Psychological research on death attitudes: an overview and evaluation

Death anxiety and death acceptance in atheists and other nonbelievers

This study explores how age, certainty of belief, belief in science and gender is related to death anxiety and death acceptance. Results from a sample of atheists and other nonbelievers (N = 270) in the United States suggested that age and certainty of belief were significantly related to death anxiety and death acceptance, while belief in science was not a significant predictor. In addition, women reported higher levels of death anxiety compared to men. Implications and directions for future research in death perspectives for atheists and other nonbelievers are discussed.

Wisdom as the mediator in the relationships between religious meaning system and attitude toward death among older adults

The objective of the present research was to investigate whether wisdom is a mediator in the association between the religious meaning system and the attitude toward death in the period of late adulthood. The study included 315 persons aged 60-75. Three measures were used: Religious Meaning System Scale (RMSS), Three-Dimensional Wisdom Scale (3D-WS), Death Attitude Profile-Revised (DAP-R). The analyses allowed for a partial verification of the hypothesis that wisdom is a mediator in the relationship between the explicit religious meaning system and the multidimensional attitude toward death in late adulthood. It was confirmed that the relationship of the religious meaning system with fear of death, death avoidance, neutral acceptance, escape acceptance and approach acceptance is mediated by at least one (cognitive, reflective and/or affective) of the dimensions considered in the study.

Lived Experiences of Canadian Women with Metastatic Breast Cancer in Preparation for Their Death: A Qualitative Study.: Part II-Enabling and Inhibiting Factors; the Paradox of Death Preparation

Objectives

This study examined the essence of lived experiences of a sample of women with metastatic breast cancer in preparing themselves for their own death, with the goal of informing health provider interventions that support an acceptance of and preparation for death.

Methods

A phenomenological qualitative approach was used. Five women with metastatic breast cancer were interviewed on two occasions. Themes were analyzed, described, and validated, until saturation was met. Qualitative outcomes of the thematic analysis related to the enabling and inhibiting factors involved in preparing for one's own death.

Results

Factors that enabled and inhibited death preparation tasks in these women included: personal past death experiences; the availability of time and a place to think, learn, and work on death preparation activities; a chance to connect with others in similar situations; and personal and cultural attitudes towards death. Gaps and unmet needs within the health care system were identified. Finally, the paradoxical nature of various aspects of death preparation was highlighted.

Conclusions

Death preparation can be accomplished through enhancing supportive care from health care professionals, with beneficial outcomes for patients and families. Nurses should be conscious of the paradoxical nature of death preparation, and help women to confront and manage these.

Lived Experiences of Canadian Women with Metastatic Breast Cancer in Preparation for Their Death: A Qualitative Study. Part I-Preparations and Consequences

Objectives

This study aimed to detail the tasks of death preparation and the consequences of such preparation for women with metastatic breast cancer.

Methods

A phenomenological qualitative approach was used. Five women with metastatic breast cancer were interviewed on two occasions. Themes were analyzed, described, and validated, until saturation was met. Outcomes of thematic analysis related to the impetus, process, and consequences of preparing for one's own death.

Findings

The women prepared for their death by: acknowledging their grief; preparing mentally; seeking information and support; preparing the family; and preparing for the end of life. They also engaged in creating life projects that enhanced their connections with loved ones, and lived full and joyful lives. These activities helped increased their readiness to die in peace.

Conclusions

Preparing for their own death can help women with incurable cancer live full, satisfying lives, and be prepared to face their own death with peace. Helping women express their feelings around their own death and their preparation for death should be a key interdisciplinary psychosocial nursing intervention.

Characterizing death acceptance among patients with cancer

OBJECTIVE

Death acceptance may indicate positive adaptation in cancer patients. Little is known about what characterizes patients with different levels of death acceptance or its impact on psychological distress. We aimed to broaden the understanding of death acceptance by exploring associated demographic, medical, and psychological characteristics.

METHODS

At baseline, we studied 307 mixed cancer patients attending the University Cancer Center Hamburg and a specialized lung cancer center (age M = 59.6, 69% female, 69% advanced cancer). At 1-year follow-up, 153 patients participated. We assessed death acceptance using the validated Life Attitude Profile-Revised. Patients further completed the Memorial Symptom Assessment Scale, the Demoralization Scale, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Questionnaire. Statistical analyses included multinomial and hierarchical regression analyses.

RESULTS

At baseline, mean death acceptance was 4.33 (standard deviation [SD] = 1.3, range 1-7). There was no change to follow-up (P = 0.26). When all variables were entered simultaneously, patients who experienced high death acceptance were more likely to be older (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.07), male (OR = 3.59; 95% CI, 1.35-9.56), widowed (OR = 3.24; 95% CI, 1.01-10.41), and diagnosed with stage IV (OR = 2.44; 95% CI, 1.27-4.71). They were less likely to be diagnosed with lung cancer (OR = 0.20; 95% CI, 0.07-0.58), and their death acceptance was lower with every month since diagnosis (OR = 0.99; 95% CI, 0.98-0.99). High death acceptance predicted lower demoralization and anxiety at follow-up but not depression.

CONCLUSIONS

High death acceptance was adaptive. It predicted lower existential distress and anxiety after 1 year. Advanced cancer did not preclude death acceptance, supporting the exploration of death-related concerns in psychosocial interventions.

