Death and dying from old people's point of view. A literature review

Experiences of the older spousal caregivers of patients with cancer during palliative chemotherapy: a qualitative descriptive study

BACKGROUND

Several studies have characterized the experiences of family members caring for patients undergoing chemotherapy; however, information about the experiences of older spousal caregivers with intensive caregiving burdens is unclear. Recently, more older patients have been diagnosed with cancer due to the aging population worldwide. Therefore, this study evaluated the patterns in the experiences of older spousal caregivers of patients undergoing palliative chemotherapy for advanced cancer.

METHODS

Qualitative research using semi-structured interviews was used in this study involving 10 older spousal caregivers of patients undergoing palliative chemotherapy at a hospital providing advanced cancer care in Japan. The data obtained were analyzed qualitatively and inductively using thematic analysis by Braun and Clarke.

RESULTS

Four themes were identified from the narratives of the participants in this study. The first theme was "getting used to living with the disease," indicating that the older spouses gradually became accustomed to living with the patient through continued caregiving. The second theme was "deepening view of life and death," indicating that the older spouses' views of life and death were deepened by being confronted with patients' quality of life until death. The third theme was "anxious about the future," indicating the fear regarding the patient's progressive diseases and anxiety pertaining to continuing care for the patient while dealing with their health problems. The final theme was "desire for a better rest of life," indicating that the couple felt their bond was strengthened through caregiving and wishes to live well for the rest of their lives.

CONCLUSIONS

The patterns in the experience of older spousal caregivers caring for patients undergoing palliative chemotherapy indicated an aspect of rebuilding their lives as they became accustomed to caregiving, while strengthening their marital bond. The caregiving process involved a mix of emotions, including anxiety about the spousal caregiver's health problems worsening. However, the caregivers recognized the value of their remaining time. Therefore, they had deep concern for the patient's comfort, concealing their feelings so that the patient would feel comfortable. This study can contribute to understanding the challenges faced and support needed by older spousal caregivers.

Intergenerational conversations on death and dying during the COVID-19 pandemic: A pedagogical approach

This exploratory study examined how twenty-two undergraduate students and fifty-six older adults experienced discussing dying, death, and the COVID-19 pandemic with one another, using the book Tuesdays with Morrie as a conversational guide. The timing of these conversations is significant as discussions took place in March 2021, one year into the COVID-19 pandemic. Thematic analysis of students' and older adult's reflections on the discussion was employed and three themes were identified: the inevitability of death, gaining and giving perspective, and the importance of relationships. The pandemic was especially influential within two of the three themes. The findings highlight the benefits of bringing previously unknown people together to engage in conversations about dying and death during the pandemic using contemporary literature. This study also presents a pedagogical technique for educators to use to help students engage in discussions about death and dying.

'Do you have a future when you are 93?' Frail older person's perceptions about the future and end of life - a qualitative interview study in primary care

OBJECTIVE

To explore frail older persons' perceptions of the future and the end of life.

DESIGN

Qualitative content analysis of individual semi-structured interviews.

SETTING

Nine primary health care centres in both small and middle-sized municipalities in Sweden that participated in the intervention project Proactive healthcare for frail elderly persons.

SUBJECTS/PATIENTS

The study includes 20 older persons (eight women and 12 men, aged 76-93 years).

MAIN OUTCOME MEASURES

Frail older persons' perceptions of the future and end of life.

RESULTS

The analysis uncovered two main categories: Dealing with the future and Approaching the end of life. Dealing with the future includes two subcategories: Plans and reflections and Distrust and delay. Approaching the end of life includes three subcategories: Practical issues, Worries and realism, and Keeping it away.

CONCLUSION

This study highlights the diverse ways older people perceive future and the end of life. The results make it possible to further understand the complex phenomenon of frail older persons' perceptions on the future and the end of life.KEY POINTSThe study found that older persons described their future as contradictory- with a broad spectrum of approaches, where some wanted to deal with these subjects and others wanted to ignore them.•Older persons that consciously planned for the future had tactics that often were related to goals that functioned as motivators to live longer.•Those who adopted a more passive approach did not think about what the future might hold in terms of losing autonomy and deteriorating health.•Older persons that approached end of life in a more proactive way wanted to plan practical arrangements around death but often found it hard to address this issue with relatives.•Those older persons that had a more passive approach to end of life preferred not to think about those issues, and some explicitly stated that they did not want to address the final period of life.

Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients

IMPORTANCE

Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis.

OBJECTIVE

To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years.

DESIGN, SETTING, AND PARTICIPANTS

A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021.

EXPOSURES

Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6.

MAIN OUTCOMES AND MEASURES

Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage.

RESULTS

Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14).

CONCLUSIONS AND RELEVANCE

In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.

[Attitudes and anxiety towards death in elderly people from 2different cultures: Spain and Egypt]

BACKGROUND AND OBJECTIVE

There are multiple variables that influence fear of death, as well as attitudes towards it, including age, religiosity, emotional and cultural aspects. Due to the proximity to death, the study of attitudes and death-related anxiety and the variables that influence it in the elderly population is of great relevance. The aim of the present study was to compare the levels of death anxiety, fear of death, attitudes towards death and associated emotional aspects (anxiety and depression) in older adults from 2different cultures, Western and Arab.

MATERIALS AND METHOD

A total of 91 people over 60 years old took part and were divided into 2groups, one of people born in Spain (n=46) and the other of people born in Egypt (n=45). In an individualised assessment, participants completed the DAS, PRAM and the anxiety and depression subscales of the SCL-90-R questionnaires.

RESULTS

Statistically significant differences between groups were observed in fear of death, acceptance and emotional aspects. Predictors of anxiety and fear of death were different for each group.

CONCLUSION

The results show the importance of taking into account cultural, religious and emotional aspects in the evaluation of fear and attitudes towards death in the elderly population.

