A Theoretical And Practical Study On Intervention Of Decision-making Willingness Of Community Elderly In Hospice-and-palliative Care From The Perspective Of Cultural Psychology

ObjectiveHospice-and-palliative care(HPC)is an important part of medical services for healthy aging.However,the taboos of life and death culture hinder the utilization of HPC for the elderly in the community.This study aims to advance the planning and decision-making window of HPC for the elderly.By exploring the internal relationship between life-and-death awareness and HPC decision-making of the elderly in the community,the theoretical framework of HPC decision-making of the elderly was constructed under the background of Chinese culture.The HPC decision-making willingness scale was developed to investigate the current situation and influencing factors.This study analyzed the effect of death awareness on the decision-making willingness of HPC,constructed an intervention program,and carried out practice and evaluated the effect.The aim of this study is to provide theoretical support and practical basis for improving HPC decision-making willingness of community elderly and promoting the comprehensive implementation of community HPC services.Methods1.Literature review and in-depth personal interview were used to construct the theoretical framework of HPC decision-making willingness of community elderly in Chinese culture.Guided by Terror Management Health Model,a semi-structured interview outline was established based on the previous literature study and the discussion of the research group,with the themes of life and death attitudes and HPC willingness.Through purposive sampling,community elderly people who are over 60 years old participated in the interview.According to the principle of information saturation,a total of 20 elderly people were included.The content analysis method was used to define themes through deduction and induction.Finally,the theoretical framework of terror management-HPC decision-making was constructed.2.Scale development method was used to develop the HPC decision-making willingness scale for the elderly in the community and test its reliability and validity.Based on the theoretical framework of terror management-HPC decision-making and cognitive-emotional decision-making theory,combined with literature analysis of previous HPC scales and expert content validity evaluation,a community elderly HPC decision-making willingness scale was developed.Convenience sampling method was adopted.In the first stage,296 community elderly questionnaires were collected to carry out item analysis and exploratory factor analysis on the pre-test scale,and the scale was revised to form a formal one.In the second stage,312 community elderly questionnaires were collected to carry out confirmatory factor analysis,convergent validity,discriminant validity and reliability tests on the formal scale.3.The questionnaire survey was used to analyze the current situation and influencing factors of HPC decision-making willingness of the elderly in the community,revise and improve the theoretical framework.A multi-stage sampling method was used to select 683 community elderly people from different administrative districts in the main city of Chongqing according to the gross domestic product per capita and the proportion of streets under jurisdiction.The general information questionnaire,Decision-making Willingness of HPC Scale,Life Attitude Profile Scale,Meaning in Life Questionnaire,Perceived Social Support Scale,Death Attitude Profile-Revised and Coping with Death Scale were used in the survey.Epidata 3.1 was used to check and input data,and SPSS 24.0 software was used for descriptive statistical analysis and influencing factor analysis,and SPSS Process v3.3 program was used for path analysis.4.The Delphi method was used to construct an intervention program to improve community elderly HPC decision-making willingness.Based on the results of the previous investigation and literature review,guided by terror management-HPC decision-making,an intervention program to improve community elderly HPC decision-making willingness was initially formed.A total of 23 experts all over the country from the fields of life-and-death education,HPC,elderly psychology,humanistic ethics,geriatric nursing,and other fields were invited to participate in the consultation.Through anonymous iteration,three rounds of consultation were conducted on the intervention program for the elderly in the community,and the final consensus was made.A life-and-death education program was developed to increase the willingness of community elders to make HPC decisions.5.Quasi-experimental research method was used to carry out the practice of intervention program on decision-making willingness of HPC for community elderly and evaluate its effect.An administrative district of Chongqing was randomly selected,and a total of 30community elderly people were recruited to participate in this quasi-experimental study.They were divided into the intervention group or the control group according to their own willingness.The intervention group carried out life-and-death education guided by terror management-HPC decision-making framework,while the control group carried out daily health education.Before the intervention,at the end of the intervention,and 2 months after the intervention,the elderly were investigated for their decision-making willingness of HPC,life attitude,meaning of life,social support,death attitude,and death coping ability.The changes of the research variables were compared by repeated measures analysis of variance.At the end of the intervention,focus group interviews were used to understand the harvest of the elderly in the intervention group and their subjective evaluation of the education to provide a reference for the optimization of the subsequent life-and-death education program.Results1.Construction of the theoretical framework of terror management-HPC decision-makingAccording to the analysis results of the in-depth interviews with the elderly in the community,a total of 7 themes and 18 sub-themes were extracted from the two aspects of life and death attitude and HPC.Based on the Terror Management Health Model,through deductive and inductive analysis combined with interview results,the theoretical framework of terror management-HPC decision-making in Chinese culture was initially formed.The framework includes two modes of proximal defense and distal defense of death awareness,the corresponding threat avoidance,death-quality-oriented and self-dignity-oriented three HPC decision-making pathways and social support as an external moderating factor.2.Development and psychometric test of HPC