Grief, Part 3

 “When the first stage of denial cannot be maintained any longer, it is replaced by feelings of anger, rage, envy, and resentment.” Elizabeth Kubler-Ross, MD[1]

According to Swiss-American psychiatrist, Elisabeth Kubler-Ross, the initial stage of dying is denial and isolation, which I reflected upon in last week’s Life Note. The next stage, as described in her book On Death & Dying[2] is anger. After we have been convinced that this terminal condition is actually happening to us, it is natural to wonder why. Am I being punished by God? Did one or more of my sins bring this upon me? Was I cursed with bad genes from my parents? Did the power company place high-voltage electric lines too close to my house? When we feel out of control, like something awful is being done to us, anger is a natural reaction. We need someone or something blame or to strike back against. Obviously, this is a difficult stage for loved ones and care-givers to suffer through with the patient. What would normally be a minor annoyance can trigger a ferocious barrage of rage from the patient.

Anger is a secondary emotion, and that is clearly illustrated in the anger stage of a terminal patient. They are not irritated for the sake of being irritated. They are angry because they are in a situation they cannot control and that will be fatal regardless of what they or anyone else does now. Anything that might have prevented the current situation is in the past and is too late to reverse the inevitable fate awaiting them.

Because the stages of dying are stages, most people eventually find themselves moving out of one into another. This is as true for the denial and isolation stage as it is for the anger stage. Kubler-Ross writes, “A patient who is respected and understood, who is given attention and a little time, will soon lower his voice and reduce his angry demands. He will know that he is a valuable human being, cared for, allowed to function at the highest possible level as long as he can.”[3] This description helps name some of the primary frustrations that are likely triggers behind the anger being displayed: not feeling respected, listened to, or understood. While these may or may not be the reality, if a patient perceives that is what is occurring, the patient will react as if it were happening. Most of us, given a similar perception, would also react angrily.

The third stage of dying is bargaining. Kubler-Ross describes the succession of first three stages in this way: “If we have been unable to face the sad facts in the first period and have been angry at people and God in the second phase, maybe we can succeed in entering into some sort of an agreement which may postpone the inevitable…”[4] I remember my 14-year-old self bargaining with God as I waited to hear from my mother after the ambulance took my unconscious father from our home to the hospital. “If you let my dad be okay, I will dedicate the rest of my life to you,” or some such plea. God did not take me up on the offer, but I tried as a last-ditch effort.

Terminally ill patients and their loved ones often try something similar. The wish may be for their life to be extended or for their pain to be relieved, if only for a short time. Kubler-Ross describes the typical bargaining request as one for a postponement of death as opposed to a cure, such as to live long enough to see the birth of a grandchild or a temporary reprieve from the pain. In return, the patient’s implicit offer is to submit to their fate peacefully after the wish has been granted. She notes that, in some cases, the patient’s bargaining may be associated with guilt for something they wish to resolve but may not know where to begin. She cites the importance of staff training to help recognize such concerns, which are often unspoken, and to help the patient work through them. Some patients feel guilty about not attending church more often or of various estrangements from formerly close friends or family members. To the extent the patient is bargaining to cover their guilt, they will have a difficult time coming to grips with their situation and moving towards a more peaceful acceptance until the guilt is named and resolved, at least to the extent possible.

I will consider the last two stages of dying, depression and acceptance, next week.

This is the 36th in the series of Life Notes titled, If I Should Die Before I Wake. I invite your thoughts, insights, and feedback via email at ghildenbrand@sunflower.com, 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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[1] Elisabeth Kubler-Ross, MD, On Death and Dying. Scribner, New York, 1969, p. 49.

[2] Ibid.

[3] Ibid, p. 51.

[4] Ibid, p. 79.