End-of-Life Needs of Patients Who Practice Tibetan Buddhism
Practitioners of Tibetan Buddhism are rapidly increasing in the United States. The care they request at the end of life is different in many aspects from traditional end-of-life care. It is necessary for hospice professionals to understand these needs and prepare to care for Buddhist practitioners who may utilize their services. This article will describe how to use the nursing process to plan for their end-of-life care and suggest how each member of the hospice team can support the dying patient and bereavement needs of the family.

Buddhism, like other religions, is not a single entity. The two main traditions of Buddhism are the Theravadin philosophy practiced in Thailand, Cambodia, Laos, and other countries in Asia. The second is the Mahayana tradition practiced in many places throughout the world, including China, Japan, Vietnam, and Tibet. The Vajrayana subcategory of Mahayana, including the Tibetan Buddhist practices discussed in this article, are from this philosophical tradition. Although the Dalai Lama is the most recognized representative of Tibetan Buddhism, many very realized masters live in the United States and are accessible to hospice care providers. Because some requests from Buddhists are very different from those in the dominant culture, this article aims to create some dialogue with hospice nurses about these end-of-life needs. This article should be considered a beginning rather than a conclusive description of hospice practices for Tibetan Buddhists.

Tibetan Buddhism is one of the fastest growing religions in the United States. The major population centers of native Tibetans and newer practitioners are New York, Minnesota, California, and Colorado. However, many teachers have extended access to Buddhism throughout the country. It is likely that a center of practitioners is within reach of most hospices. An Internet search with the term "Buddhism" and the name of your city or county will give you an idea of the center closest to your agency.

Practitioners honor the Buddha or "Awakened One," who was born approximately 2500 years ago. He was "awakened" in India and traveled extensively throughout his life. Born a prince, he turned his life's work to attaining enlightenment when he realized the suffering of the people around the palace in which he lived. His teachings emphasize the pervasive suffering of sentient beings, and meditation as a means to tame the mind and emotions. There are variations in the teachings from one tradition to another. For example, the period for special rituals and prayers for the deceased has sometimes been reported as 100 days; however, in the Vajrayana tradition, the period is generally 49 days. Although this may seem like a subtle difference, it is highly relevant in the provision of individualized bereavement services in hospice.

In all Buddhist traditions, four fundamental contemplations compose the foundation of understanding and meditation: first, that a human rebirth is extremely precious and should be used to its highest spiritual potential; second, that all compounded phenomena are impermanent, and whoever is born is bound to die; third, that beings experience relative reality as compared to ultimate nature that arises interdependently with their own actions; fourth, that all beings suffer, and human beings suffer particularly from birth, sickness, old age, and death (Figure 1).



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Tibetan death mantra recitation. Data from Rinpoche.





Despite the clear acknowledgement of the suffering of sickness and death, the teachings of Buddhism offer no support for any type of physician-assisted suicide. Should a patient make a request to end his or her life, a teacher should be contacted immediately, in addition to incorporating the traditional hospice interventions for a situation that requires immediate psychological attention.

Since the notion of eliminating suffering is a central focus of hospice care, further explanation is warranted. A famous story told by Sogyal Rinpoche illustrates the basic belief about the universality of suffering and the inability to eliminate suffering from life. Krisha Gotami lived in the time of the Buddha. She was completely grief stricken after the death of her infant. She searched throughout her area for someone to restore her baby to life. A wise man told her the Buddha had the power to restore life. She went to the Buddha and asked that he restore her child to life. The Buddha indicated he would bring the baby back from the dead if she obtained mustard seeds from any house in the local village in which a death had not occurred. After searching the entire area, Krisha Gotami was not able to find any home where death had not occurred. When her search proved unsuccessful, she realized that suffering is universal and she should direct her efforts toward spiritual practice.

All Vajrayana practices are focused on training the mind, and it is considered wise to start early, especially in preparing for death. Chagdud Rinpoche, a Tibetan lama, used to say, "When you have to go to the bathroom, it's too late to build a latrine." Preparation for death is a central feature of the tradition, and recognizing that there is no certainty about how and when death will occur is implicit in all practices. Hospice professionals are experienced in supporting the needs of patients from many religions. Although many Tibetan Buddhists' requests differ from more common expectations at the end of life, they are well within the ability of hospice workers. This article will describe how to use the nursing process to plan for end-of-life care and suggest how each member of the hospice team can participate in order to support the dying patient and the bereavement needs of the family.

The most widely known and useful book on death and dying from a Buddhist perspective is the "Tibetan Book of the Dead", which describes each step of the dying process in detail. There are many editions of the text, with different styles of explanations, and it is widely available in a variety of printed and multimedia formats. Basic versions of this text can be read by volunteers or family members. If no one is available to read to the patient, tapes or CDs can be played as part of the plan of care.

The place to begin is the Tibetan Buddhist definition of "death". This definition, as described by Chagdud Khadro, is quite precise and based on the perception of subtle energies in the body (Tibetan rlung, usually translated as "wind" but ranging from respiratory breath to synapses). According to the Tibetan teachings, after the last breath, the subtle energies of the body draw toward the heart area. Then the subtle energy that maintains the white, masculine energy, received from one's father at the moment of conception and maintained in the crown of the head throughout one's life, drops toward the heart. The deceased has a visual experience like moonlight. Then the red, feminine energy, received from one's mother at conception and maintained below the navel, rises toward the heart. The deceased has a visual experience of redness, like the sky at dawn or sunset. The masculine and feminine energies merge and one swoons into unconsciousness, like passing into a clear, dark night. This is death, beyond resuscitation.

However, it is believed that the nexus of consciousness—at its most subtle level of cognizance and movement—can remain in the body for up to 3 days or longer, depending on the circumstances of death. If the body dies by accident or violence, if the body is undisturbed, or if certain rituals are performed to liberate it from the body, the consciousness may exit immediately. In these cases, the body is merely a corpse and nothing unusual needs to be considered. But, after a peaceful death, Tibetan Buddhists are exceptionally concerned about what happens to the body in the moments and days after death, and they try to ensure that the consciousness exits from the crown of the head.