Music therapy in palliative medicine

Effectiveness of Medical Music Therapy Practice: Integrative Research Using the Electronic Health Record: Rationale, Design, and Population Characteristics

Background: Several clinical trials support the efficacy of music therapy (MT) for improving outcomes in hospitalized patients, but few studies have evaluated the real-world delivery and integration of MT across multiple medical centers. This article describes the rationale, design, and population characteristics of a retrospective study examining the delivery and integration of MT within a large health system. Methods: A retrospective electronic health record (EHR) review was conducted of hospitalized patients seen by and/or referred to MT between January 2017 and July 2020. MT was provided across ten medical centers, including an academic medical center, a freestanding cancer center, and eight community hospitals. Discrete demographic, clinical, and MT treatment and referral characteristics were extracted from the EHR, cleaned, and organized using regular expressions functions, and they were summarized using descriptive statistics. Results: The MT team (average 11.6 clinical fulltime equivalent staff/year) provided 14,261 sessions to 7378 patients across 9091 hospitalizations. Patients were predominantly female (63.7%), White (54.3%) or Black/African American (44.0%), 63.7 ± 18.5 years of age at admission, and insured under Medicare (51.1%), Medicaid (18.1%), or private insurance (14.2%). Patients' hospitalizations (median length of stay: 5 days) were primarily for cardiovascular (11.8%), respiratory (9.9%), or musculoskeletal (8.9%) conditions. Overall, 39.4% of patients' hospital admissions included a mental health diagnosis, and 15.4% were referred to palliative care. Patients were referred by physicians (34.7%), nurses (29.4%), or advanced practice providers (24.7%) for coping (32.0%), anxiety reduction (20.4%), or pain management (10.1%). Therapists provided sessions to patients discharged from medical/surgical (74.5%), oncology (18.4%), or intensive care (5.8%) units. Conclusions: This retrospective study indicates that MT can be integrated across a large health system for addressing the needs of socioeconomically diverse patients. However, future research is needed to assess MT's impact on health care utilization (i.e., length of stay and rates of readmission) and immediate patient-reported outcomes.

Acute Inpatient Palliative Medicine in a Cancer Center: Clinical Problems and Medical Interventions—A Prospective Study

The clinical characteristics and medical interventions of the 100 consecutive cancer admissions to the acute care inpatient palliative medicine unit at the Cleveland Clinic for 2 months are described. Median age was 62 years (range, 31 to 92 years). The male-female ratio was 1:1. Most admissions were referred by hematology-oncology and had prior antineoplastic therapy. Reasons for admission were symptom control and cancer-related complications. Patients underwent invasive diagnostic and therapeutic procedures, hydration, transfusions, radiation, or chemotherapy, or a combination, during their admission. Most were discharged home with hospice care or had outpatient clinic follow-up. The mortality rate was 20%. Aggressive multidisciplinary management of symptoms, disease complications, comorbid conditions, and psychosocial problems were provided. Palliative medicine physicians provided continuity of care in the outpatient clinic and at home. An acute inpatient palliative medicine unit within a tertiary level medical center has a definable and important role in comprehensive cancer care.

Music Therapy References Relating to Cancer and Palliative Care

Hospitals and clinics worldwide have incorporated music therapy in their work with cancer patients and in palliative care. As the music therapy profession has developed internationally, so has its role in palliative care. The arts and creative arts therapies are being seen as a form of spiritual care in healthcare settings, particularly where individuals are confronting life-threatening illnesses. By offering opportunities to engage in the arts and develop creative expression, people with cancer can be enabled to mourn, grieve, celebrate life, be empowered to endure their situation, and find healing and meaning. In many studies we find that music therapy is not simply used with the identified patients but also with their families and carers. As well as noting the importance of work with patients and their families, music therapists also emphasise the importance of music for their own healing. This is necessary to meet personal needs when working with the dying and in the context of a broader hospital milieu of colleagues and friends.

The World Health Organisation's recommendations for cancer relief and palliative care are to affirm life and regard dying as a normal process, to provide relief from pain and distressing symptoms, to integrate the psychological and spiritual aspects of patient care, to offer a support system to help patients as actively as possible until death, and to offer a support system to help the family cope during the illness and in their own bereavement. Music therapy has the potential to meet all of these recommendations.

