Fear of death in medical professionals and social workers

INTRODUCTION

The category of “fear” has been described in the source literature in a way that allows broadly characterization of the functioning of a person experiencing it. In the beginning, however, it should be emphasized that moderate anxiety, as an emotional state, is a natural feeling that prepares a person to act when under threat or in dangerous situations, thus making it easier for him/her to maintain emotional balance. However, when it becomes an excessive or unjustified feeling that makes functioning difficult, the human condition deteriorates [1]. Based on the available sources, it can be concluded that the perceived fear causes many symptoms in all spheres of life and may apply to every person. Thus, a person may feel its consequences in somatic, emotional, or behavioural spheres. As a result of experienced anxie­ty, there may be physical ailments, anxiety, worry, and fear, as well as at a behavioural level – e.g. palpitations, numbness up to stupor, or difficulties with speaking [2]. Indeed, it is a condition that affects human life, decision making, and everyday functioning.
When defining the concept of anxiety, it is worth referring to the root of the term ‘anxiety’. For example, the Indo-European word angh has been transformed into the Greek angkito and is translated as ‘choking’, ‘narrowing down’, or ‘squeezing’. On the other hand, the German and English words Angst, existentielle Angst, and ‘anxiety’, also referring to existential anxiety, derive their pedigree from the Latin anxietas [3]. Referring to the definition, anxiety is an unpleasant, intensely felt state of malaise caused by a vague impression of an unspecified and imminent threat, towards which a person feels helpless and powerless [4]. The reason for experiencing such a state can be varied, depending mainly on external events interpreted by a person as disturbing, causing concern, or threatening [1]; then anxiety can take various forms [2].
One of the categories of anxiety is the so-called thanatic anxiety – ‘thanatos’. In the semantic analysis of the concept, it is essential to show the etymology of the concept of thanatos. It has its source in the Greek θα′νατος, meaning death, dying [5]. Thanatic anxiety means an unpleasant emotional state related to the existential experience of one’s mortality and that of relatives (significant ones) and the passing of the surrounding reality [6]. Above all, the analysis of the scientific literature shows 2 main contexts of exploring and characterizing thanatic anxiety. The first one contains theoretical considerations on the fear of death in philosophical [7-12], theological [13], psychological [14-20], anthropological, and cultural [17, 20-25] literature. Furthermore, although these analyses in the original version refer to the dying person, it seems that these characteristics can also be extrapolated to other groups, including help workers.
The second context focuses mainly on presenting the results of thanatic anxiety based on research conducted in psychology [16, 26-32] and sociology [33-35]. In the literature to date, however, there are no broader considerations and studies covering the category’s pedagogical aspect in question. According to our previous research [6, 36], the essence of thanatic anxiety is the entirety of experiences and emotional experiences related to the perception of death, such as fear and thanatic phobias [6]. The basis of such interpreted fear is the reflections of Paul Tillich, according to whom the anxiety of death permeates the whole human existence, and is a basic experience that takes the form of specific fears related to experiencing everyday life [37]. In this context, fear is a space for experiencing oneself, one’s reality, and one’s own environment, both by the patient, the charge, and their family, as well as by the medical, therapeutic, and caring staff. How this fear is experienced and the degree of coping with it are of fundamental importance for the quality of the patient-doctor (nurse, therapist, caregiver) relationship, as well as the patient’s family-doctor (nurse, therapist, caregiver) relationship [36].
Our experience in therapeutic work with children dying from cancer, mourning people, and people experiencing war-related death and violence contributed to deepening the analysis of thanatic anxiety, and the development of a simple diagnostic and therapeutic tool showing the image of the experienced trauma related to thanatic anxiety [6, 36]. Thanatopedagogical relational replacement therapy (TRRT) is a response to the need characterized above. Its essence is in therapeutic practice and its pedagogical approach, by creating and modifying educational and upbringing goals related to the broadly understood thanatic experiences. The very essence of TRRT is included in the name. The first element refers to the basis and sources of therapies included in thanatopedagogy, while the second relates to the issue of action determined by the context of the therapist-patient, educator-foster relationship. The therapy refers to the modification, replacement, or correction of educational and upbringing goals. Both upbringing and socialization can generate traumatic experiences of thanatic anxiety. The image and ways of experiencing thanatic anxiety are closely related to the process of socialization and upbringing, and they should be used to seek ways to alleviate thanatic traumas. The advantage of the tool mentioned above is its simplicity, because it has the form of several questions addressed to a respondent, and the fact that this tool can be used among various groups of people, both adults and children [6].

