Thinking About the End of Life When It Is Near: A Comparison of German and Portuguese Centenarians

Abstract

This study examined how common thinking of and planning for the end of life (EOL) is among German and Portuguese centenarians, and whether patterns of EOL views are shaped by cultural and individual characteristics. A significant portion of centenarians in both countries reported not thinking about the EOL, not believing in the afterlife, and not having made EOL arrangements. Latent class analysis identified three EOL patterns: Class 1 (EOL thoughts with EOL arrangements and afterlife beliefs), Class 2 (EOL arrangements and afterlife beliefs without EOL thoughts), and Class 3 (Overall low endorsement of EOL items). The proportion of Portuguese centenarians was higher in Class 1 and of German centenarians higher in Classes 2 and 3. Centenarians’ demographic, social, and health characteristics were significantly different across EOL patterns. As lack of EOL planning can result in poor EOL quality, enhancing communication among centenarians, family, and health-care professionals seems imperative.

Keywords

end-of-life planning death cultural context very old adults

Centenarians per definition are approaching the end of their lives. Yet little is known about their views and thoughts when it comes to the end of life (EOL) and death. To date, very old adults (aged 80+) represent the fastest growing population in most industrialized nations (Vaupel, 2010). This includes centenarians, the oldest old within this age segment. Worldwide, the number of centenarians is expected to increase from approximately 441,000 in 2013 to 3.4 million in 2050 (United Nations, 2013). As more and more individuals are likely to reach age 100, it is imperative to learn more about how centenarians experience this final phase of life—particularly, their views on death, in order to be attuned to what their support needs with respect to this sensitive topic may be. To offer well-suited help and care, further information is also needed on the role of culture. Might the way centenarians think about their EOL be shaped by their closeness to death and would therefore be comparable across countries, or are their views different due to cultural influences? To address this knowledge gap, the present study compared EOL thoughts of centenarians in Germany and Portugal, two countries that vary in key cultural, religious, and historic aspects. Also, we identified patterns of EOL thoughts and examined correlates of the patterns, including country and individual characteristics.

EOL-Related Thoughts Among the Very Old

It is often assumed that very old individuals think about death and should be prepared for it, given that their advanced age comes with substantial loss experiences in major domains of functioning, primarily due to health impairments (e.g., Andersen-Ranberg, Schroll, & Jeune, 2001; Jopp, Boerner, & Rott, 2016) and shrinking social networks (e.g., Boerner, Jopp, Park, & Rott, 2016; Martin, Poon, Kim, & Johnson, 1996). However, this question has rarely been addressed empirically for the oldest old; centenarians have received even less attention.

We found only one U.S. study that directly asked elders aged 81–96 whether they would think about dying and how often, and whether the prospect of dying would worry them (Rao, Dening, Braine, & Huppert, 1997). Notably, only 40% reported ever thinking about dying, and merely 10% reported thinking about death often or worrying about death. This study also showed that elders who thought about death more frequently were more likely to be unmarried, had less contact with their proxy informants, and showed more signs of depressed mood.

However, recent evidence based on an analysis of a portion of the sample reported on in the present article (German centenarians) and their proxy informants suggests that even if close network members are involved they are not necessarily aware of their relative’s thinking about the EOL (Boerner, Kim, Kim, Rott, & Jopp, 2018). In fact, in almost half of cases, the proxy misjudged whether the centenarian had thought about the EOL. While only few centenarians perceived the EOL as threatening and about a quarter reported longing for death, proxies overestimated centenarians’ reports of perceiving the EOL as threatening and underestimated centenarians’ reports of longing for death.

To our knowledge, only three additional qualitative studies addressed EOL thoughts in very old individuals. Two studies from the UK offer some insight on perceptions of death and dying. One study with 40 elders aged 80–89 identified several EOL issues, including fear of how to die, wanting to prepare for and have a choice regarding where and when to die, and issues relating to assisted dying (Lloyd-Williams, Kennedy, Sixsmith, & Sixsmith, 2007). The second study examined attitudes toward death and preferences for EOL care among 42 elders aged 95–101 and their caregivers and revealed as key topics “not wanting to think about death,” “accepting that death is inevitable,” and “wanting to die” (Fleming et al., 2016). All participants expressed desiring a “peaceful death” without burdensome treatments and hospitalizations. In line with the abovementioned German study, both UK studies highlighted important practical issues regarding EOL communication and planning. They indicated that elders seemed willing to discuss dying and EOL issues but rarely ever did, as they had very limited opportunities for doing so. One of the studies further revealed that little or no planning for EOL seemed to have taken place even when death was expected to be near and that even when a palliative EOL approach was preferred, these preferences were not documented (Fleming et al., 2016). Thus, while being important concerns, very old adults’ EOL issues were not discussed with others nor planned for, despite apparent closeness to death.

