Thesis For Graduation

LEVEL OF ACCEPTANCE IN DEATH AND DYING AND
PALLIATIVE CARE OF THE MIDDLE AGED CLIENTS WITH CHRONIC

ILLNESS
An Undergraduate Thesis
Presented to
The Faculty of the College of Nursing
University of Perpetual Help System-DALTA, Molino Campus
Molino, Bacoor, Cavite
In Partial Fulfilment
Of the Requirements for the Degree
Bachelor of Science in Nursing
DELOS SANTOS, ARIELLE SAMANTHA B.
OCTOBER 2017
ii
APPROVAL SHEET
This thesis entitled

“The Level of Acceptance in Death and Dying and Palliative Care
of the Middle-Aged Clients with Chronic Illness”
Prepared and submitted by Arielle Samantha B. delos Santos in partial fulfilment of
the requirements for the degree of Bachelor of Science in Nursing is recommended
for acceptance and approval for ORAL EXAMINATION.
MARY GRACE S. PROWEL

ACADEMIC ADVISER
Approved by the Committee on Oral Examination Committee with a grade of

PASSED on October 2017.
LERMA B. MALUBAG
CHAIR
JENNIFER O. LEDESMA MARK ANTHONY G. TORIO

MEMBER MEMBER
Accepted in partial fulfillment of the requirements of the degree of Bachelor of

Science in Nursing.
LERMA B. MALUBAG
Dean, College of Nursing
iii
ACKNOWLEDGEMENT
With boundless love and appreciation, the researcher would like to extend her
heartfelt gratitude and appreciation to the people who helped bring this study into
reality. The researcher would like to extend her profound gratitude to the following:
First and foremost, to the LORD ALMIGHTY, for the wisdom and renewed
supply of strength He has given the researcher throughout the fulfilment of the study.
MARY GRACE S. PROWEL, RN, MSN, the thesis adviser for giving her
guidance, directions, and insights for the completion of this study.
LERMA B. MALUBAG, RN, MAN, the Dean of the College of Nursing and the
chairman of the panel for providing her brilliant ideas and sharing her expertise
throughout the completion of this study.
JENNIFER O. LEDESMA, RN, MAN, for her ideas, suggestions, and

constructive criticism as member of the panel.
MARK ANTHONY G. TORIO, RRT, DPHEd, MAEd, for his
MS. JOCELYN SANTOS, for allowing the researcher to gather data and
information and for contributing her ideas and expertise in the betterment of this
study as the head of the Research and Development Center.
MR. ELISEO TALLA, for his expertise on statistical treatment of data.
MY PARENTS, for their unconditional love and undying support during the
course of the study, for without their financial provision and passionate
encouragement, this academic achievement would not be accomplished.
v
Worldwide, there is a lack of education and knowledge in caring for people in

the palliative phase of illness, yet the need for palliative care at the end of life care is
significant and increasing, (WHO, 2014). At present, according to Ruth Foundation
(2012), there are about 36 organizations focused in providing palliative care among
those with chronic and life-limiting illness in our country. However, these
organizations are continually challenged with the need for manpower and funding;
while palliative care and hospice activists are continuously driven because of the
significant rise in number of Filipinos with chronic illnesses. Thus, the study
investigated through the survey, the level of acceptance in palliative care and death
and dying of the middle-aged clients with chronic illnesses in General Trias, Cavite.
It also wanted to know if there is a significant difference on the socio-demographic
profile of the respondents and if there is a relationship between the level of
acceptance in palliative care and death and dying. The study used the quantitative
exploratory design. There were 140 adults aged 40-65 with chronic illnesses in
General Trias, Cavite who participated in the study. Multi-stage sampling technique
was used for data gathering. Data analysis used independent sample t-test, Duncan
test, Pearson Correlation and analysis of variance (ANOVA). The study revealed that
there was an above average level of acceptance in palliative care (𝜇 =4.68) and
average level of acceptance in death and dying (𝜇 =4.30) among the respondents.
The socio-demographic profile had no significant difference on the level of
acceptance in death and dying. However, on the level of acceptance in palliative care,
there was no significant difference among the socio-demographic profile of the
respondents except when they were grouped according to civil status. Literature
suggests that being married or partnered is associated with better health care
outcomes, while being single, widowed, or otherwise unpartnered is associated with
worse health care outcomes. Marital or partnership status is therefore related to health
care outcomes, precedes care delivery and is not a consequence of the quality of care,
is not something the provider can manipulate, and meets practical considerations,
(Committee on Accounting for Socioeconomic Status in Medicare Payment
vi
Programs, 2016). It is concluded that there is a moderate correlation (𝜇 =0.53)

between the level of acceptance in palliative care and level of acceptance in death and
dying. In the light of the findings of the study, the following recommendations are
proposed by the researcher: (1) The researcher recommends the government and
NGO’s to heighten community and professional awareness on the scope and benefits
of palliative care, (2) the middle aged clients with chronic illnesses to be concerned
about their health status and reach out to the professionals for the options on the
appropriate management of their condition, (3) the nursing profession to undergo
trainings and seminars to enhance their knowledge on palliative care and death and
dying, (4) and the future researchers to make further researches on the updates,
progression, and implementation of Palliative care and death and dying.
vii
TABLE OF CONTENTS
TITLE PAGE
APPROVAL SHEET ii
ACKNOWLEDGEMENT iii
ABSTRACT iv
TABLE OF CONTENTS vii
LIST OF TABLES ix
LIST OF FIGURES x
CHAPTER 1: THE PROBLEM AND REVIEW OF RELATED LITERATURE

AND STUDIES
1.1
Introduction 1
Review of Related Literature and studies 5
Synthesis 14
Theoretical Framework and Conceptual Framework 15
Research paradigm 19
Hypothesis 21
Significance of the study 22
Scope and delimitation 23 viii
Definition of terms 23
CHAPTER 2: METHODOLOGY
Research design 25
Population sampling 27
Respondents of the study 27
Research instrument 27
Data gathering procedure 30
Statistical treatment of data 32
CHAPTER 3: RESULTS AND DISCUSSION
37
CHAPTER 4: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Summary 64
Conclusion 70
Recommendations 71
REFERENCES 85
APPENDICES
RESEARCH INSTRUMENT
SAMPLE COMPUTATION
CERTIFICATION
LETTER OF REQUEST
ACCORD
LIBRARY REQUEST
CURRICULUM VITAE
ix
LIST OF TABLES
1. Level of Acceptance in Palliative Care of the Middle Aged 44
Clients with Chronic Illness
2. Level of Acceptance in Death and Dying of the Middle Aged 47
Clients with Chronic Illness
Clients with Chronic Illness in terms Civil Status
Clients with Chronic Illness in terms Educational Attainment
Clients with Chronic Illness in terms of Family Structure
Clients with Chronic Illness in terms Gender
Clients with Chronic Illness in terms Annual Income
Clients with Chronic Illness in terms Religion
Clients with Chronic Illness in terms Civil Status
Clients with Chronic Illness in terms Educational Attainment
Clients with Chronic Illness in terms Family Structure
Clients with Chronic Illness in terms Gender
Clients with Chronic Illness in terms Annual Income
Clients with Chronic Illness in terms Religion x
15. Relationship between the Level of Acceptance in Palliative 62
Care and Death and Dying of the Middle Aged Clients with Chronic Illness
LIST OF FIGURES
1. The Variable and their Relationships 19

2. Profile of Respondents in terms of Civil Status 37
3. Profile of Respondents in terms of Educational Attainment 38
4. Profile of Respondents in terms of Family Structure 40
5. Profile of Respondents in terms of Gender 41
6. Profile of Respondents in terms of Annual Income 42
7. Profile of Respondents in terms of Religion 43
1
CHAPTER 1
THE PROBLEM AND RELATED LITERATURE
INTRODUCTION
Palliative care is an approach that improves the quality of life of patients and
their families facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and
spiritual, (WHO, 2002). Palliative care, which is generally provided on an inpatient
basis, is designated for patients regardless of their life expectancy, who have a
progressive, debilitating and/or life-limiting illness that adversely affects their daily
functioning or will predictably reduce life expectancy, (National Guideline 2
Clearinghouse, 2013).
The issues are that worldwide, there is a lack of education and knowledge in
those caring for people in the palliative phase of illness, yet the need for palliative
care at the end of life care is significant and increasing, (WHO, 2014). While people
thought of Palliative Care as services being rendered only for cancer patients for
many years now, patients with end-stage disorders with probably much worse
symptoms and prognoses were denied of such services. At present, according to Ruth
Foundation (2012), there were about 36 organizations focused in providing palliative
care among those with chronic and life-limiting illness in our country. However these
organizations are continually challenged with the need for manpower and funding.
And these palliative care and hospice activists are continuously driven because of the
significant rise in number of Filipinos with chronic illnesses.
The prevalence of chronic illness is steadily on the rise, and will possibly
increase exponentially in the future. According to the Department of Health (2013),
Diseases of the Heart had been consistently the number one cause of death for several
years in the Philippines already. Recent studies indicate that these among other
chronic illnesses greatly affects the work age population or the middle aged group.
According to Benson (2014), in his book entitled: A History of the Middle Aged in
Twentieth Century in Britain, It seems that the middle class and working class reacted
differently to the physical changes of middle age. It is also well-known that working
people of all ages were less concerned- and less able- than those from other classes to
protect themselves against threats to their health.
Having a chronic illness affects people in multiple ways. Many chronic

illnesses reduce a person’s quality of life and/or limits their performance of normal
and daily activities. There are several factors that may contribute to the increase of
3
chronic illnesses according to several books such as harmful use of alcohol and
tobacco, hypertension, obesity, and physical inactivity. According to the National
Center for Health Statistics (2013), those who reach age 65 years can now expect to
live another 20 years. With this longevity comes the risk of chronic illness, and that
risk increases dramatically with age, (Howell & Sherraden, 2014). Individuals ages
45-65, or the so-called middle-aged adults, are soon going to comprise the age group
declared to have the highest rate of chronic illnesses, which is the late adulthood ages
65 to death.
According to the 2013 reports on the top 10 leading causes of mortality in

Cavite by the Provincial Health Office, it is comprised mostly of Chronic Illnesses
with Heart disease at number 1, followed by Cancer, Pneumonia, Hypertension,
Stroke, Renal Failure, Diabetes Mellitus, Tuberculosis, COPD and Asthma.
Globally, according to the World Health Organization (2014), the great

majority of adults in need of palliative care died from cardiovascular diseases
(38.5%), and cancer (34%), followed by chronic respiratory diseases (10.3%),
HIV/AIDS (5.7%), and diabetes (4.5%). In all regions, adults in need of palliative
care for progressive non-malignant disease represent the highest proportion. On the
Global Atlas of Palliative Care at the End of Life (2014) by the WHO, report 4
estimates that 37.4% of all deaths from all causes need palliative care.
With improving medical advances and the predicted increase in life

expectancy of many individuals living with chronic and terminal illnesses, palliative
care as an emerging field is poised for unprecedented expansion. This recognized
need for expansion has led to the evaluation of palliative care as a key community
health resource, particularly with recent clear evidence suggesting that early palliative
care involvement can even lead to an improvement of both quality of life, and, at
times, its longevity, (Huyn, L., Henry, B., Dosani, N., 2015).
With the conversion of the Municipality of General Trias into a city in 2015,
it is assumed that along with it being a premier city is the advanced development in
its health care services to cater to the clients specifically with chronic illnesses. Up to
this date, there is no facility nor hospital in the city of General Trias, Cavite that
offers Palliative and Hospice Care.
The recent morbidity reports submitted by the different barangays of General

