Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Holly Stith

Clinical Mentor

Dr. Abigail Latimer

Committee Member

Dr. Holly Chitwood



Background: Recent studies have shown that upwards of 80% of patients with advanced cancer suffer from death anxiety resulting in increased physical and psychological suffering. Despite death anxiety’s ubiquitous nature and negative impact, the literature regarding this condition consistently indicates that it remains under-identified and undertreated in patients with advanced cancer. The “Death and Dying Distress Scale” (DADDS) is a clinically validated tool used to identify, measure, and guide effective treatment modalities for death anxiety specifically in patients with advanced cancer, but is scarcely used routinely in practice. Incorporating this screening tool to be used regularly could improve identification of death anxiety and subsequent treatment in patients with advanced cancer.

Purpose: The purpose of this project was to develop, implement and evaluate the impact of a death anxiety screening protocol on identification of death anxiety and treatment referral rates in patients with advanced cancer in the outpatient palliative care setting, where no previous death anxiety screening was taking place.

Methods: This was a prospective observational quality improvement (QI) project incorporating the FOCUS-Plan-Do-Study-Act (PDSA) model to develop, implement, and evaluate a death anxiety screening protocol. A literature review was conducted to determine the appropriate death anxiety screening instruments for use in the advanced cancer population. Results of the literature review were used to develop a death anxiety screening protocol for implementation utilizing the DADDS. The protocol was then piloted in an outpatient palliative cancer care clinic at a Comprehensive Cancer Center recognized by the National Cancer Institute (NCI). Evaluation of the protocol was conducted by interpreting descriptive statistics.

Results: Over 20-clinic days 34 patients were seen at the clinic and 31 who met eligibility criteria were approached for the study. Of these, 24 patients completed the DADDS screening and seven declined. All 24 patients screened positive for death anxiety with six scoring mild, 11 scoring moderate, and seven scoring severe. Moderate and severe death anxiety warranted a referral to outpatient palliative social work to facilitate treatment referral to mental health services. Of the 18 that met this criterion, 11 referrals were initiated, five declined referrals, and two already were referred prior to implementation of the protocol. The data from this pilot project demonstrated an increase in identification of death anxiety and treatment referrals after protocol implementation.

Conclusions: Results from this study suggest that implementation of a death anxiety screening protocol can be effective in identifying death anxiety in patients with advanced cancer and increasing access to mental health services. In the future we should consider launching this protocol to all clinics within UK Healthcare’s Markey Cancer Center. We would be able to aim to include more patients and thus examine relationships with death anxiety, including risk factors and other details that would allow us to better understand barriers to referrals and engagement.