music therapy in palliative care

When I’m dying, will you sing to me?

Dignity

in Dying

The Therapeutic Use of Music in End-of-Life Aged Care: A Resource for Service Providers, Caregivers, Community and Family

Alexandra Morse

Registered Music Therapist

Cover:

Death Lilies by Norah Lillas

This publication was funded by an Australian Government Initiative under Better Access to Palliative Care

in Tasmania, through the Tasmanian Association for Hospice and Palliative Care (TAHPC).

When I’m Dying Will You Sing to Me? The Therapeutic Use of Music in End-of-Life Aged Care

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When I’m Dying Will You Sing to Me?

The Therapeutic Use of Music in End-of-Life Aged Care A Resource for Service Providers, Caregivers, Community and Family

Alexandra Morse

Registered Music Therapist

January 2016

Alexandra Morse, is a registered music therapist, practicing in North and North West Tasmania.

She holds a Bachelor of Music Therapy from the University of Queensland and a Graduate

Certificate of Business from the University of Tasmania. Alexandra specialises in dementia and

palliative care in both residential and community aged care facilities. Alexandra currently conducts

music therapy programs in five aged care organisations, include Tandara Lodge in Sheffield,

Meercroft Home in Devonport, Rubicon Grove in Shearwater, Aged Care Deloraine in Deloraine and

Baptcare Karingal in Devonport.

Alexandra is a passionate advocate for quality creative arts programs to increase quality of life in

older adults. She conducts a number of unique music therapy programs including,

intergenerational music therapy, personalised music on iPods and music listening applications on

iPads, movement to music sessions, choir therapy, Montessori and music groups and community

engagement through music programs. Alexandra has run music therapy and creative ageing

workshops in Tasmania, Adelaide, regional Victoria and Brisbane for older adults and their

caregivers.

Alexandra Morse

Email: [email protected]

Website: musicistherapy.com.au

Social Media: Music is Therapy Page on Facebook


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If music be the food of love, play on;

give me access of it, that, surfeiting, the appetite may sicken,

and so die. That strain again!

It had a dying fall, O, it came o’er my ear like a sweet sound.

William Shakespeare

It is common Australian culture to put one’s self and each other down in regard to their musical

abilities. Phrases such as ‘You wouldn’t want to hear me sing’, or ‘I’ve only got a rough passage

out’ are common remarks among caregivers in residential aged care homes. However, thoughtful

musical engagement with a person receiving end-of-life care, either through recorded or live music

can provide far greater benefits than simply musical entertainment. This paper offers practical

ideas for carers on how to use music effectively with the dying.

Sincere thanks go to the Tasmanian Association for Hospice and Palliative Care for their

contributions towards this paper, workshops and musical kits.


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Music Therapy in Palliative Aged Care Music Therapy in hospice and palliative care aims to improve a person’s quality of life by addressing their physical, emotional and spiritual needs. In addition, music therapy may provide support for family and caregivers by providing a non-invasive and compassionate approach in assisting with grief.

This resource aims to provide service providers, caregivers, family and the wider community of individual’s accessing palliative care in residential aged care the tools to effectively implement the use of music in end-of-life care.

What is Music Therapy?

The Australian Music Therapy Association defines Music Therapy as:

‘a research-based practice and profession in which music is used to actively support people as they strive to improve their health, functioning and wellbeing. Music therapy is the intentional use of music by a university trained professional who is registered with the Australian Music Therapy Association Inc. Registered music therapists draw on an extensive body of research and are bound by a code of ethics that informs their practice. Music therapists incorporate a range of music making methods within and through a therapeutic relationship. They are employed in a variety of sectors including health, community, aged care, disability, early childhood, and private practice. Music therapy is different from music education and entertainment as it focuses on health, functioning and wellbeing. Music therapists are committed to supporting people of any age and ability regardless of musical skill, culture or background (AMTA, 2015)’.


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Music to Celebrate Life

Since the beginning of human existence, music has been used to celebrate life across all continents

and cultures. Music has been universally enjoyed and treasured throughout generations.

Throughout our life, we connect important memories to music. Music is used to celebrate

significant milestones, such as a marriage, the birth of a child, the end of a year and the beginning

of a new one. For example, a person may recall a song which was a number one hit during the year

of their graduation from high school, or a first dance as husband and wife. Most people have

experienced listening to a ‘shiver song’, the moment when listening to a piece of music gives chills

up the spine and goose bumps because the song is particularly meaningful. Music is an effective

tool for reminisce and life review, as it assists in triggering a person’s memories, allowing for greater

reflection on one’s life. Music can provide opportunities to affirm life and give it meaning.