Trias in March 2017 show that there is only a small number of individuals with
chronic illnesses in the middle age that seek health care from the barangay health
centers despite the chronic illnesses being one of the major leading causes of death.
Based on the foregoing premise, this study aims to determine the level of
acceptance in Palliative care of its future possible clients, the middle-aged clients’
acceptance on death and dying for it is known as the end, and the relationship
between the level of acceptance in Palliative care and death and dying.
REVIEW OF RELATED LITERATURE
This section includes relevant data and carefully sought information that are
of big importance in the better understanding of the study.
LOCAL LITERATURE AND STUDIES
In the Manual of Palliative Medicine (2005) by Medina, he defined Palliative

Care as comfort and support to individuals who are living with life-threatening and
life-limiting illnesses, and their families. Palliative medicine aims to relieve pain and
discomfort, improve quality of life, minimize suffering, and preserve dignity.
Palliative care strives to meet the physical, psychological, social, and spiritual
expectations and needs of patients and families. Unfortunately, in the past, although
many patients might benefit from palliative care, it was almost exclusively confined
to patients with advanced cancer.
Health promotion practitioners struggle to develop strategies to encourage
change in health-seeking behavior that are effective and sustainable in reducing risk
factors for lifestyle diseases. A reason for the difficulty may be the mismatch between
individuals’ and programs’ priorities, (Maneze, et al., 2015). The health seeking
behavior of patients with chronic illness will definitely play a major role in the
determination of their health care utilization. A positive health-seeking behavior may
lead to a faster diagnosis and better treatment compliance. On the other hand, a
negative health-seeking behaviour might impede the treatment and enhance the 6
disease progression.
The efforts for Palliative Care in the Philippines can be traced back in the
1980’s, when Dr Josefina Magno, a Filipino Oncologist who was one of the pioneers
of the hospice movement in the States, and one of the founders of the American
Academy of Hospice and Palliative Medicine in 1988, returned to the Philippines to
strengthen the Hospice and Palliative Movement in the country. Up to this date, more
than 20 years later, there are around 36 organizations focused on providing palliative
care among those with chronic and life-limiting illness in our country, especially to
those under privileged, (The Ruth Foundation, 2012).
The Ruth Foundation for Palliative and Hospice Care in the Philippines is a
non-government, non-stock, non-profit organization founded in 2012 by Dr. Rumalie
Corvera which caters to the needs of patients and their families with cancer and non-
life limiting illnesses through home visits and through empowering them with the use
of community-based health teaching.
Based on the Quality of Death study by the Economist Intelligence Unit, the
Philippines is one of the worst places to die ranking 78 out of 80 countries. In the
study of Joaquin in 2013, “Own Mortality on the Death of a Dying Patient: A
Grounded Theory”, results show that majority of the dying patients were chronically
and critically ill who were left untreated to the point that there were no available
treatment or cure to be done; most have been brought there when the patient was too
weak dying or near death. In the 4th issue of the magazine by the Ruth Foundation
7
entitled “Hopefull” in March 2017, Dr. Rumalie Corvera stated that unlike more
developed countries, home-based palliative and hospice care is not yet integrated in
the Philippine health care system. The cost is still paid out-of-pocket by the majority.
She further stated that 100% of the population will at some point need “end-of-life”
care or “quality of life” care. In the Philippines, Filipinos often seek health care only
when their condition has worsened already. According to the study of Joaquin,
financial instability had been mentioned as a reason for this eventuality.
The mentioned financial instability was just one of the several factors that can
be associated with health in general. Chronically ill individuals have added a new
interpretation to spirituality as an energetic and supportive reality, adding drive or
momentum to healing and dying beyond medical assessment, (De Guzman, et al,
2014). In 2008, Balein conducted a study on the factors associated with good death as
perceived by terminally-ill patients, family members, and healthcare providers at the
Cancer Institute and Supportive Palliative and Hospice Care Clinic of UP-PGH. The
study revealed that patients, family members and health care professionals perceive
that to have a good death, first and foremost, one needs to come to peace with God.
Results of Balein’s study also suggests that spirituality and medical care are not seen
as conflicting. It can be concluded that acceptance of illness through spirituality 8
benefited the patients and does not contradict the desire for medical care.
As humans have the capacity to conceptualize a future, and along with it an

inevitable death, the meaning and attitudes toward death that we hold can be an
important factor in determining what we do with our lives in the present, (Nati &
Magracia, 2015). The Palliative Care approach does not only focus on the relief of
symptoms, but also emphasizes and gives importance on finding the real purpose and
meaning of life which will then reflect in the way a person manages his/her condition.
FOREIGN LITERATURE AND STUDIES
Palliative care is a philosophy of care that provides a combination of disease-

modifying and supportive, compassionate therapies intended to alleviate pain and
other symptoms while addressing the emotional, social, cultural, and spiritual needs
of patients and families who are experiencing life-threatening, progressive illness,
(Matzo & Sherman, 2014). The nature of diseases (Multiple Sclerosis, COPD, heart
failure, etc.) all entail periods of exacerbations and remissions and the challenge is to
identify when an exacerbation precedes the terminal phase of illness. While most
people believe that it’s a sign of giving up hope of a cure or giving up on treatment
too early if they seek assistance care or consider undergoing palliative care, the key,
as stated by O’rourke & Dufour in 2012, is to find out as much information as
possible early in the disease process, as much assistance is available to people long
before they are actively dying. One may argue that introducing palliative care at an
earlier stage may also dispel the myths and image of palliative care specialism as end
of life care, therefore encouraging people who are struggling with symptoms to be
less apprehensive and fearful of palliative care involvement or referral should it be 9
needed, (Brown, 2016).
The National Council for Palliative Care (2014) suggests that individuals
approaching the end of life have the right to the highest quality of care and support,
whether they live and whatever their condition, and that those with a life-limiting
condition other than cancer should have the same equity of access to high-quality
palliative care as those with a cancer diagnosis. Intensified pain and symptom
alleviation and non-treatment decisions are more likely to occur in higher educated
than in lower educated patients. These decisions were less likely to be discussed with
either patient or family, or with colleague physicians, in lower educated patients,
(Chambaere et al., 2013). Because they don’t have cancer, they don’t see their disease
as terminal and therefore would never consider working with a palliative care team.
Although we should celebrate the successes of new technologies that prolong life and
provide a better quality of life, the fact remains that these chronic diseases have a
terminal phase. We are all going to die, and may spend months, even years, living
through the process, (Brown, 2016).
Chronic Illness is a general term that refers to a diagnosed illness, functional

limitation, or cognitive impairment that lasts at least a year, places limits on a
person’s daily activities, and often requires regular attention and medical care,
(Schraeder & Shelton, 2011). In addition, chronic disease or disability can lead to
poverty at the level of the patient and family, a society, or country as a whole because
deaths attributable to chronic diseases or disorders occur most often during a person’s
most productive years, (WHO, 2011).
How people react to and cope with chronic illness is usually similar to how
they react to other events in their lives, depending, in part, on their understanding of
the condition and their perceptions of its potential impact on themselves and their
family’s lives, (Hinkle & Cheever, 2014). One good example to cite is the Filipinos
bravery and resiliency in most events in their lives, be it a man-made disaster or a
natural calamity. In a survey conducted by the Sun Life Financial Asia in 2014
among 5000 middle-income Asians from Philippines, Hong Kong, Malaysia,
Indonesia, Vietnam, China, Singapore and Thailand with regards to their attitudes
toward healthy and active living, health concerns for the future and expectations on
access to vital health care, Filipinos were the most optimistic in the region. According
to the same report, Filipinos had the highest levels of family history of chronic illness
(19% versus the average of 13%). They also scored highest in terms of largely
preventable health conditions such as diabetes (47% versus the region’s average of
32%) and heart disease (43% compared to 23% for the region). Despite these results,
Filipinos also showed the highest motivation to attain and maintain a healthy lifestyle
with a score of 86.8 on the Asia Health Index which measures attitudes, perceptions,
and behavior relating to health, lifestyle, priorities, healthcare access and personal
finances, outpacing the region’s average of 80.1. Many citizens, particularly in rural
areas, but also urban dwellers, continue to have low incomes and little savings,
(Naerssen, et al., 2016). The prevailing view of Filipino society, the ideal Filipino
family consists of a husband/father who is the income provider, and a wife/mother
who is principally responsible for what happens at home, (Naerssen, T.V., Smith, L.,
Marchand, M.H., 2016). Marital or partnership status is therefore related to health
care outcomes, precedes care delivery and is not a consequence of the quality of care,
is not something the provider can manipulate, and meets practical considerations,
11
10
(Committee on Accounting for Socioeconomic Status in Medicare Payment

Programs, 2016). According to Berman, et al., (2014), the financial impact of the
illness, which is influenced by factors such as loss of income and ability of the ill
member to return to work, is one of the major factors in determining the overall
impact of illness on the family. The results of the survey conducted by Sun Life
Financial Asia show that Filipinos being the most optimistic among the other
countries in Asia have a high chance of having a positive attitude towards health care
utilization given the adequate support and assistance and appropriate resources from 12
government and other health care organizations in the Philippines.
Life-threatening illness causes not only the patient but the family to be curious
about the profound meaning of life. Nyatanga and Nyatanga in 2011 stated that as
you grow from an infant to an adult (living), you are also gradually dying. Meaning
to say, what we call living is the same as what we call dying because these two
aspects or processes happen at the same time. Within the Filipino culture, confronting
a serious illness often results in a fatalistic perception of the problem knowing that it
can somehow lead to its terminal phase, followed by death. The topic of death and
dying has become a taboo subject culminating in people fearing death, (Nicol &
Nyatanga, 2014). It is of no exception here in the Philippines. Every living thing dies,
but human beings are probably the only creatures that can imagine their own deaths.
Most people fear death and try to avoid thinking about it. Traditionally, people have
confronted death within a set of religious beliefs that gave it meaning outside the
natural world. Other people see death as a threatening topic and choose to deny it.
According to Milosevic & McCabe in their book Phobias: The Psychology of
Irrational Fear in 2015, Women generally report greater death anxiety than men.
Several researches have been made but there is no single explanation regarding this
occurrence. However, some studies in the past suggests that one possible rationale for
the spike of women’s anxiety is that it often coexist with the average onset of
menopause for women which happens at the middle adulthood stage and is a major
change in life that marks the end of a woman’s productivity, and therefore serves as a
stark reminder that she is getting older.
Death is a salient issue for midlife adults. One of the major midlife tasks to be
completed is to accept death as a reality. Middle Adulthood is said to be a period of
great change in most people. The Middle-aged adults are sometimes referred to as the
sandwich generation, because they are being caught in between caring for their
children and their parents. By middle age, one is exposed to the finality of life with
death of parents, friends, and siblings, (Sinoff, 2017). During this period of transition,
adults may face new responsibilities and therefore may feel the need to have an
appraisal of the quality of life they’ve lived so far. In addition, failing health, deaths
of parents and close friends, and changes in physical appearance contribute to a 13
heightened awareness of death, (Leming & Dickinson, 2016).
Denial, hostility, and depression are factors that often accompany an illness of
the middle aged, (Leming & Dickinson, 2016). Research has shown that depression
can complicate and influence general decisions about health. When patients have
depression in addition to other physical illnesses, they are less likely to follow
treatment plans and tend to be higher users of health services, (Buckley & Feldt,
2013). Thus, Chronic Illness when accompanied by depression can greatly afflict a
person’s decision making skills when it comes to health such as whether or not to
receive Palliative care when needed, and whether to accept the concept of death and
dying or deny it.
In the study of Koenig in 2016, it was mentioned that a large volume of

