The limits of DT

Chochinov’s DT remains the most widely used attempt to operationalize dignity in palliative care (Chochinov et al. Reference Chochinov, Hack and Hassard2005, Reference Chochinov, Cann and Cullihall2012). It has demonstrated measurable benefits in reducing existential distress and promoting continuity of self through structured life review (Chochinov et al. Reference Chochinov, Kristjanson and Breitbart2011; Juliao et al. Reference Juliao, Oliveira and Nunes2017). However, its underlying assumptions privilege coherent autobiographical narrative, cognitive capacity, and linear memory reconstruction, thereby excluding many of the most vulnerable patients – such as those with advanced cognitive decline, severe frailty, fluctuating consciousness, or fragmented self-expression (Johnston et al. Reference Johnston, Donmez and Juliao2023).

Furthermore, DT’s scripted structure may unintentionally reinforce fixed biographical identities. By relying on recollection rather than reinterpretation, DT can confine dignity to a stable continuity of self, insufficiently sensitive to the ruptures, ambiguities, and temporal fragility characteristic of terminal illness. This narrative dependency limits the model’s applicability in contexts where identity is episodic, relationally mediated, or expressed through silence, gesture, or presence rather than through coherent storytelling.

The ethics of presence and its constraints

Julião’s contributions highlight the ethical and symbolic depth of dignity, grounded in attentive presence, listening, and the “last word” of the patient (Juliao et al. Reference Juliao, Oliveira and Nunes2017, Reference Juliao, Johnston and Antunes2022). This approach illuminates essential dimensions of recognition and meaning-making near the end of life. Yet an exclusive focus on the interpersonal encounter risks idealizing the dyadic moment and underemphasizing the structural and organizational realities that profoundly affect dignity. Time constraints, digital documentation demands, institutional hierarchies, and technological mediation can erode the very conditions that make ethical presence possible (Tronto Reference Tronto1993; Brown-Johnson et al. Reference Brown-Johnson, Schwartz and Maitra2019).

Presence, while indispensable, requires systemic support: protected time, relational continuity, team culture, and technological environments that do not dominate the clinical encounter. Without such scaffolding, presence becomes morally significant yet structurally fragile – too dependent on individual virtue and too vulnerable to the pressures of efficiency-driven, digitally mediated care.

Toward a relational–temporal turn

Both DT and the ethics of presence reveal dignity’s indispensability but also its conceptual fragility. DT risks reducing dignity to a structured narrative product; presence risks relying on an interpersonal ideal insufficiently protected by institutional or technological arrangements. Neither framework fully addresses the relational, temporal, and structural forces shaping dignity in contemporary care.

What is needed is a relational–temporal reframing: a perspective that understands dignity as something co-created between patients, families, and clinicians; that fluctuates across illness trajectories; and that is mediated by organizational cultures, digital infrastructures, and modes of listening. This need becomes even more urgent in the algorithmic age, where AI, ePROMs, and predictive analytics increasingly shape clinical perception and time allocation (Floridi Reference Floridi2013; Topol Reference Topol2019). These technologies risk compressing relational time, subordinating narrative depth to data-driven logic, and redefining vulnerability through predictive profiles.

The DiRePal model emerges in response to these challenges, offering a conceptual grammar for dignity that is relational, temporally sensitive, and structurally aware – capable of resisting technological reductionism while affirming the ethical essence of care in end-of-life settings. Existing models illuminate partial dimensions of dignity; DiRePal integrates them within a broader relational–temporal and institutional framework required for digitalized care environments.

Other approaches, including legacy-oriented and reminiscence-based frameworks, further contribute to the understanding of dignity by emphasizing continuity, meaning-making, and symbolic transmission across time. While not exhaustively reviewed here, these perspectives reinforce the importance of narrative, relationality, and memory and are conceptually integrated within the broader relational–temporal horizon proposed by DiRePal (Webster et al. Reference Webster and Haight2002).

Narrative identity and the dialectic of idem/ipse (Ricoeur)

Ricoeur interprets identity as a dynamic narrative synthesis of idem (sameness) and ipse (selfhood), sustained through interpretative labor over time (Ricoeur Reference Ricoeur1992). This dialectic undermines attempts to reduce dignity to the preservation of a fixed biographical essence. In advanced illness, bodily decline, interruptions in routine, and existential rupture destabilize continuity of self. Dignified care must, therefore, support both recognition of what has been (idem) and opportunities for re-narration (ipse), allowing patients to reinterpret or “re-promise” themselves in the face of loss and finitude.