The third study was a small qualitative study conducted in Germany, exploring how centenarians think about and prepare for EOL (Eggert, Kuhlmey, Suhr, & Dräger, 2017). The interviews with 15 centenarians revealed that participants’ worries and wishes regarding their own EOL were shaped by having witnessed the dying of others. Moreover, key aspects of EOL planning, such as “putting things in order,” “making care arrangements,” and “having conversations about EOL” were raised as important areas, but, similarly to the other studies, centenarians had done little in terms of actual planning.

While the scope of these studies was very limited and they did not all ask the same EOL questions, it is noteworthy that the findings came from three different countries (United States, United Kingdom, and Germany) and that even though some similar EOL themes emerged (e.g., wishing for a peaceful death but lacking documentation of EOL care preferences), there were also notable differences with respect to one specific question that was asked in two studies (e.g., worrying about death and dying seemed more prevalent among UK compared to U.S. participants). These findings underscore the importance of considering the cultural context when examining EOL thoughts and planning among very old adults.

Role of the Culture, Religion, and Historical Environment

Whether and how individuals think about EOL and death may not only depend on personal aspects (e.g., own health status and witnessing experiences of others; Carr, 2012a) but also on the wider cultural context, religious tendencies, or historic events. Naturally, cultural contexts also vary within national cultures, but comparisons between countries can provide valuable information about predominant country-specific differences in EOL views and practices. For example, a review revealed clear differences across seven European countries (i.e., Germany, Norway, Belgium, the Netherlands, Spain, Italy, and Portugal) with respect to views on best practices in EOL care, such as obligation to open information about diagnosis, criteria for a good death, and views on euthanasia (Gysels et al., 2012). A similar review of EOL care in Italy, Spain, and Portugal found different EOL care practices and preferences across these Southern European countries but mainly highlighted culture-based similarities, driven by the role of religion and importance of family ties (Meñaca et al., 2012).

Cultural traditions regarding the dying process and burial or memorial rituals can be unique as nearly every religion has specific and meaningful traditions and customs around death. Specifically, in early modern Europe, Christians had believed that the ability to face death without fear through a calm fading away, a “good death,” was an intimation of salvation. The rituals of death preparation (e.g., last confession, extreme unction, funeral rites, prayers, and masses for the deceased) sustained the social community of the living (Muir, 2005). Religious beliefs and practices anchored in past traditions have been shown to play a role for attitudes toward death (Daaleman & Dobbs, 2010) and EOL treatment preferences (Sharp, Carr, & MacDonald, 2012). Along with spirituality and religiosity, a broader historic background may also shape EOL thoughts of long-lived individuals. Cohort-specific experiences (e.g., social and economic crises, scientific developments, wars) in specific countries may therefore also influence perspectives on life and death. German and Portuguese centenarians, while of the same generation, likely experienced different life conditions and influences due to unique cultural and historical developments surrounding them.

German centenarians who were born on the verge of World War I likely experienced a childhood in turmoil and deprivation caused by war and the postwar period. They were young adults during the Third Reich, World War II, and reached middle adulthood during the end of the war and postwar era, which again were extremely difficult time periods. Overall, the context of the wars came with high exposure to and frequency of deaths, often unnatural and traumatic in nature. Concerning the role of religion in German society, it should be noted that a questioning of religious traditions goes far back historically, starting with the Protestant movement splitting from Catholic traditions in 1530. After efforts to reduce the influence of the Catholic church, the Prussian monarchy had a rather liberal attitude toward religion, and shelter was provided to religious minorities from across Europe (Lauersberg, 2007). During the Nazi dictatorship, parts of both the Protestant and the Catholic churches supported the regime, other parts did not, leading to extensive critical reflections about the role of the church and religious beliefs among Germans after the war (Strohm, 2017). A rather open and progressive societal orientation after the war then further reduced the importance of both churches during the past decades, to the point that a majority of Germans to date self-identify a not religious and report that religion does not play a role in their daily lives (Pickel, 2017).

