The Stages of Dying Checklist

This is a chronology of the physical and psychological changes that people pass through as they approach death.

If you know an ill person quite well, you can probably guess which stage he or she is currently passing through. Yet a person will not necessarily experience all of the steps listed within each of the stages of dying. Unless you ask, you may not realize which step or steps a person is currently experiencing.

Use The Stages of Dying Checklist to guide your conversations with your loved one so that you can more easily offer comfort during these last stages of life.

The physical and psychological stages of dying are as follows:

STAGE ONE: The 45-Year Warrantee on the Body Expires

1. The first minor physical problem occurs. This might be a difficulty with hearing or seeing, or, perhaps, chronic pain in the knee, hip or back. It could involve weight-gain related issues, like having high blood sugar levels or high blood pressure. People often cover over these issues or even deny they are a problem. Others simply get treatment and heal. A person may become a believer in nutritive supplements at this time.

2. There is a second minor physical loss. This might be the start of a systemic problem, like diabetes, hypothyroidism, rheumatoid arthritis, or fibromyalgia. It is important at this point to keep a healthy lifestyle—exercising, proper eating, limited drinking, weight-watching, socializing, spiritual activities—because this greatly influences how rapidly your medical and psychological issues will progress.

3. Medications become a part of one’s daily routine. Yet many people do not take them as prescribed. Physicians know this. This is why doctors generally make a quarterly review of what a person is taking. Family members should ask their relatives what medication they are taking and which they are leaving out. Be sure to ask why they are skipping them if that is the case.

4. One starts to move slower because there is a general decline in physical energy. You notice that you cannot keep up with younger folks. Some people deny this is an issue and often become critics of youth.

5. Doctors become an important part in a person’s life. They order loads of tests and try to retrofit a person for a second go-around at life. They perform things like colonoscopies, arthroscopies, sonograms, MRIs, wrinkle relaxers, fillers, and lifts.

6. The first big medical event takes place. This could involve a leaky heart valve, breast cancer, or a transient ischemic attack (TIA). Whatever the case, it can set people back for months. And, if it doesn’t kill them, they wonder, “Why me?” Alternatively, if there is good social support, a person may take a more positive approach to life by saying, “I’m still doing OK, and there is no reason that I cannot be happy.” Some people don’t know how to react during their first stay at a hospital. That is why it is important to ask when visiting relatives and friends if they need any help—like contacting a particular nurse or doctor.

7. A person cuts back on the size of his or her social group. At this time, you generally get closer to the people who are most meaningful to you—increasingly by text message, phone calls, or by social media.

8. Some people struggle to continue to accomplish their goals. Others stop looking toward the future, or they use aging as an excuse to give up on all their plans.

9. Naps become a regular part of one’s daily routine.

STAGE TWO: Late Life Emotional Makeover

10. One begins to ruminate about one’s life. You might think more and more about the past and less about the present. A person relives close relationships with lovers and thinks about the jobs he or she has held. In his or her dreams, a person might visit old friends and do some of the things he or she can no longer do. People often appear to have an increased sense of wisdom due to their having seen so many patterns of how life plays out. At the same time, financial status becomes less important to perceived happiness.

11. Several of one’s goals are forfeited. Looking forward, there realistically is not enough time and energy to achieve them all. With a positive attitude, you can find satisfaction in accomplishing fewer things. And doing less, in many cases, has more meaning than doing a lot more. Meanwhile, social and family activities take on an increasing sense of importance.

12. There is a focus on accomplishing one and only one activity per day. That takes up about all the energy one has. This is the beginning of a cycle where an individual’s energy level peaks generally in late morning or midafternoon, leaving one absolutely exhausted by early evening—despite taking a nap.

13. One has fears about the future and anxieties about the present. You might feel cheated, like you are death’s prisoner. You could even question your sense of self that was built on your relationships and life’s work. One mourns the fact that life cannot go on for another round, and that you may not have any more great experiences. So you become anxious—or even obsessed—about the certainty of death.

14. Depression may set in due to loneliness, social isolation, and the feeling of a loss of self-control. This is the number one psychological issue with older adults. You may be prescribed an antidepressant or a medication to help tolerate anxiety and frustration.If there are a supportive family and healthcare professionals, a person works his or her way through this very emotional stage. It is recognized that “talk therapy” is an important factor in the successful treatment of depression and should be used conjointly with medications. Likewise, being offered choices and getting attention from others can raise ones sense of self-control. Mental exercise becomes a valued activity, whether it be reading or playing cards and bingo.

15. One discovers that he or she can no longer successfully take care of one’s own home. One might move to a smaller home or hire a maid. Home ownership increases one’s feeling of life satisfaction and it promotes psychological well-being. Hence, aging people try to hang onto their homes as long as possible. This is why families should encourage it by helping their relatives feel secure, such as by upgrading security and providing mobile emergency call phones. Yet, some people are unwilling or unable to properly take care of their property. In many such cases, the mess is simply ignored, as if it didn’t exist. This is why it is important to have a family cleaning day every few months and not let psychological problems, like hoarding, go untreated.

