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The Rübler-Koss model or 7 stages of grief is a series of emotional stages an admitting provider experiences when faced with an impending admission.  The 7 stages are best remembered by the acronym DABDDAH, which stands for Denial, Anger, Bargaining (or Blocking), Deflection (or Delaying), Depression, Acceptance, and Hilarity, and are briefly reviewed below.

Sorry kids, mommy has another chest pain rule-out admission on a 27 year-old
Sorry, kids, Mommy has another chest pain rule-out admission on a 27 year-old

Denial

The first stage of denial focuses on avoiding reality.  “This is not an admission” is the prevailing thought.  A provider such as a nurse, nurse practitioner, physician assistant, or physician in this stage might ask, “Is it really a STEMI, are you sure it’s not just seasonal allergies?” or “I’m pretty sure a troponin of 53.22 is the upper limit of normal, right?”  A provider may also look at their pager and say, “Nah, can’t be an admission,” and delete the callback number.

Anger

In this stage, anger may be directed in many directions: “Why me?” “Why now?” or “Why not the night shift?!” A provider may shout “What now?!” at their pager before throwing it down the hall.  Anger may be directed at a supernatural source: “Why would God let this admission happen?”  Some may curse the natural environment (“F**k you, sunlight!”), while some may curse their immediate surroundings (“F**k you, stapler!”).  Reasoning with a provider in this stage can prove very difficult, particularly if sleep-deprived or hungry.

Bargaining (or Blocking)

In this third stage, a provider tries to bargain or block to stave off the inevitable admission. A provider may ask the ED, “If you turf this to Cardiology, I’ll be your best friend” or “If you discharge this one, I swear I’ll do the next one… maybe.”  Similar to anger, bargaining or blocking may be targeted at a supernatural source: “God, if you block this admission, I will never say a bad thing about Taylor Swift ever again.”  In an extreme scenario, a provider may declare, “Admit me, just not anyone else!”  The best example of a provider in this stage is U.S. goalkeeper and hospitalist Tim Howard.

Deflection (or Delaying)

In this fourth stage, a provider gently seeks out alternative scenarios: “Can we maybe do a pan-CT and biopsy everything first?” or “I think we’re on diversion forever, can you try another hospital?”  Other common phrases include: “Let me call you back in a day or two” or “Call me back when you’ve drawn a flowchart of their family history since 1492.”

Depression

A provider in the depressed stage will say things like “I’m so sad I have to admit this person, why bother with anything?” or “I miss not admitting patients, why go on?”  The admitting provider begins to acknowledge the certainty of an admission, but the idea of an admission seems pointless (“Ugh, I guess I’ll admit this neutropenic fever, whatever”).  It is common for a provider to become isolated and cry constantly, soothed only by a favorite blanket or warm milk.

Acceptance

The admitting provider reaches closure: “I am going to be okay, I cannot fight this admission, I might as well admit the hell outta this patient!”  The provider has accepted reality.  The provider has accepted the terribly soft admission for further evaluation and management.  In other words, the admitting wall has been torn down and broken.

Hilarity

In this seventh and final stage, a provider is repeatedly exposed to admissions in a very short-time frame, leading to a psychological mindset where everything is perceived as futile but hilarious.  A provider often thinks, “Wow, so much for good care haha!” or “Why relax on a beach when you can admit 85 drug-seekers in 1 hour hehe?!”  Rectal bleeds ooze amusement and glee (“LOL!”), diabetic foot ulcers reek laughter and merriment (“ROFL!!”), and vaginal secretions leak gaiety and fun (“LMFAO!!!”).  It is a learned helplessness and is by far the most important defense mechanism for surviving the admission process.

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  • Kasie Pettus

    Rudy Diaz thought you might like this! :)

  • Pat Baker

    Take this to heart David and internalize it — you will need it in the days to come.

