Research Proposal: Palliative Care and the role of Improvisational Music Therapy

A single-subject design: exploration of music therapy in the geriatric population to treat depressive symptoms in a home health Palliative care setting

Erik M. Andersen

School of Social work

Portland State University

Key Variables: empowerment, personality style, social support, isolation, emotional distress, music therapy technique, and quality of life

Quantitative Exploration

“There would be no music and no need for it if it were possible to communicate verbally that which is easily communicated musically.” E. Thayer Gatson, 1958

Introduction

 

The study I propose explores the question: does improvisational music therapy, in conjunction with traditional prescription based pain management, improve depressive symptoms in terminally ill patients? The question explores the role of music therapy for people diagnosed with a terminal illness, and rely on family member’s for caregiver support to manage multiple chronic health conditions.

The clinical technique of improvisational music therapy is important to the field of Social work for a number of reasons. First, as members of the Hospice and Palliative care teams, our foremost ethical duty to the client is to do no harm. For example, according to Cooke (2010), improvisational music therapy reduces depressive symptoms, improves self-esteem, and belonging in some elder people with dementia, (pgs. 765-776). Second, improvisational music therapy is an art, and clinical research studies suggest proven effective in capturing conscious, and unconscious personal memories through melodic harmony’s. The inclusion of music in practice provides invaluable opportunities for the patient to develop meaning, express, and interpret difficult emotions while processing the end-of-life. Music therapy is one of the least invasive interventions in comparison to the dominant cultures abrasive behavioral based interventions. As an artistic expression for the patient, music therapy is an asset to the field of Social work because we must actively seek out, synthesize, and apply the least invasive intervention. Thirdly, improvisational music therapy as a complementary therapy, to medical treatment is important to the field of Social work because a substantial amount of clinical evidence suggests that the inclusion of the technique in practice, generally improves the patients quality of life.

Largely, literature reviews, medical journals and experts practicing in the field suggest that improvisational music therapy is a highly effective, client driven, and family-centered intervention that is minimally invasive (Gallagher, 2006). The hypothesis for my study is that flexible; client-driven; improvisational music therapy in conjunction with family and social support will improve depressive symptoms in patients diagnosed with a terminal illness.

My desire to explore the role of music therapy in Palliative care Social work practice is based on a case debrief meeting following group supervision while working as a student intern within Providence home services: Connections Palliative Care Partners’ program. I had been seeing the client and interacting with the clients’ family twice a week for a month and a half or eight weeks.

I hope to gain deeper insights into the benefit of music therapy and conversely identify practice areas of improvement within the facilitation of music therapy. I also wish to gain a deeper understanding of the application of a single-system design while conducting an exploratory research study. The primary motivation I have in selecting to pursue the role of music therapy in Social work practice, is based on relevant practice experience working as a student intern within Providence Connections Partners Palliative Care program. I also wish to develop a greater sense of the assessment, intervention, evaluation, and debriefing process following the termination of the intervention.

Procedure for Single-Subject Design

The first four weeks, also known as the engagement or holistic assessment phase, also considered the baseline phase (Single-Subject design, Chapt. 7), served as time for myself as a student intern, and the client to build rapport. I soon learned after building a relationship with the partner of the client, that the client despite appearing pleasant, agreeable, and easy-going, was anticipating her own death while dual-processing the recent loss of her brother (pg. 214). During the baseline phase, the primary caregiver and partner of the client suggested the goal, or outcome should be decreasing her social isolation, and what she labeled to be cyclical depressive symptoms as the dependent variable. She mentioned that her partner enjoys music, sports, science-fiction novels, and listening to classic country musical artists including: George Jones, Waylon Jones, Kris Kristofferson, and Johnny Cash. She also suggested we consider collaborating to teach her partner brail using the, “Hadley School for the Blind,” instructional videos to stimulate active listening and comprehension.

