Pediatric Palliative Aquatic Therapy

(by  Tamara Nelson, BSN, RN, with Rachel Anticoli, BSN, RN / Dawn Constantine, RN / Francesca Loayza, BSN, RN / Nancy Ricci, BSN, RN)

The Pediatric Palliative Aquatics program was pioneered by Sheila Pyatt, RN, over 15 years ago at the George Mark Children’s House (GMCH), a free-standing pediatric palliative care center based in San Leandro, California. Sheila was inspired by her own WATSU and Jahara aquatic training. She adapted this warm water therapy for the patients at GMCH.  Over the years this unique palliative aquatics program has gradually expanded and become a beloved adjunct to the child life services offered at GMCH. It is currently run by five on-call registered nurses who come 3-4 times a week to provide this alternative palliative care therapy. Pediatric Palliative Aquatics aims to follow the goals of palliative care by improving quality of life, promoting relaxation, and contributing to pain and symptom management.

The children at GMCH, all with life-limiting conditions, have multiple and complex diagnoses. A vast majority are wheelchair and bedbound, often with neurological impairment, significant contractures, and restrictive lung disease.

This warm water modality aids in providing improved circulation, improved respiratory function, decreased agitation and irritability, increased range of motion, and relief of spasticity, stiffness, and pain. The human connection and nurturing physical touch, in conjunction with the warm water experience, provide a feeling of emotional support, freedom, and joy.

Bedside nurses have reported that following aquatic sessions patients will
appear calmer, have increased range of motion, and have better quality rest and sleep. Families have reported that their child experiences a sense of freedom in the water, along with an improved sense of relaxation and calm. Some GMCH families have gone on to ask “Make A Wish” for a hot tub for their own home after witnessing the advantages of this warm water therapy.

Preparation for an aquatic session includes:

  • Patient is assessed for suitability by bedside and aquatic nurses
  • Physician and guardian consent is obtained
  • Aquatic RN and a second adult are present for all sessions (*depending on complexity, the second adult may be a volunteer, parent, or a second RN)
  • Pool environment is prepared (toys, music, and medical equipment as needed; oxygen, portable suction, Hoyer lift)
  • Routine safety and equipment checks are performed

During a session the aquatic RN will complete an assessment of the child’s overall well-being, paying attention to body, mind, and spirit to offer an individualized experience each session. Sessions may include music, gentle stretching, passive range of motion, massage, and effortless floating.  Collaboration with child life and music therapy may be included. Sessions are creatively tailored to a child’s needs and interests, for a peaceful or active session. 

With few exceptions (open wounds, infectious process, diarrhea, contraindication for full water immersion),  all children are eligible for a palliative aquatic session. Children with gastric tubes, VNS implants, and vesicostomy, or requiring supplemental oxygen, can all participate.  With appropriate modifications and precautions, even children with tracheostomies can receive sessions.

Sessions last approximately 30-60 minutes in a 98 ̊ F pool. Most sessions’ sweet spot is 45 minutes, which allows time for integration into this full sensory experience. Exceptions may include thermoregulation issues, seizure precautions, and other physical or emotional sensitivities, which would dictate a shorter session. Children who are over 15kg and immobile are lifted into the pool via a Hoyer to maintain patient and nurse safety. Others are lifted onto a mat for transfer.

While it can be difficult to discern or quantify benefits of aquatic therapy in a predominantly non-verbal patient population, these children appear to “lighten up.” This weightless, warm water environment, unburdens joints and bodies, thereby allowing a sense of freedom and peace. This may be evidenced by a smile, a laugh, relaxed facial expression, deep breaths, or by (our gold standard) huge audible sighs. Interactive children enjoy the freedom of unrestricted movement and the normalization of childhood water play. For bedbound children, the experience of floating free of the strictures of gravity can be profound.