Music Inside an Intensive Care Unit

Abstract

This paper reports on the music therapy work performed in the intensive care unit of a university hospital. Clinical practice is inserted with in the hospital psychology department and acts jointly with some of the other health departments in the same hospital. The text presents the employed methodology, techniques, and repertoire, along with some considerations, comments, and observations on the practical side of the treatment. Music therapy imposes itself as a valuable element for the health area and becomes particularly meaningful as a part of the hospital's humanization program which is being developed in the institution. Striving for care quality, all the while it helps integrating all involved personnel interacting with the patients, music can be a powerful stimulus for the improvement of health care, particularly in the reception and support of the difficult situations terminal patients are faced with.

Introduction

In this paper, I intend to show some general aspects of the music therapy activities performed within the facilities of the Intensive Care Unit (ICU) of the University Hospital, an institution belonging to the Universidade da Regi„o da Campanha (Southern Plains Area University), or URCAMP, located in Bag√©, state of Rio Grande do Sul, Brazil. This is a town of approximately 130,000 inhabitants, situated almost on the border with the neighboring Republic of Uruguay, some 380 kilometers (237 miles) south of Porto Alegre, the state capital city and around 2,400 km (1,500 miles) south of Brasilia, the country capital.

The music therapy project to be stablished within the facilities of the University Hospital Intensive Care Unit (ICU) started on May 2002, as a part of the Hospital Humanization Program designed by the Psychology Department of the University Hospital. Within the framework adopted for this program, some Art Therapy, Music Therapy, and Hospital Pedagogy projects were planted in some of the institutional units. Art Therapy was installed in the Dyalisis Unit and directed by a team of Art Major trainee students. The Music Therapy activities were incorporated into the ICU and involve also some trainees. The Hospital Pedagogy project was placed in the Pediatrics Department.

The Institution

Situated in the downtown area of the town of Bagé, the University Hospital is classified as a medium-sized medical facility, offering 115 beds, which are distributed in four clinical wards, an Intensive Care Unit (ICU), and a Surgical Block. It caters to both private patients and Health Plan patients . The hospital was also chosen as a training site for those pupils who are taking courses in the University health and pedagogy areas.

Clientship includes patients from the government-sponsored Sistema √önico de Sa√ļde (Merged Health System) or SUS, providing free consulting and health care, especially the wards assigned to Medical Clinical II, Medical Clinical III, and the ICU. Medical Clinics I and IV take care of health plan patients and a very small number private (paying) patients.

Approximately 50 medical doctors belong in the Hospital Clinical Corps, but only eight of these are employed full-time by the Institution as permanent duty residents. There is a Chief Nurse responsible for all the nursing staff, of which there is a registered nurse for each ward. Auxiliary technical nursing staff are assigned to every ward and unit. Two dietician-nutritionists and a graduate in Home Economics, three physiotherapists (one of which is also a trainee supervisor), a psychologist in charge of Clinics I and IV (Health Plan and private patients), who is also a trainee supervisor, an art-therapist and a music-therapist also work in the hospital.

Laboratorial, X-Ray, Dyalisis, and Physiotherapic services in Medical Clinics I and IV, though performed within the Hospital facilities, were handed over to third parties, that is, to private firms.

The Intensive Care Unit - ICU

This is a general service ICU offering nine beds and not yet equipped with isolation area facilities. It was classified by Surgeon General officials as a Standard I facility. The assigning of such a classification was decided according to its physical area, available equipment, medium grade complexity of patient care, as well as the number and technical qualifications of staff who actually belong (n) in the permanent professional team. It is managed by an Intensive Care postgraduate physician and staffed by night-and-day-shift MDs. The facilities are not directly connected to the Emergency Room or the Surgical Block. It is equipped with mechanical fanning, an oxymeter, monitoring devices to every bed, infusion pumps, and defibrilators. When a patient requires isolation, a room is specially prepared with the proper equipment. The MD on duty stays by the ICU around the clock along with the nursing technical support personnel. A registered nurse supervision is afforded to the nursing technicians 24 hours a day while the technical staff stays for 6-hours shifts. Physiotherapy, nutrition, and psychology professionals also attend whenever necessary, along with trainees from graduation courses in the health area.

