REVISITING ELISABETH KUBLER-ROSS:
DEATH AND DYING STAGE MODEL IN THE CARING PROCESS
Professor in Pastoral Theology, Personality and Culture
Inter-American University of Puerto Rico Metropolitan Campus
(Kálathos 1, no. 1, 5-10/2007)
ers' interest in studying the human experience of death and dying. A significant event in
1941, a fire in which 300 persons died at the Coconut Grove night club in Boston, per-
suaded Erich Lindeman
to study the experience of grief among surviving family members.
authors like Elizabeth Kübler-Ross (1926-2004)
became a leading figure in unveiling
has generated a fresh new interest in understanding the experience of dying.
Two distinct areas of study have led research in this field.
One is the biomedical per-
spective, which includes sciences such as thanatology and pathology. The other is the psy-
chosocial perspective, represented primarily by the fields of psychology, sociology, theology
and psychiatry. Together, these fields conduct research seeking to understand how humans
cope and respond emotionally, socially and spiritually to the experience of dying.
This article will explore some of the studies produced from the psychosocial perspective,
stages of death model. I have chosen her work for one basic reason. Having arrived to Puerto
Rico after years doing clinical work abroad, it was surprising to me that her theory continues
to be a dominant theoretical framework used by the pastoral caregivers engaged in under-
standing the patient's dying experience. To a certain extent, Kübler-Ross' model or theory
seems to be the rubric by which most arrive at their theological and pastoral care decisions.
In my work experience, this issue did not come as a surprise. Already I was aware that,
amidst scholarly critique to Kübler-Ross' work, the model had greatly influenced most dis-
ciplines and had prevailed. To find some answers to this dilemma, the next following dis-
cussion will focus on understanding the basic axioms of Kübler-Ross' theory and the pas-
toral and clinical implications in the caring process.
Erich Lindeman, “Symptomatology and Management of Acute Grief,”
Their Own Families
(New York: McMillan Co., 1969).
For a complete survey of the development and direction of Thanatology literature see: Samuel Southard,
and Dying: A Bibliographical Survey
(New York: Greenwood Press, 1991).
Genesis of Kübler-Ross Stage Model Theory
At popular levels, people relate, and usually limit their understanding of Kübler-Ross
"On Death and Dying." However, it is in the
less notorious subtitle of her work, "
What the Dying Have to Teach Doctors, Nurses, Clergy
and Their Own Families," where one can find a better summary of the intentions and mo-
tivations of her book. The subtitle suggests that Kübler-Ross' attempt was to increase care-
givers' and health care providers' levels of sensitivity and awareness concerning the dying
person's needs. In her words, "We have asked him [the patient] to be our teacher so that we
may learn more about the final stages of life with all its anxieties, fears, and hopes."
in order to facilitate our understanding of the patient's experiences during the dying pro-
The stages are: denial and isolation, anger, bargaining, depression, and acceptance. Alt-
and will replace each other or exist at times side by side,
the way she articulates her theory
hough one can read in her description of the stages the non-progressive aspect of her theory,
one can also see in the visual design of her model the interconnected and ascendant aspects
of her theory. Clearly this aspect suggested the perceived concept of a sequential progres-
sion, whether this was her intention or not. The following table represents the model as
proposed in her book.
On Death and Dying
Kübler-Ross: Dying Stages Model
PG = Preparatory Grief
PD = Partial Denial
-"Stages" of Dying-
Kübler-Ross explains that she developed her model as a result of her "experiment," with
over two hundred terminally ill patients. Concerning the genesis of her study, she states:
In the fall of 1965 four theology students of the Chicago Theological Seminary ap-
"crisis in human life," and the four students considered death as the biggest crisis
people had to face.
This request motivated her to engage with the students in the study of the dying at the
research protocol are not clear in her book.
The Death and Dying Stages: A Review
1. Denial and Isolation. Kübler-Ross states that, "Among the over two hundred patients
"No, not me, it cannot be true!" The patients, she argues, made use of denial not only in
the initial stages of their illness, but in later periods also. Hence, denial “... functions as a
buffer after unexpected shocking news, allows the patient to collect himself and, with time,
mobilize other, less radical defenses."
Eventually, she states, "Denial is usually a tempo-
rary defense and will soon be replaced by partial acceptance."
