Five Stages of Death and Dying

Question 1. 

A well-lived, balanced life is usually broken down into three parts: the beginning, middle and the end. The society that we live in is generally accepting of the first two stages, and fearful of the last. In the late 1960s, Dr. Elizabeth Kubler-Ross did some ground-breaking work on society’s approach to death and mortality. She says that the end of life, much like the beginning and middle, is something that can be prepared for. From years of working with dying patients, Dr. Kubler-Ross came to the conclusion that the process of dying usually happens in five stages. This assignment examines the features and challenges of each stage. These stages are:

1. Denial 

Most dying patients have a difficult time coming to terms with the news that they are living their last days. Humans are not wired to accept death as a natural part of life. By definition, death is intrusive and unnatural. It is the end of life. A patient newly diagnosed with a terminal illness will therefore often request for reexaminations and counter-prognoses. All this is denial in action. When I was ten years old, one of my aunts was diagnosed with ovarian cancer. She was young, pretty and vivacious. None of us wanted to believe the news, let alone herself. We trooped into one hospital after the other, always looking to see a different physician every time. 

As the number of doctors that we saw grew, so did our realization that the original diagnosis was true. The lump observed was indeed a malignant type of cancer. Looking back at our actions at the time, it is now clear that all of us, my aunt included, were in denial. Denial usually serves as a patient’s very last shield against the unexpected news that they are indeed dying. In the most cases of patients studied, it is usually short-lived, later to be replaced by a partial or complete acceptance of the situation. It is reasonable to see denial as the knee-jerk reaction to the news of one’s mortality so suddenly exposed. Most times, it is later replaced by a gradual acceptance and possible confrontation of the whole scenario. 

2. Anger 

When a dying individual can no longer keep up with the denial charade, it progresses to the next stage, anger and resentment. This comes from the fact that the patient’s life is being so suddenly interrupted. The patient may look around, see other people going about their businesses and grow more resentful. “Why me?” they ask. From Dr. Kubler-Ross’ interviews, this anger comes from the fact that the patient is getting extracted from normal life to get treatment or specialized care. This leaves unattended projects, people and goals in suspense, further compounding the feelings of anger and resentment. 

When my aunt was no longer able to deny that she had been diagnosed with a terminal illness, she slipped into an angry, depressed existence. She was forced to leave her job and was relegated to an isolated room in the house. The interruption of daily life in order to attend treatment and get rest will anger anyone who was previously accustomed to an active daily life. She became distant and hard to communicate with, even plain rude. This was rather difficult to deal with, as close family members. Looking back, I realize this as one of the stages of dying that she was going through. 

It is required of the caregivers to be understanding and tolerant with patients at this stage of dying. Close friends and family may even be forced to accept some of the irrational demands levelled by terminally ill patients. Expressing and verbalizing anger is therapeutic to some patients and should be encouraged. 

3. Bargaining 

This third stage is not very common as some dying patients may not explicitly go through it. Additionally, some caregivers, hospices and psychiatrists openly discourage this stage. Dr. Kubler-Ross however feels that it may be beneficial for the patient to bargain for brief instances of time. The bargaining stage is characterized by patients asking for favors from their caregivers. A bus-driver may ask for one last ride in the city bus. A dying grandmother may request to attend the wedding reception held for her favorite grandson. 

After my aunt had been diagnosed with ovarian cancer, she went through the denial and anger phases. The third stage was however not immediately perceptible. She may have asked for a favour or two, like special meals and special gifts, but the bargaining stage was not something that she experienced in a major way. That being said, her caregivers and the family around laboured to give her the best care that we could, attending to her every need. Our goal was to make her as comfortable as possible. 

According to psychologists, this bargaining stage may be an attempt by the dying patient to cover up their guilt for things that they may have done in their lifetime. It is therefore important that close family and nurses not ignore these requests. They may be in instrumental in helping the dying patient to better come to terms with certain death. 

4. Depression 

As the dying patient’s condition deteriorates, depression sets in. They become weaker. Medication and hospitalization takes their toll. The brave smile and stoic disposition fades away. The series of losses being incurred, financial or otherwise, begin to be felt. Some patients may begin to feel sorry for themselves in the event that they have been forced to be away from their jobs for extended periods of time. Those who were breadwinners for their families may feel bad about the inability to provide any more. 

I remember my terminally ill aunt gradually slipping into this stage as her treatment progressed. She lost her job and her hair. She could no longer spend time with close friends. Every time one would visit her in her room, she would have this resigned look about her. As a family it was very easy to also fall into the same state. Seeing our once vivacious aunt like this was a hard hit to take. Psychologists, however advise that the best way to cope with a situation like this is to offer respite to the dying patient. Other than falling into the same state of depression, offer a word of encouragement to lift the patient’s spirits. 

5. Acceptance 

Patients who have sufficiently gone through the previous four stages will at some point reach a stage of acceptance. This will come of their own volition, unsolicited. At this stage they are neither depressed, in denial, nor envious of the healthy. It is an emotionless stage. The patient is calm and mostly weak. This stage should not be mistaken for happiness. It is just a resigned state where they are not too eager to hold conversations or engage in physical activity. 