The present generation of Portuguese centenarians was born during the final period of the monarchy. By 1910, both democrats and anarchists had overthrown the monarchy and declared a liberal republic. Yet, only a few years later, an era of economic recession, authoritarian police government and polarized social stratification began, giving rise to Salazar’s dictatorship that lasted from 1926 to 1974 (Birmingham, 2003). Following the motto “God, Fatherland and Family,” the church and the military represented society’s pillars. The dictatorship fostered religious thought to stabilize the regime, leading to even more recognition and power of the church; it also interfered in education and intellectual life. During this period, Portugal had the lowest level of compulsory education in Europe, and adult illiteracy was 22% for men and 35% for women in 1970 (Gomes, Amorim, Correira, & Menezes, 2015). While a revolutionary upheaval in 1974 brought about the end of the dictatorship, the previous mentality toward education and predominance of blue-collar professions remained, especially in rural areas and in older generations. The importance of religion, reflected not only by religious beliefs and practices but also in social and cultural domains, is still characterizing life in Portugal today. Often people make pilgrimages, sometimes for miles, to hilltop shrines and chapels. In the last Portuguese Census, in 2011, almost 85% of the population identified as being religious, mostly Roman Catholic (INE, 2012).

To sum, German and Portuguese centenarians were each exposed to some unique life circumstances and challenges due to the larger sociocultural context they lived in, which evolved in different ways in the two countries despite spanning the same historical times. The cultural context also differed significantly with respect to the role of both education and religion, which we suspect could have influenced these centenarians’ thoughts and beliefs about the EOL, death, and a time beyond death.

Study Aims

Our primary aim was to explore how centenarians think about and plan for the EOL and death by comparing German and Portuguese centenarians. We sought to not only identify individual thoughts, such as whether or not centenarians think about death, but to capture the overall Gestalt of EOL-related thought in the two countries/cultural contexts. Our secondary aim was to examine the extent to which sociodemographic, social network, physical and mental health indicators are associated with different patterns of EOL thoughts.

Method

Procedures and Samples

Data were drawn from the Second Heidelberg Centenarian Study (Jopp et al., 2016), and the Portuguese Centenarian Study (Ribeiro, Araújo, Teixeira, Brandão, Duarte, & Paúl, 2017), which undertook, in large parts, population-based recruitment and a parallel data collection using the same assessments tools with the goal of yielding data that can be harmonized for comparative analyses. Birth years of centenarians in the two studies differ by 1 year because the Portuguese data collection started about 1 year after the German data collection.

Second Heidelberg Centenarian Study

Contact information of all individuals born in 1911/1912 living in and up to 60 km around Heidelberg, Germany, were requested from the city registries. All 485 individuals identified were invited to participate in the study. Of these, 298 had died between initial identification and first contact, refused any participation, or no contact could be established. For another 80 centenarians, only basic information was collected via telephone, mostly from their primary caregivers (i.e., proxies). One-hundred seven centenarians from the original pool and five additional centenarians who nominated themselves after having heard of the study participated in the full in-person interview conducted at their residence. Of these 112 centenarians, 87 answered the questions about their thoughts on EOL (for 78 centenarians, proxies provided additional data about the centenarians’ functional health).

Portuguese Centenarian Study

Contact information of all residents from two regions of Portugal (Oporto Metropolitan Area and Beira Interior, each within an approximately 60 km radius), and born in 1912/1913, were requested from voter registries. Recruitment was further facilitated by contacting all nursing homes listed in the Social Security Institute, and via announcements in community councils, churches, and regional public media. All the 291 centenarians identified were invited to participate in the study, and 241 centenarians were interviewed face-to-face. Of these centenarians, 131 answered the set of questions about their thoughts on EOL (for 125 centenarians, proxies provided additional data about the centenarians’ functional health).

Thus, the final sample for the present study included 87 German centenarians (M _age = 100.45, SD = 0.52) and 131 Portuguese centenarians (M _age = 101.20, SD = 1.65). Table 1 presents a descriptive summary of centenarians’ characteristics by country. Selectivity analysis comparing those who did and those who did not respond to the EOL questions in both the German and Portuguese Study indicated that the former group was more educated, reported higher perceived income adequacy, and had higher functional ability as well as better cognitive functioning (ps < .05).

