“It’s about fulfilling my role”: a qualitative study of dignity and life narrative meanings for older adults in palliative care within a Confucian-family context

Abstract

Background

Dignity is a cornerstone of quality palliative care. While Dignity Therapy has been developed to support dignity, its cultural foundations are rooted in Western individualistic values. In Confucian-family contexts, where interdependence and familial roles are paramount, the conceptualization of dignity and the relevance of life narratives may differ significantly. Understanding these culturally embedded perspectives is crucial for developing person-centered care that is truly resonant.

Aim

This study aimed to explore how older adults in a Confucian-family context perceive and articulate the concepts of dignity and the meaning of their life narratives during palliative care.

Methods

A descriptive qualitative study was conducted. Purposive sampling was used to recruit 18 older adults (aged 70+) receiving palliative care from a hospital and a community care center in East Asia. Data were collected through in-depth, semi-structured interviews focusing on experiences of dignity, meaning in life, and family relationships. All interviews were transcribed verbatim and analyzed using reflexive thematic analysis within a constructivist paradigm.

Results

The analysis yielded three interrelated themes: (1) Dignity as Familial Role Fulfillment and Burden Avoidance; (2) Narratives as Legacy and Continuity; and (3) The Family as Co-author and Validator. Dignity was predominantly experienced through fulfilling familial roles, contributing to harmony, and avoiding being a burden. Life reviews focused on imparting values and history to ensure family continuity. The meaning-making process was inherently social, requiring family acknowledgment to validate the narrative and sustain dignity.

Conclusion

This study reveals that for older adults in a Confucian-family context, dignity and life narrative meaning are fundamentally relational and family-centric. These findings challenge the direct application of individualistically framed dignity interventions. They highlight an urgent need for culturally adapted approaches to narrative care in palliative nursing that actively incorporate familial roles and intergenerational bonds, moving beyond the individual patient to engage the family system as a unit of care.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04454-w.

Introduction

Dignity is universally recognized as a foundational principle and a primary goal of high-quality palliative care [1]. The perceived loss of dignity is a significant source of suffering for patients nearing the end of life, correlating strongly with diminished will to live, increased desire for hastened death, and poorer psychological well-being [2, 3]. In response, Chochinov and colleagues developed Dignity Therapy, a brief, individualized psychotherapy designed to address psychosocial and existential distress by helping patients articulate a generative legacy document [4]. Empirical studies, predominantly conducted in Western settings such as Canada, Australia, and the United Kingdom, have demonstrated its potential to alleviate depression, improve spiritual well-being, and enhance a sense of meaning and purpose for terminally ill patients [5, 6].

However, Dignity Therapy is deeply rooted in a Western, individualistic ethos. Its conceptual underpinnings and operational mechanics prioritize personal autonomy, self-identity, and the creation of a unique, personal legacy [5]. This paradigm assumes that dignity resides primarily within the individual and that life review is a process of inward reflection aimed at achieving personal coherence and closure. Such an individual-centric model may not fully resonate within cultural contexts where the self is conceptualized relationally and identity is derived from one’s position within a familial and social network [7, 8]. Indeed, the principle of respect for individual autonomy, upon which such interventions are predicated, has been shown to have limited applicability in family-centric societies, necessitating a shift towards frameworks of ‘relational autonomy’ [9].

This is particularly salient in societies influenced by Confucianism, a philosophical and ethical system predominant in East Asia. The Confucian worldview emphasizes interdependence, familial piety (xiào, ), social harmony, and the fulfillment of role-specific obligations [10, 11]. Within this “Confucian-family context,” an individual’s worth and dignity are often externally validated through their successful performance of social roles (e.g., as a devoted parent, a responsible spouse, a filial child) and their contribution to family continuity and collective welfare [12]. The notion of a legacy, therefore, may be less about a personal narrative for an external reader and more about the tangible and moral transmission of values, responsibilities, and family history to the next generation [13].

It is important to note that family involvement is widely recognized as a cornerstone of quality palliative care across diverse cultural settings, providing essential emotional and practical support [14]. However, within the Confucian-family context, the role of the family transcends supportive involvement to assume a constitutive and morally obligatory character [12]. Here, the family operates as the primary unit of identity and care, governed by the normative ethics of filial piety (xiào), which mandates reciprocal obligations [15]. This transforms the family from a supportive ‘context’ into an active ‘co-author’ and ‘validator’ of the patient’s narrative and dignity [16].

