ABSTRACT

Background:

Ischemic cardiomyopathy is a major public health concern in Spain. Death from ischemic disease accounts for approximately a third of all deaths due to cardiovascular disease, and imposes a serious burden on already overstretched public health system owing to the tendency to chronicity. This study aimed to evaluate the psychometric properties of Templer’s Death Anxiety Scale (DAS) in a sample of patients with ischemic cardiomyopathy (acute myocardial infarction and angina pectoris).

Methods:

This study applied the Spanish version of Templer’s Death Anxiety Scale (DAS). The sample consisted of 141 patients (61% men) with ischemic cardiomyopathy, mean agede 71.57 years (SD=5.76). A descriptive statistical analysis was performed, and factorial analysis of the principal components.

Results:

The corrected element-total correlation was positive in all items, with values ranging from 0.32 and 0.54. Four factors jointly explained 51.85% of the data variance. The reliability coefficients were high in all of the variables analysed, with a total Cronbach Alpha of 0.77.

Conclusions:

The results obtained in this study revealed ischemic cardiomyopathy was susceptible to the process of death anxiety. This underscores the need for educating patients with this pathology to help them adapt to the process of chronicity, and to develop an understanding of the naturalization process of dying bearing in mind each person’s multidimensionality.

Key words:
Ischemic heart disease; Death; Attitude to death; Anxiety; Psychometrics

INTRODUCTION

The term “death anxiety” was included by the North American Nursing Diagnosis Association (NANDA) in its 2007-2008 biennial taxonomy. The diagnostic term was defined as an unspecified feeling of discomfort or malaise produced by a perceived threat, real or imaginary, to one’s own existence¹1. Tomás-Sabado J, Fernández-Narváez P, Fernández-Donaire L, et al. Revision of the diagnostic label 'death anxiety'. Enferm Clin. 2007;17:152-156. Currently, NANDA defines it as a vague and unsettling feeling, distress, and/or fear provoked by the perception of a threat, real or imaginary, to one’s own existence²2. Heather T, Kamitsuru S (eds). NANDA Nursing Diagnoses: Definitions and Classification 2018-2020. 11th ed. New York: Thieme Medical Publishers, 2017.

Numerous studies have identified variables that may be significantly related to death anxiety. Tomás-Sábado³3. Tomás-Sabado J. Miedo y ansiedad ante la muerte. Madrid: Herder Editorial, 2016 has identified the following: age, gender, religious beliefs, health status, occupation, and education concerning death; and found anxiety and fear of death were influenced by an individual’s cultural background.

Though death anxiety has been analysed in relation to an array of pathologies such as chronic renal insufficiency⁴4. Rivera-Ledesma A, Montero-López M, Sandoval-Ávila R Templer´s Death Anxiety Scale: Psychometric Properties in Terminal Chronic Renal Failure. Journal of Behavior, Health & Social Issues. 2010;2:83-91, cancers⁵5. Royal KD, Elahi F. Psychometric properties of the Death Anxiety Scale (DAS) among terminally ill cancer patients. J Psychosoc Oncol. 2011;29:359-371, and HIV⁶6. Braunstein JW. An investigation of irrational beliefs and death anxiety as a function of HIV status. J Ration Emot Cogn Behav Ther. 2004;22:21-38^,77. López-Castedo A, Calle I. Psychometric properties of the Death Anxiety Scale (DAS) among HIV/AIDS patients. Psicothema, 2008;20:958-963, studies on patients with cardiac diseases are scarce. Moreover, the data suggests anxiety and depression may reduce the quality of life and increase physical symptoms that may even lead to death in coronary ill patients⁸8. Siew H, Chee L, Das S, et al. Anxiety and depression in patients with coronoary hearth disease: a stady in a tertiary hospital. Iran J Med Sci 2011;36:201-206.

