Peaceful Acceptance of Illness Among Older Adults With Advanced Cancer: A Randomized Clinical Trial

Abstract

Context.

Peaceful acceptance of illness is associated with lower psychological distress and increased engagement in advance care planning among adults with advanced cancer. Limited data exist on factors influencing illness acceptance in older adults.

Objectives.

To examine patient, caregiver, and oncologist characteristics associated with peaceful acceptance of illness in older adults with advanced cancer.

Methods.

A secondary analysis of a cluster-randomized trial evaluating the impact of geriatric assessment (GA) on cancer care in community oncology practices (NCT02107443). Participants included 333 patient-caregiver dyads. Patients were aged ≥70 years, had incurable stage III/IV solid tumors or lymphoma, and ≥1 GA impairment. Peaceful acceptance of illness was measured using the 5-item PEACE scale (range 5−20; higher scores indicate greater acceptance). Multivariable linear regression examined associations between PEACE scores and patient (e.g., GA impairments), caregiver (e.g., education), and oncologist factors (e.g., confidence).

Results.

The mean (standard deviation, SD) age was 76.8 (5.4) years for patients and 66.6 (12.1) years for caregivers. Common cancers included lung (27%), gastrointestinal (26%), and genitourinary (16%). Mean (SD) PEACE score was 17.4 (2.5), indicating high illness acceptance. Lower acceptance was associated with psychological impairment (b = −0.92; 95% CI, −1.56 to −0.29), shorter patient-estimated life expectancy (b = −1.06; 95% CI, −2.06 to −0.06), and caregiver education ≤high school (b = 0.90; 95% CI, 0.32−1.49). No oncologist factors were significantly associated.

Conclusion.

Patient psychological health, perceived prognosis, and caregiver education were linked to PEACE. Triadic interventions addressing these factors may enhance end-of-life care for older adults with advanced cancer.

Introduction

Cancer is one of the most prevalent health problems and the second leading cause of death worldwide.¹ Despite advances in early detection and treatment,¹ living with a terminal illness like cancer can have severe and debilitating effects. In particular, individuals with advanced cancer face numerous challenges that significantly affect their psychological and existential well-being.² These patients commonly experience a range of physical symptoms, emotional distress, and complex social dynamics.³ Despite these hardships, many patients strive to maintain a sense of connection, autonomy, and quality of life (QOL).⁴

The realization of a poor prognosis and limited curative treatment options can be profoundly distressing. Learning that one’s illness is incurable, and that time is limited, often triggers intense emotional reactions—fear of death, grief over loss of control, and anxiety about becoming a burden to loved ones. As QOL declines and death becomes imminent, existential concerns frequently intensify.⁴ Some patients may cope by denying the reality of their illness⁵ and suffering alone in silence.⁶ In these situations, caregiver and oncologist interactions become crucial; can significantly influence patients’ QOL and attitudes toward illness. Caregiver interactions are especially integral in shaping patients’ ability to achieve peaceful acceptance, with dyadic factors influencing emotional adaptation and care decisions.^7,8

Peaceful acceptance refers to a patient’s acknowledgment of both the physical and emotional realities of their illness, accompanied by a sense of harmony, while preparing for death.⁵ In the context of cancer, achieving peaceful acceptance can facilitate continued engagement in daily life, enabling patients to “live while dying” rather than being consumed by fear of the future.⁹ Peaceful acceptance has been associated with reduced psychological distress, increased engagement with advance care planning, and a greater focus on comfort over burdensome end-of-life (EOL) care.¹⁰ In contrast, patients who lack acceptance are more likely to pursue aggressive EOL care and experience heightened psychological distress.^2,3

Adults over the age of 65 account for about 70% of all cancer cases.⁴ This group presents unique complexities, as they often face aging-related needs in addition to their cancer. These factors may influence how patients experience and process illness acceptance, distinguishing them from their younger counterparts. Understanding how older adults’ approach to peaceful acceptance is, therefore, essential to EOL care.⁴ In this secondary analysis, we sought to describe peaceful acceptance of illness among older adults with advanced cancer and assess its associations with patient-, caregiver-, and oncologist-related factors.

