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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.47 no.3 São Paulo June 2013

http://dx.doi.org/10.1590/S0080-623420130000300015 

Artigo Original

Musical meetings as a resource in oncologic palliative care for users of a support homes *

Vladimir Araujo da Silva I  

Catarina Aparecida Sales II  

INurse. MSc in Nursing. Member of the Nucleus of Family Studies, Research, Assistance and Support of Universidade Estadual de Maringá. Maringá, PR, Brazil.vladimir_araujo_silva@hotmail.com

IINurse. PhD in Nursing. Professor with the Postgraduate Program in Nursing of Universidade Estadual de Maringá. Member of the Nucleus of Family Studies, Research, Assistance and Support of Universidade Estadual de Maringá. Maringá, PR, Brazil.casales@uem.br

ABSTRACT

This was a phenomenological investigation into musical meetings, structured according to the existential analytics of Martin Heidegger, that aimed at scrutinizing the perception of patients with cancer living in a support home. Seven users of the support home of the Rede Feminina de Combate ao Cancer in Maringá, Paraná, took part in the study, during which eight musical meetings took place during the months of January and February 2011. For the purposes of data collection individual interviews were used, starting with the following question: What do these musical meetings represent to you at this time of your life? During the process of understanding the investigated phenomenon, two ontological themes emerged: a feeling of being taken care of in the musical meetings; and transcending their existential facticity. It was observed that a meeting mediated by music represents a resource in oncologic palliative care nursing; and that it brings inspiration to the patients' daily life, instilling a feeling of being cared for and giving a new meaning to their being-in-the-world.

Key words: Oncologic nursing; Music; Music therapy; Palliative care

INTRODUCTION

Scientific and technological advances in the diagnosis and treatment of cancer have increased cure and survival rates, and improved patients' quality of life. However, the complexity in which the individual and his family become immersed transcends comprehension(1), because cancer carries a social stigma involving the connotation of pain, suffering and death(2).

In Brazil, the reduction in mortality and birth rates has increased life expectancy, leading to an aging population with a greater incidence and prevalence of chronic degenerative diseases such as cancer(3). The National Politics of Oncologic Care (PNAO), consolidated on 3 September 2009 by Government Directive n. 2048, recognized cancer as a public health problem and established systems of health promotion, prevention, diagnosis, treatment, rehabilitation and palliative care to reduce its incidence and mortality(4).

However, many sick individuals still need to travel to major centers to access the necessary resources for treatment. The vicissitudes of such travel, together with physical weariness and financial costs, make such journeys difficult, and so patients stay in support homes during the week. However, apart from the cancer diagnosis and the adverse effects of treatment, the absence of their relatives brings feelings of sadness, abandonment, insecurity and failure(5).

Palliative care is a philosophy of care that improves the quality of life of individuals suffering life-threatening diseases, preventing and relieving suffering by early identification, correct evaluation and treatment of the pain and other problems, whether physical, psychosocial or spiritual(6). Based on philosophical and humanistic principles, countless initiatives have been instituted, such as the use of music as a therapeutic resource, both for its multidimensional contributions and for enabling the expression of affections, emotions and gestures, which are often forgotten in the face of imminent death, transcending fragmented and inhuman care(7).

As a health intervention, music transcends the domain of symptoms and emotions, encouraging closeness between individuals and personal introspection, imbuing life with understanding and a sense of unity with an experience that is both subjective and yet integrates all human dimensions(8). In institutional environments the therapeutic potential of music can improve vitality, evoke reminiscences and facilitate interpersonal relationships and communication, favoring the restoration of healthy feelings and transcendence in situations of pain, suffering and death. In the context of fragility and vulnerability, music becomes an invitation to the art of meeting and interaction(9).

The interest of nurses in using music as a resource has been increasing, and research has shown its importance in the humanizing of care(10). In the environment of individuals involved with terminal cancer, it has been proven that music brings pleasant sensations and contributes to the comfort and wellbeing of both patients and their families, bringing meaning to their days, increcareasing feelings of happiness and making patients more communicative, as if the disease has been suspended in time and space; it represents a psychosocial and spiritual support creating the strength and courage to overcome the anguish of their existential condition(11).

