Nursing and external applications for restlessness in palliative patients

We distinguish between restlessness in the thinking, restlessness in the feeling and motor restlessness. It is mostly the motor restlessness of the critically ill patient that is noticed by those around them, while the erratic spinning of thoughts, the brooding without any advance in understanding, or an emotional restlessness are more difficult to notice and are expressed more indirectly, e.g. in sleeplessness or moodiness. It is precisely the awareness of being in the last phase of life, and thus in the greatest threshold situation, that can lead to an increase in restlessness in those affected when falling asleep or in darkness. In order for carers to notice the hidden restlessness triggered by thoughts and feelings, they need to be able to empathise. Motor restlessness may be accompanied by a tendency to fall, e.g. out of bed or from a chair. It can also lead to the critically ill patient showing a tendency to run away from where they are resident. Sometimes it is less a running away than a "running towards" as an expression of the restless longing to finally get "home".

Causes of restlessness

Especially in the case of motor restlessness, it is important to consider whether physical problems are present, such as shortness of breath, pain, urinary or faecal urgency or itching. In these situations, the physical causes of the restlessness should be specifically treated. In addition, restlessness often occurs in threshold situations: for example, falling asleep is often associated with restlessness for many critically ill patients, which frequently leads to insomnia and states of anxiety and even panic. This is where a great need for talking arises, especially at night. And it leads to the question that is usually difficult to answer: where does the restlessness come from? The critically ill patient is often unable to give us an answer to this question. As carers, it is then up to us to obtain pointers from their past life or through their social circle. What difficulties did the person have to go through in their biography? Are they still (unconsciously) preoccupied with unfinished business?

Fear of dying is a multifaceted phenomenon. It is frightening to look at ourselves in the nature of our being, including the parts of our I that we have so far split off in everyday life, that belong to our doppelganger, the shadow in our soul. It is frightening to stand in front of an absolute unknown, without any idea of how it might "feel" to be no longer of the earth, to no longer have a physical body. Many patients have not yet dealt with death and dying in their imagination, nor have they had the opportunity in their lives to assist a dying person or to see a deceased person. Many do not ask themselves the question of whether and how things continue after death.

The sedation often used in the palliative situation to control restlessness does not mean that the dying person no longer suffers anxiety. Does it, on the contrary, deprive them of the possibility of awakening from a nightmare-like world of experience and gaining a new orientation? As nurses we have to ask ourselves: do we develop loving and attentive support for the sedated patient in the same way, so that they can go through the most difficult of all crises in life in an enriching way?

Nursing attitude

In the context of restlessness, the nursing attitude is of great importance, especially:

• Being authentic, showing presence of I. 
• Self-reflection on own anxieties, helplessness and insecurity.
• Fostering security in the patient and their social environment.
• Communicating in a confidence-building and calm manner. 
• Continuity in nursing care.  
• A questioning attitude in the encounter: What are you missing? What do you need?
• Faith and trust in the higher, spiritual being of the critically ill patient.
• Advice for relatives and family members.
• Permanent watches
• Oneself not getting into a spiral of anxiety and restlessness or encouraging it through one's own restlessness.

Support and advice for the family members and persons close to the critically ill patient

Family members and persons close to the patient are confronted with unfamiliar and sometimes existential challenges. For it is mostly about taking leave of a loved person and the conclusion of a period of life together that will never return in this way. The preciousness of the moment is particularly perceived, as well as the things that may not have been able to develop or remain unfinished. Often family members wrestle with these issues, which can affect their relationships with each other as well as their relationship with the patient. In addition, there are the practical questions regarding everything that needs to be arranged and agreed upon.

• Family members and persons close to the patient can also get caught up in a spiral of anxiety and restlessness.
• Too many visitors at once or too long a visit to the critically ill patient should be avoided.
• Similarly too much external commotion (movement, voices) in the patient's room.
• If possible, no or little television and a circumspect use of media, so that a free space can develop and calm in general can set in.
• Permanent watches.

Nursing applications

Wraps and compresses

• Aurum/Lavandula comp. ointment WELEDA heart ointment compress at night, if necessary also after lunch and as needed.
  Lavender has a calming and relaxing effect, essential rose oil is harmonising and gold strengthens the power of the I. For procedure see https://www.pflege-vademecum.de/aurum-lavandula-herzauflage.php?locale=en. 
  
