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Music as a Therapeutic Resource in End-of-Life Care 
Beth Perry Black PhD, RN 
Patricia Penrose-Thompson MA 

Journal of Hospice and Palliative Nursing 
March/April 2012 
Volume 14 Number 2
Pages 118 - 125

Abstract

Music has been used in a variety of settings by nurses and other providers to ease their patients' physical, emotional, and spiritual distress. In end-of-life settings, music has been shown to improve quality of life. Nurses have noted the usefulness of music in practice but perceive that they have limited knowledge and skills about how to use music and lack the resources to implement its use. Drawing on knowledge from music therapy and music-thanatology, we describe the receptive approach to the use of music in palliative care and hospice settings. This approach is characterized by active listening and using techniques that are accessible to nurses who may not have music training. Nurses can help patients select music that evokes memories or feelings and helps divert their attention from emotional and physical distress. Music may be an effective tool for reviewing one's life, through which a patient moves toward acceptance of death by giving meaning to his or her life. Near the end of life, prescriptive music may be used during bedside vigils to accompany the patient in the transition from life to death.


Music is basic to the human experience. From lullabies that calm fretful babies to mournful dirges over the dead, music marks lives' ordinary and extraordinary events. William Congreve, an English playwright and poet, in 1697 penned the famous line "Music has charms to soothe a savage breast" in his tragic play The Mourning Bride. Two hundred thirty years later, another English writer, Aldous Huxley,1 noted, "After silence, that which comes the nearest to expressing the inexpressible is music." Music can engage the human spirit and reach the deeper realms of a person's psyche and spirit, lending itself to easing physical and emotional distress as well as serving as a vehicle of transcendence from suffering to ease, and from life to death. Nurses have noted the usefulness of music in practice but perceived that they have limited knowledge and skills about the use of music and resources to implement its use.2 The purposes of this article are dual: (1) to describe the therapeutic use of music in hospice and palliative care settings using examples from practice and (2) to inform nurses and other clinicians of resources to enhance their use of music in their practice with patients at the end of life. Drawing from the music therapy literature, this article details the roles of music in palliative and hospice care and describes ways in which clinicians can use music effectively in supporting their patients who are approaching the end of their lives.

Healthcare providers in a variety of settings have found music's remarkable attributes to be beneficial. A burgeoning literature exists on the effective use of music in long-term-care facilities, care of the elderly, and care of persons with dementia. Similarly, terminally ill children and adolescents benefit from music, which can help them feel supported, improve self-esteem, express emotions, resolve conflicts, and create a safe, less threatening environment within the hospital setting.3 Bradt and Dileo4 noted that music is used in end-of-life (EOL) settings to improve quality of life. Neugebauer5(p131) observed that in the care of patients with terminal illnesses, music offers the opportunity for "confronting death and dying in a way not accessible[horizontal ellipsis] at any other level" and can "open up opportunities for communications and relationships beyond the spoken word." Although music is used by healthcare providers in many settings to help ease patients' symptoms and distress, two specific types of trained professionals-music therapists and music thanatologists-have demonstrated greater effectiveness in using music in end of life care than untrained music volunteers and healthcare workers.6 These disciplines provide training for musicians in specific therapeutic techniques and skills for use with patients in EOL care. Although music therapy requires a trained professional, nurses and other providers in EOL settings may enhance their own practices through the use of music as a therapeutic intervention by understanding some basic elements from the disciplines of music therapy and music thanatology.

USE OF MUSIC IN EOL CARE

Evidence of the efficacy of music interventions for EOL care is mounting. Specific goals for the use of music in palliative and hospice care vary from reducing physical symptoms and increasing tolerance for treatment to easing emotional pain and spiritual distress.7-9

Physical Symptoms and Pain Management

Music can be used to create a calm environment, which in turn can improve management of other distressful symptoms. Brown et al10 showed through positron emission tomography scans of the brains of 10 healthy subjects that even unfamiliar instrumental music can activate the limbic and paralimbic areas of the brain, resulting in "strongly pleasant feelings."10(p2033) Autonomic functions can be affected through music's effects on the central nervous system and hormone production, thereby lowering blood pressure and heart rate, slowing or speeding up respirations, and decreasing nausea by decreasing the brain wave frequency, which affects gastric activity.8

