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 Palliative medicine is the treatment of patients with advanced diseases such as cancer, AIDS, ALS (Lou Gehrig’s Disease), Alzheimer’s Disease, aortic aneurysm, blood disorders, chronic obstructive pulmonary disease (COPD), chronic pain, congestive heart failure (CHF), dementia, end stage cardiac diseases, end stage liver disease (ESLD), end stage renal disease (ESRD), multiple sclerosis, neurodegenerative disorders, neurological disorders, sickle cell disease, and stroke. Although cure is no longer possible, symptom management, comfort, dignity, and quality of life are possible. Symptoms are assessed routinely and are managed effectively. Some commonly addressed symptoms include pain, nausea, shortness of breath, anorexia, fatigue, constipation, anxiety, and depression.
With the recognition of the benefit of this approach, many hospitals have begun dedicating acute inpatient beds for palliative medicine. Some hospitals also have inpatient beds dedicated to patients on hospice. A patient is eligible for hospice once he/she has a life expectancy of less than six months. The patient is no longer seeking active treatment, and the focus is on comfort and quality of life. The patient and family are considered to be the unit of care. Hospice units may also be found in nursing homes, but the majority of hospice services (80%) are provided in patients’ homes.
 The palliative medicine approach is multidisciplinary in nature, and it takes into consideration the needs of the patients and their families. These needs may be physical, emotional, social, or spiritual in nature. Adjustment to the disease, coping skills, and distress are also addressed. Treatment is individualized based on each patient’s and family’s identified needs. The patient’s religion, culture, and age are also taken into consideration. Education is provided regarding the diagnosis, symptoms, disease process, decisions that need to made, etc. The patient and family are invited to take an active role in making the decisions they deem to be appropriate for their circumstances. Other team members include physicians, physician’s assistants, nurses, case managers, social workers, discharge planners, chaplains, dieticians, and music therapists.
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
 It is the music therapist that will be the focus of the rest of this paper. According to the 2005 American Music Therapy Association definition, “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”. In the United States in order to obtain a degree in music therapy, courses must be taken in music, music therapy, psychology, special education, and anatomy. A six to ten month internship must also be successfully completed. Once these requirements are met, the individual must take a national board certification exam through the Certification Board for Music Therapists. Recertification is required every five years.
 Music therapists work with a wide variety of client populations, such as autism, learning disabilities, mental retardation, psychiatric disorders, speech impairments, substance abuse issues, and various medical disorders. Music therapists identify goals and objectives based on their client’s communication, academic, cognitive, physical, emotional, social, and spiritual needs. They also take into consideration the client’s age, culture, and religion before developing a treatment plan. The identification of needs, individualized treatment, and variety of areas to be addressed are similar to that of the philosophy of palliative medicine. Music therapists can also help provide support, symptom management, coping skills, comfort, and quality of life. For these reasons music therapists play an integral role as a member of a palliative medicine team.
In June of 1994 the Harry R. Horvitz Center for Palliative Medicine was opened at The Cleveland Clinic in Cleveland, Ohio. It is an acute care 23 bed unit for adults, with 13 of the beds being private rooms. It is a very comfortable atmosphere with pastel colors, pleasant art work, and hand-made quilts hanging in each private room. In order to further make it less of a medical environment, music therapy services were added in September of 1994 with music therapists being contracted through The Music Settlement. Financial support was provided through the Jack Belcher Music Therapy Fund and later through the Kulas Foundation. Several years later the program expanded to include music therapy services with the Hospice of the Cleveland Clinic in patients’ homes, nursing homes, and inpatient hospice units.
 From the beginning, the board certified music therapist was seen as a member of the team. The music therapist attends morning report every day where updates are shared regarding every patient on the unit. Medical, psychosocial, and spiritual concerns are all discussed, and the plan of care is determined. Dr. Susan LeGrand, palliative medicine physician from The Cleveland Clinic once said, “I suggest the music therapist for many patients that I bring in the hospital if I think they’re struggling with depression or if they are struggling with anxiety…I watched as it truly made a difference. So, the music therapist was able to touch them in a way that I had been unable to do.”
Referrals for music therapy have been received in many ways. Physician orders for music therapy have been given through the standardized physician order form which is part of the written chart or as a formal consult through EPIC, the electronic medical record. The social worker, nurses, physician’s assistant, and other team members also verbally can request music therapy services for a patient. Housekeeping has even been known to make referrals. Information received during morning report may also help to identify a patient in need. Brochures about music therapy are included in the patient admission packet, so patients and families can request it for themselves.
Reason for referrals (in order of frequency) have included increasing enjoyment (aesthetic pleasure and normalization), decreasing anxiety, decreasing depression, decreasing pain, providing family intervention, increase coping and support, improving mood, providing distraction, helping as a patient is actively dying, providing relaxation and comfort, decreasing agitation and restlessness, processing end of life issues, decreasing confusion, decreasing loneliness, and decreasing shortness of breath. There have been many other reasons for referral as well, but they occur with less frequency than those mentioned above. Once a referral is received the music therapist must prioritize first based on the patient’s immediate need and then on his/her availability.
