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J Clinic Care Skill 2025, 6(2): 83-88 |
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Ethics code: IR.IAU.NAJAFABAD.REC. 1403.140
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Received: 2025/05/1 | Accepted: 2025/06/8 | Published: 2025/06/19
Received: 2025/05/1 | Accepted: 2025/06/8 | Published: 2025/06/19
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Rezaei G, Salmani F. Death Anxiety and Related Factors in Coronary Artery Bypass Grafting Candidates. J Clinic Care Skill 2025; 6 (2) :83-88
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Authors
G. Rezaei1, F. Salmani *1
1- “Department of Midwifery” and “Nursing and Midwifery Sciences Development Research Center” Najafabad Branch (NaC), Islamic Azad University, Najafabad, Iran
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Introduction
Coronary artery disease (CAD) is a prevalent cardiovascular condition resulting from the accumulation of atherosclerotic plaque within the coronary arteries, which are responsible for delivering oxygen-rich blood to the myocardium. Plaque buildup in these arteries reduces blood flow, leading to symptoms such as chest pain, shortness of breath, nausea, vomiting, radiating pain to the arm, neck, jaw, or abdomen, and fatigue [1]. According to the American Heart Association, by 2030, approximately one in every three individuals will be affected by some form of cardiovascular disease [2]. In recent years, the prevalence of CAD in Iran has increased by an estimated 20-25% [3].
Coronary artery bypass grafting (CABG) remains the most commonly performed surgical intervention for patients with coronary artery stenosis [4]. This procedure can be performed either with cardiopulmonary bypass (on-pump) or without it (off-pump) [5]. CABG significantly improves myocardial perfusion, enhances patients’ quality of life, extends life expectancy, and reduces mortality. However, it is also associated with various psychological challenges, among which death anxiety is particularly significant.
Death anxiety is defined as a persistent fear, worry, or distress triggered by thoughts of death or dying [6]. It is a universal phenomenon that manifests differently across individuals. Some may experience intense fear, while others report mild concern [7, 8]. The causes of death anxiety vary and may include fear of the unknown, separation from loved ones, or anticipated pain and suffering before death.
In patients undergoing CABG, death anxiety may lead to anxiety disorders, depression, hopelessness, increased stress, social isolation, decreased quality of life, panic attacks, non-adherence to treatment, and physiological changes, such as elevated blood pressure and heart rate [9, 10]. Numerous factors can influence the development and intensity of death anxiety, including age (with older adults experiencing higher levels due to proximity to the end of life) [11-13], gender (with some studies suggesting higher rates in women) [14], and the individual’s religious and spiritual beliefs (where stronger beliefs are often associated with lower anxiety) [15].
Additionally, physical and mental health status, the presence of chronic diseases, psychological disorders, fear of surgery, socio-economic status, and unfavorable cultural attitudes toward death can contribute to increased anxiety levels [16-20]. A lack of social support is also a critical factor, while the presence of strong support networks can mitigate anxiety and enhance coping mechanisms [21].
Despite the clinical significance of death anxiety in CABG candidates, limited research has been conducted on this topic. Understanding its contributing factors is essential for developing effective psychological and therapeutic interventions. Therefore, the present study was designed to investigate the level of death anxiety and its related factors among patients scheduled for CABG at Shariati Hospital in 2024.
Instrument and Methods
Design
This correlational descriptive study was conducted on patients hospitalized in the heart surgery department of Shariati Hospital in Isfahan in 2024.
Sample
The sample size was calculated using the Cochran formula, with a standard deviation of 0.26 and an error rate of 0.05 for 100 samples. Sampling was performed using a convenience method, and individuals who met the criteria for inclusion were selected. The researcher entered the study environment after obtaining permission from the vice president of research and hospital officials and receiving written informed consent from the research participants.
Inclusion criteria
The criteria for inclusion in the study included the patient being a candidate for CABG, the patient being hospitalized in the surgical department, being literate, and being willing to participate in the study. The exclusion criteria included the death or transfer of the patient to other medical centers and failure to complete the questionnaires.
Data collection
To conduct the study, the process for completing the questionnaire was explained to the patients. The data collection tool consisted of a questionnaire that included two parts. The first part gathered the demographic characteristics of the research samples, including age, gender, marital status, number of children, education level, place of residence, employment status, economic status, duration of illness, and duration of treatment. The personal profile form contained objective and clear questions; thus, content validity was employed to determine the validity of this section.
