Use of Palliative Care Music Therapy in a Hospital Setting during COVID-19

Introduction

Music, with its powerful sensory and emotional immediacy, can uniquely bridge “social distances,” reduce stress, and promote well-being during the COVID-19 pandemic. Music therapy (MT) is the clinical use of music in relationship with a board-certified music therapist to achieve specific therapeutic goals.¹ In palliative care, MT has been shown to alleviate pain, depression, anxiety, and breathlessness, and enhance patients' sense of spiritual connection.^2–4

In this report, we describe case examples of evidence-based MT interventions for patients with severe COVID-19 infections, their families, and staff at UMass Memorial Medical Center, a 781-bed safety-net hospital in central Massachusetts. We also discuss barriers and opportunities for growing MT as a best practice for palliative care teams during the pandemic and beyond.

Use of MT for Healing and Recovery

In the intensive care unit (ICU), music interventions of only 20–30 minutes have been effective in reducing pain for adult patients who can self-report.⁵ MT has been shown to reduce vascular sympathetic tone, which can lower cardiac workload and oxygen consumption in patients on mechanical ventilation.⁶ These reductions in pain and the stress response can result in a decreased need for sedating medications and a faster recovery in the ICU.⁷ MT may also help patients with cognition and orientation in a chaotic hospital environment^8,9 as well as emotional expression and connection amidst restrictive visitor policies and wearing of personal protective equipment (PPE) during the pandemic.

Our inpatient palliative care consult service deployed our board-certified music therapist to partner with ICU teams on the care of patients with severe COVID-19 infection. We obtained a small internal grant to increase her part-time work by a half day and expand access through MT interns. An illustrative case is a 57-year-old man with cerebral palsy admitted with COVID pneumonia and intubated for acute respiratory failure. He lived in a group home and his legal guardian described him as “a radiant person, always clapping and smiling.” He was deaf, and experienced music by feeling vibrations, watching other people dance, and moving his own body in response. In the ICU, he slowly improved on mechanical ventilation but could not be extubated as he remained unconscious despite removal of sedation.

The ICU and palliative care teams met virtually with his legal guardian and other caregivers to discuss his guarded prognosis, goals of care, and treatment options. His guardian elected to proceed with tracheostomy placement to allow further attempts at weaning the ventilator; however, if unsuccessful, she would consider withdrawing life support if he could not return to his life and friends at the group home.

The music therapist first teamed up with the patient's ICU nurse, who donned PPE and brought a small wireless speaker and a handheld drum into the negative pressure room. Through the window, the music therapist coached the nurse, modeling movements suggested by the guardian. The patient did not react.

At subsequent visits, the patient was seen directly by the music therapist, and his eyes opened upon being touched. The music therapist held the patient's gaze as she clapped slowly and steadily in front of him. She laid a small handheld drum on his abdomen and tapped it. Soon, the patient was tapping the drum on his own. Over 30 minutes, he was able to grasp the mallet and play the drum in a “call and response” manner (Fig. 1). Of note, the patient was more alert than he had been since being admitted and became tearful when his drumming session ended.

At follow-up visits, the patient spent long periods drumming with his hands or the mallet. The music therapist noted the patient's patterns of rhythmic drumming mirrored his facial expressions of happiness and sadness. Over the following month, the patient tolerated longer periods of spontaneous breathing trials, and eventually liberated from the ventilator after discharge to a long-term acute care facility. The guardian expressed great appreciation for the role of palliative care MT in the patient's recovery and ability to return home.

Use of MT for End-of-Life Care of Patients and Families

MT has been associated with perceptions of meaningful spiritual support for patients at end of life and their families.¹⁰ During the COVID pandemic, palliative care teams have cared for unprecedented numbers of patients dying alone in the hospital, including arranging of virtual visits for family members to say goodbye. At our institution, the palliative care MT led virtual family meetings and provided music after listening to their personal stories. Family members then sang as they held virtual vigil through a tablet device near their loved one's hospital bed, often accompanied by nurses and residents.