While Dignity Therapy emerges from an individualistic paradigm, its core mechanism—facilitating structured life review—holds trans-cultural potential [5]. The critical insight from a Confucian perspective is not that such narrative work is irrelevant, but that its purpose, content, and process may be fundamentally re-oriented within this relational matrix. For instance, the therapeutic goal may shift from personal closure to intergenerational ethical transmission, and the ‘legacy document’ might be co-created with family [17]. Therefore, a promising direction lies not in rejecting one framework for the other, but in exploring synergistic, hybrid models of care that integrate narrative techniques with familial validation systems.

A growing body of literature acknowledges the critical importance of such cultural adaptation in palliative care interventions [18]. Direct translation and application of psychosocial tools without cultural sensitivity risk being ineffective, irrelevant, or even disrespectful to patients’ core values [19]. While a few studies have begun to explore the application of Dignity Therapy in non-Western settings like China and Korea, they have primarily focused on feasibility and quantitative outcomes [18]. However, these studies often report challenges related to family dynamics and differing expectations without providing an in-depth qualitative exploration of the participants’ own perspectives. Consequently, a significant gap persists in understanding how older adults in a Confucian-family context themselves conceptualize dignity and the meaning of their life narratives as they approach the end of life.

Therefore, this descriptive qualitative study aims to address this gap by exploring the meanings of dignity and life narratives from the perspectives of older adults receiving palliative care within a Confucian-family context. The research question guiding this study is: How do older adults in a Confucian-family context perceive and articulate the concepts of dignity and the meaning of their life narratives during palliative care?

Methods

Study design

A descriptive qualitative study was conducted between August and November 2025. This design was selected to provide a rich, straightforward account of participants’ experiences and the meanings they ascribe to dignity and life narratives, without imposing a strong theoretical framework. This approach aligns with Sandelowski’s recommendation for keeping close to the data [20]. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure comprehensive reporting [21].

Study setting and context

The study was conducted in Jinzhou, a prefecture-level city in Northeast China with a population characterized by traditional Confucian-family values and a rapidly aging demographic. Participants were recruited from two distinct yet complementary palliative care settings to capture a breadth of experiences:

The Palliative Care Unit of a municipal tertiary hospital, providing specialized end-of-life care for patients with complex symptoms.

A community-based hospice service center, offering home-based and day-care support, which often involves greater family presence and engagement in daily care.

The hospital setting typically involved formal, scheduled family conferences, whereas the community setting facilitated more organic, daily family interactions and multigenerational involvement, offering complementary insights into family dynamics in care.

Ethical considerations

This study received ethical approval from the Ethics Committee of First Affiliated Hospital of Jinzhou Medical University (Approval No: KYLL2025328). All procedures were conducted in accordance with the ethical standards of the committee, the Declaration of Helsinki (2024 revision), and relevant data protection regulations (e.g., principles analogous to the GDPR). Prior to participation, the study’s purpose, procedures, potential risks, and benefits were fully explained to each participant. Written informed consent was obtained from all participants; for those physically unable to write, a witnessed verbal consent procedure was used. All audio files were stored on a password-protected, encrypted device accessible only to the primary research team (YL, WH). Verbatim transcripts were pseudonymised during the transcription process (i.e., all identifying names, places, and institutions were replaced with codes or generic descriptors) and stored separately from any identifying information. Participants were assured of the confidentiality of their information and of their right to withdraw at any time without affecting their ongoing medical care.

Participants and sampling

Participants were purposefully sampled to ensure they could provide information-rich cases relevant to the research question [22]. Inclusion criteria were: (1) aged 70 years or older; (2) diagnosed with a terminal, life-limiting illness (e.g., advanced cancer, end-stage organ failure) and identified by their treating physician as receiving palliative care; (3) ability to communicate coherently in Mandarin; (4) a Palliative Performance Scale (PPS) score of ≥ 40%, indicating sufficient energy and clarity for a sustained conversation [23]; and (5) residence in a multigenerational household or having regular, close contact with adult children, ensuring active engagement within a Confucian-family structure.