Considering the above, the objective of this investigation was to investigate the perceptions of individuals with cancer staying in a support home with regard to musical meetings intended as a group care strategy with music as a therapeutic resource. The incentive of music incites expression and interaction, narratives and dialogue; it promotes comfort and wellbeing and reduces anxiety, resulting in the elaboration of coping strategies(1). Taking into consideration its potential as a resource in nursing care, as well as the need to implement creative therapeutic resources, we sought to verify the importance of musical meetings in oncologic palliative care.

METHOD

This was a phenomenological qualitative study, structured according to the existential analytics of Heidegger(12). This philosophical referential subsidizes indispensable resources to disclose phenomena, the singularity, subjectivity and authenticity of others' way of being, as well as sensitizing nurses to reflect on their experiences, in their existence as caregivers(13). The phenomenological approach allows the researcher to become absorbed in the quotidian of the human who seeks to understand that is, it brings him closer to the world of the other. Following these thoughts, the researcher believes that lived experiences give meaning to each person's perception of a particular phenomenon, it being the goal of phenomenological research to describe the lived experience and the perceptions it brings(14).

Therefore, the inquiry area or ontological area embraces the latent subjectivity in the existence of users of the support home of the Rede Feminina de Combate ao Cancer (RFCC) of Maringá, Brazil. This is a nonprofit organization that welcomes approximately 25 users a month, adults of both genders who are undergoing outpatient treatment. Patients come from other municipal districts and States to undergo chemotherapy or radiotherapy in Maringá, and from Monday to Friday the home offers bed, bath, food and free transportation to the relevant clinic or hospital. Independent of the patient's clinical situation, a companion is allowed but not obligatory.

The research project was evaluated and approved by the Permanent Committee of Ethics in Research Involving Human Beings (COPEP) of the State University of Maringá - UEM, Report nº. 614/2010, for observing the ethical aspects delineated by Resolution 196/96 of the CNS-MS. Following authorization from the president of the above-mentioned organization, the familiarization stage began with the scenario of the study and the approach to users.

To describe the musical meetings with transparency and specificity, the guidelines recommended for reports of musical interventions in the health area were adopted, always considering the complexity of musical incentives and other factors, such as the choice of music, the way it is delivered, or the combination of music with other intervention strategies(15).

When the users noticed the presence of one of the researchers, he introduced himself, talked about the musical meetings, and because of the show of interest, tried to identify their musical preferences so as to better plan the intervention and involve everyone.

In this way, the songs that composed the repertoire were selected by the participants in advance, and during the meetings they chose the ones that they would like to hear at that precise time. The songs they chose most often after the intervention were: 'Hold in the Hands of God' in the key of A major, 'My Enchanted Kingdom', in the key of B major, 'The Day I Left Home', in the key of E major, and 'The Ipe and the Prisoner', in the key of G major , with quaternary and ternary predominance of rhythms.

Music can welcome and promote the establishment of relationships and bonding for a humanized conception of nursing care, reducing the sensation of impersonality. It may increase self-esteem, provide comfort and wellbeing, and stimulate the autonomy of the client by allowing his or her participation in the choice of repertoire(10). Its use as a resource can have significant results by mobilizing emotions connected to the listener's past, and by providing amusement and entertainment(8). It intensifies the process of relaxation in the individual, encouraging the exposure of perceptions, emotions and hidden feelings.

During the months of January and February 2011, eight musical meetings ,took place on Mondays, starting at 5:30 pm and lasting about an hour and a half, so as not to exhaust the participants, taking into account the weakness caused by chemotherapy and/or radiotherapy, as well as the fatigue due to the sometimes long and exhausting trips home on the weekends. This schedule was established so as not to interfere in the routine of the institution and to offer the therapeutic resource to all users, taking into consideration that in the mornings or afternoons the patients go to the clinics or hospitals for their treatments.

The intervention strategy was a musical concert, in association with the patients' expressions and interaction. The method of delivery was live music - voice accompanied by a six-string Tagina Dallas guitar, as well as 10 copies of printed material containing the lyrics for the participants (a suggestion made by one of them at the first meeting), a Hunter(r) music stand, and chairs and sofas laid out in a circle, with the intention of encouraging interaction by the group.

