title: Patient Perspectives of Dignity, Autonomy and Control at the End of Life: Systematic Review and Meta-Ethnography.
abstract: BACKGROUND
  Research in the end-of-life context has explored the sense of dignity experienced by patients with advanced disease, examining the factors associated with it. Whereas certain perspectives regard dignity as an intrinsic quality, independent of external factors, in the clinical setting it is generally equated with the person's sense of autonomy and control, and it appears to be related to patients' quality of life. This study aims to explore the relationship between perceived dignity, autonomy and sense of control in patients at the end of life.
  
  
  METHODS
  We conducted a systematic review and meta-ethnography using reciprocal translation and line-of-argument synthesis. The search strategy used MeSH terms in combination with free-text searching of the Pubmed, Web of Science, CINAHL, PsycINFO and Cochrane databases, from their inception until 2015. This identified 186 articles, after excluding duplicates. The inclusion criterion was primary qualitative studies in which dignity, autonomy and control at the end of life were explored. Studies were evaluated using the CASP guidelines.
  
  
  RESULTS
  Twenty-one studies recording the experiences of 400 participants were identified. Three themes emerged: a) dignity mediated by the loss of functionality, linked to the loss of control; b) dignity as identity; and c) autonomy as a determining factor of perceived dignity, understood as the desire for control over the dying process and the desire for self-determination. We propose an explanatory model which highlights that those patients with an intrinsic sense of dignity maintained a positive view of themselves in the face of their illness.
  
  
  CONCLUSIONS
  This synthesis illustrates how dignity and autonomy are intertwined and can be perceived as a multidimensional concept, one that is close to the notion of personal identity. The ability to regard dignity as an intrinsic quality has a positive impact on patients, and the design of care strategies should take this into account.
authors.affiliation: Faculty of Humanities, Universitat Internacional de Catalunya. Barcelona. Spain.
authors.forename: Andrea
authors.initials: A
authors.lastname: Rodríguez-Prat
authors.affiliation: Nursing Department, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Monforte-Royo
authors.affiliation: Palliative Care Service, Institut Català d'Oncologia, Barcelona, Spain.|School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Porta-Sales
authors.affiliation: Faculty of Humanities, Universitat Internacional de Catalunya. Barcelona. Spain.
authors.forename: Xavier
authors.initials: X
authors.lastname: Escribano
authors.affiliation: School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Albert
authors.initials: A
authors.lastname: Balaguer
mesh_terms: D000884:Anthropology, Cultural; D006801:Humans; D026684:Personal Autonomy; D028723:Personhood; D036301:Qualitative Research; D011788:Quality of Life; D012297:Right to Die; D017236:Suicide, Assisted / Q000941:ethics / Q000523:psychology; D013727:Terminal Care / Q000941:ethics* / Q000523:psychology*