Psychological research on death attitudes: an overview and evaluation

Sense of failure in end of life care: Perspectives from physicians and nurses

Limited knowledge exists regarding sensed failure resulting provision of end-of-life (EOL) care. Among medical health professionals (MHP), a sense of failure is associated with impaired patientcare and reduced worker wellbeing, including higher rates of burnout and secondary traumatic stress. As part of a larger mixed-methods study on the effects of EOL-care provision on MHP in general hospitals, semi-structured in-depth interviews were conducted with 22 physicians and nurses at three tertiary Israeli hospitals, representing a wide range of medical specialties, training, experience, and cultural backgrounds. Qualitative thematic analysis of the interviews led to the identification of the theme 'sense of failure' with the sub-themes 'sources' and 'lived meanings' of the sensed failure. Apart from the source 'losing a patient' all other identified sources were recognized as work-related risk factors, including 'unsupportive environments' and 'shortcomings of the medical practice.' Two of the lived meaning 'sense of personal responsibility' and 'moral injury' were also recognized as work-related risk factors. Surprisingly, albeit the adverse context of EOL-care, the two remaining lived meanings 'learning from failure' and 'sense of purpose' were recognized as protective resilience factors. Changes in workplace norms by focusing on leadership and mentoring programs and implementation of evidence based interventions aimed at reducing the sense of failure and enhancing feelings of purpose are recommended. Finally, the findings described in the study would benefit from continued studies on larger scales.

The relationship between fear of old age, loneliness and death anxiety in adults

BACKGROUND

The increase in the number of elderly people in the world, individuals' perspectives on older adults, and false beliefs and ideas about old age negatively affect adults in terms of ageing. This study was conducted to determine the relationship between fear of old age, loneliness and death anxiety in adults.

METHOD

This study, which was designed in a correlational cross-sectional descriptive model, was conducted with 1074 adult individuals living in one province in eastern Turkey. Data were collected using Personal Information Form, Fear of Old Age Scale, UCLA Loneliness Scale and Turkish Death Anxiety Scale. Data were analyzed using SPSS 25.0, AMOS 24.0, G*Power 3.1 statistical package programs.

RESULTS

In our study, it was determined that the model created in line with the hypotheses was compatible and the model fit indices were within the desired limits as χ2/df = 4.737, root mean square error of approximation = 0.05, comparative fit index = 0.93, goodness-of-fit index = 0.92, adjusted goodness-of-fit index = 0.90, IFI = 0.93. There is a significant relationship between loneliness and death anxiety (P < 0.05). There is a significant relationship between loneliness and fear of old age (P < 0.05). There is a significant relationship between death anxiety and fear of old age (P < 0.05). It was determined that death anxiety has a mediating role in the effect of loneliness on fear of old age (95% confidence interval: 0.112-0.226; P < 0.05).

CONCLUSION

As the level of loneliness increases, the level of death anxiety and fear of old age increases. Fear of old age also increases in the mediating role of death anxiety. It is recommended to conduct intervention studies to reduce fear of old age. Longitudinal study on fear of old age is recommended.

Validation of the Collett-Lester fear of death scale in occupational therapy students: psychometric testing and implications for palliative care education

BACKGROUND

The fear of death is a common experience among healthcare students and professionals that may impact the quality of care provided to patients, particularly those receiving palliative care. The Collett-Lester Fear of Death Scale is a widely used instrument to assess this fear, although its psychometric properties have not been extensively studied in Occupational Therapy students. The present study aimed to validate the Collett-Lester Fear of Death Scale (CL-FODS) in a sample of Occupational Therapy students and to explore its implications for palliative care education.

METHOD

A cross-sectional study was conducted to perform psychometric testing of the CL-FODS in Occupational Therapy undergraduate students. Structural validity, internal consistency, and test-retest reliability were analysed. A total of 195 Occupational Therapy students were included in this study. Additionally, the participants completed a brief survey on their experiences and attitudes towards palliative care.

RESULTS

The internal consistency was satisfactory (α = 0.888). The exploratory factor analysis to evaluate the internal structure yielded four factors. The model fit indices were: comparative fit index = 0.89, and root mean square error of approximation = 0.06). The test-retest reliability was satisfactory and demonstrated an intraclass correlation coefficient of 0.939.

CONCLUSION

The Spanish version of the CL-FODS showed satisfactory psychometric properties; therefore, assessing fear of death in Occupational Therapy students is helpful. This study highlights the importance of addressing fear of death and palliative care education in Occupational Therapy undergraduates to improve future professional attitudes and, consequently, the quality of patient care at the end of life.

Spiritual-Cultural Needs as the Main Causative Factor of Death Anxiety in Iranian COVID-19 Patients: A Qualitative Study

COVID-19 patients have been reported to more than likely experience a variety of difficult physical and psychological problems. This qualitative study aims to perceive psychological experiences in COVID-19 patients in Iran. The study method is qualitative, with a conventional content analysis approach adopted. Purposive sampling was applied to 20 COVID-19 patients admitted to medical wards at hospitals in Tehran, Iran. Additionally, data were collected using semi-structured interviews. All data were analyzed based on the method proposed by Lindgren et al. (Int J Nurs Stud 108:103632, 2020). Data analysis identified the main theme to be "death fear and anxiety" with five main categories. These categories included the feelings of death panic and apprehension, uncertainty and ambiguity, fear of abandonment, fear of an unknown future for the family, and fear of unmet spiritual-cultural needs. Accordingly, the patients' experiences of COVID-19 contraction were unique. Against this backdrop, understanding COVID-19 patients' complexities, experiences, beliefs, and attitudes about anxiety and death, can lead to an  improved awareness and understanding of the psychological consequences of COVID-19 by executive decision-makers, healthcare personnel and mental health professionals.

