Music Therapy in Palliative Care

Mary-Carla MacDonald, MA MT-BC FAMI Vandana Nagpal, MD FACP FAAHPM

Eli was rocking, straining and tearing against his restraints, sweat beading on his forehead, when we

(MCM+VN) first met him. Eli had terrible anxiety; his family told us that he had worn holes in the carpet at home. Anxiety prevented him from getting treatment for his cancer before he ended up in the hospital. The agitation and restlessness in the hospital unfortunately led to physical restraints which worsened the symptoms and required medications that only were partially effective. The staff was exhausted and there was no time to waste.

“What kind of music do you listen to? Can we listen together?” A quick nod and high intensity music started (MCM), matching his thrashing: “Immigrant Song” followed by “Moby Dick” by Led Zeppelin. Repeat, repeat! This was about getting a net of sound around and in him and with the help of music, slowly and carefully pulling him into the rhythm and therefore regulation. He started to entrain to the rhythm; the music hooked him. Next came “White Room” by Deep Purple and he allowed himself to lay back against the bed. Carefully and slowly, the tempo and intensity of music decreased with The Who, Pink Floyd, and more Zeppelin until his eyes closed and his breathing slowed. Now everyone could breathe. The music therapy sessions continued over the next few days allowing for deescalation of chemical and physical restraints and leading to increased engagement of Eli with his family and providers (VN). The treatment plan was formulated with input from everyone, and Eli was home by the next week.

Sound is a powerful sense. When sound is organized into music, it addresses the limbic system directly. Rhythm, tonality (the organization of pitches into melody), and timbre (the voice, color, or quality of a sound) fire up large-scale neural networks throughout the brain (1). By selectively using the elements of music to prime the neuro-circuitry of resilience, we can induce the relaxation response (2), create empathic social connections through increased oxytocin from singing and improvisation (3), organize cognition and behavior, orient attention, increase motivation, access memory and integrate positive resources and coping skills (4). Through music, we can bypass cognition and reach people in crisis, even with altered mental status and communication disorders. That is why, even within the loud hospital chorus of alarms, beeps, overhead pages, and human voices, music therapy is powerful and effective.

Music therapy (MT) is a person-centered, evidence-based discipline in which board certified therapists use music pur- posefully within the therapeutic relationship. At UMass Memorial Medical Center, it is a collaborative therapy which utilizes the patient’s own positive resources, relationship with music, and healthy core-self in combination with the multifaceted elements and functions of music to achieve greater wellbeing. MT has been shown to help with cognition, mood and can reduce pain, dyspnea, and stress responses (5). Music therapists are specialized providers with extensive training in providing supportive care because music can open up vast landscapes of feeling, memory, and pain, but can cause harm if not used judiciously and cautiously in a therapy session. The open dialogue, mutual respect and deep listening between the therapist and patient informs the music selection. Selected music acts as a friend to the patient and is the co-therapist — someone familiar with whom they already have a relationship. The therapist’s job is to facilitate a safe space and be a witness many times to raw emotion where the patient has agency in deciding the pace and length of the journey. The sessions are sometimes hard, charged with deep meaning, and other times they are lighthearted and joyous. There are also sessions where the support is more subtle like during a terminal extubation where music is in the background, providing emotional support and nervous system regulation for patients, families, and even teams.

Palliative care is team-based care of people living with serious illness and their families. It is beautiful and challenging at the same time, as we carefully step, for some amount of time, into people’s lives when they are at their most tender and vulnerable. The relationship of palliative care and MT makes sense, as together they enhance the patient’s quality of life through patient/family-centered care, increased patient engagement, better symptom control, and legacy work.

Music therapy availability in the hospital setting is variable across the nation. At UMass Memorial Medical Center, MT has been available for palliative care and neurology patients at the University site since 2019. We used MT successfully for varied reasons during COVID-19 surges and we hope to further grow the program through continued support. It is an integral part of the treatment plan, whether through opening the relationship or through symptom management. When Colina* woke up panicked and confused after weeks of intubation and ventilatory support for acute respiratory failure, the first sound that registered to her and centered her was that of an ongoing music therapy session in her hospital room. Later she told the team that it made her feel safe; she did not know that the music therapist (MCM) had been working with her the last few weeks, but her brain, body, and heart knew it. Such can be the great power of music therapy!