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Abstract Hospice care seeks to address the diverse needs of terminally ill patients in a number of physical, psychosocial, and spiritual areas. Family members of the patient often are included in the care and services provided by the hos- pice team, and hospice clinicians face a special challenge when working with families of patients who are imminently dying. When loved ones are anticipating the patient’s impend- ing death, they may find it difficult to express feelings, thoughts, and last wishes. Music therapy is a service modality that can help to facilitate such communication between the fam- ily and the patient who is actively dying, while also providing a comfort- ing presence. Music therapy as a way to ease communication and sharing between dying patients and their loved ones is discussed in this article. The ways in which music therapy can facilitate a means of release for both patients and family members in an acute care unit of a large US hospice organization are specifically described. Case descriptions illustrate how music therapy functioned to allow five patients and their families to both come together and let go near the time of death. Elements to consider when providing such services to imminently dying patients and their families are discussed. Background Music therapy is a complementary treatment modality which increasing- ly is being recognized as an important adjunct service within hospice and palliative care organizations. 1-8 A number of patient and family needs can be addressed simultaneously through music therapy as a creative holistic service within hospice care. 9 When these needs are addressed, the patient and family can express and share feel- ings, as well as continue to communi- cate and interact in a meaningful man- ner, even as the patient declines and ultimately dies. 10-13 A critical and often difficult period for families and loved ones is the time immediately before the patient’s death. Although patients receiving hospice care have a life expectancy of six months or less, should a disease process follow its anticipated course, determining exactly when a patient will die is impossible for doctors and other hospice care team members. 14 However, terms such as “imminent death,” “approaching death,” “impend- ing death,” and “actively dying” are used to describe patients whose vital signs are rapidly declining towards expiration. 15-20 Some signs and symp- toms of approaching death include a cooling of the extremities, coloring or mottling of the skin, slow and/or irreg- ular breathing, an increase in sleeping, a buildup of fluids and secretions in the lungs and throat, apparent confu- sion, and restlessness and agitation. 5 Various rating scales may be used to describe the patient’s status as he or she declines toward death. The Kar- nofsky Performance Scale, which is used at the Hospice of Palm Beach County in West Palm Beach, Florida, rates a patient whose fatal processes are rapidly progressing as being mori- bund, with a score of 10 out of a possi- ble 100. A score of zero indicates that the patient has died. 21 When imminent or impending death is noted in a patient’s care plan, family members are often informed 129 American Journal of Hospice & Palliative Care Volume 20, Number 2, March/April 2003 Music therapy with imminently dying hospice patients and their families: Facilitating release near the time of death Robert E. Krout, EdD, MT-BC, RMTh Robert E. Krout, EdD, MT-BC, RMTh, Music Therapy Programme Leader, Conservatorium of Music, Massey University, Mt. Cook, Wellington, New Zealand; formerly Music Therapy Manager, Hospice of Palm Beach County, West Palm Beach, Florida.

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Page 1: Music therapy with imminently dying hospice patients … · pice team, and hospice ... Music therapy with imminently dying hospice patients and their families: ... patient’s life,

Abstract

Hospice care seeks to address thediverse needs of terminally ill patientsin a number of physical, psychosocial,and spiritual areas. Family membersof the patient often are included in thecare and services provided by the hos-pice team, and hospice clinicians facea special challenge when workingwith families of patients who areimminently dying. When loved onesare anticipating the patient’s impend-ing death, they may find it difficult toexpress feelings, thoughts, and lastwishes. Music therapy is a servicemodality that can help to facilitatesuch communication between the fam-ily and the patient who is activelydying, while also providing a comfort-ing presence. Music therapy as a wayto ease communication and sharingbetween dying patients and their lovedones is discussed in this article. Theways in which music therapy canfacilitate a means of release for both

patients and family members in anacute care unit of a large US hospiceorganization are specifically described.Case descriptions illustrate howmusic therapy functioned to allow fivepatients and their families to bothcome together and let go near the timeof death. Elements to consider whenproviding such services to imminentlydying patients and their families arediscussed.

