Virtual Reality Linked to Higher Death Literacy
Family carers of patients with advanced cancer often face the responsibility of managing symptoms, making medical and legal decisions, and preparing for the end of life. Many have limited knowledge of available care options and support services. A study conducted in northern Taiwan found that a virtual reality (VR) education programme improved death literacy among family carers, particularly those who began with lower scores. Published in Supportive Care in Cancer, the study also examined whether the intervention affected participants’ physical and mental health.
Death literacy refers to the knowledge and skills needed to access, understand and act on information about death, dying and end-of-life care. The Caring at End-of-Life research team at Western Sydney University developed the concept. It covers four areas: practical knowledge of end-of-life care and available resources; experiential knowledge gained through caregiving and personal interactions; factual knowledge of medical and legal procedures; and community knowledge of social networks and support services.
Researchers measured these areas using the 29-item Death Literacy Index (DLI). They also assessed participants’ health using the Chinese Health Questionnaire-12, which covers physical symptoms, anxiety, social dysfunction and depression.
Hsiao-Lan Yu of MacKay Memorial Hospital led the research team, with colleagues from National Yang Ming Chiao Tung University. It recruited 66 family carers through a palliative care consultation service at a medical centre in northern Taiwan. None of the patients they cared for had been enrolled in hospice care at the time of the study.
The researchers used a quasi-experimental design and assessed participants before and after the intervention. One group received traditional face-to-face consultations focused on end-of-life care needs. The other received the same consultations followed by a VR-based education session. Both groups completed the DLI and the Chinese Health Questionnaire-12 before and after the intervention.
The VR programme used Meta Quest 3 headsets, Insta360 X4 cameras, high-performance workstations and the HTC Virti immersive learning platform. Participants entered simulated end-of-life scenarios guided by a virtual nurse developed through 3D modelling and real-time motion capture.
The programme contained three sequential modules lasting approximately 25 minutes in total. The sessions covered the four domains of death literacy and included interactive knowledge quiz games and solution guides. Before using the programme with participants, five specialists assessed the scenarios. The panel included a palliative care physician, a specialist nurse, a clinical nurse, a social worker and a spiritual care practitioner.
The specialists rated the scenarios for importance, relevance and cultural appropriateness on four-point scales. The mean scores were 3.87, 3.78 and 3.82 respectively. A separate usability assessment involving five family carers produced a mean System Usability Scale score of 79.5, generally interpreted as good user satisfaction.
The main analysis found a statistically significant group effect on overall DLI scores. After accounting for baseline death literacy and factors including economic status and the availability of additional caregiving support, an analysis of covariance produced an F statistic of 25.99, a p-value below 0.01 and a partial eta-squared value of 0.427. The effect size was considered large under conventional statistical benchmarks.
All four DLI domains improved significantly. These covered practical, experiential, factual and community knowledge. Community knowledge recorded the largest effect size among the four subscales, with a partial eta-squared value of 0.392.
Further analysis examined whether the intervention’s effect differed according to participants’ initial death literacy scores. Using the Johnson-Neyman procedure, the researchers identified specific baseline thresholds below which the conditional effect of VR education was statistically significant. These were an overall DLI score below 117.94, experiential knowledge below 24.94, factual knowledge below 30.95, and community knowledge below 29.26.
The analysis found no significant additional benefit among carers with higher existing death literacy scores. The results indicate that healthcare teams could use the DLI to identify carers with lower baseline scores and prioritise them for VR education. The findings did not show that the same intervention would benefit all carers equally.
Before the intervention, Taiwanese family carers reported a neutral level of death literacy, indicating limited confidence in their knowledge and skills. Survey studies involving Australian and Chinese populations have reported higher confidence levels. Within the Taiwanese sample, community knowledge scored lowest. Average responses fell between disagreement and strong disagreement, reflecting limited awareness of available resources, legal options and social support systems.
The study placed the results within the cultural context of discussions about death in Taiwan, where the subject can be treated as taboo and open conversations may be difficult even within families. Taiwan has introduced two major laws, the Hospice Palliative Care Act and the Patient Right to Autonomy Act, to expand palliative care services and support patient autonomy. However, practical implementation still lags. The findings show the distinction between the existence of legal provisions and carers’ awareness of the options and services available to them.
The intervention did not produce a statistically significant change in participants’ Chinese Health Questionnaire-12 scores. The VR group recorded a slight improvement in health scores, while the control group experienced a slight decline. The difference between the groups was not statistically significant, and the assessment did not identify deterioration following the intervention.
The study measured health outcomes only one hour after the programme. Participants were also caring for patients in the palliative phase, which can involve rapid deterioration, heightened stress and intensive caregiving demands. The short assessment period meant that the study could not establish whether VR education had longer-term effects on carers’ physical or mental health.
The study had several limitations. Participants were allocated to groups according to the timing of the VR system’s construction rather than through randomisation. The quasi-experimental design therefore limits the strength of causal conclusions. The study also took place at a single medical centre, restricting the extent to which its findings can be generalised to other settings. The short follow-up period and reliance on self-reported measures also introduced limitations, including potential response bias.
Further research should use randomised study designs, longer follow-up periods, and participants recruited from multiple centres. The VR content could also be refined through more locally relevant case studies and legal resources customised to Taiwanese families. The study was presented as the first known development and evaluation of a VR application specifically targeting death literacy among family carers of patients with cancer.
The findings show that a brief VR education programme was associated with considerable improvements in death literacy across all four measured domains, with the conditional effects concentrated among carers who began with lower scores. However, the intervention did not produce a statistically significant improvement in measured physical and mental health outcomes. The study therefore provides evidence of improved end-of-life knowledge while leaving the longer-term effects on carers’ well-being unresolved.
