As a hospice clinician, I frequently walk into the rooms of comatose patients and find music being played (by CD player or other device). More often than not, this music is too loud, too stimulating/too varied in dynamic changes, and/or too incongruent with the patient’s musical preferences. This scenario is always a problem because it can cause a comatose person to experience discomfort, distress, disorientation, and agitation. This is especially troublesome because the comatose patient is often unable to verbally communicate their needs or make adjustments to their own environment.
In an effort to share solutions to this phenomenon, I have decided to provide some basic pointers that may help readers use music more effectively in efforts to create peaceful environments for persons who are comatose. The thoughts shared in this article are intended to address the needs of comatose patients who are incoherent and/or non-verbal. While I feel this information will be helpful, I would strongly encourage readers to consult the appropriate care team when introducing music to a comatose patient’s environment (especially if the patient’s care team includes a board certified music therapist!).
For starters, here is some introductory information about individuals who are comatose:
A person who is comatose experiences a state of unconsciousness that can occur for a variety of reasons*. A physician must conduct a series of medical tests to determine if a person is indeed in a comatose state. Once the diagnosis is made, a plan for treatment (of symptoms and/or the underlying cause of the coma) can be approached.
While in a comatose state, a person may appear unresponsive, and may not react overtly to sights, sounds, smells, or touch. A person in a coma may also display random/spontaneous movements, irregular respirations, and/or visual signs of agitation (i.e. grimace, respiratory distress, moaning/calling out, tooth grinding, clenching, restlessness, scratching at the skin, disrobing, and/or tugging at clothing/linens). If a friend or loved one is displaying any of the latter symptoms, music might be a good idea…but before you whip out the iPod, share your observations with the patient’s care team! I cannot stress this enough :O) There are several medicines and other interventions that the care team can implement to help your loved one with comfort and symptom management. Here are a couple more tidbits about being comatose:
1. Patients in comatose states are still partially aware of you! As such, they are still sensitive to your presence, your voice, your touch, the music that you play in their rooms, and other forms of sensory stimulation present in their environments (even if they don’t show it).
2. Individuals in comas are often easily agitated. As a result, sensory should be applied very carefully. Your friend or loved one’s care team can help you determine how much stimulus is too much.
Now for the music part!
Music can be beneficial to persons in comatose states for many reasons. Because music is familiar, it can assist a comatose patient with feeling a sense of normalcy as well as a greater sense of orientation to the environment. Since music involves structured patterns of sounds, it can help comatose patients with self-organization (of thoughts and bodily functions). As a diversional tool, music can aid comatose patients in achieving decreased levels of perceived pain and discomfort. Also, music (with its ability to convey human emotion) can serve as a non-verbal means of communication and family bonding.
Once you’ve consulted with your loved one’s care team, you’re ready to consider incorporating music into his/her environment. Remember that unless you’re a board certified music therapist, you should only use music to support a comatose patient’s comfort level (as opposed to approaching therapeutic domains such as stimulation, family dynamics/coping, pain management, etc). If you’re unsure how to go about accomplishing this, think Day Spa :O) Imagine that your loved one’s room has been transported to the Red Door. Now think about what that environment might look like…feel like…smell like…sound like…Inspired yet? If not, that’s okay lol Here are some important considerations that will help you when you’re contemplating music for a person in a comatose state:
1. Not everyone finds music to be soothing! If a patient didn’t seem to enjoy music while they were active, they may not be interested in music while comatose. Try not to assume that music will be the best medicine.
2. If you plan to provide music for a person who is comatose, be prepared to stay with him/her whenever music is playing. This will enable you to observe if the sounds are doing more harm than good (see above for my description of signs of agitation). Whatever you do, don’t switch on the tunes and then leave the room!
3. If you’re not sure how the music is affecting the patient, stop the music. Better safe than sorry.
4. If you find that you need to start or stop music, adjust the volume gradually instead of pressing the ‘stop’ or ‘pause’ buttons. This will help to prevent any abrupt/distress causing changes in the sensory stimulation being produced by the music. For this reason, I absolutely looooooove music players that have remote controls!
Here are some tips for using music to support a comatose patient’s comfort level:
1. Always consider the patient’s musical preferences when selecting music, then try to balance those preferences with music that features soothing characteristics. See Table One** below for some very basic descriptions of traits in music that are generally considered to be soothing.
2. Perceptions of music are very subjective. What seems soothing to one person may seem stimulating to someone else. This is another reason why it is so important to remain present with a comatose patient during music to observe his/her responses.
