Initial Validation of the Death and Dying Distress Scale for the Assessment of Death Anxiety in Patients With Advanced Cancer
Open accessAbstract
Context The experience of death anxiety in patients with advanced cancer has been understudied partly because of the lack of a tailored measure for this population. The Death and Dying Distress Scale (DADDS) was constructed to address this gap. Although an initial version of this instrument has shown promising psychometric properties, validation of the finalized version is needed. Objectives This study aims to validate the recent 15-item DADDS by examining its factor structure and construct validity. Methods Sixty participants with advanced or metastatic cancer were recruited from the Princess Margaret Cancer Centre, University Health Network, Toronto, Canada, into a pilot trial of a psychological intervention. This article analyzes the baseline measures on death anxiety, depressive symptoms (Patient Health Questionnaire-9, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Axis 1 Disorders), generalized anxiety (Generalized Anxiety Disorder-7), and preparation for end of life (Quality of Life at the End of Life-Cancer Scale). Exploratory factor analysis was conducted. Construct validity was assessed by correlations between measures. Results Factor analysis revealed a dominant single factor explaining more than 75% of the shared variation between items. Factor loadings were high, ranging from 0.57 to 0.86. Item communalities were evenly ranged from 0.33 to 0.75 and with the 15:1 variable to factor ratio, suggest the viability of parameter estimates despite the small sample size. Cronbach's alpha was 0.95. Death anxiety was associated with less preparation for end of life (r = -0.68, P < 0.0001), more generalized anxiety (r = 0.63, P < 0.0001), and more depressive symptom severity (r = 0.50, P < 0.0001). Individuals with major depression had greater death anxiety than the nondepressed (mean difference = 17; 95% CI = 1.5-33), as did individuals with minor depression (mean difference = 25; 95% CI = 10-41). Conclusion The DADDS is a valid measure of death anxiety in patients with advanced cancer. It may provide useful information in the assessment and treatment of distress in patients near the end of life.
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Postolică, R., Enea, V., Dafinoiu, I., Petrov, I., & Azoicăi, D. (2018) · Death Studies · doi:10.1080/07481187.2018.1430083 · Cited by 17 · see citing works
Letzner, R. D. (2023) · Death Studies · doi:10.1080/07481187.2023.2230556 · Cited by 16 · see citing works
A cross-sectional gender-sensitive analysis of depressive symptoms in patients with advanced cancer
Shapiro, G. K., Mah, K., de Vries, F., Li, M., Zimmermann, C., Hales, S., & Rodin, G. (2020) · Palliative Medicine · doi:10.1177/0269216320947961 · Cited by 17 · see citing works
Self-citationPerry, L. M., Mossman, B., Lewson, A. B., Gerhart, J. I., Freestone, L., & Hoerger, M. P. (2022) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228221107723 · Cited by 15 · see citing works
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Self-citationAnsiedade relacionada à morte em cuidados paliativos: validação do diagnóstico de enfermagem
Abreu-Figueiredo, R. M. S., de Sá, L. O., Lourenço, T. M. G., & de Almeida, S. S. B. P. (2019) · Acta Paulista de Enfermagem · doi:10.1590/1982-0194201900025 · Cited by 14 · see citing works
Eren, M. G., Üçgül, K., & Sert, H. (2023) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228231167725 · Cited by 13 · see citing works
Smith, N. D. W., Boone, D. M., Schimmel‐Bristow, A., Rawlins, J., Ellingham, L., Sobalvarro, S., & Faith, M. A. (2023) · Journal of Psychosocial Oncology · doi:10.1080/07347332.2023.2241855 · Cited by 9 · see citing works
Measuring double awareness in patients with advanced cancer: A preliminary scale development study
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Self-citationHealth care utilization as a predictor of death anxiety in older adults
Becker, T. (2020) · Death Studies · doi:10.1080/07481187.2020.1774942 · Cited by 8 · see citing works
