Developing a Double Awareness Model Among Patients With Advanced Cancer in China: A Constructivist Grounded Theory Study.

Abstract

Objective: Double awareness, defined as the capacity to engage with life while acknowledging mortality, has been conceptualized primarily within Western cultural contexts. This study aimed to develop a contextually informed interpretive model of double awareness among patients with advanced cancer in China.

Methods: A constructivist grounded theory approach was adopted. Semi-structured interviews were conducted with 10 patients with stage IV or recurrent/metastatic cancer recruited from an oncology department and a hospice care facility in China. Data were analyzed iteratively using initial, focused, and theoretical coding, together with constant comparison.

Results: Double awareness was conceptualized as an interpretive model comprising three interrelated experiential domains: Life Engagement, Death Contemplation, and Legacy Continuation. These domains were described as coexisting and interconnected rather than unfolding as a fixed sequence. Psychosomatic Adjustment, encompassing fluctuations in physical symptoms, emotional states, temporal perception, and energy allocation, emerged as a regulatory process that shaped how participants sustained, negotiated, or experienced these domains. In this sample, Legacy Continuation was particularly salient in some participants' accounts, especially in relation to family relationships, intergenerational responsibilities, and the transmission of values.

Conclusions: Among Chinese patients with advanced cancer, double awareness was conceptualized as a multidimensional and contextually situated experience. The model provides a preliminary conceptual framework for generating hypotheses and informing future culturally responsive psychosocial and palliative care research, with further validation needed across diverse populations, care settings, and longitudinal contexts.