This stage was clear with my aunt. A few days to her death, she developed a certain calmness and acceptance of her state. She requested not to be seen by too many people anymore. Even those that got to see her were not able to get as much as a word out of her. These final visits were mainly made of nods and squeezes of the hand. I wrongly took this as a signal that she was responding well to medication. I was still hopeful that she would eventually come out of her suffering. In retrospect, I see that this was the stage of acceptance that she was experiencing. 

A few patients will hold out for the hope of a cure or discovery to do with their illness. Even in their darkest despair, they do not discount the possibility of a miraculous end to their misery. As caregivers and close family, it is our duty not to give up on our patients. It is this last-minute hope that drives a lot of patients through the most difficult periods. 

Question 2. 

Most people are not comfortable speaking and relating to a person who is dying. It is often either impossible or extremely difficult to see things through the dying person’s perspective. It is even more difficult to try to figure out what they are experiencing spiritually and emotionally. The Dr. Kubler-Ross model assists in making the dying process more familiar and relatable. The model provides insight into what goes through a dying person’s psyche in their last days. Such information makes it easier for caregivers and close family to provide adequately for their terminally ill patient. This assignment discusses these stages in depth. 

Denial and Isolation 

Every patient who is given information about a matter of the magnitude of their own mortality will go through this stage in one way or the other. It is only human. They will attempt to rationalize their way out of the possibility that they are dying. Isolation usually arises when close loved ones are either unwilling or unable to cope with the news that this person is dying. This inability to cope leaves the patient mostly to themselves, leading to isolation. 

The symptoms of this stage are usually characterized by patients shuttling from one doctor to the next, hoping for a different diagnosis. Indicative phrases heard are “This can’t be true. Are you sure?” Patients may be helped to pass through this stage by explaining to them calmly the state of their condition. Doctors may suggest ways to take care of the patient in order to mitigate further damage as they go through this phase. 

Anger 

This is the stage where the patient experiences rage or anger at being the one having to face their mortality. They are angry at God, other people, themselves and even their loved ones. They grow envious at people who are well and healthy. The symptoms of this stage may involve rude words and actions directed at nurses, doctors, close friends or family. Indicative phrases include “Why me?” and “Stay away from me.” One effective way of dealing with the anger phase is by being accepting of the patient’s rage. One needs to understand that any rational human being would react this way. If there are visits to the patient involved, keep them short and far apart during this phase. 

Bargaining 

This stage involves the dying patient negotiating for last-minute favors and gifts. They figure that if their previous state of anger didn’t work, maybe being nice will. This is the first step towards the patient finally accepting the state of their condition. Symptoms of this stage include patients asking to see certain people or to be taken to certain places. Examples of indicative phrases are “It would be nice if John would let me visit him in Glasgow.” Psychologists advise that there is no harm in fulfilling the more rational wishes being suggested by the patient at this point. After all, it helps the patient to move along these stages of dying less tumultuously. 

Depression 

Continuous loss has a way of taking happiness from even the most cheerful of people. Loss of body parts after surgery. Loss of energy due to continuous medication. Loss of money to hospital bills. Loss of freedom to move and associate. These losses will get to even strongest stoic, causing them to slip into a depressed state. The symptoms of this stage may involve verbalised regret and mourning of past losses, for instance the job and money. Future losses may also be anticipated and mourned about. Some indicative phrases may be verbalized as “I’m sorry this has cost you so much money.” The most recommended way to cope with a patient undergoing this stage is to grieve with them. The more mourning and grief that the caregiver and the patient can both share at this point, the more bearable it will be when the patient eventually passes away. 

Acceptance 

This is the final stage of the dying process. Here the patient is resigned to their state. A certain calm ensues. Physical activity reduces to subtle movements of the eyes and hands and occasionally the mouth. This should not be mistaken for happiness, just a final resting stage before the eternal journey of death. Symptoms of this stage are finally realizing that there is no escape from death. An example of an indicative phrase for this stage is “It’s going to be fine” 

At this point the patient may begin to gradually withdraw themselves from their loved ones and their environment. They will request for less visits, often by less and less people. At the final stages, the spouse and children may be the only people allowed to see the dying patient. Be supportive by respecting this wish. 

Dr. Kubler-Ross’ analysis has often come under criticism mainly owing to the unavailability of extensive numbers and data to support this model. This study was conducted predominantly through interviews, some of which lasted as little as 3 minutes. Many dying patients do not necessarily go through these five phases. This often calls to question the validity and applicability of the whole model. On the other hand, though, there are numerous examples of families of dying patients that can attest to this exact progression from denial to acceptance. It is therefore upon every person’s discretion to assess their patient objectively. Some dying patients may skip various stages later to come back to them. It is the responsibility of the caregivers to recognize this possibility and address each instance as it comes. 