Exclusion criteria included severe cognitive impairment (as screened by the treating physician) or uncontrolled psychiatric symptoms that would impede meaningful interview participation.

Potential participants were identified and initially approached by their treating physician or palliative care nurse. The first author (YL), trained in palliative assessment, then explained the study, obtained written informed consent, and administered the Palliative Performance Scale (PPS) within 48 h prior to the interview to confirm eligibility.

Recruitment continued until thematic saturation was achieved, defined as the point where subsequent interviews yielded no substantially new themes or insights related to the core research question [24]. Thematic saturation was determined through ongoing analysis and team discussion, guided by the criterion of ‘conceptual repetition’—whereby new data primarily reiterated existing codes and themes rather than generating new conceptual categories. A final sample of 18 participants was recruited (10 from the hospital setting, 8 from the community setting).

A total of 18 older adults participated in this study. Participants were predominantly in their mid-to-late seventies, with the majority recruited from a hospital palliative care unit (n = 10); the remainder were recruited from a community hospice service (n = 8). The primary diagnosis for two-thirds of participants was advanced cancer (n = 12); the remaining one-third had end-stage chronic organ failure. Participants’ functional status, as measured by the Palliative Performance Scale (PPS) [23], was moderately impaired (mean score: 54.2%, SD = 8.5, range: 40%-70%), confirming their retained capacity to engage in sustained reflection and conversation. A summary of the sample’s demographic and clinical characteristics is presented in Table 1.

Table 1.

Summary of demographic and clinical characteristics of the study sample (N = 18)

Characteristic	Category	n (%) / Mean ± SD (Range)
Age (years)	70–74	5 (27.8)
	75–79	7 (38.9)
	≥ 80	6 (33.3)
Primary Diagnosis	Advanced Cancer	12 (66.7)
	End-stage Organ Failure (COPD/Heart)	6 (33.3)
Care Setting at Interview	Hospital	10 (55.6)
	Community	8 (44.4)
PPS Score, %		54.2 ± 8.5 (40–70)
Family Co-residence Pattern	Living with spouse (with/without children)	7 (38.9)
	Living with adult child(ren)’s family	9 (50.0)
	Living alone (with daily family visits)	2 (11.1)

Notes: The Palliative Performance Scale (PPS) assesses functional status, with higher scores (range 0%–100%) indicating greater ambulation and self-care ability. ‘Family Co-residence Pattern’ categories are defined as follows: ‘Living with spouse’ includes participants co-residing with a spouse, with or without adult children present; ‘Living with adult child(ren)’s family’ indicates residing in the household of one’s adult child; ‘Living alone’ refers to independent living, with all such participants in this study receiving daily family visits

Data collection

Data were collected through in-depth, semi-structured interviews conducted by the first author (a trained qualitative researcher with a background in palliative nursing). An interview guide was developed based on a review of the literature on dignity and narrative meaning, and was pilot-tested with two volunteers (not included in the final sample) to ensure clarity and cultural appropriateness. The interview guide was refined slightly after piloting with two older adults (not included in the study) to improve clarity.

The guide included open-ended questions and prompts such as:

In your current situation, what does the word ‘dignity’ mean to you? Can you describe a moment recently when you felt your dignity was respected, or perhaps not respected?

Looking back on your life, what stories or memories feel most important to you now? Why are they important?

What role do your children and other family members play in how you feel about your life and your current situation?

If you were to leave something behind for your family, what would you most want it to be?

Interviews were conducted in a private room at the care facility or in the participant’s home, according to their preference and condition. Interviews lasted 40–75 min depending on participant stamina; breaks were offered. All interviews were audio-recorded with permission and transcribed verbatim in Mandarin within 48 h to preserve linguistic nuances. Transcripts were pseudonymised at the point of transcription. Field notes documenting non-verbal cues and contextual observations were made immediately after each interview. Audio files were stored on a password-protected device; transcripts were anonymized. Field notes were integrated during thematic analysis to provide contextual depth.

Data analysis

The transcribed data were analyzed using reflexive thematic analysis within a constructivist paradigm, as described by Braun and Clarke [24, 25]. This approach acknowledges the researcher’s active role in knowledge construction while systematically identifying patterns of meaning across the dataset. The analysis followed an iterative, six-phase process:

Familiarization

The research team read and re-read the transcripts and field notes to immerse themselves in the data. The field notes provided essential contextual information (e.g., participant tone, emotional state, family presence during the interview) that informed the initial interpretation of the transcripts and the subsequent coding process.

