Restlessness

Patients in need of palliative care frequently complain of restlessness, which often leads to considerable distress. It places great demands on family members as well as on the therapeutic team. At issue here is not primarily symptom control but understanding this "language" that expresses itself through restlessness and seeks to be understood as well as treated. Restlessness can go hand in hand with anxiety, but we are also familiar with restlessness without the anxious experience. Restlessness can show itself in the flow of thoughts, express itself mentally as inner restlessness and lead to motor restlessness. The S3 guideline on palliative care (1) lists diagnostic and therapeutic aspects. Additional measures have proven themselves in practice and are summarised below.

The nature of calm

The understanding of restlessness is deepened by that of calm, silence. Calm is not only the absence of movement, silence is more than soundlessness. We are familiar with the fulfilled silence after listening to a piece of music or the fulfilled mood after inner meditative contemplation. It is not emptiness, but in the silence of the soul spiritual speaking and listening develops. The human being can connect with the spiritual world through calm: long sought ideas and resolving thoughts do not arise from the hustle and bustle of everyday life, but in moments of tranquillity and silence. When our own soul is silent, the spirit can speak and become audible to the human being. Conversely, the spirit of the human being speaks in moments of silence – "But in the mute silence what human beings speak will one day ripen into stars" (2) is how Rudolf Steiner described it. For these reasons, a prerequisite for the human being's path of development and cognition is "inner calm", the moments in which the essentials are separated from the non-essentials. For many patients requiring palliative care the question of what is essential is particularly important. It provides orientation, helps with the setting of values and opens up perspectives.

For the cultivation of calm, reflection on the following words can be helpful:

When calmness smoothes the surges of the soul
And patience in the spirit spreads
The word of gods
Infuses human beings' inwardness
And weaves the peace
Of eternities
Into all life
Belonging to the course of time. (3)

Causes of restlessness

Restlessness often has bodily causes. Thus somatic complaints lead to the patient's restlessness: sometimes it is the urge to urinate that needs to be remedied; likewise restlessness subsides after a successful enema. Shortness of breath, pain can equally express themselves in restlessness of the patient. If a toddler becomes restless, we look for the cause and can help. Under no circumstances do we start by dealing with symptoms in such a situation. The same applies to the patient in palliative care, in that we understand their restlessness as a language for something that they may not be able to communicate to us.

Much that is hidden in the biography can lead to restlessness. Some patients express stressful biographical experiences and memories of life in their restlessness. But the people around can also contribute to unrest and, conversely, also improve it. Much that is unresolved in human relationships, in the daily affairs of life leads to restlessness. This can even be "contagious", that is, it can spread to the people around and have a negative effect back on the patient.

Finally, there is a restlessness that relates to what is coming: our everyday life teaches us that any wait makes us restless after a certain time. The feeling of powerlessness in the face of what may come also leads to restlessness. Likewise, the uncertainty of what is to come creates restlessness. What is to come is often veiled. Restlessness arises at thresholds of consciousness that separate the known from the still unknown. Conversely, crossing the threshold requires inner calm. It belongs to the inner development of the human being and is one of its essential qualities: "Provide for yourself moments of inner tranquillity..." (4). In palliative care, we often observe borderline and threshold situations in which restlessness arises. This also includes darkness at night, which often leads to restlessness and is relieved when the morning and daylight arrive. Borderline and threshold situations do not primarily need control of their symptoms but understanding. The therapeutic measures then follow from this.

Guiding principles for therapy

In restlessness, the human I feels as if powerless and exposed. Promoting self-efficacy and competence of the I through spiritual help, interpersonal encounters, medicinal therapy as well as nursing and art therapy measures can help here.

Restlessness also improves when the soul is supported in its connection with the body through body-oriented treatments – such as foot rubs. Touch has a comprehensive therapeutic effect (5), which is particularly important in the palliative care of patients.

Restlessness leads to degenerative processes, weakens the life organisation and reduces the patient's vitality. Therapeutically, the life organisation of the restless patient must therefore be supported. By supporting the restorative powers that healthy sleep gives, for example, the patient can wake up stronger and better able to cope with restlessness.

Physically, restlessness is expressed by an urge to move, clammy hands, which can also be cool when tense, rapid breathing and heart rate, but also by a restless gaze. Taking care of physical causes of restlessness (e.g. urinary and faecal urgency) improves the restlessness. Thus all four human constitutional elements are affected to different degrees and require therapeutic consideration.

1 German Guidelines Programme in Oncology (German Cancer Society, German Cancer Aid, AWMF).  Palliative care for patients with incurable cancer. Short version 2.2, 2020. AWMF-Registernummer: 128/001OL. Available at https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Palliativmedizin/Version_2/GGPO_Palliative_Care_ShortVersion_2.2.pdf (22.08.2022).

2 Steiner R. Verse for Marie Steiner 25 December 1922. In: Wahrspruchworte. GA 40. 8th edition. Dornach: Rudolf Steiner Verlag; 1998, p. 107.

3 Steiner R. Verse for Helmuth von Moltke in response to a photograph 11 December 1915. In: Wahrspruchworte. GA 40. 8th edition. Dornach: Rudolf Steiner Verlag; 1998, p. 273.

4 Steiner R. Inner Tranquillity. In: Knowledge of the Higher Worlds. How is it achieved?, CW 10. Forest Row: Rudolf Steiner Press; 2011, p. 20.

5 Müller-Oerlinghausen B. Berührungsmedizin – ein komplementärer therapeutischer Ansatz unter besonderer Berücksichtigung der Depressionsbehandlung. Deutsche Medizinische Wochenschrift 2022;147(4):e32-e40. DOI: https://doi.org/10.1055/a-1687-2445. [Crossref]


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