Crucially, this narrative orientation ensures that suffering is approached as lived experience rather than as an abstracted symptom or data point. Dignity, in this view, is preserved when the patient’s embodied vulnerability is interpreted within a relational and temporal horizon.

Three ethical implications follow. First, dignity cannot rest solely on recollection; it requires interpretive space for transformation. Second, narrative identity is mediated by listeners, witnesses, and institutional scripts – meaning dignity is co-constituted through relational practices of acknowledgement rather than authored alone. Third, clinical dignity depends on kairotic time – opportune, irreplaceable moments of recognition – rather than chronometric pressures of throughput. DiRePal, therefore, adopts Ricoeur’s notion of “narrative hospitality”: the disciplined readiness to host fragmented, nonlinear, or symbolic stories that sustain selfhood even when coherence falters (Ricoeur Reference Ricoeur1992; Guite-Verret et al. Reference Guite-Verret, Vachon and Girard2023).

The asymmetrical ethics of the Other (Levinas)

Levinas situates ethics not in autonomy but in the encounter with the vulnerable Other, whose face calls the caregiver into responsibility prior to reciprocity or contract (Lévinas Reference Lévinas1972). In end-of-life contexts, the Other’s fragility – often silent, dependent, or disoriented – does not diminish dignity; it intensifies its ethical claim. On this account, dignity is not exhausted by a patient’s ability to articulate a narrative but arises from the moral demand their vulnerability places upon those who care.

Levinas also highlights that caregivers are not neutral intermediaries. Their own dignity becomes implicated in responding to the Other, and this responsibility persists even under time scarcity, digital mediation, or systemic constraint. Where health systems risk reducing persons to data profiles or algorithmic risk categories, Levinasian ethics reasserts the primacy of singular encounter. For this reason, DiRePal regards recognition, attentiveness, and presence not as optional features of care but as its ethical ground (Lévinas Reference Lévinas1972; Rushton Reference Rushton2018).

Capabilities and supported agency under dependency (Nussbaum)

Nussbaum’s capabilities approach anchors dignity in the real opportunities individuals must be and to act under just conditions (Nussbaum Reference Nussbaum2011). Severe illness erodes many central capabilities – bodily integrity, expression, affiliation, and agency – yet capability loss does not equate to the loss of dignity. Dignity persists where relational and institutional scaffolding sustains opportunities for participation, decision-making, and symbolic presence.

For DiRePal, 2 consequences follow. First, dignity-preserving care requires not only attitudes, but material supports protected time for presence, communication aids, and ethically designed technologies. Second, the capabilities perspective widens the moral field to include families and clinicians. Without supporting the capability of professionals to be attentive, present, and morally resilient, patient dignity cannot reliably be upheld. The temporal dignity indicator emerges from this insight, repositioning time-for-presence as an ethical and organizational resource rather than a dispensable luxury (Brown-Johnson et al. Reference Brown-Johnson, Schwartz and Maitra2019; Andersson et al. Reference Andersson, Svensson and Frank2022).

Care ethics and the structural conditions of dignity (Tronto)

Tronto’s ethics of care emphasizes that caring practices are shaped by attentiveness, responsibility, competence, and responsiveness, all embedded within political and institutional arrangements (Tronto Reference Tronto1993, Reference Tronto2013). This perspective exposes a blind spot in dignity frameworks that focus solely on the clinician–patient dyad: dignity is variably enabled or undermined by systemic factors such as staffing ratios, digital workflows, bureaucratic pressures, and leadership culture.

From a care-ethical lens, these institutional and technological structures must be treated as ethical determinants of dignity. Digital infrastructures can either compress relational time or create space for presence; AI-mediated triage can support prudent reasoning or impose opaque directives. DiRePal’s “architecture of prudence” translates Tronto’s insights into design principles for digital systems: contestability, reversibility, traceability, and temporal proportionality must be embedded into algorithmic workflows to ensure that technology remains subordinate to human dignity (Floridi Reference Floridi2013; Dignum Reference Dignum2019).