The Effect of Mindfulness on Death Escape Acceptance in Young People: Emotion Regulation as a Mediator

Few studies have examined young people's attitudes toward death escape acceptance and its relationship to mindfulness. This study addressed this issue and examined the mediating role of emotion regulation. In Study 1, 61 undergraduate students aged 19-22 years participated in a mindfulness intervention program, and the results showed that increasing young people's levels of mindfulness could improve their attitudes toward death escape acceptance. The Study 2, which recruited 440 young people aged 18-26 years to complete a cross-sectional survey, replicated the main effect and showed that young people's difficulty in emotion regulation fully mediated the coping effect of mindfulness. These findings suggest that individuals with high levels of mindfulness may have low levels of difficulty in emotion regulation and in turn promote healthy attitudes toward death escape acceptance.

Death Anxiety in Caregivers of Chronic Patients

This study aimed to determine the extent to which caregivers of patients with chronic illnesses experience death anxiety, and which variables from caregivers and patients might potentially be related to their death anxiety. It also aimed to compare the levels of death anxiety between patients and caregivers. Web of Science, Scopus, PubMed, Psychology Database, Cochrane, and Google Scholar were searched for original studies available until December 2022 that quantitatively addressed death anxiety in family and informal caregivers of individuals with chronic illnesses. The methodological quality of the included studies was assessed, and a meta-analysis was conducted using Hedges' g as the effect size index and the DerSimonian-Laird method to analyze differences between patients and caregivers in death anxiety. The results of the 11 included studies showed moderate levels of death anxiety in caregivers, and the meta-analysis (k = 7; 614 patients and 586 caregivers) revealed non-significant differences between the death anxiety experienced by patients and caregivers (pooled Hedges' g = -0.03, 95% CI = -0.29 to 0.25, p = 0.802). Some sociodemographic and psychological factors (e.g., gender, depression, and anxiety) might be related to the death anxiety experienced, but additional research is necessary to validate these findings.

Dimensions of Death-Related Attitudes in a French-Speaking Sample

This study examines the structure of death-related attitudes among French-speaking people. Participants from Canada, Belgium, France, and from Switzerland whose mother tongue was French in an online survey responded to the French adaptation of the item pool of the Multidimensional Orientation Toward Dying and Death Inventory (MODDI; N = 373). Exploratory factor analyses with orthogonal and oblique rotation yielded a 5-factor Fear domain and a 3-factor Acceptance domain, thereby reproducing the a-priori conceptualization. These results are discussed with respect to the issue of universal dimensions of death-related attitudes across cultures.

Examination of the relationship between thanatophobia and resilience levels of nurses working in intensive care and palliative care units

BACKGROUND

Nurses in critical care and palliative care units care for patients suffering from severe pain and suffering and at high mortality risk. For this reason, nurses working in these units should be psychologically resilient. However, nurses who are constantly exposed to the death process face the risk of thanatophobia. The aim of this study is to examine the relationship between thanatophobia levels and the psychological resilience of nurses working in intensive care and palliative care units.

METHODS

The sample of this descriptive and cross-sectional study included 158 nurses working in intensive care and palliative care units. Personal information form for nurses, Thanatophobia Scale and Psychological Resilience Scale for Adults were used. Data were collected through an online questionnaire in the study. Percentage calculations, mean measurements, Kruskal Wallis test and Mann Whitney U test were used in the statistical evaluation of the data.

RESULTS

The mean of thanatophobia scale and psychological resilience scale was found 31.74 ± 10.08 and 108.34 ± 7.12, respectively. There was a statistically significant difference between the tanatophobia total scale score and age, receiving training on psychological resilience (p < 0.05). A statistically significant difference was found between perseption of self, family cohesion and perception of future and the status of receiving training on psychological resilience (p < 0.05). A statistically negative significant correlation was determined between the thanatophobia scale and the psychological resilience scale total scores.

CONCLUSIONS

As a result, it was determined that as the thanatophobia of the nurses increased, their psychological resilience decreased. This situation may negatively affect nurses working in critical departments to provide quality health care to patients. Establishing and maintaining training programs to reduce thanatophobia and increase psychological resilience of nurses working in intensive care and palliative care units will ensure that nurses provide quality health care to the patient and reduce the physiological and psychological wear of nurses.

Show and Tell: Photography and Storytelling to Better Understand the End-of-Life Experience of Families in the Intensive Care Unit

End-of-life in the Intensive Care Unit (ICU) is common, costly, and can contribute to negative health outcomes for bereaved family members. Insufficient understanding of the family experience results in poor quality, highly variable care riddled with deficiencies including effective identification and application of evidence-based clinical interventions. Successfully managing the multitude of transitions, for example changes in family role or personal identity requires creative practice guided by theory. This project supports the feasibility of using peri-mortem photographs captured by family members with story-telling and a standardized measurement of grief to explore the family experience of end-of-life in the ICU. Project findings reveal shared experiential themes and emphasize the value of photography and storytelling as meaning-making interventions for families. Further study to generalize findings and develop additional preventative and therapeutic interventions at and beyond end-of-life in the ICU is needed to better meet family needs and improve their health outcomes.

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.

