Many people in the baby boomer generation, who were raised in the Jewish and Christian faiths, have turned to Tibetan Buddhism and other Eastern religions. As this generation ages and enters hospice care, it will be important for health care providers to understand their unique needs at this sacred time in their lives.
Broadly speaking, Buddhist practice emphasizes a deep understanding of the mind, the importance of karma (cause and effect) and preparing for death. For Buddhist practitioners, the moment of death is considered the most important moment of life. Developing a calm and aware mind, acting virtuously for the benefit of other beings and abandoning harmful actions are the most important practices for preparing for death. If the Buddhist practitioner is able to stay relatively aware at the time of death, he or she can be reborn in what is called a “Pure Land” and continue on the path toward enlightenment.
The most important practice for Tibetan Buddhists and those supporting them at the end of their lives is called “Phowa”, or transference of consciousness. Phowa is aimed at assisting practitioners to be reborn in a Pure Land, where the cycle of suffering, or samsara, ceases.
An important concept in Tibetan Buddhism is the concept of the “bardo”, which means “in-between.” Every moment can be considered a bardo, or a transition to the next moment. In fact, our present life is a bardo between what came before and what will happen next. The bardo between this life and the next is called the “bardo of becoming” and is traditionally considered to be forty-nine days. It is a time of self-review and purification of negative acts, in order to be reborn if not in a Pure Land, then at least as a human being who has the potential of attaining enlightenment. It is said to be a very vivid and at times intense and frightening experience, and the practitioner’s spiritual community, or sangha, traditionally practices at the end of each week to assist the deceased’s journey through the bardo. The dying process is seen as a separation of the mind from the body, and it is the mind that continues into the bardo between this life and the next. Therefore it is important for the mind to be clear and calm at the time of death. It is said that whatever thought one dies with is the one that will return most powerfully when one reawakens in the bardo. Traditionally, it is said that it takes 72 hours for the mind to completely separate from the body and begin the journey into the bardo between this life and the next.
As death nears, clinicians and others should refrain from touching the body, especially the feet, because doing so may direct the patient’s consciousness downward to rebirth in a lower realm, where he or she cannot benefit others and have the potential for enlightenment. The patient may wish to be in the traditional posture of dying, lying on the right side in the posture of the “sleeping lion”, which is the posture in which Buddha died.
In developing a plan of care for Tibetan Buddhist practitioners, the hospice team and other caregivers need to consider the patient’s views on suffering, alertness and karma. The following are some considerations in developing a plan of care for dying Tibetan Buddhist practitioners:
1. Determine if the patient has a spiritual teacher (or guru) and the patient’s wishes for contact with the guru, and how to contact him or her.
2. Determine if the patient has a community of fellow practitioners (the sangha), and if so, how to contact them.
3. Provide a quiet space for sangha members to come and sit with the patient to meditate or do Phowa practice.
4. Help the patient arrange an altar with pictures of the guru and other pictures that are important to the patient for his/her practice, as well as any meditation tapes, prayer beads, etc.
5. Clarify issues and wishes regarding the use of pain medications. Many practitioners may believe that the use of pain medications may unduly cloud their minds, but unrelieved physical pain may do the same. As with all patients, this is a balancing act.
6. For the social worker and bereavement coordinator, understand any family dynamics issues — there may be unfinished business or at least conflicting feelings if the patient was raised in a different faith. The chaplain, in doing his/her spiritual assessment may want to do a “spiritual ecomap”, which is like a genogram, which is useful for families who practice multiple faiths. This will be more and more important as the baby boomer generation continues to age.
7. It is also important to facilitate discussions with family members about the patient’s wishes for end of life and at the time of death. Educate family members on the need for a calm and peaceful environment, and let them know that if they are too outwardly emotional, they may be asked to leave the room.
8. Clarify after-death wishes. Does the patient want the body to stay untouched for 72 hours in order for the mind to separate and enter the bardo? Sangha members and others may come to be with the body during that time to recite prayers and read from the Tibetan Book of the Dead. If on the other hand, the patient wants to donate his or her organs, that is totally acceptable, and most Buddhist teachers say it is a great way to generate good Karma. Cremation is traditional, but confirm wishes, and if they want to be cremated, and determine if they want a ceremony or viewing.
9. Bereavement support may also need to be modified — grieving sangha members may not want bereavement support in the first 49 days after the death, so that they can turn inward to help their fellow sangha member’s journey in the bardo. With respect to non-Buddhist family members, listen for and validate any feelings they may have in regard to their loved one’s Buddhist practice.
Smith-Stoner, M. (2006). Phowa: End of Life Ritual Prayers for Tibetan Buddhists. Journal of Hospice and Palliative Nursing, Vol. 8, No. 6.
Sogyal Rinpoche (1994). The Tibetan Book of Living and Dying. San Francisco: Harper San Francisco.