Music can be an effective means of promoting a state of relaxation in patients and improving sleep. The tempo and rhythms in a musical piece can be matched with a patient's breathing to slow and deepen the breaths.11 In addition, music can be combined with progressive muscle relaxation techniques and meditation to enhance the effectiveness of each.12 Relaxing tunes have repeated motifs and long, sustained tones. Simple rhythms and repeated chord progressions, often using arpeggios (notes in chords played separately in sequence), create a flowing sensation in the music.6

Music can be an effective complement to analgesia and can affect positively the physiological, psychological, social, and spiritual aspects of pain.13,14 Music may alleviate pain by disrupting the connection of pain to psychological variables (eg, past pain experiences, expectations of pain, interpretation of sensations as pain) and by otherwise reducing anxiety and helping the patient to relax. In addition, music can reduce the perception of pain by offering a competing stimulus, as well as raising the level of endorphins by listening to pleasurable music.15 Also, by distracting patients' attention from painful stimuli, music can change their perception of pain, stimulate positive thoughts and sensations, and elevate their moods,16-18 thereby decreasing the need for medication, increasing coping and sense of control over pain.19

Clinical Case: The "Goldberg Variations"

Louise was a 42-year-old single woman terminally ill with advanced breast cancer. She was an excellent pianist and a beloved music teacher in her community. Admitted for care at a local inpatient hospice facility, she was surrounded almost constantly by musician friends who played various instruments at her bedside to soothe and comfort her. One restless night, she whispered to her nurse a phrase the nurse could not understand. Thoughtfully, the nurse repeated it to one of the musician friends in the room who knew exactly what Louise wanted: to hear Bach's Goldberg Variations, her favorite piano music that Louise had worked years to master. Soon, the lovely strains of the first notes filled the room. Conversation ceased as Louise's fingers began to move over her sheets as if she herself was playing the piano. For the first time in hours, she became peaceful and calm. Louise "played" the entire 50-minute piece, never opening her eyes, and fell into a deep sleep as the recording ended. Her friends sat wordless as Louise finished her last performance for them-a flawless, silent rendering of her cherished Variations. She died before morning, peacefully, without pain, her final recital complete.

Psychosocial, Emotional, and Spiritual Needs

Persons at the end of life may experience a wide array of emotions, including anger, fear, sadness, and hopelessness, yet find comfort in the expression of such emotions through music.20 A sense of isolation may accompany persons as they approach death, and they may find it difficult to relate to others. The illness itself may impede the ability to communicate with friends and relatives, or patients may feel overwhelmed by the feelings, needs and wishes they want to express. Music may provide an environment to explore these issues, encouraging social interactions with providers, friends, and family. Even passive musical activities can foster social interaction through a shared enjoyment and discussion about the music itself, memories it presents, and thoughts or feelings it evokes. Enjoying music with others provides a sense of intimacy and gives the patient a sense of belonging.18 Moreover, music accesses a larger area of cognitive functions in the brain than verbal language alone,21 making its use a robust intervention in caring for patients with cognitive or other communicative impairment.

Spiritual support is needed for patients facing death, whether one is affiliated with an organized religion. Such support can help patients find meaning in the lives they have lived and the purpose of their earthly existence.6 Engaging both cognitive and affective domains, music can be effective in helping patients explore spiritual issues. Magill23 observed patients encounter spiritual themes such as faith, hope, peace, and life's purpose through music. Music activities may move to patients experience joy, empowerment, connectedness, remembrance, and hope.24

Music can be used to facilitate relationship completion, as it can increase feelings of closeness, acceptance, and intimacy.25 Clinicians have witnessed the ability of music to sustain and even mend relationships with its ability to foster and intensify feelings of love, as well as giving voice to its expression.26 Music can stimulate memories of loving experiences shared between patient and family members and can be used to encourage conversations and interactions that lead to a renewed sense of connection, often bringing resolution and relationship completion.24 Berger27 described "music moments" that can occur without instruments or recordings by simply asking the patient, "If there is a time, place, or person you would like to revisit, what music would take you there?" Importantly, Berger noted the intense emotions that music can evoke, reminding providers that the patient's "timetable and internal defenses must be honored."27(p127) Furthermore, patients may become overwhelmed with memories; the provider needs to attend to cues that indicate the patient needs or wants the music to be turned off.27(p134) The following case exemplifies the way a particular song allowed a patient to express his deepest regrets and come to a place of healing.

