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I) Description of Presentation

Baxter Jennings

Charlene Gemmill

Brandie Bohman

Kristin Lamb

Introduction

Our presentation will be discussing different theoretical models of the dying process, of which Kubler-Ross is probably the most familiar. Often times, people feel uncomfortable talking to and interacting with a person who is dying. This is at least partly because we have no way to understand their perspective, and what they are experiencing mentally, emotionally, and spiritually. Studying the Kubler-Ross theory and other approaches to the dying process can help us become more comfortable by increasing our understanding and adding insight into the perspective of the dying person. Hopefully this can begin to help increase communication and interaction during a dying person's last days. After a short video, we will cover the Kubler-Ross stage theory, criticisms of Kubler-Ross and stage theories in general, and additional theoretical models.

Video: Series of clips from the movie My Life, which help illustrate and provide concrete examples of theoretical stages to be mentioned later.

Kubler-Ross Theory

• In 1969 Elizabeth Kubler-Ross wrote On Death and Dying. Research and interviews began in 1965 and encountered problems because (1) There is no real way to study the psychological aspects of dying and (2) Patients were often willing to talk but it was hard to convince the doctors.

• Stage Theory: From this research, Kubler-Ross saw a pattern emerging that she expressed in the way of stages. These stages begin when the patient is first aware of a terminal illness. While Kubler-Ross believed this to be universal, there is quite a bit of room for individual variation. Not everyone goes through each stage and the order may be different for each person.

• Stages of Dying

1. Denial and Isolation: Used by almost all patients in some form. It is a usually temporary shock response to bad news. Isolation arises from people, even family members, avoiding the dying person. People can slip back into this stage when there are new developments or the person feels they can no longer cope.

2. Anger: Different ways of expression

-Anger at God: "Why me?" Feeling that others are more deserving.

-Envy of others: Other people don't seem to care, they are enjoying life while the dying person experiences pain. Others aren't dying.

-Projected on environment: Anger towards doctors, nurses, and families.

3. Bargaining: A brief stage, hard to study because it is often between patient and God.

-If God didn't respond to anger, maybe being "good" will work.

-Attempts to postpone: "If only I could live to see . . ."

4. Depression: Mourning for losses

-Reactive depression (past losses): loss of job, hobbies, mobility.

-Preparatory depression (losses yet to come): dependence on family,

etc.

5. Acceptance: This is not a "happy" stage, it is usually void of feelings. It takes a while to reach this stage and a person who fights until the end will not reach it. It consists of basically giving up and realizing that death is inevitable.

• Hope is an important aspect of all stages. A person's hope can help them through difficult times.

Criticisms of Kubler-Ross

• There exists no real evidence that stages are present in coping with death: Kastenbaum offers this as his first criticism of the stage theory. Using the term "stages" implies a set order of set conditions. He asserts that there is no evidence that dying people go through the exact Kubler-Ross stages in their proper order. Any patient could experience the stages in a different order, or could experience emotions not even mentioned in the Kubler-Ross stages.
• More specifically, there is no evidence that people coping with their impending death move through all of stages one through five: Kastenbaum explains that in her research Kubler-Ross showed that various patients exhibited qualities from the five different stages, but no one patient demonstrated all five stages in order. Knowing this, any emotional experience during the dying process of a person could be considered a stage.
• The limitations on the method of research employed by Kubler-Ross have not been adequately considered: Her method of personal interview was a good start to her research process, but it needed to be followed up by another form of data gathering. Had Kubler-Ross done this, her theory would be more valid. Suggestions for other methods of research are behavioral studies and personal diaries kept by patients. This might make up for some of the flaws of the interview process. Some flaws are the fact that the information gathered by the interviewer may vary depending on the relationship between the researcher and the patient. Also, what a patient feels and what a patients reveals in an interview may be two different things.
• The Stage Theory tends to prescribe rather than describe: The theory has become very well-known, and it is common for positive value to be placed on the attainment of each new stage. Patients may rush themselves, or may be pressured by family members, to move through the stages on some imaginary schedule. Patients may feel that they need to accept their death to die properly simply because that's what the famous theory prescribes. Also, the stages of dying can become an easy and convenient way for patients to deal with their death, rather than doing what comes naturally to them, or having to seek out answers of their own.
• A person's whole life may be over-looked in favor of the stages they are supposed to be going through: As we near death it is easy to focus on the last months or weeks of life rather than to celebrate a person's life as a whole. Also, the person's unique personality and identity may be lost as they supposedly move through these generic stages. Each person's experiences are unique and different, so each person's death process is unique.
• Environmental factors play a role too: A patient's environment can have a great affect on their attitude towards death. A patient in a positive and supportive environment is likely to exhibit very different "stages" of dying that a patient in a negative and unsupportive environment.
• Good things about the model: If Kubler-Ross did nothing else, she really had an impact on society and got us thinking about coping with death. We're realizing that we do need help understanding and caring for the needs of those in their final weeks and days. We are lacking in any real research to help us to deal with issues surrounding dying. Half of the problems with the Kubler-Ross model are in society's interpretation and misuse of her research, and also in society's failure to follow-up her study with more research and data.

