Supportive Care in Cancer (2021) 29:2319–2326

https://doi.org/10.1007/s00520-020-05732-2

ORIGINAL ARTICLE

Effects of meaning in life and individual characteristics on dignity

in patients with advanced cancer in China: a cross-sectional study
Xiaocheng Liu 1 & Zhili Liu 2 & Qinqin Cheng 3 & Nuo Xu 1 & Hui Liu 1 & Wenjuan Ying 2

Received: 6 April 2020 / Accepted: 1 September 2020 / Published online: 11 September 2020
# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose This study was conducted to evaluate the effects of meaning in life and individual characteristics on dignity in patients
with advanced cancer.
Methods One hundred sixty-seven patients with advanced cancer participated in this study. Dignity was assessed with the Patient
Dignity Inventory (PDI), meaning in life was assessed with the Meaning in Life Scale (MiLS), and performance status was
defined as the Karnofsky Performance Status (KPS). Sociodemographic and clinical variables were also measured. Independent
T tests and one-way ANOVA were performed for the PDI scores and sociodemographic and clinical variables. Relationships
among the PDI, MiLS, and KPS scores were evaluated with bivariate analyses (Spearman rank correlation). A multiple linear
regression analysis was conducted to determine the predictors the of PDI score.
Results Patients reported a mean of 4.2 (SD 4.9) problems affecting their sense of dignity; 21.6% reported moderate to severe loss
of their sense of dignity. Multivariable regression analyses revealed that a lower MiLS score, younger age, inpatient status, and a
lower KPS score predicted the loss of dignity. Stepwise regression showed that 49.8% of dignity-related distress could be
explained by the MiLS score, age, inpatient status, and the KPS score.
Conclusion Self-perceived dignity is significantly negatively associated with meaning in life, age, inpatient status, and perfor-
mance status. The early recognition of risk factors for the loss of dignity and interventions to enhance meaning in life may prevent
the loss of dignity in patients with advanced cancer.

