Music thanatology (Chalice of Repose)

1. Introduction

Version followed: music-thanatology as the Chalice of Repose Project (founded by Therese Schroeder-Sheker) publishes it on its own site and in the abstract of Schroeder-Sheker's 2017 Music and Medicine report, with certification standards from the Music-Thanatology Association International (MTAI) and bedside detail from training papers by Chalice of Repose and Lane Community College students, hosted by MTAI. Sources include MTAI's certification requirements, MTAI's overview of training programmes, the Lane Community College programme's hours (2011 archived page), the published outcome studies (Freeman et al. 2006; Ganzini et al. 2015) and the evidence on hearing near death (Blundon et al. 2020, via a news report). Not drawn on: the full 2017 article, the founder's books, including Transitus (only the Project's review page is drawn on), and the Chalice of Repose school's own curriculum pages. Most step-by-step bedside detail therefore still rests on practitioner papers, not on the founder's own texts [uncertain]. [source: Chalice of Repose "In Brief" pages; Schroeder-Sheker 2017 abstract; MTAI]

What it is. The Chalice of Repose Project calls music-thanatology "a contemplative practice with clinical applications": a sub-specialty of palliative medicine and a pastoral art, caring for the physical and spiritual needs of the dying through prescriptive music. One or more certified musician-clinicians deliver it live at the bedside, with harp and voice. MTAI describes it as a professional field within palliative care that adjusts live music moment by moment to the patient's heart rate, breathing and temperature. It is not meant to entertain or distract. [source: Chalice of Repose, What is Music-Thanatology; MTAI home page]

It is not psychotherapy and not music therapy. The 2017 abstract stresses "quiet reception rather than clinician-patient interaction". The patient listens and does nothing. Nobody makes music together, sets goals or talks the music through. In the US it is a separate occupation from board-certified music therapy (MT-BC through CBMT): it has its own certification through MTAI, no state licensure, and is usually paid for by grants, foundations or hospice and hospital budgets rather than insurance. [source: Schroeder-Sheker 2017 abstract; Nazareth College Therapeutic Music Services At-A-Glance, 2012]

How change is understood. The Project's premise is that sound organises. Live, individually shaped music can therefore calm or stir the patient's physiology and inner state. Its pages list these aims:

relieve physical pain and inner suffering
support reconciliation and meaning
support a peaceful or "conscious" death
change how families and communities experience dying

A vigil usually "begin[s] with silence, move[s] toward synchronization" with the patient's breathing and other rhythms, and ends in or near entrainment. Effects the Project reports include a slower pulse, steadier breathing, deep sleep, emotional or spiritual release, and fewer requests for opioids. [source: Chalice of Repose, What is Prescriptive Music]

The spiritual framing is the tradition's own. The Project describes the music as helping the dying person begin "unbinding" and "let go". It uses the Latin transitus (crossing over) for dying, and calls the music "a medicine of peace". The 2017 report lists "spirituality", "transitus", "monastic medicine", "contemplative practice" and "letting go" among its keywords. The Project describes the founder as a Benedictine oblate, and her work is described as rooted in Cluniac (medieval Benedictine monastic) spirituality and "monastic medicine". Her monograph Transitus: A Blessed Death in the Modern World (listed as 2001, St. Dunstan's Press; the Project's own page gives no date) is not drawn on [uncertain]. These are the tradition's concepts, not established physiology. Physiological claims such as entrainment and opioid sparing are the Project's own reports, and the music is never a substitute for medical symptom control. [source: Chalice of Repose, What is Prescriptive Music and About the Founder; Schroeder-Sheker 2017 abstract and keywords; Martin 2019 interview; Wikipedia bibliography]

Professional frame for a psychotherapist. Only someone who has completed a music-thanatology training programme and MTAI certification may deliver vigils. MTAI certification requires:

completion of a music-thanatology programme
50 supervised vigils, each with a written narrative
clinical reviews with certified music-thanatologists
proficiency on the shared core repertoire

