The Relationship Between Authenticity and Death Anxiety in Cancer Patients

Abstract

One of the many problems cancer patients experience is death anxiety. This descriptive-analytical cross-sectional study aimed to investigate the relationship between authenticity and death anxiety in cancer patients. The participants were 172 cancer patients who referred to medical centers in southeast Iran. The data were collected using authenticity inventory, and death and dying anxiety scale. There was a negative correlation between authenticity and death anxiety, i.e. patients who indicated higher authenticity scores showed lower levels of death anxiety. It seems that developing a comprehensive care program for increasing awareness of authenticity in patients, may be effective in reducing patient death anxiety.

Keywords

authenticity death anxiety cancer patients

Cancer is the second most common cause of death, accounting for one in six deaths worldwide (Collier et al., 2020). The physical consequences of cancer make patients feel that they are close to death (Razban et al., 2020). Thus, many patients are overwhelmed and disturbed by recurring thoughts of death (Mavrogiorgou et al., 2020). Death anxiety is a term used to describe the particular anxiety caused by the awareness of death (Grossman et al., 2018).

Death anxiety is defined as an unpleasant feeling that has an existential origin and is triggered by thinking about one's own or others' death (Thiemann et al., 2015). In other words, anxiety about death is a constant, irrational, and morbid fear of death (Jani et al., 2014). Death anxiety is associated with negative psychological consequences such as depression, dependence, and fear of suffering and mortality (Lo et al., 2010). Awareness of the inevitable reality of death and its conflict with a strong desire for survival can cause severe fear in a person (Dadfar et al., 2018). Previous research indicates that people with higher levels of self-actualization, self-awareness, and self-esteem have lower death anxiety, and that negative emotional states are related to death anxiety; this occurs in part because of the importance of these factors for creating a healthy self-image through a positive attitude towards oneself (Abeyta et al., 2014; Du et al., 2013; Gedik & Bahadır, 2014). People with high self-esteem are confident in their abilities and success and show a positive and healthy mental attitude towards life (Chung et al., 2015). Terror management theory proposes that self-esteem provides protection against the anxiety of death (Du et al., 2013). A study revealed an inverse correlation between self-esteem and death anxiety among Korean university students (Chung et al., 2015). In another study, researchers manipulated participants' self-esteem by means of positive or neutral feedback on a bogus personality test. Participants then wrote about either their own mortality. The manipulation was clearly effective in modifying reactions to mortality salience. Self-esteem reduces not only anxiety and anxiety-mediated behavior, but also symbolic defensive responses to concerns about death (Harmon-Jones et al., 1997).

More than 90% of Iranians are Muslim (Shahin, 2016). In Islam, death is considered the beginning of spiritual life based on the consequences of worldly life (Ahmad & Lakhvi, 2015). Islam advises people to think about death because it is believed that accepting and thinking about death saves man from corruption. Both Islam and ancient Persian literature such as the works of Mawlana promote the concept of dying before death. In fact, this refers to the death of the ego, not of the body. In fact, this is the inauthentic and false self that dies before the body ends its life (Ghavami, 2016). However, in the current culture of Iran, facing death causes anxiety for cancer patients and their families (Soleimani et al., 2016). Cancer is the third leading cause of death in Iran (Farhood et al., 2018). The idea of this disease is so unpleasant to people that in effect, it has become a taboo, and people even prefer not to use the word “cancer” at all, to the extent that healthcare providers and patients' families try to hide the patient's cancer diagnosis (Hassankhani et al., 2019). This is because Iranians consider cancer incurable and equal to death. In many cases, even the fear of disability and death makes people unwilling to take part in cancer screening. Due to the sense of pity observed in social behaviors, people prefer to avoid screening in order to avoid being subjected to pity as well as being asked questions about their health. Sometimes, they even hide suspicious tumors, which exposes them to the risk of developing cancer (Safizadeh et al., 2018). Identifying the factors associated with death anxiety can be helpful in this regard. Some existential philosophers such as Heidegger believed that people who deny death have an inauthentic life while those who bravely face and accept the temporary and mortal nature of their lives lead an authentic life (Hoelterhoff, 2015).

