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when music, song or other arts-based activities are introduced without careful planning and consent, they may be perceived as unwanted noise, which may add to patient stress (Cunha and Silva, 2015).

Thus, it is important that nurses lead the way in exploring, introducing and rigorously evaluating strategies that will cultivate an environment that is uplifting, comfortable, comforting and will curtail issues that can trigger or exacerbate distress. Being alert to personcentredness and open to innovative ideas are crucial in bringing comfort and compassionate care to people who are dying.

Studies have also reported on the impact that choirs—with and without musical accompaniment—can have in providing calm and comfort, and improving mood for patients, their visitors and care staff (Wilkerson and DiMaio, 2013). In addition to community choirs, there are choirs that have been established to promote wellbeing in people who are aging, living with pain, canceror mental illness. There are also choirs, such as threshold choirs, that perform for patients to provide comfort and human connection.

Kate Munger initiated the threshold choir movement in the United States in the 1990s. At the time, Munger had an opportunity to sing at the bedside of a dying friend and on reflection, the experience was transformative. Not only did her friend become relaxed and enjoy the music, she also felt it offered them a sense of peace and serenity (Fannon, 2007). Munger too experienced profound positive effects, because she no longer felt helpless and could see that what she offered was uplifting and connecting. She went on to formalise a process for individuals to come together to learn the process of singing for patients at the threshold of birth, life or death. Songs are written especially for the choirs, and members practice regularly to ensure they are unobtrusive when near the dying person and respectful of the palliative process. As of 2019, there were 170 threshold choirs operating in the US, UK, Canada and Australasia (Biggar, 2019). This study conducted a literature review to understand how effective these choirs have been from the points of view of patients, family, staff and services.

Methods

The unique identifying number for this review is: reviewregistry864. This review was guided by the PICo model of questioning: Participants, phenomena of Interest, Context (Lockwood et al, 2020). The review question was; What is known of the challenges and benefits of a threshold choir for carers, patients and their significant others experiencing palliative and end of life care?

An initial broad search of CINAHL using the terms ‘threshold’, ‘choir’, ‘palliative’ and ‘end-of-life care’ returned no records. These results informed the decision to include the medical and non-medical truncated Boolean terms: threshold choir, sing* and nurs* combined with audience, bedside singing, choir, dying, die, death, end-of-life care, group singing, hospice, music, palliation, palliative care, therapy and threshold. Then, a second wider search of the databases CINAHL, PUBMED, Medline, Proquest, Google Scholar and Google (to include grey literature, polemics and unpublished reports), was undertaken.

Reference lists of the 36 accepted full-text articles were also scanned for further evidence. The search was limited to English language documents that were published between 1990 and 2020. Reports in the literature featuring choir, music and singing in palliative settings, as well as bedside music including voice and instruments were included. Reports on music without voice were excluded.

Green et al’s (2006) approach to searching for evidence and structuring a thematic literature review was modified and integrated with Bhana’s (2014) suggestions for distilling meaningful themes to reveal patterns, regularities and inconsistencies in the results. In addition to these methods, the Johanna Briggs Institute (JBI) critical appraisal checklist for qualitative research and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (Moher et al, 2009) informed inclusion and exclusion decisions. Authors CR and JM independently reviewed the accepted full texts before meeting with the third author, MM, to reach consensus on the included studies. Combining the approaches and the critical appraisal tools meant the themes of greatest relevance were robustly critiqued, resulting in an argument to provide a context for future research on threshold choirs in Australian healthcare settings.

Results

A total of 26 articles were identified that detail the benefits and challenges of palliative patients, such as those with cancer, chronic pain, chronic mental health concerns, chronic respiratory conditions and end stage renal failure. Some of these studies examined patients’ families and the staff who cared for them. The search summary is outlined in Figure 1. Countries represented were United Kingdom (11) (Eades and O’Connor,

International Journal of Palliative Nursing  August 2022  Vol 28, No 8

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