  • Sarpoma Sefa-Boakye

    Mohammad Naqvi Sarom Pyun I usually never get past stage one lol

  • Debbie Stegall

    Very true

  • Mike McInnis, MD

    Who knew “turf to psych” was a Kubler-Ross stage? MT The 7 Stages of Grief When Faced with an Admission http://t.co/pScdPlIg1w

  • Jeremy Langley

    The only way to reach the 7th stage is to admit them about 15 minutes before YOUR shift is over. That means you don’t have to do the 125 question Adult History Interview that nobody, except YOU, will ever look at again.

  • Stay Sea

    Donald Leveille

  • Anna Kate Oppert

    Thinking of you Katy Hoffman.

  • Susan Stiff

    Omg, so funny.

  • Ator Yacoub

    Totally Jordan!

  • Jordan Winston

    Haha I feel like I’m constantly in stage 7

  • Kimberly Carter Cerveny

    So funny!

  • Nicole Adcock

    This is hilarious!

  • Abigail Guessfeld

    I love it!!!

  • Abigail Guessfeld

    I love it!!!

  • Makiko Sawada

    I’m sure I’ll go through all 7 as I start the first of my 3 night shifts tonight…

  • Makiko Sawada

    I’m sure I’ll go through all 7 as I start the first of my 3 night shifts tonight…

  • Ator Yacoub

    Van Luu, Makiko Sawada I’m thinking of you ladies! I definitely reached the 7th stage in HAL shifts

  • Ator Yacoub

    Van Luu, Makiko Sawada I’m thinking of you ladies! I definitely reached the 7th stage in HAL shifts

  • Belinda Smith

    Raechal Stoops this had me in hysterics

  • Erica Sanderson

    “Call me back when you’ve drawn a flowchart of their family history since 1492″ Hahaha!!!! This is so true

  • Maylinda Reeves

    Tennille Onyx so true.

  • Saundra Sinclair

    Joshua Sandy Martin too funny

  • Maüde Roberge

    Depend, Tropinine T or I and other factors
    For T yes is just the high side of normal

  • Anne-Sophie Laberge

    Maüde Roberge Carole-Anne Lavoie-Bérard Hugo Labbé

  • Angela Darby

    Ha! For all my fellow medical friends

  • Mark Saab

    Sanaa Rizk Abi Rached , it sounds familiar jack, ha? :)

  • Caitlin Dawicki

    Jeremiah Darnell this was me in a nutshell hahaha

  • Ashley Celis

    Hahaha! Holly Black-Smith Misty Maybee Floersch

  • Heather Harris

    “May they code in the cath lab and never make it to the unit…..”- prayer of a psycho nurse

  • M-Djee M-ounette

    Anne-Sophie LabergeCassandre Beauvais

  • Zach Fowler

    Paul Warlick

  • Liz Rose

    Tania Jacobson

  • Sarpoma Sefa-Boakye

    lol 53.52 mmmh maybe that’s his baseline and CKD acting up again Revery Barnes, Keasha Shindana Guerrier lol

  • Tennille Onyx

    Maylinda Reeves, thought of you

  • Jessy Saini

    Neeraj Gujral

  • Rob Kent

    Zahra Kent

  • Siddharth Mushrif

    The life of an immigrant Hospitalist from India.

  • Vivek Patel

    I once received 8 admission pages in one minute. It was pretty easy to go from denial to hilarity.

  • Stephen Meyer

    So true

  • Becky Collins

    “Eff you, sunlight” lol lol

  • Cyndi Holley

    Angela Pizzolato Scott Debbie Stegall Angela Coleman Felisa Griffin Burnside Britny Washington ….this has been us lately

  • Kelly Summers Koch

    Omg yes! Lol there’s help for us

  • Michele Petruccelli

    Probably not too far off!!!

  • Allison Marr Casey

    A troponin of 53.27 is just the high side of normal, right?

  • Jamie Kirby Lynch

    Kelly Summers Koch

  • Trina McIlhargey

    I had so many nights like this :/

  • Jamie Schulz

    David Yerkes

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