research shows that people who are more religious and spiritual have better mental
health and adapt more quickly to health problems compared to those who are less
religious and spiritual. These possible benefits to mental health and well-being have
physiological consequences that impact physical health, affect the risk of disease, and
influence the response to treatment. Religion and spirituality is often used together.
Religion is a personal set or institutionalized system of religious beliefs, (Merriam-
Webster Dictionary, 2014). On the other hand, spirituality, as defined by Hinterkopf
in 2014, is a subtle, bodily feeling with vague meanings that brings new, clearer
meanings involving a transcendent growth process. It is a universal human
expression, is individual and subjective, and means different things to different
14
people. Since the colonial period, Catholicism has been the cornerstone of Filipino
identity for millions in the Philippines, (Catholicism in the Philippines, n.d., para. 1).
Aside from Catholicism, the Philippines is known to have many religions. Most often
issues arise due to the differences in belief and practice of these religions. From the
book of A Trinitarian Theology of religions: An Evangelical Proposal by McDermott
and Netland in 2014, The Dalai Lama emphasizes that we should focus on what the
religions have in common and not their differences: “All of the different religions
faiths, despite their philosophical differences, have a similar objective. Every religion
emphasizes human improvement, love, respect for others, and sharing other people’s
sufferings. On these lines, every religion has more or less the same viewpoint and
same goal.” Furthermore, Arthur Schopenhauer in 2012 stated that all religions and
philosophical systems are directed principally to the end which he referred to as
death.
SYNTHESIS
The purpose of this synthesis is to express the central conclusion of the

research findings on the acceptance of middle-aged clients with chronic illness on
Palliative Care and Death and Dying.
Palliative Care and Death and Dying are two different terms which can have
common factors that may interconnect them and affect the people’s reception about
them. One of these factors is the religion, by which Arthur Schopenhauer (2012)
concluded that all religions and philosophical systems are directed principally to the
end which he referred to as death. This is supported by O’rourke and Dufour (2012)
who stated that our faith shapes how we are called to respect the dignity and life of
every person, and stresses the importance of pursuing justice, peace and holistic
healing. Another factor mentioned is the financial stability which resulted as the
15
primary reason for the majority of chronically ill and critically ill to be left untreated
in the study of Joaquin (2013).
With the increase in number of people living with chronic illnesses as
presented by the DOH (2013) and in the recent study of Sun Life Financial Asia
(2014), the need for Palliative Care is ever-growing. Early identification and
introduction of Palliative Care in the beginning of the disease process can actually
help the patient and the family to deal with what is ahead, keeping them comfortable
and aware of the condition and the following treatments they need. This is supported
by Brown (2016), and O’rourke & Dufour (2012) who further stated that giving as
much assistance as possible by giving out sufficient information on Palliative Care at
an earlier stage may encourage people to be less reluctant and apprehensive in
accessing it and therefore intensify the utilization of Palliative Care.
In the study of Buckley & Feldt (2013), research has shown that depression
can complicate and influence general decisions about health which is supported by
Leming & Dickinson (2016) stating that depression is one of the factors that often
accompany an illness of the middle-aged. Without the proper knowledge on their
disease and its process, this can then affect the patient’s likeliness tin engaging with
Palliative Care alongside their perspective in life. Nati & Magracia (2015) and
Leming & Dickinson (2016) both argued that our outlook in life and the way we
behave and act towards an illness has a significant impact on the way we perceive
death. Conversely, our standpoint in death and dying also has a great effect on the
actions we decide to make in the present.
THEORETICAL FRAMEWORK
This study is grounded on the following theoretical models: (1) Erik Erikson’s
Psychosocial Theory (1950), (2) Health Belief Model by Hochbaum, Rosenstock and
Kegels (1988), (3) Andersen and Newman’s Model of Health Care Utilization (1968)
and (4) Stages of Grief by Kubler Ross (1969).
16
Erik H. Erikson is without a doubt one of the most outstanding psychoanalysts

of the last century. It is Erik Erikson’s basic assumption that in the course of a
lifetime, the human being goes through eight developmental phases, which are laid
out in an internal development plan. On each level, it is required to solve the relevant
crisis, embodied by the integration of opposite poles presenting the development
tasks, the successful handling of which is in turn of importance for the following
phases, (Scheck, 2014). Erikson stated that the primary psychosocial task of middle
adult‐ hood—ages 45 to 65—is to develop generativity, or the desire to expand one's
influence and commitment to family, society, and future generations. In other words,
the middle adult is concerned with forming and guiding the next generation. The
middle adult who fails to develop generativity experiences stagnation, or self‐
absorption, with its associated self‐indulgence and invalidism. Being included in the
middle aged group or the working population, facing chronic illness poses a great
threat in developing positive outcomes on Erik Erikson’s psychosocial task. The
theory of Erik Erikson shows that middle adulthood is a critical point in life to carry
the burden of an illness along with the amount of responsibilities a middle adult bears
upon his/her shoulders.
The HBM or Health Belief Model by Hochbaum, Rosenstock, and Kegels was
at first discussed in terms of four concepts that represents the perceived threat and net
benefits: perceived susceptibility, perceived severity, perceived benefits, and
perceived barriers. These concepts were proposed as the reasons for people’s
readiness to act. An added concept, which is cues to action, activates the readiness
and stimulate overt behavior. The last added concept, the concept of self-efficacy, or
one’s confidence in the ability to successfully perform an action was included by
Rosenstock and others in 1988 to make the HBM more suitable for the challenges of
changing habitual unhealthy behaviors, such as sedentary lifestyle, smoking, or
overeating which are all risk factors of chronic illnesses. To sum it up, there were a
total of six concepts. This model can greatly explain the reasons for seeking health as
well as the reception on a specific health care service. As the study aims to determine
the level of acceptance in palliative care, the Health Belief Model can be of use to
17
expound on the components that might influence a client’s understanding and

18
decision in undertaking palliative care.
The next theory is Andersen’s Behavioral Model of Health Care Utilization

which was initially developed in the late 1960’s. It suggests that people’s use of
health services is an outcome of their inclination to use services, factors which enable
or impede use of services, and their need for care, therefore providing a way to
conceptualize the variations in utilization rates and consumption of medical
resources. In this behavioral model, the use of services is defined as a function of 3
main elements: need, enabling, and predisposing factors. The Need factors which
have been shown to account for the majority of the explained variability in physician
use, include the individual’s perceived health care need and other indicators of their
health status. Factors such as self-reported number of symptoms, self-perceived
health, and number of bed days, restricted activity, and activities of daily living are
part of the patient’s perceived need of health care. Enabling factors include items
such as the individual’s income, health insurance status, and access to a source of
regular care. Finally, predisposing factors include demographic variables,
socioeconomic status, attitudes, and beliefs, This Behavioral model gives the specific
possible factors, by which some of it are included in this study such as the
demographic variables and socioeconomic status, that might affect the acceptance
and usage of Health Care services, be it of help or an impediment. Unlike the HBM,
this model focuses on the utilization of health care alone.
Lastly, the 5 stages of grief that were first proposed by Elisabeth Kubler-Ross
in her 1969 book in Death and Dying will be significant in determining the level of
acceptance in death and dying of the target population. The 5 stages of grief and loss
are: Denial and Isolation, Anger, Bargaining, Depression, and Acceptance. People
who are grieving does not necessarily undergo the stages in the same order or
experience all of them. The stages of grief and mourning are universal and are
experienced by people from all walks of life, across many cultures. Mourning occurs
in response to an individual’s own illness, the loss of a close relationship, or to the
death of a valued being, human, or animal, (Axelrod, 2016). The grief associated with
death is familiar to most people, but individuals also grief in connection with a
variety of losses throughout their lives such as having an illness. Kubler Ross’ 5
stages of grief will be valuable in interpreting the level of acceptance in death and
dying of the middle aged clients with chronic illness.
19
RESEARCH PARADIGM
Level of
Acceptance in Level of Acceptance in
Death and Dying Palliative Care
Intervening Variables
Civil Status,
Educational
Attainment, Family
Structure,
Gender, Annual Income,
Religion
Figure 1
The Variable and their Relationships

20
As shown in Figure 1, the first box contains the independent variables which
are the Middle-Aged Clients with Chronic Illnesses. The two boxes by which the
Independent Variable is pointing contains the Dependent Variables which include the
Level of Acceptance in Palliative Care and the Level of Acceptance in Death and
Dying. The last box, which is the Intervening Variable namely civil status,
educational attainment, family structure, gender, monthly income, occupation, and
religion is pointing towards both the Independent and Dependent Variable.
STATEMENT OF THE PROBLEM

This study sought to determine the relationship between the level of acceptance in
Palliative Care and the level of acceptance in Death and Dying of the Middle-aged
clients with chronic illness. Specifically, this study sought to answer the following:
1. What is the socio-demographic profile of the respondents in terms of:

a. Annual Income
b. Civil Status
c. Educational Attainment
d. Family Structure
e. Gender
f. Religion
2. What is the level of acceptance in Death and Dying of the middle-aged clients
with chronic illness?
3. What is the level of acceptance in Palliative Care of the Middle aged clients with
chronic illness?
4. Is there any significant difference in the level of acceptance in Death and Dying
of the middle-aged clients with chronic illness when grouped according to Civil, 21
Status, Educational Attainment, Family Structure, Annual Income, and Religion?

5. Is there any significant difference in the level of acceptance in Palliative Care of
the middle-aged clients with chronic illness when grouped according to Civil, Status,
Educational Attainment, Family Structure, Gender, Annual Income, and Religion?
6. Is there any significant relationship between the level of acceptance in Death and
dying and Palliative Care of the middle-aged clients with chronic illness?
HYPOTHESIS OF THE STUDY
The following hypothesis was tested in this study:
1. There is no significant difference in the level of acceptance in Death and Dying

of the middle-aged clients with chronic illness when grouped according to Civil,
Status, Educational Attainment, Family Structure, Gender, Annual Income, and
Religion.
2. There is no significant difference in the level of acceptance in Palliative Care of
Educational Attainment, Family Structure, Gender, Annual Income, and Religion.
3. There is no significant relationship between the level of acceptance in Death and 22
Dying and Palliative Care of the middle-aged clients with chronic illness.
SIGNIFICANCE OF THE STUDY
This study hopes to establish an understanding on the Level of Acceptance in

Death and Dying and Palliative Care of the Middle-Aged Clients with Chronic
Illnesses and the relationship of the two variables with one another. Furthermore, the
researcher believes that this study could be of great importance to the following:
Respondents. The results of the study may enable them to assess and evaluate
their own selves on their level of acceptance in Palliative Care and Death and Dying.
This will also help them learn and understand the concept of Palliative Care which is
advantageous for them as future possible receivers of the said health care service. The
middle-aged clients will somehow be able to grasp the idea and clear some
misconceptions of undergoing Palliative Care and Death and Dying.
Family Members. The results of the study may significantly help them gain a
realistic understanding on the concept of Palliative Care and death and dying as well
as enhance their commitment in caring for a relative with chronic illness and in
providing them with psychosocial and physical assistance.
Nursing Profession. The outcome of the study may assist them in better
understanding and in formulating a more effective and efficient strategy and patient-
centred approach to deliver holistic care to the middle-aged clients with chronic
illnesses.
Government and Non-Government Officials. The results and conclusion of

the study may bring an impact and encourage them to heighten community and
professional awareness on the scope of, and benefits of timely and appropriate access 23
to palliative care services.
Future Researchers. The ideas presented may serve as a basis in conducting

a more comprehensive research and may also be used as a reference that will give
them an overview on the factors that may or may not affect the acceptance in
Palliative Care and Death and Dying.
SCOPE AND DELIMITATION OF THE STUDY
This study focused on the Level of Acceptance in Palliative Care and Death
and dying of the Middle Aged Clients with Chronic Illnesses in selected barangays of
General Trias, Cavite.
The scope and delimitation of the study included the middle-age bracket of
40-65 years old. The study covered sixteen barangays in General Trias, Cavite
namely Javalera, San Francisco, Bacao II, Pinagtipunan, Pasong Camachile I, Pasong
Camachile II, Buenavista I, San Juan I, San Juan II, Vibora, Panungyanan, Pasong
Kawayan II, Tapia, Santiago, Manggahan, Buena Vista III.
DEFINITION OF TERMS
The following terms have been defined as used in the study:
Annual Income. This refers to how much the middle-aged clients earned
from work, investments, or business in a span of a year. This is categorized as Under
40,000, 40,000-59,999, 60,000-99,999, 100,000-249,999, and 250,000 and over.
Civil Status. This refers to the options that describes the person’s relationship 24
with significant others. This is categorized as married, single, divorced, and widowed.
Death and Dying. Death refers to the inevitable last stage of human life,
while dying refers to the process of approaching death.
Educational Attainment. This refers to the highest level of schooling that a
middle-aged client has reached. This is categorized as No schooling, Elementary,
Secondary, Vocational, College, Masteral, and Doctorate.
Family Structure. This refers to the way in which the components of the
families of the middle-aged clients are arranged. This is categorized as Nuclear and
Extended.
Gender. This refers to the state of being male and female.
Level of Acceptance. This refers to the middle-aged clients assent to receive