Methods

Study Design and Population

We conducted a secondary analysis of the “Improving Communication in Older Cancer Patients and Their Caregivers” (COACH) study (University of Rochester Cancer Center [URCC] 13070, clinicaltrials.gov ID: NCT020107443; Principal Investigator: Mohile).⁴ The parent study was a cluster-randomized trial enrolling patients nationwide from the URCC National Cancer Institute (NCI) Community Oncology Research Program (NCORP) network. Patients were enrolled between October 2014 and April 2017 from 31 practice affiliate sites. The primary goal of the parent study was to evaluate the use of geriatric assessment (GA) data in improving communication between patients and their oncologists, as well as patient satisfaction with aging-related concerns. Primary and secondary outcomes have previously been published.⁴ The study was approved by both the University of Rochester Research Subjects Review Board, and all patients provided informed consent at the time of study enrollment.

Eligible patients were ≥70 years old, had incurable stage III/IV cancer, and ≥1 GA domain impairment (other than polypharmacy). Following informed consent, patients completed a baseline assessment including demographic information, a GA, and additional self-administered questionnaires. The parent study included 541 patients and 414 caregivers.

Dependent Variable: Peaceful Acceptance of the Illness

Peaceful acceptance of the illness was measured using the previously developed PEACE scale.⁵ The PEACE scale is a validated measure of illness acceptance, previously shown to be inversely associated with artificial nutrition and hydration use and positively correlated with self-reported peacefulness. It has been further validated across multiple palliative care populations, with recent studies confirming its two-factor structure and demonstrating associations with mindfulness, self-compassion, and body image distress.^11,12 This questionnaire consists of two sub-scales: peaceful acceptance and struggle with illness. For this study, we included only the five questions pertaining to the peaceful acceptance subscale. For each of the five questions, the patient was asked to choose the answer most applicable to their current situation on a scale of 1−4, with 1 meaning “not at all” and 4 meaning “to a large extent.” The sum of the answers to the five questions was calculated and ranged from 5 to 20; a higher PEACE score indicated greater peaceful acceptance of illness.

Independent Variables

Patient Variables.

Patient variables included demographics, clinical and cancer characteristics, and aging-related conditions assessed using the GA. Demographics included age, gender (male or female), race (White, Black, or other), marital status (partnered or single), education level (<high school, college, or postcollege), annual household income (<50k, >50k, or declined to answer), insurance type (Medicare only or Medicare with supplementary), living situation (independent or other), and employment status (employed or unemployed [i.e., not earning money]). Clinical and cancer characteristics included cancer type (breast, gastrointestinal, genitourinary, lung, or other), stage (stage III or IV), treatment (oral, monoclonal, hormonal, or chemotherapy), and patient estimated life expectancy (<1, 1−2, 2−5, or >5 years). Aging-related conditions were collected using a GA that evaluated impairments in comorbidity, functional status, physical performance, cognition, nutrition, medical social support, polypharmacy, and psychological health (using the Geriatric Depression Scale and the Generalized Anxiety Disorder-7 [GAD-7] assessment).⁴ Assessment tools and thresholds for impairments have previously been reported.⁴

Caregiver Variables.

Caregiver variables included demographics and health status. Demographics included age, gender (male or female), race (White, Black, or other), marital status (partnered or single), education level (<high school, college, or postcollege), annual household income (<50k, >50k, or declined to answer), insurance type (Medicare only, Medicare with supplemental, private insurance, or other), relationship to patient (partner, relative, or other), employment status (employed or unemployed [i.e., not earning money]), and living situation (independent or other).⁴ Caregiver health status was assessed using the Older Americans Resources and Services comorbidity questionnaire,⁶ the Distress Thermometer to determine level of distress in the past week (patients answering 4 or more of 0−10 were considered distressed),⁷ the 12-Item Short-Form Health Survey to assess QOL,⁸ the Patient Health Questionnaire-2 to assess depression,⁹ and the GAD-7 assessment.¹⁰

Oncologist Variables.

