2015 Katherine Halliwell – Achieving Harmony: Music Therapy and Music-Thanatology in End of Life Care.pdf – Music-Thanatology Association International

Halliwell, 2015

Achieving Harmony:
Music Therapy and Music-Thanatology
In End-of-Life Care

By Katherine E. Halliwell, MT-BC

A Final Project Submitted in Partial
Fulfillment of the Requirement
For Certification in Music-Thanatology

August, 2015

Halliwell, 2015

Introduction
To use a concept that is deeply familiar to both music therapists and music-thanatologists, the
idea of harmony can serve as a guiding principle for the endeavor of peaceful, and perhaps even
collaborative, relations between the two fields in end-of-life care. Music therapist Kenneth
Bruscia, Ph.D., MA, MT-BC, FAMI (1998) affirms that “an important characteristic of
wholeness, both in health and in music, is harmony.” To provide some context, the original use
of the word “harmony” was to describe a wood-working technique of joining pieces of wood by
utilizing the grains of wood running in opposite directions, which joined and held them together
by the original elements and characteristics of each individual piece (Schroeder-Sheker, 2010b).
In music, participation in harmony calls the musician to be in touch with both the music of self,
and the music of others, withstanding any tension or dissonance that may be present. From a
more contemplative perspective, harmony is a process of bringing contrasting, conflicting
elements into peaceful coexistence, which requires listening and receiving with intentionality,
while acknowledging and respecting personal boundaries (Schroeder-Sheker, 2010b). In each of
these conceptualizations of harmony, the common theme is bringing together contrasting
elements in order to create something new.

Former American Academy of Nursing president Pamela Mitchell, Ph.D., RN, FAHA, FAAN
and colleagues recognize that collaborative teamwork in healthcare is “an essential tool for
constructing a more patient-centered, coordinated, and effective health care delivery system”
(Mitchell, et al., 2012). Consistent themes in current literature on effective teamwork and
collaboration include understanding and valuing the unique work and roles of fellow team
members, developing mutual trust, maintaining ongoing communication, and having a clear set
of shared goals (Mithcell, et al., 2012; National Hospice and Palliative Care Organization, 2015).
Mitchell, et al. (2012) further assert that it is imperative for all team members to possess the five
core virtues of curiosity, humility, honesty, discipline, and creativity. With these virtues in place,
understanding, trust, and communication can more readily begin to develop.

One prior investigatory study has been conducted by music therapist Kathryn Taylor, MA, MT-
BC (2005) regarding music therapist and music-thanatologist relations, in which some concerns
about collaboration between the two fields were identified, primarily within the music therapy
community. A common sentiment among some music therapists at that time was that music
therapy services are comparable to those offered by music-thanatologists, thus sensing an
unnecessary threat to job security (Taylor, 2005). This sentiment is echoed and expanded upon
by music therapist Russell Hilliard, PhD, LCSW, LCAT, MT-BC as he points out that music
therapists are qualified to provide services throughout the entire end-of-life experience, up to and
including bereavement (Hollis, 2010). It is understandable that music therapists would be
concerned if the services provided are truly interchangeable, and music-thanatologists have
nothing unique to offer patients and families at the end of life.

Another concern is that there may be difficulty distinguishing between the two modalities among
other professionals and consumers (Taylor, 2005). Taylor identified some overlapping of terms
in music-thanatology literature, which could potentially lead to the assumption that music-
thanatologists are engaged in intentional misrepresentation. A further challenge with such

Halliwell, 2015

confusion is the lack of distinction and clarity of roles in the workplace, which could impact the
accuracy of referrals and effective care (Taylor, 2005). In a phone interview with music therapist
Fran Felton, she shares that she senses much concern about identity and misrepresentation
among colleagues, and suggests that “identifying differences between the professions appears
essential to avoid misrepresentation” (personal communication, July 13 & 16, 2015).

From the other end of things, music-thanatologists can find themselves facing territorialism
among some music therapists. Music-thanatologist Tony Pederson, CM-Th relates that in his
experience, friction between music therapists and music-thanatologists can surface if members of
either discipline believe that they have sole rights to the client base (personal communication,
July 9, 2015). Taylor (2005) recognizes that “professional tensions between music therapists and
music-thanatologists contribute to bias and non-collegial relationships between the two
professions”, which can hinder not only professional relations, but also patient care. Music
therapist Erin Fox, MT-BC acknowledges that “there has been a lot of rigidity to defend each
profession, and we need to get away from that and fully understand everyone’s role and try to
work together as much as possible for the benefit of the patients” (personal communication,
April 30, 2015). This sentiment is shared by Dr. Martha Twaddle, MD, FACP, FAAHPM, Senior
Vice President of Medical Excellence and Innovation at JourneyCare in Barrington, Illinois, in
her statement during a recent phone interview that “there’s plenty of need, and when we get
[territorial] it’s really about us and not about the patient” (personal communication, July 8,
2015).

Perhaps this idea of territoriality is fueled, at least in part, by a lack of understanding. In their
description of effective team-based health care, Mitchell and colleagues (2012) identify that “the
incorporation of multiple perspectives in health care offers the benefit of diverse knowledge and
experience”, and music therapist Virginia Anderson, MM, MT-BC, NMT (2011) asserts that
“music therapy in hospice could be enhanced by studying the benefits of joint treatment with
other disciplines”. Therefore, there may be value in exploring the perspectives of both music
therapy and music-thanatology in end-of-life care in an effort to diversify knowledge and
experience and perhaps move toward deeper understanding and appreciation for each field.

Considering that the primary goal of hospice and palliative care is to promote patients’ quality of
life, calling upon the various skill sets of the interdisciplinary team members to alleviate pain and
suffering and enhance comfort and overall well-being (National Hospice and Palliative Care
Organization, 2015), it can be deduced that music therapists and music-thanatologists working in
an end-of-life setting have this goal in common. With this shared goal serving as a common
ground, collaborative relationships can be built. If music therapists and music-thanatologists can
embrace the virtues identified above, (curiosity, humility, honesty, discipline, and creativity),
working together toward the shared goal of compassionate patient-centered care, it is possible to
create a harmonious relationship through which each can thrive in end-of-life care, together
contributing to a culture of care that is beneficial for both professions, for the organizations
which offer their services, and most importantly for the patients and families in need at this
vulnerable stage of life.

Halliwell, 2015

This paper will explore these issues in depth, referencing the current available literature from
both fields, sharing accounts from personal interviews with professionals from each field as well
as recipients of their services, and reporting on the response trends from survey results regarding
the applications of and collaboration between music therapy and music-thanatology in end-of-
life care, in an effort to facilitate mutual understanding and build the foundation for trust and
communication in order to achieve harmony and provide the best end-of-life care possible.

Review of Literature
In an effort to facilitate awareness and understanding, the following literature review is intended
to provide at least some preliminary information about music-thanatology and music therapy in
end-of-life care.

Music therapy definition. According to the American Music Therapy Association (AMTA),
music therapy is “the clinical and evidence-based use of music interventions to accomplish
individualized goals within a therapeutic relationship by a credentialed professional who has
completed an approved music therapy program, using music to address physical, emotional,
cognitive, and social needs of individuals” (American Music Therapy Association, 2015). In
music therapy, the relationship and rapport developed between client and practitioner are a
significant part of the therapeutic process (Bruscia, 1998). Music therapist Judith Pinkerton, MT-
BC/L adds to this definition in her comment that “The music therapist is the agent of change,
using music as the tool, manipulating musical elements so that musical and non-musical goals
are achieved in any setting” (Pinkerton, 2010).

Music-thanatology definition. Music-thanatology is a musical/clinical sub-specialty of palliative
care, through which certified music-thanatologists provide a contemplative musical presence,
combining the concepts of music, medicine, and spirituality to serve the physical, social,
emotional, and spiritual needs of “the terminally ill or dying and their loved ones” (Music-
Thanatology Association International, 2015). Music-thanatology specifically focuses on end-of-
life (Pasquesi, 2015), and is grounded in spiritual practice, which informs the work carried out at
the deathbed (Cox & Roberts, 2006). In music-thanatology practice, the music is “the location of
the relationship,” and the clinician strives to be an invisible yet supportive presence for patients
and families (Hollis, 2010, p. 129). This is quite a different role than that of music therapists.

Music therapy in end-of-life care. Music therapy, as noted by Bruscia (1998), is a very diverse
field. Its applications are utilized in schools, hospitals, group homes, nursing homes, hospices,
prisons, community centers, institutes, private practices, and more (Bruscia, 1998). Although the
field of music therapy has been around longer than music-thanatology, preceding it by more than
30 years (Hollis, 2010), its origins in the end-of-life setting began around the same time that
Therese Schroeder-Sheker started developing music-thanatology in the mid-1970s, also
coinciding with the development of the American hospice movement (Anderson, 2011; Hollis,
2010). Music therapy is increasingly recognized as an important service which organizations can
provide to patients and families at the end of life as a component of holistic care (Krout, 2003),
and by the year 2004, music therapy ranked as one of the most-utilized forms of alternative
therapy in hospice and palliative care, along with massage therapy (Anderson, 2011).

Halliwell, 2015

Music-thanatology in end-of-life care. Music-thanatology, as a field of practice, was officially
founded in the 1980s by Therese Schroeder-Sheker, and by 1992 began being used as a standard
component of end-of-life care in some hospitals (Schroeder-Sheker, 2012). The inspiration for
the work of music-thanatology comes from the monastic medicine practices of the 11
th
century
Benedictine monks of Cluny, France, in which the concept of healing is primarily about
integration and wholeness brought about from within the ill or dying patient rather than from
some external source (Schroeder-Sheker, 2001). Thus, music-thanatology is about reflecting and
supporting the processes of those served with minimal imposition from the musician-clinician.
Another tenet of monastic medicine which influences the practice of music-thanatology is the
concept of “care of the body, cure of the soul” (Schroeder-Sheker, 2001, p. 24). In this light,
music-thanatology finds its perfect place in a hospice setting, when the emphasis ceases being
curative and focuses rather on opportunities for spiritual growth and inner transformation as the
entirety of the life cycle is embraced and celebrated with reverence (Black & Penrose-
Thompson, 2012).

Music therapy education. For music therapists, the basic training involves the completion of an
undergraduate degree or its equivalent, which includes a 1,040-hour supervised internship
(Bruscia, 1991). Successfully passing the standardized national exam given by the Certification
Board of Music Therapists (CBMT), and demonstrating competency in musicianship, clinical
expertise, and knowledge of music therapy foundations, history, methods, techniques, and
applications are requirements to receive the credentials MT-BC (Music Therapist-Board
Certified) (Bruscia, 1991; Hilliard 2005). There is also the option to pursue a master’s degree in
music therapy, which may at some point become the basic requirement for certification (Bruscia,
1991).

Coursework for music therapy typically includes music therapy history and theories; music
theory; musicianship; behavioral, health, and natural sciences; general education; assessment and
measurement techniques; research literature, methods and materials, and ethics; physiology;
biology; psychology; counseling; anthropology; and movement/dance (Davis, Gfeller, & Thaut,
1999; Taylor, 2005). Other areas of focus can include human anatomy, musical improvisation,
and repertoire-based interventions (Taylor, 2005). In her study, Taylor identified education
trends among professional music therapists, noting that “less than half of the music therapists
surveyed indicated having received training in areas of terminal disease processes, hospice
philosophies, cultural death rituals, and medication management,” and only 15% reported having
studied bereavement and grief models. When asked to report on the degree to which music
therapy training prepared them to work in a hospice/end-of-life setting, less than a fourth of them
indicated feeling well prepared to work in an end-of-life setting (Taylor, 2005). These findings
indicate that training specific to end-of-life care and the application of music at the deathbed is
not routinely covered in basic music therapy education.

Music therapists interested in working in the end-of-life setting can pursue additional training in
the form of continuing education credits after initial certification (Anderson, 2011). Additionally,
a training program has been developed through the Center for Music Therapy in End of Life

Halliwell, 2015

Care which offers music therapists the extra recognition of “Hospice and Palliative Care Music
Therapist” upon completion of three four-day trainings. These trainings consist of experiential
and didactic learning opportunities as well as hands-on clinical practice. In total, the time
involved is approximately 107 hours, including classroom time, clinical experience, and
homework assignments. Topics covered include cultural awareness; the importance of self-
empowerment and self-expression at the end-of-life; learning various arrangements of popular
hymns and gospel music as well as how to appropriately apply them to the end-of-life setting;
grief and loss; counseling theories and techniques; role-playing of counseling skills; the use of
music to support various end-of-life scenarios; and business and funding concepts to further the
field of music therapy in end-of-life and bereavement care. As of July 21, 2015, 94 board
certified music therapists are listed as having completed all 3 levels of coursework from the
institute (Center for Music Therapy in End of Life Care, 2015).

Music-thanatology education. To become certified in music-thanatology, training includes
covering topics of anthropology; medical history; epistemology; phenomenology; cultural
history; spiritual psychology; musicology; hermeneutics; cultural, theological and biomedical
thanatology; prescriptive music analysis and practical application; composition; the history of
music in medicine; anatomy and physiology; religion and ritual; ethics in healthcare;
contemplative musicianship; disease processes; practical marketing skills; cymatics; narrative
medicine; modes; palliative medicine; pharmacotherapy; vital sign measurement; and
synchronization (Lane Community College, 2015; Schroeder-Sheker, 2001). Certification
requirements also include delivery of professional presentations, participation in schola
cantorum, demonstration of proficiency in shared thematic material, writing of a
professional/academic paper, and passing various comprehensive exams throughout the course of
training (Music-Thanatology Association International, 2015). One-hundred percent of music-
thanatologists in Taylor’s study reported feeling completely satisfied and greatly prepared by
their training to work with terminally ill patients in end-of-life settings. These findings confirm
that the sole focus of music-thanatology training is in end-of-life care, and that there is
consistency among practitioners in terms of the training and shared skill set which they offer.
There are currently 57 certified music-thanatologists through the MTAI (Partenheimer, personal
communication, August 31, 2015).

Seemingly unique to the field of music-thanatology is its emphasis on a contemplative practice.
Schroeder-Sheker (2001) reports that, “we study to change and grow, to become transformed,
and more realistically prepared for service” (p. 64-5). The training programs are perceived and
explained in light of “formation”, rather than strictly “education”, emphasizing inner
transformation through metanoia and the contemplative perspective, which are infused
throughout the curricula (Chalice of Repose Project, 2015; Lane Community College, 2015).
This inner transformation and ongoing contemplative practice are what prepares students
“spiritually and emotionally to meet the daily challenges of a high-pressure service profession”
(Chalice of Repose Project, 2015). Music-Thanatology Association International Associate
member Terese Cullen shares that this contemplative element in the training gave her specific
tools and a clear framework that has helped her to be present with the dying, preparing her for
service more so than her own faith practice. She believes that the contemplative dimension is

Halliwell, 2015

transformative, and is one thing that separates music-thanatology from other end-of-life fields
(personal correspondence, May 19, 2015).

