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The Seven Factors of a Peaceful Death:
A Theravada Buddhist Approach to Death in Thailand

Ven. Paisal Visalo
Buddhika Network for Buddhism and Society

 

Buddhist Care for the Dying and Bereaved

Edited by JONATHAN S. WATTS and YOSHIHARU TOMATSU

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Care for the Dying in Thailand

In the past, most people in Thailand died in their own houses. When a person was going to die, a monk or a group of monks would be sent for in order to guide him or her to a peaceful death. Monks would perform Buddhist chanting or remind the dying of the Three Refuges of Buddha, Dharma, and Sangha as objects of veneration. The dying, with the help of relatives, would perform their last act of merit-making by giving offerings to the monks. In some parts of the country, such as the Northeast, the dying would hold flowers to pay homage to the Buddhas sacred tooth relic believed to be located in heaven where they were hoping to be reborn. If the dying was conscious enough, they would sit upright, leaning against a pillar, and meditate or chant to calm the mind.

A peaceful mind at the moment of death was very important for Thai people since, according to Buddhism, it will lead to beneficial next life; whereas a negative state of mind will contribute to a harmful one. The atmosphere around the dying, therefore, was to be peaceful. Cousins would gather around the dying, reminding them of their good deeds in the past and helping to relieve them of all anxiety. Some would ask forgiveness from the dying or vice versa. Everyone was discouraged from crying near the deathbed.

However, nowadays the pattern of dying in Thailand has changed. There are more industrial diseases that require long and intense hospitalization. Thus, there is an increased need for palliative care, and this changes the sense of how to care for people in general. There is an increased focus on terminal care, and so spiritual and psychological care have become more important in the hospitals. The concept of holistic health (physical, social, psychological, and spiritual as defined by WHO) is becoming part of the mainstream and part of actual Thai law. Many hospitals are speaking about these four aspects, which are being put into practice in large hospitals and university hospitals, especially for the terminally ill. However, in practice, it is still difficult to provide such care because of a lack of understanding and skills among staff.

Palliative care is still centered in the hospital in Thailand, not in the home or in hospices. Some hospitals have programs for psychological and spiritual care without religious connections, especially for children. At Chulalongkorn University Hospital, there is the Wishing Well program where children are granted their last wish. Other large hospitals have encouraged some religious support by providing space for nurses or monks to do this work, since doctors cannot do it.

In Thailand, in the ICU or in a regular room, monks are typically invited to come and to provide the opportunity for the patient to make merit (Thai. tan-bun) or perhaps to guide the patient in meditation. Nurses also have begun to take charge in offering psychological and counseling care. Such counseling often involves calming the patient or helping them have reconciliation with their family. Nurses may also be active in getting the family more involved in supporting the patient, which helps the family with their guilt in not being able to do more. Nurses may even offer spiritual care, like meditation.

Recently, there is more encouragement for doctors and nurses to support home care and be involved in home care, especially pain control. Pain care management skill is important so as to enable patients to maintain clarity without pain. Doctors may also predict what physical stages will come next. For example, a friend of mine died at home from breast cancer a few years ago with good home support from her doctor. At a certain point, her doctor told her that her breathing would get difficult, so then she began to change her meditation method away from mindfulness with breathing (anapanasati).

In Thailand, there are only a few hospices. They are still not so popular, because the Thai health system is still centralized, and there is not the appropriate infrastructure for them. Today, only the rich can afford to pay for a hospice. The most famous and largest with over two hundred beds is the Dhammarak Niwet Hospice established in 1992 and located on the grounds of Phrabat Nampu Temple in Lopburi, a few hours north of Bangkok. However, this hospice is specialized for destitute and abandoned AIDS patients. There are also a few Christian and private hospices, but in general home care is more popular than hospice care.

After the success of the Dhammarak Niwet Hospice, other temples have begun establishing hospices. However, they are now decreasing, because it is quite difficult to maintain them. Monks still do such work, but on a small, temple by temple level, mostly in the countryside and mostly through home visits. In some ways, this a continuation of their old, traditional roles. However, this tradition is weakening as monks tend to focus now more on funerals, even in the countryside.