Oncologist demographics included age, gender (male or female), and race (White or other). We also included the estimated number of patients seen daily, years in practice since finishing oncology fellowship, and confidence in discussing advance directives using, “How confident are you discussing advance directives on a scale of 1−5,” where 1 is “not confident at all” and 5 is “very confident.” Oncologists responding 4 or 5 were considered confident.¹¹

Statistical Analyses

Descriptive analyses were used to summarize this dataset to assess factors that may affect peaceful acceptance of the illness. To quantify the association between patient, caregiver, and oncologist-related factors and peaceful acceptance, t-tests were performed for continuous variables, and chi-squared tests were used on categorical variables. Variables that had a P-value of <0.1 were included in a subsequent linear regression model for peaceful acceptance of the illness. Model fit was assessed using R², adjusted R², residual standard error, and F-statistics. All statistical analyses were performed using R, version 4.2.3.

Results

Patient, Caregiver, and Oncologist Characteristics

For this secondary analysis, we included all patients who had complete data for the variables included in the patient-caregiver-oncologist triad (n = 333; Fig. 1). Patients had a mean (standard deviation, SD) age of 76.8 (5.4) years, and 39% (131/333) were female; 90% (300/333) of patients had stage IV cancer, and 69% (230/333) were receiving chemotherapy. Table 1 shows patient and caregiver characteristics and the prevalence of GA domain impairments.

Fig. 1.

Consort diagram for coach peace.

Table 1.

Patient and Caregiver Characteristics

Variable		Patient (n = 333)	Caregiver (n = 333)
Age, mean (SD)		76.8 (5.4)	66.6 (12.1)
Gender, N (%)	Male	202 (60.7)	75 (22.5)
	Female	131 (39.3)	258 (77.5)
Race, N (%)	White	307 (92.2)	306 (91.9)
	Black	19 (5.7)	18 (5.4)
	Other	7 (2.1)	9 (2.7)
Marital status, N (%)	Partnered	246 (73.9)	273 (82.0)
	Single	87 (26.1)	60 (18.0)
Education level, N (%)	≤High school	154 (46.2)	120 (36.0)
	College	131 (39.3)	167 (50.2)
	Postcollege	48 (14.4)	46 (13.8)
Annual income, N (%)	≤50k	156 (46.8)	125 (37.5)
	>50k	117 (35.1)	146 (43.8)
	Declined to answer	60 (18.0)	62 (18.6)
Living situation, N (%)	Independent	319 (95.8)	327 (98.2)
	Other	14 (4.2)	6 (1.8)
Employment status, N (%)	Employed	15 (4.5)	82 (24.6)
	Unemployed	318 (95.5)	251 (75.4)
Insurance type, N (%)	Medicare only	65 (19.5)	49 (14.7)
	Medicare with Supplementary	268 (80.5)	174 (52.3)
	Private insurance	-	79 (23.7)
	Other	-	31 (9.3)
Cancer type, N (%)	Breast	31 (9.3)
	Gastrointestinal	86 (25.8)
	Genitourinary	54 (16.2)
	Lung	89 (26.7)
	Other	73 (21.9)
Cancer stage, N (%)	IV	300 (90.1)
	III	33 (9.9)
Oral treatment, N (%)	No	273 (82.0)
	Yes	60 (18.0)
Monoclonal treatment, N (%)	No	249 (74.8)
	Yes	84 (25.2)
Hormonal treatment, N (%)	No	280 (84.1)
	Yes	53 (15.9)
Chemotherapy, N (%)	No	103 (30.9)
	Yes	230 (69.1)
Impaired comorbidity, N (%)	No	123 (36.9)	204 (61.3)
	Yes	210 (63.1)	129 (38.7)
Impaired functional status, N (%)	No	132 (39.6)	-
	Yes	201 (60.4)
Impaired physical performance, N (%)	No	21 (6.3)	-
	Yes	312 (93.7)
Impaired cognition, N (%)	No	218 (65.5)	-
	Yes	115 (34.5)
Impaired nutrition, N (%)	No	125 (37.5)	-
	Yes	208 (62.5)
Impaired social support, N (%)	No	263 (79.0)	-
	Yes	70 (21.0)
Impaired polypharmacy, N (%)	No	50 (15.0)	-
	Yes	283 (85.0)
Impaired psychology, N (%)	No	245 (73.6)	-
	Yes	88 (26.4)
Patient life expectancy, N (%)	<1 yr	32 (9.6)
	1−2 yrs	70 (21.0)
	2−5 yrs	100 (30.0)
	>5 yrs	131 (39.3)
Relationship to patient, N (%)	Partner		227 (68.2)
	Relative		81 (24.3)
	Other		25 (7.5)
Caregiver distress, N (%)	No		193 (58.0)
	Yes		140 (42.0)
SF-12 total score, mean (SD)			98.4 (14.1)
Caregiver total GAD-7, mean (SD)			2.91 (4.21)
Total caregiver PHQ-2 score, mean (SD)			0.59 (1.11)

ABBREVIATIONS: GAD-7 = Generalized Anxiety Disorder-7; PHQ-2 = Patient Health Questionnaire-2; SF-12 = Short Form Health Survey.

