Here they met with Phra Paisal Visalo, a well-known Thai Buddhist monk of the forest tradition, and advocate for death literacy and spiritual dialogue around dying within Thailand.
They spent some time discussing the Buddhist perspective on issues pertinent to domains of palliative care, spiritual care, and living and dying well.
How would one support an unprepared terminally ill person during their last hours of life?
People surrounding the patient, their caregiver or relatives can help. They can be there to provide support, reminding the person about the good things in their life, things that they are proud of, and their values, to make them become more mindful.
Would meditation help?
Yes. Mindfulness breathing also helps. In some people, who aren’t able to control their breath, hand movements can make them become more focused and aware of their own body.
What if they could not move at all? Is there anything else that can help them become more mindful?
The mantra: “Buddho,” a touch, or light squeeze, can make them more focused.
How do we help people who are terminally ill or bed-bound, find meaning in their lives?
Remind them that it is an opportunity to ‘make merit’. Also remind them that they are not a burden, but that this is an opportunity for their children to ‘make merit’, to express gratitude to their loved ones. Sickness is also a great opportunity to contemplate the meaning of life and realise that life is full of pain and suffering.
What if someone questions: “Why does this happen to me? Why do I have cancer, have pain, or why am I, ‘dying horribly’?”
There are many things we cannot understand, such as past lives and also our present life sometimes. But the more important thing is how we react to the present.
We have to become more accepting of the present. The more we resist, the more anger and pain we have.
Be in the present. Don’t worry about the future or be attached to your healthier, happier past. Appreciate the present situation. Also appreciate the rest of your body, the parts of your physical body that are still functioning, not overly focusing on the organ that is not functioning well.
Some might ask what would happen after tomorrow, or after I die? They are worried about the uncertain future.
Be focused on the present.
Some of them can’t.
Why worry? You can enjoy life, food, why dwell on the future? Do not miss the precious present moment.
What do you think happens after death?
In Buddhism, if you perform good deeds, you will have a better future in your next life. Try to do good deeds and make merit in the present moment.
What is your opinion of relatives who can’t accept their loved one’s terminal illness, demanding that they have to live as long as they can, not taking account of the person’s quality of life at all?
From my experience, they mostly try to relinquish their guilt. They may not have been good towards their loved one before, so they try to make up with this during the terminal hours. In this situation, try to consider what would be the best for the person who is ill and also for the family members.
What about modernised technology that could prolong bodily functions, extending life via medications and machines; would you consider it futility?
I think it’s ok if it is for some purposes, to wait and say goodbye with someone or resolve some unfinished business. It’s not only about the medical technology, but also socioeconomic as well, and also political.
However, this is a phenomenon that may have started 40-50 years ago or so. Attitude changes reflect the underlying healthcare system. So we may need to change infrastructure and the system, so that people can have other options, besides just dying in a hospital.
Do you think this kind of situation is a failure of a religion?
More or less, yes. In the past, people have accepted death more easily, but people’s attitudes towards death have changed.
Is this also because people have become less religious?
How do you resolve this?
Just try to spread Buddhist messages about death.
So, on one hand people have become less interested in religion but more aware of death?
Yes. High tech and low touch. But the trend is changing to high tech and high (human) touch now.
Tell us more about your Peaceful Death Workshop
The Peaceful Death Workshop is a workshop to allow people to accept death as it is and make them understand that death is not as bad as they think, to help them die peacefully. The workshop is more a spiritual approach, rather than a religious one.
Are there other people holding other workshops?
Yes. Some adopt a more Buddhist approach, some less.
But yours is based on Buddhist beliefs?
Yes. But like I said, it’s more spiritually-based, so people from other religions can join as well. I used to hold one at a Christian church.
Moving on to another topic, what about your opinion, when some people find their situation unacceptable, and ask for euthanasia?
In Buddhism, pain is not meaningless. It’s not something we try to avoid. It has some meaning and we can make it beneficial. But I agree that some cases are miserable. Those who ask for euthanasia, to my knowledge, are mostly not concerned about pain. It’s about dignity, which is in your mind, in your head. They believe that they’re losing self-dignity, loss of who they were.
