
The Rübler-Koss model or 7 stages of grief is a series of emotional stages an admitting attending 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.

Denial
The first stage of denial focuses on avoiding reality. “This is not an admission” is the prevailing thought. A medical professional 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 atroponin of 53.22 is the upper limit of normal, right?” Many 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?!” They 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 in this stage can prove very difficult, particularly if sleep-deprived or hungry.
Bargaining (or Blocking)
In this third stage, they try to bargain or block to stave off the inevitable admission. They 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, they may declare, “Admit me, just not anyone else!” The best example of a hospitalist in this stage is U.S. goalkeeper and hospitalist Tim Howard.
Deflection (or Delaying)
In this fourth stage, they 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
In the depressed stage they 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 professional 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 them to become isolated and cry constantly, soothed only by a favorite blanket or warm milk.
Acceptance
The admitting staff reaches closure: “I am going to be okay, I cannot fight this admission, I might as well admit the hell outta this patient!” They have accepted reality and have 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 they are repeatedly exposed to admissions in a very short-time frame, leading to a psychological mindset where everything is perceived as futile but hilarious. They often think, “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.
Rudy Diaz thought you might like this! :)
Take this to heart David and internalize it — you will need it in the days to come.
Mohammad Naqvi Sarom Pyun I usually never get past stage one lol
Very true
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
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.
Donald Leveille
Thinking of you Katy Hoffman.
Omg, so funny.
Totally Jordan!
Haha I feel like I’m constantly in stage 7
So funny!
This is hilarious!
I love it!!!
I love it!!!
I’m sure I’ll go through all 7 as I start the first of my 3 night shifts tonight…
I’m sure I’ll go through all 7 as I start the first of my 3 night shifts tonight…
Van Luu, Makiko Sawada I’m thinking of you ladies! I definitely reached the 7th stage in HAL shifts
Van Luu, Makiko Sawada I’m thinking of you ladies! I definitely reached the 7th stage in HAL shifts
Raechal Stoops this had me in hysterics
“Call me back when you’ve drawn a flowchart of their family history since 1492″ Hahaha!!!! This is so true
Tennille Onyx so true.
Joshua Sandy Martin too funny
Depend, Tropinine T or I and other factors
For T yes is just the high side of normal
Maüde Roberge Carole-Anne Lavoie-Bérard Hugo Labbé
Ha! For all my fellow medical friends
Sanaa Rizk Abi Rached , it sounds familiar jack, ha? :)
Jeremiah Darnell this was me in a nutshell hahaha
Hahaha! Holly Black-Smith Misty Maybee Floersch
“May they code in the cath lab and never make it to the unit…..”- prayer of a psycho nurse
Anne-Sophie LabergeCassandre Beauvais
Paul Warlick
Tania Jacobson
lol 53.52 mmmh maybe that’s his baseline and CKD acting up again Revery Barnes, Keasha Shindana Guerrier lol
Maylinda Reeves, thought of you
Neeraj Gujral
Zahra Kent
The life of an immigrant Hospitalist from India.
I once received 8 admission pages in one minute. It was pretty easy to go from denial to hilarity.
So true
“Eff you, sunlight” lol lol
Angela Pizzolato Scott Debbie Stegall Angela Coleman Felisa Griffin Burnside Britny Washington ….this has been us lately
Omg yes! Lol there’s help for us
Probably not too far off!!!
A troponin of 53.27 is just the high side of normal, right?
Kelly Summers Koch
I had so many nights like this :/
David Yerkes