Certified practitioners use the post-nominal "CM-Th". It appears after certified practitioners' names (Schroeder-Sheker's among them) in MTAI's education overview, but none of the MTAI pages defines it. MTAI's certification page sets no hour count. It says the full requirements, a 20-page document, are available on request. [source: MTAI Professional Standards; MTAI, Education in Music-Thanatology]

Training routes named by MTAI [source: MTAI, Education in Music-Thanatology: An Overview]:

Chalice of Repose Project (Mount Angel, Oregon), led by Schroeder-Sheker. Students spend a first year on a contemplative "chaplaincy focus" before studying music-thanatology. The curriculum integrates music history, monastic medicine, phenomenology, psychology and thanatology. The Project's own pages describe five stages: classroom teaching, a pinning ceremony, a clinical internship, a thesis or professional paper, and comprehensive exams. The school ran in person in Montana from 1992 to 2002 and has run as a low-residency online programme in Oregon since 2005. Its curriculum pages are not drawn on, so current hours and courses are not verified [uncertain]. [source: MTAI overview; Chalice of Repose, What is Music-Thanatology; Cerddeu 2002/2010]
Lane Community College Music-Thanatology Training Program (Oregon). Former Chalice students created it, and it teaches to MTAI's six certification competencies. Its 2011 archived page describes a two-year, non-degree training. Teaching was in 20 didactic weekend intensives in Portland. Students did a clinical internship of about five hours a week in a hospital or hospice, paired with an MTAI-certified mentor, until they had 300 hours on site. The page gives "over 600 contact hours" in total. This corrects the earlier reading of "about 600 classroom plus 300 practicum hours": the page does not say whether the 300 internship hours are inside or on top of the 600 [uncertain]. Whether the programme still runs in this form is [uncertain]. [source: Lane CC 2011 archive]
Lyrica Precaria (Tokyo). Carol Sack developed this two-year pastoral-care adaptation, with courses in harp, voice and theological reflection, in a Lutheran context. Check whether a given graduate holds MTAI certification [synthesis]. [source: MTAI overview]

No regulated profession covers this work in the UK or US, and it is not an HCPC-registered or state-licensed therapy. A psychotherapist without this training should not deliver vigils. Your role is to refer, coordinate and support the patient and family psychologically alongside the vigil. [source: MTAI Professional Standards; Nazareth 2012; synthesis for UK]

2. Framework

Music-thanatology has no therapy phases. Each vigil is complete in itself, and it is offered at two points in illness [source: Chalice of Repose, What is Music-Thanatology]:

Terminal diagnosis (about six months from death): vigils for pain, distress and adjustment. None of the sources gives a standard number or frequency of vigils per patient [uncertain]. Those sources are the Project's pages, MTAI, Freeman et al. 2006, Ganzini et al. 2015 and a 2013 report on a hospital service. In that hospital service, the music-thanatologist phoned the palliative-care medical director once a week to ask which patients or families might benefit [source: Tufts Now 2013]. In practice, repeat vigils are arranged as needs change [synthesis].
Imminently dying (roughly 24–48 hours from death): vigils supporting comfort and the process of dying, often with family present.

Format. The music is played live at the bedside in hospitals, hospices, long-term care, parishes and homes. It may be played solo or by a small team, with the musicians "positioning themselves on either side of the dying patient". The 2017 abstract says patients may be of any age. A retrospective analysis of vigil records from 65 patients found that vigils lasted 25 to 95 minutes. The same analysis reported less agitation and wakefulness and slower, deeper, less effortful breathing at the end of vigils (Freeman et al. 2006). A survey of 55 family members found modest perceived benefits for breathing, relaxation, comfort and sleep, weaker benefits for pain, and almost no negative effects (Ganzini et al. 2015). [source: Chalice of Repose, Prescriptive Music; Schroeder-Sheker 2017 abstract; Freeman et al. 2006 abstract; Ganzini et al. 2015 abstract]

Sequence of a single vigil. This composite is drawn from the Project's outline and Julien's 2015 practitioner account, and is not an official protocol. Phases 1–2 and 4 come mainly from Julien; phase 3 from the Project's outline ("silence → synchronization → entrainment"); phase 6 from the Freeman record and MTAI competencies.