Attitudes of Nurses in Turkey Toward Care of Dying Individual and the Associated Religious and Cultural Factors

The aim of this study was to determine the attitudes of nurses working in two university hospitals located in the west and east of Turkey toward care of dying individual as well as religious and cultural factors that influence their attitudes. The descriptive and comparative study was conducted with a total of 189 nurses who were working in adult inpatient clinics of two university hospitals in western (101 nurses) and eastern (88 nurses) Turkey between July and November 2016. The data were obtained by using the questionnaire and Frommelt Attitudes Toward Care of the Dying Scale. As a result of this study, it was determined that in terms of the status of receiving training the end-of-life care the majority of nurses received this training; however, this rate was higher (51.0%) in nurses working in the eastern hospital (p = 0.025). The nurses working in the east (51.6%) were determined to have more problems during caregiving due to their religious and cultural beliefs, the most frequent problem they experienced was "being uncomfortable due to privacy when giving care to patients from opposite gender" (57.1%). The emotions felt mostly by nurses during the care of dying patient were grief (nurses in the east = 48.5%, nurses in the west = 51.5%) and despair (nurses in the east = 40.4%, nurses in the west = 59.6%). Nurses working both in the east (98.27 ± 7.71) and in the west (97.19 ± 8.99) were determined to have positive attitude toward death, and there was no statistically significant difference between both groups in terms of the mean scores of the Attitudes Toward Care of the Dying Scale (p = 0.373). In accordance with these results, it is recommended to focus on death issues in end-of-life care during the nursing education and to support nurses with in-service trainings regularly after the graduation.

Death anxiety and its association with hypochondriasis and medically unexplained symptoms: A systematic review

OBJECTIVE

To systematically review of the available literature to (1) examine the association between death anxiety and hypochondriasis and (2) examine the association between death anxiety and medically unexplained symptoms (MUS).

METHODS

A systematic literature search was conducted in Embase, PsycINFO, Pubmed and Ovid databases and reference lists of selected articles. Articles were included when the research population concerned people with hypochondriasis and/or MUS in who death anxiety was assessed by a validated research method. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of the studies and extracted relevant characteristics and data. The data were descriptively analysed.

RESULTS

Of the 1087 references identified in the search, six studies on the association between death anxiety and hypochondriasis and three studies on the association between death anxiety and MUS met inclusion criteria. All studies found a positive association of death anxiety with hypochondriasis and/or MUS. The design of all studies was cross-sectional and the overall quality of the studies was low. The influence of age or sex on these associations was not analysed in any of the studies. Given the diversity in setting, population, study design, and methods used, a meta-analysis was not possible.

CONCLUSION

All studies found a positive association of death anxiety with hypochondriasis and/or MUS. Acknowledging that death anxiety may play a prominent role in hypochondriasis/MUS populations, future research should address (potentially modifiable) determinants of death anxiety in these populations.

Death preparation of Chinese rural elders

In this qualitative study, we explored how Chinese rural elders narrate death-related issues and death preparation. Adopting a phenomenological approach, we interviewed 14 participants regarding the particular actions they employ to prepare for death. The findings revealed a death preparation system for rural Chinese elders that is instrumental in how they converse about death, wish for a good death, make objects and symbols, and anticipate an afterlife as a worshiped ancestor rather than a wandering ghost. Family and family honor provide the context for death preparation. We discuss implications and the need for the death preparation education of younger generations.

In memory: Predicting preferences for memorializing lost loved ones

People's preferences for memorializing loved ones vary and may depend on their personal attitudes and experiences with death. Participants (N = 145) completed the memorializing preferences checklist and measures of personal attitudes and life experiences with death. Factor analysis identified four memorializing preferences. In terms of predicting preferences, greater acknowledgment of death, and having experienced more losses, predicted preference for memorializing through societal tradition, community legacy, and continuing intimacy. Greater death resistance and less closeness to the deceased predicted preference for memorializing through confronting loss. Findings are discussed in terms of the range of preferences for and motivations behind memorializing.

A Cross-Sectional View of Fear of Death and Dying Among Skydivers

The literature lacks a consistent pattern on the relationship between attitudes toward death and dying across occupations and recreational pursuits. The present cross-sectional study categorized a group of individuals engaging in a high-risk recreational activity (i.e., skydivers) on the basis of experience and classified them into student, intermediate, and experts. There were more negative attitudes of death and dying among student skydivers compared with more experienced skydivers. It was also found that expert skydivers had more negative attitudes toward death and dying on some of the measures compared with the intermediate level experienced skydivers. It may be the case that factors such as perceived personal control, overconfidence, and metacognition may be related to these observed differences between the two more experienced groups of skydivers. The possibility of the factors playing a role in skydivers' attitudes toward death and dying should be taken into consideration in the training programs for skydiving.