The primary caregiver, confirmed consent and assent to observe, evaluate, and record the perceived degree of support, peace, and degree of pain on a scale of 1-10, using the Providence Wellbeing Scale as a measurement tool (2013), to screen the spiritual and emotional dimensions of the clients health beginning with the initial four-weeks, and agreeing to continue recording scores in the treatment phase for the remaining four-weeks. The client was asked to record the three scores once in the morning, and once in the afternoon for three days each week: Monday, Wednesday, and Thursday, the selection of the days of the week are a random assignment, and were chosen at the convenience of the clients primary caregiver. After reading a notice of informed consent the client and primary caregiver are aware that they can withdraw from the single-subject design research proposal study at any time with anonymity and autonomy.

The single-subject design, Chapter 7 requires the behavioral measurement of depressive symptoms to be measured in the related areas of: frequency, duration, and magnitude (pg. 215). Next to the score for each day, the primary caregiver was asked to also record the amount of times in the day, the length in time, and degree of perceived discomfort based on the Providence Wellbeing, self-rating tool from: 1 as strongly content, and 10 as strongly miserable. The evaluation monitors when the client appears to display the depressive symptom described as: sad, non-responsive, and irritated.

In the treatment phase, given the remaining four weeks, we will repeat the same procedure as described above, in order to explore, and include the qualitative and intimate perspective of the primary caregiver in the study, the partner of the client agreed to keep a reflection journal (tool for self-monitoring) that will include her feelings, behaviors, and activities included in her daily schedule with the aim of the intervention to decompress and release strong emotions of guilt, shame, and fear that she identified as barriers to her own emotional, physical, and spiritual well-being at the beginning of the study.

Further, improvisational music therapy is important in the field of Social work and in the palliative care setting, because the client and the family are facilitating the change, not the worker. Saunders and Mount (1978) substantiate the importance of complementary therapies in the field of Social work as holistic, “excellence in symptom control,” meaning through the co-production of music therapy between the Social worker and the client, the whole person is valued, including the dimensions of social, spiritual, physical, psychological and cultural practices. According to Friedman, who expands on the importance of music in practice (2006), “The multidimensional qualities of music allow it to touch many levels of consciousness. Mobilizing deep feelings and can assist in both verbal and nonverbal communication,” (pg. 2-3).

Secondly, the exploration of improvisational music therapy to improve depressive symptoms is important to the terminally ill population because according to Kubler-Ross (1969) interventions must heal the entire person while directly reflecting the cultural, spiritual, and personal values of the patient and the family in the treatment plan, including the caregivers who go through mental adjustments. The population demands flexible, client-centered, and meaningful interventions which improvisational music therapy provides on multiple levels.

For example, Clements (2004) suggests that people who are dying often encounter preparatory grief, which is a normal response to the anticipation of death. Subsequently Clements (2004) suggests that music therapy decreases depressive symptoms related to preparatory grief. Clements (2004) explains that music therapy in Palliative care helps patients and families process emotions that cannot be verbally expressed nor entirely understood. Lastly, Clements (2004) explores the purpose and benefit of music therapy for the terminally ill population by suggesting that melodies in music spark both conscious and unconscious memories that reflect intimate memories that refocus the mind of the patient from the chronic pain towards reminiscing on past memories—and healing.

I also want to clarify the differences between Hospice and Palliative care. Both services aim to provide comfort measures including; therapy, both behavioral and physical, spiritual advice and support from the Chaplain, and assistance with care coordination, guidance navigating various treatment options. In both Hospice and Palliative care the treatment team consists of: physicians, social workers, chaplains, registered nurses, mental health nurses, and physical therapists (Providence Home Services).

Patients receiving both services are in the advanced stages of disease progression. Palliative care patients typically receive a prognosis of a year to live, where as Hospice patients prognosis are typically six months or less to live. The diagnosis and perceived duration of prognosis is determined by the clinical judgment of the primary care physician. At Providence Portland Medical center, anyone can receive Palliative care services (comfort care) or Palliation in conjunction with chemotherapy, radiation, and dialysis. Where as in Hospice care, patients can be referred from Palliative care based on the Medicare guidelines that apply to all diagnoses including: disease progression, weight loss, falling blood pressure, dependence on staff to complete two or more activities of daily living, progressive dementia, and medical need for immediate intubation (Providence Home Services).

