With an increase in aging population, the health of older adults has become one of the main public health issues in China [34]. Considering older adults are getting close to the end of their lives and more susceptible to diseases, as well as experiencing the loss of others inevitably [5], it is necessary to know their attitudes towards death and demands for death education. This study aims to take death as a window to a better life and help older adults to think about their life plans. It is helpful for maximizing the social value of older adults and realizing healthy and active aging. In the context of a traditional Chinese culture in which talking about death is a taboo [13], this study is one of the few studies on the attitudes towards death and their demands for death education in the community dwelling older adults. The findings may provide support for community health education and hospice and palliative care promotion.

Attitudes towards death among the community-dwelling older adults

A study of death anxiety among older adults in the UK shows that anxiety levels decrease with age [35]. The Korean older adults have a slightly positive attitude towards death, which is consistent with the results of this study [36]. In this study, the score of neutral acceptance of death among the older adults was the highest, but still lower than positive attitude towards death (3.45 ± 0.58) among the older adults in Taiwan, China [37]. The results of this study showed that the attitude towards death in the study participants was neutral acceptance of death mainly. Although the education level of the older adults in this survey is not high, 66.67% had not receive education higher than senior school, and all the participants in this survey had not receive death education before, they can still view death as a stage of life rationally. This may be related to the participants’ life experience and psychosocial development.

The score of death avoidance ranked second. To some extent, it shows that although the study participants can accept death as a part of life, most of them still avoid talking about death-related issues, such as planning before dying. Avoiding talking about death is a way to reduce the awareness of death, but it also reduces the acceptance of hospice and palliative care [38], and the quality of death [39]. In addition, avoiding talking about death may put the older adults who have experienced the death of their loved ones in a long period of sadness, even depression or other psychological diseases [40], which is not conducive to their mental health [41]. This is something that health professionals need to pay attention to.

The scores of escape acceptance and approach acceptance toward death in the older adults were close, and both were higher than the theoretical median 2.5, indicating that when older adults have to face death, they can accept death from the point of view of reality and/or their longing, rather than extreme fear.

Fear of death scored lowest in this study is different from that in Iran. Death anxiety among older Iranians was relatively high [42]. Nearly 80% of the community-dwelling older adults in this study suffer from chronic diseases but 98.05% have no care problems according to their self-assessments. It may be that the older adults have less near-death feelings or experiences, and they also avoid the topic of death, so their fear and anxiety are relatively low.

The study by Lockhart, L. K. et al. showed that the score of approach acceptance of death in American older adults was 3.94 ± 0.93, which was higher than the 2.83 ± 0.68 in this study, while the scores of escaping acceptance of death and fear of death were 2.52 ± 0.68 and 2.15 ± 0.58 respectively, which were lower than those in this study [43]. It showed that the characteristics of death attitudes of the older adults in the United States are more clear than that of the older adults in this study. It is worth noting that the scores of attitudes towards death in all dimensions are between 2.5 and 3.5, indicating that the attitudes towards death of community-dwelling older adults are complex and multi-dimensional. No obvious attitude tendency towards death in older adults indicates that the cognition towards death is still in a vague stage, and professional guidance and education are required.

Influencing factors of attitudes towards death among the community-dwelling older adults

Many studies have come to different findings about the influencing factors of attitudes towards death [15, 44], and this is related to the unique cultural background of the research objects [45]. In Chinese culture, the study community-dwelling older adults’ attitudes towards death were influenced by the number of diseases, discussion about life and death, marital status, and average income per month.

The item “number of diseases” has an impact on fear of death, death avoidance and escape acceptance of death. When the investigated group was not sick, the scores of fear of death, death avoidance and escape acceptance of death would decrease. This indicates that diseases will bring changes in the older adults’ thoughts and attitudes towards death. When the number of diseases increased, the negative effect on fear of death, death avoidance and escape acceptance of death disappeared, indicating that the presence or absence of diseases is the key to affect attitudes towards death in older adults. Only when the number of diseases increased to two, there was a positive impact on death avoidance. With the number of diseases increasing, older adults may be aware of the proximity of death, deepening their avoidance of death. However, when the number of diseases increased beyond two, the positive and negative effects on attitudes towards death all disappeared. The above results suggest that community health professionals should pay more attention to the emotional and psychological changes of the older adults when the diseases are first diagnosed and the number of diseases increases to two.

The discussion about life and death is the factor that affects fear of death, neutral acceptance of death, approaching acceptance of death and escape acceptance of death. The discussion about life and death has a positive effect on the community-resident older adults’ scores of approaching acceptance of death and escape acceptance of death. The life and death relevant discussions increase older adults’ recognition of approaching acceptance of death and escape acceptance of death. The scores of fear of death and neutral acceptance of death will decrease if there is no discussion about life and death. Overall, the life and death discussion has an impact on all dimensions of the community-dwelling older adults’ attitudes towards death except death avoidance. The discussion about life and death is a double-edged sword, which should be carried out cautiously. On one hand, it may generally improve the awareness of death and promote older adults to accept death neutrally to some extent. On the other hand, it may also arise fear of death, approach acceptance of death and escape acceptance of death. Therefore, more in-depth, and detailed research is needed in how to standardize or appropriately carry out the life and death discussion within older adults.