Keywords Dignity . Meaning in life . Loss of dignity . Palliative care

Introduction cancers will increase further because of the large population

Cancer is one of the primary causes of morbidity and mortality
worldwide. The GLOBOCAN 2018 database indicated that
there were 18.1 million new cases of cancers and 9.6 million
deaths from cancer in 2018, among which 23.7% of new cases
and 30.2% of cancer-related deaths were in China [1, 2]. Local
reports indicate that the incidence and mortality rates of
* Wenjuan Ying
yingwenjuan@126.com
1
Shantou University Medical College, Shantou People’s Republic of
China
2
Nursing Department, The First Affiliated Hospital of Shantou
University Medical College, Shantou 515000 People’s Republic of
China
3
Pain Management Department, Hunan Cancer Hospital, Changsha
People’s Republic of China
size and aging. Cancer is a life-threatening illness that may
pose different challenges for patients and caregivers, who un-
doubtedly suffer worsening health conditions, physical symp-
toms, and psychological distress. For terminally ill cancer pa-
tients, this situation is more pronounced. However, palliative
care is still in its infancy and less than 1% of patients have the
opportunity to access palliative care in mainland China [3].
Dignity is considered a fundamental human need and is
generally defined as “the quality or state of being worthy,
honored, or esteemed” [4, 5]. The loss of dignity is related
to symptom burden, depression, demoralization, psychologi-
cal distress, and lower quality of life [6–8]. More importantly,
the loss of dignity is an important reason for requests to hasten
death in advanced cancer patients [9]. Thus, maintaining the
dignity of patients with advanced cancer is crucial to provid-
ing high-quality palliative care. The loss of dignity is common
in cancer patients, and awareness of its predictors is essential.
The Dignity Model was developed by Chochinov et al. for
2320
terminally ill patients to determine how dying patients under-
stand and define the term dignity [5]. According to the model,
a terminally ill patient’s dignity comprises three major cate-
gories: illness-related concerns, a dignity-conserving reper-
toire, and the social dignity inventory. Illness-related concerns
are those that arise from or are related to the patient’s disease
and threaten or actually infringe upon the patient’s sense of
dignity. The dignity-conserving repertoire refers to the pa-
tient’s way of looking at his or her situation and the personal
actions that can help enhance or reinforce the patient’s sense
of dignity. The social dignity inventory refers to social con-
cerns or relationships that enhance or reduce a patient’s sense
of dignity. Based on the Dignity Model, a growing body of
research has explored what is meant by dignity and identified
factors that threaten it [10, 11].
Previous studies found various sociodemographic
characteristics that influence dignity, including gender,
age, education, partnership, inpatient status, and religion
[12–14]. Apart from these sociodemographic characteris-
tics, studies examining factors associated with dignity in
cancer patients have largely focused on health status pa-
rameters, such as physical symptoms, the disease burden,
or a few specific factors related to psychological and
emotional distress, such as anxiety, depression, and de-
moralization [6–8]. Although dignity-related research is
widely documented in Western cultures, including re-
search on influencing factors, assessment tools, and
dignity-related therapy [15], whether the findings of that
research can be applied to other cultural groups are de-
batable. Several dignity measurement tools have been
developed, including the Patient Dignity Inventory
(PDI) [16], Dignity Card-Sort Tool [17], and Palliative
Patients’ Dignity Scale [18]. Based on the Dignity
Model, two qualitative studies described perceived digni-
ty in cancer patients in China. A Hong Kong study sup-
ported the three major categories that are the themes in
the Dignity Model, although the subthemes were differ-
ent and four newly emerging themes were identified,
including endurance of pain and moral transcendence
[19]. Another study in mainland China also supported
the three major categories of themes and added commu-
nication, openness, and financial burden as subthemes
[20]. As discussed previously, the identification of risk
factors for the loss of dignity among Chinese cancer
patients is necessary, but few studies have been
performed.
As with dignity, meaning in life has increasingly been ex-
amined in studies performed with cancer patients and is gen-
erally defined as a person’s subjective feelings of meaningful-
ness, including a sense of purpose or direction, comprehen-
sion of life circumstances, and significance [21]. Regarding
meaning in cancer, some evidence has indicated that the as-
sessment of meaning in life may be most important in the late
Support Care Cancer (2021) 29:2319–2326
stage of cancer. Meaning-centered therapy is a treatment used
to improve spiritual well-being and reduce psychological dis-
tress in patients with advanced cancer [22, 23]. An earlier
study showed that meaning in life significantly predicted
self-esteem among older adults [24]. Another study found that
meaning-making interventions could improve self-esteem
among cancer patients [25]. Self-esteem is described as “the
general tendency to evaluate oneself in a positive or negative
way” [26]. Some studies showed that dignity and self-esteem
shared certain components and had a strong association, but
the concepts of dignity and self-esteem were not equivalent
[27, 28]. Furthermore, a study reported that dignity interven-
tions could reduce emotional distress and enhance meaning in
life in advanced cancer patients [29]. Although a sense of
dignity and meaning in life are important in patients with
advanced cancer, the effect of meaning in life on dignity in
patients with advanced cancer has not been reported.
Therefore, the current study focused on two main objec-
tives. First, we analyzed how various sociodemographic and
clinical variables are related to personal dignity in a sample of
Chinese patients with advanced cancer receiving palliative