Death Acceptance in Vietnamese Cancer Patients: A Phenomenological Study

Introduction: To date, death acceptance is not well investigated in the Vietnamese population. Cultural influences may affect death acceptance. The purpose of this phenomenological study is to describe Vietnamese cancer patients’ lived experience with death acceptance. Method: Eleven Vietnamese patients with various cancer diagnoses participated in the study. Data were analyzed using the Giorgian method of data analysis. Results: Themes of death acceptance found were (1) accepting destiny, (2) knowing and sacrificing the self, (3) believing in living persons and handing over responsibilities, (4) accepting death while continuing to fight for life, and (5) looking for a “role model death.” Discussion: Death acceptance is a contextually bound concept, which needs further investigation. To help patients with their death acceptance, nurses should include spiritual support and the involvement of loved ones in patients’ care plans.

Measuring attitudes towards the dying process: A systematic review of tools

BACKGROUND

At the end of life, anxious attitudes concerning the dying process are common in patients in Palliative Care. Measurement tools can identify vulnerabilities, resources and the need for subsequent treatment to relieve suffering and support well-being.

AIM

To systematically review available tools measuring attitudes towards dying, their operationalization, the method of measurement and the methodological quality including generalizability to different contexts.

DESIGN

Systematic review according to the PRISMA Statement. Methodological quality of tools assessed by standardized review criteria.

DATA SOURCES

MEDLINE, PsycINFO, PsyndexTests and the Health and Psychosocial Instruments were searched from their inception to April 2017.

RESULTS

A total of 94 identified studies reported the development and/or validation of 44 tools. Of these, 37 were questionnaires and 7 alternative measurement methods (e.g. projective measures). In 34 of 37 questionnaires, the emotional evaluation (e.g. anxiety) towards dying is measured. Dying is operationalized in general items ( n = 20), in several specific aspects of dying ( n = 34) and as dying of others ( n = 14). Methodological quality of tools was reported inconsistently. Nine tools reported good internal consistency. Of 37 tools, 4 were validated in a clinical sample (e.g. terminal cancer; Huntington disease), indicating questionable generalizability to clinical contexts for most tools.

CONCLUSION

Many tools exist to measure attitudes towards the dying process using different endpoints. This overview can serve as decision framework on which tool to apply in which contexts. For clinical application, only few tools were available. Further validation of existing tools and potential alternative methods in various populations is needed.

Exploring the Relationship Between Spiritual Well-Being and Death Anxiety in Survivors of Acute Myocardial Infarction: Moderating Role of Sex, Marital Status and Social Support

Previous empirical studies have shown that both spiritual well-being (SWB) and death anxiety (DA) significantly affect the mental health of patients with acute diseases. In this regard, our paper contributes to the extant literature by scrutinizing the conditional relationship between SWB and DA as well as the various mechanisms underpinning such a relationship in patients with acute myocardial infraction (AMI). A descriptive, correlational methodology was utilized. Our main sample consisted of 300 patients with acute myocardial infraction who were hospitalized in a specialized medical institution in Iran throughout a two-month period (i.e. August-October 2015). Patients completed Spiritual Well-Being Scale (SWBS) and Templer's Death Anxiety Scale (TDAS). Even though our study showed that the relationship between SWB and DA in patients with AMI is non-significant, we found that (1) single patients with higher SWB have lower DA, (2) single patients with higher SWB as well as social support have significantly lower DA, and (3) for single men/men without social support, there is a negative relationship between SWB and DA. The relationship between SWB and DA is influenced by factors such as sex, marital status and social support. In addition, the specific nature of this relationship (i.e. strength and sign) is dependent upon the sociodemographic characteristics of patients as well as other contextual influences. Result revealed that although relationship between SWB and DA is non-significant, this is influenced by factors such as sex and social support. In addition, the specific nature of this relationship (i.e. strength and sign) is dependent upon the sociodemographic characteristics of patients as well as other contextual influences.

Polish Adaptation of the Death Attitude Profile—Revised

The article presents the results of work on the Polish adaptation of the Death Attitude Profile—Revised by Wong, Reker, and Gesser (1994). The psychometric properties of the Polish version of the tool have been described. The results are consistent with the original version of the questionnaire and confirm that the Polish version of Death Attitude Profile—Revised fulfils the psychometric requirements for psychological tests and, as a result, can be applied in scientific research. The final version of the questionnaire consists of 32 items (including 31 diagnostic ones) that make up five dimensions of attitudes toward death: (a) Fear of Death, (b) Death Avoidance, (c) Neutral Acceptance, (d) Escape Acceptance, and (e) Approach Acceptance. The questionnaire was tested on 1,285 subjects aged 13 to 90 years ( M = 47.27, SD = 18.21). Reliability values (Cronbach’s α) for individual scales vary from α = .63 to α = .89. Confirmatory factor analysis was used to evaluate the validity of the questionnaire.

A time to be born and a time to die: Exploring the determinants of death anxiety among university students in a western Canadian city

Using data collected from a questionnaire survey of 501 university students in a western Canadian city, this article explores the death anxiety among young adults and the factors influencing their levels of death anxiety. Results demonstrated that respondents displayed a moderate level of death anxiety. Multiple regression analysis further revealed that females, non-Caucasians and those who demonstrated to be less religious, indicated a higher level of loneliness, scored lower on the purpose in life scale, expressed dissatisfaction with their self-image, and reported a higher socio-economic status were found to exhibit a higher level of death anxiety.