Authenticity means an honest awareness of the inner truth or the real self (Hassankhani et al., 2019). Facing the truth of death calmly instead of fearing and denying it enables people to regain their freedom (Razban et al., 2020). Authenticity consists of four components including awareness, unbiased processing, behavior, and relational orientation. Awareness means understanding one’s real self, accepting it, and being willing to develop it. Unbiased processing examines one’s ability to objectively evaluate the characteristics of the self and avoid the distortion of incoming external feedback. Behavioral authenticity refers to the feeling that intrinsic motivation is consistent with one's values, preferences, and needs. Relational orientation is concerned with valuing and pursuing openness and honesty in one's close relationships (Tou et al., 2015). Understanding the realities of the world enables cancer patients to better accept the diagnosis of cancer and its associated issues such as death and the uncertain future (Hvidt, 2017). One study revealed that loneliness, which appeared less frequently among those who were higher in authenticity, was associated with increased anxiety and more physical symptoms. Individuals who had higher loneliness scores and lower authenticity reported increased alcohol-related problems. The Key finding is that authenticity is able to buffer the effects of loneliness on health, suggesting that while loneliness is detrimental to health, authenticity can act as a cushion, lessening these negative effects (Bryan et al., 2017). It seems that the authentic self-experience reduces the social dysfunctions associated with social anxiety disorder, and self-alienation and that lack of authenticity play the most important role in a person's emotional loneliness (Plasencia et al., 2016). Besides, social loneliness and loneliness are the best predictors of self-alienation (Shafiee & Ghamarani, 2017)

In some countries, including Iran, the knowledge of palliative care, including the reduction of death anxiety, has not been adequately developed, and some health care providers are not prepared to provide this type of care. On the other hand, there is a lack of interest in the subject of death among the general public and researchers. Thus, studies on authenticity and death anxiety are scarce. Therefore, this study seeks to address this gap in literature by evaluating the relationship between authenticity and death anxiety and confirming the levels of authenticity and death anxiety in cancer patients and to provide basic data for the development of a program aiming to help this population increase their authenticity and develop positive attitudes towards death. This descriptive-analytical cross-sectional study was conducted using authenticity and death anxiety scales with the hypothesis that authenticity is negatively associated with death anxiety.

Method

Study Design and Setting

This study had a descriptive-analytical cross-sectional design. The study setting included the oncology wards of two teaching hospitals affiliated with Kerman University of Medical Sciences in southeast Iran.

Sample Size and Sampling

The study population consisted of 188 cancer patients referring to oncology wards in the aforementioned hospitals. Inclusion criteria were having basic literacy so as to have less difficulty in understanding the concepts and questions in the questionnaires and being aged over 18. Besides, patients who completed less than 15% of the questions in the questionnaire were excluded from the study. The number of participants in this study was 172 patients (response rate = 91.48%). The data collection process lasted from April to July 2019.

Instrument

Demographic information form, authenticity inventory, and death anxiety scale were used.

Demographic Information Form

The questions collecting sociodemographic information included questions on age, sex, marital status, place of residence, ethnicity, level of education, occupation, monthly income, type of cancer, and whether the participant has experienced the death of a family member or not.

Authenticity Inventory

We used a questionnaire that was previously used by Kernis and Goldman in the United States to assess patients' perception of authenticity (Kernis & Goldman, 2006). The inventory includes 45 items, 12 of which measure awareness (for example “I do not know what is important for me”), 10 items measure unbiased processing (for example “I try to be honest in expressing interest in others”), 11 items measure behavior (for example “I usually act according to my real needs and desires”), and 12 items measure relational orientation (for example “When I'm not really myself and I play a role for others, I am aware of playing my own role”) . This instrument measures patients' perception of authenticity using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Following the method used in the original questionnaire, the mean score of the items was calculated as the overall score (45). The mean score obtained was between 1 and 5. A higher score indicated a higher degree of authenticity. This questionnaire was provided to fifteen faculty members to determine content validity. The content validity index was determined to be 0.93. Also, this questionnaire was provided to 30 cancer patients to confirm its reliability (internal consistency), and a Cronbach’s alpha coefficient of 0.87 was calculated.

Death Anxiety Scale

The death anxiety scale was developed by Krause et al. in Canada to assess death anxiety and the concerns of patients with advanced cancer . The questionnaire included 15 items using a 6-point Likert scale (0 = I was not distressed; 1 = I experienced very little distress; 2 = I experienced mild distress; 3 = I experienced moderate distress; 4 = I experienced great distress, and 5 = I experienced extreme distress). The sum of scores received was reported as overall questionnaire score and ranged from 0 to 75, with a higher score indicating higher death anxiety. The content validity index was determined to be 0.92 by faculty members. Cronbach’s alpha coefficient was calculated to be 0.93 through the completion of this questionnaire by 30 cancer patients to confirm the reliability (internal consistency).

