We all owe a big debt of gratitude to the Swiss-American psychiatrist, Elisabeth Kubler-Ross (1926-2004) for her work with the dying. Based at the University of Chicago’s Pritzker School of Medicine in the 1960s, she often challenged contemporary approaches to those who were terminally ill. Kubler-Ross spent countless hours with these patients, bravely asking them directly what they would find helpful in their journey towards the end of their lives. The result was a book, On Death and Dying, published in 1969 which set the tone for much of the care of the terminally ill that has been provided subsequently.
The stages of dying
The most famous part of the book was the stages of dying that Elisabeth Kubler-Ross laid out. These stages apply also to the family and friends of the dying as they deal with their own reactions to what’s happening to their loved one. And they apply to the process of bereavement once the person has died.
Although I’ll list the stages of dying in order, it can only be a rough guide because the reality is that they usually don’t come in a neat order but will jump around and repeat.
Denial
The first stage is denial. The news, perhaps broken by a doctor, that a person’s condition is terminal sounds foreign to them. It may feel like it applies to someone else or that a mistake has been made. A second opinion may be requested. A sensitive doctor will already have made a judgement about how much to say to a patient, taking their cues from what the person has asked. Communications along the lines of ‘I’m okay, aren’t I?’ may mean ‘Don’t tell me’ while those approximating to ‘It’s bad news, isn’t it?’ may be an invitation to speak more openly.
Anger
The next stage is anger. The patient may demand a different doctor or even wish to take action against the one who gave the diagnosis. They may also take their anger out on other health professionals or their family. The cause of the anger is a sense of powerlessness and being out of control. Everything seems to be in the hands of the medics. It can be very helpful at this point if loved ones are able to accept the dying person’s anger and also give them back some control by offering them as many choices as possible. This might take the form, for example, of saying, ‘I’ll be here when you want to talk. Just tell me.’
Bargaining
Bargaining is the third stage. A person may attempt to reverse or delay the progress of their illness with a plea to God that involves some kind of a deal. For instance, they may promise to become a better person in return for healing or for their death to be postponed until a particular event, such as the wedding of a son or daughter, has taken place.
Depression
For all its apparent negativity, the fourth stage of dying, depression, may actually be positive in that it’s the beginning of accepting reality. There may be a sense that life is or has been futile, accompanied by a generally flat mood, difficulty in concentrating and an inability to find motivation for or pleasure in anything. A relative of the dying person is losing that one individual. The person who is dying is losing everyone and everything. Again encouragement to give voice to this can be hugely beneficial. The same goes for the loss of self-esteem that may accompany a sense of disfigurement caused by illness.
Acceptance
In time depression, along with the other stages, may gradually shade into a full acceptance that life is coming to an end – the final stage of dying. A person may say things like ‘It’s a terrible shame this had to happen but I have to think of the future now.’ They may sleep a lot and not want to talk much. Rather, it may be a time for silence and holding hands. The person is preparing for a journey and, in the last phases, may even say that someone is coming to collect them on a particular day. Family members and friends shouldn’t be surprised or feel guilty if the one who is dying now chooses just one person they want to see. That individual represents the others. Similarly they may fix on one last task they wish to be accomplished. They may have a clear picture of what’s really important to them and focus on that. It has been said that death trivializes the trivial.
If all goes well, there will in the end be a readiness to die, a readiness suffused with peace and even hope.