AUTUMN 1994
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Music
for the Dying:
Using Prescriptive Music in the Death-Bed Vigil |
"Infirmary music" was an intimate expression of French monastic medicine in eleventh century Cluny, and anticipated the holism of modern hospice and palliative-medical movements by almost 800 years. Today, while no longer an expression of any specific institutional religion, music-thanatology (thanatos means "death") is nevertheless concerned with the possibility of a blessed death and the gift that conscious dying can bring to the fullness of life.
Therese Schroeder-Sheker began tending the dying with music 21 years ago. She defines "music-thanatology" as "a palliative medical modality employing prescriptive music to tend the complex physical and spiritual needs of the dying". As founder of the Chalice of Repose Project in Missoula, Montana, she works with music-thanatology interns to integrate and model contemplative and clinical values in daily practice. During the past year and a half, 18 music-thanatology interns have attended more than 320 death-bed vigils in hospitals, hospices, geriatric homes, and private home settings. Their work has been particularly effective for people dying of cancer and other slow degenerative diseases, respiratory illnesses, AIDS, end-stage dementia and Alzheimer's.
A critical recent development involves patients about to be removed from mechanical life-support systems. While the medical ethical issues of euthanasia and patient autonomy engender serious debates, Chalice workers offer patients, their loved ones, and health-care providers alike an important healing option at the end of life. This article is adapted from Advances: The Journal of Mind-Body Health, Vol. 9, No. 1, ©1993, the Fetzer Institute. —Ed
In the early fall of 909, a wise Burgundian monk named Berno was summoned to visit the aging William III, Duke of Aquitaine, a seasoned aristocrat. The death of William's only son had left him in pain and without an heir. In preparing for his own death, William reasoned that he could not take his vast worldly possessions with him, and decided to found a monastery free from all secular and immediate diocesan jurisdiction. The duke urged Berno to choose freely from his lands. When the monk cited the sheltered valley of Cluny, with ancient forests and quarries of red and gray stone, William choked. This was the finest hunting ground in the entire duchy! Quietly, the Benedictine inquired, "Which would serve you better before God, the prayers of the monks or the baying of hounds?" William, stinging with desire and attachment, hesitatingly conceded, and composed the charter for a new French monastery that was to change the face of Europe.
Central to Cluniac spirituality was the understanding of the human need for beauty. At the heart of this notion is a commitment to music experienced in solemn, elaborate liturgies.
During the next 200 years, more than a thousand other Cluniac houses were founded across Europe, leading to a crescendo of an already flourishing monastic medicine. The twofold domain of monastic medicine was care of the body and the cure of the soul, through rational medicine (medical and surgical) and religious or interior practices (including prayer, counsel and confession), respectively. While monasticism in general had always provided for the needs of the sick and aged in Holy Rule, Cluny fully developed a series of infirmary practices concerning the care of the dying that clearly predate modern palliative medicine by 800 years. A strong focus of the monastic infirmarius was with the physical, emotional, mental and spiritual pain that might impede or prevent anyone from a blessed death. The monastic infirmary at Cluny left detailed accounts of the musical ways in which the dying were tended. These accounts are found in a genre of monastic manuscript called customary (or consuetudine).
Although the surviving monastic customaries present research problems, they nevertheless offer an inexhaustible historical resource for clinical practices that model an extended art of palliative medicine.1 If the monastic infirmary was once a sanctuary to complete the last stage of life and a gateway to a conscious death, the pioneering field of music-thanatology is working to provide just such a renewed palliative art and science for patients again. The major difference, of course, in the pluralism of the modern world is the effort to meet the diverse needs of each patient, regardless of race, creed, ethnicity, gender, age, or affliction. In general, sacred music is placed at the service of the needs of the dying in an atmosphere of love and support.
The infirmary music that my colleagues and I practice at the Chalice of Repose is dynamic and prescriptive, individual to each patient, for each death-like the miraculous delivery of each baby—is unique in timing, content and context. Therefore, live prescriptive music at the bedside (rather than taped music) is the sole application in this endeavor, specifically singing and harp playing.