Coronary disease or ischemic cardiomyopathy is a cardiomyopathy produced by arteriosclerosis of the coronary arteries supplying blood to the myocardium. Two prominent types are acute myocardial infarction and angina pectoris (stable and unstable). Though cardiomyopathy is a multifactorial process, 90% of cases are estimated to have an arteriosclerotic aetiology, with numbers rising according to variables such as gender and age (predominantly men in general, and myocardial infarction in particular in all groups)⁹9. Go AS, Mozzaffarian D, Roger VL, et al. Executive summary: hearth disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013;127:143-152. Moreover, studies have revealed a north-south European cline in the death rate and in the number of deaths caused in both men and women by cardiovascular diseases such as coronary disease)¹⁰10. Puddu PE, Schiariti M, Torromeo C. Gender and Cardiovascular Mortality in Northern and Southern European Populations. Curr Pharm Des. 2016;22:3893-3904. The initial clinical presentation of coronary disease (infarction or angina) may be influenced by other factors such as drug treatment with beta-blockers and/or statins¹¹11. Go AS, Iribarren C, Chandra M, et al. Statin and beta-blocker therapy and the initial presentation of coronary heart disease. Ann Intern Med. 2006;144:229-238.

Approximately 15.4 million people aged 20 years or over in the United States suffer from ischemic cardiomyopathy⁹9. Go AS, Mozzaffarian D, Roger VL, et al. Executive summary: hearth disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013;127:143-152, and forecasts estimate that 50% of men and a third of middle aged women in the United States will suffer an episode of ischemic cardiomyopathy throughout their lives¹²12. Lloyd-Jones DM, Larson MG, Beiser A, et al. Lifetime risk of developing coronary heart disease. Lancet. 1999;353:89-92. Several studies in Spain have estimated the incidence rate of myocardial infarction will grow annually between 135-210 new cases per 100.000 men, and between 29-61 new cases per 100.000 women between the ages of 25 to 74 years¹³13. Medrano MJ, Boix R, Cerrato E, et al. Incidence and Prevalence of Ischaemic Heart Disease and Cerebrovascular Disease in Spain: a Systematic Review of the Literature. Rev Esp Salud Publica. 2006;80:5-15. In 2006, 31% of deaths from cardiovascular diseases in Spain were due to ischemic heart disease, which translated into a death rate of 84.2 per 100.000 habitants¹⁴14. Ministerio de Sanidad y Consumo. Mortalidad por cáncer, por enfermedad isquémica del corazón, por enfermedades cerebrovasculares y por diabetes mellitus en España. Madrid: Ministerio de Sanidad y Consumo, 2006. In 2014, heart diseases accounted for 20.2% of all deaths in Spain¹⁵15. Ministerio de Sanidad, Servicios Sociales e Igualdad. Patrones de mortalidad en España, 2014. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad, 2017.

In spite of recent progress in reducing the incidence of coronary disease, it remains one of the main causes of death in industrialised countries¹⁶16. Ergin A, Muntner P, Sherwin R, et al. Secular trends in cardiovascular disease mortality, incidence, and case fatality rates in adults in the United States. Am J Med. 2004;117:219-227. Although the incidence rate in Spain has tended to fall¹⁷17. Dégano IR, Elosua R, Marrugat J. Epidemiology of Acute Coronary Syndromes in Spain: Estimation of the Number of Cases and Trends From 2005 to 2049. Rev Esp Cardiol. 2013;66:472-481^,1818. Ferreira-González I. The Epidemiology of Coronary Heart Disease. Rev Esp Cardiol. 2014;67:139-144, it continues to be a major health issue for public health authorities. Factors such as the gradual ageing of the population and immigration indicate the absolute number of coronary episodes, and thus the prevalence of coronary disease, will not fall and may even rise in the near future¹⁸18. Ferreira-González I. The Epidemiology of Coronary Heart Disease. Rev Esp Cardiol. 2014;67:139-144, which underpins it is a crucial factor to be borne mind in the management of public health services.

Chronic diseases, in particular an abrupt life-threatening illness such as the different types of coronary disease expose individuals to their own mortality. It appears that a good psychological frame of mind regarding terminal illness can optimize a patient’s quality of life, induce positive attitudes, and probably improve resistance to physical and psychological deterioration⁴4. Rivera-Ledesma A, Montero-López M, Sandoval-Ávila R Templer´s Death Anxiety Scale: Psychometric Properties in Terminal Chronic Renal Failure. Journal of Behavior, Health & Social Issues. 2010;2:83-91. Owing to ethical considerations, most of the studies on death anxiety have been undertaken on healthy subjects, and no studies have been published on the impact of coronary disease on these variable.