The musical program was conducted by the one of the researchers (musician and male nurse with clinical experience) with the participation of users, at a volume pleasant to the ears. The meetings took place in the social room, where employees, users and beneficiaries of RFCC usually have access. The surrounding environmental noises did not interfere with the outcome, as in that room the users usually watch TV, talk with friends, or even fall asleep on the sofa.

Twenty users participated in the musical meetings: eight in the first, 11 in the second, eight in the third, 12 in the fourth, nine in the fifth, eight in the sixth, seven in the seventh and four in the eighth. However, only seven users were the subject of research, because they took part in at least three meetings, an established criterion for inclusion in the study. It is pointed out that group interventions in can add value in terms of support to participants, and that the therapeutic effects of the social interaction can transcend those of the intervention itself(15).

For data collection we used field observation and individual interviews, which took place in each user's room, the environment in which they experienced the most subjective nuances of their existence. The invitation to participate in the study was through the Term of Free Consent (TCLE), which covered the objectives of the research, the guarantee of privacy of the information obtained, and anonymity whenever the results were published.

In phenomenology, the researcher 'tries to enter into the world of the informer, to have full access to his experiences', through participation, observation and introspective reflection(14). Therefore, the observation notes registered in the field diary enriched the data analysis. To unveil the feelings of the individuals who experienced the researched phenomenon, the following guiding question was formulated: 'What do these musical meetings represent to you at this time of your life?'

With the intention of capturing the full expression of the subjects in their own languages, we opted for individual analysis of each speech. Thus, attentive readings of each deposition were carried out, separating the texts or units of sense (US) that were shown to be fundamental to the individual's existence. Subsequently, the units of sense were analyzed; a phenomenological selection of each subject's dicourse was carried out, because a unit of sense is, in general, composed of feelings that contemplate the ontological interrogation(16). The speeches were transcribed and interpreted in the light of some of Heidegger's ideas, as well as those of others that study the subject.

To avoid designating individuals in a generic fashion, the names of musical notes were used as pseudonyms. These are symbols that represent the duration of notes, as well as the discourses revealing the reality of life at the support home.

RESULTS

In the process of understanding the investigated phenomenon, two ontological thematic emerged: feeling taken care of in the musical meetings; and transcending their daily reality.

Feeling taken care of in the musical meetings

In Heidegger's philosophy, tuning, or affective tonality, represents one of the three essential behaviors used by an individual to reveal himself to the world(12): A tuning is a way, a melody to which the man is immersed and that supplies him a certain tone, which adjusts and determines the way he should be(17). It is the condition of playing and being played, of being able to share feelings with others.

In this way, the musical meetings encouraged the tuning of the study subjects, revealing how they felt taken care of by special attention from the nurses, with the therapeutic effects of the music and the opportunity to express their feelings and share life experiences.

These meetings for me were the most wonderful thing! Because I could calm down, it made me happy. I loved it; I adored it ... it made us marvelously well. We were very happy. It alleviated our anxiety ... It is very good to watch you sing, listen to what you say, the force that you give us (Semibreve).

Oh! It represented a lot of peacefulness ... It was a very big support that we received ... We feel safer, calmer ... That helps a lot in our sickness ... We stop thinking nonsense ... It seems that the things every day are getting better ... What I liked the most was the affection and your sympathy, of communicating with us ... If we had it twice a week it was would be better. We had more time to reflect ... I didn't worry so much, I was less concerned (Minim).

Ah! I tried to live that moment ... I tried to be happy in that moment ... It seems that the week is better. The music helps a lot. ... When you are singing... You are not remembering anything. You are living that pleasant moment. You look at one face, look at the other, you know! You see people participating, you see people singing. I sought on at that moment, to forget the rest ... Ah! I think it is cool what you are doing, very important... for us, in at this moment... so hard on our lives ... Perhaps, like this... in your face, in your glance, in the way you look at me, I notice an affection that in my house I don't have (pause/cry). ... Perhaps I don't find it in the people that I wanted to find, I don't find.... (cry) (Semiquaver).

