Spiritual Care for the Dying

Spiritual Care for the Dying

 By Phra Paisal Visalo

       Illness not only affects the body, but also the mind. Thus, when most people fall ill, they must contend not only with physical pain, but also mental pain. Especially in the case of patients who are close to dying, mental anguish is no less a cause of suffering than physical pain, and indeed it can even be the greater cause. This is because what these patients face right in front of them is death, along with separation and loss that is final. All this provokes feelings of fear, anxiety, and isolation to surge up very intensely, in a way they have never experienced before.

       For this reason, patients need their spiritual well-being taken care of just as much as their physical well-being. Especially in the case of final-stage patients, whom doctors have determined to have no hope of recovery or improvement, taking care of spiritual well-being in fact becomes more important than physical well-being. Because even though the body is irrevocably breaking down, the mind still has the opportunity to improve. It can cease its agitation and reach a state of peace, even in the last moments of life. For even though the body and mind are closely related, when the body suffers, the mind does not necessarily have to suffer too. One can take care of one’s mind such that it does not suffer along with one’s body.

       In the time of the Buddha, there were many occasions wherein the Buddha and his disciples helped those who were sick and close to dying. The kind of help they gave directly focused on treating the suffering of the mind. In the Tipitaka, there are several stories of people on the verge of death who were told by the Buddha to contemplate their imminent death and the true nature of all conditioned things, whereupon they were able to realize high levels of attainment. Some were even fully enlightened. 

       From these stories, there are two major points to consider:

        1. Even though being ill and close to dying is a time of crisis and physical disintegration, at the same time it can also be an opportunity to liberate the mind or elevate one’s state of mind. Being ill and close to dying are thus not conditions that are negative in and of themselves. If one knows how to use them well, they can be of great benefit to one.

       2. The Buddha’s teachings on illness and dying can be classified into two main parts:

              1) Incline the mind to have faith in the Triple Gem (the Buddha, the Dhamma, and the Sangha) and confidence in the morality one has upheld or good deeds one has done in the past. In other words, incline the mind to recollect that which is good and wholesome.

              2) Let go of worries and all things, having seen with wisdom that there is nothing at all that one can hold on to. 

       These teachings of the Buddha provide an excellent model of how to give spiritual help to dying persons that can be applied to cases in the present day. This article will adopt the principles put forth by the Buddha and adapt them for use by doctors, nurses, family and friends in helping dying patients. Experiences from other real-life cases have also been drawn on to create the following guidelines.

       1. Extending Love and Sympathy

       Dying persons not only have to contend with physical pain but also fear, such as fear of dying, of abandonment, of dying alone, of what will come after death, or of pain. The fear may cause even more suffering than the physical pain. Love and moral support from family members and friends is very important during this time because it can reduce the fear and help them feel secure. One should remember that patients in their final stages are feeling very vulnerable. They need someone they feel they can rely on, someone who is ready to be there for them during times of crisis. If they have someone who can give them unconditional love, they will have the strength of spirit to deal with all the various forms of suffering that are converging on them at this time.

        Being patient, forbearing, sympathetic, gentle, and forgiving are ways to show your love. Physical pain and a vulnerable state of mind can make patients act out in ill-tempered and abrasive ways. We can help them by patiently bearing with these outbursts and not reacting in negative ways. Try to forgive them and sympathize with them. If we are peaceful and gentle it will help them calm down more quickly. Pointing out their negativity may be something we ought to do sometimes, but always in a gentle and loving way. Family and friends need to have mindfulness at all times, which helps us not to lose control of ourselves and keeps our hearts filled with kindness, love, and restraint.

       Even if you don’t know what to say to make them feel better, just physically touching them in a gentle way will enable them to feel your love. We may hold their hand or touch their arm and squeeze it gently, embrace them, or touch their forehead or abdomen with our hands, while sending them our good wishes. For those who have some experience practicing meditation, while touching the patient, bring your mind to rest in a peaceful state. Loving-kindness (metta) that emanates from a mind that is peaceful and concentrated will have an energy that the patient will be able to feel. 

