My Last Sound

Hello. My name is Yoko. How are you?

I’m an ambient electronic musician. I was born and raised in Japan and originally trained as a pianist, but now I compose, produce and engineer this kind of music.

People say my sound is soothing, so I’ve created music for museums, art galleries, airlines and spas.

Several years ago, I became ill and had to spend hours and hours in hospitals. As a musician who is sensitive to sound, I was disturbed by the noise.

Lying in a hospital bed, I used to wonder: Some people say hearing is the last sense to go when we die, so what is the final sound I’ll hear at the end of my life? Will it sound like this?

[Hospital alarm sounds]

“Unnecessary noise is the cruelest absence of care,” Florence Nightingale said more than a hundred years ago.

Since then, medicine has progressed tremendously. Technology has progressed tremendously. But the quality of our sound environment has not.

Here’s a quick example. A cardiac monitor produces a high-pitched C. A bed alarm produces an F-sharp. When they beep together, they create a diminished fifth.

In music theory, we call this a tritone. During medieval times, this particular combination of notes was called “the devil in music” because people found it so unsettling. The Church even banned musicians from playing this combination of tones.

And this may be what we’re hearing in hospitals today.

Why does it have to be this way?

In the context of today’s conversations, consider that 80 percent of Americans wish to die at home, yet 60 percent ultimately die in acute-care hospitals.

Noise affects everyone. Studies show that for patients, it hinders recovery and sleep and increases the perception of pain, anxiety and fear. For clinicians, alarm fatigue is a safety hazard that contributes to stress, burnout and a sense of learned helplessness.

Illness has a way of affecting life.

After I recovered, I felt that this part of my life was a lucky bonus in which I could do almost anything. So I started a social enterprise, Sen Sound, with a vision of transforming the sound environment in hospitals through human-centered design.

We partnered with the Johns Hopkins Sibley Innovation Hub to study how sound affects people’s emotions, experiences and environments.

How many of you have ever been to a hospital? What do you remember hearing? What was the most disturbing sound you remember?

Screaming? Alarms? Beeps? “Code blue”? People talking? Pagers? Carts rolling?

What about the rhythm of a cardiac monitor? It keeps going like a ticking time bomb, reminding me every second that my time here is finite.

What about silence?

The devastating silence after unexpected news has been delivered.

Inside disinfected walls, surrounded by the echoes of machines beeping and beeping and beeping, hospitals are filled with deeply human moments.

Much of the noise people reported was caused by human behavior: alarms not being answered promptly, people talking loudly and doors being slammed.

The typical response to this kind of noise is to put up a bunch of posters that say, “Shh,” which is never effective and can feel disrespectful.

So we spent more time with people, especially nurses working on the unit, and realized that noise causes stress, but stress also causes noisy behavior.

It’s common sense. When we’re stressed, we talk loudly. We become sloppy. We kick things. We don’t care. We become noisy.

How might we alleviate the stress experienced by people on the unit and help create a healing environment?

We converted an empty space in the hospital into an immersive relaxation experience called a Tranquility Room.

We told the clinicians, “You take care of other people all day. Let this space take care of you, even if only for a moment when you need it.”

They liked it.

Some of them came to me and said, “The tranquility I feel is affecting the way I care for my patients.”

Others brought us ideas. They asked, “Can we bring an experience like this to patients and family members at our cancer center or special care nursery?”

We learned that to promote a culture of quiet, we have to care for the people who care for others.

Going back to alarms, can anyone guess the average number of alarms heard per patient each day?

Three hundred and fifty.

And what percentage of those alarms are false positives or clinically insignificant?

Between 85 and 99 percent.

We are studying the ecology of alarms, including their pitches, how they interact with one another and how they affect people’s behavior.

We are collaborating with hospitals, patients, clinicians and researchers in psychoacoustics and neuroscience around the world to reimagine the hospital soundscape. We are also beginning to work with medical device companies to redesign some of the beeps.

Things are happening.

Ideas are fun, but execution and implementation are a marathon. It isn’t easy, as many of you know. Sometimes I become burned out while confronting those challenges.

When that happens, I return to human-centered design, which taught me to learn from extreme scenarios. One of the most extreme scenarios in healthcare is the end of life.

So I return to my original question: What is the last sound you wish to hear at the end of your life?

We collaborated with the communities of OpenIDEO and Stanford Medicine X to record hundreds of people sharing the final sound they would like to hear.

One of them was Morgan, a palliative care nurse in New York. She said, “Oftentimes, I am part of the difficult and intimate process of liberating someone from a ventilator with the expectation that the person’s remaining life will be very short.”

Since encountering this question, her team has begun playing a meaningful piece of music in the moments before a person’s death. She said this has had a tremendous impact on everyone in her unit.

The beauty of our sensory experience is part of what makes us human.

I think of my friend John, whom I met at Medicine X. At first, he told me that the entire concept of a final sound frightened him because he had been close to death.

He survived a difficult condition and received a double lung transplant on January 1 several years ago.

He said, “Every New Year’s Eve, while the donor’s family watches fireworks in the sky, that family is also grieving. I think about this every day. During the worst time of their lives, they gave me the greatest gift of mine, and I work hard to honor what has been given to me.”

John said he would like to hear the sound of water at the end of his life because it is genetically calming. We all slept beside water before we were born.

May I invite you to close your eyes for a moment and reflect together?

Consider this question as a playful invitation rather than something heavy or depressing. When the sound could be anything you choose, what is the last sound you would wish to hear at the end of your life?

[Video plays]

“The last sound I want to hear at the end of life is the first sound I heard at the beginning of life.”

“The last sound I wish to hear would be a gentle breeze through the trees, being on a mountainside and hearing the wind pass.”

“The ocean. Ocean waves hitting the beach. The crash of waves.”

“Why?”

“It’s life. It’s movement. It’s transformative.”

“It’s genetically calming. I think we slept by water.”

“A happy place.”

“Every illness is a love story. Love surrounds illness because it takes something away from someone who is hurting.”

“The last sound I would wish to hear is the voice of someone I love, so I would know they were there for me in those final moments.”

“The voices of my loved ones.”

“Loved ones having a connected, human moment. Even when it isn’t with me, perhaps my friends and family talking about the good experiences we shared in life.”

“My father’s voice.”

“The sound I want to hear is my mother’s voice.”

“My children.”

“It’s so easy to say. My mother’s voice.”

“A lullaby and a bedtime song. Going off to sleep feeling relaxed and safe.”

“The last sound I’d like to hear is some kind of validation that my life was meaningful: ‘You were important. What you did mattered to many people. You left a statistically significant mark on the human condition.’”

“The last sound I wish to hear at the end of life is a toilet flushing.”

“The last sound I wish to hear is my husband farting.”

“The last sound I wish to hear before I die is laughter. I would love that because joy is what I want to carry with me into whatever comes next.”

“I want to hear applause. People are clapping because I’ve done something. I succeeded. I did well. The curtains are going to close, and it’s such a great way to go.”

“Being born into life and then living it can be a hard task. It takes energy to become a person. Then, to shut down, die and leave this space, perhaps someone carries you back into that place. There is something about that.”

“I kind of want to hear a big engine starting, like a crescendo in music. I want to hear the awakening of a powerful machine, something really loud that pushes through my body so I can feel the beat and let that be my departure.”

“A baby laughing, because the universe has a sense of humor.”

“The final sound I would like to hear is something I have never heard before, something I have never imagined.”