Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

order. It is not a resigned and hopeless "giving up," a sense of "what's the use" or "I just cannot 
fight it any longer," though we hear such statements too. (They also 
 
(P100) 
 
indicate the beginning of the end of the struggle, but the latter are not indications of acceptance.) 
 
Acceptance should not be mistaken for a happy stage. It is almost void of feelings. It is as if the 
pain had gone, the struggle is over, and there comes a time for "the final rest before the long 
journey" as one patient phrased it. This is also the time during which the family needs usually more 
help, understanding, and support than the patient himself. While the dying patient has found some 
peace and acceptance, his circle of interest diminishes. He wishes to be left alone or at least not 
stirred up by news and problems of the outside world. Visitors are often not desired and if they 
come, the patient is no longer in a talkative mood. He often requests limitation on the number of 
people and prefers short visits. This is the time when the television is off. Our communications then 
become more nonverbal than verbal. The patient may just make a gesture of the hand to invite us to 
sit down for a while. He may just hold our hand and ask us to sit in silence. Such moments of 
silence may be the most meaningful communications for people who are not uncomfortable in the 
presence of a dying person. We may together listen to the song of a bird from the outside. Our 
presence may just confirm that we are going to be around until the end. We may just let him know 
that it is all right to say nothing when the important things are taken care of and it is only a question 
of time until he can close his eyes forever. It may reassure him that he is not left alone when he is 
no longer talking and a pressure of the hand, a look, a leaning back in the pillows may say more 
than many "noisy" words. 
 
A visit in the evening may lend itself best to such an encounter as it is the end of the day both for 
the visitor and the patient. It is the time when the hospital's page system does not interrupt such a 
moment when the nurse does not come in to take the temperature, and the cleaning woman is not 
mopping the floor-it is this little private moment that can complete the day at the end of the rounds 
for the physician, when he is not interrupted by anyone. It takes just a little time but it is comforting 
for the patient to know that he is not forgotten when nothing else can be done for him. It is 
gratifying for the visitor as well, as it will 
 
show him that dying is not such a frightening, horrible thing that so many want to avoid. 
 
There are a few patients who fight to the end, who struggle and keep a hope that makes it almost 
impossible to reach this stage of acceptance. They are the ones who will say one day, "I just cannot 
make it anymore," the day they stop fighting, me fight is over. In other words, the harder they 
struggle to avoid the inevitable death, the more they try to deny it, the more difficult it will be for 
them to reach this final stage of acceptance with peace and dignity. The family and staff may 
consider these patients tough and strong, they may encourage the fight for life to the end, and they 
may implicitly communicate that accepting one's end is regarded as a cowardly giving up, as a 
deceit or, worse yet, a rejection of the family. 
 
How, then, do we know when a patient is giving up "too early" when we feel that a little fight on 
his part combined with the help of the medical profession could give him a chance to live longer? 
How can we differentiate this from the stage of acceptance, when our wish to prolong his life often 

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contradicts his wish to rest and die in peace? If we are unable to differentiate these two stages we 
do more harm than good to our patients, we will be frustrated in our efforts, and will make his 
dying a painful last experience. The following case of Mrs. W. is a brief summary of such an event, 
where this differentiation was not made. 
 
Mrs. W., a married fifty-eight-year-old woman, was hospitalized with a malignancy in her 
abdomen which gave her much pain and discomfort. She had been able to face her serious illness 
with courage and dignity. She complained very rarely and attempted to do as many things as 
possible by herself. She rejected any offer of help as long as she was able to do it herself and 
impressed the staff and her family by her cheerfulness and ability to face her impending death with 
equanimity. 
 
Briefly after her last admission to the hospital she became suddenly depressed. The staff was 
puzzled about this change and asked for a psychiatric consultation. She was not in her room when 
we looked for her and a second visit a few hours 
 
(P102) 
 
later found her still absent. We flnally found her in the hallway outside of the Y-ray room where 
she lay uncomfortably and obviously in pain on a stretcher. A brief interview revealed that she had 
undergone two rather lengthy 1-ray procedures and had to wait for other pictures to be taken. She 
was in great discomfort because of a sore on her back, had not had any food or drink for the past 
several hours, and most uncomfortable of all, needed to go to the bathroom urgently. She related all 
this in a whispering voice, describing herself as being "just numb from pain." I offered to carry her 
to the adjacent bathroom. She looked at me-for the first time smiling faintly-and said, "No, I am 
barefoot, I'd rather wait until I am back in my room. I can go there myself." 
 
This brief remark showed us one of the patient's needs: to care for herself as long as possible, to 
keep her dignity and independence as long as it was possible. She was enraged that her endurance 
was tested to the point where she was ready to scream in public, where she was ready to let go of 
her bowel movements in a hallway, where she was on the verge of crying in front of strangers "who 
only did their duty." 
 
When we talked with her a few days later under more favorable circumstances, it was obvious that 
she was increasingly tired and ready to die. She talked about her children briefly, about her husband 
who would be able to carry on without her. She felt strongly that her life, especially her marriage, 
had been a good and meaningful one and that there was little left that she could do. She asked to be 
allowed to die in peace, wished to be left alone-even asked for less involvement on the part of her 
husband. She said that the only reason that kept her still alive was her husbands inability to accept 
the fact that she had to die. She was angry at him for not facing it and for so desperately clinging on 
to something that she was willing and ready to give up. I translated to her that she wished to detach 
herself from this world and she nodded gratefully as I left her alone. 
 
In the meantime, unbeknown to the patient and myself, the medical-surgical staff had a meeting 
which included the husband. While the surgeons believed that another surgical procedure could 
possibly prolong her life, the husband pleaded with them to do everything in their power to "turn 

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