       One way of extending loving-kindness that Tibetan Buddhists practice (called phowa) is done the following way. Invoke the divine being or spiritual presence that the dying patient (or you) has faith in, such as the Buddha, a Boddhisattva, or Guan-Yin (or God, Jesus, or the Virgin Mary for Christians, or the embodiment of whatever truth you believe in). Visualize the spiritual presence appearing above the patient’s head. Then imagine that the presence is sending out compassion and healing in a stream of radiant light that bathes the dying person’s entire body, purifying her whole being, until she dissolves into light and merges into the spiritual presence. While doing this practice, you may hold the patient’s hand or sit quietly by her bedside.

       2. Helping Patients Accept Impending Death

       If patients do not have long to live, letting them know will give them time to prepare themselves while they are still physically able to. But there are a great many patients who have no idea that they have a serious terminal illness and are now in their final stages. To let time pass while keeping them in the dark will leave patients with less time to prepare themselves. Still, telling them the bad news without preparing them psychologically in some way beforehand may cause their condition to worsen. In general, doctors play the important role in telling the news, especially after they have built up close relationships with patients and earned their trust. Nonetheless, patients’ acceptance of their impending death involves a process that takes a long time. In addition to love and trust, doctors, nurses, family and friends need to have patience and forbearance and be ready to listen to the patient’s thoughts and feelings. 

       Sometimes, however, it is up to the family to break the news. Many families tend to think that it is better to conceal the truth from the patient. But according to a survey done of patients, the majority responded that they would rather be told the truth than be kept in the dark. And even when relatives try to conceal it, ultimately the patient can discern the truth from the changed manner and behavior of family and friends, such as unsmiling faces, softer speaking voices, or greater effort made to please the patient. 

       Not all patients can accept the truth after they are told. But there could be several reasons for this besides the fear of death. They could have some unfinished business or other worries. Relatives ought to help them express their concerns. If they feel they have someone ready to listen to and understand them, they will feel safe to confide their inner thoughts. Posing appropriate questions can also help them identify what it is that is preventing them from accepting death or help them realize that death may not be so fearsome. What relatives can do is listen to them with an open, nonjudgmental, and sympathetic heart. They should focus more on asking questions rather than lecturing or sermonizing. 

       Helping patients lessen their worries about their children, grandchildren, spouse, or other loved ones may help them accept their death

       Patients may become angry at doctors, nurses, and family for telling them the bad news, or concealing the bad news from them for a long time. Be understanding of these angry outbursts. If the patient is able to get past their anger and denial of death, they will be more able to accept the reality of their situation. 

       When patients are told the bad news, they should at the same time be given moral support and reassurance that family, friends, doctors, and nurses will not abandon them, but will stay by their side and help them to the utmost of their abilities until the very end. Giving moral support during crisis points when a patient’s condition takes a turn for the worse is also very valuable. 

       One useful benefit of telling patients the truth in a timely way is that it enables them to decide in advance what level of medical intervention they would like to receive when they reach crisis point or fall unconscious, i.e. whether they would like doctors to prolong their lives as long as possible using all technological means available such as CPR, respirator, feeding tube, etc., or whether they would like doctors to refrain from using these measures and just maintain their condition and let them gradually pass away peacefully. Many times patients did not decide in advance because they did not know the real state of their condition. The result is that when they fall into a coma, relatives have no choice but to ask the doctors to utilize every possible measure to sustain the patient’s life. This often causes much suffering to the patient, with the only effect being to prolong the process of dying without helping to improve their quality of life at all, while wasting a lot of money in medical expenses. 

       3. Helping Patients Focus Their Minds on Goodness

       Thinking of goodness helps the mind become wholesome, peaceful, bright, less fearful, and better able to deal with pain.

       What the Buddha and his disciples often recommended to those on the verge of death was to recollect and have firm faith in the Triple Gem, i.e. the Buddha, the Dhamma, and the Sangha. Then, he had them establish themselves in morality (sila) as well as recollect the morality they had upheld in the past. The Triple Gem can be thought of as something virtuous or sacred that the patient worships and sila as his or her good deeds.

        There are many ways to help incline patients to recollect these things. For example, you can:

        - Place in the patient’s room a Buddha statue or other sacred object or pictures of respected spiritual teachers to serve as aids to recollection
        - Invite the patient to chant or pray together
        - Read dhamma books out loud to the patient
        - Play recordings of dhamma talks or chanting
        - Invite monks, especially ones the patient has a connection with, to visit the patient and provide counseling. This will help greatly in raising the patient’s spirits. 

