MUSIC, DEATH, AND DYING: A SYSTEMATIC REVIEW OF HOSPICE AND PALLIATIVE CARE LITERATURE By Virginia A. Anderson A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTERS OF MUSIC Music Therapy 2011 ABSTRACT MUSIC, DEATH, AND DYING: A SYSTEMATIC REVIEW OF HOSPICE AND PALLIATIVE CARE LITERATURE By Virginia A. Anderson The purpose of this research was to categorize, code and summarize articles and abstracts on music therapy and palliative care and hospice in order to highlight themes and trends, as well as provide direction for future research. Findings included data summaries on treatment settings, population trends, diagnoses, and treatment focuses or areas of investigation. Of 79 articles reviewed, 17 were quantitative, 12 were qualitative, 31 were clinical, 8 professional, 7 theoretical/philosophical, 2 historical, and 2 uncategorized. The common goal of the majority of the 79 articles was to look at emotional wellbeing and benefit, with the most prevalent population being adult patients. In the early 2000’s there was an explosion of literature and a push toward empirical studies. Within the past 40 years we have gone from theorizing about the benefits of palliative care and hospice to producing empirical studies measuring quality of life and length of life, as well as creating songwriting tools to measure grief in children. Further breakdowns are given as well as implications for future research. Copyright by Virginia A. Anderson DEDICATION I would like to dedicate this thesis to the families and their loved ones that I have had the honor and privilege to care for through hospice music therapy at end of life. You have deeply touched my life, and I am eternally grateful. 
 iv ACKNOWLEDGEMENTS I would like to acknowledge: my mother and father Ruby and Tom Anderson for their endless love and unfailing support in any and all things that I endeavor. my professors and committee, Roger Smeltekop, Dr. Ted Tims and wife Sue Tims, and Dr. Cynthia Taggart for their inspiration and gentle nudges along this journey. my close friends Jody, Rebecca, Angie and Jody for their rallying support. my best friend and “partner in crime,” Ron, for sitting up late hours at the table not letting me get discouraged. my Lord and Savior Jesus Christ for through him, all things are possible. 
 v TABLE OF CONTENTS LIST OF TABLES………………………………………………………………………………..vi LIST OF FIGURES...…………………………………………………………………………...viii CHAPTER ONE INTRODUCTION TO HOSPICE…………………………………………………………….….1 Music Therapy and Hospice……………………………….……………………………..3 CHAPTER TWO RELATED RESEARCH………..………………………………………………………………..5 Specific Population Analyses in Music Therapy………………………………………..10 Systematic Reviews and Meta-Analyses in Hospice Care ……..……………………….12 CHAPTER THREE METHODOLOGY…………..…………………………………………………………………..16 Qualifying Articles for Study…………………………………………………………….16 Procedure………………………………………………………………………………...17 CHAPTER FOUR RESULTS………………………………………………………………………………………..19 All But Quantitative Studies…...………………………………………………………...19 Settings …………………………………………………………………………………..20 Populations……………………………………………………………………………….20 Areas of Focus Within Research…………………………………………………………22 Qualitative Research Results…………………………………………………………….23 Populations Served……………………………………………………………………….24 Quantitative Settings……………………………………………………………………..24 Focus Within Research…………………………………………………………………..25 CHAPTER FIVE DISCUSSION…………………………………………………………………………………....26 Qualitative vs. Quantitative……………………………………………………………...27 Individual Study Components……………………………………………………………29 Populations and Settings…………………………………………………………………29 Implications for the Future……………………………………………………………….32 APPENDICES A………………………………………………………………………………………….35 B………………………………………………………………………………………….41 C………………………………………………………………………………………….49 BIBLIOGRAPHY………………………………………………………………………………..58 
 vi LIST OF TABLES Complete List of Articles Studied in Chronological Order………………………..…………….35 Qualitative articles……………………………………………………………………………….41 Quantitative articles……………………………………………………………………………...49 
 vii LIST OF FIGURES Qualitative/Non-Empiric Studies.……………………………………………………………….19 Qualitative Settings Pie Chart……………………………………………………………………20 Qualitative Populations Graph…………………………………………………………………...21 Goals of Qualitative Articles…………………………………………………………………….22 Qualitative Populations…………………………………………………………………………..24 Quantitative Settings………………………………………………………………………......…24 Quantitative Research Goals…..…………………………………………………………………25 Article Frequency………………………………………………………………………………...26 
 viii Chapter One Introduction to Hospice The word hospice originated from the Latin word hospitium, meaning guesthouse. It was originally used to describe places of shelter and rest for tired and/or sick travelers on religious pilgrimages. The modern day hospice movement as we understand in America, began in England in 1967 with Dame Cicely Saunders, an Englishwoman trained as a social worker, nurse and physician who founded St. Christopher’s Hospice near London. (Berzoff & Silverman 2004, 151). “All hospice care is palliative, but not all palliative care is hospice” (www.nhpco.org). Palliative Care seeks to address illnesses with a holistic approach utilizing an interdisciplinary team, including physician, nurse, social worker, aide, spiritual caregiver, and volunteers. This can include seeking curative methods of treatment, for example radiation and chemotherapy in the instance of cancer, and can also be the primary modality of care. Palliative care can transition to hospice should treatment not be effective in curing the diagnosed illness. Hospice, which also uses a holistic interdisciplinary approach, requires a referral from a physician that identifies a patient with a diagnosis of a terminal illness and a life expectancy of 6 months or less. Curative treatment must stop, and the main focus of care becomes comfort, symptom management, and quality of life. Cicely Saunders’ inspiration to begin an inpatient Hospice came from her work and relationship with a Polish Jewish man who escaped WWII. Throughout the time she cared for 
 1 him, they openly discussed issues and needs of dying that went beyond just the physical. He spent his final days on a busy surgical unit that did not provide the quality of life or peace that he felt was appropriate to address the spiritual and emotional needs and issues that one faces at endof-life. From this relationship grew a whole-person philosophy. In 1948 when he died, he bequeathed 500 pounds to Saunders to create the much-needed facility that they discussed during his end-of-life care, a place where the terminally ill could receive the care they needed to make a peaceful transition to death. In 1967 Saunders opened the first freestanding hospice, St. Christopher’s Hospice in a London Suburb, formally initiating the official birth of the contemporary hospice movement (Saunders, 1977). Cicely Saunders introduced the concept of hospice care for the dying to the United States in 1963 during a lecture at Yale University. Saunders delivered her lecture to pre-professionals representing the areas of that are now included in the modern hospice team; medical students, nurses, social workers, and chaplains. She included photos of terminally ill patients and their families, presenting the apparent differences before and after the symptoms were managed. “This lecture prompted the series of events, that resulted in the development of hospice care as we know it today.” (http://www.nhpco.org/i4a/pages/index.cfm?pageid=3285) In 1986 guidelines were developed for Medicare to reimburse hospice programs for services at a daily rate, and hospice treatment was formally added to these government benefits. (http://www.nhpco.org) Recently, effective December 2nd 2008, guidelines for hospice and palliative care were revised and updated to address the needs of our current and rapidly changing society. Some of these revisions include; greater flexibility in care, more person/family centered, increased focus 
 2 on quality improvements and patient outcomes as well as utilizing more interdisciplinary language throughout. (http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf ). Music Therapy and Hospice Music therapy was introduced to hospice in the mid 1980s. Since then, research has steadily increased and supports the benefits of music therapy in physical, mental, emotional, and spiritual realms for both the patient and the family. Demmer (2004) conducted a survey with 300 randomly selected hospices to investigate the most popular forms of complimentary therapies. The survey found that the most popular forms reported were massage therapy and music therapy. This comes as no surprise, as hospice-focused presentations at national and regional music therapy conferences are on the rise, and scholarly literature in a broad variety of refereed journals is steadily increasing. Specialized credentials are now offered in the area of hospice and palliative care music therapy as well as continuing education credits for certification maintenance (www.hospicemusictherapy.org). With new programs developing in hospice and palliative care each year, it is of great interest to the profession and clinicians who work with this population to understand the growth and development of music therapy treatment with this population and the implications for future needs. The field of hospice continues to grow and change, as does the field of music therapy. With the continued growth in the area of hospice it is the opinion of the author that Hospice guidelines and criteria that are in the near future will include provisions for complimentary therapies, including music therapy. With that being said, one must understand the current direction of the field and also address the potential needs of the future. Music therapy is now 
 3 becoming a necessity rather than a luxury in Hospice programs. From the vantage point of the author, as little as five years ago music therapy in Mid-Michigan hospice programs was considered a complimentary addition only provided by the for-profit programs. Now to stay competitive with other agencies in the Mid-Michigan area, the inclusion of some form of complimentary therapy (music therapy, massage therapy, or reiki therapy) is considered essential. Of the eight hospice programs reported in the Mid-Michigan region in 2009, five of them employ a music therapist. 
