As a registered nurse with numerous years experience in caring for the oncology patient, one of the most rewarding fields has been preparing the individual, family and friends for the end-of-life process. Unfortunately, however, all too often there are inexperienced nurses that jump into this arena with little or no advice and/or knowledge of the death and dying stages. According to Elisabeth Kubler-Ross, there are 5 distinct stages, which are outlined in the graft below:
|1 – Denial||Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It’s a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death of course is not particularly easy to avoid or evade indefinitely.|
|2 – Anger||Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps keep detached and non-judgmental when experiencing the anger of someone who is very upset.|
|3 – Bargaining||Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. For example “Can we still be friends?” when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it’s a matter of life or death.|
|4 – Depression||Also referred to as preparatory grieving. In a way it’s the dress rehearsal or the practice run for the ‘aftermath’ although this stage means different things depending on whom it involves. It’s a sort of acceptance with emotional attachment. It’s natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality.|
|5 – Acceptance||Again this stage definitely varies according to the person’s situation, although broadly it is an indication that there is some emotional detachment and objectivity. People dying can enter this stage a long time before the people they leave behind, who must necessarily pass through their own individual stages of dealing with the grief.|
It has been my experience that not all patients follow these stages in the exact order. In fact, many skip from stage to stage and the nurse needs to know precisely what stage the patient is in to properly communicate and care for the cancer victim and their loved ones. My prior nursing colleagues were frequently unaware of the consequences that can occur; for example, if a patient is in denial but the caregiver believes they are actually in the bargaining stage. I have found that families and doctors are great references in establishing the proper stage and then adequate consultation with the patient can proceed.
The oncology nursing field is certainly not for all nurses. Some of the most common ingredients for the successful cancer nurse include education on death and dying, great communicators, having empathy versus sympathy, understanding the patient is extremely ill and anger is not to be taken personally, and having a good support system. In addition, most patients are receiving blood, platelets, radiation/chemotherapy and/or mind-altering drugs that can have a huge effect in one’s personality. A caregiver could see a cancer victim go from sleeping peacefully to crying, screaming and being confused.
In summation, the field of oncology can be rewarding, fulfilling, stressful, sad, happy and precise. My advice for nurses is to follow the protocols of patient rights – remain comfortable, clean, emotionally and physically safe in an environment that promotes a strong relationship between the patient and their health care providers. Furthermore, the patient has the right to participate in their care, access emergent services, be treated with respect and non-discrimination, and the right to privacy and confidentiality of health information. Nurses that do not have the proper education, training and knowledge in this ever- so-careful and specialized field should not attempt to deal with these very delicate patients!
“Elizabeth Kubler- Ross Grief Cycle model, five stages of grief in death, dying and bereavement.” On Death and Dying, 1969.