Assessing the Will to Live: A Scoping Review

Validation of the death reflection scale among older people

Background

Human beings possess the capacity to cognize their own mortality, which compels them to process death awareness. The present study seeks to validate the Death Reflection Scale (DRS) among older individuals, which measures growth-oriented cognitions and prosocial behavior following confrontation with death awareness.

Materials and methods

DRS was validated using a cross-sectional online survey of older adults (50+). To assess configural, metric, and scalar measurement equivalence across age groups of older adults, a multi-group confirmatory factor analysis was conducted in conjunction with dynamic fit index cutoffs. Construct validity was evaluated using Pearson's correlation and analysis of variance (ANOVA). The data were obtained from an online survey. The survey was conducted in May 2023 and people aged 50 and over were recruited from an online panel using quota sampling (by age, gender and federal state). A total of 1,806 individuals completed the survey.

Results

Confirmatory factor analysis showed a good fit of the originally proposed 5-factor (CFI 0.949, SRMR 0.058, RMSEA 0.070) and bi-factor model (CFI 0.956, SRMR 0.067, RMSEA 0.067) with a general factor and five subscales. In light of several considerations, it is recommended that the DRS should be considered as a five-factor model, as originally proposed. Alpha ranges from 0.807 to 0.875 and Omega from 0.811 to 0.875, indicating good reliability. Partial scalar invariance was obtained, therefore mean comparisons can be made between groups of older people. Testing the construct validity showed only a partial confirmation. The exploratory analysis of the DRS with the Big Five personality traits revealed a correlation structure that can be plausibly explained by considering the facets of personality traits.

Conclusion

The value of the DRS lies in its perspective that death awareness should not only be viewed as a threat, but rather as a potential for a positive and growth-oriented perspective on death awareness and has been validated for older adults. The present study demonstrated that mean comparisons could be conducted between groups of older adults. Tests of construct validity yielded inconclusive results, indicating the necessity for further analysis.

The influence of ageism on the hallmarks of aging: Where age stigma and biology collide

Ageism encompasses the creation of negative stereotypes of aging that culminate in the development of prejudicial thoughts and discriminatory actions against people in advanced age. Stereotypes refer to major characteristics, overgeneralized, not supported by observations, that are created to categorize, simplify, and combine complex characteristics, attributes, and behaviors shared by members of a group into more simplistic categories. Negative aging stereotypes include the assumption that old people are weak, reminiscent, sick, and tired, to quote a few. In early age, these views may generate intergenerational conflicts between young and old people, but they seem to have little effect on other aspects of life. However, in middle-aged and older adults, the presence of negative-self stereotypes of aging are significantly associated with several health parameters, including walking speed, cognitive function, mental health problems, and accumulation of amyloid plaques and neurofibrillary tangles. Furthermore, observational studies found that ageism might be associated with cardiovascular events, obesity, dementia, and death. These harmful effects are possibly mediated by the interaction between ageism and fundamental mechanisms of aging, mainly inflammation. Given the clinical implications of this relationship, the present manuscript provides a critical review of the available literature that examined associations between ageism and health parameters. We also discuss the main possible mechanisms underlying this association, the main limitations of the current literature, candidate strategies to counteract ageism, and directions to future studies. Finally, we provide a critical opinion of the current scenario and its potential adaptability to the clinical practice.

The double awareness of the wish to hasten death and the will to live: A secondary analysis of outlier patients from a mixed-methods study

BACKGROUND

Patients with serious illness frequently report (temporary) wishes to hasten death. Even until the end-of-life, many patients also harbor a will to live. Although both phenomena are negatively correlated according to some studies, they can also co-exist. Knowledge about the complex relationship between the seemingly opposing wish to hasten death and will to live is limited, but crucial for delivering adequate care and understanding potential requests for assisted dying.

AIM

To study the correlation of and explore the relationship between wish to hasten death and will to live over 6 weeks.

DESIGN

Observatory, prospective cohort study following a mixed methods design. Analysis of quantitative (Schedules of Attitudes Toward Hastened Death, a visual numerical scale and (additional) validated questionnaires) and qualitative (semi-structured interviews) data with illustrative case descriptions.

SETTING/PARTICIPANTS

Patients receiving palliative care with heterogenous underlying diseases from various care settings, before and after an open conversation on a possible desire to die.