Clinical Case: "Take Me Out to the Ballgame"

Mr Jeffers was a 74-year-old man terminally ill with pancreatic cancer; his main physical complaint stemmed from a surgical wound infection in his abdomen. He was very withdrawn and barely spoke to Anna, his hospice nurse who visited daily to do wound care. Mrs Jeffers was a pleasant, talkative woman who was very upset over Mr Jeffers' silence. One day, he was wearing a New York Yankees tee-shirt; it was one of several team shirts that he had worn when Anna was visiting. Wanting to make some kind of connection with Mr Jeffers, Anna began humming "Take Me Out to the Ballgame" as she went about changing his dressing. To her great surprise, Mr Jeffers began crying silently, tears coursing down his cheeks. She asked him if she was hurting him, and he responded, "It's just that song."

Anna sensed that this was an important moment, so she asked him, "What does that song make you think of?" At first haltingly, and then in a flood of words, Mr Jeffers began to talk about his son, a promising baseball player who had died in an automobile accident decades earlier. Anna realized that in humming the familiar baseball tune, she had gained access into something very important and painful for Mr Jeffers. She sat in silence, listening to him talk about his profound sadness and regret that he had put away all evidence of his son's life after his death, "as if he had never lived." He reminisced about their afternoons at baseball games and how desperately he had missed him, but how he had wanted to protect his wife from his own profound grief. Now as he was dying, he was afraid that his memory would be treated as if he, too, had never lived. Anna worked carefully and sensitively with Mr and Mrs Jeffers with the assistance of a hospice social worker. By the time he died 7 weeks later, he had shared his regrets with his wife, sought forgiveness from her, and extended forgiveness to her. They brought out mementos that Mrs Jeffers had carefully preserved for almost 30 years. Mr Jeffers found comfort in the smell of his son's baseball glove; in his last weeks, it lay next to his head on his pillow, and later, it was buried with him.

MUSIC INTERVENTIONS IN CLINICAL PRACTICE

Music therapy per se requires skilled and credentialed practitioners; however, nurses and other providers may find certain techniques drawn from the music therapy profession to be effective in caring for palliative and hospice patients. Four approaches characterize therapeutic music techniques-receptive, creative, recreative, and combined-with differing levels of patient involvement and provider expertise.28 The receptive approach is the one that is most consistent with care at the end of life and accessible to persons untrained in music.

Assembling a repertoire of music for use with patients requires time and thoughtfulness; however, with the ease and availability of music downloads from various internet sources, assembling a variety of music is relatively easy (Table 1). In addition, patients may have their own collection of music in the form of old records, tapes, and CDs that are particularly meaningful to them. Taking time to assess a patient's amenability to the use of music in their care can yield powerful benefits when used conscientiously and purposefully.

Table 1 - Click to enlarge in new window TABLE 1 Useful Web Resources for Incorporating Music in End-of-Life Care

Receptive Approach to the Use of Music

The receptive approach engages the patient in passive interaction with music. Because of the physical limitations patients often face at the end of life, activities involving listening to music are commonly used by music therapists in palliative care28 and are the most convenient to and easily instituted by nurses. Passive interaction refers to lack of physical involvement with the music, such as moving or singing with the music; the patient, however, is engaged with the music and listens to songs actively. Hunter et al,29 in a study of emotional responses to music, found a strong relationship between persons' emotional responses and particular characteristics of the music, such that fast tempo and songs in major keys made their participants feel happier; conversely, slow-tempo and songs in minor keys made them feel sadder. Not surprisingly, fast songs in minor keys and slow songs in major keys caused mixed responses. Their findings underscore the need for clinicians to consider the characteristics of the song and the needs of the patient and family when using music in EOL care. O'Kelly,30 in a poignant description of songs themselves, also highlighted the potential of songs to meet the goals of palliative care:

Songs are ways that human beings explore emotions. They express who we are and how we feel; they bring us closer to others; they keep us company when we are alone. They articulate our beliefs and values[horizontal ellipsis] as the years pass, songs bear witness to our lives[horizontal ellipsis]. They are our musical diaries, our life stories.30(p283)

