Musical Prescriptions for End of Life Care
League Connections, June, 2010, Vol. 11, Num. 6
League for Innovation in the Community College
"Where words fail, music speaks." So mused Hans Christian Andersen, perhaps contemplating the twilight moments between life and death. In the 21st century, the final transition still challenges the voyagers and those left behind.
Even as medical technology becomes more advanced, some suffering still eludes the most sophisticated medical treatment. Many physicians and caregivers welcome the music-thanatology vigil as an integral form of care that offers an opportunity for relieving suffering and providing comfort.
Integrating music with supportive care of the dying is becoming more common in hospice and palliative care programs. The conscious use of music as an adjunct support service is a good example of how the multidisciplinary approach to hospice care addresses the total person and their family.
What is music-thanatology?
Music-thanatology is a musical/clinical therapy that unites music and medicine in end of life care. The music-thanatologist utilizes harp and voice at the bedside in a vigil to lovingly serve the physical, emotional, and spiritual needs of people who are terminally ill or dying and their loved ones. Results from studies suggest that prescriptive vigils conducted by trained music-thanatologists may offer an effective form of palliative care for dying patients.
"Thanatology" comes from the Greek word for death, "thanatos." The Center for Thanatology Research and Education defines thanatology as "the study of everything that has to do with dying, death, and grief." Music has been a source of healing since ancient times. Healing rites have been performed through the ages by religions and cultures around the world. Music-thanatology is a twentieth-century field based on these ancient traditions. Today there are music-thanatologists practicing throughout the United States and the world.
Music-thanatologists offer live, prescriptively delivered music that responds to the physiological needs of the patient moment by moment. For example, by observing vital signs such as respiration, heart rate and temperature, the music-thanatologist provides music that is tailored to each specific situation. The warmth of this living music can bring solace, dignity, and grace to those nearing the ultimate journey at the end of life.
Music-Thanatology Vigils
A music-thanatology vigil takes place in the patient's room, often with family and close friends present. A growing number of hospitals and hospices across the U.S. are providing vigils at no cost to the patient. Quiet, meditative music is played on a harp to help ease physical symptoms such as pain, restlessness, agitation, sleeplessness and labored breathing. The comfort and serenity of the music can soothe the sadness, fear, anger, and grief experienced by the patient and family. "We offer music in a manner that allows patients and loved ones to receive it on many different levels," said Jane Franz, coordinator of Strings of Compassion at Sacred Heart Medical Center in Eugene, Oregon.
Patients may not have the energy to respond actively to the music. They may be weak and unable to communicate, comatose, or in a state of altered consciousness on the threshold of death, only able to receive stimuli from the environment. The music-thanatologist is aware of this and gently crafts sounds to support the patient during this final transition.
Sharilyn Cohn, director of SacredFlight, a non-profit music-thanatology organization that contracts with hospitals and hospices in Portland, Oregon, says every encounter is unique. "We try to gather information about them as a person, what's going on with them right now, any physical stress, anxiety, fears, or restlessness. We try to get a sense of the whole person before we go into the room." Music-thanatologists have access to medical charts, reading notes made by doctors and nurses, and recording their own observations in the charts. "We generally use music that is not familiar to people," explained Franz, "because if we use familiar music, people might think, 'What are the words to that?' or, 'The last time I heard that song, this happened.' The experience becomes very different from the focus of our work." The patient need not respond during the vigil, but may simply receive. Common responses to the music include reduced anxiety, decreased pain, deeper rest, and lessened fear.
Although music vigils may take place at any time during hospice care, they can be of particular benefit during critical times such as the days immediately prior to death, during times when hard decisions must be made, or when artificial life-support equipment is being removed. Patients may receive more than one vigil. Vigils usually last 30 to 60 minutes; each vigil is unique depending on needs of the patient. The music-thanatologist does not try to control what patients experience, but rather to support them in whatever they are experiencing. Creating a supportive musical field may be helpful to a patient who is anxious by making it easier to calm down or become more at peace. "It can change from moment to moment," Franz added. "We follow them. They lead." The intention is to help patients let go when they are ready.
Meeting the Demand for Music-Thanatologists
The Chalice of Repose Project School of Music-Thanatology in Missoula, Montana, was the primary source for training music-thanatologists in the U.S. from 1992 until the school closed in 2002. With the majority of working music-thanatologists retiring within the next decade or so, Franz and Cohn recognized the need for a training program to educate successors to the craft. The two women took on the many tasks of organizing a two-year, master's level training that would prepare students to apply for certification through the Music-Thanatology Association International (MTAI), the independent certification body for music-thanatology worldwide.