care. Second, we examined whether meaning in life affected
personal dignity at the end of life. We tested the hypothesis
that higher levels of meaning in life are associated with a
lower risk of the loss of dignity.
Methods
Study design
This study was a cross-sectional investigation of dignity in
advanced cancer patients receiving palliative care in China.
Participants
Patients who received palliative oncological treatment or
home-based palliative care services at the First Affiliated
Hospital of Shantou University Medical College and were
older than 18 years were invited to participate in this investi-
gation from July 2019 to January 2020. The hospital provides
comprehensive inpatient care and home-based palliative care
services. The Li Ka-shing Foundation supports the home-
based palliative care services, which provide free home-
based services for patients diagnosed with advanced cancer,
including those with a low socioeconomic status. The scope of
the services includes home visits, pain control and alleviation,
clinical visits, psychological services, grief counseling, and
volunteer services. The inclusion criteria were as follows: pa-
tients aged 18 or older who were, diagnosed with stage III or
IV cancer, living in hospital-based palliative care or at home,
and able to read and write Chinese. We excluded patients if
they refused to participate or were cognitively impaired.
Support Care Cancer (2021) 29:2319–2326
Written informed consent was acquired from all participants.
This study was approved by the First Affiliated Hospital of
Shantou University Medical College, protocol number
2019088.
Procedure and data collection
After informed consent was obtained, participants were invit-
ed to complete the Patient Dignity Inventory (PDI) [30],
Meaning in Life Scale (MiLS) [31], and a demographic ques-
tionnaire by themselves. Medical information was collected
from each patient’s medical record. All questionnaires were
collected by a research nurse, who used the same way to
describe the purposes, contents, and potential benefits/risks
of the study to all participants. When the patient was unable
to complete the questionnaire, the research nurse read the
items aloud and recorded the patient’s responses. All ques-
tionnaires were collected immediately.
To assess dignity-related distress, we used the PDI,
which was developed by Chochinov et al. [16] in 2008
and translated into Chinese by Yanmei [30]; the
Chinese version has been shown to be reliable and val-
id. The PDI includes 25 items in five dimensions,
namely, symptom distress, dependency, existential dis-
tress, peace of mind, and social support, with each
question answered on a five-point scale (1 = not a prob-
lem, 2 = a slight problem, 3 = a problem, 4 = a major
problem; 5 = an overwhelming problem). The total PDI
score ranges from 25 to 125 points. The higher the
score is, the worse the dignity-related distress. The
PDI has been shown to have good internal consistency
in a Chinese population (α = 0.924). In this study, PDI
scores were divided into four categories: 25–49 points,
“mild”; 50–74 points, “moderate”; 75–99 points, “se-
vere”; and 100–125 points, “very severe” [30].
To assess meaning in life, we used the MiLS [31], which is
a 28-item self-report questionnaire with each question an-
swered on a five-point scale. The items are classified into
dimensions: control of life (the degree to which an individual
is free to make life choices and is responsible for his or her
life), existential frustration (the degree to which an individual
suffers from existential frustration caused by the lack of mean-
ing or purpose and the feeling of emptiness and anxiety),
meaning and satisfaction in life (the degree to which an indi-
vidual has a clear, strong, and meaningful life purpose and is
satisfied with his or her life purpose), will to seek meaning
(the motivation of an individual to seek meaning in and a
purpose for self-existence), bearing suffering (the degree to
which an individual understands the meaning of suffering
and accepts it), and acceptance of death (the degree to which
an individual is not afraid of death). A higher score indicates
greater meaning in life. The MiLS has been shown to have
2321
good internal consistency in a Chinese population (α = 0.725,
0.577–0.736 for each dimension).
To assess performance status, we used the Karnofsky
Performance Status (KPS) score, which is an eleven-point
scale correlating to a percentage score ranging from 100 (nor-
mal, no signs or symptoms) to 0 (death). A higher score indi-
cates less physical impairment.
The continuous independent variables were age, MiLS
score, and KPS score. The nominal independent variables
were gender, care venue (inpatient or home-based care), mar-
ital status, education, self-perceived religiosity, employment
status, family monthly income per capita (RMB), place of
residence, medical insurance payment method, primary care-
giver, number of children, primary cancer site, cancer stage,
whether they had metastasis, and time since the confirmation
of the diagnosis.
Statistical analysis
The data analysis was performed with SPSS 23.0. All statisti-
cal analyses were two-tailed and significance was accepted at
the p < 0.05 level. First, both demographic and clinical vari-
ables were analyzed using descriptive statistics. Means ± stan-
dard deviations (SDs) are presented for continuous variables,
and numbers and percentages are presented for ordinal
variables.
First, independent T tests and one-way ANOVA were
performed for the continuous dependent variables (total
PDI score), sociodemographic variables, and clinical
variables.
Second, associations between the PDI, MiLS, and KPS
scores were explored using bivariate analyses (Spearman rank
correlation). The correlation was classified using Evans’ clas-
sification, 0–0.19 indicated a very weak relationship, 0.20–
0.39 indicated a weak relationship, 0.40–0.59 indicated a
moderate relationship, 0.60–0.79 s indicated a strong relation-
ship, and 0.80–1 indicated a very strong relationship [32].
Third, an analysis was performed to investigate the contri-
butions of the independent variables to the total PDI score. To
