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A concept map of death-related anxieties in patients with advanced cancer
  1. Sigrun Vehling1,
  2. Carmine Malfitano1,
  3. Joanna Shnall1,
  4. Sarah Watt1,
  5. Tania Panday1,
  6. Aubrey Chiu1,
  7. Anne Rydall1,
  8. Camilla Zimmermann1,2,3,
  9. Sarah Hales1,3,
  10. Gary Rodin1,3 and
  11. Christopher Lo1,3,4
  1. 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  2. 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
  4. 4 Department of Psychology, University of Guelph-Humber, Toronto, Ontario, Canada
  1. Correspondence to Dr Sigrun Vehling, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 16-724 Toronto, ON, M5G 2M9, Canada; s.vehling{at}


Objectives Fear of death and dying is common in patients with advanced cancer, but can be difficult to address in clinical conversations. We aimed to show that the experience of death anxiety may be deconstructed into a network of specific concerns and to provide a map of their interconnections to aid clinical exploration.

Methods We studied a sample of 382 patients with advanced cancer recruited from outpatient clinics at the Princess Margaret Cancer Centre, Toronto, Canada. Patients completed the 15-item Death and Dying Distress Scale (DADDS). We used item ratings to estimate a regularised partial correlation network of death and dying-related concerns. We calculated node closeness-centrality, clustering and global network characteristics.

Results Death-related anxieties were highly frequent, each associated with at least moderate distress in 22%–55% of patients. Distress about ‘Running out of time’ was a central concern in the network. The network was organised into two areas: one about more practical fears concerning the process of dying and another about more psychosocial or existential concerns including relational problems, uncertainty about the future and missed opportunities. Both areas were yet closely connected by bridges which, for example, linked fear of suffering and a prolonged death to fear of burdening others.

Conclusions Patients with advanced cancer may have many interconnected death-related fears that can be patterned in individual ways. The bridging links between more practical and more psychosocial concerns emphasise that the alleviation of death anxiety may require interventions that integrate symptom management, advance care planning and psychological treatment approaches.

  • death anxiety
  • death distress
  • advanced cancer
  • psycho-oncology
  • network analysis
  • end of life

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  • Contributors Conception and design: SV, GR, CL. Data analysis: SV, CL. Interpretation and manuscript writing: SV, CM, JS, SW, TP, AC, AR, CZ, SH, GR, CL. Final approval: SV, CM, JS, SW, TP, AC, AR, CZ, SH, GR, CL. Guarantor: SV, GR, CL.

  • Funding This study was funded by research grants from the Canadian Institutes of Health Research (CIHR#MOP 106473) and the German Research Society (DFG). This research was also supported, in part, by the Princess Margaret Cancer Foundation (Al Hertz, Kirchmann and Kirsh Family Funds), the Campbell Family Cancer Research Institute and the Ontario Cancer Institute at the Princess Margaret Cancer Centre, and by the Ontario Ministry of Health and Long Term Care (OMOHLTC). The viewsexpressed do not necessarily reflect those of the OMOHLTC. Dr. Rodin is also supported by theUniversity of Toronto/UHN Harold and Shirley Lederman Chair in Psychosocial Oncology andPalliative Care. The funders had no role in the final design, analysis, and writing of this study. Theviews expressed do not necessarily reflect those of the funders.

  • Competing interests None declared.

  • Ethics approval University Health Network Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.