       In applying these ideas, keep in mind patients’ cultural background and personal habits. For example, patients of Chinese background may respond best to pictures of Guan-Yin. If the patient is Christian or Muslim, one may use the appropriate symbols of these religions instead. 

       Another way to incline the patient’s mind towards goodness is by encouraging them to do good deeds such as offering requisites to monks and making charitable donations.

       It is also essential to encourage the patient to think of the good deeds they have done in the past. This does not necessarily have to mean religious activities only, but also such actions as raising one’s children to be good people, taking care of one’s parents in a loving way, being faithful to one’s spouse, being helpful to one’s friends, or being dedicated in teaching one’s students. All of these are good deeds that can make the patient feel happy, proud of themselves and confident that when they die they will go to a good place. 

       This pride in the good deeds they have done, and faith in the beneficial effect of such deeds, becomes very important for those close to dying for at this time it is becoming clear to them that they can’t take any of their material wealth with them when they die. It is only the merit they have accrued that they can take with them. 

       Everybody, no matter how rich or poor, or what mistakes they have made in the past, has to have done some good deeds worth recollecting, to greater or lesser extent. No matter how many terrible things they have done in the past, when they are close to dying, what we should do is help them to recollect their good deeds. If they are overwhelmed with feelings of guilt, they may not be able to see any of their good deeds. But any good deeds, even small ones, will be valuable to them if remembered during this time of crisis. At the same time, patients who have been doing good deeds all along should not let any unwholesome deeds (of which there are very few) overshadow all the goodness they have done, making them feel badly about themselves. In some cases, family and friends may need to list out their past good deeds as a way of confirming and reiterating them, giving patients confidence in the life they have led. 

       4. Helping Patients Settle Unfinished Business

       One major cause of suffering that prevents people from dying peacefully is unfinished business. Such anxieties or other negative feelings need to be released as soon as possible. Otherwise it will cause the patient to suffer, feel heavy-hearted and push away death, and thus be unable to die peacefully, resulting in an unfortunate rebirth. Patients’ family and friends should be very concerned about these matters and be quick to act on them. Sometimes patients may not bring the matter up directly. Those who are around the patients should thus be very sensitive to it and ask them about it with genuine concern and kindness, not annoyance.

       - If they have remaining work or responsibilities or a will that has not been settled yet, find a way to help bring these matters to a conclusion.
        - If they wish to see someone for the last time, especially a loved one or someone they wish to ask forgiveness from, hurry and contact that person.
        - If they are nursing an angry grudge against someone or hurt feelings and grievances against a close intimate, advise them to forgive that person and let go of any anger.
        - If they are feeling nagging guilt over some wrong they had done, now is not the time to judge or criticise them. Instead, one should help them release their feelings of guilt. One can help them open up and feel secure enough to ask forgiveness from someone while at the same time guiding the other party to accept the apology and forgive the person.

       Asking for forgiveness is not easy to do. One way to make it easier for dying patients is to have them write down their apology and everything they wish to say to the other person. They can have someone deliver it to that person or choose to keep it to themselves. The important thing is that by doing this exercise they have begun to open their hearts. Even if no real communication has ensued with the other person, there has still been some release of those feelings of guilt. If at some point they feel more ready to talk to that person directly, they may decide to do so on another occasion.

       Oftentimes the person that dying patients seek forgiveness from is someone close, who is right there by their bedside, such as a spouse or a child. In this case, it is easier if such a person initiates the conversation by offering her/his forgiveness first and telling the patient s/he does not bear any ill-will towards them for their past mistakes. But in order to do this, the person must first let go of any pride or anger s/he may feel. By making the first move, the person opens the channel for dying patients to ask for forgiveness more easily. Feelings of guilt, as long as they are not released, can greatly disturb the dying and make them unable to die peacefully. But once they have been able to say sorry and ask for forgiveness, they are able to die without distress.

        In some cases, it is the child, relative, or friend of the dying patient who ought to ask for forgiveness. There is no other occasion where an apology is as important as it is at this point, but oftentimes children do not dare to open up to their parents even when they are about to die. Partly it could be because they may not be accustomed to talking to their parents openly. Partly it could be because they think their parents do not hold their misdeed against them or do not even know about it at all. This could be a serious and irreparable miscalculation. 