reduce the number of independent variables in the multiple
linear regression analysis, only variables with a statistically
significant value (p < .05) in the previously performed inde-
pendent T tests, one-way ANOVA, and bivariate analyses
were included.
To improve comparability, the continuous variable of age
and the nominal variables of gender and care venue were used
as control variables. Finally, a stepwise regression analysis
was performed with the total PDI score as the dependent var-
iable and the total and domain scores on the MiLS, marital
status, cancer stage, whether they had metastasis, self-
perceived religiosity, age, gender, care venue, and KPS score
as independent variables.
2322
Results
Participants
In total, out of 172 initially eligible patients, six patients
(3.5%) met the exclusion criteria: two had severe cognitive
impairment, one could not read and write Chinese, and three
refused to participate. Finally, 167 patients (97.1%) completed
the questionnaires. Among the 167 patients, 87 were male and
80 were female, 88 were inpatients, and 79 were at home. The
mean (SD) patient age was 60.3 (11.7) years, with a range of
31–89 years. The mean (SD) number of months since the
diagnosis was confirmed was 26.1 (29.9) months, with a range
of 1–228 months. The mean (SD) KPS score was 65.3 (2.0)
points, with a range of 20–100 points. The analysis of the
variables associated with the PDI indicated that patients who
had no partner (p = 0.042), stage IV cancer (p < 0.01), and
metastasis (p = 0.002) experienced a loss of dignity. Further
details on the demographic and medical characteristics of the
participants and the analysis of the variables associated with
the PDI are presented in Table 1.
Perceived sense of dignity and meaning in life
Patients reported a mean of 4.2 (SD 4.9) problems affecting
their sense of dignity. The distribution of patients in categories
of the severity of the loss of dignity was as follows: 131
patients (78.4%) suffered a mild loss of dignity, 31 patients
(18.6%) suffered a moderate loss of dignity, 4 patients (2.4%)
suffered a severe loss of dignity, and one patient (0.6%) suf-
fered a very severe loss of dignity. The most frequent dignity-
related problem (a significant loss of dignity was defined as a
PDI item with a score ≥ 3 [12]) was “experiencing physically
distressing symptoms” (96 of 167, 57.5%), followed by “feel-
ing that I am a burden to others” (70 of 167, 41.9%), and “not
being able to carry out tasks associated with daily living (e.g.,
washing myself, getting dressed)” (63 of 167, 37.7%). The
least common dignity-related problem was “not feeling sup-
ported by healthcare providers” (3 of 167, 1.8%), followed by
“not being treated with respect” (4 of 167, 2.4%) and “not
feeling supported by friends or family” (6 of 167, 3.6%), all
of which belonged in the dimension of social support. The
mean PDI and MiLS scores are presented in Table 2.
Correlations of PDI with MiLS and KPS scores
The Spearman’s rank coefficients were calculated between the
PDI score, the six MiLS dimensions, and the MiLS total score.
A moderate negative correlation was found between the total
PDI score and the total MiLS score (r = − 0.568, p < 0.01).
Significant correlations were found between the PDI score and
the scores for the five MiLS dimensions other than the accep-
tance of death (r = − 0.029, p = 0.713). The total dignity score
Support Care Cancer (2021) 29:2319–2326
had the strongest correlation with controlling one’s life (r = −
0.584, p < 0.01), followed by existential frustration (r = −
0.440, p < 0.01), meaning and satisfaction in life (r = −
0.361, p < 0.01), the will to seek meaning (r = − 0.289, p <
0.01), and bearing suffering (r = − 0.177, p = 0.022).
Weak to moderate negative correlations were also found
between the MiLS total score and the four PDI dimensions
other than social support (r = − 0.138, p = 0.075).
A strong negative correlation was observed between the
total PDI score and the KPS score (r = − 0.658, p < 0.01).
Multiple linear regression of dignity on patient
characteristics and meaning in life
Multiple linear regression was performed with the total PDI
score as the dependent variable and the total MiLS score,
MiLS dimension scores, age, gender, marital status, institu-
tion, cancer stage, metastasis, self-perceived religiosity, and
KPS score as the independent variables. Four stepwise linear
regression equations were constructed. The first model includ-
ed the KPS score, the second model added the total MiLS
score, the third model added the care venue, and the fourth
model added age. Dignity was negatively related to the KPS
score, total MiLS score, care venue, and age. The results of the
multiple linear regression analysis showed that 49.8% of
dignity-related distress could be explained by MiLS score,
age, inpatient status, and KPS score (Table 3).
Discussion
This study was conducted to evaluate the effect of meaning in
life and individual characteristics on the sense of dignity in
patients with advanced cancer. One hundred sixty-seven pa-
tients with advanced cancer participated in the study. Our
hypothesis was confirmed, as higher levels of meaning in life
were significantly associated with a reduced degree of the loss
of dignity. Age, the KPS score, inpatient status, and the total
meaning in life score had significant negative associations
with dignity in the multiple linear regression analyses. This
study may provide information that can be used when devel-
oping interventions aimed at providing psychological support
for people with advanced cancer.
The most important finding of this study was that patients
with advanced cancer who had greater meaning in life had a
lower risk of impaired dignity. This finding provides a new
perspective on the prediction of the loss of dignity. Some
previous studies indicated that people could benefit from en-
hancing meaning in the late stages of life. For example, im-
proving their sense of meaning in life may help patients reduce
their level of psychological distress (e.g., reduce depression,
demoralization, and anxiety) [33], enhance their physical
health, and even reduce their risk of mortality [34], which in
Support Care Cancer (2021) 29:2319–2326 2323