In the second part of the questionnaire, Templer’s Death Anxiety Scale was used, which includes 15 questions. The score range for this scale varies between 0 and 15, with a higher score indicating greater anxiety about death. This questionnaire was first introduced in 1970 [22]. It is a standardized tool that has been widely used in research globally, and it has been translated and validated in Iran. Its internal consistency was reported in Rajabi & Bohrani’s study [23]. To estimate the reliability of the questionnaire, it was initially administered to 30 patients (who did not participate in the study) as a pilot test. The reliability for the death anxiety questionnaire was obtained using Cronbach’s alpha, which was found to be 0.88.
Data analysis
Descriptive statistical methods were used to calculate the mean, standard deviation, and absolute frequency distribution tables of the results. Pearson’s correlation coefficient was applied to examine the relationships between the parameters. The data were then analyzed using SPSS version 20 software.
Findings
The mean age of participants was 59.55±17.74 years. A total of 88 individuals (60.3%) were male, 92 individuals (63%) were married, 103 individuals (70.5%) lived in the city, 60 individuals (41.1%) were self-employed, 67 individuals (45.9%) had an average economic status, 60 individuals (41.1%) were illiterate, 79 individuals (54.1%) had a disease duration of less than 6 months, and 81 individuals (55.5%) were treated in less than 6 months. Additionally, 100 individuals (68.5%) had underlying diseases, and 39 individuals (26.7%) had 5 to 6 children (Table 1).
Table 1. Frequency of demographic parameters of the research samples (n=146)
The independent t-test showed a significant difference in death anxiety between the male and female groups, with the level of death anxiety being higher in women than in men (p<0.001). Furthermore, the independent t-test indicated a significant difference in death anxiety between the two groups with and without underlying diseases, revealing that the level of death anxiety is higher in individuals with underlying diseases (p<0.001).
The independent t-test showed no significant difference in death anxiety between the two groups living in the city and the village. The one-way ANOVA indicated that death anxiety had a significant relationship with marital status, with higher levels of death anxiety observed in widowed individuals (p=0.002). Additionally, the one-way ANOVA demonstrated that death anxiety was significantly related to employment status, with higher levels of death anxiety found in unemployed individuals (p=0.002). The one-way ANOVA also revealed a significant relationship between death anxiety and treatment duration, indicating that individuals who have been receiving treatment for less than 6 months experience higher levels of death anxiety (p=0.05).
Furthermore, the one-way ANOVA showed that death anxiety had no significant relationship with education level. Death anxiety had no significant relationship with the duration of illness. Pearson’s correlation coefficient revealed an inverse and significant relationship between death anxiety and age, indicating that as age increases, death anxiety also increases (p=0.05; Table 2).
Table 2. Relationship between demographic information and death anxiety in samples
Discussion
This study was conducted to investigate death anxiety and related factors in CABG candidates admitted to the surgery department of Isfahan Shariati Hospital in 2024. There was a significant difference in death anxiety between male and female groups, with the level of death anxiety being higher in women than in men. These findings are consistent with the study by Nafei et al., showing that death anxiety among elderly women is greater than among men, thereby confirming our results, although Nafei et al. conducted their intervention on the elderly population [24].
Additionally, our findings align with those of Kakabaraei & Maazinezhad [14] and Sharma et al. [25]. However, the findings contradict those of Khalvati et al., reporting that death anxiety is lower in women than in men among Iranian elderly individuals [13]. Similarly, the findings are contrary to those of Salehi et al., reporting no significant relationship between death anxiety and gender in cancer patients in Kermanshah [26].
The differences in findings across various studies may be attributed to the differing roles of men and women, as well as the varying levels of expression of fear and anxiety between genders. Women are generally more willing to express feelings, such as fear, while men tend to be less inclined to share their emotions [27].
Death anxiety had an inverse and significant relationship with age, indicating that as age increases, death anxiety also increases. Our findings are consistent with those of Shahbazpour et al., demonstrating that death anxiety increases with age [28]. These findings also align with those of Nafei et al. [24]. However, Chegini et al.'s study does not support the relationship between death anxiety and age [29], which contradicts the present study’s findings. Additionally, Kakabaraei & Maazinezhad explored the relationship between age and finding meaning in life, concluding that it is not consistent with death anxiety in elderly men and women. They found that, with increasing age, death anxiety decreases almost equally in elderly men and women. The elderly are more susceptible to death anxiety due to various factors such as loneliness, physical illnesses, disabilities, increased dependence on others, and the death of loved ones [14].