Death attitudes and Chinese college students' mental health: A latent profile analysis

Death attitudes can have significant impacts on individuals' mental health. The present study used a person-centered approach to identify 588 Chinese college students' profiles of death attitudes (i.e., fear of death, death avoidance, neutral acceptance, escape acceptance, and approach acceptance), as well as their associations with socio-demographic factors and mental health outcomes. Latent profile analysis identified five subgroups of students: healthy (28.8%), acceptant (11.7%), indifferent (43.5%), paradoxical (10.7%), and avoidant (5.3%). The healthy profile had the most favorable mental health outcomes, whereas the paradoxical profile had the least favorable mental health outcomes. Moreover, women and students from better-resourced universities were more likely to report adaptive patterns of death attitudes. Our findings demonstrated the advantages of using a person-centered approach to achieve a more nuanced understanding of Chinese college students' death attitudes in relation to their mental health. The findings can inform death-related education and mental health interventions for college students.

The Uncertain Certainty: A Mixed Methods Exploration of Personal Meanings of Death and Preliminary Insights Into Their Relationship With Worldview

The present mixed methods study investigated personal meanings of death, i.e., concepts, views, and expectations associated with one's own death, and explored their relation to worldview. To this end, a sample of 202 young, German-speaking adults completed the Death Statements Test, a new qualitative assessment tool, as well as quantitative measures of religiosity, spirituality, atheism, and agnosticism. Qualitative data was transformed to enable quantitative analyses. Results indicated that the spectrum of personal meanings of death is generally broad and multifaceted. The most prevalent view on death was "death as source of motivation and meaning in life." The frequencies of emotionally positive and negative death meanings were relatively balanced, while neutral statements dominated. Relationships between participants' death meanings and worldview dimensions turned out to be small but existent. The Death Statements Test proved to be a valuable and economic assessment tool, eliciting rich qualitative material on personal meanings of death.

Effect of Sociodemographic Variables on Health Anxiety and Death Anxiety Levels in COVID-19 Pandemic

The aim of this study was to evaluate health anxiety and death anxiety levels in adult cases during the COVID-19 pandemic and to evaluate the effect of sociodemographic variables. In this online study, 334 patients over the age of 18 were included. Health Anxiety Scale, Death Anxiety Scale and Sociodemographic Data Form were used in the research. The subscales of health anxiety showed a meaningful correlation between hypersensitivity to bodily findings and negative consequences of the disease and death anxiety. Death anxiety and health anxiety were found to be higher in women. It is statistically significant that health anxiety is more common in individuals aged 20-30 years and women with primary education degrees. Death anxiety was found to be associated with low socioeconomic status and health anxiety was associated with average socioeconomic status. Death anxiety was found to be associated with two of the health anxiety subscales. Sociodemographic variables such as age, gender, educational status and socioeconomic status are thought to be effective in both death anxiety and health anxiety.

Investigation of The Relationship Between Nursing Students' Fear of Death and Their Perceptions of Patient Care

Amaç: Bu araştırma hemşirelik öğrencilerinin yaşadıkları ölüm korkusu ile hasta bakım algıları arasındaki ilişkinin incelenmesi amacıyla gerçekleştirilmiştir. Yöntem: Araştırma kesitsel, tanımlayıcı ve ilişki arayıcı tipte olup araştırmanın örneklemini, Ekim-Kasım 2021 tarihleri arasında bir üniversitenin hemşirelik bölümünde öğrenim gören 326 öğrenci oluşturmuştur. Verilerin toplanmasında, ‘Kişisel bilgi formu’, ‘Ölüm korkusu Ölçeği’ ve ‘Bakım Davranışları ölçeği-24’ kullanılmıştır. Veriler yüz yüze toplanmış olup form ve ölçeklerin doldurulması ortalama 15 dakika sürmüştür. Bulgular: Çalışmaya katılanların çoğunun 280’inin (%85,9) kadın olduğu, 179’unun (%54,9) ölmekte olan hasta bakımı ile ilgili bilgi kaynaklarını okuduğunu, 245 öğrencinin (%75,2) çevresinde ölüm olgusuyla karşılaştığı, 306’sının (%93,9) yaşam sonu dönemde olan hastaya bakım verme deneyiminin olmadığı ve 175’inin (%53,7) ölümden korktuğu belirlenmiştir. Cinsiyete bağlı olarak kadınların hem ölüm korkusunun hem de yaşam sonu hasta bakımı hemşirelik algılarının, BDÖ-24 Ölçeği alt boyutlarından bağlılık ve saygılı olma alanlarında daha yüksek puan aldıkları belirlenmiştir. Yaşam sonu dönemde bir hastaya bakım verme deneyimi olmayan hemşirelik öğrencilerinin, ölüm korkusu ve bakım davranışları arasında anlamlı bir fark olmadığı belirlenmiştir (p&gt;0,05). Sonuç: Hemşirelik öğrencilerinin hemşirelik bakım algıları yüksektir. Kadın öğrencilerin hem ölüm korkuları hem de hemşirelik bakımı algıları erkeklerden yüksek olarak bulunmuştur. Yaşam sonu dönemde olan hastaya bakım verme deneyimi olmayan hemşirelik öğrencilerinin daha fazla güvence verme algısına sahip oldukları belirlenmiştir. Öğrencilerin yaşam sonu dönemde olan hastaya güvence verme algılarının yüksek olması açık bir şekilde yaşam sonu hemşirelik bakımı konusunda yetersiz bilgiye sahip olduklarını göstermektedir. Bu nedenle lisans eğitimi boyunca yaşam sonu dönem hasta bakımı ve ölüm korkusu konularında müfredatta daha fazla başlığın ve eğitim metodlarının yer almasının gerekli olduğu düşünülmektedir.