The effects of confronting one's own end of life on older individuals and those with a life-threatening disease: A systematic literature review

BACKGROUND

Awareness of the impending end of one's life can pose profound existential challenges, thereby impairing well-being. Confronting one's own end of life may be an approach to meet the psychological needs and consequently enhance overall well-being. Different approaches of confrontation have been evaluated positively using measures of psychosocial comfort. To date, there exists no systematic overview on the different ways of confrontation (e.g. psychosocial or individual coping approaches).

AIM

To synthesize the existing knowledge on the effects of different approaches of confronting one's own end of life on older individuals and those with a life-threatening disease.

DESIGN

A systematic review of quantitative, qualitative, and mixed-methods full research reports was conducted. The retrieved studies were screened and appraised for methodological quality by two independent reviewers based on MMAT and CASP. The findings were synthesized narratively using the meta-summary technique by Sandelowski and Barroso.

DATA SOURCES

Medline, PsycINFO, and Web of Science were searched from inception to 12/2020.

RESULTS

N = 49 studies reported on different approaches of confronting one's own end of life, including psychosocial interventions, meaning-enhancing approaches, educational programs, and learning from lived experiences. The results suggest a clear trend toward beneficial effects on psychosocial comfort (e.g. anxiety, sense of meaning, well-being).

CONCLUSION

Low-threshold opportunities of confrontation have the potential to improve well-being and should be emphasized in practical implementation. The results can serve as a comprehensive basis for future research aiming to investigate the determinants of psychosocial comfort for people nearing the end of life.

Documentation of older people's end-of-life care in the context of specialised palliative care: a retrospective review of patient records

Background

Palliative care focuses on identifying, from a holistic perspective, the needs of those experiencing problems associated with life-threatening illnesses. As older people approach the end of their lives, they can experience a complex series of problems that health-care professionals must identify and document in their patients’ records. Documentation is thus important for ensuring high-quality patient care. Previous studies of documentation in older people’s patient records performed in various care contexts have shown that such documentation almost exclusively concerns physical problems. This study explores, in the context of Swedish specialised palliative care, the content of documentation in older people’s patient records, focusing on documented problems, wishes, aspects of wellbeing, use of assessment tools, interventions, and documentation associated with the person’s death.

Methods

A retrospective review based on randomly selected records (n = 92) of older people receiving specialised palliative care, at home or in a palliative in-patient ward, who died in 2017. A review template was developed based on the literature and on a review of sampled records of patients who died the preceding year. The template was checked for inter-rater agreement and used to code all clinical notes in the patients’ records. Data were processed using descriptive statistics.

Results

The most common clinical notes in older people’s patient records concerned interventions (n = 16,031, 71%), mostly related to pharmacological interventions (n = 4318, 27%). The second most common clinical notes concerned problems (n = 2804, 12%), pain being the most frequent, followed by circulatory, nutrition, and anxiety problems. Clinical notes concerning people’s wishes and wellbeing-related details were documented, but not frequently. Symptom assessment tools, except for pain assessments, were rarely used. More people who received care in palliative in-patient wards died alone than did people who received care in their own homes.

Conclusions

Identifying and documenting the complexity of problems in a more structured and planned way could be a method for implementing a more holistic approach to end-of-life care. Using patient-reported outcome measures capturing more than one symptom or problem, and a systematic documentation structure would help in identifying unmet needs and developing holistic documentation of end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00771-w.

Older Age: A Protective Factor Against Perceived Dignity-Related Distress in Patients With Advanced Cancer?

CONTEXT

Most older adults will face threats to loss of health and social support, which can affect their perceived dignity. Although problems with perceived dignity increase in the context of cancer, the specific experience for those older compared with younger patients with advanced cancer has not been described despite its contributions to the wish to hasten death (WTHD).

OBJECTIVES

To understand the influence of age group to the perception of dignity, considering changes in quality of life and the WTHD in patients with advanced cancer.

METHODS

The Patient Dignity Inventory was administered to 194 patients with advanced cancer. The data were analyzed by separating the sample into age groups younger than 65 years (N = 106) or 65 years and older (N = 88). Linear regression models were adjusted with the explanatory variables of WTHD, quality of life, as well as functional status, physical dependence, depression, anxiety, and sociodemographic variables.

RESULTS

Older patients showed a 2.6% decrease in the total scores of perceived dignity-related distress compared to younger patients.

CONCLUSION

Older age could be a protective factor against the perception of loss of dignity in patients with advanced cancer, a more positive perspective of the aging experience.

Quality of life among frail older persons (65+ years) in nursing homes: A cross-sectional study

AIM

To assess the quality of life in frail older persons (65+ years) living in nursing homes and to examine differences between quality of life perceptions among different gender and age groups.

DESIGN

Cross-sectional.

METHODS

Data were collected during 2015-2017 based on two questionnaires (WHOQOL-OLD and WHOQOL-BREF). Seventy-eight older persons living in nursing homes in southern Sweden answered the questionnaires in structured interviews. Descriptive and comparative statistics were used to analyse the data. The study was guided by Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines.

RESULTS

The frail older persons reported low autonomy related to few opportunities to engage in everyday activities and were unable to do the things they liked to do and not feeling in control of their future. Another important result was that frail older persons seemed to have no or little fear of death and dying. No significant differences between gender or age on quality of life were revealed.

Perception of death and preference for end-of-life care among Asian Buddhists living in Montreal, Canada

Dying with dignity is important in Western culture. The aim of this qualitative study was to explore how Asian Buddhists, exposed to Western cultures, perceive death and dying with dignity, and examine their preferences for end-of-life care. We interviewed 15 Asian Buddhists living in Montreal (Canada). Participants regarded death as inevitable, while a good/dignified death had to be natural, peaceful, and, most of all, conscious. Most preferred palliative care to medical-aid-in-dying and emphasized death preparation through daily contemplation of impermanence. Care providers' understanding and respect of Buddhist patients' perception of a dignified death might help facilitate this important transition.

Older persons' thoughts about death and dying and their experiences of care in end-of-life: a qualitative study

Background

Few studies have focused on how older persons living in nursing homes perceive their last period of life. Furthermore, previous research on older persons’ perceptions of death and dying is limited. Hence, there is an urgent need to explore their experiences during their final period in life.