Palliative Care and recognizing the process of Death and Dying. This is classified as
Strongly Disagree, Disagree, Moderately Disagree, Uncertain, Moderately Agree,
Agree, and Strongly Agree.
Palliative Care. This refers to a type of care that is focused on early

identification and provision of relief from the symptoms of a chronic or terminal
illness with improvement of the quality of life of the patients and their families as its
main goal.
Religion. This refers to the middle aged clients’ particular system of faith and
worship and is classified as Catholic, Iglesia ni Cristo, Christian, Muslim, Jehova’s
Witness and Protestant.
25
CHAPTER 2
METHODOLOGY
This chapter describes the research design and methods used in the study and
is presented in the following order: research design, population sampling,
instruments, data gathering process, data analysis, and methodological limitations.
RESEARCH DESIGN
The research design used was quantitative exploratory, descriptive-

correlational design.
The characteristics of quantitative design center on the why, where, who,

what, when, and how questions, (Boswell & Cannon, 2015). Quantitative research is
scientific investigation that includes both experiments and other systematic methods
that emphasize control and quantified measures of performance. Quantitative
researchers are concerned with the development and testing of hypotheses and the
generation of models and theories that explain behaviour, (Hoy & Adams, 2015). In
this study, the researcher used a questionnaire to gather data from the middle aged
adults with chronic illnesses. Quantitative research is used to quantify attitudes and
opinions and generalize results from the selected population.
Exploratory studies are those that investigate little-known phenomena for

which a literary or experiential search fails to reveal any significant examples of
earlier research. Exploratory studies are useful in nursing research in finding out
more about the nature of a nursing-related problem or issue and there usually is a
small sample that focuses on one particular area of interest or one or two variables,
(Fitzpatrick, J., 2017). Utilizing exploratory design in this study was useful in
gathering baseline information on a particular variable that is difficult to measure,
such as concepts of death and dying and palliative care which is considered as a new
and emerging health care service in the country. The exploratory design was used in
the development of the tool that was used in the data gathering phase of the study.
Descriptive design examines the characteristics of just one sample population.

A descriptive design delineates or explains the variables being studied and provides
26
flexibility in examining a problem from many different angles. Descriptive research

provides data describing the “who, what, when, where, and how” of a health issue,
not what caused it. Therefore, studies that reveal who either is at risk or has a
particular health issue or condition; that document incidence, prevalence, or both; that
examine risk factors; that look at the effects of a health issue; and that assess scale
properties designed to measure a construct related to a health issue would be
categorized as descriptive research, (Crosby, R.A., DiClemente, R.J., Salazar, L.F.,
2011). One purpose of this study is to describe the relationship between the level of
acceptance in Palliative Care and the level of acceptance in death and dying of the
middle aged clients with chronic illness.
Perhaps the most widely used type of descriptive design is the correlational
study. Simply stated, a correlational design examines the relationships between two
or more variables within a situation without knowing the reason for the relationship,
(Boswell & Cannon, 2015). The whole purpose of using correlational study is to find 27
out if the two variables, Palliative Care and Death and Dying, are connected.
POPULATION SAMPLING
Simple random sampling is a sampling design in which n distinct units are

selected from the N units in the population in such a way that every possible
combination of n units is equally likely to be the sample selected. The sample may be
obtained through n selections in which every step every unit of the population not
already selected has equal chance of selection. Equivalently, one may make a
sequence if independent selections from the whole population, each unit having equal
probability of selection at each step, discarding repeat selections and continuing until
n distinct units are obtained, (Thompson, 2012). In the first stage of sampling, the
total number of people with chronic illnesses was divided by the number of
barangays in General Trias, Cavite. A simple random technique was then used to
select the participating barangays. For the next stage, the sampling size was divided
by the number of the chosen barangays. Thus, at each stage, the size of the sample
has become smaller and the research study has become more precise.
RESPONDENTS OF THE STUDY
All listed adults aged 40-65 with chronic illnesses in General Trias, Cavite
were the respondents of this study. A total of one hundred forty (140) middle-aged
adults were identified and were asked to participate in the study.
28
RESEARCH INSTRUMENT
A structured questionnaire was used in determining the level of acceptance in

Palliative Care and Death and Dying of the middle aged clients with chronic illnesses
in General Trias, Cavite. In the first part of the questionnaire, demographic data such
as civil status, educational attainment, family structure, gender, annual income and
religion will be collected. The questionnaire was prepared in Tagalog and was
composed of 54 questions.
The second part was for the assessment on the level of acceptance of the
middle aged clients with chronic illness in Palliative Care. Exploratory design was
used in the development of the tool wherein a focus group discussion was conducted
with people having the same characteristics as the respondents. 4 participants were
gathered together with the researcher to discuss the possible factors to include in the
study, what they believe will be the benefits of these results, and what their insights
about the outcome of the study would be.
A researcher-made questionnaire was made which uses seven-point Likert

scale that measures their level of agreement and was composed of 22 items. The scale
was comprised of nine subscales: knowledge, goals, control of symptoms, coping,
cost/resources, relationship/family, psychological, spiritual and social. Knowledge
pertains to the awareness or familiarity on Palliative Care by experience or education
and includes items 1, 2, 3, 4, 5. Goals refer to the person’s ambition or desired result
in relation with their choice of action towards their condition and includes items 6
and 9. Control of symptoms pertains to the way they manage and acknowledge the
indicators brought about by their condition and includes items 8 and 11. Coping is
29
concerned with how they get through with their lives while living with a chronic
illness and includes items 7 and 10. Cost/resources involves money, materials, and
other assets that can be used in managing one’s health care issues and includes items
12, 13, 15. Relationship and family takes into account the possible effects of
Palliative Care to the family of those middle-aged clients living with chronic illnesses
and is comprised of items 14 and 16. Psychological subscale is concerned with
impact of Palliative Care on the mental and emotional aspect of health of the said
group of people and includes items 17, 21, and 22. Spiritual subscale covers questions
relating to the deep feelings and beliefs of the respondents affecting the human spirit
and soul and includes items 18 and 19. Social subscale refers to the individuals’
ability to socialize or relate to the society and includes items 20 and 21. Analysis of
the responses will be done by assigning weight to the responses. As a seven-point
Likert scale was used, 7 was assigned as the strongly agree, and 1 was assigned as the
strongly disagree. The mean sub-scale scores is computed by adding the scores on
each of the individual sub-scales.
The third part contains an existing instrument that was used to assess the level
of acceptance of the middle aged clients with chronic illness in death and dying, the
DAP-R questionnaire was adapted from its rightful owners. Full authority to use the
tool was given to the researcher by the author, Dr. Paul T.P. Wong. It is a 32-item
scale that uses a seven point Likert scale to measure respondent’s attitudes towards
death and dying. The scale is made up of five sub-scales that will determine
respondent’s feelings of (a) fear of death (7 items), (b) death avoidance (5 items), (c)
neutral acceptance (5 items), (d) approach acceptance (10 items), and (e) escape
acceptance (5 items). The scores for all items are from 1 to 7 in the direction of
strongly disagree to strongly agree. For each sub-scale, a mean scale score can be
computed by dividing the total scale score by the number of items forming each
scale. Analysis of the response was done by assigning weight to the responses. Seven
(7) is considered to be the most favourable measurement or “strongly agree” and one
(1) is considered to be the least favourable measurement or “strongly disagree”. The
mean sub-scale score is then computed by adding the scores on each individual sub-
scales, from one (strongly disagree) to seven (strongly agree) and then dividing it by
the number of items included in that sub-scale.
30
VALIDATION OF INSTRUMENT
The researcher-made developed questionnaire has undergone face and content

validation. Face validity concerns whether the measure seems valid to those who are
taking it while content validity concerns whether or not the actual content of the items
on a test makes sense in terms of the construct being measured, (Goodwin &
Goodwin, 2016). The researcher submitted the questionnaire to three experts in the
field of nursing. The remarks and comments given by the validators were applied to
improve the content of the tool.
The questionnaire had gone through pilot testing to determine its feasibility and
reliability despite being validated by the experts. Pilot test is the preliminary test of
your questionnaire. It is a cardinal rule in research that you must “try out”, or pilot
test, your questionnaire to determine whether it operates properly before using it in a
research study, (Johnson, 2016). The importance of doing pilot testing is to discover
errors in the instrument and ensure that the questions are understandable and
apprehendable. The problems identified will then be addressed before the
administration of the questionnaire to the real respondents. The pilot testing was
conducted at Malagasang 2G, Imus, Cavite to respondents of the same characteristics
as the actual one. Some of them have raised questions and noticed some
typographical errors in the questionnaire which the researcher addressed and taken
into account. The survey instrument was then submitted to reliability testing after the
data collection. Cronbach Alpha is a test of internal consistency in which each item is
simultaneously compared with others, and a total score is then used to analyse the
data, (Lobiondo-Wood, G., Haber, J., Cameron, C., Singh, M., 2014). The Cronbach
Alpha which is 0.829 can be interpreted as good and acceptable. All questions
consistently measures what’s it’s supposed to measure and none of the items had to
be eliminated from the questionnaire.
31
DATA GATHERING PROCEDURE
The process by which the researcher will gather data was divided into two
parts:
Social Preparation (Part 1). The researcher made a letter addressed to the
School Director recommended and signed by the Research and Development Center
and Dean of the College of Nursing of UPH-Molino. Furthermore, the researcher
picked ten (10) out of twenty two (22) barangays in General Trias, Cavite that has
middle-aged clients with chronic illness. Some of the barangays selected were not
able to reach the identified number of respondents per barangay so additional
barangays were picked in order to complete the total number of respondents. The
researcher then secured a written permission from the respective authorities to
conduct a study from the barangay captains of each participating barangays.
Data Gathering (Part 2). In the second part of data gathering, the researcher 32
personally handed out the questionnaires to the selected population.
The data was gathered from July 26, 2017 to August 3, 2017. The purpose of
the study and instructions were explained to the respondents. The respondents were
asked for their consent to participate in the study. Copies of the validated and
approved questionnaire were distributed in order to gather relevant data. They were
assured that their answers in the survey sheets will be kept confidential. Since the
identities were of no value, the researcher gave the participants the option of being
anonymous and since the study tries to gauge not the knowledge per se, a short
introduction about palliative care was given by the researcher as most of the
respondents questioned what it was. 15-20 minutes were the allotted time given to the
respondents to accomplish and analyse their answers. The questionnaires were
collected immediately after the participants have answered. After the collection of the
questionnaire, the researcher tabulated and analysed the data. The data gathered was
then sent to the statistician for statistical treatment of data.
STATISTICAL TREATMENT OF DATA
The following statistical treatment was used by the researcher to answer the
specific problems and in testing the hypothesis.
Frequency Distribution. This is a method used to organize the research data,

