Construction of life-and-death education contents for the elderly: a Delphi study

The population and proportion of the elderly have increased rapidly in recent years, and virtually all countries are experiencing population ageing [1]. According to the World Health Organization (WHO), the number of the global population aged over 60 and above is estimated to be doubled to two billion in 2050, and 80% of the elderly are in low and middle-income countries [2]. China is now one of the fastest aging countries [3]. The results of China's seventh census indicate that the population aged above 60 is approximately 264 million people [4].

With the expansion of people’s life span, the quality of life and death are of vital significance [3]. Medicine is both scientific and humanistic [5] because it not only cures diseases and prolongs life, but also brings about dignity and rights of decision to the elderly. To improve the quality of life of the elderly worldwide, WHO has proposed programs of healthy ageing, active ageing, and others [3]. Palliative-and-hospice care has become one of the principal measures to ease the pressure on medical care and to improve quality of life of the older people [6]. Palliative-and-hospice care provides physical, psychological, social, and spiritual care as well as humanistic care for end-of-life or elderly patients before their deaths, so that their pains and discomfort symptoms can be alleviated, by improving the quality of life and helping patients relax and leave with dignity [7, 8]. With the promotion and application of this mode of care, the topic of death is inevitable for the elderly. On the other hand, as the age increases, the body experiences weakness in both physical strength and decline in physical abilities [9]. Moreover, experience of the loss of important persons occurs more frequently [10]. The factors turn death into an inescapable fact for the elderly. Additionally, the threats of chronic diseases and infectious diseases, such as cancer, COVID-19, and Ebola keep reminding us that death is close at hand [11]. If older people know less about death, they are more likely to experience aggravated suffering about death, which is not conducive to the physical and mental health of them [12].

Unfortunately, the topic of death is often avoided or denied in eastern and western cultures [13]. Human attitudes and behaviors are deeply rooted in culture [14]. Actually, most of people are usually negative to the topic of death. They are afraid of mentioning it and reluctant to discuss dying matters [15]. It is therefore that people focus more on life planning, healthy birth, excellent education, and a better life whereas death is rarely mentioned. China ranks 9th from the bottom in the 2015 Quality of Death Index Ranking released by The Economist Intelligence Unit [16], which also reveals that Chinese people are far from the goal of good quality of death. Regarding the issue of death, Western society has carried out research related to thanatology as early as the 1920s [17]. Death awareness campaigns arose in the United States in the 1960s [18]. Courses of life-and-death education were instructed in colleges and universities in the 1980s [19]. As Herman Feifel stated in the early days of the death awareness movement that the attitude towards death affects the content and quality of our lives [20]. The quality of death in Western countries is generally better than that in Mainland China. Therefore, how to construct a set of life-and-death education content system integrated with culture, allowing the elderly to face death squarely and build a scientific concept on death has become the key to improving the quality of life and death in contemporary society and medical background.

Life-and-death education offers death information which is helpful for the educated to understand the finiteness of life and the naturalness of death objectively, so as to cherish life and appreciate life [21]. Life-and-death education transmit not only knowledge and skills related to death, broaden the understanding of dying, death, and bereavement, it is also thought provoking. "Acceptance the naturalness of life" and "development of the concept of death" contribute to a better self-realization [10, 22]. In addition, life-and-death education can also provide more options for dying and health care.

Life-and-death education highlights the review of the meaning of life and the discussion of death and helps to better promote advance directives or establish a advance care planning, allowing to achieve the goal of palliative-and-hospice care and improve the quality of death [23, 24], which is intimately related to palliative-and-hospice care. Based on the terror management theory, life-and-death education can activate reminders of death or mortality salience effect, trigger a distal defense mechanism to improve the meaning of life [25, 26]. As the concept of death influenced by many factors [27, 28], especially culture, the development of life-and-death education in accordance with local conditions can benefit the elderly to recognize relevant knowledge and change their negative attitudes towards death escapes or denies. Gradually, they recognize the finiteness of life, and then cherish the moment of life, live more valuable lifestyles, and select optimal medical treatments, thereby living an optimistic life and truly realizing active aging [18].