Aim

To explore thoughts about death and dying and experiences of care in end-of-life among older persons living in nursing homes.

Methods

This study employed a qualitative approach including individual interviews with 36 older persons living in Swedish nursing homes. Questions related to quality of life; physical health; thoughts about death, dying, and the future; and experiences related to the living condition and environment were asked. The interview transcripts were analysed through content analysis. The study was approved by the Regional Ethics Review Board (reference number: 2015/4).

Results

The analysis resulted in the identification of three main thematic categories: The unavoidable and unknown end of life, Thoughts on control and Living your last period of life at a nursing home. The older persons did not fear death itself but had some worries about dying. Spending the last stage of life at a nursing home contributed to different thoughts and feelings among the older persons. With a few exceptions, older persons characterized life at the nursing home as boring and felt they were surrounded by people who did not belong there.

Conclusions

This study indicates a need for older persons to talk about death, dying and end-life issues. Furthermore, this study highlighted that the co-residence of cognitively healthy persons and persons with dementia in the same ward adversely affected cognitively healthy persons. This situation resulted in there being not enough time to both handle the care needs of persons with dementia and have the conversations that cognitively healthy persons desired, such as conversations about thoughts about existence, that could have improved their quality of life.

Trial registration

NCT02708498 Date of registration 16 February 2016.

The intertwining of reconciliation and displacement: a lifeworld hermeneutic study of older adults' perceptions of the finality of life

PURPOSE

This study aimed to explain and understand the existential meaning of the finality of life from the perspective of healthy older adults.

METHOD

Participants were recruited from a major project on older adults' life situations. They were interviewed about their thoughts on the end of life, and their responses were interpreted using a lifeworld hermeneutic approach.

RESULTS

The findings showed that thinking about the inevitable finality of life involves feelings of liberation, frightening thoughts, a comforting promise of something beyond death, acceptance of the concept of death as a companion in life and a desire to live. Philosopher Simone de Beauvoir's existential ideas about ageing and death were then used to further explain and understand the meaning of the finality of life and to support a comprehensive understanding. de Beauvoir suggests that when the temporal horizon of existence shrinks, one lives closer to the finality of life. For a comprehensive understanding, attributing meaning to the finality of life required the intertwining of reconciliation and displacement. The interpretations were further discussed using ideas from the fields of existential philosophy and caring science in order to develop a basis for caring practice.

CONCLUSIONS

The conclusions suggested that professional health care for older adults would benefit from a lifeworld-led caring science approach that includes readiness for a caring dialogue that focuses on existential issues.

Reminiscence in the Face of Death of a Filipino Elderly With Substance Use Disorder: The Case of Burt

Death is an important reality that the elderly face. In preparation for death, old people engage in reminiscence. However, the presence of addiction in the elderly may influence this process. The current study examined the life of Burt, a sixty-five year old man with substance use disorder, his reflections on death, and the different types of reminiscence he uses. Using a case study, six themes were uncovered. Burt's reflections on death revealed his awareness of his death, how he plans to spend his dying days, and his idea of a symbolic death by losing his loved ones. Burt engages in reminiscence patterns that are composed of identity recollections, life milestones, and painful experiences. These themes were examined in order to understand how an elderly person with addiction prepares for his own death. Research limitations, recommendations, and implications in clinical practice and human development research are also discussed.

Experiences of oldest-old caregivers whose partner is approaching end-of-life: A mixed-method systematic review and narrative synthesis

Population ageing has rapidly increased the number of people requiring end-of-life care across the globe. Governments have responded by promoting end-of-life in the community. Partly as a consequence, older spouses are frequently providing for their partner's end-of-life care at home, despite potentially facing their own health issues. While there is an emerging literature on young-old caregivers, less is known about spouse carers over 75 who are likely to face specific challenges associated with their advanced age and relationship status. The aim of this review, therefore, is to identify and synthesise the literature concerning the experiences of caregiver's aged 75 and over whose partner is approaching end-of-life. We conducted a mixed-method systematic review and narrative synthesis of the empirical literature published between 1985 and May 2019, identified from six databases: Medline, PsychINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Sociological Abstracts and Social Service Abstracts. Hand searching and reference checking were also conducted. Gough's Weight of Evidence and Morgan's Feminist Quality Appraisal tool used to determine the quality of papers. From the initial 7819 titles, 10 qualitative studies and 9 quantitative studies were included. We identified three themes: 1) "Embodied impact of care" whereby caring was found to negatively impact carers physical and psychological health, with adverse effects continuing into bereavement; 2) "Caregiving spouse's conceptualisation of their role" in which caregiver's navigated their self and marriage identities in relation to their partner's condition and expectations about gender and place; 3) "Learning to care" which involved learning new skills and ways of coping to remain able to provide care. We identified a recent up-surge in published papers about very old spousal caregivers, which now comprise a small, medium-quality evidence base. This review outlines a range of potential lines of inquiry for future research including further clarification of the impact of caregiving on the likelihood of mortality, the incidence of men and women providing end-of-life care amongst this age group, and the role of anticipatory grief in shaping their perceptions of their relationship and their own longevity.

Exploring Existential Loneliness Among Frail Older People as a Basis for an Intervention: Protocol for the Development Phase of the LONE Study

BACKGROUND

International research concerning end-of-life issues emphasizes the importance of health care professionals (HCPs) being prepared to deal with existential aspects, like loneliness, in order to provide adequate care. The last phase of life is often related to losses of different kinds, which might trigger feelings of isolation in general and existential loneliness (EL) in particular. There is a large body of research concerning loneliness among older people in general, but little is known about the phenomenon and concept of EL in old age.

OBJECTIVE

This study aims to describe the framing, design, and first results of the exploratory phase of an intervention study focusing on EL among older people: the LONE study. This stage of the study corresponds to the development phase, according to the Medical Research Council framework for designing complex interventions.