Background

Music therapy is a complementarytreatment modality which increasing-ly is being recognized as an importantadjunct service within hospice andpalliative care organizations.1-8 Anumber of patient and family needs canbe addressed simultaneously throughmusic therapy as a creative holisticservice within hospice care.9 Whenthese needs are addressed, the patientand family can express and share feel-ings, as well as continue to communi-cate and interact in a meaningful man-ner, even as the patient declines andultimately dies.10-13

A critical and often difficult periodfor families and loved ones is the timeimmediately before the patient’s death.Although patients receiving hospice

care have a life expectancy of sixmonths or less, should a diseaseprocess follow its anticipated course,determining exactly when a patientwill die is impossible for doctors andother hospice care team members.14

However, terms such as “imminentdeath,” “approaching death,” “impend-ing death,” and “actively dying” areused to describe patients whose vitalsigns are rapidly declining towardsexpiration.15-20 Some signs and symp-toms of approaching death include acooling of the extremities, coloring ormottling of the skin, slow and/or irreg-ular breathing, an increase in sleeping,a buildup of fluids and secretions inthe lungs and throat, apparent confu-sion, and restlessness and agitation.5

Various rating scales may be used todescribe the patient’s status as he orshe declines toward death. The Kar-nofsky Performance Scale, which isused at the Hospice of Palm BeachCounty in West Palm Beach, Florida,rates a patient whose fatal processesare rapidly progressing as being mori-bund, with a score of 10 out of a possi-ble 100. A score of zero indicates thatthe patient has died.21

When imminent or impendingdeath is noted in a patient’s care plan,family members are often informed

129American Journal of Hospice & Palliative CareVolume 20, Number 2, March/April 2003

Music therapy with imminently dying hospice patients and their families:Facilitating release near the time of death

Robert E. Krout, EdD, MT-BC, RMTh

Robert E. Krout, EdD, MT-BC, RMTh, MusicTherapy Programme Leader, Conservatorium ofMusic, Massey University, Mt. Cook, Wellington,New Zealand; formerly Music Therapy Manager,Hospice of Palm Beach County, West PalmBeach, Florida.

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that they may wish to plan their lastvisits with the patient as soon as possi-ble. During this last period of thepatient’s life, family members oftenare faced with the challenge ofexpressing their feelings without thepatient being able to overtly commu-nicate in response to them. Familymembers may feel frustrated when thepatient cannot look at or speak withthem, or even hold or squeeze theirhands. The patient’s appearance mayalso be disturbing to the family, as itmay have drastically changed or dete-riorated since a previous visit. Forexample, apnea, sounds of congestedbreathing, or observed restlessnessand agitation may be troubling to visi-tors. For loved ones, even being ableto determine the exact time at whichthe patient dies can be difficult. AsKastenbaum noted, the perceptiblemoment at which life ends is notalways clear to the observer, as vitalsigns may slowly diminish and fadealmost imperceptibly at the actualmoment of death.22 Visitors may notrealize that the patient has expireduntil a physician or nurse has checkedvital signs and pronounced the patientto have died.

Music as therapy

Active expression of feelings ofgrief and anguish by loved ones dur-ing this time is considered to be bothnormal and healthy, and the entirehospice interdisciplinary care teamhelps to facilitate this process.23 Theteam can include a wide variety ofprofessionals, including the physician,nurse, nursing aide, social worker,pastoral counselor, dietician, physicaltherapist, music therapist, a volunteer,and additional clinicians such as an arttherapist, massage therapist, acupunc-turist, movement therapist, Reikipractitioner, and others. When familymembers and other loved ones visitshortly before an anticipated death,the hospice music therapist has a

unique opportunity to engage themand create a meaningful experiencefor them with the patient.

