutic massage. These practices have established themselves as relevant strategies for managing physical and emotional symptoms in patients with advanced, incurable illnesses. ^{5,7,12,24,25)}

The literature reviewed demonstrates that, when incorporated into conventional treatment, ICPs contribute to the control of physical symptoms such as pain, nausea, vomiting, fatigue, insomnia, dyspnea, and muscle discomfort, in addition to positively addressing anxiety and depression. ^{3,5-7,20,21,23,26} Acupuncture, for example, is recognized as an effective intervention for reducing physical and emotional symptoms and is highlighted for its potential to improve overall well-being and quality of life. ^5,23 Silva y Martins (2021) argue that the effects of acupuncture go beyond the physiological realm, also promoting emotional and spiritual benefits and strengthening treatment adherence through the involvement of family members and caregivers. ²⁶

Similarly, aromatherapy has been linked to reducing anxiety, stress, and depression, as well as improving the care environment, making it more welcoming for patients and their families. ^5,27 Reiki and music therapy, in turn, offer emotional support, promote relaxation, and alleviate psychological and physical symptoms, being valued for their ability to create a therapeutic space for listening and emotional expression. ^(7,23,24 Therapeutic massages contribute not only to physical relaxation, but also to mental comfort, the reduction of insomnia and the relief of muscle tension.

Although the focus is on symptom relief, several studies also point to the contributions of Integrative and Complementary Therapies in strengthening the therapeutic bond, in restoring autonomy in the face of terminal illness, and in valuing subjective dimensions of care, such as spirituality and emotional expressiveness. ^{(14, 27, 28)} This is particularly important in palliative care contexts, where maintaining dignity and meaning in life become a priority. ^22,28 These aspects, however, are little explored in the literature and almost absent from the discussion, highlighting a significant interpretative gap.

Integrative and Complementary Therapies allow care to go beyond the physical body, opening up space for the patients to be perceived as a whole, with their pain, desires, and values. The integrative review by Silva ITS et al. (2023) reinforces this view by pointing out that, even with the existence of public policies such as the NPICP, challenges still exist in the effective implementation of these practices, especially due to the lack of trained professionals and the institutional structure for their application. ¹³

Another point that deserves attention is the scarcity of studies that address the inclusion of ICPs in the context of home care. Palliative care provided at home offers a favorable scenario for the adoption of these practices, as it allows for greater proximity to the patients and their support network, favoring person-centered care. However, investments are needed in training and awareness-raising for multi-professional teams, as well as greater coordination between levels of care and public health policies. ^(22,28

The incorporation of ICPs in healthcare services therefore requires more than scientific evidence; they require changes in institutional culture, appreciation of the comprehensiveness of care, and recognition of patients’ autonomy, with active listening and humanized care focused on palliative care. In this sense, the findings of this review can support the creation of evidence-based care protocols, strengthen ongoing team education, and encourage practices that expand the therapeutic scope of palliative care.

Finally, the strategic importance of the coordination between two Brazilian public policies is highlighted: the National Policy of Integrative and Complementary Practices (NPICP) and the National Palliative Care Policy (NPCP). The interweaving of these guidelines can expand care possibilities and promote more ethical, compassionate, and person-centered care. The effective integration of these policies represents a necessary advance to ensure equity in access to qualified and respectful palliative care, especially in the context of terminal illness. ^29,30)

Conclusion

This integrative review shows that integrative and complementary practices (ICPs), such as massage therapy, acupuncture, auriculotherapy, Reiki, aromatherapy, and spirituality/religiosity, contribute significantly to promoting the quality of life of cancer patients in palliative care, acting to reduce physical and emotional symptoms such as pain, anxiety, depression, insomnia, nausea, vomiting, dyspnea, and anorexia. However, despite advances, it is observed that cancer fatigue, although frequently reported by patients and with a significant impact on functionality and well-being, remains underexplored in studies specifically evaluating the effectiveness of ICPs in its management. This gap highlights the need for specific research on the topic.

It is recommended that future studies adopt clinical designs with an emphasis on the assessment of cancer fatigue as a primary outcome, as well as on the subjective perception of patients and family members regarding the benefits of ICPs. Furthermore, the importance of developing and testing standardized protocols, promoting continuing professional training, and analyzing the impact of these practices on the comprehensiveness of care and the structure of health services is highlighted.

Such initiatives can strengthen the incorporation of ICPs as complementary strategies in palliative care and contribute to the development of public policies.