Music therapy for end‐of‐life care
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
1. To investigate the effectiveness of music therapy in end‐of‐life care.
2. To compare the effects of music therapy combined with standard care with
(a) standard care alone or
(b) standard care and other therapies.
3. To compare the effects of different types of music therapy interventions (e.g. music listening, songwriting, improvisation).
Background
Music therapy is increasingly used in end‐of‐life care, with a growing number of music therapists being employed in hospices and hospital‐based palliative care programs each year (Hilliard 2005). Data from a survey study of 300 randomly selected hospices in the U.S. indicated that the most popular forms of complementary therapies were massage therapy and music therapy (Demmer 2004). Music therapists in end‐of‐life care work with a broad range of populations with many types of illnesses including cancer (Hanser 2005; Hilliard 2003; Magill 2001), HIV/AIDS (Lee 1996; Neugebauer 1999), congestive heart failure (Dileo 2005c), dementia (Patrick 2005) and neurodegenerative disorders (Magee 2004; Scheiby 2005). The primary aim of music therapy in this context is to improve a person's quality of life by helping relieve symptoms, addressing psychological needs, offering support and comfort, facilitating communication, and meeting spiritual needs. In addition, music therapists assist family and caregivers with coping, communication, and grief/bereavement (Dileo 2005b).
Research on the effects of music and music therapy in healthcare has grown rapidly during the past 20 years and has included a variety of outcome measures in a wide range of specialty areas (Dileo 2005a). It is important, however, to make a clear distinction between music interventions administered by medical or healthcare professionals (music medicine) and those implemented by trained music therapists (music therapy). A substantive set of data (Dileo 2005a) indicates that music therapy interventions are more effective than music medicine interventions for improving physiological as well psychological outcomes in medical patients. This difference might be attributed to the fact that music therapists individualize their interventions to meet patients' specific needs, more actively engage the patients in the music making, make use of the therapeutic relationship established with the patient to meet clinical goals and employ a systematic therapeutic process that includes assessment, treatment, and evaluation. As defined by Dileo 1999, interventions are categorized as 'music medicine' when passive listening to pre‐recorded music is offered by medical personnel. In contrast, music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences. These music experiences include:
1. listening to live, therapist‐composed, improvised, or pre‐recorded music;
2. performing music on an instrument;
3. improvising music spontaneously using voice or instruments, or both;
4. composing music; and
5. music combined with other modalities (e.g., movement, imagery, art) (Dileo 2007).
In end‐of‐life care, receptive approaches, i.e. listening to live or pre‐recorded music, are common due to the physical limitations of many patients. An example of a receptive intervention aimed at providing psychosocial support is song choice in which the patient selects a song according to specific criteria, e.g., how he or she is feeling (Dileo 2005b). For terminally ill patients, verbally expressing their emotions may be too difficult or threatening. In advanced stages of cancer, for example, speech impairments due to brain damage may prevent patients from verbally expressing their emotions, thoughts, and needs. Other patients may be hesitant to openly express their emotions because of the intensity of the feelings or the need to protect their loved ones. These patients may benefit from song choice as it gives them an "alternative, creative, and non‐threatening medium through which to experience and express their emotions" (Hogan 1999, p 70). If the patient is able to engage in music making, active music therapy methods such as songwriting, instrumental improvisation and vocal improvisations are used to improve sense of empowerment, enhance self‐esteem, facilitate expression of ideas and emotions, increase socialization, facilitate creativity, and find meaning and hope (O'Callaghan 1997). Music listening, as well as active music making, is also used to help manage physical symptoms such as labored breathing, pain, agitation, and insomnia. Finally, music therapists play an important role in addressing the spiritual needs of patients as music can offer the "creative, lyrical, and symbolic means to address existential and spiritual needs during the process of dying" (Magill 2002, p 996).
Several research studies on the use of music in end‐of‐life care have reported positive results. For example, positive effects of music on pain, nausea/vomiting, anxiety, depression, mood and sense of well‐being were reported in a meta‐analysis combining studies conducted with cancer, terminally ill and AIDS patients (Dileo 2005a). However, this meta‐analysis did not examine terminally ill patients as a separate group. In addition, differences in factors such as study designs, methods of interventions, and intensity of treatment have led to varying results. A systematic review is needed to more accurately gauge the efficacy of music therapy in end‐of‐life care as well as to identify variables that may moderate its effects.
Objectives
1. To investigate the effectiveness of music therapy in end‐of‐life care.
2. To compare the effects of music therapy combined with standard care with
(a) standard care alone or
(b) standard care and other therapies.
3. To compare the effects of different types of music therapy interventions (e.g. music listening, songwriting, improvisation).
