KÜBler-Ross's Stages of Dying

Elisabeth Kübler (1926–2004) described herself as stubborn, opinionated, independent, and unconventional. As a youth growing up in Switzerland, she was determined to become a doctor despite a childhood experience of hospitalization in which she was isolated and separated from her family by what she viewed as an impersonal and uncaring system.

After qualifying as a physician and marrying a fellow medical student from America, Emanuel (“Manny”) Ross, the couple moved to the United States. As a new doctor, Kübler-Ross accepted a residency in psychiatry because becoming pregnant disqualified her from one in pediatrics.

In the fall of 1965, Kübler-Ross was a faculty member at a University of Chicago hospital when four theological students asked her to help them understand death as the ultimate crisis in life. She offered to identify dying patients with whom to conduct interviews, but many of the other physicians at the hospital were critical of their new colleague. They were concerned about exploiting vulnerable patients and unwilling to grant access to their patients. Still, by early 1967, Kübler-Ross was leading an unorthodox but popular weekly seminar in which she would interview a patient behind one-way glass with subsequent discussion after the patient had left.

In 1969, an article in Life magazine and publication of what was to become an international best seller, On Death and Dying, led to worldwide fame and countless requests for Kübler-Ross to give [Page 627]interviews, lectures, and seminars on subjects that soon became the focus of her professional life.

Kübler-Ross had views on many subjects, including the afterlife, spiritual guides, out-ofbody experiences, and near-death experiences, but she is best known for her theory of the five stages of dying.

The Five Stages

The stage theory of dying arose from interviews that Kübler-Ross conducted with some 200 adult patients over a period of roughly 3 years. Each of the stages can be associated with a typical expression.

Each stage of the theoretical model represents a typical human reaction:

• 1.
  Denial involves reactions to the shock of the diagnosis. It reflects unwillingness to acknowledge or outright rejection of the fact that one is dying. Denial is also a kind of protective barrier aimed at holding off the implications of terminal illness.
• 2.
  Anger arises when denial can no longer be sustained. It at least partially acknowledges that the individual is dying but also complains this is not fair or right. Anger is often projected toward care providers, God, or other perceived contributors to the illness.
• 3.
  Bargaining involves resignation combined with efforts to regain some degree of influence by focusing (realistically or unrealistically) on what might be done to postpone death or arrange for that outcome to occur in ways more acceptable to the individual in return for pledges of various types to God or the doctors (Kübler-Ross did not expect most individuals to keep these promises).
• 4.
  Depression focuses on the individual's sense of loss, either on past and present losses, or on future, anticipated losses, such as the expected loss of all love objects.
• 5.
  Acceptance is described as a reaction when the end may seem positive or there may not be enough strength to live. Different individuals may experience acceptance in different ways, ranging from looking forward to impending death as relief from suffering or an opening to the afterlife, on the one hand, to grudging acknowledgment of one's fate, on the other hand.

Kübler-Ross suggested that with adequate time and support dying people can or may work through each of these five stages. She emphasized that hope usually persists throughout, informing care providers of the importance of allowing dying people to sustain hope, whether or not the care provider agrees with the form hope takes. This important aspect of the theory has often been overlooked.

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