John looked at me quizzically. “I'd never really thought about it,” he said, “But I think I'd like music during the procedure.”

As a music therapist based in Canada, I have been present at the bedside of many patients who have received assisted dying.¹ I’ve sung or provided patient’s specifically chosen music. Many patients have created playlists, choosing a “final soundtrack,” or have participated in music psychotherapy sessions at bedside prior to their assisted death.¹

John’s case was different.

John and I met on the palliative care unit of the hospital where I work. He shared some of his most treasured memories, prompted by songs that represented various life events, or lyrics that resonated so deeply that he would be moved to tears as he quoted them. “Ring the bells that still can ring, there is a crack in everything,” he smiled. “That's how the light gets in,” we said in unison. “Leonard Cohen…”, he trailed off as his eyes welled up. “I can’t really explain.”

The practicality with which he spoke about his decision to have an assisted death was striking. He was clear and firm in his request. Yet alongside his practicality, he revealed a side that opened up to the possibilities of having music accompany his death, to paint the soundscape of his hospital room prior to his procedure so that both he and his family could connect over shared memories and feelings.

As a music therapist I support patients physically, emotionally, and psychosocially.^2,3 John and I worked on breathing and relaxation techniques, coupling a symptom management approach with a broad look at how music told John’s life story.^4,5 On the morning of John’s procedure, interdisciplinary rounds were bookended by a team discussion. “Two o’clock, that’s when the doctor will arrive,” Dawn, our clinical nurse specialist, told us. “I’m going to meet with the family to make sure they have this playlist,” I said, holding up an iPod, aware that I wouldn’t be present during the procedure.

As I left rounds, Dawn stopped me. “The patient in 415 wants to see you,” she said. I made my way to John’s room where his siblings had gathered outside. His brother sighed when he saw me. “John asked for you, he’s in a lot of pain.” John was lying in bed with his eyes tightly closed, his brow furrowed. I sat next to him, and touched his hand. “John? It’s SarahRose,” I said quietly. John slowly opened his eyes. “Can you play? They’re saying two o’clock, but I want this now, and I really don’t want any meds. Could you play?” I quickly went to get my keyboard, which sits atop my mobile musical cart that travels with me from patient to patient. Dawn pulled me aside in the hallway. “He’s refusing pain meds, he’s worried that drowsiness might affect his chances of getting approved. We’ve offered but he’s declining. Anything you can do would be great.” One of the legal stipulations of the procedure is being able to give informed verbal consent right before the intervention. I saw John’s wife leaning over him, her head buried in his neck. We locked eyes. I stood close enough that I could watch John’s breathing, and far enough away so that his family could sit at the bedside. Ten o’clock in the morning. I began to play.

I tailored slow keyboard chord progressions to his respiratory rate, trusting the principles of neuro-entrainment, knowing his breath would eventually synchronize with the music. This would activate his parasympathetic nervous system, sending signals to his brain to trust that any threat was at bay. Nurses came in and out quietly. John occasionally opened his eyes “Can you stay? It helps,” he whispered. I smiled. “I’m here, John. I’ll stay.”

Time passed. The palliative care physician arrived. “The intervention doctor is coming at two, but we are trying to see if he can come earlier. I’m sorry John”. I glanced at my watch. Eleven o’clock. John moaned. “I just want to die now!” The doctor bent down. “I know. We’re doing everything we can. Can you stay focused on the music?” Time wasn’t passing fast enough.

I tempered the volume of the keyboard and the style of my improvised vocalizations as John’s family took turns reassuring him. I modulated through major and minor keys, employing both neutrally associative modes and intimately familiar songs as John went in and out of sleep. “You’re what’s getting me to two o’clock, you know that right?” he whispered. I smiled at him, and at his brother, who smiled back with tears streaming down his face. Eleven thirty. Emma, one of the nurses, stepped into the room. “You ok?” she whispered. I nodded. An automatic response. Eleven forty-five. I had not stopped playing.

“Remember those car rides out to the country when we were five, John? You guys made me sit in the middle and you’d pull my hair,” John’s sister laughed, wiping away tears. John smiled, eyes closed. Reminiscence. “Your life inspires us. Please know that,” his brother said, taking the tissue box from his sister. Reflection. It was noon. I had begun to realize that I would be here at least until the intervention doctor arrived. John had invited me into the sacred ritual of saying goodbye: of witnessing, of parting, of suffering, of dying. Drawing on soothing lullaby modalities and familiar folk songs, making use of meter changes and texture shifts, I trusted that the music was holding the space for John’s family. One fifteen p.m. “I don’t know how you’re doing this right now,” John said, looking up at me. “How do you have the stamina?” Laughter. “I’m wondering the same thing about you,” I said grinning. He sighed, a tiny smile. His wife leaned in. “You’re almost there.”

Ten minutes past two. The doctor walked in. I felt my knees buckle. “I’m so sorry I couldn’t be here earlier, John,” he said kindly. “I know you’ve been struggling.” “Yes, now. I’m ready,” he said. The doctor nodded to Dawn. “I just need to ask you a couple questions. Protocol. It won't take long, I promise.” The doctor gently took John through a series of questions, ensuring that he indeed wanted to receive medical assistance in dying. He explained to John’s family that John would fall asleep when he administered the first medication. I continued to play softly. “John?” I asked. “Do you want me to stay? It’s entirely up to you” John locked eyes with me. “Stay,” he said firmly. His wife nodded. My eyes met hers. “Hallelujah. And Anthem,” John said. “Can you sing me through this?” I smiled. “I’ll be right here.” The doctor pulled out the syringes and looked around the room. “Ok, John. It’s time.”

“I heard there was a secret chord, that David played and it pleased the Lord, but you don’t really care for music do you?” I slowly arpeggiated the C major and A minor chords in a lilting triple meter. John’s eyes closed as his veins filled with medication. “There is a crack in everything,” I sang softly. “That’s how the light gets in.” John’s family held each other as he stopped breathing.

“Time of death, two thirty-two p.m.,” the doctor said quietly. “Thank you all so much for being here for him.”

D major seven. F sharp minor seven. G major. Fade. Stop.

I exhaled and quietly left the room.

Months later, I was sitting in a coffee shop on a rainy Saturday morning with a friend. The mellow opening guitar riff of Jeff Buckley's Hallelujah cover had begun to seep into our conversation, piped into the coffee shop through a barista's playlist. My friend, a palliative care physician, looked at me. “Everyone has a story about this song. Why?” he asked, putting down his mug. “I don't know,” I shrugged. “It just seems to be one of those songs that tells everyone's story, no matter what the story is.” “Maybe,” he nodded.

I thought of John. There is a crack in everything. That's how the light gets in.

References

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