Spirituality in older men living alone near the end-of-life.

Older people living alone has been reported to be socially isolated and suffering from loneliness. Although spiritual care is a core element of end-of-life care for older people, a clear-cut definition of spirituality has not been established yet. It remains unclear how spirituality is perceived by heath care professionals and how spiritual care is delivered in the end of life. Also, most of the previous studies on perspective of older people living alone targeted women, while very few researches shed light on the experience of older men. The aim of the present study was to investigate the spirituality of older men living alone near the end-of-life. We conducted group interviews targeting 30 care managers and individual in-depth interviews to 15 older men living alone. Qualitative content analysis was used. Five main themes emerged: worthlessness and hopelessness, autonomy and independence, comfort and gratitude, past experiences, and well-being indicator. Our findings provide important additional information that can help clinicians, nurses and care managers achieve better patient-centered care for older men living alone and enhance their dignity. Our investigation found that Japanese older men living alone were enjoying their autonomous status and freedom, despite wide spread negative views of them. Their spiritual health was found to be enhanced through gratitude to everyone with whom they had crossed paths in their life, yearning for the presence of a female companion, and confirming their health measurements were comparative or better than those of others in the same age group.

INTRODUCTION

The normal process of ageing involves physical, psychological, and social changes, all of which may influence the quality of life of older people.[1] End-of-life care for older people involves treating the whole person rather than simply catering to their physical needs.[2] Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain, and can help him or her heal emotionally as well as physically, and regain hope and meaning in life.[3,4] Although spiritual care is a core element of end-of-life care for older people,[2,5] a clear-cut definition of spirituality has not been established yet. It remains unclear how spirituality is perceived by heath care professionals and how spiritual care is delivered in the end of life.

The number of older people living alone has increased significantly in recent decades in Japan. In 1980, the Japanese population aged 65 years or older living alone accounted for 4.3% (193,000) for men and 11.2% (688,000) for women. In 2010, this rate climbed to 11.6% (1,456,000) for men and 20.8% (3,523,000) for women (Japanese Ministry of Health, Labour, and Welfare, 2013).[6] And by 2030, this rate is expected to rise up to 15.4% (2,433,000) for men and 23.1% (4,865,000) for women (National Institute of Population and Social Security Research, 2013).[7]

Older people living alone has been reported to be socially isolated and suffering from loneliness. Social relationships are central to human well-being and are critically involved in maintaining health. Socially isolated older people are thus at increased risk of severe diseases and deaths. There are several reasons why social isolation and morbidity and mortality are closely related. First, some older people who live alone often do not prepare full, balanced meals, and are lead to malnutrition, because meal preparation and eating habits are affected by social environment.[8] Second, older people with cognitive impairment may not notice new or worsening symptoms by themselves. Third, many older people who live alone have difficulty following directions for prescribed treatments.[9]

Until recently, older age groups were dominated by women, many of whom lived alone as widows.[10] However, due to men’s prolonged life expectancy and increased number of men who never married, more men are now living alone. There is a growing interest in the health of older men and in helping them continue to live independently in the community. A number of studies suggested that older men were more likely to be susceptible to social loneliness and death due to their inaptitude for self-support and care.[10-13]

Most of the previous studies on perspectives of older people living alone have targeted women,[10] but very little research shed light on the experience of older men living alone. The aim of the present study was to investigate the spirituality of older men living alone near the end-of-life, considering regional characteristics and differences in perceptions between the older men themselves and their care providers.

METHODS

The study was designed using qualitative research strategies with an emphasis on daily experiences and end-of-life. We conducted group interviews targeting care managers from April to July 2016 and individual in-depth interviews to older men living alone from August to December 2016 in order to conduct data triangulation.

Data collection

Study site. The study was conducted in the suburban areas of the following prefectures in Japan: Miyagi, Akita, Kanagawa, Gifu, Aichi, Mie, Hyogo, Tokushima, and Fukuoka. The prefectures were purposively selected in consideration of geographic distribution and regional differences in social capital. Social capital refers to direct and indirect resources of social networks and social support systems amongst family, friends or community members, and public support mechanisms. We chose suburban areas as study setting because they represent the average social capital level in each prefecture.