Toward a relational–temporal ontology of dignity

Taken together, these philosophical traditions support a composite ontology of dignity grounded in 3 claims:

1. 1. Dignity is hermeneutic and diachronic (Ricoeur): it requires kairotic time and interpretive space for re-narration, hosting fragmentary or symbolic expressions of selfhood.

2. 2. Dignity is ethical and asymmetrical (Levinas): it arises from responsibility toward the vulnerable Other, not merely from autonomy or narrative capacity.

3. 3. Dignity is capability-dependent and structurally mediated (Nussbaum; Tronto): it is sustained by enabling conditions – organizational, technological, relational – that support agency, affiliation, and recognition.

From these claims follow 2 operational corollaries central to DiRePal. The temporal dignity indicator reframes time allocation as an ethical metric – the ratio of dialogical presence to screen-facing tasks. The architecture of prudence reframes digitalization as a site of moral design, requiring algorithms to remain contestable, reversible, and temporally proportionate (Floridi Reference Floridi2013; Dignum Reference Dignum2019; Topol Reference Topol2019).

These foundations also clarify the inclusion of a post-biographical horizon of dignity. When speech ceases or life ends, dignity persists as a claim of memory, recognition and ethical stewardship – how bodies are honored, names preserved, and digital traces governed. A relational–temporal account, therefore, extends care beyond biological life into the communal work of remembrance, resisting anonymity and affirming worth (Butler Reference Butler2004; Guite-Verret et al. Reference Guite-Verret, Vachon and Girard2023).

Taken together, these philosophical traditions converge into a coherent relational–temporal ontology of dignity. Ricoeur provides the narrative and temporal structure through which identity is continuously reinterpreted; Levinas grounds dignity in ethical responsibility toward the vulnerable Other; Nussbaum situates dignity within conditions that enable or constrain human flourishing; and Tronto exposes the structural and institutional dimensions that sustain or undermine care. The DiRePal model emerges from this convergence, integrating these dimensions into a unified ethical grammar capable of addressing the complexities of contemporary, technologically mediated end-of-life care.

Core axes of DiRePal

DiRePal is articulated around 3 interdependent axes that translate its philosophical foundations into clinical and institutional sensibilities: Relational Recognition, Temporal Sensitivity, and Situated Co-Narrative.

1. 1. Relational Recognition

Dignity emerges in the encounter through attentiveness, presence, and the recognition of the other as irreducible. Such recognition is expressed not only in speech but also in silence, gesture, and naming. It encompasses patients, families, and clinicians, affirming the dignity of all participants in the caring relationship (Lévinas Reference Lévinas1972; Rushton Reference Rushton2018).

1. 2. Temporal Sensitivity

Across the illness trajectory, dignity fluctuates and requires openness to kairotic time – the singular, opportune moment of listening or presence. Temporal sensitivity resists the colonization of clinical encounters by chronometric metrics or algorithmic logic and requires institutional arrangements that protect time for narrative, interpretation, and human meaning (Ricoeur Reference Ricoeur1992; Tronto Reference Tronto1993).

1. 3. Situated Co-Narrative

Dignity is sustained and reshaped through stories – linear or fragmented – co-authored between patients, families, and professionals. Co-narrative recognizes that meaning-making often occurs through shared testimony, gestures, rituals, or digital traces. Unlike the scripted structure of DT or the purely existential depth of presence, co-narrative offers a flexible, relational space where identity can be renegotiated in the face of illness (Butler Reference Butler2004, Reference Butler2005; Guite-Verret et al. Reference Guite-Verret, Vachon and Girard2023).

Together, these axes establish DiRePal as a grammar of dignity understood as event rather than possession, and as relational becoming rather than static essence.

DiRePal invites medicine to remember that, even in an algorithmic age, dignity is not measured but received – through presence, time, and shared recognition.

Differences with prevailing models

DiRePal advances beyond existing models by addressing conceptual gaps left by both DT and the ethics of presence.

DT depends on structured interviews and coherent autobiographical recall; DiRePal instead welcomes fragmented, nonlinear, or collective storytelling, emphasizing interpretive re-narration rather than textual legacy (Ricoeur Reference Ricoeur1992).

The ethics of presence rightly centers attentiveness and listening but depends heavily on individual virtue and remains vulnerable to structural erosion. DiRePal embeds presence in institutional arrangements – supported by the temporal dignity indicator – ensuring that time-for-presence is protected rather than assumed (Brown-Johnson et al. Reference Brown-Johnson, Schwartz and Maitra2019).