Music therapy clinical application. Needs addressed by music therapists in end-of-life care
include social, emotional, cognitive, psychological, communication, physical, and spiritual needs
of the patient (Hilliard, 2005), symptom management, affirmation of identity, family/caregiver
support, and grief/bereavement support (Bradt & Dileo, 2010). Common referral reasons include
anxiety, depression, isolation, withdrawal, difficulty communicating, pain, difficulty coping,
isolation, and interest in music (Horne-Thompson, Daveson, & Hogan, 2007). A music therapist
may address these issues utilizing various combinations of active and passive musical and/or
verbal processing techniques, (including listening, improvising, performing, composing,
structured instrument play, lyric analysis, and music therapy-assisted relaxation), with the
possibility of utilizing other supplemental modalities including dance/movement, art, guided
imagery, progressive muscle relaxation, individual counseling, drama, and poetry (American
Music Therapy Association, 2015; Bradt & Dileo, 2010; Bruscia, 1998; Hanser, 1999; Hilliard,
2005). Music therapy interventions can also be tailored for family members and/or caregivers to
help them cope with anxiety, fatigue, grief, and bereavement (Center for Music Therapy in End
of Life Care, 2015).

One music therapy technique used in end-of-life care which is referenced frequently throughout
the literature is song choice. This technique can be used to support creative exploration and
expression of emotions, self-empowerment and self-esteem, a sense of control at a time when the
patient experiences increased loss of control, and communication between patient and family
members when words alone do not suffice (Bradt & Dileo, 2010; Bruscia, 1991). Song choice
can also help facilitate life review and reminiscence, sometimes through the creation of a living
legacy project (making an audio or audio-visual recording to leave as a message or positive
memory for the family), which can support meaning-making, honor the life of the person who is
dying, promote positive communication/interaction between the patient and family, allow for
emotional expression and bereavement, and provide opportunities for closure (Martin, 1991).
Music therapist Jennifer Martin, MT-BC (1991) also recognizes the effectiveness of preferred
music in helping to diminish anxiety, as it brings something familiar to an environment filled
with what is largely unfamiliar.

In a case study described by music therapist Robert Krout, Ed.D., MT-BC, RMTh (2003), song-
choice was utilized by the music therapist to allow the patient and family members to select
preferred hymns. This was reported to have helped everyone in the room feel connected to each
other as they held hands with the patient and said goodbye. The familiar hymns are what seemed
to have enhanced the sense of support among family members. A second case study describes the
use of a song that was meaningful to the patient and family as a catalyst for sharing memories
and stories about the patient, and allowing family members to cry and comfort each other during
the music (Krout, 2003). A third case study highlighting the use of song choice with a 42-year-
old woman with terminal cancer describes how the patient gained emotional insight through her
selection of songs and was able to reach “emotional resolution about leaving her loved ones”
(Whittall, 1991).

Halliwell, 2015

Other interventions which can be used to address patient and family needs include improvisation
and songwriting (Bradt & Dileo, 2010). Martin (1991) recognizes the importance of such
creative activities in providing opportunities for patients to have enjoyable experiences with their
loved ones, offering a sense of respite from the difficult situations often present at the end-of-
life, which can in turn assist with coping and help the patient and family feel ready for whatever
happens next. To support patient and family spiritual needs, hymns or other sacred songs may be
utilized to facilitate exploration and/or expression of existential considerations, as well as
provide a means of religious expression when it is no longer possible to attend religious services
in the community (Krout, 2003; Lipe, 2002; Pierce, 2011). Music may also be combined with
prayer and worship (Bradt & Dileo, 2010; Wlodarczyk, 2007), opening the door for possible co-
treatment with spiritual care providers.

Music therapy has been used as a non-pharmacological approach to addressing physical
discomforts, including pain, labored breathing, stress and anxiety, agitation, nausea,
hypertension, tachycardia, and insomnia, by shifting focus to the music or musical activity and
altering affective, cognitive, and sensory processes (Bradt & Dileo, 2010; Nightingale, et al.,
2014). Music therapist Janelle Pierce, MT-BC (2011) references a technique known as the ISO-
principle, which can be used to match respiratory rate while playing patient-preferred music,
gradually reducing the tempo to assist with relaxation and reduce the perception of distressing
symptoms. Incorporating additional supplementary modalities such as guided imagery,
progressive muscle relaxation, deep breathing exercises, and massage, can further assist in
symptom management (Groen, 2007). Music therapist Kathy Jo Gutgsell, RN, MT-BC and
colleagues have identified a protocol for relieving pain which integrates guided relaxation
techniques with live harp music, and has been demonstrated to be effective among patients in a
hospital setting (Gutgsell, et al., 2013).

Many, though not all, music therapy techniques involve some form of active participation, even
if only at the level of selecting preferred music. Even the Bonny Method of Guided Imagery and
Music, though focusing on journeying through imagery experiences while lying physically still,
involves discussion between the “traveler” and the facilitator throughout sessions, which requires
energy and awareness of the traveler (Association for Music and Imagery, 2015). One exception
in the literature highlights a standardized technique to reduce pain, developed by Gutgsell,
involving live, therapist-selected harp music adjusted to match the patient’s respiration rate after
providing verbal prompts to guide him/her through a relaxation protocol (Gutgsell, et al., 2013).
In this music therapy technique, the music is pre-selected, and the patient is encouraged to
simply lie down and journey through the music, thus creating a more passive, receptive
experience for the patient.

Familiar music is widely used throughout music therapy practice, and many music therapy
techniques incorporate patient- and/or family-preferred music as a means of achieving
therapeutic goals. The use of familiar/preferred music in end-of-life care can be extremely useful
in achieving clinical goals, including developing rapport, facilitating family interaction,
supporting life review and reminiscence, and providing spiritual support (Bradt & Dileo, 2010;

Halliwell, 2015

Lipe, 2002). In a case study described by music therapist Lucy Forrest, RMT (2002), an 84-year-
old Australian woman of Russian descent was able to explore past memories regarding difficult
and traumatic life events from her time in Russia through the use of familiar Russian folk songs,
which resulted in the resolution of internal conflicts related to these memories so that she could
be more present and available to her family in the present moment. She was able to re-establish
and affirm her identity in its entirety, piecing together layers that had previously been forgotten
or repressed and relieving the distress and anxiety that had been surfacing due to unresolved
feelings of guilt and regret. In this case, familiar music was an extremely powerful catalyst for
healing.

In some cases, unfamiliar music can be used as the preferred therapeutic agent. Music therapist
Anne Lipe, Ph.D., MM, MT-BC (2002) suggests that “as an individual draws closer to death,
there may be little energy left to actively participate in music experiences”. Music therapist
Miranda Eden, MT-BC also recognizes that familiar music may not always be suitable for every
situation, as she relates “I might do something more contemplative that they don’t know, so they
can relax a little bit. If you play all songs that everybody knows, there’s not that moment to
really be in the music and let the music take you to other places” (personal correspondence, May
11, 2015).

All of these examples of music therapy applications represent some of the most commonly used
techniques, though there are certainly many ways music can be used at the end of life to support
patients and their families. In one unique circumstance, the music therapist supported a dying
patient’s wife in singing an original song she composed for her husband, which facilitated
intimacy and a shared meaningful experience between the couple (Krout, 2003). In another
unique case, an 86-year-old man who had been an amateur violinist was supported by his music
therapist in putting on a performance for his family, hospital staff, and other patients. Through
this experience, the patient was able to enjoy a sense of success and independence while coming
to an acceptance of his limitations as he approached the end of life (Beggs, 1991).

Music-thanatology clinical application. Music-thanatologists have been compared to midwives,
working on the other end of the spectrum to support an individual’s transition out of this world
(Cox & Roberts, 2006; Hollis, 2010). Similar to the role of the midwife in accompanying and
supporting the birthing process, the music-thanatologist attends to the dying as a witness to the
transformation taking place without imposing upon any of what is taking place, using live harp
and vocal music to accompany the transition from life to death (Freeman, et al., 2006; Hollis,
2010). The music-thanatologist will often be provided with information about the patient and
family, including details specific to disease process, symptoms, prognosis, family dynamics,
psychosocial factors, and the patient’s level of comfort in order to be prepared to address and
support these various needs when entering the patient’s room. Common referral reasons include
restlessness, agitation, pain, respiratory distress, delirium, insomnia, grief, anxiety, fear,
difficulty coping, family conflicts, or unresolved spiritual or religious questions (Hollis, 2010;
Pasquesi, 2015). The music-thanatologist accompanies whatever is going on for those present in
a vigil, at times facilitating and supporting transformation toward completion and wholeness
(Pederson, personal correspondence, 2015).

Halliwell, 2015

In music-thanatology, harp and voice are used across the board as primary instruments. Utilizing
the concepts of synchronization and entrainment, music-thanatologists adjust the music in
response to the physiological changes of the patient (entrainment) in order to remain in sync with
them, so as to ease physical, emotional, and spiritual suffering (Black & Penrose-Thompson,
2012). It is this relief of suffering that can allow the patient and family to re-connect with their
sources of meaning or forgotten parts of the self, thus facilitating the possibility for a peaceful,
blessed, and/or conscious death (Pasquesi, 2015; Schroeder-Sheker, 2012).

While the image of the harp is undeniably laden with associations of “angels” and “heaven”,
there are very practical reasons for its use. These include portability and the flexibility to draw
upon melodic and harmonic structure simultaneously. The range of tones available on the harp is
also greater than many other acoustic instruments. Another important characteristic about the
harp is its ability to produce very warm, resonant tones, which allows for the possibility of bone
conductivity (Schroeder-Sheker, 2012). In one vigil, the pillar of the harp was propped against
the side of the bed, as close to the man’s body as possible so that he could feel the vibrations, and
within minutes he shifted from a state of agonal thrashing to stillness and rest (Cox & Roberts,
2013). Music-thanatologist Jennifer Hollis, CM-Th (2010) even speaks to the significance of
possible associations people have with the harp, recognizing that in many cases the imagery can
evoke a sense of beauty, reverence, or of bridging the gap between life and death. While for
some the image of the harp may provoke anxiety, individuals can be reassured by speaking with
the music-thanatologist and personally experiencing the benefits of the music, often changing
their minds about their desire to receive a vigil upon hearing the music down the hall being
played for someone else (Cox & Roberts, 2013; Hollis, 2010).

Music-thanatologists use the term “vigil”, which means “watchfulness or a period of watchful
attention”, to refer to their time spent with the patient and family at the deathbed (Music-
Thanatology Association International, 2015). There are two kinds of music vigils; processing
and imminency. Typically, an imminency vigil is for someone who is very near to death (perhaps
having 24-48 hours or less to live), and may or may not be having an experience of suffering.
This kind of vigil can bring beauty and reverence to the last moments of a person’s life and the
impact of this can reverberate to the patient, family, and surrounding medical community. A
processing referral can be made for someone who is not so near to death, but may be
experiencing physiological or interior suffering (Chalice of Repose Project, 2015), and can also
be beneficial for family members as they work to process and cope with the impending death of
their loved one (Hollis, 2010; Music-Thanatology Association International, 2015).

In a music-thanatology vigil, the focus is primarily on the patient and family experience of
receiving from the music and the supportive presence of the music-thanatologist.
Communication between and among family members, and expression of feelings may very well
be part of the experience, but rather than directing or facilitating any form of active participation
or verbal discussion, a music-thanatologist will respond to the situation by reflecting and
supporting the patient and family dynamics through the music itself, allowing the experience to
speak for itself (Cox & Roberts, 2013). The patient is always in control of the vigil, directing the

Halliwell, 2015

changes in the music without having to do or say anything requiring extra energy, and can rely
on the sensitivity and attentiveness of the music-thanatologist to follow without asserting his/her
own voice (Freeman, 2004; Hollis, 2010; Music-Thanatology Association International, 2015).
Music-thanatologist Music-thanatologist Suzanne Cerddeu, CM-Th (2009) refers to this
personal/musical presence as “generative empathy”. One family member’s experience of this
was that “the music would create silence and stillness where people could just be there, feeling
comfortable with the silence” (Cox & Roberts, 2013, p. 222).

Often, the music vigil will involve the intentional use of contemplative silence, both within the
music and between music deliveries, which can lead to an experience of what has been referred
to by clinicians, patients, family members, and staff as “sacred space” (Baker, 2010; Cox &
Roberts, 2013). Unmetered and modal music can be used to facilitate spaciousness within the
music delivery, which can further support this sense of sacred space. It is within this space that
deep peace becomes possible, as the patient, family members, and anyone else present begin to
transcend into a shift in consciousness and become more present in the moment (Chalice of
Repose Project 2015; Cox & Roberts, 2013).

The use of music in a prescriptive manner is another concept espoused by music-thanatologists,
distinguishing the clinical application of music from that which is used as performance or
entertainment. This prescriptive application is not dependent on specific repertoire, but rather
emphasizes being fully present to the situation, responding musically to both overt and subtle
signs at the deathbed (Music-Thanatology Association International, 2015). An example of this
is illustrated by music-thanatologist Peter Roberts as he relates his recollection of one particular
vigil in which “the choice of music, the lack of words and the way it was being offered was no
accident”: the “male and female qualities” of the harmonized voices of the two music-
thanatologists intentionally mirrored and supported the affection between a dying patient and his
wife as they held each other in their arms in bed (Cox & Roberts, 2013, p. 134-5).

Music-thanatologists are often called upon for symptom management (Chalice of Repose
Project, 2015; Danna, 2012; Nightingale, et al., 2014), and work to synchronize the music with
physiological indicators, primarily the breath, also considering pulse rate and quality,
countenance, skin color and quality, temperature, and body language. The music is always
delivered live on harp and voice, and the music-thanatologist remains intently focused on the
patient, responding to the slightest of changes in an effort to maintain synchronization and follow
the patient to the state of ease that he/she is naturally inclined towards (Schroeder-Sheker, 2012).

