Caring for the Dying Buddhist,
and the Buddhist Caring for the Dying
by Sean Hillman
Religion Department
University of Toronto
April 2008
Introduction
Humans have always died. Many religious systems hold the view that the human life-span has been degenerating through the ages. The Hebrew texts assign the earliest patriarchs with life spans over 900 years, and amazingly show an exponential decay curve after the flood leading to an equilibrium of seventy years of age after 20 generations. ^1 Both Hinduism and Buddhism refer to our current age as a degenerate one. The "Kali Yuga" is the final phase before the world system ends. In this age, morality has hit a low point and results in shorter life spans. In Buddhist cosmology, lifetimes are shorter in comparison to those during more pure ages, times very long ago (such as those during previous Buddhas) and also during times not as long ago (during the time of our current historical Buddha Shakyamuni and thereabouts). For example, "in the age when [the] human lifespan was 20,000 years, [Lord Buddha] had been a Brahmin disciple of the [previous] Buddha Kasyapa"^2 and five hundred years after Shakyamuni Buddha, the great scholar-saint Arya Nagarjuna is said in some sources to have lived for 700 years. From the earliest time in Buddhist history, Buddhist practice and teachings have spent a great deal of time addressing impermanence and death. "In the present aeon-ending Kali-yug, [Lord Buddha] saw that by the time human lifespan has decreased to less that one hundred years, and people are increasingly tormented by poverty and strife, they are better prepared to grasp the truths of impermanence and dependent arising, and more receptive to the teachings of spiritual liberation."^2 The above excerpt shows that recognizing the reality of impermanence is a necessary component in the process of becoming liberated. In cyclic existence, the most visceral experience of impermanence is death. The Buddha told His cousin and attendant Arya Ananda that a Buddha can live for an indefinite period of time, and yet He still manifested the appearance of passing away. The texts often point to this as one of the twelve particularly crucial deeds the Buddha performed for our benefit. If a fully realised being such as the Buddha passes away, how can we unenlightened hope to escape this? Although death and dying is a constant throughout the ages, what is perhaps unique to our current time is the phenomenon of Buddhists being cared for by non-Buddhists. We have the existence of different types of institutions and organisations that provide end-of-life care: free-standing hospices, hospice outreach programmes where care is provided in the dying person's own home, nursing and retirement homes, long-term care facilities, hospitals and so on. As well, we find growing numbers of examples of Buddhists caring for non-Buddhists at death-time. These two phenomena, non-Buddhists caring for dying Buddhists and Buddhists caring for the dying, lead to two specific and important areas of Buddhist social engagement: 1) educating palliative caregivers who have Buddhist clients about the unique needs of Buddhists at death time, and 2) Buddhists actively caring for the dying as a practice. The latter often includes not only front-line, hands-on palliative care delivery, but also the activities involved in building resources to increase and ensure equal opportunity access to palliative care for those who need it.
To put end-of-life care into a Buddhist context, first we will first look at the Buddhist philosophical understanding of death. Next, although there is often cultural variety in how Buddhists deal with death, teasing out some common Buddhist practices at death will demonstrate the sensitivities needed by non-Buddhists who care for Buddhists in multifaith care-delivery environments. Finally, the attitude and inner exercises used in a Buddhist approach to caregiving will show the practical application of Buddhist mental training in the context of palliative care usually kept private within the mind of a practitioner. These three explorations, hopefully, will not only give a glimpse into the world of palliative care given to, and given by, Buddhists, but also be useful in general to anyone concerned with preparing for their own death and helpful to anyone who cares for the dying and bereaved.
