The Geriatric Cancer Experience at the End of Life: Testing an Adapted Model

Harleah G. Buck

Janine Overcash

Susan C. McMillan

end-of-life care, geriatric nursing
ONF 2009, 36(6), 664-673. DOI: 10.1188/09.ONF.664-673

Purpose/Objectives: To test an adapted end-of-life conceptual model of the geriatric cancer experience and provide evidence for the validity and reliability of the model for use in practice and research.

Design: Nonexperimental and cross-sectional using baseline data collected within 24-72 hours of admission to hospice.

Setting: Two hospices in the southeastern United States.

Sample: 403 hospice homecare patients; 56% were men and 97% were Caucasian with a mean age of 77.7 years.

Methods: Confirmatory factor analyses using structural equation modeling with AMOS™ statistical software.

Main Research Variables: Clinical status; physiologic, psychological, and spiritual variables; and quality of life (QOL).

Findings: A three-factor model with QOL as an outcome variable showed that 67% of the variability in QOL is explained by the patient's symptom and spiritual experiences.

Conclusions: As symptoms and associated severity and distress increase, the patient's QOL decreases. As the spiritual experience increases (the expressed need for inspiration, spiritual activities, and religion), QOL also increases.

Implications for Nursing: The model supports caring for the physical and metaphysical dimensions of the patient's life. It also highlights a need for holistic care inclusive of physical, emotional, and spiritual domains.