(Tan, 2011). Frequency distributions organize and present frequency counts so that
the information can be interpreted easily.
Formula Σ f = N
Where f= the number of times each category occurs

33
N= the number of respondents
The frequency distribution was used to determine the profile of the

respondents in terms of Civil Status, Educational Attainment, Family Structure,
Gender, Annual Income, and Religion.
Percentage Distribution. This shows the percentage of the sample subjects in

a sample which scores fall into a specific group and the number scores in that group,
(Tan, 2011).
Formula %= F/N x 100
Where F= is the frequency of responses
N= is the total number of respondents
100= is the constant in order to get the percentage
This was used to identify the profile of the respondents when they are grouped
according to Civil Status, Educational Attainment, Family Structure, Gender, Annual
Income, and Religion.
Mean. It is the sum of all scores divided by the number of scores, (Myers, J.,
Well, A., Lorch, R., 2013).
Formula (x) = Σx
N
Where x= the mean value of the group scores
Σ= the individual scores in the group of scores 34
X= the individual scores in the group scores
N= the total number
Mean was used to determine the level of acceptance in Palliative Care and the
level of acceptance in Death and Dying of the middle-aged clients with chronic
illnesses in selected barangays of General Trias, Cavite.
T-Test. It compares the responses of two respondent groups in the study
on the phenomenon under investigation. This is used to test for significant differences
between two samples (Tan, 2011).
Formula
Where:
x1=Mean of first set of values
x2= Mean of second set of values

S1 = Standard deviation of first set of values
S2 = Standard deviation of second set of values
n1 = Total number of values in first set
n2 = Total number of values in second set.
This was used to determine the level of acceptance in Palliative Care and
Death and Dying of the middle-aged clients with chronic illnesses in selected
barangays of General Trias, Cavite when they are grouped according to Civil Status,
Educational Attainment, Family Structure, Gender, Annual Income, and Religion.
35
F-test ANOVA (analysis of variance) can test the differences between two
means which can be used to examine data from two or more groups, (Tan, 2011).
F-test is simply a ratio of two variances. ANOVA uses the F-test to statistically test
the equality of means.
Formula: F= MSbetween
MSwithin
This was used to determine the significant difference in the level of
acceptance in Death and Dying and Palliative Care of the middle-aged clients with
chronic illnesses when they are grouped according to Civil Status, Educational
Attainment, Annual Income, and Religion.
DMRT. Duncan (1955) used a different approach to compare means, called the
multiple range test. To apply the method, instead of comparing the difference
between any two means with a constant least significant difference, each pair of
means is compared against a different critical value which depends on the ranks of
these means in the ordered array.
Formula:
This was used to determine the significant difference in the level of acceptance in
Death and Dying and Palliative Care of the middle-aged clients with chronic illnesses
when they are grouped according to Civil status.
Pearson Correlation. It measures quantitatively the extent to which two variables

are correlated (Sharma, 2012). It is a number (r=correlation coefficient) that describes
the strength of the relationship between two variables (Tan, 2011).
Formula r= N Σxy- (Σx)( Σy)

√ [N Σx2- (Σx)2] [N Σy2- (Σy)2]
Where:
N= number of pair of scores
Σxy= sum of the products of paired scores
Σx= sum of x scores

36
Σy= sum of y scores
Σx2= sum of x squared scores
Σy2= sum of squared y scores
This was used to measure the strength and direction of association that exists between
the level of acceptance in Palliative Care and the level of acceptance in Death and
Dying of the middle-aged clients with chronic illness in selected barangays of
General Trias, Cavite.
37
Chapter 3
RESULTS AND DISCUSSIONS
This chapter deals with the presentation, analysis and discussions of data in
relation to the level of acceptance in Palliative care and the death and dying among
the middle age clients with chronic illness.
Problem 1. What is the socio – demographic profile of the respondents in terms
of civil status, educational attainment, family structure, gender, annual income and
religion?
Profile of Respondents in terms of Civil Status
Figure showed the socio – demographic profile of the respondents in terms of
civil status.
Figure 2. Profile of Respondents in terms of Civil Status
38
Figure showed the percentage distribution of the socio – demographic profile

of respondents in terms of civil status. It showed that out of 140 respondents, more
than half of them were married having a total share of 68%. In addition, it also
showed that 29% of them were single. However, it showed that there were very few
or 3% of them were widowed.
This implies that majority of the respondents were married.
Middle adulthood usually refers to the years between 40 and 65. For many, it
is a period when one has both grown children and older-adult parents, (Potter, P.A.,
Perry, A.G., Stockert, P., Hall, A., 2014). This means that individuals are expected to
be married by the time they reach middle adulthood.
Profile of Respondents in terms of Educational Attainment

educational attainment. 39
Figure 3. Profile of Respondents in terms of Educational Attainment

of respondents in terms of educational attainment. It showed that out of 140
respondents, majority of them were at least able to reach secondary education having
40% total share in the distribution. Hence, it also showed that there were 33.6% of
them who have college education, 14.3% with vocational education and 7.1% of them
have elementary. Furthermore, there were 2.9% and 2.1% who have master’s degree
and no formal education, respectively.
This implies that majority of the respondents reached secondary level of
education.
There are several factors as to why education is restricted at the grassroots
level. With the low income of these families, their educational background could be
predicted and they are most likely to have attended a public school. Philippine public
schools do not charge tuition fees, but it’s not the only financial consideration. School
supplies, uniform costs, meals, and transportation add up to the costs as well. When
an emergency occurs, such as a family member falling ill, or a parent losing his job, it
also usually forces the child to drop out of school, (Reyes, T., 2015).
Profile of Respondents in terms of Family Structure
40
family structure.
Figure 4. Profile of Respondents in terms of Family Structure

of respondents in terms of family structure. It showed that out of 140 respondents,
majority of them belonged to nuclear type of family with 65% share in the
distribution. On the other hand, there were 35% of them who were from extended
family.
This implies that majority of the respondents belong to nuclear type of family.
"Modernity" involves changes and innovations in the process and focus of
production, or a shift from agriculture to industrial production, (Torres, A.,
1995).This has had consequences on the location of families, with many rural-based
individuals coming to cities in search of purportedly better-paying jobs. Thus, one
outcome of modernization is migration from rural areas urban ward, especially of-
young people. Migration therefore alters the family composition.
According to the official website of the city of General Trias, Cavite, the
increasing rate of household formation is primarily induced by the significant number
of in-migrating families to the municipality. Hence, migration from rural to urban
41
areas like the developing city of General Trias alters family composition from
extended which is the typical Filipino family structure to nuclear composed of a
father, mother, and a child or children.
Profile of Respondents in terms of Gender

gender.
Figure 5. Profile of Respondents in terms of Gender

of respondents in terms of gender. It showed that out of 140 respondents, majority of
them were female respondents with 70% share in the distribution. On the other hand,
there were 30% of them who were male. 42
This implies that majority of the respondents were female.
The prevailing view of Filipino society, the ideal Filipino family consists of a
husband/father who is the income provider, and a wife/mother who is principally
responsible for what happens at home, (Naerssen, T.V., Smith, L., Marchand, M.H.,
2016). The reason why majority of the respondents are female is because at the time
of data gathering, they are the ones staying at home while their husbands go to work.
Profile of Respondents in terms of Annual Income

annual income.
Figure 6. Profile of Respondents in terms of Annual Income

of respondents in terms of annual income. It showed that out of 140 respondents,
majority of them have annual income of Php 40,000.00 and below. In addition, it
showed that respondents with P40,000 – 59,999 have 19.3%, P60,000 – 99,999 with
43
15.7%, respondents with P100,000 – 249,000 have 13.6% and 6.4% of them have
P250,000 and above as annual income.
This implies that majority of the respondents have P 40,000 and below annual
income.
Many citizens, particularly in rural areas, but also urban dwellers, continue to
have low incomes and little savings, (Naerssen, et al., 2016). Having females as
majority of the respondents depict that they may or may not be full-time housewives
wherein being one reduces the source of family income and welfare prospects.
Profile of Respondents in terms of Religion

religion.
Figure 7. Profile of Respondents in terms of Religion
44

of respondents in terms of religion. It showed that out of 140 respondents, dominant
majority of them were Catholic in religion having 78% total share in the population.
In addition, there were 16% of them who were Christian. Furthermore, it showed that
Iglesia ni Cristo and Muslim have an equal share in the distribution with 3% each
group.
This implies that majority of the respondents were Catholic.
Since the colonial period, Catholicism has been the cornerstone of Filipino
identity for millions in the Philippines, (Catholicism in the Philippines, n.d., para. 1).
The Philippines’ Catholicism has its origins in the islands’ long periods ago. This is
supported by the Philippine Demographics Profile of 2017, who stated that
Catholicism is the predominant religion in the country with estimates of
approximately 82.9% of the population belonging to this faith.
Problem 2. What is the level of acceptance in death and dying of the middle
aged clients with chronic illness?
Level of Acceptance in Death and Dying of the Middle Aged Clients with
Chronic Illness
Legend:
Level of Agreement Interpretation Range
7- Strongly Agree Very High Level of Acceptance 6.17-7.00
6- Agree High Level of Acceptance 5.31-6.16
5- Moderately Agree Moderately High Level of Acceptance 4.45-5.30
4- Uncertain Neutral 3.59-4.44
3- Moderately Disagree Moderately Low Level of Acceptance 2.73-3.58
2- Disagree Low Level of Acceptance 1.87-2.72
1- Strongly Disagree Very Low Level of Acceptance 1.00-1.86
Table 1. Level of Acceptance in Death and Dying of the Middle Aged Clients
with Chronic Illness
Mea
Statement Interpretation
n
1 death is no doubt a grim experience 4.55 Above Average
2 the prospects of my own death arouses anxiety in me 4.32 Average
3I avoid death thought at all costs 4.84 Above Average 48
4 I believe that I will be in heaven after I die 4.99 Above Average
5 Death will bring an end to all my troubles 3.55 Average
6 Death should be viewed as a natural, undeniable, and
4.80 Above Average
unavoidable event
7 I am disturbed by the finality of death 4.50 Above Average
8 Death is an entrance to a place of ultimate satisfaction 4.04 Average
9 Death provides an escape from this terrible world 3.60 Average
10 Whenever the thought of death enters my minds, I try to push
4.74 Above Average
it away
11 Death is deliverance from pain and suffering 3.42 Average
12 I always try not to think about death 4.65 Above Average
13 I believe that heaven will be a much better place than this
4.56 Above Average
world
14 Death is a natural aspect of life 5.08 Above Average
15 Death is a union with God and eternal bliss 4.95 Above Average
16 Death brings a promise of a new and glorious life 3.96 Average
17 I would neither fear death nor welcome it 4.74 Above Average
18 I have an intense fear of death 4.24 Average
19 I avoid thinking about death altogether 4.62 Above Average
20 The subject of life after death troubles me greatly 4.03 Average
21 The fact that death will mean end of everything as I know it
4.23 Average
frightens me
22 I look forward to a reunion with my loved ones after I die 4.42 Above Average
23 I view death as a relief from earthly suffering 3.67 Average
24 Death is simply a part of the process of life 4.94 Average
25 I see death as a passage to an eternal and blessed place 4.57 Above Average
26 I try to have nothing to do with the subject of death 4.38 Average
27 Death offers a wonderful release of the soul 3.95 Average
28 One thing that gives me comfort in facing death is my belief
4.34 Average
in the afterlife
29 I see death as a relief from the burden of this life 4.17 Average
30 Death is neither good nor bad 4.42 Average
31 I look forward to life after death 4.98 Above Average
32 The uncertainty of not knowing what happens after death
4.14 Average
worries me
Overall 4.30 Average
The highest computed mean is item number 14, which states that Death is a
natural aspect of life while the lowest computed mean is item number 11 which
states that death is a deliverance from pain and suffering.
Table showed the overall computed mean level of acceptance in death and dying
among the middle aged clients with chronic illness. It showed the overall computed
mean of 4.30 which is verbally interpreted as average level of acceptance.
This means that the there was an average level of acceptance in death and dying
among the respondents.
In contrary to what Nicol and Nyatanga has stated in 2014, that the topic of death
and dying has become a taboo subject culminating in people fearing death, results
show that the participants regarded to death as a natural aspect of life, erasing the
stigma that death is a taboo subject. Accepting this statement supported the lowest
computed mean or the item number 11 which asserts that death is deliverance from
pain and suffering. Knowing that death is a natural occurrence, participants do not
see it as a relief from the hardship and agony of living.
Problem 3. What is the level of acceptance in palliative careof the middle aged
clients with chronic illness?
Level of Acceptance in Palliative Care of the Middle Aged Clients with Chronic
Illness
Legend:
Level of Agreement Interpretation Range
7- Strongly Agree Very High Level of Acceptance 6.17-7.00
7- Agree High Level of Acceptance 5.31-6.16
5- Moderately Agree Moderately High Level of Acceptance 4.45-5.30
4- Uncertain Neutral 3.59-4.44
3- Moderately Disagree Moderately Low Level of Acceptance 2.73-3.58
2- Disagree Low Level of Acceptance 1.87-2.72
1- Strongly Disagree Very Low Level of Acceptance 1.00-1.86
Table 2. Level of Acceptance in Palliative Care of the Middle Aged Clients with
Chronic Illness
Statement Mea
Interpretation
n
1. Palliative Care is a specialized medical care to people with 4.74 Above Average
serious illness. 45
2. Palliative Care focuses in providing relief of symptoms of
4.50 Above Average
a serious illness.
3. Palliative Care caters Cancer patients alone. 4.33 Average
4. Palliative Care is offered for people with Chronic Illnesses
such as Alzheimer’s Disease, Arthritis, Asthma, Cancer,
COPD, Crohn’s Disease, Cystic Fibrosis, Diabetes, 4.84 Above Average
Epilepsy, Heart Disease, HIV/AIDS, Multiple Sclerosis,
Parkinson’s Disease
5. Palliative Care is patronized in the Philippines 4.43 Average
6. Palliative Care is more important than any other goals in
4.14 Average
my life.
7. I will have better control over my life if I choose to
4.97 Above Average
undergo Palliative Care
8. Palliative Care will help me enjoy my life 4.79 Above Average
9. My life is going well even though I have Chronic Illness
4.96 Above Average
10. I need to concentrate on getting rid of my symptoms 4.94 Above Average