Table 1.

Descriptive Summary of Centenarians’ Characteristics by Country.

Characteristics	Germany (n = 87)	Portugal (n = 128)
Characteristics	M (SD)	M (SD)	t or χ²
Demographic characteristics
Age	100.45 (0.52)	101.21 (1.66)	−4.88***
Female, %	86.2	85.9	0.00
Education^a	2.87 (1.57)	0.57 (0.93)	12.28***
Perceived income adequacy^b	1.54 (0.90)	0.79 (0.81)	6.08***
Social network characteristics
Widowed, %	83.9	83.6	0.00
Has at least one living child, %	73.6	78.4	0.67
Sees family as often as desired, %	54.7	40.2	3.18^†
Time with people outside household^c	1.34 (1.04)	1.82 (1.03)	−2.83**
Lives alone in own household, %	34.5	7.0	26.29***
Lives in elder care facility, %	34.5	39.1	0.47
Physical and mental health
Cognitive impairment^d	2.51 (1.48)	2.93 (1.79)	−1.77†
ADL^e	9.54 (3.05)	7.84 (4.36)	3.37***
IADL^e	5.81 (3.69)	3.58 (3.35)	4.56***
Depressive symptoms^f	0.22 (0.30)	0.34 (0.32)	−2.45*
EOL thoughts
a. Think about EOL, %	52.9	68.5	4.98*
b. Made arrangements for EOL, %	56.9	68.0	2.19
c. Perceive EOL as threatening, %	1.2	29.5	27.27***
d. Long for death, %	24.1	27.0	0.21
e. Believe in an afterlife, %	53.4	73.5	6.80**

Note. ADL = activities of daily living; IADL = instrumental activities of daily living; EOL = end of life.

^a0 = no formal education, 1 = elementary school, 2 = up to grade 6, 3 = up to grade 10, 4 = up to grade 12, 5 = high school degree, 6 = some undergraduate, 7 = completed undergraduate degree, and 8 = doctorate. ^b0 = can’t make ends meet to 3 = money is not a problem. ^c1 = not at all, 2 = once, 3 = 2–6 times, and 4 = once a day or more. ^d1 = no cognitive decline to 7 = very severe cognitive decline. ^eSum of 7 items; 0 = dependent/no longer possible to 2 = can do without help/no difficulty. ^fSum of 5 items; 1 = yes and 0 = no.

^† p < .10. *p < .05. **p < .01. ***p < .001.

Measures

EOL thoughts

Centenarians were asked to respond to the following set of questions (1 = yes and 0 = no): (a) Do you think about the EOL? (b) Have you made arrangements for the case of your death? (c) Do you perceive the EOL as threatening? (d) Do you long for death? and (e) Do you believe in an afterlife?

Sociodemographic characteristics

Sociodemographic characteristics included age, gender (1 = female, 0 = male), education, and perceived income adequacy. Education was measured with years of formal education and completion of degrees (0 = no formal education, 1 = elementary school, 2 = up to grade 6, 3 = up to grade 10, 4 = up to grade 12, 5 = high school degree, 6 = some undergraduate, 7 = completed undergraduate degree, and 8 = doctorate). For income adequacy, we asked whether centenarians’ income would suffice given their needs (0 = can’t make ends meet to 3 = money is not a problem).

Social network characteristics

Several questions assessed centenarians’ social networks characteristics: (a) marital status (given all options for current marital status; later recoded to 1 = widowed and 0 = others because over 80% were widowed), (b) whether or not the centenarian had at least one living child (1 = yes, 0 = no), (c) whether or not centenarian saw family as often as desired (1 = yes, 0 = no), (d) how often centenarian spent time during past week with people she or he did not live with (1 = not at all, 2 = once, 3 = 2–6 times, 4 = once a day or more), and (e) living arrangement (i.e., living alone in own household; living in elder care facility; 1 = yes, 0 = no).

