It's What You Learn After You Know It All That Counts

I thought I would devote my final blog post to processing how much I've grown throughout the past six months.

When I began my internship, I was proficient in guitar, meaning I could play simple chords and barre chords (although with some buzzing and sore fingers). I knew a few strumming patterns and a couple of picking patterns that I used over and over again. I could not read tab to save my life and playing licks was completely out of the question for me. My tone quaility wasn't great, as I strummed with the nails of my right hand. I can now say I have fully formed calluses not only on the tips of my fingers, but also on my left index finger from using barre chords and on the thumb of my right hand from changing the way I strum. My tone quality has improved immensely, I can play clear and clean sounding barre chords, and I have learned how to play diminished chords, which has helped expand my repertoire! I can read tablature (although it still takes me a while to figure out) and I have learned a lot of licks to familiar songs. I have seen such a great change in my guitar skills, which was something I came into this internship needing and wanting to improve.

I can remember back when I took the Arts in Medicine class at FSU, which was meant to give music therapy students a feel for interacting with patients in the hospital setting. I was TERRIFIED to even knock on a patient's door and ask if they wanted company. A classmate and I went together and saw patients because I was so uncomfortable going alone. I got nervous every time I had to interact with a new patient and took it personally when they turned me down. When I began my internship at Hospice of Palm Beach County, I was so nervous the first time I had to make a phone call to a patient's house to arrange an assessment visit. Now, I do it all the time, without fear! I have become so comfortable initiating relationships with patients, knocking on their doors, introducing myself to their families, etc. It's like I'm a completely different person.

When I got to HPBC, I was well prepared for their style of documentation. My music therapy lab class at FSU had us practice writing SOAP, DAR, and free-text style notes. My documentation was proficient, but I was so lucky to have supervisors that gave me a crash course in making my documentation more clinical
 and have seen such a huge improvement in my note writing abilities. They use SOAP here at HPBC and I have become really good at listening for a good "S" during my sessions, making sure I am observant and remember important details about the patient such as whether or not they were using oxygen at the time of my visit. I also had the opportunity to attend Russell Hilliard's session on documentation in end of life care, which really helped me think more about painting the picture of a declining patient. Since then, I've made it a personal goal to really capture the patient's hospice diagnosis within my notes.

When I started my internship at HPBC, I was bashful when interacting with other HPBC staff. I was hesitant to contact them if I needed to and was really shy about introducing myself when meeting them. Now, I can say that I have established great rapport with nurses, social workers, chaplains, CNAs, doctors, integrative therapists, bereavement counselors, and team supervisors alike. I've also met many employees who work in accounting, education, and human resources.

Something I was really uncomfortable with at the beginning of my internship was explaining music therapy to others. One of my competencies the first month of my internship was to write out seperate explanations for a doctor, a patient, and a patient's family. I got used to explaining music therapy to patients and families throughout my internship and even had a new HR employee observe a session that I led. I was able to explain the education and training needed to be an MT, the goals and care-plans that we are able to work on, the referral and assessment process, the outcomes, etc. I just forgot to mention the MAJORLY important fact that it is evidence-based!! At AMTA '11, I attended a session on how to explain music therapy to people and it really helped me pinpoint the important things to mention.

Throughout my practicum at Big Bend Hospice in Tallahassee, I worked a lot with imminently dying patients, but never really became comfortable doing so. I didn't know what to say when patients were unresponsive, or if I was supposed to say anything at all. I was afraid to see a dying person, scared that one would die while I was in the room. I have become so comfortable with death, it's kind of frightening. I know the signs to look for when death is imminent, I know the smells associated with it, I've even watched someone die before my eyes, which was difficult, but I did it! That's not to say that death has lost its sting. When a patient of mine dies, I do feel really sad and have to go through my own little grieving process and I never want that part of it to go away. To feel grief when a patient dies is human and I don't ever want to become numb to it.

