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Spiritual Care for the Dying
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.

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 ones mind such that it does not suffer along with ones body.

The 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. Experiences from other real-life cases have also been drawn on to create the following guidelines.

1. Extending Love and Sympathy

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.

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. 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. 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.

2. Helping Patients Accept Impending Death

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. Patients acceptance of their impending death involves a process that takes a long time

There could be several reasons for anxiety and lack of acceptance by the dying besides the fear of death. They could have some unfinished business or other worries. 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.

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 or whether they would like doctors to refrain from using these measures and let them gradually pass away peacefully.

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. There are many ways to help incline patients to recollect these things, through sacred objects or pictures of respected spiritual teachers to serve as aids to recollection, chanting or praying together, reading dhamma books out loud to the patient, and inviting monks to visit and provide counseling.

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.

4. Helping Patients Settle Unfinished Business

One major cause of suffering that prevents people from dying peacefully is unfinished business, such as remaining work or responsibilities, seeing someone for the last time, and letting go of grudges or guilts. 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.

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.

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, beginning by speaking of the dying persons 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. A feeling of deep attachment can be experienced by people even if they do not have any lingering feelings of guilt in their hearts. 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 family, friends and legacies will be taken 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. Of all attachments, there is none that is as deep 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. But for people who dont believe in heaven or rebirth, death becomes the most terrifying thing.

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. 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.

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 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 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. 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 is another way to bring about a peaceful atmosphere.

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. And once we realize that we really do not have such a thing as a self, then there will be no me that dies. Dying itself becomes just a change of state from one form to another, according to causes and conditions.

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, 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 persons 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

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 patients life, even though when people are close to dying, what they actually need the most is spiritual help. Thus, 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 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 patients home.

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