Social distress associated with love and belonging play a role in this stage. McPherson cited multiple studies where 40-84% of dying individuals report feeling like a burden to their families or as a source of hardship to others (2007). These feelings of burden are exacerbated by fears about things ranging from physical safety to the fear of death itself because they require the presence and emotional support of others to overcome (Zalenski & Raspa, 2006). The lack of independence that occurs with the dying process becomes burdensome as well. The dying person is acutely aware of their inability to continue in their current role and fears a lack of respect from their family or being taken advantage of (McPherson et al., 2007). The accommodations that the dying individual must face will also have an impact on their sense of emotional well-being. Depression is perhaps the most difficult stage in the DABDA model; however, it is an important one. This is seen as a period of grieving and growing essential for coming to terms with the circumstances at hand (Schroepfer, 2007).
Acceptance is the final stage in the DABDA theory of coping with impending mortality, and is an important part of a life review. When a dying person accepts their death as an inevitable part of life it, he or she in fact surrenders to natural order. This can be an important step towards dying in peace. The acceptance stage also involves forgiveness. Of particular importance to the life review are unresolved conflicts (Clarke, 2007). The life review represents a final opportunity for the individual to resolve and come to understand the conflicts of earlier life. It is not acceptance of wrongful behaviors or injuries from others; rather, it is a release of hurt feelings and resentments that perhaps preventing living a peaceful life. Impending mortality may make it easier to forgive others for past hurts. Reflective time may be spent in asking others (or a higher power) for forgiveness and offering one's own forgiveness to others (Harmes, 2012). In this way inner peace receives a welcome invitation prior to the end of one's life.
Carlander identifies what most people define as being the most important things to say before you die: "Thank you," "I forgive you," "Will you forgive me?," and "I love you" (2011). Two of the four phrases concern forgiveness, illustrating its importance during a life review. After experiencing all other stages, a dying person will often experience extreme gratitude for their life. This includes thankfulness for the people and experiences of life. There may be an overwhelming sense of joy and expressions of gratitude to friends and loved ones for a fulfilling life (Clarke, 2007).
Kubler-Ross noted that people may not experience emotions in this particular order, but a work laid a strong foundation for categorizing and counseling those facing death. Other theorists have expanded the application of this model to include various types of losses such as the disintegration of a marriage, the loss of a career, or the loss of a physical function. Abraham Maslow hierarchy of needs also plays a role in one's ability to adapt to the losses associated with impending death. Maslow's theory asserts that a human's needs exist in an order of significance and that basic needs must be met before the individual can turn attention to higher needs (Zalenski & Raspa, 2006). In addition, Viktor Frankl's contribution to the existential theory recognizes man's desire to find meaning in life as the basis of all human motivation. Viktor Frankl believed that the desire to find meaning in life is more than chance, but is a core motivator within man (Breitbart et al., 2004). Achieving a strong sense of meaning in life results in a new self-image that guides an individual forward in the face of great loss (Knight & Emanuel, 2007).
The impact of loss can be lessened through the use of meaning as a coping mechanism. This is accomplished by revising goals, participating in positive experiences and focusing on religious beliefs. Enhanced meaning has also been shown to counteract demoralization (Sand et al., 2009). When faced with continual helplessness, resulting hopelessness can ensue which leads to the loss of morale. A healthy sense of meaningfulness combined with strong social connection can protect against this decline in morale (Clarke, 2007). Enhanced meaning also plays a role in preventing the desire to hasten death. "Loss of meaning in life" was one of ten contributing factors influencing a dying individual's desire for a hastened death over living (Schroepfer, 2007).
Finding meaning in life and coming to an acceptance of one's impending death are significant. Meaning has been defined as a correlation between the facts of a given situation and one's understands of themselves (Langle, 2005). Alfred Langle states that "personal meaning is a complex achievement of the human spirit" and "is a nonphysical power underlying our conscience, our mind, our capacity to feel and to sense and even our body" (2005). More simply stated, meaning is an orientation to life, a personal significance, a mechanism for coping, causality, and an outcome (Breitbart et al., 2004). Taking ownership of one's feelings, beliefs and choices leads to a genuine connection with the individual and others -- something so important when approaching the final chapter of life.
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