Group interviews to care managers. We interviewed care managers, who have a deep understanding of what is going on in the lives of the people living and working in the community. Care managers are a group of professionals responsible for drawing up care plans and coordinating long-term care services for individual clients under Japan’s long-term care insurance system. The Care Manager Certificate is awarded to licensed health or welfare professionals, e.g., nurses, social workers, etc., and professional caregivers, who have successfully passed an examination and completed prescribed on-the-job training. Care managers play a vital role in assessing their clients’ needs, creating care plans and monitoring their condition from the early stages of frailty; they can potentially contribute to enhancing the quality of life of older men in the community.

We purposively recruited 30 care managers (7 men and 23 women) from a list of care managers of different establishments. Each one group interview was conducted in each selected prefecture (Miyagi, Akita, Kanagawa, Aichi, Tokushima, and Fukuoka). Each group consisted of three to seven participants. The group interviews took place in meeting rooms in the prefectures where the care managers work, or through an electronic conference system.

We used an open-ended questionnaire, designed to capture the full scope of the work involved in caring for older men living alone from the perspective of care managers. The questionnaire focused on the daily routine, including contact with friends and family, meal preparation, exercise, interests and hobbies, and end-of-life wishes of their patients, such as a pre-established advance care planning form. The participants were encouraged to discuss the various responses obtained in detail during the group interviews. Interviews were carried out by the first author, a geriatrician with ample qualitative research experience. The individual interviews lasted about 60 minutes. The interview data were processed and recorded on a pre-established advance care planning form.

Individual in-depth interviews to older men living alone. We targeted older men living alone in their own home, having the ability to provide competent consent, and not suffering from serious mental disorders. The care managers participated in the group interviews were asked to enroll older clients willing to be interviewed, considering the diversity of participant characteristics (including age, housing, physical condition, and life history) and reasons for living alone. The care managers explained the purpose of the study, the inclusion criteria, and the confidential nature of the project to their clients. The final sample of participants consisted of 15 men ranging from 77 to 96 years of age (Table 1). We prepared an interview guide, based on the preliminary findings of the group interviews of care managers and Five Wishes, a popular American advance care planning document for adults.[14] The interviews were carried out at each participant’s home by the first author and a number of research assistants who had previous experience of in-depth interviews. Visiting their home, we also observed their living conditions.

Table 1

Characteristics of in-depth interview participants

(older men living alone) (n=15)

Variable	M±SD	n
Age	85.5±6.1
Prefecture
Akita		2
Gifu		2
Aichi		3
Mie		2
Hyogo		2
Tokushima		2
Fukuoka		2
Marital status
Separated/divorced		1
Never married		2
Widowed		12
Financial status
Wealthy		6
Borderline		8
Poor		1
Family relationship
Healthy		11
Estranged		4
Length of living alone (year)
Less than 1		2
1–4		5
5–10		5
11–15		1
More than 15		2
Living condition
Home ownership		12
Apartment for rent		3
Personal support
Family caregiver		10
Formal home care use		12
Mild dementia		2
Physical and functional evaluation
Independence		8
House-bound		2
Chair-bound		4
Bed-bound		1
Hospitalization experience		6

Data analysis

All interviews were audio-recorded, and then transcribed word for word. The written text data of the transcription and the field notes were analyzed. Qualitative content analysis was used to systematically identify ideas and patterns emerging from the qualitative data on older men’s daily experiences and end-of-life wishes collected during the interviews.[15] The process began with several readings of all the transcriptions and the field notes to familiarize the authors with the overall content of the data. The data collected from the group interviews of care managers and individual interviews of older men were merged, proofread and finally arranged into meaning units in order to identify emerging topics. Subsequently, meaning units were grouped into common meaning groups in order to identify larger themes emerging from them. Some themes were included if they captured a significant aspect of the participants’ experiences, even though they were not supported by data from all the study participants.

Trustworthiness

We contacted care managers participated in the group interviews and/or in introduced older men who participated interviews after the transcription of the interviews to validate the transcription and analysis. All of them acknowledged the transcriptions and made no further comments. At each stage of the process, the findings were discussed with the other authors and the care managers to make sure they were interpreted accurately. In case of differing opinions, theme identification was decided by consensus.

