Poetry of the Soul

Come See What's Within

The Pains of Dying

This essay looks at the Kubler-Ross model, the five stages of dying, and makes one think about how the medical field should be changed in order to aid a patient as they pass through the 5 steps. Written in example of a nursing journal article.

The Pains of Death: 5 Steps from Denial to Acceptance

ABSTRACT The idea of death has been the focus of civilians and scientists for many years. In 1969, Elisabeth Kübler-Ross published her book, On Death and Dying, which would help to shape the way individuals view the death process forever. Kübler-Ross stated that there were five stages that an individual goes through from the time that the individual realizes they will die until the time that they actually die. These five theories have become known as the Kübler-Ross model and have become a source of great debate in the medical community. Some studies show that the stages might not occur in any certain order, while some may be skipped altogether or revisited multiple times. Despite all the debate and discussion, the Kübler-Ross model still stands as the centerpiece of death research and is still used in hospitals around the world. In fact, a lot of Kübler-Ross’s writing was intended to be read by the medical community so that treatments could evolve to fit the emotions of the patient. This essay will analyze the five elements and demonstrate the need for better understanding of the five stages in hospitals so doctors and nurses can better help the patients they watch over. It will also place you in the shoes of a patient so that you can grasp a better understanding of what a dying individual has to go through.

INTRODUCTION

Research has turned up many different ideas on the process of death as human beings mix science and faith, while searching for comfort and understanding on a subject that individuals find confusing and painful. One collection of research, published in a book called On Death and Dying, would forever change the way individuals and health care providers view death as a whole. In her book, Elizabeth Kübler-Ross theorized that there are five stages that an individual goes through when dying. The idea is also presented that loved ones may go through the same stages while trying to cope with the news. These five stages are: denial, anger, bargaining, depression, and acceptance. While Kübler-Ross admitted that individuals might not follow these stages in perfect order, she theorized that they do experience them at some point (Kübler-Ross, On Death). More thought and attention to these five stages is needed in the healthcare field so that doctors and nurses can better treat their patients with terminal illnesses. If they can better identify what stage the patient is going through, then they can know what actions to take around them, and when to offer comfort and when to pull back. Through the extensive research of Elizabeth Kübler-Ross, modern science and healthcare have been shaped differently based on the five stages of dying she created, and with the greater understanding of dying she provides, comfort can be delivered in more effective ways.

The five stages of dying

The first stage that Kübler-Ross discussed in her five stage theory is denial. Webster defines denial as: (The) refusal to admit the truth or reality (Merriam-Webster). Kübler-Ross discussed denial in an essay “What Is It like to Be Dying?” She said, “Most patients, when told they have a serious illness, react with shock and denial. “No, it can't be me. It isn’t possible." Only three of our 400 patients, however, maintained this denial to the very end, although many have maintained denial in the presence of other people-- usually staff or family members-- who need denial themselves (Kübler-Ross, American journal). Kubler-Ross brought up two interesting ideas in this essay. First, she disproved the idea that a majority of patients get stuck in just the denial phase, unable to move on from the shock that it “couldn’t be me.” Kübler-Ross also presented an interesting theory in her research that deals with those individuals close to the patient. She theorized that when a patient enters denial so does the family and doctors dealing with the patient. If one carries Kübler-Ross’s idea further, then the idea that the family goes through the same five stages begins to emerge. Based on Kübler-Ross’s theory, the five stages of dying may be experienced by the dying and their family simultaneously.

The middle three stages, anger, bargaining, and depression, are the barriers that stand between a patient and their acceptance that the end is near. Anger is the point at which a patient stops asking “could it be me” and starts asking “Why me? What did I do wrong?” Bargaining usually involves talking to God or some other higher being and is a plea for life, similar to “Well if you’ll save my life/give me another year to live, then I’ll give my lifesavings to the church.” Finally, depression sets in, and the person starts to ask themselves, “Well, if I’m going to die, what’s the point” (Kübler-Ross, Of Death). These stages are usually present as the patient battles with the acceptance that he is out of control and has no power over what is happening to his body. Kübler-Ross stated that these stages can mix together, or can be skipped all together. While some form of denial and acceptance always takes place, it isn’t always clear if an individual is going through the middle three, as they are largely internal.

Finally, the patient reaches the stage of acceptance, where he can reach peace with himself and make mental preparations for death. It’s at this stage that Dr. Laurie J. Lyckholm, an Oncologist at VCU, recalls a case from years back. She says, “Years ago, a Jewish patient explained to me that the best a physician can aspire to is to be the good Schliach, which she translated as messenger of God’s will.” This is the greatest blessing of our vocation and the greatest service we can provide our patients” (Lyckholm). At this stage, the best thing that a doctor can do for the patient is comfort him and encourage him in whatever religious beliefs he has, whether if the doctor believes it or not. Once acceptance has occurred, what good does it do to try and change the person’s views on the afterlife? Patients have a new peace and acceptance that will carry them over until the day they die. Kübler-Ross mentioned the fact that some people never find comfort in their sickness, and that some die angry and bitter before they can find acceptance (Kübler-Ross, On Death).

Critics of Kübler-Ross say that her own feelings interfered with her interviews with dying patients she used as basis for her theory. Russell Friedman and John James explain that, “When you read about Kübler-Ross' life, you sense how much her painful past may have colored her interpretation of her interviews with dying patients. Interestingly, anger is the only stage Kübler-Ross contends is absolute for everyone— in dying, or in grieving relationships with those who have died. It seems as if the palpable anger she carried for years caused her to insist we all must have anger about loss.” They even go as far as to ask, “If these conditions are this arbitrary (erratic), can they truly be called stages?” (Friedman) Despite sharp criticisms about her personal feelings and methods, the Kübler-Ross model is still used in practice today. Even if personal feelings came in the way of solid research, all of her work shouldn’t be discredited.