Physical and mental health

To capture centenarians’ health status, we assessed cognitive impairment, functional health, and depressive symptoms. Cognitive impairment was evaluated by the interviewer using the Global Deterioration Scale (Reisberg, Ferris, de Leon, & Crook, 1982). The interviewer rated the cognitive capacity of the participants from 1 (no cognitive decline) to 7 (very severe cognitive decline). Functional ability was assessed with the Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire (Fillenbaum, 1988), which included both physical (activities of daily living [ADL]; 7 items) and instrumental ADL (IADL, 7 items). Proxies rated these items on a 3-point rating scale (0 = dependent/no longer possible to 2 = can do without help/no difficulty). It should be noted that no proxy assessments were available for about 3% of participants; in these cases we used centenarians’ own assessments. Items were summed with higher scores indicating better functioning (a = .88 for ADL and a = .86 for IADL). For depressive symptoms, 5 items were selected from the Geriatric Depression Scale (Sheikh & Yesavage, 1986; 1 = yes, 0 = no). Sum scores of these items were calculated with higher scores indicating more depressive symptomatology (a = .73).

Analytical Strategy

First, we examined centenarians’ responses to all EOL items and differences between two countries. To identify patterns of EOL thoughts, we conducted a latent class analysis (LCA). The optimal number of patterns was selected based on model fit indices, including the Akaike information criterion, the Bayesian information criterion, the Vuong-Lo-Mendell-Rubin likelihood ratio test, and entropy. After the optimal number of patterns was determined, we described and labeled each pattern based on the item response probabilities. Next, we examined how the probabilities of being a member of each class differ by country. We estimated the bivariate relationship between the derived EOL patterns and individual characteristics (i.e., demographics, living arrangements and social network, physical and mental health), using a series of analysis of variance and χ² tests. For this, “most-likely” class membership that was constructed via the latent class posterior distribution was used.

Results

EOL Thoughts by Country

Descriptive findings on centenarians’ responses to the EOL questions are depicted in Table 1. Thinking about EOL and belief in an afterlife were significantly more common among Portuguese (69% and 74%, respectively) compared to German centenarians (53% for both). Perceiving the EOL as threatening was substantially less common in both groups, but significant country differences existed (30% Portuguese vs. 1% German). The two groups were more similar with regard to making EOL arrangements (68% Portuguese and 57% German) and longing for death (27% Portuguese and 24% German). While differences by country emerged, a significant portion (26–47%) of centenarians in both countries reported “not” thinking about the EOL, “not” believing in the afterlife, and “not” having made EOL arrangements. Further, even though perceiving the EOL as threatening and longing for death were less commonly endorsed (1–30%), it is noteworthy that there were centenarians in both groups who reported these thoughts.

Patterns of EOL Thoughts

LCA identified three latent patterns of EOL thoughts as optimal; that is, when adding another latent class to the three-class model, the model fit did not improve significantly (Supplemental Table 1 for model fit). The solution of the three-class model is presented in Table 2, including latent class membership probabilities and item response probabilities (Figure 1).

Table 2.

Three-Class Solution of End-of-Life Thoughts Among Centenarians.

		Class 1	Class 2	Class 3
	Total	EOL thoughts with EOL arrangements and afterlife beliefs	EOL arrangements and afterlife beliefs without EOL thoughts	Overall low endorsements of EOL items
		“Latent” class membership probability (γ_c)
Total		.58	.25	.16
		“Most-likely” class membership proportion
Total		.60	.21	.18
Germany		.48	.26	.25
Portugal		.69	.18	.13
		Item response probability (ρ_i\|c)
EOL thoughts
a. Think about EOL	.62	1.00	.00	.21
b. Made arrangements for EOL	.63	.71	.85	.00
c. Perceive EOL as threatening	.17	.24	.03	.14
d. Long for death	.26	.32	.24	.06
e. Believe in an afterlife	.64	.77	.70	.00

Note. Total N = 215 (German n = 87, Portuguese n = 128). EOL = end of life.

Figure 1.

Three-class solution of end-of-life thoughts among centenarians.

