Grief, Part 4

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Grief, Part 4

 When the terminally ill patient can no longer deny his illness, when he is forced to undergo more surgery or hospitalization, when he begins to have more symptoms or becomes weaker and thinner, he cannot smile it off anymore. His numbness or stoicism, his anger and rage will soon be replaced with a sense of great loss. Elizabeth Kubler-Ross, MD[1]

The first three stages of dying identified by Swiss-American psychiatrist, Elisabeth Kubler-Ross, in her book On Death and Dying,[2] are denial and isolation, bargaining, and anger. I reflected on these stages in Life Notes over the past couple of weeks. The fourth stage is depression. Kubler-Ross identifies two types of depression, each requiring different responses from care-givers. They are reactive and preparatory depressions. Reactive depression is activated by the various and increasingly uncomfortable changes occurring in one’s physical health and environment as the terminal condition progresses. Some of these factors may include increases in pain – either in its intensity or frequency, decreased ability to function as one has always functioned, inability to visit with friends or care for family as one would like, and the often-crippling financial burden of the treatments. Changes in one’s body from disfiguring surgeries or the unpleasant side-effects of powerful medications can also contribute to reactive depression. This understandable reaction to the difficult realities of some illnesses is often exacerbated by feelings of guilt – “I need to be fixing supper for my family” — or shame – “No one could possibly accept the way I look.”

Clearly, one’s self-esteem and sense of self-worth take significant hits in reactive depression. It can be helpful for care-givers to identify and emphasize positive traits that remain while assisting in rearranging household duties or other areas of obligation causing guilt or shame to the patient. Helping them understand that yes, they are missed, but the world continues to function in their absence, albeit in a different way. They still belong and have an important place in the world. Care-givers can help them focus on other sources of self-worth. No one’s value is determined by what is happening to them.

Where reactive depression is caused by what one is losing and has actually lost, preparatory depression arises as one anticipates what they will lose in death – the objects and people they have known and loved for so long. Kubler-Ross writes, “Our initial reaction to sad people is usually to try to cheer them up, to tell them not to look at things so grimly or so hopelessly. We encourage them to look at the bright side of life…”[3] While this type of response may be helpful with reactive depression, it is often detrimental in preparatory depression. At this point, sadness is a natural and appropriate response. Losing contact with those we love is difficult and that difficulty should not be minimized or trivialized. And the more deeply we have loved, the more painful will be the parting. Allowing the patient to express his or her sorrow or just sitting in silence beside them is often the best we can do for them and may help ease a transition into the final stage of acceptance. The best medicine I received after my father’s sudden death was provided by my best friend. He came to my house a few hours after dad died and sat beside me on my bed while I cried. There was nothing to say, nor would any words have been helpful. There are no words for that type of suffering. He did, however, make sure I did not suffer alone.

The experience of depression, like the other stages of dying, is not limited to the person dying. Loved ones and friends may also fall into a reactive and/or preparatory depression for similar reasons. We may react to a parent’s inability to care for us as they once did or a friend’s inability to listen to our problems. We may miss being able to give a full-body hug, or we may be unable to hide our discomfort with the altered body or mental state of our loved one. The guilt and shame then lands upon us, possibly plunging us into depression, too. We find ourselves unable to care for and support the person as we believe we should. Likewise, as the death of our loved one nears, we may find ourselves in a preparatory depression, knowing this person we have loved and depended upon so heavily is about to be taken from us.

I will consider the fifth stage of dying, acceptance, next week.

This is the 37th in the series of Life Notes titled, If I Should Die Before I Wake. I invite your thoughts, insights, and feedback via email at, or through my website, 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. 83.

[2] Ibid.

[3] Ibid, p. 85.

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