Buddhist Hospice : Compassionate Care for the Dying

I am of the nature to grow old. I cannot avoid aging. I am of the nature to become sick. I cannot avoid sickness. I am of the nature to die. I cannot avoid death. I will become separated from all that is dear to me. I am responsible for my own actions.

– Rev. Joseph Rogers, Hospice Chaplin

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Hospice care is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure.

The goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible.

Buddhist understandings of death and of practices developed for dying and the specific moment of death have been hallmarks of the tradition since its beginning in India twenty-five hundred years ago.

Over the last forty years, they have been an important part of the global revival of Buddhism, especially in the West—from the popularization of the Tibetan Book of the Dead, to Zen poetry about death, to Theravadan meditation on the decaying body, to belief in the welcome of Amida Buddha on one’s deathbed.

Today there is a plethora of new titles and study material by various authors on how to use Buddhist teachings and practices to face death and the dying of loved ones—a quick search for “Buddhism” and “death” on amazon.com pulls up 543 entries.

These entries by and large focus on how an individual or family member can face and prepare for death, either as an inner journey or as a journey with intimate relations.

Relatively little is known, however, about the number of Buddhist Hospice / Buddhist-based initiatives for caring for the dying and bereaved that focus on the development of trained professionals and the building of facilities, though these facilities have mushroomed since the late 1980s.

While a number of these initiatives have been created by high-profile Buddhist teachers, like Sogyal Rinpoche and Joan Halifax, who have written heart-moving books on death, their initiatives and others are not as highly publicized in the mass media.

In fact, when one even speaks of “hospice” one is drawn back to its Christian origins in eleventh-century Europe—the Irish nun Mother Mary Aikenhead (1787–1858) and the Religious Sisters of Charity, who created the modern hospice archetype; and Dame Cicely Saunders, the Anglican nurse who founded the first modern hospice, St. Christopher’s Hospice, in London in 1967.

The modern-day Buddhist hospice movement is, however, one with a long historical precedent. The Vihara Movement in Japan has consciously named itself using the traditional and ancient Buddhist term for “temple,” vihara.

Like the term “hospice,” vihara has also had the meaning of a place for travelers to take rest in addition to a place that might offer social welfare and medical care for the poor. Rev. Yozo Taniyama explains how the famous Jetavana Vihara established by Buddha Sakyamuni eventually developed into such a comprehensive center for spiritual, economic, and medical care.

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The great Indian monarch, Emperor Ashoka (r. 270–232 BCE), who is credited with first unifying the Indian subcontinent under one rule, was also known to have promoted the development of herbal medicine and dispensaries through Buddhist temples.

This tradition of social service by Buddhist temples, first established in India, eventually spread throughout the Buddhist world. Japan, the last frontier of the ancient spread of Buddhism, inherited this tradition from the beginning with the establishment of Shitenno-ji temple in present-day Osaka in AD 593.

Shitenno-ji was not only the first officially administered Buddhist temple in Japan but also included a hospital, a poor house, and a pharmacy that grew and cultivated medicinal plants. In this way, there is a long-standing template for Buddhist institutions serving as centers of care for the ill and dying.

Buddha Sakyamuni himself offers an original template for the role of the Buddhist caregiver. One of the Buddha’s epithets is the “Great Physician”—which refers to his core teaching of the Four Noble Truths examining the nature of suffering as dis-ease, its causes, its cure, and the course of cure.

There are also numerous examples of the Buddha and his close disciples guiding both ordained persons and laypersons through painful physical illnesses to illumination on their death beds; these stories serve as the primary Buddhist template for dying with a monk as a deathbed counselor (in Sanskrit, kalyanamitra).

However, two striking examples show the Buddha as much more than a deathbed counselor. The first is the story of the monk Putigatta Tissa, who had become gravely ill and had festering sores that emitted smells so foul that all his fellow monks abandoned him. The Buddha, upon finding out about his situation, not only admonished the other monks to care for him but also was the first to go clean his body, his robes, and his room and establish a plan for his further care.

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The second story, is about the laywoman Kisa Gotami whom the Buddha supported in her grieving over her dead child; by asking her to find a house that had not experienced death, the Buddha not only led her to a realization of the impermanence of life and the reality of death but also initiated her into a support community with all those others who had faced death.

Buddhism has many other ancient and contemporary examples of dedicated practitioners working to support both the dying and those who live on afterward in grief. The important point to make here is that many Buddhists today are drawing upon this long and deep tradition to find their own models for developing forms of Buddhist engagement that not only confront but also transform the many problems facing people dying in the world today.

Buddhism is documented as a tradition of tolerance, which affirms freedom in matters of belief, worship and religious practice. A basic principle of Buddhism is that caring for others is a source of happiness and that if you are self-centered and care only about yourself that is a cause for sadness.

So actually, the two things go hand in hand: your own happiness, your own satisfaction and being of service to others. It is what the Dalai Lama calls being “wisely selfish”. If you can generate compassion and kindness towards others you will have your own happiness.