The Psychometric Parameters of the Farsi Form of the Arabic Scale of Death Anxiety

The aim of this study was to describe the psychometric properties of the Farsi Form of the Arabic Scale of Death Anxiety (ASDA). The original scale was first translated into Farsi by language experts using the back translation procedure and then administered to a total of 252 Iranian college students and 52 psychiatric outpatients from psychiatric and psychological clinics. The one-week test-retest reliability of the Farsi version in a sample of college students was 0.78, indicating good temporal stability and corroborating the trait-like nature of scores. Cronbach's α was 0.90 for the college students and 0.92 for the psychiatric outpatients, indicating high internal consistency. Scale scores correlated 0.46 with Death Obsession Scale scores, 0.56 with Death Depression Scale scores, 0.41 with Death Anxiety Scale scores, and 0.40 with Wish to be Dead Scale scores, indicating good construct and criterion-related validity. A principal component analysis with a Varimax rotation yielded four factors in the sample of Iranian college students, indicating a lack of homogeneity in the content of the scale. Male students obtained a significant higher mean score than did females. It was concluded that the Farsi ASDA had good internal consistency, temporal stability, criterion-related validity, and a factor structure reflecting important features of death anxiety. In general, the Farsi ASDA could be recommended for use in research on death anxiety among Iranian college students and psychiatric outpatients.

The Existential Concerns Questionnaire (ECQ)-Development and Initial Validation of a New Existential Anxiety Scale in a Nonclinical and Clinical Sample

OBJECTIVE

Existential anxiety (EA) is a construct that refers to fears that are provoked by core threats of human existence, such as death, meaninglessness, and fundamental loneliness. The objective of this study was to develop an EA measure that can be used in research and clinical practice.

METHOD

The Existential Concerns Questionnaire (ECQ) was completed by a nonclinical sample of 389 adults, together with questionnaires measuring death anxiety, intolerance of uncertainty, neuroticism, distress, meaning, and life events. Adaptations were made based on item analysis and factor analysis. A total of 99 adults who had an anxiety and/or depressive disorder completed the final version.

RESULTS

The ECQ was demonstrated to be essentially unidimensional and showed good reliability and stability. Correlations with other measures were within the expected range of strength, except for a weak association with life events.

CONCLUSION

Initial results regarding the psychometric properties of the ECQ are promising.

Death Attitudes Among Middle-Aged Koreans: Role of End-of-Life Care Planning and Death Experiences

The purpose of this study was to examine factors affecting death attitudes among middle-aged Koreans. In addition, the study explored the interaction effect between knowledge about end-of-life care planning and the experience of death of family or friends on death attitudes. The sample was obtained from a national survey with middle-aged adults in South Korea ( n = 2,026). Multivariate regression analysis revealed significant main effects and an interaction effect between knowledge about end-of-life care planning and the experience of death on death attitudes. Greater knowledge of end-of-life care planning was associated with more positive attitudes toward death; however, the effect was stronger for those who had not experienced the death of family or friends. Being older and having greater life satisfaction were also associated with more positive attitudes toward death. This study suggests that end-of-life education can help middle-aged adults embrace the final stage of life and prepare for their own death.

Relationships between Death Anxiety and Quality of Life in Iranian Patients with Cancer

Objective:

The purpose of the study was to examine relationships between death anxiety and quality of life (QOL) parameters of patients with cancer in the Iranian sociocultural context.

Methods:

A descriptive, correlational methodology was used. The sample included 330 patients. Demographics, health information, religious behaviors, death anxiety, and QOL data were collected.

Results:

Overall death anxiety levels were moderate with satisfactory overall QOL. Death anxiety was predictive of lowered QOL. Female patients had lower QOL and higher death anxiety compared to men

Conclusions:

Findings support that higher death anxiety negatively impacts QOL in an Iranian sample with cancer. Alleviation of existential concerns in vulnerable patients may palliate mental health distress associated with facing cancer and its challenging treatments.

Psychometric evaluation of the Persian version of the Templer's Death Anxiety Scale in cancer patients

In this study, 398 Iranian cancer patients completed the 15-item Templer's Death Anxiety Scale (TDAS). Tests of internal consistency, principal components analysis, and confirmatory factor analysis were conducted to assess the internal consistency and factorial validity of the Persian TDAS. The construct reliability statistic and average variance extracted were also calculated to measure construct reliability, convergent validity, and discriminant validity. Principal components analysis indicated a 3-component solution, which was generally supported in the confirmatory analysis. However, acceptable cutoffs for construct reliability, convergent validity, and discriminant validity were not fulfilled for the three subscales that were derived from the principal component analysis. This study demonstrated both the advantages and potential limitations of using the TDAS with Persian-speaking cancer patients.

Death and Help Expected from Nurses when Dying

This project was undertaken to ascertain the perceptions of a group of Taiwan’s fourth-year bachelor of science in nursing (BSN) students regarding death and help expected from nurses during the dying process. Within the Chinese culture, death is one of the most important life issues. However, in many Chinese societies it is difficult for people to reveal their deepest feelings to their significant others or loved ones. It was in this context that this project was developed because little is known about how Taiwan’s nursing students perceive death and the dying process. Using an open-ended, self-report questionnaire, 110 senior BSN students recorded their thoughts on: (1) their fears before physical death; (2) afterlife destinations; and (3) the help they would expect from nurses when dying. The data were analyzed using a three-layer qualitative thematic analysis. The students’ reported needs during the dying process were directed towards three main goals: (1) help in reaching the ‘triple targets of individual life’; (2) help in facilitating in-depth support so that both the dying person and significant others can experience a blessed farewell; and (3) help in reaching a destination in the afterlife. The results support the belief of dying as a transition occurring when life weans itself from the mortal world and prepares for an afterlife.