Data Collection

After obtaining the code of ethics (No. IR.KMU.REC.1397.430) and necessary permits, the researcher referred to the study setting and invited participants to take part in the study. Every participant provided written informed consent, and was assured that their information would remain confidential. At first, the sociodemographic questions were completed by the participants, and then the authenticity inventory and death anxiety scale were offered to the participants.

Data Analysis

Data were analyzed using SPSS 18. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to describe sociodemographic information, authenticity, and death anxiety scores of the participants. Spearman correlation coefficient was used to determine the correlation between authenticity and death anxiety. Pearson correlation, spearman correlation coefficient, independent t-test, and ANOVA were used to determine the correlation between death anxiety and sociodemographic information. Linear regression was used to examine the data more accurately. Significance level was set at 0.05.

Results

The mean age of the patients was 63.53 ± 13.11 years, their mean duration of illness was 29.96 ± 38.36 months, and 43% of them suffered from breast cancer (Table 1).

Table 1.

Participants’ Demographic Characteristics and Their Correlation With Death Anxiety.

Variable	Categories	N	%	Death anxiety		Statistic test	p value
Variable	Categories	N	%	M	SD	Statistic test	p value
Gender	Female	127	73.8	39.2	17.83	1.71^a	0.09
Gender	Male	45	26.2	33.64	19.63	1.71^a	0.09
Marital status	Married	144	83.7	37.68	23.21	–0.01^a	0.99
Marital status	Single/Widow	28	16.3	37.73	17.30	–0.01^a	0.99
Education	Illiterate	43	25	40.93	16.63	1.27^b	0.29
	Elementary, high school	36	20.9	33.03	17.95
	Diploma	44	25.6	38.53	18.94
	Higher education	49	28.5	37.50	19.12
Occupation	Employee	52	30.2	36.30	18.29	0.37^b	0.7
	Retired	15	8.2	36.21	21.18
	Unemployed/housewife	106	61.6	38.85	18.0
Type of cancer	Colon	20	11.6	33.65	22.61	0.98^b	0.4
	Breast	74	43	38.10	17.71
	Lymphoma	25	14.5	34.26	16.64
	Other	53	30.8	40.24	18.03
Type of treatment	Chemotrapy	39	23.2	35.64	16.16	1.66^a	0.18
	surgery	13	7.7	34.46	15.36
	Combind	107	63.7	39.81	18.93
	other	9	5.7	29.54	19.87
Experiencing a crisis in the last six months	Yes	50	34.7	43.17	16.42	2.01	0.047
Experiencing a crisis in the last six months	No	97	65.3	36.77	19.11	2.01	0.047
Family members having cancer the recent years	Yes	64	37.2	41.36	17.9	2.01^a	0.046
Family members having cancer the recent years	No	108	62.8	35.58	18.33	2.01^a	0.046
The death of family members during the last year	Yes	61	35.4	40.12	18.73	1.37^a	0.17
The death of family members during the last year	No	111	64.6	36.13	18.0	1.37^a	0.17
Age (years)				53.63	13.11	r = –0.04^c	0.72
Duration of disease (month)				29.94	38.34	ρ = 0.12^d	0.12

Independent t-test.

ANOVA.

Pearson correlation.

Spearman correlation.

The mean score of patient authenticity was 3.32 ± 0.29, and of the items in the authenticity questionnaire, the highest scores were related to awareness (3.53 ± 0.47) and relational orientation (3.53 ± 0.38). The lowest score of patient authenticity was related to unbiased processing (2.87 ± 0.51). The total score of the patients’ death anxiety was 37.69 ± 18.28 (Table 2).

Table 2.

The Mean Scores for Authenticity, Its Dimensions, and Death Anxiety.

