People, when faced with imminent death, react in vastly different ways.
AS a young oncologist in the early 1980s, I was struck by Elizabeth Kübler-Ross’ “stage theory”. Kübler-Ross, a Swiss-born psychiatrist, postulated in her book, Of Death and Dying (1969), that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance. She provided a compass for doctors like me who dealt with the dying. Her thoughts and philosophy made sense to me at that time.
When a patient was told she had cancer, she would first go into the stage of denial. “It can’t be true. Cancer only happens to those who drink, smoke, or are profligate in their ways.” “It is only a small ulcer that will go away when I wake up tomorrow.”
And soon, there would be the “Why me?” laced anger and vitriol. This anger was directed at loved ones, doctors and sometimes God. The usual form that bargaining took was “God, if I am cured, I shall be penitent and reverent. I shall not be remiss in my prayers. I will do good on my pledges of sacrifice.”
The depression phase set in when food, sex, and physical activity were no longer desired. Low moods and sometimes suicidal tendencies plagued the patient.
Finally, the stage of acceptance. The cancer patient, and for that matter any person facing impending death, finally accepted his lot. He was no longer despondent and looked forward to each new day as a bonus.
A generation or two of healthcare workers (who dealt with the dying) accepted this conventional wisdom and tried to see their wards through using this formula. This reminded me of Freud’s stages of psychosexual development. The oral stage, the anal stage, the genital stage, and finally the mature, adult, sexual stage. If you were stuck in one of the stages, that was it. You became a hoarder, a stutterer, or a compulsive masturbator.
A decade or two after the publication of Kübler-Ross’ Of Death and Dying, many of my fellow oncologists and I realised that humans, when faced with imminent death, reacted in vastly different ways. Some patients manifest only one or two of the five stages. Many a patient will speak to me, two weeks before their death, of their plans that stretch over 10 to 20 years. The unborn grandchild they will cherish. The house in Sydney they will buy, with a view of the Opera House. They deny their death till the end.
Some others are depressed all the way to their dying day despite our clichés and pills.
Yet others accept their finite existence with equanimity hardly a month after knowing they have end-stage cancer.
Very few patients I have cared for underwent the five neat stages of dying as postulated by Kübler-Ross. One or more of these stages are either missing or truncated. There was no “normal” or “usual” way of facing death. At each and every step of the dying process, I facilitated the patient. I did not wait for one stage to morph into another. The better I could do all that in a non-judgemental, non-proselytising, non-formulaic way.
Kübler-Ross’s five stages – denial, anger, bargaining, depression and acceptance – are also applied to the process of grieving. When we counsel the bereaved, and apply this teaching, we realise how inadequate it is. We are often surprised by the many trajectories grieving can take.
Some people take a long time – years, decades, never – to get over the loss of a loved one. Nothing we can say or do will pull them from one stage to the other. That is how they cope (or not cope) and we should not unduly intrude into a private pain and a personal way of coping.
Some others get on with it well. They get remarried within a year of their spouse’s demise. Are we to cast the first stone as we moralise about their “indecent” haste?
Freud is very relevant as a historical figure. It was he who taught us that mental disorders had a scientific basis. He was studious and methodical. Even though we do not now accept most of his theories of psychoanalysis, we still regard him as the Father of Modern Psychological Medicine.
In the same vein, I acknowledge and praise Elizabeth Kübler-Ross as one of the pioneers who took the taboo out of death and dying. Her work has inspired many of her intellectual descendants – me included – to try to make sense of it all.
Loss, grief, and poetry are a natural threesome that reflects life and its sorrows and fights. Emily Dickinson, one of my favorite poets, captures how heavy her grief is and wonders about other people’s grief in her poem, I Measue Every Grief I Met. I cannot say it better than her.
I wonder if It weighs like Mine, Or has an Easier size.
I wonder if They bore it long, Or did it just begin,
I could not tell the Date of Mine, It feels so old a pain,
I wonder if it hurts to live, And if They have to try,
And whether, could They choose, between,
It would not be, to die.
Source : The Star Online