In doing so, DiRePal offers a broader ethical grammar that responds both to the reductionism of scripted interventions and to the idealization of purely interpersonal models. It brings relational, temporal, and structural dimensions together in a way that is responsive to contemporary clinical complexity.

Operational concepts

Two operational concepts translate the DiRePal model into institutional practice and offer concrete handles for ethical implementation in clinical environments increasingly shaped by digital tools.

Architecture of prudence

Drawing on Aristotelian phronesis adapted to digital systems, the architecture of prudence embeds contestability, reversibility, traceability, and temporal proportionality into AI-mediated care. Algorithms must remain auditable and open to human revision; patients must retain access to explanation and second opinion; and technological mediation must remain proportionate to relational and ethical needs (Floridi Reference Floridi2013; Dignum Reference Dignum2019). These 2 tools express DiRePal’s commitment to ensuring that digital systems serve dignity rather than displace it.

No existing dignity framework offers operational instruments for protecting dignity through temporal allocation or structural governance. DiRePal is, therefore, the first model to articulate dignity not only philosophically but also through concrete tools that safeguard relational presence and prudential oversight in digitalized care.

Clinical illustration

Consider a patient with advanced lung cancer, fluctuating cognition, and limited capacity to generate a coherent narrative. Within DT, such a patient may be excluded due to the demands of structured storytelling. In DiRePal, however, dignity can be sustained through brief narrative fragments captured through ePROMs, complemented by family testimony and gestures of recognition by clinicians. The temporal dignity indicator ensures that time-for-presence is not overshadowed by digital workflow, and the architecture of prudence guarantees that AI-derived prognostic outputs remain contestable and secondary to clinical judgment.

This illustration shows how DiRePal reframes dignity as an evolving, co-constructed, and institutionally supported practice rather than the by-product of narrative coherence or singular presence. It foregrounds relational and temporal processes while accommodating technological mediation within an ethical horizon.

A second illustration concerns a non-verbal patient with advanced neurodegenerative disease whose family members disagree about escalating technological interventions. One group request aggressive monitoring based on algorithmic predictions of potential deterioration, while another prioritizes comfort, presence, and minimizing digital mediation. Within DiRePal, dignity is not determined by decisional capacity but by relational and temporal recognition. Care teams would, therefore, privilege kairotic time – attentive presence at the bedside – and use digital projections only as dialogical prompts rather than directives. The temporal dignity indicator would ensure that clinician time is anchored in human encounter rather than in digital surveillance, while the architecture of prudence would require that algorithmic alerts remain contestable, reversible, and proportionate to the patient’s relational and embodied context. This scenario illustrates how DiRePal orients difficult decisions not toward technological escalation or withdrawal but toward the preservation of dignity as a co-created and temporally unfolding practice.

Dignity beyond the biographical self

Ricoeur emphasizes that identity is always mediated by narrative and shaped by the interpretations of others. When self-narration becomes impossible in dying, dignity becomes radically dependent on external narrators – families, clinicians, and communities – who preserve, interpret, and honor the patient’s story (Ricoeur Reference Ricoeur1992). J. Butler adds that grievability, the extent to which a life is considered worthy of mourning, is a central ethical measure of dignity. To be forgotten, anonymized, or reduced to a datapoint is to be denied dignity in the post-biographical realm (Butler Reference Butler2004).

This perspective highlights the moral importance of remembrance rituals, naming practices, and symbolic gestures of continuity. It also exposes structural injustices: some lives remain less “grievable” due to systemic inequities affecting migrants, socioeconomically marginalized groups, or those without access to well-resourced healthcare (Walter Reference Walter1996). Dignity-preserving care, therefore, cannot end at death. It requires an aftercare of memory that prevents persons from being consigned to anonymity once biological life ceases.

Digital legacy and the algorithmic afterlife

In contemporary practice, post-biographical dignity is increasingly mediated by digital environments. Patients leave behind not only embodied memories but also extensive data traces – electronic health records, ePROM responses, social media archives, audio recordings, photographs, and digital-legacy platforms (Brubaker et al. Reference Brubaker, Hayes and Dourish2013; Savin-Baden et al. Reference Savin-Baden and Mason-Robbie2020). These traces can provide comfort and continuity for families, but they also raise urgent ethical questions concerning consent, control, representation, and potential misuse.