MATERIAL AND METHODS

This study aimed to investigate how people perceive or think about the fear of their own death, its causes, and ways of dealing with it by employees in professionally assisting facilities. The project’s essence was also getting to know the types of experienced fears and naming them by the respondents. The planned procedure was approved by the Ethical Committee of the Faculty of Philosophy and Social Sciences at Nicolaus Copernicus University in Torun, Poland (approval no. 9/2021).
In connection with the aim of the project, the following main research question was asked: How do respondents in selected countries experience the fear of death, and what variables differentiate this experience?
The specific questions that the authors of the text tried to answer in the conducted research were as follows: How do people surveyed in selected countries think about their fear of their own death? What are the sources of fear of death among the surveyed professional helpers? What is the perception of fear among the respondents due to the selected variables? What methods of coping with fear of death do the respondents indicate?
In 2010-2014 we carried out research on the perception of fear of death in the context of thanatopedagogical relational replacement therapy in the Czech Republic, Poland, Ukraine, and Italy. For this purpose, 791 people from among medical care workers and social workers were examined using a questionnaire.

Sample selection criteria.
1. Occupational criterion: studying in a field preparing to take up a profession characterized as supportive, or pursuing such a profession in facilities providing routine or intervention-compensatory care.
2. Participation criterion: participation in group and individual classes devoted to the perception of fear of death, conducted and designed by the author of this study.
3. Statehood criterion: having citizenship of one of the randomly selected European countries (Czech Republic, Ukraine, Republic of Poland, Italian Republic).
The study used the diagnostic poll method and the questionnaire technique using the WWH questionnaire (What/Why/How) developed by Józef Binnebesel [6]. The primary research tool was the WWH diagnostic and therapeutic questionnaire, which consisted of 3 modules: C1 – “What are you afraid of thinking about concerning your death?”; C2 – “Why are you afraid of this?”; J – “How can you deal with this fear?” [6, 17]. The specificity and nature of the tool referred to the following issues:
the existential understanding of the fear of death formulated by Tillich as the experience of the fear of non-existence [38], which casts a shadow “on all specific fears” and gives them “ultimate seriousness” [36], the original concept of the formation of thanatic attitudes by Binnebesel [6],
the original understanding of the pedagogical therapy itself, referring to the structure of educational environments [6].
In descriptive statistics, Shapiro-Wilk test was used to test normality, mean values and 95% confidence intervals (95% CI) were applied for normally distributed continuous variables, and medians and quartile values (Q25, Q75) for the others. Frequency analysis was performed using the c exact test. For non-parametric data, the Mann-Whitney U test was applied. The correlation between non-parametric (ordinal numeric) measures was tested with Spearman’s rank coefficient. P-values less than 0.05 were considered statistically significant. The exact p-value is presented whenever possible, and a 95% CI is applied. The analysis was performed in Statistica 13.3 (TIBCO Software Inc., 2017, http://statistica.io).

RESULTS

All respondents participated in the classes on the fear of death, during which, based on the WWH tool, the experienced fears, their causes, and the ability to cope with them were analysed. Before the research procedure, the persons who qualified for the study were asked if they knew what thanatic anxiety was [36]. All of these people replied that it was related to the fear of death.
Table 1 presents the demographic data of the studied sample.
As can be seen, the study involved a wide range of employees from different countries, performing various roles and functions in randomly selected medical facilities. The respondents also differed from each other in terms of gender, age, education, religion, and marital status.

