Music therapy in UK palliative and end-of-life care: a service evaluation

Music therapy for supporting informal carers of adults with life-threatening illness pre- and post-bereavement; a mixed-methods systematic review

BACKGROUND

Music therapy interventions with informal carers of individuals with life-threatening illness at pre- and post-bereavement is an increasingly important clinical area. This systematic review is the first to synthesise and critically evaluate the international evidence associated with music therapy with adult informal carers pre- and post-bereavement. Specifically, the objectives were: i) to describe the characteristics and effectiveness of music therapy interventions which aim to improve health-related outcomes for adult informal carers of adults with life-threatening illness (pre- and post-bereavement), and ii) to describe the experience of music therapy for adult informal carers of adults with life-threatening illness (pre- and post-bereavement).

METHODS

Eligibility: adult informal carers of adults at end of life or bereaved; music therapy interventions for improving health-related outcomes; qualitative; mixed-method; and quantitative studies including comparators of any other intervention; published in English from 1998 onwards. Six databases were searched up to July 2022. A JBI mixed-methods systematic review approach was followed throughout, including quality appraisal, data extraction and a convergent segregated approach to synthesis and integration.

RESULTS

A total of 34 studies were included, published between 2003 and 2022. Most were conducted in North America (n = 13), Australia (n = 10), or Europe (n = 8). No studies were conducted in low- and middle-income countries or in the UK. The majority were qualitative (n = 17), followed by quasi-experimental (n = 8), mixed-methods (n = 7) and two RCTs. The majority focused on carers of individuals with dementia (n = 21) or advanced cancer (n = 7). Seventeen studies were purely quantitative or included a quantitative component. During meta-synthesis, findings were aligned to core outcomes for evaluating bereavement interventions in palliative care and previously identified risk factors for complicated grief. Commonly targeted outcomes in quantitative studies included quality of life and mental wellbeing, showing equivocal effectiveness of music therapy with significant and non-significant results. Twenty-two studies either purely qualitative or with a qualitative component underwent meta synthesis and suggested a diverse range of improved pre- and post-bereavement outcomes for informal carers across all core outcomes, and across all risk and protective factors, including psychological, spiritual, emotional, and social outcomes.

CONCLUSIONS

Qualitative studies provide moderate to strong evidence for improved health-related outcomes for adult informal carers of adults with life-threatening illness pre-bereavement. Limited studies including those bereaved negates conclusions for the bereavement phase. Comparisons and explanations for effectiveness across quantitative and qualitative studies are equivocal, with a high risk of bias and small samples in the limited number of quantitative studies, demonstrating a need for high-quality RCTs.

SYSTEMATIC REVIEW PRE-REGISTRATION

PROSPERO [CRD42021244859].

Developing a best-practice agenda for music therapy research to support informal carers of terminally ill patients pre- and post-death bereavement: a world café approach

BACKGROUND

Informal carers of terminally ill patients play a vital role in providing palliative care at home, which impacts on their pre- and post-death bereavement experience and presents an up to 50% greater risk for mental-health problems. However, developing and implementing effective bereavement support remains challenging. There is a need to build the evidence base for music therapy as a potentially promising bereavement support for this vulnerable population. This study aimed to co-design an international best practice agenda for research into music therapy for informal carers of patients pre- and post-death bereavement.

METHODS

Online half day workshop using a World Café approach; an innovative method for harnessing group intelligence within a group of international expert stakeholders (music therapy clinicians and academics with experience of music therapy with informal carers at end-of-life). Demographics, experience, key priorities and methodological challenges were gathered during a pre-workshop survey to inform workshop discussions. The online workshop involved four rounds of rotating, 25-minute, small group parallel discussions using Padlet. One final large group discussion involved a consensus building activity. All data were analysed thematically to identify patterns to inform priorities and recommendations.

RESULTS

Twenty-two consented and completed the pre-event survey (response rate 44%), from countries representing 10 different time zones. Sixteen participated in the workshop and developed the following best practice agenda. The effectiveness of music therapy in supporting informal carers across the bereavement continuum should be prioritised. This should be done using a mixed methods design to draw on the strengths of different methodological approaches to building the evidence base. It should involve service users throughout and should use a core outcome set to guide the choice of clinically important bereavement outcome measures in efficacy/effectiveness research.

CONCLUSIONS

Findings should inform future pre- and post-death bereavement support research for informal caregivers of terminally ill patients. This is an important step in building the evidence base for commissioners and service providers on how to incorporate more innovative approaches in palliative care bereavement services.

