Karuna Hospice Services

In the 1996 census there were 199,812 Buddhists living in Australia (ABS, 1996). Fourteen percent of Buddhists in Australia are Australian born (Adam & Hughes, 1996). The majority of Buddhists have come from Asia, particularly Vietnam, Cambodia and Laos with the single largest ethnic group of Buddhists being those from Vietnam. Chinese Buddhists also comprise a large proportion of Australian Buddhists, coming from many countries including Singapore, Hong Kong, Malaysia, Taiwan and the Peoples Republic of China. A smaller group of Buddhists of the Theravada traditions have come from Sri Lanka, Burma and Thailand and there is also a number of Tibetan Buddhists. BuddhaNet, an Australian Internet Buddhist information service has a list of 167 Buddhist societies operating in Australia.

1. General Beliefs
Buddhism was founded on the Indian subcontinent around 560BC. Its founder was an Indian prince, Siddartha Gautama, who renounced his wealthy life after encountering sickness, death and the suffering experienced by his people. Through meditation, Guatama discovered the four noble truths. That the nature of existence is suffering, the cause of which is karma, produced by our deluded thoughts, actions and ignorance keeping us trapped in samsara (the cycle of death and rebirth). The cessation of these causes of suffering results in permanent peace (nirvana) and the path to cessation (the eightfold path) is to develop true understanding of the interdependent nature of all phenomena and to conduct ourselves in a way which is compassionate rather than harmful to others (Gyatsho, 1965). The components of the eightfold path are: Right View, Right Intention, Right Speech, Right Action, Right Livelihood, Right Effort, Right Mindfulness, and Right Concentration.

The cessation of all suffering is the goal of Buddhists spiritual practice. Meditation is an important component 0f this practice, although some traditions give it higher importance than others. While there are many forms of meditation, the main purpose is to train the mind, bringing it under control, clearing it of impurities, and opening it to wisdom, awareness and observation. This training then influences how we live our daily life. In general a Buddhist is trying to live with correct understanding and correct moral action. The tenet of the “middle way” or moderation in everything is also an important part Buddhist philosophy and practice.

Known as Buddha after attaining enlightenment, Guatama’s teachings (Dharma) were passed down orally. By emphasising different aspects of the original teachings different lineages have developed. These different lineages spread to other countries, where the existing cultures influenced the form of practice and the aspects that were taught. Buddhism now consists of two main schools. Theravada, or Hinayana, emphasises the monastic tradition and holds that the path to Nirvana, is an individual pursuit. This tradition predominates in Sri Lanka, Burma, Thailand, Laos and Cambodia. Mahayana, the more liberal tradition, holds that the belief of its followers will in time encompass the whole of humanity and lead to its salvation. This tradition predominates in China, Taiwan, Korea, Vietnam, Bhutan and Nepal. There are also major schools within this stream, such as the Vajrayana tradition found in Tibet and the Zen tradition of Japan (Klein, 1991).

2. Perceptions of Death and the Terminally Ill Patient.
Buddhist’s needs at the time of death will vary depending on the particular lineage and culture of the person, and where possible one needs to learn from the dying person themselves what environment, rituals, practices and people they would personally find supportive. The many rituals surrounding death are closely linked to the cultural context of particular adherents of Buddhism. There is no uniform set of procedures or rites. Particular practices that are adhered to by one tradition and culture, may not be universally adhered to by all Buddhists.

However there are some common elements of belief for Buddhists that may help in developing an understanding of a Buddhists needs at death time. Buddhists believe life is a precious opportunity to progress on one’s spiritual path. It is an opportunity to forgive, to purify past mistakes and to increase one’s familiarity with positive qualities until they become part of one’s nature. Therefore Buddhists would usually not contemplate euthanasia but attempt to utilise all situations they encounter as opportunities for spiritual development right up until death occurs.

