A Buddhist Approach to End-of-Life Care

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A Time for Listening and Caring: Spirituality and the Care of the Chronically Ill and Dying Christina M. Puchalski

https://doi.org/10.1093/acprof:oso/9780195146820.001.0001

Published: 2006 Online ISBN: 9780199999866 Print ISBN: 9780195146820

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CHAPTER

https://doi.org/10.1093/acprof:oso/9780195146820.003.0008 Pages 131–138 Published: July 2006

Abstract

Keywords: Tibetan Buddhism, death, dying, end of life, terminal care

Subject: Patient Care and End-of-Life Decision Making, Palliative Medicine for Elderly People Collection: Oxford Scholarship Online

8 A Buddhist Approach to End-of-Life Care ^

Christina M. Puchalski

This chapter aims to present the Tibetan Buddhist perspective that o ers a rationale, experiential richness, and understanding in the area of death and dying, explaining the underlying principles of Tibetan Buddhism, which serve as the basis of death and dying practices. It also explores di erent practices during the various phases of death and evaluates how they can be incorporated into present- day end-of-life care.

Being with a dying patient, totally and completely, brief as it may be, helps us to be in the presence of death and dying in a deeply personal way, which has the potential of activating in us its constant presence. In being informed this way, we may value our daily experiences, both pleasant and otherwise, in a di erent way.

Lobsang Rapgay

For Tibetan Buddhists, life and death are seen as part of an ongoing cycle propelled by the power of karma—

the law of cause and e ect. The goal of each practitioner, therefore, is to untie the knot that binds him or her to cyclic existence. This chapter seeks to present the Tibetan Buddhist perspective that o ers a rationale, experiential richness, and understanding in the area of death and dying. This chapter will discuss the underlying principles of Tibetan Buddhism, which serves as the basis upon which death and dying practices are founded. It will also discuss the di erent practices during the various phases of death—the initial signs of death, the actual death phase, and nally the aftermath of death—and explore how many of these practices may be incorporated into present-day end-of-life care.

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Buddhist teachings begin early, often at birth, in the life of a Tibetan Buddhist. The child is taught how to be compassionate toward all life by recognizing that every being is impermanent and subject to death. Such early training makes the child sensitive to how birth, sickness, old age, and death constantly play out in their environment, whether it is their pet becoming sick, the insect that is crushed, or the dying elderly neighbor. Often stories and parables are used to reinforce the message. Many of the stories are centered around the Buddha's own life. One of the most powerful stories often told is about a day when Buddha entered a village as he and his disciples traveled from town to town, never staying at anyone too long. A middle-aged woman came wailing up to the Buddha, crying out about the death of her only child. she prostrated at the feet of the Buddha, pulling her hair apart, and in total grief said, “You are the Buddha, the Awakened One, you can do anything if you so desired, please save my child, bring her back.” The Buddha listened silently as the woman wept. Finally, feeling deep compassion for her, he said, “Go to every doorstep in the village and see if you can nd one family where death has not occurred, and when you do, come back with a mustard seed, and I will bring your child back to life.” With great expectation and hope, the woman wiped her tears away and ran toward the rst home. As she knocked at each door, she heard the endless sadness and misery of deaths that had occurred: of a father, a mother, a child, some sudden and unexpected, some after protracted illnesses. As she knocked at the last few doors, her hopes begin to diminish, and as she felt the heavy sadness of her pain return, she also became aware that there is no one who is free of death. Finally, with a heavy heart she returned to the Buddha, and as she reported that she had not found any family in the whole village who was free from death, the Buddha blessed her and patiently explained to her that death is an extension of life and that by accepting it can we nd relief from our fears about it.

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Practices and Beliefs about Death and Dying

When the novice observes that life and death are extensions of each other, just like the woman nally did in the story, he or she is then introduced to the formal practice of the nine cycles of death meditation. The intention is not to engage in a macabre preoccupation with death, but rather to develop a deeper recognition of death's eventuality and the need to acknowledge its presence in order to help us appreciate and live our lives more meaningfully. The practitioner begins by entering into a contemplative state of mind, to explore the three principal premises that govern death and dying. He or she meditates on the rst premise in order to develop increasing awareness of the certainty of death, by looking for supporting evidence about the certainty of death as well as looking for evidence to the contrary. Once the practitioner nds evidence of the certainty of death, he or she meditates on this understanding for extended periods of time in order to integrate the realization into a conviction.³

Buddhists believe that insight alone does not lead to integration and that acquiring conviction about an understanding is critical for change. The technique of total concentration on the insight is the means by which conviction is achieved. Extended concentration on the insight for days and weeks results in a direct experience of the insight—described as being at one with the experience of that which is being observed and studied. Being convinced about death's certainty, the practitioner now contemplates its implications for him or her.

The above process of analysis and concentration is applied to the second and third premises, which are that the time of death is uncertain and only spiritual practice matters. A similar process described for the rst premise is carried out, with the aim of acquiring convictions about these two subsequent premises. These convictions are then translated into daily living, by learning to accept death as it happens around him or her and by providing support to dying people as well as to those grieving for the loss of a loved one.

