Clinical approach: noticing death anxiety in patients

What is death anxiety?  We spend the first 15 minutes of the podcast addressing this question.  And maybe this was unfair to our guests, the fabulous dynamic duo of palliative psychiatrists Dani Chammas and Keri Brenner (listen to their prior podcasts on therapeutic presence and the angry patient).  After all, we invited them on to our podcast to discuss death anxiety, then Eric and I immediately questioned if death anxiety was the best term for what we want to discuss!

Several key points stood out to me from this podcast, your key points may differ:

• The "anxiety" in "death anxiety" is not a pathological phenomenon or a DSM diagnosis;  it references an existential concern that is fundamental to the human experience .  To me," awareness of mortality" might be a better term, but in fairness, the idea of "death anxiety" was coined well before the formal establishment of "anxiety disorders."

• The ways in which death anxiety manifests in our patient's choices and behaviors varies tremendously, and our responses as clinicians must be individualized. There is no "one size fits all" approach. In one example Dani discusses, a pain level of 1.5/10 might be overwhelming, because for a patient  in remission from cancer any pain might signal return of cancer. 

• Some manifestations of death anxiety can be debilitating, others lead to tremendous personal growth, connection to others, and a drive toward finding meaning in their illness experience.  

• Death anxiety impacts us as clinicians, not only through countertransference, that word that I still can't define (sorry Dani and Keri!), but also through our own unexamined fears about death.

• As clinicians who regularly care for people who are dying, we might find ourselves becoming "used to" death. Is this a sign that we are inured to the banality of death, and less able to empathize with the death anxiety experienced by our patients or their families? Or could it reflect our acceptance of the finitude of life, prompting us to live in the present moment? Perhaps it is something else entirely. The key is that looking inwards to understanding our own unique relationship with mortality can deepen our ability to authentically accompany the experiences of our patients.

I mean, don't fear the reaper, right?  Sorry, no cowbell in my version, but you do get my son Kai, home from college, on guitar for the audio only podcast version.

Here are some resources for listeners wanting to learn more about this topic:

Books:

• Yalom ID. Existential Psychotherapy. New York, NY: Basic Books; 1980.

• Yalom ID. Staring at the Sun: Overcoming the Terror of Death. San Francisco, CA: Jossey-Bass; 2008.

• Solomon S, Greenberg J, Pyszczynski T. The Worm at the Core: On the Role of Death in Life. New York, NY: Random House; 2015.

• Becker E. The Denial of Death. Free Press; 1973.

Articles:

• Emanuel LL, Solomon S, Chochinov HM, et al. Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care. J Palliat Med. 2023;26(2):235-243.

• Chochinov HM, McClement SE, Hack TF, et al. Death anxiety and correlates in cancer patients receiving outpatient palliative care. J Palliat Med. 2023;26(12):1404–1410. doi:10.1089/jpm.2022.0052.

• Clark D. Between hope and acceptance: the medicalisation of dying. BMJ. 2002;324(7342):905–907. doi:10.1136/bmj.324.7342.905.

• Vess M, Arndt J, Cox CR, Routledge C, Goldenberg JL. The terror management of medical decisions: The effect of mortality salience and religious fundamentalism on support for faith-based medical intervention. J Pers Soc Psychol. 2009;97(2):334–350.

• Menzies RE, Zuccala M, Sharpe L, Dar-Nimrod I. The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomized controlled trials. J Anxiety Disord. 2018;59:64–73. doi:10.1016/j.janxdis.2018.09.00

• Brown TL, Chown P, Solomon S, Gore G, De Groot JM. Psychosocial correlates of death anxiety in advanced cancer: A scoping review. Psychooncology. 2025;34(1):45–56. doi:10.1002/pon.70068.

• Tarbi EC, Moore CM, Wallace CL, Beaussant Y, Broden EG, Chammas D, Galchutt P, Gilchrist D, Hayden A, Morgan B, Rosenberg LB, Sager Z, Solomon S, Rosa WE, Chochinov HM. Top Ten Tips Palliative Care Clinicians Should Know About Attending to the Existential Experience. J Palliat Med. 2024 Oct;27(10):1379-1389. doi: 10.1089/jpm.2024.0070. Epub 2024 Mar 28. PMID: 38546453.