16. A person identifies as being a patient and being disabled, or he or she rejects the idea entirely. In the latter case, one might frantically hang on to his or her identity from one’s work, family, relationships, or hobbies—perhaps even successfully. For most people, this is the time they acknowledge that they simply cannot keep up with hardly any of the things they used to do. So they settle for what they can do. Otherwise, a person tries to keep moving forward, regardless of one’s limited energies and physical problems. In other words, he or she becomes determined to squeeze every last great moment out of his or her life before the bubble finally bursts.

17. One learns to love life for what it is, or you start to hate it. On the one hand, you get closer to God in a personal sense, and seek to understand the meaning of your life. This transforms one’s feelings about what life is and may provide a renewed belief that life is worth living. You feel a connection to the future and the past. These changes allow you to feel more tolerant of things you do not understand. Otherwise, one begrudges everything and everybody, while feeling cheated out of the only life one will ever known.

18. There is often a family discussion about aging and an advanced care directive may be filled out. This gives one’s next of kin the authority to make decisions for you if you become incapacitated. It states your preference for end-of-life resuscitation, the use of CPR, and under what circumstances you want to be kept alive by medical technology. Aging people often realize there are certain things about life and death that will never be understood. And so the majority of people have little difficulty discussing their death and funeral arrangements with their families. A few will romanticize or dramatize their death, seeing it in popular terms, emblematic of a resurrection or a critical changing of the guard. There is often a lack of valid communication between doctor and patient about these end-of-life issues.

STAGE THREE: Losing Independence

19. You strive to maintain the feel of living independently while you are still mobile. Some people move into an assisted living facility at this time. Others hire non-medical home attendants. This is because they cannot take care of all of the tasks of daily living by themselves—like preparing three meals a day and doing all of the housekeeping. Because of economic or other reasons, some live alone in utter misery within a disheveled mess.

20. A second major medical event occurs. A person may spend weeks in a rehabilitation facility.

21. Friends and family may appear to treat your life-and-death issues with indifference. It may look like they’ve adjusted to your medical condition and now expect you to do the same. You may think—falsely—that they’re pretending to act especially nice during visits just to please you. It may even appear at times that they have already written you off as dead. This feeling may make you regret that you cannot say, “to heck with them,” and go on and start all over.

22. A person becomes so weak or overweight that he or she cannot get out of the bathtub or lift oneself up off the floor without assistance. A person may have to call relatives to help them up. Some even call 911. This happens because elderly people sometimes lose the will power to control their diet, find comfort in eating, or take certain medications that give the feeling of always being hungry. Some say, what’s the point in dieting if you’re going to die anyway? The same can be true for alcohol consumption. Weakness itself generally results from a lack of physical activities or from actual physical disabilities. When it is deemed medically safe, the elderly should be encouraged to walk more, to stoop and pick things up, or do other activities that exercise one’s muscles.

23. There is the stark realization that one has entered a new stage of life. Most people see that the past is behind them and live simply from day-to-day. Some may feel an increasing sense of fulfillment. Perhaps they are dismissive of their physical problems, or rather, are encouraged by the emotional support rendered by friends and family. Or you may deny that much of anything important is happening at all.

24. A person spends almost half the day sleeping, mostly to conserve energy. Small medical issues like lung congestion, coughing, and trouble swallowing may interrupt even the good days that you have when your family visits. Yet you may enjoy telling stories about your life when you have company.

25. An individual becomes an over-medicated zombie. While going through a limited set of daily routines, one begins to be more and more disengaged from the world. A person might stay this way the rest of one’s life. Or, one’s physician and family may take note and help a person to recover a reality-based perspective. For the physician, that requires checking to see if there are medications that conflict with each other, or reviewing the medications to see if the doses are too high. As one grows older, medications metabolize slower and, therefore, remain in the blood stream longer, achieving a larger effect. For the family, this lost sense of reality calls for engaging their aging relative and discovering activities that can be shared. It is also important to take responsibility and set up eye, hearing, and dental examinations. Nursing homes are not generally responsible for these issues.

26. The first major fall occurs. It could land a person in the hospital, followed by 10 weeks in a rehabilitation center. While in rehab, one might socialize and try to enjoy the attention that the nurse and therapists provide. Or, you might get doped up so heavily that you may come close to dying—or even die. The fall itself may be precipitated by an increasing sense of dizziness as one ages.

27. You might have profound dreams, while sleeping or in a semi-awake trance. In these dreams, a person probably settles with the idea of not having achieved all of one’s life goals. He or she may also solve old scores with one’s next of kin.

STAGE FOUR: Knocking on Heaven’s Door

28. A person loses his or her ability to think abstractly. He or she now speaks in short, concrete sentences about what’s obvious and in the here-and-now. This is usually a gradual process that begins while a person is in his or her seventies. After age 85, a person generally stops being able to learn new things.