Jump to a section


    Anderson, F., Downing, G.M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1), 5-11.
    Ano, G.G., & Vasconcelles, E.B. (2005). Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology, 61(4), 461-480.
    Balducci, L. (2003). New paradigms for treating elderly patients with cancer: The comprehensive geriatric assessment and guidelines for supportive care. Journal of Supportive Oncology, 1(4, Suppl. 2), 30-37.
    Balducci, L., & Beghe, C. (2000). The application of the principles of geriatrics to the management of the older person with cancer. Critical Reviews in Oncology/Hematology, 35(3), 147-154.
    Balducci, L., & Extermann, M. (2000). Management of cancer in the older person: A practical approach. Oncologist, 5(3), 224-237.
    Binstock, R.H., & George, L.K. (2006). Handbook of aging and the social sciences (6th ed.). Burlington, MA: Elsevier.
    Brown, P., Clark, M.M., Atherton, P., Huschka, M., Sloan, J.A., Gamble, G., et al. (2006). Will improvement in quality of life (QOL) impact fatigue in patients receiving radiation therapy for advanced cancer? American Journal of Clinical Oncology, 29(1), 52-58.
    Buchanan, D.R., O'Mara, A.M., Kelaghan, J.W., & Minasian, L.M. (2005). Quality-of-life assessment in the symptom management trials of the National Cancer Institute-supported Community Clinical Oncology Program. Journal of Clinical Oncology, 23(3), 591-598.
    Byrne, B.M. (2001). Structural equation modeling with AMOS: Basic concepts, applications, and programming (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates.
    Chochinov, H.M., & Cann, B.J. (2005). Interventions to enhance the spiritual aspects of dying. Journal of Palliative Medicine, 8(Suppl. 1), S103-S115.
    Cooley, M.E. (2000). Symptoms in adults with lung cancer: A systematic research review. Journal of Pain and Symptom Management, 19(2), 137-153.
    Donnelly, S., Rybicki, L., & Walsh, D. (2001). Quality-of-life measurement in the palliative management of advanced cancer. Supportive Care in Cancer, 9(5), 361-365.
    Emanuel, E.J., & Emanuel, L.L. (1998). The promise of a good death. Lancet, 351(Suppl. 2), SII21-SII29.
    Emanuel, L.L., Alpert, H.R., Baldwin, D.C., & Emanuel, E.J. (2000). What terminally ill patients care about: Toward a validated construct of patients' perspectives. Journal of Palliative Medicine, 3(4), 419-431.
    Erickson, E.H. (1963). Childhood and society. New York: W.W. Norton and Company.
    Garson, G.D. (2009). Structural equation modeling. Retrieved November 15, 2007, from
    George, L.K. (2002). Research design in end-of-life research: State of science. Gerontologist, 42(Spec. No. 3), 86-98.
    Hermann, C. (2006). Development and testing of the spiritual needs inventory for patients near the end of life. Oncology Nursing Forum, 33(4), 737-744.
    Hermann, C.P. (2001). Spiritual needs of dying patients: A qualitative study. Oncology Nursing Forum, 28(1), 67-72.
    Hofer, S., Benzer, W., Alber, H., Ruttmann, E., Kopp, M., Schussler, G., et al. (2005). Determinants of health-related quality of life in coronary artery disease patients: A prospective study generating a structural equation model. Psychosomatics, 46(3), 212-223.
    Hu, L.T., & Bentler, P.M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model mispecification. Psychological Methods, 3(4), 424-453.
    Hurria, A., Lachs, M.S., Cohen, H.J., Muss, H.B., & Kornblith, A.B. (2006). Geriatric assessment for oncologists: Rationale and future directions. Critical Reviews in Oncology/Hematology, 59(3), 211-217.
    Hwang, S.S., Chang, V.T., Cogswell, J., Alejandro, Y., Osenenko, P., Morales, E., et al. (2004). Study of unmet needs in symptomatic veterans with advanced cancer: Incidence, independent predictors, and unmet needs outcome model. Journal of Pain and Symptom Management, 28(5), 421-432.
    Irwin, M., Artin, K.H., & Oxman, M.N. (1999). Screening for depression in the older adult: Criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Archives of Internal Medicine, 159(15), 1701-1704.
    Katz, S., Downs, T.D., Cash, H.R., & Grotz, R.C. (1970). Progress in development of the index of ADL. Gerontologist, 10(1), 20-30.
    Klinkenberg, M., Willems, D.L., van der Wal, G., & Deeg, D.J. (2004). Symptom burden in the last week of life. Journal of Pain and Symptom Management, 27(1), 5-13.
    Kris, A.E., & Dodd, M.J. (2004). Symptom experience of adult hospitalized medical-surgical patients. Journal of Pain and Symptom Management, 28(5), 451-459.
    Levinson, D.J. (1986). A conception of adult development. American Psychologist, 41(1), 3-13.
    Lichtenberg, P.A. (Ed.). (1999). Handbook of assessment in clinical gerontology. New York: Wiley.
    MacCallum, R.C., Roznowski, M., & Necowitz, L.B. (1992). Model modifications in covariance structure analysis: The problem of capitalization on chance. Psychological Bulletin, 111(3), 490-504.
    MacCallum, R.C., Wegener, D.T., Uchino, B.N., & Fabrigar, L.R. (1993). The problem of equivalent models in applications of covariance structure analysis. Psychological Bulletin, 114(1), 185-199.
    McMillan, S.C., & Small, B.J. (2002). Symptom distress and quality of life in patients with cancer newly admitted to hospice home care. Oncology Nursing Forum, 29(10), 1421-1428.
    McMillan, S.C., & Weitzner, M. (2000). How problematic are various aspects of quality of life in patients with cancer at the end of life? Oncology Nursing Forum, 27(5), 817-823.
    Murray, S.A., Kendall, M., Boyd, K., Worth, A., & Benton, T.F. (2004). Exploring the spiritual needs of people dying of lung cancer or heart failure: A prospective qualitative interview study of patients and their careers. Palliative Medicine, 18(1), 39-45.
    National Hospice and Palliative Care Organization. (2008). NHPCO facts and figures: Hospice care in America. Retrieved September 23, 2009, from
    National Institutes of Health. (2004). National Institutes of Health state-of-the-science conference statement on improving end-of-life care. Retrieved September 23, 2009, from
    Nuamah, I.F., Cooley, M.E., Fawcett, J., & McCorkle, R. (1999). Testing a theory for health-related quality of life in cancer patients: A structural equation approach. Research in Nursing and Health, 22(3), 231-242.
    Portenoy, R.K., Thaler, H.T., Kornblith, A.B., Lepore, J.M., Friedlander-Klar, H., Coyle, N., et al. (1994). Symptom prevalence, characteristics, and distress in a cancer population. Quality of Life Research, 3(3), 183-189.
    Portenoy, R.K., Thaler, H.T., Kornblith, A.B., Lepore, J.M., Friedlander-Klar, H., Kiyasu, E., et al. (1994). The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics, and distress. European Journal of Cancer, 30A(9), 1326-1336.
    Rao, A., & Cohen, H.J. (2004). Symptom management in the elderly cancer patient: Fatigue, pain, and depression. Journal of the National Cancer Institute. Monographs, 32, 150-157.
    Raykov, T., & Marcoulides, G.A. (2006). A first course in structural equation modeling (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates.
    Steele, L.L., Mills, B., Hardin, S.R., & Hussey, L.C. (2005). The quality of life of hospice patients: Patient and provider perceptions. American Journal of Hospice and Palliative Care, 22(2), 95-110.
    Sulmasy, D.P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist, 42(Spec. No. 3), 24-33.
    Taylor, E.J. (2003). Spiritual needs of patients with cancer and family caregivers. Cancer Nursing, 26(4), 260-266.
    Tranmer, J.E., Heyland, D., Dudgeon, D., Groll, D., Squires-Graham, M., & Coulson, K. (2003). Measuring the symptom experience of seriously ill cancer and noncancer hospitalized patients near the end of life with the Memorial Symptom Assessment Scale. Journal of Pain and Symptom Management, 25(5), 420-429.
    Weaver, A.J., & Flannelly, K.J. (2004). The role of religion/spirituality for cancer patients and their caregivers. Southern Medical Journal, 97(12), 1210-1214.
    Wilson, I.B., & Cleary, P.D. (1995). Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. Journal of the American Medical Society, 273(1), 59-72.
    Yancik, R. (2005). Population aging and cancer: A cross-national concern. Cancer Journal, 11(6), 437-441.