Palliative rehabilitation is relationship-centered care

Introduction

This article highlights the importance of a person-centered palliative rehabilitation approach that includes a focus on relationships among those engaged in the care of people with advanced diseases and chronic conditions. We present a data-driven case vignette of a hospitalized patient to illustrate some of the complexities and dilemmas encountered by rehabilitation professionals in caring for a person with advanced disease to underscore missed opportunities to include person-centered palliative rehabilitation care practices that could enhance their care. One consensus definition of person-centered care is that “individuals’ values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person-centered care is achieved through a dynamic relationship among individuals, others who are important to them, and all relevant providers. This collaboration informs decision-making to the extent that the individual desires” (1). The broader concept of relationship-centered care, which is closely related to person-centered care, “recognizes that the nature and quality of relationships in health care influence the process and outcomes of health care” (2,3). To align with the principles of person-centered care (4,5) when delivering rehabilitation services to persons with advancing medical conditions, we recommend that rehabilitation services be provided in a sensitive, caring, flexible manner in all hospital- and community-based rehabilitation and interdisciplinary interactions (e.g., relationship-centered care). This emphasis on relational factors may facilitate greater alignment between the increasingly unpredictable goals of individuals facing life threatening illness and their care partners—termed palliative rehabilitation.

Methods

A broad literature search was performed using electronic databases including PubMed, CINAHL, and Google Scholar from 2015 through 2025. Search terms and combinations included “palliative rehabilitation, relationship-centered care, shared decision making, communication, person-centered care, interdisciplinary rehabilitation, and advanced illness”. For the topic of relationship-centered care and patient-centered care some older or seminal articles were identified. Reference lists of key articles and relevant review papers were also examined to identify additional sources.

Articles were included if they addressed communication, decision-making, or relational processes within rehabilitation or palliative care settings, or if they examined the integration of relationship-centered or person-centered approaches into clinical practice. Both peer-reviewed empirical and conceptual papers were eligible for inclusion, as were consensus statements from authoritative professional organizations and governmental agencies, and clinical summaries derived from authoritative book chapters. Publications were required to be written in English, with a primary focus on adult populations with advanced or life-limiting conditions.

Studies were excluded if they focused exclusively on traditional restorative rehabilitation without reference to palliative principles, addressed pediatric or non-human populations, or emphasized technical intervention procedures without attention to communication, decision-making, or relationship dynamics. Conference abstracts, opinion pieces, and non-peer-reviewed materials lacking substantive conceptual or methodological detail were also excluded.

The authors independently reviewed and organized the literature according to emergent topics and themes relevant to the aims of this paper, including communication strategies, team collaboration, patient-clinician relationships, and the integration of palliative principles within rehabilitation. A representative case vignette was developed from our past professional experience to exemplify the practical and ethical complexities of decision-making in advanced illness. The literature synthesis was iterative and interpretive, emphasizing conceptual clarity, clinical applicability, and the translation of evidence into relationship-centered palliative rehabilitation practice.

Key content and findings

Rehabilitation within life-threatening illness

Functional decline and increased dependence when performing daily activities are nearly inevitable in the course of advanced disease and chronic illness (6,7). A person’s physical and functional decline from advanced disease and aging presents medical and rehabilitation care teams with numerous logistical and ethical dilemmas that some providers are not sufficiently prepared to navigate (8). The literature indicates that rehabilitation professionals like physical therapists (PTs) and occupational therapists (OTs) are frequently not included as part of the palliative care team and do not regularly participate in key activities such as palliative care rounds (9-13). Even the term “rehabilitation” as traditionally described—restoration of loss of function—may contribute to role confusion as some people may not have the physical capacity for functional recovery (14). However, maintaining or attenuating (e.g., slowing physical or functional decline) a person’s condition are common and appropriate goals with these individuals (14). Indeed, Tiberini et al. postulated that “Rehabilitation in palliative care aims to optimise people’s function and wellbeing and to enable them to live as independently and fully as possible, with choice and autonomy, within the limitations of the advancing illness. It is an approach that empowers people to adapt to their new state of being with dignity and provides an active support system to help them anticipate and cope constructively with losses resulting from deteriorating health” (15).

As palliative care is a relatively new specialty area, rehabilitation providers do not often receive substantial entry-level or post-professional training in palliative care principles, which can lead to uncertainty, role confusion, and defaulting to a “traditional rehabilitation” patient care approach (e.g., strenuous efforts focused toward physical recovery), despite the person’s overall disease trajectory and limited ability to physically improve (16-19). This lack of formal training and complex care navigation likely contributes to underutilizing the tools that palliative rehabilitation can offer, resulting in increased physical, emotional, and psychological distress of individuals living with a life-threatening disease and their families (20). As with other medical providers, rehabilitation professionals have cited that their level of comfort and skill with communicating complex or difficult news plays a substantial role when providing care to these individuals (21).