MUSIC THANATOLOGY AND MUSIC THERAPY
Music thanatology is not the same thing as music therapy, but is a close relative and ally. In the strictest sense of the word, music therapy has been defined as a recent behavioral science, although it is also rooted in ageless wisdom. It is concerned with the systematic application of music to engage and support life processes and produce deep relaxation in the patient, which, in turn, contributes greatly to the alleviation of physiological and emotional pain. The use of music in this way presupposes a reserve of patient energy, and the therapeutic application engages interaction, participation, or response from the attentive client either by music-making activities or in deeply responsive and controlled listening environments.
Music thanatology, on the other hand, is historically rooted in monastic medicine, and today flourishes as a palliative medical modality. In its clinical focus, it includes all of the characteristics of music therapy, but differs from it because it is solely concerned with addressing the complex needs of the dying. The dying person is most often weakened, sometimes even comatose, and should not "spend" energy making new connections. In music-thanatology, the patient only receives. The entire surface of the skin can become an extension of the ear, thus enabling the patient to absorb infirmary music, creating the possibility for even deeper emotional, mental and spiritual reception. In these vulnerable moments, the dying person becomes a chalice and is anointed with very specific music, sound or tonal substance. The sole focus is to help the person move toward completion and to unbind from anything that prevents, impedes, or clouds a tranquil passage. Each person receives the music differently, and on a variety of levels: physically, emotionally, mentally or spiritually. Music-thanatology is a contemplative practice with clinical applications.
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THE FIRST VIGIL This work began for me spontaneously 21 years ago in my exchanges with two dissimilar figures, a priest and a patient.2 The priest lived in a nearby town, and knew of my work tending to the dying elderly in a local geriatric facility. I had been deeply troubled by routine practices in which bodies of the recently deceased were treated in a cavalier fashion. Because of my own youth at the time, this caused me to wonder and to discuss with the priest if I should disassociate myself from that home and seek other employment. The priest saw those disturbing problems as opportunities. He took me aside for a long quiet walk and said with simple but burning solemnity: "Protect them." He suggested memorizing special lines from the world's sacred scriptures, from the Bhagavad Gita, from the Torah, from the "Prologue" to the Gospel of St. John, and to pray these internally at each bedside. He challenged me to deepen and expand beyond the limitations of personal religious identity. The second person in this story was an elderly man in the geriatric home who was sometimes vicious, often brittle and selfish. None of the workers was fond of him, but he was dying of emphysema. One evening when I entered his room, it was clear he was nearing death. No more mechanical ventilations, tracheotomies, or surgical procedures were available to resolve his disintegrated lungs. He could take no more in, could swallow no more, and, in his complete weariness, there was little he could return to the world. The room was filled with his fear and agony. Without much thought, I closed the door quietly and climbed into his hospital bed and propped myself up behind him in midwifery position. With my head and heart lined up behind his, and my legs folded near his waist, it was possible to bolster his diminished body and even suspend his weight slightly. Before I had time to think, I had been singing quietly to him, and rocking very gently. I made my way through the entire Mass of the Angels, the Adoro te devote of Thomas Aquinas, the Ubi Caritas, the Salve Regina, the Mass of the Blessed Virgin Mary. For all I knew, he could have been Eastern Orthodox Christian or Jewish, since all the residents were Russian emigres, but I never knew the details of his life. All I know is that he began to rest in my arms and breathe much more regularly, and we, as a team, breathed together. The chants seemed to bring him balance, dissolving fears and compensating for those issues still full of sting. How could they do anything less? These chants are the language of love. The repertoire had become the chalice that held him up into true repose. Long after his heart ceased to beat, I was allowed to hold him. I was completely lacking in any medical or philosophical sophistication, and had not known then about "systems of entrainment" or even "symptom management". Initially, my understanding of what had happened was a matter of heart, but the interior observer was also finding voice. Although questions were forming, I had responded to the needs of the immediate moment out of a pure common sense and caring, in the same way that concerned parents have always rocked and sung to crying babies. My response had more to do with relationship and resolution than it did with what geriatric medicine was in 1973, before holism was a widespread notion. The silence that replaced the man's struggle and was present in his room has continued to penetrate the core of my life even 20 years later. This pulsating silence created a spiritual reservoir that began the initial teaching for me about the importance of alternating sound with periods of silence. I came to see this repeatedly in the years that followed that first death: alternation between contraction (silence) and expansion (sound) is critical. |
RHYTHMIC ENTRAINMENT
Chalice workers must thoroughly understand and employ the phenomenon of entrainment, discovered by the Dutch scientist Christian Huygens in 1665. Entrainment refers to a phenomenon in which one source of rhythmic vibrations causes another source to vibrate in lock-step and to oscillate at the rate of the first source. Itzhak Bentov illustrated this in Stalking the Wild Pendulum.3 He wrote about leaving a room full of grandfather clocks, the pendulums of which were all swinging at different rates and times. Upon return 24 hours later, they were all swinging together.