In hospital settings, medical professionals and monks unfortunately do not collaborate well. There is a gap between doctors and monks. Doctors do not know how to treat or talk with monks properly. Monks are welcomed into hospitals as ritualists or advisors but not as part of the care team or the advising medical team. They have to be invited first and are not part of the system. They are not on call, but they do often visit hospitals during festival seasons. Furthermore, not many monks are interested in this kind of work. More and more, monks are being seen as harbingers of death, so some people feel uncomfortable when they appear. In this way, families are actually better than monks in providing spiritual guidance since they have a close, personal relationship with the patient.

The End-of Life Care Network established in 2004 coordinates between the personnel of various hospitals and other concerned people like monks to amass and share knowledge on how to take care of the terminally ill. Every two months, this network holds a study session to develop skills and knowledge. It is hoped that this network can help promote change in the medical system for more spiritual care for the dying and in the curriculum in the medical schools. Spiritual care training is not provided by medical schools, but this network has begun to offered such training for nurses of all units and some doctors. There is increasing demand but limited human resources in this area.

Buddhist Spiritual Care for the Dying

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 a 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. This is 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. 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 ones mind such that it does not suffer along with ones 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 Pali Buddhist Canon, 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, and eventually were able to realize high levels of attainment. Some even became fully enlightened.

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

1. Being ill and close to dying is a time of crisis and physical disintegration, yet at the same time it can also be an opportunity to liberate the mind or elevate ones 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.

2. The Buddhas teachings on illness and dying can be classified into two main parts:
1) Incline the mind to have faith in the Three Refuges (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 applicable to the present day. This article will show how these principles put forth by the Buddha can be adapted 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 feel 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 dont 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.

For example, when two volunteers from my network came to visit a patient, they found him screaming out of suffering from the pain in his abdomen. They asked if the patient would allow them to receive (or share) some pain from him. After getting permission, they asked the patient to close his eyes while they touched his body gently with their hands. They began visualize his pain as grey smoke emerging from his body and entering theirs before being transformed into a white ray emitting back to him. After about five minutes of this compassionate practice, the patient said that he felt much better.

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. However, 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 a relationship 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 patients 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. However, according to a survey done of patients in Thailand, the majority responded that they would rather be told the truth than be kept in the dark. 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. However, 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 to understand them, they will feel safe enough 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 patients condition takes a turn for the worse is also very valuable.

In Thailand, the patients right to information is not respected very much. Many cancer patients are not informed about their real situation, because their family or relatives are afraid that the patients situation will worsen. Since the doctor wants to have good relationship with the patients relatives, he or she has to conform to their wishes. In Thailand, relatives have a big say in dealing with the patients situation. Informed consent is therefore not practiced when two volunteers from my network visited. However, this right is becoming increasingly known and exercised by patients, especially those who have a high level of education. Furthermore, living wills and advance directives by patients are now legal and are being promoted in Thailand.

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 a 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, just maintain their condition, and let them gradually pass away peacefully. Many times patients do not decide in advance, because they do 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 patients life. This often causes much suffering to the patient, with the only effect of prolonging the process of dying without helping to improve their quality of life at all, and at the same time wasting a large amount 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 Three Refuges. These can be thought of as something virtuous or sacred that the patient can worship. The Buddha also had them re-establish themselves in the observance of morality (sila) as well as recollect the good deeds they had done in the past. There are many ways to help incline patients to recollect these things. For example, you can:

- Place in the patients room a Buddha statue, other sacred objects, or pictures of respected spiritual teachers to serve as aids to recollection
- Invite the patient to chant or pray together
- Read dharma books out loud to the patient
- Play recordings of dharma talks or chanting
- Invite monks, especially ones the patient has a connection with, to visit the patient and provide counseling.

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

Another way to incline the patients 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 ones children to be good people, taking care of ones parents in a loving way, being faithful to ones spouse, being helpful to ones friends, or being dedicated in teaching ones 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. At this time, it is becoming clear to them that they cant take any of their material wealth with them when they die. It is only the merit they have accrued through good intentions and actions (karma) that they can take with them.

Everyone, no matter how rich or poor, or what mistakes they have made in the past, has to have done some good deeds worth recollecting. 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. However, 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.