Four Year Cross-Sectional Comparison of Death Distress among Nursing College Students

The aim of the present study was to determine the change in death distress (anxiety, depression, and obsession) among four cross-sectional samples during four years of academic study in two Arabic woman nursing colleges ( N = 570). The Templer's Death Anxiety Scale, the Arabic Scale of Death Anxiety, the Death Depression Scale-Revised, and the Death Obsession Scale were administered to students in small group sessions. It was found that the only significant difference was between freshmen and sophomores on death obsession. We tend to consider this single difference as negligible. In general, the differences between the four groups on the three scales of death anxiety and death depression were not significant. That is, no significant change in mean scores on these scales had happened over time, as a result of shifting from theoretical study courses to practical ones, including dealing with the terminally-ill patients. The main aspect to elucidate this finding was the insufficient number and hours of practicum courses in general and, in particular, the experience to deal with the critical patients was not sufficient.

Aging Prisoners' Concerns toward Dying in Prison

Prison populations are experiencing rapid increases and many more offenders are dying in prison. This study investigated key variables associated with death anxiety among a group of aging prisoners. For this research, 102 respondents residing in a maximum security prison with a mean age of 59 completed Templer's Death Anxiety Scale. A regression analysis showed that age, inmate social supports, and a number of health related variables were important predictors of death fear. The findings revealed that fear of death is slightly higher among older prisoners than for similar age groups in the community. Qualitative information based on personal narratives found that some inmates see death as an escape, while others expressed fears of dying in prison or the stigma associated with imprisonment.

The Chinese Version of the Multidimensional Orientation toward Dying and Death Inventory (Moddi-F/Chin): An Introduction

Preliminary data on the test criteria of the Chinese version of the Multidimensional Orientation Toward Dying and Death Inventory (MODDI-F/chin) are presented. Data from a sample of Hong Kong college students ( N = 256) revealed internal consistencies of the eight subtests between .68 and .91, on the whole favorable shape of frequency distributions, and evidence of construct as well as differential validity of the instrument. The use of the full set of 47 items is recommended for the time being.

Patients Feeling Severely Affected by Multiple Sclerosis

Eleven months after being interviewed in a study on unmet needs of severely affected multiple sclerosis patients, one participant died by assisted suicide. We reanalyzed the data to find out if our 15 study patients might have brought up the topic of death and dying during episodic interviews that had not primarily addressed this issue. Secondary analysis with regard to the thematic field of death and dying revealed that patients unsolicited brought up this issue within the following categories: “Passing over death and dying,” “Death is not relevant to me,” “We want to keep up the life challenge,” “Death as an option,” and “Wish to have the opportunity to address end of life issues.” We conclude that the topic of death and dying is of importance to these patients, as they spontaneously mentioned it in multiple varieties. Health professionals should individually acknowledge patients' needs to address death and dying.

Death Anxiety in Adolescents: The Contributions of Bereavement and Religiosity

Possible relationships between bereavement and religiosity to death anxiety levels of adolescents were investigated. Scales measuring religiosity, bereavement, and death anxiety were incorporated into one questionnaire. Two hundred and twenty-six adolescents between the ages of 11 and 18 participated in the study based in urban and rural private schools within Manitoba. Females exhibited significantly higher death anxiety levels than did males; differences between the death anxiety levels of adolescents having a no-previous-death-experience death and those who had experienced a familial death were not significant; while religiosity levels were significantly higher for students attending religion-based schools, the relationships between measurements of religiosity and death anxiety were weak. Grief due to bereavement was the major factor in determining death anxiety for the adolescent.

Overcoming barriers in care for the dying: Theoretical analysis of an innovative program model

This article explores barriers to end-of-life (EOL) care (including development of a death denying culture, ongoing perceptions about EOL care, poor communication, delayed access, and benefit restrictions) through the theoretical lens of symbolic interactionism (SI), and applies general systems theory (GST) to a promising practice model appropriate for addressing these barriers. The Compassionate Care program is a practice model designed to bridge gaps in care for the dying and is one example of a program offering concurrent care, a recent focus of evaluation though the Affordable Care Act. Concurrent care involves offering curative care alongside palliative or hospice care. Additionally, the program offers comprehensive case management and online resources to enrollees in a national health plan (Spettell et al., 2009).SI and GST are compatible and interrelated theories that provide a relevant picture of barriers to end-of-life care and a practice model that might evoke change among multiple levels of systems. These theories promote insight into current challenges in EOL care, as well as point to areas of needed research and interventions to address them. The article concludes with implications for policy and practice, and discusses the important role of social work in impacting change within EOL care.

Toward an understanding of late life suicidal behavior: the role of lifespan developmental theory

OBJECTIVES

Suicidal behavior in late life differs in important ways from suicidal behavior that occurs earlier in the lifespan, suggesting the possibility of developmental differences in the etiology of suicidal behavior. This paper examines late life suicidal behavior within the context of lifespan developmental theory.