In the context of the Connections program, the agency is a home health outpatient service instead of in-patient hospice care. Palliative care serves as a transitional service, providing consultations regarding available treatment options, and comfort care. Palliative care aims to ease the transition into Hospice care by coordinating advanced care planning including: completing advanced directives and POLST forms (Providence Home Services).

For the purposes of this study I have decided to pursue an exploratory design. Given time constraints and the fact that Palliative Care is not a linear process but rather an abstract and creative opportunity to uniquely begin placing the healing pieces together, I feel that exploration is the best representation of this particular population with respect to the clients I have served. To conclude the population served within the Palliative Care setting is vastly diverse and according to, “The Practice of Research in Social Work: Chapter 7, Single Subject Design,” the structure of the single subject design places underrepresented groups in the center by engaging and including the cultural variations factoring into the outcomes of the intervention (pg. 241).

There are multiple ethical considerations to be made when conducting an exploratory, single-subject design, research proposal. For example, (Single Subject Design, Chapter 7) single subject Design studies require confirmation of informed consent, and also that the conditions of the study are clearly discussed (pg. 242). In the context of home health Palliative Care, and in relation to the patient and caregivers vulnerable state of health, it can become an ethical and moral hazard if the language used in the informed consent procedure and explanation of conditions are unclear and overly reliant on medical jargon, and impersonal references to quality care. To conclude, in the context of Providence as an organization, ethical considerations are approached using Providence Ethical decision-making framework that demands clinical integrity, beneficence, autonomy, and justice to guide Social work practice and care coordination.

Literature Review

The literature suggests that music therapy is an effective and least invasive intervention in improving depressive symptoms in terminally ill patients receiving Palliative care services.

According to Gallagher, Lagman, Walsh, Davis, and Legrand (2006) music therapy is invaluable in a Palliative care setting. Through participation in improvisational music therapy patients are given space to reflect upon their conscious and unconscious hopes, wishes, and fears associated with anticipated loss and coping (pg. 859-866). Ideally, patients participating in music therapy will succumb to, “psychocatharsis,” which means to purge and purify ones emotions through listening, internalizing, and renewing ones purpose through playing or listening to music. The role of the Social worker in facilitating music therapy as defined by the authors (2006) is to listen, nurture, and compassionately interact.

The ideal benefits of music therapy for the patient are outlined by Legrand (2006) and are holistically oriented within the categories of health: physical, psychological, social, and spiritual. Physically music therapy aims to promote muscle relaxation and aims to discontinue the cycle of chronic pain by softening symptoms of anxiety and depression through conscious and unconscious reflection. Psychologically, ideally music therapy reinforces self-concept and stabilizes the emotional stages of the primary caregiver. The psychological process within the interaction between the patient and the melodies of the music is deeply feelings oriented: reinforcing reality, expressing fantasy, and the direct appeal to emotions. Socially, music therapy is an opportunity for the patient to interact with the Social worker/music therapist; bond, express, and entertain one another, with the focus of jointly cultivating a unique healing perspective. Spiritually, music therapy facilitates a space where patients can express doubts, anger, fear of punishment, and contemplate the meaning of life.

Further, Clements-Cortes (2004) shares the finding that the majority of music therapists describe improvisation to be the most powerful techniques in palliative care music therapy. Improvisation provides space for the patient to explore and non-verbally express painful emotions that are too strong to discuss verbally. Typical examples of non-verbal communication within the palliative care setting using music therapy include, the closing of the eyes, and relaxation of the shoulders. A head nod, foot tapping, and laughter, when patients feel empowered and encouraged to explore, they begin to heal. Lastly, improvisation music therapy decreases a client’s sense of isolation and may spur additional exploration of various forms of music and the resulting emotions. Family members are also encouraged to participate and empirical studies have shown that music serves to assist families in expressing confusing emotions.