One example that I learned from our network concerned an old terminal cancer patient who was suffering episodes of pain that need to be treated repeatedly in the hospital. In his last month, a niece came to visit him almost every day. Each time he asked the grandpa about his life in the past. The patient was delighted to speak about his heroic role in the World War I and his life as honest civil servant. Finally, they began to talk about the impermanence of life according to Buddhism. In his last days, he seemed happy and finally died in peace. It was remarkable that during his last month he never suffered from the pain that rushed him to hospital as before.

Another example was policeman who was trembling despite being in a comatose state. Witnessing this situation, his wife burst into tears, but the attending nurse warned her that her crying would make thing worse. She was encouraged to speak good things about her husband. After composing herself, the wife told her dying husband that she was proud of him as good policeman and loving husband who eagerly helped her to sell food in the market. His son also told him how a good father he had been. Gradually, the patients trembling calmed, and he died in peace.

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, they will cause the patient to suffer, feel heavy-hearted and push away death, thus becoming unable to die peacefully and resulting in an unfortunate rebirth. A 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. These are some general guidelines that can help in such situations:

- If they have remaining work, responsibilities, or a will that has not been settled\, 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 criticize 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.

Often times the person that the dying patient seeks 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 their forgiveness first and telling the patient they do not bear any ill-will towards them for their past mistakes. However, in order to do this, the person must first let go of any pride or anger they may feel. By making the first move, the person opens the channel for the dying patient 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. However, once the patient has been able to apologize 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. However, oftentimes children do not dare to open up to their parents even when they are about to die. Partly, this is 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.

Asking for forgiveness does not actually 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 apologize 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 a dying patient ought to ask for forgiveness from them while they are still conscious and able to understand. This provides the opportunity for dying patients to 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 persons bedside and select a representative to speak for the group. They can begin by speaking of the dying persons virtuous qualities and the good things they have done for their descendants. Then they can ask 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. A reason for such refusal can be that they are still deeply attached to certain things and unable to be separated from them. These things could be children or grandchildren, lovers, parents, work, or the entire world with which they are familiar. 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 advised that after helping them recollect and have faith in the Three Refuges and then establishing them in goodness of their past deeds, the next step is to advise them to let go of all their concerns. 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, 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 deeply and firmly rooted as attachment to self. In some peoples 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. However, for people who dont 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. However, 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 identifies 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. However, 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. In the past, there were many people who died peacefully in an upright sitting posture, 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. The method that is widely suggested is the practice of mindfulness of the breath (anapanasati), which helps to calm the mind and keep it from identifying with the pain.

It should be noted that a large amount of pain is caused by anxiety, fear, and other negative emotions. Pain can be reduced if the patient is thus relieved of these emotions. In one example that a doctor related to me, a patient was agitated during the terminal stage of his death. The painkiller worked for only ten minutes, after which he began to tremble again. Since he did not know how to do meditation, the doctor offered to guide him in total relaxation. He asked the patient to be aware of each part of his body, starting from the feet and moving to the head. He guided him to be just aware and to relax with the help of light music. After thirty minutes, he became peaceful, both in body and emotion. The doctor also taught his relatives how to help him do this exercise. With this practice, he became more responsive to the medicine, requiring smaller doses to help calm him.

I know of another case in which a woman got cancer. She was from a modern, urban, Chinese Thai family, and in her last stage also suffered from toxins in her liver. She declined to get further medication and decided to go home for her last period of life. According to the doctor, she was very likely to be unconscious and in pain during her last days. However, on the contrary, she retained her awareness until the last hour, because she tried to keep her mind in a positive way with the help of her relatives, as related below.

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. This includes a peaceful social environment as well as physical, such as a peaceful family. A quarrelsome or deeply mourning family is not helpful. That is why some people choose to die in their homes.

For example, a good friend of mine named Supaporn who had developed terminal breast cancer refused hospitalization and eventually decided to die in her home. She prepared an atmosphere in her home that was conducive to a peaceful death. She had cultivated a beautiful garden that could be appreciated from her bed. In her room, she had a Buddha image and pictures of her great teachers like Buddhadasa and Maha Ghosananda. Sometimes, she also listened to nice, spiritual music.