 4 Chapter Two Related Research Because of the continued growth and expansion of hospice music therapy and new clinical and therapeutic techniques developing each year, research concerning the need for music therapy, as well as to validate its effectiveness within a specific population, is in high demand. With the increase in research comes the necessity to look at past studies to have a better understanding of areas that have been studied, including treatment techniques and populations, areas that need further investigation, and populations or age groups that are neglected by the literature. Previous content analyses and meta-analyses have served to assist the profession of music therapy in doing just that. They identified trends in populations served, areas of need for future research, and the effectiveness of new techniques utilized in clinical practice. These studies also served to identify the origin, as well as a timeline and a direction for this branch of the profession. One of the first music therapy content analysis research articles was published by Jellison in 1973. She analyzed the frequency and general mode of inquiry of research in music therapy from 1952 to 1972. In 1979 Gilbert replicated this study design by examining the content and focus of research articles published in the Journal of Music Therapy (JMT) from 1973 to1978. Categories established for this analysis included general emphasis of the paper, setting for research, mode of inquiry, basis for research, and type of clientele. Gilbert reported a continued 
 5 decline in the total number of published articles, which agreed with Jellison’s findings. Gilbert found increases in the areas of “hard research”, shown by the high proportion of descriptive and experimental studies. In relation to those increases, Gilbert found a decrease in the proportion of philosophical and historical studies. Six years later James (1985) examined the sources of articles published in the Journal of Music Therapy from 1964-1983. Data were arranged by four topic areas: year of publication, affiliation of the author, gender of the author, and credentials of the author. James found that the previous findings of Jellison and Gilbert were not verified by his study, due to her more comprehensive range and scope of the literature. While Gilbert and Jellison investigated the articles’ research methods and content, James examined the articles’ sources, comparing these of two decades 1964 to 1973 and 1974 to 1983. James identified that there was a stable frequency of articles published throughout the 20-year period, with a recent trend toward more female authors. Unfortunately, according to James, information identifying the authors’ professional credentials was poor. James also found that, from 1974 to1983, there was an increase of articles originating from university settings, identifying key institutions on the forefront of scholarly writing. Codding (1987) also replicated both Jellison’s and Gilbert’s studies to examine JMT articles published between 1977 and 1985. These articles were categorized to describe trends in focus, research setting, and mode of inquiry. Also noted were the frequencies of the statistical and behavioral designs present in the articles. Like James, Codding (1987) found that the frequency of articles published had remained the same; the percentage of research-oriented articles continued to be greater than position papers and critical articles. Also, when investigating research settings, Codding identified a greater number of studies performed in clinical settings 
 6 verses university settings, with the mode preference being experimental over descriptive, historical and philosophical methodologies. In Codding’s conclusion, along with other statistical information related to her findings, she noted that research in the public schools had increased. She is the first of the above-mentioned content reviewers to isolate and report growth within the literature on a single population. Gfeller (1987) conducted a content analysis of the JMT from 1964 to1984, investigating theory and practice in relation to psychological theory, physiological response to music, and theories developed within the music therapy profession, seeking to identify prominent principles and themes. Results from the analysis concluded that there was no single theory central to music therapy, but areas of emphasis could be detected; for example, the prominence of psychological theories and behavioral theories that influenced music therapy practice. From her analysis, Gfeller also asks, “whether the theoretical foundations of music therapy practice have been adequately defined.” In 1987 Decuir sought to analyze Journal of Music Therapy articles by disability area, also listing the mode of inquiry (type of article). One year later, Wheeler’s research method followed the model used by Decuir (1987) with a few alterations, including: applying the analysis to more than just JMT, adding authors’ names, adding several categories, and altering the order found in Decuir, but leaving the basic content unchanged. Wheeler (1988) sought to classify music therapy literature in three other published journals and compare findings with Decuir’s analysis of JMT. She analyzed literature from selected music therapy journals and was one of the first to include multiple sources outside of JMT for music therapy research. The journals included were Music Therapy (Journal of the American Association for Music Therapy), Music Therapy Perspectives, and Arts in Psychotherapy. Wheeler found that, compared to JMT, 
 7 which focused mostly on research articles, the other three journals published a relatively even balance of articles focused on clinical, research, and general topics. Wheeler concluded that the focus of the other three journals was more clinically based in comparison to JMT, which was research driven. Gregory (2002) examined all research articles from JMT from 1964 through 1999 to ascertain if the methodology included a behavioral research design such as reversal, changing criterion, or multiple baseline; case studies that did not meet the design criterion where not included in this study. Gregory examined experimental studies that used a behavioral research design, analyzing them to determine the type of design, observation method and reliability report, the client population, and the music application. As the diasporas of music therapists trained in America took root overseas, music therapy programs developed in other countries. The need for research, reporting and validation increased the need for more refereed journals from other countries. Because of the increasing diversity of research from other countries and cross-disciplinary publications, there became a need to review and catalog findings regarding music therapy on a broader global scale. Brooks (2003) investigated historical trends in mode of research reported in articles published in the major music therapy periodicals written in the English language but not limited to journals originating from the United States. She further categorized whether studies were quantitative, qualitative, historical, philosophical, theoretical, clinical, or professional. Brooks desired to identify historical trends within each specific journal. Brooks also compared percentages of article types within each journal as well as across all of the selected journals. Brooks analysis covered nine journals: Journal of Music Therapy, Music Therapy: Journal of the American Music therapy Association, Music Therapy Perspectives, The Arts in Psychotherapy, 
 8 Journal of the Association for Music & Imagery, The Australian Journal of Music Therapy, The Nordic Journal of Music Therapy, The British Journal of Music Therapy, and The New Zealand Society for Music Therapy Journal, including all years of publication. Her criteria for including a journal were as follows; a minimum of 5 years in publication, a minimum of one issue per year, and a minimum total of 40 articles on music therapy. Her findings provided specific statistical data on the rise and fall of various research and article types. From these statistics Brooks asked the question, “To what extent do the present journals address the needs of the field in each area of inquiry?”(p. 166). The author arrived at this question based on the limited number or low percentage of historical, philosophical/theoretical, and qualitative research articles found in her study. She followed up with, “Is it possible that researchers do not see the value of and significance of these types of research as a major contribution to the literature or field?”(p. 166). Brooks’ second question related to the typical developmental process for a journal. Do music therapy journals follow the same or similar developmental patterns? If so, what are those patterns? Her assessment of the development of a journal based on her research concluded that initially a young journal begins with a strong clinical focus, and, as the journal develops and editorial boards are formed, criteria and screening standards are created, and article submissions begin to diversify to include other types of inquires. The value of Brooks’ study lies in the numerous follow-up questions derived from the research statistics. Further understanding the reasons for establishing a publication and the relationship to the direction and overall impact on the field help to identify whether the relationship between the journal and the field is healthy. For example, does the journal enhance the credibility of the discipline or the justification for funding for new programs? 