Many different pathologies are () provided care within the ICU facilities, although cardiological, neurological, and pneumological conditions are predominant.

The Hospital Humanization Program

This program is intended to optimize the resources available in the institution.. Its goal is to provide the patients and their families with better care quality and a greater stimulation in the quest for health. The strenghtening of caretaking personnel has been receiving particular attention from the Hospital Psychology Department, while some alternates are being proposed for future development of this goal.

Departing from joint brainstorming reflections on the different possible strategies to be taken for the health area, the Psychosomatic Approach was chosen as the most promising way for the improvement of actions taken along this line of work. In Brazil, Psychosomatics has particulary blossomed out of the psychoanalytic work performed in School Hospitals mostly located in the cities of Rio de Janeiro, S√£o Paulo, Porto Alegre, and Recife. According to Eksterman, all professional personnel involved with general patient care and the social dimensions of pathologies, as considered in that they reach beyond the existential conditions of the () ailing are supposed to open themselves to new perspectives connected with psychosomatics and refer to it when in search of theoretical support (Eksterman, 1992, p.77).

Psychosomatic Medicine is herein understood as that part of Medical Science that studies the mind/body relationship, emphasizing the psychological explanations for somatic pathologies. It proposes a complete assistance for the individual along with a transcription of bodily symptoms into the psychological language.

Mello Filho (1992) asserts that in the current state of the medical art, to wit, the multidisciplinary one, the "importance of the social factors and that of the psychosomatic approach () is an essentially interactive activity, that is, an interconnection between several different professionals in the area" will emerge. In this approach (p. 19) the performance of those professionals interested on the improvement of the individual patient's quality of life, herein considered in its wholeness, will begin by a change of viewpoint in their regard over sickness and over the sick. This approach will promote the surfacing of primitive man and that of the natural healer who still dwell inside everyone's mind and heart and turns definitely toward interdisciplinary action. Embased on such subsidies, the Hospital Psychology Department in 2002, developed the Hospital Humanization Program as a pilot project meant to be gradually implanted (Marques Dias, M. H. S. S., 2003).

The program was designed to make more human-friendly such services as are performed by the hospital staff, beginning with the training of the professional team and reaching out to broaden stepwise its scope to embrace the patient and his/her family. It may be stated that its major intent is that of improving institutional prophylaxis, or, in other words, to foster an attentive listening to whatever the caretaking staff thinks and to establish an affectionate interaction.

Music Therapy

Responding to the Psychology Department entreaties, a Music Therapic Project for the ICU was designed. Grounded upon existential humanism and appreciating its phenomenological roots, this project was embedded into the Hospital Humanization Program. As an initial step the strategies of the work plan were presented and submitted to discussion and opinion-gathering from the ICU acting professional personnel. In the very beginning, a space was opened for the staff to report their own life experiences and their musical preferences and background. Previous knowledge of the ways in which music happened in the lives of those who perform their duties in the ICU was deemed important because these are the very people who make up the music therapeutic setting and therefore will perform oftentimes the most significant roles in the unwinding of the process.

Within the ICU facilities music therapy presents as its major target the offering of emotional support to such people who are rendered frail not only by their illness but also by the very fact that they are in an ICU unit. For the general public, intensive care units are seen as places where care is taken of people presenting grave, irrevertible pathologies, although these are also meant for potentially recoverable patients whose treatment requires intensive care anyway. In such cases, the support brought in by music can help both as a stimulation to their quest for health and as a helping, supportive measure for the elaboration of meaningful emotional aspects within sometimes hard, complex clinical situation. Specific targets will be designed according to each patient's particular needs.