METHODS

The LONE study contains both theoretical and empirical studies concerning: (1) identifying the evidence base; (2) identifying and developing theory through individual and focus group interviews with frail older people, significant others, and HCPs; and (3) modeling process and outcomes for the intervention. This project involves sensitive issues that must be carefully reviewed. The topic in itself concerns a sensitive matter and the study group is vulnerable, therefore, an ethical consciousness will be applied throughout the project.

RESULTS

The results so far show that EL means being disconnected from life and implies a feeling of being fundamentally separated from others and the world, whether or not one has family, friends, or other close acquaintances. Although significant others highlighted things such as lack of activities, not participating in a social environment, and giving up on life as aspects of EL, the older people themselves highlighted a sense of meaningless waiting, a longing for a deeper connectedness, and restricted freedom as their origins of EL. The views of HCPs on the origin of EL, the place of care, and their own role differed between contexts.

CONCLUSIONS

The studies focusing on identifying the evidence base and developing theory are published. These results will now be used to identify potential intervention components, barriers, and enablers for the implementation of an intervention aimed at supporting HCPs in encountering EL among older people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/13607.

The context of care matters: Older people's existential loneliness from the perspective of healthcare professionals-A multiple case study

AIM

To explore existential loneliness among older people in different healthcare contexts from the perspective of healthcare professionals.

BACKGROUND

Professionals meet and care for older people in most care contexts and need to be prepared to address physical, psychological, social and existential needs. Addressing existential loneliness can be both challenging and meaningful for professionals and is often not prioritised in times of austerity.

DESIGN

A multiple case study design was used.

METHODS

Focus group interviews were conducted with healthcare professionals (n = 52) in home, residential, hospital and palliative care settings. The analysis was performed in two steps: firstly, a within-case analysis of each context was conducted, followed by a cross-case analysis.

FINDINGS

Differences and similarities were observed among the care contexts, including for the origin of existential loneliness. In home care and residential care, the focus was on life, the present and the past, compared to hospital and palliative care, in which existential loneliness mainly related to the forthcoming death. The older person's home, as the place where home care or palliative care was received, helped preserve the older person's identity. In hospital and palliative care, as in institutional care, the place offered security, while in residential care, the place could make older people feel like strangers. Creating relationships was considered an important part of the professionals' role in all four care contexts, although this had different meanings, purposes and conditions.

CONCLUSIONS

The context of care matters and influences how professionals view existential loneliness among older people and the opportunities they have to address existential loneliness.

IMPLICATIONS FOR PRACTICE

Support for professionals must be tailored to their needs, their education levels and the context of care. Professionals need training and appropriate qualifications to address existential loneliness related to existential aspects of ageing and care.

Enabling At-Homeness for Older People With Life-Limiting Conditions: A Participant Observation Study From Nursing Homes

At-homeness, as an aspect of well-being, can be experienced despite living with life-limiting conditions and needs for a palliative approach to care. In nursing homes, older residents with life-limiting conditions face losses and changes which could influence their experience of at-homeness. The aim of this study was to explore how nursing staff enable at-homeness for residents with life-limiting conditions. Interpretive description was employed as the design using data from participant observations and formal and informal interviews related to nursing care situations. The strategies found to be used to enable at-homeness comprising nursing staff presenting themselves as reliable, respecting the resident's integrity, being responsive to the resident's needs, collaborating with the resident in decision-making, and through nurturing comforting relationships. The result on how to enable at-homeness could be used as strategies for a person-centered palliative approach in the care for residents in nursing homes.

Encountering existential loneliness among older people: perspectives of health care professionals

PURPOSE

Existential loneliness is part of being human that is little understood in health care, but, to provide good care to their older patients, professionals need to be able to meet their existential concerns. The aim of this study was to explore health care professionals' experiences of their encounters with older people they perceive to experience existential loneliness.

METHOD

We conducted 11 focus groups with 61 health professionals working in home care, nursing home care, palliative care, primary care, hospital care, or pre-hospital care. Our deductive-inductive analytical approach used a theoretical framework based on the work of Emmy van Deurzen in the deductive phase and an interpretative approach in the inductive phase.

RESULTS

The results show that professionals perceived existential loneliness to appear in various forms associated with barriers in their encounters, such as the older people's bodily limitations, demands and needs perceived as insatiable, personal shield of privacy, or fear and difficulty in encountering existential issues.

CONCLUSION

Encountering existential loneliness affected the professionals and their feelings in various ways, but they generally found the experience both challenging and meaningful.

Being disconnected from life: meanings of existential loneliness as narrated by frail older people

OBJECTIVES

This study illuminated the meanings of existential loneliness (EL) as narrated by frail older people.

METHOD

Data were collected through individual narrative interviews with 23 people 76-101 years old receiving long-term care and services. A phenomenological hermeneutical analysis was performed, including a naïve reading and two structural analyses as a basis for a comprehensive understanding of EL.

RESULT

Four themes were identified related to meanings of EL: (1) being trapped in a frail and deteriorating body; (2) being met with indifference; (3) having nobody to share life with; and (4) lacking purpose and meaning. These intertwined themes were synthesized into a comprehensive understanding of EL as 'being disconnected from life'.

CONCLUSION

Illness and physical limitation affects access to the world. When being met with indifference and being unable to share one's thoughts and experiences of life with others, a sense of worthlessness is reinforced, triggering an experience of meaninglessness and EL, i.e. disconnection from life. It is urgent to develop support strategies that can be used by health care professionals to address older people in vulnerable situations, thereby facilitating connectedness.

Nursing staff's responses to thematic content of patients' expressed worries: observing communication in home care visits

Background

The aim of the study was to explore the thematic content of older persons’ expressed worries in home care visits, and how nursing staff respond to different thematic contents.

Methods

The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff’s responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff’s responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson’s chi-squared test, Fisher’s exact test, and adjusted residuals.

Results

The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). “Ageing and bodily impairment” was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about “Relationships with others” (9%), “Health care-related issues” (15%) and “Life narratives and value issues” (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of “Ageing and bodily impairment”, Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher’s exact test, p< 0.001). For the sub-themes of “Relationships with others”, Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher’s exact test, p = 0.009).