Life-and-death education should be implemented among groups of all ages, and it is particularly significant for the elderly [14]. However, the elderly has always been one of the groups that is easy to ignore in the research of life-and-death education [14]. Previous life-and-death education researches mostly focused on adolescents [29, 30], medical and healthcare professionals [31], and cancer patients [21] to explore the benefits of life-and-death education in reducing negative death emotions, managing the risk of commit suicide, and alleviating alexithymia [32, 33]. Most the education contents only focus on the sharing of living wishes and discussion of death recognition, while lacks contents of bereavement, mourning, and death preparations [34], and scientific construction of the life-and-death education contents, especially for the elderly. Therefore, this research attempts to establish expert consensus on a set of scientific and systematic life-and-death education contents for the elderly by Delphi technique. This project may provide a foundation for better implementation and promotion of life-and-death education among the elderly, and help improve the quality of death and well-being of the elderly.

This study was approved by the Ethics Committee of the University (NO. 2021.06–03) on June 21, 2021. Delphi method has been widely used in education, health related fields which make full use of the wisdom of experts to construct and improve the new research content. This method is suitable for the purpose of this study. Delphi is a research method that achieves expert consensus through the anonymous and iterative multistage process [35, 36]. The trustworthiness of Delphi can be confirmed by credibility, dependability, confirmability, and transferability [37]. The credibility of Delphi can be gained by ongoing iteration and feedback to experts, which can be viewed as member checks [38]. Recruiting authoritative experts with in-depth research and interest in the topic will help increase the content validity and dependability of Delphi method [39]. Confirmability can be assessed through experts’ opinions collection, data analysis and detailed description of the consultation process [37]. Transferability of Delphi can be verified by application of the research findings [40].

Education undertakes the functions of cultural selection, transmission, transformation, criticism, innovation, and remodeling [53]. Life-and-death education can not only convey knowledge of life and death, but also alleviate the negative emotions towards death, help people prepare for death, and improve the quality of death [18]. Based on the social background of aging, this study designed life-and-death education contents for the elderly to provide a buffer in the process of demise as well as references for other countries.

According to Terror Management Theory, life-and-death education plays a role as a mortality reminder for the elderly [54]. "Life-and-death literacy promotion in the elderly" gradually transitions the knowledge from life, life cycle and aging that are easily accepted by the elderly to end of life and death. This part aims to reduce the avoidance of death for the elderly through realistic knowledge explanations, and help the elderly face up to the problems of life and death. Proximal defenses may be activated when the elderly receive life-and-death knowledge, that is, the elderly begin to think about death consciously. And the elderly may take effective health behaviors in order to reduce perceived vulnerability and avoid death threats [55]. “Life-and-death planning of the elderly” provides the elderly with more options for end-of-life care beyond rescues. The purpose of this part is to put autonomy back into the elderly themselves and to let older adults know that they can plan for their own death. When thoughts of death are active but not conscious, distal defenses are activated. The elderly would defend against death by seeking cultural identity, meaning in life [56]. “Life-and-death concept establishment of the elderly” helps the elderly deepen their understanding of life and death from the perspective of history and culture, and initially form their own views on life and death. Through the introduction of life quality and death quality, the elderly are guided to attach importance to their own death and express their pursuit of good death. "Life-and-death thoughts of the elderly" enables the elderly to consciously explore their own value and meaning according to their life experiences, religious beliefs or cultural background. This part also discusses the source of happiness for the elderly, with the purpose of enriching the life of the elderly and improving their own wellbeing. The contents of life-and-death education for the elderly constructed in this study include 4 first-level items from the aspects of knowledge, culture and concepts, behavior planning and meaning of life.