 9 Specific Population Analyses in Music Therapy As outlined previously, content analyses and literature reviews have proven to be valuable in forwarding the movement, progression, and growth of music therapy as a profession. As the profession expanded and the scope of practice continued to broaden, music therapy began to impact a wider variety of populations. As acceptance for music therapy grew in the medical and therapeutic communities, with the help of strong qualitative and quantitative research, the research community in turn began accepting and publishing studies in journals not exclusive to music therapy or art therapies. With continued research and the broader spectrum of journals that accept music therapy studies, there comes a need for more focused literature reviews in regard to population. Consequently, the need has increased for population-specific analysis to assist in the identification of needs that are addressed by the broader range of journals that are now publishing music therapy research. Brotons, Koger, and Pickett-Cooper’s 1997 article, Music and Dementia, focused on comprehensively reviewing literature published in the areas of music, dementia, and music therapy from 1985 (the date of the earliest music and dementia publication) to1996. The purpose of this study was to categorize, code, and summarize the dementia research outcomes with the objective of outlining recommendations for clinical practice and future research. The methodology that was utilized to identify the 69 articles analyzed in this study included the use of four online databases (MEDLINE, PsycLit, MBI database of MuSICA, and CARL UNCOVER), as well as complete searches of the Journal of Music Therapy and Music Therapy Perspectives. Of the 69 references, 42 of were empirical studies, including 30 clinical 
 10 empirical reports identified by the author as experimental, descriptive, or case study utilizing music as a therapeutic intervention as the independent variable. By identifying these articles according to the dependent variable, the author was able to outline the functional areas addressed. These areas included participation/preference for music, social and emotional skills, cognitive skills, and behavior management. The remaining 12 studies were from a neuropsychological perspective in the area of assessment or music cognition. Narrative case studies and anecdotal accounts of music in therapy or articles describing nonmusical goals accomplished through musical means were itemized as well; the authors uncovered eight (p. 207). Brotons, Koger, and Pickett-Cooper’s objective was to discuss and describe, and they included questions and implications for future research. Included in their findings and discussion was that, of the 69 studies involving music and dementia, over half (n=36) were written by other healthcare professionals. Of the professionals outside of music therapy conducting research with music, the majority were nurses. Brotons et al., highlights that while other health professionals studying and reporting the beneficial effects of music with people diagnosed with dementia might benefit the development and reputation of music therapy as a profession, it is disconcerting that people without formal training as a music therapist are implementing programs. Implications for future research included the need for a follow-up study in the form of a meta-analysis of empiric dementia music therapy literature to isolate specific music therapy practices. Also, research comparing the effectiveness of interventions applied by non-music therapists compared to professionally trained music therapists was needed. Brotons et al also posed research questions and research suggestions including but not limited to, comparison of 
 11 the stages of dementia and the corresponding response to music, responses to live versus taped music, and investigations into type, number and frequency of treatments required to effect change, as well as longevity of the changes in behavior. This study serves as a strong example for systematically reviewing the literature regarding a specific population in the field of music therapy. Systematic Reviews and Meta-Analyses in Hospice Care Within the past five years, literature reviews and meta-analyses in several areas of hospice care and hospice-related studies have been published. The following studies were helpful in formulating a research method and problem questions by serving as a model for this kind of investigation into hospice music therapy. Like Brotons, Koger, and Pickett-Cooper’s 1997 review of dementia literature, the following articles reviewed the literature utilizing various database search engines to identify literature applicable to the investigation, focusing the search with specific key words or phrases. These studies were also helpful in identifying databases that would filter published studies that were related to hospice, palliative care and bereavement. In 2008, Woods, et al, investigated literature on palliative care for people with severe persistent mental illness. In this study both empirical and non-empirical studies were reviewed. The methodology used to identify articles appropriate for this study employed the use of database searches. Eight databases were used, an inclusion criterion set, and articles selected through the agreement of two researchers. Disagreements were settled through a third author to insure validity. Article search keywords consisted of palliative care or terminal care or hospice, and mental disorders or mentally ill person. Of the sixty-eight articles found, Woods, et al, 
 12 discovered that there were not many empirical studies in existence (11), and even less information identifying the needs of severe, persistent mentally ill palliative care patients. Four main themes were uncovered when analyzing the literature; decision-making and advance care planning, access to care, provision of care, and vulnerability. By reviewing the literature for this study the author was able to identify many needs and implications for future research, including problems related to the current literature available. For example, Woods (2008) reports, “With the dearth of empirical studies there is an even larger void of information related to the palliative care needs of people with severe persistent mental illness. Potentially the literature found does not adequately represent the experience of the people, drastically limiting the generalizability of the studies’ results (p. 733).” Woods regarded future research with this specific population a research priority. As a result of the research he conducted, Woods asked for increased disclosure related to the challenges of researching marginalized, vulnerable, very ill populations where access to patients is difficult, capacity is questionable, consent is difficult to obtain, and benefit-to-burden ratio is difficult to determine. Ultimately encouraging more studies that are methodologically sound will improve outcomes of studies and better define the issues that exist for this population. In 2008, Washington, Bickel-Swanson, and Stephens conducted a systematic review entitled Barriers to Hospice Use among African Americans. The goal of this meta-analysis was to review and explore professional literature directly pertaining to the frequency of use of hospice services by African Americans, as well as barriers and interventions designed and utilized to increase the number of African Americans served. Like studies mentioned previously, the method for finding research relevant to this study was achieved through a systematic process using a database search. Three databases were 
 13 accessed using consistent key words (African Americans paired with hospice and minorities paired with hospice) for a thorough search. Findings were sorted and limited to studies published in peer reviewed journals in the English language excluding conceptual pieces, reviews, editorials, meta-analyses, and dissertations, as well as case studies and research with a sample size of less than or equal to three. The total number of articles that qualified for this study was eight. Of the eight studies, five were qualitative in nature. Two studies used secondary data in a quantitative method, and the eighth study combined both quantitative and qualitative methods in the research, interviews and scales, to collect data and arrive at a conclusion. There has yet to be an analysis of the total body of hospice music therapy literature. However, in 2005 Hilliard published a review of solely empiric data from the existing hospice music therapy literature drawing from not only refereed journals but also masters theses and doctoral dissertations. He isolated a total of eleven quantitative studies spanning from 1986 to 2004 in hospice music therapy literature, of which six reported a significant difference in outcome that supported the benefit of music therapy interventions and services. In these studies Hilliard identified the dependent variables of pain, physical comfort, fatigue and energy, anxiety and relaxation, time and duration of treatment, mood, spirituality, and quality of life, as the areas positively affected by music therapy. Hilliard (2005) argued that similar to the findings of Woods, et al. though there are empiric articles to support hospice music therapy, there is an over abundance of qualitative research and a lack of quantitative studies, leaving a large disparity between the two approaches. Within the few empirical studies he found, he also highlighted the lack of large control groups and randomization of subjects. For future research he encouraged the use of a standard 
 14 measurement tool designed specifically for hospice care, as well as diagnosis-specific studies, since death trajectories vary by terminal diagnosis. The previous article review served to outline the history of content analysis throughout the music therapy literature and to make the argument that more population specific analyses will be needed as the profession grows and expands. With the growing acceptance of hospice and the growing demand for music therapy within hospice, there are compelling grounds for the analysis of all the current literature to date to assess and identify implications and directions of the discipline in serving this population. The articles reviewed in this study served to guide and formulate the methodology with which this research was conducted. 
 15 Chapter Three Methodology. The intent of this study was to review, analyze, and catalogue literature published in the area of music therapy and hospice/palliative care. The purpose was to categorize, code and summarize articles in order to highlight themes and trends, as well as provide direction for future research and to forecast the direction of the profession as it relates to hospice patients, a growing population served by music therapists nationally. The research problems addressed by this study were to determine (1) setting of the study (home/inpatient hospital/AFC/ECF), (2) population served under the death and dying umbrella (bereaved-child/teen/adult, patient-child/teen/adult, extended family/close Friend), (3) average age of patients studied, (4) diagnosis of the patients studied and frequency of each diagnosis found in the article, (5) method of research (Qualitative vs. Quantitative), (6) If Qualitative, what type of article: Historical, Professional, Clinical, Philosophical/Theoretical, (7) goal of research (physical, emotional, social, spiritual), (8) and variety and frequency of the dependent variables or themes found in the literature. These results are reported in aggregate as well as individually. Qualifying Articles for Study For articles to qualify for this study they had to meet the following criteria: • The study must be printed in a refereed journal available in the English language, regardless of country of origin. 
 16 • The study must include the populations of hospice and/or palliative care, including bereavement programs that address grief concerns after a love ones death (parent, sibling, extended family, close family friend). Procedure Articles were acquired and cross-referenced through the usage of four search engines; Temple University Music Therapy search engine, ProQuest-Illumina, PsycINFO, and M-CAT. The initial search engine identified the majority of the articles pertaining to music therapy research in hospice and palliative care. The same key words used in the original search were cross-referenced in four other data bases--ProQuest-Illunina, M-CAT and psycINFO--to insure that all available articles had been located. The search included articles from the earliest possible date located (1977) through December of 2010. The key words used in all four database searches were: music therapy and hospice, music therapy and palliative care, music therapy and bereavement, and music therapy and death and dying. After identifying and qualifying the articles based on the above criteria, the articles were categorized, interpreted, and examined with the above identified research questions in mind. The previous content analyses and systematic reviews served to generate and outline these study questions. When full articles were not available abstracts were utilized. Of the 79 articles found, 55 were full text and 20 were full abstracts. Four articles were descriptive notes or qualified because of descriptive information in the title. See page 37 for the complete table of references. 
 17 Chapter Four. Results With the intent of reviewing, analyzing and cataloguing literature in the area of music therapy and hospice and palliative care, 79 articles that met the above criteria were indentified through the use of the aforementioned search engines. These articles were reviewed and catalogued based on the following criteria developed by Brooks and taken directly from her 2003 study published in the JMT. Her criteria were as follows: 1. Quantitative Research: Any article wherein numeric data were statistically summarized or analyzed for the purpose of making generalizations. This included experimental and descriptive research as well as studies in applied behavior analysis. Also included in this category were writings about research methods and the presentation of research protocols. 2. Qualitative Research: Any article involving systematic collection and analysis of non-numeric data for the purpose of deriving idiographic insights or meanings in relation to a phenomenon. This included research (individual case or small groups) labeled as naturalistic, action based, participatory, hermeneutic, heuristic, phenomenological, constructive, critical, or discursive. Also included in this category were writings about qualitative research methods and the presentation of research protocols. 3. Clinical Reports: Any article describing actual clinical work with clients where there was no intent to use clinical data for research purposes. This included clinical case studies, reports of clinical programs, and presentations of treatment protocols, methods, or techniques. 4. Philosophical & Theoretical Research: Any article that involved philosophical inquiry or the elaboration of theoretical constructs, but did not involve the gathering of new data. This included articles aimed at clarifying, evaluating, relating or arguing basic assumptions, beliefs, hypotheses, constructs, paradigms, principles, or discoveries guiding practice or research. 5. Historical Research: Any article aimed at gaining knowledge or 
 18 insights about the past by systematically studying past practices, materials, institutions and people, and so forth. This included biographies, histories of music therapy, bibliographic studies, and literature reviews. 6. Professional Articles: Any article that dealt with professional aspects of music therapy. This included position papers, articles dealing with music therapists, clinical training, ethics, standards, competencies, employment, credentialing and so forth. (p.154-56) All But Quantitative Studies Of the 79 articles, 62, (79%) were classified under the heading of qualitative research, clinical report, philosophical/theoretical research, historical research or professional articles, based on Brooks (2003) criteria. These articles will be reported together and for the sake of this study will be referred to as belonging under a “qualitative umbrella” since these articles do not include any statistical data. In this grouping, 31, (51%) were clinical, 12, (18%) were qualitative research, 8, (13%) were professional, 7 (12%) were theoretical/philosophical, 2, (3%) were historic and 2, (3%) were unknown/unidentified because of lack of availability of the article or abstract (see figure 1). Qualitative/Non­Empirical
Studies
 Qualitative
 13%
3%
 20%
 3%
 11%
 Clinical
 Philo/Theo
 50%
 Historical
 Professional
 Unknown
 Figure 1 (For interpretation of the references to color in this and all other figures, the reader is referred to the electronic version of this thesis) 
 19 Settings Within the non-empirical studies the settings discussed in the articles were as follows; 19 inpatient/hospital/care unit, 15 home, 2 school, 2 private practice/clinic, 1 work/professional, 26 unknown/not applicable/unidentified because of type of article and lack of relevance to setting, or lack of availability of the article or abstract. The total number of settings exceeded 62 because some articles and studies identified more than one setting. Based on this information, inpatient/care units/hospital settings were the most discussed within the selected article cluster (see figure 2). Qualitative
Settings
Pie
Chart
 In‐patient/hospital/unit
 41%
 30%
 Home
 23%
 School
 Private
Practice/Clinic
 2%
 1%
 3%
 Figure 2 Population The populations served or discussed within the 62 articles were as follows; 32 adultpatient articles, 2 adult-caregiver, 2 adult-bereaved, 7 child-patient articles, 4 child-bereaved, 2 teen-bereaved, 13 unknown/not applicable/unidentified, 1 professional. One article included ages 12-18 and was included in teen bereaved and child bereaved results. Based on this information, adult patients are 52% of the population served or studied in this grouping (see figure 3). 
