Endnotes: Music Therapy in Palliative Care

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Music, with its intrinsic capacity for beauty and expression, has been employed throughout time to convey the gamut of human emotion and experience, to soothe and stimulate, and to speak directly to our hearts and souls. Music therapists are health care professionals trained to use the potency and almost universal appeal of music to address a variety of physical, educational, psychosocial, and spiritual needs.

The very breadth and depth of music makes it a wonderful tool in palliative care. Music therapy benefits people at the end of life by promoting relaxation, pain control, and a sense of well-being, as well as by acknowledging and celebrating life, stimulating meaningful memories, bringing loved ones together, and supporting emotional and spiritual expression.

Consider the following scenarios, which are everyday stories from my practice of music therapy in palliative care:

I am making my first visit to an elderly bed-bound woman. We discuss the importance of music in her life, and explore what seems to bring her meaning and pleasure. She speaks of her youth in Hungary, and of how she loved to dance. Soon we are involved in re-creating some of those memories and emotions. She chooses favourite Hungarian tunes from a collection of world music and provides rhythm on the tambourine while I play the melodies on my flute. Her husband arrives and begins to dance the folk dances of their youth. Both reminisce, eyes sparkling, the love between them palpable in the room.

In another room, a middle-aged, hard-living bachelor is showing signs of confusion as he nears the end of his life. He is a connoisseur of country music, and we've spent several sessions listening to, singing, and discussing his favourites. On this day he is agitated, his thoughts disorganized. I wonder if we can use the predictable structure of a country-western song to help provide him with a greater sense of order and a means of expression. Slowly, by repeating the familiar chord progressions on the guitar, and incorporating his thoughts into lyrics, we compose a country song. What appeared disjointed in his speech seems poetic in song and he is proud of his creation. The song is about going home, seeing his parents again, and the wish that he could return to his drinking buddies. Later, at multidisciplinary team rounds, his song provides the team with another means of understanding him.

Some patients engage in music-relaxation techniques to help cope with anxiety, insomnia, or physical discomfort. Together we create "personal sanctuaries" composed of nourishing images and calm, nurturing music. In one such case, a young man managed his night-time fears by breathing deeply to the rhythm of a chosen CD of gentle music with ocean sounds, while imagining that he was drinking piña coladas with his friends on a favourite beach. Here the music therapist's role was to help him discover and practice the relaxation techniques that worked most effectively for him.

Other patients and family members welcome opportunities to make music through improvising with the music therapist on simple percussion instruments. These improvisations allow for the pleasure of creative activity as well as a non-verbal means of expression. The music, instruments, and therapist all serve to facilitate the safe release of emotion that may be difficult to verbalize. One 11 year old boy, whose mother was close to death, came to my office and played the rhythm instruments with great, noisy energy. After a while, his music became quieter and he began to create a rap song about a sad monkey whose parent had gone away. His anger and sadness could be expressed through creative music-making, and the song recorded to later share with his dad.

It is a great privilege to work with people who are at the end of life; I am so often moved by their courage and grace. One woman who particularly inspired me to live my own life more fully was a musician, poet, educator, and philosopher. She could barely move or speak due to end-stage amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), but was nonetheless an incredible communicator. We shared a love for classical music, especially Bach, and as I played for her she would soak in the music and visibly relax. One day, while sitting in her wheelchair at the piano, she composed a melody, indicating tones by pointing to the piano keys with a stick, and dictating rhythm by making rhythmic vocal sounds. Together we added a harmony and, delighted, she entitled her composition Opus One. This piece became a precious legacy for her family and was played at her funeral.

In the Palliative Care Service of the McGill University Health Centre, music therapy has been an integral part of patient care since palliative care's inception at the Royal Victoria Hospital in 1975. The music therapist visits each patient on the Palliative Care Unit to assess if and how music therapy might be beneficial, and to offer individualized interventions. Musicians from the community regularly play on the unit on a volunteer basis, and there is a sizeable CD/cassette library as well as a CD/cassette player at every bedside.

Music has the power to touch our hearts and lift our spirits, to bind us together and give expression to the inexpressible, to transport us to other times and places, and to soothe or stimulate our bodies, minds and spirits. It reaches us on so many levels and, as a therapeutic tool, has great potential to enhance end-of-life care.

Deborah Salmon, MA, MTA, CMT, is a music therapist at the Palliative Care Service of the McGill University Health Centre. For more information on music therapy, contact the Association québécoise de musicothérapie at 514-987-3675, or the Canadian Association for Music Therapy at 1-800-996-CAMT, or www.musictherapy.ca .