The mean (SD) age of caregivers was 66.6 (12.1) years. Of the total, 78% (258/333) were female, 68% (227/333) were the patient’s partner, 75% (251/333) were unemployed, and 64% (213/333) had a college or postcollege degree (Table 1). Oncologists had a mean (SD) age of 47.3 (10.2) years. On average, they reported seeing 17.5 (6.0) patients in a day. A total of 82% (91/111) of oncologists surveyed stated that they were confident in discussing advance directives (Table 2).

Table 2.

Oncologist Characteristics

Variables	Empty Cell	Oncologists (n = 111)
Patients seen daily, mean (SD)		17.5 (6.0)
Years in practice, mean (SD)		13.2 (10.1)
Confidence in discussing advance directives, N (%)	No	20 (18.0)
	Yes	91 (82.0)
Age, mean (SD)		47.3 (10.2)
Gender, N (%)	Male	74 (66.7)
	Female	37 (33.3)
Race, N (%)	White	74 (66.7)
	Other	37 (33.3)

Patient’s Peaceful Acceptance of the Illness

The mean (SD) patient PEACE score was 17.4 (2.5). Fig. 2 presents the distribution of patient PEACE scores across the five items. Approximately 71% (236/333) of patients accepted their cancer diagnosis, 45% (150/333) had an inner sense of peace and harmony, 48% (159/333) made peace with their diagnosis, and 90% (300/333) felt well-loved. Additionally, 43% (143/333) of patients felt a sense of inner calm and tranquility.

Fig. 2.

Patient responses to the items on the PEACE questionnaire (Peace, Equanimity, and Acceptance in the Cancer Experience).

Factors Associated With Peaceful Acceptance of the Illness

Patient and caregiver variables in the final regression model included patient psychological impairment, patient life expectancy, and caregiver education level (Table 3). The final linear regression model demonstrated moderate fit and generalizability, explaining 18% of the variance in PEACE scores (adjusted R² = 0.114, residual standard error = 2.32 on 307 degrees of freedom, f-statistic P < 0.0001). Regression analyses demonstrated that patients’ psychological impairment (not impaired vs. impaired, b = −0.93; 95% CI −1.56 to −0.29), lower estimated life expectancy (>5 vs. <1 year, b = −1.06; 95% CI −2.06 to −0.06), and lower caregiver educational attainment (≤high school vs. college, b = 0.90; 95% CI 0.32−1.49) were associated with lower peaceful acceptance of illness. No oncologist-related factors yielded statistically significant associations with PEACE.

Table 3.

Multivariate Linear Regression Analysis Evaluating Factors Associated With Peaceful Acceptance of Illness