Death anxiety had a significant relationship with marital status, indicating that death anxiety is higher in widowed individuals. Our findings align with the study by Nafei et al., reporting that single individuals and those who have lost a spouse experience higher levels of death anxiety compared to married individuals [24]. It appears that having companionship and communicating with others at home positively affects the level of death anxiety. The findings of the present study also align with those of Salehi et al. [26]. However, they are contrary to the study by Moudi et al., showing no significant relationship between death anxiety and marital status [30].
There was a significant difference in death anxiety between the two groups with underlying diseases, with the level of death anxiety being higher in individuals with underlying conditions. This finding aligns with that of Valikhani & Firouzabad, indicating that death anxiety in cancer patients is higher than in healthy individuals [31].
Our findings are also consistent with those of Sherman et al. [32]. Masoudzadeh et al. demonstrated that the risk of death is high in the majority of patients with the disease [17], which aligns with the present study. Patients with serious illnesses, such as cancer or heart disease, tend to experience higher levels of death anxiety. This anxiety may stem from concerns about their illness, the consequences of the disease, an uncertain future, and feelings of hopelessness.
Death anxiety had a significant relationship with employment status, with levels of death anxiety increasing among unemployed individuals. This finding is consistent with that of Nafei et al., reporting that employed and retired elderly individuals have lower anxiety levels than unemployed elderly individuals and those covered by a support organization (aid committee) [24]. However, the findings of this study are inconsistent with those of Gong et al., showing no significant relationship between employment status and death anxiety [33].
One limitation of this study was that the patients participating in the research were culturally, socially, and emotionally diverse. Efforts were made to control for this issue by randomly selecting samples. Additionally, some patients may have a history of living in stressful family environments.
CABG surgery is a major operation that induces fear and anxiety in patients, including death anxiety. Death anxiety is influenced by various factors, such as age, gender, employment status, marital status, and religious beliefs. Therefore, paying attention to these factors and providing appropriate psychological interventions can help reduce death anxiety and improve the mental health of patients after CABG surgery. It is recommended that the effective and beneficial solutions implemented in other countries be adopted by the health system in our country.
Conclusion
Death anxiety is influenced by various factors, such as age, gender, employment status, marital status, and religious beliefs.
Acknowledgments: The researchers would like to thank all the participants who assisted us in conducting this research.
Ethical Permissions: This study received ethics committee code 1403.140 IR.IAU.NAJAFABAD.REC, dated 6/22/2015.
Conflicts of Interests: The authors reported no conflicts of interests.
Authors' Contribution: Rezaei G (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (50%); Salmani F (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (50%)
Funding/Support: The authors declared that no funds, grants, or other forms of support were received during the preparation of this manuscript.
Coronary artery disease (CAD) is a prevalent cardiovascular condition resulting from the accumulation of atherosclerotic plaque within the coronary arteries, which are responsible for delivering oxygen-rich blood to the myocardium. Plaque buildup in these arteries reduces blood flow, leading to symptoms such as chest pain, shortness of breath, nausea, vomiting, radiating pain to the arm, neck, jaw, or abdomen, and fatigue [1]. According to the American Heart Association, by 2030, approximately one in every three individuals will be affected by some form of cardiovascular disease [2]. In recent years, the prevalence of CAD in Iran has increased by an estimated 20-25% [3].
Coronary artery bypass grafting (CABG) remains the most commonly performed surgical intervention for patients with coronary artery stenosis [4]. This procedure can be performed either with cardiopulmonary bypass (on-pump) or without it (off-pump) [5]. CABG significantly improves myocardial perfusion, enhances patients’ quality of life, extends life expectancy, and reduces mortality. However, it is also associated with various psychological challenges, among which death anxiety is particularly significant.
Death anxiety is defined as a persistent fear, worry, or distress triggered by thoughts of death or dying [6]. It is a universal phenomenon that manifests differently across individuals. Some may experience intense fear, while others report mild concern [7, 8]. The causes of death anxiety vary and may include fear of the unknown, separation from loved ones, or anticipated pain and suffering before death.
In patients undergoing CABG, death anxiety may lead to anxiety disorders, depression, hopelessness, increased stress, social isolation, decreased quality of life, panic attacks, non-adherence to treatment, and physiological changes, such as elevated blood pressure and heart rate [9, 10]. Numerous factors can influence the development and intensity of death anxiety, including age (with older adults experiencing higher levels due to proximity to the end of life) [11-13], gender (with some studies suggesting higher rates in women) [14], and the individual’s religious and spiritual beliefs (where stronger beliefs are often associated with lower anxiety) [15].
