"Where Words Fail, Music Speaks"
~ Hans Christian Andersen
Integrating music with supportive care of the dying is becoming more common in hospice and palliative care programs. The conscious use of music as an adjunct support service is good example of how the multidisciplinary approach to hospice care seeks to address the total person and their family. There are several ways that music can be of help. This overview will cover the most common uses of music at different stages of the support continuum, ranging from stress relief for the relatively healthy, to beside support for the acutely dying, the use of music in funerals and memorial services, and as part of supportive care for grief recovery.
Because music reaches a deep, non-rational part of the human spirit, it is ideally suited as an adjunct service that can affect feelings such as grief, fear, anxiety, sadness, and anger that stand in the way of a clear passage. Music can release blocked or painful feelings and can stimulate positive ones such as hope, love, and gratitude. Sharing music together can lead to sharing of the emotions that the music brings up. Ackowledging these emotions together can help bring closure to old issues and enable reflection.
History of music in care of the sick
People have used music and song to comfort one another since time immemorial. Who has not been touched by hearing a lullaby? Aristotle and Plato wrote about their beliefs in the healing power of music. During medieval times, a tradition of monastic chant for the sick developed. The Benedictine Order, which embraced communal living, supported their sick or dying community members through formal musical rituals.Hospitals as we know them are a relatively recent development in health care. After the two World Wars, volunteers at Veterans hospitals began to play music and sing for patients. Postive responses to this musical support led hospitals to hire musicians directly, and formal music training programs for health care applications began to appear. In 1944, Michigan State University offered the first college degree in music therapy.
Music as a medical discipline
Music Therapy
The use of music as a therapeutic tool falls into the realm of behavioral and psychological support services. With persons who are not actively dying, music can be used to stimulate interaction, memory, and affective response. It encourages interaction between listeners and between listeners and the performer. This active stimulation presumes that the clients are awake and capable of response. It can be used to stimulate energy if the patient is lethargic, or to calm the patient if there is too much energy. Music therapy presumes that a positive change in mood or behavior can be brought about in the listener.American Music Therapy Association (AMTA)
In 1950 the National Association for Music Therapy was founded, followed in 1971 by the American Association for Music Therapy. Those two organizations merged in 1998 to create the American Music Therapy Association (AMTA), the largest professional association representing over 5,000 members. Persons who complete one of the AMTA-approved college music therapy curricula (including an internship) are then eligible to sit for the national examination offered by the Certification Board for Music Therapists. Music therapists who successfully complete the examination hold the music therapist-board certified credential (MT-BC). The National Music Therapy Registry (NMTR) serves qualified music therapy professionals with the following designations: RMT, CMT, ACMT. These individuals have met accepted educational and clinical training standards and are qualified to practice music therapy.The Canadian Association for Music Therapy
The Canadian Association for Music Therapy was formed in 1974. The organization furthers the practice of music therapy in clinical, educational, and community settings throughout Canada.The Music for Healing and Transition Program
The Music for Healing and Transition Program (MHTP) provides training in the use of music and voice in the care of the sick and dying. MHTP students may use a variety of instruments, not just harp, at the discretion of their instructors. Graduation from this program generally takes two to three years, including a supervised internship in a medical facility. MHTP does not lead to a degree in Music Therapy. MHTP graduates are called "Music Practitioners" or "Certified Music Practitioners" (CMP).The Chalice of Repose Project and the emergence of Music Thanatology as a discipline
Therese Schroeder-Sheker developed a field specifically called "music thanatology" through The Chalice of Repose Project. The term "thanatology" is derived from "thanatos," the Greek term for death. The term "music thanatology" sometimes is used in a strict sense to refer to a specific way of using live harp music at the bedside of acutely dying patients. Music thanatologists view their work as a compassionate, spiritual, and contemplative practice.Music thanatology does not presume that the listener has a reserve of energy that can respond actively to the music. A person who is actively dying may be very weak, with limited communication capacity. In some cases the person may be comatose or in a state of altered consciousness on the threshold of death. As a result, the person can not be expected to exert effort to respond to the music, make new associations, or even respond. In this vulnerable and receptive state the person can only receive stimuli from the environment. This places a profound obligation on the musician to craft sounds that will only help, and never harm, the delicate passage that is taking place.
