On Death and Dying revisited

Feb. 22, 2018
In recent weeks I have been re-reading On Death and Dying, the groundbreaking work about managing the terminally ill, written by the brilliant psychiatrist Elizabeth Kübler-Ross (1926-2004). Few works of scientific research have been as widely read by the general public, and deservedly so.

In the mid-1960s, Kübler-Ross, then working at the University of Chicago School of Medicine (and its hospitals), along with hospital chaplains and graduate students, began a project in which they interviewed terminally ill patients, mostly cancer patients, with the goal of better understanding the problems they faced and the ways they responded to the approaching end of their life. The project turned into student seminars, and transcripts from the seminars eventually formed the backbone of On Death and Dying, which was published in 1969.

The book made an immediate impression. Time magazine’s reviewer wrote: “The Chicago seminar has vanquished the conspiracy of silence that once shrouded the hospital’s terminal wards. It has brought death out of the darkness.” Life magazine called the book “a profound lesson for the living.”

Part of the book’s thesis is that death, always a fearful prospect for human beings, had become even more frightening in modern times, because it was often slower (due to cancer or other progressive disorders rather than infectious diseases, which had been mostly conquered by antibiotics) and more impersonal. People used to die among the comforts of home, Kübler-Ross argues; now, more often they died in the stressful environments of hospitals, tended more by technicians than loved ones, connected to ventilators and other machinery, and dehumanized in many ways. Dying in the twentieth century (it is only more true today) was emotionally harder, and the psychological burden on patients was greater.

Another part of Kübler-Ross’s thesis, and one that inspired howls of protest from some clinicians, was that doctors, nurses, and others who come into contact with the terminally ill unconsciously bring their own fears of death and unresolved conflicts into those interactions, to the detriment of good practice. Being in the presence of dying people reminds us that we are going to die, too—so the unempathetic doctor, and the cold nurse who focuses more on the machines than the patients, are actually engaged in self-protective psychological strategies, defending themselves through denial or detachment. The patient whom they are there to serve becomes secondary.

The most famous part of On Death and Dying, which has become part of American popular culture, is Kübler-Ross’s division of the stages of dying into Denial, Anger, Bargaining, Depression, and Acceptance. Some critics have complained that the progression is too schematic, and Kübler-Ross herself later acknowledged that she wished her book had made clearer that not all patients go through all five stages, or in that order, or finish one and then enter the next without sometimes going back. But the thrust of her generalizations remains valid and extremely useful for healthcare workers, who can better serve the dying if they understand what the dying person is going through from his or her own perspective and recognize that a dying person does not surrender his human dignity. Is the “difficult” or “hostile” patient, for instance, really being difficult or hostile, or is he working through his Anger or Depression?

On Death and Dying should be required reading for physicians and nurses; for social workers and psychologists and other hospital personnel; for phlebotomists. I think laboratorians should read it too, even though they rarely see the patients whose imminent deaths they sometimes view through the microscope.

In my experience with readers of MLO, I am struck by how aware most are of the human stories that lie beyond those slides. It is to your credit that you are not hardened or cynical. But On Death and Dying is a good refresher course on how important and valuable your work is.