       Actually, asking for forgiveness does not have to be done only with specific persons, because we all have probably done others harm without intending to or realizing it. As such, to have peace of mind and to avoid any lingering hostility with anyone, family and friends should advise dying patients to say sorry and ask for forgiveness from anyone with whom they have had mutual hostility or from anyone whom they have ever offended or harmed.

       Likewise, the family and friends of dying patients ought to ask for forgiveness from them while they are still conscious and able to understand. This provides the opportunity for dying patients to say they grant their forgiveness. In the case where the dying person is a parent or elder relative, the children, grandchildren, and other family members may join together to hold a ceremony to ask forgiveness at the person’s bedside and select a representative to speak for the group, beginning by speaking of the dying person’s virtuous qualities and good things s/he had done for her/his descendants, and then asking for forgiveness for anything they have done that may have caused harm or offense. 

       5. Helping Patients Let Go of Everything

       A refusal to accept death and the reality of its imminence can be a great cause of suffering for people who are close to dying. And a reason for such refusal can be that they are still deeply attached to certain things and unable to be separated from them. This could be children or grandchildren, lovers, parents, work, or the entire world they are familiar with. A feeling of deep attachment can be experienced by people even if they do not have any lingering feelings of guilt in their hearts. Once attachment is felt, it leads to worry and fear of separation from that which they love. 

       Family and friends as well as doctors and nurses should help dying persons let go of their attachments as much as possible, such as by:

       - Reassuring them that their children and other descendants can take care of themselves
        - Reassuring them that their parents will be taken care of well.
        - Reminding them that all their material possessions are only theirs temporarily. When the time comes, they have to be given to others to take care of. 

       In giving spiritual guidance to the dying, the Buddha had advised that after helping them recollect and have faith in the Triple Gem and establishing them in goodness, the next step is to advise them to let go of all their concerns, such as their parents, children, spouses, material possessions and all other tangible and intangible things they are attached to. They are to let go even of any aspirations for rebirth in heavenly realms. All these things, if they are still attached to them, will hold their minds back and make them resist death and be agitated until the end. Thus, when death approaches, there is nothing better than to let go of everything, even the notion of self. 

      Of all attachments, there is none that is as deep and firmly-rooted as attachment to self. In some people’s view, death means the annihilation of self, which is something they cannot tolerate and find very hard to come to terms with. Because deep down, we humans need to feel our self continues on. The belief that heaven exists helps satisfy this deep-seated need because it makes us feel reassured that we will live on after death. But for people who don’t believe in heaven or rebirth, death becomes the most terrifying thing. 

       From the Buddhist point of view, there is actually no such thing as a self. It is something we have concocted ourselves out of ignorance. Those who have some grounding in Buddhism may understand this matter to some extent. But for those whose experience of Buddhism has been limited to rituals or basic forms of merit-making, it is probably not an easy matter to understand the concept of no-self (anatta). Nonetheless, in cases where family, friends, doctors, and nurses have an adequate understanding of this truth, they should advise dying patients to gradually let go of their attachment to self.

       Start with advising them to let go of the body, recognizing that we cannot control our bodies to be as we wish them to be. We have to accept their condition as they really are. One day, all our organs will have to deteriorate. 

       The next step is to let go of their feelings, to not identify with or attach to any feelings as being theirs. Doing this will help greatly to reduce their suffering and pain, because suffering tends to arise when one attaches to pain and identify with it as being ours. One holds that “I” am in pain instead of just seeing that the condition of pain has arisen.

      To be able to let go in this way requires considerable experience in training the mind. But it is not beyond the reach of ordinary people to do so. Especially if one starts training the mind when one first becomes ill. There have been many cases of people with serious   illnesses who have been able to deal with extreme pain without using any painkillers at all or only small doses. This is because they were able to let go of their identification with the pain as being theirs. It could be said that they used spiritual medicine to heal their minds.