Franz and Cohn were practicing music-thanatologists, not professional educators. Thus they needed to spend several years studying and researching to gain the skills and knowledge required to develop a curriculum. Fortunately, they had the help of a chaplain at Sacred Heart Medical Center with a PhD in higher education administration. With a complete curriculum in hand, the women presented the training to Lane Community College in Eugene, Oregon.
Initially, Lane administrators felt this was a master's level course, which, as a community college, Lane could not offer. Yet Lane was very interested in the full-featured curriculum, and after much discussion offered to allow Franz and Cohn to present the course as a continuing education non-degree training course with an internship through the Cooperative Education program at Lane. Students pay the full cost of instruction and materials for the non-degree courses they take at Lane. With the curriculum already written, no research and development costs would be incurred by the college. So Lane was able to approve the training as a part of their continuing education curriculum. Three years after Franz and Cohn began working on the idea of a training program, it was finally approved and the first class was set to begin in 2007.
More than 16 music-thanatologists and other full-time professionals from around the Pacific Northwest came forward to teach the wide variety of subject matter in their personal time, from anatomy and physiology to prescriptive musicianship. Franz acknowledged, "It has truly taken a village to create this training."
The first two-year course of study began in September 2007, graduating nine new music-thanatologists in August of 2009. These graduates have gone on to receive certification from the MTAI and are working in hospitals, hospices, and independent practices in four states. This is the true test of any school: Can its graduates find work and make a living wage in their field? Franz says, "We have a very successful start on our hands. Nine students who will graduate in 2011 are now attending monthly didactic weekends at Providence St. Vincent Medical Center in Portland and are engaged in what will amount to over 300 classroom contact hours and over 300 hours of one-on-one clinical internship hours alongside a certified music-thanatologist mentor in hospitals and hospices in Oregon and Washington." The next training will begin in September 2012.
Music-Thanatology Training at LCC
Students receive over 600 contact hours in this two year, non-degree training, which includes 20 didactic weekend intensives in Portland, Oregon, and one-on-one clinical internships. The training is designed to prepare students to meet the Standards and Competencies of the MTAI. Non-paid clinical internships, also known as cooperative education co-ops, provide the student with over 300 hours of onsite experience in hospitals and hospices working one-on-one alongside an MTAI certified music-thanatologist mentor. These co-ops are regular credit and grade-earning courses through Lane's Cooperative Education Division and are the only credit portion of the training. This relationship is important because it allows Lane to cover the students' worker compensation insurance and medical liability during the co-op.
Faculty consists of MTAI certified music-thanatologists, medical doctors, registered nurses, and other professionals who work closely with music-thanatologists. Students take harp and voice lessons with an MTAI certified music-thanatologist or approved teacher throughout the training. The training includes a contemplative component in which each student is supported to grow in their own personal and spiritual life.
To qualify for the training, students must demonstrate proficiency on an instrument, preferably harp, by submitting an audio example with the application. Students must also have a basic understanding of music theory, including reading and notating music. Applicants meeting all program requirements are invited to attend a two-day, on-site, interview process in Portland, including music proficiency and theory skill assessments.
Graduates of music-thanatology training programs can network with one another through the MTAI—www.mtai.org. MTAI has developed a set of standards for practice within the field and offers a formal process of certification for persons trained in this professional specialty. There are no other clearly-defined degree-granting or certification processes for persons who wish to refer to themselves as music-thanatologists as a professional specialty.
Challenges Faced and Conquered
Lane worked closely with Franz and Cohn to arrange the appropriate number of internships needed. Setting up internships takes a substantial amount of time and coordination; fortunately many of the music-thanatology instructors agreed to supervise students where the instructors work. Lane has partnered with eight different facilities in Oregon, Washington, and Utah to get sites developed and contracts signed. Tamara Pinkas, faculty Cooperative Education coordinator and lead Cooperative Education faculty at Lane, is responsible for facilitating the development of the music-thanatology co-op sites and working with the students during their internships. "We had to sign eight different contracts, which was very time consuming," noted Pinkas. "Having really good affiliation agreements is critical to our success. Hospitals want them due to liability issues." Because of the many legal issues involved in the medical arena, Pinkas suggests consulting with legal counsel regularly.
