What nursing can learn from a proper appreciation of the five stages

Abstract

When Dr. Elisabeth Kübler-Ross published her now-famous book, On Death and Dying (1969) (1) , she wrote that she "had over 200 interviews over a period of almost three years" (p. 250) and she described a theoretical model of five "stages" (denial, anger, bargaining, depression, and acceptance) experienced by these adults as they were living out their journey after a diagnosis of a terminal illness. In this book Kübler-Ross described nurses as "the most helpful assistants" in her work (p. 245). She reported that some nurses were angry at physicians about the ways they avoided communicating the seriousness of an illness to patients, or about the use of "many unnecessary tests they ordered as a substitute for spending time with [patients]" (p. 250). Also, "Many nurses felt a great lack of training in this area and had little instruction as to their role in the face of such crisis" (p. 251). However, Kübler-Ross wrote that over time attitudes changed and nurses "have been both students and teachers to us and have contributed a great deal to the seminar" (p. 252). Many nursing and other textbooks continue to teach the five-stage model for understanding coping with dying 50 years after its original appearance (2-3). In the interim, numerous things have changed including causes of death, longer living/dying trajectories, new cure-oriented interventions, increased life expectancy, new and intensified challenges for family care providers, improved attitudes toward communication with patients and truth telling, and the development of the hospice/palliative care movements. As a result, I think nursing educators and textbooks should teach this theoretical model, but only if they do so in light of a critical perspective concerning its strengths and weaknesses. In addition, I believe that nurses should only include this model in their clinical practice with a keen awareness of its limitations and potential pitfalls.