Preparation and triage. The practitioner centres themselves, and staff identify comfort-care patients who might benefit. The practitioner then reviews the chart.
Entry, consent and baseline. The practitioner introduces the vigil, obtains the patient's or proxy's agreement, places the harp, and records baseline breathing, pulse, temperature and perfusion, agitation and wakefulness.
Music. Opening silence leads to synchronisation with the patient's breathing and pulse, then to gradual slowing and spaciousness that aims at entrainment. Throughout, the practitioner keeps observing and adjusting.
Closing. The music slows, then silence follows. The practitioner leaves quietly.
Release moments. If the patient appears to be actively dying, the music may turn toward "letting go" (Cerddeu).
After the vigil. The practitioner reassesses the same signs, writes a narrative and charts the vigil, and the work is reviewed with peers.

Moving on within a vigil. The music moves from synchronising to slowing when the patient's breathing pattern is matched and the patient is not more distressed. It moves to closing when breathing has settled, agitation has eased or sleep has come, or when signs show the music is no longer serving. These criteria are inferred from the sources' descriptions [synthesis].

3. Guiding principles

Prescriptive, not performed. The music is chosen and shaped for this patient's physiology and state right now, not taken from a set list. Practical meaning: watch breath and pulse first and let them set the tempo, density and loudness. [source: Chalice of Repose; Cerddeu]
Quiet reception. The patient need not respond, applaud or interact. Practical meaning: tell the patient and family that nothing is required of them. [source: Schroeder-Sheker 2017 abstract; Julien 2015]
Live and responsive. The music changes moment by moment with the patient. Practical meaning: no recordings. Adjust whenever a sign changes. [source: MTAI; Nazareth 2012]
Contemplative presence. Inner preparation is part of clinical competence. Practical meaning: centre yourself before entering the room. In Cerddeu's words, "First, the world is left outside." [source: MTAI 110.1; Cerddeu; Julien]
Silence is equal to sound. Practical meaning: plan silence before, between and after the music, but watch for patients who find silence frightening. [source: Cerddeu; Julien]
No agenda or expected outcome. Practical meaning: do not aim for sleep or death. Serve what the moment shows. [source: Cerddeu; Julien]
Not entertainment or distraction. Practical meaning: avoid requests or medleys that break the reception of the music. If a family wants songs, offer that separately [synthesis]. [source: MTAI home page]
Whole-person care. The practice attends to physical, emotional and spiritual needs. Practical meaning: document both physiology and the inner atmosphere of the room. [source: MTAI Professional Standards]
Respect for diverse faiths. MTAI's clinical competencies include respecting different religious and cultural systems. Practical meaning: check the patient's tradition before using liturgical chant. [source: MTAI 110.4; Scherer 2009]
Interdisciplinary and documented. The practice includes reading medical records, charting and team communication. Practical meaning: coordinate with nurses on medication timing, and record vitals before and after the vigil. [source: MTAI 110.6]
Vocation and inner development. Training joins clinical skill and musical artistry to ongoing inner formation. Practical meaning: keep up personal contemplative practice and peer review. [source: Chalice of Repose, What is Music-Thanatology]
The instrument is tuned, and so is the player. The harp is tuned before each patient, and the Project treats this as a metaphor for inner attunement. Practical meaning: tune before every vigil. [source: Chalice of Repose, What is Music-Thanatology]

4. Intervention inventory

Interventions 4.1–4.16 are carried out only by certified music-thanatologists or by supervised trainees. They are described here so you can refer patients well, prepare them and their families, and work alongside a vigil. Item 4.17 is for you, the psychotherapist. The following are not drawn on: the founder's books (Transitus; the Chalice of Repose Project Clinical Handbook, 1994–2000; The Principles of Prescriptive Music; the Contemplative Musicianship series, all as listed on Wikipedia), the full 2017 article, or the school's curriculum. Some techniques taught in training may therefore be missing from this list [uncertain].