Ah! For me it was good. You grow with the group, our partners. We are in a group of people that come from different places. It is a companionship, a fun way for us and also a form of promoting harmony, a wellbeing, among the group and even a wellbeing for us. It is good! You start to relax, loosen up. ... My own problem is a light cancer, but we feel fragile, I think. And there are songs that touch us very much (Demisemiquaver).

Transcending your daily life

Another important aspect in Heidegger's existential analytics is the capacity to understand the transcendental: Being-there, that is, 'that individual is capable of, by himself, through reflection, transcending himself, that is, of existing', being projected beyond himself discovering his own sense of being-in-the-world(18). Thus, the musical meetings gave the study subjects indispensable resources to transcend the reality of being-in-the-world with cancer, and gave a new meaning to the reason for going through the treatment in an unfamiliar environment.

Oh, I found it wonderful! Because we arrive here, we are alone, we are far away from home, we are sad.... (pause/cry). We already arrive already reminding remembering that on that day you come;, then when you go, it seems that we take that peace with us. ... Then later I lie down in the bed and I remember. ... Every day passes faster and the nights also, for us to leave. ... Because it is not easy to be here we can hardly can wait for Friday, to go home. There, already remembering that we will return on Monday, but that on Monday afternoon we have you, to cheer us (laughter). It is pleasant to wait for that afternoon (Crotchet).

It is good! Our hearts become more cheerful. And the suffering is plenty, but in the music hour we are happy and we forget a little the treatment, the past, the things that we are going through. But, it is very good to sing, to pray, to sing to God. It is the most beautiful thing (laughter).... Everybody joins in, the friends, with some faces... each one different from the other. ... To cheer! To please the eyes! Praising life (laughter), to know that living is the most important thing. I have a lot of people waiting for me (laughter), my grandchildren, children, and I have to hang in there, firm, not giving up. ... It is one hour that passes calmly. You don't even realize the hour has gone. (laughter) (Quaver).

To me the music brought liberation... of my soul. ... The praise is, as it is said, who sings, your evils frighten. It brings happiness inside our hearts, which doesn't give leaves no room to be thinking negative thoughts ... Music is something very special for the sick people. And also the affection that you have with all the people here. ... Everybody is here in retreat, in treatment, ... everybody depressed, ... and listening to music, uau wow! It changes of a lot the life of each one. As for me, it was great! I didn't use to sing! I didn't know how to sing. I was I oppressed and depressed, nor and even in the church I didn't used to sing. I opened myself here, with the suffering on behalf of Jesus. Praising God and singing. ... I was a sad woman, full of inferiority complexes. And with the cancer, I became even sadder, without any vitality or anything in life. It seems that I had stopped in time, I had closed myself in a world that was mine alone. I didn't share it with anybody, it was closed. ... From now on I will sing. ... Sometimes we don't even notice that we have been slaves to ourselves. I was a slave to myself and I didn't know' (Hemidemisemiquaver).

DISCUSSION

When he finds himself being-in-the-world, the individual also discovers himself as being-with-the-other: that is, he visualizes the possibility of being with somebody, not just as an object of care, but in an involving and significant way(12). In that respect, I understand that for Semibreve those moments of mutual opening that bring her out of hiding to live for a time in the clarity of life, will strengthen her to face her reality.

The existential phenomenology of perception analyzes the body not as a physical organism, but as a whole, a structure related to the things that are there: in other words, the sense is something that happens in your own body. Thus, the body is a 'work of art, as in knots of live significances; the tactile, visual and hearing perceptions are always part of a gesture. The body is a group of significances lived in the sense of your balance: a new knot of significances'(19).

The context allowed an understanding of aspects of the nonverbal communication expressed by Semibreve during the musical meetings, when she closed her eyes and leaned her head on the sofa, invaded by the music as if it roused the life made dormant by the cancer. In fact, bodily language is always associated with a meaning, which can be adaptive, expressive or defensive, conscious or unconscious(9). The behavior of Semibreve reflects the intention of hiding the intensity of the emotion or feelings experienced at that moment, or of isolating, leaving her existential condition, carried away by the music.

In Heidegger's philosophy, existence does not itself bring in a commonly used definition of reality, such as the existence of a tree or a stone, but rather a portal for the Being-there to open up to the world. This openness of man to relate with the world (Being-in) Heidegger denominates Being-there illumination, basically in that clarity that any meeting becomes possible, which can happen in an authentic or inauthentic form (genuine or impersonal)(12).