The music therapist also created “HeartSongs,” inspired by the work of Brian Schreck, MT-BC, and refined for use in end-of-life care, to support grieving families and honor dying patients.¹¹ After discussion with families and obtaining their consent, the music therapist recorded a patient's heartbeat through a stethoscope equipped with a microphone. The MT intern then edited the sound for clarity and interlaid the heartbeat with music meaningful to the patient as a legacy gift for the family (Supplementary Video S1). In one case, a survivor of severe COVID-19 pneumonia requested a second HeartSong after hearing an earlier recording when he was near death. Of note, the music therapist reported no hospital staff declined to don PPE and assist with heartbeat recordings, but instead viewed them with relief and enthusiasm.

Use of MT for Staff Support

Reports from health care workers during the global COVID-19 pandemic underscore experiences of isolation and fear, with extreme cases even resulting in self-harm or suicide.¹² MT interventions have been shown to elicit positive emotional and cognitive states and reduce sympathetic nervous system arousal.^13,14 Among hospice teams, MT has been demonstrated to improve team building and relieve compassion fatigue.^15,16

Throughout the pandemic, the music therapist looked for ways to offer MT for staff, especially after exceptionally stressful days. For example, in one ICU, staff cared for an elderly woman with severe dyspnea from COVID pneumonia. She did not want intubation and mechanical ventilation. The team included newly redeployed staff who had never worked together before the patient surge. There was confusion over her clinical management, and staff were distraught after the patient endured a difficult death.

The next day, the music therapist asked to provide a drop-in MT session at a convenient time in a conference room adjacent to the ICU. She brought a tablet device and portable speaker, and invited staff to listen to a piece of music without judgment and notice their breath. She noticed people swaying or tapping their feet to the music, some laughter and even spontaneous dancing. Others listened as they multitasked on computers and joined in conversation between songs. Afterward, a nurse said she felt “rebooted” for the rest of her shift. For staff uncomfortable in a group setting, the music therapist stayed alert for opportunities to privately sit with individuals and play music for brief moments.

As colleagues learned about MT through word of mouth, electronic newsletters and hospital-wide “virtual town halls,” the music therapist received numerous requests to provide MT for staff support. She developed a structured virtual program (“Music for Resilience”) and partnered with the health system's physician experience officer who sponsored these free hour-long sessions for >14,000 employees within four large hospitals and multiple outpatient practices. A sample evaluation comment included: “the group offered me a much-needed space to pause and check in with myself during such a challenging time.”

Discussion

Around the country, palliative care teams have responded to our field's call to action as frontline providers during the pandemic. At our institution, we bolstered our response by strategically scaling our limited MT resources to address the “suffering beyond words” during an unprecedented public health crisis. We achieved this through a small grant to increase our music therapist's hours and purchase additional equipment, including portable speakers and handheld drums. We leveraged her role as preceptor for MT interns, who increased the numbers of MT sessions, assisted with technology support, and edited patients' HeartSongs. We showcased their work in system-wide newsletters and forums, which garnered support from hospital leadership for a virtual “Music for Resilience” program for all staff.

Ongoing barriers to MT include the challenge to obtain adequate sustainable funding and the misunderstanding of MT as entertainment. We need to educate hospital staff and leadership about neuroscience of MT, its evidence base, and the rigorous training of board-certified music therapists. In palliative care, there is a significant need for tools and strategies to argue the business case for MT program development as part of high-quality interdisciplinary palliative care.

Conclusion

At our institution, music therapists demonstrated themselves as essential frontline providers with unique and evidence-based interventions during a public health crisis. We utilized MT's ability to create social connection and catalyze optimal brain and nervous system responses to bridge the gap created by physical distance. Just as the pandemic has showcased the urgent need for palliative care around the world, our experience demonstrates the value of MT and a call for its program development as a best practice within our field.

Authors' Contributions

All authors contributed to the design, analysis, and revisions to the final version for publication.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Video S1