4.1 Contemplative preparation of the practitioner

Purpose: move from a busy state into calm, receptive presence before meeting a dying patient. Done before every vigil.
Steps:
1. Spend a few minutes in breath-focused meditation before entering the building.
2. Walk in with attention on your breath.
3. At the patient's door, pause and set a silent intention for the patient's good.
4. Leave your own concerns and musical agenda "outside".
Example language: none. This is done silently.
Watch for: rushing, irritation or your own grief following you in. Signs it is working: steady breathing, softer hands and voice, and less urge to fill silence. [source: Julien 2015; Cerddeu 2002/2010; MTAI 110.1]

4.2 Tuning the harp

Purpose: keep the instrument exact. The Project also treats tuning as inner attunement.
Steps: tune throughout the day, including before each patient visit.
Watch for: strings that drift with ward heating or air conditioning. Retune between patients. [source: Chalice of Repose, What is Music-Thanatology]

4.3 Triage and referral with the care team

Purpose: offer vigils where they are most needed. Referrals usually come from nurses, physicians, chaplains or families.
Steps:
1. Check in with the charge nurse or reception and listen to which patients are on comfort care.
2. Agree together who might benefit most.
3. Ask about recent medication, imminent procedures, infection-control precautions, and who is present.
Example language (illustrative): "Who on the unit is most uncomfortable or restless today, and is anyone close to dying?"
Watch for: vigils that clash with care tasks. Agree a time when the patient will not be disturbed. [source: Julien 2015; MTAI 110.6] [synthesis: medication and infection questions]

4.4 Chart review

Purpose: know the diagnosis, symptoms, medications and goals of care before entering.
Steps:
1. Read the medical record.
2. Note respiratory problems, pain-medication timing, delirium, hearing impairment, and any faith or cultural preferences recorded.
3. Pause to centre yourself before approaching the room.
Watch for: recorded wishes not to receive spiritual or musical visits. [source: Julien 2015; MTAI 110.3, 110.6]

4.5 Introduction and consent at the bedside

Purpose: offer the vigil, make clear that no response is required, and get agreement from the patient or, if they cannot give it, from a proxy or family member.
Steps:
1. Knock and enter, and greet the patient. Some practitioners touch an arm or hand. Ask first, and leave it out if unwelcome [synthesis].
2. Explain what you are offering, that the patient need not "do" anything, and that there will be silences between pieces.
3. Accept a "no" without persuading.
Example language (illustrative): "I play the harp for people who are very ill. You don't need to do anything or say anything, just rest. There'll be quiet in between. Would you like that now?"
Watch for: non-verbal refusal in a patient who cannot speak, such as turning away, grimacing or rising agitation. Treat that as a no. [source: Julien 2015] [synthesis: non-verbal refusal]

4.6 Positioning

Purpose: place the sound close to the patient without blocking care.
Steps:
1. Place the harp near the side or foot of the bed.
2. With two practitioners, sit on either side of the patient.
3. Keep clear of oxygen tubing, lines, call bells and the nurse's access.
Watch for: trip hazards and blocked emergency access. Clean the harp's contact surfaces between patients in line with the setting's infection-control rules. [source: Julien 2015; Chalice of Repose, Prescriptive Music] [synthesis: safety and cleaning]

4.7 Baseline bedside assessment

Purpose: record the starting point so the music can be prescribed and its effects judged.
Steps:
1. In near silence, observe breathing rate, depth, effort and rhythm, along with anxiety, restlessness, wakefulness and responsiveness.
2. If permitted, palpate for skin temperature, perfusion and pulse rate and quality, or read the monitor.
3. Note facial expression.
Watch for: sudden changes that need a nurse, such as new respiratory distress or pain crisis. Pause the vigil and call staff. [source: Julien 2015; Freeman 2004 record; Cerddeu]

4.8 Opening silence and centring at the instrument

Purpose: settle the room, and let the practitioner tune to the patient before sounding.
Steps: sit silently at the harp for a few minutes, breathing and centring, then begin very softly.
Watch for: a patient who becomes anxious in silence. Shorten it. [source: Julien 2015; Chalice of Repose, Prescriptive Music]