Additionally, physical and mental health status, the presence of chronic diseases, psychological disorders, fear of surgery, socio-economic status, and unfavorable cultural attitudes toward death can contribute to increased anxiety levels [16-20]. A lack of social support is also a critical factor, while the presence of strong support networks can mitigate anxiety and enhance coping mechanisms [21].
Despite the clinical significance of death anxiety in CABG candidates, limited research has been conducted on this topic. Understanding its contributing factors is essential for developing effective psychological and therapeutic interventions. Therefore, the present study was designed to investigate the level of death anxiety and its related factors among patients scheduled for CABG at Shariati Hospital in 2024.
Instrument and Methods
Design
This correlational descriptive study was conducted on patients hospitalized in the heart surgery department of Shariati Hospital in Isfahan in 2024.
Sample
The sample size was calculated using the Cochran formula, with a standard deviation of 0.26 and an error rate of 0.05 for 100 samples. Sampling was performed using a convenience method, and individuals who met the criteria for inclusion were selected. The researcher entered the study environment after obtaining permission from the vice president of research and hospital officials and receiving written informed consent from the research participants.
Inclusion criteria
The criteria for inclusion in the study included the patient being a candidate for CABG, the patient being hospitalized in the surgical department, being literate, and being willing to participate in the study. The exclusion criteria included the death or transfer of the patient to other medical centers and failure to complete the questionnaires.
Data collection
To conduct the study, the process for completing the questionnaire was explained to the patients. The data collection tool consisted of a questionnaire that included two parts. The first part gathered the demographic characteristics of the research samples, including age, gender, marital status, number of children, education level, place of residence, employment status, economic status, duration of illness, and duration of treatment. The personal profile form contained objective and clear questions; thus, content validity was employed to determine the validity of this section.
In the second part of the questionnaire, Templer’s Death Anxiety Scale was used, which includes 15 questions. The score range for this scale varies between 0 and 15, with a higher score indicating greater anxiety about death. This questionnaire was first introduced in 1970 [22]. It is a standardized tool that has been widely used in research globally, and it has been translated and validated in Iran. Its internal consistency was reported in Rajabi & Bohrani’s study [23]. To estimate the reliability of the questionnaire, it was initially administered to 30 patients (who did not participate in the study) as a pilot test. The reliability for the death anxiety questionnaire was obtained using Cronbach’s alpha, which was found to be 0.88.
Data analysis
Descriptive statistical methods were used to calculate the mean, standard deviation, and absolute frequency distribution tables of the results. Pearson’s correlation coefficient was applied to examine the relationships between the parameters. The data were then analyzed using SPSS version 20 software.
Findings
The mean age of participants was 59.55±17.74 years. A total of 88 individuals (60.3%) were male, 92 individuals (63%) were married, 103 individuals (70.5%) lived in the city, 60 individuals (41.1%) were self-employed, 67 individuals (45.9%) had an average economic status, 60 individuals (41.1%) were illiterate, 79 individuals (54.1%) had a disease duration of less than 6 months, and 81 individuals (55.5%) were treated in less than 6 months. Additionally, 100 individuals (68.5%) had underlying diseases, and 39 individuals (26.7%) had 5 to 6 children (Table 1).
Table 1. Frequency of demographic parameters of the research samples (n=146)
The independent t-test showed a significant difference in death anxiety between the male and female groups, with the level of death anxiety being higher in women than in men (p<0.001). Furthermore, the independent t-test indicated a significant difference in death anxiety between the two groups with and without underlying diseases, revealing that the level of death anxiety is higher in individuals with underlying diseases (p<0.001).
The independent t-test showed no significant difference in death anxiety between the two groups living in the city and the village. The one-way ANOVA indicated that death anxiety had a significant relationship with marital status, with higher levels of death anxiety observed in widowed individuals (p=0.002). Additionally, the one-way ANOVA demonstrated that death anxiety was significantly related to employment status, with higher levels of death anxiety found in unemployed individuals (p=0.002). The one-way ANOVA also revealed a significant relationship between death anxiety and treatment duration, indicating that individuals who have been receiving treatment for less than 6 months experience higher levels of death anxiety (p=0.05).
Furthermore, the one-way ANOVA showed that death anxiety had no significant relationship with education level. Death anxiety had no significant relationship with the duration of illness. Pearson’s correlation coefficient revealed an inverse and significant relationship between death anxiety and age, indicating that as age increases, death anxiety also increases (p=0.05; Table 2).
