Anjarwani, et al.
Nurse and Health : Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index PEACEFUL END OF LIFE IN LATE-STAGE CANCER
PATIENTS: CONCEPT ANALYSIS BY WALKER AND
AVANT
Sushanty Anjarwani1*.
Wahyuni1.
Aric Vranada1.
Siti Aisah1 Universitas Muhammadiyah Semarang *Corresponding author: shantyaloha@gmail.
ABSTRACT
Background:The increasing number of malignant cancer patients makes end-of-life care an inseparable element of nursing services.
The concept of peaceful end-of-life is very popular , but it is complex and abstract.
Understanding the concept of peaceful end-of-life helps professional nurses improve the quality of care outcomes for patients suffering from terminal or life-threatening illnesses.
Objective:The researcher's goal was to clarify and clarify the understanding of the concept of peaceful end-of-life in end-stage cancer patients using the approach of Walker and Avant .
Methods: This concept analysis was conducted using the eight steps proposed by Walker and Avant.
Results:Attributes of peaceful end-of-life in advanced cancer patients include: freedom from pain, a feeling of comfort, acceptance of the disease, and the presence and support of those closest to them.
Antecedents, consequences, and empirical referents are explained.
Model cases, related cases, threshold cases, and conflicting cases are illustrated to further clarify the Conclusion: Four attributes are interconnected and play a role in forming a complete state of peace for terminal cancer patients according to Walker & Avant's analytical approach.
Keywords: Concept Analysis.
Peaceful End Of Life.
Terminal Cancer Received: December 15th, 2025.
Revised: December 24th, 2025.
Accepted: December 26th, 2025 DOI:https://doi.
org/ 10.
36720/nhjk.
This is an Open Access Article distributed under the terms of the Creative Commons Attribution Ae NonCommercial 4.
0 (CC BY-NC) 4.
Copyright A 2025 Health Polytechnic of Kerta Cendekia.
ISSN:(E)2623-2448.
(P)2088-9909
Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index BACKGROUND End-stage cancer is a condition that not only brings physical suffering, but also causes profound psychological, spiritual, and social stress for patients and their families (Han & Kim.
Puchalski et al.
, 2.
In the final phase of life ( end of life ), patients often experience anxiety, fear of death, a sense of loss of control, and uncertainty about the future.
This condition emphasizes the importance of a holistic approach in health care, especially nursing, to help patients achieve calm and peace towards the end of their lives.
One important concept that is the focus of palliative nursing is " peace end of life ", namely a state in which patients achieve acceptance, inner peace, and emotional harmony despite being in a terminal condition (Buntari Agustini et al.
, 2025.
D'Andria Ursoleo et al.
, 2025.
Ngabonziza et al.
, 2.
The concept of peaceful end of life continues to evolve in nursing, and a comprehensive understanding of its attributes, antecedents, and consequences is necessary to provide appropriate and meaningful interventions.
Therefore , concept analysis is a crucial step in clarifying the meaning, boundaries, and key components of peaceful end of life , thus providing a basis for developing effective nursing interventions.
Peaceful end of life differs from the concept of comfort care .
The concept of peaceful end of life is not merely free from discomfort, but involves other attributes such as feelings of comfort, appreciation, sincerity/acceptance of the disease condition, and the presence and support of those closest to them.
Improving the concept of peaceful end of life can be done by providing optimal physical management, including analgesic therapy, providing access to those closest to them, reconciling social and family relationships, spiritual and psychological guidance, providing meaning and legacy , and a calm care environment (Delgado-Guay et al.
Smith et al.
, 2024.
Tim et al.
, 2.
The Walker and Avant method is one of the most frequently used concept analysis approaches in nursing because it provides systematic steps for developing conceptual clarity (Gunawan et al.
, 2.
Through this method, the concept of peaceful end of life can be analyzed in depth, starting from its definition, essential characteristics, antecedent factors, consequences, and the development of a case model that illustrates the application of the concept in nursing practice.