Some of the complex issues that are encountered during the delivery of rehabilitation services with persons living with late-stage chronic and advancing medical conditions include unclear healthcare goals (and therefore unclear rehabilitation goals); lack of role clarity among practitioners; unpredictable, variable disease trajectories and functional capacity; increasing physical, emotional, and psychological distress; as well as unclear clinical outcomes (18,22). Decision-making in this context is characterized by many factors including the person’s likely imminent physical decline, their shifting personal and well-being care goals, potential for impaired cognition or communication abilities, and complex and emotional family or care partner dynamics (23,24). In earlier stages of a disease process, therapists’ interventions may more closely resemble traditional rehabilitation goals that emphasize improving physical function, strength, and community integration (23). With an advancing disease process, the person’s goals often shift toward symptom control and attempts to preserve independence with basic activities of daily living (ADLs) (25). One major concern for persons living with an advanced or terminal disease is fear of being a burden on their family and caregivers (26,27). Rehabilitation providers can help alleviate this concern via palliative rehabilitation interventions by supporting persons to maintain as much personal independence and dignity as well as preparing caregivers to provide support while not impeding this dignity (28,29). Care partners report only feeling moderately prepared to provide care however, increasing their preparedness helps improve their confidence and reduces the perceived care burden (30). Addressing these key components of person-centered care requires intricate knowledge of a person’s goals, wishes, and values that would not otherwise be determined without a relationship-centered care approach (31,32). For instance, rehabilitation professionals can provide training for persons and families on adapted methods for basic daily skills such as toileting, bathing, grooming, and participating in home and community occupations as able, as well as facilitating use of emotional, chaplaincy, and peer support community resources (15,28,29). In the end stage of a person’s disease process, supportive rehabilitation procedures include empowering patients and care team members, including care partners, to comprehensively and proactively address pain, disease symptoms (e.g., dyspnea, fatigue), and focus on a meaningful death with dignity and comfort (33). This approach to caring for persons focuses on building trustworthy relationships; is flexible and attentive to emerging needs; and aims to recognize, respect, and attend to the social and emotional needs of the person served and their care partners (34,35). It is challenging to deliver services in this manner within healthcare systems that prioritize efficiency as a key performance indicator (36,37). It is even more challenging when rehabilitation providers are not consistently and fully included as part of the teams that can address the needs of those they serve.

The moving target of patients’ goals, values, and preferences

Care planning and decision-making become more complex when living with serious or terminal illness. Shared decision-making in advanced disease and end-of-life tends to revolve around advance care planning (ACP), advance directives, and do-not-resuscitate discussions (38). Though these are important considerations, there are limitations to the ACP process including the fact that these ACP discussions rarely include the person’s wishes as they relate to participation in rehabilitation, their preferred place of care, their remaining life goals, or the extent to which they wish to depend on others for performing daily tasks. Morrison et al. (38) noted, “Patients’ preferences are rarely static and are influenced by age, physical and cognitive function, culture, family preferences, clinician advice, financial resources, and perceived caregiver burden (e.g., need to provide personal care, time off from work, emotional strain, out-of-pocket or non-covered medical costs), which change over time.” Advanced care plans are often excessively prescriptive in some areas (e.g., end-of-life decisions) and too vague in other areas (38), which could limit planning for rehabilitation encounters to facilitate care that meets the person’s emergent needs and goals (38), such as specifying key aims and goals of rehabilitation services throughout disease progression, how much and which rehabilitation therapies should/could occur, what the person and family feel that therapy should focus on, or what is a reasonable discharge plan for post-hospitalization or rehabilitation care. From our point of view, ACPs are very valuable and important, but based on the concerns raised by Morrison and others, the process by which they are enacted may not comprehensively advance the principles of person-centered care. Furthermore, the ACP process or core documents rarely speak to a patient’s movement-related life goals and the implications of permanent or temporary changes in a patient’s functional or participatory status. In the authors’ experience, emotionally charged situations frequently arise during care, including challenges with discharge planning, perceptions by the family that the person is “giving up on life” by not participating in rehabilitation, and decisions about the use of physical restraints during episodes of confusion. Facilitating discussions with persons and their care partners regarding rehabilitation preference, preference for future locations of care, and discussing various likely or unlikely scenarios that impact physical functioning can improve the likelihood that rehabilitation providers provide patient-centered rehabilitation. Given that patients’ needs for physical and cognitive support, engaging with care partners (family or paid) is a variable that matters for how to plan one’s remaining life.

Despite the good intentions and aims of providers, studies in person-centered care argue that the potential of person-centered care is not yet realized (39,40). This is especially true when palliative rehabilitation aims and approaches differ substantially from traditional rehabilitation interventions. The “why” and “when” a patient might participate in rehabilitation becomes more complex and unpredictable in the context of serious or terminal illness. Briggs and colleagues (41-43) described several clinical approaches that rehabilitation professionals can use to adapt their traditional patient management models for patients facing life threatening illness based on the person’s goals, disease trajectory, social determinants of health, and rehabilitation potential. These included modifying treatment sessions to be less intensive with more frequent breaks, preparing the person for future decline, maintaining functional status, and finally, facilitating a “good death” (43). These different care models allow the person, family, and healthcare team to tailor rehabilitation interventions most applicable to their overarching goals and anticipated disease trajectory (41). Briggs’ care models provide guidance and elaboration on the varying contributions from rehabilitation therapies and align with the principles of person-centered care. They address “what” practitioners can do and the relationships built and maintained between practitioners, persons, and their care partners can help determine “why” and “when” these various models should be applied.

Case vignette

This vignette demonstrates some of the challenges inherent with rehabilitation during an acute hospitalization with patients living with advanced or life-threatening diseases and their families.

John is a 57-year-old White male, married to Kathleen (54-year-old White female), and works as an executive at a major automaker in suburban Detroit, Michigan, USA. He has advanced prostate cancer with metastases to the thoracic spine and pelvis. He is currently hospitalized in an acute care hospital after a decline in his function and strength of both legs. John reported his legs started feeling weaker and heavier approximately one month ago but reported no recent falls. During this hospitalization, John’s medical oncologist consulted a PT and OT to evaluate and manage his physical and functional needs. The palliative care team was not consulted.