Conclusion

“Ageing and bodily impairment” was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients’ spontaneous expressions of pain. Further research should explore the influence of nursing staff’s responses on quality of care and patient satisfaction.

End-of-life care in a nursing home: Assistant nurses’ perspectives

Background:

Worldwide, older persons lack access to palliative care. In Sweden, many older persons die in nursing homes where care is provided foremost by assistant nurses. Due to a lack of beds, admission is seldom granted until the older persons have complex care needs and are already in a palliative phase when they move in.

Objective:

To describe assistant nurses’ perspectives of providing care to older persons at the end of life in a nursing home.

Research design:

Data were collected in semi-structured individual interviews and analyzed with inductive qualitative content analysis.

Participants and research context:

Seven assistant nurses from a nursing home in Sweden were randomly selected.

Ethical consideration:

The research was approved by the local ethics committee.

Results:

Three main categories emerged; “Death a natural part of life”; “The older person’s well-being”; and “Care in the moment of death”; and seven sub-categories. The assistant nurses described themselves as knowing the older persons well enough to provide good end-of-life care. This was achieved by making small-talk while providing daily care. Relying on experience-based knowledge, they strove to provide end-of-life care built upon respect and engagement with the ambition to strengthen older persons’ dignity, for example, by lowering the tempo of care at the end of life, in spite of organizational restrictions.

Discussion:

The assistant nurses offered attentive end-of-life care, focusing upon bodily care. The existential needs of the older persons were not foregrounded.

Conclusion:

To develop their work, and to promote an ethical foundation for such care, assistant nurses might need support and education to be able to offer a care more in line with the aims of palliative care. Furthermore, the organization of care needs to promote, not impede, the realization of this development.

A Focused Review of Language Use Preceding Death by Execution

Executions are one form of death that can be assumed to be maximally anxiety provoking. Words spoken by death row inmates moments before their execution can provide valuable insights into people's end-of-life communication needs and themes, conveying what individuals choose to express to others in the face of imminent death. In this focused review, we describe findings from quantitative and qualitative text analysis studies that have analyzed affective experiences and meaning-making attempts in transcriptions of actual statements made by Texas death row inmates. Overall, the most prevalent content themes identified in these final acts of verbal communication in the reviewed studies consisted of a strong predominance of emotional positivity, messages to relevant social others, and spiritual references. We subsequently view the reviewed findings in the light of additional research in which people's conceptions of death and dying were explored and language studies in which people's communication before other forms of death was analyzed. Finally, we describe open questions and directions for future analyses of death row inmates' final statements, and we outline practical implications.

Life values of elderly people suffering from incurable cancer: A literature review

OBJECTIVE

Due to aging Western societies, older patients suffering from incurable cancer will present themselves more often to health care professionals. To be of service to these severely ill elderly patients, more knowledge is needed on which life values are guiding them through their last phases of life. This review aims to describe which life values play an important part in the lives of elderly people suffering from incurable cancer.

METHODS

We conducted a literature review with a structured search to identify empirical studies (January 1950-February 2016) using six databases.

RESULTS

The analysis of thirty articles resulted in the extensive description of eight life values: comfort, continuity, humility, dignity, honesty, optimism, hope and preparedness.

CONCLUSION

Elderly patients suffering from incurable cancer use the abovementioned life values to give meaning to a life interrupted by disease. Furthermore, these values will play a role in communication and decision-making.

PRACTICE IMPLICATIONS

Knowledge about life values can help professionals discuss and clarify personal preferences with elderly patients suffering from incurable cancer, contributing to more personalized care and treatment. Communication should focus on to what extent patient empowerment, life-prolonging treatment and the involvement of the patient's supporting systems suit the wishes of these patients.

Thanatophobia (Death Anxiety) in the Elderly: The Problem of the Child's Inability to Assess Their Own Parent's Death Anxiety State

Thanatophobia is omnipresent in our lives. Research has shown separate but connected constructs: fear of death or fear of the dying process. The influences on death anxiety are varied including religiosity, gender, psychological state, and age. It is often assumed by the children of the elderly that the fear of death is prevalent in their parents. Daily the medical staff encounters the presence of death anxiety: from family members or the staff itself. In order to understand this phenomenon, a three-tier study was conducted on non-terminal elderly inpatients in an acute geriatric care ward. The study showed that the elderly had low levels of anxiety (scoring 4/15 on Templer's Death Anxiety Scale) but their children scored higher for themselves (6.9/15) and for their parents (8.9/15). A regression model showed that only the presence of generalized anxiety and religiosity of parent had an effect explaining 33.6% of the variance. Death anxiety of death is usually absent in the elderly but rather they fear the dying process. On the other hand, their children do fear death, which they extrapolate onto their parents. This causes conflicts since the children prevent disclosure of relevant medical information to their parents. This has to be addressed by the staff when dealing with family members, to allow open and honest communication with their patients. The staff need to explain to the family that the elderly are not afraid of death but of the suffering from the dying process.

[Centenarians preparing for the end of life?]

BACKGROUND

The population of centenarians has grown immensely in Germany but has yet hardly been considered in research on dying and death. Due to their very old age centenarians are especially intensively confronted with the challenge of the end of life.

OBJECTIVE

The aim of this study was to analyze how centenarians handle the existential challenge of the end of life and which aspects are especially significant for them. Conclusions drawn from this analysis were used to identify factors to improve the needs-based provision of care.

MATERIAL AND METHODS

Trained interviewers interrogated 15 centenarians living in Berlin using semi-structured interviews based on theoretically developed and tested guidelines. Subsequently, the interviews were transcribed, computer coded and analyzed following the method of the qualitative content analysis according to Kuckartz.

RESULTS

In the categories "experience with dying and death" and "preparing for the end of life" it was shown to be significant that respondents often referred to the dying of others with respect to their worries and wishes at the end of their life. Additionally, the subcategories "putting things in order", "settling provision of care" and "having conversations" were shown to be highly relevant for the participants in the study.