4.9 Synchronisation and entrainment (prescriptive music)

Purpose: this is the core intervention. The live music first meets the patient's own rhythm, then gently leads it toward calmer breathing and pulse. Use it for pain, restlessness, laboured breathing, fear and agitation.
Steps: these elements are described by Julien (2015):
1. Match the music's pace to the breathing. With rapid breathing, play in half-time (half the breathing rate) rather than at the full rate.
2. Let strings ring and fade.
3. Add space: hold notes longer, and rest or pause at the ends of phrases.
4. Repeat a short melody or figure, like a mantra.
5. Use a sparse open drone bass, for example root–fifth–octave.
6. Begin with soft preludes. Use gradual crescendos and decrescendos, and thin the texture toward the close.
7. Keep watching. Change the "prescription" as the patient or the situation changes.
Example language: none. The intervention is wordless.
Watch for: signs it is working include softer eyes, less muscle rigidity, slower and deeper breathing with less effort, a slower heart rate, and less agitation and wakefulness. If restlessness rises, the music may be too dense, too loud or too fast, so simplify or pause. [source: Julien 2015; Freeman 2004 record; Chalice of Repose, Prescriptive Music; MTAI]

4.10 Unmetered chant and sacred repertoire

Purpose: offer free-flowing music without a fixed beat that can follow shallow, irregular breathing. The tradition draws on Gregorian chant and Cluniac antiphons, including antiphons on pain sung repeatedly. Training includes a shared core repertoire.
Steps:
1. Choose modal chant melodies with a simple, narrow range.
2. Sing them unmetered, or play them on harp.
3. Repeat them, treating the repetition itself as active.
4. Let a minor-feeling melody meet the patient's distress, and use major harmonies to temper pain, as one trainee describes.
Example language: sung text from the liturgical tradition. Choose it only after checking the patient's faith (see 5.6).
Watch for: a Christian liturgical sound may comfort some patients and alienate others. Trainees themselves note sometimes wishing for music from other traditions. [source: Scherer 2009; MTAI 110.2 and 110.74; Martin 2019 interview]

4.11 Voice

Purpose: add a human, breath-borne layer to the harp.
Steps:
1. Sing on a vowel or hum, or sing words, often as the music builds.
2. Keep the voice soft and unforced.
3. Avoid vocal bracing and breath-holding, which make the tone harsh.
Watch for: strain or coughing in the singer. Watch also for the singer's own emotional release, as trainees describe tears and trauma-linked blocks when singing. [source: Julien 2015; Cerddeu 2002/2010]

4.12 Silence between pieces

Purpose: give rest, and let the patient absorb the music. Silence is valued as much as sound.
Steps: leave silences between offerings, at the start and at the end, and stay still and attentive during them.
Watch for: fear, loneliness or distress that some patients feel in silence. If you see it, shorten the silences or keep a soft drone going. [source: Julien 2015; Cerddeu]

4.13 Music for transition ("letting go")

Purpose: support a patient who appears to be actively dying.
Steps: when the patient shows signs of moving toward death, offer music that supports the transition. Seek no particular outcome.
Watch for: family distress at the change. Make sure staff know if death seems imminent. The spiritual reading of this moment (transitus, unbinding) belongs to the tradition, so do not impose it on the family. [source: Cerddeu; Chalice of Repose, Prescriptive Music] [synthesis: family and staff steps]

4.14 Closing the vigil

Purpose: end without abruptness.
Steps:
1. Slow the music gradually, then sit in silence.
2. Quietly thank the patient. Some practitioners pray silently.
3. Leave quietly with the harp, and thank the staff.
Example language (illustrative), to family: "I'll leave you together now. The nurses know how to reach me."
Watch for: a sleeping patient. Do not wake them to say goodbye. [source: Julien 2015]