Through a study conducted by music-thanatologist Lindsay Freeman, MS and colleagues, it was
discovered that music-thanatology can effectively decrease agitation and promote a calm and
restful state among individuals at the end of life, as evidenced by decreased levels of
wakefulness, decreased respiration rate and effort, and increased respiration depth from the
beginning to the end of the vigil (Freeman, et al., 2006). Hollis (2010) also quotes a palliative
care physician who witnessed “patients’ blood pressures come down, heart rates slow down, and
levels of anxiety come down” (p. 111). Additionally, Twaddle shared in an interview with Amy
Paturel, writer for Spirituality and Health magazine, that from 1995 to 2003 sedation therapy had

Halliwell, 2015

been used on the inpatient hospice unit in an average of 12 cases per year, but that it dropped to
only three cases in 2003, notably the same year two music-thanatologists were hired to work on
the unit. Twaddle shared that “patients are so quickly calmed by the music they never get to the
point where sedation is necessary” (Paturel, 2013). (Palliative sedation is a procedure which
involves the monitored use of medication to induce a state of decreased consciousness to relieve
severe physical distress when other options have been unsuccessful and when the individual has
days or hours to live (Bruce, 2006)).

Music-thanatologists may also be called upon to accompany a patient through the process of
removing life support (Chalice of Repose Project, 2015; Cox & Roberts, 2013; Twaddle, 2015).
In multiple accounts of music-thanatology used during removal of ventilator support, the
common sentiment seems to be that a sense of reverence had been brought into a most difficult
moment, and rather than leaving the room to avoid the discomfort and sense of failure, staff and
family members actually ended up gathering in the room to be part of the experience (Cox &
Roberts, 2013; Hollis, 2010; Twaddle, 2015). In a situation that is often very difficult to witness,
a transformation can occur through the music delivery which offers a sense of reverence in spite
of the difficulty.

In music-thanatology, the musician-clinician tends to draw largely upon the weaving together of
elements of music, rather than playing preferred songs, allowing the patient and family to go
where they need to. One patient shared that she could feel light streaming out of her fingers and
that the music took her to “another world”, which she entered into more and more deeply with
each successive vigil over the course of two months before she died (Cox & Roberts, 2006).
Another patient shared that the music took him to “a place of relaxation, where he could remove
himself from thinking”, which he called “the haven; the place of no fear” (Cox & Roberts, 2013,
p. 27). Another shared that “the atmosphere of the room seemed to change; it was as though a
cloud of peace and calmness was hovering” (Cox & Roberts, 2013, p. 37). Music-thanatologists
also recognize that familiar music may have the effect of eliciting associations or memories that
encourage and sustain a sense of “holding on” to life, which may not be desired if the patient is
actively dying and working to release from the body. Instead, using the elements or “raw
materials” of music prescriptively is employed in the musical deliveries so that the focus can be
on the present moment, on the task at hand (Music-Thanatology Association International, 2015;
Schroeder-Sheker, 2001). (A future study to investigate the effects of familiar versus unfamiliar
music during the last 24-48 hours of life may be of value.)

There are many similarities between music therapy and music-thanatology professional
competencies, as put forth by their respective certification bodies. Both place emphasis on
ethical practice, documentation, and appropriate implementation of services among specific
client populations. The competencies which seem to be unique to the field of music-thanatology
include a commitment to personal inner development and spiritual growth; the ability to enter
into a contemplative relationship with the patient, family, and the music at the vigil; self-
reflection and emotional integration; clinical utilization of the raw materials of music; an
understanding of the relationship between the prescriptive qualities of music and the
physiological and phenomenological responses in the patient; and the ability to reflect on a vigil

Halliwell, 2015

and write a contemplative clinical narrative of the experience (Music-Thanatology Association
International, 2015). To help illustrate the contemplative element of these competencies and the
intricacy with which music-thanatologists need to be “virtuosos in composing with spontaneity”,
as former president and Chief Executive Officer of Midwest Palliative and Hospice CareCenter,
Jamie O’Malley, MS, RN, related in an interview with Chicago Tribune reporter Jeff Danna
(2012). The following excerpts have been selected from clinical narratives written about the vigil
experience:

Case 1: BL is lying in bed, eyes closed and minimally responsive. Her breathing is
moderately labored and the muscles in her neck are contracting vigorously as her body
works to suck in air.

Occasionally, BL will let out a moaning sigh on an “oh” vowel. Mirroring this
vocalization, the prescriptive delivery utilizes simple a cappella vocal harmonies between
the two music-thanatologists with a soft echo effect to let her know she is being
supported. As we sing, BL raises her eyebrows and takes a slightly deeper, terraced
inhale, with a slightly more relaxed exhale. After a few moments of purely vocal
harmonies, harp is added to the delivery for extra stability and support for both BL and
her family. Noticing that BL raises her eyebrows during pronounced shifts or changes in
the music, a clear melody is emphasized with alternation between major and minor
chords for novelty and an opportunity for mental focus. The family has become still and
silent, and one woman in the room is sniffling while BL continues to take terraced inhales
followed by sighs or slight vocalization.

Continuing to follow BL’s lead with her vocalizations, and considering the family’s
emotional release and state of ease, the music returns to vocal harmonies to reflect and
support the intimate family dynamic while offering reassurance to BL that we are still
there and moving with her. As the music closes, the family is quiet for a moment and I
notice that BL’s inhales have become slightly deeper. A family member who had been
crying earlier wordlessly reaches her arms out toward me and we embrace tightly for a
few seconds. As we release our embrace, she looks into my eyes tearfully, and we both
nod in understanding. (Halliwell, 2015a)

Case 2: JS is lying in bed, eyes wide open, breathing through his mouth and staring
toward the ceiling. A tear is gleaming down the outside corner of his right eye as he lays
motionless save for the rise and fall of his chest. I speak to him softly, letting him know I
will be playing harp for him, then wipe the tear from his eye.

Considering JS’s impalpable pulse, the music offers a spacious and rubato melody line,
focusing on simplicity and a narrow ambitus to mirror and support his process of
physiological simplicity as his vitals diminish, cadencing with his exhales when possible.
During a brief silence I notice that JS’s respirations have become shallower and less
frequent. The color of his skin has shifted from grayish-white to a yellow hue, and his
eyes are glazed over.

Halliwell, 2015

JS shifts his head to the right and lets out a soft sigh as the music delivery shifts into a
lilting 3/4 meter with rubato phrasing and warm vocals offering soothing, supportive text
as an archetypal image of security and safety. His face muscles and eyelids relax so that
his eyes are no longer wide, but gently open. Following his breaths as they become even
shallower and less frequent, the music offers very sparse harp accompaniment under soft
and simple vocals sustaining for the duration of a complete respiration cycle. The music
becomes softer and more echo-like along with JS’s breaths, until I can barely discern an
inhale.

JS’s partner and brother enter the room and become tearful. In response to the family’s
open grieving, I play one final delivery focusing on spacious, unmetered phrasing with
sung text offered as a prayer for peaceful departure. (Halliwell, 2015b)

Music therapy and music-thanatology relations. Though there has not been a great deal of
collaboration thus far between music therapists and music-thanatologists, based on some
foundational guiding principles and at least one example of successful collaboration, there is
hope for future collaborative relations between the two fields. Music therapist Fran Felton, MT-
BC believes that having an open conversation about collaboration and role differentiation is very
important for both music therapists and music-thanatologists (personal correspondence, July 13
& 16, 2015). Hollis asserts that “we have to collaborate to serve patients in the best ways, and I
think this is the best way to care for patients” (personal correspondence, May 19, 2015). The
standards of practice for both music therapy and music-thanatology speak to the importance of
professional ethics, which includes maintaining cooperative and harmonious relations with
members of other professions (American Music Therapy Association, 2015; Music-Thanatology
Association International, 2015), which speaks to the possibility of open-mindedness and
creative solutions for working together.

One example of an organization which successfully employs both music therapists and music-
thanatologists is Midwest Palliative and Hospice CareCenter, in Glenview, Illinois. Both services
are highly valued from an administrative perspective, and can be used as a marketing tool,
especially because having both is a “really distinguishing characteristic” (Hollis, 2010; Twaddle,
2015). Music-thanatologists Margaret Pasquesi, MA, CM-Th and Tony Pederson, CM-Th, both
Midwest CareCenter employees, speak to the ways roles are differentiated: “The patients can
have their scheduled ‘dose’ of music [therapy], and can have a ‘PRN’ dose of music-
thanatology” to ensure that their needs are being met at all times (personal correspondence, July
9, 2015). If there are acute symptoms or if the patient becomes imminent, a music-thanatologist
may be called upon to address these needs on an as-needed basis, and Twaddle adds that if a
relationship is already established with a music therapist, “we certainly support them being there
to the end of life” (personal correspondence, July 8, 2015).

Pasquesi, who is also the Team Lead of the Music Care Services department, reports that the
current music therapists on staff tell her they “really love having a caseload and being able to
develop a therapeutic relationship” with the patients, without being overwhelmed with having to

Halliwell, 2015

respond to imminent referrals (personal correspondence, July 9, 2015). Pasquesi and Pederson
respond primarily to imminent situations, and have anything but a set schedule. This is of
particular importance because an imminency call can be clear on the other side of the county,
and it is helpful to have employees who are available to respond to these calls on a daily basis.
Twaddle also speaks to some of the differences that make each service unique and valuable:
“music therapists develop a therapeutic relationship which absolutely impacts the patient and
family, and music-thanatologists have the prescriptive intent with raw elements around the
physiologic interaction at the very end of life” (personal correspondence, July 8, 2015). In
response to a comment about budget concerns around employing both music therapists and
music-thanatologists, Pasquesi responded,
Music Care Services is philanthropically funded, but both music therapy and music-
thanatology salaries are written into the operating budget so that patient and families are
not charged for services. The organization is able to receive grants they normally
wouldn’t be able to apply for because of having a clinical music department. For
example, Midwest Palliative and Hospice CareCenter receives an Illinois Art Council
Grant because of its music-thanatology program (personal correspondence, July 9, 2015).

While the arrangement at Midwest CareCenter may not work for every organization, it can at
least serve as an example of a working model of collaboration between music therapists and
music-thanatologists that meets the needs of the patients and families, as well as those of the
service-providers themselves and the organization as a whole. The following are a few case
examples of how patients have benefited from having both services as part of their end-of-life
care:

Example 1: J.W., daughter of former hospice patient L.M., recalls that her mother really
connected with the music therapy because of her love of music and experience playing piano in
her younger years. She got a lot of enjoyment from the music therapy sessions. When speaking
about music-thanatology, J.W. shares, “it helped me realize it was time for Mother to go; it was
not a traumatic situation” (personal correspondence, June 25, 2015). She thought both were
wonderful, and felt grateful to have had the experience of music therapy and music-thanatology
as part of her mother’s end-of-life care.

Example 2: B.A., wife of former hospice patient M.A., was present for every music therapy
session, which took place once a month for the 15-month duration of M.A.’s hospice experience.
She recalls how music therapy helped bring back some of his memories, even as he declined
with late stage dementia, sharing that “the music therapy sessions were an opportunity for us to
share personal time together in a meaningful way” (personal correspondence, July 13, 2015).
B.A. also shared that because her husband’s music therapist could sing in Yiddish, she was able
to sing songs from his childhood which was very special for both of them: “It gave him joy and
was very enriching, and it made me emotional when I heard him respond. It was helpful to have
that sort of release” (personal correspondence, July 13, 2015). B.A.’s husband received one
music-thanatology vigil the night before he died, and her experience of it was that it was “the
most inspirational, beautiful, and peaceful experience, and it gave him a beautiful death”
(personal correspondence, July 13, 2015). She recalls that her husband’s heart rate went down

Halliwell, 2015

during the vigil, and that it was “completely different from the music therapy”, something she
had never experienced before (personal correspondence, July 13, 2015). When asked to sum up
her experience with both services, she said, “the music therapy was joyful and helped him
remember, and the music-thanatology was peaceful and quiet and helped us to cry and let go”
(personal correspondence, July 13, 2015).

Example 3: P.R., husband of former hospice patient J.R., recounts his wife’s experience with
music therapy and music-thanatology as being helpful through the different stages of regression
from Amyotrophic Lateral Sclerosis: “They kind of go together; it was the whole package, one
being a little more active and interactive, and the other not at all” (personal correspondence, July
14, 2015). P.R. remembers his wife receiving music therapy services about every other week for
two months before she died, “while she was still able to move” so she could be more active, and
she enjoyed getting to play castanets and strum the guitar [with assistance] (personal
correspondence, July 14, 2015). Once in a while, when other family members or friends were
present, they might pick up an instrument and join in, and P.R. remembers this being a “fun
activity to do together, where she could be as active as possible, which also met my emotional
needs” (personal correspondence, July 14, 2015). P.R.’s wife received one music-thanatology
vigil about three hours before she died, and he recalls “most of the music was not anything you
could put your finger on; one piece of music kept going up and up and up, then sort of
disappeared” (personal correspondence, July 14, 2015). The most vivid memory he has is that
“She was having difficulty breathing, it was coming in gasps, her heart was irregular, breathing
shallow and irregular, pretty obvious she was struggling. After the harpist finished, my wife’s
breathing was deep and regular, her heartbeat had leveled out and was not as arrhythmic, which
made her last hours more comfortable” (personal correspondence, July 14, 2015).

Example 4: P.Z., wife of former hospice patient P.Z., was present for every music therapy
session and music-thanatology vigil her husband received. Music therapy services started almost
immediately, and lasted for the duration of his hospice experience (about one year). The music
therapist learned a song in Hebrew and “it meant a lot to him” (personal correspondence, June
29, 2015). P.Z.’s experience of the music therapy was that it “took some of the pressure off,
some of the sadness; it brought some life into the house” (personal correspondence, June 29,
2015). She recalls that her husband had “gone down so far” in terms of dementia, and the music
brought in “some of what he knew from before, which he loved … it gave him a taste of things
he wasn’t able to enjoy anymore, and gave a kind of normality” (personal correspondence, Juny
29, 2015). Music-thanatology services started later in their hospice journey, when he was mostly
sleeping and unresponsive. P.Z. shares, “I think that the music-thanatology was calming and
comforting for him, and also for the family” (personal correspondence, June 29, 2015). She
remembers the last vigil with great clarity, recalling that she heard chirping during the vigil, and
at the moment her husband passed, “there was a huge cry of chirping – a cacophony of birds
chirping – and then I never heard them again; it’s as if they saw the soul passing” (personal
correspondence, June 29, 2015). Of the music, she shares that “it was so mystical, and it gives
you a religious feeling, and I liked looking at [the harp]; it gave me hope for his passing”
(personal correspondence, June 29, 2015). When asked how it was having both services, she said
“It was perfect, because it was for the different stages. There’s something about the harp. It

Halliwell, 2015

wouldn’t have been the same with the guitar. Guitar was more for his fun side. But there’s a time
for each thing” (personal correspondence, June 29, 2015).