Buddhist philosophical understanding of death
The Buddhist view of death actually begins with birth. When a being is born, they begin to move towards death and, inevitably, move progressively through the experiences of the four sufferings of birth, sickness, old age and death. The Four Arya Truths, the main summary of the Buddha's teachings and the content of His first public lecture, establishes the reality of suffering as the starting point for entering into the Buddhist path. This First Noble Truth is not a morbid dwelling on suffering but is presented in conjunction with the other three: that there is a cause to this suffering, there is an end to this suffering and there is a cause to the end of this suffering. Seeing all four components of this paradigm instills hope that there is true relief, and motivates the spiritual aspirant to seek this freedom and to stop creating the causes of pain. The ultimate goal of practising Buddhism is freedom from suffering, and much more. The definition of a Buddha, a fully enlightened being, is a being free of all mental and physical suffering who is both omniscient, able to directly perceive all objects of knowledge, and possesses infinite compassion: the wish to remove all of the suffering of all beings. It is no accident that freedom from suffering and omniscience abide together in the mind of a Buddha. All sufferings come from ignorance. Generally, ignorance is a wrong understanding of reality which sees things as existing inherently and independently when in fact they exist interdependently. This root ignorance (a delusion itself) breeds more delusions which in turn bring about all wrong actions of body, speech and mind and result in suffering. Conversely, removing this ignorance ends the chain of cause and effect just mentioned: no ignorance means no delusions and the wrong actions they cause, and thus no suffering result. When applied to the actions of sentient beings, this chain of cause and effect is what is referred to as karma (Skt: “action”) and its manipulation is required for improving the quality of life. The logic of karma is that all happiness comes from virtuous actions of body, speech and mind, and all misery from non-virtuous actions from these same "three doors." From the Buddhist perspective, karma is totally changeable. That we can change our future by what we do now, and purify every negativity imprinted on our mind from past misdeeds, induces hope. It is the reasoning which shores up the view that each of us has the potential to become free from all suffering. It is of crucial importance to note that sufferings, including death, are not seen in Buddhist thought as a "punishment." Karma is not controlled by any one, human or divine, but rather our experiences are the mere ripening of past actions. Considering the seemingly cold and calculating nature of the natural law of karma, one may see a reasonable basis for feeling that oneself or others "deserve" what they are getting. To be sure, the etymological root of the word "deserve," from the Latin deservire meaning "to be worthy of," supports this.^3 However, the saying "they will get what they deserve" in modern colloquial usage, although in essence reinforces the reality and efficacy of cause and effect, usually has a negative connotation. It implies that the agent will suffer and, therefore, does not accurately represent the “like cause, like effect” aspect of karma. The agent also deserves happiness as a result of past positive actions! To defeat another modern misunderstanding, instant karma is generally nonexistent, despite the wonderful song by John Lennon. Although extremely positive and negative deeds can have ripening results immediately, such as those actions directed towards powerful objects (enlightened beings or one's parents), for the most part, actions ripen long after the fact, often many lifetimes later. The "why me?" syndrome comes from the fact that beings may not be able to trace what ripens now to a cause in this life. Despite this, through logic, we do have a natural sense of the cause. It makes good sense that poverty is a result of greed, separation from loved ones is the result of causing others to separate, and so on.
Death is the transition time where the mind leaves the body and moves onto the next life and must be seen in the context of karma and rebirth. The scriptures subdivide death into various types, as shown in Buddhaghosa's "Visuddhi Magga" (Pali: “Path of Purification”) where this prolific 5th Century Indian Buddhist commentator distinguishes between timely and untimely death:
"Timely death comes about with the exhaustion of merit, with the exhaustion of life potential (ayu), or with both. Untimely death comes about through kamma that interrupts [other, life-producing] kamma.
"Death through exhaustion of merit, here, refers to the death that comes about entirely through the finished ripening of [former] rebirth-producing kamma even when favourable conditions for prolonging the continuity of the life-potential may still be present. Death through exhaustion of life potential refers to the death that comes about through the exhaustion of the natural life potential of human beings, which amounts to only 100 years…
"Untimely death refers to the death of those whose continuity is interrupted by kamma capable of causing them to fall from their place [on a particular level of being] at that very moment…or for the death of those whose continuity is interrupted by attacks with weapons etc., due to previous kamma. All these are included under the [term] interruption of life faculty."^4
In addition to the division of death into types, the process of death itself is divided into stages which are determined by the sequential dissolution of the elements. As illustrated by the chart below, each elemental dissolution affects particular bodily functions, are accompanied by external signs and symptoms and internal visions that the dying person experiences. This happens long before clinical death and can a very useful measuring tool. For example, at the dissolution of the earth element, even if the dying person is safely supported by caregivers and bed-rails, they still have the experience of falling.