This analysis is expected to strengthen the theoretical basis in providing palliative nursing care that is centered on the emotional and spiritual needs of endstage cancer patients.
OBJECTIVE
This concept analysis aims to clarify the theoretical definition of peaceful end of life in patients with terminal cancer and explain the concept comprehensively including antecedents, attributes and consequences, as well as case examples including model cases, threshold cases, related cases and conflicting cases.
METHODS
This concept analysis was conducted using the eight steps proposed by Walker and Avant.
The first step involved concept selection.
the second step clarified the purpose of the and the third step identified an overview of all uses of the concept.
This included a search of all literature that uses the term " peace end of life ," which also assisted in describing Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index the attributes that define the concept .
tep fou.
This process was followed by the development of a model case and additional cases .
teps five and si.
In step seven, the attributes, antecedents, and consequences of the concept were identified for refinement.
In the final .
step, empirical references were selected to determine the attributes that define the concept of " peace end of life " (Gunawan et al.
, 2023.
Pranata & Wulandari, 2.
Concept analysis was conducted to clarify the meaning of the concept of peace end of life based on the Walker and Avant method .
The search for related concepts in the literature was conducted by searching article data in databases such as PubMed.
Google Scholar , and Science Direct for the period 2010-2025.
The keywords used were peaceful end of life , concept analysis , support from loved ones , acceptance , spirituality , pain , comfort , and terminal All articles were independently reviewed by members and selected articles related to peaceful end of life .
The search focused on the terms peaceful end of life and terminal cancer.
Literature synthesis was used to identify attributes.
The use of attributes can be seen in examples of model cases, borderline cases, related cases, and conflicting cases.
RESULTS
Identification of Peaceful End of Life in End-Stage Cancer Patients Part of Walker and Avant's concept analysis process involves identifying all the concepts used.
In the Oxford dictionary, "peace" has the primary meaning of freedom from war or violence, or a state of harmony and tranquility .
The Oxford Dictionary also defines "peace" as a state of calm, undisturbed, or undisturbed.
"End of life" in a medical/human context refers to the state of approaching death, usually due to old age or prolonged illness (Assefa, 2.
The use of the concept of peaceful end of life can be viewed from various perspectives.
From a linguistic perspective, " Peace " means tranquility, calmness, or serenity.
In medical and spiritual contexts, peace describes a state free from suffering, anxiety, and internal conflict (Xi & Lee, 2.
From a nursing perspective, peaceful end of life refers to the condition of a patient who achieves a state of peace through pain management, emotional support, spiritual guidance, and acceptance of the terminal condition (Ngabonziza et al.
, 2021.
Zaccara et al.
From a psychological perspective, " peace end of life" describes the acceptance phase in Kybler-Ross's theory, where individuals accept death as part of the journey of life (Pasopati et , 2.
From a spiritual/religious perspective, peaceful end of life refers to a state of surrender, sincerity, fulfillment of worship or prayer needs, receiving spiritual support from religious leaders, and belief in a peaceful transition.
(Murni et al.
, 2025.
Wijaya et al.
, 2.
Meanwhile, from a family and social perspective, peace at the end of life is defined as an atmosphere of intact relationships, forgiveness, resolution of family conflicts, and strong social support (Marco et al.
, 2.
Advanced cancer refers to cancer that has spread from its original location .
to other parts of the body .
or has grown larger and spread to surrounding tissue.
This term is also often used to describe cancer that is likely incurable, although some cases can be controlled or cured with treatment.
Advanced cancer is often also called metastatic cancer or stage 4 cancer (Welch & Hurst, 2.
Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index Attribute definition Walker and Avant's conceptual analysis process included defining attributes.
Four attributes are identified in advanced cancer patients related to the concept of peaceful end of life : a physical sense of freedom and adaptability from pain, comfort, acceptance of reality and a sense of peace, and the presence and support of those closest to them.
