Measuring the quality of dying and death in advanced cancer: Item characteristics and factor structure of the Quality of Dying and Death Questionnaire

Background: Ensuring a good death in individuals with advanced disease is a fundamental goal of palliative care. However, the lack of a validated patient-centered measure of quality of dying and death in advanced cancer has limited quality assessments of palliative-care interventions and outcomes. Aim: To examine item characteristics and the factor structure of the Quality of Dying and Death Questionnaire in advanced cancer. Design: Cross-sectional study with pooled samples. Setting/participants: Caregivers of deceased advanced-cancer patients (N = 602; mean ages = 56.39-62.23 years), pooled from three studies involving urban hospitals, a hospice, and a community care access center in Ontario, Canada, completed the Quality of Dying and Death Questionnaire 8-10 months after patient death. Results: Psychosocial and practical item ratings demonstrated negative skewness, suggesting positive perceptions; ratings of symptoms and function were poorer. Of four models evaluated using confirmatory factor analyses, a 20-item, four-factor model, derived through exploratory factor analysis and comprising Symptoms and Functioning, Preparation for Death, Spiritual Activities, and Acceptance of Dying, demonstrated good fit and internally consistent factors (Cronbach's alpha = 0.70-0.83). Multiple regression analyses indicated that quality of dying was most strongly associated with Symptoms and Functioning and that quality of death was most strongly associated with Preparation for Death (p < 0.001). Conclusion: A new four-factor model best characterized quality of dying and death in advanced cancer as measured by the Quality of Dying and Death Questionnaire. Future research should examine the value of adding a connectedness factor and evaluate the sensitivity of the scale to detect intervention effects across factors.