As each patient’s and family’s situ-ation and needs are unique, musictherapists provide individualized in-terventions based on these needs at thetime of the session. The music usedduring a session with patient andloved ones can include original, folk,contemporary or popular, jazz, classi-cal, spiritual, and many other styles.The music can function in a number ofways during the therapeutic process.The first consideration is maintainingthe physical comfort of the patient.Music therapy with imminently dyingpatients may include techniques tofacilitate pain control, help providephysical and emotional comfort, assistin relaxation, and reduce anxiety.Music therapy may also involve pas-sive or active participation by the fam-ily. As one example, the selecting,singing, or listening to familiar orfavorite songs of the patient and fami-ly may stimulate discussion relating tolife memories, reminiscence, and lifereview. Family members may requesta specific song, listen to or sing withthe therapist, and then reflect on thesignificance of that song to them andthe patient. The music may elicit anemotional response that can thenallow for the sharing of feelings andemotions. These feelings can then bevalidated, normalized, and exploredby the therapist. Teahan24 used theacronym VINE to describe the workof the hospice team in facilitating theValidation, Identification, Normali-zation, and Expression of feelings ofanticipatory mourning on the part ofthe patient’s loved ones, a process thatcontributes to a healthy grievingprocess. For families with a strongreligious base, hymns or other sacredsongs may result in sharing feelings ofspiritual strength with the patient andone another. Each session is unique,and the music therapist must be flexi-ble about the needs of the family and

patient at the time of the session. Following are five single-session

case descriptions, vignettes that aredesigned to illustrate how music ther-apy enabled a joining of the patientwith family members shortly beforethe patient’s death. Music therapyoffers release in different ways. Theactual clinical death may be a consid-ered a physical release for the patientat the end of her or his life. The deathmay also provide a release for thefamily and loved ones, in their know-ing that the patient is no longer ill or indiscomfort. While this release is a clo-sure of sorts, it is also just one event inthe grief journey of a family memberor other loved one.

Case examples

The following sessions all tookplace at the C.W. Gerstenberg HospiceCenter at Hospice of Palm BeachCounty, Florida, an organization thatserves approximately 650 patients perday. The Gerstenberg Center housesan acute care unit. Some patientsadmitted for skilled care physicallydecline as a result of their diseaseprocess, and then further declinetoward eventual and imminent death.Family and friends of patients are freeto visit 24 hours a day, seven days aweek. Each private room has convert-ible sofas and chairs for sleeping. It isnot uncommon for family members toremain continuously at a patient’sbedside during the final days andhours, including the time of death.While none of the patients were overt-ly responsive at the time of these ses-sions, the patients’ caregivers were allpresent. The caregivers gave theirconsent for a brief description of thesession to be shared in an article to beused for educational purposes, with theunderstanding that no actual patient orfamily names or specific identifyinginformation would be used. As such,the names or initials of the followingpatients have been changed, with the

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exception of Ms. T, whose first namewas Rose. The sessions are describedin the first person from the author’sperspective as the clinician.

Case one: Ms. P

Ms. P was a 37-year-old womanwith ovarian cancer. Immediately be-fore meeting with Ms. P and her fami-ly, I had been visiting with anotherpatient in the common area of an inpa-tient unit. As I provided live songs ascomfort and support for the otherpatient, Ms. P’s aunt and brotherwalked through and stopped to listen.They entered Ms. P’s room, andremained there while I finished myvisit in the common area. After con-cluding the first visit, I entered Ms. P’sroom to offer music therapy services.Ms. P was reclining in bed with herhead leaning to her left on her pillow.Her eyes were partly open, and herbreathing sounded shallow and dry.Ms. P seemed to be minimally respon-sive and not able to communicate withher family members. Impending deathwas noted on Ms. P’s care plan.

I asked Ms. P’s aunt and brother if Icould share some music with Ms. Pand them to provide comfort. Ms. P’sbrother replied. “She can’t hear us,she’s almost gone.” I told them thatMs. P might be able to hear eventhough she could not speak. I ad-dressed Ms. P directly, telling her “Myname is Robert. I’m a music therapist,and you are with us here at hospice.You are very safe, and your family ishere with you. We will keep you com-fortable. I am going to sing some songsto help you relax. Just listen to the music.It is a gift from your family to you, and itis a privilege to visit with you.”

