Elisabeth Kübler-Ross and the “Five Stages” Model in a Sampling of Recent Textbooks Published in 10 Countries Outside the United States

Abstract

A previous article in this journal examined some aspects of the enduring influence of Elisabeth Kübler-Ross’s “five stages” model through a sampling of recent American textbooks in selected academic disciplines and professional fields. This article offers a parallel sampling of 47 textbooks published in 10 different countries outside the United States. The questions to be answered are as follows:

Does the “five stages” model appear without significant change in the textbooks described here?

Is the “five stages” model applied in these textbooks to issues involving loss, grief, and bereavement as well as to those involving terminal illness and dying?

Is the “five stages” model criticized in some or all of these textbooks?

If so, is the criticism sufficient to argue that, while the “five stages” model might be presented as an important historical framework, it should no longer be regarded as a sound theory to guide contemporary education and practice?

Keywords

Elisabeth Kübler-Ross the “five stages” model dying grief textbooks

Introduction: Why Kübler-Ross?

In her autobiography, The Wheel of Life: A Memoir of Living and Dying , Elisabeth Kübler-Ross (1997) describes (among other things) the origin, format, and conduct of the seminars she led in the late 1960s during which she interviewed adults in a Chicago hospital who were living with a diagnosis of a terminal illness. That work led to the publication of On Death and Dying (Kübler-Ross, 1969), a book that (coupled with an article in Life magazine, Wainwright, 1969) unexpectedly made her in her own words a “world–famous author” (Kübler-Ross, 1997, p. 15). In that book, she wrote that she “had over 200 interviews over a period of almost three years” (Kübler-Ross, 1969, p. 250), and she described a theoretical model of five “stages” experienced by these adults, as they were living out their illness journey. The five stages are denial, anger, bargaining, depression, and acceptance (leading to the acronym DABDA used by some). In calling these reactions and responses “stages,” Kübler-Ross used a term that is familiar in many medical diagnoses of disease, but she did not otherwise say much about the background or sources of her theory. She did explain that the stage of depression could be divided into “reactive depression” and “preparatory depression” (p. 86), and she added that “The one thing that usually persists through all these stages is hope” (p. 138).

It is not completely clear whether the individuals interviewed by Kübler-Ross did or were obliged to “go through” all of these stages and to do so in the order given, although that is the impression that many drew from reading On Death and Dying. In fact, there is no example in that book of a single individual who is traced through all five stages. However, Kübler-Ross certainly wrote as if all or most individuals do move from one of these five stages to the next in the order given. Also, the very language of “stages” implies a linear ordering of experiences in dealing with a terminal illness.

Soon after its initial appearance, the “five stages” model became well known to many professionals and to the general public. It is recognized by ordinary people and seems to appear even today in many forms of professional education and practice. The 50th anniversary of the publication of On Death and Dying provides a suitable occasion to begin an exploration of some ways in which the “five stages” model is presented to contemporary readers in a sampling of 47 books from 10 countries outside the United States.

Introduction: Why Textbooks?

Textbooks are tools widely employed in many types of educational programs. Such books can have a wide-ranging and lasting influence on the educational programs they serve. Although translations of On Death and Dying have been published in many countries around the world, for some readers, textbooks published in those countries may be the only means by which they gain access to the work of Kübler-Ross and her “five stages” model as well as to critical assessments of that theory. Language, economic, and other barriers may mean that textbooks and journals published in the United States containing such critical assessments may not be easily available to readers in some other countries. A previous article in this journal examined some aspects of the enduring influence of Elisabeth Kübler-Ross's “five stages” model through a sampling of recent American textbooks in selected academic disciplines and professional fields (Corr, 2019). Even so, some international readers may not be aware of criticisms of this model or alternatives to it that have been proposed in recent years.

The potential influence of a textbook can be especially notable when the subjects it discusses are popular and of broad human interest. This is especially true for textbooks that address, at least in part, subjects like coping with dying and coping with loss, grief, and bereavement. These subjects are of interest to readers who are, have been, or expect to be involved in such coping situations, who are providing or are preparing to provide care to dying or bereaved individuals, or who are simply curious.

Because it is difficult to gain access to different textbooks in different subject areas and from different countries, a brief article can only offer an initial sampling of textbooks published outside the United States. Still, the examples offered here can indicate how the work of Elisabeth Kübler-Ross and her “five stages” model is presented to readers of these books. It can also suggest opportunities for future research in greater depth in countries considered here, in other countries, in textbooks written for specific professional or academic audiences, and in the educational programs which such textbooks serve. The following two sections address: (a) issues related to dying and (b) issues related to loss, grief, and bereavement. In each case, subsections are organized alphabetically under the names of the countries considered.

Kübler-Ross and the “Five Stages” Model in Some Recent Textbooks: Dying

Australia

Some textbooks in Australia and New Zealand are unique to that area of the world; others are editions of American books adapted to the needs of local users. For example, in the sixth edition of a uniquely Australian lifespan developmental psychology book, Peterson (2014) describes each of the five stages in the Kübler-Ross model and offers the following critical comments:

Kübler-Ross’ theory has been challenged by those who argue that evidence derived solely from a theorist’s intuition-based counselling procedures requires independent and objective validation. Also, the question of whether the stages apply to everyone and occur in the same order must remain open until the theory has been subjected to the rigorous tests for sequentiality and universality that have been developed for theories in other domains of psychological development.

A more subtle criticism concerns what some feel is an implicit prescription in Kübler-Ross’ theory that the stage system outlines the ideal, “right way” to die. Individuals who fail to traverse all five stages are sometimes made to feel guilty as though they have not fully mastered the major developmental task of the terminal phase of psychological functioning. Kübler-Ross adamantly denied the view that acceptance is an intrinsically better state in which to meet death than (say) rage or denial. In other words, the stage theory of dying is seen by its author to describe a possible developmental progression that may be appropriate to some individuals but not at all appropriate to others. (p. 600)

Peterson then describes “some of the variables that may influence the possibility of a dying person’s progression through the various attitudinal and adjustment changes described in Kübler-Ross’ theory,” such as cause of death, sex differences, cultural, ethnic, and socioeconomic factors, historical context, personality and cognitive style, developmental level and current goals, and social and physical surroundings.

In her chapter in an Australian edition of an American lifespan development textbook, Breen (2014) explains each of the Kübler-Ross “five stages of dying.” She then asks: “What is the current evaluation of Kübler-Ross’ approach?” Her response is in two parts: first, she cites some of the criticisms of this model made by Robert Kastenbaum (see later in this article) and second, she offers the following comment:

However, Kübler-Ross’ pioneering efforts were important in calling attention to those who are attempting to cope with life-threatening illnesses. She did much to encourage attention to the quality of life for dying persons and their families.