Death Depression Among Older Adults: A Concept Analysis Utilizing An Evolutionary Approach

Background and Purpose: The reality of death is a source of concern for humans. Managing issues associated with preparation for the inevitability of death may contribute to onset of death depression for aging individuals. The study purpose was to clarify the death depression concept in older adults including relevant features, antecedents, and consequences to further nursing knowledge development.Methods: Rodgers' evolutionary concept analysis was performed using the following steps: determination of concept and appropriate scope; collection of data for identifying concept attributes, antecedents, and consequences; and evaluation of relevant and alternative concepts for further clarification. A search for articles published between 1995 and 2020 relevant to death depression in older adults was conducted in the databases PubMed, Ovid, ProQuest, CINAHL and Persian databases SID and Magiran. Fifty-three articles met the inclusion criteria and final sampling. Findings were reviewed by two independent researchers familiar with the field.Result: Based on the study findings, death depression is characterized by cognitive, affective, and behavioral attributes. Antecedents of death depression include: health concerns associated with aging such as life-limiting or psychiatric illnesses; loneliness and loss perceptions related to social relationships; socio-cultural context; identity issues; and environmental changes. Consequences of death depression include negative adjustment in later life and the potential for adaptation.Implications for Practice: Death depression in older adults may contribute to adverse mental health sequelae. Therefore, assessment for ruminative death cognitions in older adults may lead to interventions that help prevent the onset of death depression. This study provides a foundation for further research, and it contributes to the development of nursing knowledge via concept clarification.

Different Death Attitudes in Internalizing Symptom Context Among Norwegian and Turkish Women

The aim of the present study was to examine the association between death attitudes and depressive and anxiety symptoms among Norwegian and Turkish women. 304 participants were recruited (NNorwegian = 127 [41.8%]; NTurkish = 177 [58.2%]). The Beck Depression Inventory, the trait anxiety subscale of the State-Trait Anxiety Inventory, and the Death Attitude Profile-Revised were administered. The results showed that Fear of Death was positively correlated with anxiety symptoms among Turkish respondents; Approach Acceptance was negatively correlated with depressive and anxiety symptoms among Norwegian participants; and none of the death attitudes had significant negative associations with depressive and anxiety symptoms among Turkish participants. The analysis showed that Escape Acceptance was the only death attitude positively associated with depressive and anxiety symptoms for both countries. We may thus hypothesise that Escape Acceptance is the most maladaptive death attitude for both countries. Patients with this death attitude should be paid closer attention.

[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.

Expectations, end-of-life fears and end-of-life communication among palliative patients with cancer and caregivers: a cross-sectional study

OBJECTIVES

During serious illness, open communication with caregivers can ensure high-quality care. Without end-of-life communication, caregivers may become surrogates and decision-makers without knowing the patient's preferences. However, expectations and fears may influence the initiation of communication. The present study investigates differences between palliative patients with cancer and caregivers regarding expectations of end-of-life communication, end-of-life fears and experiences with end-of-life communication.

DESIGN

A cross-sectional study using a semi-structured interview and a paper-based questionnaire SETTING: University Hospital in Germany.

PARTICIPANTS

151 participants: 85 palliative cancer patients (mean age: 62.8 years, 65.9% male) and 66 caregivers (mean age: 56.3 years, 28.8% male).

PRIMARY AND SECONDARY OUTCOME MEASURES

Expectations, end-of-life fears and experiences of end-of-life discussions.

RESULTS

Patients and caregivers wish for the patient to be self-determined. In general, participants reported more positive than negative expectations of end-of-life discussions. Importantly, concerns about emotionally burdening other person was rated much higher in an informal context than a professional context (F(1,149)=316 958, p<0.001, η_p²=0.680), even though the emotional relief was expected to be higher (F(1,149)=46.115, p<0.001, η_p²=0.236). Caregivers reported more fears about the last period of life and more fears about end-of-life discussions than palliative patients, whereas palliative patients tended to avoid the topics of death and dying to a greater extent.

CONCLUSIONS

There seems to exist a 'self-other' asymmetry: palliative patients and their caregivers expect substantial personal relief when openly talking about end-of-life issues, but also expect the other person to be burdened by such communication. Professionals repeatedly need to initiate end-of-life communication.

"My life became more meaningful": confronting one's own end of life and its effects on well-being-a qualitative study

Background

The perception of being closer to death can be experienced due to old age or life-limiting diseases, and can pose profound existential challenges. Actively confronting death-related issues and existential questions may increase psychosocial comfort and stimulate personal growth, whereas dysfunctional coping may lead to existential distress.

To date, research on individual and (semi-)professional approaches to confronting the own end of life and the effects on one’s well-being remain scarce. Therefore, the aim of this study was to explore individual strategies and wishes in order to derive ideas for appropriate support concepts.

Methods

Twenty semi-structured interviews were conducted with people over the age of 80 (n = 11) and with a life-limiting disease (n = 10). The interviews were transcribed verbatim and independently coded by two researchers according to Braun and Clarke's thematic analysis approach.

Results

While the use of (semi-)professional approaches (e.g., therapeutic support) to confronting existential questions in the shape of one’s impending death was rare, individual coping strategies did have a positive impact on psychosocial comfort. There were hardly any significant differences between the participants aged 80 and over and those with a life-limiting disease in terms of individual coping strategies or how they approached the ends of their lives. Both groups reported that theoretical education, preparing for the ends of their lives (e.g., funerals), talking about death-related topics, reflecting on death-related topics, and contemplating death in a spiritual sense had positive effects on their assurance, self-determination and relief. The necessity of confrontation and a desire for low-threshold, accessible and flexible services to meet their existential and spiritual needs were highlighted.