29. Pain becomes a central focus of your life. Generally, most of the elderly are not suffering from constant pain. But there are some people whose pain is so intense that their lives become centered around controlling it. Family members have a difficult time imagining what life with intense, chronic, moment-by-moment pain is like. Occasionally, they need to discuss it with their relative who is experiencing it. Remember, each and every pill is accounted for, and some doctors are unwilling to prescribe major painkillers, like methadone.

30. You are moved to a nursing home. Your family or professional caregivers simply cannot take care of your medical needs. If a person cannot walk with assistance, he or she is put into diapers and is expected to get around in a wheelchair. All possessions must be labeled with your relatives name or they will be lost. Valuables like expensive watches or memorabilia like wedding rings must be kept elsewhere. They will be stolen, especially by other residents.

31. People often feel isolated, anxious, and abandoned in response to the new atmosphere in the care facility. But as you forget about your old life, the nursing facility starts to feel like home. You bond emotionally with the caregivers, and they add meaning to your life. Otherwise, you might feel trapped like a prisoner and want to escape, especially if you are developing Alzheimer’s disease and are left to your own devices to create a paranoid theory about what is going on.

32. One’s memory becomes foggy, short-lived, and unrealistic. A widow might recall her husband, speaking of him by a different name, and as if he is still alive. Sometimes, elderly people cannot recall which relative is which or who visited them. Don’t try to convince your ageing relative who you are. Instead, attempt to engage them in a conversation or in a simple game like tic tac toe.

33. An individual’s ideas and conversations fade in and out of touch with reality. Ageing people sometimes internalize and suppress their anxiety about feeling alone or abandoned. That could cause them to have childlike ideas, about, say, how their cat or dog visited them in the night. It can cause thought distortions, too, like seeing gold flakes dropping off your ring. On the other hand, a person might only appear concerned about the next event, like the mid-day snack. Regardless, he or she is probably not afraid of dying and may talk about it like it’s an ordinary event.

34. One loses the ability to feed oneself and must be spoon fed.

35. Another major medical issue occurs. The 9-1-1 responders will take you to an emergency room at a hospital. You will have no idea what is going on as the ER team fights to keep you alive. If you live, you will be taken back to the nursing home.

36. If your physicians see death as imminent, your family may move you to a hospice. There you will be kept pain free, if it is possible, as you die, usually in a few weeks. Aside from providing companionship, caregivers will attempt to assist you in facing your death in a healthy emotional fashion. If you are not too mentally impaired, they will help you to reframe your sense of helplessness, such that you accept dying as an important stage of life. This step could come much sooner in life for people diagnosed with advanced degenerative diseases.

Some people may experience a morbid feeling while reading about these stages of dying. Others may feel relived because it helps them to understand what a loved one is going through. The important thing to remember is that these are normal stages of change.

Generally, people pass through most of the steps involved in the four stages of dying, though not necessarily in this exact order. Some people may experience more than one of these steps at the same time. Alternatively, individuals, who die from sudden trauma—as from a car crash—will bypass most of these changes altogether. Regardless, ninety percent of all people die slowly. So they will experience a majority of these life junctures during their dying process.

© 2012 Dr. Billy Kidd

For more information, contact Dr. Kidd at BillyKidd.com.

Dr. Kidd advises that this list should not be used as an alternative to diagnosis, treatment, and care provided by qualified medical and psychological professionals

Resources

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● Hwang, J. E. (2010). Reliability and validity of the health enhancement lifestyle profile (HELP). Occupation, Participation and Health, 30(4), 158-168.

● Johnson, C. J., & McGee, M. (2004). Psychosocial aspects of death and dying. The Gerontologist, 44(5): 719-722.

● Kastenbaum, R. (1997). The end of life at the second millennium. The Gerontologist, 37(5), 698-701.

● Laakkonen, M. L, Pitkala, K. H., Strandberg, T. E., Berglind, S., & Tilvis, R.S. (2004). Living will, resuscitation preferences, and attitudes towards life in an aged population. Gerontology,50(4), 247-254.

● Law, R. (2009). ‘Bridging worlds’: Meeting the emotional needs of dying patients. Journal of Advance Nursing, 65(12), 2630–2641.

● Mathie, E., Goodman, C., Crang, C, Froggatt, K., lliffe, S., Manthorpe, J., and et. al (2011). An uncertain future: The unchanging views of care home residents about living and dying. Palliative Medicine 26(5), 734-743.

● Tumminello, M., Micciche, S., Dominguez, L. J., Lamura, G., Meichiorre, M. G., Barbagallo, M., & et. al (2011). Happy aged people are all alike, while every unhappy aged person is unhappy in its own way. PLOS ONE, 6(9). Retrieved on January 16, 2013 from http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0023377

● von Gunten, C., & Knight, S. J. (2004). Understanding the psychological and social experiences of a dying person. EndLink: An Internet-based End of Life Care Education Program. Retrieved on 12/10/2012 from

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● Wright, K. (2003). Relationships with death: The terminally ill talk about dying. Journal of Marital and Family Therapy, 29(4), 439-455.

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