Some religions, Christian and Muslim, for example, prohibit suicide. What about yours?
According to Buddhism, suicide is an unwholesome action that comes from a negative mind state of mind, and will bring consequences later on.
Discouraged but not prohibited?
And you don’t see this as an alternative?
To me, it’s ok. People should have a freedom to choose. I don’t object, but as a Buddhist monk, I object.
So you find this acceptable?
Yes. But it has to come with a clear understanding of the consequence. For example, you have your own freedom of choice to drink alcohol, but you have to have a clear understanding about the consequence.
How do you do to talk about religions in a practical way? For example, people talk about religions and they think of sermon, they attend and appreciate it but there has been no difference after the sermon at all.
It also happens in other areas as well. Old habits die hard. People read about healthy foods, but eat junk food anyway. It’s their way of life.
How do you propose to change it?
I myself conduct workshops that try to change the behaviour of people, to change their thinking and learning processes. We can help some but not all. I also find that experiential learning is better than learning by reading. Our head, heart, hands are joined together. This is more likely to change people’s behaviour.
Is this experiential learning part of your workshop?
Can this knowledge be transferred into another field?
Yes. Through practice and reflection. Without both, knowledge will disappear.
What about in other religions?
I don’t know.
How often do people come to you to talk about death?
People in Thailand don’t usually ask these kinds of question but there are some people who keep coming, wanting to know more.
For people who are working in palliative care, do you have any advice for them, about how to protect their own minds? Or some advice regarding managing work stresses and compassion fatigue?
As I told you, head, heart and hands are important. Knowledge, compassion, mindfulness and empathy will help you with this process.
What advice would you have for those supporting people who are expressing regrets from their lives, or are expressing remorse and distress as they face their own deaths?
Try to give them a chance for forgiveness either directly or indirectly. Writing or thinking about it also helps. The forgiveness ritual (Ko-Kamah ritual) also helps.
What is your opinion regarding palliative sedation?
I think mindfulness is the best choice and sedation is the second best.
Sedation is from our (doctors’) side, but the mindfulness is from theirs and when we perform sedation, we don’t always have their consent. Do you think it’s a bad practice?
No. I find that if someone has been very restless or in intractable pain, they will have a negative mentality, and might end up in hell. To me, sedation helps to prevent this. But this is just my opinion, other schools or monks might oppose sedation. Some people might need sedation on a certain level, but first it’s best to relieve their suffering.
Will palliative sedation suppress their underlying suffering, spiritual pain or psychological distress, merely masking it from surfacing? Also, is there a negative karmic connotation for the clinician that administers terminal sedation?
Before sedation, we have to make sure that it’s not mental or spiritual pain. Sometimes it manifests like a physical pain. If we’re sure then I think sedation is a good choice, and at the same time we have to make sure that they have said what they wanted to say otherwise they will miss the chance. As for karma, it’s about your intention. If we’re certain that it’s about physical pain, and our intention is to relieve suffering, it’s not negative karma.
What about conspiracy of silence, of not disclosing the truth to patients within the family? (Particularly in Thailand, since some families won’t tell their loved ones that they are terminally ill, believing that it make them lose their will to live).
I think it’s about the relative of the caregiver denying death. So it would help if doctors or other healthcare providers use their time to build trust with the family, to make them see that their loved one’s time is short and precious. If they could see that, the patient can then express their last wishes and resolve unfinished business.
To find out more about Phra Paisal Visalo’s teaching, please visit his website.
Part One of this interview was published on ehospice in 2014.
Dr Suresh Kumar is Technical Advisor of Institute of Palliative Medicine, Calicut, India, Dr Tharin Phenwan is a medical doctor with a basic certificate in palliative medicine, and Camille Doyle R.N. holds a Graduate Certificate Health Promoting Palliative Care, Graduate Certificate in Palliative Care, and is currently completing Masters in Spiritual Care, Masters in Nurse Practitioner.