Although most older people living in nursing homes die there, there is a dearth of good quality evaluations of interventions to improve their end of life care . Residents usually have multiple health problems, making them heavily reliant on staff for their care, which can erode their sense of dignity. Maintaining dignity is given a high priority in health and social care strategy documents in most European countries, and particular concerns have been raised about loss of dignity in care . Loss of dignity for people reaching the end of their lives is associated with high levels of psychological and spiritual distress and the loss of the will to live . Pride, self-respect, quality of life, well-being, hope and self-esteem have been shown to be associated with dignity. For some people, a sense that nothing of one's life will be transcendent of death was associated with loss of dignity, and many felt that maintaining dignity was highly dependent on how they perceived themselves to be seen by others. Chochinov's study also found that in-patients were more likely to suffer from loss of dignity.
An empirically-based model of dignity has been developed from interviews with hospice patients , which forms the basis of a brief psychotherapy to help promote dignity and reduce distress at the end of life . The therapy addresses physical, psychosocial, existential and spiritual domains of concern or distress. It is brief, can be done at the bedside and aims to help both patients and their families. It comprises an interview with a trained therapist (usually a nurse or other health care professional), which is recorded, transcribed, edited then returned to the patient, who, when they are satisfied with it, can share or bequeath the resulting "generativity" document to people of their choosing. A preliminary evaluation of Dignity Therapy conducted with hospice patients in Canada produced positive findings for patients  and their families . Randomised controlled trials of Dignity Therapy for hospice patients are underway in Canada, Australia and the USA, however, their findings may not be generalisable to those with a diagnosis other than cancer or the older people reaching the end of life in care homes.
An exploratory study of the views of older people in care homes on maintaining dignity supported many of the constructs in Chochinovs's dignity model, suggesting that Dignity Therapy has the potential to be of benefit to older people in care homes . However, this is a very different context to that in which Dignity Therapy was developed, namely, specialist palliative care. This is likely to impact on the feasibility, acceptability and effectiveness of the intervention. One important difference to be considered is the high prevalence of cognitive problems in residents, the majority of whom are following a frailty rather than cancer illness trajectory. In-depth piloting which includes an exploration of the feasibility of delivering an intervention and attention to the context in which interventions take place, as planned here, is recommended in the new Medical Research guidance for developing and evaluating complex interventions . As recommended in the MRC framework, we will also test our proposed outcome measures. The results will inform the design of a Phase III randomised controlled trial.