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66 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 9 disease, congestive heart failure, or metastatic processes, the wisdom of applying bandaging is tenuous. • Compression adds to the discomfort of dying and is always discontinued when a patient is nearing terminal decline. • When a patient lives in a skilled nursing facility and reliance on staff can be a helpful benefit to the therapist, the maintenance and application of bandaging by staff is often a practice in futility. Often, bandaging is lost, soiled beyond ability to reuse, discarded onto the floor, or consistently imperfectly applied. Even with conscientious training and consistent oversight, problems inevitably arise, requiring the practitioner to either abandon bandaging or be responsible for the total effort of reapplication. Therefore, it is wise to examine the case in detail. If the patient presents a significant need for compression, it is best to perform all sessions without reliance on facility staff or colleagues. Use compression primarily only for severe cases of lymphatic fistula formation (draining/weeping legs). INTAKE CONSIDERATIONS In standard hospice practice, MLD is not offered to every candidate referred by medical personnel for lymphedema or edema management. Every hospice patient poses complex multidimensional issues that often exacerbate or influence, in some manner, the task at hand—especially given the wide range of diseases and comorbidities that are encountered. For instance, engaging a patient in MLD who clearly has days or weeks to live may not be wise given the tactile invasiveness of the procedure. Patients experiencing psychological fluctuations may find touch too stimulating or escalation of their condition could arise due to misinterpretation. Even the living conditions surrounding a patient could warrant refusal to treat if the patient had been a victim of physical or sexual abuse psychologically active with previous or current counseling. Prior to performing an intake, there are a few requirements that should be garnered from the medical record: The patient should have reasonable function of the kidneys, heart, and lungs; the patient should have the ability to tolerate the invasiveness of the procedure, with regard to frequency and duration of treatments; the patient should have the ability to assume variations COMPRESSION ISSUES Normally in the management of various swellings, compression therapy is provided to patients as standard practice. This typically occurs through the use of short-stretch bandages. These are eventually replaced by compression garments or other materials that are worn daily for life. In hospice, unless otherwise directed by the physician, desired by the patient, or deemed appropriate by the therapist, the practice of bandaging is discarded or significantly altered. For instance, Tubigrips, while not as effective as short- stretch bandages, are a compromise in many cases. This is a complex subject and worthy of discussion in a separate article. Here are a few considerations: • Most hospice patients do not have the strength to manage the weight, bulk, and binding quality of compression. These not only impact their mobility and comfort, but also negatively influence their quality of life. It can often mean the difference between participating in a social outing with friends or staying in bed because of the effort involved. Or worse—especially with a confused patient—it can be the precipitating and contributing factor in falls. A practitioner should have a "least restrictive environment" mentality when deciding on the use of compression. • The comorbidities encountered in most patients warrant adaptation. When presented with frail skin, altered sensation or paralysis, hypertension, frequent infections, cardiac edema, diabetes, peripheral vascular Manual lymph drainage should be performed as a loving intervention that serves to accompany patients through the transition from this life to the next.