Example 5: M.A. was on hospice for 6 months with late stage dementia. Her daughter, S.A., was
present for weekly music therapy sessions, and also for one music-thanatology vigil which took
place a few days before her mother died. S.A. remembers, “My mother liked to sing, and I like to
sing, and I think the best stuff was when [the music therapist] played songs that my mother was
familiar with, songs from her own era, and even from her dad’s era. This is what she responded
to the most” (personal correspondence, July 2, 2015). She also recalls that it was fun, and gave
them something pleasant to experience together “without getting anxious and feeling like she had
to talk about things that she couldn’t follow; it was a very low-anxiety type of visiting” (personal
correspondence, July 2, 2015). When music-thanatology services were called upon, S.A. was
“very stressed out by that stage,” as she was the only family member who was available and had
the stamina to stay with her mother until she passed (personal correspondence, July 2, 2015).
“Apparently I responded more than my mom or my dad,” she shares. “I had been very stressed
out, hadn’t been getting enough sleep. I laid down on the couch and ended up falling asleep. It
was very relaxing for me. It was a blessing to really deeply relax and fall asleep and get some
rest” (personal correspondence, July 2, 2015). Of the music, she recalls that “The [music-
thanatologist] wasn’t really playing songs; he was playing very calming music without a
detectable repeating melody, which was very relaxing and very healing to me. It was comforting
in a really difficult emotional time, and it was probably the most spiritual experience of my
entire life” (personal correspondence, July 2, 2015). When asked to share about her experience
with both, S.A. expressed, “For me, I would say the music-thanatology was important at a very
stressful time. My mom responded to the music therapy. Having both was really good” (personal
correspondence, July 2, 2015).

Method
Survey respondents included 20 board-certified music therapists who work (or have recently
worked) in an end-of-life setting, and 10 certified music-thanatologists currently working in an
end-of-life setting. A total of 46 survey questions were divided into sections: general questions,
clinical questions, personal practice questions, and questions regarding collaboration. Questions
were open-ended, and respondents were free to answer each with as little or as much detail as
desired. General questions included questions about employment location and status, referral
trends, and outreach and education efforts to promote the field. Clinical questions included
questions about clinical goals, techniques used, and patient constituency trends. Personal practice
questions included questions about self-care and personal spiritual practice. Questions regarding
collaboration included questions about familiarity with each field, potential benefits of
collaboration, and concerns about collaboration. Completed surveys were analyzed for response
trends, which were calculated into percentages when possible for comparison and generalization
purposes. (See Appendix A for the complete list of questions.)

Music therapists were recruited to participate in the survey via five different means: 1) Through
the American Music Therapy Association (AMTA) website, www.musictherapy.org, using the

Halliwell, 2015

“find a music therapist” link and searching for keyword “hospice/bereavement services”; 2)
Contacting music therapists who presented on hospice music therapy at the 2015 Great Lakes
Region Music Therapy Conference held in Minneapolis, MN; 3) Contacting hospice music
therapists who completed the training program established by Dr. Russell Hilliard, as listed on
the website www.hospicemusictherapy.org (Not all music therapists listed were registered
members of AMTA, so not all contact information was available); 4) Recruiting music therapist
colleagues; 5) Referrals from music therapists to colleagues whose names are not listed on any
website database. A total of 191 music therapists were identified and e-mailed with a detailed
description of the purpose of this paper and a request to participate in the survey. Twenty music
therapists (11% of those contacted,) completed the survey questions, either in writing or through
an over-the-phone interview.

All music-thanatologists listed on the MTAI website, as well as one music-thanatology student
intern, were contacted with the same detailed description of the paper and a request to participate
in the survey. Of the 53 total music-thanatologists identified and contacted, 10 (19%) completed
the survey questions via e-mail response, or over the phone.

Results
General
Work experience
Of the music therapists who responded to this survey, 65% (13) have worked in an end-of-life
setting for one to ten years; 20% (4) between 10-20 years; and 10% (2) over 20 years. (Two
music therapists did not answer this question). Of the music-thanatologists who responded, 40%
(4) have worked in end-of-life for one to ten years; and 40% (4) for 10-20 years. Forty-five
percent (9) of the music therapists who responded are employed full-time as hospice/end-of-life
music therapists; 30% (6) are employed part-time; and 25% (5) are private contractors. Twenty
percent (2) of music-thanatologists are full-time employees; 20% (2) are part-time employees;
20% (2) are part-time private contractors; and 10% (1) is a substitute/on-call contractor. (Three
music-thanatologists did not answer this question.)

Forty-five percent (9) of music therapists said they were not the first at their workplace, and that
a music therapy program was already in place and had been well-established (10-20 years) at the
time of hire; 10% (2) said they were not the first music therapist, and the existing program was
fairly well-established (3-4 years); 10% (2) said they were the first full-time music therapists
after a 6-month pilot program was conducted by a different music therapist; 5% (1) said they
were not the first music therapist, but the program had not been well-established; and 30% (6)
said they were the first music therapist and had to pioneer to create a program. Fifty percent (5)
of music-thanatologists reported being the first at their place of hire, having to pioneer and
advocate for a program to be established; 10% (1) was hired at a facility where music-
thanatology was already well-established; 10% (1) was not the first, but reported doing a “great
deal of education and advocacy to get the position and pay deserved”; and three did not respond.

Location of employment

Halliwell, 2015

The music therapists who responded to the survey represented 12 different states across the
United States (California, Florida, Illinois, Iowa, Michigan, Minnesota, Missouri, New York,
Ohio, Oregon, Washington, and Wisconsin). Of the music-thanatologists who responded, 40%
(4) work or have worked in Illinois in the Chicago area, 40% (4) work in Everett, Washington,
and 10% (1) works in Geelong, Australia. (One did not respond to this question.) While this is
not a comprehensive tally of music therapists and music-thanatologists, this basic snapshot
suggests that music therapists are fairly well-represented throughout the country, while perhaps
there are certain pockets where music-thanatology has taken root.

Umbrella of services
Thirty-five percent (7) of music therapists reported that their services are housed under “Music
Therapy” at their place of work; 20% (4) are housed under “Music Care Services”; 10% (2) are
housed under “Integrative Therapies”; 10% (2) under “Supportive Care Department”; 5% (1)
under “Memory Care Services”; 5% (1) under “Spiritual Care Services”; and 5% (1) under
“Expressive Arts Program”. (Three music therapists did not respond to this question.) Thirty
percent (3) of music-thanatologists said their services are housed under “Music Care Services”;
30% (3) under “Spiritual Care Team”; 10% (1) under “Pastoral Care”; 10% (1) under “Music
Ministry”; and 10% (1) under “Complimentary Therapy”. (One music-thanatologist did not
answer this question.)

Education and outreach
The most common methods of outreach and education done by music therapists are community
presentations (28%), in-services for staff (21%), new-hire orientations (9%), presentations at
state hospice conferences (7%), presentations at music therapy conferences (7%), and music
therapy brochures (5%). The most common methods of outreach and education done by music-
thanatologists are presentations for new employees (21%), community presentations (16%),
conference presentations (11%), and conducting research (11%).

Funding for services
Regarding funding, 40% (8) of music therapists didn’t know or didn’t answer how their services
are funded. Based on the responses of those music therapists who did know, 41% of funding
comes from grants or donations, 24% through Medicare or Medicaid, 18% from the company
budget, 12% through private pay, and 6% from a combination of donations and budget. Forty
percent (4) of music-thanatologists did not respond or reported that they did not know where
funding came from. Based on the responses of those music-thanatologists who did know, 50% of
funding is through philanthropy, and 50% is from the company budget.

Interdisciplinary team experience
Seventy-five percent (15) of music therapists reported that interdisciplinary team members have
at least a basic understanding of what they do and make referrals appropriately; 20% (4) said that
team members still need more education; 5% (1) said that team members do not have a good
understanding of the role of music therapy in patient care, due to constant turnover in staff; and

Halliwell, 2015

5% (1) shared that music therapy is occasionally confused with music-thanatology. Music
therapists reported that 24% of referrals come from nurses or social workers, 14% from
volunteers, and 14% chaplains, doctors, physical therapists, occupational therapists, and
activities directors. Fifty percent (5) of music-thanatologists said that they feel understood and
supported by interdisciplinary team members, 20% (2) shared that educating team members is an
ongoing, gradual process, and 10% (1) said they do not currently attend IDT meetings. (Two
music-thanatologists did not answer this question.) Music-thanatologists reported that 50% of
referrals come from nurses, chaplains, or social workers, 30% come from the patient, a family
member, or caregiver, 10% from music therapists, and 10% by self-referral from the music-
thanatologist.

Education
Regarding education, both groups were asked to describe their level of training in end-of-life
care. One-hundred percent (10) of music-thanatologists received preparation through one of three
programs (Chalice of Repose Project, Missoula, Montana; Chalice of Repose Project distance
learning program, Mount Angel, Oregon; Lane Community College, Eugene, Oregon). In
addition to this, 40% (4) receive training at the facility where they work, 30% (3) have volunteer
experience in a hospice setting, 10% (1) attend seminars and webinars sponsored by the National
Hospice Association, and 10% (1) learned about caring for the dying as an ordained Swami and
Yoga Seminary Program graduate.

Twenty-five percent (5) of music therapists responded that they had no specific hospice/end-of-
life training other than what they learned through the basic music therapy coursework. Another
25% (5) received hospice training during internships. Thirty-five percent (7) completed the
Hospice and Palliative Care Music Therapy training through the Center for Music Therapy in
End of Life Care. The other 15% of responses included training through undergraduate clinical
experience, “some training with Russell Hilliard”, conference lectures and CMTE classes,
agency training at place of hire, on-the-job experience, personal reading and study, and hospice
volunteer work. Consistent with the results of the 2005 study conducted by Taylor, while music-
thanatologists appear to receive the same training across the board, music therapists’ end-of-life
training varies and is dependent upon each therapist’s initiative to pursue further training specific
to end-of-life. It is also worth noting that, even though music-thanatologists receive
comprehensive training through one of the two training programs, many also have additional
end-of-life training or experience.

Clinical
Caseload
The average caseload of patients for music therapists is between 15 and 50 in a given month, and
these patients are seen 1-4 times per month. For music-thanatologists, the average caseload
ranges from 10 to 30 patients per week, or 40 to 120 in a given month, and these patients are
seen as needed, which may be as often as once a day. On rare occasions a patient may be seen
more than once a day if necessary.

Halliwell, 2015

Twenty percent (4) of music therapists reported that they may see a patient one to five times
before they die; 25% (5) said they see a patient on average six to twelve times; and 45% (9) said
it varies depending on how long the patient lives, and that they may see a patient up to 50 times
before they die. Forty percent (4) of music-thanatologists reported seeing patients one to four
times before they die; and 30% (3) said that it varies, and that it’s possible to see a patient up to
10 times before they die. Based on these findings, it appears that, in general, music therapists see
fewer patients on a more regular basis, suggesting that they do have more of an opportunity to
develop ongoing therapeutic relationships with them, while music-thanatologists see more
patients fewer times before they die, which speaks to the more on-call nature of their work, being
called upon for cases of symptom management or for patients who are actively dying.

Session/vigil trends
Both music therapists and music-thanatologists said that the duration of sessions/vigils varies,
with the majority of them lasting between 30-60 minutes, depending on individual needs. One
music therapist said that a session once exceeded two hours, but shared that this is extremely
rare. Both music therapists and music-thanatologists provide services in a variety of settings.
Based on music therapist responses to this survey, 24% of music therapy sessions take place in a
private residence; 20% in a skilled nursing facility; 17% in an assisted living facility; 12% in a
hospital; 11% in an inpatient hospice unit; 9% in a group home, 3% in an independent living
facility; and 1% in a long term care unit, memory care unit, religious order, or other location.
According to music-thanatologist responses, 24% of vigils take place in a hospital; 18% take
place in a private residence or skilled nursing facility; 15% take place in a hospice inpatient unit;
9% take place in an assisted living facility; and 3% take place in a memory care unit.

Instruments used
In terms of instruments used, 100% (20) of music therapists responded that guitar and voice are
their primary instruments, and 100% (10) of music-thanatologists shared that harp and voice are
their primary instruments. Music therapists may also use other instruments in their sessions,
including keyboard or piano (40%), harp (15%), ukulele (15%), and mandolin (5%). When asked
to list any supplemental materials used in sessions/vigils, those most commonly used by music
therapists include hand-held percussion instruments (18%), an iPad or iPhone with downloaded
sheet music and chords (10%), drums (8%), flutes (7%), and an ocean drum (6%). Other less-
commonly used (<5%) supplemental materials include art and writing materials, tone chimes,
xylophones, lyric sheets, reverie harp, lap dulcimer, accordion, speakers, Q-chord, photos of the
patient and family, CDs, music stands, singing bowls, song lists, songwriting prompts, nature
sounds app on iPhone, microphone, recording software, autoharp, scarves, Orff instruments, and
table chimes. Two music-thanatologists reported using supplemental materials (a “native drum”,
a reverie harp, and simple rhythm instruments), though very rarely. (One of the two has former
experience as a board-certified music therapist.)

Referral reasons
The top five reasons for referral to music therapy services are pain and symptom management
(11%), isolation and loneliness (8%), anxiety (8%), family/caregiver support and coping (8%),
and depression (7%). Other referral reasons include agitation, spiritual needs, socialization and

Halliwell, 2015

meaningful interaction, reminiscence, respiratory distress, comfort, emotional needs, actively
dying, enjoyment, sensory stimulation, insomnia, anticipatory grief, terminal restlessness,
“quality of life”, withdrawal, coping, nausea, stress, communication needs, cognitive needs,
decline/approaching death, coping with symptoms of dementia, and “for closure”. The top five
reasons for referral to music-thanatology services are pain (13%), agitation (13%), anxiety
(11%), restlessness (11%), and emotional support/coping with fear (9%). Other referral reasons
include difficulty breathing, nausea, confusion, insomnia, “TLC”, psycho-spiritual needs,
actively dying, and to “increase peace”.