Thus, the language of Minim suggests that the musical meetings gave her the sensation of not being-alone in that moment, and the consciousness that someone worried about her, about her existential fate, in this way silencing her anguishes and worries. Especially when she says 'we stop thinking nonsense', it shows that the music did not just have the capacity to fill the emptiness of her soul, but was a coping mechanism that allowed her to reflect upon her being-in-the-world with cancer, softening the negative thoughts that appeared in her moments of solitude.

In terms of existence, the human being can develop as a caregiver, becoming a true discloser of his own being, looking for possibilities of wider openings originating from his own capabilities. When Minim says 'it seems that things are getting better every day', she implicitly reveals that through music the nurse can be present with the sick person, transforming the discomfort to comfort. In palliative care, the role of the professionals is sometimes to cure, frequently to alleviate, and always to comfort(20).

In Semiquaver's discourse, the musical meetings also represented moments of forgetting the sadness of being with cancer. And, when she says Oh! I tried to live that moment (...) be happy in that moment (...) to forget the rest, it shows that through the musical meetings and the thoughtfulness received, she could forget her fears and forget for a moment her existential condition. However, when saying in your glance, in the way you look at me, I notice an affection that I don't have at home, Semiquaver lowers her head and cries in silence. The user's speech and body language lead us to think that, at that moment of her life, she felt deprived not only of her health, but also of thoughtful gestures from her family.

Music is a universal language with multiple communication possibilities that encourage one's mutual existence. However, it is the nonverbal communication that underpins the demonstration of affection, compassion and solidarity. The look assures the presence and the importance of the meeting at that moment(9). Thus, Semiquaver felt welcome in the meeting, mediated by the music.

In Heidegger's philosophy, if on the one hand the inauthentic existence harms the moment of meeting among individuals, the authentic opening reveals in itself the capacity of Being-there to manifest attitudes of companionship for oneself and for the world around one(12). Demisemiquaver states that the musical meetings represent a moment of social interaction with the individuals that became co-present in her temporality at the support home. Structured in the nurse's intention of care giving, in the co-construction of an atmosphere of physical, emotional and social reconstruction, the musical meetings promote comfort and wellbeing, resulting in growth and strengthening of the patients to cope with the vicissitudes of their life with cancer(1).

The music facilitates the meeting of the nurse with the patient and stimulates the communication process, encouraging the expression of different emotions, perceptions of and reflections on the time already lived(1). Also referenced in the philosophical presuppositions of palliative care, communication, an essential attribute of interpersonal relationships, should be emphatic and compassionate, providing support and nourishment at the end of life and expressing with words and attitudes messages that denote attention and care(21).

The Being-there in his being-in-the world does not exist in an isolated fashion because there other worlds around: Mitwelt and Umwelt, the first representing the world of the individuals around you, and the second related to the entities around you(18). In saying we are alone, we are far away from home, we are sad, Crotchet is referring to the absence of relatives and the shelter of her home, absences that caused her to immerse herself in an existential solitude, so that it often became difficult to reach her.

Crotchet's words imply that the tears that marked the intensity of her suffering were replaced by thoughts of peace and happiness, and that the musical meetings gave her the interior peace that comforted her heart, leaving good memories, which were revived in the silence of the night. The expectation of each meeting strengthened her in her temporality, when she says It is pleasant to wait for that afternoon. Thus, the anxiety caused by the monotony of her environment was softened, because the musical meetings helped to make that temporality less sad and encouraged her in her transcendence, bringing meaning to being in the support home.

In Quaver's language, the music led her to partially forget her situation at that moment of her life. She was happy to be part of the group, to be accepted by others, especially when she praised God, giving thanks for the gift of life, because, for her, to live is the most important thing.

Concerning the spiritual dimension, music comforts and enables the expression of spirituality; it allows the manifestation of feelings and uncertainties about the meaning of life and its finiteness(22), connected to hope and fear. In Heidegger's existential discourse, if on the one hand the Being-there relates the fear to a malum futurum, it visualizes in hope the development of a bonum futurum, because hope brings to the Being-there the necessary strength to emerge from anguish to new possibilities. The one that has hope is carried, so to speak, by himself to inside the hope, opposite to what is expected (12). In Quaver's discourse the radiotherapy treatment brings her fear in relation to her future; on the other hand it revives the hope of returning home to her family, without the cancer.

