Kubler-Ross Stages of Dying or Grief

Precipitating Factors of Grief

• Death in family
• Separation
• Divorce
• Physical Illness
• Work failure disappointments

1. Denial

• Initial response to protect the self from anxiety.
• “No not me”, “Its not true”, “Its not impossible”
• May continue to make impractical/unrealistic plans
• May comment that a mistake has been made about the diagnosis of terminal illness
• May appear normal and can continued ADL as if nothing is wrong
• May not conform with the advised treatment regimen
• Adaptive response – crying, verbal denial
• Maladptive response – absence or reaction such as crying.

2. Anger

• Individual feel that they are victims of incompetence or a vengeful God (they did something wrong so they are being punished), fate (karma), circumstances (wrong place and wrong time).
• “Why me”, “What did I do to deserve this?”
• They seek for reasons, answers and explanations
• May express anger overtly – being irritable, impatient, critical verbally abusive.
• May express anger covertly by neglecting self, not eating, nor going to check ups, committing suicide, drinking alcohol.
• Adaptive response – verbal expression
• Maladaptive – persistent guilt or low self esteem, aggression, self destructive ideation or behavior.

3. Bargaining

• The person try to inhibit good behavior, make up for perceived wrong doings or other engage in behaviors that would please GOD so he will be given more time-an extension of life or granted recovery.
• “Yes, me but”
• “If I live until Christmas or until my child’s graduation ( So many if’s), I will do this…”
• Adaptive response – bargains for treatment control, express wish to be alive for specific events in the near future.
• Maladaptive response – bargains for unrealistic activities or events in the distant future.

4. Depression

• Occurs when the reality of loss or impending loss cannot be ignored anymore and the person grieves for himself and those he will leave behind, for the things that he can no longer accomplish or experience.
• “Yes, I’m dying”
• Withdrawn, has no energy and interest to interact.
• Cries
• Makes few demands
• Adaptive response – crying, withdrawing from interaction
• Maladaptive response – self destructive actions, despair.

5. Acceptance

• Occurs when the person has come to peace with himself and others
• “Yes, I am ready”
• Stage of affective void – not happy nor sad
• Only persons who are highly significant to him stimulates a reaction. Others are merely tolerated.
• Makes realistic preparation
• Adaptive response – may wish to be alone, limit conversation, complete personal and family business.

Nursing Interventions:

• Assess; specific loss, meaning of loss, coping skills, support persons.
• Accept the client; do not respond personally to the client.
• Support adaptive responses; allow to express feelings
• Support defense mechanism – reassure client that denial and wanting to be alone is normal.
• Help find constructive outlets of anger. Do not take clients hostility personally. Do no retaliate.
• Monitor for self destructive behaviors
• Help express feelings: Ask how they feel
• Meet needs
• Allow as much decision making as possible to maintain dignity by giving choices and alternatives.

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