Family/staff participation
Ninety percent (18) of music therapists reported that family members are present “some of the
time”, 5% (1) said that family is “usually present”, and 5% (1) said that family is “rarely present”
during sessions. Common goals addressed when family is present include emotional support and
expression (14%), reminiscence and life review (13%), spiritual support and expression (10%),
social interaction and communication (9%), shared meaningful experience/encouraging intimacy
(8%), grief/anticipatory grief support (4%), relationship resolution (4%), and respite (4%). Other
goals include funeral and memorial planning, promotion of relaxation for family members, and
end-of-life education. Forty percent (4) of music-thanatologists shared that family is “sometimes
present” during vigils. The other 60% (6) did not report on how often family is present. Forty
percent (4) responded that when family is present, they are welcome to participate in any way
that is comfortable for them; 20% (2) shared that the vigil is an opportunity for family members
to express grief, which is supported by the music; 20% (2) shared that vigils are opportunities for
increased intimacy; 10% shared that family can use this time for rest and sleep which is
supported by the music; and 10% shared that the vigil can be an opportunity for respite.

Fifty-five percent (11) of music therapists responded that staff members are “sometimes present”
during sessions; 25% (5) said staff members are “rarely present”; and 5% (1) said that staff
members are never present. (Three did not answer.) If a staff member is present, music therapy
goals may focus on procedural support (22%); meaningful social interactions with staff (20%);
spiritual support from a chaplain (15%); emotional support for staff (10%); enhanced job
satisfaction for staff (7%); communication of patient needs (5%); gross and fine motor
movement (5%); relaxation (5%); anxiety management (5%); increased positive mood in the
patient (2%); support during the dying process (2%); and patient education (2%). Forty percent
(4) of music-thanatologists shared that staff members are sometimes present, and 20% (2) said
that staff members are rarely present. (Four did not answer.) When staff members are present for
a music-thanatology vigil, areas of focus include co-treatment with a chaplain for spiritual
support (10%); and emotional support for staff (10%).

Interventions used by music therapists
According to the music therapists who responded to this survey, 48% of music therapy
interventions utilize familiar/preferred music (for group singing, song choice, song dedication,
family interaction, life review/reminiscence, legacy projects, family discussion, and to support

Halliwell, 2015

spiritual needs); 8% utilize entrainment to match, validate, acknowledge, and “transform” an
experience of pain or suffering; 5% use music as a distraction or masking stimulus during
unpleasant procedures or to help cope with pain; 5% use music to create a comforting, supportive
environment; 4% incorporate songwriting; 4% utilize music-assisted relaxation for pain
management; 4% utilize vocal/instrumental improvisation to “support the dying process”; 3%
utilize music listening, lyric analysis, or instrument playing; 2% utilize improvisation,
instrumentally and/or vocally, to support pt self-expression (active or empathic), use background
music to support a faith ritual, or utilize supportive presence w/ pt and family. Less-frequently
used interventions include movement to music, sharing stories w/ family members who could not
be in the session, guided imagery, singing/playing messages to a dying patient, and using “The
Four Gifts” by Ira Byock as a template for completing life goals.

Eighty percent (16) of music therapists said they come to each session with a list of standards,
most popular, and most requested songs; 20% (4) have no set song list, and personalize their
repertoire for each patient based on preference; and 10% (2) memorize the music so they can
focus on the patient. Fifty-five percent (11) shared that they incorporate new music when the
patient or family makes a special request; 10% (2) reported learning new songs almost every
day; 5% (1) learns new material when the generation changes or patients request new music; 5%
(1) reported learning new music for personal interest; and 5% (1) reported learning one new song
or revisiting an old song once a week for professional maintenance of skills.

Twenty-five percent (5) of music therapists reported that they might use unfamiliar music to
encourage or facilitate discussion, or for improvisation; 20% (4) use unfamiliar music for
relaxation purposes; 20% (4) use it if they feel familiar music might be too emotionally
provocative or if the patient becomes agitated listening to familiar music; 15% (3) use it to
support guided imagery and relaxation techniques; 15% (3) use it if the patient or family requests
something unfamiliar or asks for the “therapist’s choice”; 15% use therapist-selected music if
they don’t know the patient’s preferred music and the patient can no longer respond; 10% (2) use
unfamiliar music during the actively dying phase to help the patient “let go”; 10% (2) use it for
“novelty or stimulation”; and 5% (1) uses it during entrainment or songwriting activities.

Ninety-five percent (19) of music therapists reported using text/song lyric often in sessions; 5%
(1) did not answer. Forty-five percent (9) shared that they use text when singing for patients for
enjoyment; 20% (4) utilize the lyric of a song to help the patient or family express themselves
and/or explore their feelings; 10% (2) use text for lyric analysis and discussion; and 5% (1)
reported using text for songwriting prompts. Thirty percent (6) of music therapists shared that
they avoid text when the patient is actively dying, believing that text can be “too much to
process”; 30% (6) avoid text if the lyric of a song is too emotionally provocative or if the patient
seems agitated by it; 10% (2) avoid text if the patient or family requests instrumental music; 10%
(2) avoid text when the patient is in pain, anticipating that it might be too much stimulation; 5%
(1) avoids text with patients who have dementia so they do not have too much information to
process; 5% (1) avoids text to allow the patient and family to engage in conversation with quiet
background music; and 5% (1) avoids text to give the patient or family an opportunity to sing or
speak if they wish.

Halliwell, 2015

Regarding the use of recorded music, 5% (1) of music therapists reported never using recorded
music in sessions; 70% (14) use it when the patient requests something that cannot be achieved
through live music (the therapist doesn’t know it, it’s in a different language, or played by an
orchestra or band, etc.); 15% (3) use recorded music if they need to assist the patient with
movement and cannot do so while holding an instrument; 10% (2) use recorded music to
facilitate lyric analysis; 5% (1) uses it if the patient is “unresponsive to live music”; 5% (1) uses
it for progressive muscle relaxation and meditation with verbal prompts; and 5% (1) uses it to
make playlists for the patient and family to listen to between sessions.

Twenty percent (4) of music therapists shared that they never use modal music in their sessions;
15% (3) said they rarely use modes/modal music; 45% (9) replied that they occasionally use
modal music; and 20% (4) did not share whether or not they use modal music. For those who
occasionally or rarely use modal music, 100% (12) of them intentionally use modes when
improvising; 25% (3) may use it for entrainment with the breath; 25% (3) said they may use it
for relaxation purposes; and 17% (2) use modal music with patients who are actively dying.
Eight percent (1) of the twelve who reported using modal music do so if preferred by the patient
or family, or “when familiar music is undesirable”.

When asked to report on their intentional use of silence, 65% (13) of music therapists shared that
they use silence to “create space” for the patient or family to speak or reflect between music, or
to just “give them a break” from constant stimulation; 25% (5) implement silence when music
“may not feel right”; 15% (3) reported implementing some silence before and after songs; 15%
(3) transition into silence if someone in the room seems to be affected emotionally; 15% (3) use
moments of silence as opportunities to re-assess the patient and/or check in with the family; 5%
(1) uses silence to “make room for the elements” (birds, thunder, etc.); 5% (1) uses it if the
patient is agitated; 5% (1) uses silence as the patient is dying to “create space”; and 5% (1) uses
silence at the end of the session for relaxation.

Both groups were asked to share how they might address specific issues including
spiritual/existential issues; emotional issues such as grief, anxiety, depression, or fear; physical
pain; and labored/distressed breathing. For spiritual/existential issues, 65% (13) of music
therapists use songs that might help address the expressed concerns; 45% (9) engage in verbal
processing with the patient or family; 15% (3) involve the chaplain if possible; 10% (2) will pray
with the patient and/or family or incorporate scripture if they request it; 10% (2) will verbally
validate feelings that arise; and 5% (1) uses songwriting or improvisation to help patients and
family members express themselves.

For emotional issues, 90% (18) of music therapists will facilitate verbal discussion, incorporating
songs that relate to the expressed feeling(s); 40% (8) use song-writing or improvisation for self-
expression; 15% (3) use mood-vectoring techniques, incorporating the ISO-principle; 10% (2)
use guided relaxation or breathing exercises; 5% (1) involves other team members when
necessary; 5% (1) will check in with the patient/family between songs, reassuring them of the
safe space of the session; 5% (1) reported using music as “a container for their feelings”; and 5%

Halliwell, 2015

(1) uses Associative Mood and Memory Training (AMMT) which is a Neurologic Music
Therapy (NMT) technique.

To deal with pain, 55% (11) of music therapists reported using music to redirect the patient’s
focus; 25% (5) use the ISO-principle for vectoring; 15% (3) use guided relaxation and breathing
techniques; 15% (3) use specific musical elements (suspension and resolution, slow tempo,
simplicity of texture) to help reduce pain; 10% (2) consult with a nurse if there is pain; 10% (2)
use songwriting or improvisation; 5% (1) uses song selection with lyric discussion; 5% (1) said
they try to be familiar with and advocate for the patient’s specific pain medication regimen; and
5% (1) uses a practitioner-created relaxation protocol for pain management. For
labored/distressed breathing, 75% (15) of music therapists reported using the ISO-principle and
entrainment for relaxation; 5% (1) uses receptive music listening; 5% (1) uses songwriting; 5%
(1) uses song re-creation; and 5% (1) uses improvisation.

When asked to describe how they use music to support the dying process, 30% (6) of music
therapists said they use music to provide a comforting and supportive environment for the patient
and family; 30% (6) said they use music to support the family if the patient is unresponsive,
continuing to provide music after the patient dies and allowing family members to choose
preferred music; 15% (3) use music that the patient liked when they were still responsive, to
make them feel comfortable during the dying process; 5% (1) uses music to support the breath;
5% (1) uses “continuous improvised music” to relax body systems through entrainment; and 5%
(1) uses music to mask unpleasant sounds associated with the removal of life support. (Two did
not answer.)

Regarding the use of session plans, 95% (19) of music therapists said they might have a general
idea based on patient goals, but remain flexible, assessing and modifying in the moment based
on patient status and response to the music. (One music therapist did not answer this question.)

Techniques used by music-thanatologists
One-hundred percent of music-thanatologists responded that they utilize synchronization,
following the patients breathing and creating music to support them in the moment, drawing
upon the “raw materials of music”. To describe this “music of the present moment,” 30% (3)
shared that they may focus on something as simple as an intervallic relationship or chord pattern
in order to support some aspect of the patient dynamic, and 10% (1) shared that they might
mirror patient vocalizations to support the patient’s physiological process. Seventy percent (7) of
music-thanatologists said they may incorporate familiar music on occasion, if requested by the
patient or family, or if they feel it may help the family “connect to the vigil experience”. Other
reasons for using familiar music included to support emotional release, relaxation, family
participation (some family members like to sing along to familiar hymns), or as a starting point
from which the vigil can gradually “move into the unfamiliar”. No music-thanatologists reported
using recorded music for any vigil experiences.

One-hundred percent (10) of music-thanatologists utilize text judiciously, sometimes using the
lyric of a song, chant, or hymn, sometimes improvising lyrics, and sometimes avoiding words

Halliwell, 2015

altogether. Fifty percent (5) of music-thanatologists reported using text to reflect and/or support
what is being witnessed in the room with the patient and family dynamics; 20% (2) use text for
comforting purposes; 10% (1) uses text that is meaningful to the patient or family; 10% (1) uses
text to provide a sense of security or structure if the patient needs something to “hold on to”; and
10% (1) uses text to facilitate emotional release. Reasons for avoiding text include minimizing
conscious thought (20%); minimizing the amount of stimulation for the patient to process (20%);
reducing agitation (10%); minimizing confusion if the patient has dementia (10%); and during
the actively dying process (10%).

Twenty percent (2) of music-thanatologists reported using silence for “rest and stillness”; 10%
(1) use silence to allow space for emotional and/or spiritual processing; 10% (1) uses silence for
“deepening, expanding, and loosening”; 10% (1) shared that “virtually all the playing is leaning
toward silence, using more and more space” as the vigil progresses.

All music-thanatologists work from a basic list of shared thematic material, though some branch
away from the shared themes more than others. Ten percent (1) of music-thanatologists shared
keeping familiar songs in mind, based on patient and family requests, in case it becomes
clinically appropriate to use familiar material. Sixty percent (6) of music-thanatologists shared
that they incorporate material which is not on the shared list, including Christian hymns, Jewish
music, Celtic music, and personally composed music.

Music-thanatologists utilize music as the primary supportive element in all situations, providing
space/silence for the patient and family to talk or process when clinically appropriate. Ten
percent (1) shared that they will verbally validate patients and family, gradually guiding them
back into the non-verbal through music; 10% (1) shared that they utilize simplicity, such as
incorporating a repeating phrase for support to help cope with spiritual/existential issues; 10%
(1) uses themes with text that reflects pleas for divine assistance and mercy. To address
emotional issues, 10% (1) shared that they might utilize a mode that mirrors suffering, gradually
offering a “lifting gesture” as the vigil continues. 20% (2) of music-thanatologists shared that
they will notify a nurse if pain is extreme; and 10% (1) shared that they are conscious not to
overwhelm the patient with sound, playing and singing with great simplicity in the presence of
pain. Ten percent (1) uses unmetered themes to support the patient when there is labored or
distressed breathing; and 10% (1) uses a specific vocal tone quality and spaciousness within the
music to support deeper breathing.

In response to the question about how music is used to support the patient/family at the moment
of death, fifty percent (5) of music-thanatologists said they always follow the patient’s lead,
supporting their unique process by following and synchronizing with the breath and mirroring
other physiological responses in the moment; 10% (1) said they specifically use unmetered
chant; 10% (1) intentionally plays “more spaciously”; and 30% (3) did not answer.

One-hundred percent (10) of music-thanatologists continually assess and re-assess in the
moment, keeping in mind essential information such as diagnosis, vital signs, family dynamics,
and other information relayed by the referring party.

Halliwell, 2015

Patient trends
When asked to report the percentage of actively dying patients seen, responses varied quite a bit.
Five percent (1) of music therapists responded “not at all, because I work with music-
thanatologists”; 5% (1) responded that it varies from 10-80% depending on the census; 30% (6)
responded that about 5% of patients they see are actively dying; 20% (4) responded that 5-10%
of patients they see are actively dying; 15% (3) said that 10-20% of their patients are actively
dying; 15% (3) said 20-25% are actively dying; 5% (1) said that 25% of patients are actively
dying; and 5% (1) did not answer. Thirty percent (3) of music-thanatologists responded that less
than 50% of their vigils are with actively dying patients; 40% (4) said that more than 50% of
vigils are with the actively dying; 30% (3) said that 90-95% are actively dying.