According to Bruscia (2000, p. 201), in this clinical practice two different foci are intertwined, to wit, the biomedical and the psychosocial ones, because both changes in the physical status of the person and mood shifts in his/her psychological condition can be strived for, so as to encourage desirable modifications on the patient's mental, emotional, social, and spiritual states, all of which will favor the improvement of his/her medical condition. Music Therapy can also act out as a psychosocial support during the individual's permanence in the ICU facility.

Work Development

Music therapic activities inside the ICU happen twice a week and the number of sessions with each individual patient depend on his/her period inside the ICU facilities. Since the beginning of this project only two people didn't actually accept to work with music, a figure representing only 0.8% of the total population attended until now. From those people who did participate, 67% received only a single music therapy treatment, while 33% participated in two to ten sessions.

Time length for each session varies. It will depend on the person's moods, interests, and needs. Conditions presented by the sick people assigned to this Unit show a wide range of variation. Some sessions will last 15 to 20 minutes while the length of others are from fifty minutes to an hour's duration. It seems important to record here that we seek to conduct each session in a properly rational way, each presenting a beginning, a middle part and a conclusive ending, leaving no room for pending questions because, in the largest majority of cases, we have no inkling whether a second time will happen or not.

Before starting each case, we search for data in the patient's medical clipboard. Then we chat with that person, whenever this seems feasible. The presence of music inside the Unit is explained to the patient and we find out whether there is an interest in the music therapy. We listen to the person to determine his/her former musical experience and such preferences he/she may present. The establishment of an empathetic relationship allows for the building of a therapeutic rapport, which in this case is understood as the setting up of one another's roles, specifying the commitments of both partners, therapist and patient, as stated by Barcellos (1992, p.39).

Considering that we are in an Intensive Care Unit, such alliance will necessarily show some unique features and it can present some differences in relation to rapport established with patients within different clinical contexts. For instance, when roles are being distributed, there's no guarantee the patient's commitment will actually happen, as it will depend upon his/her state of lucidity as well as his/her communication capacities. In such cases, the therapist's commitment will be settled after a contact with the closest relations and/or according the professional opinion of the ICU team. That's when performing within the framework of a "receptive music therapy", by which we mean a session where no patient interaction is expected.

With such ill people who feel prepared to communicate, it becomes generally possible to perform "active music" sessions. He or she will suggest or request some particular tunes and try to sing along, even in such situations where singing isn't an easy activity, e.g., when the patient was equipped with a nasoentheric probe, a nasal catheter or some other uncomfortable equipment.

Guitar and voice are the most commonly used instruments. Eventually, some sort of mechanical recording is also brought in. We always try to get to every bed, regardless of the person's conditions, as sometimes these patients are in dizzy states, lacking orientation, or even comatose. A general attitude of acceptance, receptivity, and empathy is practiced upon us when facing such situations. Both attention and openmindedness must work together in the quest for supporting intuitive techniques aimed toward perceived needs that will then perceived.

Many times, members of the nursing staff participate in the activities, either singing along or helping us to remember the lyrics of seldom-requested tunes. This endows the meetings with a special stimulus, which involves both the achieving of a fellowship during the session and the actual pleasure of collective voice performances.

The music therapy is also performed in an integrated fashion with physiotherapy, mostly in the case of neurological and pneumological conditions.In such cases we try to play the patient's favorite tunes, so as to adapt the performance, its intensity and rhythm to the treatment being performed by the physiotherapist. Sometimes we sing along and/or improvise some lyrics aimed directly to the person being take care of. The treatment acceptance and the patient's welfare are targeted as is the focus of attention.

Clinical Modes

Patient care is performed on an individual basis. Sometimes one or two patients from the next beds will pipe in allowing us to broaden the job setting to enclose a small group.

Music therapeutic techniques adopted here are detailed according to the frequency in which they present themselves: Re-creation, listening, and improvisation. Such follow the musical experiments described by Bruscia (2000, p. 121).

Re-creation of such tunes that are requested or that spring up naturally during the session is performed by voice and instrument both, as well as by means of gestures and bodily movements. Sometimes the lyrics are changed, the melody is enriched by some variations, and even the rhythm is modified.