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As the novice becomes more attuned to the play of impermanence, not only in death but virtually all human experiences, he or she is now introduced to an advanced training of death and dying practices known as the

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eight dissolution practice. The purpose of this practice is to rehearse for death, a process conducted during meditation sessions. The practice is primarily designed for advanced practitioners, to help them activate a psychophysiological practice that involves control and regulation of autonomic sensory-motor activities as well as subtle mental and neurological activities during actual death, in order to minimize and eliminate all the negative processes of death. As a rst step, the practitioner learns to identify both the gross and subtle psychophysiological processes involved during death. The training involves understanding how energies in the body sustain mental activities, becoming familiar with the physiology of the channels in which they

ow. He or she then learn show a variety of factors can result in the cessation of these energies, resulting in the collapse of consciousness that signals the beginning of the death process. Such awareness of the functioning of the body during death is designed to help the practitioner to regulate these activities in order to facilitate the death process, which is conducive to spiritual practice.

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The Death Process

According to the Buddhist explanation of the psychophysiological process of death, the sequential dissolution of the energies that sustain the four elements—earth, water, re, and air—results in nal death. Each of the elements of energy is associated with general and speci c psychological and

physiological functions, so that when the initial stages of death begin, these general and speci c functions begin to deteriorate. During the rst stages of death, the energies that sustain the earth element begin to gradually dissolve. The structures of the body that are primarily formed by the earth element-such as the bones, muscles, and so forth—begin to degenerate. The limbs become weak, the body loses weight and luster. The body feels as if it is sinking. The corresponding sensory organ of sight undergoes change. The eyes become weak and cloudy, with occasional hallucinations, and the dying person has di culty closing or opening them. When the earth energy and the earth structures collapse, the water energy and its structure take over the lost functions. This cycle of elemental dissolution is repeated, and nally, after the elemental energies are dissolved, at the fth cycle, the gross consciousness that deals with conceptual thinking begins to dissolve, while more subtle states of consciousness of white light, free of gross conceptual processes, appear. This subtle consciousness eventually dissolves into a total state of vacuity and darkness, resulting in the person becoming unconscious. In time, the dark vacuity dissolves into a clear state of emptiness. This is the state known as clear light. Actual death, according to Buddhists, occurs at this eighth cycle, not at the fourth cycle when clinical death occurs. It is believed that a person may abide in the state of clear light for up to 3 days. Final death is determined when there is discharge from the ori ces.

Understanding the psychophysiology of death is critical to dying well, according to Tibetan Buddhism. By rehearsing during life, dying becomes more familiar, easier to monitor, and therefore, contains the uncertainty of the changes that take place, as well as facilitates the appropriate cognition, a ect, and spiritual behavior during each of the psychophysiological changes.

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As a sta psychologist at UCLA, I was consulted by the psychiatry department to talk to a Hispanic family whose adult son was in a coma, dying from a major liver disease. For weeks the family conducted a 24-hour vigil by his bedside. However, they did not know what to do and say when they were with him and dreaded their helpless feelings of watching him struggle and su er. I explained to them that their son was dying, and that changes in the breathing pattern and coloration of the skin and lips are a part of the process. I also explained that there is a gradual dissolution of sensory, cognitive, and motor functions, and that other parts of the body then compensate for these losses. And though their loved one was in a coma and appeared not to know or hear them, it is possible that if they held his hand from time to time, and rubbed it in the more sensitive areas while they gently whispered to him, that he might sense and hear them in his own way. The family began to do so and reported how comfortable they now felt being with him through the long nights, knowing that when he labored and su ered they could comfort and communicate with him.

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Caring for the Dying

In order to provide care to a dying person, one has to rst determine how conscious the person is and whether the person believes in Buddhist principles and practices. This di erentiation helps to determine whether the individual is capable of conducting his or her own dying process. If the individual is

unconscious, someone else may help the person through the process. Furthermore, if the individual has any religious belief, he or she is encouraged to utilize it, while those who do not have such beliefs are simply asked to think positively about things they have done in their lives,⁸

Central to the dying process is the individual's personal spiritual teacher, who plays a very important part in facilitating the initial phase of dying. He is often the one who may let the person or family members know the time to begin the dying process and educate them on what to do. He teaches them the importance of dying peacefully and calmly and the importance of acceptance of death and how to work through their fears and concerns. The lama also recommends speci c prayers and rituals that may help the individual through this process, both symbolically as well as emotionally. One of the rst instructions that the lama may recommend is for the dying person to begin resolving family and material issues and con icts, such as dividing up the family assets among the children, resolving individual disputes, and nding closure.