Variable		b-Estimate	95%CI	P-value
Patient education level	<High school	Reference
	College	−0.24	−0.84 to 0.35	0.42
	Postcollege	0.53	−0.34 to 1.40	0.24
Patient cancer type	Breast	Reference
	Gastrointestinal	−0.17	−1.31 to 0.98	0.78
	Genitourinary	−0.43	−1.51 to 0.64	0.43
	Lung	−0.56	−1.70 to 0.57	0.33
	Other	−0.11	−1.23 to 1.02	0.85
Patient cancer stage	Stage 3	Reference
	Stage 4	−0.40	−1.26 to 0.47	0.37
	Other	−1.88	−3.75 to −0.01	0.05
Patient hormonal treatment	No	Reference		-
	Yes	0.43	−0.62 to 1.48	0.42
Patient chemotherapy	No	Reference		-
	Yes	−0.19	−0.82 to 0.45	0.56
Patient impaired comorbidity	No	Reference		-
	Yes	−0.17	−0.72 to 0.39	0.56
Patient impaired function	No	Reference		-
	Yes	0.13	−0.44 to 0.71	0.65
Patient impaired	No	Reference		-
polypharmacy	Yes	−0.61	−1.34 to 0.13	0.11
Patient impaired psychology	No	Reference		-
	Yes	−0.93	−1.56 to −0.29	<0.01
Patient life expectancy	<1 yr	−1.06	−2.06 to −0.06	0.04
	1–2 yrs	−0.48	−1.22 to 0.25	0.20
	2–5 yrs	−0.32	−0.95 to 0.32	0.32
	>5 yrs	Reference		-
Caregiver education level	≤High school	Reference		-
	College	0.90	0.32–1.49	<0.01
	Postcollege	0.59	−0.30 to 1.48	0.19
Caregiver impaired comorbidity	No	Reference		-
	Yes	−0.03	−0.63 to 0.56	0.91
Caregiver distress	No	Reference		-
	Yes	0.18	−0.42 to 0.78	0.55
Caregiver total SF-12 (higher = more QOL)		0.01	−0.02 to 0.04	0.49
Caregiver total GAD-7 (higher = more anxiety)		−0.09	−0.18 to 0.01	0.09
Caregiver total PHQ-2 (higher = more depression)		0.12	−0.25 to 0.49	0.53
Oncologist Confidence in Discussing Advance Directives	No	Reference		-
	Yes	−0.36	−1.07 to 0.34	0.31

ABBREVIATIONS: GAD-7 = Generalized Anxiety Disorder-7; PHQ-2 = Patient Health Questionnaire-2; SF-12 = Short Form Health Survey.

Discussion

In this secondary analysis, we investigated patient-, caregiver-, and oncologist-related factors associated with peaceful acceptance of the illness among older patients with advanced cancer. We demonstrated that three key factors were significantly associated with lower peaceful acceptance: greater psychological impairment in patients, shorter patient estimated life expectancy, and lower caregiver educational attainment. We did not detect any association between oncologist-related factors and peaceful acceptance.

Peaceful acceptance of illness, distinct from awareness or cognitive understanding of prognosis, is a vital yet under-recognized component of high-quality, person-centered EOL care.^6,13 Unlike prognostic awareness and understanding, peaceful acceptance reflects an emotional and existential readiness to face the incurability of illness and the imminence of death.^2,3 This distinction has profound implications for how patients engage in advance care planning, communicate their preferences, and cope with the psychological burden of terminal illness.^14–17 Although emerging research indicates that peaceful acceptance is linked to lower distress, improved QOL, greater use of palliative care, and reduced burdensome EOL interventions, it remains understudied, particularly in older adults with advanced cancer.^14,18 Furthermore, most studies overlook the critical roles caregivers and oncologists play in shaping patients’ illness acceptance. Our study addresses this gap by exploring peaceful acceptance through a holistic lens, recognizing its potential to alleviate suffering, foster goal-concordant care, and better prepare patients and families for the realities of serious illness.

Psychological health emerged as a key determinant of peaceful acceptance. Patients with greater psychological impairment reported significantly lower PEACE scores, reinforcing the importance of psychological and emotional health in EOL preparation. This finding is consistent with a growing body of literature emphasizing the interconnection between psychological distress and illness acceptance among patients with advanced cancer. For instance, Chochinov et al.¹⁵ introduced the concept of dignity therapy and demonstrated that depression, hopelessness, and loss of meaning significantly undermined patients’ ability to accept their terminal condition and maintain a sense of dignity at the end of life, which parallels barriers to peaceful acceptance. Similarly, Prigerson et al.¹⁴ found that psychological factors such as depression, anxiety, and lack of emotional preparedness were associated with poorer quality of EOL and increased desire for hastened death among terminally ill patients, indicating how emotional distress can obstruct peaceful adaptation to prognosis. The relationship between psychological distress and illness acceptance is likely bidirectional: distress undermines acceptance, while low acceptance exacerbates distress. This dynamic process warrants longitudinal investigation.¹⁹

Studies have shown that patients who exhibit greater emotional and existential acceptance of their condition are more likely to engage in advance care planning, choose comfort-focused treatments, and report higher QOL. For example, Maciejewski et al. found that terminally ill patients who achieved emotional acceptance of their illness experienced less psychological suffering and were less likely to receive aggressive medical care at EOL, demonstrating that peaceful acceptance serves as a protective psychological factor. Their work also distinguished emotional acceptance from mere cognitive awareness of prognosis, underscoring the deeper emotional readiness required for adaptive EOL experiences.²⁰ In a longitudinal study, Philipp et al.²¹ similarly found that higher levels of death acceptance among patients with cancer were associated with lower existential distress and anxiety over time, further emphasizing that acceptance is a dynamic process crucial to emotional adaptation to terminal illness.