11. I would gladly sacrifice important things in my life to 4.35 Average
manage my condition better
12. Palliative Care will help me manage the cost of my health
4.96 Above Average
care expenses
13. With Palliative Care, I will be able to avoid unnecessary
4.62 Above Average
hospitalizations, diagnostic, and treatment interventions
14. Palliative Care will ease the burden among my family
4.91 Above Average
members
15. Palliative Care will bring harmonious relationship among
3.97 Average
family members in managing my condition
16. Undergoing Palliative Care will help improve the well-
4.91 Above Average
being of my caregivers/family members
17. Palliative Care will give me a sense of peace
4.72 Above Average
18. I will achieve spiritual growth and transformation through
Palliative Care 5.00 Above Average
19. I will develop a deeper connection with the Creator if I 4.74 Above Average
undergo Palliative Care
20. Palliative Care will increase my social support system 4.48 Above Average
through various support groups
21. Palliative Care will lessen my fear of living with a chronic 4.66 Above Average
46
disease/life-limiting illness
22. Palliative Care will prepare me to meet my end 4.97 Above Average
Overall 4.68 Above Average
Items number 15 and 18 garners the lowest and highest scores, respectively.
Table showed the overall computed mean level of acceptance in palliative
care among the middle aged clients with chronic illness. It showed the overall
computed mean of 4.68 which is verbally interpreted as above average level of
acceptance.
This means that the there was an above average level of acceptance in
palliative care among the respondents.
The lowest computed mean falls under the resources subscale. According to
Batra in 2012, the decline in family size suggests that influences from outside the
nuclear family may accordingly decline while, on the other hand, the influence from
within the nuclear family may increase. As most of the participants belong to the
nuclear family structure, the human resources is much smaller in number, and is
therefore much easier to have a connection with and live together in harmony. This
is in contrast to the results which show that family structure has no impact on the
acceptance in palliative care. Meaning to say, the size of the family is not relevant in
describing the relationship among family members, most especially that Filipinos
are known to have strong family ties which then clarify why harmonious
relationship among family members is not a concern regardless of the family
structure.
Moreover, the highest computed mean is under the spiritual subscale. Spirituality
as defined by Hinterkopf in 2014 is a subtle, bodily feeling with vague meanings that
brings new, clearer meanings involving a transcendent growth process. It is a
universal human expression, is individual and subjective, and means different things
to different people. It is different from religion, from which result has no effect on the
acceptance of palliative care, though this provides a spiritual expression and spiritual
community for some people. Spirituality is an important factor that helps people
achieve the balance needed to maintain health and well-being and to cope with
illness. Current evidence shows that spirituality positively affects health, quality of
life, health promotion behaviors, and disease prevention activities, (Potter e. al.,
50
2014). This explains why the statement under the spiritual subscale has the highest
computed mean and shows a high acceptance in palliative care.
Problem 4. Is there a significant difference on the level of acceptance in death

and dying of the middle aged clients with chronic illness when grouped in terms of
civil status, educational attainment, family structure, gender, annual income and
religion?
Hypothesis: There is no significant difference on the level of acceptance in
death and dying of the middle aged clients with chronic illness when grouped in
terms of civil status, educational attainment, family structure, gender, annual income
and religion.
with Chronic Illness in terms of Civil Status 57
Sum of Mean
Source of F-
Square df Squar Significance
Variation value
s e
Between
.342 2 0.171
Groups
0.583 0.560
Within
40.198 137 0.293
Groups
Total 40.540 139
Table showed the overall computed F – value as 0.583 with 0.560 significant
level which is greater than the 0.05 level of significance. The null hypothesis that
there is no significant difference on the level of acceptance in death and dying of the
middle aged clients with chronic illness when grouped in terms of civil status is
accepted.
This finding means that there was no significant difference on the level of
acceptance in death and dying of the middle aged clients with chronic illness when
grouped in terms of civil status.
This is in contrast to the study of Siegler, et. al in 2013, who stated that Social
ties during midlife are important to help us understand premature mortality. The
study concluded that consistency of marital status during midlife suggests that lack of
a partner is associated with midlife mortality.
However, civil status has shown no consequence to the acceptance of death and
dying which may implicate that people in the middle adulthood, no matter what their
marital status is, must already had experienced a death of a family member, a friend,
or anybody in his or her social circle because social ties cannot be limited only to
romantic relationships.
with Chronic Illness in terms of Educational Attainment 58
Sum of Mean
Source of F-
Square df Squar Significance
Variation value
s e
Between
1.309 5 0.262
Groups
0.894 0.487
Within
39.232 134 0.293
Groups
Total 40.540 139
middle aged clients with chronic illness when grouped in terms of educational
attainment is accepted.
grouped in terms of educational attainment.
The level of educational attainment holds no value in the acceptance of death
and dying. While it is known that having higher education will lead to a greater and
wider perspective on subject matters, it was revealed that one doesn’t need a high
level of education in accepting the concept of death.
with Chronic Illness in terms of Family Structure
Family Mea Significanc
N SD df t - value
Structure n e
0.55
Nuclear 91 4.300
9 13
-0.016 0.988 59
0.50 8
Extended 49 4.302
9
Table showed the overall computed t – value as – 0.016 with 0.988 significant
middle aged clients with chronic illness when grouped in terms of family structure is
accepted.
grouped in terms of family structure.
This is supported by Sinoff (2017) who stated that by middle age, one is
exposed to the finality of life with death of parents, friends, and siblings.
Regardless of the family structure, whether nuclear type or extended type, one
has definitely a family member from which he/she has seen and experienced death of
a loved one.
with Chronic Illness in terms of Gender
Mea Significanc
Gender N SD df t - value
n e
0.53
Male 42 4.213
3 13
-1.265 0.208
0.54 8
Female 98 4.339
1
60
middle aged clients with chronic illness when grouped in terms of gender is accepted.
grouped in terms of gender.
In contrast with the study of Milosevic & McCabe (2015), Women generally
report greater death anxiety than men.
with Chronic Illness in terms of Annual Income
Sum of Mean
Source of F-
Square Df Squar Significance
Variation value
s e
Between
0.409 4 0.102
Groups
0.344 0.848
Within
40.132 135 0.297
Groups
Total 40.540 139
middle aged clients with chronic illness when grouped in terms of annual income is
accepted.
acceptance in death and dying of the middle aged clients with chronic illness when 61
grouped in terms of annual income.
This negates the study of Jahangiri and Dehghani (2017) who stated that the
more modern one’s lifestyle is, the more negative his attitude towards death. The
more traditional lifestyle is also associated with more positive attitude and approach
acceptance. It can be assumed that with the presence of many life and death
insurances, the financial aspect is not a concern of the participants which led to the
result that annual income has no impact on the acceptance in death and dying.
with Chronic Illness in terms of Religion
Sum of Mean
Source of F-
Square Df Squar Significance
Variation value
s e
Between
1.236 3 0.412
Groups
1.426 0.238
Within
39.304 136 0.289
Groups
Total 40.540 139
middle aged clients with chronic illness when grouped in terms of religion is
accepted.
grouped in terms of religion.
In the book The World as Will and Representation Vol. 2 by Arthur
Schopenhauer in 2012, he stated that all religions and philosophical systems are
directed principally to the end which he refers as death. Having metaphysical points
62
of view regarding death is a common ground to all religions that could explain why
religion in this study has no impact on the acceptance in death and dying.
Problem5. Is there a significant difference on the level of acceptance in

