Occupational therapists are trained to assess function, set goals, and measure progress. Palliative care unsettles all three. When a client's condition is not improving — when the trajectory is decline rather than recovery — the clinical frameworks most OTs rely on start to feel inadequate.
A recent focus group study published in the Australian Occupational Therapy Journal maps out what palliative care occupational therapy actually looks like in practice: the cultural forces that shape every clinical encounter, the ethical tensions that rarely fully resolve, and the professional gaps the field still needs to close. Sixteen experienced palliative care OTs across Singapore’s hospitals, community settings, and hospices took part — making it one of the few studies to examine this population through the lens of practitioners who work with it daily.
Three themes emerged. Each has direct clinical implications.
The Family Is Not Background — It Is the Unit of Care
The study’s most consistent finding is one that experienced clinicians will recognise immediately: in Singaporean Chinese families, decisions are rarely made by individuals. They are made with — and often by — the family. Clients factor in how their choices will affect their children. Caregivers make decisions about their loved one through the lens of what is right for the household, not just for the person in their care.
This is collectivism in practice, and it has concrete consequences for palliative care occupational therapy. A client-centred approach that treats the patient as the sole decision-maker will miss the actual clinical picture. Participants in the study described families where caregivers effectively acted as gatekeepers — managing which activities their loved one could participate in, when, and how.
Engaging the family is not optional. It is the work.
Filial Piety and the Caregiver’s Dilemma
The study adds a layer of nuance that is easy to miss: the cultural expectations shaping these families are not static, and they can pull in opposite directions simultaneously.
Filial piety — the Confucian obligation of adult children to honour and obey their parents — runs deep in Chinese family culture. Adult children are accustomed to deferring to their parents, to treating their elders’ wishes as authoritative. When those same adult children become primary caregivers, they are suddenly placed in the opposite position: responsible for managing, limiting, and sometimes overriding what their parent wants to do, in the name of safety.
The internal conflict this creates is real and, according to participants, particularly acute in new caregivers. One therapist described a daughter who felt she had no right to restrict her mother’s movements around the home — not because she disagreed with the clinical rationale, but because doing so felt like a fundamental violation of who she was supposed to be in the family.
Palliative care OTs who surface this tension early — who name it, normalise it, and help caregivers think it through — are doing something that goes well beyond functional assessment. They are addressing the relational and ethical weight that caregiving carries in a collectivist family structure.
Not Every Family Follows the Same Script
While the study confirmed many of the patterns identified in earlier research — families prioritising rest, caregivers acting from love and obligation — participants were careful to resist overgeneralisation. Some families strongly encouraged their loved ones to stay active. Some caregivers were motivated primarily by practical necessity rather than devotion. Individual variation within any cultural group is always present.
This matters because cultural competency is not about applying a template. It is about developing the clinical sensitivity to read what is actually in front of you — to understand where a particular family sits relative to the broader cultural patterns, rather than assuming they conform to them.
The Institutional Pressure Against “Being”
Occupational therapy has a strong professional identity built around activity — around engagement, function, and doing. In palliative care, that identity requires revision. Clients and families in end-of-life settings often prioritise rest. Being with someone — present, attentive, unhurried — can be as meaningful as any structured intervention.
Participants in the study described how difficult this was to internalise, particularly for those who had come from acute hospital settings where activity engagement was the constant clinical goal. One therapist reflected on the shift it required: what counted as therapeutic in a ward environment was often precisely the wrong instinct in a palliative caseload.
The difficulty is compounded by systemic pressure. Organisations tend to favour interventions that produce visible, measurable outcomes. Therapeutic presence — the quality of connection between therapist and client — is intangible, even when its effects on hope, coping, and sense of being understood are well-documented in palliative care literature. Participants across all three focus groups described discomfort billing for sessions that consisted primarily of conversation, even when that conversation was clinically purposeful.
This is a structural problem, not an individual one. Management in palliative care settings carries a responsibility to protect the time and space that therapeutic relationship-building requires — and to resist defining clinical value purely by what can be counted.