Generating initial codes

Meaningful segments of text relevant to the research question were systematically coded using NVivo 14 software.

Searching for themes

Codes were collated and organized into potential themes.

Reviewing themes

Themes were checked against the coded extracts and the entire dataset to ensure they formed a coherent pattern.

Defining and naming themes

The essence of each theme was refined, and clear, descriptive names were generated.

Producing the report

The final analysis was woven into a narrative, supported by vivid, anonymized participant quotations that were translated into English by a bilingual researcher, with back-translation checks performed to ensure conceptual fidelity.

To enhance the trustworthiness of the analysis, several strategies were employed [19]: (1) Peer debriefing: Regular analysis meetings were held among the research team to discuss coding decisions and thematic development, challenging assumptions; (2) Reflexive journaling: The first author maintained a reflexive journal throughout to document her positionality as a palliative nurse and cultural insider, and how this might influence interactions and interpretations. Regular team debriefings served to challenge assumptions and enhance interpretive rigor; and (3) Member checking: A summary of the preliminary findings was presented to five willing participants to confirm whether the interpretations resonated with their experiences.

Results

The analysis revealed that the meanings of dignity and life narrative for older adults in this Confucian-family context are fundamentally relational, intergenerational, and family-centric. These meanings are constructed through three interconnected themes, which together illustrate how dignity is derived from familial roles, how life stories are purposefully oriented towards legacy, and how the family unit is indispensable for validating both. The following sections detail these themes, supported by participant accounts.

Through reflexive thematic analysis, three central and robust themes were constructed regarding the meanings of dignity and life narratives. These themes were consistently evidenced across the dataset, with rich supporting data drawn from participants in both clinical settings. The themes are: (1) Dignity as Familial Role Fulfillment and Burden Avoidance; (2) Life Narrative as a Vehicle for Intergenerational Ethical Transmission; and (3) The Family as the Essential Audience and Validator. The interrelationships among these themes are visually summarized in Fig. 1.

Fig. 1.

Thematic map of dignity and life narrative meanings among older adults in a confucian-family context receiving palliative care. Note: Solid lines indicate hierarchical relationships (themes to sub-themes). Dashed red lines illustrate key dynamic interactions between themes

Theme 1: Dignity as familial role fulfillment and burden avoidance

For participants, dignity was not an intrinsic, individual attribute but a state achieved and maintained through relationships, primarily within the family. This theme comprised two interrelated sub-themes.

Fulfilling one’s role to maintain family harmony

Participants consistently linked their sense of worth and dignity to the successful performance of their lifelong familial roles. Being a “good parent” or “responsible grandparent” was paramount. Dignity was experienced when they could still contribute, however symbolically, to family well-being.

Participant 07: “My dignity now? It’s about still being a father they can respect. When my son asks for my opinion on a family matter, even a small one, I feel I am still me. I am not just a sick body in bed.”

Participant 14: “If I can hold my granddaughter’s hand and tell her an old story, and she listens, that is dignity. I am doing what a grandmother should do.”

Conversely, the inability to fulfill these roles due to illness was a profound source of dignity loss. Participants expressed distress over being unable to perform expected duties, such as attending family gatherings or helping with childcare.

Avoiding being a ‘burden’ as a core moral imperative

A dominant and emotionally charged concern was the intense desire not to be a physical, emotional, or financial burden to their children. This was framed not merely as a preference but as a moral obligation tied to their parental role.

Participant 03: “The worst feeling is needing my daughter to help me bathe. A father should take care of his children, not the other way around. This dependence… it eats away at my dignity more than the pain.” (See Supplementary Material 1 for an extended narrative excerpt on this tension).

Participant 11: “I worry about the medical costs. My son’s family has their own pressures. If my illness drains their savings, what kind of mother am I? To die without causing too much trouble, that would be a dignified end.”

This sub-theme highlights that personal autonomy, a cornerstone of Western dignity models, was often willingly subordinated to the principle of minimizing burden on the family collective.