John’s imaging studies revealed significant spinal cord compression causing progressive paraplegia. He has a history of hypertension, hyperlipidemia, and chronic lumbar pain from degenerative disc disease. His prostate cancer was diagnosed three years ago, and he has undergone multiple cancer treatment regimens, including androgen deprivation therapy, radiation therapy to the spine, and chemotherapy. Despite these treatments, John’s disease has worsened over the past few weeks and during this hospitalization his oncologist told him and his wife that he has no more viable cancer treatment options to control or cure his cancer.

John’s two-story home lacks an accessible entry and has narrow hallways that are not wheelchair accessible. His bedroom and bathroom are located upstairs, making immediate discharge without extensive home adaptations unsafe. John’s reluctance to accept the necessity of wheelchair use and home adaptations complicates discharge planning. He has resisted recommendations for a home safety evaluation, stating, “I’ll be back on my feet before I need any of that.”

Social and psychological information

John is accustomed to high levels of autonomy and authority in personal and professional decision-making. His professional identity and belief that ‘nothing is gained without hard work’ have been central to his sense of self, making his increasing need for assistance in ADLs especially distressing. Kathleen is a supportive spouse. They have two adult children in their 20s who live out of state and visit intermittently. Kathleen has expressed concern about John’s ability to manage his ADLs and her ability to assist him given her history of back pain, compounded by the fact that John is substantially taller and larger than her. John and Kathleen live in a large two-story suburban home with significant environmental obstacles, including stairs to enter the home, a second-floor bedroom, and narrow doorways. John has substantial financial resources as well as comprehensive health insurance. They both hold higher education degrees and though their health literacy was not formally examined, they appear to generally understand the medical information shared by professionals. They live in a neighborhood with readily available high-quality healthcare services as well as basic life necessities (e.g., food, safety, utilities).

Rehabilitation practitioners’ perspectives

Functional independence

Using clinical assessments commonly used in medical rehabilitation, John’s PT and OT evaluations demonstrate that he has severe weakness in his legs [left leg grossly 3-/5 (Fair—gradual release from test position occurs), right leg 1 to 2-/5 (Trace—tendon becomes prominent or feeble contraction felt in muscle with no visible movement to Poor—movement through partial range of motion) via manual muscle testing] but has full strength and range of motion in his arms. John demonstrates impaired sensation below the T10 dermatome but has retained his bowel and bladder control. Currently, he is unable to stand independently or ambulate. He requires maximal assistance for sit-to-stand transfers with a standard walker but is independent with bed mobility by using his arms to assist his right leg out of bed. He requires maximal assistance from another person for standing pivot transfers to a bedside chair and needs moderate assistance with lower body dressing. His severe thoracic pain is managed with opioids and corticosteroids. John rates his pain on the Numeric Pain Rating Scale as a 6/10 in supine and 10/10 with standing (0= no pain, 10= worst pain imaginable).

Goal setting & planning

From the rehabilitation therapists’ perspective, John’s emotional distress may interfere with his ability to engage fully in planning for a safe and realistic discharge which complicates therapy goals. They assess that short-term improvement in standing and walking is unlikely during this hospitalization. However, John insists on pursuing gait training and standing-level ADLs, expressing frustration when alternative goals are suggested. His comments reflect his values and lifestyle approach: “I just need to push harder—I’ve overcome bigger challenges before.” He shows anger during therapy sessions when wheelchair skills are introduced, saying that a wheelchair “won’t help me get back to work”. John avoids discussing long-term care needs, home modifications, or ACP, stating, “I don’t need to think about things that aren’t going to be needed.”

A rehabilitation session

During a session, Jessica (PT) and Jasmine (OT) anticipated John’s mood and preference to focus on practicing walking despite their recommendations to focus on safer, more achievable goals like improving wheelchair mobility and transfers or performing seated leg exercises. They decided to accommodate his request in the hope that John would realize the need to adjust his expectations and therapy goals. Kathleen is present and doesn’t talk much.

Jessica and Jasmine anticipate that John might become overexerted and not be able to accomplish his goal of walking, so they invite a third practitioner, William, who holds a chair behind John in the event John’s legs buckled unexpectedly. Jessica stands on one side and Jasmine on the other to stabilize John with a gait belt while John holds on to a standard walker.

John’s efforts are strenuous, and his movements are slow, uncoordinated, and extremely painful. On several occasions, his legs buckle and he has to sit down. Kathleen observes closely and offers John emotional support and encouragement to work harder in therapy. She seems concerned by his severe pain level. Despite the obvious physical toll and his verbal acknowledgment of the pain, he adamantly declines to stop, stating, “I’ll never walk again if I don’t push myself now.” During a moment of rest, Jessica and Jasmine take the opportunity to explain to John the medical risks in continuing to practice walking but he appears not to listen, repeating “I have to try harder”. Frustrated, Jessica and Jasmine end the session soon after, and judge that it is not safe to continue.

After several extremely painful and emotionally-laden therapy sessions, the therapists speak with John’s medical oncologist, Mark, about the challenges encountered during therapy sessions as well as the lack of alignment between John’s expectations for recovery and the medical reality of his current disease trajectory. Mark is appreciative of the information and requests that the therapists continue to do “the best they can” for John but no other relevant recommendations or consultations ensue (e.g., palliative care, social work, or psychological consultations). During subsequent therapy sessions, John’s distress, anxiety, and pain levels remain high and he eventually, reluctantly, agrees to also work on some wheelchair utilization in addition to his gait training and transfers. Kathleen is present for some therapy sessions and offers verbal encouragement and emotional support. After a thirteen-day hospital stay, John is transported home via ambulance with homecare nursing and rehabilitation therapy. Kathleen arranges for a bed on the first floor and a temporary wheelchair ramp. John and Kathleen decline offers for a palliative care team consultation.