Conclusions

There is both a desire and a need for the addressing of existential questions. Outside of private contexts, however, the participants possessed little awareness of support services that focused on confronting end-of-life issues, and rarely used such services. Efforts to raise awareness for psychosocial and spiritual needs should be implemented within the care system, together with low-threshold support concepts, in order to increase psychosocial well-being. More research evaluating individual approaches to confronting the own end of life are needed to better understand this determinant of well-being and its mechanisms of action.

Trial registration

www.germanctr.de, DRKS-ID: DRKS00020577.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00950-3.

Spanish Version of the Death Attitude Profile-Revised. Translation and Validation Into Spanish

The Death Attitude Profile-Revised (DAP-R) was developed in English-speaking cultures with the aim of measuring attitudes towards death. This measure consists of 32 items, grouped into five factors (Fear of Death, Avoidance of Death, Neutral Acceptance, Approach Acceptance, and Escape Acceptance). The DAP-R was translated and adapted to Spanish (DAP-RSp), and the psychometric properties were analyzed accross a general sample. The face validity was evaluated by 20 experts in palliative care. N = 417 (X = 39.06 years) took part in the validation. DAP-RSp showed adequate internal consistency (Cronbach's alpha ranging from 0.67 for Neutral Acceptance to 0.95 for Escape a Acceptance, and 0.88 for the total), a multitrait scaling analysis and a confirmatory factor analysis reproduced the five dimensions of the original scale. The Spanish version of the DAP-R can be used as a valid scale to assess attitudes towards death in Spanish speaking population.

Effects of COVID-19 on Mental Health and Its Relationship With Death Attitudes and Coping Styles Among Hungarian, Norwegian, and Turkish Psychology Students

The purpose of this study was to investigate mental effects of coronavirus disease 2019 (COVID-19) and its relationship with death attitudes and coping styles among Hungarian, Norwegian, and Turkish psychology students. A total of 388 participants from Hungary (N = 122, 31.4%), Norway (N = 96, 24.7%), and Turkey (N = 170, 43.8%) were recruited during the pandemic. The Depression, Anxiety and Stress Scale, the Impact of Event Scale-Revised, the Carver Brief COPE Inventory, and the Death Attitude Profile-Revised were used. The results indicated that escape acceptance might be the most maladaptive death attitude during COVID-19, as it was related to poorer mental health among the Hungarian, Norwegian, and Turkish psychology students. Self-blame, behavioral disengagement, self-distraction, and substance use coping styles were also related to poorer mental health, whereas positive-reframing (only among the Hungarian and Turkish participants) and humor (only among the Norwegian participants) were related to better mental health among our sample in the context of COVID-19. The findings implied that death attitudes and coping styles may differ in their efficacy among the Hungarian, Norwegian, and Turkish participants. These differences were discussed in detail in the discussion part. During the pandemic, practitioners might pay closer attention to patients with higher escape acceptance death attitude and patients who use dysfunctional coping styles. Additionally, patients can be encouraged to use techniques involving positive reframing and humor coping styles.

Meaning in life, psychological hardiness and death anxiety: individuals with or without generalized anxiety disorder (GAD)

Generalized anxiety disorder (GAD) is a widespread psychiatric disorder. According to the transdiagnostic approach, death anxiety can underpin predominantly somatic manifestations of GAD. Personal resilience factors such as a sense of a meaningful life, and psychological hardiness, which can protect people from developing clinical symptoms, may be lower in individuals with GAD. So far, there has been no study examining the role of meaning in life dimensions, death anxiety, and hardiness in individuals with GAD in Turkey. Thus, we aimed to investigate to what extent the GAD sample differs from the non-anxious control group in terms of death anxiety, meaning in life dimensions, and hardiness. Secondly, we examined how conceptually predicted death anxiety by meaning in life dimensions and hardiness regardless of diagnosis, age, and gender. Just before the spread of the Covid-19 pandemic, we could only recruit 38 individuals with GAD and 31 non-anxious control subjects. The Death Anxiety Scale, The Meaning in Life Questionnaire and the Psychological Hardiness Scale were administered to all the participants. The one-way MANOVA results with Bonferroni adjustment revealed that individuals with GAD significantly differed from the control group in every way. Hierarchical regression analysis displayed that the presence of meaning made the most significant contribution in predicting death anxiety. In conclusion, existential issues such as death anxiety, hardiness, and meaningful life can be emphasized for the treatment of GAD, and the presence of meaning is the most crucial antidote to avoid death anxiety in all individuals.

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.

Validation of the Revised Collett-Lester Fear of Death Scale in a French Population

Death and dying are processes that every human being encounters in his or her lifetime and perhaps the greatest loss an individual can suffer. In this sense, fear of death is regarded as a risk and maintaining factor of psychopathology. As such, effective and efficient measurement of this construct becomes a priority. While the Revised Collett-Lester Fear Of Death Scale (CL-FODS) is a brief, commonly used assessment, such a tool is lacking in French clinical practice. The present study aimed to adapt the revised CL-FODS in a general French sample and to determine its psychometric properties, namely its factorial structure, concurrent and convergent validity, and internal consistency. A sample of 590 participants responded to the French revised CL-FODS, as well as three instruments assessing death anxiety (DAS), neuroticism and spirituality (FACIT-Sp), to examine the internal consistency, validity and factorial structure of the scale. Both exploratory and confirmatory factor analysis confirmed a four-factor model: (1) One’s Own Death,” (2) The Death of Others, (3) The Dying of Others, and (4) One’s Own Dying. Five items did not load on these four factors, suggesting that the revised CL-FODS might require further psychometric refinement. The revised CL-FODS showed good internal consistency. The scale was found to be significantly associated with the Death Anxiety Scale. When the appropriate psychometric characteristics are taken into account, this scale can be used in clinical and research settings to assess death concerns in French society.