When asked how often they have been present at the moment of death, 10% (2) of music
therapists said “often”; 40% (8) said they have “occasionally” been present; 35% (7) have
“rarely” been present; and 25% (5) said they have never been present at a death. Fifty percent of
music-thanatologists reported being “occasionally” present at a death; 10% (1) said they are
“rarely” present at a death; and 40% (4) did not respond.

Understanding of the ISO-principle, synchronization, and entrainment
When asked to report on their current level of understanding regarding the ISO-principle and
synchronization/entrainment, 85% (17) of music therapists said their understanding of the ISO-
principle is to match the music and rhythm with the current feelings of the patient, then gradually
shift the music to encourage a more desirable feeling or condition. (Three did not answer.)
Twenty-five percent (5) of music therapists reported using the ISO-principle often; 25% (5) said
they use it sometimes; and 15% (3) said they always use it. Sixty percent (12) of music therapists
understand synchronization and entrainment to mean matching music to a physical state or to
biological rhythms; 15% (3) see them as being closely related to the ISO-principle, and that they
can be used together to ease physical and emotional pain; 5% (1) see them as applying to the
“mood and energy in the room”. Forty percent (8) of music therapists reported using
synchronization and entrainment techniques in their sessions “sometimes”; and 10% (2) reported
that they do not use these techniques very often.

Twenty percent (2) of music-thanatologists are not familiar with the ISO-principle; 70% (7)
believe it has to do with meeting the person “where they’re at” physically and emotionally to
achieve a connection; and 10% (1) shared that it means “bringing like to like”. No music-
thanatologists reported consciously/intentionally using the ISO-principle in vigils. All music-
thanatologists utilize synchronization techniques in every vigil, accompanying the patient via the
breath. Ten percent (1) of music-thanatologists shared that they do not consciously use
entrainment. No other music-thanatologists reported on their use of entrainment in vigils.

Personal
When asked to share their level of spiritual practice and self-care, 10% (2) of music therapists
did not answer; 10% (2) shared that they do not have a spiritual practice; and 80% (16) have a
regular spiritual practice that “greatly informs” their work and “sustains” them in their work. Ten

Halliwell, 2015

percent (2) of music therapists shared that they need to incorporate more self-care; 80% (16)
have a regular self-care practice which they view as essential to preventing burn-out and being
available to others. One-hundred percent (10) of music-thanatologists reported having some form
of spiritual practice and self-care practice, which they also believe to be essential to their work.

Collaboration
Current knowledge about the other field
When music therapists were asked to report on their current knowledge about music-thanatology,
30% (6) reported having done some level of research on music-thanatology, ranging from
general internet searches to writing scholarly articles about music-thanatology; 10% (2)
contemplated pursuing music-thanatology training; 50% (10) understand music-thanatology to
be used primarily at the very end of life during the actively dying process; 35% (7) understand
harp to be the primary instrument used in music-thanatology; 20% (4) understand the music to be
live and improvised on harp and voice; 15% (3) understand the music to be heavily based on
monastic chant repertoire, created in the moment based on vital signs and physiological
responses; and 10% (2) understand the music to be “prescribed” rather than preferred. Ten
percent (2) of music therapists shared that they have a great deal of respect for music-
thanatologists; 10% (2) shared that they have heard of it but don’t know much about it; and 5%
(1) shared that they are familiar with the company Sacred Flight and know that they provide
services at no charge to the pt/family. Other knowledge about music-thanatology includes: that
the terms “vigil” and “prescriptive music” are used to describe the work of music-thanatologists;
that training involves a two-year curriculum covering liberal arts, including an internship; that
music-thanatologists use modes and un-metered music; that music-thanatologists “rely much on
their musicianship”; that some measure vitals and some do not; that music-thanatology supports
individuals “transitioning from this world into the next”; and that music-thanatologists record
more biological data than music therapists do; that most music-thanatologists volunteer their
time; that only music is used in the vigil (no talking); and that music-thanatologists make no
contact with family members.

When music-thanatologists were asked to report on their current knowledge about music therapy,
70% (7) reported understanding that music therapy has “broad applications across the lifespan”,
that music therapists work with a variety of populations, and that end-of-life care is a
specialization in which music therapists can receive continuing education and specific training if
they choose; 60% (6) understand music therapists to use mostly familiar and patient-preferred
music to support cognitive processing, to provide support and comfort to the patient and family
members, and to evoke memories and invite conversation and expression; 30% (3) believe that
music therapy focuses more on cognitive processes and psychology than on physiological
processes and symptom management; 30% (3) know that music therapists are required to be
proficient in guitar, voice, and piano; 20% (2) believe that music therapists engage the patient in
active participation and focus on the ongoing therapeutic relationship; 20% (2) shared that they
have former experience as board-certified music therapists; 10% (1) believes that music
therapists’ perspectives will differ depending on particular training and school; 10% (1)
recognizes that music therapists “can do a lot of great work with guided imagery and relaxation”;
10% (1) shared that they have a lot of respect for the field of music therapy, promoting and

Halliwell, 2015

defending it regularly, correcting people who inappropriately refer to what they’re doing as
“music therapy”; 10% (1) shared that they had a bad experience with music therapists, leaving
them with the sentiment that they tend to “guard their territory”.

Current level of interaction
Eighty percent (16) of music therapists said they have no experience working with music-
thanatologists (one sharing the desire to do so); 15% (3) said they do have experience working
with a music-thanatologist; and 5% (1) did not answer. Seventy percent (7) of music-
thanatologists have had experience working alongside a music therapist; 20% (2) have not; and
10% (1) did not respond. Of the three music therapists who have experience working with music-
thanatologists, two of them said that their roles were differentiated in the following way: the
music-thanatologists saw mostly actively dying patients, and music therapists saw those who
were not actively dying. Of the seven music-thanatologists who have experience working with
music therapists, all shared that their roles can overlap: music therapists can continue seeing
patients until the very end of life while music-thanatologists may be called upon for symptom
management. They also shared that music therapists keep a more regular schedule of patients
while music-thanatologists are more “on call” and respond to emergency or imminency
situations. One music-thanatologist shared that the music therapist at her facility also plays harp,
that their roles are fluid, and that they work together to serve patient needs.

Benefits of collaboration
When asked to share their opinions on potential benefits of collaboration between fields, 95%
(19) said there would be greater options for the patient and family for more comprehensive care
from the beginning of hospice through the last breath; 20% (4) shared that the two fields can
learn a lot from each other; 15% (3) thought it would be helpful to allow music therapists and
music-thanatologists to focus on their “areas of specialization” (music therapists can focus on
developing more long-term therapeutic relationships and keeping a consistent schedule, music-
thanatologists can focus on seeing patients at the very end of life); 5% (1) shared that co-
treatment would be beneficial so that music therapists could help the patient and family process
feelings brought about from the music-thanatology vigils; 5% (1) suggested that music-
thanatology could serve as a music experience for patients who don’t need therapy, allowing
music therapists to focus on patients who need therapeutic support, with the music-thanatologists
carrying out more of a volunteer role.

Ten percent (1) of music-thanatologists shared that they are not sure that there are any benefits to
collaboration; 90% (9) believe that music therapy and music-thanatology are very
complementary and can work together to support the patient and family needs with more
precision and specifically-tailored care; 20% (2) believe that collaboration would allow
clinicians to focus on their skills for a particular area of expertise (music-thanatologists with the
actively dying, music therapists with everyone else); 20% (2) believe the two fields can learn a
lot from each other and share skill sets; 10% (1) believes that collaboration allows for ongoing
education of all members of the team, facilitating better patient care; and 10% (1) shared the
belief that there is no lack of patients who could benefit from music, and collaboration would
give them more opportunities to benefit from it.

Halliwell, 2015

Concerns about collaboration
When asked to share any concerns about collaboration, 30% (6) of music therapists expressed
concern about role differentiation, stating that there might be confusion among staff members
about knowing how to make appropriate referrals; 20% (4) have no concerns or hesitations about
collaboration; 20% (4) have budget-related concerns (that facilities won’t be able to afford both,
and that professionals from each field might feel threatened by one another); 20% (4) are
concerned that music therapists would not have as many opportunities to see patients at the end
of life, which could diminish job satisfaction for some and prevent music therapists from being
with their patients as they transition; 20% (4) have concerns pertaining to the patient’s and
family’s best interest (the patient might want their music therapist with them during the
transitional phase, some patients may not want music-thanatology or may be intimidated by the
harp, and music-thanatologists may not be equipped to deal with difficult emotions that arise);
15% (3) express concern about misrepresentation; 15% (3) don’t think co-treatment would be a
good idea because it’s better to focus on individual specialty areas so more patients can benefit
from services; 10% (2) are concerned about territorialism; 5% (1) believes that music-
thanatologists aren’t very open to music therapy; and 5% (1) is concerned that the credentials
and expertise of music therapists would be overlooked or devalued.

Music-thanatologist concerns about collaboration include apprehension about territorialism and
competition for jobs and funding (60%), and role differentiation (10%). Twenty percent (2)
shared that they did not have any concerns about collaboration. Ten percent (1) remembers that
at their mother’s death, someone (not necessarily a music therapist) was playing a Native
American flute, which was loud and seemed inappropriate for the end-of-life setting, so is
concerned about instruments other than harp potentially being too invasive.

Other thoughts on collaboration
When asked to share any other thoughts about collaboration, three music therapists shared their
desire to see more education opportunities and skill-sharing between music therapists and music-
thanatologists, and two think it would be nice to have music-thanatology as a specialized training
or certification option under the music therapy umbrella. One music-thanatologist would like
there to be more open communication between the two fields, and one shared the sentiment that
members of both fields should be respectful to each other.

Conclusion
Due to small sample size in both groups, it is difficult to generalize survey results. Another
limiting factor is that some respondents did not answer some of the survey questions.
Nevertheless, the response trends that did emerge can be helpful in getting a preliminary glimpse
of some similarities and differences between music therapists and music-thanatologists, as well
as sentiments about collaboration. In general, despite some anecdotal cases of having a bad
experience, the overall sentiment among music therapists and music-thanatologists in this study

Halliwell, 2015

seems to be that of good-natured curiosity and genuine willingness to explore the possibilities for
collaborative relations.

Based on survey results, the majority of music therapists and music-thanatologists have worked
in the end-of-life setting for fewer than ten years, suggesting that both fields are continuing to
graduate and certify new practitioners. Although perceptions emerged in some survey responses
about music-thanatologists holding primarily volunteer positions, results indicate that members
of both fields represent full-time employees, part-time employees, and private contractors in a
fairly evenly distributed manner, which points to a commonality in employment status between
music therapists and music-thanatologists.

One noticeable difference between music therapist and music-thanatologist employment patterns
is that music therapists appear to be well-represented throughout the country, while there seem to
be “pockets” of areas where music-thanatologists work. Due to the limited scope of this study,
there is no way to fully understand why this trend among music-thanatologists has emerged.
Perhaps it has something to do with the location of the educational programs, and/or that there is
no real advertisement of music-thanatology programs, thus it is by exposure and word-of-mouth
that individuals learn about music-thanatology and it stands to reason that more music-
thanatologists would begin to emerge where one or more already exist. A future study could
attempt to shed more light on this trend.

Another area of difference is in education and training. All music-thanatologists reported
receiving training from one of two programs available, both of which cover comparable
curricula. While all music therapists receive comparable training through their undergraduate or
equivalency programs, the level of preparation for end-of-life work varies depending on personal
initiative to seek additional training beyond what is required for basic certification. Perhaps this
points to music-thanatology being a highly specialized profession, with its sole emphasis in end-
of-life. Another factor which reinforces this is the fact that 40% of music-thanatology
respondents reported seeing actively dying patients more than half of the time, while the majority
of music therapist respondents (90%) reported that fewer than half of the patients they serve are
actively dying. However, due to the highly unique and unpredictable nature of death, both music
therapists and music-thanatologists reported variation in being present at the moment of death.

Both music therapists and music-thanatologists can relate to having to pioneer and educate others
in order to gain and maintain deserved recognition for the work that they do. Thirty percent (6)
of music therapists and 50% (5) of music-thanatologists reported being the first at their place of
hire, having to do a great deal of advocacy and outreach to become established. One-hundred
percent of both music therapists and music-thanatologists participate in continuing outreach so
that the community and other team members are aware of their roles and the benefits of their
services. The fact that more music therapists (70%) have the experience of entering a pre-
existing program at their place of hire, some in place for as many as 20 years, that the majority
(75%) feel understood and that their services are properly utilized by interdisciplinary team
members, and that Medicare and Medicaid provide some funding for services (24%), points to
the possibility of music therapy being generally better recognized in end-of-life care. While there

Halliwell, 2015

are a variety of labels under which music therapy services may be housed, 35% (7) are housed
under “Music Therapy”, signifying that perhaps the work and roles of music therapists are at
least somewhat well-recognized and integrated into the care team structure.

Both music therapists and music-thanatologists experience variation in session/vigil duration, as
well as type of care setting, which speaks to the variety of constituencies served, and the high
level of awareness and sensitivity espoused by both types of practitioners. There is noticeable
overlap in referral reasons. The number one reason for referral for both services is pain/symptom
management, and both include anxiety in the top five reasons for referral, suggesting that both
modalities can be effective in addressing these issues. In terms of family and staff support, music
therapy appears to be better suited for goals of socialization, expression, and communication,
while music-thanatology may better serve rest, relaxation, sleep, and respite needs. Both groups
shared being able to respond to needs for intimacy between patients and family members, as well
as needs for spiritual/emotional support and expression. These findings also point to the fact that,
despite perceptions expressed in some of the survey questions, both music therapists and music-
thanatologists can serve the needs of family members, simply in different ways.

There are some differences in clinical trends and applications between music therapists and
music-thanatologists. For one, it appears that, in general, music therapists see fewer patients on a
more regular basis, suggesting that they do have more of an opportunity to develop ongoing
therapeutic relationships with them, while music-thanatologists see more patients, fewer times
before they die, which speaks to the more on-call nature of their work. Another key difference is
in the instruments used in sessions/vigils. Due to the very specific nature of the primary
instruments used by music-thanatologists, this further speaks to the specialization of music-
thanatology as a distinctive modality, as the harp and voice have been purposefully selected for
their clinical effectiveness in the end-of-life setting.