With regard to a patients spiritual well-being, the least that family, friends, doctors, and nurses can do is to help create a peaceful atmosphere for them. They should 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 can try to keep their minds in a healthy state - not sad or depressed - this will already be a great help to dying patients. The states of mind of the people surrounding the dying patient can affect the atmosphere in the room and the persons mind. The human mind is sensitive; it can sense the feelings of other people even if they dont 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. When put together, Buddho is the recitation of the Buddhas name. 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 many painkillers. Supaporn is one who preferred clear awareness over painkillers. Her regular practice of meditation helped her to withstand the pain without painkillers, much to the surprise of her doctor.

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 patients mental state.

In the aforementioned case of the woman from a modern, urban, Chinese Thai family who died of cancer, she was actually more devoted to Theravada Buddhism than Chinese Buddhism. However, her mother liked the Chinese chanting of Amitabha Buddhas name (namo ami-to-fo). It had more of a musical feel than what Thais typically chant at death, which is refuge in Shakyamuni Buddha (namo tassa bhagavato arahato samma-sambuddhassa). Chinese will typically chant to the Medicine Buddha up until the last possible moment, and then switch to Amitabha Budhha when death has become certain.

Until the very end, she retained awareness. In the end, she showed no signs of pain or struggle, and much of this was through the help of her family. They reminded her of all the good things she had done in her life. In the final hour, her family chanted Amitabhas name in Chinese one thousand times, and she passed away almost unnoticeably, like a candle. This shows what the family can do without the help of monks, and this is why our network has started to hold workshops for nurses, doctors, and families so they can do this process by themselves.

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. However, 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, then death will become something that is natural. Finally, 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.

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

Even if one has said goodbye to someone when they were still conscious, it is still useful to say goodbye again just before they die. The important thing to keep in mind is that being able to say goodbye and to guide the dying persons 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 in Thailand, 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 patient 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. Thus, they tend to support the use of all available forms of medical technology to prolong a patients life, even though when people are close to dying, what they actually need the most is spiritual help. Most relatives want the doctor to do whatever possible to prolong the life of the patient, because they think that this is the only way to help them. However, once they know that there is better choice, which is to help them die peacefully, most of them prefer this choice.

If the patients condition worsens to the point where there is no hope of recovery, family members ought to give greater consideration to taking care of the patients state of mind than of the body. This may mean asking others not to crowd around the patient, allowing them to die peacefully, surrounded by close family and friends who join together to create a wholesome and positive atmosphere that will help lead them to a good rebirth. In general, the place that is the most conducive to creating this kind of atmosphere tends to be the dying patients 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.

Six years ago our network initiated The Facing Death Peacefully Project, which aims to educate Thai people about peaceful death. Books and other media have been produced to give advice about this topic. It is interesting to find that many hospitals need such advice. Our workshops on peaceful death are now in much demand by many hospitals all over the country.

Conclusion

When death is imminent, nothing is more important than peaceful death. Whatever success one earns in this life, however, it does not guarantee a peaceful death. Only the appropriate quality of mind can enable one to die peacefully. Influenced by a materialistic worldview, people tend to focus on the physical aspects of illness, while ignoring the emotional or spiritual ones. Such an approach tends to increase the suffering of the dying and diverts them from a peaceful death.

A peaceful death is possible when the dying are embraced by love and relieved of anxiety. It is possible when one lets go of everything or focuses on the goodness either in ones life or as represented by the sacred beings. Living a decent life also contributes to a good death. Life and death are actually one and the same matter. We will die in more or less the same fashion as how we have lived. If we live in ignorance, our final moment will likely be spent in agony, without any sense of peace and mindfulness. However, if we constantly cultivate merit and self-awareness, we should be able to pass away peacefully, being in a state of mindfulness until our last breath.

Health care systems should be geared to support a peaceful death, instead of prolonging life at all costs. Saving life is important, but when that mission is impossible, no other choice is better than facilitating a peaceful death by promoting an atmosphere conducive to spiritual practice and spiritual assistance to the dying. Hospitals should not be only the theatre to fight with death, but also the place where one can be at peace with death.

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