Implementation and outcomes of complementary therapies in hospice care: an integrative review

Complementary therapies are increasingly integrated into hospice care, emphasizing the need to examine the evidence regarding implementation and effects on end-of-life outcomes. This review synthesizes the evidence regarding the implementation of complementary therapies and effects on end-of-life outcomes in hospice care. Whittemore and Knafl's five-step integrative review process was applied. Using predefined search terms, research-based articles between 2006 and 2020 were reviewed. Twenty-three quantitative/mixed method studies conducted across eight countries met the final review criteria. Most commonly used complementary therapies were music, biofield therapies (reiki, therapeutic touch), and massage therapy. Most studies reported significant findings on physical symptoms (pain, dyspnea, fatigue, gastrointestinal symptoms, agitation) and/or psychosocial/spiritual symptoms (anxiety, depression, spirituality, well-being, quality of life); 40% of studies had both significant and nonsignificant findings. Methodological limitations included study design (few randomized controlled trials), small sample size, high attrition rate, lack of racial/ethnic diversity, unstandardized intervention implementation, and multiple outcome measurement instruments. Complementary therapies are promising components of hospice care; however, rigorous studies are needed to validate the effect on end-of-life outcomes and determine the most efficacious implementation. Complementary therapy studies face challenges consistent with end-of-life research; however, efforts to design rigorous trials and address methodological issues are required to enhance the state of the science.

Top Ten Tips Palliative Care Clinicians Should Know About Music Therapy and Art Therapy

Palliative care is provided by an interdisciplinary team, including physicians, advanced practice providers, nurses, social workers, chaplains, and other disciplines based on need. Music therapists and art therapists are becoming increasingly available to palliative care teams and are advancing the diverse and unique clinical services available to effectively meet the holistic needs of patients with serious illnesses and their families. This article provides a concrete exploration of clinical music therapy and art therapy within palliative care and hospice paradigms, with discussion of therapists' training and expertise, therapeutic approaches within the setting of interprofessional team-based care, and discussion of evidence-based symptom management and outcomes supporting the inclusion of music and art therapies within medical education and clinical employment.

Music Therapy Interventions in Palliative Care: A Systematic Review

BACKGROUND

Palliative care is an interdisciplinary medical approach for people with illnesses that are unresponsive to curative treatment. Music therapy has been gaining ground in this field since the 1970s, with a not-always-standardized range of interventions and musical techniques.

OBJECTIVE

The purpose of this systematic review is to analyze interventions with music therapy and new developments in this area in the field of palliative care.

METHODS

The primary source of data for this review was the online database Web of Science (WOS). We also used other databases such as Medline and Scopus. A systematic search was performed of the past 6 years following the PRISMA criteria.

RESULTS

From a selection of 310 documents, we reviewed 54 completed articles and included 19 studies in the review. The percentage of agreement in the selection of articles was 87.5% and the Cohen Kappa index of inter-rater reliability was 0.727. In 5 of the articles, the musical interventions were not specified. However, in the remaining 14 they were, including new developments such as use of the monochord and the body tambura, and adaptation of the RBL (Rhythm, Breath & Lullaby) method.

CONCLUSIONS

There has been notable improvement in the specification of musical interventions during music therapy sessions in palliative care. However, articles in this field need to describe how these techniques are carried out and any new developments. All this without forgetting that the patient's musical preferences are a fundamental aspect when performing music therapy sessions.

A randomised controlled pilot and feasibility study of music therapy for improving the quality of life of hospice inpatients

BACKGROUND

Evidence about the effectiveness of music therapy for improving the quality of life of palliative care patients is positive but weak in terms of risk of bias.

METHODS

This study aimed to determine the feasibility of a randomised controlled trial to evaluate the effectiveness of music therapy for improving the quality of life of hospice inpatients, as measured by the McGill Quality of Life questionnaire. Objectives included recruitment of 52 participants over 12 months and provision of data to support the calculation of the required sample size for a definitive randomised trial, taking into account the retention rates of recruited participants; and evaluation of the viability of the intervention and the acceptability of the assessment tool. The design was a single-centre, researcher-blinded randomised pilot and feasibility study involving two parallel groups. Participants were recruited from one inpatient hospice unit in Northern Ireland. Eligibility criteria were an Eastern Cooperative Oncology Group performance status of two or lower and an Abbreviated Mental Test score of seven or more. Consenting patients were randomly allocated to the intervention or control group using a 1:1 allocation ratio. The intervention group received up to six individual music therapy sessions over 3 weeks in addition to usual care. The control group received usual care only.

RESULTS

Fifty one participants were recruited over 12 months. Twenty five were allocated to the intervention group and 26 to the control group. Seventy one percent of participants were lost to follow up by week 3, the proposed primary endpoint. The primary endpoint was moved from week 3, when 71% were lost to follow up to week 1, when 33% were lost. The McGill Quality of Life questionnaire was generally acceptable to participants. In order to detect a small to moderate effect size of 0.3, a fully powered study would require the recruitment of 698 participants.

CONCLUSIONS

A Phase III randomised controlled trial to evaluate the effectiveness of music therapy in improving the quality of life of hospice inpatients is feasible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02791048 . Registered 6 June 2016.