2. Anger. This is the substituting stage to denial. From her perspective, "When the first
envy, and resentments."
This stage is distinguished from denial in the fact that patient's
Kübler-Ross suggest that since the patient's reasoning to be angry may be
3. Bargaining. From her point of view, although this stage is not well known, it is equally
If we have been unable to face the sad facts in the first period and have been angry
sort of an agreement which postpone the inevitable happening: If God has decided
to take us from this earth and he did not respond to my angry pleas, he may be more
favorable if I ask nicely.
From her perspective, this stage could be related to children first demanding, then ask-
maneuvers. In her words:
He [the patient] knows, from past experiences, that there is a slim chance that he
wish is most always an extension of life, followed by the wish for a few days without
pain or physical discomfort.
In Kübler-Ross' conception, the bargaining stage is a period of negotiation with a higher
...[bargaining] is really an attempt to postpone; it has to include a prize offered "for
form on stage, the chance to attend the son's wedding), and it includes an implicit
promise that the patient will not ask for more if this one postponement is granted.
and the preparatory depression. The reactive depression is associated to the feelings dis-
placed by a patient before what they perceive has been lost, or what they are about to force-
fully surrender as a consequence of their illness (i.e., the amputation of a leg or the los
movement of the extremities).
The preparatory depression is one "...which does not occur
Kübler-Ross sees in
loss of all the love objects, in order to facilitate the state of acceptance."
To further elabo-
The patient is in the process of losing everything and everything he loves. If he is
time when the patient may just ask for a prayer, when he begins to occupy himself
with things ahead rather than behind."
Kübler-Ross concludes her remarks on this stage by suggesting that this type of depres-
Only patients who have been able to work through their anguish and anxieties are able to
achieve this stage."
5. Acceptance. In her conception, patients who have been assisted in working with the
Characteristically of this stage is that patients’ feels tired, quiet and weak, with a need
to doze off to sleep and in brief intervals very similar to that of a newborn.
signed and hopeless giving-up, rather they are indicators of the beginning of the end of the
struggle, but they are not acceptance.
As she describes it, "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."
She distinguishes between the patient who fights
detach from their loved-ones and this world, as the patients who are in acceptance. Con-
cerning the first type of patient she states, "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."
Though not specifically stated, it seems that
she considers the second type of patient, (those who gradually detach from family, hus-
the human experience of dying with her book
On Death and Dying. It should be noted that
she undertook this task at a time when at a societal level, the subject was considered taboo.
In this book she elaborated what popularly came to be known as
the crisis stages of the
terminally ill patient. Although most contemporary scholars at the time the book was pub-
lished initially questioned and resisted her theory and model, her work has survived her
critics and her popular stages on death and dying has permeated most disciplines to this
As I will demonstrate, in this brief critical analysis of her work, Kübler-Ross' model was
strate, experts in the field consider the use of Kübler-Ross' model (as originally stated) a
serious hazard, both to the patient and the care provider.
In general terms, it could be said that critique of her work will focus on three specific
the clinical use and misuse of the stages. I will proceed to examine each of these areas of
began with her work. In other words, many think of her as the pioneer in the field. I assume
that such attributions are the result of her own claims, when she stated that she lacked
direction when she was asked to write the book, or to her claims that her research was
limited by the lack of data on the subject. Concerning her lack of direction, she states:
siastically accepted the challenge. When I actually sat down and began to wonder
what I had got myself into, it became a different matter. Where do I begin? What to
Concerning the lack of existing data in the subject and how to establish a protocol for
Then the natural question arose: How do you research on dying, when the data is so
We met for a while and decided that the best possible way we could study death and
dying was by asking terminally ill patients to be our teachers... I was to do the inter-
tire to my office and discuss our own reactions and the patient's response. We be-
lieved that by doing many interviews like this we would get a feeling for the termi-
nally ill and their needs which in turn we were ready to gratify if possible.
From her own words, we can assume that Kübler-Ross did not make use of traditional
this field had been in existence since 1955. Some literature predating Kübler-Ross' work
was: K.R. Eissler,
The Psychiatrist and the Dying Patient; Herman Feifel, The Meaning of
Death; Robert Fulton, Death and Identity; Barney G. Glasser and Anselm L. Strauss, Aware-
ness of Dying; Edwin S. Shneidman, Essays In Self-Destruction, and David Sudnow, Passing
These authors seem to be the real pioneers in the field, however, Kübler-Ross made
acceptance) have been vastly scrutinized by leading researchers. Early as 1973, critique con-
cerning the usefulness of the Stage model began to emerge.