I then asked Ms. P’s aunt and broth-er what type of music she enjoyed.Both replied “hymns and gospel.” Ms.P’s aunt asked to hear “AmazingGrace” and “anything else you like.” Ibegan with “Amazing Grace,” andthen continued to play a medley of

spiritual songs, including “Michael,Row the Boat Ashore,” “He’s Got theWhole World in His Hands,” “ThisLittle Light of Mine,” and “Kum-baya.” During the music, Ms. P’s auntsang with me (I had provided copiesof the words), and Ms. P’s brother satnext to the patient with his hand on herleft shoulder. I began the songs at amoderate tempo and then slowed thepace and lowered the volume throughthe final verse. “Kumbaya” was thussung in a gentle and tender manner.The final words of the song were “OhLord, come by here,” the translationof the song title from Angolan toEnglish. Both Ms. P’s aunt and broth-er appeared to appropriately expressfeelings and emotions during the ses-sion, crying lightly at several points.

After concluding the music, Istayed with the patient and family toprovide support and to thank them fortraveling across the country to visit. Ialso explored their support systemwith them and validated their feelingsof impending loss. Ms. P’s aunt andbrother thanked me several times forvisiting, saying that the music helpedthem interact with Ms. P in a meaning-ful manner. Ms. P died later that night.

In summary, Ms. P’s aunt andbrother had offered a cue that musicwas meaningful to them by stoppingin the unit to listen as I provided musicfor another patient. In the room, theirinteraction with the patient shiftedfrom passive (“She can’t hear us”) toactive. Both family members told methat the music helped them say good-bye to their loved one.

Case two: Ms. G

Ms. G was a 78-year-old womanwith a terminal diagnosis of dementia.I had provided some music for her andseveral of her adult children the previ-ous day, and the family requested thatI return again. During the first visit,Ms. G presented as minimally respon-sive, as she did on this visit.

When I entered the room, Ms. Gwas lying in bed with her eyes closed.She appeared to be comfortable andrelaxed. Six family members, includ-ing adult children and some of theirspouses, were present. During the pre-vious visit, the family had asked forspiritual songs from the RomanCatholic faith. These had included“On Eagle’s Wings” and “Be NotAfraid.” During the current visit, adaughter asked me to play and sing“Wind Beneath My Wings.” Webriefly spoke about the meaning of thesong, and she shared that “Beaches”had been a favorite movie of thepatient. She also shared that the pa-tient had “always been there” for thefamily. I validated and reinforced thissentiment for the family, noting thatthis was a time that the family wasable to “be there” for their loved one.We briefly explored the theme of thesong and movie (support of a lovedone during a long terminal illness),with the support metaphor being “thewind beneath the wings.” I alsoaddressed the patient directly, saying,“This is a song of love and supportfrom your family. It is a gift theywould like to share with you now.”

During the singing, family mem-bers focused their eyes and attentionon the patient. Two daughters, one oneach side of Ms. G’s bed, held herhands. Several family members graspedtissues and dabbed their eyes. Thepatient appeared comfortable through-out but did not appear to respond tothe music in an overt manner. Afterthe song ended, a wonderful stillnesswas present in the room. No one spokefor 30 seconds. This silence was notuncomfortable for me, nor did itappear uncomfortable to the familymembers. It was nothing that can bemeasured quantitatively, but the still-ness felt like it was comforting for allpersons in the room. I waited until afamily member spoke before I spoke,to avoid intruding upon the family’smoment. A son then expressed sincere

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appreciation for the song. I shared thatthis was a special time, and that hav-ing the family together in such a sup-portive manner made the music muchmore powerful than if I had been visit-ing with the patient alone. The work ofhospice is best realized when weallow families to come together andshare meaningful moments during theend-of-life transition. The family thenrequested several spiritual songs,including “On Eagle’s Wings” and the“Prayer of St. Francis.” Again, therewas a comfortable feeling in the roomboth during and after the music. Thefamily thanked me several times forthe visit, and Ms. G died within onehour of that visit.