decision-making willingness scale for the elderly in the communityIn this study,the community elderly HPC decision-making willingness scale with 12items in three dimensions including HPC cognition,HPC attitude,and HPC behavior intention was developed.The content validity,I-CVI of the scale items is between 0.833 and1.000,the overall content validity of the scale is S-CVI/Ave=0.974,S-CVI/UA=0.842;exploratory factor analysis extracted a total of three common factors,cumulative explained variance 78.962%;confirmatory factor analysis:χ~2/df=1.829,Absolute fitness index:RMSEA=0.052,GFI=0.951,Value-added fitness index:IFI=0.984,TLI=0.979,CFI=0.983and Simple fit index:PGFI=0.622,PNFI=0.745,etc.all meet the fit criteria;the AVE value of the scale is above 0.687,the CR value is between 0.898 and 0.917,and the AVE root value is greater than any two-dimensional correlation coefficient;Cronbach’s alpha coefficient and split-half reliability coefficient of the scale and each dimension were all higher than 0.850,and the test-retest reliability coefficient was between 0.847 and 0.974.3.Current status and influencing factors of decision-making willingness for HPC among community-dwelling elderly and revision of the theoretical framework for terror management-HPC decision-makingIn this study,the score of decision-making willingness of HPC for the elderly in the community was 40.65±6.32(total score range 12-60),among which the HPC cognition dimension score was the highest(14.45±2.82),and the HPC attitude dimension score was the lowest(12.80±2.90).The decision-making willingness of HPC of the elderly in the community was affected by the type of work before retirement,education level,experience of talking about life and death,death coping ability,life meaning experience and social support(P<0.05).The death attitude of the elderly negatively affected the decision-making willingness of HPC(β=-0.104,P=0.005)and was affected by the suppression effect of death coping ability(effect coefficient 0.129),which proved the dual path of threat avoidance and health orientation under the proximal defense model of terror management-HPC decision-making theoretical framework.The life attitude of the elderly in the community positively affected the decision-making willingness of HPC(β=0.169,P=0.000)and was mediated by the meaning of life(effect coefficient 0.123),which proved the self-dignity-oriented behavior path under the distal defense model of terror management-HPC decision-making theoretical framework.However,social support only positively moderated the path of meaning in life to decision willingness of HPC(B=0.006,P=0.001),and the role of social support in the revised terror management-HPC decision-making framework was only the path of distal defense self-dignity.4.Construction of the intervention program for community elderly HPC decision-making willingnessIn this study,three rounds of expert consultation were conducted on the intervention program of decision-making willingness of HPC for the elderly in the community,namely the life-and-death education program.The expert positive coefficients were 100.00%,95.65%and 100.00%,and the expert authority coefficients were 0.883,0.898 and 0.896,respectively.The Kendall’s concordance coefficients of experts were between 0.119 and 0.370,and statistically significant(P<0.05),and the coefficients of variation were less than 0.250.After the modification based on expert opinions,the research group finally formed a life-and-death education content consisting of 4 first-level items including the popularization of life-and-death knowledge,the establishment of life-and-death concept,the planning of life end,and the appreciation of life value for the elderly,9 second-level items and 23 third-level items.This program has formed 17 knowledge goals and 5 practical behavior goals,a variety of teaching methods including theory teaching,video viewing,scenario simulation,activity experience and a total of 10 class hours.5.Practical application and effect evaluation of the community elderly HPC decision-making willingness intervention programIn this study,after the intervention of decision-making willingness of HPC,the scores of life attitude,death coping ability and decision-making willingness of HPC of the elderly in the community were all improved and statistically significant compared with before(P<0.05).At the same time,the scores of life attitude,meaning of life,social support,death coping ability and decision-making willingness of HPC of the elderly after life-and-death education were higher than the other group(P<0.05).Focusing on the intervention effect and program evaluation,the results of the focus group interviews of the elderly in life-and-death education group were extracted 3 themes and 8 sub-themes including the improvement of life and death literacy(increased knowledge of life and death,open-minded concept of life and death,and emphasis on life value),HPC planning(improved decision-making willingness,simulation of advance directive,end-of-life arrangements),educational practice evaluation(approval of this activity,suggestions for optimization of practice).Conclusion1.The terror management-HPC decision-making framework initially explained the role of death awareness in HPC decision-making of the elderly in community under the background of Chinese culture,clarified the possible path of improving the decision-making willingness of HPC,and provided a theoretical basis for academic research related to HPC.2.The community elderly HPC decision-making willingness scale had good reliability and validity.The content of the scale was in line with the real background of Chinese culture and HPC.The expression of the scale was simple and easy to understand.This scale was a reliable tool for evaluating the willingness of HPC decisions in community elderly people.3.The decision-making willingness of HPC for the elderly in the community was still uncertain.In addition to sociodemographic factors,improving the experience of life meaning,death coping ability,and social support,and increasing the opportunity for life and death discussions will help the elderly to improve their willingness to make HPC decisions.4.The HPC decision-making willingness intervention program for the elderly is scientific,systematic,and practical.It comprehensively includes educational objectives,educational content,educational methods,and educational hours.5.Life-and-death education for the elderly in the community can improve the decision-making willingness of HPC.It has been approved by the elderly and plays an important role in improving the quality of life-and-death and HPC planning.It is a favorable intervention for the popularization and full utilization of HPC.