 20 Number
of
Articles
 Qualitative
Article
Population
Graph
 40
 35
 30
 25
 20
 15
 10
 5
 0
 Uncatagorized
 Bereaved
 Caregiver
 Patient
 Population
 Figure 3 The ages of the participants or individuals in the case studies and articles were difficult to quantify due to the wide ranges in age discussed in various case studies. The children served ranged from 6 months to 14 years old. Children and adolescents (ages 11to 14) were variously grouped together based on how the study discussed and reported findings. This created a gray area in regard to a definitive line between children and teens. For the sake of this study teens served ranged from 15 to 18 years old. Adults served ranged from 26 to 100 years old. Some studies did not list participants’ ages while others, for example, focused on five patients with a range of 50 years between the oldest and youngest. To take averages of this information would be a misrepresentation of the data given. For these reasons the author did not report an average or mean age of study participants. 
 21 Areas of focus within the research The areas of focus within the articles were classified into four categories in the procedure, and a fifth category, quality of life, was added after the articles were analyzed. Additionally, some articles were categorized as informative based on the educational direction of the writing and content, the type of qualitative write-up, e.g., historical or professional, or the outcome of the research. Some studies had more than one area of focus. The ALL category was added because several studies identified all of the four initial goal areas as focuses of the article. Each item within the ALL category (spiritual, emotional, social and physical) was reflected independently in the individual categories’ as well. The goals of five studies were unidentifiable based on the lack of information in the abstract or lack of available abstract. The goals of the 62 articles were as follows: 12, (20%) physical, 22 (36%) emotional, 12 (20%) social, 11 (18%) spiritual, 2 (3%) quality of life, 7 (12%) ALL, 3 (5%) unidentified, and 25 (41%) informative. Based on this information, emotional needs were the main focus of the qualitative research and other articles under the qualitative umbrella as it relates to this study. (see figure 4.) Goals
of
Qualitative
Articles
 3%
 11%
 Physical
 18%
 Emotional
 17%
 Social
 18%
 33%
 Spiritual
 Quality
of
Life
 ALL
 Figure 4 
 22 Quantitative Research Results Of the 79 articles reviewed, 17 (22%) were found to be quantitative based on the criteria devised by Brooks (2003). Below are the results of age, population, setting, goal and dependent variable(s) for the quantitative articles. As with the qualitative studies, ages were difficult to quantify. In some reports ages were already averaged or offered as a mean or a range not identifying specifically what was involved in the study. For this reason age will not be offered as an average or a mean so as to not misrepresent the studies reviewed. 
 23 Populations served The populations served within the quantitative research were as follows; 53% adultpatients, 29% adult-professional, 12% children bereaved and 6% adult-caregiver. Adult-patient being the main focus of the 17 quantitative articles reviewed, by more than half (see figure 5). Quantitative
Populations
 12%
 6%
 Adult‐Patients
 53%
 29%
 Adult‐Professionals
 Adult‐Caregivers
 Child‐Bereaved
 Figure 5 Quantitative settings The settings served within the quantitative research were as follows; 7 care unit setting/hospital, 5 office/professional, 3 home, 3 nursing home, and 2 school. Some studies reported more than one setting, which caused the total number of settings to exceed 17 (see figure 6). Quantitative
Settings
 10%
 15%
 15%
 Unit/Hospital
 35%
 OfRice/Professional
Setting
 Home
 25%
 Nursing
Home/AFC/EFC
 School/Educational
 Figure 6 
 24 Focus within research The research focus’ identified from the quantitative research reviewed including the following; 7 emotional, 4 physical, 4 clinical investigation (dealing with patient music preference, patient time of death, administrator knowledge of music therapy, and reasoning for music therapy referral), 2 informative (dealing with professional aspects), 2 spiritual, 2 quality of life, and 1 social. Some studies investigated more than one item. For this reason the total number of goals exceed 17 (see figure 7). Quantitative
Research
Goals
 Emotional
 10%
 20%
 Physical
 35%
 Social
 Spiritual
 10%
 5%
 20%
 Clinical
Investigation
 Quality
of
Life
 Figure 7 Dependent variables Dependent variables were only identified in 12 of the 17 quantitative studies. The reason being, one study was only available through abstract, and four studies were surveys. Of the 13 studies with dependent variables, four measured pain/physical comfort, three measured mood, three measured stress/anxiety, three measured quality of life, two measured behavior, and two studied spirituality. Some research listed more than one dependent variable based on the design; for this reason, the sum of these figures is greater than 13. 
 25 Chapter Five. Discussion The purpose of this study was to look in-depth at the palliative care and hospice music therapy literature, catalog findings, and investigate trends, to determine where the field has come and where it is headed. With those results formulate conclusions. When viewing the 79 articles by 5 year increments, it is obvious when music therapy truly took hold in palliative care and hospice (see figure 8). Article
Frequency

 2010‐
 2005‐09
 2000‐04
 Professional
 1995‐99
 Historical
 1990‐94
 Theoretical/Philosophical
 1985‐89
 Clinical
 1980‐84
 Quantitative
 1975‐79
 Qualitative
 0
 2
 4
 6
 8
 10
 12
 Figure 8 For the first 20 to 25 years, hospice and palliative care music therapy literature consisted of mostly clinical and theoretical articles. This made sense, as music therapy was new to the 
 26 hospice and palliative care field. Toward the later 90’s qualitative researchers began exploring more in-depth the specific benefits of The Bonny Method of Guided Imagery and Music and songwriting with palliative care patients. Then in the span of 2000 to 2004, 7 qualitative articles were written (4 from a single author) and professional papers made their way into journals, some discussing music therapy work in hospice from a personal perspective. The first historical article was written in (2003) in the Australian Journal of Music Therapy, reviewing literature and consolidating music therapy’s future much like this study. Theoretical/philosophical articles declined and clinical articles seemed to peak, making way for a continued growth of empiric studies in the 2005 to 2009 time frame. The evidence in this graph raises the question, are empirical studies the future method of studying hospice? Between 2000 and 2010, qualitative research has remained static, but quantitative research is on the rise, at least in contrast to the prior 25 years. When reviewing articles for this study, the author identified two contrary opinions in regards to the best method of conducting palliative care and hospice inquiries. These contradictory views are discussed in the following section. Quantitative vs. Qualitative studies Russell Hilliard, a music therapist and a well-published researcher, has been pivotal in the area of quantitative research in palliative care and hospice within the last decade. He has both contributed to and advocated for an increase in empirical data under the rationale that, “it provides greater assurance of reliability and results that can be more readily generalized than 
 27 those of qualitative research” (Hilliard 2005, p. 177). Hilliard also believes that, because the dying process is such a complex experience, more empirical research needs to be conducted to evaluate the efficacy of the support we as music therapists provide our patients. He states that, though qualitative research is valuable in illustrating the benefits to a small number of individuals, reliability is questionable and generalizing results to other terminal patients can be limited. Hilliard continues to explain that research in general needs to be conducted to ensure not only a high standard of care throughout the field but also clinical interventions that consistently meet the needs of individual patients and families. New and existing interventions need to be tested to ensure their effectiveness. Music therapists working in the field will be able to establish “best practices” in the field through creating an evidence base in hospice and palliative care music therapy (2005). In contrast, Clare O’Callaghan and Phillipa Barry, also music therapists and researchers, argue that there are inherent methodological problems in quantitative studies in palliative care. Some of the problems include: high attrition rates and short survival times, the difficulty in assigning patients blindly into a group due to the need for informed consent (leading to potential bias due to the knowledge that they are in a treatment group, or receiving care related to a study, not wanting to disappoint), the large variability of patients and their illness manifestations, diverse backgrounds, unique treatment histories that lead to an inability to locate comparable matches for a control group, and treatment delivery variations from different therapists involved in the same study. O’Callaghan/Barry also believe that qualitative research can not only offer the same conceptual generalizations as quantitative, but provides means to insure reliability including inter-rater reliability, audit trials, member checking, and triangulation. Qualitative 
 28 research provides information that is important to the researcher but also expresses what is important to the patient involved (2009). Further investigation is needed to better understand the benefits and limitations in both qualitative and quantitative research in the area of palliative care so as to adequately support the use of music therapy interventions, validate research findings so that they are accepted by the medical field, and properly reflect the philosophy of palliative care and hospice and the individualistic person-centered approach. Individual Study Components Age was extremely difficult to represent in this study for two reasons. First, in the qualitative or clinical research and case study write-ups, age ranges were at times greater than 40 years. Second, taking an average of that information would misrepresent the participants involved. In the quantitative research, often a mean was already offered, to average that with other studies that reported a breakdown would also be misrepresentation. Population and Setting The population most studied within the literature was adult cancer patients, and the setting most utilized was a hospital, in-patient, or unit setting. Potential reasons for this would include the availability of patients within a hospital and the localization of them on one unit together, for example on an oncology ward. Another reason for the large focus on adults is the ease in collecting data and conducting interviews. Adults require fewer consent forms and offer more ability to self-disclose about the process they experience. 