Digital ethics scholars warn against the commodification of the dead and the exploitation of personal data for purposes misaligned with the person’s values (Öhman et al. 2018). The emerging “algorithmic afterlife” can become a site of injustice: identities reconstructed without consent, digital remains harvested for commercial gain, or individuals effectively excluded from digital continuity due to inequities in access.

For these reasons, DiRePal calls for a prudential governance of digital legacy. Ethical care requires that digital remains be handled with consent, respect, and alignment with the patient’s values. Just as corporeal remains are treated with symbolic care, so too must digital traces be stewarded responsibly. Extending dignity beyond biological life thus becomes a matter of relational and temporal responsibility for the traces a person leaves behind.

Memory as relational continuity

Tony Walter’s work shows that modern death is mediated through communal practices of remembrance. Families, clinicians, and institutions co-author the continuing bonds that endure beyond the final breath (Walter Reference Walter1996). In this light, post-biographical dignity becomes a relational practice enacted through how we recall, narrate, honor, and symbolically sustain the memory of those who have died.

This has direct implications for clinical practice and education. Professionals must be prepared not only to accompany the dying but also to support the bereaved, recognizing that dignity extends into the domain of memory. Institutional rituals – memorial services, remembrance spaces, anniversary acknowledgements, or digital-legacy practices – embed this continuity into the fabric of care.

For DiRePal, relationality is not interrupted by death. Care continues as an ethical obligation of memory and presence, affirming that dignity transcends the boundaries of biography. In this perspective, palliative care is not merely the management of dying but the cultivation of a narrative community that safeguards dignity even when voices fall silent.

Potentials and risks of AI in end-of-life care

AI systems are increasingly used for prognostication, triage, and referral within palliative pathways (Heinzen et al. Reference Heinzen, Wilson and Storlie2023; Wilson et al. Reference Wilson, Ramar and Philpot2023). Their statistical logic, however, is oriented toward population-level regularities rather than singular narratives. Even when technically robust, such systems can displace kairotic clinical time with chronometric predictions (Floridi Reference Floridi2013; Topol Reference Topol2019). Two major risks follow from a DiRePal perspective. First, patients may be re-identified primarily as algorithmic risk profiles, narrowing the perception of their lived experience. Second, clinicians may become supervisors of machine recommendations rather than interpreters of human stories, eroding the prudential reasoning (phronesis) essential in end-of-life care.

Justice concerns compound these issues. Algorithmic systems can reproduce or amplify inequities encoded in their training data, influencing access to palliative services – an effect already documented in health-system algorithms outside palliative care (Obermeyer et al. Reference Obermeyer, Powers and Vogeli2019). These risks demand explicit governance. For DiRePal, the ethical risk is not only technical but phenomenological: suffering must remain grounded in the patient’s embodied, relational experience.

When AI reframes distress as a risk category, the model reorients interpretation back to the lived reality of the dying person, resisting the displacement of suffering by data-driven abstraction.

DiRePal’s architecture of prudence calls for institutional safeguards such as (i) guaranteed human review and second-opinion pathways; (ii) auditable model lineage and transparent updates; (iii) “pause” or opt-out functions when algorithmic outputs conflict with relational or temporal priorities; and (iv) clear role boundaries ensuring that AI remains advisory rather than directive in intimate end-of-life decisions. Far from rejecting technology, this stance subordinates it to an ethic of presence, recognition, and prudent timing.

ePROMs: Amplifying or reducing ethical listening

When used well, ePROMs can improve symptom detection, quality of life, and timely intervention (Howell et al. Reference Howell, Molloy and Wilkinson2015; Greenhalgh et al. Reference Greenhalgh, Gooding and Gibbons2018). Randomized and pragmatic studies show that structured symptom self-reporting may even improve survival in oncology (Denis et al. Reference Denis, Basch and Septans2019), while trials of PRO-CTCAE confirm the feasibility of patient reporting in complex clinical contexts (Basch et al. Reference Basch, Deal and Dueck2017). Yet their ethical role depends on how they are integrated into clinical practice.