The importance of death in Buddhist practice is shown in the story of the Buddha Himself, an Indian Prince who lived 2500 years ago and who was inspired to entirely dedicate his life to becoming fully developed for the sake of others after seeing four sights: an old person, a corpse, a sick person, and a mendicant. Like for Prince Siddhartha, exposure to and contemplation of death prompts an urgent motivation for practising spiritual methods diligently and without delay. A practitioner ideally will prepare for death by contemplating it as often as possible because it is the most crucial time in one's life, since (due to karma), the last moment of one's mind in one life will determine what type of experience and existence one will have next. The inevitability of death is the great equaliser. Whether beautiful or ugly, poor or rich, all must die. It is even possible to see death as the ultimate challenge, showing how well one has prepared. Rather than a solemn and mournful event, with a worn-out body naturally comes the time to trade in the old ride for some new wheels. Normally we don’t wear old clothes because they no longer protect our body. Likewise, a broken body is no longer an effective basis for the mind. It must have a new support. This process of leaving the body is also an opportunity to practice. It is a means of purification since any suffering we have, as the experienced result of a former misdeed, is the burning off of some of our accumulated bad karma. Death is one of five events (along with sleeping, yawning, sneezing, and sexual orgasm) experienced by ordinary sentient beings where they naturally, without training, catch a glimpse of the Clear Light nature of mind. As such, the stages of dissolution at death, which are accompanied by changing states of consciousness including the arousal of the Clear Light Mind, are utilised by the Tantric meditator to develop accomplishments on the path to enlightenment. Such practices can be done long before death as well, as a practice in and of itself as well as a preparation for impending death.
"Buddhist tantra...is aimed at stopping death...and transforming [it] into Buddhahood. This is done through a series of yogas that are modelled on the process of death...until the yogi gains such control over them that he or she is no longer subject to dying. Since these yogas are based on simulating death, it is important for the yogi to know how humans die-the stages of death and the physiological reasons behind them."^6
Death is a vital time where the difference between an ordinary person, a practitioner and a realised being is displayed. An ordinary person might enter into death out of awareness and terrified, however the practitioner at the very least has the conscious wish to not have this experience. The consciousness of both the practitioner and non-practitioner will linger in the body out of attachment. A high being, one who has achieved realisations of a certain level, will not only meditate at the time of death but also have the ability to consciously leave the body, as well as wilfully direct their rebirth. They also will linger in the body, but not out of attachment. This lingering of the mind in the body shows a distinguishing characteristic of the Buddhist exposition of death in relation to modern medicine. Clinical death is generally defined as vital signs being absent and, with the exception of determining brain-function for those on life-support, is the only thing required for a physician to note when pronouncing death. In the Buddhist exegesis the mind does not necessarily leave when vital signs are absent. Clinical death, although a sign of a particular phase in the process of death, is not actually death. The Tantric texts explain that when the mind leaves the body, actual death, a drop of blood comes from the nose and a drop of semen (for males) is emitted from the penis. Displaying the simple beauty of nature, these vital fluids coming together at conception coincide with the entrance of the consciousness into the womb, and their appearance at death indicates its departure.
Common Buddhist Practices at death
It is important to emphasize that what is taught by the Buddha and what is understood, or even accepted, by a Buddhist don't always match. Buddhism, as a practise of mental and emotional development that is based on logical reasoning and not a system of tenets, is a religion that promotes questioning and healthy skepticism. The Buddha encouraged His students to check out the teachings "as a metal-worker burns gold to remove impurities." In Buddhism, we find not a system of belief, but rather methods that bring about ever-increasing mental and emotional stages leading toward the direct realisations of reality and compassion. Everyone has the freedom to practise as they wish, so the ways that people’s personal practices manifest are quite diverse. Suffice to say, the overriding theme with death practices is to ensure a peaceful and virtuous state of mind for both the dying and everyone around them, including spiritual and health caregivers and the bereaved.
There are some religious practices that are applied, or encouraged, in all cultural forms of Buddhism and some that are done only in some traditions. Starting with those that are common to both the Southern and Northern schools of Buddhism, many practices at death are mental exercises and some of these, in spirit, are common to other faiths as well. Generating virtuous states of mind such as love and compassion can come from analytical contemplation or even the mere remembrance of such qualities and those who embody them. Purification practices can be performed inwardly as well with such practices as the Four Opponent Powers during which one engages in recognizing past mistakes, feels remorse, resolves to discontinue harm and applies a virtuous counter-action. The Northern school often uses visualisation and mantra recitation (Skt: “mind protection” in the form of mnemonic formulas) to purify as well. As it was for the Buddha, for any practitioner, one's own or other's illness can be used as an opportunity to generate empathy. Feeling such things as "may no one suffer like this," or “may I experience this suffering on their behalf” are powerful means to both strengthen concern for others and generate merit. The First Panchen Lama verbalised such feelings of exchange in his Guru Puja text (Skt: “Offering to the Religious Master”):
"As no one desires even the slightest suffering nor ever has enough of happiness, there is no difference between myself and theirs; therefore, inspire me to rejoice when others are happy.