In the process of researching
shared with me an unpublished essay in which he and Glen A. Davidson undertook the
task of examining in depth the work of Kübler-Ross.
A unique contribution in their work,
passed work analyzing Kübler-Ross' theory against five major topics in thanatology, and
clinical thanatology (the scientific, humanistic, moral, management, and training programs
in Kübler-Ross' theory and Stage model). Being that this particular area of their research is
beyond the intentions of this segment, I will limit myself to acknowledge Fitchett and Da-
vidson's work in this respect.
Some literature predating Kübler-Ross work was: K.R. Eissler,
The Meaning of Death
(New York: McGraw-
Hill Book Co., 1959); Robert Fulton,
Death and Identity
(New York: John Wiley and Sons, Inc., 1965); Barney
G. Glasser and Anselm L. Strauss,
Awareness of Dying
(New York: Aldine Publishing Co., 1965); Edwin S.
Essays In Self-Destruction
(New York: Jason Aronson Inc., 1967), and David Sudnow,
(New Jersey: Prentice Hall Inc., 1967).
Some important literature addressing the use and misuse of Kübler-Ross model are: Charles A. Garfield, ed.,
Psychological Care of the Dying Patient
(New York: McGraw-Hill, 1978); Richard Schultz and David Ader-
man, "Clinical Research and the Stages of Dying."
and Folly in Death and Dying."
Journal of Religion and Health
19, no. 3 (Fall 1980):
George Fitchett and Glen W. Davidson,
Toward Understanding "On Death and Dying"
Unpublished. I have
asked permission to Fitchett to state in this note that if any reader wishes to contact them to request copies of
this magnificent essay they shall contact Fitchett at Rush-St Luke's Medical Center, Chicago Illinois.
and Aderman's evaluation of Kübler Ross' Stage model. Schultz and Aderman's came to the
Unfortunately, the usefulness of Kübler-Ross' work is limited by its ambiguity, in
obtained and interpreted. Kübler-Ross failed to explicitly specify assessment proce-
dures for determining through which stages of dying a patient has passed. Judging
from the interview protocols Kübler-Ross has presented as evidence in support of
her stage model, it appears that she depended more on intuition to define a partic-
ular stage than any systemic pattern of responses from the patient.
Concerning the reliability and replication problems of Kübler-Ross' model, Schultz and
Aderman compared her model and findings, with researchers who plotted the emotional
trajectory of the dying patient with more objective methods. Their study concluded that:
On the basis of her interviews with terminally ill patients, Kübler-Ross proposed a
insight and more objective measurement, have reported data which call into ques-
tion the validity of Kübler-Ross' observations. Whereas these researchers have gen-
erally found, in agreement with Kübler-Ross, that most terminal patients experience
depression shortly before death, they have failed to obtain any consistent evidence
that other affect dimensions also characterize the dying patient.
Furthermore, Edwin Shneidman, in his diverging with Kübler-Ross concerning the uni-
versal attributions of her model states:
My own limited work has not led me to conclusions identical with those of Kübler-
sion and acceptance, I do not believe that these are necessarily "stages" of the dying
process, and I am not convinced that they are lived through in that order, or, for that
matter, in any universal order. What I do see is a complicated clustering of intellec-
tual and affective stages, some not unexpectedly, against the backdrop of that per-
son's total personality, his "philosophy of life.
Garfield also expressed concerns about Kübler-Ross' theory and stage model, or any
Ibid., 15. Fitchett and Davidson quote: Schultz and Aderman, "Clinical Research and the Stages of Dying,"
Ibid., 15. Fitchett and Davidson quote: Schultz and Alderman, "Clinical Research and the Stages of Dying,"
Ibid., 16. Fitchett and Davidson quote: Edwin S. Shneidman,
(Baltimore: Penguin Books,
To date, no researcher or systemic clinical observation has verified any prepro-
not yet empirically identified any set of linear, unidirectional, and invariant stages.