CONCLUSION

Decisions related to care in the process of dying, for example by advance directives, arrangements for inheritance and funeral as well as communication about dying and death, are central needs of centenarians when preparing for the end of life. There is sometimes considerable need for professional support and protection.

[Healthcare preferences of the very elderly: A review]

The preferences of the very elderly are not taken into account in healthcare planning. For this reason, a medical literature review was performed in order to fill the gap in appropriate information on this issue. The majority of them think that they receive good healthcare. They favour building a trusting relationship, with the physician handling their decision-making. They also maximise their quality of life at the expense of quantity, and give great importance to comfort and safety. Most of them express the wish to be cared for and die at home. But when an acute event occurs, they want to be transferred to hospital. More explicit communication must be encouraged between very elderly patients, providers, and families to meet their subjective needs, through on-going discussions, focused on expected outcomes and patient care goals. A healthcare system designed to look after them should be based on individual and flexible care, with coordination between healthcare services. Such a healthcare system could enable a growing number of them to die in their preferred conditions.

Association Between Attitude Toward Death and Completion of Advance Directives

Advance directives provide health-care instruction for incapacitated individuals and authorize who may make health-care decisions for that individual. Identified factors do not explain all variance related to advance directive completion. This study was an analysis of an association between advance directive completion and death attitudes. Surveys that included the Death Attitude Profile—Revised were completed anonymously. Comparisons of means, chi-square, and logistic regression tests were conducted. Among individuals who did not consider themselves religious, the mean death avoidance attitude scores differed significantly among those with advance directives (mean = 1.93) and those without (mean = 4.05) as did the mean approach acceptance attitude scores of those with advance directives (mean = 5.73) and those without (mean = 3.71). Among individuals who do consider themselves religious, the mean escape acceptance attitude scores differed significantly among those with advance directives (mean = 5.11) and those without (mean = 4.15). The complicated relationships among religiosity, advance directives, and death attitudes warrant further study.

Race and Gender Differences in Correlates of Death Anxiety Among Elderly in the United States

BACKGROUND

Death anxiety among elderly is a major public health concern. Few studies, however, have been conducted on factors associated with death anxiety.

OBJECTIVES

This study investigated race and gender differences in psychosocial correlates of death anxiety among elderly in the US.

MATERIALS AND METHODS

With a cross-sectional design, we used data of the Religion, Aging, and Health survey. 1,074 White and Black elderly (age > 65 years, 615 women, 359 men) were entered to this study. Demographic (age, gender, and race), socio-economic (family income, perceived financial difficulty), health (number of chronic medical conditions and self-rated health), and psychological (perceived control over life) factors were measured. Death anxiety was measured using four items. We used linear regressions to determine factors associated with death anxiety based on race and gender.

RESULTS

Although race and gender did not have main effects on death anxiety (P > 0.05), they altered correlates of death anxiety. Age was a predictor of death anxiety among women (B = 0.165, P = 0.002) but not men (B = 0.082, P = 0.196). Self-rated health was associated with death anxiety among Whites (B = - 0.120, P = 0.050) but not Blacks (B = - 0.077, P = 0.268). Total family income was only associated with death anxiety among White men.

CONCLUSIONS

Demographic, socio-economic, health, and psychological determinants of death anxiety in United States differ based on race, gender, and their intersection. Findings advocate that geriatric psychiatrists and gerontologists who wish to reduce death anxiety among elderly people may need to tailor their interventions to race and gender.

Death and the Oldest Old: Attitudes and Preferences for End-of-Life Care--Qualitative Research within a Population-Based Cohort Study

INTRODUCTION

Increasing longevity means more people will be dying in very old age, but little is known about the preferences of the 'oldest old' regarding their care at the end of life.

AIMS

To understand very old people's preferences regarding care towards the end of life and attitudes towards dying, to inform policy and practice.

METHODS

Qualitative data collection for n = 42 population-based cohort study participants aged 95-101 (88% women, 42% in long-term-care): topic-guided interviews with n = 33 participants and n = 39 proxy informants, most with both (n = 30: 4 jointly + separate interviews for 26 dyads).

RESULTS

Death was a part of life: these very old people mainly live day-to-day. Most were ready to die, reflecting their concerns regarding quality of life, being a nuisance, having nothing to live for and having lived long enough. Contrasting views were rare exceptions but voiced firmly. Most were not worried about death itself, but concerned more about the dying process and impacts on those left behind; a peaceful and pain-free death was a common ideal. Attitudes ranged from not wanting to think about death, through accepting its inevitable approach to longing for its release. Preferring to be made comfortable rather than have life-saving treatment if seriously ill, and wishing to avoid hospital, were commonly expressed views. There was little or no future planning, some consciously choosing not to. Uncertainty hampered end-of-life planning even when death was expected soon. Some stressed circumstances, such as severe dependency and others' likely decision-making roles, would influence choices. Carers found these issues harder to raise but felt they would know their older relatives' preferences, usually palliative care, although we found two discrepant views.

CONCLUSIONS

This study's rare data show ≥95-year-olds are willing to discuss dying and end-of-life care but seldom do. Formal documentation of wishes is extremely rare and may not be welcome. Although being "ready to die" and preferring a palliative approach predominated, these preferences cannot be assumed.

Mental disorders and the desire for death in patients receiving palliative care for cancer

OBJECTIVES

The desire for death in terminally ill patients is associated with depression and anxiety, but not all patients who report it meet criteria for mental disorders. We examined the characteristics of subgroups of palliative cancer patients who expressed a desire for death that occurred either with or without a concurrent depressive or anxiety disorder.

DESIGN

Cross-sectional survey.

SETTING

Eight Canadian palliative care programs.

PARTICIPANTS

377 patients with cancer.

MAIN OUTCOME MEASURES

Desire for Death Rating Scale; Structured Interview of Symptoms and Concerns.

