Collaborative care for relationship completion: Case reports from intensive care units

Abstract

Palliative care plays an important role in intensive care units, where critically ill patients and their families often experience significant psychosocial, emotional and spiritual needs. One significant factor enhancing the quality of life for dying patients is being able to achieve a sense of relationship completion during end of life. Allied health professionals such as music therapists and medical social workers play an important part in managing the psychosocial aspects of the care of the dying patient. However, data on collaborative efforts between these professionals to support the sense of emotional and relational completion is under-reported. This paper presents two case reports illustrating the collaborative roles of a board-certified music therapist and medical social worker in facilitating this completion for imminently dying patients and their loved ones in critical care. Data was extracted from the institution’s electronic medical records. Consent for de-identification publication was sought.

Plain Language Summary

The end-of-life period for imminently dying patients in intensive care units is a challenging period for patients and their families. Patients and families frequently experience emotional stress as they try to say goodbye to their loved ones and seek peace in their relationships. Healthcare professionals including the medical, nursing and allied team play an important role in supporting family members and patients to achieve that sense of relational completion prior to a patient’s death. While music therapists and medical social workers are recognised for their individual contributions to end-of-life care, their collaborative approaches within intensive care units remain underexplored. This paper presents two case reports describing the complementary roles of a music therapist and medical social worker in supporting patients and their families using information from electronic medical recordings.

Introduction

For individuals nearing the end of life, relationship completion – expressing “I love you”, “thank you”, “I forgive you” and “Please forgive me” – is integral for emotional and existential peace.^1,2 In intensive care units (ICUs), critically ill patients and families often experience high psychological distress while making decisions surrounding high morbidity and mortality risks. ³ Within this challenging environment, music therapists ^a and medical social workers provide psycho-emotional and spiritual support.

In Singapore, music therapy is deepening as an allied health discipline ⁵ alongside national arts in healthcare initiatives, including the 2025 Healing Arts Singapore initiative. ⁶ While the individual contributions of music therapists ⁷ and medical social workers ⁸ in end-of-life care are documented, their collaborative efforts within ICUs remain underexplored.

This report illustrates music therapy-medical social work collaboration facilitating relationship completion for imminently dying ICU patients.

Case reports

Method

This paper describes two case reports following CARE reporting guidelines. ⁹ As per institution guidelines, ethical approval was not required for publication. Pseudonyms were used to ensure confidentiality. Written informed consent was obtained from families. Each case describes a single session ^b due to the acute nature of critical care, involving one board-certified music therapist and one medical social worker. Data was retrieved from the institution’s electronic medical records.

Case report 1

Patient A, a middle-aged man admitted to the ICU following a severe cardiac event. Due to his actively deteriorating condition and guarded prognosis, the palliative team referred the case for psycho-emotional support for his young family. Interventions were delivered through a collaborative 90-min two-part session involving a music therapist, medical social worker, and nurse clinician.

The first part of the session was a preparatory session, conducted outside the ward with Patient A’s spouse and young children. The medical social worker and nurse clinician assessed their understanding of the clinical condition, and provided lay explanations. The spouse was experiencing significant distress and caregiving demands. The children appeared fretful and overwhelmed by the hospital environment. The medical social worker used developmentally-appropriate language to prepare them for what they might see, hear, and feel in the ICU. The music therapist also introduced age-appropriate instruments such as ukulele, egg shakers, and baby maracas. The elder child engaged readily, while the younger remained apprehensive. This initial musical play aimed to reduce anxiety before the subsequent bedside session.

At the bedside with the entire family and three professionals, the music therapist initiated a singing intervention using a familiar children’s song, ‘I Love You’ to facilitate connection between the mildly sedated and intubated Patient A and his children. Initially distant, the children gradually moved closer to Patient A, with the elder child singing along and eventually holding his hand—a physical gesture of connection.

The music therapist facilitated a lyric substitution intervention, incorporating family-specific expressions of love into the song. The children’s increasing participation through movement and singing indicated emotional openness. Patient A tapped his hand to the music, synchronising non-verbally with his family. The music therapist adjusted the tempo and volume to support Patient A’s participation while monitoring his vitals. Concurrently, the medical social worker and nurse clinician held therapeutic space for supportive counselling with Patient A’s spouse. Both the music therapist and medical social worker served as conduits to express love between Patient A and his family, with the song serving as a gift to each other.

This collaborative session fostered emotional connection and normalcy amidst a stressful clinical setting. Following the session, Patient A’s condition improved, leading to discharge home. His spouse expressed gratitude for the initial single ICU session, noting children’s increased comfort during subsequent hospital visits which provided her the mental space to process her emotions.