Opportunities to improve the rehabilitation process

To address John’s need in more person-centered ways, we need to consider healthcare system and organizational, practice-based, and individual factors that impact service delivery. In the United States, system and organizational factors include a for-profit, free-market economic system that valorizes a biomedical orientation in which medical practitioners are the experts and short lengths of stays and avoiding unwarranted readmissions are important key performance indicators and metrics of success. Practice-based factors include disciplinary or profession-based priorities, goals, definitions of care and delivery modalities that silo practitioners from working with each other and with persons served. The canon of rehabilitation purports to support inter-disciplinary teams, but it’s questionable how well persons served and their advocates are included in shared decision-making, such as in goal setting (44).

From the rehabilitation therapists’ perspective, John’s disease trajectory and current functional limitations raised the risk of nerve damage and worsening his paralysis or falling during therapy if John’s goals of standing and walking were respected without achievement of preliminary steps such as improving leg strength and standing. Understandably, John’s focus on standing-level tasks such as walking (as opposed to pivot transfers or wheelchair management) may reflect that the medical and rehabilitation teams did not sufficiently or successfully address his difficulty in acknowledging his deteriorating health condition and that he may never return to his independent personal and professional self. Kathleen stated that she was concerned about caring for John, but it’s unclear if and how the medical teams have supported her in assisting John in this stage of his healthcare and life journey. The inclusion of psychological support services and social work may have helped both John and Kathleen begin to develop coping strategies, adjust expectations, and foster acceptance of his declining condition. By the time of discharge, John and Kathleen were not yet able to respond to the long-term changes in his physical status or that his progressive disease was increasingly likely to result in death.

The therapists recognized John’s frustration and emotional distress and attempted to balance the need to validate his feelings and maintain hope while guiding him toward safer goals that aligned with his functional abilities. Nonetheless, the rehabilitation therapists, oncologist, and primary care professionals were not fully and proactively able to attend to John’s and Kathleen’s circumstances, which were not just medical but personal, psychological, emotional, and existential, which all affected their overall well-being. Not attending to patient and family well-being is a common concern that has been well documented in the literature on person-centered care and can cause substantial distress, unwarranted pain and suffering, increased healthcare costs, disruption to healthcare operations such as delayed discharge, and increased likelihood of readmission (45-50).

Inspired by a person-centered care approach that is committed to appreciating relationships among all participants, attends to relational autonomy, and embraces inclusion of personal, emotional, and social determinants of well-being (51-56), we elucidate opportunities to attend to John and Kathleen’s well-being and circumstances. In this section, we ask: what would caring for John and Kathleen look like if the healthcare professional team espoused a relationship-centered palliative rehabilitation care approach? We are not striving to provide prescriptive answers; our goal is to remind the reader of the value of rehabilitation within palliative care and inspire considerations as to how relationship-focused palliative rehabilitation can facilitate and align with person-centered care.

For example, care planning for John would involve proactively determining which interventions are most appropriate given his current functional status and goals, while actively including his wife, Kathleen, in decision-making. Through interdisciplinary collaboration, the team can develop a cohesive care plan and ensure consistent communication. This approach may include:

• Supporting John’s evolving emotional and psychological needs by coordinating with his medical team to facilitate open communication and understanding of his condition;
• Empowering Kathleen through education—delivered by PTs, OTs, and other team members—on how to safely assist John at home, reinforcing her role as a partner in care;
• Integrating John’s beliefs and values into the rehabilitation plan, using input from spiritual care, social work, and therapy disciplines to ensure that care remains meaningful, productive, and comfortable;
• Advocating through the interdisciplinary team for coordinated discharge planning as well as addressing long-term care and symptom management needs to optimize quality of life and ensure continuity of care across settings.

Relationship-centered information exchange for collaborative planning

During his early physical therapy sessions, John expressed frustration over his reduced mobility and uncertainty about his prognosis. The rehabilitation therapists could plan to share information with John and Kathleen to help them understand his condition and the potential trajectory of his illness. This information should be easy to understand, without medical jargon, and transparent. The therapists would be attentive to not overwhelm John and Kathleen with too much information, perhaps using an incremental approach. For example, therapists could explain medical information such as his imaging to inform them about what spinal cord compression is and how it contributes to the weakness in his legs and paraplegia. While acknowledging the challenges of his condition, the therapists would emphasize the potential to maintain some level of independence and prioritize the activities that mattered most to John. They would inquire into what John’s preferred activities are, what he hopes to be able to do both in his professional and personal life after he leaves the hospital. These activities would become meaningful goals and treatment approaches during rehabilitation treatment. The therapists would use John’s expressed goals and hopes to plan treatment sessions in ways that resonated with him and aligned with his current and future needs and functional abilities. These co-created goals would be revisited frequently during subsequent therapy sessions to ensure that John’s evolving needs and priorities were being addressed. By providing consistent, easy-to-understand and transparent information, the therapists would help John be informed and empowered to make decisions about his care based on his evolving medical, physical, and emotional status. Kathleen would be explicitly invited to these sessions.

Deliberate and active inclusion of family/care partners

Kathleen expressed concerns about John’s ability to transition safely back home and the physical and emotional toll this might take on her as a caregiver. Intentionally building trustworthy relationships with John and Kathleen could allow therapists to communicate medical information and difficult information, learn about their beliefs and social circumstances, and co-create short and long-term goals that support safety and well-being. Jasmine, the OT, could proactively facilitate a thorough planning session with both John and Kathleen, focusing on strategies to ease caregiving responsibilities and ensure safety at home for both John and Kathleen. For example, Smith et al. described a family training program for people with advanced disease in an inpatient rehabilitation setting to prepare patients and their families for safe care after hospitalization (57). Jasmine could discuss practical options like installing grab bars in the bathroom, using a shower chair, utilizing safe patient handling equipment (e.g., mechanical patient lifts), and arranging for a hospital bed if needed. Recognizing the strain on Kathleen, Jasmine might also introduce the idea of respite care to provide her with occasional breaks to prevent burnout or excessive stress. Additionally, Kathleen could have been provided with local or virtual resources for support groups or other community-based caregiver or coping organizations. As a care team, a collaborative plan could be developed that balances John’s goal of returning home with Kathleen’s need for sustainable caregiving support, fostering a sense of collaboration and shared decision-making.