Class 1 (EOL thoughts with EOL arrangements and afterlife beliefs) was the largest group representing almost 60% of the total sample. Centenarians with this profile all reported thinking about the EOL, had a high likelihood of having made EOL arrangements, and believing in an afterlife. They also had some likelihood of longing for death and perceiving the EOL as threatening. Class 2 (EOL arrangements and afterlife beliefs without EOL thoughts) represented about a quarter of the total sample. Centenarians with this profile were similar to Class 1 in terms of having made EOL arrangements and believing in an afterlife, but they reported not thinking about the EOL, and there was no indication of perceiving the EOL as threatening. Class 3 (overall low endorsement of EOL items) represented the smallest portion of the sample (16%) and differed from Classes 1 and 2 in all regards. Centenarians with this profile showed low likelihood of thinking about the EOL and perceiving the EOL as threatening and indicated having not made any arrangements, low likelihood of longing for death, and no afterlife beliefs. Regarding country differences in the class membership, we found that the proportion of Portuguese centenarians was higher in Class 1, and the proportion of German centenarians was higher in Classes 2 and 3 (Table 2).

Characteristics Differentiating Patterns of EOL Thoughts

We also examined whether patterns of EOL thought were associated with specific centenarian characteristics (Table 3). Differences for demographic characteristics, including gender and education, were found. Specifically, Class 3 (overall low endorsement of EOL items) was comprised of a smaller proportion of females than the other two classes, and Class 1 (EOL thoughts with EOL arrangements and afterlife beliefs) showed the lowest levels of education. Regarding social network characteristics, Class 2 (EOL arrangements and afterlife beliefs without EOL thoughts) was less likely to contain centenarians with a living child and more likely to include those living alone than the other two classes. In terms of health characteristics, Class 2 appeared to be a better-off group with higher cognitive and physical functioning as well as lower levels of depressive symptoms.

Table 3.

Centenarian Characteristic Differences by Class Membership of End-of-Life Thoughts.

	Class 1	Class 2	Class 3
	EOL thoughts with EOL arrangements and afterlife beliefs	EOL arrangements and afterlife beliefs without EOL thoughts	Overall low endorsements of EOL items
Characteristics	M or % (SD)	M or % (SD)	M or % (SD)	F or χ²
Demographic characteristics
Age	101.03 (1.51)	100.58 (0.69)	100.84 (1.45)	1.88
Female, %	88.5	91.3	71.8	8.29*
Education^a	1.24 (1.50)	2.11 (1.93)	1.76 (1.72)	5.16**
Perceived income adequacy^b	1.04 (0.90)	1.26 (0.96)	1.11 (0.97)	0.90
Social network characteristics
Widowed, %	84.6	78.3	87.2	1.43
Has at least one living child, %	79.8	59.1	84.6	9.63**
Sees family as often as desired, %	45.2	47.2	48.1	0.10
Time with people outside household^c	1.64 (1.04)	1.44 (1.03)	1.92 (1.12)	1.51
Lives alone in own household, %	13.1	30.4	20.5	7.08*
Lives in elder care facility, %	36.9	45.7	28.2	2.76
Physical and mental health
Cognitive impairment^d	2.77 (1.70)	2.28 (1.36)	3.32 (1.82)	4.06*
ADL^e	8.24 (4.02)	9.28 (4.04)	8.59 (3.63)	1.19
IADL^e	4.00 (3.34)	5.93 (4.30)	4.38 (3.44)	4.93**
Depressive symptoms^f	0.33 (0.32)	0.18 (0.27)	0.29 (0.33)	3.33*

Note. ADL = activities of daily living; IADL = instrumental activities of daily living; EOL = end of life.

^a0 = no formal education to 8 = doctorate. ^b0 = can’t make ends meet to 3 = money is not a problem. ^c1 = not at all, 2 = once, 3 = 2–6 times, and 4 = once a day or more. ^d1 = no cognitive decline to 7 = very severe cognitive decline. ^eSum of 7 items; 0 = dependent/no longer possible to 2 = can do without help/no difficulty. ^fSum of 5 items; 1 = yes and 0 = no.

*p < .05. **p < .01.

Discussion

Our study is the first to systematically examine EOL thoughts among centenarians and to collect corresponding data in two countries, Germany and Portugal, considering how views on EOL may be shaped by the cultural context or to what extent they may represent more general age-associated features this late in life.