Theme Summary
| Theme | Core Finding | Practice Implication |
|---|---|---|
| Culture and occupations | Collectivism means the family, not just the client, is the unit of care; filial piety creates role conflict in new caregivers | Involve family actively in goal-setting; identify and address caregiver role conflict early |
| Challenges of OT practice | OTs face pressure to prioritise observable activity over therapeutic presence; billing for relational sessions creates ethical tension | Organisations must protect space for non-observable clinical work; supervision should address this directly |
| Moving forwards | Mentorship is essential but scarce; training gaps include communication, grief literacy, cultural knowledge | Build mentorship structures; embed palliative content in OT curricula |
What the Profession Still Needs to Build
Almost all participants identified mentorship as indispensable — and largely absent. Palliative care is a relatively new area of occupational therapy practice, and most therapists entering it do so without a senior OT to guide them through the clinical, ethical, and emotional demands of the caseload. Processing a client’s death, navigating conflicting goals within a family, justifying non-physical interventions to colleagues — these require experience and reflection that cannot be acquired from textbooks alone.
Participants suggested practical workarounds: peer discussion groups, video-conferencing clinical mentoring, reflective practice frameworks, and partnerships with countries where palliative OT is more developed. These are not substitutes for in-person mentorship, but they are viable starting points where structural gaps exist.
On training, the study’s findings align with international literature. The priority areas are communication skills for difficult conversations, grief and bereavement knowledge, palliative-specific assessment and symptom management, and cultural competency — including explicit coverage of how local cultural norms shape occupational choices and family dynamics. Many of these remain underrepresented in entry-level OT curricula. [INTERNAL LINK]
What Home-Based Palliative OT Makes Possible
The therapists in this study were navigating palliative care largely within institutional settings — acute hospitals, community hospitals, and inpatient hospices — each carrying its own pressures around throughput, documentation, and measurable outcomes. Many of the challenges they described become considerably more workable when the clinical encounter happens in the client’s home.
Home-based palliative care occupational therapy operates in the environment where family dynamics are most visible, where caregiving arrangements reveal themselves in real time, and where the texture of a person’s daily life is directly observable. The cultural nuances the study raises — deference to elders, unspoken family hierarchies, the way rest and participation are negotiated around household rhythms — do not need to be inferred. They are in the room.
Lifeweavers’ home-based rehabilitative palliative care is built around exactly this kind of practice. Working with clients and families in their own spaces, our therapists encounter the real clinical picture — not a snapshot of it — and can respond to the full complexity of what they find.
Frequently Asked Questions
What does an occupational therapist do in palliative care? Palliative care occupational therapists help clients engage in activities that are meaningful to them, adapt their environment as functional needs change, support caregivers, and manage symptoms through non-pharmacological means. In end-of-life care, this often includes facilitating rest, supporting family communication, and maintaining quality of life rather than restoring lost function.
How does collectivist culture affect OT practice with Chinese older adults? In collectivist cultures, clients rarely make decisions in isolation — they consider the impact on family members, and family members often play an active role in determining what the client does or does not participate in. Effective palliative care occupational therapy engages the family unit, not just the individual, and treats family-level goals as clinically relevant.
What is filial piety and why does it matter for palliative OT? Filial piety is the deeply held Confucian obligation of adult children to respect and obey their parents. When those same adult children become caregivers who must restrict a parent’s activities for safety reasons, they often experience significant role conflict. Occupational therapists who identify and address this tension early can provide more effective support to new caregivers.
Why do occupational therapists sometimes struggle in palliative settings? OTs are trained in an activity-focused model in which visible engagement and measurable outcomes are the markers of good practice. Palliative care requires a different orientation — one that values presence, relationship, and rest alongside structured activity. Making this shift can be challenging without mentorship and reflective supervision.
What training does an OT need for palliative care practice? Priority areas include communication skills for difficult conversations, grief and bereavement literacy, knowledge of palliative assessments and non-pharmacological symptom management, cultural competency, and emotional self-care. Many of these are not yet standard in entry-level OT programmes.
What are the advantages of home-based palliative occupational therapy? Home-based practice allows the therapist to observe the client’s actual daily environment, understand family dynamics as they naturally present, and deliver care in the context where it needs to work. For clients with life-limiting conditions, avoiding institutional settings can also reduce stress and support dignity and comfort at end of life.
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