Because of the criticisms of Kübler-Ross’ stages, some psychologists prefer to describe them not as stages but as potential reactions to dying. At any one moment, a number of emotions may wax and wane. Hope, disbelief, bewilderment, anger and acceptance may come and go as individuals try to make sense of what is happening to them. In facing their own death, some individuals struggle until the end, desperately trying to hang on to their lives. Acceptance of death never comes for them. Some psychologists believe that the harder individuals fight to avoid the inevitable death they face and the more they deny it, the more difficulty they will have in dying peacefully and in a dignified way; other psychologists argue that not confronting death until the end may be adaptive for some individuals. (p. 667)

Another example of an American life span development textbook adapted for the Australasia market offers these comments:

Our understanding of how people deal with their own dying has been greatly influenced by the work of Elisabeth Kübler-Ross. Working within a psychoanalytic framework, Kübler-Ross (1969) interviewed 500 [sic] terminally ill patients in the United States and proposed five distinct stages that individuals pass through … Although the stages are distinct, they are not necessarily progressive and are likely to overlap … Kübler-Ross emphasises the importance of informing patients about their condition so that dying can be a time of growth as individuals come to terms with their past and who they really are. (Hoffnung et al., 2016; p. 726)

An Australian and New Zealand adaptation of a well-known American nursing textbook (Crisp, Douglas, Rebeiro, & Waters, 2017) remarks that Kübler-Ross “enabled death to be viewed as a meaningful experience—dying with dignity—rather than as a medical failure” (p. 181; their emphases). As well, there is a longer comment under the heading “Theories of Grief and Loss” (see later in this article).

Brazil

In Brazil, there are no specific courses in thanatology, but undergraduate courses in nursing, medicine, and psychology already include short-term units on death and dying. Also, the popularity of palliative care as a new medical specialty among Brazilian professionals has led to some courses that address issues of death and bereavement. Accordingly, Santos, Schliemann, and Solano (2014) edited a book as a broad source for consultation and education on these subjects. In discussing dying, this book comments that

Elisabeth Kübler-Ross, with the publication of her book, On Death and Dying: What the Terminally Ill Have to Teach Their Doctors, Nurses, Clergy, and Their Own Relatives, pioneered studies on death and the process of dying. In this work she establishes what have come to be widely known as the “stages of death” characterized as five phases that the terminal patients would cross during the process of dying. (p. 74)

Elsewhere, this book observes that lack of education in this field results in “greater suffering at the end of life” (p. 224), an outcome Kübler-Ross struggled against.

Canada

In the Canadian edition of a well-known American textbook on medical-surgical nursing, Pooler and Olson (2016) write:

Although useful in understanding the overall experience of the dying process, the stages that Kübler-Ross described have been misinterpreted as following a linear, expected trajectory. Not every person or family member experiences every stage, many patients never reach a stage of acceptance, and patients and families fluctuate on a sometimes day-to-day basis in their emotional responses. (p. 436)

In the Canadian edition of their health psychology book, Sarafino, Smith, King, and DeLongis (2015) address the question: Does adapting to dying happen in “stages”? After referring to a table describing each of the five stages, they write:

Not all the patients she interviewed showed this pattern—a few, for example, continued to deny that they were dying to the very last. But the pattern of adjustments seemed sufficiently regular for Kübler-Ross to propose that coping in most dying people begins with denial and advances through the stages in order. (p. 259)

These authors then pose a second question: “Do Kübler-Ross’s stages correctly reflect the emotional reactions most dying patients experience as they cope with terminal illness?” Their answer is as follows:

Available evidence does not support the idea that most individuals adjust to dying with a predictable and orderly sequence of reactions … An overview of this evidence indicates that some terminal patients do follow an orderly and predictable sequence of adjustment, but most people’s emotions and coping patterns fluctuate. Some people may go through a specific stage, such as anger, more than once during their adjustment; others have more than one emotional reaction simultaneously; and some seem to skip stages. And some evidence indicates that people who achieve an “acceptance” of their impending death die much sooner than those who do not reach this stage. (p. 259)

These authors close with the following comment:

Despite these shortcomings, Kübler-Ross’s work has had many positive effects. For one thing, it has been influential in stimulating people’s awareness and discussion of the dying process and the needs of terminal patients. It has also led to important and very beneficial changes in the care and treatment of dying people, thereby improving the quality of the last weeks and days of their lives. (p. 259)

French-Language Books

Books in French appear in many different French-speaking countries whose research, education, and cultural traditions on dying and grief can vary widely. For example, with few exceptions most of the educational programs offered to French-speaking professionals that deal with death, dying, and bereavement are conducted outside university settings. Thus, the following examples differ in many ways.

A Belgian author (Druet, 1981) provides a historical description of Kübler-Ross’s work and the origins of her theory, taking note of the “powerful movement against denial [of death]” that she initiated (p. 74). He then presents “the seven [sic] stages of agony” (i.e., shock, denial, anger, depression, bargaining, acceptance, decathexis/détente), commenting that “they can overlap partially, come up in a different order or not be all experienced; in addition, their respective duration is very variable. As any schema, this thus constitutes a generalization” (p. 76). Druet acknowledges criticisms of the Kübler-Ross model but notes that she did succeed in helping dying patients.

Two authors from Quebec (Canada) have books on the psychology of dying, death, and grief (Hétu, 1989; Jacques, 1998). Both describe the Kübler-Ross model, but in six stages rather than five, including shock as an initial stage that differs from denial. Jacques (1998) explains that

the model is composed of three underlying ideas: (1) the dying person has predicable and typical reactions, (2) in the dying process, these reactions follow a sequence and are interrelated, and (3) the last stage is to be favored. The counsellor’s role is to facilitate the passage from one to the other stage. (p. 40)

A critique follows, highlighting three shortcomings (i.e., absence of empirical support as Kübler-Ross was the only one to evaluate the emotional state of her patients; sequential presentation of the stages versus individual differences; acceptance presented as appropriate or ideal) and two strengths (i.e., its simplicity facilitates understanding of the dying process; and it provides a landmark which practitioners can expect and indicating how adjustment can be facilitated by emotional expression).

A chapter on palliative care in a health psychology textbook published in Paris warns the reader

that all patients do not go through all of the phases, that these will not happen in this order, and that the time needed for each person to work through the grief of one’s life, one’s dear persons, one’s possessions, and one’s dreams is variable. (Coppens et al., 2013, p. 244)

These authors then describe the dying process in six stages (shock appearing before the traditional five stages) before concluding that,

In practice, this model is the most used. However, it bears some shortcomings, in particular the fact that there is no satisfactory empirical validation and that the reality (of these patients) is more dynamic and large individual differences in the order and rhythm of the stages exist. (p. 246)

They end by saying that “This model is still useful for professionals to be prepared and to understand patients’ reactions (e.g., their aggressiveness, their seemingly senseless projects, etc.)” (p. 246).

