Abstract
About 10 years ago I had a patient in an inpatient hospice that was in crisis, struggling with legacy issues. She was estranged from her family and wanted to leave something meaningful for them, but there were no photos for an album, and she was unsure if any letters would be read, or if a tape of her speaking would be listened to.
My own life took me on a journey that lead me to nursing as a career, but I have a strong background in music and was classically trained as an oboist. I have played the oboe semiprofessionally over the years, while practicing as a nurse. I always yearned to find a way to weave my love for music into my hospice care, but I was always reluctant, not knowing the best way to bring them together appropriately. One night, my patient was in acute distress related to her existential crisis. It was the night shift and the two nursing assistants were busy preparing the other nine hospice residents for bed. I was unable to find a way to comfort this woman. She was in no physical pain. There was no dyspnea, no obvious physical etiology for the suffering I was seeing. It was all psychic pain, and any attempts to calm through talk, touch, presence, or active listening did not seem to diminish her anguish.
I found myself struggling with what to do in that critical moment. In retrospect, there might have been other things I could have done or tried, but for whatever reason, I felt compelled to demonstrate empathy through what I hoped would be an appropriate use of self-disclosure. I shared with her my own story about how I had managed to cope with one of the most difficult periods of my life – the loss of my parents, my sister, and my spouse, all within a seven-year period. I told her that I believed that my love of music, and its cathartic effect, had helped me through. She paused and looked at me curiously and asked what music could possibly have made such a difference. I excused myself, went to my car and grabbed a treasured CD. I found the hospice's portable CD player and shared with her one of my favorite pieces of music, one of many pieces that had somehow helped me through that dark period in my life: the Nimrod variation from Edward Elgar's Enigma Variations. It is a beautiful, broadly sweeping piece of music with ebbs and flows, peaks and valleys, crescendos and decrescendos, eventually rising to a triumphant climax, then winding down in a gradual diminuendo to silence – a symphonic metaphor of life. As we quietly listened, her tears fell just as quietly, and the music, which had been beating with a very rhythmic and pulse-like beat, seemed to have calmed her. After the music ended, the silence continued briefly. Neither of us wanted to break the spell the music had woven, and I could see that the music had affected her deeply. She went to sleep soon afterward. It called to mind the words of Congreve 1 who aptly said, “Music has charms to sooth a savage breast. To soften rocks, or bend a knotted oak.”
The next evening when I came to work she told me that, while the music I had shared had calmed her, it really wasn't her “cup of tea.” I asked her if she would share with me some of the songs that had special meaning for her, and why they were important. I realized later that all the songs she shared had a positive memory associated with them, the birth of a child, a car ride to the church to get married, her wedding night, and more. When I got home the next morning, I couldn't sleep out of enthusiasm for having found an intervention that was working to curb her despair. I went online and downloaded some of the songs that she had mentioned in our talk. I burned them onto a CD and gave it to her to listen to. I passed by her room from time to time, and saw her with the earphones on, listening to that CD over and over again, sometimes smiling, and sometimes crying, but overall it seemed to be therapeutic for her.
Then it occurred to me that this could be her legacy. She could make a CD of her favorite songs to leave to her family. I suggested the idea to her and I could tell by her enthusiasm that we had found her legacy project. Over the couple of weeks, we worked on the project. She told me about the songs that she thought of as the musical accompaniment to the major events and memories of her life. I also tape recorded her descriptions of why each song was important to her and the memories they triggered. We put together a full CD. It was a chronological life review in music. On the inner CD jacket, the tracks were numbers and named. Underneath each track name were typed transcriptions of why that particular song had significance to her, in her own words. She wanted a copy to be sent to her son and daughter when she died, and she provided the addresses. This was going to be her legacy to her estranged children. As she lay dying, even when she was no longer responsive, I played the CD quietly for her whenever I was working. I'd like to think that it was comforting.
After she passed, I sent copies of the CD to her children, as I had promised. I wish I could say that they contacted me to say how moved they were by the music and words, and that the forgiveness she had sought in life had been granted in death, but I never heard from either of them. It would make for such a wonderful ending to this story, but I realize that the beautiful ending to this story happened long before the CDs were ever sent. My patient, who had been in crisis, had discovered a way to express herself through music. While the musical content of the CD and the writing on the jacket was important, I believe that it was the process of making the CD that was transformative. She had found a voice, and had experienced her own catharsis through music selections that had special meaning for her, just as I had found succor through my own songs years before. Our musical project had brought us together, and gave her a sense of purpose. I believe that this project not only helped her complete an important life review through music, but it helped her to focus that life review on some of the more positive times. As a result, I think that this project helped her to have some degree of ego integrity as she was dying, and gave her hope that the reconciliation that she had hoped for in life might still happen after she was gone.
The experience was also transformative for me. I remember thinking at the time that the concepts of personal and aesthetic knowing, 2 which had previously only been theoretical for me, were suddenly rich, real, and meaningful; and helped me to imagine a whole new realm of possibilities for care. I have since wondered if musical legacy projects such as this could help other hospice patients in crisis, particularly for those who express or demonstrate a strong connection to music. Perhaps a qualitative study could be done to look at the construction of chronological musical life reviews as legacy work.
I am grateful for many colleagues and mentors in palliative/hospice care who have continually shown, through their examples, that dignified, respectful, and caring interactions with patients and their families can do as much to promote human dignity, comfort, and well-being at life closure as the best anxiolytics or pain medications, perhaps even more. Let us always remember the humanity and comfort that can be found in simple things like a caring smile, a listening ear, a gentle touch, a hand held, a knowing glance, and even a piece of music shared.