Theme 2: Life narrative as a vehicle for intergenerational ethical transmission

When reflecting on their life stories, participants did not focus primarily on personal achievements or individual introspection. Instead, their narratives were outwardly oriented, serving as purposeful tools for imparting values and wisdom to the next generation.

Transmitting values and practical wisdom

The “important” memories participants chose to share were typically lessons on hard work, honesty, resilience, or familial loyalty learned through life challenges. These stories were curated as pedagogical tools.

Participant 09: “I want my grandchildren to know about the year our family faced the famine. How we shared one sweet potato and survived through unity. That story isn’t about my suffering; it’s to teach them about sharing and perseverance in hard times.”

Participant 16: “I always tell them how I started my little sewing business to support their father’s education. Not for praise, but so they understand: education is the family’s future, and sacrifice for it is right.”

Ensuring family continuity and historical grounding

Participants saw themselves as living repositories of family history. Narrating stories about ancestors, past family events, and traditions was a way to root younger generations in a familial identity, ensuring continuity beyond their own lives.

Participant 05: “If I don’t tell them where our family came from, which village, who our ancestors were, that chain will break. My duty is to pass this on, so they know they belong to a lineage.” This process is visually conceptualized in Fig. 2, which illustrates the directional flow of the narrative legacy from the older generation to the younger within the family system.

Fig. 2.

Directional flow of narrative as ethical legacy in a confucian-family context

Theme 3: The family as the essential audience and validator

The meaning-making process was intrinsically social. The value of one’s life narrative and the sustenance of dignity were contingent upon family recognition and response.

Narrative validation through listening and remembrance

A narrative told was not complete until it was received and acknowledged by family members. Participants expressed a deep need for their stories to be heard, remembered, and later recounted.

Participant 12: “When I told my daughter about her late grandfather, and she later repeated the story to her own child, that meant everything. It meant my words mattered, they entered the family’s memory. That is how I know my life had meaning.”

Participant 02: “If they listen just to be polite, I can tell. True dignity comes when you see in their eyes that they are really taking it in, that they will carry it with them.”

Dignity as a socially conferred state

Ultimately, dignity was experienced as something granted or affirmed by the family. Respectful care, attentive listening, and consulting them on family matters were the acts that conferred dignity. Its absence was felt keenly when family members were dismissive, rushed, or made decisions without their input.

Participant 08: “My dignity is in their hands now. When my children discuss my care with me, not over me, I feel I am still a person. When they ignore my wishes ‘for my own good,’ I feel I am already gone.” (See Supplementary Table 1 for additional supporting quotes on family interactions and dignity perception).

Nuanced expressions and internal tensions

While the three themes presented above capture the dominant, culturally salient patterns across the dataset, our analysis remained attentive to expressions that introduced complexity or nuance. A minority of participants voiced moments of tension between personal desires and familial expectations. For example, one participant reflected, “I spent my whole life ensuring my children had opportunities I never did. I don’t regret it, but sometimes I do wonder quietly about who I might have been otherwise…” (Participant 13). Another mentioned, “There are things I wanted to do for myself after retirement, but now… the illness took that chance. It’s hard not to feel a loss, even though family comes first.” (Participant 17). These expressions did not coalesce into a counter-theme sufficient to challenge the overarching relational framework, as they were consistently framed within—and ultimately subordinate to—a narrative of acceptance and familial commitment. However, their presence is significant. They reveal the internal negotiation and potential cost embedded within the Confucian ideal of role fulfillment, suggesting that even in a strong collectivist context, the alignment between personal identity and social roles is not without its subjective complexities. Acknowledging this nuance provides a more textured understanding of our participants’ experiences.

Discussion

This study explored the meanings of dignity and life narratives among older adults receiving palliative care within a Confucian-family context. Our findings reveal a profound, culturally situated understanding that diverges significantly from the individualistic framework underpinning widely promoted interventions like Dignity Therapy [5]. The three constructed themes—(1) Dignity as Familial Role Fulfillment and Burden Avoidance, (2) Life Narrative as a Vehicle for Intergenerational Ethical Transmission, and (3) The Family as the Essential Audience and Validator—collectively depict a relational ecosystem where self-worth is externally validated, narratives are purposefully outward-facing, and the family unit is the irreducible locus of meaning. This discussion elaborates on these findings, positions them within the extant literature, acknowledges limitations, and delineates clear implications for nursing practice, policy, and research.