Germany

In Germany, there is no recognized field of death, dying, and bereavement, no courses on “death education” of the kind now common in North America. Thus, most of the books identified here are intended for students of medicine (often with titles like “Medical Psychology” and “Medical Sociology”) or perhaps for counselors and clinical psychologists. For example, Schüler and Dietz (2004) explain that Kübler-Ross proposed that “dying persons go through a very similar sequence of emotional stages” (p. 257), whose five stages (“Stufen” in German) they then describe. However, these authors and Kessler (2015) add that recent research shows that there are significant individual differences in how these reactions are experienced, such that they can combine, be repeated, or be omitted.

Hannich (2004) depicts the Kübler-Ross model as a kind of ideal typology for those coping with dying, but he adds that efforts to help need to be oriented to the individual situation of the dying person, that is, doctors need to look for the stage in which the patient finds himself and direct assistance accordingly.

Geißendörfer and Höhn (2007) caution that although this model can sometimes enable a doctor to help a patient get through specific stages, “one should not interpret the stages as a fixed rule. Every dying process is different” (p. 43). Similarly, Kasten and Sabel (2009) point out that “the sequence is variable and the participants go through these stages in a rather variable and sometimes protracted manner” (p. 362), while Muthny and Bengel (2009) observe that,

Clinical experience shows that it is not obligatory that all the stages do appear, seldom are passed in such an orderly sequence, and the (normative) expectation of them can be a burden to the patient that in turn may spoil the relationship with the patient. (p. 360)

Another author (Verres, 2016) declares that this stage theory

is frequently received as if it were a regular process [i.e., a process that follows a rule]. However, that has not been empirically confirmed. Actually, every person reacts in his or her own way to the confrontation with the end. (p. 302)

Verres cautions that helpers can be misguided by taking the stages too literally and urging patients whose condition is declining to move quickly from one stage to another in order to reach acceptance, which would not serve patients well. On the contrary, Verres points out that persons with an incurable condition often fluctuate between acceptance and denial as active (not passive) ways of coping with their situations. This author expresses the hope that this model should enable helpers to understand a dying individual’s anger, rage, and envy better so that they do not take these behaviors personally. Verres adds that it is important for physicians to make a distinction between depression taken in the strict sense as a psychiatric diagnosis (which is not what Kübler-Ross meant in her model) and sadness or grief.

Greece

A popular Greek health psychology textbook (Papadatou & Anagnostopoulos, 2012) provides a historical context referring to the work of Kübler Ross in the United States and of Cicely Saunders in the United Kingdom, both of whom did so much to “bring death out of the closet” in the late 1960s and “give voice” to dying patients, whose psychosocial and spiritual needs were recognized, described, and addressed with respect. However, these authors offer the following critical comments:

Unfortunately, Kübler-Ross’ model was misinterpreted and continues to be used in inappropriate ways by health care professionals who strive to “fit” the patients’ responses in the 5 stages, and neglect how unique is each human being … In reality, the five stages described by Kübler-Ross, are not “stages” but rather few among many possible responses; these responses are reflective of a broader psychosocial process that is affected by social factors and the conditions in which death occurs. (pp. 132, 133)

By contrast, these authors emphasize the following three contributions made by Kübler-Ross:

(1) Every dying person is alive until the very end of his or her life, he or she has needs, desires, and occasionally “unfinished business” which must be addressed.

(2) Effective end-of-life care requires an ability to listen attentively to what dying patients expresses directly, indirectly, or symbolically, as well an ability to “follow” rather than “lead” the person through his or her own dying trajectory. Accompanying people at the end of life, offers health care professionals an opportunity to face their own mortality, to develop a deeper awareness as to their values, and to recognize both their strengths and limitations when caring for people who die.

(3) Hope is maintained until the very end of a person’s life. Its content may change when, for example, the patients shifts from hoping for a cure, to hoping for the prolongation of life, for dying at home, for attending a significant family event, or for coping with an unfinished business. (p. 132)

These authors also refer to other models on the dying process that appeared in the literature in the 1970s and 1980s but did not receive the same attention as the Kübler-Ross’ model, and they provide an extensive description of Corr’s (1992) task model on coping with dying.

Another Greek health psychology textbook (Karadimas, 2005) makes the point that “These stages should not be considered as prescribed steps in one’s development, but rather as alternative responses which are included in a larger process that seeks to help the person ‘adjust’ to a new reality” (p. 233).

A Greek edition of an American health psychology textbook (Anagnostopoulos & Potamianos, 2006) offers a detailed description of Kübler-Ross’ model on the dying process. The authors agree that these are five common responses but comment that such responses do not reflect the experiences of all patents and do not occur in a predetermined order. Rather, they suggest that responses vary and often involve the experience of anxiety caused by pain, physical deterioration, and decreased quality of life, which the five-stage model does not acknowledge. The book mentions the fear of being abandoned by professionals who “have nothing else to offer” and the experience of social isolation and loneliness that many patients experience when they choose not to share personal feelings and concerns with loved ones in an attempt to protect them from suffering.

Italy

In her book designed as an introduction to thanatology, Sozzi (2014) provides a detailed account of each of

the five stages that the patient crosses, from the moment in which he is revealed to be suffering from an incurable disease until death, from the denial of the diagnosis to the acceptance of the need to leave the life. (p. 56)

She indicates how appreciation of each of these coping reactions can help a doctor understand the individual better and how they can guide constructive interactions. As she writes,

It is important for the doctor to know the way in which the patient defends himself, because that allows him to learn how to tell the truth to the patient without taking hope away and, above all, without ever abandoning the patient, allowing him to remain at his side. (pp. 56, 57)

For Campione (2003), according to Kübler-Ross,

aid to the dying person consists of ensuring that he goes through the natural stages of dying (rejection, disbelief, anger, bargaining and depression, acceptance and hope) and he arrives, having set things right with the help of unconditional love of others, to an acceptance of death that resembles the condition of the child’s primary narcissism, in which he is one with the world and he becomes indifferent to pain and death, because “he is no longer” a particular individual who suffers and dies. (pp. 10, 11)

Put another way, Campione (1986) argues that,

Kübler-Ross seems to give the term acceptance a different meaning [i.e., versus “a rational acknowledgment of the inevitability of death”]. That is like saying that what eases the acceptance and perhaps constitutes its essential, rather than a rational and conscious choice, is to give way to a condition of extreme passivity that dying in its last phases determines. (pp. 60, 61)