With Ms. G’s physical comfortneeds met, the family was able tocome together to say goodbye to herand share on a psychosocial and spiri-tual level through the music. The spe-cific choices of songs and hymnsappeared to enhance the support thatthe family provided to the patient andto each other. The music also appearedto connect all in the room—therapist,patient, and family—in a concreteway through the vibrations of the gui-tar and voice, and the eye contactbetween us. The music also stimulatedthe family to touch and hold thepatient’s hands during the music.

Case three: Ms. T

Ms. T was an 85-year-old womanwith a history of breast cancer. I hadvisited her room once during the pre-vious week. The patient was minimal-ly responsive at that time and had justthat day been admitted into the hos-pice center. The family at that timeaccepted my support and appearedappreciative of the offer of music, butdeclined, stating that the patient wasstill “getting settled.” However, thefamily had requested music therapytoday, and I was paged overhead.

Upon arrival, I observed Ms. Treclined in bed with her eyes partly

open, appearing to be minimallyresponsive. Ms. T’s nurse describedher as “actively dying,” and thepatient’s breathing sounded congest-ed. A number of family members werepresent in the room, including thepatient’s husband, children, and adultgrandchildren. One of the patient’sdaughters served as spokesperson forthe group, saying, “Ma’s close now,and we thought music might be a goodthing.” I validated that statement, say-ing, “Yes, she appears peaceful andcomfortable. Thanks to all of you forbeing with her and for asking for me.”The daughter related that the patient’sfavorite song was “The Rose” fromthe movie of the same name. She saidthat since her mother’s name wasRose, this song had been special to herfor many years. I briefly touched onsome of the images and symbolism inthe song lyrics, focusing on the finaltwo lines of the song: “Just rememberin the winter far beneath the bittersnows, lies the seed that with the sun’slove in the spring becomes the rose.”The family members shared that theyrelated to this image. The patient andher husband had lived in New YorkCity during many cold winters andthen had relocated to South Florida inthe late 1990s. We also discussed, atthe family’s initiation, the metaphor ofthe newly growing rose emergingfrom the snow, signifying the releaseof Ms. T’s soul to heaven after herimpending death.

During the song, family memberscomforted each other and the patient.Several cried lightly and hugged eachother. Following the song, I continuedto allow family members to sharememories of the patient’s life as wellas tell stories that involved the patient.Several times these stories involvedhumorous situations. At one point agrandchild said, “I don’t knowwhether to laugh or cry.” I told hergently that both are okay and can hap-pen at almost the same time. The fam-ily did not want any other live music,

but chose to simply visit with eachother and the patient. Ms. T died laterthat afternoon with the family present.

The use of a meaningful songallowed for the family of Ms. T tocommunicate on a number of differentlevels. While listening to a recordedversion of the song also may havebeen comforting for the patient andloved ones, the exploration of theimbedded meaning in the songappeared to be especially meaningfulfor the family.

Case four: Mr. J

Mr. J was an 83-year-old man withcongestive heart failure, renal failure,and Alzheimer’s disease. The socialworker had said that the patient wasactively dying. When I entered theroom, Mr. J was lying in bed with hiseyes closed, seeming to be comfort-able. Mr. J appeared to be strugglingwith apnea, and I observed pauses of20 to 30 seconds between noticeablebreaths. Seated at his bedside were hiswife and his sister-in-law. I introducedmyself and provided some supportiveand comforting words, telling themwhat I could offer as a music therapist.Mr. J’s wife asked if I knew the hymn“Beulah Land,” explaining that thehymn was a significant one for herhusband and herself. I asked to beexcused for a moment to get the musicfrom my office. Upon re-entering theroom, I observed Mr. J’s wife standingand holding his hand. Mrs. J appearedto be crying lightly, with her sisterphysically comforting and supportingher. I stood quietly for a minute, want-ing to support the family withoutintruding on their private and intimatemoment. Mrs. J turned to me andasked if I would play “Beulah Land.” Ibegan the hymn, with the family sup-porting each other and listening. As Isang the beginning of the chorus, Mrs.J began to sing with me. She sangalong with each verse and continuedto hold her husband’s hand. After the

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hymn, I told Mrs. J that I was honoredto be able to play a hymn that was someaningful for the patient and family.Mrs. J related that hearing the wordsof the hymn reinforced her belief thather husband was going “to a betterplace, Beulah Land.” We briefly dis-cussed this image and conviction asrelated to the family’s spiritual back-ground. I thanked the family and thenleft the patient’s room. Mr. J died oneand a half hours after my visit.

