Emergency Buddhism – impermanence: death and dying

Categories: Opinion.

Buddhism states that there is much to be gained from contemplating our deaths; the nature and inevitability of dying, and becoming at ease with the idea of our transient existence. The idea of Impermanence is central in Buddhism – that all phenomena, all existent things are transient. A conception of anything as permanent is delusion, for nothing is immutable. 

Indeed, for Buddhists, nothing has an independent existence but rather is interrelated and contingent upon all other things. And so it is for us and our lives. This too must pass. So in Buddhism all things are seen to have no independent, objective reality. The phenomenology that we call the world is actually an illusion that our mind regards as real and independent and concrete. 

Buddhists are taught that all things are transitory, that all phenomena come, and go. In respect of our own lives, this too can be seen to be in a constant state of flux. Within our lives there are undoubtedly periods of enormous change. These are referred to as Bardos, and the most important of these is surely the Bardo of Dying. It is therefore seen not as an end, but as a time of enormous transition.

Think about this: If something were to come to each and every one of us, without exception, why would we not come to terms with it? Yet many of us either don’t contemplate it at all or conceive of it with fear and denial. Some have even planned to freeze themselves to attempt to cheat death. The Dalai Lama, when asked about this concept, called it the greatest folly we can engage in. Surely this kind of denial is the very worst response we can make to our own or others’ mortality.

It is a useful exercise to contemplate the possibility of the dying state of a patient as one in which we must be deeply cognisant of their needs and their vulnerability. If consciousness is extinguished in death and nothing survives beyond it, then it does not matter much what we do for the dying. If, however, something of us survives death (as most of us believe) then we must act to facilitate a good death.

The case for letting the very ill die, without the intervention of resuscitation, can be expressed thus: What if our dying is a profoundly critical, transformative time in our existence? What if our existence continued in a different form, the after-death state? What if that transition were negatively affected by the traumas (physical, mental and spiritual) of our interventions? 

The reality is that we cannot be sure, in an absolute sense, what occurs for the dying person – what they can feel, perceive, or experience. Yet asking the question “Are we doing more harm than good?” is surely an important one. And there is increasing evidence, that even for the deeply comatose and unresponsive states, that there can be a very lucid level of awareness. 

Our time of dying is potentially the most confusing and fearful, or most wondrous, serene and beautiful event that we will ever experience. It would be tragic, indeed, if in this most important transformative time that the only thing we brought to a patient was more pain, disorientation and fear.

There is a saying, in the spirit of Buddhism, which perhaps might apply at times to the question of resuscitation in hospital and to give pause to our desire always to intervene. It goes thus: Don’t just do something, sit there! So perhaps we should sometimes simply sit there – perhaps holding a hand, or making sure of comfort and tranquillity in an environment which is so often frenetic and impersonal.


The Emergency Department may be filled with chaos, and indeed we are challenged by its highs and lows. Perhaps there are few workplaces where the ability to think calmly and clearly is so important. Indeed the stakes are often, literally, life or death. 

So I feel that the ability to remain undisturbed by the great dramas playing out before us is an essential quality of the Emergency Practitioner. It is a quality that most of us have engendered in our working lives through years in very challenging environments. 

Unfortunately for some, the quality of being undisturbed comes through being ‘shut off’ to the suffering around us. We become indifferent to what our patients go through, and simply go about our work with a sense of professional obligation, or self-righteous intellectual bravado, or defensiveness against litigation, or simply a kind of numbness. 

We have an alternative means of working with clarity and calmness of mind, without being indifferent to suffering. It is by being fully present in the moment, with open hearts and without judgement.

This article was originally published in Mandala. It is republished with permission. Brett Sutton is an Australian doctor who is the Regional Disease Surveillance Coordinator for the International Rescue Committee, Kenya & Ethiopia.

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