beyond death and dying

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  • 1. Beyond "DEATH and DYING" - Managing Grief to Improve Occupancy


  • Graduated Med School from Univ. of Zurich 1957
  • Psych Resident NY & CO
  • Asst. Prof U. of Chicago
  • Clinical Prof - UVA

Elisabeth Kubler-Ross, M.D. In 1969, wrote the groundbreaking treatise on how we treat terminal patients in this country! "On Deathand Dying" 3. Why You Should Study these Concepts

  • Need to be a Grief Counselor for Residents
  • Understanding your own fears of dying will help you deal with residents and their fears.
  • Much of theory applies to other losses and concerns besides just death.
  • Gain better understanding of how to support resident in their last days w/o move-out!
  • Learn how prospects go thru these same steps before making a move-in decision.


  • 1.Increasing speed of move-ins
    • Learn how the stages of death & dying also apply to other losses ; AND
    • Learn how to use this psychology inbuilding relationships with prospective residents.

Improve Occupancy by: Grief Management =Learning to Accept Loss 5.

  • Understanding more of the underlyingneeds & motivationsof existing residents,Including:
    • Whysome residents complain all the time ; AND
    • AVOIDING MOVE-OUTSby better handling of these residents complaints!

Improve Occupancy by: 6. Improve Occupancy by:

  • Avoiding move-outs in a hospice situation
    • Understandwhyresidents may move out;
    • Learn why that may be the wrong decision;AND
    • Provide insights as to how you can help them make theBESTdecision.

7. Kubler-Ross Theory

  • All people go through 5 separate and distinct stages when faced with tragic news.
  • Psychologically, these stages are different defense mechanisms enabling an individual tocopewith an extremely difficult situation.
  • The length of each stage will vary by person, but theymustexperience each stage.
  • Had she written her book after computers became more prevalent, she might have portrayed this as a FLOW CHART, such as:

8. Denial anger Bargaining depression ACCEPTANCE HOPE HOPE HOPE HOPE 9. Kubler-Ross

  • 5 Stages of Acceptance
    • [Applies to all losses not
    • only our own mortality]
    • Death of spouse or other long-term companion
    • Loss of physical capability (e.g. failing eyesight, suffered a fall with on-going limited mobility)
    • Not permitted to drive anymore
    • Suffered some diminished mental capacity and / or family expresses concern about forgetfulness
    • Child / grandchild caregiver moved away
    • Spouse /friend experiences declining health and unable to provide previous level of support


  • NO, Not me!
  • There must be some mistake, the tests were mixed up somehow.
  • That (e.g. heart attack) was no big deal, Ill be okay as soon as I get out of the hospital and back home!
  • I dont need any help, Ive always done
  • I just left the stove on that one time, normally Im very safe.


  • Normalhuman emotion / reaction.
  • Temporary state of shock .
  • Serves as abuffergives time to continue with life and avoid becoming totally consumed with bad news.


  • Often followed by ISOLATION.
    • Easier to fool yourself if dont also have to try to fool other people!
    • Can lead to living in a fantasy world.
  • Resident that moves out because doesnt want to face all their friends in the building!


  • Patient (resident) can be quite selective in using this trait:
    • Can be honest and discuss their situation quite openly with one person; while
    • Pretending to be fine with others.
      • May be more open with outsiders than own family members!


  • Resident behaviors evidencing Denial of disease
  • Diabetic refusing to eat diabetic desserts.
  • Resident w COPD on O 2& still smoking
  • Resident ignoring MD orders to exercise


  • Feelings of anger, rage, envy & resentment.
  • Why me and not _________
  • It was your fault that I left the stove on because you interrupted me by
  • Youre just saying that because you want to put me away.
  • My daughter (son) doesnt care, she/he just doesnt want to be bothered
  • Everybody here treats me like dirt.


  • Very difficult to deal with for both staffandfamily members.
  • Anger is often displaced in all directions
    • Projected onto the environment
    • Appears to be directedat random


  • Often becomes cyclical in nature
  • Visits from family & friends become painful
  • Staff avoids the resident because always complaining
  • Resident becomes more isolated andmore angryabout being ignored!
  • Leads to further acting out, raising voice, making demands, complaining, etc.


  • Dont take the anger personally (be defensive) understand that it generally has nothing to do with you!
  • Try to place yourself in residents shoes and understand what loss or fear of loss is precipitating the behavior.
      • Unresolved grief from loss of loved one
      • Anger at medical diagnosis / prognosis
      • Loss of physical or mental capabilities
      • Loss of control other people making decisions for them


  • Dont get into unnecessary arguments
    • No need to defend your stand
    • Issue is most likely irrelevant
    • Only feeds into hostile behavior
  • Understand that expressing anger (even if irrational) will help resident move thru the steps towards acceptance of their loss.
  • Show compassion, let the resident know that they are still alive, not forgottenand important to you.


  • Give assurances that they dont have to raise their voice to get your attention.
  • Encourage family members and staff to approach resident with cheerfulness andpatience instead ofAVOIDANCE.
  • Train staff to understand that, at times, anger will simply be because they still have physical and mental abilities that residents no longer possess.ENVY .


  • Encourage resident to retain independent control of their decision making.
  • Dont ignore residents wishes and deal only with the children.
  • Respect the residents feelings, wishes, and opinions especially regarding his/her own care needs.
  • Remember that each resident wants to be unique but still loved and accepted.
  • Make sure you and your staff treat the resident as an individual and not a thing!

22. Denial anger Bargaining HOPE The Next Stage is BARGAINING 23. BARGAINING

  • Looking for some type of agreement topostpone the inevitable!
  • Not unlike a child:If I am very good all week and do all my chores, then will you let me go?( after being previously told NO )
  • I just want to stay here long enough to attend
  • Ill only drive to my doctors, church and the grocery store.

24. Marketing Opportunity

  • When building relationships, identify loss(es) that prospective residents have suffered:
      • Loss of a Loved One
      • Loss or diminishment of physical ability
      • Declining mental capabilities
  • Determine which STAGE the senior is in dealing with their GRIEF over that loss.
  • In STAGE 3, Bargaining, offer them positive alternatives vs focus on disabilities.


  • Anger and rage replaced with a sense of aGREAT LOSS .
  • Effects bothCurrentandFuture Residents
  • Realization thatLIFE is GOING to CHANGE
    • Loss of Independence
    • Give up their ho