Understanding the Psychology of Dying: Kubler-Ross and Weisman Models

When a person receives a terminal diagnosis, the emotional experience that follows is anything but predictable. Fear, disbelief, anger, quiet resignation – and sometimes, unexpected peace – can all be part of the journey toward death. For decades, clinicians and researchers have worked to understand and describe this inner landscape. Two foundational models have shaped how therapists, physicians, and caregivers approach the psychology of dying: Elisabeth Kübler-Ross’s five stages of dying and Avery Weisman’s four-stage framework. Together, they offer complementary windows into what terminally ill patients go through – and why that understanding matters deeply for end-of-life care.

Why understanding the psychology of dying matters 🔗

Before the late 1960s, death and dying were largely treated as medical events. Patients were not always told the full truth about their diagnoses, and their emotional needs were seldom a clinical priority. According to research published in StatPearls, dying patients were not always given a voice or genuine choices in their own care plans. That began to change when psychiatrists and psychologists turned a more deliberate lens on the inner experience of terminally ill people. The models that emerged didn’t just describe emotions – they gave healthcare providers a practical language for understanding behaviors that might otherwise seem confusing, difficult, or even hurtful. As a review in the journal Ochsner Journal notes, the goal of quality end-of-life care is to relieve suffering across physical, psychological, and spiritual dimensions – and that requires knowing what dying patients are actually going through emotionally.

Kübler-Ross’s five stages of dying 🔗

Elisabeth Kübler-Ross, a Swiss-American psychiatrist, introduced her model in her landmark 1969 book On Death and Dying. The book drew on in-depth interviews with over 200 terminally ill patients and outlined five stages: denial, anger, bargaining, depression, and acceptance – commonly abbreviated as DABDA. Before this work, conversations about death in clinical settings were largely avoided or handled through euphemism. Her work shifted the nature of those conversations by centering the emotional experience of the dying patient and emphasizing the importance of listening to and supporting their unique needs.

It’s worth stressing from the outset that Kübler-Ross never intended her stages as a fixed, linear checklist. The model was purposely personal and subjective, and should not be interpreted as natural law – individual patients can manifest each stage differently, if at all. The stages are best understood as a set of common emotional patterns, not a prescription for how dying is supposed to unfold.

Denial: the first buffer 🔗

Denial is a common defense mechanism used to protect oneself from the hardship of confronting an upsetting reality. After the initial shock of a terminal diagnosis, patients often reject the new information – they may directly deny the diagnosis, attribute it to faulty tests, or simply avoid the topic in conversation. A period of denial is not necessarily pathological. It gives a person time to absorb information that is otherwise overwhelming, and providers generally do not need to repeatedly reeducate patients about their diagnosis unless there is adequate reason to believe the patient genuinely misunderstands it.

Anger: a natural concession 🔗

Anger is commonly experienced as patients concede the reality of a terminal illness. It may be directed at medical providers, family members, or higher powers – or it can be generalized and undirected, manifesting as a shorter temper or loss of patience. For caregivers and loved ones, this stage can be especially difficult to navigate. Beneath anger can lie feelings of hopelessness or powerlessness – and the mind would often rather feel guilty than helpless. Recognizing anger as a natural response rather than a personal attack makes it far easier for those around the patient to respond with empathy rather than defensiveness.

Bargaining: seeking control 🔗

Bargaining typically manifests as patients seek some measure of control over their illness. The negotiation can be verbalized or internal, medical, social, or religious – ranging from rational commitments to treatment adherence, to more magical thinking, such as attempts to appease misattributed guilt. A classic example is the terminally ill patient who “negotiates with God” to attend a loved one’s wedding, or offers a reformed lifestyle in exchange for more time. While bargaining can actually increase a patient’s engagement with treatment, clinicians must be careful not to mislead patients about the actual power of such negotiations.

Depression: the weight of reality 🔗

Depression is perhaps the most immediately understandable of Kübler-Ross’s stages, presenting with symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this deeper emotional pain. This type of depression is not a clinical disorder to be “fixed” – it is a profoundly appropriate response to loss. The ultimate goal of therapeutic intervention at this stage is to attenuate suffering and help patients maintain a sense of dignity, meaning, and peace as they approach the end of life.

Acceptance: not resignation, but recognition 🔗

Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may focus on enjoying the time they have left, reflecting on their memories, and preparing for death practically – by planning their funeral or helping to provide for their loved ones emotionally or financially. Importantly, acceptance is not a “better” stage than the others. As Kübler-Ross clarified, the purpose of understanding the stages has always been to anticipate patients’ experiences and offer more empathy – not to push dying people toward any particular emotional destination.