The aims of the present study were twofold: to examine the psychometric characteristics of the DAS¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177 in patients with ischemic cardiomyopathy by using the Spanish version of the scale²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120, and to analyse the results of the DAS in a clinical sample.

MATERIAL AND METHODS

Study population and procedure

The data was gathered from a sample of patients with ischemic cardiomyopathy from the Coronary Disease Unit of the University Hospital of Ourense, Spain. The initial sample consisted of 165 subjects, 24 subjects experienced experimental death; thus, the total sample was composed of 141 subjects; age range 46 to 80 years, mean age 71.57 years, and standard deviation 5.76 years. In terms of gender, men (86) predominated over women (55), representing 61%, and 39% of the sample, respectively. Regarding cardiac diagnosis, myocardial infarction (63.8%) predominated over angina pectoris (36.2%). As for occupational status, 78% (119 patients) were retired, 12.1 (17) were housewives, and 9.9 (14) were unemployed. In relation to perceptions of disease, the experience was moderate for 57.4%, good for 24.1%, and bad for 18.4%. All patients freely volunteered to participate in the study, and were informed they could withdraw from the study at any time. Written informed consent was obtained from all patients, and they were assured their data would remain anonymous and confidential.

Patients were handed a written presentation of the research project explaining the aim of the study and the importance of their collaboration in responding to the questionnaire. Owing to the specific characteristics of this group, the questionnaire was applied in groups during the daily routine of the Heart Nursing School of the University Hospital of Ourense. The subject inclusion criterion was previous diagnosis of ischemic cardiomyopathy. The research team remained constant throughout the entire study, and maintained the same attitude, motivation, and presence in all of the sessions.

The experimental design was in accordance with the Declaration of Helsinki.

Measurements and Statistical analyses

An ad hoc structured questionnaire of socio-demographic variables: age, gender, clinical diagnosis, occupation, and perception of disease. As a direct measure of death anxiety, the Spanish version of Templer’s Death Anxiety Scale (DAS)¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177, adapted by Tomás-Sábado and Gómez-Benito²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120, was administered. This instrument is extensively used and cited in the literature, and is a benchmark for all scholars in this field²¹21. Tomás-Sábado J, Gómez-Benito J. Death anxiety, death depression, and death obsession: Conceptual approach and assessment instruments. Psicol Conductual. 2004;12:79-100^,2222. Aradilla-Herrero A, Tomás-Sábado J, Gómez Benito J. Death attitudes and emotional intelligence in nursing students. Omega (Westport). 2012;66:39-55. This instrument consists of 15 items with a dichotomous “true”-“false” response. Scores range from zero to fifteen, with high scores indicating high levels of death anxiety. The experimental design was in accordance with the underlying tenets of the work of Templer¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177. The analysis of the reliability of the scale showed internal consistency values ranging from 0.76 to 0.87 (Kuder-Richardson Formula 20), and temporal stability with intervals ranging from 0.71 to 0.84. The data of other studies has substantiated good discriminant and construct validity.

Descriptive statistical analyzes were performed, and asymmetry and kurtosis as well. Likewise, a factor analysis of the main components was carried out. Both differentiated analyzes are presented in the results block below. All of the analysis were performed with the statistical software package SPSS 22.0.

RESULTS

Analysis of items

Table 1 shows the descriptive statistics, asymmetry, and kurtosis obtained after administering the DAS. The means ranged from .22 (item 10) to .81 (item 9), whereas the standard deviations with similar scores were far from zero, indicating the items discriminated. The corrected item-total coefficient was positive in all of the items, with values ranging from .32 to .54, indicating all of the items contributed to the measure of the construct measured by the test (Death Anxiety), and were in the same direction. Inclusion of items on the scale was determined on the basis of the Cronbach Alpha. The alpha coefficient for all the tests was .77, and the elimination of any of the items did not improve the overall reliability of the questionnaire.