"Cherishing myself is the doorway to all downfalls, while cherishing my mothers is the foundation for everything good; inspire me to make the core of my practise the yoga of exchanging self for others.
"Therefore, O Venerable Compassionate Gurus, Bless me that all karmic obscurations and sufferings of mother migrators ripen on me right now, and that I may give others my happiness and virtuous deeds in order that all sentient beings have happiness." ^8
As in the merit generated by developing empathetic concern, merit can be generated internally by any virtuous mental practice. Concentration (Skt: Shamata), analytical (Skt: Vipassana) and visualisation meditation are practices found in most Buddhist contexts. The Seven Limb practice, although some of which is Mahayana specific, contains elements that are found in most traditions and can be recited inwardly or outwardly. It includes taking refuge in the Three Jewels of Buddha, Dharma and Sangha, making offerings, confessing past mistakes, rejoicing at one’s own and other’s virtues, requesting Dharma teachings, requesting the religious teacher to remain and dedicating the merit for the benefit of all beings. Making offerings can be done mentally but is a very strong external practice in every Buddhist community. Offering can be seen in every environment, from temple to the hospice, and can go from being as elaborate as offering up pleasing objects for each of the five senses, to being as simple as arranging some flowers and fruit. The same goes for virtuous verbal recitation and chanting. Almost every Buddhist will engage in, and resonate with, some form of recitation of scripture, prayers and mantras. Most religions will have some form of virtuous verbalisation before, during and after the death of a member, but in Buddhism it is of crucial importance for helping the mind of the dying person. It is held in Tantric texts that the last sense faculty to cease to function is that of hearing. When the mind leaves the body, the in-between state (Tib: Bar-do) is also described as one where the being has a subtle body that has the same faculties as in life, and thus can also hear. For these reasons, recitations are used to both trigger virtuous states of mind in the transmigrating being, as well as to guide them through the stages of transmigration, both in aid of a smooth transition. The famous “Tibetan Book of the Dead,” written by the Indian pandit Guru Padmasambhava, is used in the Tibetan tradition to navigate the bardo being through the tumultuous experience of being in between bodies. The Tibetan tradition has appropriated some other practices from the Indian tradition as well, well-suited to the time of death. Transmitted secretly, Phowa (Tib: “transference of consciousness”) is a very popular Tantric visualisation exercise involving both the red Buddha of longevity Amitabha as well as a wrathful, red female Buddha in the form of a yogini, or female tantrika. One projects one’s consciousness out of the crown with the purpose of going to Buddha Amitabha’s Pure Land, which is a refined plane of existence where becoming enlightened is the main activity. This practice, like all death practices, can be done at any time and is not reserved for the time of death. A common theme in Buddhist practice, it is something to be mastered in life in anticipation for death. Growing out of the tradition of mentally exchanging oneself for others, found in the Indian texts of both Arya Nagarjuna and Arya Shantideva, Tonglen (Tib: “giving and taking”) is aimed at transforming one's own and other's suffering. Visualising other people’s problems as black smoke, one takes it into one’s heart where it becomes light that, in turn, radiates out to the afflicted. They are then imagined to be free of all problems. One might wonder how, and for what purpose, a person who is afflicted themselves would imagine taking on more suffering. The suffering is not absorbed, but rather is transformed, and the overwhelming emotional event that occurs is the arising of exceptionally strong compassion. It is safe to say that this practice in general, and at death-time in particular, is one that is held in the highest of esteem in the Tibetan tradition because of its ability to make remarkable mental changes with a very simple method. Lastly is another practice that, although having some precedence in the Southern schools, manifests uniquely and with great fervour in the Tibetan and the Indian tradition that it arose from. Life-extension practices, often tantric and very often involving longevity deities such as the tantric aspect of Amitabha known as “Amitayus,” are used both to ward off untimely deaths caused by interference from other karma that would interrupt life, and also to ward off death caused by the exhaustion of life-enhancing merit by generating more of such. One very simple life-extension practice is in the saving and caring for other beings, such as in releasing bait to save their lives or caring for the sick and dying, because the karmic ripening result of such practices is long life.