Comparatively, Bruscia (1998) suggests that clinical goals are developed through improvisation while participating in music therapy. When patients are asked to simply play or process the music, on the spot they may develop clarity of intention and decisiveness. This clarity as a result of the patients interaction with the melodies played, assists in stimulating cognitive senses and distracting the patients perception from the chronic pain of the terminal illness to a feeling, image, event, or a relationship.

Lastly, Bruscia (1998) describes music therapy as a methodical and strategic form of healing that is implemented through the processes of: assessment, treatment, and evaluation. In the assessment and treatment phase the music therapist must monitor and match the musical melody to the experiences that are most pertinent to the client. In the evaluation phase the clinician and the patient must reflect upon the important aspects and possible problems discovered while listening, recreating, and playing. Music therapy improvisation is largely intuitive and requires a strong, skilled, and creative worker.

Method

Quantitative/Qualitative

            The primary participant in the single-subject design is a 69-year old female, who has multiple chronic conditions and recently received a prognosis of a 1-year or less to live. The participant is representative of the population I will be examining as late adulthood is considered to be 65-years and older. From a demographic standpoint, the participant was chosen on a referral basis from her primary care physician to receive companionship from the Connections Palliative Care program. The steps I will take to ensure that the participant is not harmed include: detailed informed consent, explanation of the conditions of the study, explanation that the participant can withdraw from the study at any time, and also I we will debrief the study together following termination of our professional relationship. The ethical considerations that need to be made include: clinical integrity, beneficence, autonomy, and justice. Please see directives outlined by “Ethical and Religious Catholic Health Care Services,” (Abbott, 2009), at the end of the proposal for detailed considerations.

Design

I chose the single-subject design as a method because it is, “practice-based,” (Single-Subject Design, Chapter 7)

            The subject is a 69-year old female, who has multiple chronic health conditions including: Type 1 diabetes, cardiac arrhythmia, neuropathy, and due to multiple health complications is considered legally blind. The client is incontinent and fortunately receives support and assistance from her partner and daughter with the activities of daily living. The client is pleasant, kind, and curious in nature when discussing sports, music, and science fiction novels.

The partner, and primary caregiver of the client who also has a diagnoses of multiple chronic health conditions, including a recent mild stroke, remains challenged to take care of her own needs while supporting her partner with activities of daily living. The primary caregiver of the subject verbally contemplates and dual-processes recent losses within the family, and labels the feelings as guilt, while specifically attributing the subjects’ recent death of her brother to the subjects observed depressive symptoms. The primary caregiver mentioned that the subject is taking Zoloft, and she is concerned that because her partner is communicating less frequently while appearing uninterested in activities she used to enjoy, that impending decline will ensue.

“The Practice of Research in Social work, Chapter 7: Single-Subject design (2013),” suggests that the complexity of the case outlined above demands a flexible, detailed, and inclusive assessment of the client and all family members in order to develop a clear target goal, and begin to operationalize the outcomes characterized by the single-subject design.

To begin the baseline phase, I started by developing rapport with the primary caregiver. Once the primary caregiver felt comfortable and non-verbally confirmed her trustworthiness that I was genuinely willing to serve and understand the complexity of the situation, she communicated the target goal as: decreasing her partners social isolation, and increasing interaction through conversations consisting of her partners interests. I further explored the severity of her perceived effects of the social isolation in relation to her partners’ depression and overall health to find that the subject was grieving the loss of her brothers’ death.

Prior to the discussion, the partner of the subject signed a notice of informed consent outlining the purpose, duration, and magnitude of the proposed study. The primary caregiver agreed to complete the pre-test (Single-Subject design, Chapt.7), requesting that three times a week she record her partners overall health, degree of pain, perceived degree of peace, and perceived degree of support (pg. 238). Further, the primary caregiver was also asked to record the number of times her partner displayed the depressive behavior throughout the week (frequency). Lastly, the primary caregiver was asked to record the time of day the behavior occurred, and also record how long the episode lasted (pg. 218). The recording process is based on the Providence Wellbeing scale-screening the dimensions of Health, for the purposes of the target goal, to improve depressive symptoms, the primary caregiver decided to focus and rate her partners degree of perceived peace and support. The rating is as follows 0=most support and 10=least support. The Providence Wellbeing Scale uses varying expressive smiley faces to illustrate the degree of pain or comfort, while also requiring Social workers provide a referral to the Chaplain, if there are scores of seven and above when self-rating the perceived degree of peace.

