Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

The world rushes on over the strings of the lingering heart making the music of sadness. 
 
Tagore, from Stray Birds, XLIV 
 
When the terminally ill patient can no longer deny his illness, when he is forced to undergo more 
surgery or hospitalization, when he begins to have more symptoms or becomes weaker and thinner, 
he cannot smile it off anymore. His numbness or stoicism, his anger and rage will soon be replaced 
with a sense of great loss. This loss may have many facets: a woman with a breast cancer may react 
to the loss of her figure; a woman with a cancer of the uterus may feel that she is no longer a 
woman. Our opera singer responded to the required surgery of her face and the removal of her teeth 
with shock, dismay, and the deepest depression. But this is only one of the many losses that such a 
patient has to endure. 
 
With the extensive treatment and hospitalization, financial burdens are added; little luxuries at first 
and necessities later on nay not be afforded anymore. The immense sums that such treatments and 
hospitalizations cost in recent years have forced 
 
any patients to sell the only possessions they had; they were unable to keep a house which they 
built for their old age, unable to send a child through college, and unable perhaps to make many 
dreams come true. 
 
There may be We added loss of a job due to many absences or the inability to function, and 
mothers and wives may have to become the breadwinners, thus depriving the children of the 
attention they previously had. When mothers are sick, the little 
 
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ones may have to be boarded out, adding to the sadness and guilt of the patient. 
 
All these reasons for depressions are well known to everybody who deals with patients. What we 
often tend to forget, however, is the preparatory grief that the terminally ill patient has to undergo 
in order to prepare himself for his final separation from this world. If I were to attempt to 
differentiate these two kinds of depressions, I would regard the first one a reactive depression, the 
second one a preparatory depression. The first one is different in nature and should be dealt with 
quite differently from the latter. 
 
An understanding person will have no difficulty in eliciting the cause of the depression and in 
alleviating some of the unrealistic guilt or shame which often accompanies the depression. A 
woman who is worried about no longer being a woman can be complimented for some especially 
feminine feature; she can be reassured that she is still as much a woman as she was before surgery. 
Breast prothesis has added much to the breast cancer patient's self-esteem. Social worker, physician, 
or chaplain may discuss the patient's concerns with the husband in order to obtain his help in 
supporting the patient's self-esteem. Social workers and chaplains can be of great help during this 
time in assisting in the reorganization of a household, especially when children or lonely old people 
are involved for whom eventual placement has to be considered. We are always impressed by how 
quickly a patient's depression is lifted when these vital issues are taken care of. The interview of 
Mrs. C. in Chapter X is a good example of a woman who was deeply depressed and felt unable to 

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deal with her own illness and impending death because so many people had to be attended to and 
there seemed to be no help forthcoming. She lost her ability to function in her old role but there was 
no one to replace her. 
 
The second type of depression is one which does not occur as a result of a past loss but is taking 
into account impending losses. Our initial reaction to sad people is usually to try to cheer them up, 
to tell them not to look at things so grimly or so hopelessly. We encourage them to look at the 
bright side of life, at all the colorful, positive things around them. This is often an expression of our 
own needs, our own inability to tolerate a long face over 
 
any extended period of time. This can be a useful approach when dealing with the first type of 
depression in terminally ill patients. It will help such a mother to know that the children play quite 
happily in the neighbor's garden since they stay there while their father is at work. It may help a 
mother to know that they continue to laugh and joke, go to parties, and bring good report cards 
home from school-all expressions that they function in spite of mother's absence. 
 
When the depression is a tool to prepare for the impending loss of all the love objects, in order to 
facilitate the state of acceptance, then encouragements and reassurances are not as meaningful. The 
patient should not be encouraged to look at the sunny side of things, as this would mean he should 
not contemplate his impending death. It would be contraindicated to tell him not to he sad, since all 
of us are tremendously sad when we lose one beloved person. The patient is in the process of losing 
everything and everybody he loves. If he is allowed to express his sorrow he will find a final 
acceptance much easier, and he will be grateful to those who can sit with him during this stage of 
depression ;.without constantly telling him not to be sad. This second type of depression is usually 
a silent one in contrast to the first type, during which the patient has much to share and requires 
many verbal interactions and often active interventions on the part of people in many disciplines. In 
the preparatory grief there is no or little need for words. It is much more a feeling that can be 
mutually expressed and is often done better with a touch of a hand, a stroking of the hair, or just a 
silent sitting together. This is the time when the patient may just ask for a prayer, when he begins to 
occupy himself with things ahead rather than behind. It is a time when too much interference from 
visitors who try to cheer him up hinders his emotional preparation rather than enhances it. 
 
The example of Mr. H. will illustrate the stage of depression which worsened because of the lack of 
awareness and understanding of this patient's needs on part of those in his environment, especially 
his immediate family. He illustrates both types of depression as he expressed many regrets for his 
"failures" when he was well, for lost opportunities while there was still time to be with his family, 
and sorrow at being unable to provide 
 
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more for them. His depression paralleled his increasing weakness and inability to function as a man 
and provider. A chance for additional promising treatment did not cheer him up. Our interviews 
revealed his readiness to separate himself from this life. He was sad that he was forced to struggle 
for life when he was ready to prepare himself to die. It is this discrepancy between the patient's 
wish and readiness and the expectation of those in his environment which causes the greatest grief 
and turmoil in our patients. If the members of the helping professions could be made more 
 

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