4.15 Post-vigil assessment, narrative and clinical review

Purpose: record effects and refine practice.
Steps:
1. Re-record breathing rate, pulse rate and rhythm, wakefulness, agitation and depth of breath, comparing the end of the vigil with the start.
2. Write a contemplative clinical narrative and a chart entry.
3. Take part in clinical reviews with certified colleagues. Trainees write a narrative for each of their 50 supervised vigils.
Watch for: under-documented adverse responses. Record these too [synthesis]. [source: Freeman 2004 record; MTAI 110.6, 110.72–110.73]

4.16 Family presence and participation

Purpose: the vigil offers loved ones a quiet space to be present.
Steps:
1. Invite family to sit, hold hands, rest or sleep.
2. Family may join quietly in singing. One practitioner sang a traditional antiphon with a sibling at her own mother's bedside.
Example language (illustrative): "You're welcome to stay, hold her hand, close your eyes, or step out. Whatever you need."
Watch for: relatives who want a performance or particular songs. Acknowledge the wish and offer a separate time [synthesis]. [source: MTAI home page; Cerddeu]

4.17 For the psychotherapist: referral and working alongside a vigil [synthesis]

None of the sources describes a psychotherapist's role, so this whole item is synthesis.

Purpose: connect a dying client or a family with a certified music-thanatologist, and integrate the experience into psychological care.
Steps:
1. Find out whether the hospice or hospital has a music-thanatology service, or find a practitioner through MTAI.
2. Explain to the client that it is receptive music, not therapy, and that nothing is required of them.
3. Ask about musical, religious and trauma history that might affect the vigil (see 5.6–5.7), and pass relevant cautions on with consent.
4. Keep your own sessions separate in time and frame.
5. Afterwards, invite reflection if wanted, and attend to family grief, including memories of the vigil at the death.
Example language (illustrative): "There's a harpist on the hospice team who plays quietly at the bedside. It's not a performance, and you don't need to do anything. Would you like me to ask?"
Watch for: blurring roles. Do not improvise a vigil yourself, and do not interpret its music clinically.

5. Handling problems

The sources describe only a few difficulties: patients who refuse, patients distressed by silence, hospital noise, the practitioner's own stress and vocal blocks, and the need to stay flexible. Everything else here is marked [synthesis].

5.1 Patient declines, or seems to decline

Accept a refusal respectfully and without persuasion [source: Julien 2015].
With patients who cannot speak, read turning away, grimacing or rising agitation as a refusal. Stop, and offer to return another time [synthesis].
Families sometimes request a vigil the patient seems not to want. The patient's own signals take precedence [synthesis].

5.2 Rising agitation or no settling (the clinical equivalent of a "stuck" response)

Simplify the music: slower or half-time pace, thinner texture, softer, more space, more repetition. Change the prescription in response [source: Julien 2015].
If agitation continues, consider delirium, uncontrolled pain, a full bladder, positioning or breathlessness. Pause and call the nurse. Music does not replace symptom control [synthesis].
Do not chase an outcome. If nothing helps, close gently and document what happened [source: Cerddeu; synthesis].

5.3 Silence is distressing

Some patients feel fear or loneliness in silence [source: Julien 2015].
Shorten the pauses, keep a soft drone, or speak a brief, reassuring word [synthesis].

5.4 Noisy or chaotic environment

Hospital noise makes calm hard to reach [source: Julien 2015].
Ask staff to dim alarms where it is safe, close the door, and agree a time with no interruptions. Accept some imperfection [synthesis].

5.5 Practitioner stress, grief and ego

The practitioner's stress, for example after a hard commute, carries into the vigil. Meditation beforehand is the answer the sources give [source: Julien 2015].
Trainees describe managing ego so that they serve without taking centre stage. They also describe vocal bracing, tears, and blocks linked to past trauma [source: Cerddeu].
Use peer clinical review and supervision. Watch for cumulative grief and burnout, and take personal therapy where needed [source: MTAI 110.1, 110.73; synthesis].