Another fundamental Buddhist belief is that all phenomena including one’s own body, mind and life are impermanent by nature, changing moment to moment. This concept is frequently meditated upon and leads to an acceptance of death. Death is merely the separation of body and mind and the mind is believed to continue on and to take rebirth in a new body. Nevertheless most Buddhists will still experience the fear and pain associated with death and loss.

Followers of the Mahayana tradition believe that the process of death involves eight stages. The body becomes powerless, sight becomes unclear and eyes immovable. Liquids in the body dry up and hearing ceases. The body becomes cold and inhalations grow weak while exhalations are strong. Breathing stops. The conceptual mind becomes more subtle and the dying person experiences visions, white, red, dark and then a vision of clear empty space. The consciousness then leaves the body and this is considered the actual time of death. A sign of final death is red liquid coming from the nostrils. All heat leaves the heart centre and the body slumps. The complete process may take a day or more after the breathing stops (Mullin, 1986).

3. Procedures Prior to Death
A) Notification of the condition:

While there is no universal requirements of notification of impending death, notification should take place as soon as possible after a prognosis is reasonably certain. This will enable both the patient and their family to prepare. The patient may want to begin the spiritual practices in preparation for the death process as soon as possible. In some traditions, particularly the Vietnamese, there is a strong desire for the person to die at home surrounded by their family (Crawford, 1961). Thus if a prognosis of death is imminent the family will wish to know promptly in order to make suitable preparations.

B) Role of the family:

The cultures of many Buddhist countries contain a strong sense of family. Buddhist teachings emphasise compassion and care and a loving duty towards elders. Thus it is probable that the families of the dying person will want to aid in their care. It is not uncommon for some family members to be continually by the bedside (Crawford, 1961). These needs should be accommodated where possible for the peace and comfort of the patient. However, practices may vary and some may prefer to be in solitude in order to meditate. The patient should be consulted to find out which are the preferred conditions.

C) Spiritual needs:

The state of the mind of the dying person at the moment of death is of utmost importance since it is believed to influence the rebirth process. Many Buddhists will want to spend a great deal of time in spiritual practices such as meditation in preparation for the time of death. It would be appreciated if staff could allow them this time without interruption (Trutner & Trutner,1990). To assist in spiritual practices the patient may wish to set up a simple shrine to have an image of Buddha, or other spiritual objects, in view. They may also wish to burn incense or play spiritual music (Kirkwood, 1993).

The dying Buddhist or their family may wish to have an ordained Buddhist (Sangha) or spiritual teacher perform blessings, or chant over the dying person. This is believed to help the patient achieve a peaceful state of mind and to remind them of their spiritual practice. It is of great importance in some traditions (Khadro, 1996). The basic principle, when considering the spiritual needs of a dying Buddhist, is to aid the patient to maintain a calm and peaceful mind, to avoid the generation of anger or attachment, and to provide support for their spiritual practice (Hawter, 1995).

D) Physical needs:

Due to the practice of not taking the life of any living being, many Buddhists are vegetarian, although this may vary between Buddhist countries (Neuberger, 1987). The types of food considered appropriate will also vary between countries of origin, although rice is a staple food of many Asian countries and is usually seen as an essential part of a meal (Buddhist Society of Western Australia, 1987).

Fasting is a common Buddhist practice, although special days of fasting vary among the different schools. Many special festival days require fasting after 12 noon rather than throughout the whole day. For others fasting may be for other than religious reasons. Patients should be consulted on their dietary and fasting practices (Kirkwood, 1993).

E) Medical procedures:

Buddhists do not object to the majority of medical procedures, such as blood transfusions, and generally have the freedom to follow medical advice. However, as the state of mindful awareness and control is of such importance to the death process, some Buddhist patients may be reluctant to take any kind of medication which may cloud the mind. This means that many pain relieving, and other drugs, may be unacceptable to the Buddhist patient. The patient should be fully informed of the effects of a particular drug and their decision upon taking the medication respected (Neuberger, 1987).