Collectively, these findings support the notion that peaceful acceptance is not merely a cognitive recognition of prognosis but a deeper emotional state influenced by psychological resilience, spiritual well-being, and supportive care. Hence, addressing psychological health—particularly targeting symptoms of depression, anxiety, and existential distress—may be a critical focus for interventions seeking to promote more peaceful, patient-centered EOL experiences.^14,15

Shorter estimated life expectancy was also significantly associated with reduced peaceful acceptance. This association may reflect the inherent emotional challenge patients face, especially when robust coping mechanisms or psychological support are lacking. While prior studies demonstrated the role of psychological distress in undermining acceptance, the emotional burden of confronting a limited prognosis adds another layer of complexity, often manifesting as heightened anxiety, denial, or avoidance behaviors.^7,13,14,17 Wright et al.¹⁸ showed that patients with limited life expectancy who lack acceptance or emotional preparedness were significantly more likely to receive intensive care, in their final days, rather than hospice or palliative interventions. The timing and manner in which prognostic information is communicated may further influence these outcomes. Mack et al. found that patients who experienced more compassionate, clear, and timely communication about their prognosis were more likely to engage in advance care planning and express preferences for comfort care. In contrast, patients who were psychologically overwhelmed or in denial were less likely to have these conversations and more likely to pursue aggressive treatments inconsistent with their values.¹³

These findings suggest that emotional readiness, not merely cognitive awareness, plays a crucial role in shaping treatment decisions near EOL. Consequently, interventions aimed at fostering early emotional adaptation, especially among those with shorter life expectancies, might be critical. Temel et al.²² found that early palliative care led to improved QOL, lower rates of depression, and less aggressive care at EOL, in part by helping patients process and accept their prognosis. Philipp et al. further emphasized that emotional readiness, shaped by psychological and existential factors, was more predictive of peaceful EOL experiences than clinical prognosis indicators alone. Together, these findings underscore the importance of timely, empathetic communication and comprehensive supportive services—including palliative care, psychosocial counseling, and spiritual care. By promoting emotional readiness and reducing psychological distress, such interventions may enhance QOL, foster peaceful acceptance, and reduce the likelihood of burdensome, goal-incongruent care near death.²¹ Interventions such as dignity therapy, meaning-centered psychotherapy, and early palliative care may foster emotional readiness, reduce psychological distress, and promote peaceful acceptance, particularly among those with impaired psychological health or uncertain prognosis.^15,22 Compared with younger cancer patients, older adults may rely more on life experience, spirituality, and caregiver support.²³ Prior studies in general cancer populations link acceptance with lower distress and less aggressive EOL care. In noncancer older adults, acceptance is shaped more by frailty and comorbidity, whereas prognosis and psychological health are central in cancer.²⁴

Caregiver educational attainment emerged as another significant factor in patient illness acceptance. Patients with caregivers who had some college education or more had higher PEACE scores compared to those whose caregivers had a high school education or less. This finding may reflect higher health literacy among more educated caregivers, facilitating more informed, supportive communication and advocacy. Older adults often rely on their caregivers for information, decision-making, and emotional support^25,26; thus, caregiver preparedness may shape both patient understanding and acceptance of illness. Our findings contribute new evidence to a small but growing body of research suggesting that caregiver characteristics— such as preparedness, communication skills, and emotional acceptance—can directly influence patient well-being. Prior work by Dionne-Odom et al.²⁷ and Waldrop et al.²⁸ has shown that caregiver distress and uncertainty can hinder effective decision-making and influence patient preferences for care. However, the specific association between caregiver education and illness acceptance has not previously been reported, making our findings a novel contribution to the literature. Lower caregiver educational attainment may reflect reduced health literacy rather than diminished preparedness or emotional acceptance. Prior work shows caregiver health literacy and distress influence patient outcomes.^27,28 Our findings highlight caregiver education as a signal that caregiver-focused interventions may be needed. Our findings underscore the dyadic nature of acceptance, suggesting that interventions should simultaneously address patient and caregiver needs to enhance emotional adaptation and EOL preparedness.