If treated as checklists or completed by clinicians instead of patients, ePROMs risk flattening existential concerns into binary responses and eroding the patient’s narrative voice (Snyder et al. 2009). DiRePal interprets ePROMs as potential dignity triggers: prompts that reveal hidden suffering, invite elaboration, and legitimize expression. This requires relational time, training, and narrative sensitivity – all supported by the temporal dignity indicator, which reframes clinical time as an ethical resource.

Practically, this means that ePROM collection should not consume more time in screen interaction than it returns in listening; results should be discussed with patients and families rather than silently archived; and alert thresholds should trigger relational responses – conversation, shared meaning-making – rather than purely transactional escalation (Al Sayah et al. Reference Al Sayah, Lahtinen and Bonsel2021; Giesinger et al. Reference Giesinger, Efficace and Aaronson2021; Johnston et al. Reference Johnston, Donmez and Juliao2023).

Integrating technologies within DiRePal

For DiRePal, the question is never simply whether to use AI or ePROMs, but how to integrate them ethically within a relational–temporal framework. Three principles follow:

1. 1. Dialogical mediation

ePROMs must function as openings for narrative, not replacements for it; AI outputs must be explained in accessible language that invites participation, preserves the possibility of dissent, and recognizes silence as meaningful.

1. 2. Institutional embedding

Safeguards such as human-in-the-loop review, audit trails, proportionate alert thresholds, and ethics oversight must be built into digital infrastructures (Dignum Reference Dignum2019; Topol Reference Topol2019). These are ethical necessities, not technical luxuries.

1. 3. Prudential proportionality

The degree of reliance on digital tools should vary with context. In large-scale triage, algorithms may support distributive justice; in intimate end-of-life conversations, human presence must predominate (Topol Reference Topol2019).

Operationally, this means redesigning workflows around dignity: scheduling ePROM review within consultations; presenting dashboards that foreground narrative cues rather than only numerical scores; and configuring AI tools to default to explainable outputs and relational decelerators (e.g., “discuss before order”). Technologies that displace relational time compromise dignity; technologies that create time for presence become allies of DiRePal.

Clinical practice

For clinicians, DiRePal reframes dignity as a task grounded in presence and narrative hospitality. This involves 3 essential commitments.

First, prioritizing time-for-presence: relational listening must not be overshadowed by digital interfaces or throughput pressures. The temporal dignity indicator supports clinicians in protecting kairotic time, reframing clinical time from a neutral commodity into an ethical resource (Topol Reference Topol2019).

Second, co-narrative care: interventions should include the voices of families and caregivers, moving beyond strictly dyadic models. Structured moments for shared storytelling – oral, written, or digital – affirm dignity as intersubjective and co-authored (Guite-Verret et al. Reference Guite-Verret, Vachon and Girard2023).

Third, dialogical integration of digital tools: ePROMs and AI systems must serve as prompts for deeper narrative exploration rather than mechanistic endpoints. When handled dialogically, digital outputs can enrich, rather than erode, ethical listening (Greenhalgh et al. Reference Greenhalgh, Gooding and Gibbons2018).

Professional education

Palliative care education has traditionally emphasized technical competence and symptom management. DiRePal argues for a complementary emphasis on relational and ethical competencies.

Curricula should include narrative ethics, relational communication, moral resilience, and literacy in digital dignity. Clinicians must be prepared not only to interpret symptoms but also stories, silences, and digital traces as elements of dignity-preserving care (Rushton Reference Rushton2018; Andersson et al. Reference Andersson, Svensson and Frank2022).

Pedagogically, reflective writing, narrative supervision, simulations of relational scenarios, and interdisciplinary ethics rounds help cultivate attentiveness to relational–temporal dynamics (Brown-Johnson et al. Reference Brown-Johnson, Schwartz and Maitra2019).

Finally, moral resilience is essential: professionals need tools to protect their own dignity, recognizing that patient dignity is inseparable from the moral well-being of those who care for them (Rushton Reference Rushton2018).

Institutional and policy implications

Institutions are not neutral backdrops but active mediators of dignity. The DiRePal framework underscores the need for organizational structures that protect relational and temporal recognition.

The architecture of prudence calls for embedding contestability, reversibility, traceability, and proportionality into digital infrastructures, ensuring technology enhances rather than colonizes care (Tronto Reference Tronto1993; Dignum Reference Dignum2019).