There is a cohort that argues that these stages do not exist at all. Some contend that the stages are not as defined ar Dr. Kluber-Ross would like to propose. There is no indication that people facing imminent death move through all the five stages of dying. Other criticisms point out that a person’s surrounding in their final days will influence their attitude towards death more than any theory or model out there. Another criticism is that this model focuses on the last few weeks of a dying person’s life, often ignoring the totality of their whole life. A person’s unique traits and personality are lost as they supposedly move through these 5 stages of dying. 

One does not require special training to be useful to a patient facing death. A general awareness of the stages through which one will go when facing imminent death, is mostly sufficient. There are also models that exist that show alternate ways of dealing with patients facing imminent death. For instance, Charles Corr, a researcher psychologist, insists on a model that recognizes individuality. He says that one may attempt several methods to cope with the situation, only to reject them all or stick to one that works. He also emphasizes that a person who is dying is still a living person, who ought to be empowered as much as possible to deal with the stresses of progressively dying. Charles Corr therefore provides practical guidelines for both patients and caregivers on how to cope with these stresses and challenges of the dying. 

Hospices are centers that care for the terminally ill as they await to die. They try to foster an environment that feels like home, while offering services like management of pain and palliative care. Hospices prepare their patients for death. They are important because they offer the terminal patients alternatives to where they’d like to spend their last days. Most patients, given the choice, would not spend their last weeks in an institutional or hospital environment. Thus hospices are essential as they empower the terminal patient in their last few days or weeks of their life. 

Question 6. 

Dr. Elizabeth Kubler-Ross’ book On Death and Dying offers incomparable insight into the process of dying, which all human beings will go through at some point. The book helps to shed light on what is ultimately important in life. This way, one is able to program their life to cater to these important things. Through her book, Dr. Kubler-Ross has inspired a more detailed empathy for dying patients. One is therefore more aware of the needs, wants and necessities of a dying patient. 

Rather than treating all terminal patients as case studies going through similar stages, the book advises that the process of dying is as individual and special as the life of each dying patient. Individualized care is therefore paramount. I agree with what Dr. Kubler-Ross terms as the stages of dying. Having been in the presence of a terminally ill patient before, I acknowledge the five stages of death: Denial, Anger, Bargaining, Depression and Acceptance as real. I am in full support of the methods proposed in the book to offer support to both the patients and the caregivers of the terminally ill patients. 

More than anything, I also agree that each and every terminally ill patient is a special individual case. No blanket solutions should be used in their care and treatment. Although the stages of dying are roughly similar across all patients, this is not to mean that each patient does not have personal and uniquely individual experiences. The process of dying for each patient is as individual and as unique as the very life that they lived. 

From this book, it is clear that dying patients have a lot of lessons to offer. For instance, most dying patients have a relatively high capacity for kindness. Learning from them, one may pass these lessons along to children and friends. Another lesson that one gets from studying dying patients is hope. Even the most accepting and strong of patients still leaves some room for the possibility of cure or a groundbreaking discovery concerning their illness. Throughout the five stages of dying, terminal patients hold on to hope that maybe their illness will be cured and they shall get a new lease of life. This avails to them a reserve of strength that would normally not be available were it not for hope. 

From the final days of a terminally ill patient, one sees what really matters in life. As a terminally ill patient goes through the bargaining phase, one rarely sees a terminally ill patient wishing that they had a better car or a bigger house. This is all just stuff. There is a bigger emphasis on spending time with loved ones and mending broken or strained relationships. Requests at this stage range from spending time with certain people, to going through certain experiences. Rarely do you find terminally ill patients requesting for physical stuff and possessions. 

If there is a lesson we should learn from the dying, it is that these material possessions are not as important as the relationships that we form and maintain. Spend time with your loved ones and create memorable experiences with them. Parts of the book that were difficult for me involve the interviews with dying patients. It is depressing to witness a person come to terms with the end of their life. 

The possibility of death seems to humble and soften even the most hardened of hearts. Reading the interviews and seeing what the dying have to say about life in general is a sad sight to see. It is also difficult to read about people who are dying young. With so much life yet to live, it must be difficult to have to face death before finishing your projects like raising the children, building a house or getting that promotion at work. Witnessing the process of promising lives getting cut short is difficult. 

Parts of the book that I enjoyed the most are those that shed light on the fact that it is possible to have a peaceful death. A terminally ill patient who has sufficiently gone through all the five stages of dying can die in peace knowing that they have no pending business left to take care of. As a future caregiver to dying patients and as a future dying patient myself, I intend to be fully aware of the features and requirement of each stage. If there was an updated version of this book, I would include a chapter on how the caregivers and close family should deal with the grief of losing a terminally ill patient to death. 

Dr. Kubler-Ross’ book is a gift to both the terminally ill patients and caregivers alike. Doctors, nurses, close family, friends and patients of terminal diseases find in this book an objective and rigorous examination of one of life’s most important yet often ignored phenomena. This book answers the some of the patients’ most pressing questions, while allowing doctors and their fellow caregivers to take a step back and further understand exactly what goes on in the mind of a patient who is experiencing their last few days alive. Overall, it is a very useful book that would interest anyone with even the slightest interest in the meaning of life and death. 

Reference  

Kübler-Ross, E. (2011). On death and dying. Routledge