RESULTS

In n = 85 patients, wish to hasten death and will to live were strongly negatively correlated at three time points (baseline: r(65) = -0.647, p ⩽ 0.001; after 1 week: r(55) = -0.457, p ⩽ 0.001 and after 4-6 weeks: r(43) = -0.727, p ⩽ 0.001). However, visual assessment of scatterplots revealed a small, but substantial number of outliers. When focusing on these outlier patients, they showed clinically relevant changes between baseline and 6 weeks with the wish to hasten death changing in n = 9 (15% of n = 60) and the will to live changing in n = 11 (18.6% of n = 59). Interview data of three outlier cases illustrates unusual trajectories and possible factors which may influence them.

CONCLUSIONS

As they can co-exist in different possible combinations, a high wish to hasten death does not necessarily imply a low will to live and vice versa. Patients receiving palliative care can hold such seemingly opposing positions in mind as a form of coping when confronted with an existential threat of serious illness. Therefore, health professionals are encouraged to proactively engage patients in conversation about both phenomena.

Interdisciplinary research approach based on a mixed-methods design to explore patient altruism at the end of life: a study protocol

INTRODUCTION

In the end of life context, patients are often seen as somewhat passive recipients of care provided by health professionals and relatives, with little opportunity to be perceived as autonomous and active agents. Since studies show a very high prevalence of altruistic dispositions in palliative care patients, we strive to investigate the concept of patient altruism in a set of six interdisciplinary studies by considering three settings: (1) in the general palliative context-by studying to what extent patient altruism is associated with essential psychological outcomes of palliative care (subproject 1a), how altruism is understood by patients (subproject 1b) and how altruism expressed by patients is experienced by palliative care nurses (subproject 1c); (2) in two concrete decision-making contexts-advance care planning (subproject 2a) and assisted suicide (subproject 2b); and (3) through verbal and non-verbal patient communication in palliative care settings (subproject 3).

METHODS AND ANALYSIS

Subproject 1a: a cross-sectional study using validated and standardised questionnaires. Subprojects 1b and 1c: a constructivist grounded theory method aiming at developing a novel theory from semistructured interviews in both patients and nurses. Subproject 2a: a thematic analysis based on (1) audio-recordings of advance care planning encounters and (2) follow-up semidirective interviews with patients and their relatives. Subproject 2b: a qualitative study based on thematic analysis of interviews with patients actively pursuing assisted suicide and one of their relatives.Subproject 3: a conversation analysis based on audio and video-recorded interactions in two settings: (1) palliative inpatient unit and (2) advance care planning discussions.

ETHICS AND DISSEMINATION

The study project was approved by the Ethics Committees of the Canton of Vaud, Bern and Ticino (no: 2023-00088). In addition to participation in national and international conferences, each project will be the subject of two scientific publications in peer-reviewed journals. Additional publications will be realised according to result triangulation between projects. A symposium opened to professionals, patients and the public will be organised in Switzerland at the end of the project.

Will-to-Live and Self-Rated Health in Older Hospitalized Patients Are Not Predictive for Short-Term Mortality

Background: Self-assessed will-to-live and self-rated health are associated with long-term survival in community-dwelling older persons but have not been examined in frailer older patients in relation to short-term prognosis. The aim was to explore whether will-to-live and self-rated health are predictive for six-month mortality and can guide ceiling of treatment decisions in hospitalized patients in an acute geriatric ward. We included the Surprise Question as reference, being a well-established clinical tool for short-term prognostication. Methods: This multicentric prospective study included patients of 75 years and older admitted at acute geriatric wards of two Belgian hospitals. Will-to-live and self-rated health were scored on a Likert scale (0-5, 0-4) and assessed by junior geriatricians. The senior geriatricians answered the Surprise Question for clinical judgment of prognosis. Receiver-operator characteristic (ROC) curves were constructed to determine diagnostic accuracy. For time-dependent analysis, Cox regression was performed with adjustment for age and gender. Results: Of 93 included patients in the study, 69 were still alive after six months and 24 died, resulting in a six-month mortality of 26%. The mean age was 86 years (range 75-100), 67% of the patients were women. Median will-to-live and self-rated health were 3 (moderate and good). Both will-to-live and self-rated health were not predictive for six-month mortality (area under the ROC curve [AUC] 0.496, p = 0.951 for will-to-live; 0.447, p = 0.442 for self-rated health) as opposed to Surprise Question (AUC 0.793, p < 0.001). After correction for sex and age, the hazard ratio of six-month mortality was 0.92 for will-to-live (p = 0.667), 0.86 for self-rated health (p = 0.548), and 10.28 for Surprise Question (p < 0.001). Conclusion: Will-to-live and self-rated health are not predictive for six-month mortality in patients admitted to the acute geriatric ward, unlike prognostic tools such as Surprise Question. Clinical Trial Registration Number: B670202100792.