Table 1 Sociodemographic and clinical characteristics and the associations of single factors with the PDI in patients with advanced cancer (n = 167)

Variables Number (%) t/F p

Gender Male 87 (52.1) − 1.500 0.136

Female 80 (47.9)
Marital status No partner (unmarried/divorced/widowed) 30 (18.0) 2.049 0.042
Partner (married) 137 (82.0)
Education level Junior high school 133 (79.6) − 0.979 0.329
High school or above 34 (20.4)
Self-perceived religiosity Not religious 144 (86.2) − 0.612 0.546
Religious 23 (13.8)
Employment status Employed 11 (6.6) − 1.447 0.150
Unemployed/retired 156 (93.4)
Place of residence Urban 67 (40.1) 0.932 0.353
Rural 100 (59.9)
Number of children ≤2 40 (24.0) − 0.542 0.589
>2 127 (76.0)
Primary caregiver Spouse 108 (64.7) 0.595 0.553
Child/children 50 (29.9)
Others 9 (5.4)
Family monthly income per capita (RMB) ≤ 1500 71 (42.5) 2.629 0.075
1500–4000 63 (37.7)
≥ 4000 33 (19.8)
Care venue Inpatient setting 88 (52.7) − 0.368 0.713
Home 79 (47.3)
Primary cancer site Nasopharynx 5 (3.0) 1.275 0.260
Esophagus 13 (7.8)
Stomach 7 (4.2)
Lung 44 (26.3)
Breast 19 (11.4)
Liver 14 (8.4)
Colon/rectum 39 (23.4)
Gynecological 7 (4.2)
Others 19 (11.4)
Cancer stage III 26 (15.6) − 3.759 < 0.01
IV 141 (84.4)
Metastasis Yes 145 (86.8) − 3.266 0.002
No 22 (13.2)
Time since confirmed diagnosis (months) ≤ 12 58 (34.7) 0.055 0.947
12–36 76 (45.5)
≥ 36 33 (19.8)
Medical insurance payment method Rural new cooperative medical scheme/urban 103 (61.7) 0.934 0.352
resident-based basic medical insurance scheme
Employee-based basic medical insurance scheme 64 (38.3)

turn would enhance their sense of dignity. To the best of our
knowledge, the present study is the first to show a significant
association between meaning in life and loss of dignity in
patients with advanced cancer. Future studies should investi-
gate diverse populations before definitive conclusions can be
drawn regarding the associations between meaning in life and
dignity.
All six dimensions of meaning in life assessed by the MiLS
showed weakly to moderately significant associations with the
total PDI score. The results imply that those patients with a
poor health status who are unable to continue with their usual
routines could experience a greater perceived loss of meaning
or purpose in life. A systematic review and meta-analysis also
showed that physical health was related to meaning in life
[35]. Meaning in life can not only help patients manage their
disease effectively but can also help advanced cancer patients
achieve personal well-being [36]. Dignity-conserving prac-
tices in clinical care may benefit from improving patients’
sense of meaning in life, which would be appreciated by each
patient and their family [4].
2324 Support Care Cancer (2021) 29:2319–2326