Furthermore, for Campione (2009),

This could be the reason why Kübler-Ross is a thanatologist on whom opinion is divided between those who are faithful followers and those who are irreducible detractors. As it happens between those who have faith in the afterlife and those who do not have it: they cannot talk because they belong to two different cultures that, only respecting one’s own limits, could empathize and build a language to understand each other. (pp. 11, 12)

Japan

Three chapters have emerged from a survey of 35 well-known Japanese nursing textbooks as representative of teachings in this area. Hirose, Kojomon, and Shikimori (2013) present the Kübler-Ross five-stage model in a box and describe it as a guide to understanding psychological processes seen among patients dying of cancer. They then observe:

Of course, not all the patients move through these stages accordingly. People experience swings of various feelings as long as they live. Their life history also affects them. EKR herself explained that, “These stages are sometimes experienced in different order, and sometimes experienced at the same time.” On the other hand, these five stages are experienced not only by the dying people. These are psychological processes common to those who are facing the most shocking and unacceptable facts. EKR continued to write that they can hold on to hope once they are through the shock after being told of the fact. She wrote that hope is maintained while getting closer to death. And the last stage of decathexis (the attachment to life is released) is reached. (pp. 307, 308)

Arao (2018) agrees that “The dying person’s psychological process toward death varies depending on diseases and conditions they experience” (p. 258). And Kojomon, Akazawa, and Sonehara (2017) concur that “not all patients go through this process” (p. 346), explaining that in recent years, treatments of some diseases such as cancer, HIV infection, or AIDS, which once implied death, have developed and those patients now follow a longer process similar to chronic disease, fighting with fear and anxiety. Nevertheless, they insist that these patients must feel cared for continuously.

The United Kingdom

Books published in the United Kingdom that discuss the “five stages” model are often critical of this theory both as regards dying and as regards broader issues of loss, grief, and bereavement. For example, Payne, Horn, and Relf (1999) begin by observing that “Kübler-Ross (1969) developed a five stage model of the grief of terminally ill people that is often applied to grief following bereavement” (p. 72). They then describe each of the five stages and offer the following critical comments as regards individuals diagnosed with a terminal illness:

Whereas Kübler-Ross may be criticized for being too simplistic, focusing on the experiences of relatively young people and those who die in hospital, her work has had a profound impact. By illustrating the isolation of terminal illness she has challenged the practice of protecting them by surrounding them with conspiracies of silence. However, her model is rather simplistic and there is a danger that those working with the dying may assume that they know how people are reacting and respond accordingly … There is a danger that, rather than being enabled to explore their situation, dying people may find that their reactions are dismissed because they are recognized as “normal.” Individual reactions that do not conform to the model may be ignored. (p. 73)

In her book, Negotiating Death in Contemporary Health and Social Care, Holloway (2007) has the following to say about the Kübler-Ross “stages of dying”:

It is now commonplace for “stage theory,” as it came to be known, to be criticised as overly prescriptive, generalising from subjective data and failing to recognize the range of individual variation. However, Kübler-Ross’s theory, generated from her observations as a psychiatrist of terminally ill patients in a Chicago (US) hospital, has been one of the most widely applied with an enduring popularity with trainers in grief counselling. Kübler-Ross claimed that people who know that they are dying pass through five stages in linear fashion: denial, anger, bargaining, depression, until finally reaching acceptance. This is essentially a psychological process and emotional response, without attention to either social context (although she does link denial to isolation) or philosophical underpinnings (although in her later life Kübler-Ross became obsessed with near-death experiences as psychic phenomena with spiritual overtones). The processes which she described continue to be identified by theorists, but it is the deterministic fashion in which her stages have been applied to all experiences of loss and the conflation of Kübler-Ross’s work with other work on the process of grief and mourning under the umbrella of stage theory, which has led to the greatest criticism. (p. 80)

Kübler-Ross and the “Five Stages” Model in Some Recent Textbooks: Loss, Grief, and Bereavement

Actually, Kübler-Ross did not use the phrase “stages of grief” in On Death and Dying, despite the fact that many textbook authors cite that book to support their use of this language. The obvious reason she did not write about “stages of grief” is because she was writing about reactions and responses to a diagnosis of a terminal illness, not loss, grief, or bereavement in general. As Kemp (2014) explained,

While Kübler-Ross later applied her stage-based model to grief, it was not initially intended as a way of understanding grief. Rather, it was developed as a way to understand the reactions of people who had been informed by their physicians that they were going to die. (p. 214).

In fact, coping with a terminal illness involves different challenges than loss and grief alone. Also, there is a significant difference between (a) coping with a terminal illness, that is, struggling with a life-threatening disease and its implications from diagnosis through the disease trajectory to an outcome in death whose precise timing is often unknowable in advance and (b) coping with grief, which applies to a much larger range of losses or to bereavement when survivors are coping with the actual fact of the death of someone they love and of the losses entailed thereby. In On Death and Dying, Kübler-Ross correctly wrote that “The dying patient’s problems come to an end, but the family’s problems go on” (p. 160) but problems and challenges to be faced after the death of a loved one are different from those faced prior to that death.

Nevertheless, not long after the publication of On Death and Dying, Kübler-Ross began to speak of the five stages not only as describing coping with dying but also as applying to coping with other losses, including postdeath experiences. Eventually, shortly after her death in 2004, a book she coauthored with David Kessler was published bearing the title On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss (Kübler-Ross & Kessler, 2005). The five “stages of grief” are described in detail in Chapter 1 but are only rarely mentioned in the remainder of the text (Corr, 2015). That may be, in part, because of what the authors write on page 7:

The stages have evolved since their introduction, and they have been very misunderstood over the past three decades … They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grief is as individual as our lives.

The five stages—denial, anger, bargaining, depression, and acceptance—are a part of the framework that makes up our learning to live with the one we lost. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief. Not everyone goes through all of them or goes in a prescribed order.

If these responses to loss are no longer thought to be universal or experienced in a linear or prescribed order, it is not clear why they should be called “stages” (see, e.g., Konigsberg, 2011). However, many textbook authors continue to write about “stages of grief,” typically attribute their source to On Death and Dying, and most do not cite the Kübler-Ross and Kessler book.