Cancer doesn't always cause pain, but nearly 80% of metastatic cancer patients report The pain is not solely a consequence of the disease process but is often due to the effects of treatment, radiation, and chemotherapy.
Methods used to reduce cancer-related pain are numerous and varied, ranging from powerful pain relievers to interventional procedures to supportive care approaches.
Being pain-free doesn't necessarily mean zero pain.
it can mean the patient can tolerate pain, feels comfortable, is not disturbed in activities, including sleep, does not cause distress, and has a positive perception of pain management (Welch & Hurst, 2.
Comfort in advanced cancer patients is a holistic condition encompassing physical, emotional, spiritual, and social well-being, where patients experience reduced suffering, a sense of security, acceptance of their disease, and the ability to live each day with an optimal quality of life despite being in the terminal phase.
Comfort in advanced cancer patients is a multidimensional condition involving physical, psychological, spiritual, social, environmental, and existential factors ( acceptance and meaning of lif.
(Edirisinghe et al.
, 2025.
Harrop et al.
Acceptance in advanced cancer patients is a psychological condition where the patient is able to accept and accept the fact that he/she has advanced cancer, the patient fully understands and accepts that his/her disease is likely incurable, and integrates this reality into his/her life, attitude and behavior so that the patient is able to live the rest of his/her life calmly, realistically and meaningfully (Babaei et al.
, 2017.
Dekker et al.
, 2.
The presence and support of those closest to you is an important attribute in a peaceful end-of-life experience .
The presence and support of those closest to you can provide a sense of security and emotional protection.
A hug, a touch, or simply the presence of a loved one at your bedside can provide a sense of security and a feeling of not being alone in facing the situation.
The presence and support of those closest to you can also strengthen feelings of love and appreciation, and enhance the experience of meaning in life, as you feel a loving connection remains intact until the very end.
The process of acceptance is also easier to achieve with the presence of those closest to you (Article & Access, 2018.
Jimenez et al.
, 2.
Case study Model case: Mrs.
A , a 65-year-old woman, comes from a family where Islamic values grew up in her family.
About 10 years ago she was diagnosed with breast cancer.
Mrs.
A had undergone surgery and chemotherapy.
In January, the medical team informed Mrs.
A and her family about the progression of her breast cancer, which had metastasized to her liver and Due to her worsening condition .
Mrs.
A was referred to a palliative care unit in her Organ function decline and physical weakness were evident within the first week of treatment.
Mrs.
A feels comfortable with her condition, this is due to the treatment she received and her self-acceptance of her illness.
Mrs.
A expressed her desire to actively participate in planning her final separation from her family.
Mrs.
A wanted to be accompanied by her husband and all her children.
Mrs.
A wanted her body to be washed by her husband and Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index children and her funeral procession to be carried out in an Islamic way .
Mrs.
A asked her family to be buried in the family cemetery next to the graves of her mother and father.
Realizing that her family would be sad.
Mrs.
A helped minimize her family's sadness by building important messages about happiness during life, gratitude for all God's gifts in the midst of her family, sincerity in accepting her illness and hoping for forgiveness of her sins with patience against her Borderline case: Mrs.
B , a 60-year-old woman, comes from a devout family with her husband and four children.
About 8 years ago she was diagnosed with breast cancer.
Mrs.
B had undergone surgery and chemotherapy.
In January, the medical team informed Mrs.
B and her family about the progression of her breast cancer, which had metastasized to her liver and Due to her worsening condition .
Mrs.
B was referred to a palliative care unit in her Her organ function decline and physical weakness were evident within the first week of treatment.
Mrs.
B expressed her desire to actively participate in planning her final separation from the family.
Mrs.
B wants to be accompanied by her husband and all her However, her other two children were on national duty and could not accompany their mother in the hospital.
Realizing that her family would be sad.
Mrs.
B helped minimize her family's sadness by making video calls with all her family members, building important messages about happiness during life, gratitude for all God's gifts in the midst of her family, sincerity in accepting her illness and hoping for forgiveness of her sins with patience in dealing with her illness.