Both music therapists and music-thanatologists reported using text in their sessions/vigils, but
the ways in which they are used can be quite different. In a music therapy context, the lyric of a
song may be used for self-expression or for the exploration of feelings, as well as reminiscence
and life review. When music-thanatologists incorporate text, it may not even be in a language
that the patients or families are familiar with, and sometimes this is the point. The purpose of text
may be to support an overarching sentiment or emotion shared or expressed, without engaging
conversation or other form of active participation, or to facilitate emotional release. Both music
therapists and music-thanatologists appear to be aware of when to avoid text, and when to be
silent altogether, reinforcing the fact that both have a heightened sensitivity to the needs of each
patient in the moment.

Another distinct difference is in the application of familiar versus unfamiliar music. Music
therapists utilize familiar and patient-preferred music in more scenarios than do music-
thanatologists, and maintain repertoire specific to the generational, religious/spiritual, and
cultural needs of patients. Music-thanatologists utilize the “raw materials of music” rather than
specific songs, to tailor each vigil delivery to the needs of each situation, cutting across specific
identifying factors such as generational, religious or cultural preferences, and ministering

Halliwell, 2015

directly to the needs of the present moment as demonstrated by patient physiology. In order to
have better access to these “raw materials,” music-thanatologists use modal music on a regular
basis in their deliveries, while music therapists generally do not. Again, this may speak to the
specialization of the music-thanatology approach to providing support through basic musical
elements in a way that is unique to the field.

Perhaps the clearest distinction between music therapy and music-thanatology practice is in the
implementation of music in general. While music therapists may deal with spiritual/existential
issues, emotional issues, and physiological pain/discomfort in a variety of different ways,
occasionally incorporating verbal discussion, music-thanatologists rely solely on the concept of
the “raw materials,” using, shaping, and layering them in a variety of ways to meet specific
needs. Music-thanatologists consciously and intentionally implement synchronization as a
foundational element of every vigil, focusing primarily on the physiological signs and symptoms
of the patient (and family), always working to follow in order to remain in sync with the
leader(s) (the patient and family). Music therapists will largely focus on meeting the patient and
family where they are at emotionally, implementing the ISO-principle in their sessions in an
effort to gently guide and direct the patient to a more desired state. This is a subtle difference,
and the outcome may appear to be the same, but it is worth noting that music-thanatologists
largely view their role as that of follower while music therapists focus on gently leading. These
distinctions signify the differences between approaches, but do not mean that one approach is
better than the other. Perhaps this is one area where the two fields could learn from one another
and explore the benefits and appropriateness of each approach.

The majority of music therapists (80%) and music-thanatologists (100%) follow some form of
spiritual practice and implement regular self-care, believing both to be essential to working with
patients and families at the end of life. This speaks to the sensitivity and self-awareness
possessed by practitioners in both fields, which could be foundational qualities for being open to
communication, discussion, and perhaps even collaboration in the future. The majority of music
therapists (90%) and music-thanatologists (90%) shared that they have at least some knowledge
about the other field, though some perceptions may not have been entirely accurate. Regarding
collaboration, 100% of music therapy respondents and 90% of music-thanatology respondents
reported at least one way in which they believed working together could be beneficial. Primary
concerns about collaboration among music-thanatologists are territorialism of music therapists
and competition for jobs and funding (60%), and the primary concern among music therapists is
role differentiation (30%), with budget-related concerns, concerns about the best interest for the
patient and family, and concerns about the impact on job satisfaction close behind (20%). The
fact that these concerns are being voiced in a constructive manner is a promising step in the
direction of open communication and a shared effort to broaden knowledge and awareness about
each field.

Discussion
Based on the survey responses, the interest in harmonious co-existence between music-
thanatologists and music therapists in the end-of-life setting overwhelmingly outweigh any sense

Halliwell, 2015

of territorialism. That said, it will continue to be important to keep in mind the principles and
values identified by Mitchell and colleagues (2012) when considering how to move forward.

One main principle is sharing a common goal or purpose, which in this case appears to be
optimal patient-centered care. Music therapists Carissa Herhuth, MT-BC and Holly Semrow,
MT-BC point out that collaboration with other professionals can actually maximize person-
centered care, optimize patient outcomes, increase the number of patients who receive services,
and make the services provided more meaningful (Herhuth & Semrow, 2015). These sentiments
are shared and expanded upon by music therapist Elizabeth Briggs, MT-BC (personal
correspondence, May 26, 2015), in sharing that patient-centered care is not “one size fits all”.
Music-thanatologist Claudia Walker, CM-Th also shares that “it’s important for the patient to
have the best they can get, no matter who gives it to them” (personal correspondence, May 19,
2015). Music therapist Anne Vitort, MBA, MT-BC adds, “There’s no shortage of hurting people,
so we don’t need to be competitive with one another; there are plenty of people who need our
help” (personal correspondence, July 2, 2015).

For the sake of bringing things full circle, it is worth revisiting the five shared values of a well-
established team in health care: curiosity, humility, honesty, discipline, and creativity (Mitchell,
et al., 2012):

Curiosity
A shared interest and curiosity can be inferred by the participation of music therapists and music-
thanatologists in the survey, especially considering that the majority of respondents knew at least
some information about the other profession and demonstrated some level of non-confrontational
interest in a discussion about collaboration. Granted, this is based on a small sample size, and it
is also possible that those who were contacted but did not respond to the survey do not share in
this sentiment. It would be of benefit to obtain the opinions of more respondents in the future.
Nevertheless, the fact that there is at least some level of curiosity and open-mindedness presents
the first step in potentially bridging whatever gaps may exist between music therapy and music-
thanatology, as it has initiated dialogue between the two.

Humility
Throughout the research and interview processes, a refreshing amount of humility has been
observed on both ends. Music therapist Judith Pinkerton notes that, although music therapists are
capable of combining music therapy interventions with counseling, they often collaborate with
licensed counselors in order to provide ethical and comprehensive support by considering the
expertise of other professionals (Pinkerton, 2003). While it is entirely possible for a music
therapist to tend to the needs of a client in the context of a music therapy session, there are
moments when it would be clinically and ethically appropriate to recommend traditional talk
therapy with a professional counselor, someone who is an “expert” in counseling. By extension,
as music therapists and music-thanatologists further explore working alongside each other in the
end-of-life setting, having the humility to know and acknowledge when an individual might be
better served by the services of the other can greatly improve the quality of care. This task of
understanding and valuing the unique work and roles of fellow team members has at least begun

Halliwell, 2015

to be undertaken by the efforts of those music therapists and music-thanatologists willing to
share their opinions and ask questions about the other field.

In an interview with Associate member of the Music-Thanatology Association International
Terese Cullen, she shares, “Sometimes I get requests that seem outside the scope of music-
thanatology practice, which may warrant a music therapist” (personal correspondence, May 19,
2015). Conversely, Eden acknowledges that sometimes she senses that there is more she could be
doing for someone who is imminent: “I think music-thanatologists rely much upon their
musicianship, and I don’t think a lot of music therapists have that extended repertoire or the
ability to creatively be in that moment with that person” (personal correspondence, May 11,
2015). Felton also shares her belief that “there is a theoretical difference between music that
keeps us tied to this world, and music that helps us transition to the next,” and that collaboration
could be very beneficial in holistically addressing the unique needs of each patient and family
(personal correspondence, July 13 & 16, 2015).

Walker, a certified music-thanatologist who also has experience working as a board-certified
music therapist, adds, “I’m finding that with a couple of [patients] who are more able to interact,
the client-therapist relationship comes into play. With music-thanatology, that’s really not the
focus” (personal correspondence, May 19, 2015). Music-thanatologist Justine Flynn, MA, CM-
Th also shares that in her experience, “At least a couple instances occurred when it would have
been nice to have the option of music therapy, because these individuals were still very
embodied, very much able to benefit from preferred music and active participation,” noting that
the patients still benefited from music-thanatology, but that it would have been nice to have the
option of music therapy available (personal correspondence, May 22, 2015).

The beauty in these candid accounts lies in the willingness of the speakers to be humble in
recognizing their own limitations as professional practitioners working with the dying. Through
this humility begins a process of making room for one another in clinical practice, and therein
lies the possibility of expanding and enhancing patient-centered care. The more music therapists
and music-thanatologists know about each other, the more a shared sense of humility and respect
can be fostered. Pederson shared in an interview, “When I describe what I do to a music
therapist, they will generally respond that they can do that, or that’s what they do, but when they
sit in on a vigil with me, they say, ‘Oh, this is completely different than what I do.’ Clearly I
need to do a better job of explaining what it is that I do” (personal correspondence, July 9, 2015).
On paper, it can be difficult to get across exactly what it is about music-thanatology that is
uniquely different from music therapy, but Pederson points out an important consideration that
perhaps learning by observation and experience may be essential to raising awareness and
understanding. The interview responses from family members whose loved ones received both
music therapy and music-thanatology are of great value in that they provide first-hand insight as
to the differences between the two modalities and how each affected them personally.

Honesty
According to Mitchell and colleagues (2012), the value of honesty entails developing mutual
trust, which can be established through “appropriate representation, speaking to personal skills

Halliwell, 2015

and letting others do the same”. Pasquesi and Pederson share this sentiment in stating, “We’ve
learned over the years that, rather than get into distinctions of ‘we do this and they do that’, it
works best to talk about what you as a clinician do in your personal practice. When you talk
about the practical things you do, or when a person is sitting in the vigil, it all becomes really
clear” (personal correspondence, July 9, 2015). Honesty and humility go hand-in-hand, and when
professionals can be honest about what they have to offer while at the same time realizing their
limitations, this opens the door for new possibilities, surpassing previous boundaries in providing
the best possible care for patients and families at the end of life.

Discipline
Another value addressed by Mitchell and colleagues (2012) is discipline. Part of this discipline is
the ability to maintain ongoing communication among team members: “Team members must
engage in honest, ongoing discussions about the level of preparation and capacities of individual
members to allow the team to maximize their potential for best utilization of skills, interests, and
resources” (Mitchell, et al., 2012). This characteristic goes hand-in-hand with humility, as it
requires team members to acknowledge their training and specialties and those of other team
members in order to appropriately determine how patients and families will best be served. This
discussion also needs to include patients and caregivers so they can be fully informed about the
roles of team members (Mitchell, et al., 2012). This may be something music therapists and
music-thanatologists could do together, co-presenting at conferences and community education
meetings, which may help assuage the concern presented by both groups about role confusion.

Creativity
Perhaps creativity is the key element which brings all the other values together, because truly,
creativity is needed in order to put goals, beliefs, and desires into practice. This may mean
having to “think out of the box,” but who better to do that than a group of individuals who use
music creatively to overcome limitations on a daily basis?

One way to facilitate successful teamwork is by “providing time, space, and support for inter-
professional education and training, including explicit opportunities to practice the skills and
hone the values that support teamwork” (Mitchell, et al., 2012). Felton shares, “I think we can
learn a lot from each other. For example, differences in repertoire, spiritual considerations,
philosophy, instrumentation, documentation… all are essential to treating the patient and family,
educating staff, and furthering the acceptance of our professions as viable treatment” (personal
correspondence, July 13 & 16, 2015). If a venue existed for open discussion between music
therapists and music-thanatologists, with opportunities to educate and inform each other, maybe
better understanding would lead to more harmonious and potentially collaborative relationships.
One possibility for this would be to invite music therapists to present at music-thanatology
conferences, and vice versa.

Another area where creativity is needed is in the area of role differentiation. Mitchell and
colleagues (2012) assert that “team members must anticipate and embrace flexibility as needed”.
Bruscia (1998) acknowledges that “the transdisciplinary nature of music therapy makes it very
difficult to establish clear boundaries between it and all of its related disciplines”. Hollis shares

Halliwell, 2015

her perspective that “organizations and the professionals who are collaborating will likely find
that there will not be absolute distinctions between the two roles”, likening the difference
between music-thanatologists and music therapists to that between a chaplain and a social
worker:
If you peeked in the door of a patient's room and saw a social worker, and then a
chaplain, you might think they are doing the same thing. But the patient needs both. Each
has their own training, certification, and assessment tools for the visit. Each has
a particular skill set that they draw on and the way they interpret and record what is
happening. At the same time, the fields are not completely distinct from each other. A
social worker with a close relationship with a patient might pray with them or offer
spiritual guidance. A chaplain might offer counseling to a patient or family member, or
might connect them with outside resources for support. They draw on various tools to
serve the patient and some of these tools will be the same. (personal correspondence,
May 19, 2015).

At the end of the day, one thing that music therapists and music-thanatologists can both agree on
is the importance of meeting the needs of patients and families with love, compassion, and the
unique skill sets which they offer. It has been the hope of this author that this paper would
provide some clarity as to what music therapists and music-thanatologists offer in an end-of-life
setting, highlighting ways in which they are similar and ways in which they are different, not as a
competitive means of comparison, but rather as a way of delineation of their capacities and level
of preparation as a starting point from which practitioners in both fields can gain awareness and
sensitivity to the specializations of the other, all in an effort to optimize the experience of the
patients, families, organizations and team members, as well as the larger community that is
grappling with the best way to serve people at the end of life.

Halliwell, 2015

Bibliography

A., B. (2015, July 13). Interview with the wife of hospice patient M. A. [Telephone interview].

A., S. (2015, July 2). Interview with the daughter of hospice patient M. A. [Telephone
interview].

American Music Therapy Association. (n.d.). Retrieved June 10, 2015, from
http://www.musictherapy.org/.

Anderson, V. (2011). Music, Death, and Dying: A Systematic Review of Hospice and Palliative
Care Literature . (Masters thesis). Retrieved from
etd.lib.msu.edu/islandora/object/etd%3A1000/datastream/OBJ/view.

Association for Music and Imagery (n.d.) Retrieved August 9, 2015, from http://ami-
bonnymethod.org/the-bonny-method-2/.

Baker, R. (2010). Advance Healthcare Network for Nurses, July, 2010. Music-thanatology.
Retrieved from file:///G:/Music-
Thanatology/Chicago%20Internship/Final%20Paper/Articles/Music-Thanatology.htm.

Beggs, C. (1991). Life review with a palliative care patient. In K. E. Bruscia (Ed.), Case studies
in music therapy (pp. 611-616). Phoenixville, PA: Barcelona.

Black, B., & Penrose-Thompson, P. (2012). Journal of Hospice and Palliative Nursing,
March/April 2012, p. 118-125. Music as a therapeutic resource in end-of-life care.

Bradt J., & Dileo C. (2010). Music therapy for end-of-life care. Cochrane Database of
Systematic Reviews, Issue 11. DOI: 10.1002/14651858.CD007169.pub2.

Briggs, E. (2015, May 26). Interview with music therapist Elizabeth Briggs. [E-mail interview].