Music therapy appeared to help thepatient’s wife and sister-in-law activelyexpress their belief that their loved onewas leaving his physical body to go to“a better place.” The singing and shar-ing of that hymn at that time appearedto help them with a release of their feel-ing, and may have helped the patientexperience release as he died.

Case five: Mr. Y

Mr. Y was a 77-year-old man withcancer of the pancreas. While check-ing with a unit nurse regarding newpatients, I learned that Mr. Y was min-imally responsive and that his wifewas keeping a vigil by the bedside.Upon entering the room, I observedMr. Y lying in bed with his eyes openbut with his gaze fixed and his eyesappearing to be cloudy. His wife wassitting by his side, gently massaginghis forehead. Upon seeing the guitararound my neck, she exclaimed “Ohhow wonderful, music for you” (say-ing the patient’s first name). I intro-duced myself, and Mr. Y’s wife begansharing about her husband and theirrelationship of over 40 years. When Iasked about their family, Mrs. Ydescribed their adult children andgrandchildren and where each familylived. Although none lived locally, shetold me that many had been to visit thepatient at home during the past severalmonths “while he was good.”

Mrs. Y then turned to her husbandand said, “It’s okay to let go, we’regoing to have some music.” Turning

my attention again to Mr. Y, Iobserved that his breathing appearedquite shallow, with a pause of 10-15seconds between each breath. I askedif there was a special song that I couldsing to provide comfort. Mrs. Y said,“I have a spiritual song that I wrote formy husband. Can you follow me?”She then began to sing, and I foundchords on the guitar that supported hermelody. The words related to herbelief that God would take her hus-band from her when He was ready forhim. The words also said, “I will seeyou again in the arms of the Lord.”Mrs. Y sang the words several times,and I observed Mr. Y’s breathingappear to quicken. Mrs. Y indicatedafter the song that she wanted to bealone with her husband. I left the roomvery quietly, not wanting to break thewonderful stillness and love that I feltin that room. Mr. Y died that night.

Hearing her original spiritual songappeared to have specific meaningand significance for the patient’s wife.Getting to sing that special song to herhusband one last time seemed to beespecially important for her. It mayhave been a stimulus for Mr. Y to beable to let go as well.

Conclusions

In each of the above sessions,music therapy played an importantrole by helping family members to beactively involved in the last hours ofthe lives of their loved ones. Themusic therapist did not set a specificagenda or plan for each session.Rather, each session unfolded basedon the presenting needs of the patientand family at that moment. The timeimmediately before the death of a per-son can be especially difficult for thefamily. Within the context of the inter-disciplinary care team, music therapycan help to bring comfort to patientand family alike.

It is important for the music thera-pist and other care team members to

remember that the final days andhours of a patient’s life are times forhelping loved ones to visit and saygoodbye in their own ways and styles.There are times when family membersdo not want others, including staffmembers, to intrude on that privatetime. In other cases, loved ones lookto the hospice clinicians for help andsupport in finding ways to visit andsay goodbye. It is during these timesthat we as members of the hospiceteam can provide support and facili-tate meaningful release for both thepatients and those who love them.