Despite Buddhism being a non-theistic religion, one which is based on self-development and personal responsibility, often times a Buddhist will call on the Buddha for assistance, despite the Buddha Himself saying that "a Buddha cannot remove suffering like rain washes away dirt; only one's own effort can remove suffering." Although the result will not be the removal of suffering of one by another, such a plea at least directs the mind towards the Buddha and is therefore necessarily, from the Buddhist perspective, virtuous. It is even said that feeling anger towards the Buddha is still virtuous because of the limitless beneficial power of the Awakened One.
A Buddhist Approach to Caregiving
In general, caregiving emanates from our natural predisposition to care for one another. Because of this, all traditions, both cultural and religious, have developed methods over time to address the problem of illness and death. Some of the activities of a Buddhist who engages in caregiving as a part of their practice will be similar, if not identical, to those found elsewhere. That being said, there are some strong themes found in Buddhist caregiving that of course grow out of Buddhist practise and philosophy in general, and Buddhist death-practices in particular. Unlike the Christian monastic tradition of nursing, Buddhist monastic caregiving has historically been reserved for monks caring only for fellow monks. This comes from the admonition in the monastic discipline texts (Skt: Vinaya) against monks nursing, or providing medical treatment for, householders. Perhaps due to the overriding influence of the Bodhisattva texts and vows in the Northern schools of Buddhism, which place a greater emphasis on helping others as much as one is able, there is a new historical precedent of Tibetan monks becoming doctors and Western monastics in the Tibetan tradition engaging in caregiving in every possible way, to people of every background, including non-Buddhist householders who are dying. There may be a greater accessibility for Buddhist caregivers to deliver care to non-Buddhists, especially in the area of hospice, because of a lack in very strong family and religious community organisational infrastructure found in traditional Buddhist communities. Another possibility is that the statistically high number of Tibetan Buddhists engaging in hospice and caregiving with the sick might be the result of the Tibetan community being one that is oppressed within their borders, and composed of struggling refugees outside. Thus lacking the cohesive individual and systemic infrastructure found in more stable Buddhist communities, there is a greater need for, and more opportunity to, help.
Musings aside, as with the common Buddhist practices mentioned earlier, there are some aspects to Buddhist caregiving that are shared by every tradition, and some specific to the Northern school. As a practicing Buddhist, the Buddhist caregiver will be engaging in personal, inner development in some capacity. They will already have within their mind a habit of developing, feeling and expressing love and compassion to some degree. However small, they have some sense of wanting the recipient of their care to be happy and free from suffering. They will also have spent some amount of time contemplating death and impermanence, and thus will have done some preparation for their own death. Working on one’s own feelings about death will naturally help others approach it more realistically and with less fear if they are at all influenced by the caregiver. The Buddhist caregiver has at least heard about the inevitability and unpredictability of death, if they haven’t realised it yet, and they may even see themselves reflected in the dying person. They may even go farther and, through analysis, come to realise that since they themselves must definitely die, there is essentially no difference between the dying person and themselves. This is a simple form of selflessness. Another common practice will be seen across the tradition, and that is equanimity. The caregiver who is familiarised with equalising their feelings towards those close to them, those distant or against and those of neutral status, will have an easier time having affection for the dying person they are caring for. If the Buddhist caregiver takes the advice of the Buddha to develop a concern for others as a mother does for their only child, one can imagine the potential for very deep concern being generated in the caregiver’s mind.