• Arnica essence WELEDA, thoracic compress as well as pulse wrap with diluted arnica essence for thoracic complaints. 
• Oxalis 20% essence; Oxalis ointment WELEDA stomach compress or Einreibung for nocturnally arising, burdening and unresolved soul content. Also in the case of the effects of shock. Here Oxalis guides the soul and spiritual element, which has been separated from the body, back into the body. Oxalis has an antispasmodic effect and is used for restlessness due to abdominal complaints, e.g. as the result of peritoneal carcinomatosis.
• Solar plexus compress with red copper ointment or Aurum/Lavandula comp. cream

Restlessness may be felt abdominally. Sometimes just placing a hand on the upper abdomen (solar plexus) is calming. An external application with Oxalis ointment WELEDA or Oxalis oil WELEDA can enhance the calming effect. For nervous, restless and tense patients, the warming, antispasmodic, relaxing and calming copper ointment compress with Cuprum metallicum 0.4% ointment WELEDA or red copper ointment WALA may be considered; to centre and calm, Aurum/Lavandula comp. ointment WELEDA.

Rhythmical and other Einreibung

• Cuprum metallicum 0.4% ointment WELEDA or red copper ointment WALA foot Einreibung. 
  Cool acra as an expression of mental tension can be warmed through by the copper application. The patient feels mentally relieved and can relax.
• Pentagram Einreibung , centres the person and strengthens the efficacy of the I. See also https://www.pflege-vademecum.de/pentagrammeinreibung.php?highlight_words=pentagramm.
• Lavandula Oleum äthericum 10% foot Einreibung . Lavender soothes, relaxes and warms cool extremities.
• Melissa oil WALA Einreibung as an oil wrap or abdominal Einreibung, has an antispasmodic, anti-flatulent effect. For restlessness with cramp-like, meteorism-related complaints. 
• Solum uliginosum comp. oil WALA Einreibung . Solum gives an enveloping warmth and shields from external influences; in restless, emotionally too open patients.
• Pallasite ointment WELEDA calf Einreibung . Meteoric iron can strengthen courage and self-efficacy in cases of restlessness and anxiety.
• Hand Einreibung with Aurum/Lavandula comp WELEDA or rose oil WALA as required, e.g. for motor restlessness. Through the hand Einreibung, breathing between contraction and release, inhalation and exhalation are harmonised. Patients become calmer and sometimes fall asleep.

Baths and washes

• Tinkling wash (1) for debilitated and restless patients. The flow and the sound of the splashing water have a calming and stimulating effect.
• Oil dispersion baths (1) with brushes. Oil dispersion baths carried out with different oils have an effect on suitable patients that is calming, invigorating, stimulates the body's own warmth and has a regulating effect.

Other nursing options

• "Warm touch": It has proven useful to touch or support the back – e.g. the coccyx or the shoulders – ("I've got your back") or to perform foot rubs. It is often helpful if the patient sits up with the support of several carers or family members. Feeling warmed and sheltered leads to calm.
• If the critically ill patient does not allow any touching, a silent presence is often helpful. Sometimes a softly sung song or a hummed melody has a calming effect. It is important that the carer themselves radiate calm.
• Arnica cap especially in patients with brain metastases or brain tumours. For instructions see https://www.pflege-vademecum.de/arnika-kopfhaube.php?highlight_words=kopfhaube.

Nursing options and applications to support rhythm – restlessness when falling asleep or waking up

In the evening:

• A rhythmical foot Einreibung with lavender oil or an Aurum Lavandula heart ointment compress at night are calming and enable the transition from day to night, which is often accompanied by anxiety. Often the patient already finds rest during the Einreibung and falls asleep. The heart ointment compress can be held "at the heart" and taken into the night – like a cuddly toy, for example.
• Rituals: Provide a verse, a prayer for the night and, if the patient wishes, speaking it with them or for them. Many patients have a desire for spiritual support which they barely articulate and which therefore often goes unnoticed. Some patients know verses that are valuable and supportive for them. Suggestions can be found, for example, in Rudolf Steiner's Truth-Wrought-Words (2).
• Salt crystal lamps are a warm, reassuring source of light even at night. Sometimes the slightly open door of the room can reduce the restlessness. The patient feels that they are not alone. As in childhood, everyday sounds do not have a disturbing but rather a calming effect.

In the morning:

• In order to start the day well after waking up, a warming rosemary footbath with Rosemary bath milk WELEDA or a lemon footbath or foot wash with Citrus Oleum aethereum 10% WALA that strengthen the efficacy of the I have proved to be effective.

Experience regarding the application of individualised nursing measures tailored to the patient grows through practical nursing and the observation of its efficacy.