Stages of Dying


Article Author:
Patrick Tyrrell


Article Editor:
Waquar Siddiqui


Editors In Chief:
Susan Johnson
Alexandra Caley


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
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Saad Nazir
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Pritesh Sheth
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Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/3/2019 12:10:15 PM

Introduction

Medical professionals encounter dying patients throughout all disciplines of healthcare. This patient becomes unique as the focus of their care shifts from becoming well to preparing for death. This is a difficult transition for patients, their loved ones, and healthcare providers to undergo. A better understanding of the process of moving toward death allows providers to address the unique needs of their patients and guide them and their loved ones through the process.[1][2][3]

Function

The most commonly taught system for understanding the process of grieving and preparing for death is the DABDA model which states the patient will progress through 5 stages: denial, anger, bargaining, depression, and acceptance. The DABDA stages are based on works of Elisabeth Kubler-Ross, a Swiss psychologist whose work revolved around grief, dying patients, and those who care for them. Her book, On Death and Dying which was published in 1969, was the first work to outline these stages. Her model has been applied to many types of grief and loss such as amputation of a limb or loss of a job. Further work by Kubler-Ross and other scholars has to lead to the understanding that these stages may not occur in sequential order. Additionally, each stage may manifest very differently, or not at all, in individual patients due to differences in personality, culture, the rate of disease progression, and many other factors. The DABDA stages model remains popular as it provides an uncomplicated system for providers, especially those who only rarely care for dying patients, to better understand and provide for the needs of the dying patient.[4][5][6]

Issues of Concern

DABDA Model: Five Stages of Grief[7][8][9]

Denial

At first, the patient reacts with denial. This may initially manifest as shock or speechlessness. It is common to believe a mistake in the prognosis has been made due to inaccurate test results, having not attempted the correct treatment, or deficits in knowledge of their provider. Some patients may exist in an alternate reality. They may tell loved ones, who are already aware of their prognosis, “We will go on a vacation as soon as I’m better."

Anger

The patient moves to the second phase when they are no longer able to deny their imminent death. They become frustrated and angry. They typically direct their aggression toward friends, family, and providers. Examples statements include: “how can you let this happen to me,” "this is your fault," and “why is this happening to me?”

Bargaining 

The third stage manifests as a patient negotiates to avoid death. It is common for him or her to negotiate with a higher power in their religion, typically asking them to cure the disease or prolong life in exchange for reforming their lifestyle. Examples include: “if you cure this lung cancer I’ll never smoke cigarettes again” or “give me one more year, and I will be a better father.” It is not uncommon for an individual who has not actively practiced religion throughout his or her life to become strongly religious. A patient may ask for a spiritual leader, begin praying, or ask others if they believe the patient will be accepted into the afterlife.

Depression

The fourth phase begins as the patient recognizes the inevitability of death. Despair is a common reaction, as if they have been defeated as they battled for life in the earlier stages. They typically show symptoms traditionally associated with depression: sadness, fatigue, self-harm, self-pity, or social avoidance. They may refuse visitors and medications or make statements such as, "I'm going to die soon, why does it matter?"

Acceptance

In the last stage of death, emotions become more calm and stable. They may focus on finding joy in what time they have left. They will commonly reflect on joyful memories or tell stories from the past. Spending time with loved ones can create pleasant memories for survivors to reflect on. The patient may begin to prepare for death by planning their funeral or making sure loved ones will be taken care of financially and emotionally after their death.

Clinical Significance

The transition in care, from attempting to heal the patient to caring for them as they near death, is difficult for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead to patients, and their loved ones, are feeling that healthcare providers abandon them as they near death. They often wish for guidance on the complex changes that the patient is going through emotionally and physically. Actions which are a normal part of the dying process, such as anger and refusing visitors, can leave loved ones confused and upset. Understanding the stages of grief allows providers to give support and guidance during the dying process.[10]

Other Issues

Other Models of Grief

The DABRA model is frequently criticized for being too rigid. Other models include Bowlby and Parkes' Four Phases of Grief and Worden's Four Basic Tasks In Adapting To Loss.

Bowlby and Parkes' Four Phases of Grief

Bowlby and Parkes proposed a reformulated theory of grief based in the 1980s. Their work is based on Kubler-Ross' model. Their model has 4 stages and emphasizes that the grieving process is not linear. 

Shock and Disbelief 

The initial phase replaced the term "denial" due to negative connotations. In this phase, the reality is altered as the mind responds to a stressful situation by becoming unresponsive, or numb, to the new situation. Over time, the mind processes the new reality, and the patient moves to a new phase.

Searching and Yearning

This phase is closely related to the Anger and Bargaining stage of the DABDA model. The patient will attempt to undo the new reality and question the reason for it. 