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Once the family concerns and disputes are addressed by the dying person, the lama will then help the person and his or her family to begin the practices related to the dying process. The lama will be consulted

repeatedly throughout the entire process. When the nal dissolution signs and symptoms begin, the lama may recommend cessation of all medical treatment, since medical procedures during the dying process are seen as unnatural and, more importantly, a potential hindrance to the dissolution process. The lama then instructs the family to set up a very quiet, spiritual environment in the home and to restrict the dying person to any exposure of major stress. The dying person, in turn, depending on his or her level of spiritual practice, is encouraged to engage in his or her personal practices within the context of the dissolution process and practice. At the same time, special prayers and rituals to facilitate dying are conducted by invited monks.¹⁰

Post-Death Practices

Once clinical death occurs, the appropriate rituals are conducted, and the body is preserved for a few days- averaging 3 days-to ensure nal death. The cremation is conducted, and the ashes are mixed with clay to form the statutes of the deceased's personal deities. These statues are then distributed among close family members and friends, as well as placed in Buddhist holy cities all over.¹¹

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What Can We Learn?

What can we learn from these practices? The rst is the need to prepare a dying person emotionally, physically, and spiritually for the process of dying. The second is the recognition and need to help the dying person rst resolve his or her worldly con icts and concerns before he or she can begin the dying process.

Third, the dying person is educated about the various phases that he or she is likely to experience, based on the trajectory of the illness and the likely signs and symptoms that may occur at each phase, which helps the dying person di erentiate between illness-related signs and symptoms and those associated with the natural dying process. Fourth, the spiritual minister and the family should be actively involved in the process. While the, family's wishes are important to honor, the interest of the dying individual should be paramount. Consequently, if the family seeks to overlook important issues or concerns of the dying patient, the role of the minister and therapists is to help the family work through their fears and resistance to do what the dying individual seeks. Fifth, the goal—particularly when the dying person consents-is to facilitate the natural ow of dying, even at the cost of terminating medical care. Sixth, involve the dying person in planning his or her memorial.

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What are some of the actual techniques we can use from the Buddhist tradition? Initially, listening to the individual and helping him or her to facilitate his or her thinking and expressing his or her feelings, based on his or her cues, are important steps. Confronting the patient or encouraging him or her to talk about his or her true feelings should be avoided. The task here is to facilitate the expression and completion of thoughts that the patient on his or her own has initiated. As an example, one can encourage the patient to complete a thought and identify the accompanying feeling. If feasible, appropriate sentence completion tasks may be proposed to the patient. When the patient begins to express feelings and thoughts more freely about his or her impending death, then explore if the patient acknowledges his or her impending death. If acknowledged, it is helpful to facilitate some challenges he or she may face. The challenges would include symptoms such as pain, dyspnea, functionality, and disability issues. One way to help the person process his or her issues around these issues is to mirror his or her subconscious thoughts verbally (after getting permission to do so). Another indirect, e ective technique is to encourage the person to talk about how he or she feels regarding similar situations depicted in visuals such as photographs or movies, for example. In the Tibetan tradition, the wall painting depicting the cycle of existence, the 12 stages of the Buddha's life, and the personal deity of the person are placed in the room of the dying person to experience and re ect upon.¹²

Another important task for the dying person is to learn how to gradually manage and reduce noise and extreme stimulation, such as bright light. What is equally important is to plan a day-to-day schedule, by learning to pace medical treatment and care with rest, prayer, and TV: If the person is receptive and could bene t, it is also important to educate him or her about the potential physiological, psychological, and emotional changes that may occur over the course of his or her dying. The patient should be told about the processes and accompanying experiences and how best to deal with these phases. Often, breathing

techniques can be used to facilitate rapport and connection with the other, by getting the permission of the patient to breathe like the patient and then asking the patient to also breathe with yoU. Also, gazing into his or her eyes and their doing the same maybe a wonderful way to communicate to each other.

Touching, as well as whispering in the dying person's ear, is a another way to communicate, particularly when the patient is not fully conscious. It is equally important to let the patient know that he or she might have certain perceptions and explain to him or her that it maybe normal when the dying process ensues to have such perceptions. I remember a profess or who was dying from bone cancer who refused to be fed and would not respond or talk to anyone in the hospital. His young wife dreaded being with her husband and stayed outside his room. He was in constant agony from pain and could not lie down. I held his hand and began to place my warm hands on his pain area and very soon he began to relax. He gestured for the writing

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Notes

pad and for the rst time communicated by writing down the words, “Why can't I love anyone?” I told him that he felt so alienated from others, and they from him. And because he chose not to communicate to others, they in turn gave up on him, and in the process failed to communicate to him by means other than words, such as by touch. Two days later he died.

Tibetan Buddhism shows us that death becomes more manageable when we see it as a natural process in our development, so that we can identify appropriate tasks to address when we are dying. It is both an

individual as well as a family process of letting go.

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1. Gyatso, T.,& HH The Dalai Lama. (1985), Kindness, clarity, and insight. Ithaca, NY: Snow Lion.

2. Rinpochay, L., & Hopkins, J, (1979). Death, intermediate state and rebirth in Tibetan Buddhism. London: Rider.

3. Thurman, R. A. F. (1989). The Tibetan book of the dead. London: Aquarian.

4. Rinpoche, S. (1992). The Tibetan book of living and dying. London: Rider.

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9. Thurman, R. A. F. (1989). The Tibetan book of the dead. London: Aquarian.

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