Music Therapy in End of Life Care in Italy

16th August 2022

In early July, Mariagrazia Baroni, president of the Italian Association of Music Therapists, led a workshop for students on the topic of music therapy in palliative and hospice care. We asked her to share her knowledge and experience in this important and growing field with a wider European audience.

During the first weekend of July, I had the pleasure of leading a theoretical-practical workshop on music therapy in palliative care and hospice at the “A. Casella” Conservatory in L’Aquila. The two-day seminar was aimed at first and second-year music therapy students, to learn about the application of music therapy in end-of-life care, understand models of hospice work, and the specific skills required in this work.

In the workshop, we addressed several topics aimed at facilitating students’ understanding of whether music therapy in palliative care could be a suitable environment for them to work in after completing their training. In particular:

  • the philosophy of palliative care, starting from the definition of the International Association for Hospice & Palliative Care1hospicecare.com/what-we-do/projects/consensus-based-definition-of-palliative-care/definition/
  • the Italian regulations that guarantee access to palliative care and pain management; we established the minimum criteria and the required organisational set-up that a structure needs to have in order to be accredited as a hospice; the level of professional training that hospice staff must have
  • the needs of the patient and the needs of family members/caregivers in this delicate phase of life
  • the goals and objectives of hospice care and the personalized care plan  
  • how the music therapist collaborates with the team
  • the specific skills essential to dialogue with colleagues of the team
  • how to define durations and how to conduct the session with the patient and the potential presence of the family member/caregiver 
  • the levels of Hospice Music Therapy2 Dileo, C., & Dneaster, D. (2005). Music Therapy at the End of Life: State of the Art. In: C. Dileo & J. Loewy (Eds.). Music Therapy at the End of Life. (pp. xix-2). Cherry Hill, NJ: Jeffrey Books.
  • improvisation and receptive music therapy in end-of-life
  • observation and musical microanalysis in hospice music therapy
  • how to use silence and voice in sessions when the patient’s energy level is very low.

Discussion of these issues expanded to reflections on life and death, the dignity of the person until the last breath, with many questions from students on professional and ethical issues. It was a time of growth and great civility for all participants.

In Italy, the hospice movement is very new3 Baroni, M. (2020). Music therapy in dementia and end-of-life care: A report from Italy. Approaches: An Interdisciplinary Journal of Music Therapy, 12 (2) 2020. . It was initially promoted by the Floriani Foundation, which helped found the SICP – Italian Society of Palliative Care – in 1986. The first two Italian hospices were opened in the late 1980s, but their numbers have considerably grown only since the 2000s, particularly following the passing of Palliative Care Laws. There are currently 230 hospices throughout Italy, which may be public or private health care facilities.

Music therapy began to be used sporadically in Italian hospices as early as the late 1990s. It was offered to patients in palliative care, and the music therapist began to be included in the interdisciplinary and multi-professional team to help meet the needs of patients and their families.

It has since gradually spread: more and more music therapy projects are being requested, and hospices are interested in hiring a music therapist as part of their interdisciplinary and multi-professional team.

Over the years, Italian music therapists have referred to numerous international research articles (e.g. Aldridge, 19994 Aldridge, D. (1999). Music therapy in palliative care: New voices. London: Jessica Kingsley Publishers) as they support the idea that music therapy can enhance the physical, psychological, and spiritual wellbeing of terminally ill patients.

Over the past 20 years, many music therapy projects have been implemented in hospices, allowing music therapy to spread in this context and creating important opportunities for discussion and collaboration with other professionals, including nurses, doctors, psychologists and others.

In Italy a lot of hospices have incorporated music therapy into the care they provide on an ongoing and sustained basis, and employment opportunities are likely to increase in the future.

Currently in Italy, there is a great debate about ethical issues related to end-of-life care, and in hospices there has been a growing awareness that a bio-psycho-socio-spiritual approach is needed to care for and meet the needs of patients in advanced stages of illness. This model of care is implemented through teams composed of various professionals who are able to recognize and attend to the different needs on the various physical, emotional, psychological, and spiritual/existential levels of the patient.