Dignity: from intrinsic autonomy to relational fulfillment

Our participants conceptualized dignity not as an inherent, static property of the individual, but as a dynamic state contingent upon successfully performing familial roles and minimizing perceived burden. This stands in direct contrast to the Western bioethical principle of autonomy, which positions individual self-determination and control as the cornerstone of dignity [5]. For our participants, autonomy was often willingly subordinated to the higher value of relational harmony and filial responsibility (xiào). The profound moral distress expressed over becoming a “burden” (Sub-theme 1.2) was not merely about personal inconvenience but about failing in the core Confucian duty of a parent to provide for, and not deplete, the family [12]. This finding resonates with studies in other collectivist cultures, where maintaining social harmony and fulfilling obligations are central to a “good death” [26, 27]. It challenges the direct exportation of autonomy-centric dignity models and suggests that in Confucian contexts, supporting dignity may paradoxically involve helping patients relinquish certain types of control in ways that affirm their ongoing familial contribution and moral identity. This paradigmatic shift points to potential implications, particularly for nursing communication and assessment within the interdisciplinary palliative team. Given nurses’ central role in ongoing psychosocial assessment and therapeutic communication, our findings suggest that it necessitates moving beyond standard tools focused on individual autonomy and symptom control. Instead, nurses require communication skills that sensitively explore relational concerns and assessment frameworks that explicitly incorporate domains such as ‘role fulfillment’, ‘perceived burden’, and ‘family harmony’ as vital signs of psychosocial well-being.

Life narrative: from personal closure to ethical bequest

The function of life review for our participants was distinctly teleological and generative. Narratives were curated not primarily for personal catharsis or closure—a key goal of Dignity Therapy [28]—but as vehicles for intergenerational ethical transmission. Stories were selected and framed to impart practical wisdom, moral values (e.g., resilience, honesty), and family history, aiming to fortify the lineage’s future (Sub-theme 2.2). This transforms the narrative act from a retrospective summing-up of one’s life into a prospective contribution to the family’s continuity. This aligns with the Confucian concept of leaving a virtuous legacy (li dé, [17] and empirical work in Taiwan and Hong Kong highlighting the importance of “socially meaningful” life review focused on relationships [18]. Our study deepens this understanding by revealing the pedagogical intent behind narrative sharing. The “legacy document” in this context may be less a curated autobiography and more a set of lived lessons embedded in family memory, raising questions about the format and focus of narrative interventions.

The family as co-author and conferred of dignity

Perhaps the most salient finding is the reconceptualization of the family from a supportive backdrop to the essential co-author of narrative meaning and the primary conferrer of dignity. Dignity was experienced as “socially conferred” (Sub-theme 3.2) through acts of attentive listening, consultation, and respectful care by family members. Similarly, a life narrative’s validity and worth were contingent on being received, remembered, and re-told within the family (Sub-theme 3.1). This positions the family as an active, participatory audience without whose engagement the narrative process remains incomplete and dignity fragile. This challenges the predominantly dyadic, therapist-patient model of Dignity Therapy. While Chochinov et al. acknowledge involving families [17], our data suggest that in Confucian contexts, the family is not merely involved but is constitutively central. Ignoring this dyad risks rendering an intervention culturally void or even iatrogenic, if it amplifies a sense of isolation or misalignment with familial expectations [13].

Implications for nursing practice and policy

These findings carry urgent implications for palliative nursing:

Assessment Nursing assessments must incorporate relational and role-based dimensions. For example, nurses should actively explore questions like: ‘What family roles are most important to you now?’ and ‘What are your biggest concerns about your illness for your family?’ This approach moves the focus beyond solely personal autonomy or symptom distress.

Towards a family-integrated narrative care model We propose moving beyond “family-centered” care to develop a Family-Integrated Narrative Care (FINC) model (Fig. 3). In this model, the core nursing role is to actively facilitate the family‘s process of co-creating a legacy. This involves three key actions: (1) creating structured opportunities for intergenerational storytelling; (2) guiding the older adult in imparting values and wisdom; and (3) coaching family members to become “validating listeners.” Together, these actions operationalize our findings by addressing the relational source of dignity (Theme 1), the outward-oriented purpose of narratives (Theme 2), and the essential validating role of the family (Theme 3).