Music Listening, Song Choice, and Lyric Analysis

Music-listening activities can incorporate both prerecorded and live music. Passive listening to music can provide a structure that captures the patient's attention and redirects it away from the effects of the illness. Patient engagement can be enhanced by changing the musical genre or style or incorporating moments of silence.12 Two caveats apply here. First, like any environmental element, music played constantly in the background will soon become ignored or, worse, become an irritant. Second, the volume must be set so as not to interfere with the patient's rest, sleep, or interactions with others. For elderly patients or others with hearing impairment, the volume may be louder than the clinician would normally listen to; furthermore, hearing loss may be confined to upper registers (higher notes), making some musical selections more difficult to hear than others. Song choice allows patients to participate by selecting music that reflects their mood, thoughts, and emotions. Patients choose songs from a wide variety of themes, ranging from those that elicit hope and memories of happier times to those that reflect feelings of loss.31 Such themes can be further explored through lyric analysis of the selected songs, opening up communication with the patient by relating the words of the song to the patient's reasons for choosing the song, and the thoughts and feelings the song lyrics evoke in the patient. The simple act of choosing songs may also increase self-esteem, help patients regain self-identity, encourage choice making, and promote social interaction.32 The provider can engage the patient by asking, "What does this song make you [think of/remember/feel]?" the technique used by Anna in the earlier example.

Guided Imagery

Imaging is a process through which the patient's internal experiences are reflected through imagery invoked by music. Imaging can help the patient divert attention from emotional distress and physical symptoms, explore spiritual issues and transcend the physical confines of the dying process. Patients may visualize freely with the music, or the provider may direct the imagery with verbal cues.33 As the patient verbalizes the images and feelings evoked by the music, the provider then aids the process by providing comments to support and guide the patient. This safe environment allows the patient to access subconscious emotions that may be threatening to the conscious psyche,34 such as deep sadness, fear, and regret. Clinicians in EOL settings are very sensitive to and able to respond to the profound emotions that are manifested at the end of life and that may be elicited through music.

Life Review

A life review can help a patient move toward acceptance of death by giving meaning to the life lived. As patients review memories of experiences, relationships, and places they have lived in their lives, they can evaluate the quality of their lives, reflecting on achievements and reviewing disappointments in an effort to bring an understanding of life's significance.35 Music then is an effective tool for evoking memories that can be used to review one's life and may be more effective than verbal review.36 A musical life review often involves listening to musical selections suggested by the patient, who may sing songs from his/her past if physically able. Some persons will create their own songs based on past life events. (A recent example of this technique was shown in the movie "The King's Speech," when Prince Albert puts words to his childhood trauma to the tune of "Camptown Races"). This may be followed with a dialogue about the memories and associations that the music evokes for the patient.35

Encouraging the involvement of family members can make a life review a poignant and joyful means of remembering through music. Making CDs or playlists of music that represents different times in the life of a family can serve as a "musical scrapbook." For instance, recordings of nursery tunes, songs sung in youth musical groups or performed in recitals, and music played at family weddings and anniversaries help families recall these events and can encourage reminiscing, even if it is not a recording of a specific performance by a family member. Some patients appreciate having the opportunity to plan the music for their own funerals or memorial services, creating the chance for them to talk about favorite music in their lives and, for some, to know that family traditions and rituals will be honored at the time of their own death.

Entrainment

Music entrainment is a technique that transports the patient's mind away from physical pain to focus on more pleasant images. Entrainment refers to synchronization of rhythm cycles, a phenomenon that is found throughout nature. With this technique, the provider and patient work together to discover music with qualities that will evoke and draw attention to pleasurable sensations; this in turn diminishes the patient's perception of pain. The music's melodies, rhythms, and harmonies may create overall images that bring relaxation and peace, such as floating in clouds or peaceful places from the patient's own experiences.13 Reducing the dynamics in the music from louder to softer can induce relaxation, and changing music from a minor key to a major key can inspire a positive mood. For example, a patient may find Pachelbel's popular Canon in D for stringed instruments to be more relaxing than Beethoven's famous but more percussive Symphony No. 5.

Lullabies have been found to be one of the most effective song types for meeting patients' psychosocial and spiritual needs especially as end of life grows near.37 The word lullaby is thought to be a combination of lull, as in soothing or calming, and bye, as in goodbye. The soothing nature of lullabies relaxes the patient and helps ease stress and anxiety.38 O'Callaghan39 found lullabies, with their inherent qualities of "nurturance, love, support, and grief expressions [to be most helpful as they are used in expressing and validating themes of] attachment and detachment, sadness/tears and happiness/laughter, privilege and loss, nurturance and grief, and deterioration, stasis, and moving forward."39(p97) Lullabies bring images of the safety and care of childhood and decrease the anxiety of abandonment felt at end of life.40 By playing the lullabies familiar to a patient from childhood, or from care of the patient's own children, the nurse brings the patient into a place of comfort and safety. This helps to create a transitional space between living and dying, completing the circle from birth to death.38