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The Buddhist duty not to harm is seen as important in human relationships in general, but especially in medicine (in this case the care of the dying), where one is dealing with the vulnerable, those already experiencing the harm of pain and helplessness of disease and disability of terminal illness.

Indeed, the duty of ahimsa, when applied to those suffering from illness that cannot be cured, has a conceptual paralleled with Western ideas on palliative care. The idea is to ‘cloak’, alleviate, or lessen the distress.

This Buddhist ethical notion was expressed by Ratanakul as, “if one cannot remove it [harm or disease], our duty is to alleviate it, lessen it [i.e. relieve the suffering, care for and comfort the dying and maintain as best we can those beyond our capacity to cure] “.

Similarly, the philosophy of hospice/palliative care grew out of a response to the distress caused to the dying by the invasive processes of highly technologized, institutional, curative treatments. The aim of hospice care, similar to ahimsa, was to provide a less harmful approach which offered death with the dignity of caring designed to comfort, not to cure aggressively.

The central concepts in Buddhist discourse such as Karuna, Prajna, & Ahimsa, have been shown to have a similarity and compatibility to ideas in hospice/palliative care. The resemblance between these two discourses is further strengthened by the shared view of the significance of the dignity and importance of death.

Having studied the Tibetan literature on death and dying, I am totally convinced of the amazing understanding that the Tibetan understanding of dying can make. Buddhism is a metaphysic which points to an understanding of the significance of death as an essential ingredient in understanding the meaning of life.

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The intense significance attributed to the time of dying flows from the Buddhist idea of reincarnation. A calm and peaceful death can positively improve the next rebirth (or samsara), despite negative karma of past lives.

According to Rinpoche, such a privileging of the significance of the moment of death is predicated on the assumption that the last thought and emotion individuals have before death has an extremely powerful determining effect on their immediate future, their rebirth into a new life.

A core Buddhist belief is that the whole of life is a preparation for death: the mark of a spiritual practitioner is to have no regrets at the time of death.

The basic aim is to avoid any objects or people that generate strong attachment or anger in the mind of the dying person. From the spiritual viewpoint it is desirable to avoid loud shows of emotion in the presence of the dying person.

We have to remind ourselves that the dying process is of great spiritual importance and we don’t want to disturb the mind of the dying person, which is in an increasingly clear and subtle state. We have to do whatever we can to allow the person to die in a calm/happy/peaceful state of mind.

In Hospice care, as with Buddhist philosophy, the final days and hours of death are given particular attention, with opportunities provided for patients to experience their final moments in a way meaningful to them.

Tashi Delek!

Courtesy : Notes by Pam McGrath, Jonathan Watts and Yoshiharu Tomatsu

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Additional information :

Ceremonies and Funeral Rites for the Dead

The early Buddhists followed the Indian custom of burning the body at death. The Buddha’s body was cremated and this set the example for many Buddhists, even in the West. When someone is dying in a Buddhist home, monks come to comfort them by chanting verses to them, such as:

“Even the gorgeous royal chariots wear out; and indeed this body too wears out. But the teaching of goodness does not age; and so Goodness makes that known to the good ones.”

After death, while the dead person is being prepared for the funeral fire, the monks continue to chant in order to help the dead one’s good energies to be released from their fading personality.

The monks come with the family to the funeral. The family and all their friends give food and candles to the monks. Goodwill is created by these gifts and it is believed that the goodwill helps the lingering spirit of the dead person.

In Tibet the day of death is thought of as highly important. It is believed that as soon as the death of the body has taken place, the personality goes into a state of trance for four days. During this time the person does not know they are dead. This period is called the First Bardo and during it Lamas (monks) saying special verses can reach the dead person.

It is believed that towards the end of this time the dead person will see a brilliant light. If the radiance of the Clear Light does not terrify them, and they can welcome it, then the person will not be reborn. But most flee from the Light, which then fades.

The person then becomes conscious that death has occurred. At this point the Second Bardo begins. The person sees all that they have ever done or thought passing in front of them. While they watch they feel they have a body but when they realize this is not so, they long to possess one again.

Then comes the Third Bardo, which is the state of seeking another birth. All previous thoughts and actions direct the person to choose new parents, who will give them their next body.

In Japan a form of Mahayana Buddhism called Zen is practiced. Japanese Zen masters sometimes know when they are going to die.

Once master Hofaku called his monks together and said: “This last week my energy has been draining – no cause for worry. It is just that death is near.”

A monk asked: “You are about to die! What does it mean? We will go on living. And what does that mean?”

“They are both the way of things,” the master replied.

“But how can I understand two such different states?”

Hofaku answered: “When it rains it pours,” and then calmly died.

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Further Reading :

The Buddhist Hospice Directory

Article and E-Books on Death & Dying

Caring for the Dying and Bereaved

Death & Dying in the Tibetan Buddhist Tradition

Traditional Chinese Funeral Arrangements

Buddhist Funeral Rites in Thailand & other South East Asian Countries

The Sangha Metta Project

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