Advanced Cancer in Young Adults (YAs): Living in a Liminal Space
Avery, J., Campbell, K. L., Mosher, P. J., al‐Awamer, A., Goddard, K., Edwards, A., Burnett, L., Hannon, B. L., Gupta, A. A., & Howard, A. F. (2023) · Qualitative Health Research · doi:10.1177/10497323231204182 · Cited by 9 · see citing works
Miyamoto, S., Yamazaki, T., Shimizu, K., Matsubara, T., Kage, H., Watanabe, K., Kobo, H., Matsuyama, Y., Rodin, G., & Yoshiuchi, K. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-056136 · Cited by 9 · see citing works
Self-citationde Vries, F. E., Mah, K., Malfitano, C., Shapiro, G. K., Zimmermann, C., Hales, S., & Rodin, G. (2022) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2021-003408 · Cited by 9 · see citing works
Self-citationReduction of death anxiety in patients with advanced cancer in short-term psychotherapy
Oberth, P., Springer, F., Lehmann‐Laue, A., & Mehnert, A. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1491734 · Cited by 8 · see citing works
Bennett, A., Sharpe, L., & Boyse, J. B. (2025) · Journal of Cancer Survivorship · doi:10.1007/s11764-025-01856-8 · Cited by 9 · see citing works
Oh, Y. J., In, K., & Jeon, Y. H. (2020) · Korean Journal of Adult Nursing · doi:10.7475/kjan.2020.32.3.235 · Cited by 8 · see citing works
Menzies, R. E., Connery, T., Macdonald, D., & Riotto, G. D. (2025) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2025.112373 · Cited by 6 · see citing works
Guo, J., Wister, A., Mitchell, B., & Li, S.-Z. (2024) · Journal of Aging and Health · doi:10.1177/08982643241289516 · Cited by 6 · see citing works
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Heidari, A., Arefi, M., & Amiri, H. (2019) · Avicenna Journal of Neuro Psych Physiology · doi:10.32598/ajnpp.4.3.405 · Cited by 6 · see citing works
The Italian validation of the Death and Dying Distress Scale
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Self-citationA bibliometric analysis of studies on death anxiety in patients with cancer
Li, W., Li, H., Wen, J., Pang, D., Lu, Y., & Yang, H. (2024) · Journal of Psychosocial Oncology · doi:10.1080/07347332.2024.2398098 · Cited by 5 · see citing works
Computergestütztes Screening auf Palliativbedarf bei onkologischen Patienten
Lukasczik, M., Seekatz, B., Radina, S., Häckel, A., Neuderth, S., & van Oorschot, B. (2015) · Der Onkologe · doi:10.1007/s00761-015-3075-1 · Cited by 5 · see citing works
Will Ihr Patient wirklich sterben?
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Shapiro, G. K., Mah, K., de Vries, F. E., Zimmermann, C., Li, M., Hales, S., & Rodin, G. (2022) · Journal of Psychosocial Oncology Research and Practice · doi:10.1097/or9.0000000000000076 · Cited by 4 · see citing works
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Self-citationThe Psychopathological Predictors and Effects of Death Anxiety
Husain, W., Malik, M., Shakeel, A., Riaz, A., Mahnoor, & Jahrami, H. (2024) · Omega · doi:10.1177/00302228241272502 · Cited by 5 · see citing works
Back, A. L., McGregor, B. A., Thorn, L. L., Baker, K. K., Gooley, T., Kaelen, M., Harvey, K., Guy, J., Myers, S., Perez, J., et al. (2026) · Psychedelic Medicine · doi:10.1177/28314425251413856 · Cited by 4 · see citing works
Fears of Death and Their Relationship to Mental Health
Zuccala, M., & Menzies, R. E. (2022) · Springer eBooks · doi:10.1007/978-3-031-06932-1_4 · Cited by 3 · see citing works
The Effect of Death Anxiety Related to COVID-19 on Travel Behavior
Şengel, Ü., Işkın, M., Genç, G., & Çevrimkaya, M. (2020) · Gaziantep University Journal of Social Sciences · doi:10.21547/jss.787466 · Cited by 5 · see citing works
Measuring American adults’ perceptions about human existence: A cross-sectional study
LaPorte, M. R. C., Emanuel, L. L., Solomon, S., Poffo, C. V., Joshi, I., Yao, Y., & Wilkie, D. J. (2025) · Palliative & Supportive Care · doi:10.1017/s1478951525100497 · Cited by 3 · see citing works
The trajectory of death anxiety in patients with advanced cancer and their family caregivers
Walbaum, C., Philipp, R., Bokemeyer, C., Härter, M. C., Koch, U., Oechsle, K., & Vehling, S. (2025) · Death Studies · doi:10.1080/07481187.2025.2585927 · Cited by 2 · see citing works