On a descriptive level, we found both commonalities and differences in EOL thought patterns in the two groups. We were surprised by the notable portion of centenarians in both groups who reported not thinking about the EOL, not believing in the afterlife, and not having made EOL arrangements; among German centenarians, these reports even applied to nearly half of the sample. The assumption that individuals who by definition of their age are close to the EOL and most of whom experience substantial health problems and social network loss would have EOL-related thoughts and arrangements on their mind is not far-fetched. Yet our findings are consistent with the one prior study that asked elders in their 80s and 90s directly about thoughts about death (Rao et al., 1997), even though our sample was older and we asked about thoughts related to the EOL, not specifically death. Further, as the few existing studies with findings on EOL planning among very old adults have suggested, having reached a high age does not necessarily mean that one has made EOL arrangements. Given available evidence of a positive impact of EOL care planning on EOL quality (e.g., Weathers et al., 2016), this finding should be of concern for families and professionals involved in elder care. Also, in both groups, about a quarter of the centenarians reported longing for death. One may wonder, when a person at such a high age expresses a longing for death, could this just reflect a state of “befriending” the inevitable? However, given that centenarians who expressed this also had significantly higher levels of depressive symptoms, it seems very possible that longing for death reflected depressed mood, which could be addressed by the means of supportive interventions. This interpretation highlights the need for continued access to mental health services among the very old.

Besides these commonalities, the emerging differences added another layer of understanding and raised new questions. Portuguese centenarians were more likely to report thinking about the EOL, perceiving the EOL as threatening, and believing in an afterlife. The latter is likely a reflection of the higher importance of religion in the Portuguese compared to German society. Greater likelihood of believing in an afterlife among Portuguese centenarians, however, did not mean that the EOL was perceived as less threatening compared to the German group rather the opposite was the case. One may argue that whether the prospect of an afterlife is comforting or worrisome depends on what the afterlife is expected to hold in store. It is possible that Portuguese centenarians’ concerns were religion based, related to concepts of sin and punishment in Christianity. However, since our question addressed the EOL rather than being worried about what happens after death, we have no way of telling whether participants’ responses reflected concerns about the final days of life, or death and the time after. Prior work identified desiring a “peaceful death” as a priority for very old adults (e.g., Fleming et al., 2016). Perhaps Portuguese centenarians were more worried about the dying experience than German centenarians. It is also possible that they worried more about the EOL because they were in poorer health than the German centenarians. To adequately interpret this finding, we would need to know what exactly they thought of when they endorsed this item. Future work exploring this question would be helpful.

While comparing responses to individual EOL items gave us a basic idea of centenarians’ views by country, findings from the LCA yielded a portrayal of the Gestalt of EOL-related thoughts in the two cultural contexts, as expressed in a three-class model. Of note here is that Class 1 (EOL thoughts with EOL arrangements and afterlife beliefs) represented the largest and Class 3 (overall low endorsement of EOL items) the smallest group. In other words, the combination of a high likelihood of thinking about the EOL, having made arrangements for death, believing in an afterlife, and some likelihood of longing for death and perceiving the EOL as threatening was the most common, and the combination of a low endorsement on all items was the least common. In between that was Class 2 (EOL arrangements and afterlife beliefs without EOL thoughts), which was similar to Class 1 except for the low likelihood of thinking about the EOL and of perceiving the EOL as threatening. These findings suggest that while EOL arrangements and believing in an afterlife may go together, having made EOL arrangements at some point is not necessarily associated with current thinking or worrying about the EOL. It is possible that having made arrangements earlier in life put these centenarians at ease so that they no longer felt concerned about it or that they literally “outlived” the point of being concerned about death.

Beyond these general findings, class membership differences by country also emerged, suggesting that culture influences EOL thought patterns. Specifically, the proportion of Portuguese centenarians was higher in Class 1, while the proportion of German centenarians was higher in Classes 2 and 3. This suggests that the seemingly more common combination of EOL thoughts and planning really just gave a better reflection of Portuguese centenarians’ reports, whereas German centenarians spread more across the other two profiles characterized by less thinking about death and nearly no reports of perceiving the EOL as threating. The latter may be understood in the sociohistorical context that surrounded this cohort of German centenarians, particularly their war experiences and the associated high frequency of deaths. As one centenarian explained in an interview with the weekly newspaper Die Zeit, “I don’t worry about death. We really lost our fear of death through the war. Because we survived the war” (July 13, 2017, p. 55). The same cohort of Portuguese centenarians had different defining life circumstances, such as the long-standing dictatorship, and the central role of religion in the Portuguese society that apparently did not provide a mind frame reducing fear of the EOL.