Listening, also known as "receptive experience", is being used in two ways: either with live performances or by playing recorded music. In the first mode, the person listens passively to whatever we choose to play - this is often the case of comatose patients; the second mode will be resorted to in such cases when the requested melody is unknown and in such occasions when we are prepared to schedule a second meeting with this particular patient, allowing for the time to do some research to find whatever was asked for.

Of these, improvisation is the least frequent activity. It will seldom happen during individual caretaking. But it will appear somewhat more frequently when physiotherapic activities are being performed, in those occasions when we may improvise rhythm, tune, and lyrics.

Repertoire

Of the population served, 38.83% of the patients were not able to communicate in order to let us know about their musical tastes or preferences. We observed the requests and statements of the remaining 61.17%, and solicitations were sorted out according to the kind of music mentioned: Gaucho folklore music (26.33%); national or international popular music (22.75%); religious and international folk music (4.51%); others types of music (7.58%).

Age bracket and sociocultural conditions are determinant choice factors. Musical lifestyles are directly connected to these aspects. Most patients are on the 65 to 90 age brackets.

It is interesting to highlight some points related to the order of preferences shown above.

a) The category Gaucho Music refers to a characteristic regional type, the Ga√ļcho and the etimology of this word, according to Aur√©lio Porto (as quoted by Meyer) derives from Tupy-Guaranian Amerindian words and means people who sing sadly ( Meyer, 1957, p 53). This is the characteristic ethnic type of this geographical area. In the beginning, only country dwellers were referred to by that name. These country folks' ethnic descent was an admixture or Portuguese, Spaniards, and Amerindians. Nowadays, the term became a nickname for all native inhabitants of the state of Rio Grande do Sul, including as well the hinterland Uruguay citizens and the inhabitants of some Argentinian provinces (Novo Dicion√°rio Aur√©lio, 2000, p. 975), both of which countries have common borders with the southernmost section of Brazil

The Gaucho music, which presents a rather regionalistic character, though initially nostalgic, shows today somewhat faster tempos due to the influence of immigrational flows, specially those integrated by Italian and German immigrants who settled in great numbers in this geographic area of Brazil. Today its rhythms are rather diversified, ranging between simple or composed double time to triple and quadruple beats.

b) In the area of national and international popular music we can classify mostly waltzes, tangos, and boleros. There are both European and Brazilian waltzes, presenting a slightly different tempo, accompaniment, and musical treatment. Tangos and boleros are imported unmodified from Spanish-speaking Latin-American countries. Here are also included Shrovetide (Mardi Gras) marches, romantic songs, and samba tunes or rhythms, which are favorite among national popular music preferences stated.

c) Shrovetide marches, particularly, when included in a session, are often sung along by the patients, though lyrics are seldom remembered completely. Such marches are usually composed after well-humored lyrics set to music, which deal with the most diversified individual and/or collective social problems. It is interesting to stress that the golden age of Shrovetide music lasted from 1930 to the late sixties, the childhood and youth periods of most ailing persons in the ICU.

d) Religious music appears especially in the case of patients who were raised or converted to the Protestant religious denominations and are mostly made up of God-praising hymns.

e) As to folklore music, children's tunes are the most often required. Lyrics mostly remain in the patients' memories and are easily sung by them. Likewise, when some bars of these melodies are strung out on the guitar under the guise of improvisation, these are promptly recognized and the patients start to sing them freely and spontaneously.

Among those patients who are able to communicate, very few won't ask for a particular tune, leaving the choice to the music therapist alone. On an intuitive basis some melody is picked and performed. Usually, from this point on, they start remembering and presenting their own requests. These patients were classified in the 7.58% who mentioned they liked every kind of music.

Observations And Final Considerations

It is possible to muse on the clinical practice of music therapy for a long time and we can add a series of observations therein. In the framework of this paper, however, we'll present only a few of these, precisely the most evident at the present moment, after one and a half year's implementation in this specific hospital care area.