Thanatic anxiety perception
Qualitative analysis of the responses obtained with the use of the WWH questionnaire in module 1 allowed us to identify 27 types of indications regarding experienced anxiety related to death. In this part, the respondents answered the question: “What are you afraid of when you think about death?”. The distribution of responses is shown below in Figure 1.
Based on the results presented in Figure 1, most people indicated that, when thinking about their death, they are most afraid of pain (67.6%) and fear of abandoning their loved ones (46.0%), loneliness (43%), the suffering of relatives (39.1%), and existential anxiety – what will happen after death (35.7%). To a much lesser extent, the respondents indicated that when thinking about death, they were afraid of their helplessness (28.8%), the poor taste of life (28.4%), or being forgotten (25.6%). The respondents were the least afraid of being cold (1.5%) and leaving property (1.6%).
Figure 2 shows the respondents’ answers based on which the sources of anxiety can be characterized, defined by the respondents as the most important and the first.
In first place the respondents indicated fear related to the abandonment of loved ones (19.2%), the suffering of relatives (10.5%), experiencing pain (9.6%), loneliness (8.0%), and leaving unfinished business (6.7%). Leaving a property was the least source of fear (0.3%), and the fear of death was not related to the anxiety that they would be eaten by worms and the feeling of disappointment.
Another aspect we analysed was the perception of fear among the respondents, taking into account selected variables: gender, religion, and country of origin.
We found significant differences in the anxiety pattern between men and women. Men were more afraid of loneliness (p = 0.0001), a sense of nonsense (p < 0.0001), and not tasting life (p = 0.0001). Women, on the other hand, more often feel the fear of being buried alive (p < 0.0001), abandoning loved ones (p < 0.0001), helplessness (p = 0.003; value on the borderline of statistical significance), and what will happen next (p = 0.0015).
Age turned out to be positively weakly correlated (p < 0.002) with fear of the dark (r = 0.18;), leaving loved ones (r = 0.18), uncertainty (r = 0.14), leaving property (r = 0.20), and violence (r = 0.15) and weakly negatively correlated with fear of helplessness (r = –0.13), suffering of relatives (r = –0.14), insufficient taste of life (r = –0.13), and being forgotten (r = 0.16).
Married people less often than single people reported fear of loneliness (p = 0.012), suffering of relatives (p = 0.002), and being forgotten (p = 0.0006) and more often reported fear of uncertainty (p = 0.037) and abandonment of relatives (p < 0.0001).
People with higher education were more often afraid of the suffering of their relatives (p = 0.002) and had less fear of relatives' abandonment (p < 0.0001) and uncertainty (p = 0.001). Perhaps they were also more likely to fear pain (p = 0.048), helplessness (p = 0.007), being buried alive (p = 0.01), and being forgotten (p = 0.012), but these results should be considered with caution due to the Bonferroni correction.
There were no differences in patterns of thana­tic anxiety, depending on the declaration of faith in God. However, such differences were noticed depending on the declared religiosity. People who considered themselves irreligious more often indicated fear of helplessness (p = 0.024), of being buried alive (p = 0.004), that they would not have time to say goodbye to their loved ones (p = 0.039), and of pity (p = 0.029) and less often of punishment for sins (p = 0.0025). Due to the Bonferroni correction, these results should be interpreted with caution.
We found the differences in the perception and indication of the sources of fear between nationalities (Fig. 3). The issue of fear of pain was most often mentioned among respondents from the Czech Republic (72.1%), Poland (70%), and Ukraine (72.3%), while the fear related to abandoning loved ones was dominant in the respondents from Italy (66.7%). However, the differences are statistically insignificant. Nonetheless, after the Bonferroni correction, significant statistical differences were shown for the fear of being buried alive (p < 0.0001), leaving unfinished business (p < 0.0001), what will happen next (p < 0.0001), punishment for sins (p < 0.0001), disappointment (p = 0.0001), failure to taste life (p = 0.0003), and that the dying person will not have time to say goodbye to their loved ones (p < 0.0001).