Disorganization and Repair 

This phase closely relates to the Depression stage of the DABDA model. The patient experiences full acceptance of the new reality. They show signs of depression and apathy. 

Rebuilding and Healing 

In this phase, the patient experiences a "renewed sense of identity" which represents overcoming the sense of loss and feels in control of their destiny. They no longer show signs of depression. 

Worden's Four Basic Tasks In Adapting To Loss

Woden's model of grief does not rely on stages but instead states that 4 tasks must be completed by the patient to complete bereavement. These tasks do not occur in any specific order. The grieving person may work on a task intermittently until it is complete. This model is more applicable to the grief of a survivor but may also be applied to a patient facing death.

Accepting Reality of Loss

Initially, the patient may have difficulty accepting the reality of impending death. Typically, acceptance is viewed as being ready to move forward with the process of preparing for death.

Experiencing Pain of Grief 

Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel "normal" again.

Adjusting to Environment 

An all-consuming focus on impending death will cause the patient to ignore other roles in life that are important to them. To complete this task, the patient will resume typically daily activities such as resuming work or hobbies or becoming engaged as a spouse or parent.

Redirecting Emotional Energy

This task is generally applicable to grieving survivors. Survivors redirect their emotional energy from suffering the loss of a loved one to engaging in new activities that bring pleasure and new experiences.

Enhancing Healthcare Team Outcomes

For the healthcare team, the most difficult patients are those near death, it is difficult for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead to patients, and their loved ones, to feel they have been abandoned by the healthcare team as they near death. They often wish for guidance emotionally and physically. The healthcare team should have an understanding of the stages of grief which allows providers to give support and guidance during the dying process and provides a coordinated effort to provide the patient and family with much needed emotional support. [Level V]


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Stages of Dying - Questions

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A patient you are caring for with end-stage liver disease was recently informed they do not qualify to receive a liver transplant. The patient's family asks why the patient is refusing to see them this morning. Based on the five stages of grief model, what should you do?



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Your patient was recently diagnosed with a terminal illness. Based on current models for stages of grief, which of the following statements are correct?



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You are caring for a patient with multiple severe medical problems who has chosen palliative care. This morning another caregiver complains the patient is upset with family members, blaming them for causing the problems. In which stage is the patient according to the Kubler-Ross model of grieving?



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Yesterday, your patient was informed their disease has progressed and is no longer curable. They have been given a grim prognosis with less than a month to live. When you visit the patient this morning, they are in the process of planning a three-month vacation. According to the Kubler-Ross model, how would you explain the patient's reaction?



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You are working in a hospice facility, and one of the patients is laughing with family members as they tell stories from the past. Recalling the Kubler-Ross model, what is the best explanation for this behavior?



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Stages of Dying - References

References

Hirdes JP,Heckman GA,Morinville A,Costa A,Jantzi M,Chen J,Hébert PC, One Way Out? A Multistate Transition Model of Outcomes After Nursing Home Admission. Journal of the American Medical Directors Association. 2019 Apr 4;     [PubMed]
Bregman L, Kübler-Ross and the Re-visioning of Death as Loss: Religious Appropriation and Responses. The journal of pastoral care     [PubMed]
Tang HM,Tang HL, Anastasis: recovery from the brink of cell death. Royal Society open science. 2018 Sep;     [PubMed]
Pravin RR,Enrica TEK,Moy TA, The Portrait of a Dying Child. Indian journal of palliative care. 2019 Jan-Mar;     [PubMed]
Powell MJ,Froggatt K,Giga S, Resilience in inpatient palliative care nursing: a qualitative systematic review. BMJ supportive     [PubMed]
Thurn T,Borasio GD,Chiò A,Galvin M,McDermott CJ,Mora G,Sermeus W,Winkler AS,Anneser J, Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis. Amyotrophic lateral sclerosis     [PubMed]
Corr CA, Elisabeth Kübler-Ross and the     [PubMed]
Lazzarin P,Marinelli E,Orzalesi M,Brugnaro L,Benini F, Rights of the Dying Child: The Nurses' Perception. Journal of palliative medicine. 2018 Sep 25;     [PubMed]
Friedrichsdorf SJ,Bruera E, Delivering Pediatric Palliative Care: From Denial, Palliphobia, Pallilalia to Palliactive. Children (Basel, Switzerland). 2018 Aug 31;     [PubMed]
Berbís-Morelló C,Mora-López G,Berenguer-Poblet M,Raigal-Aran L,Montesó-Curto P,Ferré-Grau C, Exploring family members' experiences during a death process in the emergency department: A grounded theory study. Journal of clinical nursing. 2018 May 12;     [PubMed]

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