Music in palliative care: a qualitative study with patients suffering from cancer

End of life situations are accompanied by psychological, emotional and social changes. Palliative care practitioners should adopt a patient-centered approach to address the complex needs of their patient [1]. The therapeutic effects of art in the context of palliative care have received increasing attention in recent years. A survey study of 300 hospices in the United States showed that music therapy is the second most common complementary therapy [2, 3]. A randomized study conducted by Hilliard showed improved quality of life measured on the scale of the Hospice Quality of Life Index-Revised (HQOLI-R) among 80 patients treated at home for terminal stage cancer following music therapy [4]. A meta-analysis by Bradt et al. reports that music may reduce anxiety, pain, fatigue and improve quality of life in cancer patients, although the level of evidence was low in the research considered in the study [5]. A pilot study conducted in Japan used salivary cortisol to show decreased stress levels after a musical intervention in the hospice [6]. The effects of music therapy are often reported in the form of direct accounts, as in the patient narratives gathered by music therapist Claire Oppert [7]. These accounts can complement evidence from quantitative studies by helping explain the mechanisms involved in the process, thus refining our understanding of the effects of the intervention [8]. They unravel existential and psychological aspects of the patient [9]. Reminiscence of various memories could play a role in the effectiveness of musical interventions [10]. Music therapy techniques may be classified as active (where patients participate in music creation) or receptive [11]. Live music has been shown to elicit more favorable responses than recorded music in cancer patients [12]. Our palliative care department hosts two artists each week. They are not music therapists, but their participation is more than musical entertainment since the goal is not to distract patients but rather to open a range of possibilities beyond care. The goal of this qualitative study was to examine how patients hospitalized in the palliative care unit experienced a musical intervention.

Ten patients were interviewed (Table 1). One interview was carried out for each patient. The mean age was 69, with a range (rounded to the nearest decade) from 50 to 90. All patients except one were interviewed the same day as the intervention. Numerous patients were excluded because they could not communicate. One patient among those who could have been interviewed refused the interview. One interview was stopped because the patient was tired. The interviews lasted from 11 to 39 min. Saturation was reached with the ninth interview.

The accounts we gathered led us to weigh the positive emotions engendered by this musical intervention against the potential difficulties encountered. The themes that emerged from our study differed from other similar studies [15] by the addition of concepts related to the shortcomings of music therapy. Although music appeared to benefit the patients, sometimes it reminded them of their altered state. The difficulties experienced by patients during the experience were also related to physical exhaustion. Clinical psychologist and music therapist Edith Lecourt [16] writes that “music can provide a restful space when it acts as a container, but it can also be a sphere for pleasure and play” (translated here). This sentence is a good illustration of the statements made by the patients interviewed. For many, their emotions were drawn from the register of pleasure, relaxation and contentment.

Sometimes, what was felt remained in a raw state, below the level of words. Music can be felt more than it can be explained: some of the patients interviewed indeed used sensory terms or terms connected to movement to express their experience. Their testimonies remind us of the “psycho-physiological change” described by Schmid et al. [1]. Several patients referred in their own manner to a feeling of envelopment, immersion, to express their wellbeing. For Edith Lecourt [16], a good share of musical pleasure is indeed tied to this ability to become attuned with others.

The artists in our study adjusted to each other and also adjusted to the patients and family members present. Such adjustment is one of the foundational tenets of analytical music therapy. For many of the patients interviewed, sharing this musical experience with family or care staff turned the occasion into a moment of joy. For a short time, their room became a place of interaction, a playful space. The inclusion of care staff and family reinforced a sense of belonging and safety in patients, helped overcome their sentiment of solitude. This finding can be contrasted with Bieligmeyer et al. [17], where a vibroacoustic musical therapy intervention using a sound-bed did not alter social extraversion scores of cancer patients. This suggests that the effects of musical interventions can be as diverse as the interventions themselves. Likewise, Peng mentions that each encounter in her study of music in the palliative care setting was idiosyncratic [15].

A good number of patients recalled with pleasure details from their personal and cultural history after the performance. The songs and music worked like “acoustic reminders of childhood memories” and encouraged patients to open up, to travel back and forth between the past, the present and the future. Musical interventions with patients in end of life situations allow them to take stock of their lives, to share anecdotes with others. The artists as such become witnesses to patients’ “path of effort to restore the self” in a period of existential crisis (an expression from Jacquemin [18], translated here). For a moment, their identities are reframed from patients to “people with unique pasts, interests and personalities” [8]. This theme resembles the “reflections” cluster in Peng’s study of music in palliative care [15]. Themes related to spirituality were less developed in our study, perhaps for cultural reasons [19].

During the interviews, many of the patients mentioned the renunciation and mourning work they still needed to accomplish regarding their illness and their loss of autonomy in connection with the resurgence of memories provoked by the songs. Sometimes, the topic of death was also present. However, the interaction with the artists filled them with hope for improvement. This psychological upsurge [20], was also found in the desire of patients to participate in singing and to make plans for the future.

One possible limitation of our study is the small number of participants. Further studies could include more centres to search for other themes. The investigator tried to minimize interaction with patients prior to their interview as much as possible, but she was nevertheless the unit psychologist, which increases the “desirability bias” always present in this type of study.

This qualitative study examined the benefits that the introduction of music and song can have on hospitalized patients receiving palliative care.

The results suggest that this living art form has a role to play in care facilities, that it fosters dialogue and calls on patients – who often see themselves primarily as objects of care – as people, as individuals. Music can help to humanize relationships in the palliative care setting. This finding was consistent throughout the patient narratives in the study. Flusser has argued that the interaction with artists allows “dialogue between subjects that creates a sphere of freedom in care-based relationships, creating pleasure and desire, fuelling an energy to become, a desire to live” (translated here) [21]. However, music can elicit negative reactions from patients due to fatigue or by provoking thoughts about their disease and loss of autonomy.

It is important for music therapists not to work alone, to have sufficient resources to tackle situations which are sometimes disconcerting [22] – there are indeed many reasons why it is necessary to include the living arts in the care project of a unit, but the project needs to be backed by a trained, multidisciplinary team.

Further research could include interviews of the families of patients in the palliative care unit regarding the benefits they derived from the intervention [23]. The involvement of artists could help families see the patient no longer through the lens of someone who is dying, but rather as a person living out the end of their life. It could as such help with the attachment/detachment process. Remembering these moments could later help families with the mourning process [24].