Stages of Dying

Evidence that many people were interested in the subject of death was the
remarkable popularity of a book published in 1969. On Death and Dying was
written by Elisabeth Kübler-Ross, a physician who had come to the United
States from Switzerland. Perhaps the best-known aspect of Kübler-Ross’s
book, based on her informal research, was her outline of a series of stages
which she had found many dying patients go through. She became convinced
that modern medicine, in its efforts to keep the patient alive, treated
dying patients in ways that were often inhumane. She found that very little
was known about the psychology of the dying person; she pointed out that
there were no courses on death and dying in medical schools or, for all practical
purposes, anywhere else at the time.

Kübler-Ross interviewed several hundred persons who were dying of
chronic illnesses—generally long-term illnesses, such as heart disease and
cancer, which are the major causes of death in older Americans. She found
that most dying patients go through five stages in the terminal period of
their lives. The first stage is one of denial: “This is not really happening.
Someone has made a mistake. I am not really going to die.” In most people,
the probable reality of the diagnosis eventually replaces the denial with a
sense of anger: “Why me? Why now?” Generally, the anger is displaced onto
the most available candidate—a physician, a family member, a nurse, God.
The real object of the anger is death, but it is difficult to express anger toward
an abstract and ill-defined concept. The third stage is one of bargaining:
“If only I do not die, or at least if my life is extended, then I will change
my ways.” It generally becomes clear that the bargaining is not going to
work, and the fourth stage is depression. Kübler-Ross describes it as “a sense
of great loss.” Losses of any kind are one of life’s major difficulties, and
death is the ultimate loss of everything. Finally, the fifth stage that Kübler-
Ross observed is the stage of acceptance. This is not the same as saying that
the patient now wants to die or is looking forward to death. Kübler-Ross describes
this stage as “almost void of feelings.” It is the acceptance of the inevitability
of what is about to happen.

Kübler-Ross’s five-stage theory has come under criticism. Edwin Shneidman,
one of the first professionals to be called thanatologists because they
specialize in working with the dying and the grieving, stated that in his experience he rarely sees the neat progression through the five stages that
Kübler-Ross enumerates. Many others believe that the five-stage theory is
too simplistic to describe the way things happen in the real world. (Kübler-
Ross agrees that the five-stage theory does not apply to all dying people.)
Undoubtedly, factors such as the length of the terminal illness, the religious
beliefs of the dying person, the amount of support, and even the age of the
patient may make a difference in the way people deal with their dying. Nevertheless,
a framework such as the five stages, if not held too literally, seems
to be a great aid for many who have to support or work with someone who is
dying.