Additionally, music can be an important tool at the end of a person’s life, bringing it to a close.

Evidence shows that music has a wide variety of emotional, physical and spiritual benefits for those

receiving end-of-life care (Aldridge,1998; Bruscia & Groke, 2002; Krout, 2001).

These may include:

- Decreasing feelings of isolation, depression, fear, confusion and anxiety

- Reducing physical symptoms of pain and agitation

- Providing meaningful interactions with family members

- Assist with relationship completion and resolution

- Connection to spiritual beliefs

- Providing emotional support for family and caregivers


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These benefits occur through engaging in a variety of musical experiences such as:

- Listening to live music

- Listening to pre-recorded music

- Listening to therapist-composed music

- Engaging in musical improvisation

- Composing music

- Song (lyric) discussion

- Music appreciation

- Somatic listening

- Performing on an instrument

- Music combined with other modalities such as art or movement therapy (Dileo & Bradt,

2005)

For patients at the very end-of-life, it may be difficult to verbally express their emotions or needs

and engage with the music therapist. In this instance receptive music therapy methods such as

pre-recorded or live music listening may be effective in reducing pain, anxiety, depression or

nausea and increase mood and wellbeing (O’Callaghan, 1997).


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Case Example

Lora, was an 85-year-old woman who lived in residential aged care for the last three years of her

life. Lora was an intelligent woman, she raised three sons, taught at the local primary school and

thrived on English literature and history. She had extensively traveled the world with her husband

and wrote a biography about her family’s history. Lora loved the creative arts, but particularly

enjoyed painting. Every one of her paintings had a story. Lora was a social person, and transitioned

into living in residential aged care with apparent ease. Lora was loved by the residents and the staff

who cared for her.

Music had also played a significant part in her life. Lora learnt to play the piano as a child and

shared fond memories of singing in community choirs. Since moving into the aged care home, Lora

engaged in weekly group music therapy sessions, based around choir therapy. Lora loved to sing,

but especially enjoyed pointing out other resident’s achievements during each session to the music

therapist. Lora rarely missed a music therapy session. On the occasions when her friends or family

came to visit her, she would insist that they partake in the session, which was warmly welcomed by

the music therapist.

Lora’s health declined rapidly after a stroke, after which she received specialised palliative care

support. During Lora’s final weeks, the music therapist conducted sessions individually. During

these sessions, Lora engaged in receptive music therapy techniques such as music listening of live

and pre-recorded music. In moments of lucidness, Lora would verbalise lyrics of songs which she

recognised. During her final music therapy session, the music therapist came to Lora’s bedside.

Lora was alone, but peaceful. The music therapist took Lora’s hand and slowly and softly sang one

of her favourite songs “You are my Sunshine”. Lora immediately opened her eyes, looked up to the

ceiling of her room and smiled. Lora took a deep breath, gave a big smile and closed her eyes

again. At the conclusion of the session, as the music therapist was leaving her room, she was

approached by two other residents. Both had tears streaming down their faces. One woman

stated, “thank you so much for singing to Lora”, the other said, “when I die, will you sing to me?”

The music therapist reassured the women that all efforts would be made for this to occur. Lora dies

two days later, surrounded by her family, with her faviourite music playing in the background.


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Accessing Music

Whilst it is most ideal that a residential aged care facility provides music therapy services to its

residents. In Australia, the opportunity to access a registered music therapist is rare. There is

currently one music therapist for every thirty-five residential aged care service providers. However,

this should not limit a person’s access to quality music for care programs.