        6. Creating a Peaceful Atmosphere

       For dying patients to be able to feel at peace and let go of all lingering concerns and attachments in a sustained manner, it is necessary for them to have the support of a peaceful atmosphere around them. If their room is swarming with people coming in and out, and filled with the sounds of people talking all the time or the sounds of the door opening and closing all day, it will naturally be difficult for them to maintain their mind in a wholesome and peaceful state. 

       With regard to patients’ spiritual well-being, the least that family, friends, doctors, and nurses can do is to help create a peaceful atmosphere for them. Avoid talk that disturbs the patient. Family members should refrain from arguing amongst themselves or crying. These things would only increase the anxiety and unease of the patient.

        If family and friends just try to keep their minds in a healthy state - not sad or depressed - this will already be a great help to dying patients. Because the states of mind of the people surrounding the dying patient can affect the atmosphere in the room and the person’s mind. The human mind is sensitive; it can sense the feelings of other people even if they don’t say anything out loud. People do not only have this sensitivity when they are normal and conscious. It is possible even for patients in comas to sense the mental energy of those around them. 

       In addition, family and friends can create a peaceful environment by encouraging dying patients to practice meditation together with them. One form of meditation is anapanasati, or mindfulness of breathing. When breathing in, mentally recite “Bud”. When breathing out, mentally recite “Dho”. Alternatively, with each out-breath, count 1, 2, 3….10 and then start again.

       If it is not easy for them to be mindful of the breath, they can focus their awareness on the rising and falling of the abdomen as they breathe in and out by placing both hands on top of the abdomen. On the in-breath, as the abdomen rises, mentally recite, “rising”. On the out-breath, as the abdomen falls, mentally recite, “falling”. 

        There have been reports of cancer patients who have dealt with physical pain using meditation. By keeping their minds focused on the breath or abdomen, they ended up needing to use very little pain medication. Moreover, their minds were clearer and more alert than patients who used a lot of painkillers.

         Encouraging dying patients to do chanting together with family and friends in a room that has been set up to create an aura of serenity and sanctity (as mentioned earlier, such as by placing a Buddha statue or other objects of veneration in the room) is another way to bring about a peaceful atmosphere around dying patients and incline their mind in a wholesome way. 

       Even playing soft instrumental music has a beneficial effect on a patient’s mental state.

       Even though a peaceful mind is important, from the Buddhist viewpoint it is wisdom that is considered the most important thing for a person close to dying (and indeed all humans, ill or otherwise). Wisdom means clear knowledge of the truths of life: impermanence (anicca), subjectivity to change (dukkha) and selflessness (anatta). These three truths about all things show us that there is not a single thing that we can cling to. We will find death fearsome if we are still clinging to some things. But once we fully understand that there is actually nothing we can cling to, death will no longer be fearsome. Once we realize that everything by nature must change, that there is nothing that is permanent, death will become something that is natural. And once we realize that we really do not have such a thing as a “self,” then there will be no “me” that dies. There will be no-one that dies. Dying itself becomes just a change of state from one form to another, according to causes and conditions. Wisdom, the knowledge and understanding of these truths, is what makes death no longer fearsome or loathsome, and enables one to meet death peacefully.

       When the Patient is in a Coma or Has Lost Normal Brain Functioning

        Many of these various ways of helping dying persons expounded on above can also be applied to those who are in comas or are unconscious. Even though such persons may not show any discernible signs of response, that does not mean they have lost all forms of awareness. There have been many cases of such patients who were able to hear or even see things happening around them. They were also able to feel the mental energy of people around them. There was one patient who reported that when she was in a coma, she was able to hear the doctors and nurses talking and the sound of chanting from recordings relatives played for her. There was another case where a person lost consciousness because his heart stopped beating. He was rushed to the hospital where the doctors revived him using electric shocks. Before attaching him to a respirator, one nurse took out his false teeth. In a short while, his condition improved. The following week, when he saw that nurse again, he was able to recognize her face immediately even though at the time that she removed his false teeth he was unconscious and on the brink of death. 