The Meaning of the Music: The Role of Music in Palliative Care Music Therapy as Perceived by Bereaved Caregivers of Advanced Cancer Patients

In an earlier qualitative research study exploring the meaning of preloss music therapy to bereaved caregivers who participated in sessions through a home-based hospice program, various narrative accounts revealed the significance of music in music therapy sessions. In this study, the role of music in palliative care music therapy is examined and representatively summarized, followed by a review of strategies provided by this author to home hospice patients and their caregivers. The reported perceptions of the meaning of music to 7 bereaved caregivers are presented, including a review of themes and associated narrations that illustrated its significance. The caregivers described these aspects of music in sessions to have memorable and lasting effects as follows: ``music is a conduit,'' ``music gets inside us,'' ``live music makes a difference,'' and ``music is love.'' Findings support the benefits of preloss music therapy for bereaved caregivers.

The clinical effects of music therapy in palliative medicine

GOAL

This study was to objectively assess the effect of music therapy on patients with advanced disease.

PATIENTS AND METHODS

Two hundred patients with chronic and/or advanced illnesses were prospectively evaluated. The effects of music therapy on these patients are reported. Visual analog scales, the Happy/Sad Faces Assessment Tool, and a behavior scale recorded pre- and post-music therapy scores on standardized data collection forms. A computerized database was used to collect and analyze the data.

RESULTS

Utilizing the Wilcoxon signed rank test and a paired t test, music therapy improved anxiety, body movement, facial expression, mood, pain, shortness of breath, and verbalizations. Sessions with family members were also evaluated, and music therapy improved families' facial expressions, mood, and verbalizations. All improvements were statistically significant (P<0.001). Most patients and families had a positive subjective and objective response to music therapy. Objective data were obtained for a large number of patients with advanced disease.

CONCLUSIONS

This is a significant addition to the quantitative literature on music therapy in this unique patient population. Our results suggest that music therapy is invaluable in palliative medicine.

Music as Therapy

Music is widely used to enhance well-being, reduce stress, and distract patients from unpleasant symptoms. Although there are wide variations in individual preferences, music appears to exert direct physiologic effects through the autonomic nervous system. It also has indirect effects by modifying caregiver behavior. Music effectively reduces anxiety and improves mood for medical and surgical patients, for patients in intensive care units and patients undergoing procedures, and for children as well as adults. Music is a low-cost intervention that often reduces surgical, procedural, acute, and chronic pain. Music also improves the quality of life for patients receiving palliative care, enhancing a sense of comfort and relaxation. Providing music to caregivers may be a cost-effective and enjoyable strategy to improve empathy, compassion, and relationship-centered care while not increasing errors or interfering with technical aspects of care.

A syllabus for fellowship education in palliative medicine

Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.

Integrating complementary and alternative medicine (CAM) into standard hospice and palliative care

In the United States, there are 629 million visits to complementary and alternative medicine (CAM) providers each year. Many adults appear to value both conventional and CAM approaches. Because of this public interest and promising evidence that CAM relieves suffering and improves quality of life, we established a program of CAM, known as Integrative Palliative Care (IPC), in a US hospice. This paper outlines our strategy of collaborative relationships with community schools of traditional Chinese medicine (TCM), massage, and harp therapy. It also describes the use of volunteers and small grants and donations to develop and maintain a program of CAM in the hospice setting. The difficulties of research design, problems with tracking outcomes, and the shortcomings of providing therapies with this model are discussed.

Music therapy with imminently dying hospice patients and their families: facilitating release near the time of death

Hospice care seeks to address the diverse needs of terminally ill patients in a number of physical, psychosocial, and spiritual areas. Family members of the patient often are included in the care and services provided by the hospice team, and hospice clinicians face a special challenge when working with families of patients who are imminently dying. When loved ones are anticipating the patient's impending death, they may find it difficult to express feelings, thoughts, and last wishes. Music therapy is a service modality that can help to facilitate such communication between the family and the patient who is actively dying, while also providing a comforting presence. Music therapy as a way to ease communication and sharing between dying patients and their loved ones is discussed in this article. The ways in which music therapy can facilitate a means of release for both patients and family members in an acute care unit of a large US hospice organization are specifically described. Case descriptions illustrate how music therapy functioned to allow five patients and their families to both come together and let go near the time of death. Elements to consider when providing such services to imminently dying patients and their families are discussed.