Note: Extracted from part of book report I submitted for the course Grief Counselling in 2017 Spring
“On Death and Dying” was first published in 1969, authored by Elisabeth Kübler-Ross based on her experience working with terminally ill patients and their families. That was the time when medical practitioners were highly authoritarian leaving almost no room for patients to participate in decisions and society also avoided talking about death openly and privately.
Death is a universal fear. When the time comes, patients will be increasingly fearful and lonely as they were taken out from their familiar environment and medical personnel in hospital are “busily preoccupied with his heart rate, pulse, electrocardiogram or pulmonary functions, his secretions or excretions” but no one try to understanding their needs, worries and feelings making the process impersonal to repressing medical personnel’s anxieties inside. (Chapter 1)
In Chapter 2, Kübler-Ross expressed that we are less able to defend physically as technology advanced, new weapons of increasing power of destruction continue to be invented, and this intensified our fear of destruction and anxieties towards death. Medical development to prolong life and depersonalized medical care was used to master death. Kübler-Ross invited us to face our own death for inner peace so we have the courage to encounter patients’ death and re-think how science and technology can bring us a more humanistic world.
Chapter 3 – 7 explained the five stage of grief, also known as Kübler-Ross model.
Stage 1: Denial and Isolation (Chapter 3)
It is a temporary defense of not accepting the shocking news. They tends to believe that the diagnosis is not right or they are recovering and need not to go through further diagnosis and treatment in a short while.
Stage 2: Anger (Chapter 4)
Patients’ anger will be displaced and projected randomly to family members and hospital staff through complaints and guilt or shame induction resulting in less visit and avoidance. This, then, intensifies the anger in patients — a vicious cycle of alienation is thus formed. Inside their anger and attention seeking acts are the fear of being forgotten, and sometimes envy of healthy people. Thus, anger shouldn’t be taken personally.
Stage 3: Bargaining (Chapter 5)
Patients attempt to ask, towards God usually, for the last reward (i.e. postponing death according to the self-imposed deadline) in exchange with good behavior. Behind this could be quiet guilt towards God (e.g. not attending church, not devoted enough into the religion) or “deeper, unconscious hostile wishes” that needs to be taken care of.
Stage 4: Depression (Chapter 6)
As patients’ illness progress, they became weaker, more hospitalization and operations were imposed, sooner or later “sense of great loss” will become dominate. This is the stage which patients are preparing themselves to separate from this world and losing everything they love through grief (aka. preparatory grief), communications will shift to non-verbal one and their circle of interest decreases. Thus, there aren’t need to “cheer them up” as this normally serves our own inability to face death.
Some complications may result if patients had unresolved griefs as a result of past losses or regrets of haven’t taking certain opportunities when they are well.
Stage 5: Acceptance (Chapter 7)
It is a stage which patients are “void of feelings” and death could be a relief. Patients’ family will need more support than patients themselves. Their circle of interest further shrank. Nonverbal communication reminds them that they won’t be left alone until the very end.
If patients’ family failed to distinguish or accept that patients are under this stage, blaming them for giving up “too early” or try real hard to prolong their life, they will feel dismay and angry to their family.
Kübler-Ross talked about Hope in patients that exist in all stages in Chapter 8. Hope maintains that their sufferings will “pay off eventually” by recovering, by a new drug or treatment plan that helps, if they endure it a bit longer. Hope also gives them a sense of meaning in their sufferings. Kübler-Ross reminded family members and caring professionals to “maintain hope” but not “reinforce hope” at the stage of final acceptance.
Chapter 9 focuses on how patients’ family can help and the adjustment and preparation needed by family members when patients become weaker and eventually pass away. Family members should maintain a balance between taking care of patients and their own needs for their well beings during patients’ hospitalization.
Direct communications, discussions and expression of feelings between patients and their family members about the impending death not only can avoid anger, alienation and isolation but bring closeness and deeper sense of meaning to all. After all, patients can see through the make-believe mask of their family members. This not only prepares patients to go through anger and preparatory grief and eventually accept their impeding death, but their family members to go through similar stages.
Kübler-Ross suggests that family members will feel “void and emptiness” after the funeral when relatives depart, thus right timing for “human beings” to talk and care them, and allow them to express their angry, despair or loneliness. Children and adolescence should be taken care of as well. For members who are pre-occupied with fantasies with the deceased, we should understand and allow them to express their feeling and not to ridicule or confront them too frequently.
Additional interviews, their transcripts and analysis can be found in Chapter 10. For Chapter 11 & 12, Kübler-Ross shared the adversaries and oppositions from medical personnel throughout her works of interviewing terminally ill patients, and how this helps bringing a whole new perspective to medical personnel to provide “humanistic” and less impersonal medical care, and the courage to face death for both medical personal, patients’ themselves and their families.