Therese Schroeder-Sheker began using music in care for the dying in 1973. She pioneered the use of terms such as "music thanatology," "music vigil," and "prescriptive music." The original Chalice of Repose Project operated in Colorado for nineteen years. It relocated to Missoula, Montana, in 1992. In Missoula the project operated a multi-institutional clinical program providing music for dying patients in a variety of settings, including geriatric homes, hospices, and two hospitals, including St. Patrick's Hospital. It also developed a training program for people seeking to work with the dying. Similar in form to a graduate degree program, people who completed the program became practitioners of harp music at the bedside of acutely dying patients. In 2002 the project relocated to Mt. Angel, Oregon. The Chalice of Repose Project web site [ www.chaliceofrepose.org ] reaches an international audience. The project continues to offer several educational programs including both intensive residency and distance learning, with clinical internships at various institutions.
Some graduates of the Chalice of Repose Project, and other music-thanatology training programs, network with one another through the Music-Thanatology Association International [ www.mtai.org ]. That organization has developed a set of standards for practice within the field and offers a formal process of certification for persons trained in this professional specialty. Other than that specific training program there is currently no clearly-defined degree-granting or certification process for persons who wish to refer to themselves as music thanatologists as a professional specialty.
Music for the acutely dying
Music vigils
In hospices and hospital facilities that provide musical support, a family can arrange for a bedside visit by one or two specially-trained musicians to sing or play live music for someone who is dying. The purpose of such a music vigil is to provide comfort and support both to the person who is dying and to loved ones. A music vigil can be scheduled by speaking with the hospice staff, palliative care staff, chaplain, or other support staff depending on the facility. Music vigils may take place at any time during hospice care, but they can be of particular benefit during critical times such as the days immediately prior to death, during times when hard decisions must be made, or when artificial life-support equipment is being removed. Typically a vigil will last from thirty minutes to an hour. During a music vigil the musicians will try to respond to the situation in the room by playing music that is responsive to the particular needs of the patient.The goal is to support the patient and family, not to seek applause. Some musicians avoid using words like "perform" or "performance" to describe what they do, because these words may put focus on the person creating the music rather than on the patient for whom the music is being played.
Musicians differ in the details of how they prefer to conduct a music vigil. Some prefer that those in the room remain silent, while others encourage participants to talk quietly with one another and to the dying person as the music plays in a supportive manner in the room, honoring and reinforcing the importance of the family gathering. Some musicians allow families to make a recording of the music vigil as a remembrance of this special time together.
Prescriptive music
The term "presciptive music" refers to the way in which musicians observe body processes and mental states, and then adjust their playing in ways that are appropriate to what the patient is feeling at the time. Prescriptive music is improvised or modified at the moment it is created to adjust to the immediate needs of the patient. For this reason, recorded music is not used in a formal music vigil. The music is offered uniquely for the needs of that patient. If family or friends are present in the room, naturally they will also react to the music. The entire group present may be affected, but the process of creating the music is primarily guided by the state of the dying patient.People who use music in health care are convinced that music can have somatic benefits when used as one component of holistic multidisciplinary palliative care for dying patients. Music thanatologists are formally trained to adjust their harp music to respond to specific organic changes taking place in their listeners, such as changes in breathing rates or circulation. The goal is to support the patient in their own process by offering harp music in a prescriptive manner to create a field that can allow the patient to experience what they need to experience in the most supportive way. Prescriptive music is not specifically outcome-based. That is, the music thanatologist does not try to control what the patient is experiencing, but rather to support the patient in whatever they are experiencing. Creating a supportive musical field may be helpful to a patient who is anxious by making it easier for them to calm down or become more at peace.