The effect of remarriage on fear of death of community-dwelling older adults is negative. Marital status was also an influencing factor in cancer patients’ death anxiety [46]. The proportion of remarried older adults is relatively low, but marital status is statistically significant in both univariate and multivariate regression analysis of fear of death. Older adults who were remarried had a lower score of fear of death and were less afraid of death than older adults in other marital status. This may be due to an unhappy life experience and the courage to make a change of remarried older adults. To some extent, remarriage shows older people’s ability to integrate into life and find happiness again [47], and this experience may reduce the feelings of fear when they are in face of death.

This study found that an average monthly income of more than 750 $ had a negative effect on the score of escape acceptance of death for the study participants. Escape acceptance of death refers to that death is accepted as a way of escaping from a life of misery [9]. High income can improve the quality of life. An average monthly income of more than 750 $ can provide a better guarantee for the real life needs of older adults in China. Hence, it is possible that the older people at this income level do not find life painful and the tendency to escape acceptance of death is weak.

In addition to the above factors that had statistical significance in the multiple linear regression analysis, age, self-care ability and experience of others death or dying were statistically significant in the univariate analysis of death attitudes of the community-dwelling older adults in this study.

Age was a significant influencing factor on the attitudes towards death between the young and old groups in many studies [8, 14]. In this study, the attitudes towards death among the young-old (60–69 years old), the middle-old (70–79 years old) and the old-old (over 80 years old) population differ only in the approach acceptance of death dimension. The score of approach acceptance of death among the middle-old is the lowest, which may be because the physical function of the middle-old is weaker than that of the young-old, and the psychological preparation for death is not sufficient when compared with that of the old-old. However, in the multivariate analysis, age did not enter any regression equation of death attitudes. So, under the comprehensive influence of multiple social factors, age of older adults has no significant impact on their attitudes towards death. Older adults in this study with different self-care abilities have different degrees of fear of death. Those who are fully capable of self-care have the lowest score of fear of death, but it is not statistically significant in multivariate analysis. Older people with the slow reduction of self-care ability may have a better death preparation compared with receiving a sudden shocking diagnosis, so it is not a significant factor in a comprehensive setting. Chronic, or severe illnesses seriously affect older adults’ acceptance of death [22]. The experience of others death or dying was also an influencing factor in the univariate analysis of death attitudes of the community-dwelling older adults. By witnessing other people’s death, the community-dwelling older adults may have a higher score of neutral acceptance of death, indicating that the inevitable experience of witnessing the death of others unconsciously acts as a reminder of death and makes older adults realize that death is a natural law [48].

Demands for the content of death education within the community-dwelling older adults

Through analysing the influencing factors of death attitudes, we found that the discussion of life and death is an important way for community health professionals to improve the awareness about death and dying and affect death attitudes of older adults. In fact, if we want to make the best of the positive guidance of such discussion, professional and scientific death education need to be carried out for older adults. Death education is the opportunity and window for discussing life and death for Chinese older adults [28]. Therefore, this study surveyed the contents of death education that the community-dwelling older adults are interested in and demanded.

In terms of the overall degree of demands, the percent for ways to reduce the burden of end-of-life care is the highest. The demands proportion of “wills and advance directives, policies about geriatric care and hospice care, psychological preparation for death” followed, indicating that older adults in this study hope to plan their terminal stage, improve the quality of death effectively, and achieve a good death. The community-dwelling older adults in this study have relatively low demands for medical knowledge, meaning of life, euthanasia (not allowed by Chinese law [49]) and culture about life and death. The degree of demands for the ten death education items in this study were all more than 70%, and this means that the study participants are eager to know more about death and hope to communicate with others about life and death [12].

However, there is no universal death education for the community-dwelling older adults in China. Although there have been a few death education studies for cancer patients [50], health professionals [51] and medical students [52], the community-dwelling older adults have been neglected. Different from the developed countries such as United States, United Kingdom and Canada, where death education has become universal in primary and secondary schools [24, 53], death education in China is carried out only in older adults sporadically [54]. In view of sociocultural traditions, mention of death is still considered sensitive or emotionally damaging, especially when discussing death with older adults. Therefore, the content design of death education for community-dwelling older adults should pay more attention to the actual demands of them. In this way, death anxiety of older adults can be avoided as far as possible, and at the same time, older adults can be motivated to think about death, plan their end-of-life care, and cherish the present time, thus improving the quality of life and acquiring happiness [55].

Limitations

The proportion of some groups varies greatly such as ethnicity, religions, and marital status. But this is also the reality in China. Influenced by the research contents, older adults who are very sensitive to the topic of death or extremely afraid of death may be reluctant to participate in this study. In fact, this is difficult to avoid under the premise that the survey respondents voluntarily participate in the death attitude survey. And this study was completed in a small sample in Chongqing, southwest China, replicating it in an area where random sampling could be used is recommended. Future studies should expand the sample size and maximize the characteristics of different older adults’ groups, to better explore the factors affecting attitudes towards death.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Disclaimer:

This article is autogenerated using RSS feeds and has not been created or edited by OA JF.

Click here for Source link (https://www.biomedcentral.com/)