Integrating John’s beliefs and values into decision-making

Despite his physical limitations, John expressed a strong desire to continue working in some capacity as an executive at a major automaker. He was conflicted, however, about how his condition might affect his ability to serve in this role. Both during and after his hospitalization, the PT and OT have the opportunity to explore adaptive strategies that would support John’s goal of staying professionally engaged and retaining this portion of his personal identity. During their discussions, the therapists could inquire about the aspects of work that matter most to him and emphasize ways to align his health with his professional identity. Suggestions might include ergonomic adjustments and wheelchair accessibility for his office setup, remote work options, and pacing strategies to help him conserve energy. These recommendations should be framed as ways to honor his values while protecting his health and physical functioning. These efforts will empower John to make informed decisions about his role, enabling him to maintain a sense of purpose while managing his condition.

Team-based, coordinated care

The PTs and OTs must recognize that John’s needs extend beyond mobility and self-care training and that a key component of trust within the healthcare system is assuring high quality continuity of care to assure comfort and dignity while minimizing unwarranted hospital readmissions. Given the physical changes and emotional strain on John and his wife, the therapists have the opportunity to advocate for an interdisciplinary approach, initiating conversations with the medical team to recommend a referral to key team members, including palliative care specialists and pastoral care, to address symptom management, advanced care planning, as well as emotional and spiritual support. The therapists also should collaborate with social workers and case managers to explore home modifications, durable medical equipment, and caregiver support resources to ensure a smooth transition from hospital to home. Finally, the therapists could explain the resources and benefits of outpatient rehabilitation, home health services, and potential long-term care options, helping John and Kathleen anticipate and navigate future challenges. By actively engaging in referral, collaboration, and advocacy, the PTs and OTs can serve a vital role in ensuring that John’s rehabilitation plan aligns with his evolving medical, functional, psychosocial, and spiritual needs to achieve a person- and family-centered approach to care.

Discussion and clinical implications

There is growing evidence that palliative rehabilitation provides improved healthcare outcomes and has the potential to contain healthcare costs (29,58-61). In a large systematic review of 27 randomized controlled trials of palliative rehabilitation, Pryde et al. (29) concluded that effective practices included “symptom management, goals of care discussions, psychological support, exercise training, education, care coordination and breathlessness intervention”. Furthermore, Pryde et al. emphasized the importance of the palliative rehabilitation approach being interdisciplinary, as opposed to being solely delivered by palliative care specialists. van Zuilekom et al. (62) wrote that “As so many people need palliative care, it has been argued that all healthcare professionals (HCPs) should be able to provide it. This entails, among other things, that HCPs should be able to provide advance care planning, align treatment with a patient’s goals, wishes, and needs, and essential symptom management, avoid futile or burdensome treatments, and care for people who are dying” which also implies that palliative rehabilitation should be the responsibility of all professionals, not just rehabilitation therapists. Yet, it remains challenging to integrate palliative rehabilitation care in contemporary medical settings in the United States because of limited awareness, training, and time of providers and healthcare infrastructure (24). However, the outcomes to patient/family quality of life and healthcare systems (e.g., decreased length of stay, reduced admissions, unwarranted medical procedures and their accompanying costs) are anticipated positive effects of this integration and may be worth the time and resource investment (13,63-66).

Despite its potential to improve quality of life, palliative rehabilitation is not consistently or easily integrated into routine care (14,20). Several factors contribute to this gap. Many rehabilitation professionals lack formal training in palliative care principles, leading to low confidence in managing patients with advanced illness and uncertainty about appropriate goals and interventions (16,24). Additionally, rehabilitation services in a hospital setting are often viewed through a narrow biomedical lens focused on functional restoration and discharge readiness, which can marginalize the value of care aimed at comfort, adaptation, and quality of life (67).

Financial and systemic barriers also play a role—rehabilitation is frequently perceived as a cost rather than a strategic investment in person-centered outcomes, particularly for individuals with progressive or terminal conditions (29). Moreover, limited time and staffing pressures often force clinicians and administrators to prioritize patients with clear recovery trajectories (e.g., elective orthopedic surgeries or emergent neurologic or cardiovascular conditions such as cerebrovascular accident or myocardial infarctions) over those with complex diseases or declining prognoses (68,69). To embed relationship-centered principles, reimbursement and funding models must recognize communication, collaboration, and goal-concordant care as essential components of care. Structural reform should incentivize interdisciplinary integration and continuity of care across settings, while educational initiatives can cultivate clinicians’ skills in presence, listening, and shared meaning-making. Extending this approach into the home requires intentional transitions, caregiver engagement, and the use of community or telehealth supports. Ultimately, relationship-centered palliative rehabilitation will become the norm only when systems value human connection and relational processes and outcomes as integral components of high-quality care.

This confluence of educational, cultural, and systemic barriers contributes to the underutilization of palliative rehabilitation, despite growing evidence of its value. In this paper, we offered some suggestions as to how rehabilitation practitioners can co-create care goals, become more nimble with their care provision, and provide short- and long-term planning for anticipated disease advancement and associated functional changes.