In terms of reliability of the data, related to the quantitative scoring and recording process facilitated by the primary caregiver, using the Providence Wellbeing scale, I suggest based on practice observations that including the clients partner as the facilitator and assessor to operationalize and define what depressive symptoms are instead of the Social worker will limit professional bias, and encourage interaction between the caregiver and her partner.

There are threats to external validity because this particular measurement tool relies heavily on the past history and observations of the primary caregiver and also on the professional judgment between the Social worker and the chaplain. Further because improvisational music therapy is a spontaneous, creative, and abstract methodical process, in terms of external validity it would be extremely difficult to replicate the findings outside of the research conditions—and there are no current studies that can entirely generalize and displace the outcomes of one study to the next. I am also concerned that the study could cause cohesive reactivity, and alter the patient’s behavior and moods.

The threats to internal validity are not entirely clear, as improvisational music therapy is an authentic expression and reflection of the experience. Although, because the proposed study lasts 8-weeks, one could assume based on prospective data, that the depressive symptoms are cyclical and largely confounded with physical pain, that the indicators on the Providence Wellbeing scale of peace, pain, and support may decrease given the extra interaction with her partner and physical rehabilitation from Providence Home Health services. According to the Single-Subject design, Chapter 7, it is impossible to say that the A-B design of a single subject study (intervention) caused the proposed change (pg. 229). Also the repeated measurement produces an association and causality, not causation.

Proposed Analysis and Dissemination

            According to the Single-Subject design, Chapter 7 (2013), the most effective tool to analyze and disseminate data is through visual analysis, using a line graph. The frequencies for the depressive symptoms are plotted along the y-axis, while the individual weeks will be plotted separately on the x-axis. The scores will be averaged combining the scores of all three days for the week. The average score will then be plotted to operationalize the patients perceived degree of peace, support, and comfort (pain management). There will no breaks in time intervals while conducting the study during the 8-weeks. We will know whether or not we have found pertinent associations between music therapies in palliative care practice by operationalizing the outcome prior to the actual implementation of the study.

The operationalization of the variables and treatment goals will be strictly collaborative and client-driven. In the single-subject design case above the variables of, empowerment, quality of life, personality style, social support, emotional distress, and music therapy technique can be explored and operationalized. According to the Journal of Psychosocial Oncology, (2013) the empowerment perspective is most important when caring for the demands of a terminal illness. The empowerment perspective consists of healing the whole person rather than merely treating the illness by including music therapy and collaboration in medicine. The proposed study will use the empowerment perspective to guide practice. Empowerment in the single-subject design case as defined by the primary caregiver is increasing her social interaction and decreasing her unresponsive sadness. Personality style in the case of the subject is easy going, agreeable, and often relaxed. The client has social support from family and partner. The client is experiencing sadness and is mourning the recent loss of her brother. The role of music therapy technique is improvisational and consists of classic country music as the primary melody for interaction, and active life-review—healing. The single-subject design is flexible and the operationalization of the variables is merely a reflection of the client-driven intervention, where the client actively defines and refines of what the variables mean to them.

The intended audience for the proposed study is Providence Home Health Services, Providence Portland medical center, and the greater healthcare community. The results will be presented during the Providence Connections Palliative Care team monthly meeting, the case study will be reviewed, and healthcare professionals will be encouraged to dialogue and explore the role of music therapy in the scope of the team and individual practice and what the findings mean to them personally and professionally.