The entrainment phenomenon can be employed in human beings to great benefit; we work directly with a patient's breathing and/or respiration. The phenomena of entrainment can also be a detriment with the ever-present external auditory stimulus in intensive care units. Sadly, these phenomena have not yet been studied or acknowledged by health care teams, but it seems inevitable that they soon will be. The constant clicks, hisses, beeps, and buzzes generated by life-support systems remain a serious source of environmental pollution especially for the vulnerable comatose patient.
All the original Western infirmary music is a specific development of Gregorian chant. Readers might wonder what significance this form of plainchant has for the dying patient: Wouldn't their favorite music be just as helpful? No—sometimes it is the opposite. I often tell our students to differentiate between music for the living and music for the dying. Music for the living is meant to engage us; music for the dying is meant to free us, to help us let go.
The hymns, antiphons, and sequences within chant repertoire are fully developed exquisite melodies. The more developed the melodic content, the closer the relationship to the thinking process and, therefore, the central nervous system. The psalms and litanies tend to be composed of small phrase-motifs or snatches of repeated melodic formulae and, therefore, related to the rhythmic and circulatory systems.
Plainchant is the only body of melodic repertoire in the Western tradition in which the breath marks are written into the score, intrinsic to the sung prayer. This reminds us of the relationship between breathing and spirit. Plainchant is also monodic; it is not harmonized. However, we can extend the original indications and make great use of the possibilities inherent in harmonization. One can bring in very skillful concentrations of light and dark as well as space with immediate and conscious use of intervals.
THE DEATHBED VIGIL
Musical-sacramental-midwifery, the contemplative dimension of music thanatology, is delivered through the media of harp and voice. Ordinarily, the Chalice worker plays for any patient in pain (or peace) if there is a physician or nursing referral or the family or dying person requests this service. It would be safe to say that a Chalice worker must be prepared for anything, and it is best to work in teams of two, weaving tonal substance over, around, and above the physical body of the patient, from head to foot. We actually place ourselves on either side of the patient lying in bed, and play the prescriptive music on the harps. These are the sound anointings; they last typically for an hour to an hour-and-a-half at the most. If the patient dies, if transitus occurs during the vigil, we stay and continue for the washing of the body, whenever possible.
We differentiate between terminal diagnosis and the critical moments at the very end. Terminal diagnosis, for example, can be a time for music therapy. We do not replace but rather augment the hospice system, and literally come in at the very end, although we recognize two kinds of referrals: processing calls and immanency calls. Often, we are with someone only for a day or a few hours, but now, because there are many interns, we can tend someone for a few days or even a few weeks prior to death.
By the time our office receives the referral call, most patients are suffering, although many do so quietly. Even when my first impression of a patient has been: What good could we possibly do here? this impression has been almost always false; often, some relief can be effected, even in the most difficult cases. However, it is true that we sometimes deliver patient services where it seems that the patient is so agitated and racked with pain that we might doubt the applications. When nurses report patient relief, deep unmedicated 10 to 16 hour sleep, or radically decreased morphine requests, we are all humbled and relieved. Both conscious and comatose patients receive the prescriptive music very deeply; something substantial is going on here and we don't begin to have all the explanations.