Several prominent professional organizations have recently begun to provide guidance on the intersecting role of rehabilitation and palliative care. The World Health Organization European Region published a “Policy Brief on Integrating Rehabilitation into Palliative Care Services” that discusses the opportunities and challenges to improving fundamental and high-quality access to rehabilitation for those facing a life-threatening illness (20). In this document, it is stated that “Rehabilitation and palliative care services increasingly occupy shared spaces in health systems. There is an opportunity to improve access to high-quality function-oriented care for people with life-limiting conditions.” This document recommends a systems approach to healthcare change and integration of palliative care within rehabilitation.

Accreditation guidelines for quality care also have the potential to positively impact implementation of best practices for integrating palliative care and rehabilitation. In 2025, CARF International (aka Commission on Accreditation of Rehabilitation Facilities) established standards for programs to be accredited as a Palliative and End-of-Life Care Specialty Program (4). These standards include advocating for approaches that focus on relationships with persons served; respect for values, wishes and choices; quality of life through the end of life; autonomy in decision-making; holistic support for persons and their families; and empowering persons to serve as their own decision makers. As CARF International is seen as a public and professional leader in the area of rehabilitation, these standards may assist in the further integration of palliative care and rehabilitation services.

Future research

Future research should explore the practical implementation and outcomes of palliative rehabilitation, especially as it relates to person and relationship-centered care. Investigations should focus on facilitating its application in clinical practice, assessing its impact on patient and caregiver satisfaction, quality of life, and other outcomes that are meaningful for the persons served.

Conclusions

Palliative rehabilitation presents a new opportunity to approach how healthcare is conceptualized and delivered to individuals with life-limiting conditions. This approach acknowledges the complexity of patients’ medical realities and the profound emotional, psychological, and physical challenges they and their care partners face. By fostering collaborative, dynamic interactions among patients, their care partners, and the multidisciplinary care team, a palliative rehabilitation care model ensures that rehabilitation strategies align with the evolving priorities and capacities of the individual. Palliative rehabilitation that is relationship-centered promotes dignity and quality of life, even in the face of inevitable physical decline, by prioritizing collaborative care strategies that are both meaningful and achievable.

Acknowledgments

During manuscript refinement, Chat GPT 4.0 was utilized to assist with refinement of the data-driven patient case and minor grammar and flow of some sentences.

