Grief, Part 2
“Those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening nor painful, but a peaceful cessation of the functioning of the body. Watching a peaceful death of a human being reminds us of a falling star…” Elizabeth Kubler-Ross, MD
Swiss-American psychiatrist, Elisabeth Kubler-Ross, authored the book On Death & Dying: What the Dying Have to Teach Doctors, Nurses, Clergy & Their Own Families. It was first published in 1969. I read it in the 1970’s and was fascinated by her research with terminal patients, family members, and the staff caring for them. It was the first work I read, perhaps one of the first ever published, that was so up-front and matter-of-fact about the dying process. She found that, contrary to popular belief, many dying patients wanted to talk about what they were experiencing as their life on earth was winding down. Many people, including doctors and other care-givers, believed it was best to deny the nearness of death in the patient’s presence. Whispered conversations about the gravity of the situation were reserved for hallways and meeting rooms out of ear-shot of the patient.
What most caught my attention about the book, and what I wish to focus on for this discussion of grief, are the stages of dying that she identified. The stages are denial and isolation, anger, bargaining, depression, and acceptance. It is important to understand that these stages do not represent a formulaic or chronological progression that everyone goes through as they approach physical death. Rather, they are common experiences Kubler-Ross noted in many of her patients and their loved ones. One person might go through all five stages, but in a different order. Another may keep returning to the anger stage. Another may have seemed to reach acceptance, only to revert to bargaining. Still others may skip one or more of the stages. The knowledge gained from her work is in identifying these as common, but not universal, stages we experience as our own death or the death of a loved one approaches. As we seek to support those nearing physical death, understanding the stages as normal experiences may help us better accept and love the patient as and where they are. Such understanding can also help the patient navigate the dying process, including us when our time comes.
What Kubler-Ross identified as the first stage is denial and isolation. As the title implies, the patient denies that their condition is dire. Perhaps test results have been switched or there was a misreading of the results. Another doctor might understand the results differently. Other countries might have treatments that have not been approved in the United States, yet. Patients experiencing denial simply cannot believe this is happening to them. There is too much left undone, it is not a good time, or this must be someone’s idea of a joke. Kubler-Ross describes temporary denial as an often healthy way of dealing with the stress and discomfort of the initial diagnosis because it serves as a “buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less-radical defenses.” For the majority of patients expressing denial of their condition, the disavowal is a temporary reaction that soon gives way to another stage.
While it is a common initial reaction to a fatal diagnosis, denial may reappear at various stages in the dying process, sometimes appearing as isolation. Isolation may manifest with the patient drawing a distinction between their condition and their self, as if they were twins. They may speak of their condition in the third person or may choose to discuss their condition only with different staff or family members than whom they confided in earlier.
As I write this, the world is in the grips of the COVID-19 pandemic. When the wide-spread threat and how easily and quickly it is passed to others became known, a common reaction was denial. Even now, some months and several hundreds of thousands of deaths after the world first witnessed its seriousness, and with many of our daily activities forbidden or discouraged, some people continue to deny the threat. The social isolation encouraged for all at this time is a prescribed defense mechanism to help protect everyone. Likewise, the isolation often shown by terminal patients in the denial stage is a defense mechanism to help them not be overrun by their condition – physically, emotionally, or psychologically.
I will continue considering the stages of dying next week.
This is the 35th in the series of Life Notes titled, If I Should Die Before I Wake. I invite your thoughts, insights, and feedback via email at firstname.lastname@example.org, or through my website, www.ContemplatingGrace.com. At the website, you can also sign up to have these reflections delivered to your Inbox every Thursday morning, if you are not receiving them in another manner.
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 Elisabeth Kubler-Ross, MD, On Death and Dying. Scribner, New York, 1969, p. 262.
 Ibid., p. 38.