Australia

In relation to grief and bereavement, the authors of an Australian and New Zealand edition of a well-known American fundamentals of nursing textbook (Crisp et al., 2017) offer the following comments:

Perhaps one of the best-known grief theories has emerged from the work of Elisabeth Kübler-Ross (1926–2004), a Swiss-American psychiatrist who interviewed dying people to better understand their experiences as their lives came to an end (Kübler-Ross, 1969). In its application to bereavement, Kübler-Ross’s theory proposes that people move through stages of grief not unlike the phases suggested by Bowlby. This theory has gained tremendous traction both with healthcare professionals and with the general public, and is often assumed to be the most accurate description of “normal grieving.” However, all theories are subject to criticism and this theory of bereavement has been strongly criticised for assuming that stages of grief take place sequentially. (p. 515)

In her chapter on “Death, Dying and Grieving” in an Australian edition of an American lifespan development textbook, Breen (2014) writes:

Kübler-Ross’ ideas on dying were embraced by some health professionals who also applied her stage theory to grief, despite the model being criticised for being methodologically limited, conceptually simplistic and lacking empirical validation (Corr, 1993). However, one recent study provided some empirical support for the stage-based progression of grief (Maciejewski, Zhang, Block, & Prigerson, 2007) by revealing that the death of a loved one is most frequently followed by yearning (an intermittent recurrent wish or need to recover the lost person) and acceptance, with most of the negative feelings associated with the death diminishing by six months after the death. In this study, yearning was more common than depression following a loved one’s death. (p. 670)

Breen ends with this comment: “Rather than a linear progression of stages, contemporary models of grief highlight a more complex progression.” This is shown by mentioning alternative theories and some variables that may affect an individual’s grief and mourning, such as type of death and cultural diversity.

Another lifespan development book (Hoffnung et al., 2016) notes that “More recently Kübler-Ross and Kessler (2005) have argued that the five stages model can also be applied to people who are grieving … Kübler-Ross’s model has also been applied more generally to loss unrelated to bereavement” (p. 726). However, Hoffnung et al. (2016) add the following criticisms:

Although Kübler-Ross’s stage formulation has been widely used by clinicians who work with dying patients, it has also been challenged by research, theory and practice (Corr, Doka, & Kastenbaum, 1999), particularly because of its unidirectional, prescriptive nature. The patients Kübler-Ross studied were young and middle-aged adults dying of cancer, which may account for the anger and bargaining she found. The age range of her sample makes generalising to older adults problematic [because they may be more accepting of death or may die with diminished capacity]. [Also,] Kübler-Ross’s work focused on people whose death was likely within a six to twelve-month period. Her stage model is less helpful for understanding the experience of people with a long living-dying period … in which the course of dying is much more variable than Kübler-Ross’s stages imply. (p. 727)

Brazil

In a chapter on “Models of Normal Mourning,” the book by Santos et al. (2014) describes grief theories, including those by Worden, Bowlby, and Parkes, as well as the continuing bonds and dual process models. Among these, the Kübler-Ross model of the “stages of grief” is said to be the most popular and one of the oldest. But it is noted that this model is based on psychiatric-type interviews with terminal patients, has limitations, and should be used with reservations:

The danger of the model of the Kubler-Ross phases is that, appearing in a linear sequence of steps, it is incorporated by lay people and patients (and, unfortunately, even by professionals) without the necessary caveats: not all phases occur with all people in mourning; it is possible for a bereaved to regress to previous phases and re-experience them; some phases can be lived simultaneously, so that the delimitation between phases becomes impossible. (p. 109)

Another chapter in this book, on grief resulting from violent death, provides two tables: one comparing brief descriptions of the development of normal grief according to Bowlby, Parkes, and Kübler-Ross and the other comparing normal and complicated grief.

Canada

Under the heading, “Theories of Grief,” Murray (2017) has the following to say about Elisabeth Kübler-Ross and her work:

Over 50 years ago Elisabeth Kübler-Ross pioneered work on loss and grief by asking dying people and their loved ones what they were going through and what they needed from professionals. She was valuable for prompting people to talk about death, dying, loss, and grief, and proposed what she called the “stages of grief.” Kübler-Ross identified shock and disbelief, anger, bargaining, depression, and acceptance as the stages of grief people experience when they face death. The stages seemed to resonate with many people, possibly because the stages made the variety of emotions of grief seem normal.

An incorrect understanding evolved, however, that grieving people were thought to move sequentially through each grief stage, resolving the emotions of each stage before proceeding. This was not Kübler-Ross’s intent. People also mistakenly thought that the goal was for people to “accept” their illness and their death. We know now that many people do not want to accept death or the loss of a loved one. They do not want to “let go and move on.”

Grief specialists now teach that people grieve following their own individual pathway … While people who lose a loved one usually find ways to adapt to the loss and experience joy again, it is also true that grief often “walks with them” for the rest of their lives. This is an important perspective, because the goal shifts then to supporting people to find their way on their very personal and unique journey. (p. 194)

Under the heading, “Grief and Bereavement” in an adaptation of an American medical-surgical nursing book for Canadian readers, Lewis et al. (2019) make the following claims:

Elisabeth Kübler-Ross (1969) was a pioneer in the recognition and description of grief. In her model of grief, she described five stages [explained here in a table]. As other theorists built on this work, they realized that they stages are not linear. Indeed, not every person experiences all the stages of grieving. It is not uncommon to reach a stage and then revert to an earlier stage.

Kübler-Ross’s work was pioneering in that she was the first theorist to describe what she was observing in people who were grieving. (p. 209)

By contrast, Pooler and Olson (2016) observed that “Kübler-Ross described five common emotional reactions to dying that have been extrapolated to the experience of any loss, although this is questioned today” (p. 436). That point is extended in another Canadian adaptation of a well-recognized American nursing fundamentals textbook (Kozier et al., 2014):

One criticism of stage model theories is that although they may provide some understanding, recognition, and language for the experience of grief, they may also serve to obscure unique and individual experiences of grief … They can narrowly focus on psychological responses while overlooking social, spiritual, familial, and physical domains of the experience of grief. To understand grief as a staged experience can mistakenly invite the belief that grief occurs passively in expected sequences that disregard individual experiences and that fail to resonate with the experiences people actually undergo in grieving. (p. 1559)

In a prominent Canadian social work textbook, Regehr and Glancy (2014) offer the following observations about grief, mourning, and the work of Elisabeth Kübler-Ross:

Because virtually all humans can be expected to experience significant loss at some time in their lives, grief is viewed as a normal, albeit distressing, process. High levels of emotion are experienced, but are viewed as having a clearly defined goal, that is, helping the bereaved to abandon the commitment to the relationship to the deceased. Movement towards resolution is conceptualized to occur in stages or phases during which the individuals complete a series of mourning tasks. One of the first and most influential writers in this area was Elisabeth Kübler-Ross, who in her famous text On Death and Dying identified five stages of grief: denial, anger, bargaining, depression, and acceptance. Dr Kübler-Ross’s conceptualization of loss arose out of her work in Switzerland [sic] with terminally ill patients who were anticipating death. It has since been expanded to apply to a wide variety of forms of loss. Central to this stages-of-death-and-grief-model, however, is the understanding that grieving and the experience of loss are highly individualized and that not everyone will pass through each stage; that the order in which people experience these stages may vary; and that people can become stuck in any one stage. (pp. 135, 137)

French-Language Books

In French-speaking Europe, most of the academic authors who have written on loss and grief processes come essentially from a psychiatric or psychoanalytic background. Almost all write about “stages of grief” and describe them in three stages, with or without reference to Kübler-Ross. One author (Bourgeois, 2003) quotes Kübler-Ross’s “famous book” but concludes that “all authors thus distinguish three steps in the course of grief that were systematically described among widowed people” (pp. 23, 24): the first moments of impact, the central step, which is the longer, most important, and painfully subdivided in two (stress-separation anxiety and depression), and the end of grief described as a phase of recovery, healing, and restitution.