Bruscia, K. E. (1991). Case studies in music therapy (pp. 5-12). Phoenixville, PA: Barcelona.

Bruscia, K. (1998). Defining music therapy (2
nd
ed.) (pp. 6-199). Gilsum, NH: Barcelona
Publishers.

Burgard, A. (2015, May 14). Interview with music-thanatologist Annie Burgard. [Telephone
interview].

Center for Music Therapy in End of Life Care. (n.d.) Retrieved July 14, 2015, from
http://www.hospicemusictherapy.org/.

Halliwell, 2015

Cerddeu, S. (2009). Music thanatology as narrative practice. Retrieved from
http://www.journal.mtai.org/index.php/print_article/121/.

Chalice of Repose Project (n.d.). Retrieved July 14, 2015, from http://chaliceofrepose.org/.

Cox, H., & Roberts, P. (2006). Spirituality & Health International, p. 80-91. From music into
silence: An exploration of music-thanatology vigils at end of life.

Cox, H., & Roberts, P. (2013). The harp and the ferryman: Journeys of healing (pp. 27, 37, 222,
134-5). Melbourne, Vic.: Michelle Anderson Publishing.

Cullen, T. (2015, May 19). Interview with Associate member of the Music-Thanatology
Association International Terese Cullen. [Telephone interview].

Danna, J. (2012). Chicago Tribune, March 2012. Experimental music for palliative care:
Patients appear to find calm, comfort in playing done in sync with vital signs. Retrieved
from file:///G:/Music –
Thanatology/Chicago%20Internship/Final%20Paper/Articles/Music-
thanatology,%20music%20vigils%20-%20tribunedigital-chicagotribune.htm.

Davis, W., Gfeller, K., & Thaut, M. (1999). An introduction to music therapy: Theory and
practice (2
nd
ed., pp. 11-285). Boston, Mass: McGraw-Hill.

Eden, M. (2015, May 11). Interview with hospice music therapist Miranda Eden. [In person
interview].

Felton, F. (2015, July 13 & 16). Interview with music therapist Fran Felton. [E-mail interview].

Flynn, J. (2015, May 22). Interview with music-thanatologist Justine Flynn. [Telephone
interview].

Forrest, L. (2002). Addressing issues of ethnicity and identity in palliative care through music
therapy practice. In Contemporary voices in music therapy: communication, culture, and
community (pp. 67-82). Oslo, Norway: Unipub forlag.

Fox, E. (2015, April 30). Interview with music therapist Erin Fox. [Telephone interview].

Freeman, L. (2004). Music thanatology: Prescriptive harp music as palliative care for the dying
patient. (Masters project.) Retrieved from
http://content.lib.utah.edu/cdm/ref/collection/ehsl-GerInt/id/58.

Freeman, L., Caserta, M., Lund, D., Rossa, S., Dowdy, A., and Partenheimer, A. (2006).
American Journal of Hospice and Palliative Medicine, 23(2), (p. 100-104). Music

Halliwell, 2015

thanatology: Prescriptive harp music as palliative care for the dying patient. Retrieved
from http://ajh.sagepub.com/cgi/content/abstract/23/2/100.

Groen, K. (2007). Journal of Music Therapy, 44(2), p. 90-112. Pain assessment and management
in end of life care: A survey of assessment and treatment practices of hospice music
therapy and nursing professionals.

Gutgsell, K., Schluchter, M., Margevicius, S., DeGolia, P., McLaughlin, B., Harris, M.,
Mecklenburg, J., & Wiencek, C. (2013). Journal of Pain and Symptom Management,
May 2013, 45(5). Music therapy reduces pain in palliative care patients: A randomized
controlled trial.

Halliwell, K. (2015a, March 18). Music-thanatology clinical narrative for patient BL.

Halliwell, K. (2015b, March 30). Music-thanatology clinical narrative for patient JS.

Hanser, S. (1999). The new music therapist’s handbook (2
nd
ed.). Boston: Berklee Press.

Herhuth, C. (2015, May 9). Interview with music therapist Carissa Herhuth. [E-mail interview].

Herhuth, C., and Semrow, H. (2015, April 11). Collaboration Station: Working Together to
Optimize Patient Care. Music therapy Great Lakes Region annual conference.
Presentation conducted from Minneapolis, MN.

Hilliard, R. (2004). Journal of Music Therapy, 41(4), p. 266-281. A post-hoc analysis of music
therapy services for residents in nursing homes receiving hospice care.

Hilliard, R. (2005). Advance Access Publication, April 2005, 2(2), p. 173-178. Music therapy in
hospice and palliative care: a review of the empirical data.

Hollis, J. (2010). Music at the end of life: Easing the pain and preparing the passage. Santa
Barbara, CA; Praeger.

Hollis, J. (2015a, May 19). Interview with music-thanatologist Jennifer Hollis. [E-mail
interview].

Horne-Thompson, A., Daveson, B., & Hogan, B. (2007). Journal of Music Therapy, 44(2), p.
139-155. A project investigating music therapy referral trends within palliative care: An
Australian perspective.

Krout, R. (2003). American Journal of Hospice & Palliative Care, March/April 2003, 20(2).
Music therapy with imminently dying hospice patients and their families: Facilitating
release near the time of death.

Halliwell, 2015

Lane Community College (n.d.). Retrieved July 14, 2015, from
https://www.lanecc.edu/ce/healthoccupations/music-thanatology.

Lipe, A. (2002). Journal of Music Therapy, 33(3), p. 209-240. Beyond therapy: Music,
spirituality, and health in human experience: A review of literature.

Martin, J. A. (1991). Music therapy at the end of a life. In K. E. Bruscia (Ed.), Case studies in
music therapy (pp. 617-632). Phoenixville, PA: Barcelona.

Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C., Rohrbach, V., Von &
Kohorn, I. (2012). Institute of Medicine of the National Academics. Core principles &
values of effective team -based health care. Retrieved from
https://www.nationalahec.org/pdfs/VSRT-Team-Based-Care-Principles-values.pdf.

Music-Thanatology Association International: What Is Music-Thanatology? (n.d.). Retrieved
June 10, 2015, from http://mtai.org/index.php/faq.

National Hospice and Palliative Care Organization, (n.d.). Retrieved June 14, 2015, from
http://www.nhpco.org/about-nhpco.

Nightingale, C., Cranley, N., Kacel, E., Wong, S., Pereira, D., & Carnaby, G. (2014). OA
Alternative Medicine, April 2014, 2(1). Music interventions during end-of-life care.

Partenheimer, R. (August 31, 2015). Personal correspondence with music-thanatologist Raya
Partenheimer, record keeper for the Music-Thanatology Association International. [E-
mail correspondence].

Pasquesi, M. (Team Lead) (2015, February 17). Music-Thanatology: Blending Art & Science at
the End of Life. Employee Orientation. Lecture conducted from Glenview, IL.

Pasquesi, M. & Pederson, T. (2015, July 9). Interview with music-thanatologists Margaret
Pasquesi and Tony Pederson. [Telephone interview].

Paturel, A. (2013). Ease suffering with music. Retrieved from file:///G:/Music-
Thanatology/Chicago%20Internship/Final%20Paper/Articles/Ease%20Suffering%20with
%20Music.htm.

Pierce, J.A., (2011). Hospice Music Therapy Song Repertoire and Music Therapy Techniques
(Masters thesis). Retrieved from The Florida State University DigiNole Commons
Electronic Theses, Treatises and Dissertations at http://diginole.lib.fsu.edu/etd.
(Accession No. 810)

Pinkerton, J. (2003). The sound of healing: Customize your music for enhanced well-being (p. 4).
Las Vegas, NV: SeminarConcerts International, Inc.

Halliwell, 2015

Pinkerton, J. (Producer). (2010, April 23). Widow of a loved one with cancer [Audio podcast].
Retrieved from http://itunes.apple.com.

R., P. (2015, July 14). Interview with the husband of hospice patient J. R. [Telephone interview].

Schroeder-Sheker, T. (2001). Transitus: A Blessed Death in the Modern World. St. Dunstan’s
Press.

Schroeder-Sheker, T. (Director) (2010a, June 14). The spirituality of the voice and pitch.
Contemplative Musicianship Program, Cycle 13. Lecture conducted from Mt. Angel,
Oregon.

Schroeder-Sheker, T. (Director) (2010b, September 13). The nature of music: New studies in
melody, harmony, and rhythm. Contemplative Musicianship Program, Cycle 13. Lecture
conducted from Mt. Angel, Oregon.

Schroeder-Sheker, T. (2012). Natural Transitions Magazine, Spring 2012, p. 20-23. Prescriptive
palliative music: How musician-clinicians serve the needs of the dying.

Schroeder-Sheker, T. (Director) (2013a, May 13). Module 14 Lecture. Music-Thanatology
Program, Cycle 8. Lecture conducted from Mt. Angel, Oregon.

Schroeder-Sheker, T. (Director) (2013b, August 12). Module 16 Lecture. Music-Thanatology
Program, Cycle 8. Lecture conducted from Mt. Angel, Oregon.

Taylor, K. (2005). Harps in hospice – music thanatology and music therapy in the care of the
dying: A description of philosophies, training, clinical practices and implications in
hospice care. (Masters thesis). Retrieved via personal e-mail.

Twaddle, M. (2015, July 8). Interview with Dr. Martha Twaddle. [Telephone interview].

Vitort, A. (2015, July 2). Interview with music therapist Anne Vitort. [Telephone interview].

W., J. (2015, June 25). Interview with the daughter of hospice patient L. M. [Telephone
interview].

Walker, C. (2015, May 19). Interview with music-thanatologist Claudia Walker. [Telephone
interview].

Whittall, J. (1991). Songs in palliative care: a spouse’s last gift. In K. E. Bruscia (Ed.), Case
studies in music therapy (pp. 603-610). Phoenixville, PA: Barcelona.

Halliwell, 2015

Wlodarczyk, N. (2007). Journal of Music Therapy, 44(2), p. 113-122. The effect of music therapy
on the spirituality of persons in an in-patient hospice unit as measured by self-report.

Z., P. (2015, June 29). Interview with the wife of hospice patient P. Z. [Telephone interview].

Halliwell, 2015

Appendix A
Interview Questions
General Questions
1. Are you a music therapist or music-thanatologist, or both?
2. How many years have you worked in a hospice/palliative care/end-of-life setting?
3. What is your hospice/end-of-life training?
4. What is your average caseload?
5. On average, how many sessions/vigils do you have with the same patient? How frequent
are your sessions/vigils? How long does a session/vigil normally last?
6. In what settings do you conduct your sessions/vigils? (Home, hospice, hospital, nursing
home, other?)
7. Are you a private contractor or employee? Full time or part time?
8. If you work for a facility/agency, what is the name and location? What is the average
census of patients?
9. What are some reasons an individual would be referred to you for services? What is the
referral process? Who can make a referral?
10. Do you work within an IDT? If so, do you feel that members of the IDT have a good
understanding of what it is that you do and have a collaborative spirit about working
together?
11. What are your services “housed” under? (Spiritual care services? Alternative health
services? Etc.)
12. How is the program funded?
13. Were you the first at the facility/agency? If so, how did you become established? If not,
how well established was the program when you began?
14. What, if any, outreach and education have you done to promote and advance the field of
music therapy/music-thanatology? (At your particular facility/agency, in the community,
etc.)
Clinical Questions
15. What role does/can family play in your sessions/vigils?
a. What clinical goals do you focus on when incorporating family members?
b. How are these goals achieved?
16. What role does/can staff play in your sessions/vigils?
a. What clinical goals do you focus on when incorporating staff?
b. How are these goals achieved?
17. What instrument(s) do you use in your sessions/vigils?
18. What supplemental materials, if any, do you use in your sessions/vigils?
19. Roughly what percentage of sessions/vigils are with patients who are actively dying?
a. What clinical goals do you focus on in these situations?
b. How does the use of music help you achieve these goals?
20. Roughly what percentage of sessions/vigils are with patients who have a terminal
diagnosis, but are not actively dying?
a. What clinical goals do you focus on in these situations?
b. How does the use of music help you achieve these goals?

Halliwell, 2015

21. What assessment tools do you use? Is this the same for patients who are actively dying
and patients who are not?
22. How often are you present when someone dies? How does the use of music help you to
support this process?
23. How and when might you incorporate listening in your sessions/vigils?
24. How and when might you incorporate active participation?
25. How and when might you use familiar/favorite music in your sessions/vigils?
26. How and when might you intentionally use unfamiliar music?
27. How and when might you use recorded music?
28. How and when might you use modal music? Unmetered music?
29. How and when might you use text? When might you intentionally avoid text?
30. How and when might you implement silence?
31. Are there any ways you might specifically use elements such as melody, harmony,
rhythm, meter, tempo, etc. to address specific goals?
32. Do you have a set “song list” that you work from? How and when might you incorporate
new material?
33. Do you generally work from a set session plan or do you continually assess and modify
as you go?
34. How might you address spiritual/existential issues in your sessions/vigils?
35. How might you address grief, anxiety, depression, fear, or other emotional issues that
arise in your sessions/vigils?
36. How might you address physical pain in a session/vigil?
37. How might you address labored/distressed breathing in a session/vigil?
38. What is your understanding of the Iso Principle? How does this inform your approach in
your sessions/vigils?
39. What is your understanding of synchronization and entrainment? How does this inform
your approach in your sessions/vigils?
Personal Practice Questions
40. How, if at all, does a spiritual practice inform and/or affect the work that you do?
41. How, if at all, does a practice of self-care inform and/or affect the work that you do?
Questions Regarding Collaboration
42. If you are a music-thanatologist, what is your current knowledge about music therapy? If
you are a music therapist, what is your current knowledge about music-thanatology?
43. Do you have experience working alongside a music-thanatologist/music therapist? If so,
how were/are the roles differentiated?
44. What benefits, if any, can you see about music therapists and music-thanatologists
working collaboratively in end-of-life care? (For the patient, family, staff, clinicians?)
45. What concerns or hesitations, if any, might you have about collaborative work between
music therapists and music-thanatologists in end-of-life care? (For the patient, family,
staff, clinicians?)
46. Please share any other comments, suggestions, or questions you may have about the
possibility of collaborative work between music-thanatologists and music therapists in
end-of-life care.

2015 Katherine Halliwell – Achieving Harmony: Music Therapy and Music-Thanatology in End of Life Care.pdf

2015 Katherine Halliwell – Achieving Harmony: Music Therapy and Music-Thanatology in End of Life Care.pdf

Share This Story, Choose Your Platform!

About the Author: Romeo Montague