When seeing a patient it is important to conduct a music therapy assessment. This includes the patient’s symptoms (current rating of pain, depression, anxiety, shortness of breath, and mood), as well as the patient’s musical background (previous experience playing instruments or singing). It is also necessary to determine a patient’s preferred music as that is the music that will be the most effective for him/her, so favorite styles of music, singers, and songs are identified.
Goals are determined on an individual basis. These may be based on the symptoms that were identified during the assessment, the reason for referral, the patient’s stated need or preference, or the therapist’s observation. Common goals (in order of frequency) include: improving mood, decreasing pain, increasing participation, decreasing stress, decreasing anxiety, promoting relaxation, and providing opportunity for self-expression. Music therapy is also part of the unit’s protocols for actively dying and for palliative sedation, so there may also be goals of maintaining or improving level of comfort, decreasing shortness of breath, decreasing agitation and restlessness, and providing support to the patient and/or family.
Live music is always the best as it can be controlled by the therapist, but on rare occasions recorded music may also be utilized. A wide variety of styles are utilized. The most common is gospel, but other styles include classical, big band, jazz, country, musicals, polkas, ethnic, relaxation/new age, rhythm and blues, hip hop, rap, etc. The repertoire needed has grown as new music has emerged and as the patient population has become younger.
 The music therapist uses a variety of interventions based on the patient’s need and ability to participate. Many of the patients are acutely ill and are unable to actively participate; however, they are able to listen as the music therapist plays for them. Other common interventions include: singing, participation (tapping foot, clapping, etc.), musical life review, song choices, instrument playing, verbal processing, lyric analysis, music-assisted relaxation (breathing, progressive muscle relaxation, imagery), song-writing, musical entrainment, planning funeral music, and memory sharing.
Upon the completion of the session the music therapist asks the patient to again rate his/her mood and symptoms. This helps the therapist to objectively evaluate the effectiveness of the session. This data, as well as behavioral data, session information, and therapist comments are documented in the electronic medical record. Some of the information is also transferred into a computerized database that was created by the music therapist to gather large amounts of session data for clinical and research purposes. The music therapist also returns to the referral source to provide any helpful information obtained during the session.
If family members are present they are included in the session. At times the music therapist is asked to provide support to the family and/or to provide a positive bridge between the family and the staff. Goals are often identified for family members as well, and they are encouraged to participate as they are able and willing. This once again matches the palliative medicine and hospice philosophy as the patient and family together become the unit of care.
The music therapist also provides support to the nurses and other staff on the Harry R. Horvitz Center for Palliative Medicine. There are times that the staff members are under a lot of stress, so the music therapist provides sing-alongs, stress management, and /or relaxation sessions for the staff. They have found this to be effective and helpful. Some have even said that it helps to make their job easier and more enjoyable when there is music therapy on the unit.
Research has been done on the effectiveness of music therapy in this setting. In 2006, a study of 200 palliative medicine patients demonstrated that music therapy was effective in improving mood, facial expression, body movement, and verbalization; and in decreasing pain, anxiety, and shortness of breath – all at a statistically significant level. Another study has been completed, but the manuscript is currently in draft form, compares and contrasts the goals, interventions, and results of music therapy sessions between palliative medicine and hospice patients. These studies demonstrate the importance of utilizing music therapy in palliative medicine and hospice.
One example of the effectiveness of music therapy was that of Ms. W. The music therapist arrived right as Ms. W. returned from her radiation treatment. At that time she rated her pain as 8 out of 10, with 10 being the worst possible pain. After singing her favorite hymns with the music therapist she rated her pain as 0 out of 10. She said her pain was gone and that she had been so excited that the music therapist was there when she returned from radiation that she forgot to take her pain medicine. She attributed her pain relief totally to the music.
 Another story that demonstrates the power of music therapy is that of Mr. S. He was a 70 year male with colon cancer and lung cancer. When asked to rate his symptoms he said that nothing was so bad that music couldn't help. He spoke about his shortness of breath and said that it was something he had to live with. When he spoke about being re-hospitalized he joked that he came back because he missed the music. He hummed along quietly during the first song and then sang along on all other songs and played the doumbek (a small drum) on the last song. After the first song he said, "I feel better already." During the session he discussed the songs and shared memories. At the end of the session he said, "That made my day," "Music is part of the healing process," and "That sure uplifted my day. I didn't think about my shortness of breath during the music."
Music therapy is a powerful tool that should be incorporated into palliative medicine and hospice programs. It is cost-effective, does not have harmful side effects, and is beneficial to patients and families alike. It is effective with a variety of patients to achieve multiple goals; it creates a more pleasant environment; it can reach resistant patients; and it can promote positive interaction between patients, families, and staff.
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Thank you!
Mary Wright Indiana Wesleyan University RNBSN 322-Greenwood Campus