Case report 2

Elderly Patient B, with multi-organ complications during a prolonged ICU admission, was referred to medical social services and music therapy to address psycho-emotional burdens. Despite multiple medical interventions, Patient B’s remained in multi-organ failure, and deemed medically irreversible with a poor prognosis. His family consented to withdraw life-sustaining procedures, opting for a compassionate discharge ^c for Patient B to spend his final hours at home.

Goal shifting to palliative care presented challenges: His wife struggled to fully comprehend the prognosis, while his adult children grappled with their emotional distress alongside complexities of arranging for his end-of-life logistics. To mitigate psychosocial risks, both allied health professionals conducted a collaborative 30-min bedside session prior to the planned discharge with the aim of facilitating a sense of relationship completion.

Different coping styles were observed pre-loss: Patient B’s children focused on maximising remaining quality time, while his wife, struggling to grasp illness severity, intermittently diverted focus away from impending discharge and emotional closure.

As such, the medical social worker first validated differing coping styles among family members and refocused the session as an opportunity for meaningful connection. Building upon therapeutic relationship with Patient B and his musical preference from the prior eight individual music therapy sessions, the music therapist initiated song communication intervention enabling the family to choose and perform songs to convey unspoken emotions and messages. One chosen song 月亮代表我的心 (translated to ‘The Moon Represents My Heart’) conveyed unwavering love between Patient B and his family. The music therapist repeated significant lyrics of the song to strengthen the communication. Between songs, the professionals invited the family to express messages of love, gratitude, forgiveness and goodbye. While Patient B was unable to verbally respond, he connected with his children through physical touch of the hands and shared tears. The professionals then served as Patient B’s voice, acknowledging and returning the communication of gratitude and love, thereby reciprocating relationship completion.

Subsequently, the music therapist facilitated an Amplified CardioPulmonary Recording (ACPR), capturing a recording of Patient B’s heartbeat. This tangible product provided the family with a lasting keepsake and a materialisation of their continued connection.

The session enabled Patient B and family to spend quality time. The children reported feeling an increased internal sense of connection after the session. Patient B demised the next day after discharge.

Discussion

This report described the collaborative efforts of a board-certified music therapist and medical social workers in facilitating relationship completion for imminently dying ICU patients and their loved ones.

In both cases, the music therapist leveraged creative, non-verbal interventions such as instrumental play, song communication, therapeutic singing and facilitating ACPR to reduce anxiety, normalise the environment, and give non-communicative patients and their families concrete ways to express love and say goodbye. Before each session, the music therapist considered patients’ medical condition and their relationship with music, family preferences, and cultural background when deciding on the music type, musical experience, and legacy work to facilitate. During sessions, the therapist monitored patients’ and families’ breathing, movement, facial expressions and verbal reactions to guide the therapeutic process.

For example, in Case 1, age-appropriate music-making eased the children into the ICU environment and closer to Patient A while the therapist entrained the tempo and volume to his breathing and movement, enabled him to participate in the musical connection with his children. In Case 2, the therapist led repetition of key song lyrics to emphasise love, initiating communication of relationship completion between Patient B and family. In both cases, the medical social workers provided psychosocial support, offering supportive counselling for distress and navigating complex family dynamics, thereby fostering an environment of trust essential for delicate end-of-life conversations.

The strength of this collaborative approach lies in the interplay of these two disciplines. While the music therapist created emotionally safe “containers” through interventions ¹² and mirrored patients and families’ emotional states, ¹³ the medical social worker anchored these time-sensitive single sessions with knowledge of family dynamics, logistical expertise, and verbal counselling. The collaboration allowed both professionals to reflexively navigate the complex end-of-life transitions, enabling patients and their loved ones to convey and receive love and farewell. The complementary nature of these two professions and benefits of this collaborative approach has been documented in literature for families of paediatric cancer patients, though not in the adult population. ¹⁴

Strengths and limitations

This report on collaborative approaches between music therapy and medical social work within ICU is the first in Singapore. While this paper utilised two case reports, it offers valuable and novel insights which may be generalised to other units with similar patient populations. Further research could explore the impact and effectiveness of such approaches as well as how this collaborative work could be scaled to involve the rest of the multidisciplinary ICU team.

Conclusion

In highly distressing and time-sensitive critical care settings, it is possible for healthcare workers to adopt collaborative approaches when supporting imminently dying patients and their loved ones. Music therapists and medical social workers serve as key members of the team, providing psychosocial and spiritual support when medical interventions can no longer alter prognosis. Drawing from their caring disciplines and lens of attunement, their complementary skill sets yet distinct roles enable them to support patients and their family members as they navigate end-of-life transitions meaningfully, fostering a profound sense of connectedness and relationship completion.