How strong is the will-to-live in frail older persons? A survey study in acute geriatric wards and nursing homes in Belgium

INTRODUCTION

Will-to-live is defined as the psychological expression of one's commitment to life and the desire to continue living. It is an important indicator of subjective wellbeing. This study aimed to assess the will-to-live in frail older hospitalized patients and nursing home residents as well as to evaluate its association with physical frailty, tiredness of life, depression and wish-to-die.

METHODS

Between March and September 2021, we interviewed 186 older adults in six nursing homes and two acute geriatric wards across Belgium. Will-to-live was assessed using a single-item numeric rating scale from 0 to 5. A linear regression analysis was performed to assess the association between will-to-live and frailty (Clinical Frailty Scale) with adjustment for age, gender and setting. Mann-Whitney U test was used to evaluate the association between will-to-live and depression, tiredness of life and wish-to-die.

RESULTS

Mean age was 85 (± 6.2) years. Mean score on the Clinical Frailty Scale was five (± 1.5) and four on the will-to-live (± 1.3). No statistical significant association was found between will-to-live and age (p = 0.991), gender (p = 0.272), setting (p = 0.627) and frailty (p = 0.629). Multiple linear regression showed no significant association with Clinical Frailty Scale (p = 0.660), after adjustment for age, gender and setting. Will-to-live was negatively associated with tiredness of life (p = 0.020) and wish-to-die (p < 0.001), but not with depression (p = 0.186).

DISCUSSION

Both nursing home residents and older hospitalized patients expressed a strong or very strong will-to-live. Will-to-live was not associated with physical frailty as measured by the Clinical Frailty Scale. Nursing home residents with a weak will-to-live were more likely to have depressive symptoms. Most nursing home residents with a wish-to-die had also a low will-to-live, although some residents had both a high will-to-live and wish-to-die.

Social isolation and loneliness: Undervalued risk factors for disease states and mortality

Social isolation and loneliness are two common but undervalued conditions associated with a poor quality of life, decreased overall health and mortality. In this review, we aim to discuss the health consequences of social isolation and loneliness. We first provide the potential causes of these two conditions. Then, we explain the pathophysiological processes underlying the effects of social isolation and loneliness in disease states. Afterwards, we explain the important associations between these conditions and different non-communicable diseases, as well as the impact of social isolation and loneliness on health-related behaviours. Finally, we discuss the current and novel potential management strategies for these conditions. Healthcare professionals who attend to socially isolated and/or lonely patients should be fully competent in these conditions and assess their patients thoroughly to detect and properly understand the effects of isolation and loneliness. Patients should be offered education and treatment alternatives through shared decision-making. Future studies are needed to understand the underlying mechanisms better and to improve the treatment strategies for both social isolation and loneliness.

Recognizing the Death Motif in the Near-Death Experience

The typical near-death experience (NDE) is generally understood as an altered state of consciousness in which the experient has the impression of existing as an extrapersonal self out of and/or away from their physical body during real or presumed life-threatening and/or near-death circumstances. This presumed extrapersonal self can sometimes have a perception of being located within the proximity of the physical body whereas at other times it is under the assumption of having ventured to a transcendental location such as an otherworldly realm. The ego, while in this presumed disembodied state, often has the impression of encountering NDE personages such as deceased people, otherworldly spirits, and/or divine beings, especially during transcendental NDEs. However, this paper suggests that all of these noted features are part of a broader recognizable death motif in NDE reports, and provides qualitative examples of different types of this death symbolism for examination and exploration. It then discusses how the death motif in NDE reports possibly indicates a purposeful psychological function to heighten awareness of a threat to life though death symbolism that is meant to boost the desire and resilience to live and survive.

Social Support and Commitment to Life and Living: Bidirectional Associations in Late Life over Time

OBJECTIVES

This study aims to enhance the understanding of longitudinal associations between two important facets of well-being in late life: social support and commitment to life and living (CTL).

METHODS

Structured home interviews were conducted with 824 Israelis ≥75 years of age, with three annual data collection timepoints. We hypothesized and tested a cross-lagged, longitudinal structural equation model (SEM) in which CTL and social support were assumed to predict each other over time, covarying for previously reported CTL and social support.

RESULTS

Social support has a positive, contemporaneous effect, predicting commitment to living at T1 and T3, while CTL predicts social support the following year (i.e., T1-T2 & T2-T3). Satisfaction with relationships significantly contributes to measurement of both latent constructs at each point of data collection.

DISCUSSION

Commitment to life and living and social support are intertwined phenomena. Whereas social support has a concomitant effect on CTL, the effect of CTL on social support emerges over time. This suggests that greater social support fosters greater CTL, leading older adults to nurture social networks and relationships; the effect of which is greater social support in the future. The implications of these results warrant further research over longer periods and across cultures.