Beyond caregiver influences, we also examined oncologist-related factors. We did not find any oncologist-related factors associated with patient acceptance. Although previous studies, including those by Tulsky et al.²⁹ and Epstein et al.,³⁰ emphasized the importance of high-quality communication in shaping patient outcomes, our findings suggest that oncologist characteristics alone may not be sufficient to influence illness acceptance. Although no oncologist-related factors were associated with acceptance, reporting these null results is important. Demographic and workload measures may be insufficient proxies for communication quality, highlighting the need for future studies incorporating structured communication training (e. g., Vital Talk, Serious Illness Guide). Instead, it may be the content, style, and emotional responsiveness of prognostic communication that play a more decisive role. Further research is needed to explore how oncologist behavior and communication styles affect acceptance, especially in the context of multidisciplinary care.

Our findings support the development of multifaceted, multidisciplinary interventions targeting both patient and caregiver domains. Key strategies may include 1) psychological support interventions that provide mental health resources to reduce distress and promote emotional well-being in the context of serious illness; 2) training programs to enhance prognostic communication skills among clinicians, delivered in a supportive, person-centered manner; and 3) caregiver-focused interventions to foster health literacy and emotional preparedness. These interventions can empower both patients and caregivers, fostering greater illness acceptance, improving emotional outcomes, and promoting care that is more closely aligned with patients’ values and preferences. Based on our findings, interventions should prioritize psychological health and caregiver support. Although oncologist factors were not significant in this dataset, future studies should examine whether structured communication training influences acceptance.

Strengths and Limitations

Our study has strengths. We included a large cohort of older adults with advanced cancer, their caregivers, and their oncologists, who were recruited from community oncology practices. Older adults with advanced cancer are infrequently included in cancer trials. Several limitations should be noted. First, this was a cross-sectional analysis, and therefore, we cannot determine causality. Second, excluding approximately 20% of patients with incomplete data may have introduced selection bias. In addition, women represented only 39% of our sample, which may limit generalizability given that women constitute the majority of the older adult population. The high mean PEACE score suggests possible ceiling or social desirability effects. However, meaningful variance remained, allowing detection of significant associations. Third, our sample included predominantly White individuals, and our findings may not be generalizable to patients of other races. Fourth, we did not assess how communication with oncologists related to patient acceptance of illness. Similarly, we did not assess how caregiver acceptance of patients’ illnesses was associated with patients coming to terms with their illnesses. Both have been shown to be significant factors in patients’ attitudes toward the illness and achieving peaceful acceptance of both incurability and the imminence of death. Fifth, we did not assess spirituality, a potential variable associated with illness acceptance. Prior studies have shown that spirituality has a significant influence on decision-making and EOL care and is associated with reduced psychological distress.¹² Similarly, exposure to palliative care or psychosocial counseling was not captured in the parent study, which may have influenced patients’ psychological well-being, coping, and level of acceptance. While we could not assess whether exposure to palliative or psychosocial services influenced acceptance, it should be addressed in future studies. Moreover, although the data were collected between 2014 and 2017, the existential and psychological processes influencing illness acceptance are unlikely to have changed substantially over time. Importantly, this remains one of the few large datasets focused specifically on older adults with advanced cancer.

Conclusions

Peaceful acceptance of illness in older adults with advanced cancer is shaped by a number of factors. Lower psychological functioning, limited life expectancy, and lower caregiver educational attainment were all associated with decreased acceptance. While oncologist characteristics were not directly linked to acceptance, the broader triad of patient-caregiver-oncologist interactions remains essential in shaping EOL experiences. Understanding these dynamics is paramount for developing targeted, whole-person interventions.

Supplementary Material

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpainsymman.2025.10.007.

Key Message.

Psychological health, patient life expectancy, and caregiver education may influence illness acceptance, highlighting the need for targeted, triadic approaches to end-of-life care.