At the beginning of my internship, I was completely uncomfortable using music to increase spiritual comfort and freaked out when I had to discuss spirituality and religion with patients. I've been so immersed in it now that I almost feel MORE comfortable playing and singing hymns and working on spiritual needs with patients than I do playing secular music. I had to overcome the nervousness I felt when patients asked me personal questions about my religious beliefs and had to think of things to say and ways to address those situations, which I have become really good at! I even led a session yesterday where the patient expressed to me her fear of God judging her and sending her to Hell when she dies. I was able to choose a song in which the lyrics discuss that fear, we discussed it and the song was able to bring her a lot of comfort. It makes me so happy to know that I can have an effect on a patient's spirituality even if their beliefs differ from my own.

I honestly cannot believe how much I've grown as a music therapist and as a person throughout the past six months of my life and I can't believe how quickly the time has gone!! I feel like I just started and now it's time to close this chapter in my life and begin a new one. Soon, I will be heading back to Tallahassee to complete my master's degree in music therapy. I will be continuing this blog throughout my journey, it will just have to take on a different title because one week from Friday, I will no longer be a music therapy intern.

Things I Would Not Have Made it Through My Internship Without

I can't  believe I only have three weeks left of my internship here at Hospice of Palm Beach County! These six months have really flown by! As my time here is coming to an end, I want to share with you the things that helped me succeed throughout this experience.

1. YouTube and Grooveshark: When patients and family members requested songs, YouTube became my saving grace! Without this website, I would not have been able to afford to buy the recordings in order to learn these songs. When I could not find a song on YouTube (for instance, spanish, creole, and yiddish songs) Grooveshark was extremely helpful! Just type in the song you need to learn, and you can listen to recordings by many different artists.
2. E-Chords, Chordie, and Ultimate Guitar: These three websites provided me with correct chords (most of the time) to songs that I learned throughout my internship.
3. Snark: A Snark is a guitar tuning device that clips on to your guitar! It measures frequencies by vibrations instead of by sound input, so you can tune your guitar while there are other noises in the room. This was AMAZING especially in the nursing homes when patients are screaming and such. If you are like me and cannot tune your guitar by ear to save your life, invest in a Snark!! You can order one from their website.
4. GPS: When I had to drive to a patient's house and the patient's chart did not include directions, this device became my best friend.
5. Tripod stool: Although it was uncomfortable and I felt like I was going to fall on my butt, I wouldn't have survived this internship without my tripod stool. It folded up easily and I could carry it with me to the nursing homes. This way, I didn't have to worry about finding a place to sit if there were no chairs in the room and I didn't have to worry about what was ON the facility chairs. Nursing homes can be scary places! I definitely felt a lot more comfortable sitting on my own chair.
6. Rolling cart: This has got to be the best investment I made throughout my internship. I bought mine at staples. I somehow managed to fit all of my repertoire books, my folding stool, some extra instruments (shakers, tamborines, etc), my purse, and my guitar into this thing! This made traveling to facilities A LOT easier than carrying everything and a lot more sanitary because I could keep all of my stuff in my cart and not have to put my guitar case on the floor of the nursing home. AMAZING. You should get one :)
7. NPR, therapist-preferred music: After playing a lot of the same songs every single day, I got really tired of listening to music. I found that the radio REALLY started to get on my nerves, so I decided to start tuning into my local NPR station. This was refreshing while driving in between sessions and also gave my voice a rest! If I were to listen to music that I enjoyed, I would probably want to sing along, but when you sing all day, it's good to take a little break. After work however, I listened to some therapist-preferred music. After singing someone else's favorite songs all day long, I found it really nice to just listen to some music that I enjoy!!
8. Exercise: After a long, emotionally taxing day, it was really good for me to just go to the gym and get some exercise. This helped me process what I experienced that day and clear my head so that I could be ready for the next day!
12. My dog: Moving to a new place for six months is hard especially if it's your first time living alone. Having my dog here with me has been so helpful. He eased my fear of living by myself and gave me companionship and love throughout this incredible adventure. I don't know what I would have done here without him!!!

What IS Music Therapy???