DISCUSSION

As a result of the analysis of the obtained responses, we formed a pattern of 27 causes of anxiety. The pain was the most common cause given by respondents from the Czech Republic, Poland, and Ukraine. Contrary to respondents from Slavic countries, for Italians, the pain was the third most common cause of anxiety. The most often, they indicated the fear of leaving loved ones, and the second most important was the fear of not getting the taste for life. On the other hand, the distribution of results in terms of the causes of anxiety indicated by the respondents in the first place and as the most important is different. Respondents from all 4 countries indicated abandonment of their loved ones as the first and most important cause of anxiety. The second most important was the anxiety associated with experiencing the suffering of relatives (Fig. 2). The fear of pain ranked third.
People who fear pain point to it because they have experienced it in their life. The strategy of dealing with this fear is, first of all, searching for the meaning of its experience. In the case of the fear of abandoning loved ones, most respondents’ indications related to personal experience. It refers firstly to experiencing the fear of facing the death of a loved one and mourning after their death due to an illness, and secondly to experiencing loneliness in life after the departure of a spouse, friend, or partner.
In the presented project, the respondents were also asked about techniques of coping with anxiety. Two strategies were preferred as a way of coping with experienced anxiety. The first one, indicated by one-third of those who were afraid to leave their loved ones, concerned the repair of the relationship and referred to the need to take action to repair the relationship. The respondents indicated 2 groups of people with whom they should fix these relations. The first is family members, and the second is friends or people once met in life. The second strategy of coping with the fear related to the death of a loved one was getting used to death, treated as the necessity to recognize the inevitability of death.
Loneliness was another category studied. Statements relating to the experience of loneliness, in most cases, boiled down to the statement “I am afraid of loneliness”. In most cases, working in groups or individually allowed this indication to be developed, in which the respondents said that experiencing loneliness in them was an overwhelming feeling when they thought about their death. Qualitative analysis identified 2 forms of indicated loneliness. The first was a form of a feeling of a vague fear of being lonely. The second was the fear of dying alone. Most responses in this group referred directly or indirectly to the fear of a lonely death. The most common motive for this indication was one’s own experience, while the way to deal with the situation was a concern for another person. The suffering of relatives concerned family, spouses, partners, and friends, while in young people not in a partnership and not having children it was parents and friends. Women who had children related the anxiety connected to the suffering of their relatives to their children, less often to their husbands or partners, and only in a few cases to their parents. The respondents indicated the reason for this suffering was primarily the helplessness that they could not come to terms with a given situation, as well as in the feeling of guilt. In the first case, the inability to remedy the situation and the necessity to accept it was emphasized as a way of coping, while in the second case, taking steps to repair the bonds.
It is worth mentioning that the least frequently indicated cause of thanatic anxiety was “I am afraid of death because I am afraid of violence and war”. This answer was provided by 13 respondents from Ukraine who participated in the study after the bloody events in Kyiv on Maidan in 2014 and the anne­xation of Crimea. CONCLUSIONS Fear of death is an existential experience reflected in everyday life, which influences human functioning in all spheres. Often experienced, it may also result from unworked everyday matters or incorrect beliefs about oneself, death, and life. The state of anxiety and thanatic anxiety can be felt by every person, not only dying or suffering. Therefore, it can also occur among medical and social care workers who deal with suffering and death daily. When performing such work, constant contact with a suffering person forces questions about one’s own death and dying, making one reflect on one’s own fear and its causes. The presented research results indicate, on the one hand, the complexity of the issue of thanatic anxiety, and on the other, its universal nature. Universalism reveals common, transnational, and cultural features of experiencing fear and its causes. However, cultural differences and differences in parenting styles were also identified in the context of the perception of the fear of death and its causes. Abandonment of loved ones is the most common cause of thanatic anxiety, not the pain experienced while dying. In clinical practice, the information obtained in the research is essential for the people who work in aid, as well as for the professionals supporting the ‘helpers’. Awareness of the existence of anxiety also among the professional helping staff, knowledge of its complexity, sources, and causes gives an employee (and any other person experiencing thanatic anxiety) a chance to bend over it and look for coping strategies. Working through these fears can affect one’s overall perception and experience of thanatic anxiety. Furthermore, perhaps the ability to work through one’s own anxiety and develop coping strategies to deal with it will provide a chance to understand better the fears experienced by the wards and patients, and therefore improve the quality of care provided.

CONFLICT OF INTEREST

The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

REFERENCES