5.6 Religious or cultural mismatch

The core repertoire draws on Christian, Western chant, and MTAI requires respect for diverse religions [source: Scherer 2009; MTAI 110.4].
Before a vigil, check the patient's faith, and any wish to have no religious music. Offer the harp without words, or ask the patient's own faith community for input [synthesis].
Do not present transitus, "medicine of peace" or monastic-medicine ideas to the family as fact. They are the tradition's own concepts [synthesis].
For sacred music from another tradition, the faith community holds authority. Refer to its own ministers or musicians rather than imitate their practice [synthesis].

5.7 Musical trauma triggers [synthesis]

Particular hymns, Latin liturgy or harp sounds may be bound up with the patient's religious trauma or abuse in church settings, previous bereavements, or funerals.
Ask about these associations during referral (4.17).
If a piece prompts distress, such as crying out, tensing, or turning away, stop it, return to a neutral drone or silence, and check in gently.
Afterwards, tell the psychotherapist or chaplain, with the patient's consent.

5.8 Hearing safety and sensory issues [synthesis]

Harp and voice are quiet, but small rooms, hearing aids and hyperacusis can make them uncomfortable.
Keep dynamics soft. Ask about hearing aids, which may whistle or amplify sound. Never play close to an ear.
Hearing near death. Blundon, Gallagher and Ward (2020, Scientific Reports) recorded EEG while hospice patients in Vancouver heard tone patterns. Five patients were recorded when unresponsive, hours before death. Most of them still showed automatic brain responses to tone changes (mismatch negativity), and some showed P3a or P3b responses, broadly like healthy controls. The authors say they cannot tell whether patients were aware of, recognised or understood what they heard. They conclude only that hearing "may" be one of the last senses to lose function. [source: Neuroscience News report of Blundon et al. 2020]
Practical meaning: assume the patient may hear what is said and played in the room. Do not tell families that the patient definitely hears or understands the music [synthesis].

5.9 Physical safety [synthesis]

Place the harp clear of oxygen, IV lines and the path of the crash team.
Follow the setting's infection-control rules and clean the instrument between patients.
Avoid touch if the patient is in isolation or has fragile skin. Ask before any touch.
Never block staff access to the patient.

5.10 The patient dies during the vigil [synthesis]

Lower the music to silence. Notify the nurse according to the setting's procedure.
Stay with the family if they wish, and allow quiet.
Afterwards, debrief with your team and record what happened.

5.11 Family conflict or requests for performance [synthesis]

Keep the vigil focused on the patient's quiet reception.
Meet requests for favourite songs at another time, or point to music-therapy or volunteer bedside music services.
Where family members disagree about the vigil, pause and involve the care team or social worker.

5.12 Children and young people [synthesis]

The 2017 abstract says music-thanatology serves patients of any age [source: Schroeder-Sheker 2017 abstract]. No paediatric protocol or paediatric outcome study is cited here. The studies cited (Freeman et al. 2006; Ganzini et al. 2015) and the 2013 hospital report do not mention children [uncertain].
Obtain parental or legal consent, and the child's assent where they can give it.
Involve parents at the bedside. Follow the setting's safeguarding procedures, and report concerns under local mandatory-reporting duties.

5.13 Role and boundary problems for the psychotherapist [synthesis]

Do not label the vigil as therapy, and do not interpret patients' responses to it psychodynamically in the record.
Do not promise relief from pain or a "good death".
Keep suicide-risk, safeguarding and capacity assessments within your own role, separate from the vigil.

Sources

Sources:

Books cited (further reading, not drawn on): Schroeder-Sheker T. (2001). Transitus: A Blessed Death in the Modern World. St. Dunstan's Press. Hollis JL. (2010). Music at the End of Life: Easing the Pain and Preparing the Passage. Praeger.

Further reading (not drawn on): the full text of Schroeder-Sheker (2017); the Chalice of Repose slug pages for the education programme and writings; the MTAI FAQ; the full text of Blundon et al. 2020 on PMC; the full texts of Freeman et al. 2006 and Ganzini et al. 2015, where only the abstracts are drawn on; and Schroeder-Sheker's books, including Transitus, the Clinical Handbook and The Principles of Prescriptive Music [uncertain].

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