 29 Children were the second largest group, though only accounting for 12 percent of the quantitative articles and 18 percent of the qualitative articles. When children were included in empirical research there was usually a bereavement focus (loss of significant figure) rather than the child in the role of a patient. In the qualitative research and clinical articles they maintained a patient role and less of a bereavement focus. Potential reasons for children not being studied on a larger scale could be related to societal beliefs and cultural norms, for example; parents seeking treatment versus palliative care for their child(ren). A common phrase used in relation to death and dying, “Parents never expect to bury their children, they expect their children to bury them.” For this reason, in most cases all curative measures are exhausted when a child faces a life threatening illness. According to Children’s Hospice International (CHI), up until a few years ago, hospices did not consider taking children. Thanks to the non-profit organization CHI, today over 3,000 hospice programs will consider accepting a child for hospice, and based on a 2002 CHI survey, approximately 450 companies have a children-specific hospice, palliative care and homecare service (www.chionline.org/). While not a main focus of this study, some studies provided racial data to describe their participants or subjects. Little diversity was recorded with regard to races other than Caucasian. African Americans made up a small percentage, where as Hispanic-Latino Americans were not mentioned at all. From the author’s experience, hospice care and patient needs vary greatly along cultural lines. For this reason more music therapy studies should focus on addressing ethnicity and cultural needs. Goals of the hospice studies under both the quantitative and in the qualitative umbrella areas focused mostly on emotional health (grief process, self-expression/exploration, mood, etc…). However, a large portion of studies and articles focused on more than one area. Some 
 30 studies and articles reported or discussed all aspects of hospice (emotional, social, physical and spiritual), while a small percentage measured “quality of life,” a category not initially included in the original problem statement of this study. The term “quality of life” appears to be so diverse and individualistic that it would seem difficult to measure or study on a large scale, however quality of life research and quality of life measurement scales can be found throughout hospice and palliative care research literature. Two quality of life scales utilized are (1) the revised Hospice Quality of Life Index (r-HQLI), a 28 item self report instrument that includes three sub-scales and (2) the Missoula-VITAS Quality of Life Index, a 25 item patient centered index that measures 5 QOL dimensions. Quality of life represents a desired goal to assist healthcare specialists in deciding treatment options. Some challenges in studying and measuring quality of life include; missing data due to death or patient decline physically and/ or cognitively, lack of statistical power due to high attrition rates, nonrandomization question generalizability, and internal validity due to interpreting results (Tang & McCorkle, 2001). According to Tang and McCorkle there is a need for selecting appropriate time frames for studying quality of life. In music therapy literature Clare O’Callaghan (2001) utilized a grounded theory to investigate the multi-dimensional benefits of music therapy. Through this study she identified seven categories that spoke to various aspects of what could be interpreted as quality of life. Within the categories are references to affective response, social aspects, physical benefits in decreased perception of pain during music therapy, emotional release (identification and expression), and spiritual strength realized through hymns. In O’Callaghan’s discussion area she states, “This research demonstrates that music therapy can help life to be better “now” for many people with cancer” (2001, p.159). Hilliard (2003) investigated not only quality of life, but also 
 31 length of life of people diagnosed with terminal cancer as it related to receiving music therapy services. He also found that the experimental group, which received music therapy, reported a higher quality of life using the Hospice Quality of Life Index-Revised. Those who received music therapy treatment continued to report scores that improved despite their condition, whereas the control group, who reported a lower quality of life initially, continued to report declining index scores as their disease process progressed without music therapy treatment. Both studies investigated quality of life using different research methods but discovered similar results. Quality of life is a term used regularly in day-to-day discussion, team collaboration, treatment meetings and care conferences within the hospice and palliative care team. Continued research into assessing quality of life regarding music therapy and assisting in creating a better quality of life for hospice and palliative care patients and families is needed. Implications for the future Music therapy in the field of palliative care and hospice has been developing and evolving since the mid 1970’s. Since that time the activity has been expanding through theorizing about potential beneficial methods and program designs, implementing programs, devising and researching bereavement songwriting scales, and gathering qualitative and quantitative data that supports the multi-dimensional benefits of music therapy in end-of-life care. However, there is still room for growth. As it stands, more research is needed with other terminal diagnoses aside from cancer, for example; CHF-Congestive Heart Failure, COPD Chronic Obstructive Pulmonary Disease, Dementia/Alzheimer’s, ALS/Lou Gehrig’s Disease, etc. There is a dearth of studies investigating the needs and challenges of music therapists 
 32 working with different cultures and races. Though hospitals were the most reported setting in the literature, care is moving from hospital to home (Horne-Thompson, 2003). More studies are needed that investigate the challenges and benefits of home hospice and palliative care, with focus on creating and maintaining a therapeutic space and exploring the issues of difficult family dynamics within the home and how they affect quality patient care. A more far-reaching lens for music therapy could be provided by investigating broader populations, and additional places where it could be utilized. By moving beyond studying direct patient care alone, music therapy in hospice could be enhanced by studying the benefits to caregivers and field staff experiencing burnout, children in general, adult bereavement groups, and joint treatment with other disciplines. With the intent to review, analyze, and catalogue literature published in the area of music therapy and hospice/palliative care, the purpose of this research was to categorize, code, and summarize articles in order to highlight themes and trends, as well as provide direction for future research and to forecast direction of the profession as it relates to hospice as a growing population served by music therapists nationally. In the past 40 years we have gone from theorizing about the benefits of palliative care and hospice to producing empirical studies measuring quality of life and length of life. Hospice and palliative care have embraced music therapy as a discipline that brings comfort and resolution to patients and families at end-of-life. With the prominent focus presently on emotional needs of dying patients, along with benefits in the physical, social, and spiritual areas, music therapy research of all types is necessary to increase understanding and effective clinical service for an even broader array of individuals coping with this difficult phase of life. 