With reference to asymmetry, 7 of the 15 items had positive asymmetry with a tendency for low scores, whereas the scores for the remaining 8 items were high. Moreover, 12 items had a negative kurtosis indices, indicating a flatter distribution than normal. Consequently, there was neither extreme asymmetry (values < 3.00) nor extreme kurtosis (values < 8.00), indicating there were neither problems of asymmetry or kurtosis in the variables under analysis. Finally, in all of the items, the Kolmogorov-Smirnov Goodness-of-Fit Test (Z) confirmed the abnormal distribution (p < .05) (table 1).

Factorial estructure

To analyse the validity of the DAS construct, factorial analysis of the principal components was performed prior to varimax rotation. The determinant of the correlation matrix was zero (< .01), indicating a high presence of correlations, which confirmed the factorial model; Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was .794, which was above the recommended value of .60, and rejected the null hypothesis that the correlation matrix was an identity matrix by Bartlett’s test of sphericity (χ²[105, N = 141] = 412,679 < .01), ensuring the factorial analysis was adequate, and the model obtained good fit. Only the saturations above .45 were included, and in line with the criterion of values above 1, a total of 4 factors were identified that explained 51.85% of the variance in the data (table 2).

Factor 1 saturated items evaluating death anxiety in the cognitive-affective matrix. This factor obtained the highest percentage of the explained variance, 24.51%, with the highest factorial loading in items 5, 9, 7 and 15. The factor was termed “cognitive-affective”, with a reliability of .66. Factor 2 explained 10.19% of the variance and was composed of items relating to death anxiety associated to the awareness of the passing of time (12, 8), and the fear life is coming to its end (1, 2). The reliability for this factor was .65, and it was labelled “awareness of the passing of time”. Factor 3 consisted of items explaining 9.28% of the variance, referred to pain (4, 11) and disease (10, 6), and was named the “fear of pain and disease” factor, with a reliability of .56. Finally, factor 4 explained 7.87% of the variance, and had the highest factorial load in items 14, 3, and 13, and was referred to as the “stimuli related to death” factor, with a reliability of .49 (table 2).

DISCUSSION

The results of this study revealed the homogeneity of the items and their reliability, suggesting all of the items were evaluating the same variable i.e., Death Anxiety, which was in agreement with other studies¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177^,2020. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120^,2121. Tomás-Sábado J, Gómez-Benito J. Death anxiety, death depression, and death obsession: Conceptual approach and assessment instruments. Psicol Conductual. 2004;12:79-100^,2323. Abdel-Khalek AM. Death anxiety among Lebanese samples. Psychol Rep. 1991;68:924-926^,2424. Abdel-Khalek AM. The Kuwait University Anxiety Scale: Psychometric properties. Psychol Rep. 2000;87:478-492.

The reliability coefficients of the DAS were high in all of the variables analysed, with a total Cronbach Alpha of .77 that was comparable to previous studies⁷7. López-Castedo A, Calle I. Psychometric properties of the Death Anxiety Scale (DAS) among HIV/AIDS patients. Psicothema, 2008;20:958-963^,1919. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177^,2020. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120^,2525. Abdel-Khalek AM. Death anxiety, death depression, and death obsession: a general factor of death distressis evident: a reply. Psychol Rep. 2004;94:1212-1214, underscoring it was a reliable instrument for evaluating death anxiety.

With regards to the factorial structure of the scale, four factors were obtained and termed: “cognitive-affective” (F1); “awareness of the passing of time” (F2); “pain and disease” (F3), and “stimuli related to death” (F4). Though the structure of factor 1 failed to fully coincide with the findings of other authors, these items, except 9, coincided with factor 1 in other studies²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120^,2626. Lonetto R, Fleming S, Mercer GW. The structure of Death Anxiety: A factor analytic study. J Pers Assess. 1979;43:388-392^,2727. Saggino A, Kline P. Item factor analisis of the Italian version of the Death Anxiety Scale. J Clin Psychol. 1996;52:329-333.