Variable	M	SD
Awareness	3.53	0.47
Unbiased processing	2.87	0.51
Behavior	3.26	0.56
Relational orientation	3.53	0.38
Total authenticity score	3.32	0.29
Total death anxiety score	37.69	18.28

There was a moderate significant reverse correlation between patient authenticity and patients’ death anxiety (r = –0.19, p = 0.01). Besides, of the various dimensions of authenticity, awareness (ρ = –0.17, p = 0.03) and behavior (r = –0.25, p = 0.001) had a moderate reverse significant correlation with patients’ death anxiety while no significant correlation was observed between death anxiety and the dimensions of unbiased processing (ρ = –0.03, p = 0.7) and relational orientation (ρ = –0.01, p = 0.87) (Table 3).

Table 3.

The Relationship Between Authenticity and Its Dimensions With Death Anxiety.

Variable dimensions of authenticity	Death anxiety
Variable dimensions of authenticity	Correlation coefficient	p value
Awareness	ρ = –0.17	0.03
Unbiased processing	ρ = 0.03	0.70
Behavior	r = –0.25	0.001
Relational orientation	ρ = –0.01	0.87
Total score of authenticity	r = –0.19	0.01

r = Pearson correlation.

ρ = Spearman correlation.

Univariate analysis showed that there was a significant difference between experiencing an emotional crisis in the last six months and family members having cancer during the recent years and death anxiety (Table 1). In order to eliminate confounding effects of independent variables and to investigate the predictors of death anxiety, all variables that had a significance of less than 0.2 in univariate analysis were entered into regression model by Enter method. The results showed that none of these sociodemographic variables had a significant relationship with death anxiety, i.e. none of these variables predicted the death anxiety score (Table 4).

Table 4.

Multivariable Liner Regression for Sociodemographic Variables and Death Anxiety.

Variable	Beta	95% CI^a	p value
Duration of illness	–0.001	–18.11, –3.82	0.98
Gender
Male	Ref
Female	4.53	–0.8, –0.08	0.27
Type of treatment
Combind	Ref
Chemotrapy	–4.68	–13.11, –3.75	0.27
Surgery	–5.81	–18.85, –7.23	0.35
Other	–6.32	–19.61, –6.97	0.27
Experiencing an emotional crisis in the last six months
No	Ref
Yes	4.58	–2.37, –11.90	0.22
Family members having cancer during the recent years
Yes	Ref
No	3.58	–2.84, –10.53	0.26
The death of family members during the last year
Yes	Ref
No	0.19	–2.84, –10.53	0.96

Confidence interval.

Discussion

This study showed that all Iranian cancer patients experienced some degree of death anxiety. In similar studies, it has been shown that cancer patients have a high level of death anxiety, with 22% and 88% of them experiencing death anxiety (Majidi et al., 2019; Salehi et al., 2016; Valikhani et al., 2016; Vehling et al., 2017). It is concluded that patients with advanced cancer may have many death-related fears, which leads to more death anxiety.

This study showed that patients become involved with larger goals that lead them to authenticity. In a similar study, it was shown that a correct understanding of cancer-related experiences leads to a sense of existential change in the patients, which could result from existential integration (Hvidt, 2017). A study in Canada showed that the approach taken by the patients to deal with the existential crises was not particularly helpful. If one does not dare face challenging ideas, one will always remain in the limbo of lost meanings and will not reach authenticity (Bruce et al., 2011). A study in the United Kingdom underlined two approaches taken by cancer patients: to continue living in the past or to disconnect from the past and the future and instead, to deal with the existential crisis at hand. Cancer patients face a dilemma and are forced to choose between two paths, namely clinging to their identity and past life or abandoning it (Baker et al., 2016). Another study in Portugal also showed that cancer was presented as a catalyst for personal growth, as it reveals the important secrets of the patients’ life, leading to deep insight and change in perspective followed by a redefinition of their unique personal identity (Laranjeira et al., 2013).

The present study showed a moderate significant reverse correlation between authenticity and death anxiety, i.e. patients who indicated higher authenticity scores showed lower levels of death anxiety. Among the various dimensions of authenticity, the mean score of awareness and behavior had a moderate significant reverse correlation with death anxiety. In other words, patients who indicated higher awareness and behavior scores showed lower levels of death anxiety. Similarly, a study showed that psychological vulnerability is negatively related to authentic life (Satici et al., 2013). On the other hand, positive correlation was observed between a person's level of authenticity and increased life satisfaction, well-being, and stress reduction (Boyraz et al., 2014). Lower levels of authenticity have been associated with higher levels of anxiety, depression, and stress (Van den Bosch & Taris, 2014). Overall, it seems that existential psychotherapy allows cancer patients to solve the problem of death and improve their health by increasing their self-awareness. This approach will help the patient to accept the reality of pain and suffering in life, and thus pain and suffering become enjoyable and increase the positive feeling of well-being, life satisfaction, and self-confidence (Hoelterhoff, 2015). Accordingly, authenticity affects mood and mental health and makes a person resist external influences. Besides, people with higher authenticity experience less stress and more life satisfaction (Boyraz et al., 2014).