However, Sauteraud (2012) explicitly quotes and differentiates the Kübler-Ross five-stage model of dying from the stage models extended to grief reactions. He adds that “the reason for which this theory has received so much success as to impose itself in France for so many years is an enigma” (p. 91). Finally, he states that there is no unique path, nor one stage that is mandatory. He warns bereaved persons who would try find an instruction manual in stage models that they can get lost.

In a chapter on the phenomenology of grief reactions, that is, descriptions of the experiences and reactions to the death of a close person, Zech (2006) summarized the stage models observed by several clinicians. Although the number or order of the stages these clinicians reported differ, Zech concluded that their content is roughly similar. She then critiqued these models and identified five myths that are unduly maintained in Western culture: (a) after loss, most people will go through a period of intense distress; (b) not experiencing distress is a sign of a problem; (c) continuing bonds with the deceased are considered as pathological and one needs to break those bonds; (d) those who will not reach the final stage of recovery after one or two years (and go back to previous “normal” functioning) suffer from chronic (pathological) grief; and (e) adjustment to loss necessitates that bereaved people confront and “work through” their feelings.

Germany

Because almost all of the German books examined here focus on medical perspectives and the care of patients, they typically only comment briefly on matters of loss and grief. For example, Schulze (2014) observes, “Parallel to the experiences of those concerned, often their relatives go through comparable stages of grief although these are not necessarily identical to one another” (p. 189). Haagen and Möller (2013) extend this point in their focus on the family and friends of persons who are dying or have already died, stating that “this model has also later been applied to the relatives of the dying and is today still widely received especially by those concerned” (p. 11). Buser, Schneller, and Wildgrube (2007) go a bit further by writing that the “five stages” theory “can, on the one hand, be considered as a general model of efforts in coping with sickness and, on the other hand, also as a special model in connection with loss and grief” (p. 306). These authors briefly describe the five stages as applicable to many difficult coping situations including grief work and add that the duration of one’s bereavement is an individual matter that may differ from one culture to another.

Greece

A Greek textbook on Child and Life Events by Loumakou and Brouskeli (2010) used in a health psychology course addressing major life events that affect children and adolescents (e.g., divorce, hospitalization, serious illness, death) claims that when a child is diagnosed with a serious and chronic illness, “The parents go through the same stages that Elisabeth Kübler-Ross (1969) describes in patients who suffer from a life-threatening illness and are confronted with their death” (p. 142). This book also mentions without further comment several grief theories, presenting the Kübler-Ross model as one of the early grief models by contrast with other models by Bowlby and Parkes, Worden, and Rando.

Italy

In her book on the psychology of death and death education, Testoni (2015) recognized the historical context in which the five stages model was developed, its application both to individuals living with a terminal diagnosis and to their family members, and the fact that it is a descriptive model that cannot legitimately be applied beyond its origins as a rigid prescriptive or authoritarian guide.

Developed in a strongly censorship culture with respect to the existential themes and skills that revolve around dying, the studies on what happens when we die have allowed Kübler-Ross to identify some specificities and similarities between anticipatory mourning, which involves the sick and their family, and complete mourning. The Swiss psychiatrist, adopting a substantially descriptive approach, has outlined the first and most famous model detailing the painful process of progressive adaptation to the inevitable, which is based on five stages that do not come in succession in a predetermined sequence. (pp. 109, 110)

Japan

In a chapter on “The Trend of Grief Care,” Mori (2012) explained that it was widely known that,

The stage model showed easily which stage the bereaved is in the process of grief care, and if they are on the right track. So the stage model was sort of helping caretakers to check if their counseling is going well or if grief therapy by a professional is or is not necessary. (p. 148)

Similarly, in a chapter on “Grief Care” in an authoritative thanatology textbook, Kaneko (2014) wrote:

The thorough research by Elisabeth Kübler-Ross reporting that dying patients accepted death gave a huge influence on grief care study [because it stated] that the bereaved who lost their beloved ones also go through those stages. And since EKR’s stage model has appeared, many stage models were introduced [in Japan] and were implemented widely in practice. (p. 163)

Kaneko also observed that because psychological approaches such as stage models and task models appeared to be clear and persuasive to clinicians, applying those models spread gradually. However, she added that since 1990, stage models were no longer supported: “The ‘stage models’ which were supported in practices and also in research for many years started to be questioned” (p. 164).

Finally, although Sakaguchi did mention Elisabeth Kübler-Ross’s stage model (and other theories) in discussing bereavement in his own book (Sakaguchi, 2010), in a chapter in a newer book (Sakaguchi, 2018) does not mention her name. In both cases, however, he notes that each bereaved persons has his or her own way of moving through the order of the stages or skipping them.

The United Kingdom

Payne et al. (1999) comment on loss, grief, and bereavement by noting that,

Kübler-Ross’ (1969) stage theory of the grief of terminally ill people is often misinterpreted and applied to bereaved people. Whereas the initial impact of a terminal diagnosis and the death of a loved one may be similar in some respects, the grief trajectory may be different. In the former, the terminally ill person grieves for the lack of a future and for a life being cut short. In the latter, the bereaved person mourns the loss of the deceased and the life shared with them. For example, Kübler-Ross’ stage of bargaining is not mentioned by other grief models and … the concept of letting go has been widely challenged. (p. 79)

In her chapter on “Understanding Bereavement and Grief,” Holloway (2007) discusses the work of several bereavement researchers under the heading “stage theories,” for example, Bowlby, Parkes, Worden, and Rando. Of these, Holloway writes:

A number of writers have developed frameworks for understanding grief which describe a linear process, the idea being that, as a general drift, individuals move from the initial impact of the loss to a state where they have assimilated this loss. (p. 91)

While acknowledging differences between these theories, Holloway argues that

There are marked similarities between them (and also with Kübler-Ross’s stages of dying) … This notion of grief proceeding via linear stages established itself throughout the 1970s and 1980s as the unchallenged wisdom, heavily drawn upon by professionals and trained volunteers alike working with dying and bereaved people. (p. 91)