Footnote

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-107/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-107/coif). C.M.W. serves as an unpaid editorial board member of Annals of Palliative Medicine from September 2025 to August 2027. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. American Geriatrics Society Expert Panel on Person-Centered Care. Person-Centered Care: A Definition and Essential Elements. J Am Geriatr Soc 2016;64:15-8. [Crossref] [PubMed]
2. Nundy S, Oswald J. Relationship-centered care: A new paradigm for population health management. Healthc (Amst) 2014;2:216-9. [Crossref] [PubMed]
3. Soklaridis S, Ravitz P, Adler Nevo G, et al. Relationship-centred care in health: A 20-year scoping review. Patient Exp J 2016;3:130-45. [Crossref]
4. CARF International. Palliative and End-of-Life Care Specialty Program. In: Aging Services Program Descriptions. Tuscon, AZ: CARF International; 2025:1-6.
5. Registered Nurses’ Association of Ontario. People-Centred Care. 3rd ed. Toronto, Ontario: Registered Nurses’ Association of Ontario; 2025:39-87.
6. Gómez-Batiste X, Martínez-Muñoz M, Blay C, et al. Prevalence and characteristics of patients with advanced chronic conditions in need of palliative care in the general population: a cross-sectional study. Palliat Med 2014;28:302-11. [Crossref] [PubMed]
7. Stolz E, Mayerl H, Muniz-Terrera G, et al. Terminal Decline in Physical Function in Older Adults. J Gerontol A Biol Sci Med Sci 2024;79:glad119. [Crossref] [PubMed]
8. Silver JK, Raj VS, Fu JB, et al. Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services. Support Care Cancer 2015;23:3633-43. [Crossref] [PubMed]
9. Van den Block L, de Nooijer K, Pautex S, et al. A European Association for Palliative Care White Paper defining an integrative palliative, geriatric, and rehabilitative approach to care and support for older people living with frailty and their family carers: a 28-country Delphi study and recommendations. EClinicalMedicine 2025;87:103403. [Crossref] [PubMed]
10. Manson J, Taylor P, Mawson S, et al. Identifying aspects of physiotherapy and occupational therapy provision in community palliative rehabilitation that could improve outcomes: A realist review. Palliat Med 2025;39:734-49. [Crossref] [PubMed]
11. Wilson CM, Boright LE, Henshaw AM, et al. Role of rehabilitation in palliative care after the COVID-19 pandemic: a narrative review. Ann Palliat Med 2025;14:379-92. [Crossref] [PubMed]
12. Rivero JTM, Santos NKR, Dones Iii VC. Experiences of rehabilitation professionals in the provision of palliative care: a qualitative systematic review protocol. JBI Evid Synth 2025;23:2124-31. [Crossref] [PubMed]
13. Wu S, Emos MR, Chang P, et al. The Importance of Rehab in Treating Cancer and Palliative Care Patients. Curr Phys Med Rehabil Rep 2025;13:17. [Crossref]
14. Timm H, Thuesen J, Clark D. Rehabilitation and palliative care: histories, dialectics and challenges. Wellcome Open Res 2021;6:171. [Crossref] [PubMed]
15. Tiberini R, Talbot-Rice H, Turner K. Rehabilitation in Palliative Care: Principles in the Context of Life-Limiting Illness, Practices for the Interdisciplinary Team, and the Specialist Contribution of Physiotherapy and Occupational Therapy. In: Textbook of Palliative Care. Cham: Springer Nature Switzerland; 2025:1-36.
16. Wilson CM, Stiller CH, Doherty DJ, et al. The Role of Physical Therapists Within Hospice and Palliative Care in the United States and Canada. Am J Hosp Palliat Care 2017;34:34-41. [Crossref] [PubMed]
17. Tiberini R, Richardson H. Rehabilitative Palliative Care: Enabling People to Live Fully Until They Die. London: Hospice UK; 2015.
18. Henshaw AM, Winstead SR. Building Bridges in Palliative Rehabilitation: An Evidence-Based Toolkit to Promote Collaboration. Am J Hosp Palliat Care 2024;41:601-9. [Crossref] [PubMed]
19. Talbot-Coulombe C, Guay M. Occupational therapy training on palliative and end-of-life care: Scoping review. Brit J Occup Ther 2020;83:609-19. [Crossref]
20. World Health Organization. Policy Brief on Integrating Rehabilitation into Palliative Care. Geneva: World Health Organization Regional Office for Europe; 2023.
21. Bloomer MJ, Botti M, Runacres F, et al. Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study. Palliat Med 2018;32:1615-23. [Crossref] [PubMed]
22. Papadimitriou C, Weaver JA, Guernon A, et al. “Fluctuation is the norm”: Rehabilitation practitioner perspectives on ambiguity and uncertainty in their work with persons in disordered states of consciousness after traumatic brain injury. PLoS One 2022;17:e0267194. [Crossref] [PubMed]
23. Wilson CM, Stiller CH, Doherty DJ, et al. Physical therapists in integrated palliative care: a qualitative study. BMJ Support Palliat Care 2022;12:e59-67. [Crossref] [PubMed]
24. Harding Z, Hall C, Lloyd A. Rehabilitation in palliative care: a qualitative study of team professionals. BMJ Support Palliat Care 2022;12:e28-38. [Crossref] [PubMed]
25. von Post H, Wagman P. What is important to patients in palliative care? A scoping review of the patient’s perspective. Scand J Occup Ther 2019;26:1-8. [Crossref] [PubMed]
26. Dunn A, Litrivis E. Aligning patient preferences and patient care at the end of life. J Gen Intern Med 2011;26:681-2. [Crossref] [PubMed]
27. Gudat H, Ohnsorge K, Streeck N, et al. How palliative care patients’ feelings of being a burden to others can motivate a wish to die. Moral challenges in clinics and families. Bioethics 2019;33:421-30. [Crossref] [PubMed]
28. Ibrahim AM, Wahba NMI, Zaghamir DEF, et al. Impact of a comprehensive rehabilitation palliative care program on the quality of life of patients with terminal cancer and their informal caregivers: a quasi-experimental study. BMC Nurs 2024;23:357. [Crossref] [PubMed]
29. Pryde K, Lakhani A, William L, et al. Palliative rehabilitation and quality of life: systematic review and meta-analysis. BMJ Support Palliat Care 2024;spcare-2024-004972.
30. Karabulutlu EY, Turan GB, Yanmış S. Evaluation of care burden and preparedness of caregivers who provide care to palliative care patients. Palliat Support Care 2022;20:30-7. [Crossref] [PubMed]
31. Kmetec S, Fekonja Z, Kolarič JČ, et al. Components for providing person-centred palliative healthcare: An umbrella review. Int J Nurs Stud 2022;125:104111. [Crossref] [PubMed]
32. King G. Central yet overlooked: engaged and person-centred listening in rehabilitation and healthcare conversations. Disabil Rehabil 2022;44:7664-76. [Crossref] [PubMed]
33. Hasegawa T, Sekine R, Akechi T, et al. Rehabilitation for Cancer Patients in Inpatient Hospices Palliative Care Units and Achievement of a Good Death: Analyses of Combined Data From Nationwide Surveys Among Bereaved Family Members. J Pain Symptom Manage 2020;60:1163-9. [Crossref] [PubMed]