METHODS

This paper presents a conceptual framework for using lifespan developmental theory to better understand late life suicidal behavior.

RESULTS

We argue that the motivational theory of lifespan development, which focuses on control, is particularly relevant to late life suicide. This theory posits that opportunities to exert control over important aspects of one's life diminish in late life as a result of declines in physical functioning and other factors, and that successful aging is associated with adaptive regulation of this developmental change. Although continued striving to meet goals is normative throughout the lifespan, most individuals also increase the use of compensatory strategies in old age or when faced with a decline in functioning. We propose that individuals who do not adapt to developmental changes by altering their strategies for exerting control will be at risk for suicidal behavior in late life. This paper reviews evidence that supports the importance of control with respect to suicidal outcomes in older adults, as well as findings regarding specific types of control strategies that may be related to suicide risk in older adults with health-related limitations.

CONCLUSION

Although suicidal behavior is not a normal part of aging, the application of lifespan developmental theory may be useful in understanding and potentially preventing suicide among older adults.

The Multidimensional Orientation Toward Dying and Death Inventory (MODDI-F): Factorial Validity and Reliability in a U.S. Sample

CONTEXT

Death anxiety has been hypothesized to be a transdiagnostic construct, meaning that the fear of death may increase one's vulnerability to the development or maintenance of a number of psychological disorders. As such, effective and efficient measurement of this construct becomes a priority for hospice and palliative medicine specialists. The Multidimensional Orientation Toward Dying and Death Inventory (MODDI-F) is the only factor-analytically constructed multidimensional scale with a conceptual rationale that measures both the fear and acceptance of dying and death.

OBJECTIVES

To determine the factor structure of the MODDI-F with an English-speaking sample, so as to expand the scale's potential for use in hospice and palliative medicine, clinical psychology, and thanatology research.

METHODS

Participants comprise a random sample of 404 adults ranging in age from 20 to 85, stratified by sex, age, and ethnicity. They completed the 47-item MODDI-F/eng and were contacted five months later for a test-retest follow-up survey.

RESULTS

Although confirmatory factor analyses did not fit the models previously found for the German- and Chinese-language versions of the MODDI-F, exploratory factor analyses resulted in a five-factor fear dimension and a two-factor acceptance dimension that were empirically and conceptually similar to the German- and Chinese-language versions. Additional psychometric analyses yielded evidence for the internal consistency reliability, five-month test-retest reliability, and construct validity of the seven-factor scores of the English-language MODDI-F.

CONCLUSION

The results from this psychometric investigation of the English-language version of the MODDI-F are promising and warrant further investigation with clinical populations in hospice and palliative care settings.

Older Adults and the Fear of Death: The Protective Function of Generativity

La théorie de la gestion de terreur (TGT) indique que les visions du monde culturel apaisent les inquiétudes au sujet de la mortalité humaine. Des recherches préliminaires avec des personnes âgées ont indiqué que les personnes âgées ne répondent pas aux rappels de la mort de la même manière que leurs plus jeunes homologues. Le but de l’étude était de tester un concept de développement pertinent qui peut fonctionner comme un tampon contre l’anxiété ressenti à la mort à la fin de vie. L’hypothèse est que le concept de générativité d’ Erikson peut comprendre des propriétés niant de la mort pour les personnes âgées. Cent soixante-dix-neuf personnes âgées ont été recrutés pour déterminer si les initiations* subtiles mais saillants de la mortalité conduirait les participants à évaluer leur propre générativité comme étant plus élevé qu’après les initiations flagrantes, ou pas du tout, après contrôle de la générativité avant l’initiation. Comme prévu, les participants exposés à subtile renforcements de la mort se sont considérés comme ayant des niveaux plus élevés de la générativité que les deux autres groupes après générativité covariable avant. Les explications sont discutées à la lumière de la littérature sur la TGT et la générativité.

Are religiousness and death attitudes associated with the wish to die in older people?

BACKGROUND

A wish to die is common in older persons and is associated with increased mortality. Several risk factors have been identified, but the association between religiousness and a wish to die in older adults has been underexplored, and the association between death attitudes and the presence of a wish to die has not been investigated yet. The aim of this study is to explore the relationship between religiousness and death attitudes on the one hand and wish to die on the other hand, adjusting for clinical factors such as the presence of depression or somatic disorder.

METHODS

The sample comprised 113 older inpatients (from a psychiatric and somatic ward) with a mean age of 74 years. Psychiatric diagnoses were assessed by the Structured Clinical Interview for DSM-IV Disorders, and logistic regression analyses estimated the unique contribution of religiousness and death attitudes to the wish to die, controlling for socio-demographic variables, depressive disorder, and somatic symptoms.

RESULTS

Both religiousness and death attitudes were associated with a wish to die in univariate models. Adding these variables in a multivariate logistic hierarchical model, death attitudes remained significant predictors but religiousness did not; 55% of the pseudovariance of the wish to die was explained by these variables, with an effective size of 0.89. Major depressive episode, somatic symptoms, Fear of Death, and Escape Acceptance were the most important predictors of the wish to die.