Are the main effects of the will to exist, live, survive and fight on optimizing executive function due to its optimizing self-motivation? A longitudinal study

The study aims to identify the mechanisms underlying the findings that will to exist, live, survive and fight (WTELS-F) optimizes executive functions. Defining executive functions (EF) as having cold (working memory, inhibition, and cognitive flexibility) and hot (e.g., motivation) components, we hypothesized that WTELS-F affects executive functions positively via two pathways. The first pathway is through the hot executive function (motivation), and the second is via survival or existential processing. In a longitudinal study of 228 adult participants two times with ten weeks in between, we used measures for WTELS-F, working memory, inhibition, shift/cognitive flexibility, and self-motivation. We tested the structural validity of the four factors' executive function by exploratory factor analysis in time 1 data and confirmatory factor analysis in time 2 data. We conducted structural equation modeling WTELS-F change as a latent variable predicted by the change in its three components between times 1 and 2., affecting changes in self-motivation (the hot EF), and changes in the latent variable of cold EF as predicted by changes in working memory, inhibition, and shift. Results indicated that the model of EF fit the data well without modification. WTELS-F significantly affected self-motivation (the hot EF) and the cold EF longitudinally. It had further mediated effects on cold EF via its impact on self-motivation. The results provided evidence for the two pathways hypothesis of the effects of WTELS-F on EF. The conceptual and clinical implications of these findings were discussed.

"Life goes on": Perspectives on the will to live from residents of Swiss long-term care facilities

OBJECTIVES

While there is a growing body of literature on the wish to die in older patients, there is little research about their will to live. Exploring the subjective will to live (WTL) offers valuable insights into the patients' resources and motivations, which could help improving geriatric palliative care. The aim of this study was to examine, in long-term care facilities (LTCF), residents' definitions of and factors influencing their WTL.

METHODS

Twenty residents (mean age 85.8 ± 10.3 years, 70% women) of 3 Swiss LTCFs gave informed consent and participated in semi-structured interviews about their WTL. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify recurrent themes (40% double coded).

RESULTS

The majority of residents reported that they had not thought about the WTL. Nevertheless, they had no difficulty in describing it as innate in their lives. They spontaneously mentioned factors that contributed to their WTL, classified into 5 themes: (1) relationships - primarily with family and health professionals, secondarily with other residents; (2) living situation - the LTCF as a necessary place providing care, constant professional presence, and security, yet necessitates inconveniences such as loss of independence; (3) personality factors - positive outlook on life or spirituality; (4) engagement in routines - organized activities and individual daily routines; and (5) health status - primarily related to functional health.

SIGNIFICANCE OF RESULTS

Examining WTL provides important insights into elements that are essential to take into account in planning care and promoting well-being in LTCF residents. The themes identified provide important starting points for improving life in LTCFs.

Coping with COVID-19 Prolonged and Cumulative Stressors: the Case Example of Egypt

The current study aimed to explore how COVID-19-traumatized populations cope using a coping model based on wills to exist, live, and survive (WTELS) that leads to positive coping and posttraumatic growth (PTG). We used data from 11 Arab countries (N = 2732), including Egypt (N = 831), and included measures for COVID-19 stressors (COVID-fear, economic, lockdown, and grief stressors), WTELS, resilience, religiosity, spirituality, social support, and PTG. We conducted ANOVA on the main sample to explore the differences between Arab countries, hierarchical regressions, and path analysis on the Egyptian subsample to test a model of the effects on WTELS. In the path model, WTELS was the independent variable. Other coping strategies were mediating variables, and COVID-19 stressor types were outcome variables. ANOVA on the main sample indicated that Egypt was the highest on COVID-19 stressors (infection fears, economic, lockdown, and grief stressors), actual infection, and WTELS. Hierarchical regression indicated that social support, resilience, and WTELS were positive predictors of PTG, with WTELS had the highest effect size (β = .41) and WTELS being a negative predictor of COVID-19 stressors, while resilience and social support were not. Path analysis indicated that WTELS predicted higher religiosity, spirituality, social support, resilience, and lower COVID-19 stressors. Religiosity predicted higher spirituality, social support, and resilience and lower COVID-19 stressors. Interfaith spirituality predicted higher resilience and lower COVID-19 grief stressors. The results validated the central role of WTELS. Results helped to identify potentially effective interventions with COVID-19 victims that focus on WTELS, spirituality, and religiosity.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11469-021-00712-x.