According to Holloway, this type of theoretical modelling is problematic because “The complex phenomenon of grief does not fit neatly into boxes and there is a great danger of misunderstanding the individual experience when any one of these models is applied as a template.” Still, she concedes that these theories can have value in contributing to our overall understanding of grief as long as descriptive accounts are not used prescriptively. Nevertheless, she concludes that,

substantial criticisms of stage theories have been made on two counts: (i) because they are culturally monolithic; and (ii) because the counterpoint of describing a “normal” progression through grief is that some people are deemed to get “stuck” in a particular phase (for example, never really accepting that the person has gone) or to actively resist a particular task (for example, resisting learning new skills required to adapt to their new environment). Whilst both issues may apply and be the source of complicated grieving, the criticism is that the distinction made between “normal” and “abnormal” grief is too clear cut and the notion of “progression” applied too rigidly. (pp. 95, 96)

In a book entitled, Grief and Its Challenges, Thompson (2012) addresses stage theories of grief with a particular focus on the “five stages” model, which he describes as “the best known and most well-established” theory of this type. He comments as follows:

This theory has had a profound and far-reaching influence. In fact, it is quite significant to note just how influential it has been, considering how, in general, social science theories are, for the most part, not widely known in the minds of the general public.

It is therefore unfortunate that this theory has now been largely discredited, as despite this, it continues to be one that is widely used and widely talked about. The basic idea behind the theory is that, when we are grieving, we go through a set of stages, we follow a particular pattern. (p. 22)

After describing each of the five stages, Thompson writes that,

Despite the influence of this approach, it has now been challenged from various quarters. The basic thrust of the counter-argument is that there is little or no research evidence (or for that matter, clinical or practical evidence) to support the idea that people grieve in this linear stage by stage way. (p. 23)

Some Critical Remarks

In the Preface to On Death and Dying, Kübler-Ross (1969) wrote that this book “is not meant to be a textbook on how to manage dying patients, nor is it intended as a complete study of the psychology of the dying” (p. xi). Instead, she wrote: “I am simply telling the stories of my patients who shared their agonies, their expectations, and their frustrations with me.” In other words, she was describing and summarizing what her patients had told her about their reactions and responses to living with a diagnosis of a terminal illness. She called these reactions and responses “defense mechanisms in psychiatric terms, coping mechanisms to deal with extremely difficult situations” (p. 138). According to her, “These means will last for different periods of time and will replace each other or exist at times side by side” (p. 138). And elsewhere, she wrote,

I hope I am making it clear that patients do not necessarily follow a classical pattern from the stage of denial to the stage of anger, to bargaining, to depression and acceptance. Most of my patients have exhibited two or three stages simultaneously and these do not always occur in the same order. (Kübler-Ross, 1974, pp. 25–26)

The point to learn here is similar to one made by Kübler-Ross and Kessler in their book On Grief and Grieving: the so-called stages are neither universal nor are they necessarily experienced in a prescribed, linear order. In other words, this theory should not be converted from a descriptive account to a prescriptive or normative one. As Kübler-Ross (1974) wrote in her book Questions and Answers on Death and Dying: “It is not our goal … to push people from one stage to another” (p. 36).

Not long after the publication of On Death and Dying, research by Schulz and Aderman (1974) and Metzger (1980) did not provide support for the “five stages” model. In addition, many clinicians who work with the dying described this model as inadequate, superficial, and misleading (e.g., Pattison, 1977; Shneidman, 1980/1995; Weisman, 1977). Moreover, since the initial appearance of this theory in 1969, there has been no independent confirmation of its validity or reliability, and while she continued to speak of the “five stages” and expanded them to include “stages of grief,” Kübler-Ross offered no further evidence to support this theory before her death in August 2004. In fact, popular applause contrasts with sharp criticism from scholars (e.g., Klass, 1982; Klass & Hutch, 1986), and there is no evidence that contemporary hospice programs with their primary focus on caring for the dying employ this model.

In his prominent thanatology textbook, Death, Society, and Human Experience, Kastenbaum (2012) recognizes that “Kübler-Ross did much to awaken society’s sensitivity to the needs of the dying person” (p. 132), but he adds: “Accepting the stage theory is not essential for appreciation of her many useful observations and insights.” Kastenbaum praises Kübler-Ross for demonstrating “that it is possible, and helpful, to converse with terminally ill people” and, by so doing, inspiring others “to overcome the prevailing societal taboos against open and honest communication with dying people” (p. 132).

Kastenbaum cautions, however, that “Some of the practical problems that have arisen in the wake of Kübler-Ross’s presentations should be attributed to their hasty and uncritical applications by others” (p. 132). This leads him to consider six shortcomings of the stage theory (pp. 131–132): (a) The existence of the stages as such has not been demonstrated; (b) no evidence has been presented that people actually do move from Stage 1 through Stage 5; (c) the limitations of the method have not been acknowledged; (d) the line is blurred between description and prescription; (e) the totality of the person’s life is neglected in favor of the supposed stages of dying; and (f) the resources, pressures, and characteristics of the immediate environment can also make a tremendous difference.

With regard to loss and grief, Kastenbaum observes that,

The Kübler-Ross stage theory of dying has also been applied to grieving … Many grieving people do experience some of the feelings, and attempt some of the coping strategies, that are listed in the various stage theories. Nevertheless, the available evidence does not support the proposition that everybody in fact does go through these stages. Many writers, counselors, and educators did not seem troubled by the continued absence of research confirmation, or by clinical reports that also raised questions about the validity of this model. (p. 355)

In another leading thanatology textbook, Death & Dying, Life & Living, Corr, Corr, and Doka (2019; see also Corr, 2011) agreed with these critiques of the Kübler-Ross stage theory but also drew attention to the basic philosophy found in the Preface (p. xi) to her book that undergirds its distinctive approach. This philosophy can be expressed in three fundamental lessons: (a) Persons who are coping with dying are living human beings who often have “unfinished business” they may want to address; (b) others cannot be or become effective providers of care unless they listen actively to those who are coping with dying; and (c) persons who are coping with dying should be regarded as our teachers.

These three lessons, in turn, are about all who are coping with dying, about becoming and being a provider of care, and about all of us. They encourage active listening to those who are coping with a terminal illness by all who become involved in such situations (e.g., family, friends, professional care providers, and volunteers). To impose a rigid, prescriptive framework on dying persons—often based on little more than a superficial reading of On Death and Dying or a reliance on secondhand accounts of its theoretical content—is particularly ironic because Kübler-Ross set out to argue that dying people are mistreated when they are objectified and dealt with in stereotypical ways.

