Factors Affecting the Death Anxiety Levels of Relatives of Cancer Patients Undergoing Treatment

Cancer is a major health problem in almost every country in the world in terms of morbidity and mortality rates. While 6 million people are found to have cancer in each year in the early 2000s, it is estimated that this number will reach 12 million in later years, there will be 75 million cancer patients worldwide in 2030 and 17 million of these patients will die. In Western societies one of each 250-350 people catches cancer in every year. Despite having no cancer statistics in our country, its incidence is estimated as half of this. The incidence of cancer is increasing in the group over the age of 60 and it rises to about four-five people in each 300 people (Karabulut and Uslu, 2006). Cancer affects the diagnosed individuals and their families in a negative way in the physical, psychological and social aspects, it brings heavy costs to the family and the society. Changes created by cancer over the individuals and their families increase over time, these increasing negative developments affect the whole family in a negative way, in short, it threatents the quality of life of the individual and the family. In recent years, the subject of “cancer and cancer treatment” reinforced the idea that it is a field of important contributions to the scientific world with the studies made at the molecular level towards the treatment of the disease and the information obtained from these studies. On the other hand, the advantage of science to provide a longer period of survival to the patients has led to the emergence


Introduction
Cancer is a major health problem in almost every country in the world in terms of morbidity and mortality rates. While 6 million people are found to have cancer in each year in the early 2000s, it is estimated that this number will reach 12 million in later years, there will be 75 million cancer patients worldwide in 2030 and 17 million of these patients will die. In Western societies one of each 250-350 people catches cancer in every year. Despite having no cancer statistics in our country, its incidence is estimated as half of this. The incidence of cancer is increasing in the group over the age of 60 and it rises to about four-five people in each 300 people (Karabulut and Uslu, 2006).
Cancer affects the diagnosed individuals and their families in a negative way in the physical, psychological and social aspects, it brings heavy costs to the family and the society. Changes created by cancer over the individuals and their families increase over time, these increasing negative developments affect the whole family in a negative way, in short, it threatents the quality of life of the individual and the family.
In recent years, the subject of "cancer and cancer treatment" reinforced the idea that it is a field of important contributions to the scientific world with the studies made at the molecular level towards the treatment of the disease and the information obtained from these studies. On the other hand, the advantage of science to provide a longer period of survival to the patients has led to the emergence Kerime Derya Beydag of another side of cancer which has more social direction. The fact that cancer being a grueling process for both the patient and the relatives has become more prominent with prolonged survival periods.
In general, death is a mysterious concept which also creates curiosity which defines the end of the life of the living and create no-occurrence, uncertainty, fear, despair and lack of hope, it is a constantly researched phenomenon. Death and the effort to solve its mystery has led to the effort of solving the the secret of mortality and getting an absolute guarantee of existence. Attitudes, thoughts and behaviors towards death also show the life perspective of the individual and it show how that individual percieves life.
Term of death anxiety refers not to the anxiety which is felt in the case of an urgent threat towards a person's life, it refers to the anxiety experienced in "daily life". Yalom (2000) says, "The fear of death exists always and everywhere and it is so great that, most of the life energy is spent in the moment of death (Yalom, 2000).
Basically the thing that scares the individual is not the feeling that life will continue, but it is the feeling that it will end at some point. Deaht do not come to human mind in the normal flow of life. However, he/she feels it if he/she witnesses some events around him/her which could lead to death.
Each individual's source of death anxiety may not be the same. According to Inam, the death anxiety is stated not to be cultural, it is taught and it is not an anxiety coming "from the genes", death is stated to be always included in life and life is stated to be included in death.
This study was made as a descriptive study to determine the levels of the death anxiety levels of the relatives of the patients and the factors affecting these death anxiety levels.

Materials and Methods
The sample of the study was formed by the 106 patient relatives who had patients being treated between April-June 2011 in the oncology or chemotherapy units of the hospital located in the Asian side of Istanbul. Necessary permission was taken from the related institution; and participation was asked by giving information about the study orally to the study participants.
Data were collected with the 15-item Death Anxiety Scale developed by Templer (1970) and adapted to Turkish by Senol (1989). Templer Death Anxiety Scale is a onedimensional evaluation scale which consists of 15 items in the True/False format. Nine of the fifteen items are scored in the right way, six of them are scored in the opposite direction. Total score may change between 0 and 15. High total score points out the existence of a higher level death anxiety (Akca and Kose, 2008). In the evaluation of the data, number-percentage calculations, the Kruskal Wallis, Anova test and the t test were used.

