Table 1 Systematization of Noblit and Hare’s [33] seven phases of a meta-ethnographic review

1. “Getting started”: choosing the topic focus

The research question resulted from the gap that we identified in the empirical literature about the ethical reasoning associated with the wish to hasten death in palliative care

A meta-ethnographic review was considered appropriate and valuable to explore the meanings behind a wish to hasten death in relation to and in light of ethical principles, taking into account the perspectives of patients, family members, and healthcare professionals

2. “Deciding what is relevant to the initial interest”: identifying and selecting study accounts to synthesize

A systematic search was conducted in three databases. The search strategy included MeSH and keywords related to concepts associated with the wish to hasten death and the desire to die. Hand searches complemented the screening of multiple databases

Only qualitative studies that fitted the eligibility criteria were included as only qualitative studies could explore meanings. Qualitative data from mixed-methods studies were also included in the analysis

3. “Reading the studies”: repeated reading of study accounts and detailed recording of the concepts, themes, and metaphors

The full reading of the included articles allowed us to extract the raw data and information, and interpret meanings. Concepts, themes, and metaphors were analyzed thoroughly to identify and explore meanings in relation to and in light of ethical principles. This was done through an iterative process with ongoing discussions among all authors

4. “Determining how studies are related”: comparing study accounts by creating and juxtaposing a list of concepts from each study to judge whether the concepts are similar, contradictory, or about different aspects of the topic being researched

For each article, a list of meanings and factors/motivations behind the wish to hasten death was created. The bioethical principles were also identified in the articles, whenever they were mentioned. When not explicitly indicated, an interpretative approach was used to infer ethical principles as appropriate. Accounts from all included studies were critically analyzed and compared to judge whether concepts were similar, contradictory, or complementary

5. “Translating the studies into one another”: systematically comparing or “translating” themes, metaphors, or concepts across and within primary study accounts

Synthesis was conducted based on the type of participant included in each study. Articles were organized according to (i) the type of participants (five subgroups of participants were generated) and (ii) chronological order (from most recent). Please see Table 2. Concepts were compared among included articles and meanings were imbricated with bioethical principles

6. “Synthesizing translations”: When phase 5 results in many translations, these can be compared to see if there are common types of translations or if some translations or concepts can encompass those from other study accounts to reach new interpretations

Results were integrated and evaluated considering the similarities or disparities of concepts. Common themes between studies were summarized and contradictions were evaluated to build a new understanding of the meanings. This allowed us to identify and understand how these bioethical principles are inherent and relate to the main meanings behind the wish to hasten death

7. “Expressing the synthesis”: conveying the findings of the synthesis in a form suitable for the particular audience

The synthesis was reported following PRISMA, as appropriate. A summary of the findings and their interpretation is provided. Please see Fig. 2. Strengths, limitations, and implications for further research, policy, and clinical practice are highlighted