Now that you, the reader, have a basic understanding of the five stages of dying, you need to put yourself in the patient’s shoes. We can’t have an understanding of what someone goes through just by reading words written on a page. Instead, we have to try to feel the emotions and attempt to grasp what a terminal patient feels as he passes through the various stages. Now, close your eyes, and imagine that you have just been through a challenging series of tests that have left you fatigued and worried. After a few days, you are called back into the hospital. You eagerly go, hoping to finally discover why you have been so sore and tired, and to get the treatment that will bring your life back to a sense of normality. Now, imagine that the happiness is all gone at once. You’ve just been told that you have terminal cancer, and have only a few weeks to survive. Would your initial reaction not be shock and disbelief?

Think about what you would want your doctor to say to you. Does an explanation make it any better? Dr. Nick Christakis, a professor of medical sociology at Harvard Medical School, said doctors should cater to the individual's needs and be as honest as possible. “Some patients say they don't want to know anything, and others say, 'Give it to me straight, doc,'" Christakis said. "Once you've established what kind of patient you're dealing with, you should be as willing to be as specific as science allows" (Christakis). Surely you wouldn’t want to have to make an important medical decision while you are trying to comprehend what you have just been told. This first step is important to understand in order to prevent forcing a patient to make a decision before the full awareness of his sickness has time to set in. After denial passes, anger sets in. This can be very hard on nurses who have no choice but to go into a patient’s room and perhaps suffer a verbal assault from the patient. However, how would you feel if a beautiful, young nurse came into your room, smiling, and asking how you were doing? You wouldn’t really be angry at the individual, but instead the freedom she has to go home at the end of the day and be with her family while you are trapped in the hospital alone. Understanding how to deal with an angry patient can save a lot of bad feelings for both the doctor/nurse and the patient. When bargaining sets in, there is a certain awkwardness between the doctor and patient. Thinking that you might have any chance at saving yourself, can you not see where you may beg for a cure, or for a few days of freedom? As a doctor, reminding the patient that there is no cure or that there is no hope isn’t the option. While you can’t give in to the request, you can avoid the topic, or even give a counteroffer, giving the patient a chance to walk through a garden one more time, or possibly give him something material that will appease the individual. Just remember how you would feel if you had nothing, and didn’t even have any grounds with which to bargain on.

When depression sets in, the mood of the patient is completely different from any other stage. Imagine that the days you have to live are almost over. You couldn’t believe you were going to die. You were angry that you had to die. You tried to buy your way out, but it wasn’t possible. Now you know you’re going to die. You just want to send everyone away, be alone, and to die alone. Can you see yourself welcoming in a happy nurse, dressed in bright colors, asking you how you’re feeling? If someone wants to be isolated and alone, who are we to hinder him from the isolation he longs for? During the time that a patient seems to be depressed, it is best to stay away from him as much as possible. Limiting visits and asking as few questions as possible is critical to help a patient get through his depression. And, most of all, never force a psychologist on the patient if it is unwanted; he will work through the depression himself. If you believe you can’t relate to the patient, imagine the worst feeling you have ever had, and think back to the emotions you felt, and the strong desire you had to be alone. Once the patient breaks free of this final bond, then he will have found acceptance. Once he has gotten to this stage, the best thing for a doctor or nurse to do is whatever the patient asks for, whether it be sitting with that person, or even just listening to what he has to say. If you were about to die, wouldn’t you simply want comfort in your final days?

Kübler-Ross, in a letter to a nursing journal, left us with a final thought dealing with how we should handle patients in their last days, and how we need to shape our lives and beliefs. She says, “I guess there's no way to learn but the hard way. That's the way I had to learn. My best teachers were my dying patients. If you dare to get involved, if you dare to sit down and help them go through the stages of dying, they will help you learn not only to become comfortable in caring for them, but also to face, one inescapable day, your own death with dignity. That is, perhaps, their "good-bye gift" to you” (Kübler-Ross, Letter).

CONCLUSION

Elizabeth Kübler-Ross changed the way that modern doctors look at dying patients and how best to treat them. In On Death and Dying, Kübler-Ross stated that an individual would go through denial, anger, bargaining, depression, and acceptance on his way to finding inner peace in his death. This research that Kübler-Ross and her students did shaped the way that individuals look at a dying person, and also how the news that a loved one is dying affects loved ones much the same as the patient himself. Despite criticisms that Kübler-Ross allowed personal emotions to interfere with scientific method, the theory stands strong even today and is still used in hospitals around the world when dealing with a terminally-ill patient.

LITEARATURE CITED

Christakis, Dr. Nick. "How Doctors Tell Patients They're Dying." NHNE. 7 Mar. 2008. 15 Apr. 2009 ..

Friedman, Russell, and John W. James. "The Myth of the Stages of Dying, Death and Grief." Skeptic: Home: The Skeptics Society & Skeptic magazine. 22 Mar. 2009 .com.

Lyckholm, Laurie J. "Thirty Years Later: An Oncologist Reflects on Kübler-Ross Work." The American Journal of Bioethics, 4 (2004): 29-31.

Kübler-Ross, Elisabeth. The American Journal of Nursing, Vol. 100, No. 10, 100th Anniversary Issue (Oct., 2000), pp. 96

Kübler-Ross, Elizabeth. "Letter to a nurse about death and dying...." Nursing 21 (1991): 78-80.

Kübler-Ross, Elisabeth. On Death and Dying. New York: Routledge, 1969.

Merriam-Webster Online Dictionary. 2009. Merriam-Webster Online. 22 March 2009 /dictionary/denial

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