3. If music doesn’t seem appropriate, consider CDs that feature nature sounds (like ocean waves, forest creatures, running streams, or rain drops)
4. Music volume should be kept at a minimal level to prevent over-stimulation. Here is a good rule of thumb that I use when providing education to nurses and families on this subject: The volume of the radio/television should be so low that when someone walks into the patient’s room, they have to concentrate in order to hear it. This applies even if the comatose patient has had hearing loss (because comatose patients experience music on a semi-subconscious level, and need not be bombarded with loud sounds in order to experience music’s positive, comforting affects).
5. If you’re not sure that the music’s volume is appropriate (particularly because the radio/CD player is positioned several feet away from the patient’s ears), place your face right next to the patient’s. Go on lol get personal! Lean over, and place your head approx. one or two feet from the patient’s head so that you can experience the music from the patient’s perspective. If, while your head is close to the patient’s, you are just barely able to hear the music…turn it up a teeny bit. Adjust the volume level until you feel it’s just right, but quit poking your face into the patient’s face if this invasion of personal space seems to cause distress :O)
6. Music might be a good idea if the patient enjoyed music while s/he was active.
7. Music might be a good idea if the patient engaged in musical experiences while s/he was active (i.e. participation in a church choir, previous experiences playing instruments or dancing, etc.)
8. Music is probably a BAD idea if the patient never really liked music to begin with.
9. Music is probably a BAD idea if you notice that the patient seems calm during periods of silence, but seems agitated or distressed when music and other sound stimuli are present.
10. If a comatose patient begins twitching, jerking, rolling around in bed, or engaging in some other unorganized movement during music, (contrary to popular belief) the patient is NOT dancing!!! Instead, it is more likely that s/he is feeling distressed. Remove the music (by gradually reducing the volume) right away. Next, share your observations with the care team-especially if the movements don’t resolve on their own once the music has been removed.
11. Music can be combined with other comfort measures (i.e. fragrances, dimmed lights, or massage), but must be applied carefully to prevent agitation or discomfort.
12. Music should only be applied in accordance with a comatose patient’s care plan, and should include a board certified music therapist whenever possible (See my recent blog at http://creativeartsintherapy.com/music-therapy/music-therapy-in-medical-facilities/ for details about how to seek music therapy for your loved one if s/he is in a medical setting).
Here are a couple other factors to consider when contemplating music for a person who is comatose:
1. A patient in a comatose state may have a roommate who dislikes music. You may be able to compromise by negotiating limits for when music will be played, and at what volume. Another idea might be to use headphones for the comatose patient (but consider that the sensation of headphones might cause agitation or discomfort).
2. Often times, an inappropriate sound environment is the result of a roommate or staff member forgetting to switch-off the radio or television before leaving the patient’s room. This is especially true if/when the roommate or staff member is naïve to the potential affects of music on a patient who is comatose. If you notice this is happening in your loved one’s room, consult the care team with your concern. You can also place (polite!) little notes near the radio/television to specify the desired sound environment. For example, I once saw a note in a patient’s room next to the television that read “Our loved one has always slept with the television on. Please leave her television programmed to CNN so she can hear the news updates.”
When applied properly, music can be used effectively to create a soothing, comforting sound bath for a person in a comatose state. I encourage readers to internalize the information presented above if considering adding music to the environment of a person in comatose state. Having said that, I would like to remind everyone that only a board certified music therapist can provide an official assessment of a comatose patient’s responses to music. Music therapists are trained to observe and respond to spontaneous reactions during the assessment process, and can best prescribe a music-based program to help meet the needs of your loved one. For more information about finding a music therapist, visit the American Music Therapy Association at www.musictherapy.org or contact them by phone at 301.589.3300. Finally, please feel free to post comments, questions, and/or requests for texts/references related to this blog.
Until next time!
Ms. Terel Jackson, NMT, MT-BC
*For extensive information about comas, I recommend the following resources:
http://www.emedicinehealth.com/coma/article_em.htm
http://www.mayoclinic.com/health/coma/DS00724
http://people.uwec.edu/rasarla/research/coma/index.htm
If you have a loved one who is in a comatose state, his/her care team should also be able to provide education about comas.
**Table One
(Very!) Basic Characteristics of Soothing/Comforting Music
• Consistent/steady volume
• Consistent/steady tempo/speed
• Slow to moderate tempo/speed
• Simple lyrics, rhythms, melodies, and/or harmonies
• Music with no lyrics
• Music with few instruments
• Instruments made of natural materials (i.e. guitar, tone bars, cello, drums, mandolin)
(Very!) Basic Characteristics of Stimulating Music
• Frequent changes in volume level
• Frequent changes in tempo/speed
• Moderate to fast tempo/speed
• Complicated lyrics, rhythms, melodies, and/or harmonies
• Metallic instrumentation (i.e. metallic chimes, cymbals, bells, trumpets, trombones)
• Songs/compositions that impart imagery (i.e. movie sound tracks, operas, musicals, etc)