Additional Theoretical Models

• Charles A Corr: a social psychologist and recent researcher who wants to help caregivers, researchers, and educators move beyond limitations of the stage theory.

He stresses:

• Individual coping strategies: His model, "must encompass the fact that people may try out certain coping strategies only to reject them." In addition, a person may pursue several strategies at the same time even if they are not compatible. People differ in tasks and needs that are important to them as well as in their method of coping. Most importantly, Corr stresses that the model must respect individuality.
• Patient empowerment: Corr discusses the importance of greater empowerment for those who are dying and for those who are involved with caregiving of the terminally ill. In order to do this, people need to recognize that a dying person continues to be a living person to cope with the stresses of the illness.
• Practical guidelines for caregivers: For the caregiver to improve how they deal with the problems, stresses, and issues of the dying person.

• Debbie Messer Zlatin: She took focus away from how the observer deals with dying process and tried to learn how the dying person interprets his/her own reality.
• Exploratory study: she interviewed terminally ill people by asking them to relate the story of their illness. In this study she found that people had a variety of different "life themes".
• Life themes: An example would be one woman who characterized herself as a "crusader" who told the truth and stood up against pressures. She was able to keep her life integrated despite her terminal illness because of her sense of who she was and what her life meant.
• Importance of integration of themes: As a result of the studies conducted by Zlatin it was found that there is an important difference between people who do and do not have integrated life themes. It was also found that certain types of life themes are more important than others. If the caregiver can be informed of the dying person's life themes, then they could be more useful in understanding and helping the terminally ill person.

• William McDougall: researcher, founder of field of social psychology. He kept a journal of his own terminal illness, and provided an intellectual approach.
• He dealt with his need to avoid increasing pain and his need to remain alert and mentally fit. As a result, the last few weeks of his life dealt with this confrontation.
• He found when his intellect was the most inspired was when his pain was most intense. Therefore, he did not feel like he was defeated.
• McDougall did not concentrate on emotions, nor did he attempt to create a list of developmental tasks. Rather, he attempted to utilize his skills and knowledge to integrate his death and dying into his view of himself and his world.
• This approach stresses personal uniqueness because it is individual-centered.

Five Main Points

1. The stages of the Kubler-Ross theory include denial, anger, bargaining, depression, and acceptance.

2. Recently, the Kubler-Ross theory has come under more criticism from social psychologists.

3. Corr's model emphasizes individual empowerment and guidelines for caregivers.

4. Zlatin's theory makes use of what she terms "life themes" in the dying process.

5. The totality of a person's life as well as his/her own personality and experiences will influence their method of coping with impending death.

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Self-Evaluation

The presentation went very well, and student feedback was very positive. Most people said they enjoyed the video and the especially the fact that the group was not just reading material but actually presenting. A few people suggested that we not use Power Point, while others said they thought the multimedia approach worked well. On the whole, the class seemed to find it clear, informative, and interesting and had few suggestions for change.

II) Research

Our topic lent itself to division, so most of the research was pretty evenly split up between group members. Charlene researched the Kubler-Ross theory by using Kastenbaum p.111-112 and by reading On Death and Dying, by Elizabeth Kubler-Ross. Baxter used material from Kastenbaum p.112-116 in the introduction and in searching for and screening movies to use in the video clip. Brandie studied criticisms of Kubler-Ross using Kastenbaum p.112-114, Internet searches, and encyclopedia on disk searches. Kristin researched other approaches by using Internet searches, library searches, and studying the material in Kastenbaum p.114-116.