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The Stages of Dying Checklist

Updated on July 10, 2019
Dr Billy Kidd profile image

Dr. Billy Kidd was a psychotherapist and researcher for 20 years. He has also studied history, religion, and has been active in politics.

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

The human body is consists of cells that begin their aging process at about 45 years after birth. It generally takes 10 to 20 years before changes are noticeable.

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 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—like exercising, proper eating, limited drinking, weight watching, socializing, and spiritual activities. This greatly influences how rapidly one's 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 often 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. A person notices that he or she cannot keep up with younger folks.

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

7. A person cuts back on the size of his or her social group. At this time, a person generally tries to get closer to the people who are most meaningful—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. 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 if he or she needs any help—like contacting a particular nurse or doctor.

STAGE TWO: Late Life Emotional Makeover

Some of these emotional and cognitive changes may occur at the same time as the physical changes in section one.

1. One begins to ruminate about one’s life. One 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. Financial status becomes less important to perceived happiness. However money in savings may raise one's sense of self-esteem. The exception, of course is medical costs. They might cause one not to get recommended treatments.

2. 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, one 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. The opposite might be true, however. A person might isolate oneself from society.

3. There is a focus on accomplishing one and only one activity per day. This 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.

4. One has fears about the future and anxieties about the present. He or she might feel cheated, like a person is death’s prisoner. A person could even question his or her sense of self that was built on their relationships and life’s work. One mourns the fact that life cannot go on for another round, and that a person may not have any more great experiences. So one become anxious—or even obsessed—about the certainty of death.

5. Depression may set in due to loneliness, social isolation, and the feeling of a loss of self-control. This is the major psychological issue with older adults. One may be prescribed an antidepressant or a medication to help tolerate anxiety and frustration. If there is a supportive family and healthcare professionals, a person works his or her way through this very emotional stage. 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.

6. 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 or apartments as long as possible. 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 did not 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.

7. 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.

8. One learns to love life for what it is or start to hate it. On the one hand, one gets closer to God in a personal sense, and seeks to understand the meaning of life. This transforms one’s feelings about what life is and may provide a renewed belief that life is worth living. A person may feel a connection to the future and the past. Yet slowly one begins to focus on the immediate situation. These changes allow one to feel more tolerant of things one does not understand. Otherwise, a person begrudges everything and everybody, while feeling cheated out of the only life one will ever know.

9. 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 medical decisions if one becomes incapacitated. It states a person's preference for end-of-life resuscitation, the use of CPR, and under what circumstances one wants to be kept alive by medical technology. The majority of people have little difficulty discussing their death and funeral arrangements with their families.

Some People Shut Themselves In
Some People Shut Themselves In

STAGE THREE: Losing Independence

Losing independence is a major change that is hard to adapt to at first. Later the majority of people adapt quite well.

1. One strives to maintain the feel of living independently while one is 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.

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

3. Friends and family may appear to treat one's life-and-death issues with indifference. It may look like they’ve adjusted to a person's medical condition and now expect a person to do the same. One may think—falsely—that the kinfolk are pretending to act especially nice during visits just to please their family member. It may even appear at times that they have already written one off as dead. This it very pointed when relatives stop visiting or carry on conversations as if one was not really there.

4. A person may become 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 is the point in dieting and exercising if you are going to die anyway? The same can be true for alcohol and cigarette 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.

5. 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. One may deny that much of anything important is happening at all.

6. A person spends almost half the day sleeping, mostly to conserve energy. Some medical issues like lung congestion, coughing, and trouble swallowing may interrupt even the good days when one's family visits. Yet a person may enjoy telling stories about one's life when there is company visiting.

7. An individual may become 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. 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. This includes 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. Dosages are then decreased. 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.

8. The first major fall occurs. It could land a person in the hospital, followed by 8 weeks in a rehabilitation center. While in rehab, one might socialize and try to enjoy the attention that the nurses and therapists provide. Or a person might be so doped up that he or she may come close to dying—or even die. The fall itself may be precipitated by an increasing sense of dizziness as one ages.

9. A person might have profound dreams, while sleeping or in a semi-awake trance. In these dreams, one probably settles with the idea of not having achieved all of one’s life goals or not. He or she may also solve old scores with one’s next of kin. Dreams and trances may seem so real that they may be taken for reality.

STAGE FOUR: Knocking on Heaven’s Door

This final stage may be meaningful yet difficult for the family while being very grueling for the person who is dying.

1. A person loses his or her ability to think abstractly. He or she now speaks in short, concrete sentences about what is obvious and in the here-and-now. This is usually a gradual process that begins while a person is in his or her seventies or eighties.

2. 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.

3. One is moved to a nursing home. The family or professional caregivers simply cannot take care of a person's medical needs. If one 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 and low paid nurses aids.

4. People often feel isolated, anxious, and abandoned in response to the new atmosphere in the care facility. But as one forgets about his or her old life, the nursing facility starts to feel like home. One bonds emotionally with the caregivers, and they add meaning to life. Otherwise, a person might feel trapped like a prisoner and want to escape. This is especially true if one is developing Alzheimer’s disease and is left to one's own devices to create a paranoid theory about what is going on.

5. One’s memory becomes foggy, short-lived, and unrealistic. A widow might recall her husband, speaking of him as if he is still alive. Sometimes elderly people cannot recall which relative is which or who visited them. Do not 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.

6. 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. Ageing can cause thought distortions, 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.

7. One loses the ability to feed oneself and must be spoon fed by a nurses aid.

8. Another major medical issue occurs. The 9-1-1 responders will take one to an emergency room at a hospital. The patient will have no idea what is going on as the ER team fights to keep one alive. If a person lives, he or she will be taken back to the nursing home.

9. If your physicians see death as imminent, the family may move their relative to a hospice. There a person will be kept pain free, if it is possible. Before this, the guardian for the person's health choices will be asked if the patient wants to be kept alive with a tube that feeds the person through the stomach. This requires an operation and is used when the person stops eating.

Conclusion

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

Resources

● Baltes, P. B., & Smith, J. (2003) New frontiers in the future of aging: From successful aging of the young old to the dilemmas of the fourth age. Gerontology, 49(2), 123-135.

● Barker, C., & Foerg, M. (2001). Imminent death. Long Term Care Intensive Train-the-Trainer Series. Detroit, MI: Wayne State University Institute of Gerontology, Hospice of Michigan, and Lutheran Social Services of Michigan. Retrieved on 12/10/2012 from http://www.eperc.mcw.edu/FileLibrary/User/jrehm/EPERC/EducationalMaterials/ImminentDeathScript.pdf

● Beaver, D. S. (2003). The impact on the family therapist of a focus on death, dying, and bereavement. Journal of Marital and Family Therapy, 29(4), 469-477.

● Bowling, A. (2008). Enhancing later life: How older people perceive active ageing? Aging & Mental Health, 12(3), 293-301

● Bowling, A., & lliffe, S. (2011). Psychological approach to successful ageing predicts future quality of life in older adults. Health and the Quality of Life Outcomes, 9(13) np. Retrieved on January 16, 2013 from http://www.hqlo.com/content/9/1/13

● Fenwick, P., Lovelace, H., & Brayne, S. (2010). Comfort for the dying: Five year retrospective and one year prospective studies of end of life experiences. Archives of Gerontology and Geriatrics, 51(2):173-179.

● 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

http://endlink.lurie.northwestern.edu/social_considerations/understanding.pdf

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

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

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