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Death and Dying for the Terminal Patient

 

STAGES OF GRIEF

Doctor Elisabeth Kubler Ross, a medical doctor, was one of the earliest pioneers in the study of death and dying and the hospice system. She spent many years with dying patients to learn more about the final stages of life so people would not shy away from the dying but get closer to them. What she discovered was a coping mechanism that patients go through at the time of a terminal illness. Although her book was written for the dying person, it really is a book on grieving, helpful not only to the dying but to the bereaved as well.

The five stages as described by Dr. Elisabeth Kubler Ross are:

  • Denial and Isolation
  • Anger
  • Bargaining
  • Depression
  • Acceptance

THE FIRST STAGE IS DENIAL AND ISOLATION

Denial shows itself as claims by the patient that the tests and x-rays are wrong or mixed up with someone else's, or he requests a third or fourth opinion. Denial is a healthy way of dealing with the uncomfortable and painful situation, it functions as a buffer, it allows the patient to collect himself. The first reaction may be a state of shock because we all feel that we are immortal and it is almost inconceivable to acknowledge that we have to face death. Denial occurs at the very beginning of a serious illness and it is much later that the patient uses isolation more than denial.

THE SECOND STAGE IS ANGER

Denial is replaced by feelings of anger, rage, envy, and resentment. This stage of anger is very difficult to cope with because the anger is displaced in all directions and randomly towards the doctors, the nurses, the family members, and even God. The patient may raise his voice, make demands, complain and ask for attention perhaps to let people know that he is alive and not to be forgotten.

THE THIRD STAGE IS BARGAINING

This stage is a little difficult to explain and perhaps an example would best illustrate as an explanation. When a child asks for something and the parent says no. The child reacts by getting angry and may pout, lock himself in his room, refuse to talk to his parents or take other actions to show his anger. Shortly thereafter, he will have second thoughts and try another approach. He may volunteer for example to do the dishes, which under normal circumstances the parent never succeeded in getting him to do. He then tells his parent, "If I am very good all week and wash the dishes every evening, then will you let me have it?" Of course there is a slight chance that the parent will accept the bargain and the child will get what was previously denied. The terminally ill patient uses the same tactics. In their case, the request is usually for an extension of life or for a few days without pain or physical discomfort. The patient surmises that if God decided not to take me from this earth and he did not respond to my angry pleas, maybe he will be more favorable if I ask nicely. Most bargains are made with God and are usually kept a secret. They often are promises to dedicate their lives to God or a life in the service of the church in exchange for some additional time.

THE FOURTH STAGE IS DEPRESSION

When the patient realizes that he can no longer deny his illness since he is forced to undergo more surgery or more symptoms appear and he becomes weaker and thinner, a sense of great loss overcomes him. The loss may include the results envisioned because of the great expense of treatments and hospitalization. For example, he may feel that he has to sell his home, he may not be able to send his children to college, or his family may be forced into homelessness. It is an expression of his regrets or failures for lost opportunities while there was time to be with his family. These are called reactive depression and they usually can be alleviated by discussions with the doctor, social worker, or minister. The patient can be shown that their guilt is unrealistic by explaining the possibilities that can be pursued. Reactive depression is usually lifted when the vital issues are taken care of to the patient's satisfaction.

There is another type of depression that is called preparatory depression. That is grief that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world. For this type of depression encouragements and reassurances are not as meaningful. This depression is usually a silent one. In preparatory grief there is little or no need for words. It is more a feeling that can be mutually expressed and is often done with a touch of a hand, the stroking of the hair, or just a silent sitting together. This is a time when the patient may ask for a prayer when he begins to occupy himself with things ahead rather than behind. The patient is sad that he is being forced to struggle with life's issues when, at the same time, he is preparing himself to die.

THE FIFTH STAGE IS ACCEPTANCE

If a patient has had enough time, he will reach a stage during which he is neither depressed nor angry about his fate. He had time to express his feelings, his envy for the living and the healthy, his anger at those who do not have to face their end so soon, the impending loss of so many meaningful people and places, and so he contemplates his inevitable end with a certain degree of quiet expectation. He will be tired and quite weak. He often will have a need to doze off or to sleep often. This is not a sleep of avoidance or a rest to get relief from pain or discomfort. It is not a resigned and hopeless giving up, a sense of what's the use or I just cannot fight it any longer. It is a gradually increasing need for more sleep.

Acceptance should not be mistaken for a happy stage. It is almost void of feelings. The dying patient has found some peace and acceptance and wishes to be left alone and not be bothered with the problems of the outside world. Communications becomes nonverbal rather than verbal. He may just hold your hand and ask the family to sit in silence. The family's presence reassures him that he is not left alone when he is no longer talking. A pressure of the hand or a look may say more than words. It is comforting for the patient to know that he is not forgotten when nothing else can be done for him.

These stages will last for different periods of time and will replace each other or occur at the same time. The one thing that usually persists through all these stages is hope. The hope that a cure may be discovered is what makes them endure their situation for a little longer. If a patient loses hope, it is usually a sign of imminent death. Each patient needs to be assured that the most effective treatment will be provided. If we give up on the patient, he may give up on himself. The patient needs to be assured that there is hope so he will not feel deserted or abandoned.


 

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Last modified 1 August 2014.
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