CONCLUSIONS

This study suggests that how older adults perceive death partly determines whether they have a wish to die. There may be a clinical, patient-oriented benefit in discussing with older patients about how they perceive death, as this can play a role in the early detection (and prevention) of death or suicide ideation and associated behaviors in older adults.

Knowing, planning for and fearing death: Do adults with intellectual disability and disability staff differ?

BACKGROUND

Adults with intellectual disability (ID) are thought to understand less about death than the general population but there is no available research demonstrating this. Further, the detail of any possible differences in understanding is unknown.

METHODS

We compared the responses of 39 adults with mild or moderate ID and 40 disability staff (representing the general population) on (a) understanding the concept of death, (b) knowledge of and self-determination about end-of-life planning, and (c) fear-of-death.

RESULTS

We found that adults with ID had a significantly poorer understanding of the concept of death, knew much less about and were less self-determined about end-of-life planning, but reported greater fear-of-death.

CONCLUSIONS

We demonstrated, for the first time, the feasibility of assessing end-of-life planning and fear-of-death among adults with ID. The poorer understanding and lower levels of self-determination we found suggest that future research should develop and evaluate interventions to increase understanding and self-determination.

Anxiety trajectories in the second half of life: Genetic and environmental contributions over age

Clinically significant anxiety symptoms are prevalent among the elderly, yet knowledge about the longitudinal course of anxiety symptoms in later life remains scarce. The goals of this study were to (a) characterize age trajectories of state anxiety symptoms in the second half of life, and (b) estimate genetic and environmental contributions to individual differences in the age trajectory of state anxiety. This study was based on data from 1,482 participants in the Swedish Adoption/Twin Study of Aging who were aged 50 and older at their first occasion (512 complete twin pairs, 458 singletons) and had up to 6 measurement occasions spanning 11 years. Consistent with life span developmental theories of age-related emotional change, anxiety symptom levels declined during the transition from midlife to the mid-60s, followed by a mild increase that gradually plateaued in the 80s. There were substantial individual differences in the age trajectory of anxiety. After accounting for effects of sex, cohort, mode of testing, and proximity to death, this longitudinal variation was partitioned into biometric sources. Nonshared environmental variance was highest in the late 60s and declined thereafter, whereas genetic variance increased at an accelerated pace from approximately age 60 onward. There was no evidence for effects of rearing or other shared environment on anxiety symptoms in later life. These findings highlight how the etiology of anxiety symptoms changes from midlife to old age.

Disgust Sensitivity Accounts for Some But Not All Gender Differences in Death Attitudes

The present study investigated whether gender differences in death attitudes could be attributable to social desirability, locus of control, and disgust sensitivity. A total of 238 university students completed the Multidimensional Fear of Death Scale and the Revised Death Attitude Profile in addition to measures of social desirability, locus of control, and disgust sensitivity. Women scored higher than men on many of the fear dimensions and also on approach and escape acceptance. There were no gender differences on locus of control or social desirability, but women reported more disgust sensitivity than did men. Locus of control was unrelated to any death attitudes. Social desirability was associated only with less reported fear of premature death. Disgust sensitivity was associated with all death attitudes except neutral acceptance. Some but not all of the gender differences in death attitudes were no longer significant when controlling for disgust sensitivity.

Medical Students' Death Anxiety: Severity and Association With Psychological Health and Attitudes Toward Palliative Care

CONTEXT

Death anxiety (DA) is related to awareness of the reality of dying and death and can be negatively related to a person's psychological health. Physicians' DA also may influence their care for patients approaching death. Doctors face death in a professional context for the first time at medical school, but knowledge about DA among medical students is limited.

OBJECTIVES

This study examined medical students' DA in relation to: 1) its severity, gender differences, and trajectory during medical education and 2) its associations with students' attitudes toward palliative care and their psychological health.

METHODS

Four cohorts of core science and four cohorts of clinical students at the University of Cambridge Medical School took part in a questionnaire survey with longitudinal follow-up. Students who provided data on the revised Collett-Lester Fear of Death Scale were included in the analysis (n = 790).

RESULTS

Medical students' DA was moderate, with no gender differences and remained very stable over time. High DA was associated with higher depression and anxiety levels and greater concerns about the personal impact of providing palliative care.

CONCLUSION

The associations between high DA and lower psychological health and negative attitudes toward palliative care are concerning. It is important to address DA during medical education to enhance student's psychological health and the quality of their future palliative care provision.

Factorial validity of the death obsession scale in African University students

In this study the factor structure of the Death Obsession Scale (DOS) was examined using confirmatory factor analysis. Data used consisted of DOS reports of 328 Black African students. Confirmatory factor analysis revealed that two- and three-factor models obtained among female and male African students, respectively, provided the best fit to the data. The two factors in female African students were Death Rumination and Apprehension, and the three factors of their male counterparts were Death Ruminations, Apprehension, and Comprehensibility of Death. Factor intercorrelations did not resolve the dimensionality issue of the measure, leading to the conclusion that the factors must be investigated further.

