3-7: Stages in Adjustment to Dying

Question 1

Describe each of Kubler-Ross’ five stages of dying.

Answer 1

• Denial: Thought to be a person’s initial reaction on learning of the diagnosis of terminal illness. Denial is a defense mechanism by which people avoid the implications of an illness. They may act as if the illness were not severe, as if it will shortly go away, or as if it will have few long-term implications.
• Anger: Denial usually abates because the illness itself creates circumstances that must be met. Decisions must be made regarding future treatments, if any, where the patient will be cared for, and by whom. At this point, the second stage, anger, may set in. The angry patient is asking the question, “Why me?” and may show resentment toward anyone who is healthy, such as hospital staff, family members, or friends.
• Bargaining: At this point, the patient abandons anger in favor of a different strategy: trading good behavior for good health. Bargaining frequently takes the form of a pact with God, in which the patient agrees to engage in good works or at least to abandon selfish ways in exchange for health or more time. A sudden rush of charitable activity or uncharacteristically pleasant behavior may be a sign that the patient is trying to strike such a bargain.
• Depression: In this stage, the patient is coming to terms with the loss of control, recognizing that little can be done to stay the course of illness. Kubler-Ross refers to the stage of depression as a time for “anticipatory grief,” when patients mourn the prospect of their own deaths. This grieving process may occur in two stages, as the patient comes to terms with the loss of past valued activities and friends and later begins to anticipate the future loss of activities and relationships.
• Acceptance: At this point, the patient may be too weak to be angry and too accustomed to the idea of dying to be depressed. Instead, a tired, peaceful though not necessarily pleasant calm may descend. Some patients use this time to make preparations, deciding how to divide up their last personal possessions and saying goodbye to old friends and family members.

Question 2

Identify the strengths and weaknesses of Kubler-Ross’ theory.

Answer 2

• Strengths: As a description of the reactions of dying patients, Kubler-Ross’s theory has been invaluable. She has chronicled nearly the full array of reactions of dying patients, as those who work with the dying will be quick to acknowledge. Her work is also inestimable value in pointing out the counseling needs of the dying. Finally, along with other researchers, she has broken through the silence and taboos surrounding death, making them objects of both scientific study and sensitive concern.
• Weaknesses: Patients do not go through five stages in a predetermined order. Some patients never go through a particular stage. Others will go through a stage more than once. All the feelings associated with the five stages may be experienced by some patients on an alternative basis. Nurses, physicians, social workers, and others who work with the dying may expect a dying person to go through these stages in order, and they may become upset when a patient does not “die right”. The theory also does not fully acknowledge the importance of anxiety, which can be present throughout the dying process. Next to depression, anxiety is one of the most common responses. What patients fear most is not being able to control pain; they may welcome or even seek death to avoid it.

Question 3

Discuss the specific psychotherapeutic needs of dying patients.

Answer 3

Terminally ill patients may need help in resolving unfinished business. Uncompleted activities may prey on the mind, and preparations may need to be made for survivors, especially dependent children. Through careful counseling, a therapist may help the patient come to terms with the need for these arrangements, as well as with the need to recognize that some things will remain undone.

Question 4

terminal care

Answer 4

Medical care of the terminally ill.

Question 5

palliative care

Answer 5

Care designed to make the patient comfortable, but not to cure or improve the patient’s underlying disease; often part of terminal care.

Question 6

curative care

Answer 6

Care designed to cure a patient’s underlying disease.

Question 7

clinical thanatology

Answer 7

The clinical practice of counseling people who are dying on the basis of knowledge of reactions to dying.