THE SPECIAL CASE OF MUSIC THANATOLOGY

We refer to music thanatology as a "special case" in order to underscore its particular role in the care of dying patients. Although nurses can engage the patient in basic use of music as a means of comfort and care, music thanatology is a very specific technique used at the bedside during dying vigils. Palliative and hospice nurses and other providers may want to familiarize themselves with music-thanatology practitioners in their area (http://www.mtai.org/index.php/associates) so that they can enlist their involvement when desired by dying persons and their families. Schroeder-Sheker,41 the founder of music thanatology, described it as a palliative medical modality that uses prescriptive music in bedside vigils in order to address the complex physical and spiritual needs of dying persons. Music thanatology is based on the premise that dying is a part of a larger spiritual process that affords the opportunity for growth and healing of the inner life without curing the physical body, and as such, it is part of the life cycle that can celebrate and reflect the beauty and reverence of the life lived.41

The music thanatologist cares for dying patients by offering live harp and vocal music at the deathbed, with the goal of accompanying the patient through the transition from life to death. With the music vigil, music thanatologists create a sacred space in which they offer support to the patient through the dying process.42 The practitioner performs music that has been created for the individual patient based on his/her unique needs, which becomes a musical prescription intended to ease physical, emotional, and spiritual suffering.43 The components of the music (tempo, dynamics, rhythm, pitch) are adjusted moment by moment to meet the needs of all present in the room, including patient, family, and friends. These bedside music sessions, called music vigils, offer a soothing presence to support the patient and loved ones, both through the musical sounds that are adjusted as needed, and periods of silence designed to provide comfort and peace.44 This music is not meant to entertain or distract the patient but is intended to "provide a musical presence that draws together and responds to the various streams of diagnosis, prognosis, personal, spiritual, and social context, as well as the presenting and ever changing physiological parameters of the patient."45 Music thanatologists explain that "whether conscious or unconscious, the patient is always in charge of the musical direction because we connect at the level of breath, pulse, temperature, pain, effort, and tension."46

Music thanatology is a relatively new field, and as such, research documenting its efficacy is in its infancy. To date, two main research projects have been conducted on the effectiveness of this emerging field of palliative care. In a study of 65 patients assessing the effectiveness of prescriptive music in vigils to decrease agitation and wakefulness, and to slow breathing and pulse, Freeman et al47 found that the harp vigils reduced agitation and wakefulness, indicating a restful state. Respiration rate slowed and became less labored by the end of the vigil. These results reinforce anecdotal reports that music vigils have a calming effect on patients. No significant change was noted in pulse rate; however, researchers conclude that other factors may have affected this vital sign. Hollis43 cited research by Roberts and Cox that used qualitative techniques to evaluate the influence of music vigils on patients and found that participants experienced hope, calmness, and relaxation after music vigils. They concluded that isolation and fear were replaced with feelings of peace and acceptance of impending death. Hollis43 suggested that future avenues of research assess the effects of music vigils on physiological function and the psychological impact of music-thanatology experiences on patients.

SUGGESTIONS FOR FUTURE RESEARCH

Research on music as a therapeutic modality has been well described in descriptive case studies, which form the foundation for future studies with outcome measures. In their recent meta-analysis of studies conducted on music therapy for EOL care, Bradt and Dileo4 concluded that there is an insufficiency of high-quality research and studies in the field. Evidence of the efficacious use of music in palliative care is weakened because of small sample sizes, small numbers of quantitative assessment, and lack of randomized controlled trials. Similarly, Hilliard20 suggested that studies be conducted with larger numbers of participants over longer periods, and outcomes measures be designed that are specific to terminally ill patients. In addition, he recommended conducting studies for specific techniques and controlling for diagnosis. One of the areas in most need of further study is the use of music for children and adolescents in EOL care.9 Although there are similarities between adults and children receiving palliative care, the developmental stage of the child, as in all interventions, must be addressed to best meet his/her needs with music.

CONCLUSION

With its wide capacity for accessing the human experience, music has tremendous potential for addressing a variety of aspects in the care of terminally ill patients. O'Kelly48 characterized music as a therapeutic medium ideally suited in caring for patients at the end of life, one that can meet the needs of patients across many domains: physiological, psychological, psychosocial, and spiritual. Music is complementary to, not competing with, other therapies, and its specific use as a clinical mode of treatment has been shown to be effective in EOL care. Music thanatology and music therapy have successfully incorporated music into the palliative care setting. Nurses, social workers, chaplains, and bereavement counselors-and thereby, patients-benefit from interventions drawn from these professions that incorporate music in care at the end of life.

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