Results
Distribution of the demographic features of the participants is shown in Table 1. %36.8 of the patients included in the scope of the study were in the 45 years and over age group, %57.5 of them were female and %65.1 of them were married. %48.1 of the participants stated that their patient were under treatment for less than 6 months and %41.5 of them stated that they had a son/daughter. %56.6 of the cancer patients were male and %22.6 of them were had a diagnosis of breast cancer. %53.7 of the patient relatives stated that they were frequently afraid to lose their patients and %47.2 of them stated that they always believed that their patient would heal.
Comparison of the death anxiety scores of the patient relatives according to their age groups is shown in Table  2. There is a statistically significant difference between the age groups and the death anxiety scores of the participants (p<0.05). It was seen that the death anxiety levels of the participants in the 17-30 age group were higher.
Comparison of the death anxiety scores of the patient relatives according to their genders is shown in Table 2. There is a statistically significant difference between the genders and the death anxiety scores of the participants (p<0.05). It was seen that the death anxiety levels of the female participants were higher.
Comparison of the death anxiety scores of the patient relatives according to the treatment period of the patient of the relative is shown in Table 2. There is a statistically significant difference between the treatment period of the patient of the relative and the death anxiety scores of the participants (p<0.05). It was seen that the death anxiety levels of the patients undergoing cancer treatment for less than 6 months were higher.

Discussion
In this study, there was a statistically significant difference between the age groups and the death anxiety  scores of the participants (p<0.05). It was seen that the death anxiety levels of the participants in the 17-30 age group were higher. This result made us think that the participants did not have enough energy to cope with the things in the process of the disease and their death anxiety may be higher due to this reason. The studies which made by Stevens (1980) and Russac (2007), they were also stated that the oldest age group reported the lowest scores. Similiarly, in the study made by Wu et al. (2002), it was also stated that the high level of death anxiety was associated with younger age. Another study made by , results showed that younger as compared with older participants tended to be more death anxious. These results support the study finding. Contrary to the study finding, in a study made with nurses, it was found that the age groups of the nurses did not affect the death thought rates. Likewise, in the study made by Kizilkaya and Beydag (2010), it was stated that the age groups of the nurses working in the oncology field had no effect on their death anxiety levels (Kizilkaya and Beydag, 2010). The difference between these results and ours is thought to be occuring due to the difference in the sample group. It is an expected result that the nurses working in the oncology field and taking care of patients with similiar symptoms will have a different level of death anxiety compared to the nurses working in non-related fields. Similiarly, in the study made by Fortner and Neimeyer (1999), it was also stated that age do not appear to reliably predict death anxiety in elderly people.
There is a statistically significant difference between the genders and the death anxiety scores of the participants (p<0.05). It was seen that the death anxiety levels of the female participants were higher. There are similiar studies with similiar results in literature. For example in one case, it was stated that the female in-house caretakers of the cancer patients had more anxiety, depression and emotional stress compared to male caretakers. The reason behind these findings may be explained in several ways. First of all, female individuals take more responsibilities in the society. Women have roles such as mother, financial supporter, housewife and emotional supporter. Women caretakers show their emotions in a better way. Women, especially young women, have a tendency to report psychological distress in higher levels despite the care level is enough and the health status of the patient is under control. Likewise, in the study made by Akca and Kose, the death anxiety levels of women were found to be higher than men (Akca and Kose, 2008). Madnawat et al. reported that the death anxiety increases with age in women (Madnawat and Kachhawa, 2007). Similiarly, in the study made by Tang, Wu and Yan (2002), they were found that the death anxiety scores of the female university students were higher than the male ones (Ayten, 2009;. Another study (Neimeyer and Fortner, 1995) suggested that death anxiety is higher in elderly females than elderly males. The gender effect refers to the fact that women typically report higher levels of death anxiety than men (Dattel and Neimeyer, 1990;Kastenbaum, 2000;Depaola, 2003;Harding, 2005;Russac, 2007).
There is a statistically significant difference between the treatment period of the patient of the relative and the death anxiety scores of the participants (p<0.05). It was seen that the death anxiety levels of the patients undergoing cancer treatment for less than 6 months were higher. It was concluded that this result was obtained due to the fact that the relatives of the newly diagnosed patients could not adapt the process of the disease instantly and for this reason they experienced more negative feelings towards this process. Because of the cancer, the patients and his/her family experience feelings like fear, despair, guilt, helplessness, unbearable pain and abandonment and death anxiety and they show different reactions. Among the general principles and methods towards adapting the patient to living with cancer; approaches like individual care of the patient, protection of the autonomy of the patient in the aspect of role functions, solving the spiritual and societal adaptation problems of the patient, providing individual support systems for each patient (family, friend, work) and increasing functionality. Likewise, in another study, it was stated that the perception towards the caretaking process of the cancer patient caretakers is important; and one of factors affecting the caretaking process perception of this individual is his/her level of knowledge about this process and his/her expectations towards the course of the disease in this process.
In the light of these results, it is advised that the relatives of the cancer patient undergoing treatment should be informed in all phases without being kept seperate from the process of the disease and meetings should be organized for informing the patient and patient relatives for helping them in the adaptation to the process of the disease. It is especially advised that the psychosocial reactions of the patient and patient relatives in the beginning phases of the cancer treatment, their adaptation to the process of the disease and their quality of life should be evaluated periodically.