By Meera Sinha, MusicWorx Intern

The following blog post covers heavy topics such as experiencing cumulative grief in healthcare professions, witnessing death, and coping with loss.

End-of-life music therapy

Oftentimes, folks don’t realize the weight that can be involved in music therapy. We think of this field as full of beauty, light, and laughter. While it’s full of those positive things, heavier aspects involve emotional expression and processing, grief, trauma and coping. Music therapy is often present as a person is actively passing away in order to provide comfort and support to the patient and their loved ones; these sessions are known as end-of-life (EOL) sessions.

No matter how much you have experienced death, you will not be prepared for your first end-of-life session. I observed my first one during my second week of internship. My mentor, Adessa, told me about what would happen, what we might see, hear, and smell. She told me it’s okay to cry.

Everything happened like she said it would. The medical staff disconnected equipment, extubated the patient, and administered medications. The family was tearful and the patient was not aware or oriented to the present reality. Adessa provided live patient-preferred music as I held the iPad with chords and lyrics for her, hoping I could keep it together. The session lasted 45 minutes, but it felt like 15. The session came to a close when the family began to share lovely stories about the patient; they united in laughter through their tears. They thanked us for providing such beautiful music, and we left the room.

As we were walking out of the room, I had an out-of-body experience. I was moving and walking around, but my mind did not feel present. We sat outside the hospital and talked about the possible interventions to offer during an EOL session. In the moment, I felt numb. I hadn’t yet processed what happened in front of us, what the family may be experiencing, or the beautiful moment we had the privilege of being a part of. I shrugged the feelings off, thinking that the family must be feeling so much heavier than me. I thought about the patient and their family for the next few weeks, but did not fully process what it all meant.

Fast forward a few months to when I was haphazardly thrown into an EOL session with a fellow intern. We had not known the patient was actively passing and had expected a typical music therapy session in order to provide family support. However, the medical staff had just begun the process of withdrawing care, and the family asked us to be present during that time. We had 20 minutes to prepare ourselves for what was going to happen. I was gearing up for my first time facilitating a music therapy session during a compassionate extubation, and my fellow intern’s first time witnessing this type of session. The family was silent for most of the session, besides the few times they cried out in sadness. An hour later, my fellow intern and I walked out of the room silently. The patient had passed while we were providing music. After this session, we sat out in the sunshine and talked about what happened, how to approach EOL sessions, and then shrugged off our feelings and laughed about some meme we found on the internet.

A Personal Grief Inventory

We followed up with our supervisor because we were still holding the weight of the session on our shoulders even after a restful weekend. She asked us to do a “Personal Grief Inventory,” which was an activity in which we were to interview each other on a significant loss in our life, then write a song as a gift for each other based on the experiences shared in the interview.  We sat on my couch asking each other questions like, “What was your first significant loss?“ “How did your loved ones react to the loss?” “Who supported you and how?” It felt odd to share such intimate details of my emotional processing with the knowledge that it was later going to be turned into a song.

We wrote tunes for each other based on our answers – a lovely way to memorialize our first experiences with grief. I did not feel like it helped me process my experiences; instead, it brought up more thoughts and feelings I wasn’t expecting. I continued to seek out other ways to cope with and process grief, but it was difficult to find tools that fit my needs.

In the two months following my first EOL session without a supervisor or mentor, I encountered 5 patients who required end-of-life sessions. As each one became more and more difficult, it grew harder to shrug off the feelings of sadness and the experience of grief. I was getting very frustrated with myself. I hardly know these folks, why am I experiencing grief?

A few weeks ago, I encountered three separate patients/families in one day that needed support for an end-of-life session. I was out of my depth. I saw the patients that I could, and continued to follow up until they passed. I felt empty and unable to be refilled.  I desperately tried to cry to release all the emotions I was experiencing, but nothing came of it. I was so numb and in need of so much self-care, I had no idea where to begin. I called my friends and family, wrote in my journal, watched shows and movies, hung out with friends, but nothing was helping. 

One day, after a patient with a particularly complicated case passed away, I went home and felt compelled to pull out my ukulele. I picked a chord progression, hit record on the Voice Memos on my phone, closed my eyes, and started singing. What came out was the most beautiful and necessary release of emotions. I sang for 20 minutes with my eyes closed and recording the whole time. I listened back to what I was singing and found that a small song could come out of it. I began taking down the lyrics and melodies of the phrases I especially connected to. Over the next few days, I excitedly went home to work on this tune and couldn’t wait to share it with my peers.