Table 2 Mean scores on the PDI and MiLS In this study, patients reported an average of 4.2 problems
Variables Mean ± SD Range affecting their sense of dignity, which was lower than the aver-
age numbers of 5.7 and 8.7 reported in other studies [13, 38].
PDI 40.98 ± 14.45 26–102 This might be because an individual’s perception of and expec-
Dependency 13.21 ± 6.04 7–34 tations regarding dignity are not simply influenced not only by
Symptom distress 11.31 ± 4.40 6–28 their attitudes, values, and perceptions but also by their culture
Existential distress 7.60 ± 3.29 5–20 [19, 20]. In addition, previous studies included larger numbers
Peace of mind 5.32 ± 2.21 4–16 of patients who survived for less than 6 months [13, 38]. The
Social support 3.32 ± 0.96 3–9 closer patients are to the end of their lives, the more likely they
MiLS 100.99 ± 9.23 74–140 are to lose their sense of dignity [39].
Will to seek meaning 15.62 ± 2.13 9–20 The KPS score and age had significant negative correlations
Existential frustration 17.26 ± 2.97 10–25 with the loss of dignity in this analysis. In the present study, the
Meaning and satisfaction in life 13.71 ± 1.96 10–20 most highly endorsed items were “experiencing physically
Controlling one’s life 26.56 ± 3.37 16–35 distressing symptoms” and “not able to continue usual rou-
Bear suffering 14.10 ± 1.92 8–20 tines”; these two items were associated with a worse perfor-
Acceptance of death 13.74 ± 2.40 8–20 mance status and could undermine a patient’s sense of autono-
my and dignity, which is consistent with the findings of an
earlier study [6]. In addition, the results suggested that age
An earlier study showed that social support had a positive was a significant predictor of the loss of dignity. This was in
influence on terminally ill patients’ meaning in life [37]. line with previous studies that reported that younger cancer
However, our study indicated that there was no correlation patients had more dignity-related problems than older cancer
between meaning in life and social support. One explanation patients [13, 14, 39]. This may be explained by the idea that
was that the mean score for social support was the lowest, older patients with advanced cancer might have lower rates of
indicating that the social support dimension in the PDI was diagnosed depressive disorders and a greater acceptance of their
least endorsed by the patients. Healthcare providers, family, lives, making it easier for them to find meaning in life [14]. In
and friends could easily provide social support to patients, addition, young and middle-aged people are the “backbone” of
particularly those home-based patients receiving and benefit- society and have very important social and family responsibil-
ting from free home-based palliative care services in this ities. If they suffer from advanced cancer, they are not able to
study. Other possible explanation might be that the sample fulfill their usual vocational responsibilities and therefore feel
size was too small to allow the detection of significant effects helpless. This is because patients with poor physical health are
or that the population was skewed in some ways. Further no longer able to work and earn money, making it difficult to
studies about the correlation of meaning in life and social pay for anticancer treatments, resulting in heavy financial bur-
support are needed. dens on the patients and their families. Another reason is that

Table 3 Stepwise linear

regression analysis of factors Model B SE Beta p 95%CI Predictors
associated with the PDI in
patients with advanced cancer 1 − 0.332 0.034 − 0.602 < 0.01 − 0.399 to − 0.266 KPS
(n = 167) 2 − 0.439 0.091 − 0.280 < 0.01 − 0.618 to − 0.259 KPS
MiLS
3 − 5.042 1.675 − 0.175 0.003 − 8.350 to − 1.735 KPS
MiLS
Care venue
4 − 0.167 0.069 − 0.135 0.016 − 0.302 to − 0.031 KPS
MiLS
Care venue
Age