Prospective Limitations

            The current and foreseeable limitations of this study include: time, resources, variety of participants, researcher bias, and lack of generalizability and conclusive evidence to clearly support the financial need for music therapy in Palliative care practice. With these limitations I chose to conduct this study the way I did because the clients created the change and sustained the intervention not the worker. I chose to conduct the study striving to incorporate empowerment as the primary motive in creating a successful intervention. The participants are empowered to include their perspective as the foundation for change, because their voice matters not the workers perspective.

Conclusion/Personal Reflection

            I feel the primary contribution my proposal can make to the social work literature is the importance of empowerment through expression in Palliative care social work. The proposal will contribute a new perspective to practice that stresses the importance of client and family centered interventions, where the clients are respected and empowered to heal through complementary therapies. Above all else, I hope that the proposal will divulge a perspective that explores the complexity of the healing process in the Palliative care setting.

The process was challenging, rewarding, and hopeful. The ethical considerations I struggle with most are primarily associated with interpreting data, and operationalizing the variables. Due to the sensitivity and vulnerability of the prospective study it is difficult to know whether or not my own personal biases are influencing the interpretation of the data, and if so, I struggle with reframing and refocusing the meaning of the data.

Measurement tool & Ethical Considerations including excerpts from: “Ethical Religious Directives for Catholic Health Care Services, fifth edition, United States Conference of Catholic Bishops (Abbott, 2009)

 

Providence Wellbeing Scale, a holistic measurement used as a therapeutic tool to evaluate patient’s degree of discomfort. Patient self-evaluates degree of pain: emotionally, spiritually, psychologically, and physically. If the patients self-evaluation scores at a 7, or above the Partner, or student intern is encouraged to refer the patient to the services of the Chaplain. The self-evaluation is client-centered and inclusive of the families’ feedback.

When the score reaches 7 or above for discomfort in the clients perceived degree need for support the student intern or volunteer is encouraged to refer the client to the LCSW. The described care coordination fulfills referrals internally between professionals within the multidisciplinary team.

Abbott (2009) outlines the ethical considerations of a Catholic organization that guide professional’s judgments and mandate that both Palliative and Hospice care strive to be least invasive intervention programs.

Important directives outlined in the: “Ethical and Religious Directives for Catholic health Care Services,” (pgs. 28-31).

—-Do No Harm—

70.) “Catholic health care organizations are not permitted to engage in immediate material cooperation in actions that are intrinsically immoral, such as abortion, euthanasia, and assisted suicide (pg. 31).

Ethical Issues in Care for the Seriously Ill and Dying (pg. 27)(considerations in clinical practice) The identified need for comfort measures, an ethical consideration.

Common themes: “Patient has the right to receive support medically, emotionally, and spiritually at the end-of-life.” Ethical consideration: the moral hazards and preservation of dignity and life.

55.) “Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar condition should provide them with appropriate opportunities to prepare for death. Persons in danger of death should be provided with whatever information is necessary to help them understand their condition and have the opportunity to discuss their conditions with their family members and care providers.

            “They should also be offered the appropriate medical information that would make it possible to address the morally legitimate choices available to them.

            “They should be provided the spiritual support as well as the opportunity to receive sacraments in order to prepare WELL for death.

56.) “A person has a moral obligation to use ordinary or proportionate means of preserving his or her life.          

57.) “A person may forgo extraordinary or disproportionate means of preserving life.

59.) “The free and informed judgment made by a competent adult patient concerning the use or withdraw of life-sustaining procedures should ALWAYS be respected and normally complied with, unless it is contrary to Catholic moral teaching.

61.) Patients should be kept as free of pain as possible so that they may die comfortably and with DIGNITY, and in the place where they wish to die.

Informed Consent Form

Providence Home Health Services, Palliative Care Connections Partners Program

Research Proposal Study: “Exploring the role of Music Therapy”

Purpose: The study you are being asked to participate in involves a commitment of 8-weeks including: the client of the agency, the primary caregiver of the client, and the family members living in the home. The aim of the study is to work together and develop an understanding of the role of music therapy as a complementary therapy in Palliative Care practice. The study is informed by on-going research and active participation from the patient, primary caregiver, and the extended family living in the home.