As for the structure of factor 2, the factorial loadings of items 8,12 coincided with factor 4 of Tomás-Sábado, and Gómez-Benito²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120; Lonetto, Fleming, and Mercer²⁶26. Lonetto R, Fleming S, Mercer GW. The structure of Death Anxiety: A factor analytic study. J Pers Assess. 1979;43:388-392; and Devins²⁸28. Devins GM. Death anxiety and voluntary passive eutanasia: Influences of proximity to death and experiences with death in important other persons. J Consult Clin Psychol. 1979;47:301-309; and items 2, 1 with factor 3 of Templer¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177, and factor 1 of Tomás-Sábado, and Gómez-Benito²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120; and Lonetto, Fleming, and Mercer²⁶26. Lonetto R, Fleming S, Mercer GW. The structure of Death Anxiety: A factor analytic study. J Pers Assess. 1979;43:388-392. All of the items in factor 3, except 10, coincided with factor 3 of Saggino and Kline²⁷27. Saggino A, Kline P. Item factor analisis of the Italian version of the Death Anxiety Scale. J Clin Psychol. 1996;52:329-333, factor 2 of Tomás-Sábado, and Gómez-Benito²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120; and factor 1 of Warren, and Chopra²⁹29. Warren WG, Chopra PN. Some reliability and validity considerations on Australian data from the Death Anxiety Scale. Omega (Westport). 1979;9:293-298. Finally, the factorial structure of the factor 4 was identical to factor 3 of Tomás-Sábado, and Gómez Benito²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120. In general, the factorial structure was coherent and quite similar, and the differences were in line with those suggested by several authors in relation to the multidimensionality of the DAS¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177^,3030. Lonetto R, Templer DI. Death Anxiety. Washington: Hemisphere Publishing, 1986, which underpinned it was a valid instrument for evaluating death anxiety in patients with ischemic cardiomyopathy.

Within the main limitations found, the reduced number of participants, conditioned by experimental mortality, can be noted. However, it should also be noted as an advantage that conducting the study within a hospital context implies obtaining complementary information and making it possible longitudinal type investigations.

As previously noted, the aims of the present study were twofold: to examine the psychometric characteristics of the DAS¹⁹19. Templer DI. The construction and validation of a Death Anxiety Scale. J Gen Psychol. 1970;82:165-177 in patients with ischemic cardiomyopathy by using the Spanish version of the scale²⁰20. Tomás-Sábado J, Gómez-Benito J. Psychometric properties of the Spanish form of Templer's Death Anxiety Scale. Psychol Rep. 2002;91:1116-1120, and to analyse the results of the DAS in a clinical sample. The data provides valuable information given the current dearth in the literature, and is intended to contribute to development of new lines of empirical psychological research in a field that is of undoubtable clinical and theoretical interest for applications designed to further our understanding of the factors influencing personal and social attitudes and beliefs towards death, and to inform educational interventions aimed at helping patients to cope with life-threatening illness.

In short, the results of this study have revealed that ischemic cardiomyopathy was susceptible to the process of death anxiety. Thus, the aim of this study was to identify the factors relevant to the design of psychological interventions primarily aimed at helping patients to explore their attitudes towards death, unveil their fears, develop coping strategies, view life positively, and to do everything possible to achieve this goal³¹31. Carrobles JA, Remor E, Rodríguez-Alzamora L. Relationship of coping and perceived social support to emotional distress in people living with HIV. Psicothema. 2003;15:420-426. Hence, the need for promoting education for the “naturalization” of death and the process of dying, without ignoring the family system³²32. Sinoff G. Thanatophobia (Death Anxiety) in the Elderly: The Problem of the Child's Inability to Assess Their Own Parent's Death Anxiety State. Front Med. 2017;4:11^,3333. Shahdadi H, Rahdar Z, Mansouri A, et al. The effect of family-centered empowerment model on the level of death anxiety and depression in hemodialysis patients. Revista Publicando. 2018;5:470-482. Taking into account each person’s multidimensionality (social, somatic, psychological) but also his spiritual and religious plane³⁴34. Kula T, Erden M. Existential Anxiety and Religion. Journal of Academic Research in Religious Sciences. 2017;17:21-41^,3535. Kimter N, Kotfegul O. A Research on the Relationship Between Death Anxiety and Religiosity in Adults. Journal of Sakarya University Faculty of Theology. 2017;19:55-82, that functions as a unified, integrated, and fluctuating system, as well as being dynamic and flexible (changing through time) adapting according to the evolution of the disease, priorities, values, needs, and so forth. This approach is designed to ensure the target of intervention is aimed at improving the patient’s quality of life.

References

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