Assuming a medical viewpoint, we may watch physiological changes on the patients, like oxygen pulse saturation - which is verified by means of pulse oxymetrics showing an improvement on the patient's breathing, as well as a decrease or an increase on muscle tone, which is detected and recorded directly by the physiotherapist when he/she is working along with the music therapeutic action. Some other physical reactions can also be observed on comatose patients whenever they present some kind of movement, like opening their eyes or turning their heads toward the sound source.

Clinical practice inside the ICU confirms the importance of music listening both in its physical and social aspects, as when eliciting psychosocial effects.

From a psychosocial viewpoint we can identify many interesting features, which may be differently read according to the regard cast up on them. We can ascertain that music is very lively part of people's existence, something that belongs to the outer world, alluring the attention to what happens outside the ICU, that is, to the life unaffected by disease. Its presence within the ICU facilities is often surprising all the while it appears like a nourishing stimulation in the quest for health. The therapeutic rapport acts herein as a positive reinforcement to the possibility of this search and it may also represent a commitment with solidarity, fellowship, and sympathy in the case of irrevertible conditions.

Considering the patient's family context and his/her feeling of being exiled from it in the situation he/she finds him/herself at the time of confination, it becomes very important to set a definitive value upon each one's identity. Music therapy also fosters this aspect, by means of the sheltering welcome it provides. The professional's attitude of thoughtful listening and the utilisation of sound materials according to the needs and wishes stated by the patient have been shown as worthwhile ways to appreciate the human being as a whole, all the while respecting his/her uniqueness as an individual.

Aldridge & Aldridge (1998, pp. 271-282) states that everyone of us is an individual theme, that of our identity, a repertory of "being" within which we move throughout the world. This inventory, according to Aldridge & Aldridge, is submitted to constant improvisational exchanges, which are caused by our reactions when adapting to the challenges of life. The music therapist's task is then that of making such an improvisation easier, broadening or enhancing the individual's repertories when he/she deals with a human life decisively interrupted by some sort of adversity, mishap, or sorrow.

The openmindedness and availability of a music therapist are therefore fundamental in the search for these sonorous contents and our perseverance in this endeavour is very important for finding or rescueing it from the souls of ICU patients. In addition to this thought it is interesting to quote Campos (1995, p. 50), "each person has a unique life story which he/she needs to tell and clothe with a new meaning, i. e., each one presents an inner impetus to reprocess his/her very own personal life story."

Music can afford the patient a means to connect him/herself all over again with the outer world, even though receptive music therapy is the only technique employed. Whenever hearing is opened to listening a colloquy is also started with the surrounding environment. According to Tomatis and Vilain (1991, p. 114), "environment never ceases to reveal to the human being its own pertinency to this great vibrating entirety which manifests itself within and without every human being, leaping from a person to the next, uniting in a permanent interplay the finite in the human nature to the immovable infinity without."

Within such a context music becomes a harbinger to an awakening for life as well as a way to assign a respectful value to everyone's individuality. It alleviates his/her plight and adds a dimension to his/her universe. Oftentimes the music therapy task affords an opportunity to look behind one's life and try for a revision and a shift in values as well as granting a stimulation for adopting new purposes and plans. That's why it represents a strong support to everyone's "warrior side", a feature sometimes lying dormant that is, by the same token, awakened and prompts the individual to wish for or to opt out for a longer and steadier fight.

All these statements are manifested after careful observation of the musical choices presented by the ailing and their reactions before the results of same choices as well as to the messages contained in their lyrics. The behavior presented by people in their interaction with music has demonstrated a wide range of feelings, that is, curiosity, encouragement, a "brightness in their eyes", participation, enthusiasm, alertness, trust, tenderness, and sense of self-appreciation. Even the most depressed present a good receptivity. These are some possible interpretations of what has been expressed to us both musically and verbally during the development of our work. However, we must always keep present in our minds what Barcellos (1992, p. 17) says in relation to drawing conclusions and making interpretations after what is reaped from music therapeutic contexts, that is, from a methodological viewpoint these are but hypotheses and she assumes as a premise that no hypothesis is susceptible to a definitive verification that may bring about a condition of undeniable, complete knowledge.