34. Engel M, Kars MC, Teunissen SCCM, et al. Effective communication in palliative care from the perspectives of patients and relatives: A systematic review. Palliat Support Care 2023;21:890-913. [Crossref] [PubMed]
35. Bishaw S, Coyne E, Halkett GK, et al. Fostering nurse-patient relationships in palliative care: An integrative review with narrative synthesis. Palliat Med 2024;38:1105-20. [Crossref] [PubMed]
36. Kayes NM, Papadimitriou C. Reflecting on challenges and opportunities for the practice of person-centred rehabilitation. Clin Rehabil 2023;37:1026-40. [Crossref] [PubMed]
37. Shortell SM, Zazzali JL, Burns LR, et al. Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture in physician organizations. Med Care 2001;39:I62-78. [Crossref] [PubMed]
38. Morrison RS, Meier DE, Arnold RM. What’s Wrong With Advance Care Planning? JAMA 2021;326:1575. [Crossref] [PubMed]
39. Gibson BE, Terry G, Setchell J, et al. The micro-politics of caring: tinkering with person-centered rehabilitation. Disabil Rehabil 2020;42:1529-38. [Crossref] [PubMed]
40. Mudge S, Stretton C, Kayes N. Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disabil Rehabil 2014;36:457-63. [Crossref] [PubMed]
41. Briggs RW. Clinical decision making for physical therapists in patient-centered end-of-life care. Top Geriatr Rehabil 2011;27:10-7. [Crossref]
42. Pizzi MA, Briggs R. Occupational and physical therapy in hospice: the facilitation of meaning, quality of life, and well-being. Top Geriatr Rehabil 2004;20:120-30. [Crossref]
43. Wilson CM, Mueller K, Briggs R. Physical Therapists’ Contribution to the Hospice and Palliative Care Interdisciplinary Team: A Clinical Summary. J Hospice Palliat Nurs 2017;19:588-96. [Crossref]
44. Moore CL, Kaplan SL. A Framework and Resources for Shared Decision Making: Opportunities for Improved Physical Therapy Outcomes. Phys Ther 2018;98:1022-36. [Crossref] [PubMed]
45. Cadel L, Guilcher SJT, Kokorelias KM, et al. Initiatives for improving delayed discharge from a hospital setting: a scoping review. BMJ Open 2021;11:e044291. [Crossref] [PubMed]
46. Kwame A, Petrucka PM. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs 2021;20:158. [Crossref] [PubMed]
47. Epstein RM, Street RL. Patient-centered communication in cancer care: Promoting healing and reducing suffering. Bethesda, MD: National Institutute of Health; 2007. NIH Publication No. 07-6225.
48. Levack WM, Siegert RJ, Dean SG, et al. Goal planning for adults with acquired brain injury: how clinicians talk about involving family. Brain Inj 2009;23:192-202. [Crossref] [PubMed]
49. Entwistle VA, Cribb A, Watt IS, et al. “The more you know, the more you realise it is really challenging to do”: Tensions and uncertainties in person-centred support for people with long-term conditions. Patient Educ Couns 2018;101:1460-7. [Crossref] [PubMed]
50. Moore L, Britten N, Lydahl D, et al. Barriers and facilitators to the implementation of person‐centred care in different healthcare contexts. Scand J Caring Sci 2017;31:662-73. [Crossref] [PubMed]
51. Papadimitriou C, Clayman ML, Mallinson T, et al. A New Process Model for Relationship‐Centred Shared Decision‐Making in Physical Medicine and Rehabilitation Settings. Health Expect 2024;27:e14162. [Crossref] [PubMed]
52. Lautermilch A, Tankard A. Review of Care Work: Dreaming Disability Justice, by Leah Lakshmi Piepzna-Samarasinha. J Lit Cult Disabil Stud 2022;16:121-4. [Crossref]
53. Hansson SO, Fröding B. Ethical conflicts in patient-centred care. Clin Ethics 2021;16:55-66. [Crossref]
54. Restall G, Ripat J, Stern M. A framework of strategies for client-centred practice. Can J Occup Ther 2003;70:103-12. [Crossref] [PubMed]
55. Beach MC, Inui TRelationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med 2006;21:S3-8. [Crossref] [PubMed]
56. Ellis‐Hill C, Pound C, Galvin K. Making the invisible more visible: Reflections on practice‐based humanising lifeworld‐led research – existential opportunities for supporting dignity, compassion and wellbeing. Scand J Caring Sci 2022;36:1037-45. [Crossref] [PubMed]
57. Smith S, Wilson CM, Lipple C, et al. Managing Palliative Patients in Inpatient Rehabilitation Through a Short Stay Family Training Program. Am J Hosp Palliat Care 2020;37:172-8. [Crossref] [PubMed]
58. Nottelmann L, Groenvold M, Vejlgaard TB, et al. Early, integrated palliative rehabilitation improves quality of life of patients with newly diagnosed advanced cancer: The Pal-Rehab randomized controlled trial. Palliat Med 2021;35:1344-55. [Crossref] [PubMed]
59. Stene GB, Hauken MA, Ahmedzai HH, et al. Integration of palliative rehabilitation in cancer care: a multinational mixed method study. BMC Palliat Care 2024;23:267. [Crossref] [PubMed]
60. Bayly J, Ahmedzai HH, Blandini MG, et al. Integrated Short-term Palliative Rehabilitation to improve quality of life and equitable care access in incurable cancer (INSPIRE): a multinational European research project. Palliat Care Soc Pract 2023;17:26323524231179979. [Crossref] [PubMed]
61. Rezende G, Gomes-Ferraz CA, Bacon IGFI, et al. The importance of a continuum of rehabilitation from diagnosis of advanced cancer to palliative care. Disabil Rehabil 2023;45:3978-88. [Crossref] [PubMed]
62. van Zuilekom I, Metselaar S, Godrie F, et al. Generalist, specialist, or expert in palliative care? A cross-sectional open survey on healthcare professionals’ self-description. BMC Palliat Care 2024;23:120. [Crossref] [PubMed]
63. Wittry SA, Lam NY, McNalley T. The Value of Rehabilitation Medicine for Patients Receiving Palliative Care. Am J Hosp Palliat Care 2018;35:889-96. [Crossref] [PubMed]
64. May P, Garrido MM, Cassel JB, et al. Palliative Care Teams’ Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities. Health Aff (Millwood) 2016;35:44-53. [Crossref] [PubMed]
65. May P, Normand C, Cassel JB, et al. Economics of Palliative Care for Hospitalized Adults With Serious Illness. JAMA Intern Med 2018;178:820. [Crossref] [PubMed]
66. Luta X, Ottino B, Hall P, et al. Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews. BMC Palliat Care 2021;20:89. [Crossref] [PubMed]
67. Runacres F, Gregory H, Ugalde A. ‘The horse has bolted I suspect’: A qualitative study of clinicians’ attitudes and perceptions regarding palliative rehabilitation. Palliat Med 2017;31:642-50. [Crossref] [PubMed]
68. Mills JA, Marks E, Reynolds T, et al. Rehabilitation: Essential along the Continuum of Care. In: Disease Control Priorities: Improving Health and Reducing Poverty. Third Edition (Volume 9). The World Bank; 2017:285-95.
69. Khan HTA, Addo KM, Findlay H. Public Health Challenges and Responses to the Growing Ageing Populations. Public Health Chall 2024;3:e213. [Crossref] [PubMed]