Matters of Life and Death: An Experimental Study Investigating Psychological Interventions to Encourage the Readiness for End-of-Life Conversations

INTRODUCTION

Talking about death and dying is evoking discomfort in many persons, resulting in avoidance of this topic. However, end-of-life discussions can alleviate distress and uncertainties in both old and young adults, but only a minority uses this option in palliative care. Even in healthy populations, talking about death is often seen as alleviative and worthwhile, but rarely initiated.

OBJECTIVE

To investigate different psychological interventions (a) encouraging the readiness for end-of-life discussions and (b) changing death attitudes in healthy adults of different ages.

METHODS

168 participants were randomized to four different interventions (IG1: value-based intervention with end-of-life perspective, IG2: motivation-based intervention with end-of-life perspective, IG3: combination of IG1 and IG2, CG: control group). Primary outcome was the readiness to engage in end-of-life topics. Secondary outcomes were fear of death, fear of dying and death acceptance. Assessments took place before, directly after the intervention and at 2 weeks of follow up.

RESULTS

IG2 and IG3 reported significantly more changes in the readiness to engage in end-of-life discussions than the CG (F[5.61, 307] = 4.83, p < 0.001, ηp2 = 0.081) directly after the intervention. The effect of IG3 remained stable at the follow-up. There were no significant effects of the interventions on end-of-life fears or death acceptance. Acceptability of the interventions was very high.

CONCLUSIONS

Short interventions can be useful to encourage end-of-life discussions and could be integrated in health care programs. The efficacy and effectiveness of these short interventions in palliative patients are currently examined.

Developmental Understanding of Death and Grief Among Children During COVID-19 Pandemic: Application of Bronfenbrenner's Bioecological Model

COVID-19 Pandemic has influenced death-related attitudes and understanding during the childhood development leading to a life-long impact. Factors like pandemic-related movement restrictions, school closures, and parents' stay-at-home have exposed children to the phenomenon of grief and death. In that case, children anticipate adverse outcomes and fear while they struggle with unanswered questions. Children may not have coping skills needed to manage their grief in constructive ways to identify, normalize, and express their responses to the loss in their lives. Naming and validating these responses as distinctive aspects of grief process and providing safe space to express their feelings are essential components of a child's coping with loss and grief. This is crucial to consider, as different children react to and are influenced by their environments differently. This article aims to explore the developmental understanding of the process of death and grief by applying the conceptual framework of Bronfenbrenner's theory. Understanding mutual interaction between a child and various ecological systems determines how children perceive death and process grief can facilitate effective communication that has significant implications.

Death Anxiety and Related Factors in Schizophrenia Patients: Controlled Study

The aim of the study was to investigate the level of death anxiety and related sociodemographic and clinical variables in schizophrenia patients. One hundred and ninety schizophrenia patients and 110 healthy controls were included the study. Death anxiety measured with Templer Death Anxiety Scale (TDAS). The patients were also evaluated with scales in terms of depression, anxiety, obsessive-compulsive symptoms, and suicide. The death anxiety level in patients with schizophrenia was significantly higher than the healthy controls. The severity of depressive and psychotic symptoms were related to the level of death anxiety. Patients with schizophrenia may need more protection and psychosocial interventions about death related themes.

Attitudes toward death and death acceptance among hemato-oncologists: An Israeli sample

OBJECTIVE

Hemato-oncologists are highly exposed to patients' death and suffering during their daily work. The current exploratory and cross-sectional study examined death acceptance attitudes, in order to explore whether death acceptance attitudes are associated with fear of death.

METHOD

A convenience sample of 50 Israeli hemato-oncologists currently working in a clinical setting participated in the study. They completed the Death Attitudes Profile revised questionnaire (DAP-R), which examines levels of fear of death, death avoidance, approach acceptance, neutral acceptance, and escape acceptance. In addition, the hemato-oncologists reported on levels of exposure to patients' death and suffering.

RESULTS

A repeated measures MANOVA revealed significantly lower levels of neutral acceptance, compared with approach and escape acceptance. Path analysis for predicting fear of death by the other study variables revealed that death avoidance fully mediated the relationship between approach acceptance and fear of death as well as revealing a negative correlation between neutral acceptance and fear of death (higher neutral acceptance was related to lower fear of death). No associations were found between exposure to death and suffering and attitudes toward death.

SIGNIFICANCE OF RESULTS

In contrast to previous conceptualizations, the ability to adaptively cope with fear of death differed in accordance with death acceptance attitudes. Whereas neutral acceptance adaptively defended from fear of death, approach acceptance was associated with increased fear of death through death avoidance. As hemato-oncologists are highly exposed to patients' death and suffering, and are required to make critical medical decisions on daily basis, these findings may have substantial implications for end-of-life care and the process of medical decision-making regarding the choice of treatment goals: cure, quality of life, and life prolongment. Further research is needed to investigate the role of death acceptance attitudes among hemato-oncologists.