Garden at the "Casa Madonna dell'Uliveto" Hospice, Reggio Emilia, Italy.

My experience in music therapy at the end of life began in 2003, and I have now been working at the Palliative Care Residential Center – Hospice “Casa Madonna dell’Uliveto” in Albinea, Reggio Emilia, Italy, for 19 years.

Since the hospice was first opened in 2001, the following specific goals have been developed:

  • to offer individualized treatment plans and manage the symptoms of the disease;
  • to offer psychosocial and spiritual support, and to help alleviate the total pain that often occurs in the final stage of life.

The teamwork at the hospice is aimed at improving the quality of life of patients and their families as much as possible, respecting the patient’s wishes for a dignified death. The terminal phase of life is recognized as an important period of an individual’s existence. Support is also offered to the family, both during the illness, and in the grieving phase.

The hospice team is interdisciplinary and multi-professional. It consists of nurses, physicians, physiotherapists, a psychologist, one music therapist, spiritual assistants, and volunteers. A key aspect for the music therapist is to maintain active collaboration and consultation with the coordinating nurse, the psychologist, and the patient’s referring physician.

Music therapy at the “Casa Madonna dell’Uliveto” hospice was introduced5 Baroni, M. Musicoterapia in hospice. Comunicare quando non ci sono parole. Rivista Italiana di Cure Palliative, I – 2009 to meet the needs of patients who have difficulty adapting to their situation, difficulty in expressing and communicating their own experience (feelings, needs, thoughts, desires), emotional agitation or a tendency to withdraw. Music therapy is also indicated for relief of physical symptoms such as global pain problems, disorientation and confusion, dyspnea and insomnia. Some patients make a direct request for music therapy based on their particular musical interests, and often purely for pleasure.

Bearing in mind the fast clinical progress of terminal cancer that often causes rapid changes in the patient’s condition, the music therapist needs to develop adaptability and flexibility to complete sessions without leaving anything ‘in limbo’.

In conclusion, some advice for those interested in getting started in this field of work:

  • Working in music therapy at the end of life requires a high level of professional skills, an aptitude for getting involved in existential issues (related to the end of life) on a daily basis, a willingness to constantly engage with colleagues, and great flexibility in organizing interventions. For these reasons, it is important to deepen one’s training to be able to meet the challenges encountered in hospice work.
  • Active collaboration within multi-disciplinary teams promotes the sharing of different views of the patient so an individualized care plan can be established. It is essential that the team has ongoing training and the manager pays attention to the care and well-being of the team itself to avoid burnout.
  • Lastly, it is essential to have closure in a relationship with a patient you have met, even if only for a short time (1 or 2 sessions). I believe that, as a music therapist, it is necessary and possible to close the relationship with a patient who passed away, even in the patient’s absence, with music, improvisation, and supervision. It is essential to take care of ourselves as well. 

Mariagrazia Baroni, MA, MT-IC. 

Mariagrazia is a certified Senior Music Therapist. Since 2001 she has worked in dementia care, and palliative care with patients and families in one of the first hospices in Italy. She teaches several Palliative Care courses and is interested in spreading music therapy in hospice and end-of-life care and supporting students and young professionals in approaching this context. Since 2016 she has been the President of the Italian Association of Music Therapists

mariagrazia.baroni@icloud.com

References

  1.  hospicecare.com/what-we-do/projects/consensus-based-definition-of-palliative-care/definition/

  2. Dileo, C., & Dneaster, D. (2005). Music Therapy at the End of Life: State of the Art. In: C. Dileo & J. Loewy (Eds.). Music Therapy at the End of Life. (pp. xix-2). Cherry Hill, NJ: Jeffrey Books.

  3. Baroni, M. (2020). Music therapy in dementia and end-of-life care: A report from Italy. Approaches: An Interdisciplinary Journal of Music Therapy, 12 (2). 

  4. Aldridge, D. (1999). Music Therapy in Palliative Care: New voices. London: Jessica Kingsley Publishers. Read a review of this book here.

  5.  Baroni, M. Musicoterapia in hospice. Comunicare quando non ci sono parole. Rivista Italiana di Cure Palliative, I – 2009

hospice Italy music therapy palliative care