In residential aged care, recorded music is frequently played in common areas, such as the dining

and living rooms. During end-of-life care recorded music may also be played in a resident’s room

for a relaxation effect. When selecting songs for older adults, it is most effective to choose popular

music from when they were in their late teens to early thirties. Music may be played either through

a portable music device such as a cd player, thereby filling the room with sound. Or, music may be

played through headphones, usually on a device such an an iPod shuffle. From anecdotal

experience, playing music through the iPod is more effective than playing music through a CD

player as the music can be easily internalised. Care staff are to ensure that the resident is not left

alone when listening to music while wearing headphones. Residents like to be in control the music

their choice, volume and intensity which is not always possible when receiving end-of-life care due

to physical and cognitive limitations. Grocke and Wigram (2007) suggest some thoughtful music

listening indicators for care staff to be aware of. These include:

- Recognisable behavioural indicators of positive response

- Recognisable behavioural indicators of negative response

- Recognisable behavioural indicators of agitation or distress


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Music in End-Of-Life Kits

The Music in End-Of-Life Aged Care Kits, provided by Tasmanian Association of Hospice and

Palliative Care include a number of CDs which may be appropriate for receptive music listening and

life review for those receiving end-of-life care. Whilst every effort should be made by care staff to

insure music listening in personalised, this selection of music may be used as a starting point. It

should be noted that the music was chosen to be culturally appropriate for a ‘typical’ older

Tasmanian adult in their eighties. Each kit contains 10 albums. These include: The best of Eva

Cassidy, Classically Chilled, Andre Rieu: Mother and Child, Song from America’s Heartland:

Mormon Tabernacle Choir, The Essential Aled Jones, David Hobson: Endless Days, David Hobson:

Enchanted Way, The Ultimate Australian Songbook, Alan Jones Presents the Great Love Songs,

Wings of a Dove: Music of Serenity and Peace.

Grocke and Wigram (2007) make a significant point that some people may be unfamiliar with

classical music, therefore it is important to play ‘light’ classical music such as the selection on the

album ‘Classically Chilled’, as shown above. This is because some heavier music may induce

depressed feelings. Additionally, music with environmental noise such as a waterfall or birds calling

may confuse a person with dementia and they may begin to look for where the sound is coming

from.


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Singing During Caregiving

Singing to a person whilst administering end-of-life care such as maintaining skin integrity, nutrition,

hydration and hygiene can provide a resident with comfort and reassurance during this time.

Singing may also create an increased state of relaxation for the resident. Songs which are

appropriate to sing during care are familiar to the resident, have simple melodic lines, a small pitch

range, a slow tempo and have environmental themes. The following songs may be appropriate in

this context.

You Are My Sunshine Davis and Mitchell 1939

You are my sunshine, my only sunshine You make me happy when skies are grey

You never know, dear, how much I love you Please don't take my sunshine away

The other night, dear, as I lay sleeping

I dreamt I held you in my arms When I awoke, dear, I was mistaken

So I hung my head, and I cried



I'll always love you and make you happy

If you will only say the same But if you leave me to love another,

You'll regret it all one day



Please don't take my sunshine away


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Over the Rainbow Arlen and Harburg 1939

Somewhere over the rainbow

Way up high, There's a land that I heard of

Once in a lullaby.

Somewhere over the rainbow Skies are blue,

And the dreams that you dare to dream Really do come true.

Someday I'll wish upon a star

And wake up where the clouds are far Behind me.

Where troubles melt like lemon drops Away above the chimney tops

That's where you'll find me.

Somewhere over the rainbow Bluebirds fly.

Birds fly over the rainbow. Why then, oh why can't I?

If happy little bluebirds fly

Beyond the rainbow Why, oh why can't I?


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What a Wonderful World Theile and Weiss 1967

I see trees of green,

red roses too. I see them bloom, for me and you.

And I think to myself, what a wonderful world.

I see skies of blue,

And clouds of white. The bright blessed day, The dark sacred night. And I think to myself,

What a wonderful world.

The colors of the rainbow, So pretty in the sky.

Are also on the faces, Of people going by,

I see friends shaking hands. Saying, "How do you do?"

They're really saying, "I love you".

I hear babies cry,

I watch them grow, They'll learn much more,

Than I'll ever know. And I think to myself,

What a wonderful world.

Yes, I think to myself, What a wonderful world.

Oh yeah.


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Annie's Song John Denver 1974

You fill up my senses like a night in the forest,

like the mountains in springtime, like a walk in the rain, like a storm in the desert, like a sleepy blue ocean.

You fill up my senses, come fill me again.

Come let me love you, let me give my life to you, let me drown in your laughter, let me die in your arms, let me lay down beside you, let me always be with you.

Come let me love you, come love me again.

You fill up my senses like a night in the forest, like the mountains in springtime, like a walk in the rain,

like a storm in the desert, like a sleepy blue ocean. You fill up my senses, come fill me again.