Table 2. Relationship between demographic information and death anxiety in samples
Discussion
This study was conducted to investigate death anxiety and related factors in CABG candidates admitted to the surgery department of Isfahan Shariati Hospital in 2024. There was a significant difference in death anxiety between male and female groups, with the level of death anxiety being higher in women than in men. These findings are consistent with the study by Nafei et al., showing that death anxiety among elderly women is greater than among men, thereby confirming our results, although Nafei et al. conducted their intervention on the elderly population [24].
Additionally, our findings align with those of Kakabaraei & Maazinezhad [14] and Sharma et al. [25]. However, the findings contradict those of Khalvati et al., reporting that death anxiety is lower in women than in men among Iranian elderly individuals [13]. Similarly, the findings are contrary to those of Salehi et al., reporting no significant relationship between death anxiety and gender in cancer patients in Kermanshah [26].
The differences in findings across various studies may be attributed to the differing roles of men and women, as well as the varying levels of expression of fear and anxiety between genders. Women are generally more willing to express feelings, such as fear, while men tend to be less inclined to share their emotions [27].
Death anxiety had an inverse and significant relationship with age, indicating that as age increases, death anxiety also increases. Our findings are consistent with those of Shahbazpour et al., demonstrating that death anxiety increases with age [28]. These findings also align with those of Nafei et al. [24]. However, Chegini et al.'s study does not support the relationship between death anxiety and age [29], which contradicts the present study’s findings. Additionally, Kakabaraei & Maazinezhad explored the relationship between age and finding meaning in life, concluding that it is not consistent with death anxiety in elderly men and women. They found that, with increasing age, death anxiety decreases almost equally in elderly men and women. The elderly are more susceptible to death anxiety due to various factors such as loneliness, physical illnesses, disabilities, increased dependence on others, and the death of loved ones [14].
Death anxiety had a significant relationship with marital status, indicating that death anxiety is higher in widowed individuals. Our findings align with the study by Nafei et al., reporting that single individuals and those who have lost a spouse experience higher levels of death anxiety compared to married individuals [24]. It appears that having companionship and communicating with others at home positively affects the level of death anxiety. The findings of the present study also align with those of Salehi et al. [26]. However, they are contrary to the study by Moudi et al., showing no significant relationship between death anxiety and marital status [30].
There was a significant difference in death anxiety between the two groups with underlying diseases, with the level of death anxiety being higher in individuals with underlying conditions. This finding aligns with that of Valikhani & Firouzabad, indicating that death anxiety in cancer patients is higher than in healthy individuals [31].
Our findings are also consistent with those of Sherman et al. [32]. Masoudzadeh et al. demonstrated that the risk of death is high in the majority of patients with the disease [17], which aligns with the present study. Patients with serious illnesses, such as cancer or heart disease, tend to experience higher levels of death anxiety. This anxiety may stem from concerns about their illness, the consequences of the disease, an uncertain future, and feelings of hopelessness.
Death anxiety had a significant relationship with employment status, with levels of death anxiety increasing among unemployed individuals. This finding is consistent with that of Nafei et al., reporting that employed and retired elderly individuals have lower anxiety levels than unemployed elderly individuals and those covered by a support organization (aid committee) [24]. However, the findings of this study are inconsistent with those of Gong et al., showing no significant relationship between employment status and death anxiety [33].
One limitation of this study was that the patients participating in the research were culturally, socially, and emotionally diverse. Efforts were made to control for this issue by randomly selecting samples. Additionally, some patients may have a history of living in stressful family environments.
CABG surgery is a major operation that induces fear and anxiety in patients, including death anxiety. Death anxiety is influenced by various factors, such as age, gender, employment status, marital status, and religious beliefs. Therefore, paying attention to these factors and providing appropriate psychological interventions can help reduce death anxiety and improve the mental health of patients after CABG surgery. It is recommended that the effective and beneficial solutions implemented in other countries be adopted by the health system in our country.
Conclusion
Death anxiety is influenced by various factors, such as age, gender, employment status, marital status, and religious beliefs.
Acknowledgments: The researchers would like to thank all the participants who assisted us in conducting this research.
Ethical Permissions: This study received ethics committee code 1403.140 IR.IAU.NAJAFABAD.REC, dated 6/22/2015.
Conflicts of Interests: The authors reported no conflicts of interests.
Authors' Contribution: Rezaei G (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (50%); Salmani F (Second Author), Introduction Writer/Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (50%)
Funding/Support: The authors declared that no funds, grants, or other forms of support were received during the preparation of this manuscript.
Keywords:
References
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