Methods
Criteria for considering studies for this review
Types of studies
We will include all randomized controlled trials (RCTs), published or unpublished, in any language. We will only consider trials with quasi‐randomized or systematic methods of treatment allocation (for example, alternate allocation of treatments) if no RCTs can be found.
Types of participants
This review will include participants in specialist palliative care or hospice settings (inpatient or community) or participants in any care setting with a diagnosis of advanced life‐limiting illness being treated with palliative intent and with a life expectancy of less than two years (Hancock 2007). There will be no restrictions as to age, gender, or ethnicity.
Types of interventions
This review will include all studies in which standard care combined with music therapy is compared with:
(a) standard care alone, or
(b) standard care combined with other therapies.
In addition, studies will be considered only if
(a) music therapy is delivered by a formally trained music therapist or by trainees in a formal music therapy program; and
(b) one of the following music therapy interventions is used in an individual or group setting:
1. listening to live, therapist‐composed, patient‐composed (Dileo 2007), therapist and patient‐composed, improvised, or pre‐recorded music;
2. performing music on an instrument; and
3. improvising music spontaneously using voice or instruments, or both.
Types of outcome measures
This review will include the following outcome measures:
1. symptom relief (e.g. of nausea, fatigue, pain);
2. psychological outcomes (anxiety, depression, fear);
3. physiological outcomes (e.g. respiratory rate, heart rate, IgA levels);
4. relationship and social support (e.g. family support, isolation);
5. communication (e.g. verbalization, facial affect, gestures);
6. quality of life;
7. spirituality; and
8. participant satisfaction.
Subjective outcomes such as anxiety, social support, quality of life, and spirituality are likely to be measured by a variety of measurement tools. We will only include measurement tools (e.g. Visual Analog Scale, Spielberger Trait and State Anxiety Test) with established reliability and validity (i.e., as evidenced in at least one prior published study in a peer‐reviewed journal).
In addition, this review will include the following outcome measures for family members and caregivers:
1. Psychological outcomes (e.g. depression, distress, coping, grief).
2. Relationship and social support.
3. Communication with participant.
4. Quality of life.
Search methods for identification of studies
We will search the Cochrane Cancer Network Register and the Cochrane Pain, Palliative & Supportive Care Register.
In addition we will search the following electronic databases and trials registers:
1. Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, latest issue);
2. MEDLINE (1950 to present);
3. EMBASE (1980 to present);
4. CINAHL (1982 to present);
5. PsycINFO (1967 to present);
6. LILACS ( 1982 to present);
7. CancerLit (1983 to present);
8. CAIRSS for Music;
9. Proquest Digital Dissertations;
10. ClinicalTrials.gov (http://www.clinicaltrials.gov/);
11. Current Controlled Trials (http://www.controlled‐trials.com/);
12. National Research Register (http://www.update‐software.com/National/);
13. musictherapyworld.de.
Please see Appendix 1 for an example of our intended MEDLINE search strategy.
Handsearching
We will handsearch the following journals from their first available date:
1. Australian Journal of Music Therapy
2. Australian Music Therapy Association Bulletin
2. Canadian Journal of Music Therapy
3. The International Journal of the Arts in Medicine
4. Journal of Music Therapy
5. Musik‐,Tanz‐, und Kunsttherapie (Journal for Art Therapies in Education, Welfare and Health Care)
6. Musiktherapeutische Umschau
7. Music Therapy
8. Music Therapy Perspectives
9. Nordic Journal of Music Therapy
10. Music Therapy Today (online journal of music therapy)
11. Voices (online international journal of music therapy)
12. New Zealand Journal of Music Therapy
13. The Arts in Psychotherapy
14. British Journal of Music Therapy
15. Journal of Society for Integrative Oncology
16. Evidence Based Complementary & Alternative Medicine
In an effort to identify further published, unpublished and ongoing trials we will search the bibliographies of relevant studies and reviews, contact experts in the field, and search available proceedings of music therapy conferences. Music therapy association websites will be consulted to help identify music therapy practitioners and conference information (e.g., American Music Therapy Association (http: www.musictherapy.org), The British Society for Music Therapy (http://www.bsmt.org/), The Association of Professional Music Therapists (APMT) (http://www.apmt.org/), Music Therapy World (http://musictherapyworld.net)) will also help identify practitioners and conference information.
There will be no language restrictions for either searching or study inclusion.