Ethical consideration

This study was approved by the Bioethics Review Committee of Nagoya University School of Medicine prior to the investigation (approval number 2015-0444). Written and verbal informed consents were obtained from the care managers and their older male clients. Interviews of older men were conducted privately, and participants’ transcripts were anonymized.

RESULTS

Five main themes were identified: Worthlessness and hopelessness, Autonomy and independence, Comfort and gratitude, Past experiences, and Well-being indicator. The findings representing themes and subthemes are presented in Table 2 and Figure 1.

Table 2

Themes, subthemes and representative meaning units of living alone for older men

Themes	Subthemes	Representative meaning units
Worthlessness and hopelessness	Loneliness and Isolation	I feel like there is no one in this world who understands me
		I am usually reluctant to socialize
	No excitement in life	I am tired of living an ordinary life
		I get lost in the monotone routine of everyday life
Autonomy and independence	Refusal to accept support	I do not want to bother anybody
		It is too much to ask for more
	Strive for independence	I include tiny daily healthy habits into my daily routine
		I want to enjoy an active life till the very last day of my life
	Autonomy crisis	My life is completely out of control
		I want to die and escape from being bed-bound at home
Comfort and gratitude	Desire for family-like love	Older men living alone look for family-like relationships with health care professionals
		Older men living alone think that their pets are part of the family
	Admiration for the opposite sex	I am constantly thinking about my late wife
		I am happy to be with a lady friend
	Gratitude for chances to meet people	I appreciate my parents and ancestors who made me what I am today.
		I owe my success to everyone around me.
Past experiences	Unwanted memory	I regret not having healthy family relationships
		It is difficult to start a conversation when older men living alone don’t want to talk about the past
	Past glory	Older men living alone miss the days when they had something to brag about
		I would let older men living alone talk about their glory days if they had problems
Well-being indicator	Health status indicator	Negative lab test results are always effective in reassuring me
		I am happy to live longer than the average man
	Economic affluence	I cannot live a rich life for want of money
		I am happy about my pension

Fig. 1

Factors contributing to spirituality in older men living alone near the end-of-life

Worthlessness and hopelessness

Loneliness and isolation. Due to deteriorated eyesight, hearing loss, lower physical activities and subsequent decline in social activities, older men living alone tend to feel despair and hopeless in daily life. Some of the participants lived in isolation without maintaining any ties with relatives or friends. People around them would probably not notice, even if they developed dementia at some point and required support.

“Older men living alone often show great reluctance to attend community meetings, or to visit day service centers or other places where people come together.” (care manager, 43 years old, woman, Aichi)

“Some older men living alone seem to have been abandoned by their family.” (care manager, 32 years old, woman, Fukuoka)

“My daughter really loves her children, so it looks like she does not have the time to worry about me.” (older man, 82 years old, widowed, Aichi)

“I ask people around me not to contact my grandchildren even if something happens to me.” (older man, 82 years old, widowed, Hyogo)

No excitement in life. The daily lives of older men living alone are usually irregular and monotonous. Some older men resorted to buying boxed lunches at a convenience store instead of preparing meals. Others woke up at odd hours and had irregular daily schedules.

“Convenience stores offer a wide variety of prepared meals that meet the nutritional needs of older men.” (care manager, 49 years old, woman, Kanagawa)

“We would like to provide the type of care and conversation that allows older men to stay connected with natural environment and enjoy the seasonal changes.” (care manager, 43 years old, woman, Aichi)

“I don’t think about the future; I just want take it easy every day.” (older man, 95 years old, widowed, Mie)

“I don’t have any distractions; I do nothing but eat and sleep.” (older man, 78 years old, widowed, Akita)

Autonomy and independence

Refusal to accept support. Some older men living alone refused support from anyone. They thought that accepting help would be taken as a sign of weakness on their part due to aging or illness and refuse to be cared for by someone else. Some older men living alone hesitated to talk with their family about their own end-of-life and postmortem.

Also, a number of older men clung obstinately to their lifestyle, no matter how poor or unhealthy. However, some older people living alone were able to make time for themselves; they made a conscious choice to do only what they would like to do. Therefore, they often felt that they were happier than ever.

