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.
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.
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.”
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.
The admitting provider reaches closure: “I am going to be OK, 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.
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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