palliative care of the middle aged clients with chronic illness when grouped in terms
religion?
Hypothesis: There is no significant difference on the level of acceptance in
palliative care of the middle aged clients with chronic illness when grouped in terms
religion.
Chronic Illness in terms of Civil Status
Source of Sum of df Mean F- Significance
Variation Squares Square value
Between 2.826 2 1.413 2.692 0.046
Groups
Within 71.921 137 0.525
Groups
Total 74.747 139
level which is less than the 0.05 level of significance. The null hypothesis that there is
51
no significant difference on the level of acceptance in Palliative care of the middle
aged clients with chronic illness when grouped in terms of civil status is rejected.
This finding means that there was a significant difference on the level of
acceptance in palliative care of the middle aged clients with chronic illness when
grouped in terms of civil status.
This finding is supported by the Committee on Accounting for Socioeconomic Status in
Medicare Payment Programs in 2016 who suggested that being married or partnered is
associated with better health care outcomes, while being single, widowed, or otherwise
unpartnered is associated with worse health care outcomes. Marital or partnership status
is therefore related to health care outcomes, precedes care delivery and is not a
consequence of the quality of care, is not something the provider can manipulate, and
meets practical considerations. As majority of participants are married, they are more
likely to be concerned of their health and are more likely to incline to health care
services such as palliative care.
Chronic Illness in terms of Educational Attainment
Sum of Mean
Source of F- Significanc
Square df Squar
Variation value e
s e
Between
3.873 5 0.775
Groups
1.465 0.206
Within
70.874 134 0.529 52
Groups
Total 74.747 139
there is no significant difference on the level of acceptance in Palliative care of the
middle aged clients with chronic illness when grouped in terms of educational
attainment is accepted.
grouped in terms of educational attainment.
This is rejected by Chambaere et al., who stated that intensified pain and
symptom alleviation and non-treatment decisions are more likely to occur in higher
educated than in lower educated patients. Educational attainment has been shown to
influence access to and quality of health care, however, the results show that while
majority of the respondents reached secondary level of education, they still accept
palliative care given that they are oriented well on the said health care service.
Chronic Illness in terms of Family Structure
Family Mea t-
N SD df Significance
Structure n value
9 0.73
Nuclear 4.679
1 4 13
0.066 0.947 53
4 0.74 8
Extended 4.671
9 0
Table showed the overall computed t – value as 0.066 with 0.947 significant
middle aged clients with chronic illness when grouped in terms of family structure is
accepted.
grouped in terms of family structure.
Family structure holds no bearing in the acceptance of palliative care. This
means that no matter how small or big the family is, they still accept palliative care
and is willing to undergo such health care service.
Chronic Illness in terms of Gender
Mea t-
Gender N SD Df Significance
n value
4 0.74
Male 4.594
2 3 13
-0.865 0.389
9 0.73 8
Female 4.711
8 0
middle aged clients with chronic illness when grouped in terms of gender is accepted.
acceptance in palliative care of the middle aged clients with chronic illness when 54
grouped in terms of gender.
This shows that gender has no effect on the level of acceptance in palliative
care of the middle-aged individuals. Be it male or female, they both recognize the
benefits and the need for palliative care equally.
Chronic Illness in terms of Annual Income
Sum of Mean
Square df Squar
Variation value e
s e
Between
0.853 4 0.213
Groups
0.390 0.816
Within
73.894 135 0.547
Groups
Total 74.747 139
middle aged clients with chronic illness when grouped in terms of annual income is
accepted.
grouped in terms of annual income.
According to Berman, et al., (2014), the financial impact of the illness, which
is influenced by factors such as loss of income and ability of the ill member to return
to work, is one of the major factors in determining the overall impact of illness on the
family. Majority of the participants earn 40,000 and below a year, which is
considered as the lowest annual family income. However, an above average level of
acceptance despite having the lowest income indicates that the respondents are open
55
to the idea of palliative care given that they are well informed of its scope and
benefits.
Chronic Illness in terms of Religion
Sum of Mean
Square df Squar
Variation value e
s e
Between
1.101 3 0.367
Groups
0.678 0.567
Within
73.646 136 0.542
Groups
Total 74.747 139
middle aged clients with chronic illness when grouped in terms of religion is
accepted.
grouped in terms of religion.
This is in contrast to the study of Koenig in 2016, who mentioned that a large
volume of research shows that people who are more religious and spiritual have better
mental health and adapt more quickly to health problems compared to those who are less
religious and spiritual. These possible benefits to mental health and well-being have
physiological consequences that impact physical health, affect the risk of disease, and
influence the response to treatment. However, the level of religiosity and spirituality is
not determined in this study. Every religion has a common ground, which is to improve
the human quality of life. This explains why there is no significant difference on the
level of acceptance in palliative care when grouped in terms of religion.
Problem 6. Is there a significant relationship between the level of acceptance in

Palliative care and death and dying of the middle aged clients with chronic illness?
Hypothesis: There is no significant relationship between the level of acceptance
in Palliative care and death and dying of the middle aged clients with chronic illness.
Relationship between the Level of Acceptance in Palliative Care and Death and
Dying of the Middle Aged Clients with Chronic Illness
Table 15. Relationship between the Level of Acceptance in Palliative Care and
Death and Dying of the Middle Aged Clients with Chronic Illness
Level of Mea Pearson Interpretatio t-
Remarks
Acceptance n - r value n value
Palliative
4.68
Care Moderate Significan
0.53 7.25
Death and Correlation t 63
4.30
Dying
Table showed the overall computed Pearson – r value as 0.53 which is verbally
interpreted as moderate correlation. This means that there was a moderate
relationship between the level of acceptance in palliative care and death and dying of
middle aged clients with chronic illness. Hence, the t – value in testing the
significance relationship showed to have 7.25 which is greater the critical tabular
value of 1.658 at 0.05 level of significance. The null hypothesis that there is no
significant relationship between the level of acceptance in Palliative care and death
and dying of the middle aged clients with chronic illness is rejected.
This implies that there is a moderate correlation between palliative care and
death and dying.
This is supported by Strada, A.E., (2013) who stated that if you are new
to palliative and end-of-life care, you will benefit from unfolding your own belief
system and personal relationship with death and dying.
The ultimate goal of palliative care is to improve quality of life for both the
patient and family, regardless of diagnosis. Although palliative care does not depend on
prognosis, as the end of life approaches, the role of palliative care intensifies and focuses
on aggressive symptom management and psychosocial support. The acceptance in
palliative care is interconnected to the acceptance in death and dying, in a sense that
undertaking palliative care will enhance the understanding on death and dying and an
understanding on death and dying will lead to utilization and compliance to palliative
care.
64
Chapter 4
SUMMARY, FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
This chapter deals with the summary, findings and conclusions as well as the
recommendations which the proponent of this paper find them necessary in relation to
the level of acceptance on palliative care and death and dying of middle aged clients
with chronic illness.
Summary
This study sought to determine the level of acceptance in palliative care and
death and dying of the middle-aged clients with chronic illness. Specifically, it aimed
to answer the following questions:
7. What is the socio-demographic profile of the respondents in terms of civil status,
educational attainment, family structure, gender, annual income, and religion?
8. What is the level of acceptance in Palliative Care of the Middle aged clients with
chronic illness?
9. What is the level of acceptance in Death and Dying of the middle-aged clients with
chronic illness?
10. Is there any significant difference in the level of acceptance in Palliative Care of the
65
middle-aged clients with chronic illness when grouped according to Civil, Status,
11. Is there any significant difference in the level of acceptance in Death and Dying of
12. Is there any significant relationship between the level of acceptance in Palliative Care
and Death and dying of the middle-aged clients with chronic illness?
The study utilized quantitative, descriptive, correlational, exploratory research
design to determine the (a) level of acceptance in palliative care of the middle-aged
clients with chronic illness, (b) level of acceptance in death and dying of the middle-
aged clients with chronic illness, and (c) relationship between level of acceptance in
palliative care and death and dying of the middle-aged clients with chronic illness.
Cluster sampling was used to choose the 140 participants from the different
barangays of General Trias, Cavite. The researcher used a self-made questionnaire for
the assessment on the level of acceptance, and an adapted DAP-R questionnaire for
the level of acceptance in death and dying.
The following statistical treatment was used by the researcher to answer the
specific problems and in testing the hypothesis: Frequency Distribution, percentage
Distribution, Mean, t-test, F-test ANOVA, and Pearson Correlation.
The frequency distribution was used to determine the profile of the

respondents in terms of civil status, educational attainment, family structure, gender, 66
annual income, and religion.
Percentage distribution was used to compare the percentage of the data based
on the results being tallied such as civil status, educational attainment, family
structure, gender, annual income, and religion.
Mean was used to determine the level of acceptance in Palliative Care and the
level of acceptance in Death and Dying of the middle-aged clients with chronic
illnesses in selected barangays of General Trias, Cavite.
T-test was used to find out the significant difference on the level of
acceptance in Palliative Care and the level of acceptance in Death and Dying of the
middle-aged clients with chronic illnesses when they are grouped according to family
structure and gender.
F-test ANOVA was used to determine the significant difference in the level of
acceptance in Palliative Care and the level of acceptance in Death and Dying of the
middle-aged clients with chronic illnesses when they are grouped according to civil,
status, educational attainment, annual income, and religion.
Pearson Correlation was used to measure the strength and direction of

association that exists between the level of acceptance in Palliative Care and the level
of acceptance in Death and Dying of the middle-aged clients with chronic illness in
selected barangays of General Trias, Cavite.
67
Findings
Based on the gathered data, the following findings were drawn:
1. It was found out the socio – demographic profile of the respondents were as follows;
they were married with 68%, at least able to reach secondary education with 40%,
belonging to nuclear type of family with 65%, female with 70%, earning P40,000.00
and below yearly with 45% and they were Catholic in religion with 78%.
2. The overall computed mean of 4.68 which is verbally interpreted as above average
level of acceptance. This means that there was an above average level of acceptance
in palliative care among the respondents.
3. The overall computed mean of 4.30 which is verbally interpreted as average level of
acceptance. This means that the there was an above average level of acceptance in
death and dying among the respondents.
4. The null hypothesis that there is no significant difference on the level of acceptance
in Palliative care of the middle aged clients with chronic illness when grouped in
terms of civil status is rejected as shown in the overall computed F – value as 2.692
with 0.049 significant level which is less than the 0.05 level of significance.
terms of educational attainment is accepted as shown in the overall computed F –
value as 1.465 with 0.206 significant level which is greater than the 0.05 level of
significance.
68
terms of family structure is accepted as shown in the overall computed t – value as

0.066 with 0.947 significant level which is greater than the 0.05 level of significance.
terms of gender is accepted as shown in the overall computed t – value as – 0.865
with 0.389 significant level which is greater than the 0.05 level of significance.
terms of annual income is accepted as shown in the overall computed F – value as
69
terms of religion is accepted as shown in the overall computed F – value as 0.678
in death and dying of the middle aged clients with chronic illness when grouped in
terms of civil status is accepted as shown in the overall computed F – value as 0.583
terms of educational attainment is accepted as shown in the overall computed F –
value as 0.894 with 0.487 significant level which is greater than the 0.05 level of
significance.
terms of family structure is accepted as shown in the overall computed t – value as –
terms of gender is accepted as shown in the overall computed t – value as – 1.265 70
terms of annual income is accepted as shown in the overall computed F – value as
terms of religion is accepted as shown in the overall computed F – value as 1.426
16. The null hypothesis that there is no significant relationship between the level of
acceptance in Palliative care and death and dying of the middle aged clients with
chronic illness is rejected as shown in the overall computed Pearson – r value as 0.53
which is verbally interpreted as moderate correlation. This means that there was a
moderate relationship between the level of acceptance of palliative care and death and
dying of middle aged clients with chronic illness. Hence, the t – value in testing the
significance relationship showed to have 7.25 which is greater the critical tabular
value of 1.658 at 0.05 level of significance.
Conclusions
Based on the findings, the following conclusions were drawn:
1. that the socio – demographic profile of the respondents who were present during the
conduct of this paper were as follows; they were married, with secondary education,
71
they were from nuclear family, female with earnings of P40,000 and below yearly
and they were Catholic in religion;
2. there was an above average level of acceptance in palliative care among the
respondents;
3. there was an above average level of acceptance in death and dying among the
respondents;
4. there was no significant difference on the level of acceptance in Palliative care of the
middle aged clients with chronic illness when grouped in terms of civil educational
attainment, family structure, gender, annual income and religion. However,
significant was obtained when they were grouped in terms of civil status;
5. there was no significant difference on the level of acceptance in death and dying of
the middle aged clients with chronic illness when grouped in terms of civil status,
educational attainment, family structure, gender, annual income and religion, and
6. there was a moderate significant relationship between the level of acceptance in
Palliative care and death and dying of the middle aged clients with chronic illness.
Recommendation
In the light of the findings of the study, the following recommendations are 72
proposed by the researcher:
Respondents. The study found out that there is an above average level of
acceptance in Palliative Care of the middle aged clients with chronic illness. The
researcher recommends for the clients to be concerned about their health status and
reach out to the health care professionals for the options on the appropriate
management of their condition.
Family Members. The researcher recommends the family members to

enhance their commitment in caring for a relative with chronic illness and in
providing them with psychosocial and physical assistance.
Nursing Profession. The researcher recommends the nurses to undergo

trainings and seminars to enhance their knowledge on palliative care and death and
dying in order for them to develop a better understanding and in formulating a more
effective and efficient strategy and patient-centred approach to deliver holistic care to
the middle-aged clients with chronic illnesses.
Future Researcher. The researcher recommends the future researchers to

make further researches on the updates, progression, and implementation of Palliative
care and death and dying.
Government and NGO’s. The researcher recommends the Government and
NGO’s to heighten community and professional awareness on the scope of, and
benefits of timely and appropriate access to palliative care services.
73
APPENDIX
Computations in Detailed
Acceptance of Palliative Care
ANOVA
Palliative
Sum of Squares df Mean Square F Sig.
Between Groups 2.826 2 1.413 2.692 .046
Within Groups 71.921 137 .525
Total 74.747 139
Palliative
Duncana,,b
Subset for alpha = 0.05
Status N 1 2
Single 40 4.5160
Married 95 4.7133 4.7133
Widowed 5 5.2540
Sig. .493 .062
Means for groups in homogeneous subsets are displayed.
a. Uses Harmonic Mean Sample Size = 12.737.
b. The group sizes are unequal. The harmonic mean of the