Weisman’s four stages of dying 🔗

While Kübler-Ross focused on the emotional reactions of dying patients, Harvard psychiatrist Avery Weisman approached the question differently. As a psychiatric consultant in a hospital, Weisman observed that some seriously ill patients seemed predisposed to death while others did not – and that some deaths appeared to be “good” or “appropriate” while others were not. This led him to develop a broader framework that traces the full arc of terminal illness rather than cataloguing individual emotions. Weisman proposed four very flexible stages, explicitly stating that Kübler-Ross’s model described some common reactions to loss rather than general stages of dying. His own model was designed to map the overall trajectory of the dying process.

Stage 1: existential plight 🔗

In this first stage, the dying person experiences extreme emotional shock at the awareness of their own mortality. This is the acute crisis of confronting death – not just intellectually, but existentially. The patient is forced to reckon with the fact that their life has a defined and approaching end. Clinically, this stage calls for honest communication, emotional presence, and validation of the patient’s distress. Therapists focus on helping patients feel heard rather than rushing toward reassurance.

Stage 2: mitigation and accommodation 🔗

After first learning of the terminal nature of their illness, the individual attempts to resume a “normal” life. This stage is characterized by psychological adaptation – patients begin modifying their goals, reordering their priorities, and finding new ways to experience meaning and connection. This is not denial; it is the human capacity to absorb a devastating reality and continue functioning. For therapists, this is an important window for meaning-focused work, helping patients identify what still matters to them and how they want to live the time they have.

Stage 3: decline and deterioration 🔗

When illness and its treatment begin to take full control over one’s life, and normal living is no longer possible, this third stage begins. The patient must cope with increasing physical limitations, loss of independence, changes in body image, and growing dependence on others. Psychologically, this stage often involves fears of becoming a burden, loss of bodily autonomy, and a threatened sense of identity. Therapeutic support here focuses on preserving the patient’s dignity and sense of self, even as their body changes. Compassionate palliative care at this point requires a readiness to explore integrity-preserving issues that foster growth in dignity and transcendence.

Stage 4: pre-terminality and terminality 🔗

This final stage refers to the very end of life – when treatment is no longer helpful and the period immediately preceding death begins. The patient may become increasingly withdrawn, sleep more, and gradually disengage from the outside world. For families and caregivers, this stage can be distressing to witness, but it is a natural part of the dying process. Clinically, as patients approach the end of life, care refocuses on comfort and existential topics that may feel unfamiliar – including transparent discussions about the redefined frame of treatment with patients and families.

How the two models compare and complement each other 🔗

Kübler-Ross and Weisman were not rivals – their models address the psychology of dying from different vantage points and work well together in clinical practice. Kübler-Ross described the emotional texture of dying: the specific feelings a patient may encounter and cycle through at any point. Weisman described the structural trajectory: the broad phases through which a terminal illness progresses from diagnosis to death. A therapist drawing on both frameworks can better understand not just what a patient is feeling, but where they are in the overall course of their illness – and what psychological work is most relevant at that moment.

Both models also share an important limitation: they were developed primarily within Western, individualistic cultural contexts. Patients from different cultural or spiritual backgrounds may experience dying in fundamentally different ways – shaped by community bonds, religious beliefs about death as transition rather than endpoint, or collective values that prioritize family harmony over individual emotional processing. Culturally sensitive practice requires clinicians to hold these frameworks lightly, using them as guides rather than prescriptions.

Clinical value: how these models guide therapeutic practice 🔗

Understanding these models offers concrete benefits across the care team. Familiarity with the patterns they describe can help healthcare providers offer empathy and understanding to patients, families, and team members for whom these emotional patterns may otherwise cause confusion and frustration. For patients themselves, knowing that their emotional responses are part of a recognized pattern can reduce feelings of isolation and self-blame. Receiving a conceptualization of their concerns – one that distills what may feel like disparate and overwhelming experiences into a coherent picture – can help patients feel heard, normalized, and even relieved.

More broadly, a substantial and growing body of research has now identified best practices for end-of-life care that confirm and extend many of the therapeutic approaches originally recommended by Kübler-Ross – including dignity therapy, meaning-centered psychotherapy, and supportive-expressive group therapy. Clinicians working in palliative settings have several evidence-based interventions at their disposal, and the end of life can provide opportunity for rich and meaningful therapeutic work. The models of Kübler-Ross and Weisman don’t tell therapists what to do – but they tell therapists what to expect, which is the foundation of any compassionate clinical response.

What do you think? Do you believe there is a “right” way to die emotionally, or is every person’s journey equally valid regardless of which stages they do or do not reach? And how might a deeper cultural understanding of death change the way we apply Western psychological models to patients from non-Western backgrounds?

References

1. https://www.ncbi.nlm.nih.gov/books/NBK507885/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3241069/
3. https://www.ekrfoundation.org/5-stages-of-grief/on-death-and-dying/