What Do the Five Stages of Death and Dying Have to do With Patient Safety – Part 4

Bargaining:

            Finding that denial was no longer an appropriate response to the evidence, I moved onto my version of bargaining. It went something like this – perhaps the poor outcomes being described are true, but even if they are true the type of patients we care for are contributing to these outcomes. The complexity of medical care has increased enormously in recent year, patients live longer, they have multiple comorbidities, and they are on innumerable medications. Further, many patients are noncompliant with preventative health measures or with treatment plans that are outlined by their health team. Too often they have no idea what their medical problems are and even worse, some people seem uninterested in their own well-being. Surely, all of these things must have contributed to the bad outcomes noted by the IOM report. 

            If all of this seems like I was blaming the victim, that would probably be correct. It would also be wrong. While the patients we manage today are certainly complicated and sometimes a bit challenging, these factors were factored into the results of most studies. This does not mean that physicians and administrators should not look closely at research findings that conclude that errors occur in medical practice, we should. It is hard to adjust for all of the nuances, obstacles, and complexities of modern medical practice. However, abject refusal to recognize and acknowledge the problems within the house of medicine should not be an option. 

Table 1: Kubler-Ross’ five stages of dying

In her 1969 book, On Death and Dying [On Death & Dying, (Simon & Schuster/Touchstone), 1969] Swiss-born psychiatrist Elizabeth Kubler-Ross outlined the five stages of grief of someone who is dying: 
• Denial and isolation: “This is not happening to me.” 
• Anger: “How dare God do this to me.”
• Bargaining: “Just let me live to see my son graduate.”
• Depression: “I can’t bear to face going through this, putting my family through this.”
• Acceptance: “I’m ready, I don’t want to struggle anymore.”

References:

1. Institute of Medicine, To Err is Human: Building A Safer Health System (Washington, D.C.: National Academies Press, 1999
2. McGlynn EA, Asch SM, Adams J, et al.: The Quality of Health Care Delivered in the United States. N Eng J Med 2003; 348:2635-45
3. National Committee for Quality Assurance, State of Health Care Quality 2004 (Washington, D.C.: NCQA, Sept 2004
4. Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., “The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium,” Journal of the American Medical Association 269(18):2398-402, May 12, 1993
5. Wennberg JE, Cooper MM, eds., The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas of Health Care 1999 (Chicago: American Health Association Press, 1999)
6. Fisher ES, et al.: Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health service Research 2000; 34:1351-1362
7. Jha AK, Li Z, Orav EJ, et al.: Care in U.S. Hospitals – The Hospital Quality Alliance Program. N Eng J Med 2005; 353:265-74