Quality standards should incorporate indicators of relational and temporal care – time spent in presence, patient and family feedback, and measures of staff moral well-being – within accreditation and quality improvement programs (Johnston et al. Reference Johnston, Donmez and Juliao2023).

Ethical leadership is also essential: leaders must cultivate cultures that value presence and narrative work, incorporating relational competence into recruitment, evaluation, and reward structures (Guite-Verret et al. Reference Guite-Verret, Vachon and Girard2023).

Institutions should also develop rituals of remembrance – memorial services, farewell rituals, curated digital legacies – to honor post-biographical dignity and ensure that patients’ lives remain recognized beyond biological existence (Walter Reference Walter1996; Brubaker et al. Reference Brubaker, Hayes and Dourish2013).

Toward systemic embedding

In sum, DiRePal reframes dignity not as a fragile individual attribute but as a systemic ethical mandate. By recalibrating clinical practice, educational priorities, and institutional policies, it offers a framework capable of resisting the reduction of care to efficiency metrics and re-centering healthcare on relational and temporal recognition. Dignity, in this perspective, is not preserved solely in singular encounters but must be supported by the structures in which care unfolds. This systemic embedding ensures that the ethical grammar of DiRePal informs not only bedside decisions but also the cultural ethos and institutional architectures that shape contemporary palliative care.

“The model is too philosophical and impractical”

Objection. Some may argue that DiRePal relies heavily on complex philosophical sources and does not offer sufficiently concrete guidance for clinicians working under time pressure. In environments where clarity and immediacy are essential, philosophical nuance may appear distant from bedside practice.

Response. DiRePal is not presented as a metaphysical doctrine but as a pragmatic ethical grammar. Its conceptual foundations translate directly into operational tools such as the temporal dignity indicator and the architecture of prudence. These tools provide measurable, actionable metrics: the former reframes relational time allocation as an ethical priority, while the latter embeds contestability and reversibility into digital infrastructures. Rather than adding burden, DiRePal equips clinicians and organizations with ethical instruments for navigating technologically mediated care (Dignum Reference Dignum2019; Topol Reference Topol2019). Its purpose is precisely to make philosophical insight clinically usable.

“The framework lacks empirical validation”

Objection. A further concern is that, without large-scale empirical testing, DiRePal may appear speculative when compared with established interventions such as DT (Chochinov et al. Reference Chochinov, Kristjanson and Breitbart2011).

Response. DiRePal is explicitly offered as a philosophical–ethical framework, not as an intervention protocol. Its role is to provide the conceptual scaffolding within which empirical research can unfold. Indeed, the model is currently being operationalized through focus groups with patients, caregivers, and clinicians to examine relational and temporal dimensions of dignity in real-world settings (Johnston et al. Reference Johnston, Donmez and Juliao2023). Moreover, DiRePal integrates empirical insights already demonstrated in related fields – for example, the impact of ePROMs on quality of life and communication (Greenhalgh et al. Reference Greenhalgh, Gooding and Gibbons2018; Denis et al. Reference Denis, Basch and Septans2019). Instead of competing with empirical inquiry, DiRePal offers a reflective horizon that enables such findings to be interpreted ethically and coherently.

“It overlaps with dignity therapy or the ethics of presence”

Objection. Given its focus on dignity, DiRePal could be seen as a reformulation of existing models, particularly DT or Julião’s ethics of presence.

Response. DiRePal acknowledges its debt to these traditions but intentionally advances beyond them. Its contribution is 3-fold.

First, relational breadth: whereas DT foregrounds the patient’s voice, DiRePal includes family and professional dignity as integral elements of the ethical ecology of care (Rushton Reference Rushton2018).

Second, temporal depth: DiRePal situates dignity within temporal fluctuation, requiring sustained attentiveness across illness trajectories rather than relying on scripted interventions or isolated existential moments (Ricoeur Reference Ricoeur1992).

Third, structural integration: unlike DT or presence-based models, DiRePal directly addresses systemic and technological mediations, offering institutional principles – contestability, reversibility, proportionality – for the algorithmic age (Brubaker et al. Reference Brubaker, Hayes and Dourish2013; Floridi Reference Floridi2013; Öhman et al. 2018).

In this sense, DiRePal is not a competitor but a philosophical evolution. It deepens the theoretical grounding of dignity, broadens its relational scope, and aligns it with the ethical challenges of contemporary digital medicine.