The Stage of Dying

by Dr. Albert Lim Kok Hooi

Elizabeth Kübler-Ross, a Swiss-born psychiatrist, presented the “stage theory” in her book, On Death and Dying (1969), that the dying underwent 5 stages : denial, anger, bargaining, depression, and acceptance. She provided a compass for doctors who dealt with the dying.

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Stage 1 - Denial

When a patient was told she had cancer, she would first go into the stage of denial. "It can’t be true. Cancer only happens to those who drink, smoke, or are profligate in their ways." "It is only a small ulcer that will go away when I wake up tomorrow."

Stage 2 - Anger

And soon, there would be the "Why me?" laced anger and vitriol. This anger was directed at loved ones, doctors and sometimes God.

Stage 3 - Bargaining

The usual form that bargaining took was "God, if I am cured, I shall be penitent and reverent. I shall not be remiss in my prayers. I will do good on my pledges of sacrifice."

Stage 4 - Depression

The depression phase set in when food, sex, and physical activity were no longer desired. Low moods and sometimes suicidal tendencies plagued the patient.

Stage 5 - Acceptance

Finally, the stage of acceptance. The cancer patient, and for that matter any person facing impending death, finally accepted his lot. He was no longer despondent and looked forward to each new day as a bonus.

Many Reacted in Different Ways

A decade or two after the publication of Kübler-Ross’ Of Death and Dying, many oncologists realised that humans, when faced with imminent death, reacted in vastly different ways. Some patients manifest only one or two of the 5 stages. Many a patient will speak, two weeks before their death, of their plans that stretch over 10 to 20 years. The unborn grandchild they will cherish. The house in Sydney they will buy, with a view of the Opera House. They deny their death till the end.

Some others are depressed all the way to their dying day despite of cliches and pills. Yet others accept their finite existence with equanimity hardly a month after knowing they have end-stage cancer.

Very few patients underwent the 5 neat stages of dying as postulated by Kübler-Ross. One or more of these stages are either missing or truncated. There was no 'normal' or 'usual' way of facing death.

Grieving Process

Kübler-Ross’s five stages – denial, anger, bargaining, depression and acceptance – are also applied to the process of grieving.

Some people take a long time – years, decades, never – to get over the loss of a loved one. Nothing we can say or do will pull them from one stage to the other. That is how they cope (or not cope) and we should not unduly intrude into a private pain and a personal way of coping.

Some others get on with it well. They get remarried within a year of their spouse's demise. Are we to cast the first stone as we moralise about their 'indecent' haste?

Freud is very relevant as a historical figure. It was he who taught us that mental disorders had a scientific basis. He was studious and methodical. Even though we do not now accept most of his theories of psychoanalysis, we still regard him as the Father of Modern Psychological Medicine.

In the same vein, we acknowledge and praise Elizabeth Kübler-Ross as one of the pioneers who took the taboo out of death and dying. Her work has inspired many of her intellectual descendants – to try to make sense of it all.

More info on STAGE OF DYING here.

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