Will to Live in Older Nursing Home Residents: A Cross-Sectional Study in Switzerland

CONTEXT

The will to live (WTL) is an important indicator of subjective well-being. It may enable a deeper understanding of the well-being of nursing home residents.

OBJECTIVES

To evaluate the intensity of WTL, its association with various factors, and its temporal evolution among residents ≥ 65 years old; we also aimed to compare it with proxy assessments of WTL.

METHODS

A cross-sectional study was conducted in five nursing homes in Switzerland. Participants with decisional capacity were asked to rate the intensity of their WTL on a single-item numerical rating scale ranging from 0-10. A short-term follow-up was conducted among a sub-sample of 17 participants after three and six weeks. Proxy assessment by residents' next of kin and professional caregivers was conducted, and inter-rater agreement was calculated.

RESULTS

Data from 103 participants (75.7% women, 87.3 ± 8.0 years) was analyzed. The median intensity of WTL was 8. Higher WTL was significantly associated with better physical mobility and shorter duration of daily care but not with age, gender, pre-admission care setting, or prognosis. Significant independent predictors of WTL were physical mobility and provenance from rehabilitative care. In the short-term follow-up assessment, WTL remained highly stable. Intraclass correlation coefficients were moderate for residents' next of kin and nurse assistants but poor for physicians and nurses; all proxy assessments underestimated the participants' WTL.

CONCLUSION

Nursing home residents expressed a very strong WTL and proxy aents underestimated residents' WTL. It seems pivotal to proactively communicate with residents about their WTL.

To Live or Die: What to Wish at 100 Years and Older

Previous research has shown that will to live is a strong predictor for survival among older people, irrespective of age, gender, and comorbidities. However, research on whether life at age 100 is perceived as worth living is limited. The available literature has presented evidence for good levels of positive attitudes and life satisfaction at such an advanced age, but it has also suggested that a longing for death is common. This study aimed to add to the existing data on this matter by exploring centenarians' will to live and the associated factors. The sample comprised 121 centenarians (mean age, 101 years; SD, 1.63 years), 19 (15.7%) of whom were males, from two centenarian studies (PT100). Answers to open questions were analyzed to identify the centenarians' will to live and the reasons behind it. Three groups were created (willing to live longer, not willing to live longer, no clear positioning) and further analyzed in terms of sociodemographic characteristics, health status, social functioning, and well-being. Of the total sample, 31.4% expressed willingness to live longer, 30.6% did not, and 38% presented no clear positioning. The presence of the Catholic religion (God) was referred for centenarians in all three groups. Annoyance, uselessness, loss of meaning, disconnection, and loneliness were the most common justifications for being reluctant to live longer. Positive valuation of life and good self-rated health, followed by having a confidant and reduced pain frequency, were the factors associated with being willing to live longer. The results of the study contribute to the understanding of the psychological functioning of individuals with exceptional longevity, particularly concerning the factors behind willingness to live at such an advanced age.

The association of WTELS as a master motivator with higher executive functioning and better mental health

The goal is to test the validity of the “Will to exist-live and survive (WTELS) as a master motivator that activates executive functions. A sample of 262 adults administered different measures that included WTELS and executive functions. We conducted hierarchical regressions with working memory deficits (WMD) and inhibition deficits (ID) as dependent variables. We entered in the last steps resilience and WTELS as independent variables. We conducted path analysis with WTELS as independent variables and WMD and ID as outcome variables and resilience and social support as mediating variables. WTELS accounted for the high effect size for lower working memory deficits and medium effect size for lower inhibition deficits. In path analysis, the effects of WTELS on decreased WMD were direct, while its effects on the ID were indirect. PROCESS analysis indicated that WTELS was directly associated with lower depression, anxiety, PTSD, and COVID-19 traumatic stress, and its indirect effects were mediated by lower executive function deficits (Kira et al., Psych 12:992-1024 2021c, Kira et al., in press). The path model discussed was generally superior to the alternative models and was strictly invariant across genders (male/ female).

Will Life Extension Affect Our Social Judgments? Evidence That the Possibility of Indefinite Life Extension Increases Harshness Toward Social Transgressors

We tested the hypothesis that if indefinite life extension (ILE) through medical technologies were to become a reality, then people may become harsher in their judgment of social transgressors. In support of this hypothesis, we found that higher positive attitudes towards ILE technologies related to harshness in judgment of social transgressions (Study 1), and that making ILE plausible (compared to not plausible) led participants to endorse harsher punishments for social transgressors (Studies 2-3). We replicated this effect and found that it is not amplified by subliminal death primes, although the primes also increased harshness (Study 3). These results may have implications to understanding how social judgment may be affected by the prospect of ILE.