The findings of the present study indicated no significant correlation between the death anxiety and the dimensions of unbiased processing and relational orientation. On the other hand, a person's relationship with the real self, regardless of whether it exists or whether it is followed the individual or not, has a positive effect on satisfaction with decision-making, psychological well-being, motivation and goal pursuit, social relationships, and many other aspects of life. A sense of authenticity may reinforce psychological resistance in the face of adversity and stress (Rivera et al., 2019). Another study found significant negative correlations between collaborating with other colleagues and fear of death, avoidance of death, and escaping acceptance of death in health care professionals. participants who had greater death anxiety were less likely to collaborate with their colleagues (Black, 2007). Some researchers reported that higher total scores on authenticity and its subscale components were positively related to reported self-esteem level and life satisfaction. The overall pattern of findings suggests that authenticity and its subscales have important implications for aspects of psychological functioning and well-being (Goldman & Kernis, 2002). Allan et al. (2015) reported that only the awareness component of authenticity positively mediated the relation between mindfulness and meaning in life, and that unbiased processing had a negative relation with meaning in life; relational orientation and behavior were not significant mediators. Due to the different results in this regard, additional research may show links among aspects of authenticity and how to deal with life events such as death.

Although some literature has suggested that cancer patients may experience an existential crisis due to the feeling of impending death, and that this existential crisis could jeopardize the meaning of life (Fairlamb & Juhl, 2020; Razban et al., 2020; Yang et al., 2010), we have not been able to find any evidence that shows patient authenticity to decrease with higher death anxiety. It seems that people’s authenticity is a fundamental condition that determines many of their characteristics because authenticity determines the manner in which a person exists. Authenticity is like a painting canvas on which features such as the anxiety of death are painted. It is suggested that future studies be conducted to clarify the role of authenticity in human life.

The present study had some limitations. First, self-report method was used to gather data. Secondly, cancer patients participating in this study were mostly from southeastern Iran. Whether the present findings can be generalized to more diverse populations remains to be determined. Thirdly, convenience sampling of patients was used. Therefore, the interpretation and generalization of study results should be done with caution.

Conclusion

According to the findings, there was a moderate significant reverse correlation between authenticity and death anxiety, i.e. patients who indicated higher authenticity scores showed lower levels of death anxiety. It seems that death anxiety felt by patients may be reduced by increasing patients' awareness, acceptance, and development of their true selves. By informing patients about their true selves, health care providers may be able to help reduce patients’ death anxiety. Following the results of the study, the more a person feels that their intrinsic motivation is in line with their values, preferences, and needs, i.e. the higher the person’s authenticity, the lower death anxiety they experience. However, further research is needed to show whether increasing authenticity through a program would reduce death anxiety in cancer patients or not. Hospital officials, nursing managers, and nurses are also recommended to be aware of death anxiety and to take appropriate measures such as supporting, training and holding training classes, and creating peer groups so that cancer patients may share their experiences and help one another reduce their death anxiety. Given the limited number of studies on authenticity and death anxiety, the findings of this study can be considered an introduction for further studies in this field.

Footnotes

Acknowledgments

The authors wish to express their gratitude to participants for their collaboration in the study. This article has been derived from the MSc thesis for critical care nursing. The contribution of members of the Ethics and Research Committee of Kerman Medical Sciences University is also appreciated.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Parvin Mangolian Shahrbabaki

Author Biographies

Faezeh Nazari, MSc in Critical Care Nursing, is a nurse in the Afzalipour Hospital, Kerman University of Medical Sciences in Iran.

Zohreh Khoshnood, PhD, is an assistant professor in the department of Public Health Nursing at the Nursing Faculty affiliated with Kerman University of Medical Sciences in Iran.

Parvin Mangolian Shahrbabaki, PhD, is an assistant professor in the department of Critical Care Nursing at the Nursing Faculty affiliated with Kerman University of Medical Sciences in Iran.

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