The research proposal requests the primary caregiver observe the patient/partner and record instances of depressive symptoms three times a week: Monday, Wednesday, and Thursday. The evaluation defines depressive symptoms as sad, non-responsive, and irritated behavior.

Both phases of the intervention are experimental, for example, the first four-weeks will be the pre-test period. The caregiver will record observation’s without receiving music therapy as a part of your partners’ treatment plan. The following four weeks will be the treatment period and your partner will receive music therapy twice a week on Monday’s and Wednesday’s.

Risks and Discomfort: At any time during the study all research participants are encouraged to withdraw from participating if they feel uncomfortable or for see any moral, spiritual, emotional, physical, or financial hazards as a result of participating in this study. All participant’s in the study will withdraw with autonomy and anonymity. At any time, if you feel participating in the study, or any aspect of the study is uncomfortable you are encouraged to leave the study. As a catholic health organization we honor the values, beliefs, and spirituality of the client and family. The likelihood of any foreseeable danger’s, risks or harm to the participants is unlikely, as the study is client-driven and supportive of the unique strengths and needs of the client and the family served.

 

Costs/Payments: There are no costs or payments to participate in the study. The study is entirely exploratory and aimed at developing a clearer sense of complementary therapies that are supportive in healing.

Voluntary Participation: Participation is entirely voluntary, and refusal to participate will not result in penalty or loss of benefit

I _________, hear by consent to participate in the Providence Connections Partners 8-week music therapy program and agree to all the terms & conditions of this consent form while realizing that I can choose not to participate or leave the study at any time.

(Adopted from University of Delaware, “Guidelines for Informed Consent)

Work Cited

Abbott, W. M., (December, 2009). Ethical religious directives for catholic health care services.    Washington, D.C.

Cooke, M., W. Moyle, D. Shum, S. Harrison, and J. Murfield (2009). “The Effect of Music on Quality of Life and Depression in Older People with Dementia: A Randomized Control Trial.” Alzheimer’s & Dementia

Gallagher: Supportive Cancer Center, L. M., Lagman, R. C., Walsh, D. D., Davis, M. C., &

LeGrand, S. B. (2006). The Clinical effects of music therapy in Palliative Medicine.

Deng: Integrative Oncology, G., & Cassileth, B. R. (2005). Integrative Oncology:

Complementary Therapies for Pain, Anxiety, and Mood Disturbance. A Cancer Journal for Clinicians, 55(109), 109-116.

Mount, B. M. (1978). The problem of caring for the dying in a general hospital: the palliative

care unit as a possible solution. Canadian Medical Association, 119.

Saunders, C. (1967). The Management of terminal illness. London Hospital Medical publishers.

Ross, K. E. (1969). On Death and Dying, Macmillan.

Friedman, M. A. (2006). Some practical aids in helping yourself deal with the critically ill

patient. Psychosocial Care of the Dying Patient.

Empowerment perspective in Palliative Care practice (2000). (n.d.). Journal of Psychosocial

            Oncology, 18(2).

Clements-Cortes, A. (2004). The use of music in facilitating emotional expression in the

terminally ill. American Journal of Hospice & Palliative Medicine , 21(4).

Burns: Behavioral Cooperative Oncology Group/Walther Cancer Institute, D. S. (2001). The

Effect of the Bonny Method of Guided Imagery and Music on the Mood and Life Quality

of Cancer Patients. Journal of music therapy, 12(1), 51-65.

Providence Home Health Services (2013) Providence well-being scale, Providence Clinical

            decision-making framework.

 

Engel (2008, September 27). Chapter 7: Single-Subject Design. Retrieved November 25, 2013,

from http://www.sagepub.com/upm-data/25657_Chapter7.pdf

Bruscia, K. E. (1998). Defining music therapy. Gilsum, NH: Barcelona Publishers.

Reliability and Validity in Qualitative Research : SAGE Research Methods. (n.d.). Retrieved

from http://srmo.sagepub.com/view/the-handbook-of-social-work-research-methods/n15.xml

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