Care venue was coded 1 = inpatient and 2 = home care patient

1
R = .627, Adjust R2 = .389, F = 106.715, p < 0.01
2
R = .679, Adjust R2 = .455, F = 70.165, p < 0.01
3
R = .702, Adjust R2 = .483, F = 52.659, p < 0.01
4
R = .714, Adjust R2 = .498, F = 42.164, p < 0.01
Support Care Cancer (2021) 29:2319–2326
the cancer itself might cause the patients to be stigmatized [40],
which could have a substantial impact on negative emotions
and spiritual distress in patients with advanced cancer [40].
For these reasons, young and middle-aged patients may more
easily suffer from the loss of dignity.
We also found that being an inpatient had a negative effect
on patients’ sense of dignity. Cancer patients are vulnerable to
the loss of dignity in hospitals [11, 41]. Being cared for in the
hospital may be an indicator of disease severity. These pa-
tients might have a worse performance status, with more se-
vere physical symptoms and psychological distress, than pa-
tients receiving care at home. The hospital environment, staff
behavior, and other patient factors may affect patients’ sense
of dignity [41]. In this study, home-based cancer patients were
receiving palliative care to increase their chances of dying at
home rather than in the hospital. In China, many patients
prefer to die at home because of the traditional Chinese cul-
tural principle that “falling leaves return to their roots” [42].
Chinese culture is strongly family-oriented. Patients who are
terminally ill may fear death, but if they are in a home envi-
ronment and are taken care of by their families, they can gain
spiritual comfort, love, strength, and peace of mind.
Autonomy and independence can be maintained to a greater
degree in a home environment, which may explain why dying
at home plays a vital role in achieving a dignified death. Thus,
home-based palliative care plays an important protective role
against the loss of dignity in patients with advanced cancer.
Strengths and limitations
This study has several limitations. First, this study had a cross-
sectional design, which prevented us from drawing any con-
clusions regarding causal relationships. We cannot confirm a
causal link between dignity and meaning in life. Future pro-
spective studies are needed to confirm our findings and estab-
lish causal pathways. Second, the cross-sectional design did
not reflect the dynamic changes in the levels of dignity-related
distress and the sample size was relatively small. The home-
based patients were receiving free home-based palliative care,
were terminally ill, had a low socioeconomic status, and were
in pain. Thus, this population may not be representative of
other populations in China. More diverse populations and lon-
gitudinal studies are needed.
Despite these limitations, this study has several strengths.
Although many studies have focused on dignity in cancer pa-
tients, the study is novel in that it examined the association be-
tween meaning in life and the loss of dignity in patients with
advanced cancer. It thus contributes to a comprehensive under-
standing of dignity from the perspective of meaning in life, which
has implications for clinical practice. Our findings showed that
enhancing an advanced cancer patient’s meaning in life might
have a positive effect their sense of dignity, and this issue
2325
deserves more attention from clinicians. In this study, the outpa-
tients were receiving care from a free home-based palliative care
service, had a low socioeconomic status, were experiencing pain
due to their cancer, and had relatively less social support.
However, they experienced less loss of their sense of dignity than
did the inpatient participants. This finding supports extending
palliative care services more broadly.
In conclusion, we found that the loss of dignity can be
predicted by meaning in life, age, performance state (KPS
score), and inpatient status in patients with advanced cancer.
Our study provides preliminary evidence that meaning in life
predicts the loss of dignity in patients with advanced cancer.
Healthcare providers in oncology and palliative care should be
aware of the importance of safeguarding the dignity of pa-
tients in later stages of life, which has become a key objective
of palliative care. In fact, this awareness is not simply impor-
tant for healthcare providers but also for the patient’s care-
givers and society at large. Overall, knowledge of these risk
factors for the loss of dignity is beneficial for those seeking to
provide comprehensive palliative care. Identifying risk factors
for the loss of dignity in patients with advanced cancer and
improving their meaning in life may help enhance their dig-
nity and further improve their quality of life.
Funding This study was funded by the Shantou University Medical
College in Shantou, China (Grant number: NU201902) and the Chinese
Nursing Association of 2019 research project (Grant number:
ZHKY201927).
Compliance with ethical standards
All procedures implemented in the study involving human participants
complied with the institutional and/or national research committees on
ethics standards and with the 1964 Helsinki Declaration and its subse-
quent amendments or similar ethics standards. Written informed consent
was acquired from all participants.
Conflict of interest The authors declare that they have no conflicts of
interest.
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