I've been thinking a lot recently about what really distinguishes music therapy from other uses of music in the therapeutic setting. During my internship, I have come across nurses who believe that volunteer musicians are "music therapists," chaplains who use music in their practice to facilitate spiritual comfort, and residents of nursing homes who constantly ask if I am the entertainment.

I am used to people being unfamiliar with music therapy and I have grown accustomed to having to explain what I do on a daily basis, but when I was presented with the idea of chaplains using music in the hospice setting to further facilitate a patient's spiritual comfort, I was forced to evaluate exactly what it is that I am providing that is different. What can I offer that a chaplain playing the guitar to help a patient express their spirituality cannot? What is it about what I do that cannot be done by a volunteer musician or by a recording?

Music therapy is so much more than just providing music experiences. Certified music therapists have completed a six-month clinical internship in addition to a four year degree program from an accredited university. Throughout our schooling, we take courses in psychology, counseling, abnormal psychology, anatomy and physiology, and applied music, in addition to our specialized music therapy classes. This comprehensive education provides us with the skills necessary to be more than just entertainers. We are therapists who use music as a tool to arrive at non-musical goals. We as music therapists do not "own" music, therefore, we can keep those who are not certified music therapists from claiming to be; however, we cannot prevent the use of music by other professionals. What we are trained to do that differs from what a chaplain does with their guitar when addressing spirituality specifically is assist patients in processing their feelings evoked by music, use song-writing experiences to elicit spirituality, conduct lyric analyses to engage the patient in discussion of spirituality, and allow the patient to participate in active music making in order to facilitate spiritual expression.

With music therapy making appearances in the media, awareness of the field is continuing to grow; however, we all have to do our part and advocate! Hopefully, one day, with all of our hard work, the term "music therapy" will be as well recognized  and understood as "occupational therapy" and "speech therapy."

Making the Transfers

Working in hospice has really allowed me to use the knowledge I have gained from the classroom setting and begin to apply it to real life music therapy situations. We spent a lot of time in my Music in Special Education course discussing adaptive instruments and how to make and utilize them in the special education setting. At this point, I had already accepted my internship in the hospice setting and didn't really consider the possibility of running into a situation during my internship where I would have to implement these skills. Turns out, I have a patient at a skilled nursing facility that was born without fingers. One of my competencies this month is to use rhythm instruments in a session, as that is something I don't get to do that often with a lot of my patients. As the month came to a close, time was running out to complete this competency, and I began to consider the possibility of implementing rhythm instruments with this particular patient. Digging through the music therapy department instruments here at HPBC, I discovered this:

It is a strap of bells that is able to be velcroed around the patient's arm or wrist. I cannot wait to use this with my patient tomorrow and cannot wait to tell you all how it went! The moral of this post is: never think you won't use a particular skill or bit of information from a class geared toward a different setting than the one you are going to be working with! :) That's all for today!

Predicting Death: Not an Exact Science.

In order to be qualified for hospice services, a patient must have documentation from their physician stating that if the disease progression occurs as expected, the patient will have six months or less to live. If a patient lives longer than six months, they are still eligible for services if they are still deemed "terminally ill" by a qualified hospice physician. Once admitted to the hospice program, the patient begins two ninety day benefit periods followed by an unlimited number of sixty day periods. At the beginning of each period, the hospice physician must reassess the patient and resubmit documentation if the patient is still appropriate for services. This is regulated by Medicare. If a patient is assessed and the physician no longer believes that the patient is terminally ill, the patient may "graduate" from hospice, however when the patient's illness progresses further, services may resume.

A few of the patients that I see have been on hospice services since as far back as 2008. Then there are those whose families wait until the last few days or weeks of the patients life to apply for hospice services.

When the patient's hospice nurse believes that the patient is becoming imminent (within a few days of death), the nurse will call in continuous care. Continuous care is a part of hospice services that allows for a continuous care nurse to be with the patient 24/7 until the patient passes away. This allows the family  to refrain from sending the patient to the hospital and helps relieve the family's stress at the very end of the patient's life.