        Dr. Amara Milla told the story of one patient who had been in a serious accident. While she was lying unconscious in the ICU for a week, she felt like she was floating around. But at certain times she would feel there was a hand touching her body that was sending her energy. It would make her mind, which felt like it was adrift and about to be cut off at any moment, come together as one again. She would regain consciousness for a short time before drifting off once more. This happened everyday. Later, when she had recovered, she found out that there was a nurse who would come visit her every morning at the start of her shift. The nurse would hold her hand and send her loving-kindness (metta) to give her moral support. She would wish for the patient to have strength and regain consciousness. In the end, she did regain consciousness and recovered fully even though the doctors had predicted a very slim chance of recovery. This is another example of how even though someone may have lost consciousness, their mind is still able to feel and be aware of the energy of loving-kindness of those who are close by.
        For this reason, family and friends should not lose hope when their loved one falls into a coma or loses consciousness. There are still many things we can do for unconscious patients. To review, we can:

       - Read dhamma books to them.
        - Play recordings of dhamma teachings or chanting for them.
         - Encourage them to recollect the sacred things that they venerate and things that are wholesome, including their own good deeds in the past.
        - Say things to ease their anxiety about their children or other attachments.
       - Advise them to let go of everything.
        - Create a peaceful atmosphere around them.
        - Be careful of what you say and do at their bedside. One should not cry hysterically or argue or say anything that could trouble them.

       Remember this principle: whatever we feel we should do for people when they are still conscious, we should keep on doing the same thing when they are no longer conscious.

       7. Saying Goodbye

       For those who would like to say what is in their hearts to the dying person, such as saying sorry or goodbye, it is not too late to do so.

       There was once an old woman who was sitting by her husband’s bedside feeling deeply grieved because she had never told him how much she loved him. Now he was in a coma and about to die. She thought it was too late to do anything now. But the nurse encouraged her, telling her that he may still be able to hear her even though he showed no sign of reaction. So she asked to be left alone with him, and then told him that she loved him from the bottom of her heart and was so happy to have lived life together with him. After that, she bade him goodbye by saying, 

       “It will be very difficult for me to live without you. But I don’t want to see you suffer any longer. So if you would like to go now, please go. I give you permission to die.”

As soon as she finished speaking, her husband let out a long breath and passed away peacefully.

        As a person’s pulse weakens progressively and they approach the moment of death, if family and friends wish to say goodbye, they should first establish mindfulness, restrain their grief, then whisper their final words in the ear of the dying person. They should talk of the good feelings they have towards the person, give her/him praise and thanks for all the good s/he has done, ask for forgiveness for any wrongs committed, then guide the person’s mind to ever more wholesome states by advising her/him to let go of everything, drop all worries, recollect the Triple Gem or whatever s/he venerates. If the person has some grounding in Buddhist teachings, ask her/him to let go of the “self” and all conditioned things, incline the mind towards emptiness, and keep the mind focused on nibbana. Then, say goodbye.

         Even if one has said goodbye to someone when they were still conscious, it is still useful to saying goodbye again just before they die. The important thing to keep in mind is that being able to say goodbye and guide the dying person’s mind to a wholesome state can only be done well if the atmosphere surrounding the person is peaceful, and they are not disturbed by any attempts to perform invasive medical interventions. In most hospitals, if patients are in the ICU, and their pulse weakens to the point where they are close to dying, doctors and nurses will tend to do whatever it takes to keep them alive such as by   stimulating the heart with electric shocks (defibrillation) or using all other available forms of medical technology. The atmosphere around patients will be chaotic and it will be difficult for family and friends to say anything to them. The only exceptions are cases where patients and family members inform hospital personnel in advance of their wish that the patients be allowed to die peacefully, free of any medical interventions.

        For the most part, doctors and family members tend to think only about helping the patient in terms of their physical welfare, and neglect to think about their spiritual welfare. So they tend to support the use of all available forms of medical technology to prolong the patient’s life, even though when people are close to dying, what they actually need the most is spiritual help. Thus, if the patient’s condition worsens to the point where there is no hope of recovery, family members ought to give greater consideration to taking care of the patient’s state of mind, than of the body. This may mean asking others not to crowd around the patient and allowing her/him to die peacefully surrounded by close family and friends, who join together to create a wholesome and positive atmosphere that will help lead her/him to a good rebirth. In general, the place that is the most conducive to creating this kind of atmosphere tends to be the dying patient’s home. For this reason, many patients wish to die at home rather than in the hospital or in the ICU. If family and friends are ready to help meet the spiritual needs of dying patients, it is easier for patients to decide spending the last part of their life at home.

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