Fig. 3.

A proposed model of Family-Integrated Narrative Care (FINC) for palliative nursing in a confucian-family context

Education and advocacy

Nursing education must better equip practitioners with cultural competence frameworks that move beyond awareness to practical skills for working with relational autonomy. The consistent finding across studies—including our own and prior work in the same setting [29]—that the family is the primary locus of care and meaning-making underscores this imperative. At a policy level, care models must legitimize and resource the time-intensive work of supporting family systems, not just individual patients, in palliative care.

Synthesis: addressing the research question

The three themes developed from the data collectively provide a clear and coherent answer to our research question: How do older adults in a Confucian-family context perceive and articulate the concepts of dignity and the meaning of their life narratives during palliative care? First, participants perceived and articulated dignity not as an intrinsic, individual property but as familial role fulfillment and burden avoidance (Theme 1: Dignity as Familial Role Fulfillment and Burden Avoidance). This was expressed through their deep concern for maintaining family harmony by fulfilling roles and their moral imperative to avoid being a burden. Second, the meaning of their life narratives was articulated not as journeys of personal achievement but as vehicles for intergenerational ethical transmission (Theme 2), purposefully curated to impart values and ensure family continuity. Finally, both the experience of dignity and the validation of narrative meaning were described as contingent upon the family acting as the essential audience and validator (Theme 3). Thus, the core answer to “how” lies in this relational, family-centric ecosystem of meaning-making, where perception and articulation are inherently social acts, fundamentally challenging individualistic models of dignity and narrative.

Strengths, limitations, and future research

A key strength of this study is its in-depth qualitative design, which privileged the emic perspectives of older adults within a specific, under-studied cultural context, and its use of rigorous reflexive thematic analysis. The inclusion of participants from both hospital and community settings enhances the transferability of findings within similar contexts.

Limitations include the recruitment from one region of China, which may not capture the full diversity within the expansive Confucian-cultural sphere. Furthermore, although purposive, recruitment was conducted through clinical settings, which may have limited access to older adults with less formal care engagement or divergent family structures. The focus on older adults who were communicative and had family engagement excludes the experiences of the isolated or cognitively impaired, whose dignity needs are equally critical.

Future research should: (1) Develop and pilot-test culturally adapted family-integrated narrative care protocols based on these findings; (2) Explore the perspectives of family caregivers in this co-constructive process; and (3) Investigate how healthcare professionals can effectively mediate between biomedical “patient autonomy” and familial “relational obligation” in clinical decision-making.

Conclusion

This study illuminates that for older adults in a Confucian-family context, dignity and narrative meaning are forged within the crucible of family relationships. As our participants directly articulated—‘It’s about fulfilling my role’ (Participant 07) and ‘My dignity is in their hands’ (Participant 08)—dignity is relational, narratives are ethical bequests, and the family is the indispensable validatory audience. These insights directly answer our research question by demonstrating that dignity is perceived through the lens of familial role fulfillment and burden avoidance, while life narrative meaning is articulated as a tool for intergenerational legacy, with both processes requiring familial validation. These findings necessitate a critical re-examination of the universal application of individually-oriented psychosocial interventions in palliative care.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Yanyan Lu: Conceptualization, Methodology, Validation, Visualization, Supervision. Wubin He: Validation, Visualization, Supervision. Ning Yi: Visualization, Supervision, Writing – Review & Editing.

Funding

This study received funding from the Horizontal Project, Jinzhou Medical University (A2024007).

Data availability

The qualitative interview datasets generated and analyzed during this study are not publicly available due to the sensitive nature of the information provided by participants at the end of life and the confidentiality assurances given in the informed consent process. Supporting anonymized excerpts from the data are presented within this article. De-identified data may be made available from the corresponding author upon reasonable request, subject to review and approval by the relevant Institutional Review Board.

Declarations

Ethics approval and consent to participate

Approval for this study was obtained from the Ethics Committee of First Affiliated Hospital of Jinzhou Medical University (Approval No: KYLL2025328). The study was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to their involvement, with pictorial aids provided for low-literacy participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.