In the analytics of the Being-there, anguish represents an ontological possibility that reveals the person's ontic horizon as being. However, that revelation of Being-there emanates from an opening to the world, with disposition and understanding, because anguish originates in the individual himself in proportion to his perception that he is being-thrown-to-death. The philosopher points out that although anguish does not eviscerate an individual afflicted and disturbed by fear, it frees Being-there of his null possibilities, making him free to assume the concrete possibilities of his existence. It is in the anguish that the abandonment of the individual to himself is revealed(12).

The music brought me liberation of my soul. In the words of Hemidemisemiquaver, the musical meetings aroused in her the capacity to attribute a new sense to her being and pick up the pieces to which she was reduced, entangled in daily banalities. In anguish we become prisoners in our being-in-the-world. That belief is corroborated by the final words of Hemidemisemiquaver: Sometimes we don't even notice that we have been slaves to ourselves. I was a slave to myself and I didn't know. Nevertheless, when she stated, From now on I will sing, the music helped her to overcome her anguish and free her from her decline, manifesting her power of transcendence over the world and over herself.

CONCLUSION

This investigation allowed us to see that the musical meetings complemented the philosophical principles of palliative care because they brought life to the days of those with cancer: the sensation of being taken care of; bringing new meanings to being-in-the-world with cancer and coexisting-in-the-world with it; giving sense to living and being-in-a-house-of-support. In fact, the music mediated the co-presence among the users, making it possible to share experiences, expectations and coping strategies - in other words, the possibility of being-with-the-other in their existential reality.

Providing a resource of communication that encourages the tuning of being to be unveiled, the nurses revered the users in their wholeness and complexity, leading them to a transcendental experience: to reflect upon life and death. The insipid environment of the support home, which seemed to delay the experienced temporality, and the scenario of suffering, anguish, fear and deprivation, vanished in face of the supereminence of the music, because the musical meetings revived the hope for cure, showing a horizon of possibilities and allowing patients to accept their condition and to rush into can-be.

In the disposition of be-with those individuals in their world , the meeting mediated by the music brought together the caregiver-being to the being-sick, and the valorization of his musical preferences transmitted receptivity and the impression of not being-alone in his pilgrimage, as opposed to the biotechnological - scientific paradigm and the inauthentic care extant in the health arena. The palliative intention of comforting was rendered, to alleviate the pain and suffering of those individuals, thereby improving their quality of life.

In pondering over the estimates of cancer incidence in Brazil and the restricted availability of therapeutic resources, the support homes stand out as a resource before the need for patients to be welcomed during their treatment. Also highlighted is the importance of implementing university extension projects exploring music as a care giving resource, offering palliative care and building an atmosphere of humanized and interdisciplinary care in order to raise the interest of university students in this noble cause.

Although this is an isolated initiative, representing above all a qualitative study that does not allow generalizations, the results of this investigation may contribute to the popularization of that philosophy of care and expand the several possibilities of its application, inciting new proposals of interdisciplinary articulation between nursing care and the therapeutic properties of music.

In conclusion, there remains the invitation to reflect upon our being-in-the-world taking care, and to consider music as an innovative therapeutic resource that can contribute to the science, the foundations and the art of nursing.

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22. Leão ER. Dor oncológica: a música como terapia complementar na assistência de enfermagem {Internet} {citado 2011 set. 26}. Disponível em: http://www.musicaeadoracao.com.br/efeitos/corpo_mente/dor_oncologica.htm [ Links ]

* Extracted from the thesis "Encontros musicais como recurso no cuidado de enfermagem em cuidados paliativos oncológicos: uma análise fenomenológica" (Musical encounters as a nursing resource in oncological palliative care: a phenomenological analysis), Postgraduate program in Nursing of the Universidade Estadual de Maringá, 2011.

Correspondence: Vladimir Araujo da Silva Rua Curitiba, 360 - Centro CEP 86730-000 - Astorga, PR, Brasil