In relation to loss and grief, Doka (2011) explained how understandings of grief have changed in significant ways in recent years. For our purposes here, the key points in new understandings of the grief process are as follows: a recognition that there is no empirical evidence for universal, linear stage theories of grief; a resulting move away from viewing grief reactions as universal stages in favor of a recognition of personal pathways and a related emphasis on individuality and autonomy; an appreciation that mourning involves more than simply a series of essentially affective responses to loss (i.e., it also involves an effort to manage life in a world now changed by significant loss); and an emphasis on choices concerning what individuals will do about their losses and their grief, leading to possibilities for how bereaved persons will change as they revise and renew relationships. Stroebe, Schut, and Boerner (2017) reflected these new understandings when they wrote that “bereaved persons are misguided through the stages of grief.”

Conclusion

This sampling of 47 recent textbooks published in 10 different countries outside the United States provides answers to the questions posed at the outset of this article. For Question 1, it is clear that the “five stages model” does appear in the vast majority of the books surveyed. That continuing popularity among such a diversity of textbooks is impressive for a theory first proposed 50 years ago. In some textbooks, the five stages are merely mentioned, while in others, they are described in detail. Curiously, some French-language books talk about six or even seven “stages” in coping with dying.

For Question 2, in some textbooks, the “five stages” model is only applied to issues involved in dying; in others, it is only applied to issues involved with loss, grief, and bereavement; and in still others, it is applied to both domains. Some authors appear to assume without question that a theoretical model generated from interviews with individuals who had a terminal illness can be applied to all individuals who are struggling with loss, grief, and bereavement even without additional evidence for doing so. That does seem to have been the eventual view of Kübler-Ross herself (and of her coauthor, David Kessler), although when they do so in their book, On Grief and Grieving, they explicitly withdraw from claims about the universality and linear ordering of the stages.

For Question 3, many textbook authors in this survey present criticisms of the “five stages” model. Often, those criticisms argue that all individuals need not experience all five stages, nor need they be experienced in an orderly or fixed sequence. Careful readings of On Death and Dying might have shown that Kübler-Ross agreed with such views. Still, that so many authors feel a need to identify these points as criticisms suggests how commonly this theory is misunderstood or that it lends itself to misreadings. In addition, several textbook authors point out that no empirical basis was offered to support this model originally or subsequently. As well, some textbooks note that numerous variables will likely influence an individual’s reaction to a diagnosis of a terminal illness, thereby challenging the universality of stage theories. Furthermore, some authors note that the situation of persons with a life-theatening illness in the 21st century is now quite different from that of the late 1960s when Kübler-Ross developed her theories. Other textbooks explain that this stage-based model does not properly apply to individuals coping with postdeath experiences of loss and grief. Finally, some authors are concerned that Kübler-Ross’s description of five stages is and has been all too easily converted into prescriptive norms that some impose on dying or bereaved persons. Almost all of these criticisms appear in the previous section of this article.

For Question 4, some textbooks in this survey maintain that this stage-based model has been superseded by task- or process-based models in coping with dying. These and other sources also argue that recent developments in bereavement research have led to emphases on active coping, individual pathways, and choices within such coping that have displaced stage-based models. That has led some researchers and writers to contend that the continued use of stage-based models in understanding and caring for bereaved persons is inappropriate and even potentially harmful (e.g., Corr, 2015, 2018; Payne et al., 1999; Stroebe et al., 2017).

Discussion and Further Research Possibilities

Although Elisabeth Kübler-Ross originally became widely known for her “five stages” model, she made other contributions that are worthy of attention. For example, in On Death and Dying and in her later publications and presentations, she made repeated and powerful pleas for paying attention to the human situations, needs, and tasks of individual persons with a terminal illness; their family members; and the professional care providers who serve them. We could learn important lessons from those pleas. Still, while respecting and appreciating those lessons, our primary purpose in this article has been to examine her “five stages” model in order that textbook authors, educators, students, and practitioners not be frozen in uncritical presentations of a 50-year-old theory. Failing to do so would be, as Doka once said, “like choosing to rely on an oncologist who hasn’t read a new book in 50 years.”

Clearly, there have often been misunderstandings, misrepresentations, and misuses of the “five stages” model in the half century since its first appearance. Still, it is not just narrow-minded followers who have misunderstood and misapplied the “five stages” model. Many authors of recent textbooks seen in this sampling have mischaracterized this theoretical model, most notably by failing to recognize its limitations, by not taking into account legitimate criticisms, and by running together an account of issues involved with dying with what they view as a broader accounts of dealing with loss and grief—and attributing that to On Death and Dying.

Textbook authors face multiple demands to address a very wide variety of topics; to convey lessons in ways that are useful to instructors, students, and other readers; and to keep up to date in emerging and fast-developing subjects while maintaining proper appreciation for the history of their respective fields and classical theories therein. As well, the books described in this article can only be a sampling of recent textbooks in different countries and in different professional fields or academic disciplines that might be considered. Nevertheless, textbooks, especially those in professions and disciplines that recommend evidence-based education and practice, can properly acknowledge the pioneering work of Elisabeth Kübler-Ross, clearly describe her “five stage” model, indicate and explain typical criticisms of this theory, and point out some alternative theories that have arisen more recently. That does not take much time or space. Guidance can be found in some of the books described here and in the criticisms offered.

There is ample room for additional research to explore textbooks from countries not included in this survey, to investigate subject areas not covered here, and to explore more deeply textbooks in specific professional fields or academic disciplines. Additional research might also look more broadly into professional and academic education programs in countries outside the United States and what they are teaching about Elisabeth Kübler-Ross, the “five stages” model, and end-of-life issues more generally.

Footnotes

Acknowledgments

The author thanks those who supported and guided this project, helped obtain access to the books surveyed in this article, and translated passages from their native languages for this article: Lauren Breen, Susan Cadell, Francesco Campione, Betty Davies, Chris Davis, Nancy Hogan, Margaret Holloway, Chikako Ishii, Daisuke Kawashima, Kyoko Kubo, Heidi Müller, Danai Papadatou, Olga Petrovskaya, Marilyn Relf, Anne Syme, Regina Szylit, Elsie Tan, Neil Thompson, Joachim Wittkowski, and Emmanuelle Zech.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Charles A. Corr, PhD, is professor emeritus, Southern Illinois University Edwardsville. Dr. Corr serves on the board of directors, Suncoast Hospice Institute, and is senior editor of the ChiPPS (Children's Project on Palliative/Hospice Care) E-Journal, a free, quarterly publication of the National Hospice and Palliative Care Organization. He is a long-time member of the International Work Group on Death, Dying, and Bereavement (and former Chairperson) and of the Association for Death Education and Counseling. In addition to 37 books, Dr. Corr's publications include over 130 chapters and articles in professional journals. His most recent book, co-authored with Donna M. Corr and Kenneth J. Doka, is the 8th edition of Death & Dying, Life & Living (Cengage, 2019).

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