“Some older men living alone refuse to receive care services until they are forced to be hospitalized due to a serious illness.” (care manager, 44 years old, man, Akita)

“We are worried about the health condition of some older men living alone who would like to use supplements or over-the-counter medicines in addition to their prescriptions without consulting their physicians.” (care manager, 35 years old, woman, Miyagi)

“Because my children live their own lives, I cannot ask them to care for me. My only option is to ask the ward office to place me in a nursing home.” (older man, 77 years old, widowed, Tokushima)

“Although my children often suggest ways to improve my daily life, I do not want to make any changes on my current lifestyle.” (older man, 82years old, man, widowed, Fukuoka)

“Although my doctor recommends that I should quit smoking, I don’t want to give it up because it is my only hobby and purpose in life.” (older man, 82 years old, widowed, Hyogo)

Strive for independence. Older people generally want to live independently and comfortably to the very end of their life and strived to do so. Some participants reported maintaining healthy lifestyle to prevent from being bed-ridden.

“Some older men living alone are reluctant to show any signs of weakness resulting from end-of-life conditions to their daughters.” (care manager, 42 years old, woman, Aichi)

“I stay in shape with an original exercise program that I developed based on my research.” (older man, 86 years old, widowed, Tokushima)

“Because I am worried about memory loss, I feel I have to stimulate my brain with quizzes, personal computer, walking, and so on.” (older man, 93 years old, never married, Gifu)

Autonomy crisis. Older men living alone were worried about losing their autonomy at the end of life and not being able to partake in the decision-making process with regard to admission to nursing home and life-prolonging treatment. For instance, some people agreed to be admitted to a nursing home to satisfy their family’ wishes. Some care managers wondered how to support the decision-making process of older men living alone.

“Older men living alone frequently revise their will and treatment plan.” (care manager, 42 years old, woman,

Aichi)

“Emergency hospital admission is complicated for older men living alone with no relatives to respond for them.” (care manager, 41 years old, woman, Akita)

“I am familiar with the Act of Adult Guardianship in Japan, but I don’t feel at ease because it does not cover essential end-of-life care issues.” (older man, 82 years old, widowed, Hyogo)

“After looking at bed-ridden older people in a nursing home, I was convinced not to accept life-sustaining treatments such as tube-feeding.” (older man, 83 years old, widowed, Fukuoka)

“I have asked my daughter not to initiate tube-feeding in case I cannot eat anymore at end-of-life.” (older man, 77 years old, widowed, Tokushima)

Comfort and gratitude

Desire for family-like love. Some older men living alone yearned for their physicians, nurses or care managers to treat them as if they were close family members; they also felt the same type attachment to their pet animals. Some older people preferred to have close ties with one person than superficial relationships with many.

“Many older men living alone treat their cat as a family member.” (care manager, 55 years old, woman, Yokohama)

“Older men living alone enjoy being looked after by care or welfare staff who can handle their whims and fancies.” (care manager, 43 years old, woman, Aichi)

“When my beloved dog died several years ago, my daughter mentioned that I looked sadder than when my wife passed away.” (older man, 82 years old, widowed, Aichi)

“I would like to give special cash treats to guests and relatives who visit me.” (older man, 84 years old, never married, Hyogo)

Admiration for the opposite sex. Some older men living alone still missed their deceased wife, while others expressed admiration for a close female friend. They yearned for the presence of a female companion in their life.

“Some older men living alone have a girlfriend who takes care of them.” (care manager, 42 years old, woman, Aichi)

“I look forward to meeting my lady friend twice a month. I dress up nicely on those occasions.” (older man, 82 years old, widowed, Aichi)

“My home helper (professional caregiver) is really kind and I find her attractive. I asked her to stay with me one night, but she declined.” (older man, 95 years old, widowed, Mie)

“Every day I look at photos of my deceased wife; they are beautiful treasures to me.” (older man, 86 years old, widowed, Tokushima)

“I still keep my wife’s ashes in my room.” (older man, 82 years old, widowed, Hyogo)

Gratitude for chances to meet people. Older people are generally grateful to their ancestors and other people in their life for the opportunities that were given to them; they are especially thankful for the chances to meet people who played important roles in their life. An older man seemed to be eager to thank everyone with whom they had crossed paths in their life.

