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DABDA, the five stages of coping with dying, were first described by Elisabeth Kübler-Ross in her classic book, "On Death and Dying," in 1969.
The stages stand for the following:
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
The five stages of the Kübler-Ross stage model are the best-known description of the emotional and psychological responses that many people experience when faced with a life-threatening illness or life-changing situation.
These stages don't only apply to loss as a result of death but may also occur in someone who experiences a different life-changing event, such as a divorce or loss of a job.
These stages are not meant to be complete or chronological. Not everyone who experiences a life-threatening or life-changing event feels all five of the responses nor will everyone who does experience them do so in the order that is written. Reactions to illness, death, and loss are as unique as the person experiencing them.
In her book, Kübler-Ross discusses this theory of coping in a linear fashion, meaning a person moves through one stage to reach the next. She later explained that the theory was never meant to be linear nor applied to all persons; the way a person moves through the stages is as unique as they are.
It's important to remember that some people will experience all of the stages, some in order and some not, and other people may only experience a few of the stages or even get stuck in one.
It's also interesting to note that the way a person has handled adversity in the past will affect how a diagnosis of terminal illness is handled. For example, a woman who always avoided adversity and used denial to cope with tragedy in the past may find herself stuck in the denial stage of coping for a long time.
Similarly, a man who uses anger to deal with difficult situations may find himself unable to move out of the anger stage of coping.
Denial - Stage 1
We all want to believe that nothing bad can happen to us. Subconsciously, we might even believe we are immortal. When a person is given the diagnosis of a terminal illness, it's natural to enter a stage of denial and isolation. They may flat-out disbelieve what the doctor is telling them and seek out second and third opinions. They may demand a new set of tests, believing the results of the first ones to be false. Some people may even isolate themselves from their doctors and refuse to undergo any further medical treatment for a time.
During this stage, one might also isolate himself from his family and friends to avoid discussions about his illness. They may believe on some level that by not acknowledging the diagnosis it will cease to exist.
This stage of denial is usually short-lived. Soon after entering it, many begin to accept their diagnosis as reality. The patient may come out of isolation and resume medical treatment.
Some people, however, will use denial as a coping mechanism long into their illness and even to their death. Extended denial isn't always a bad thing; it doesn't always bring increased distress.
Sometimes we mistakenly believe that people need to find a way to accept their death to be able to die peacefully. Those of us who have seen people maintain denial until the end know this isn't always true.
Anger - Stage 2
As a person accepts the reality of a terminal diagnosis, they may start to ask, "Why me?" The realization that all of their hopes, dreams, and well-laid plans aren't going to come about brings anger and frustration. Unfortunately, this anger is often directed out at the world and at random.
Doctors and nurses are yelled at in the hospital; family members are greeted with little enthusiasm and often suffer the random fits of rage.
Even strangers aren't immune to the actions anger may bring about.
It's important to understand where this anger is coming from. A dying person may watch TV and see people laughing and dancing—a cruel reminder that he can't walk anymore, let alone dance.
In the book On Death and Dying, Kübler-Ross astutely describes this anger: "He will raise his voice, he will make demands, he will complain and ask to be given attention, perhaps as the last loud cry, 'I am alive, don't forget that. You can hear my voice. I am not dead yet!'"
For most people, this stage of coping is also short-lived. Again, however, some people will continue in anger for much of the illness. Some will even die angry.
Bargaining - Stage 3
When denial and anger don't have the intended outcome, in this case a mistaken diagnosis or miracle cure, many people will move on to bargaining. Most of us have already tried bargaining at some point in our lives. Children learn from an early age that getting angry with Mom when she says "no" doesn't work, but trying a different approach might. Just like the child who has time to rethink his anger and begin the process of bargaining with a parent, so do many people with a terminal illness.
Most people who enter the bargaining stage do so with their God. They may agree to live a good life, help the needy, never lie again, or any number of "good" things if their higher power will only cure them of their illness.
Other people may bargain with doctors or with the illness itself. They may try to negotiate more time saying things like, "If I can just live long enough to see my daughter get married..." or "If only I could ride my motorcycle one more time..." The implied return favor is that they would not ask for anything more if only their wish was granted. People who enter this stage quickly learn that bargaining doesn't work and inevitably move on, usually to the depression stage.
Depression - Stage 4
When it becomes clear that the terminal illness is here to stay, many people experience depression. The increased burden of surgeries, treatments, and physical symptoms of illness, for example, make it difficult for some people to remain angry or to force a stoic smile. Depression, in turn, may creep in.
Kübler-Ross explains that there are really two types of depression in this stage. The first depression, which she called "reactive depression," occurs as a reaction to current and past losses. For example, a woman who is diagnosed with cervical cancer may first lose her uterus to surgery and her hair to chemotherapy. Her husband is left without help to care for their three children, while she is ill and has to send the children to a family member out of town. Because cancer treatment was so expensive, this woman and her spouse can't afford their mortgage and need to sell their home. The woman feels a deep sense of loss with each one of these events and slips into depression.
The second type of depression is dubbed "preparatory depression." This is the stage where one has to deal with the impending future loss of everything and everyone they love. Most people will spend this time of grieving in quiet thought as they prepare themselves for such complete loss.
This stage of depression is an important one to go through. It's a period of grieving that is essential for the dying person to cope with their death. If they are able to grieve fully and move through depression, the stage of acceptance will follow.
Acceptance - Stage 5
The stage of acceptance is where most people would like to be when they die. It is a stage of peaceful resolution that death will occur and quiet expectation of its arrival. If a person is lucky enough to reach this stage, death is often very peaceful. They have had permission to express fear, anger, and sadness. They have had time to make amends and say goodbye to loved ones. The person has also had time to grieve the loss of so many important people and things that mean so much to them.
Some people who are diagnosed late in their illness and don't have time to work through these important stages may never experience true acceptance. Others who can't move on from another stage—the man who stays angry at the world until his death, for example—may also never experience the peace of acceptance. For the lucky person who does come to acceptance, the final stage before death is often spent in quiet contemplation as they turn inward to prepare for their final departure.
Sources:
Kübler-Ross, E. On Death and Dying. 1969. New York, NY: Scribner Publishers.
The 5 Stages of Grief. Psycom. 2017
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