Music Therapy on an Acute Palliative Medicine Unit

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Music Therapy on an Acute Palliative Medicine Unit

• A Pilot Program to Improve Care at the
  End-of-Life

Erin Montgomery MTA , Palliative Care Unit, QEII
HSC Robert Horton, Division of Palliative
Medicine, QEII HSC
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I think I should have no other mortal wants, if
I could always have plenty of music. It seems to
infuse strength into my limbs and ideas into my
brain. Life seems to go on without effort, when I
am filled with music.George Eliot (1819-1890)
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Overview

• Background
• QI Project Genesis
• Data
• Successes and Challenges
• Future

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Music Therapy

• Skillful use of music and musical elements by an
  accredited music therapist to promote, maintain,
  and restore mental, physical, emotional, and
  spiritual health.
• Music has nonverbal, creative, structural, and
  emotional qualities.
• These are used in the therapeutic relationship to
  facilitate contact, interaction, self-awareness,
  learning, self-expression, communication, and
  personal development.
• Canadian Association for Music Therapy Annual
  General Meeting, Vancouver, British Columbia, May
  6, 1994

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Music Therapy in Palliative Care

• Manage stress and anxiety
• Alter perception of pain and symptoms
• Facilitate expression of feelings
• Promote wellness
• Improve communication
• Develop new ways of coping
• Foster spiritual and existential well being

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Music Therapy in Palliative Care

• Individually
• Group setting with family, friends or other
  patients.
• Active and/or passive
• Sessions are often provided at the bedside with
  portable instruments and sound equipment.
• Both live and recorded music can be used during
  treatment sessions.

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Music Therapy in Palliative Care

• Techniques
• song choice
• lyric discussion
• listening to music
• song writing
• life review/legacy project
• relaxation to music techniques
• Guided Imagery in Music (GIM)
• improvisation, singing and playing instruments
• Sessions individualized based on current
  functioning, goals and preferences.

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Our Objectives

• Introduce Music Therapy on Acute Palliative Med
  Svc
• Improve holistic care
• Improve quality of living and dying
• Feasibility assessment
• Fragile patients
• Acceptance by patients and families?
• Measuring response to therapy?
• Explore opportunities for further development of
  music therapy services

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PCU

• 10 acute care beds
• Patients nearing EOL
• Multiple complex symptoms
• Interdisciplinary team
• Median survival 12 days
• 70 die during index admission

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QI Cycle

• PlanDevelop a plan for improving quality at a
  process
• DoExecute the plan, first on a small scale
• StudyEvaluate feedback to confirm or to adjust
  the plan
• ActMake the plan permanent or study the
  adjustments

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Plan

• 6 month pilot
• Patient/family brochure
• Staff Resource binder
• Digital Music Library (iPod and iTunes)
• Customized Referral and Assessment Forms
• Outcomes
• POS
• Patient, family and staff testimonial

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Do

• MTA 2 half days per week
• Seed funding by foundation and Tom Norwood Music
  Therapy Endowment
• Referrals generated at weekly multidisciplinary
  team rounds
• Referral by any member of the team or at family
  request
• Initial Assessment treatment goals identified
• Follow-up sessions to work on identified goals

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Study

• Reasons for referral
• Number of sessions
• Patient/Family Acceptance
• Problems identified
• Treatment goals
• Interventions used
• Demographics
• Outcomes

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• Music Therapy Referral
• Patient Name_____________________________ Date
  _______________
• Referred by______________
  ________________
• Patient Location
• ? Palliative Care Unit Room
  ___________
• ? Home
  Address _________________________________________
  
• Reason for Referral-Please Check All That Apply
• ? Anxiety ? Depression
• ? Agitation/Restlessness ? Grieving,
  anticipatory patient
• ? Caregiver strain ? Grieving ,anticipatory
  caregiver
• ? Communication impaired ? Isolation/withdrawal
  
• ? Coping Ineffective, Family/Caregiver ? Pain
  or other symptoms
• ? Coping Ineffective, Patient ? Spiritual
  needs
• Other____________________________________________
  ____________________________________

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What Worked

• Approximately 60 MT sessions/6 mos.
• Team interested and helpful bereavement
  program, volunteers
• Patients/families were receptive
• Average of 2.3 sessions
• Great feedback overall
• iPod/iTunes Music Library
• Gillian MacMichael Bursary

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What Could Have Worked Better

• More time not enough days/hours per week
• Many times MT could only see pt once
• lack of continuity ie saw them Wednesday and
  they died before MT was back on Monday
• POS was too burdensome - alternative outcomes
  needed
• Referral form did not capture all reasons for
  referral
• Could not participate in bereavement group/team
  rounds

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Patient and Family Perspectives
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Having Erin come in to play and to sing was not
only something my mom looked forward to, it also
allowed an outlet for my father and I for
emotional grief, in a context that we didn't
necessarily have to talk about it in front of
my mom, but we could just sit there and listen,
and cry and grieve and be sad, in an emotionally
supportive atmosphere.
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One Patients Perspective
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I cannot express enough how much value my
family received from the Music Therapy program
and I cannot express enough my thanks."
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• The music helped J to take his mind from his
  pain and soothed him. J has always found music to
  be relaxing and music was always playing in our
  home we even went to bed with a CD every
  night.
• My daughters and I have been so pleased to see J
  become interested in the music and to be relieved
  from his self-worry and health problems.

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• Erin walked in and asked Don if he would like to
  have some music. Ah, yes, I would love to! When
  she went to pick up her guitar, Don hurriedly
  wanted his face washed and his teeth put in his
  mouth! The nurses teased him that he had a big
  grin on his face and didnt want teeth in for
  them! When Erin started to play and sing, Don was
  enraptured even mouthed all the words with her
  as his voice is now only a whisper.

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Our Conclusions

• MT benefits patients and their loved ones, even
  if limited to a single session.
• Contributes to holistic practice meeting the
  diverse needs of patients and families
  simultaneously
• Must be respectfully and sensitively offered
• Pilot raised awareness of the benefits and
  limitations
• Expansion of music therapy services is consistent
  with the philosophy and goals of CHIPS

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Our Conclusions

• Patients too sick to participate in standard
  assessments
• Qualitative outcomes needed
• Focused quantitative outcomes
• Opens Doors to
• Acceptance
• Communication
• Healing
• Bereavement

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The Outcomes Dilemma

• The whole problem can be stated quite simply by
  asking, 'Is there a meaning to music?' My answer
  would be, 'Yes.' And 'Can you state in so many
  words what the meaning is?' My answer to that
  would be, 'No.'
• Aaron Copland

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Music Therapy in Palliative Care

• It is possible to realize ourselves in the
  moment, not solely as a body restricted by
  infirmity, but transcended as a soul realizable
  in the music. (Aldridge, 1995)

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Music Therapy in Action
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Future Directions (Act)

• The success of this pilot project has enabled us
  to secure funding to provide music therapy
  services five half days per week for a period of
  one year starting in September 2007.
• We have developed a working group to oversee
  implementation of music therapy services and
  expand beyond our inpatient population to serve
  patients in the community.
• Further expansion and evaluation is planned in
  the form of
• Video Interviews
• Follow-up survey of bereaved family members
• Patient ratings of overall well being pre and
  post therapy
• Drive to secure funding for a long term music
  therapy program

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Future Directions

• Qualitative Feedback
• Video interviews of patients, family and staff
• Survey of bereaved
• Quantitative
• Pre/post measurement of wellbeing

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Ah, music. A magic beyond all we do here!

• J. K. Rowling, Harry Potter and the Sorcerer's
  Stone, 1997