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Music therapy is becoming increasingly common as an adjunct therapy to support symptom management in palliative care settings. There is a small but promising research body identifying the effect of music therapy on patient reported outcomes, including health related quality of life. However, studies to date have paid little attention to the processes which lead to these changes in patient outcomes.To explore the processes involved in the implementation of music therapy as part of a feasibility randomised control trial to an inpatient specialist palliative care setting in the United Kingdom.A realist evaluation approach was used. A mixed-methods qualitative approach involved three focus groups with a range of healthcare professionals (n=19) and a music therapist in addition to an analysis of open-text in a quality of life questionnaire with patients (n=11).Music therapy contains multiple mechanisms that can provide physical, psychological, emotional, expressive, existential and social support. There is also evidence that the hospice context, instilled by a holistic approach to health care, is an important facilitator of the effects of music therapy. Examination of patients’ responses helped identify specific benefits for patients with particular characteristics.There is a synergy between the therapeutic aims of music therapy and those of palliative care, which appealed to a significant proportion of participants, who perceived it as effective.