Live well and die with inner peace: The importance of retrospective need-based experiences, ego integrity and despair for late adults' death attitudes

Given that prior research has provided evidence for the role of late adults' attitudes towards death in their mental health, we sought to understand its underlying sources. Guided by Self-Determination Theory and Erikson's theory of psychosocial development, two cross-sectional studies examined whether older individuals' psychological need-based experiences, as accumulated during life, relate to their death attitudes and whether their experienced ego integrity and despair play an intervening role in these associations. Whereas Study 1 (N = 394 late adults; Mage = 75.14; SD = 6.52; 62.9 % female) involved an assessment of need satisfaction only, in Study 2 (N = 126 late adults; Mage = 78.09; SD = 7.17; 61.9 % female) both need satisfaction and need frustration were assessed. Structural equation modeling showed that, across studies, experienced need satisfaction related positively to ego integrity and negatively to despair. Need frustration was related to despair only. In turn, ego integrity related positively to death acceptance and negatively to death anxiety, while despair related positively to death anxiety. Finally, the contribution of need satisfaction to death attitudes was mostly mediated by individuals' ego integrity. Theoretical and practical implications of these results are discussed.

Death anxiety, self-worth, and exposure to human donor remains: A longitudinal study of Irish medical students

This study aimed to investigate the relationship between death anxiety levels at pre-exposure to human donor remains, post-exposure self-worth, and post-exposure death anxiety levels, among a sample of Irish medical students. A multi-wave prospective study was conducted, using questionnaires administered at six time-points. Path analysis was used to investigate the effect of pre-exposure death anxiety levels and post-exposure self-worth on post-exposure death anxiety levels. Baseline death anxiety was found to predict post-exposure death anxiety. Furthermore, self-worth at one month of exposure was found to mediate the relationship between pre-exposure death anxiety levels and death anxiety levels at six months.

Is Death Taboo for Older Chinese Immigrants?

Much of the scholarly literature sees death as a taboo topic for Chinese. To test this assumption, this study held seven focus groups in the Greater Toronto Area in 2017. It found that the majority of the older Chinese immigrant participants talked about death freely using either the word death or a euphemism. They talked about various issues including medical treatment and end-of-life care, medical assistance in dying, death preparation, and so on. A small number did not talk about death, but it seemed their reluctance was related to anxiety or discomfort or simply reflected a choice of words. The study concludes death as taboo could be a myth, at least for older Chinese immigrants.

Differences in well-being and fear of death among female hospice employees and volunteers in Hungary

BACKGROUND

Voluntary work plays a significant role in hospice care, but international research has mainly been conducted on the mental health and fear of death of paid hospice staff. The aim of the present study was to compare the Hungarian hospice volunteers with paid employees with regard to attitudes and fear of death, as well as mental health in order to see their role in hospice work and their psychological well-being more clearly.

METHODS

The target population of the cross-sectional questionnaire study was hospice care providers in Hungary (N = 1255). The response rate was 15.5% (N = 195); 91.8% (N = 179) of them were women. The mean age of female hospice workers was 45.8 years (SD = 10.46 years, range: 23-73 years). One-quarter (27.9%, N = 50) of the female respondents were volunteers. The instruments were: the Multidimensional Fear of Death Scale, the Perceived Stress Scale, the WHO-5 Well-Being Index, and a shortened versions of the Beck Depression Inventory and the Maastricht Vital Exhaustion Questionnaire.

RESULTS

Volunteers scored significantly lower on 5 dimensions of fear of death than paid employees, and showed significantly lower levels of vital exhaustion and significantly higher levels of psychological well-being than paid employees. Fear of the dying process was associated with an increased perceived stress, depressive symptoms, and vital exhaustion in both groups. Psychological well-being showed a significant negative, moderate correlation with four aspects of fear of death among paid staff; this pattern did not appear in the volunteer group. In addition, the association between fear of premature death and perceived stress, vital exhaustion, and depressive symptoms was more pronounced is case of paid workers.

CONCLUSION

Higher levels of psychological well-being and lower levels of fear of death among hospice volunteers suggest that they are less exhausted than paid employees. Increasing the recruitment of volunteers in hospices may help reduce the overload and exhaustion of paid employees.

Fear of Death and Death Acceptance Among Bereaved Adults: Associations With Prolonged Grief

This study aimed to analyze fear of death and neutral acceptance of death after a significant loss and their associations with prolonged grief. The sample of the study included 239 bereaved participants. Time since the loss ranged from 6 to 72 months. We found that neutral acceptance of death was associated with older age, a natural cause of death, and the ability to find meaning in the death of a close one. Fear of death was negatively associated with the frequency of practicing religion. We found that fear of death but not neutral acceptance was significantly associated with prolonged grief symptoms.

Death-related distress in adult primary brain tumor patients

Background

A diagnosis of cancer may increase mortality salience and provoke death-related distress. Primary brain tumor (PBT) patients may be at particular risk for such distress given the certainty of tumor progression, lack of curative treatments, and poor survival rates. This study is the first to examine the prevalence of death-related distress and its correlates in PBT patients.

Methods

Adult PBT patients (N = 105) enrolled in this cross-sectional study and completed the Death Distress Scale (subscales: Death Depression, Death Anxiety, Death Obsession), Generalized Anxiety Disorder-7, and Patient Health Questionnaire-9. Prevalence and predictors of death-related distress, and the relationships of demographic variables to clusters of distress, were explored.

