Dignity Conserving Care

Overview

High quality care places an emphasis on the uniqueness of each individual and seeks to preserve their own sense of dignity. How patients perceive themselves to be seen is a powerful mediator of their dignity. [1] The more that health providers affirm a patient’s value by seeing the person as they are or as they were, rather than just within the illness they have, the more likely a person’s sense of dignity will be upheld.

  • Dignity is defined as 'the quality or state of being worthy, honoured or esteemed' [Merriam Webster, 2010]
  • Dignity provides an overarching framework that may guide the doctor, patient, and family in defining the objectives and therapeutic considerations fundamental to end of life care. [1]
  • Systematically broaching these issues within end of life care discussions could allow patients to make more informed choices, achieve better palliation of symptoms, and have more opportunity to work on issues of life closure.
  • When the preservation of dignity becomes the clear goal of palliation, care options expand well beyond the symptom management paradigm, and encompass the physical, psychological, social, spiritual and existential aspects of the patient’s terminal experience.

What is known

Palliative care practitioners are increasingly able to respond to the pain and symptom distress experienced by those at the end of life. However, the concept of providing comfort as opposed to making a person comfortable has only recently begun to be re-examined. [3]

Recent research has identified 'The Dignity Model' where three major categories emerged from the qualitative analysis of dying patients perceptions of their sense of dignity, including:

  • Illness-Related Concerns: These are issues that derive from the illness itself, and threaten to, or actually do impinge on the patient’s sense of dignity.
  • Dignity Conserving Repertoire: This category was divided into two major themes:
    • Dignity Conserving Perspectives are internally held qualities or a worldview
    • Dignity Conserving Practices refer to a variety of personal approaches or techniques that patients used to increase or maintain their sense of dignity.
  • Social Dignity Inventory: This refers to the quality of interactions with others that enhance or detract from ones sense of dignity. This inventory refers to external sources or issues that impinge on a patient’s sense of dignity. [2-3]

A recent study using these themes found that 'not feeling treated with respect or understanding' and 'feeling a burden to others' were the most highly endorsed dignity-related concerns. [4]

Implications for practice

  • Chochinov [2007] has proposed a simple mnemonic to support dignity conserving care:
    • Attitude: Suggests healthcare providers examine both their attitudes and assumptions towards patients, acknowledging that they may not be based on a patient’s reality
    • Behaviour: Awareness of attitudes can lead to modified behaviour as a way of acknowledging patient need for dignity care
    • Compassion: Refers to a deep awareness of the suffering of another combined with a wish to relieve that suffering
    • Dialogue: Refers to communication that allows a healthcare provider to know a person beyond their illness which is critical to understanding them. [5]
  • The Patient Dignity Inventory identifies dignity related distress and has been validated in older patients with cancer. [6]
  • Basic tenets of palliative care under the goal of helping patients to die with dignity include:
    • Symptom control
    • Psychological and spiritual support
    • Care of the family.

Active Research Areas/ Controversies

  • Considerations of dignity have been invoked as justification for:
    • Euthanasia and assisted suicide. [7]
    • Hydration and nutrition
    • Terminal sedation
    • Basic symptom management.
  • Research into dignity issues for specific populations such as people with dementia or those from a different cultural background is beginning. [8-11]
  • Privacy and dignity issues for all patients within the health care system are also being discussed. [12]

PubMed Searches

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Review Collection
  1. Chochinov HM, Hack T, McClement S, Kristjanson L, Harlos M. Dignity in the terminally ill: a developing empirical model.Soc Sci Med. 2002 Feb;54(3):433-43.
  2. Chochinov HM. Dying, dignity, and new horizons in palliative end-of-life care. CA Cancer J Clin. 2006 Mar-Apr;56(2):84-103.
  3. Chochinov HM. Dignity and the eye of the beholder. J Clin Oncol. 2004 Apr 1;22(7):1336-40.
  4. Chochinov HM, Kristjanson LJ, Hack TF, Hassard T, McClement S, Harlos M. Dignity in the terminally ill: revisited. J Palliat Med. 2006 Jun;9(3):666-72.
  5. Chochinov HM. Dignity and the essence of medicine: the A, B, C, & D of dignity conserving care. BMJ 2007 Jul 28;335(7612):184-7.
  6. Chochinov HM, Hassard T, Mc Clement S, Hack T, Kristjanson L, Harlos M, et al. The patient dignity inventory: a novel way of measuring dignity-related distress in palliative care. J Pain Symptom Manage. 2008 Dec;36(6):559-71. Epub 2008 Jun 24.
  7. Byk C. Death with dignity and euthanasia: comparative European approaches. J Int Bioethique. 2007 Sep;18(3):85-102, 118.
  8. Holmerová I, Jurasková B, Kalvach Z, Rohanová E, Rokosová M, Vanková H. Dignity and palliative care in dementia. J Nutr Health Aging. 2007 Nov-Dec;11(6):489-94.
  9. Hall S, Chochinov H, Harding R, Murray S, Richardson A, Higginson IJ. A Phase II randomised controlled trial assessing the feasibility, acceptability and potential effectiveness of dignity therapy for older people in care homes: study protocol. BMC Geriatr. 2009 Mar 24;9:9.
  10. Jo KH, Doorenbos AZ. Understanding the meaning of human dignity in Korea: a content analysis. Int J Palliat Nurs. 2009 Apr;15(4):178-85.
  11. Coenen A, Doorenbos AZ, Wilson SA. Nursing interventions to promote dignified dying in four countries. Oncol Nurs Forum. 2007 Nov;34(6):1151-6.
  12. Whitehead J, Wheeler H. Patients' experiences of privacy and dignity. Part 1: a literature review. Br J Nurs. 2008 Mar 27-Apr 9;17(6):381-5.
Last updated 18 January 2017