“I always thank my parents for making it possible for me to meet, be loved and be surrounded by so many kind people.... I was assigned to a military unit and sent on the battle field at the age of 21, but fortunately I was able to return home safely. I am indebted to my ancestors for this.” (older man, 92 years old, widowed, Gifu)

Past experiences

Unwanted memory. Older people living alone tended to regret that their health has deteriorated so much after years of neglect. They thought that they were responsible for the deterioration of relationships with their families and relatives. In addition, some of them refused to reveal details about their past to their care manager. In such cases, care managers were unable to communicate with them meaningfully and could only provide superficial support.

“Because older men living alone often fail to show their true feelings about the past, our exchanges remain superficial.” (care manager, 27 years old, woman, Tokushima)

“When we conduct a life history interview with older men living alone, they sometimes get angry with us.” (care manager, 43 years old, woman, Aichi)

“I wish I had gotten along better with my children. Our relationship is really bad now......My poor health condition is of my own making. I worked really hard every day, but I should have paid more attention to my heath.” (older man, 82 years old, widowed, Hyogo)

Past glory. Some older people often felt that they had become useless because of infirmities due to age. They often feel nostalgic, and talking about their past can boost their self-esteem and help them find meaning in their life. Care managers had realized that clients who are able to reminisce about their past are generally in better health.

“We strive to listen carefully to our older clients as they reminisce about the good old days so that they have a positive outlook toward daily life.” (care manager, 36 years old, man, Miyagi)

“Listening to older men reminisce about the past is a good first step to approach them.” (care manager, 50 years old, woman, Tokushima)

“I often did well in Japanese chess tournaments.” (older man, 84 years old, man, never married, Hyogo)

“I am proud that I used to have a pair of Japanese swords.” (older man, 82 years old, widowed, Hyogo)

Well-being indicator

Health status indicator. Self-rated health is an informative question to assess people’s overall health status, and widely used as an indicator of their perception of their own health and their quality of life. An older man felt he was in good health, when his health condition measured by the results of common medical tests such as blood pressure and blood lipids levels were better than that of the people of the same age group,

“My doctor always says that my health checkup results are good. So, I am not worried about my health condition at all.” (older man, 82 years old, widowed, Hyogo)

“I am happy to be able to live longer than the average lifespan of Japanese men.” (older man, 82 years old, widowed, Aichi)

Economic affluence. Regardless of age, economic affluence is an important concern of older men living alone. They made conscious efforts to save money and thrived on simplicity and frugality. An older man was proud of receiving comparatively high pension.

“I am not particularly enthusiastic about cooking every day, but I do it anyway to save money.” (older man, 83 years old, widowed, Fukuoka)

“I am happy to be able to live on a large monthly pension; I set part of it aside for my children.” (older man, 86 years old, widowed, Tokushima)

DISCUSSION

This study found that Japanese older men living alone were enjoying their autonomous status and freedom, contrary to the wide-spread views that it was miserable and undesirable to live alone. Their spiritual health was found to be enhanced through gratitude to everyone with whom they had crossed paths in their life, yearning for the presence of a female companion, and confirming their health measurements were comparative or better than those of others in the same age group.

Our results are consistent with the finding of previous Japanese studies,[10,16-18] which suggested that it is important for a number of older people to preserve their freedom, maintain their own personal pace in daily life, and avoid excessive commitments or obligations, regardless of gender. While providing livelihood support can help older people living alone emotionally, socially and economically, excessive support may have adverse effects on their sense of freedom. The importance of maintaining autonomy, independence and freedom were also reported by the previous studies in other countries.[3,11,19,22]

Our findings show a link between older men’s well-being and the presence of a person or an object they loved. Although the death of a loved one may initially trigger feelings of hopelessness and loneliness, after some time, bereaved family often feel like their loved one remains close to them in their heart. Previous studies suggest that older people miss for deceased family by reminiscing about days spent together.[11,16,23] In WHOQOL, Spirituality, Religiousness and Personal Beliefs (SRPB) Field-Test Instrument, transcendence such as connectedness to a spiritual being or force is one of the essential domains of spirituality.[24] Moreover, Chuengsatiansup suggested that “transcendence”, which includes spiritual well-being and spirituality, is one of the key factors enhancing spiritual health.[3] Our results reveal that some older male participants are grateful to their ancestors for the opportunities they provided to meet people and for everything that happened in their life. Earlier Japanese studies also suggest that spiritual well-being includes self-transcendence among older people; by recognizing their connectedness to a spiritual being or force, some older people realize that they are not alone.[25,26]