The Buddhist caregiver from a Northern tradition, or rather with a Bodhisattva intention, will have some unique aspects to their caregiving approach. For starters, although there are many examples in the Southern tradition of usage of the logic of infinitely regressing rebirths to prove the connection each being has with all other beings, it is highly emphasised in the Northern schools. So much so that texts, such as the Guru Puja quoted earlier, refer to sentient beings as “mother beings.” Seeing the dying person as related to oneself is a very powerful way to provide care that is both genuine and powerfully beneficial. What is perhaps more difficult is seeing every recipient of care as loveable! Here, logic again comes in handy for the practitioner-caregiver. Since every being has been loved by at least one person, their mother, they must necessarily have some loveable characteristics. With difficult and resistant people, to find these traits is the challenge of the Buddhists caregiver. In such a case, there are a few very powerful means that come from the Northern tradition of mind-transformation (Tib: Lo-jong). The first is the life-altering practice of seeing problems and negativity as useful tools to develop our own inner qualities. With this approach, no matter what is happening in the environment, or even within one’s own mind, one can see it as an opportunity to train the mind. This means that the more difficult the situation or person is, the greater the potential to develop good qualities! This has very far-reaching implications and completely destroys the idea that one needs to remove oneself from problematic circumstances in order to be happy. The practice of taking problems onto the path is peerlessly summarised in these lines from the Eight Verses for Training the Mind by the Tibetan scholar-monk Geshe Langri Thangpa, which state:
“I will learn to cherish beings of bad nature and those oppressed by strong negativity and suffering as if I had found a precious treasure very difficult to find.”9 Another Lojong technique is to not expect appreciation, sometimes referred to as “giving up all hope of reward.” This, along with the former practice, is not to encourage others to be disrespectful towards their caregivers. Instead, it places the caregiver in a strong mental position where the mind can remain content and happy regardless of how the caregiver is treated. Otherwise, the caregiver’s emotional state is moved according to the whims of the dying person, which means that their locus of control is without rather than within. As is commonly said about the difference between practicing in isolation versus in the marketplace, it is easy to not get angry on the mountaintop while locked away in retreat. It is very difficult to not get angry when confronted with other beings, and being able to maintain one’s integrity when in relation with others is the greatest testament as to the strength of one’s training.
Conclusion
We live at a time, and in a place, where caring institutions must engage in multi-faith care delivery. People of every type of background need care at the time of death, and likewise, those who provide such care are equally diverse. In keeping with this shift, Buddhists are receiving care outside of the traditional circle of their familial and religious community, from both Buddhists and non-Buddhists, and Buddhists are taking care of people of every possible background. Everyone is coming into contact with views and practices that are different from, and unfamiliar to, their own. Although there are more similarities than differences between the various cultural and religious traditions, such as the common effort to become better humans who are more loving and who develop an ever-increasing understanding of how things work, it nevertheless remains important not to negate fundamental differences. These do not need to be a bone of contention but can instead be a happy source of variety. It is good to recognise and accept these differences, but it is possible to even go as far as to enjoy these differences and learn from one another. In the field of caring for the dying, what is crucial is providing the best possible care, equitably, to all who need it. In general what is most important is not the manner in which this care is given, but rather ensuring that there is the deep wish for the highest benefit for the dying person, and those connected to them. In the words of Geshe Langri Tangpa: “With a determination to accomplish the highest welfare for all sentient beings, who surpass even a wish-granting jewel, I will learn to hold them supremely dear.” 9 This will beatify all caregiving activities and will especially help during difficult times.
References
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Bible Study Web Site
2. Akester, Mathew; Twelve Principle Deeds of Lord Buddha, Nagarjuna Institute, 2006
3. Harper, Douglas; Online Etymological Dictionary 2001
4. Buddhaghosa; The path of purification : Visuddhimagga; Shambhala Publications, 1976
5. Marilyn Smith-Stoner, RN, PhD, CHPN Phowa: End-of-Life Ritual Prayers for Tibetan Buddhists, Journal of Hospice and Palliative Nursing, Vol. 8, No. 6, Nov/Dec/ 2006
6. Lati Rinbochay and Hopkins, Jeffrey. Death, Intermediate State and Rebirth
in Tibetan Buddhism. Ithaca: Snow Lion, 1979
7. Tricycle Buddhist Review Fall 1997
8. Chokyi Gyaltsen, Panchen Losang; Guru Puja (Lama Choepa), Library of Tibetan Works and Archives 1979
9. Sonam Rinchen, Geshe; Eight Verses for Training the Mind Snow Lion Publications; 2006
By the merit of this research paper, and the accumulated virtue of the three times and ten directions, may all beings have boundless happiness, and especially for those who suffer from illness and the process of death and those that care for them, may they be free from all pain and may all be auspicious.
Sarva Mangalam