Life review and family interaction
In hospice care and in many nursing homes, the process of thinking back on one's life and communicating about one's life to another person is called life review. Life review is an important part of bringing one's life to a close. As life ends, we want to know that we have truly been seen by someone in this world, and that our life has had value and meaning. Musical memories, and the use of music to stimulate recall, can be an enjoyable and emotionally-engaging part of life review. Hearing specific music can help people remember meaningful times from the past. Sharing music with others and talking about "old times" with a supportive listener can reduce feelings of isolation. Family members and other loved ones may find it hard to express their feelings, fears, and final wishes when death is imminent. Music can help the social interaction both by offering opportunities for conversation, and by providing a comforting background when words just aren't needed.Other uses of music in care
The use of music in caregiving and support has many applications beyond the bedside of the acutely dying.Music can be helpful to people who are in grief. Music has been shown to be of benefit in nursing homes to stimulate alertness and social functioning of elderly persons. Some studies have shown that elderly patients in nursing homes have better appetite and improved mood when music is played during meal times. Even completely non-responsive dementia patients have been known to react in striking ways to music, including singing lyrics in response to old favorites. Music may be a useful adjunct in cases of emotional distress, grief, restlessness, agitation, and insomnia. Music can be used to calm agitated patients and to induce sleep. Music has been used for years by dentists as a way to distract the mind and reduce perceived pain.
The type of music used for these purposes will vary depending on cultural and faith preferences, the stage of illness, the immediate comfort needs of the patient and family, and available musical resources. In almost all cases the music is of a soothing, relaxing, or uplifting nature. The music may be drawn from existing songs, hymns, or lullabies, or it may be composed spontaneously to respond to the organic processes taking place. The most important thing is that it be supportive to the persons receiving it.
If existing music is used, the arrangement may be adjusted to make it more effective with seriously ill persons. Common changes in arrangement include softening volume, reducing percussion, slowing down the tempo, and reducing tonal range. Harp, recorder, and guitar are the most common instruments. Purely vocal music may be sung or chanted without accompanying instruments. Recorded music can include natural sounds such as chimes, bells, bird songs, wind, or rain. Music drawn from a specific religious tradition, such as hymns or praise, can backfire unless it is known for certain that the person who is dying loved that type of music. This is not a time to force religion on someone who cannot object.
When using any type of recorded music in hospice settings, consider using headphones to limit "sonic spillover" from the room.
Music to lighten things up
Like everyone else, people who are sick sometimes like to listen to music just to cheer themselves up. As Roger Rabbit says, "Sometimes the only weapon you've got is a laugh."Music to lift the spirits is often played at a moderately fast tempo with frequent use of rhythm changes and percussion. These features make the music unsuitable for use with people who are very close to death. When death is very near, slow (largo) music with a constant tempo, or softly arhythmical tonal background sounds are most appropriate.
Upbeat music is included at funerals more often than you might think. Playing a favorite song can recall a time when life was good and it all seemed like it would go on forever. Remember, funerals are for the living. If you have the responsibility of planning a funeral, don't be afraid to include any music that has special meaning for you or your loved one. Ever see one of those great New Orleans jazz funerals? What a way to go!
Medi Hospice would like to acknowledge http://www.growthhouse.org/music.html for this wonderful article on the use of music in caring for the dying.
Music touches the very core of our spirit and soul. As hospice caregivers we can utilize tools and resources available to enhance our volunteer experience.
I have my own particular sorrows, loves, delights; and you have yours. But sorrow, gladness, yearning, hope, love, belong to all of us, in all times and in all places. Music is the only means whereby we feel these emotions in their universality. ~H.A. Overstreet
Donalyn Gross, Ph.D., LCSW, CMP, has been a Thanatologist (Death and Dying counselor) for over 26 years. She has worked with the dying and their loved ones in hospitals, Hospices, correctional systems and Long Term Care facilities. She teaches college courses and workshops on end-of-life issues. Dr. Gross is an author of various books and music CD's relating to her work with the dying. She is a professional musician of over 34 years, and as a Certified Music Practitioner, plays the harp for the dying. She is also the creator of the Good Endings program, www.goodendings.net.
When someone is actively dying, music can play an important role by providing a sense of peace and comfort. Performed by Dr. Gross, ten non-melodic and arrhythmic songs feature the therapy harp in its simplest form.
You don't have to be a musician to incorporate music into your hospice volunteer visits.
Without music life would be a mistake. ~Friedrich Wilhelm Nietzsche
