For patients and families, there are many questions and few answers surrounding end of life issues. While there is plenty of information available, and doctors do their best to prepare both the patient and the loved ones of what's to come, death, like life, is an individual process. Sometimes there is no schedule, no "normal." Still, psychologists will say there are predictable stages to the end of life process, and that the Kubler Ross model from the seminal 1969 volume, "On Death and Dying" applies almost universally and particularly in patients who feel as though their time has come too early.
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With any bad news, the natural inclination is to deny the possibility. The first word spoken upon hearing the news of an impending death is "no." This denial often leads to isolation as the only way to remain in this early stage is to avoid talking about it. A patient may withdraw from loved ones rather than admit to the realities and talk about them with family.
The anger a patient feels (or a family member, for that matter) is most easily summarised in the question, "Why me?" That anger can manifest itself in various ways. A patient might act out by arguing with caregivers or "settling scores" with estranged family members. It's a way to say, "I'm still here. I'm not dead yet." It's a struggle for vitality, for relevance, in the face of the reality that soon, the patient won't have a voice or a presence in this world.
The urge to deal with a higher power or doctors in an effort to do one cherished thing "one last time" extends beyond the thing being discussed and more broadly is simply a wish for more time for anything. People learn to bargain early in life, like the child who promises to do extra chores in exchange for a desired toy or treat. This stage, then, is derived from a lifetime of experience, and it is the natural fallback position when there is something that is perceived to be just out of reach -- in this case, more time.
Properly managed by caregivers and family members, depression can be a healthy transition through the end of life stages. Providing it doesn't linger or draw the patient too deeply into despair, it is a way to express the sadness and feel it in all its intensity. It is a necessary cleansing step toward acceptance.
A patient in Kubler-Ross' book describes acceptance as "the final rest before the long journey." This is a time for quiet reflection, and surprisingly, often happy moments of fond remembrance. A patient often desires company during this time, even if he is unable to communicate. Just the presence of a loved one nearby is reassuring and can prevent a last minute regression to one of the earlier stages.
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