 33 Appendices 
 34 APPENDIX A Complete list of References in Chronological Order (Abstracts and full articles) Author Year Publication Gilbert, JP 1977 JMT, 14 (4) Bright, R 1979 AuMTAB, 2(4) Fagen, TS 1982 Full/Abstract only Full Type of Paper Area of Focus Clinical MT Perspectives On Death & Dying No Abstract (notes) Clinical discussion of MT At Royal Victorian Hospital MT, 2 (1) O’Callaghan, CC 1984 AJNZSMT, 7 (2) Full Clinical anxiety & fear in Terminal Pediatrics Abstract Clinical Musical Profiles of Dying Patients Clinical Brooks, M. O’Rourke, A 1985 AJNZSMT, 7 (2) Abstract Curtis, SL 1986 JMT, 23(1) Wylie, ME & Blom, RC 1986 MTP, 3 Full AuJMT, 1 Abstract Clinical Songwriting Palliative Care Pain & Symptom Management O’Callaghan, CC 1990 Full MT with Dying and Bereaved Quantitative Pain relief/relaxation Terminally Ill Clinical GIM and Hospice Pts’ MagillLeverault, L. 1993 JPC, 9 (4) Abstract Clinical Mandel, SE 1993 JPC, 9(4) Abstract Clinical MT in Hospice/ Palliative Care Team O’Callaghan, CC 1993 JPC, 9 (4) Abstract Clinical Brain Impaired Palliative Care Pts’ Abstract Professional PorchetMunro, S. 1993 JPC, 9 (4) Salmon, D. 1993 JPC, 9 (4) 
 Perspectives in Palliative Care Abstract Philosophical/Theoretical Music & emotion in palliative care 35 Complete list of References in Chronological Order (Abstracts and full articles) Cont… Author Year Publication Full/Abstract only Webster, J. 1994 AJNZSMT, Abstract Aldridge D. 1995 AP, 22 (2) Full MTP, 13 (1) Full Jackson, M. CJMT, 3 (1) Abstract O’Callaghan CC 1996 AJNZSMT, Clinical Quantitative Clinical No Abstract Full Qualitative O’Callaghan, CC 1997 Full Clinical Fuglestad, S. 1997 Skaggs, R. 1997 MTP, 15 (1) Hogan, B. 1998 AuJMT, 9 Marr, J. 1998-99 Hurk, J. & 1999 Smeijster, H. Truger1999 Querry, B. & Haghighi, KR 
 NJMT, 6 (1) Abstract Full Full JAMI, 6 Abstract JMT, 36(3) Full HJ, 14 (1) Supporting Elderly Grief and Loss Qualitative Clinical Clinical Clinical Clinical Abstract 36 Collab study of Cancer care Case study of Breast Cancer Wellbeing for Palliative Care Pts. O’Callaghan, CC 1996 JMT, 33 (2) MTP, 15 (1) Area of Focus Philosophical/Theoretical Spirituality, Hope Bunt, L. & 1995 Marston Wyld, J. 1995 Type of Paper Clinical Lyrical themes of Palliative Care Pts’ Songwriting in Palliative Care Q.O.L. using music AIDS/HIV GIM in E.O.L. care Private practice MT within context Of Palliative Models GIM case studies a E.O.L. working through grief, rediscovering identity, self esteem Pain & Symptom Management Complete list of References in Chronological Order (Abstracts and full articles) Cont… Author Year Daveson, B. & 2000 Kennelly, J. Publication Full/Abstract only Type of Paper JPC, 16 (1) Abstract Clinical Area of Focus MT in Palliative care for Children/Adolescents Forrest, L. 2000 AuJMT, 11 (also found in Voices 1(2), 2001) Full Clinical McFerranSkewes, K. Full Qualitative Psycho-dynamic grp MT w/ Bereaved teens 2000 AuJMT, 11(3) Issues of ethnicity/identity Aasgaard, T. 2001 JPC, 17 (3) Full Clinical Pediatric Oncology Gallagher, L. Steele A. 2001 JPC, 17 (3) Full Quantitative Computerized Database Hartley, N. 2001 Hilliard, RE 2001 Hilliard, RE 2001 JPC, 17 (3) Professional personal reflections on working with Terminally Ill Pts’ Full Quantitative mood/behavior in Grieving children JPC,17(3) Full Clinical JMT, 38(4) Full Krout, RE 2001 AmJHPC,18 (6) Full Quantitative Magill, A. 2001 JPC, 17 (3) Full Clinical Marmor, K. Nicholson, K. 2001 2001 JPC, 17 (3) JPC, 17 (3) Full Full Clinical Relaxation using Imagery and Music Full Qualitative Rykov, M. JPC, 17 (3) Full Professional 37 Music to address Suffering in Cancer Pts’ Indigent & Terminally Il JPC, 17 (3) 
 Pain control, physical Comfort, & relaxation Clinical O’Callaghan, CC 2001 2001 Patient/family needs MT in Palliative Cancer Hospital Introspective Personal account Complete list of References in Chronological Order (Abstracts and full articles) cont… Author Year Publication Salmon, D. 2001 JPC, 17 (3) Krout, RE 2002 Full/Abstract only AJNZSMT Aldridge, D. 2003 Full Type of Paper Area of Focus Philosophical/Theoretical Psycho-spiritual Abstract BJMT, 17 (1) Abstract Clinical Clinical Grief processing & Self expression with Bereaved children Through song MT references relating To Cancer & Palliative Hilliard, RE 2003 JMT, 40(2) Full Quantitative Terminal cancer Length of life Hilliard, RE 2003 JPC, 19(2) Full Clinical Pediatric hospice music therapy Horne2003 AJMT, 14 Thompson, A. (Also found in Voices 7(3), 2007) Full Clinical Hospital-home care implications Krout, RE 2003 AmJHPC, 20(2) Full Clinical patients & family Facilitating release Consolidating MT’s Future in Palliative Care Hogan, B. 2003 Cockayne, m. AuJMT, 14 Full Historical Salmon, D. 2003 CJMT, 10 (1) Abstract Quantitative ClementsCortes AuJHPC, 21(4) 2004 Abstract Hepburn, M. 2004 Krout, RE NZJMT, 2 No Abstract Hilliard, RE 2004 MTP, 22(2) Full Hilliard, RE 2004 JMT, 41(4) Clinical 
 Quantitative 38 Terminally ill emotional expression Meaning, purpose Transcendence, hope Spirituality at E.O.L. Quantitative Full Music Therapist & Coping loss/suffering Hospice Admin. Analysis/Survey Hospice MT in the Nursing Home Complete list of References in Chronological Order (Abstracts and full articles) cont… Author Krout, RE Year Publication Full/Abstract only Type of Paper 2004 AuJMT, 15 Full Sheridan, J. 2004 McFerran, K. AuJMT, 15 Full Clinical Burns, D. et al 2005 JMT, 42 (3) Full Quantitative Cadrin, ML. 2005-06 JAMI, 10 (1) No Abstract Hilliard, RE 2005 EBCAM, 2(2) Full Historical Krout, RE MTP, 23 (2) Full Clinical 2005 Lindenfelser, K. 2005 Voices, 5 (3) Renz, M. 2005 Mao, MS, Cerny, T. SCC, 13 Zabin, AH MTP, 23 (1) 2005 Full Professional Full Choice/Control in MT within Ped. Hospice Cancer Pts’ Music Preferences Review of Empirical Literature MT composed songs in 1-time Bereavement Grp Parent advocates in Ped. Palliative & Hospice Care Quantitative Spirituality, psychotherapy research in psychooncology Clinical Stories from a MT Clinical legacy work in Palliative Care Bereaved Adolescence MT process/protocol Cadrin, ML 2006 CJMT, 12 (1) Dalton, TA & Krout, RE 2006 MTP, 24 (2) Full Clinical Hilliard, RE 2006 AP, 33(5) Full Quantitative Compassion Fatigue/team blding MaueJohnson, EL & Tanguay, C. 2006 MTP, 24 (1) Full Clinical Hospice Assessment tool for MT Voices, 6 (3) Full Professional Personal account of Research process Roberts, M. 
 2006 Abstract Syner-disciplinary treatment team GIM at E.O.L. Clinical Abstract Area of Focus 39 Complete list of References in Chronological Order (Abstracts and full articles) cont… Author Year Roberts, M 2006 AuJMT, 17 (18) Full Clinical Homebased song-writing Bereaved Children & Adolescents Groen, KM 2007 JMT, 44 (2) Full Clinical Pain assessment & Management Hilliard, RE 2007 JMT, 44(2) Full Clinical Bereavement Horne2007 Thompson, A Daveson, Hogan JMT, 44(2) Full Quantitative Lindenfelser, KJ 2008 Grocke, McFerran JMT, 45 (3) Full Qualitative Bereaved Parents w/ Terminal children MTP Full Clinical Psychodynamics of Hospice MT Full Qualitative Meaning of music as Perceived by Bereaved Caregivers Full Quantitative Effectiveness of Hospice Japan Stress/mood Psychological indicators Maron, MK 2008 Magill, L 2009 Publication AmJHPM, 26 (1) Nakayama, H 2009 Kikuta, F. Takeda, H. JMT, 46 (2) O’Callaghan, CC 2009 & Barry, P Voices, 9 (3) Beck, J 2010 Choi, YK 2010 Dimaio, L. 2010 
 Full/Abstract only Type of Paper Voices, 10 JMT, 46 (2) MTP Full Full Clinical Area of Focus MT Referral Referral trends Practice Based Research in Cancer/Palliative Care Methods/Findings Professional dual role as a clinician & Family member Full Quantitative PMR on Anxiety/fatigue Q.O.L. in family caregivers Full Qualitative Entrainment in Hospice Pain management 40 APPENDIX B Qualitative Articles Article Type Pop./Diagnosis Age Setting Gilbert, JP. Theoretical/ Hospice 77 JMT, 14 (4) Philosophical (A-P) n/a n/a Bright, R. Clinical 79 AuMTAB, 2(4) Hospice (A-P) n/a Hospital Fagens, TS 82 MT, 2 (1) Pediatric/ latencyterminally Ill early ado(C-P) lescent Clinical O’Callaghan, CC. 84 AJNZSMT, 7 (2) Clinical (No abstract) Goal/Themes/ Intervention Theorize benefits of Music Therapy in Hospice care Hospital discuss MT program Victorian Hospital discuss MT work with Terminal Peds efficacy/areas of benefit ----- Brooks, M. O’Rourke, A. Clinical 85 AJNZSMT, 7 (2) (no abstract) ----- --- ------- ----- ----- --- ------- Wylie, ME & Blom, RC Qual. bladder CA mid-age (F) 86 MTP, 3 bowel CA 48 Y.O. (M) (A-P) Nursing Home Home O’Callaghan, CC. 90 AuJMT, 1 (abstract only) Clinical palliative care unidentified (A-P) unidentified MagillLeverault, L. 93 JPC, 9(4) (Abstract only) Clinical long term/ unknown life threatening illness (A-P) unknown Mandel, SE. 93 JPC, 9(4) (abstract only) Clinical hospice/ unknown palliative care (N/A) 