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DEATH AS A RITE OF PASSAGE: LIMINALITY In studying the Cluniac infirmary methods from the perspective of anthropology, death is seen as a rite of passage with a three-part structure: the rites of separation, the rites of liminality (from the Latin for "threshold"), and the rites of reincorporation. This structure should not be confused with psychological models of grief and loss work. For music-thanatology, the rites of liminality are most critical. Anthropologist Victor Turner saw liminality as a sacred condition in and out of time, where bonds between people ignore, reverse, cut across, or occur outside structural relationships. During the liminal period in a rite of passage, the passenger (the patient) is the ritual subject. The person passes through a realm that has few or none of the attributes of either the past or the coming state. Liminal personae—people on or in the threshold—are necessarily ambiguous. Conditions elude or slip through a network of classifications that normally locate states and positions in cultural space. In the liminal state, one is neither here nor there, betwixt and between positions assigned by law, custom, convention, and ceremony. All the liminal symbols are expressed by a rich variety of images including womb, cave, cavern, invisibility, and darkness. "Liminality," said Turner, "is unsettled and unsettling." The largest part of the Cluniac customary is concerned with the liminal or threshold condition, which can be accompanied by anything from minor pain to prolonged agony, physical or spiritual. It is during this part of the passage that the music is most effective. One of the Cluny pain antiphons (a specific chant genre) addresses liminal purification as a burning process. The text of the music states, "Free me from the burning gates" or "from the gates of fire". This antiphon is sung and played over and over, repetition being an active agent. The pain antiphon either serves as or is analogous to an analgesic, depending on the reception of the music by the patient. |
STEPS TOWARD A SCIENCE OF MUSIC-THANATOLOGY
The first 19 years' work was all done on a volunteer basis, without charge, in the monastic spirit. It would have been precocious, even presumptuous, to record this work in a rigorous scientific manner. What survives, instead, are almost two decades of clinical experience and anecdotal material recorded in personal notebooks.
From the first day of official practice, we organized and bound the Missoula clinical narratives and made them available for others to study and review. Today, these narratives number over a thousand, and would provide any historian or phenomenologist with a rich cultural repository and/or medical-research database, just waiting to be explored.
Today, the keeping of charts and accurate records is mandatory in a clinical setting in which there is internal and agency billing and in which medical research is an issue. It is too early to prove new theories based on current quantitative documentation; however, we are now creating a computer database of all vigils documented during the past 18 months-in time this will allow us to analyze the data more thoroughly. Although our first priority will always be the comfort of the patient, we hope to design noninvasive research models, and develop both quantitative and qualitative systems for evaluating the results of this work.
Music-thanatology will not be requested by everyone, but in my experience and in our project we cannot yet meet all the calls we receive locally or nationally; and each time another article goes to press, or an invitation comes to address a medical congress, the response grows greater. It will not ensure a blessed (peaceful or conscious) death, but it can comfort and can contribute to that end greatly, and it opens up possibilities that differ from those available through other medical therapies.
-RETURN TO SIDEBAR 1 "THE
FIRST VIGIL"-
-RETURN TO SIDEBAR 2 "DEATH AS A RITE OF PASSAGE:
LIMINALITY"-
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Harpist
and singer Therese Schroeder-Sheker is the Executive Director of
the Chalice of Repose Project. This article is an excerpt from her
forthcoming book, The Luminous
Wound. Earlier versions and variations of this article have previously
been published in Advances, Vol. 9, No. 1, and the Journal
of Holistic Nursing, Vol. 12, No. 1. |
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NOTES AND REFERENCES
1. I am forever grateful to Frederick Paxton of Connecticut
College for having brought the eleventh-century customaries of Bernard
and Ulrich to my attention in 1984, providing the historical context
for the work in which I already had been engaged for some ten years—to
attend to the terminally ill and dying with music, a practice that I
now call music-thanatology. With kind assistance from the Fetzer
Institute, Paxton's translation of Bernard's customary has been published
by the Chalice of Repose Project and is a basic text used in the music
thanatology curriculum, along with several other new publications.
Frederick Paxton, Christianizing Death: The Creation of a Ritual Process in Medieval Europe (Cornell University Press, 1990).
2. Therese Schroeder-Sheker, "Musical-Sacramental-Midwifery",
in Don Campbell (editor), Music, Medicine, and Miracles (Quest
Books, 1992).
3. Itzhak Bentov, Stalking the Wild Pendulum
(Inner Traditions, 1988).