Certainly many patients who are dying exhibit denial, anger, depression, and occa-
sionally acceptance, but it is inaccurate to suppose that all individuals, regardless of
belief systems, age, race, culture, and historical period die in a uniform sequence. It
is more likely that existing theoretical frameworks become self-fulfilling prophesies
imposed by health care professionals who may coerce the dying person into con-
forming to a powerfully suggested typology.
These sources are only a brief sample of the vast scholarly critique to the Stage model of
Kübler-Ross. Amidst the stated critique to her model, researchers' feedback to the model
was ignored by the health care professionals at the time her theory was gaining grounds.
3. The Clinical Use and Misuse of the Stage Theory
After the publication of Kübler-Ross' book
professionals was monumental. In a passionate essay addressing how Kübler-Ross' Stage
model was affecting adversely the health care professionals, especially in the hospital envi-
ronments, Larry Churchill states:
Kübler-Ross' portrayal of the dying person as passing through stages has become, if
ing —one without a significant rival either in the health sciences of the general cul-
Churchill perceived Kübler-Ross' model as a service as well as a disservice to the heath
He also cautions about the hazards of taking her work as more than an intention
He focused his critique in two basic areas: a) the effects that the expectations of a
progressive stage model could have in the care providers, b) the implications of a stage
model with an aesthetic appeal in the treatment of a terminally ill patients. I will briefly
examine these areas of critique.
providers. Although Churchill accepts that there is a certain utility in the stage model, in
the sense that it provides one with, " ...handles or points of entry to comprehend what
Fitchett and Davidson quote: Garfield,
Larry R. Churchill, “The Human Experience of Dying: The Moral Primacy of Stories Over Stages,”
62, no. 1 (Spring 1979): 24.
before was enigmatic even chaotic,"
he also questions the progressive bias of the stages.
Churchill sees in Kübler-Ross' Stage model an embedded dangerous appeal to implement
a stage model that could represent a hazard, both, to the patient and the care provider. In
the words of Churchill:
The temptation to engineer the process of dying for our patients… [in which] our
genuine experiences of dying are pre-empted by our sense of how people ought to
die. The progressivist philosophy carries an implicit norm, such that we even feel an
obligation to move the dying along —to get them through denial, anger, bargaining
and depression to acceptance. We feel frustrated, cheated, or that we have failed if
this does not happened. We become obsessed with the stages as normative protocol
we are treating dying as a technical problem.
b) The implications of a stage model with an aesthetic appeal in the treatment of a
does a progressive stage model that begins with four initial negative stages and concludes
in a positive final stage affect the health care professionals, when the final stage implies that
Churchill sees in this aesthetic expectation of Kübler-Ross' model a bias that:
...makes [the] acceptance [stage] morally desirable, and places an obligation on
of progressive stages culminating in acceptance has an aesthetical pleasing quality.
The tranquil, accepting dying person causes no disturbances and is simple to man-
Finally, Churchill views the aesthetic implications of the Kübler-Ross model as an at-
tempt to label and control the experience of the dying person. In Churchill's words:
Far more important than any reservations we might have about the progressivist
that the stages provide labels to place upon the dying person. The effect of the labels
is to categorize and control —to manage not only the dying person (who is "out of
Control" by Western technocratic standards), but to control the meaning of the ex-
periences as well.
Fitchett also arrives to similar conclusions regarding the implications of a stage model
the patient in any of the stages could be hazardous to the patient. He also argues that the
field of death and dying theories. When one compares the effect of prior research on death
topics, to the arrival of Kübler-Ross' theory, one can safely say that the preexisting work
remained secluded at a scholarly level, while Kübler-Ross' work impacted and shook the
foundations of our society. In that sense, it can be said that to a great extent, the current
social openness to discuss topics of death and dying can be attributed to her.
Amidst the above attribution to Kübler-Ross' work, the researched sources allow me to
never gained the same level of acceptance from her professional peers. The model was per-
ceived as lacking in coherency and cohesiveness. My sense is that these attributions relate
to several factors. On the one hand, it seems that Kübler-Ross failed to examine, and to
incorporate significant preexisting research on the topic when she developed her theory.
From my perspective, this factor led her to develop a model isolated from existing investi-
gation. Thus, leaving behind a model based mostly on anecdotal discussion of personal
experiences, and vague treatment of the dying stages.