References

1. Gallagher LM, Huston MJ, Nelson KA, etal.: Music therapy in palliative medicine.Support Care Cancer. 2001; 9(3): 156-161.2. Haghighi KR, Pansch B: Music therapy.In Complementary Therapies in End-of-lifeCare. Alexandria, VA: National Hospice andPalliative Care Organization, 2001, 53-68.3. Hirsch S, Meckes D: Treatment of thewhole person: Incorporating emergent per-spectives in collaborative medicine, empow-erment, and music therapy. J PsychosocOncol. 2000; 18(2): 65-77.4. Krout R: Hospice and palliative music ther-apy: A continuum of creative caring. InEffectiveness of Music Therapy Procedures:Documentation of Research and ClinicalPractice, 3rd Edition. Silver Spring, MD:American Music Therapy Association, 2000.5. Marrelli T: Hospice and Palliative CareHandbook. St. Louis: Mosby, 1999. 6. Trager-Querry B, Haghighi KR: Balanc-ing the focus: Arts and music therapy forpain control and symptom management inhospice care. Hospice J. 1999; 14(1): 25-38.7. Zuberbueler E: Complementary therapiesin hospice care: From skepticism to accep-tance. Hospice and Palliat Professional.2001; 4: 1-4.8. Hilliard RE: The use of music therapy inmeeting the multidimensional needs of hos-pice and families. J Palliat Care. 2001;17(3): 161-166.9. Aasgaard T: Music therapy as milieus in thehospice ward and pediatric oncology ward. InD. Aldridge (ed): Music Therapy in PalliativeCare: New Voices. London: Jessica KingsleyPublishers, 1999, 29-42.

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10. Krout R: The effects of single-sessionmusic therapy interventions on the observedand self-reported levels of pain control,physical comfort, and relaxation of hospicepatients. Amer J Hosp Palliat Care. 2001:18(6): 383-390.11. Lucchese AM, Krout R: At life’s end,music takes the pain away. NursingSpectrum. 2000; 10(23): 25-26.12. Munro S: Music Therapy in Palliative/Hospice Care. St. Louis: MMB Music, 1984.13. Starr RJ: Music therapy in hospice care.Amer J Hosp Palliat Care. 1999; 16(6): 739-742.14. Lynn J, Schuster JL, Kabcenell A:Improving Care for the End of Life. NewYork: Oxford University Press, 2000.

15. Burt RA: The limitations of protocols forend-of-life care. Respiratory Care. 2000;45(12): 1523-1533.16. de Bois J: Changing the way we care forthe dying. Health Progress. 1994; 75(2): 48-49, 52.17. De Hennezel M: Denial and imminentdeath. J Palliat Care. 1989; 5(3): 27-31.18. Soloway HB: When imminent death isinevitable. Medical Laboratory Observer.1983; 15(8): 21-22.19. Wein S: Sedation in the imminentlydying patient. Oncology. 2000; 14(4): 592,597-598.20. West TM: Psychological issues in hos-pice music therapy. Music Therapy Perspec-tives. 1994; 12(2): 117-124.

21. Karnofsky D, Abelmann W, Craver L:The use of nitrogen mustards in the palliativecare of carcinoma. Cancer. 1948; 1: 634-656.22. Kastenbaum R: The moment of death: Ishospice making a difference? Hospice J.1999; 14(3/4): 253-270.23. Krigger KW, McNeely JD, LippmannSB: Dying, death, and grief: Helping pa-tients and their families through the process.Postgrad Med. 1997; 101(3): 263-268, 270,305-308.24. Teahan M: Grief interventions. In MTeahan, T Dalton: Helping Children andAdolescents Cope with Grief and Bereave-ment. Symposium conducted at the AlumniConference of the Barry University Schoolof Social Work, Miami, Florida.

134 American Journal of Hospice & Palliative CareVolume 20, Number 2, March/April 2003

As we move into our 20th year of publication, American Journal of Hospice & Palliative Care continuesits long and respected tenure as the journal of record for hospice and palliative medicine. It provides anessential forum for articles covering all aspects of hospice and palliation from the medical and pharma-ceutical to the administrative and social. Peer-reviewed by an internationally recognized editorial reviewboard, American Journal of Hospice & Palliative Care is renowned worldwide for its comprehensiveview of the changing focus of hospice and palliation. Indexed in Index Medicus/Medline, Leeds Medical Information and Ageline Database.

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