RESULTS

Most participants (69.5%) had no desire for death. Of the remainder, 69 (18.3%) acknowledged occasional transient thoughts, and 46 (12.2%) reported an apparently genuine desire to die. In the latter group, 24 individuals (52.2%) were diagnosed with a mental disorder and 22 (44.8%) were not. Individuals with no serious desire for death and no mental disorder reported the least distress in physical, social, existential, and psychological symptoms and concerns; those with a mental disorder and a significant desire for death reported the most. The subgroup of patients with a serious desire for death but no concurrent mental disorders still reported increased distress due to physical symptoms and social concerns, as well as a higher prevalence of global suffering.

CONCLUSIONS

The expression of a desire for death by a terminally ill patient should raise a suspicion about mental health problems, but is not in itself clearly indicative of one. Nevertheless, it may serve as a catalyst to review the individual's physical symptom management and interpersonal concerns, and overall sense of suffering.

[Construction of a scale of attitude toward death in the middle-aged and elderly and its validity and reliability]

AIM

The purpose of this study was to construct a scale that measures multidimensional attitudes regarding death in the middle-aged and elderly, using scale items for adolescents, and to examine its reliability and validity.

METHODS

Twenty-nine items which were selected from the scale of Attitudes toward Death (Tange, 1999) were administered to subjects, consisting of 2,223 community-living Japanese men and women aged 40-79 years. Both exploratory factor analysis and confirmatory factor analysis were performed to examine the factor structures. The reliability and validity of the scale were examined.

RESULTS

Exploratory factor analysis was performed to examine the factor structures of death attitudes, using the data from half of the subjects, indicated 5 factors. Confirmatory factor analysis, using the data from the remaining half, supported the goodness of fit of that model. Using this structure, the attitude toward death scale for the middle-aged and elderly (ATDS-A; five subscales) was constructed; "fear of death", "belief in existence of afterlife", "intention to live out own life", "meaning of death for life", "approval of death with dignity". For these subscales, the alpha coefficients ranged from 0.59-0.87. The validity of the subscales was suggested through the relation with the ego integration score.

CONCLUSIONS

This study suggested that the ATDS-A was reliable and valid, and was useful for the measurement of death attitudes in the middle-aged and elderly.

Last three days of life in the hospital: a comparison of symptoms, signs and treatments in the young old and the oldest old patients using the Resident assessment instrument for palliative care

BACKGROUND

Knowledge concerning the provision of end of life care to the oldest old hospitalised patients is deficient.

AIMS AND OBJECTIVES

To analyse whether there were differences in registered nurses' documentation of the young old vs. the oldest old patients according to symptoms, clinical signs and treatment in the last 3 days of life.

DESIGN

Data were collected retrospectively in a cross-sectional comparative study at a hospital between autumn 2007 and spring 2009. Methods.  The study included 190 patients: 101 (65-84 years) and 89 (85+). Data were extracted from the patients' electronic records using the Resident Assessment Instrument for Palliative Care (RAI-PC).

RESULTS

Falls (OR = 4.01, 95% CI 1.47-10.90) and peripheral oedema (OR = 2.74, 95% CI 1.06-7.11) were significantly more frequent documented in the oldest old patients compared with the young old patients. Delirium was recorded in 15.3% of all patients.

CONCLUSION

With the exception of more falls and peripheral oedema in the oldest old patients, this study showed no differences in symptoms and treatment between the young old and the oldest old patients. Delirium was poorly documented compared to other studies. Implications for practice.  The oldest old patients have a higher risk of falls in the final phase of life, and fall prevention should be considered.

Having to focus on doing rather than being-nurse assistants' experience of palliative care in municipal residential care settings

BACKGROUND

Palliative care should be provided, irrespective of setting to all patients facing a life-threatening illness and to their families. The situation and needs of older people differ from those of younger people since they often have several co-existing diseases and health complaints. This implies an extensive need for care and for longer periods of palliative care. The main providers of palliative care for older people are nurse assistants, who are also those with the shortest education.

AIM

The aim of this study was to illuminate nurse assistants' experience of palliative care for older people in residential care.

DESIGN

The study had an explorative, descriptive design.

SETTINGS

Thirteen residential care units in three different districts in a large city in southern Sweden.

PARTICIPANTS

Twenty-five nurse assistants selected to represent variations in age, gender workplace and work experience.

METHODS

Data were collected from six focus-group interviews and subjected to content analysis to gain an understanding of the phenomenon.

RESULTS

The nurse assistants described palliative care as a contrast to the everyday care they performed in that they had a legitimate possibility to provide the care needed and a clear assignment in relation to relatives. Palliative care also meant having to face death and dying while feeling simultaneous that it was unnatural to talk about death and having to deal with their own emotions. They emphasised that they were in need of support and experienced leadership as invisible and opaque, but gained strength from being recognized.

CONCLUSION

In order to support nurse assistants in providing high quality end-of-life care, more focus is needed on the trajectory of older peoples' dying, on the importance of involving relatives throughout the period of care provision, and on support when encountering death and dying. There is also a need for engaged care leaders, both registered nurses and managers, to recognize the work of nurse assistants and to support care provision for older people within the framework of palliative care philosophy.

Faith and end of life in nursing homes

This paper explores the role of religious belief in the experiences of dying and death in a Catholic nursing home. The home appeals to residents and their families due to the active religious presence. Thus, religion is a salient element of the “local culture” which exists in this long-term care setting. The preeminence of faith within the organization and the personal religious convictions of staff, residents, and families may drive how death and dying are discussed and experienced in this setting, as well as the meanings that are attached to them. This paper examines the relationship between faith and the experience and meaning of death in this nursing home. We present themes that emerged from open-ended interviews with residents, family members, and staff, gathered between 1996 and 2004. The data indicate that people select the home due to their Catholic faith and the home's religious tone. Themes also show that belief in God and an afterlife helps shape the experience of dying and death for our informants. Our paper does not compare ease of dying with other nursing homes or within other belief systems.