On the other hand is the universal claims of Kübler-Ross' model. Since she did not con-
behaviors and other important variables in the analysis of death and dying, I will suggest
caution in the application of the model as originally stated. I base my concern in the fact
that common knowledge suggests that these variables play an important role in the dying
process of a person, and cannot be underestimated.
Concerning researchers' critiques in what they perceive as a fixed rigidity in the order
understand that much of the criticism is based in assumptions drawn from her own defini-
tions, and use of vocabulary to describe the transitions between the stages, I am also aware
that Kübler-Ross herself suggested in various parts of her book that the stages could coexist
or take place simultaneously. My sense is that besides the vocabulary issues, a stronger con-
tributing factor may be based in the way the model was graphically presented. From that
perspective, no matter what position one takes, if rigid stages or not, the graph leads to
contradictions between Kübler-Ross' claims of how the stages can coexist side by side, and
the sequential process suggested by the graph.
With regards to Churchill's perceived hazards of the stages to the patients and care pro-
viders who are exposed to Kübler-Ross' theory, I firmly agree that the potential of hazard
exists, as described by Churchill. Particularly when the model is accepted uncritically. My
experience in the hospital setting is that the staff who expects the patient to "progress" from
George Fitchett, "Is Time To Bury the Stage Theory of Death and Dying,”
one stage to the other, treat patients impersonally or, as Churchill suggests, as a technical
process of dying as defined by Kübler-Ross.
In other cases I have personally provided counseling to staff who developed a sense of
patient from one stage to another. I have also experienced patients who feel frustrated be-
cause they perceive themselves stagnating between stages. Furthermore, I have also invested
many hours with patients who feel confused because they have not been able to reach "the
ideal stage of acceptance" or as Kübler-Ross states, the good dying stage. At some levels I
have found myself "deprogramming" staff and patients concerning the death and dying
model as originally stated by Kübler-Ross. On the other hand, staff and patients who have
approached Kübler-Ross theory critically, make use of her theory, as Churchill suggest, as
"handles or ports of entry" to understand and initiate conversations on death and dying
Though I can agree or disagree with particular aspects of Kübler-Ross' theory and her
impact? Why has the model prevailed to this day amidst strong scholarly critique? What
remains of the model today? I will attempt to provide some answers to these questions.
the sixties. This is an important clue for me. One must remember that this period was no-
torious for the counter culture movements. People were defying authority. Social values
were changing. All fronts of society were being challenged. In that sense, in a world that
was experiencing social revolution, taboo themes, such as death, were being redefined,
questioned and freely examined by everyone. No longer did the church or the academic
institutions held the absolute truths. No longer were the powers that be remaining unchal-
lenged. In light of the context, it is my opinion that Kübler-Ross, willingly or unwillingly,
became part of the social revolution of the time by addressing a theme reserved to specific
social and academic authorities.
Along those lines, is Kübler-Ross' use of common language combined with anecdotal
minimum scholarly oriented language to describe her theory, she managed to address her
concepts to the average and less sophisticated person. In that sense, when one reads her
book, it seems that one is reading a novel. As a sort of novel, the use of terms such as anger,
denial, depression, bargaining, and acceptance, along with the anecdotes that explained the
stages, had the effect of placing the readers face to face with "real life episodes and charac-
ters" to whom they could relate. In other words, the labels she used to describe the stages
worked as metaphors of life accessible to anyone. With the same token, while able to engage
the masses with the use of "down to earth language," she lost the support of her peers.
2. Why Has the Model Prevailed to this Day,
society, and thus, the death and dying stages have been coined into our language and think-
ing, people have assumed that the model is authoritative in its claims and therefore, ac-
cepted by everyone with little critique. On the other hand no one denies that terminally ill
patients, as well as people in crisis in general experience anger, denial, depression, bargain-
ing, and acceptance, at some levels in one form or the other.
3. What Remains of the Model Today?
Although the model is still well and alive, the current use of Kübler-Ross theory is lim-
rigid or sequential stages. People mostly recognize these as episodes or ways in which crisis
may manifest in some patients, without having to subscribe to the stage model as described
by Kübler-Ross. By comparison with other theories that have influenced the world, I can
safely suggest that in the same way that hardly no one uses Freud's theory as originally
stated by him, few use Kübler-Ross as originally stated by her. Both are still vital theoretical
frameworks for various disciplines, though both have undergone revisions, actualization,