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Computergestütztes Screening auf Palliativbedarf bei onkologischen Patienten
Lukasczik, M., Seekatz, B., Radina, S., Häckel, A., Neuderth, S., & van Oorschot, B. (2016) · Wiener klinisches Magazin · doi:10.1007/s00740-016-0145-y · Cited by 2 · see citing works
Loughan, A. R., Lanoye, A. M., Willis, K. D., Braun, S. E., Davies, A., Rodin, G., Thacker, L. R., Fox, A. M., Kleva, C. S., Zarrella, G. V., et al. (2024) · Neuro-Oncology Practice · doi:10.1093/nop/npae097 · Cited by 1 · see citing works
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Guided Mindfulness of Death to Reduce Fear of Death in Cancer Patients: Randomized Controlled Study
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Self-citationExistential distress in neuro-oncology
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Death-related Distress in Advanced Cancer
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Otto, A. K. (2025) · Library, Museums and Press - UDSpace (University of Delaware) · doi:10.58088/tghp-wd25
Intricate Conversations: Caring for Clients with Severe Mental Illness
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Death and Dying: A Mediation Analysis of Fear
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Self-citationDeath Anxiety among Older Adults during the COVID-19 Pandemic: Implications for Nursing Practice
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Creating critical palliative hypnotic adjustments: temporality, hope, and meaning
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Post-traumatic growth in patients and caregivers after a primary brain tumor diagnosis
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Efficacy of psilocybin on death anxiety in terminal patients: a narrative review
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Validation of the Japanese version of the death and dying distress scale
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Self-citationInitial Validation of the Korean Version of the Death and Dying Distress Scale
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Self-citationDeath anxiety in advanced cancer patients and family caregivers: A scoping review
Sun, Q., Yorke, J., Loong, H. H. F., Luo, H., Xuexun, X. I. A. O., Liu, Q., Mao, T., & Ho, K. Y. (2026) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2026.103334
- Authors
- Krause, S., Rydall, A., Hales, S., Rodin, G., & Lo, C.
- Affiliations
- University Health Network (CA)
- Venue
- Journal of Pain and Symptom Management
- Publisher
- Elsevier BV
- Published
- 2015-01
- Volume
- 49
- Issue
- 1
- Pages
- 126-134
- ISSN
- 0885-3924 (ISSN-L)
- OpenAlex
- W2058150514
- Cited by
- 102
- References
- 49
- Citations by year
- 2026: 11 · 2025: 11 · 2024: 9 · 2023: 11 · 2022: 13 · 2021: 7 · 2020: 10 · 2019: 5 · 2018: 7 · 2017: 5 · 2016: 8 · 2015: 4 · 2014: 1
- FWCI
- 5.52
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Pain and Symptom Management (publishedVersion)
- PubMed (publishedVersion)
- ResearchOnline at James Cook University (James Cook University) (submittedVersion)
- TSpace (University of Toronto) (submittedVersion, cc-by-nc-nd)
- Funders
- University Health Network Department of Psychiatry
- Canadian Institutes of Health Research (CIHR #MOP 106473)
- Princess Margaret Cancer Foundation Hertz Center Fund
- Campbell Family Cancer Research Institute
- Ontario Ministry of Health and Long Term Care
- University of Toronto/University Health Network Harold
- Shirley Lederman Chair in Psychosocial Oncology and Palliative Care
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- fear of death, advanced cancer, end-of-life care, psychometric validation, factor structure, construct validity, depressive symptoms, generalized anxiety disorder, end-of-life preparation
- MeSH terms
- Adult, Aged, Aged, 80 and over, Anxiety, Attitude to Death, Factor Analysis, Statistical, Female, Humans, Male, Middle Aged, Neoplasms, Palliative Care, Psychometrics
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