From the experts' preference, we found that in the first round of Delphi, the experts scored the highest in “Introduction to palliative-and-hospice care”, and the two items with the approval rate reaching 100% were “Introduction to palliative-and-hospice care” and “Life-and-death concepts in Chinese traditional culture”. This shows that “palliative-and-hospice care” is the top priority that experts believe needs to be promoted to the elderly. It may be because palliative-and-hospice care can not only reduce the burden of elderly care, reduce the economic loss of the elderly, but also improve the quality of life-and-death of the elderly [57]. However, it cannot be ignored that the acceptance of palliative-and-hospice care is a medical care decision based on the cognition of life-and-death of the elderly [58]. According to behavioral decision theory, psychology is an important factor affecting people's decision-making [59]. And the influence of life-and-death culture on the psychological phenomenon and psychological process is long-term and difficult to change [60]. Therefore, we designed the concept of life-and-death from the perspective of traditional Chinese culture by analyzing the origin of the taboo of life-and-death, the neglected culture of life-and-death, the culture of life-and-death in the new era, and the development of the concept of life-and-death, this prompts the elderly to think about the concept of life and death invisibility. And “Life-and-death concepts in Chinese traditional culture” is also one of the options approved by the experts in their preferences.

Culture affects much on the formation of individual life and death attitudes and concepts, and even on the guidance of individual behavior [61]. Therefore, life-and-death education must take the local social and cultural background and the characteristics of the subjects into consideration. With reference to the contents of life-and-death education in Taiwan, China, which is well-developed [22], this study design combined the basis of traditional Chinese culture and the social reality in mainland China and generated the system of "Life-and-death concepts in traditional Chinese culture", "Good death in eastern and western cultures", "Funeral culture and bereavement", and "Four ways of emotion expressions (acknowledgment \ apology \ love \ farewell)". It contributed to the elderly to accept and recognize the educational content, and then renew their cognition and concepts. While inheriting the traditional culture, it is also reflecting on the renewal. Under additional cultural backgrounds or in different countries, this part of the content can be referred as per the actual conditions or replaced according to local conditions, thereby minimizing the restructuring work of life-and-death education for the elderly.

Compared with the life-and-death education in the past [62], the content of life-and-death education for the elderly constructed in this study is targeted at the needs of the elderly and their own characteristics. Based on the previous interview and survey needs of the elderly [43], this research integrated professional evaluation of geriatric nursing and geriatric psychologists, and generated the final content system of life-and-death education for the elderly with clear main body and refined contents. Moreover, the contents of "Aging process", "Terminal stage of the elderly", "Physical and mental counseling for the elderly after bereavement" and "Discussion on happiness philosophy of the elderly" were supplemented, which was more object-specific, systematic, and scientific, making up for the content deficiency of previous researches.

As the physical, psychological, and social characteristics of different groups are different, the contents of life-and-death education for the elderly constructed in this study were different from the related education of the rest of groups. Life-and-death education for medical and health workers focuses on palliative-and-hospice care skills [63]. The content of life-and-death education for cancer patients focuses on the acceptance of death by patients and their families and to an optimal choice of palliative-and-hospice care [24]. The contents of life-and-death education for the elderly constructed in the present research focused highly on the establishment of the death concept of the elderly and the clarification of the meaning of life, so as to help the elderly enrich their lifetime at an old age thereby improving the quality of life and death.

Under the social background of aging population, coupled with the urgent need to improve the death quality of the elderly in China, and palliative-and-hospice care pilot is being fully implemented [64], this research is accurately in line with the older population, and the scientific system of life-and-death education contents is practical and applicable [21]. We believe that life-and-death education is the right of the elderly. We can use this education to mobilize the initiative and enthusiasm of the elderly as a social resource, change the perception that the elderly is a burden on society, give full play to the social value of the elderly, and meet the self-realization needs of the elderly.

The expert consensus on the content of life-and-death education for the elderly constructed in this study provides a basis for health professionals to initiate life-and-death dialogue, death preparation, and end-of-life planning for the elderly. It also plays a positive role in acceptance and implementation of palliative care in older populations. Furthermore, the result can also assist in the planning of hospice care services to improve quality of death of the elderly. This study could enrich life-and-death education resources for the elderly, and provide theoretical support for relevant research peers and palliative care professionals around the world.