Related case: This related case uses a similar concept , but differs from peaceful end of it focuses more on comfort care.
Mrs.
C, a 48-year-old woman, lives with her husband and two children who live abroad.
About 6 years ago she was diagnosed with breast cancer.
Mrs.
had undergone surgery and chemotherapy.
In January, the medical team informed Mrs.
C of the progression of her breast cancer, which had metastasized to her liver and lungs.
Due to her worsening condition .
Mrs.
C was referred to a palliative care unit in her hometown .
Organ function decline and physical weakness were evident within the first week of treatment.
Mrs.
reported that her pain level was mild and adaptable.
During her hospitalization .
Mrs.
C became aware of her rapidly deteriorating health and repeatedly expressed her desire to die with her husband and children by her side.
However, only her husband was able to accompany her due to her children's busy schedules abroad.
Mrs.
C died beside her husband, feeling no pain from her However.
Mrs.
C was unable to fulfill her wish to meet, convey messages, and receive support from her children.
Contrary case : This case is an example of a case that is contrary to the model case that does not define attributes.
Mrs.
D is a 47-year-old woman who is a single parent with 3 children who live outside the city .
About 5 years ago she was diagnosed with breast cancer.
Mrs.
D had undergone surgery and chemotherapy.
In January, the medical team informed Mrs.
D of the progression of her breast cancer, which had metastasized to her liver and lungs.
Due to her worsening condition .
Mrs.
D was referred to a palliative care unit in her hometown .
Her organ function decline and physical weakness were evident within the first week of treatment.
Mrs.
often cried due to physical .
and psychological factors, and often uttered statements of hatred towards the conditions she experienced, and felt injustice in her life.
During her treatment .
Mrs.
D realized her health condition was rapidly deteriorating, she also repeatedly Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index expressed her wish to die accompanied by her husband and children.
However, along with the divorce and the presence of her children who were each busy with their own lives, this was difficult to realize.
Mrs.
D experienced anxiety in the last days of her life.
Mrs.
D died in a state of denial about her physical condition, not accepting it and unable to fulfill her wish to be able to gather with her family members.
Antecedents Antecedents are conditions that must occur before a peaceful end of life can occur, including: a clear terminal diagnosis .
nd-stage cance.
, adequate pain and symptom management as a basis for achieving peace, open communication between the patient, family, and health workers, consistent spiritual and emotional support, and an empathetic, safe, and non-threatening care environment.
In analyzing the concept of peace of end-of-life in terminal cancer patients, a crucial antecedent is a clear, valid, and understandable cancer diagnosis for the patient and family.
This clarity of diagnosis triggers emotional and existential responses that lead to acceptance, selfreflection, the search for meaning in life, resolution of emotional burdens, and preparation for end-of-life (De Vincenzo et al.
, 2.
Pain in cancer patients is not solely a consequence of the disease process but also a consequence of treatment, radiation, and chemotherapy.
Methods used can range from interventional procedures to supportive care approaches.
When patients receive pain management therapy, it is hoped that it will reduce or eliminate pain, allowing them to experience a sense of calm and comfort during the end-of-life process (Fallon et al.
, 2.
Open communication between patients, families, and healthcare professionals will support the development of comfort care for patients.
Open communication also makes patients feel safe and comfortable expressing their emotional needs.
Open communication can provide emotional calm and reduce interpersonal conflict in end-of-life patients (Danaher et al.
, 2023.
Kwame A & Petrucka P, 2.
Consistent spiritual and emotional support enables patients to better understand death as part of God's plan, gaining the strength to form a sense of sincerity and emotional acceptance of the patient, so that the patient feels comfort and acceptance of his/her disease condition (Murni et al.
, 2025.
Sutantri, 2.
