Music Therapy in Hospice: A Natural Vehicle for Patient-Centered Care
By Laura Kanofsky, Board Certified Music Therapist and Licensed Clinical Social Worker
Patients on hospice service, their loved ones and the professionals who work with them often experience a need for sources of comfort and avenues of communication that go beyond the pharmacological, verbal, and even the linear. Music Therapy, a professional discipline that was formally established in the U.S. in the 1940’s, but has existed, less formally, since biblical times, is remarkably well-suited to address many of the issues that arise for hospice patients and families.
“Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.” Generally, music therapy aims to restore, maintain or improve mental, physical, emotional or spiritual health.
Music therapists work with an array of clinical populations across the lifespan and in settings ranging from psychiatric and medical to educational, clinic-based and private practice. Whatever the context, there are two constants:
- Music therapy always involves three elements: the patient/client, the music therapist and music
- The music therapist meets the patient where he/she is. Since a particular pitch, piece or even style of music does not affect everyone the same way, music therapy is not prescriptive in nature. The design and delivery of music therapy is largely determined by each patient’s unique story and set of needs, and occurs in the context of the therapeutic relationship.
Thanks to research using brain imaging of the past 25 or so years, much has been learned about the complex ways music is processed in the brain. This work has revealed new and exciting information, and also has validated what music therapists and others have known for a long time – that music can dramatically enhance functioning in many domains, including verbal and motor abilities, mood and affect, self-awareness, pain perception and a host of psychosocial areas.
What is a Music Therapist?
Board Certified Music Therapists have a minimum of an undergraduate degree in music, and have also completed the coursework laid out by the American Music Therapy Association in order to fulfill the required 1040-hour clinical internship, whose successful completion, in turn, qualifies them to sit for an independently administered Board Certification exam. Music therapists possess a solid grasp of how music affects cognition and emotions, are proficient on several musical instruments, and able to improvise and compose music in multiple styles. They can effectively use live as well as recorded music, depending on the objectives of the work. Music therapists also are highly competent in non-musical ways. Because music has the power to elicit remote memories and evoke strong feelings, being highly attuned to the patient/family/group is essential in order to be able to recognize a significant reaction, and to skillfully explore, validate, or contain the feelings expressed as needed.
Music Therapy in Hospice
Often, the people served by a given hospice come from a broad spectrum of socioeconomic, cultural, religious, and family backgrounds. Each patient presents as a unique person, with strengths and needs that are much more than the sum of a diagnosis or symptoms. The music therapist, through gathering of family, medical, musical and other histories, gaining information from collateral sources and meeting, observing, talking to the patient and family assesses the needs, and ideally in conjunction with the patient and the hospice team, establishes treatment goals, and the most effective way to meet them.
In hospice, music therapists focus primarily on psychosocial issues, as well as spiritual and physical needs. Music therapy, even in the absence of verbal language, can decrease feelings of isolation, and provide a sense of familiarity and comfort. It can help someone maintain a sense of control through decision-making about most musical aspects of the session. The associations and feelings evoked by music can facilitate reminiscence and life review. Music can create a connection with one’s history, one’s faith, one’s unconscious. It can reach a person in a deep and highly individual way, yet it can transcend differences and awaken a sense of universality.
The following are a few common goals and corresponding approaches/interventions:
Goal: Provide vehicle for expression and containment of grief and other feelings
Intervention: songwriting (to familiar or co-created melodies)
When a patient is well enough to participate in this process, it can provide needed catharsis in a creative and supportive context. If starting from scratch is too daunting, substituting lyrics into known melodies can be utilized. This process can also serve to validate a patient’s sense of purpose or meaning in life.
Goal: Facilitate access to long-term memory (to connect to emotions and to experience sense of mastery)
Intervention: Singing songs that held meaning in patient’s youth/young adulthood (and if relevant and possible, in the patient’s native language so as to provide cultural affirmation)
Since music serves as a direct link to long-term memory, this type of music therapy, often with instrumental accompaniment, is common in hospice work. It is exceedingly moving for all involved when someone with advanced dementia becomes more alert and animated, more connected those around him, and more dignified due to even a fleeting moment of heightened lucidity brought about by music. Families and friends sometimes experience music’s profound ability to recover speech and memory as “magical”.
Goal: Improve/help heal family relationships and provide family support
Intervention: Semi-structured group musical improvisation; singing/lyric discussion
Hospice provides the opportunity for family members, even formerly estranged ones, to come together. Improvisational songs and chants, possibly with untuned (rhythm) instruments, enable family members to share thoughts, feelings and wishes for the patient and each other.
Selecting songs to sing or music to listen to that have had special meaning within the family can carry a symbolic message or create a collective sense of unification, as life preceding the patient’s illness may be recalled. This also provides a way to be with the patient that doesn’t rely solely on language.
Goal: Provide comfort, solace, support of pt’s faith through traditional forms of worship
Intervention: Singing of hymns, chants or playing of other liturgical music
Goal: Help alter perception of pain/induce relaxation
Intervention: listening to live music that is soothing, or recorded music, possibly with suggestion for imagery; musically matching and guiding breathing
Although there are several theories to explain how it is accomplished, research has shown music therapy to be effective in altering the perception of pain.
6 Other Ways to Positively Impact a Patient Through Music
Because of their unique skill-set, music therapists are optimally qualified to carry out musical interventions to improve the quality of life of a hospice patient. However, we are living in a time where the power of music with those at the end of life and others, is increasingly recognized. There has been an upsurge in recent years of many types of music practitioners, bedside singers, harpists, ipod facilitators and others who work with hospice patients. And, of course, family members and friends of those on hospice often find that they are able to naturally bring comfort to their loved ones, and to themselves, though music. Indeed there are many ways that family members, friends and volunteers are able to positively impact a patient using music. These include the following:
- Playing patient-requested music from a smartphone with speakers or a tablet. This enables the patient to be in control, and to enjoy an improved quality of life by being positively distracted and possibly transported. Custom CD’s or playlists can potentially fill the hours beyond visits.
- Singing with or for the patient; it is important for the patient to guide this process if possible, and if chosen by someone other than the patient, to be mindful of the era and style of the music (e.g. for someone born in the early 1930’s, most music past the 1950’s may not be experienced as familiar or meaningful).
- Facilitate gentle physical movement to a reasonable extent through use of recorded music (music activates motor centers and is naturally conducive to movement)
- Create a life-review CD or playlist
- Arrange musical portion of memorial service planning
- Engage volunteer bedside musicians such as Threshold Choir singers
“Music can lift us out of depression or move us to tears – it is a remedy, a tonic, orange juice for the ear. But for many of my neurological patients, music is even more – it can provide access, even when no medication can, to movement, to speech, to life. For them, music is not a luxury, but a necessity.” Oliver Sacks, Musicolphilia.
1) The American Music Therapy Association governs most aspects of music therapy in the U.S., and is a resource to find local music therapists as prospective employees or to provide further information/training
2) Music Therapy in Hospice and Palliative Care: a Review of the Empirical Data, Russell Hilliard
3) video of Gabby Giffords’ recovery through music therapy
4) Threshold Choir, founded in California, has many chapters throughout the U.S. and beyond
Laura Kanofsky is a Board Certified Music Therapist and Licensed Clinical Social Worker for Tranquil Care Hospice and in private practice in Santa Monica, California.
 American Music Therapy Association