Our investigation confirmed that older men living alone longed for a woman friend who would be special in their lives, while missing their spouses, similar to a Norwegian study.[11] After the death of their wives, older men struggled to adapt and found a new sense of purpose in life. However, their wives’ memory provided them with emotional and spiritual support. Also, after being alone for a while, some older men yearn for someone new to date or share their lives with. Although there have been few studies directly examining romance among older women living alone, regardless of gender, previous studies suggested that older people are sexual beings that continue to engage and be interested in sexual and intimate behaviors.[27-29]

However, from the care managers’ view point, this feeling of longing for a partner sometimes lead to inappropriate behavior, as female care workers are often exposed to sexual harassment from older male clients, as previously reported.[30] The statements made by the care manager participants also reflect this view: “Some older men living alone ask female home helpers (professional caregivers) to sleep with them”, “I know many older men living alone who have asked female home helpers to come to entertain them at night”, and “Some home helpers are worried about sexual harassment from older men living alone and are reluctant to visit”.

Our results suggested that their subjective well-being was increased by confirming their objective health measurements were comparative to or better than those of other men in the same age group. As for the objective measures, some older men living alone compared their age with the average Japanese lifespan. They also referred to previous health check results and feel healthy if the results are within normal limits. Good self-rated health correlates with spiritual well-being among older men living alone. Perceived physical health influences overall perceived health including spiritual health, and a physician’s assessment of health status and prognosis is related to spirituality. Several studies suggest mutual correlative relationships between functional and physical condition, perceived health status, life satisfaction and spirituality among older people. Shin and Sok found that in Korea perceived health status was related to life satisfaction of both older people living with family and those living alone regardless of gender.31 In their short review, Murata and Tsuda suggested that perceived physical health influences the overall perceived health including spiritual health, and that physicians’ assessments of health status and prognosis are related to perceived health.[32] Hirakawa et al[33] and Esbensen et al[1] revealed that the presence of chronic health problems or impaired physical condition have a negative impact on perceived health status among older people and stress the importance of their physicians’ or nurses’ support in coping with and overcoming ailments and limitations in everyday life.

Strengths and limitations of the study

The strengths of this study are as follows: This nationwide survey used both subjective and objective qualitative data from pairs of care managers and their older clients in each region. The study design contributed to comprehending the real-world of older men living alone and enhancing the variety of the qualitative data. All the study interviews were carried out by the first author, an experienced geriatrician skilled in qualitative research, thus the influence of the interview skills to the quality of the data is negligible.

The study also had several limitations. First, due to the scattered study settings nationwide and time constraints, our study fell short of data saturation. However, we recruited subjects from differing geographic areas and socio-economic status to maximize the variation of qualitative data. Second, to lessen the tension of the interviews with older clients which were conducted at the very first encounter, we asked that their care managers stay with us during the interview. The participants might have been reluctant to talk about such sensitive topics as end-of-life issues in front of their care managers.

CONCLUSION

Japanese older men living alone were enjoying their autonomous status and freedom, despite wide spread negative views of them. This study also found that: older men living alone missed their departed spouse or long for a companion, they experienced loneliness and anxiety, comparing objective measures of their own health status with others in the same age group increased their subjective well-being, and transcendence was one of the most significant factors enhancing spiritual health. Our findings provide important additional information that can help clinicians, nurses and care managers achieve better patient-centered care for older men living alone and enhance their dignity.

ACKNOWLEDGEMENTS

The authors are grateful to all the participants for the time and energy they devoted to this study and to the staff of Himeji Medical Cooperative and Asakura Clinic for handling data collection. Thanks also for the support from Toshiko Inai (Kitajima-cho community-based integrated care support center), Masahiko Shigezawa (Ko group), and Shunkei Hirai (Iga council of social welfare) by introducing the participants to us. This work was supported by Sasakawa Memorial Health Foundation and Japan Grants-in-Aid for Scientific Research, Grant Number 26460596.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.