74
group sizes is used. Type I error levels are not guaranteed.
Palliative
Duncana,,b
Subset for alpha = 0.05
Education N 1 2
Elementary 10 4.2310
Vocational 20 4.6075 4.6075
Secondary 56 4.6366 4.6366
College 47 4.7877 4.7877
NFE 3 5.0767
Masters 4 5.0775
Sig. .173 .265

ANOVA
Palliative
Between Groups .853 4 .213 .390 .816
Total 74.747 139
Palliative
Duncana,,b
Subset for alpha

= 0.05
Income N 1
40,000 and below 63 4.6010
100,000 - 249,999 19 4.6958
60,000 - 99,999 22 4.7218
40,000 - 59,999 27 4.7352
250,000 and above 9 4.8733
Sig. .320

ANOVA
Palliative
Between Groups 1.101 3 .367 .678 .567
Total 74.747 139
Palliative
Duncana,,b
Subset for alpha

= 0.05
Religion N 1
INC 4 4.4550
Christian 22 4.6664
Catholic 110 4.6690
Muslim 4 5.1500
Sig. .104
Means for groups in homogeneous subsets are

displayed.
b. The group sizes are unequal. The harmonic

mean of the group sizes is used. Type I error
levels are not guaranteed.
Group Statistics
Family N Mean Std. Deviation Std. Error Mean
DDying Nuclear 91 4.3003 .55883 .05858
Extended 49 4.3018 .50896 .07271

77
Independent Samples Test
Levene's Test
for Equality
of Variances t-test for Equality of Means
95% Confidence
Interval of the
Difference
Std.
Sig. Mean Error
(2- Differen Differe Lowe
F Sig. t df tailed) ce nce r Upper
DDyin Equal .13 .715 -.016 138 .988 -.00151 .09604 - .1883
g varianc 4 .1914 9
es 1
assume
d
Equal -.016 106. .987 -.00151 .09337 - .1836

varianc 589 .1866 0
es not 1
assume
d
Group Statistics
Gender N Mean Std. Deviation Std. Error Mean
DDying Male 42 4.2129 .53318 .08227
Female 98 4.3386 .54129 .05468

78
Levene's Test
for Equality
95% Confidence
Interval of the
Difference
Std.
Sig. Mean Error
(2- Differen Differe Lowe
F Sig. t Df tailed) ce nce r Upper
DDyin Equal .04 .833 - 138 .208 -.12571 .09939 - .0708

g varianc 5 1.2 .3222 0
es 65 3
assume
d
Equal - 78.72 .207 -.12571 .09878 - .0709

varianc 1.2 7 .3223 2
es not 73 5
assume
d
79
Acceptance of Death and Dying
ANOVA
DDying
81
Between Groups .342 2 .171 .583 .560
Total 40.540 139
DDying
Duncana,,b
Subset for alpha

= 0.05
Status N 1
Single 40 4.2357
Married 95 4.3195
Widowed 5 4.4680
Sig. .312

displayed.
b. The group sizes are unequal. The harmonic

80
ANOVA
DDying
Between Groups 1.309 5 .262 .894 .487

80
Total 40.540 139
DDying
Duncana,,b
Subset for alpha

= 0.05
Education N 1
Vocational 20 4.1675
Masters 4 4.2375
Secondary 56 4.2511
Elementary 10 4.2660
College 47 4.4138
NFE 3 4.5500
Sig. .231

displayed.
b. The group sizes are unequal. The harmonic mean

of the group sizes is used. Type I error levels are 81
not guaranteed.
ANOVA
DDying
Between Groups .409 4 .102 .344 .848
Total 40.540 139

DDying
Duncana,,b
Subset for alpha

= 0.05
Income N 1
100,000 - 249,999 19 4.2263
40,000 and below 63 4.2665
40,000 - 59,999 27 4.3533
250,000 and above 9 4.3544
60,000 - 99,999 22 4.3773
Sig. .456

82
ANOVA
DDying
Between Groups 1.236 3 .412 1.426 .238
Total 40.540 139
DDying
Duncana,,b
Subset for alpha

= 0.05
Religion N 1
Muslim 4 3.8125
INC 4 4.1475
Catholic 110 4.3058
Christian 22 4.3927
Sig. .062

displayed.
b. The group sizes are unequal. The harmonic 83

Group Statistics
Family N Mean Std. Deviation Std. Error Mean
DDying Nuclear 91 4.3003 .55883 .05858
Extended 49 4.3018 .50896 .07271
Levene's Test
for Equality
95%
Confidence
Interval of the
Difference
Std.
Mean Error
Sig. (2- Differen Differen Lowe Upp
F Sig. t df tailed) ce ce r er
DDyin Equal .134 .71 -.016 13 .988 -.00151 .09604 - .188

g variance 5 8 .1914 39
s 1
assumed
Equal -.016 10 .987 -.00151 .09337 - .183

variance 6. .1866 60
s not 58 1
84
assumed 9
Group Statistics
Gender N Mean Std. Deviation Std. Error Mean
DDying Male 42 4.2129 .53318 .08227
Female 98 4.3386 .54129 .05468
Levene's Test
for Equality
95%
Confidence
Interval of the
Difference
Std.
Mean Error
Sig. (2- Differen Differen Lowe Upp
F Sig. t df tailed) ce ce r er
DDyin Equal .045 .83 - 13 .208 -.12571 .09939 - .070

g variance 3 1.26 8 .3222 80
s 5 3
assumed
Equal - 78 .207 -.12571 .09878 - .070

variance 1.27 .7 .3223 92
s not 3 27 5
assumed
85
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93
Strongly Agree Uncertain Disagree Strongly
agree Disagree
I. What do you know about Palliative Care?

1. Before receiving this letter, do you consider yourself as knowledgeable enough on the
concept of Palliative Care?
2. If not, would you want to receive information about Palliative Care?
3. Do you think Palliative care should be offered to people suffering from the following
illnesses?
● Cancer
● Kidney failure
● Motor neuron disease
● Dementia
● Stroke
● Heart Disease
● HIV/AIDS
● Lung disease
● Multiple Sclerosis
● Diabetes
● All Incurable Diseases
II. Perceived Need

1. Although things have changed, I am living a normal life despite having pain/chronic
disease
2. My life is going well even though I have pain/chronic illness
3. I would gladly sacrifice important things in my life to control my pain/disease
4. I will have better control over my life if I can manage my pain/disease
5. Controlling pain or my disease is less important than any other goals in life
1. _____I am getting on with the business of living no matter what my level of pain
is.
2. _____My life is going well, even though I have chronic pain.
3. _____It’s OK to experience pain.
5. _____It’s not necessary for me to control my pain in order to handle my life well.
6. _____Although things have changed, I am living a normal life despite my chronic

pain.
8. _____There are many activities I do when I feel pain.
9. _____I led a full life even though I have chronic pain.
10. _____Controlling pain is less important than any other goals in my life.
12. _____Despite the pain, I am now sticking to a certain course in my life.
15. _____When my pain increases, I can still take care of my responsibilities.
19. _____It’s a relief to realize that I don’t have to change my pain to get on with my
life.
+1 ,
The Level of Acceptance in Palliative Care and Death
and Dying of the Middle-aged Clients with Chronic
Illness
Delos Santos, Arielle Samantha B.

Thesis For Graduation

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LEVEL OF ACCEPTANCE IN DEATH AND DYING AND

PALLIATIVE CARE OF THE MIDDLE AGED CLIENTS WITH CHRONIC

The Faculty of the College of Nursing

University of Perpetual Help System-DALTA, Molino Campus

Molino, Bacoor, Cavite

Of the Requirements for the Degree

Bachelor of Science in Nursing

DELOS SANTOS, ARIELLE SAMANTHA B.

This thesis entitled

MARY GRACE S. PROWEL

Approved by the Committee on Oral Examination Committee with a grade of

JENNIFER O. LEDESMA MARK ANTHONY G. TORIO

Accepted in partial fulfillment of the requirements of the degree of Bachelor of

JENNIFER O. LEDESMA, RN, MAN, for her ideas, suggestions, and

MARK ANTHONY G. TORIO, RRT, DPHEd, MAEd, for his

MR. ELISEO TALLA, for his expertise on statistical treatment of data.

Worldwide, there is a lack of education and knowledge in caring for people in

Programs, 2016). It is concluded that there is a moderate correlation (𝜇 =0.53)

TABLE OF CONTENTS vii

CHAPTER 1: THE PROBLEM AND REVIEW OF RELATED LITERATURE

1. The Variable and their Relationships 19

THE PROBLEM AND RELATED LITERATURE

Having a chronic illness affects people in multiple ways. Many chronic

According to the 2013 reports on the top 10 leading causes of mortality in

Globally, according to the World Health Organization (2014), the great

With improving medical advances and the predicted increase in life

The recent morbidity reports submitted by the different barangays of General

REVIEW OF RELATED LITERATURE

LOCAL LITERATURE AND STUDIES

In the Manual of Palliative Medicine (2005) by Medina, he defined Palliative

As humans have the capacity to conceptualize a future, and along with it an

FOREIGN LITERATURE AND STUDIES

Palliative care is a philosophy of care that provides a combination of disease-

needed, (Brown, 2016).

Chronic Illness is a general term that refers to a diagnosed illness, functional

(Committee on Accounting for Socioeconomic Status in Medicare Payment

In the study of Koenig in 2016, it was mentioned that a large volume of

The purpose of this synthesis is to express the central conclusion of the

Erik H. Erikson is without a doubt one of the most outstanding psychoanalysts

expound on the components that might influence a client’s understanding and

The next theory is Andersen’s Behavioral Model of Health Care Utilization

Death and Dying Palliative Care

The Variable and their Relationships

STATEMENT OF THE PROBLEM

1. What is the socio-demographic profile of the respondents in terms of:

Status, Educational Attainment, Family Structure, Annual Income, and Religion?

HYPOTHESIS OF THE STUDY

The following hypothesis was tested in this study:

1. There is no significant difference in the level of acceptance in Death and Dying

SIGNIFICANCE OF THE STUDY

This study hopes to establish an understanding on the Level of Acceptance in

Government and Non-Government Officials. The results and conclusion of

Future Researchers. The ideas presented may serve as a basis in conducting

SCOPE AND DELIMITATION OF THE STUDY

The following terms have been defined as used in the study:

Gender. This refers to the state of being male and female.

Level of Acceptance. This refers to the middle-aged clients assent to receive

Palliative Care. This refers to a type of care that is focused on early

The research design used was quantitative exploratory, descriptive-

The characteristics of quantitative design center on the why, where, who,

Exploratory studies are those that investigate little-known phenomena for

Descriptive design examines the characteristics of just one sample population.

flexibility in examining a problem from many different angles. Descriptive research