 41 unknown effects/benefits of using Guided Imagery & Music -modified BMGIM MT skills used in songwriting with Palliative Pts. MT efficacy in pain/ symptom management Hospice MT Program description Qualitative Articles Article Type O’Callaghan, CC. Theoretical/ 93 JPC, 9(4) Philosophical (abstract only) Pop./Diagnosis Age Brain Impaired unknown Palliative Pts. (A-P) Setting unknown PorchetTheoretical/ Munro, S. Philosophical 93 JPC, 9(4) (abstract only) Palliative care (A-P) n/a Salmon, D. Philosophical/ 93 JPC, 9(4) Theoretical (abstract only) Palliative Care (A-P) n/a n/a West, TM Clinical 94 MTP, 12(2) Adult Breast Ca (A-P) 74y.o. home Aldridge, D. Philosophical/ 95 AP, 22 (2) Theoretical Palliative/EOL (A-P) Jackson, M. Clinical 95 CJMT, 3 (1) (abstract only) Breast Ca (A-P) O’Callaghan, CC. Theoretical/ 96 AmJHPC, Philosophical Palliative Care (A-P) O’Callaghan, CC. 96 JMT, 33 (2) Qualitative Fuglestad, S. Qualitative 97 NJMT, 6(1) (abstract only) 
 n/a 50yrs old adults n/a Goal/Themes/ Intervention communication Through MT palliative care education w/ emphasis emot exper. Non-verb expression how music and emotion play an important role in Pall Care psychological & Spiritual needs of Hospice Pts. Q.O.L. n/a spiritual needs in Palliative & EOL home benefits of MT to Pt & family Quality of Life Home/in-patient Theory/example Of MT in pain Management Palliative Care 26-80y.o. hospital/ 8 themes emerged Patients unit setting songwriting (A-P) addressed spiritual, psycho-social physical needs Pall. AIDS/HIV (A-P) 42 unknown unknown challenges of Qualitative research work w/ HIV/AIDS Pts. usage of art therapies Qualitative Articles Article Type Skaggs, R. Qualitative 97 MTP, 15(1) Hogan, B. Clinical 98 AuJMT, 9 Pop./Diagnosis Terminally ill (A-P) Pancreatic CA Carcinoma lung (A-P) Marr, J. Clinical 1998-99, JAMI, 6 (abstract only) palliative/ hospice (A-P) Hurk, J & Qualitative Smeijsters, H. 99 JMT, 36(3) bereaved/adult (A-P) TrugerClinical Querry, B. & Haghighi, KR 99 HJ 14(1) (abstract only) hospice Pts. (A-P) Daveson, B. & Clinical Kennelly, J. 00 JPC, 16(1) (abstract only) Children/ Adolescents (C-P) Forrest, L. Clinical 00 AuJMT, 11 (also 01 Voices 1(2)) cancer (A-P) McFerranQualitative Skewes, K. 00 AuJMT, 11(3) Aasgaard, T. Clinical 01 JPC, 17(3) 
 Age Setting Various Private Practice 49,54 65 unknown Hosp/Home in-patient Clinic Models MT role within Palliative Care Home/inpatient BMGIM in Pall Care How to identify appropriate clients clinical regaining self identity after a loss unknown unknown Pain & Symptom Management through art/music therapies unknown hospital MT in Palliative care for Children/ hospital Issues of ethnicity/identity 53y.o 84yrs old bereaved 13-15y.o. teenagers (T-B) Ped. Oncology (C-P) Goal/Themes/ Intervention Benefits of BMGIM in global E.O.L. care -BMGIM 14, 8, 4, 6 43 high school hospital Psycho-dynamic grp MT w/ Bereaved teens making love/ friendship audible through MT psycho-social/ Emotional needs Qualitative Articles Article Type Gallagher et al no abstract 01 SCC, 9 (no abstract) Pop./Diagnosis Age ------ ------ Hartley, N. Professional 01 JPC, 17(3) palliative/ Hospice (A-P) Hilliard, RE 01 JPC, 1(3) Clinical Magill, A. Clinical 01 JPC, 17(3) (A-P) Marmor, K. Qualitative 01 JPC, 17(3) Nicholson, K. 01 JPC, 17(3) Clinical Setting ------- n/a n/a breast cancer cardiomyopathy Dementia Brain tumor (A-P) 53, 100 87, 35 home nursing hm LTC facility advanced CA 60 41, 54, hospital adult 9 bed home like setting indigent/ Term. Ill (A-P) adult/ Cancer (A-P) unidentified O’Callaghan, Qualitative 01 JPC, 17(3) patients/ unidentified visitors/ Staff members (A-P) (A-C/P) Rykov, M. Professional 01 JPC, 17 (3) hospice MT n/a) 
 Goal/Themes/ Intervention Palliative care/MT n/a 44 personal reflections on working with Terminally Ill Pts’ utilizing MT to cope with multi-demential hospice needs ALL Music to address Suffering in Cancer Pts’ pain management psychosocial, social spiritual Indigent & terminally Ill Cancer Center Relaxation using Imagery and Music hospital grounded theory investigation of multi-dementional Benefits of MT Pall Care, 7 themes ALL work setting Personal account Introspective Qualitative Articles Article Type Pop./Diagnosis Age Setting Salmon, D. Philosophical/ hospice Pts 1- adult 01 JPC, 17(3) Theoretical Adults (A-P) Krout, RE Clinical 02 AJNZSMT (abstract only) Bereaved Children (B-C) Home non-specific non-specific n/a Hilliard, RE Clinical 03 JPC, 19(2) Pediatric 6 mths-14 yrs Palliative care (C-P) Krout, RE Clinical 03 AmJHPC, 20(2) n/a 3-cancer, 1-CHF 1-Dementia (A-P) n/a Psycho-spiritual needs & facilitation through hospice MT unknown unknown Aldridge, D. Clinical 03 BJMT, 17(1) (abstract only) HorneProfessional Thompson, A. 03 AJMT, 14 (07 Voices 7(3)) Goal/Themes/ Intervention Grief processing & Self expression with Bereaved children Through song non-specific MT references relating to Cancer & Palliative home/inpatient Hospice Pediatric hospice music therapy n/a 77, 78, 83 home/hospital 85, 37 patients & family Facilitating release Hogan, B. Historical Cockayne, M. Palliative Care 03 AuJMT, 14 n/a n/a ClementsClinical Cortes 04 AuJHPC, 21(4) (abstract only) adult terminal (A-P) ------- ------ Terminally ill emotional expression ----- ------- ------ Meaning, purpose Transcendence, hope Spirituality at E.O.L Hepburn, M. No Abstract Krout, RE 04, NZJMT, 2 (no abstract) 
 45 n/a Hospital-home care implications Consolidating MT’s Future in Qualitative Articles Article Type Pop./Diagnosis Krout, RE Professional 04 AuJMT,15 Sheridan, J. Clinical McFerran, K. 04, AuJMT, 15 ------MD, Cystic fibrosis, Galactosemia (C-P) Cadrin, ML. Clinical 2005-06 JAMI, 10(1) also in 09 Voices, 9(1) Cancer Hilliard, RE Historical 05 EBCAM, 2(2) n/a Age Setting -------- ------- Syner-disciplinary treatment team in-patient hospice Choice/Control in MT within Ped. Hospice 6-9 y.o 47yrs old adult (A-P) n/a Review of Empirical Lit. adult various MT composed songs 1-time Bereavement Group Bereaved Community Members (A-B) Lindenfelser, K. Clinical 05 Voices, 5(3) Pediatric unspecified Palliative Care (C-P) Cadrin, ML Clinical 06 CJMT, 12(1) 
 Hospice House Parent advocates in Pediatric Palliative & Hospice Care n/a n/a n/a Stories from a MT Cancer/cancer ALS (A-P) varied Palliative unit legacy work in Palliative Care n/a Hospice Care Occupational Hazards Among MT’s 12-18 public school Bereaved Adolescence MT process/protocol ClementsClinical M.T’s Cortes A. 06 CJMT, 12(1) (A-Professional) Dalton, TA & Qualitative Krout, RE 2006 MTP, 24(2) GIM at E.O.L. n/a Krout, RE Clinical 05 MTP, 23(2) Zabin, AH Professional 05 MTP, 23(1) Home Goal/Themes/ Intervention adolescents bereaved (C-B) 46 Qualitative Articles Article Type Pop./Diagnosis MaueClinical Johnson, EL & Tanguay, C. 2006 MTP, 24(1) Age Setting Goal/Themes/ Intervention n/a n/a n/a Hospice Assessment tool for MT Roberts, M. Professional 06 Voices, 6(3) bereaved Children (C-B) n/a n/a Personal account of Research process Roberts, M Clinical 06 AuJMT, 17(18) bereaved 10-14 Children/Adolescents (C-B) Home-based Homebased songw/ bereaved Children & Adolescence Lindenfelser, KJ Qualitative Terminally Ill 5mths Grocke, McFerran Children 12 Yrs. 08 JMT, 45(3) (C-P) HomeBased Maron, MK Clinical 08 MTP, 26(1) Home, InPatient Hospice Nursing Home Cancer, Chronic 70’s-80’s Airway Obstruction, COPD, Adult Failure to Thrive (A-P) Magill, L Qualitative Adults 09 AmJHPM, 26(1) Caregivers (A-C) O’Callaghan, CC Professional & Barry, P 09 Voices, 9(3) Beck, J Professional 2010 Voices 
