Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

withdrawal, and stages of confusion with delusions of her husband's tender loving care expressed in 
the flowers, that she developed the strength to look at the reality of her situation and was able to ask 
for more palatable food and final companionship, which she sensed was not forthcoming from her 
family. 
 
Looking back at this long and meaningful relationship, I am sure that it was possible only because 
she sensed that we respected her wish to deny her illness as long as possible. We never became 
judgmental no matter how much of a management problem she presented. (Granted, that was much 
easier for us as we were a kind of visiting staff and not responsible for the balance of her diet or 
around her all day long from one frustrating experience to another.) We continued our visits even 
during the times when she was totally irrational and could neither recall our face nor the 
professional role we played. In the long run it is the persistent nurturing role of the therapist who 
has dealt with his or her own death complex sufficiently that helps the patient overcome the anxiety 
and fear of his impending death. Mrs. K. asked for two people during her final days in the hospital; 
one was the therapist with whom she exchanged few if any words at the time, occasionally just 
holding hands and expressing less and less concern about food, pain, or discomfort. The other 
person was the occupational therapist who helped her forget the reality for a while and allowed her 
to function as a creative, productive woman, making objects which she would leave for her family-
maybe as little signs of immortality. 
 
I use this example to show that we do not always state explicitly that the patient is actually 
terminally ill. We attempt to elicit the patients' needs first, try to become aware of their strengths 
and weaknesses, and look for overt or hidden communications to determine how much a patient 
wants to face reality at a given moment. This patient, in many ways exceptional, made it quite clear 
from the very beginning that denial was essential in order for her to remain sane. Though many 
staff people regarded her as clearly psychotic, testing showed her 
 
(P42) 
 
sense of reality was intact in spite of the manifestations to the contrary. We learned from it that she 
was not able to accept her family's need to see her dead "the sooner the better," she was unable to 
acknowledge her own end when she had just started to enjoy her small children, and she 
desperately grasped at the reinforcement by the faith healer who assured her of excellent health. 
 
Another part of her was, however, quite aware of her illness. She did not fight to leave the hospital; 
in fact, she made herself quite comfortable there. She surrounded herself with many familiar items 
as if she was to stay for a long time. (She never left the hospital.) She also accepted our limit-
setting. She ate what she was asked to eat, with a few exceptions when she went overboard. She 
later acknowledged that she was unable to exist with so many restrictions and that the suffering was 
worse than death itself. One may regard the episodes of excessive overeating of forbidden foods as 
a form of suicide attempt, in that they would have brought about a rapid demise if the staff had not 
interfered so vigorously. 
 
In a way, then, this patient showed a fluctuation between an almost total denial of her illness and a 
repeated attempt to bring about her death. Rejected by her family, often overlooked or ignored by 
the hospital personnel, she became a pitiful figure, a disheveled-looking young woman who sat 
desperately lonely on the edge of her bed, clutching the telephone to hear a sound. She found 

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temporary refuge in delusions of beauty, flowers, and loving care which she could not obtain in real 
life. She did not have a sound religious background to help her through this crisis and required 
weeks and months of often silent companionship to help her finally accept her death without 
suicide and without psychosis. 
 
Our own reactions to this young woman were manifold. At first there was utter disbelief. How 
could she pretend to be so healthy when she was so limited in her food intake? How was she able to 
stay in the hospital and undergo all those tests if she was really convinced of her well-being? We 
soon realized that she was unable to hear such questions and proceeded to get to know her better by 
talking about less painful things. That she was young and cheerful, that she had small children and 
a Non-supportive family contributed much to our attempts to help her in spite of her prolonged 
denial. We allowed her to deny as much as was necessary for her survival and remained available 
to her during her whole hospitalization. 
 
When the staff contributed to her isolation, we tended to be angry at them and made it a routine to 
keep the door open, only to find it closed again on our next visit. As we became more familiar with 
her peculiarities, they appeared less strange to us and began to make more sense, adding to our 
difficulties in appreciating the nurses' needs to avoid her. Towards the end it became a personal 
matter, a feeling of sharing a foreign language with someone who was unable to communicate with 
others. 
 
There is no question that we got deeply involved with this patient, beyond the usual involvement of 
hospital personnel. In trying to understand the reasons for this involvement, we also have to add 
that some of it was an expression of our frustration at being unable to have the family play a more 
helpful role for this pathetic patient. Our anger expressed itself perhaps in our taking on the role of 
the comforting visitor which we expected the husband to be. And-who knows-perhaps this need to 
extend ourselves under such circumstances was an expression of an unconscious wish that we may 
not be rejected one day if fate should have something similar in store for us. After all, she was a 
young woman with two small children-in retrospect I am beginning to wonder if I was not a bit too 
ready to support her denial. 
 
This shows the need to examine more closely our own reactions when working with patients as 
they will always be reflected in the patient's behavior and can contribute a great deal to his well-
being or detriment. If we are willing to take an honest look at ourselves, it can help us in our own 
growth and maturity. No work is better suited for this than the dealing with very sick, old, or dying 
patients. 
 
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(P44) 
 
IV 
 
Second Stage: Anger 
 
We read the world wrong and say that it deceives us. 
 

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