To successfully arrange the clinical internships, Pinkas suggests planning well in advance, as many as six months ahead of the start of training. Many questions need to be addressed, such as: Who will conduct and pay for background checks, drug tests, and immunizations? Will hospitals cover these screening costs of their interns, will the school pick up the cost, or will the students be responsible?
Lane staff has had to be creative and flexible in making the music-thanatology training fit Lane's rules and regulations. Systems needed to be tweaked to fit the unusual training period—21 months. For example, Pinkas explained that the learning management system, Moodle, wasn't set up for long-term classes. They had to figure out how to keep data in the system for two years rather than the normal one quarter.
"This is a huge feat of organization and implementation on the part of Tamara Pinkas and Lida Hergurger at LCC," said Franz. "They have worked tirelessly to achieve what had never been done before."
The music-thanatology training at Lane has been successful from the very first class, which graduated nine students out of twelve originally accepted; two of those students dropped out shortly after the training began. Lida Herburger, continuing education program coordinator at Lane, makes sure students get registered and payments are recorded so they can get transcripted. "These people definitely have a calling and feel very passionate about their careers," Herburger said, "which makes it very easy for us."
In 2009, the music-thanatology training received an Eldon F. Schafer Innovation award from Lane, chosen in the annual competition that identifies projects that embody a spirit of innovation envisioned by past president Eldon F. Schafer. Winning projects are selected based on effectiveness, efficiency, affordability, reliability and creativity, the same criteria used by the League for Innovation in the Community College for the League's annual Innovation of the Year awards.
The Future of Training Music-Thanatologists at LCC
Instruction schedules are constrained by the instructors' other full-time job commitments. "The future of the training is entirely up to the instructors," said Pinkas. "All of the instructors have other full-time jobs and we don't want to burn them out. We do the training often enough so as not to over-saturate the market with graduates."
"Lane is 100 percent supportive of the training," emphasized Pinkas. "We'll happily run the training as long as there is a demand for it, especially since the training is self-supporting." Because music-thanatology training is expensive for the students, Pinkas would like to someday be able to provide scholarships to allow more students the opportunity to apply. "We'd like to grow the training and see more students go through it."
For Franz and Cohn, the ultimate goal is for the course to be offered at the master's level. They would also like to work with other community colleges to bring this training to more cities. "Community colleges need music-thanatologists available to teach the classes to establish the training at their institutions," Cohn explained. "The curriculum is replicable if they have the faculty."
"How can we show if the training is successful?" Cohn asked. "If people graduate and go on to work in their field—of our first nine graduates, all are working as music-thanatologists."
For more information about the music-thanatology training at Lane Community College, contact Lida Herburger at herburgerl AT lanecc DOT edu. To learn more about the field of music-thanatology, contact Jane Franz at jfranz AT peacehealth DOT org or Sharilyn Cohn at sharilyn AT easystreet DOT net.
Reprinted with permission from League for Innovation in the Community College.
Copyright 2010. All rights reserved.
Created: June 19, 2010 Last updated: August 20, 2010
The Healing Art of Music
Music-thanatology as a component of spiritual care and a complement to professional chaplaincy
Healing Spirit, the magazine of the Association of Professional Chaplains, Vol 5, issue 1, Spring 2010.
by Jane Franz
Spiritual/emotional pain
Unrelenting physical pain
Anxiety/fear/agitation/restlessness
Lack of harmony in family
Difficulty accepting approaching death
Difficulty coping with the stress of illness/loss/change
In a hospital or hospice setting, these indicators are among those that appear on referrals for chaplain visits. What may surprise you is that the same indicators also appear on referrals for music-thanatologists. These two professions often address the same issues, but with different approaches. While chaplains may work with the entire patient population, music-thanatologists focus on end-of-life patients in health care settings. Chaplains most often communicate verbally with their patients. Music-thanatologists communicate mostly through the use of harp and vocal music. The collaboration of the two disciplines is becoming a common occurrence in more hospitals and hospices throughout our nation.
What is music-thanatology?
Music-thanatology
1 is a professional field within the broader subspecialty of palliative care. It is a musical, clinical and spiritual modality in end-of-life care. The music-thanatologist utilizes harp and voice to lovingly serve the physical, emotional and spiritual needs of the dying and their loved ones with the prescriptive delivery of music.
2
"As a chaplain it is a great honor and a privilege to work alongside our music-thanatologists," says Rev. Daleasha Hall MDiv BCC, lead chaplain at Sacred Heart Hospice in Eugene, OR. "The support and healing presence they bring to our work environment and the bedside of dying patients is unique and prescriptive. Their awareness of physical, spiritual and emotional movement throughout the end-of-life journey is proactive, beautiful work that complements the work of chaplains and the entire interdisciplinary team."