In the case of dizzy, disoriented, or comatose patients, the music therapeutic job is also performed, as mentioned above. As refers to the first groups, we succeed in making them more alert and brave, encouraged to face their new reality, that's to say, their need to stay in the ICU confines; in this particular point, we achieve some success in helping them accept that situation. The disoriented show more lucidity in their colloquies with the music being played and usually are able to accompany the tunes they suggest themselves, singing along or at least mumbling the lyrics. Once a patient whose medical clipboard definitely registered disorientation has dictated us the lyrics of a song, so that we could sing it along with him. This leads us to believe the possibility that disorientation cases are purely emotional and as such deserve a deeper investigation.

With the comatose, we perform only receptive music therapy, playing on the guitar such tunes that are indicated to us by their families, or, when we have no access to this data, we execute whatever the music therapist's intuition suggests or follow the promptings of the nursing staff and/or those of other people who also work with the patient and are willing to lend a hand. Every professional can acquire a vision of the patient as a whole and contribute towards the awakening of this perception besides provide his/her technical participation. This aspect has shown itself to be quite a positive aid to the clinical practice herein described. Campos (1995, p.96) reinforces this train of thought mentioning the need for an inter-relationship among the several professionals involved in the treatment, who are expected to see the patient in his/her wholeness, and adopt a humanizing stance thereon.

In the specific cases of a definite coma it is interesting to bear in mind the arguments presented by the neurologist, Ivan Izquierdo (2003, pp. 63-65), when he speaks about this kind of patient and his inability to express his thoughts or feelings, just as one affected by dementia and suffering from an advanced state of mental disease. "Worse than these", says he, "the comatose subject has no means to move himself in no way whatsoever, neither is he/she able to proffer any word or performing any gesturing, although no one is prepared to tell to what extent some patients, even the most expressionless and immobile, can still hear, even fragmentarily, whatever is being spoken around him or her." And he adds you are not supposed to utter any sort of negative comments close by a comatose patient. All cases studied reveal how difficult it is to diagnose the differences between the several levels of coma depth, which comes to show that MD's know a lot less about this condition than usually thought of.

Angerami-Camon (1994, p. 69) also refers to the comatose, calling for attention to the possibility of prodding out a patient by means of comments, visiting, and other forms of direct stimulation, all of which may bring out on him/her both positive and negative reactions. He speaks about this care as a possible new sort of treatment, devolving upon the staff the duty of keeping themselves aware of it all the time. It is rather important to keep in mind this attitude, as defended by both authors quoted in relation to the sound environment granted to this sort of patient and it is has been given proper consideration.

It is interesting also to quote that which was said by Schwarz and Richtie (1996, p. 14): "hearing is the first sense to develop and the last sense to deteriorate in the life cycle".

The group of ICU-acting health professionals has been showing itself increasingly more sensitive to such recommendations. Within this context, we strive to allow music to bring forth desirable, positive reactions in the patient. Quite often these health professionals show up for accompaniment in the singing or, at least, to lend their physical presence during the music therapeutic moment, something that is very gratifying for all those involved in it.

The testimonies of these caretakers mention music as a breakthrough factor, which they deem responsible for the alleviating of a stressing routine, all the while it provides an alternate that may lead to more tender, affectionate ways to care for the ailing who, due to their frail, insecure, and dependent condition, become rather similar to very small children.

It seems interesting to record that inside this Unit we are working with two groups of sick people: those we are backed by their families and those who have no family at all or are deserted by those relations that they do have. In the first set of patients, music can encourage dialogues and communicate messages between the ailing and their relatives and vice-versa. When caring for such subjects included in the second group, music gathers the caretakes around them, turning those temporarily into a foster family. This family can become rather affectionate to them and the music contributes a great deal towards achieving this goal. It gathers them all together around that bed while the session lasts.