End-of-life care setting , whether at home, in a hospital, or in a palliative care unit.
safe and comfortable environment ensures physical safety and emotional stability, allowing the patient to focus on the emotional-spiritual process of achieving inner peace (Zadeh et al.
, 2.
Consequence According to Walker and Avant, consequences are events or outcomes that occur after a concept has been reached.
The consequences of a peaceful end of life for terminal cancer patients include comfort, freedom from pain, acceptance, and support from those closest to Empirical references Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index Empirical references are indicators that can be measured or observed to determine whether the concept has emerged (Jarvis et al.
, 2.
Indicators that can be used to evaluate peaceful end of life include: Verbal expressions from patients such as the phrase "I am ready", "I feel peaceful".
Patient anxiety can be evaluated with indicators: HADS-Anxiety.
ESASAnxiety.
Patient pain scores can be evaluated with the Numerating Rating Scale, or ESASPai.
Patient behavior, such as relaxed facial expressions, better sleep, and reduced anxiety, can be indicators of patient comfort.
Increased spiritual activities, such as prayer, meditation, dhikr, and reading holy scriptures, express the patient's spiritual strength and support acceptance, calm, and emotional peace.
Having access to and support from those closest to the patient, who accompany the patient during the end-of-life period, demonstrates a strong relationship and open communication between the patient and family.
DISCUSSION
The concept of peaceful end of life describes a state of physical, emotional, spiritual, and social peace and tranquility in terminally ill patients.
In terminal cancer patients, this state is characterized by four key attributes: freedom from pain, a sense of comfort, acceptance, and the presence and support of loved ones.
These four elements complement each other to create a state of complete peace.
The first attribute, freedom from pain, is the most fundamental aspect in achieving a peaceful end of life.
Uncontrolled pain can cause anxiety, sleep disorders, and even spiritual Therefore, optimal pain management, whether with medication, non-pharmacological techniques, or spiritual support, is key.
When pain is reduced, patients are better able to think clearly, interact with their families, and experience a sense of peace (Fallon et al.
, 2018.
Harrop et al.
, 2017.
Ngabonziza et al.
, 2021.
Puchalski et al.
, 2.
The second attribute is a feeling of comfort, which includes physical and emotional Comfort doesn't just mean being free from symptoms like shortness of breath or nausea, but also feeling safe, valued, and treated with dignity.
A calm environment, supportive communication, and simple measures like positioning or therapeutic touch can increase A comfortable environment makes it easier for patients to navigate the final stages more peacefully (Assefa, 2020.
Kwame A & Petrucka P, 2021.
Ngabonziza et al.
, 2.
The third attribute, acceptance, refers to the patient's ability to understand and come to terms with their condition.
Acceptance typically develops through internal processes such as reflecting on the meaning of life, mending relationships, or discovering spiritual strength.
When patients reach this stage, anxiety decreases and inner calm emerges, which is the essence of a peaceful end of life (Assefa, 2020.
Dekker et al.
, 2025.
Sutantri, 2.
The fourth attribute is the presence and support of those closest to us.
Family support, whether in the form of physical presence, touch, loving words, or prayers , provides a sense of security and reduces loneliness.
Warm emotional connections help patients feel valued, supported, and less alone in facing the end of life.
In conceptual analysis, this support serves as a crucial social foundation for achieving holistic well-being (Danaher et al.
, 2023.
Imtiaz et al.
Sutantri, 2.
Overall, these four attributes are interconnected and play a role in forming a complete state of peace for terminal cancer patients according to Walker & Avant's analytical approach.
Anjarwani, et al.
Nurse and Health: Journal of Nursing.
: 72-81
http://ejournal-kertacendekia.
id/index.
php/nhjk/index CONCLUSION The definition, antecedents, attributes and consequences of peaceful end of life in terminal cancer patients have been explored.
Further study is needed as the concept develops and its implementation in other cases.
This conceptual description is expected to provide a basis for clarifying the theoretical definition of peaceful end of life in terminal cancer patients.
ACKNOWLEDGMENTS