Persons who die suddenly from an accident or other trauma have, of course, the shortest of all dying trajectories and no choice in the matter. But persons who are suffering from terminal disorders, who have been informed that their condition is terminal and even approximately how much time they have left, experience many emotional ups and downs. Elisabeth Kiibler-Ross (1969) maintained that in the interval between the time when they are informed that their illness is terminal and when they actually die, patients pass through a sequence of attitudinal or psychological stages. As shown in Figure 13-5, Kubler-Ross posits five stages in the dying process: denial, anger, bargaining, depression, and acceptance. Each stage features a different attitude or emotion on the part of the patient. At Stage 1, the patient denies the fact that the illness is terminal. Denial eventually gives way to a second stage—anger toward doctors, family, and even God. On coming to terms with the fact that anger cannot alter reality, the patient enters a third stage in which he or she attempts to strike a bargain with other people or even God if they will let him or her live. When this strategy does not work, the patient enters a stage of depression. Ideally, the depression eventually lifts and the patient becomes calm and accepts the reality of his or her imminent death.
Kubler-Ross's stage theory, which is frequently taught to doctors and nurses who work with terminally ill patients, has been criticized on a number of points. Certainly, not all patients go through the five stages in the order listed, and nurses who chide patients for their failure to do so are not practicing good medicine. Critics of Kubler-Ross's theory have proposed alternative approaches to understanding the dying process (e.g., Pattison, 1977; Shneid-man, 1987; Weisman & Kastenbaum, 1968). Pattison (1977) proposed a descriptive model consisting of three stages in the living-dying interval —the interval between the initial death crisis and the actual time of death. First, there is an acute phase, during which fear and anxiety are at their peak, and
Stage 1. DENIAL (Shock) Patient rejects reality of his or her impending death.
Denial of death provides patient with time to direct energies toward coping with the new reality.
Stage 2. ANGER (Emotion) Patient resents interruption of personal hopes and plans.
Expression of anger allows patient to move to next stage. t
Stage 3. BARGAINING Patient avoids reality of death by trying to enter into an agreement with God, the physician, or his or her family.
Patient gradually comes to understand reality of the situation.
Stage 4. PREPARATORY DEPRESSION Patient mourns for what has been and will be lost of himself or herself.
Patient moves toward self-understanding and contact with others.
Stage 5. ACCEPTANCE Patient calmer, more confident, and realistic; expresses less fear and anger
Figure 13-5 Psychological stages in the dying process. (Adapted from Kubler-Ross, 1975.)
which the patient usually copes with by means of defense mechanisms and other cognitive and affective resources. Next there is a chronic living-dying phase, in which anxiety is reduced and the patient asks questions about such things as the disposition of his or her body, what will happen to his or her "self," family, and friends while he or she is dying and dead, and what plans can be made. It is during this second phase that the patient begins to accept death gracefully, leading to a third and final stage— the terminal phase. During this last phase, the patient continues to want to live but accepts the fact that death will not go away. The patient's energy level is low, and, desiring mainly comfort and caring, he or she begins the final social and emotional withdrawal from life.
Some thanatologists are skeptical of all stage theories and emphasize that the way in which people die varies greatly from person to person. For exam ple, Shneidman (1987) maintains that, as with any crisis, a person's reactions to and ways of dealing with the prospect of his or her own death vary with culture, personality, and experience.
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