Lesson 3: Stages of Grief

When a person is diagnosed with a terminal illness, he or she will most likely experience some type of emotional distress while coming to terms with imminent death. Similarly, many caregivers and other loved ones of the patient also go through a type of mental processing in order to accept the inevitable loss of someone dear to them. This search for acceptance is often a difficult one. It begins at the time of diagnosis when grief and tension within a family often rise. Many families admit to feelings of anger over everyday stressors that now seem overwhelming. Caregivers become tired, or even exhausted as family roles are suddenly forced to shift. Obviously, it is not an easy time for anyone involved. Emotions may run high and may quickly change at a moment’s notice. For devotees, this may not differ.

In this regard, Dr. Elisabeth Kubler-Ross spent many years caring for the terminally ill and their families. Through her work she discovered a common thread of emotional thought experienced by those facing death. These emotional stages can be seen not only in the dying, but also in those experiencing any life-altering occurrence that creates a sense of loss.

Dr. Kubler-Ross has listed the five stages of grief as:

Denial, anger, bargaining, depression, and acceptance. These stages will be described below, but it is necessary to point out that they are not always experienced in a particular order. In other words, the order in which they are presented is not carved in stone. For example, some patients may feel depressed one day and angry the next. One who faces death must travel down this road at one’s own pace and in one’s own unique way. The order in which these stages are presented, however, is how they are generally thought to occur.

Denial: Denial, to some extent, is normal. After being diagnosed with a terminal illness, denial is often used as a coping mechanism in order to adjust to shocking news. It allows us time to select which aspect of the news we are able to focus on rather than taking on the entire situation at once. Denial acts as a “shock absorber” to buffer the impact of life-altering events that we may not be ready to confront head-on. Denial is a mechanism that is appropriate to a point. It becomes an obstacle when it hinders practical adjustments such as when a patient refuses pain medication, because he denies he has a terminal illness. Denial is an obstacle when it interferes with emotional or spiritual adjustments that would ordinarily assist the patient in reaching peaceful conclusions before dying. This stage requires a great deal of patience on the part of the caregiver who must allow the patient this much-needed time. It is interesting to note that I have had several patients who refused to ever discuss their terminal illness, but most reach a point where it becomes a relief to talk about their imminent death.

There are many layers to one’s denial and each layer must be gently and lovingly removed. Discussing their illness with someone who truly empathizes with them can help your patient to diminish unrealistic fears and anxieties. You may wish to begin a discussion by “testing” the extent of your patient’s denial. A gentle way to do this is to ask, “What did the doctor recently tell you about your illness?” Can you explain it to me?” You will very quickly know if your patient is not ready to discuss the situation or gives you unrealistic answers to your questions. If prolonged denial seems to be a problem, it is best to consult the hospice nurse or counselor for assistance.

Anger: A patient often moves from feelings of denial to feelings of anger. (Again, this is not always the case.) Patients may become angry when they realize that death will come sooner than expected. Families may exhibit anger when they realize that a loved one will soon be gone. Misplaced anger at one another can create turmoil within a family as each member struggles to make sense out of a seemingly unjust situation.

As a caregiver, you will naturally spend a great deal of time with your patient. Therefore, you may become the recipient of his or her anger more often than an occasional visitor. Again, your patience may become tested in this way. It may help to remember that anger is often a way of masking fear. Most likely, the patient will not be angry with you, but at the untreatable illness that faces him. This is a most difficult stage of grief, both for the person exhibiting anger and for the recipient of that anger. Caregivers may want to temporarily remove themselves from the patient’s room and return in a short while after regaining strength and feeling more refreshed.

Bargaining: For the patient, this stage may involve making promises or agreements of some type in order to live longer. For loved ones, it may also involve promises in order for the patient’s life to be extended. Watching anyone go through this stage and negotiate for more time is painful. These promises are often made to loved ones or to the Lord. If a devotee feels he did not meet certain spiritual standards throughout his life, he may promise the Lord that these standards will now be kept in an attempt to prolong his life. Damaged relationships may become his focus as he tries to mend broken communications with others. Bargaining is often linked to feelings of guilt. It may help your patient if you encourage verbalization of guilt feelings. Good communication is helpful in any stage of grief, but is especially important in the bargaining stage.

Depression: Some patients, as well as loved ones, may exhibit signs of depression. Some signs may include loss of appetite, increased weakness, and difficulty sleeping or excessive sleeping. These can also be signs of exacerbation of the disease process. Your hospice nurse can help you distinguish the causes of these behaviors and determine if your patient is experiencing depression. In any case, depression is often the beginning of realizing that death will soon occur. As symptoms worsen and the patient weakens, this realization is difficult to avoid. Patients are forced to depend more on others which often increases depression. At this stage, the reality of death can no longer be ignored.

Sadness for someone who is dying is a natural part of the grief process for the conditioned soul. Good listening skills are needed on the part of the caregiver. Your patient may repeat his or her sadness again and again. The caregiver needs to listen again and again until these disturbances are sorted out for the patient. Empathy is the key to assisting someone through this difficult stage of the dying process.

Acceptance: This is the final stage of the dying process which is hopefully, but not always, reached by a terminally ill patient. Family members are encouraged to accept the imminent death of a loved one in order to have proper emotional and spiritual closure with the patient. Patients are encouraged to reach the stage of acceptance to be able to focus on the “self” and become detached from the material world around them. This stage is a glorious one. Patients work hard to be ready to face death. I have cared for many patients from various faiths and spiritual beliefs who worked hard through the grief process and emanated peace and tranquility once reaching this final stage of acceptance. Your patient may become quiet at this stage and may wish to remain alone more often. For a Vaisnava, ask if you can play a soft bhajan (devotional song) or quietly chant the Hare Krishna mantra (Hare Krishna Hare Krishna Krishna Krishna Hare Hare/Hare Rama Hare Rama Rama Rama Hare Hare) by the bedside. It is necessary that a caregiver create a calm, Krishna conscious atmosphere in the patient’s room. Dim lighting, soft voices, quiet chanting, and reading of Srila Prabhupada’s books, for example, may assist you in providing a proper mood for your patient. Respect your patient’s wishes at this time and you will be doing a great service for this courageous Vaisnava.

More information on the life and work of Dr. Elizabeth Kubler-Ross
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