For most of us, a sense of impending mortality prompts a need to find closure, conduct a full life review and reconciliation (Clarke, 2007). The reality that death is a natural process -- leading towards an inescapable final destination -- seems implausible at first glance. For a variety of reasons, death has become a taboo subject that no longer represents an accepted progression of life, but something unnatural to be wrestled against. Coming to terms with impending mortality is challenging and calls forth a range of deep emotions that need to be expressed. Expressing these intense feelings and reviewing one's life is essential to finding peace and allowing true healing on an emotional and spiritual level (Sand et al., 2009).
The definition of the life review process is described as a "naturally occurring, universal mental process" (Butler, 1963). In other words, it is a normal developmental task of old age. The golden years of life are conducive to the life review process as individuals are typically becoming more disengaged from society and thus, have more time for self-reflection (Clarke, 2007). It is hypothesized to be experienced by all older adults either consciously or unconsciously (Butler, 1963). However, it is important to note that the life review process occurs not only in the elderly, but also the terminally ill or condemned (Breitbart et al., 2004). A sense of mortality and vulnerability motivates the individual to look back and reassess their life in view of imminent death.
The extent to which the life review is experienced varies. For some it manifests as only brief insignificant thoughts. For others, the process may take the form of mild nostalgia or regret. In its more severe form, it can be experienced as anxiety, guilt, and/or depression. The severity of the life review is in part due to the outcome of the review. According to Butler, as individuals realize that there is limited time remaining to them, they will examine what kind of life they have lived (1963). They may examine their life and deem it a success or a failure, and from there make a determination as to who they ultimately became in life and how they feel about it.
If the review results in a negative evaluation, the person may fall into despair and be filled with regrets. He or she may want to change their life, but may not feel they have enough time, thus making the prospect of death difficult to endure (McPherson et al., 2007). Psychological manifestations may take the form of guilt, depression, and anxiety. If however, the individual assesses their life to be a success, it can be therapeutic and aid in preparation for death, eliminating fear. This may account for the wisdom and serenity that one often observes in the older adult (Clarke, 2007). For some, it also prompts the desire to leave a legacy. Butler states, "There is perhaps no other group that can tell us something about the nature of human life with all of its successes and problems better than old people" (1963). Thus, the oral history can provide a means by which older adults can make their mark on succeeding generations (Clarke, 2007).
The DABDA Theory of Coping with Death, created by Dr. Elisabeth Kubler-Ross identifies five common stages of life review -- denial, anger, bargaining, depression, and acceptance. Dr. Kubler-Ross was a Swiss American psychiatrist renowned for pioneering work in near-death and her acclaimed book On Death and Dying, published in 1969. The five stages were based on her research and interviews with more than 500 dying patients. These stages describe the psychological and emotional responses that many people experience. It has been noted, that not everyone goes through all five stages, nor would they necessarily go through them in sequence (Friedman & James, 2008). Although there have been other models developed to try and explain how people cope with grief and loss, the five stages of the Kubler-Ross model are the most recognized by the lay public.
In facing one's own mortality, it would be logical that denial would be the first psychological reaction. As much as we rationally know that we all die, we do not really believe it will happen to us. Somehow the idea of death seems glaringly absurd -- it is something that happens to others. Denial is an exaggeration of the normal process of selective attention, used in order to function normally particularly in the face of challenges. The psyche allows traditional ego defense mechanisms to take over as a means to help alleviate distress (Knight & Emanuel, 2007). Denial is often reflected in a disconnected attitude towards negative news and a continuation of making plans for the future -- scheduling holidays, designing home renovations, investing -- all while being aware that time is running out.
When utilized appropriately, denial can be helpful. During this stage it is important to discover the things most important in life and take a brief rest from intense emotion. However, denial can be deemed excessive if it results in a persistent refusal to discuss an illness or situation due to fear (Sand et. al, 2009). Disbelief, shock or numbness can be experienced to such an extent that it culminates in an attitude of non-acceptance. Cancer might be referred to as a mere "rash" or there may be denial of the need for medication or a change in diet or lifestyle (Schroepfer, 2007). Often, people who fall into this category do not possess the confidence in their own abilities to face and adjust to problems.
Denial must be respected as a coping mechanism. Some people refuse to discuss or think about their illness all the way up until the time of death. However, most people reach a stage when it becomes a relief to discuss some of their fears. Extreme denial prevents the sharing and discussing of unrealistic fears, and anxiety tends to escalate. This blocks meaningful communication with loved ones.
Anger is the second stage of the DABDA theory. Once denial has passed and impending mortality is imminent, a dying person may feel the need to gain the permission of loved ones to express their anger, fearing alienating those he or she loves most (McPherson et al., 2007). However, by expressing feelings of anger - at the illness, at the unfairness of the world, or even at a higher power - a dying person is actually preparing for peace and acceptance. As the life review begins, one may begin to realize their own role in all that has happened to them. Most people describe this as a freeing experience (Carlander et al., 2011). It is characterized by an acknowledgement of not being to blame for the illness and that dying does not indicate a failure in life. This realization of responsibility is critical in overcoming feelings of anger.
Stage three, the bargaining stage, often follows denial and anger and most often begins in private conversations with God (Langle, 2005). A recent University of Chicago study revealed that a belief in God often increases with age (those 58 years of age and older), perhaps due the increasing anticipation of mortality (Harmes, 2012). In the face of death, most people begin making pledges and pleadings to their higher power -- agreeing to live a good life, help the needy, attend church more regularly, give up sin, or carry out any number of good deeds if only God will give them a second chance and more time on earth. Others take the approach of bargaining with doctors or even with the illness itself. Negotiations include bargains such as "If I can just live long enough to see my son graduate college..." Or "If only I could see my grandchildren out of state one more time..." (Carlander et al., 2011). The implied return favor is that should that one wish be granted there would be no more requests. People who enter this stage quickly come to learn that bargaining is ineffective. Inevitably he or she moves on, usually to the depression stage, once it becomes clear that the terminal illness will not be easily overcome.
The increased burden of surgeries, treatments, and the physical symptoms of illness eventually make it difficult to remain angry or deny the severity of the situation. Depression may result -- the fourth stage in Dr. Kubler-Ross's model. It is thought that there are two types of depression (Friedman & James, 2008). Reactive depression occurs as a reaction to current and past losses (i.e., the loss of hair and a breast to cancer, loss of time with the children, loss of income that results in a foreclosure, etc.). The more sickness compounds problems, the more sadness, grief, and depression take hold. The second type of depression is referred to as preparatory depression, where one has to deal with the impending future loss of everything and everyone they love. Most people will fall into quiet thought and grieving as they prepare themselves for such a complete loss (Knight…