A discourse of silence: professional carers reasoning about death and dying in nursing homes

Nursing homes are a setting in which death and dying is common. How death and dying is articulated and the actions that take place in a nursing home constitute a discourse that guides the staff in their work. The aim of this study was to explore the discourse of death and dying in nursing homes from the perspective and understanding of the staff. The study draws on Foucault's discourse analysis. Data are from five focus-group discussions held with 28 staff of four different nursing homes in Sweden. The findings show that the discourse had three characteristics: (a) dying was silent and silenced, (b) emotions were pushed into the background, and (c) attentiveness to death arose after the moment of the elderly person's death. The structure of the discourse was characterised by a movement between two positions, avoiding and confronting death, the main focus being on avoidance. The articulation and practices of silence highlight a need to regard dying as a process that requires attention. One way to ensure appropriate attention could be to instil the philosophy of palliative care in nursing homes, including training and support for the staff in their work. The study demonstrates that nursing-home staff need more knowledge and support to enable them to feel that they do a good job.

Review: what evidence is there about the specific environmental needs of older people who are near the end of life and are cared for in hospices or similar institutions? A literature review

Relatively little is known about the type of physical environment which is needed and preferred by patients aged 65 and over, with a prognosis of 1 year or less, who are receiving care in hospitals, care homes and hospices, and their families and staff. A narrative literature review was conducted to identify and analyse evidence on this issue, with twenty-nine papers meeting the inclusion criteria. The patients were found to have a wide range of views on their environment, but there was some variation between the views of patients and those of their families and staff. Four main themes emerged: the physical environment should be 'homely'; it should support patients' need for social interaction and privacy; it should support the caring activities of staff, family members and patients; and it should allow opportunities for spiritual expression. It is evident that the physical environment contributes significantly to the quality of life of older people with a life-limiting illness, and there is a need for more research in this area. Regular assessment of patients' environmental needs should form part of care planning.

Reducing the potential for suffering in older adults with advanced cancer

Objective:

To deliver quality care at the end of life, understanding the impact of various changes and life transitions that occur in older age is essential. This review seeks to uncover potential sources of distress in an elder's physical, psychological, social, and spiritual well-being to shed light on the unique challenges and needs facing this age group.

Methods:

Papers relating to older adults (aged 65 years and older or a mean age of 65 years and older) with advanced/terminal cancer receiving palliative, hospice, or end-of-life care published after 1998 were reviewed.

Results:

Older adults with advanced cancer have unique needs related to changes in their physical, psychological, social, and spirituals well-being. Changes in each of these domains offer not only the risk of causing distress but also the potential for growth and development during the final stages of advanced cancer.

Significance of results:

Being aware of the various changes that occur with aging will help health care professionals tailor interventions to promote dignity-conserving care and greatly reduce the potential for suffering at the end of life.

Prognostic Acceptance and the Well-Being of Patients Receiving Palliative Care for Cancer

Purpose

To identify the impact of prognostic acceptance/nonacceptance on the physical, psychological, and existential well-being of patients with advanced cancer.

Patients and Methods

A Canadian multicenter prospective national survey was conducted of patients diagnosed with advanced cancer with an estimated survival duration of 6 months or less (n = 381) receiving palliative care services.

Results

Of the total number of participants, 74% reported accepting their situation and 8.6% reported accepting with “moderate” to “extreme” difficulty. More participants with acceptance difficulties than without acceptance difficulties met diagnostic criteria for a depressive or anxiety disorder (χ2 = 8.67; P < .01). Nonacceptors were younger (t = 4.13; P < .000), had more than high school education (χ2 = 4.69; P < .05), and had smaller social networks (t = 2.53; P < .05) than Acceptors. Of the Nonacceptors, 42% described their experience as one of “moderate” to “extreme” suffering compared with 24.1% of Acceptors (χ2 = 5.28; P < .05). More than one third (37.5%) of Nonacceptors reported feeling hopeless compared with 8.6% who had no difficulty accepting (χ2 = 24.76; P < .000). Qualitatively, participants described active and passive coping strategies that helped them accept what was happening to them, as well as barriers that made it difficult to come to terms with their current situation.

Conclusion

The challenge of coming to terms with a terminal prognosis is a complex interplay between one's basic personality, the availability of social support, and one's spiritual and existential views on life. Nonacceptance appears to be highly associated with feelings of hopelessness, a sense of suffering, depression, and anxiety, along with difficulties in terms of social–relational concerns.

Religiosity, Spirituality, and Death Attitudes in Chronically Ill Older Adults

The aim of this study was to examine the association of religiosity and spirituality with fear of death and death acceptance attitudes in chronically ill older adults. In-home interviews were conducted with 257 community-dwelling elders with chronic illness identified through an administrative database of ambulatory care clinics from an academic health center in Kansas City and through primary care practices participating in a practice-based research network in North Carolina. Hierarchical regression models were constructed for predictor variables and the outcomes of fear of death and approach acceptance of death attitudes. Self-efficacy beliefs ( b = —.097, p < .001), anxiety ( b = .026, p < .01), and physical functioning ( b = .015, p < .01) were significantly associated with fear of death attitudes. Self-reported religiosity ( b = —.389, p < .001), closeness to God ( b = —.595, p < .001), and age ( b = —.019, p < .001) contributed significantly to the variance in the final model and were significantly associated with approach acceptance of death attitudes.

Dignity as experienced by nursing home staff

Aims and objectives.  To explore nursing home staff members' experiences of what dignity in end of life care means to older people and to themselves. Background.  Dignity is a concept often used in end-of-life care, but its meaning is rarely clarified. Design.  Qualitative descriptive study. Methods.  Content analysis. This study is based on interviews with 21 staff members in four different nursing homes in Sweden. Findings.  The results show that staff members balanced between providing for the older person's physical needs while wishing to be able to deliver a 'deeper' level of care. The older people's dignity is presented in the main theme: Feeling trust - Showing respect. The staff members' dignity is presented in the main theme: Maintaining self-respect - Being shown respect. Threats to dignity are presented in the main theme: conflicts between the ideal and the reality. Conclusions.  The results reveal that nursing home staff members deal with a moral conflict between what they are able to deliver and what they would like to provide in the care of older people. Relevance to clinical practice.  To promote older people's dignity, there is a need to take account of staff members' work situation. Supervision and continuous education could be one way of achieving this.