Publication Trends in Thanatology: An Analysis of Leading Journals

To identify important trends in thanatology as a discipline, the authors analyzed over 1,500 articles that appeared in Death Studies and Omega over a 20-year period, coding the category of articles (e.g., theory, application, empirical research), their content focus (e.g., bereavement, death attitudes, end-of-life), and for empirical studies, their methodology (e.g., quantitative, qualitative). In general, empirical research predominates in both journals, with quantitative methods outnumbering qualitative procedures 2 to 1 across the period studied, despite an uptick in the latter methods in recent years. Purely theoretical articles, in contrast, decline in frequency. Research on grief and bereavement is the most commonly occurring (and increasing) content focus of this work, with a declining but still substantial body of basic research addressing death attitudes. Suicidology is also well represented in the corpus of articles analyzed. In contrast, publications on topics such as death education, medical ethics, and end-of-life issues occur with lower frequency, in the latter instances likely due to the submission of such work to more specialized medical journals. Differences in emphasis of Death Studies and Omega are noted, and the analysis of publication patterns is interpreted with respect to overall trends in the discipline and the culture, yielding a broad depiction of the field and some predictions regarding its possible future.

Coping and Attitudes Toward Dying and Death in German Adults

The idea of an existential threat caused by the awareness of mortality has been rarely investigated within coping research. The study explores relationships between coping strategies and attitudes toward dying and death in a sample of German adults aged 20 to 93 years. Participants responded to a Stress Coping Inventory and a questionnaire for the multidimensional assessment of attitudes toward dying and death. Pearson correlations for men, women, and the young and old age-groups confirm the expectation that attitudes toward dying and death are mainly associated with disengagement and accommodative coping. Gender- and age-specific findings refer to drug intake and aggression. Results are discussed within both a coping and a thanatological frame of reference and issues for future research are outlined.

Prediction of end-of-life fears in COPD - hoping for the best but preparing for the worst

OBJECTIVE

The diagnosis of a life-threatening illness can trigger end-of-life fears. Early studies show that end-of-life fears play an important role in chronic obstructive pulmonary disease (COPD). However, predictors of these fears have not yet been identified. This study investigated the relevance of socio-demographic variables, illness severity, psychological distress and disease-specific anxieties as predictors of end-of-life fears in COPD.

DESIGN

A total of 131 COPD patients participated at two time points. Regression and mediation analyses, as well as cross-lagged panel analyses were conducted.

MAIN OUTCOME MEASURES

The participants completed questionnaires assessing end-of-life fears (Multidimensional Orientation toward Dying and Death Inventory), psychological distress (Hospital Anxiety and Depression Scale), and disease-specific anxieties (COPD Anxiety Questionnaire). Pulmonary function and a 6-min walk test served as measures of illness severity.

RESULTS

Illness severity was not predictive of end-of-life fears. However, gender and psychological distress explained incremental variance. When disease-specific anxieties were included as additional predictors, psychological distress was no longer significant. Cross-lagged panel analyses mostly supported these results. Moreover, disease-specific anxieties mediated the association between psychological distress and end-of-life fears.

CONCLUSION

Administration and intensity of end-of-life care (especially concerning end-of-life fears) in COPD patients should be based not only on illness severity, but rather on psychological distress and disease-specific anxieties.

Death Attitudes and Changes in Existential Outlook in Parents of Vulnerable Newborns

This study is an Actor-Partner Interdependence Model analysis of the relation of death attitudes with changes in outlook in 59 parent couples of neonatal intensive care newborns. Death attitudes effects with changes in outlook were mostly intrapersonal and they mainly occurred in fathers, though between gender differences were not usually significant. Death avoidance and neutral death acquiescence were positive predictors of positive changes in outlook, and fear of death and neutral death acquiescence were respective positive and inverse predictors of negative changes. Multidimensional measures of death attitudes and personal change should be used when studying these domains of psychological functioning.

Nursing care for the families of the dying child/infant in paediatric and neonatal ICU: nurses' emotional talk and sources of discomfort. A mixed methods study

BACKGROUND

The majority of in-hospital deaths of children occur in paediatric and neonatal intensive care units. For nurses working in these settings, this can be a source of significant anxiety, discomfort and sense of failure.

OBJECTIVES

The objectives of this study were to explore how NICU/PICU nurses care for families before and after death; to explore the nurses' perspectives on their preparedness/ability to provide family care; and to determine the emotional content of language used by nurse participants.

METHODS

Focus group and individual interviews were conducted with 22 registered nurses from neonatal and paediatric intensive care units of two major metropolitan hospitals in Australia. All data were audio recorded and transcribed verbatim. Transcripts were then analysed thematically and using Linguistic Inquiry to examine emotional content.

RESULTS

Four core themes were identified: preparing for death; communication challenges; the nurse-family relationship and resilience of nurses. Findings suggested that continuing to provide aggressive treatment to a dying child/infant whilst simultaneously caring for the family caused discomfort and frustration for nurses. Nurses sometimes delayed death to allow families to prepare, as evidenced in the Linguistic Inquiry analysis, which enabled differentiation between types of emotional talk such as anger talk, anxiety talk and sadness talk. PICU nurses had significantly more anxiety talk (p=0.018) than NICU nurses.

CONCLUSION

This study provided rich insights into the experiences of nurses who are caring for dying children including the nurses' need to balance the often aggressive treatments with preparation of the family for the possibility of their child's death. There is some room for improvement in nurses' provision of anticipatory guidance, which encompasses effective and open communication, focussed on preparing families for the child's death.