While adhering to this process, if we look for those musical practices described by Bruscia (2000, pp. 203-204), music can be applied both as a primary medical agent - through a client/therapist relationship aimed to make easier other medical procedures - and as a secondary, supportive mitigating action. Sound elements can tamper directly with the quality of life, which is the same as saying, these can change the quality of death.

As refers to the quality of life, music can benefit both such patients that are expected to beat their ailments as those who must coexist with some degenerative illness for which there's no present possibility of cure. As a physical energy or as an acting element in the emotional domain, a significant sound world can always afford some sort of breathing space and cheer up the ailing.

As a mitigating, palliative action for terminal patients, music therapy will help into the acceptation and preparedness to welcome death. Here it appears as an extra element to encourage and hearten the subject when he/she can glimpse the end of his/her journey. Music helps in the quest for tranquillity and can also favor stress-lessening by means of its melody and harmony. Music is also ready to work along with other therapies to generate soothing vision of past life happenings and events, as well as to awaken hope before the unknown and to create a sense of assuredness or confidence before the infinity. It makes possible that the last sounds one hears are accompanied by a feeling of serenity.

In what is related directly with the music therapist's performance, although many points may be highlighted, we can pinpoint as milestones the need for acquiring a prior knowledge of the environment in which he/she is going to perform and a special effort to achieve a good familiarity with the cultural background of such patients that will potentially be taken care of in the area within which he or she will have to work. Therefore, it is rather important that he/she gets directly in touch with the workplace wherein he/she will have to develop his/her activities within the constraints of teamwork and to act interactively with the other staff members. Such a professional must have to ready himself/herself to take on his/her stride a series of interferences and/or variables. A "plunge", that is to say, a delving into the group and individual cultural levels is also fundamental for the music therapeutic process, particularly in the case of those patients who will be served more than once.

Even though summing up only a little over a year, the experiences already lived permit us to speak about the importance of the inter-relationship with other team members and the need to know something about everyone's professional activities. The exchange of information about the patient is also fundamental, so that we can all get to know him/her better and serve him/her the best possible way.

The music therapist can and must be an important part in the workings of the social interactions gears that are made up by the ICU caretaking corps, integrating himself/herself with the other staff members in such a way that he/she can effectively help in the shaping of a "security basis" for the ailing, who are all in need of such a special care. Music therapy helps toward the build-up of a "new regard" like that which we desire to offer the patient and likewise build on his/her caretakers. It consolidates and draws nearer the work group as a means to render easier the prodding of the ailing person into pledging for a complicity to cooperate with the caretakers in the fight against his/her ailment.

This will be an ever-challenging trek to everyone who takes to it; similarly it will present constant hardships and disturbances to the music therapist bearing in mind the dynamics imposed by the most diversified situations and manifold sets of everchanging reality. It demands from the professionals much thoughtfulness and preparation, beginning with that necessary attention turned toward one's inner self. The quest for balance and integration, taking into proper consideration all characteristics and feelings of a human being is bound to happen within a framework of flowing, uninterrupted processes.

For the task of development and growth, intuition strives for the achievement of an understanding of the context. This becomes the bedrock of treatment. It can easily be perceived how necessary are situation analyses and the formulation of innovating hypotheses as well as the shaping of opportunistic syntheses is needed. Nothing of the above is an easy job and all of it demands, besides a permanent process of watchfulness, a constant lookout for priorities and much flexibility.

Herein it is worthwhile to add the words of Restrepo (2000, p. 45) about the importance of this dislocation upon the complexity of the real world, to wit, "like a flying bird amid contrary winds, against which it must now and then change its strategies and its bearings."

As concluding words, we may remark that this ICU music therapy task can be felt as something that will render more human and make richer everyone who participates in its development. It is like a spring bringing forth water from the depths, of which nowadays we only know the surface. Every person in such units is like a whole new world that must be explored and appreciated. The sound element endowed with such a constant presence all along the human existence becomes here a much more remarkable presence through the performance of music as an accompaniment to the unwinding of the greatest human mysteries: the mystery of life and that of death.

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