Associations between several sociodemographic, social network, physical and mental health indicators, and different patterns of EOL thoughts further suggest that culture-unspecific, more general aspects shape EOL thinking. Women were the least likely to have the profile of Class 3, suggesting that an approach of not dealing with EOL thought and planning at all was more of a male pattern. This is consistent with evidence that women are more likely to engage in advance care planning (e.g., Carr, 2012b). Centenarians in Class 1 showed the lowest levels of education, probably reflecting the overall lower education in the Portuguese group, which needs to be viewed in the context of living under a dictatorship that actively suppressed education (Ribeiro et al., 2017). Centenarians in Class 2 were generally better-off in terms of physical and mental health, but they were less likely to have a living child and more likely to live alone than the other two classes. This may be partially explained by the higher proportion of Germans in this profile who were more likely to live alone, and had a slightly better health status compared to their Portuguese counterparts. That they were as likely as centenarians in Class 1 to have made EOL arrangements may be related to higher educational attainment, an established predictor of EOL care planning (e.g., Inoue, 2016), and fewer centenarians with a living child. The latter may have led to feeling the need to make EOL arrangement as there would be no child to care of such arrangements for them.

Limitations

Even though we were able to embed our findings within the historical and cultural contexts in which the centenarians in our studies lived, we did not have measures to directly assess specific aspects considered. For example, regarding the role of the church and religiosity in the two countries, we did not have a measure of religiosity, which might have allowed us to directly assess cultural differences regarding religion. This is particularly important because we are aware that comparing “national cultures” glosses over potential regional specificities that may similarly apply to other countries with similar features, as well as differences within countries. Further, as mentioned above, to understand the source of worries about death, we would need to know more about what centenarians may have perceived as threatening and how such thoughts are related to belief systems such as thoughts on afterlife. Generally, we focused on whether centenarians engaged in certain ways of thinking and planning about the EOL, but our measures did not allow us to uncover why (e.g., why they made no arrangements or why they longed for death). While the present study constitutes an important starting point highlighting the necessity to investigate very olds’ EOL thoughts and plans further, more detailed information would help guide efforts to optimize support services for very old adults as they approach the EOL. Future research addressing this topic with bigger sample sizes would further be beneficial; it will allow us to test culture-specific associations of individual characteristics with EOL class membership based on multivariate analyses.

Conclusion

Having reached very old age clearly does not necessarily result in intensive preoccupation with death, which, on the one hand, casts a positive light on extreme longevity. On the other hand, given that thinking and talking about the EOL is a necessary precondition to EOL planning, which can improve EOL experiences for individuals and their families, it may also be concerning. Our findings can serve as an alert that the very old may be an overlooked group when it comes to planning, and points to the importance of stimulating discussion among centenarians, their families, and health-care professionals. That there is a significant minority longing for death at this age may be a reflection of poor mental health rather than an indicator of accepting life’s finality. This points to enhanced mental health support needs, as life quality could be improved with the help of mental health services even at this late stage of life. Embedding discussion about EOL within the centenarians’ life and cultural context, with sensitivity to religious thought, and adaptation to educational level seems further needed to facilitate EOL planning.

Supplemental Material

Supplementary_Table_1-converted - Thinking About the End of Life When It Is Near: A Comparison of German and Portuguese Centenarians

Supplementary_Table_1-converted for Thinking About the End of Life When It Is Near: A Comparison of German and Portuguese Centenarians by Kathrin Boerner, Daniela S. Jopp, Kyungmin Kim, Abigail Butt, Óscar Ribeiro, Lia Araújo, and Christoph Rott in Research on Aging

Footnotes

Acknowledgments

Special thanks to Dr. Rosa Marina Afonso and her local team from University of Beira Interior. The authors would furthermore like to thank the study team and the study participants and their families for having made this study possible.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Second Heidelberg Centenarian Study (Jopp, Rott, Boerner, & Kruse) was funded by the Robert Bosch Foundation and the Dietmar Hopp Foundation. Prof. Jopp is also grateful for the support of the Brookdale Foundation Group. The Portuguese Centenarian Study was supported by the Portuguese Foundation for Science and Technology (FCT) [Grant PEst—C/SAU/UI0688/2011].

Supplemental Material

Supplemental material for this article is available online.

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