Everywhere I look, someone is leaving and they won’t come back. They’re gone and I’m still here.

I found these words to be incredibly comforting in processing my feelings of grief and guilt associated with losing so many patients in the past few months. I am so lucky to have music as a skill I can utilize for coping; I feel like it was truly what I needed to release my pent up emotions and energy. Prior to beginning this internship process, I did not have sufficient ways to cope with loss. Below are a list of activities you can try as coping skills that have been suggested to me or that I have created for myself. My hope in sharing about grief is to bring light to a topic that is often glossed over, and to offer specific strategies you might be able to use if you find yourself in similar situations.

Strategies for Coping with Grief

The strategies outlined below are specifically for health-care professionals, and they are merely suggestions. They can be adapted to non-health-care-professionals and adapted to fit your specific needs in coping with grief.

Loving-Kindness Meditation

• This is my favorite meditation to practice; it’s all about sending loving-kindness energy to your loved ones, the world as a whole, and to yourself. The website attached here gives background on the meditation practice and provides a script that can be adapted to fit your needs.

Affirmations

• These are short phrases that can be used to validate where you are, or push you to where you’d like to be. There are many ways to approach affirmations, but I prefer: “I am _______ “ and filling in the blank with what I would like to be. “I am grounded, I have faith, I am healing.” It can also break this form and look like, “There is love in my heart.” These phrases can be repeated in a chant-like form with music in order to make it more powerful. You can create a short melody to match your affirmation and sing it over a drone.

Songwriting

• I’ve found that improvisatory songwriting is most helpful in coping. For this, I find a chord progression I like on my preferred instrument, start recording what I’m playing, and improvise lyrics and melody all at once. Recording it allows you to look back at what was said. You can also approach songwriting in a more structured way that aligns with your traditional songwriting practice. The important thing to remember when using songwriting as a coping strategy is to approach this process without judgement of yourself or your words.

Musical Improvisation

• Improvising using melody and harmony without any lyrics is also greatly beneficial. Sometimes the emotions we’re experiencing cannot be described using words, but by the combination of our fingers on a keyboard, strumstick, or HAPI drum. Musical improvisation for coping can be as structured or unstructured as you want. A supervisor once advised me to pick four random notes on the piano to improvise a motif. If you try sticking to just those notes for a motif, it can add an extra challenge and push your emotional expression.

Visual Art

• Creating mandalas, scrapbooking, collaging, drawing, sculpting, and painting are all fantastic ways to express our emotions and cope with grief. An interdisciplinary team member once recommended that I start a collage with things that remind me of specific cases. It’s a way to memorialize patients who pass that have a special place in our heart, so we don’t forget that and are able to process that experience.

Journaling

• Writing down feelings is often easier than verbalizing them to a loved one. Journaling is an excellent way to get your thoughts and feelings onto paper and begin to process.

Exercise

• For some folks, physical activity is a way to release emotions get their endorphins flowing. Running, dancing, walking, doing yoga, playing sports, swimming, among other activities are things you can try.

Disconnecting from technology

• Oftentimes being on our technology all the time does not allow us to remain in the moment. Try spending time in nature, or spending time with friends to challenge yourself to be fully present.

Moving Forward

The strategies detailed above are not meant to replace counseling services from a professional. If you suspect you may be in need of professional help, check out these resources:

• 5 Signs It’s Time to Seek Therapy
• How to Find a Therapist
• Online Grief Support Groups
• National Suicide Prevention Lifeline
• Crisis Text Line

Feelings of grief can be isolating; I hope this blog gave you an understanding that you are not alone, and that there are many coping strategies you can try and adapt to fit your needs. The past four months have been extremely challenging for me because of the cumulative grief that I have been experiencing and not processing. For the next two months I have left of internship, I feel like I finally have some concrete coping strategies in place to help me work through these tough times.

Even though the work is extremely challenging, I am incredibly grateful to be doing this work. Being part of someone’s last moments is a beautiful privilege and I cannot believe I am lucky enough to play a small part in that process for many folks. The beauty I’ve seen in many of these end-of-life sessions has been unparalleled. Though I am struggling with this work, I am grateful, I know I am not alone, and I have coping strategies to support me.