Edelweiss Oscar Hammerstein and Richard Rodgers 1965

Edelweiss, Edelweiss

Every morning you greet me Small and white, clean and bright

You look happy to meet me Blossom of snow may you bloom and grow

Bloom and grow forever Edelweiss, Edelweiss

Bless my homeland forever


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Oh What a Beautiful Morning Richard Rodgers, Oscar Hammerstein 1955

There's a bright golden haze on the meadow There's a bright golden haze on the meadow

The corn is as high as an elephant's eye An' it looks like it's climbin' clear up to the sky

Oh, what a beautiful mornin' Oh, what a beautiful day

I've got a wonderful feelin' Every thing's goin' my way

All the cattle are standin' like statues All the cattle are standin' like statues

They don't turn their heads as they see me ride by But a little brown maverick is winkin' his eye

Oh, what a beautiful mornin' And oh, what a beautiful day

I've got a wonderful feelin' Every thing's goin' my way

All the sounds of the earth are like music All the sounds of the earth are like music

The bees are so busy they don't miss a tree And an old weepin' willow is laughin' at me

Oh, what a beautiful mornin' Oh, what a beautiful day

I've got a wonderful feelin' Every thing's goin' my way now

Oh, what a beautiful day Beautiful day


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Amazing Grace Traditional

Amazing Grace, how sweet the sound,

That saved a wretch like me, I once was lost but now am found,

Was blind, but now, I see. T'was Grace that taught...

my heart to fear. And Grace, my fears relieved.

How precious did that Grace appear... the hour I first believed.

Through many dangers, toils and snares... I have already come.

Tis Grace has brought me safe thus far... and Grace will lead us home.

The Lord has promised good to me... His word my hope secures.

He will my shield and portion be... as long as life endures.

When we've been there ten thousand years... bright shining as the sun.

We've no less days to sing God's praise... than when we've first begun.


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Music for Caregivers

Music can be used to bring a closeness between family and offers opportunities for conversation.

Music may also provide a comforting environment when words are no longer needed. Music can

provide an opportunity to say goodbye to a loved one. Additionally, music can support a person

through their grief and loss. Song writing allows for a persons’ expression of emotions and can be a

tribute to their loved one. Katie Noonan’s composition Home, reflects her memories a grief for the

loss of her Aunt. Home can be listened to via https://www.youtube.com/watch?v=lEgRsHjoF4c

Home Katie Noonan 2015

I looked out across the bay and thought of you and your smile Looking out at your home town and wishing I could hold you

I remember standing round the kitchen, Corona Street Sneaking treats from your apron, and calling me your ‘Darl’

Then the rain started to fall, and it seamed to fit, my confusion But soon the suns rays made the sky sing

Cause you are with him now, in a better place, out of pain

You are with him now, in a safe place free from harm You are home

The sun was loud and mighty not a rainbow to be seen

It felt like you were saying goodbye and letting me know you were fine Cause I’m not going to focus on the fading end

But on the life that shone bright throughout It was huge just like the love you had to give

So proud, giving until the end

Cause you are with him now, in a better place, out of pain You are with him now, in a safe place free from harm

Cause you are with him now, in a peaceful place, out of pain You are with him now, in a safe place free from harm

Cause you are home

You are home

References Aldridge, D. (Ed.). (1998) Music therapy in palliative care: new voices. London and Philadelphia: Jessica Kingsley Publishers. Australian Music Therapy Association (2015). What is music therapy? http://www.austmta.org.au/content/what-music-therapy. Accessed December 2, 2015.

Bruscia, K. E., & Grocke, D. E. (eds.). (2002). Guided imagery and music: the bonny method and beyond. Gilsum, NH: Barcelona Publishers.

Dileo, C. & Bradt, J. (Ed.). (2005). Music Therapy at the End of Life. Cherry Hill: Jeffrey Books.

Grocke, D. E. & Wigram, T. (2007). Receptive methods in music therapy: Techniques and clinical applications for music therapy clinicians educators and students. London and Philadelphia: Jessica Kingsley Publishers.

Hogan, B. E. (1999). The experience of music therapy for terminally ill patients: a phenomenological research project. In D. R. Pratt & D. Erdonmez-Grocke (eds.), MusicMedicine 3: MusicMedicine and music therapy: Expanding horizons (pp. 242-252). Melbourne: The University of Melbourne.

O’Callaghan, C. (1997). Therapeutic opportunities associated with music when using song writing in palliative care. Music Therapy Perspectives. (15) 32-8.

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