Reframing Dignity at the End of Life: An Integrative Review and Ethical Framework Proposa

Background: Dignity is a central yet contested concept in end-of-life care. While frameworks such as Dignity Therapy (DT) have advanced narrative interventions, they often reduce dignity to a fixed, individual construct. Such models insufficiently account for relational, temporal, and systemic dimensions of dignity, and inadequately address caregiver and clinician perspectives, digital ethics, and institutional integration. Methods: We conducted an integrative review using adapted PRISMA methodology, synthesizing 61 articles across philosophical, empirical, and clinical domains. Thematic analysis was guided by ethical theories (Ricoeur, Levinas, Tronto, Nussbaum) and aimed to identify limitations in existing dignity models and inform a new ethical framework. Results: Four critical gaps were identified in prevailing models: individualism, temporal rigidity, professional invisibility, and lack of systemic integration. In response, we propose the DiRePal model — Dignity as Relational and Temporally Evolving — comprising five interconnected dimensions: Narrative Flexibility, Relational Emergence, Temporal Sensitivity, Professional Reciprocity, and Digital-Structural Integration. Conclusions: DiRePal reframes dignity as a co-constructed, evolving ethical phenomenon embedded in care relationships and shaped by institutional and technological contexts. It bridges philosophical depth with practical applicability. Empirical validation through focus groups with patients, caregivers, and clinicians is underway. DiRePal offers a scalable and ethically grounded framework to inform dignity-centered care, training, and policy across palliative settings.