Throughout my internship, I have seen quite a few patients that are on continuous care. Sometimes, these patients can be on continuous care for much longer than the expected few days. One man that I saw had a continuous care nurse at his house for over two weeks. Then there are others, who do not display signs of imminent death and therefore are not receiving the continuous care service at their time of death. This just goes to show that death cannot be predicted. There are certain signs that doctors and nurses look for toward the very end of life such as mottling of the skin (blue or purple coloring), apnea, and congested breathing (also known as the death rattle), but not all patients experience these changes.

One patient that I have been seeing since the beginning of my internship passed away on Friday morning. This woman had a diagnosis of Alzheimer's disease and when I saw her last week, she was the same as she had always been. I was definitely shocked to see her name on the discharge list that day. I know that I am interning in hospice and that all of the people that I am working with are terminally ill, but I did not see her death coming at all.

Throughout my internship, many patients that I've seen have passed away, but this was the first death that I was really affected by. So what do you do when a patient that you have grown close to passes away somewhat unexpectedly? You have to allow yourself a few minutes to reflect and process what has happened. It's inevitable that working in hospice, you are going to lose patients that you really enjoyed working with, but it's still incredibly important that you allow yourself to feel whatever feelings arise. It's difficult work, but it's also extremely rewarding and comforting to know that you made a difference during the end of somebody's life.

How do those of you working in hospice take care of yourselves when a patient dies?

Draco Dormiens Nunquam Titillandus: Let Sleeping Dragons Lie.

   
A Harry Potter reference was bound to occur at some point throughout this internship! The Latin phrase "draco dormiens nunquam titillandus," the Hogwarts motto, literally translates as "never tickle a sleeping dragon," but the more commonly heard translation is "let sleeping dragons lie." I was reminded of this saying today when I went to visit one of my patients in a skilled nursing facility (SNF). When I got to her room, she was asleep, so I was forced to decide whether or not I should wake her up for music therapy. This tends to happen quite often especially with patients who reside in SNFs. What I've learned from my supervisors is to consider the patient and their goals, objectives, and reasons for receiving music therapy in the first place. For someone with Alzheimer's whose goals are increased sensory stimulation and/or improved communication, it might benefit that person to wake up and participate in a short music therapy session. There are some patients however, that I've learned to just let lie as the saying goes. Patients that I would typically not wake up for music therapy include those who are extremely anxious or whose care plans include agitation. There is one patient with a diagnosis of Alzheimer's disease who often exhibits many symptoms of PTSD. This man is a World War Two veteran and was also a prisoner of war during that time. He believes that his roommate in the SNF is his cellmate and frequently makes references to pistols and bombs. During one session with this patient, he spilled crumbs on the SNF floor and began yelling "THEY'RE GOING TO REPORT MY GI NUMBER.. THEY'RE GOING TO REPORT MY GI NUMBER!" One morning, I was at the SNF with my supervisor and this man was sound asleep in his bed, looking the most relaxed I had ever seen him. My supervisor's decision to let him sleep on that day taught me a lot about assessing the patient's needs in the moment and determining an outcome that is ultimately going to be the most beneficial for them.

Death is Universal: A Note About Hospice Music Therapy

In the growing field of music therapy, there are many settings in which one can work. Each setting is unique and requires techniques and skills specific to the population that exists within that setting. Music therapists in the special education setting have different goals and interventions than music therapists in a psychiatric setting and both of those differ from music therapy in the medical setting. I have discovered throughout my internship that the hospice setting encompasses aspects from all of the aforementioned settings. If there is one thing that all humans have in common with one another, it's the fact that we will all, at some point, cease to exist. This fact is what makes the hospice setting so diverse. So far, during my internship, I've worked with adults with developmental disabilities and also with patients and families with psychiatric diagnoses including OCD, PTSD, substance abuse, and eating disorders. Of course the goals for music therapy in the hospice setting will differ from those in special education and psychiatric settings, but it is still an interesting point that I've come to realize throughout the first half of my internship.