 n/a adult cancer (A-P) unknown HomeBased n/a n/a unknown home 47 MT altered perception, source of remembrance, multifaceted experience, enhanced communication, parents shared Perceptions/ Recommendations Psychodynamics of Hospice MT Meaning of music as Perceived by Caregivers Practice Based Research in Cancer/Palliative Care Methods/Findings dual role clinician & Family member Qualitative Articles Article Type Pop./Diagnosis Age Dimaio, L. Qualitative Parkinsons, COPD 88, 69 2010 MTP Debility Unspec. 93, 63 (A-P) 
 48 Setting Nursing Hm, Home Goal/Themes/ Intervention Entrainment in Hospice Pain Management APPENDIX C Quantitative Articles Author/Year Curtis, SL. 1986 JMT, 23 (1) Gallagher, L., Steele, A. 2001 JPC, 17 (3) Setting On unit hospital Population Adults Adults Diagnosis Terminally Ill Cancer Age Unidentified (9 (5 men, 4 women) Median age 67 Range 28 to 84 years (70% were female) Independent Variables: (a) no intervention, (b) Background Sound, (c) Music music therapy session Dependent variables: pain relief, physical comfort Relaxation, contentment Patient self assessed:: Mood, Pain, shortness of Breath. Music Therapist Assessed: Facial expression, movement Sleep, and verbalization Intervention(s) used: Music listening/recorded live music listening 78, singing 29, song choice 20, music life review 16 Participation 12, instrument playing 7, Lyric analysis 6 verbal processing 5 (all others 2 or less) entrainment, relaxation, recorded listening, funeral planning, songwriting (n=90) Goal: 
 Physical Physical/emotional 49 Quantitative Articles cont… Author/Year Hilliard, RE 2001 JMT, 38 (4) Hilliard, RE 2003JMT, 40 (2) Setting Public Elementary School Home Based Care Population Children-bereaved Adults-Patients Diagnosis Bereaved (loss of a loved one) terminal illness 61% (cancer, AIDS, CHF) Sudden death accounted for 39% Terminal Cancer Age 6 to 11 years old (Black 55%, White 44%) (25% Black, 75% Whites in each grp) equal gender distribution 40, 65+ years old 40, 64 years old and under N= n=18 (9 control) (9 experimental) 80 subjects (40 Control) (40 experimental) Independent Variables: 8 Session Music Therapy Bereavement Program routine hospice service and music therapy Dependent variables: Behavior, mood, and grief Symptoms Quality of life, Length of life, relationship to time of death in Days from last MT/counselor visit Intervention(s) used: singing, song-writing, rapSong choice, music prompted reminiscence, writing, rhythmic improvisation, singing, live music listening, lyric analysis structured drumming, instrument playing, song parody, singing with lyric analysis, music listening accompaniment using iso-principle, planning funeral or memorial service, sing gifts, musicassisted supportive counseling Goal of research: 
 emotional/social emotional, physical (Quality of life) 50 Quantitative Articles cont… Author/Year Krout, RE 2001 AmJHPC, 18 (6) Salmon, D. 2003 CJMT, 10 (1) (abstract only) Setting 67-hospice center, 10- home 2 hospital, 1-nursing home international survey Population adults-patients adult-professionals Diagnosis various terminal diagnosis music therapist Age 38-97 years old unidentified-abstract N= 80 subjects, 90 sessions (33 male, 47 female) unidentified-abstract Independent variables:active and passive music therapy Experiences exposure to death, loss and paradoxically, workload Issues, etc… Dependent variables: Pain control, physical comfort relaxation stressors Intervention(s) used: active and passive music listening coping not discussed in Live music listening and imagery abstract Song choice, singing, song discussion songwriting Goal 
 physical investigative/informative 51 Quantitative Articles cont… Author/Year Hilliard, RE 2004 MTP, 22 (2) Hilliard, RE 2004 JMT 41(4) Setting professional nursing home Population Hospice administrators Across the nation Adults adults-patients Diagnosis n/a Dementia 21, cancer 20, CHF 12, Debility unspecified 7, Cerebro-vascular Accident 8, Parkinson’s 4, Chronic liver failure 2, Chronic renal failure 2, AIDS 1, Gangrene 1, Huntington’s chorea 1, Multiple sclerosis 1, Age N= n/a 40, 65+ years old 40, 64- years old (equal gender distribution) 225 of 382 surveys returned in 95’ 236 of 382 surveys returned in 01’ Independent variables: n/a 80 (40 control/40 experimental) routine hospice services and music therapy Dependent variables: n/a length of life, time of death, comparison Of contact hours and number of visits Received by subject from Social Worker and Music Therapist Intervention(s) used: n/a Singing with Guitar/piano/omnichord Instrument playing, song parody, Songwriting, rhythmic improvisation Vocal improvisation Goal: informative increased awareness of music therapy Reported from 95 to 01’ From hospice admin. Clinical Investigation Length of life, time of death comparison of contact hours received and number of visits by subject (MSW v Vs. MT) Clinical Investigation/Quality of Life 
 52 Quantitative Articles Author/Year Renz, M.2005 SCC, 13 Mao, MS Cerny, T. (abstract only) Burns, D. et al. 2005 JMT, 42 (3) Setting ---- oncology setting (unit/hospital) Population ----- Adult-patients Diagnosis cancer cancer Age ---- mean age 50 (SD 13.89) N= (98-00) 80 Patients (00-03) 251 Patients 65 (60% female) (all but 1 Caucasian) Independent variables:----- survey Dependent variables: ------ survey Intervention(s) used: ------ 1. Receptive, recorded, no therapist 2. Interactive, live, therapist Goal: 
 Spiritual identifying interest and preference for using 2 types of music therapy interventions Clinical Investigation 53 Quantitative Articles Author/Year Hilliard, RE 2006 AP, 33(5) Horne-Thompson, A. 2007 JMT, 44(2) Daveson, B. Hogan, B. Setting Settings Hospice Office Population Hospice clinicians/professionals Allied Health, Medical, nurses, (Social Workers, Chaplains, nurses) self (patient) family Adults Adults-clinicians/Professionals Diagnosis burnout/compassion fatigue Age 26-60 yrs old Working age (11 female and 6 male) (employed in hospice a min of 1 yr.) N= 17 (2 experimental groups) 9 Inpatient and Palliative Care Independent variables:6 week music therapy group not applicable to all 354 MT referrals N/A Dependent variables: group building and compassion fatigue N/A Intervention(s) used: Group 1. Improvisation Group 2. Breathing exercises, guided Meditation paired with live music Group drumming and chanting Music and movement, lyric analysis N/A Goal: Clinical Investigation 
 measure team building, measure Compassion fatigue Emotional/social 54 Quantitative Articles Author/Year Groen, KM. 2007 JMT, 44(2) Woldarczyk, N. 2007 JMT44(2) Setting hospital in-patient hospice Population adults-professionals adults-patients Diagnosis hospice care professionals MTs’ and RNs’ 5 CA (various) 1 renal failure 1 AIDS 1 ALS 1 Cardiomyopathy 1 CHF Age 20-50+ mean age 73.5 N= 72=M.T professionals 92= Nursing Professionals 10 patients (2M, 8F) Independent Variable survey 30 minute MT session Dependent Variable survey spiritual well Being Interventions used: based on care plan Song choice, music making, Improv, sing-a-longs, life review Goal informational Identify pain scale Most commonly used Intervention used for management 
 measure effect of MT session on spiritual well Being Spiritual 55 Quantitative Articles Author/Year Hilliard, RE 2007 JMT, 44(2) Setting Elementary School Population Children-bereaved Diagnosis Bereaved Age 5-11yrs old N= 26 (14 males/12 females) Independent Variable Off-Based Music Therapy Social Work Group Nothing Dependent Variable Mood, Behavior, physical Symptoms Interventions used Orff Based Improvisation Chanting, live music Goal Emotional 
 56 Quantitative Articles Author/Year Nakayama, H. 2009 JMT, 46(2) Kikuta, F. Takeda, H. Choi, YK 2010 JMT, 46(2) Setting Nikko Kinen Hospital Caress Mark Hospice home, facility Population adult-patient adult-caregiver Diagnosis Cancer n/a Age Mean age 73 (+/- 9.65 years) unidentified N= 10 (3 males and 7 females) Independent variables:Active and passive music therapy Group 32, 8 subjects per group (20 spouses of Pts’, 12 adult children) control, music only, Progressive muscle relaxation only, music combined with Progressive muscle relaxation Dependent variables: Stress, mood, fatigue, depression anxiety anxiety, fatigue, quality of life Intervention(s) used: instrumental engagement, singing, music only, music with Progressive Music listening, muscle relaxation, Progressive muscle Patient song selection Relaxation only Goal: 
 emotional emotional 57 Bibliography 
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