4. Procedures at the Time of Death
The quality of rebirth is determined by the totality of accumulated karma, of which the state of mind at death is an important factor in many traditions. Thus in these traditions, the moment of death is of great importance. Many Buddhists believe that the mind gradually separates from the body during the death process, becoming more and more subtle and experiencing various visions. 1t is considered helpful to be aware and in control during the death process in order to guide the mind to a positive rebirth. Buddhists, particularly those of the Tibetan tradition believe that the death process is not over when breathing ceases, for the dying persons consciousness is still absorbing. It may take a day or more for consciousness to actually leave the body and to reach bardo, the formless state between death and rebirth. For this reason the patient should be disturbed as little as possible in the moments before death and for as long as possible after breathing stops (Khadro, 1996).

5. Procedures After Death
A) Handling the body:

Practices relating to handling the body and other procedures after death are often determined as much by cultural factors as by religious ones. Many Buddhists believe that the spirit does not leave the body for several hours after actual death and thus the body should be left undisturbed for as long as possible. When it is time to move the body touch the crown of the head first as the consciousness is believed to depart from this point (Mullin, 1987). In the Vietnamese tradition the body should not be moved until the completion of prayers to assist the departure of the spirit from the body. Once consciousness has left the body it is viewed merely as an abandoned house and there are no special rites for the disposal of the body. Most practising Buddhist families prefer for cosmetics to be kept to a minimum as they wish to see the body as death leaves it. However, there may be some cultural differences in this arca and the family should be consulted on details (Buddhist Society Western Australia, 1987).

B) Medical procedures:

Most Buddhists will have no religious objection to autopsies as the body is no longer seen as part of the dead person. Many Buddhists leave their bodies to science as a gesture of compassion, although some Chinese Buddhists believe that the body should be maintained intact after death (Buddhist Society of Western Australia, 1987).

C) Funeral and mourning practices:

Buddhist doctrine views death as inevitable and as an opportunity for improvement through rebirth and so does not encourage grief. Some cultural and family customs may still include grieving rituals, such as wearing white cloth, walking with a stick, or even wailing, to symbolise the great effect of their grief (Trutner & Trutner, 1990). In some Buddhist communities, relatives observe strict vegetarian practices for forty nine days after the death in order to enhance the reincarnation prospects of the deceased.

Similarly, funeral practices vary. Most Buddhists prefer cremation, however Chinese Buddhists bury their dead in order to preserve the body intact (Buddhist Society of Western Australia, 1987). Vietnamese Buddhists also prefer burial, though cremation may be chosen for health related or cost reasons. In general the funeral is planned by family members. The service may be held in the home, temple, funeral parlour, graveside or crematorium. Customs include ordained or lay persons chanting sutras, a memorial eulogy, offerings of fruit or flowers, and the burning of incense (Trutner & Trutner, 1990). Chinese Buddhists may burn paper money while other traditions perform a pouring of water ceremony in order to symbolise the setting free of the spirit of the dead (Buddhist Society of Western Australia, 1987). There are no formal funeral rituals set down and so the rituals observed tend be cultural observances as much as religious practices (Trutner & Trutner, 1990).

In Vietnamese Buddhist tradition, the timing of the removal of the body to the coffin and then to the ceremony is most important, as are the prayers for the three separate stages leading up to burial: placement of the body in the coffin; removal of the body to the cemetery; and the actual burial. Specialist advice is sought as to who can be present, and participate in any or all of these states. It is believed that if such prescriptions are not followed, the fate of the spirit of the deceased could be adversely affected, and negative influences affect those present whose attendance is contraindicated. Vietnamese tradition requires that at forty nine days and one hundred days after death, special prayers are said to ensure the final safe departure of the spirit from the body.

Although all Buddhist communities have their own particular mourning and grieving practices, contact of families from workers who have been involved in caring for the deceased would not be inappropriate.

–From Death, Dying and Religion by Hurriyet Babacan and Patricia Obst (1998).