The music-thanatologist
Music-thanatologists certified by the Music-Thanatology Association International (MTAI)
3 have undergone at least two years of rigorous training. Studies span a wide range of musical, medical, spiritual, clinical, academic, personal and professional material.
4
What is prescriptively delivered music?
Prescriptively delivered music is live, contemplative harp and voice music that responds to the patient's physiological, emotional and spiritual needs moment by moment. The warmth of this living music can bring solace, dignity and grace to those nearing the end of life. The alternation of sound and silence encourages the listener to simply receive on a deep level.
Whether conscious or unconscious, the patient is always in charge of the musical direction because we connect at the level of breath, pulse, temperature, pain, effort and tension; attributes that we all share through our basic humanity. With this focus, the music can address the needs of each individual. In this way, the music seeks to be an expression of beauty and love; and as such, it transcends diverse affiliations of faith and culture.
5
"The music-thanatologist's expertise in melding the presence of the patient with the presence of contemplative and prescriptively delivered music creates, for all present, a powerful experience," says Rev. David Waggoner PhD, chaplain at Sacred Heart Medical Center, Springfield, OR. "The music-thanatology vigil crafts an aesthetic, an atmosphere at the bedside that is distinct from any other activity that happens in the room of a dying patient."
Music-thanatology in the health care setting
In an interdisciplinary team setting, music-thanatologists work closely with other caregivers. In hospital and hospice settings, chaplains, nurses, social workers, doctors, family members and patients make music-thanatology referrals.
Loved ones and caregivers who may be experiencing grief, loss, change, and a desire to support patient and family are encouraged to be present for the vigil. A quiet setting assists the music to be effective, and allows patients and families to reflect and process on a deep level during the silence between the musical offerings. The patient and others are invited to simply receive the music.
6 Chaplains are often part of the vigil, bringing God's presence into the setting. If requested by the patient or family, the chaplain may pray or perform a religious ritual, such as anointing of the sick, and that becomes woven into the vigil, which may last from 30 to 60 minutes.
"The role of music-thanatology is not an adjunct or alternative form of spiritual care," says Rev. Eddie Harrod BCC, chaplain at Sacred Heart Medical Center, Springfield, OR. "It is, in its own right, creative, focused and effective spiritual care that has a primary role in attending to the spiritual needs of the dying."
Chaplains listen and watch attentively for the spiritual needs of patients and families. They provide words of support, pastoral presence, understanding and prayer. Music-thanatologists also watch and listen deeply to the needs of patients and families. They respond with music that can touch the soul.
To learn more about music-thanatology:
www.mtai.org
To learn more about music-thanatology training:
www.lanecc.edu/ce/music
Jane Franz, a certified music-thanatologist, is the coordinator for Strings of Compassion, the music-thanatology practice that serves Sacred Heart Medical Centers at Riverbend in Springfield, OR; and University District Campus and Sacred Heart Hospice in Eugene, OR. Franz is also the co-director of the Music-Thanatology Training Program through Lane Community College in Eugene.
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Notes
1 Thanatology comes from the Greek word Thanatos meaning "death." Thanatology is a contemporary word defined as "the art and study of death and dying."
^
2 MTAI website:
www.mtai.org ^
3 The Music-Thanatology Association International (MTAI) is a professional association and independent certifying body for the field of music-thanatology. As such, MTAI established the field's standards and competencies for professional certification. In addition, MTAI offers continuing education, including an annual conference; and the peer-reviewed Journal of the Music-Thanatology Association International
^
4 The training is designed to prepare students to meet the Standards and Competencies of the MTAI. Lane Community College, Eugene, OR, is the first institution of higher education to offer this training throughout the Northwest. Students receive over 600 contact hours upon completion of this two year, non-degree training, which includes 20 didactic weekend intensives in Portland, OR, and clinical internships. The training includes over 300 hours of on-site experience in hospitals and hospices working alongside an MTAI certified music-thanatologist mentor and the interdisciplinary team. The faculty consists of MTAI certified music-thanatologists, doctors, nurses, chaplains and others who work closely with music-thanatologists.
^
5 Ibid. 2
^
6 Ibid.
^
This article originally appeared in Healing Spirit, the magazine of the Association of Professional Chaplains, Vol 5, issue 1, Spring 2010. Reprinted with permission of APC.
Created: May 19, 2010 Last updated: June 22, 2010
