The 7 Stages of Grief When Faced with an Admission

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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.

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 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.

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  • Show Comments

  • Avatar
    Kasie Pettus

    Rudy Diaz thought you might like this! :)

  • Avatar
    Pat Baker

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

  • Avatar
    Sarpoma Sefa-Boakye

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

  • Avatar
    Debbie Stegall

    Very true

  • Avatar
    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

  • Avatar
    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.

  • Avatar
    Stay Sea

    Donald Leveille

  • Avatar
    Anna Kate Oppert

    Thinking of you Katy Hoffman.

  • Avatar
    Susan Stiff

    Omg, so funny.

  • Avatar
    Ator Yacoub

    Totally Jordan!

  • Avatar
    Jordan Winston

    Haha I feel like I’m constantly in stage 7

  • Avatar
    Kimberly Carter Cerveny

    So funny!

  • Avatar
    Nicole Adcock

    This is hilarious!

  • Avatar
    Abigail Guessfeld

    I love it!!!

  • Avatar
    Abigail Guessfeld

    I love it!!!

  • Avatar
    Makiko Sawada

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

  • Avatar
    Makiko Sawada

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

  • Avatar
    Ator Yacoub

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

  • Avatar
    Ator Yacoub

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

  • Avatar
    Belinda Smith

    Raechal Stoops this had me in hysterics

  • Avatar
    Erica Sanderson

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

  • Avatar
    Maylinda Reeves

    Tennille Onyx so true.

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    Saundra Sinclair

    Joshua Sandy Martin too funny

  • Avatar
    Maüde Roberge

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

  • Avatar
    Anne-Sophie Laberge

    Maüde Roberge Carole-Anne Lavoie-Bérard Hugo Labbé

  • Avatar
    Angela Darby

    Ha! For all my fellow medical friends

  • Avatar
    Mark Saab

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

  • Avatar
    Caitlin Dawicki

    Jeremiah Darnell this was me in a nutshell hahaha

  • Avatar
    Ashley Celis

    Hahaha! Holly Black-Smith Misty Maybee Floersch

  • Avatar
    Heather Harris

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

  • Avatar
    M-Djee M-ounette

    Anne-Sophie LabergeCassandre Beauvais

  • Avatar
    Zach Fowler

    Paul Warlick

  • Avatar
    Liz Rose

    Tania Jacobson

  • Avatar
    Sarpoma Sefa-Boakye

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

  • Avatar
    Tennille Onyx

    Maylinda Reeves, thought of you

  • Avatar
    Jessy Saini

    Neeraj Gujral

  • Avatar
    Rob Kent

    Zahra Kent

  • Avatar
    Siddharth Mushrif

    The life of an immigrant Hospitalist from India.

  • Avatar
    Vivek Patel

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

  • Avatar
    Stephen Meyer

    So true

  • Avatar
    Becky Collins

    “Eff you, sunlight” lol lol

  • Avatar
    Cyndi Holley

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

  • Avatar
    Kelly Summers Koch

    Omg yes! Lol there’s help for us

  • Avatar
    Michele Petruccelli

    Probably not too far off!!!

  • Avatar
    Allison Marr Casey

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

  • Avatar
    Jamie Kirby Lynch

    Kelly Summers Koch

  • Avatar
    Trina McIlhargey

    I had so many nights like this :/

  • Avatar
    Jamie Schulz

    David Yerkes

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