Data collection and analysis
Trial selection
One review author (JB) will conduct the searches. One review author (JB) will scan the titles and abstracts of each record retrieved from the search. If information in the abstract clearly indicates that the study does not meet the inclusion criteria, we will reject the study. When a title or abstract cannot be rejected with certainty, one review author (JB) will obtain the full article and the two review authors will independently inspect the article. Both review authors will use an inclusion criteria form to assess the study's eligibility for inclusion. One review author (JB) will check the inter‐rater reliability for study selection and we will resolve any disagreements by discussion. If a study is excluded, we will keep a record of both the article and the reason for its exclusion. Excluded studies will be presented in the 'Characteristics of excluded studies' table in the review.
Data extraction
Both review authors will independently extract data from the selected studies using a standard coding form. We will discuss any differences in the data extraction and we will seek the input of an independent consultant when needed. The data to be extracted from the included studies identified is outlined in Table 1. Where data is unavailable from the studies identified attempts will be made to contact the study author for clarification.
| General info | Study info | Intervention info | Participant info | Outcome info | Stats outcome info |
| Author | Study design (parallel group, cross‐over) | Type of intervention (e.g. singing, song‐writing, music listening, music improvisation) | Total sample size | Statistical information for the following outcomes (if applicable): | Statistical information on the following outcome measures for family members and caregivers (if applicable): |
Quality assessment of studies
Two review authors, blinded to each other's assessment, will assess all included studies for quality. We will resolve any disagreements by discussion. We will use the following criteria for quality assessment.
1. Method of randomization:
‐ was the study reported as randomized? Yes or no;
‐ was the method of randomization appropriate? Yes, no, or unclear.
We will rate randomization as appropriate if every participant had an equal chance to be selected for either intervention. We will regard the use of date of birth, date of admission, or alternation as inappropriate.
2. We will use allocation concealment ratings of: A (adequate), B (unclear), and C (inadequate) in accordance with section 6.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2006).
A: adequate, where methods to conceal allocation included 1. central randomization; 2. serially‐numbered, opaque, sealed envelopes; or 3. other descriptions with convincing concealment.
B: unclear, where authors did not adequately report on method of concealment.
C: inadequate, where allocation was not adequately concealed (e.g., alternation methods were used).
3. Blinding: yes, no, or unclear.
With music and music therapy studies it is not possible to blind participants and those providing the music or music therapy interventions. However, outcome assessors can be blinded. In this review, we will mark blinding as yes, no, or unclear as it pertains to blinding of outcome assessors.
4. Intention‐to‐treat analysis: adequate, inadequate, or unclear.
We will consider an intention‐to‐treat analysis to be adequate when numbers of dropouts and reasons for drop‐out are reported. If there were no withdrawals and this was indicated in the study, the study will receive a rating of adequate.
The above four criteria will be used to give each article an overall quality rating (based on section 6.7.1 of the Cochrane Handbook for Systematic Reviews of Interventions) (Higgins 2006).
A. Low risk of bias: all four criteria met.
B. Moderate risk of bias: one or more of the criteria only partly met.
C. High risk of bias: one or more criteria not met.
We will use the overall quality assessment rating for sensitivity analysis. We will not exclude studies based on a low quality score.
Data analysis
JB will enter the data of included studies into Review Manager (RevMan 4.2.10). CD will check data entry for errors. We will present the main outcomes in this review as continuous variables. Where studies have used different instruments to measure the same conceptual phenomenon (for example, anxiety) we will report the standardized mean difference with 95% confidence intervals (CI). In such cases, we will take a cautious approach to combining results, and will detail the rationale. When there is sufficient data available from various studies using the same measurement instrument (for example, Spielberger's State Anxiety Inventory) we will compute a weighted mean difference (WMD) with 95% CI. We will calculate pooled estimates using the fixed‐effect model unless there is significant heterogeneity, in which case we will use the random‐effects model. We will determine the levels of heterogeneity by I‐squared (I2) (Higgins 2002). We will use a random‐effects model when the I‐squared value is more than 50%. In case of significant clinical heterogeneity, no statistical analysis will be performed to pool the results.
The following treatment comparisons will be made:
a. standard care and music therapy versus standard care alone;
b. standard care and music therapy versus standard care combined with other treatment.
We will conduct subgroup analyses, where data are available, as described by Deeks et al (Deeks 2001) and as recommended in section 8.8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2006), to compare:
a. different types of music therapy interventions;
b. different duration and frequency of music therapy;
c. different diagnoses.
We will examine the influence of study quality using a sensitivity analysis where the results including and excluding lower‐quality studies are compared.
| General info | Study info | Intervention info | Participant info | Outcome info | Stats outcome info |
| Author | Study design (parallel group, cross‐over) | Type of intervention (e.g. singing, song‐writing, music listening, music improvisation) | Total sample size | Statistical information for the following outcomes (if applicable): | Statistical information on the following outcome measures for family members and caregivers (if applicable): |