Results

The majority of PBT patients endorsed clinically significant death-related distress in at least one domain. Death anxiety was endorsed by 81%, death depression by 12.5%, and death obsession by 10.5%. Generalized anxiety was the only factor associated with global death-related distress. Cluster analysis yielded 4 profiles: global distress, emotional distress, resilience, and existential distress. Participants in the resilience cluster were significantly further out from diagnosis than those in the existential distress cluster. There were no differences in cluster membership based on age, sex, or tumor grade.

Conclusions

PBT patients appear to have a high prevalence of death-related distress, particularly death anxiety. Further, 4 distinct profiles of distress were identified, supporting the need for tailored approaches to addressing death-related distress. A shift in clusters of distress based on time since diagnosis also suggest the need for future longitudinal assessment.

The Comparison of Death Anxiety, Obsession, and Depression Between Muslim Population with Positive and Negative Religious Coping

Death anxiety, obsession, and depression constitute three dimensions of death distress which can be influenced by religious coping in religious individuals. The aim of this study was to compare death anxiety, depression, and obsession between Muslims with positive and negative religious coping. In a cross-sectional study, a sample of 339 participants were selected via stratified random sampling method. The participants were screened using the Brief Religious Coping Scale, in which 60 individuals were identified to have positive religious coping and 62 individuals were recognized as individuals with negative religious coping. They responded to Death Anxiety Scale, Death Obsession Scale, and Death Depression Scale. The data were analyzed using factor analysis and multiple analysis of variance. The results of principal component analysis showed that death anxiety, death obsession, and death depression were separate factors of death distress. The results also revealed that individuals with negative religious coping gained higher scores than those with positive religious coping in all the three variables of death anxiety, obsession, and depression. Consistent with the previous studies and Terror Management Theory, this finding lays emphasis on the role of positive religious coping in reducing death distress and the possible consequent psychopathology.

Young adults' perspectives on advance care planning: Evaluating the Death over Dinner initiative

We investigated how death attitudes and experience relate to perspectives on advance care planning (ACP) in young adulthood, and whether attending a Death over Dinner event affects perspectives on ACP. Participants (N = 109) were assigned to a Death over Dinner or waitlist control condition, completing pretest and post-test measures. Higher Death Rejection and having more Experience with Death predicted Reservations about ACP. Participation in a Death over Dinner decreased Reservations toward ACP compared to the control group. Death over Dinner appears to be useful in ameliorating reservations toward ACP without shortening individuals' sense of their time left to live.

Examination of the relationships between religiosity and death attitudes in Turkey and the United States

This study examined the relationship between religious orientation and death attitudes in Christian U.S. students and Muslim Turkish students. It also assessed whether meaning in life mediated these relationships. Multivariate statistics and path analyses were conducted to identify significant predictors of death attitudes in these groups. Intrinsic religiosity was more consistently associated with positive attitudes toward death than extrinsic religiosity, and these patterns remained consistent across groups. Meaning in life mediated some of these relationships, although not consistently. Evidence suggesting differential relationships between religiosity and death attitudes across groups was found, although the overall results suggest more similarities than differences.

The relationship between physical health and fear of death in rural residents: The mediation effect of meaning in life and mental health

The current research used questionnaire data to examine the direct and indirect paths between physical health and fear of death. For 386 rural residents, physical health, meaning in life, and mental health were negatively related to fear of death. Physical health affected fear of death through three paths: one was the independent mediation of meaning in life, the other was the independent mediation of mental health, and the third was the serial mediation of meaning in life and mental health. To reduce the fear of death and improve the quality of life among rural residents, educational interventions of meaning in life and mental health are imperative.

German version of the Death Attitudes Profile- Revised (DAP-GR) - translation and validation of a multidimensional measurement of attitudes towards death

BACKGROUND

In Germany, only limited data are available on attitudes towards death. Existing measurements are complex and time consuming, and data on psychometric properties are limited. The Death Attitude Profile- Revised (DAP-R) captures attitudes towards dying and death. The measure consists of 32 items, which are assigned to 5 dimensions (Fear of Death, Death Avoidance, Neutral Acceptance, Approach Acceptance, Escape Acceptance). It has been translated and tested in several countries, but no German version exists to date. This study reports the translation of the Death Attitudes Profile-Revised (DAP-R) into German (DAP-GR) using a cross-cultural adaption process methodology and its psychometric assessment.

METHODS

The DAP-R was translated following guidelines for cultural adaption. A total of 216 medical students of the Heinrich Heine University Duesseldorf participated in this study. Interrater reliability was investigated by means of Kendall's W concordance coefficient. The internal consistency of the DAP-GR Scales was assessed with Cronbach's alpha coefficients. Split-half reliability was estimated using Spearman-Brown coefficients. Convergent validity was measured by Spearman's correlation coefficient. Content validity was assessed by means of confirmatory factor analysis (CFA). All statistical analyses were performed using SPSS 24 and AMOS 22.

RESULTS

The items showed fair to good interrater reliability, with W-values ranging from .30 to .79. Internal consistency of the five subscales ranged from .61 (Neutral Acceptance) to .94 (Approach Acceptance). Split-half reliability was good, with a Spearman-Brown-coefficient of .83. The results of CFA slightly diverged from the original scale.

CONCLUSION

Our results suggest overall good reliability of the German version of the DAP-R. The DAP-GR promises to be a robust instrument to establish normative data on death attitudes for use in German-speaking countries.

Death anxiety and death acceptance in atheists and other nonbelievers

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

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

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

Objectives

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

Methods

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

Findings

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

Conclusions

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

Characterizing death acceptance among patients with cancer

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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