Giving Care

Tonight we’ll talk about caring for people who are sick and maybe dying.

In the Canon there’s the story of a sick monk who had dysentery, and no one was caring for him. The Buddha and Ven. Ānanda were taking a tour of the monks’ dwellings and found the monk lying in his own filth. So the Buddha asked him, “Is there no one to look after you?” And the monk said, “No.” “Why is that?” The monk replied, “I don’t do anything for the other monks, so nobody’s looking after me.” So the Buddha got Ānanda to fetch some water, he poured the water over the monk, and Ānanda washed him off. Then they put him up on the bed and got him some clean robes.

The Buddha then went out, called the monks together, and asked them, “Do you know about the monk who’s sick over there?” The monks said, “Yes, yes.” “Why aren’t you caring for him?” The monks said, “He doesn’t do anything for us.” So the Buddha said, “Look, you have no mother, you have no father to care for you. If you don’t care for one another, who’s going to care for you?” Then he added, “If you’d like the merit that comes from attending to me, tend to the sick.”

This principle, of course, applies directly to the monks, but also indirectly to lay people. The implication is that when you belong to a family, you’re duty-bound to look after those who are aging, ill, and dying in your family. After all, the phrase “tending to one another” implies that someday you’ll need someone to attend to you as well. We’re all in this together.

The Buddha went on to define the five qualities of a good caregiver.

Those are the five qualities.

The Buddha’s comments about caring for a sick person are designed for situations where both the patient and the caregiver are Buddhist, but they can be adapted to other situations, too. For example, giving Dhamma advice on dealing with pain, teaching about the brahmavihāras, breath meditation: These themes are universal.

Now, an important piece of advice is that as a caregiver, you have to stick to the precepts. What this means, on the one hand, is that you can’t lie to the patient. For example, you can’t lie about what the doctor’s diagnosis is. And secondly, you can’t speed up a patient’s death even if the patient requests it. This means from the Buddhist point of view you can’t engage in euthanasia or assisted suicide. We’ll talk about this a bit more later.

Here I’d like to expand on two of the points in the Buddha’s recommendations for being a good caregiver. One is: What does it mean to have goodwill for the patient? And two, what does it mean to teach the patient the Dhamma?

In terms of goodwill, there tend to be two extremes as to how people interpret the best way to express goodwill for a patient. One extreme is the idea that you have to extend life as long as possible. The other extreme is terminating life when the quality of life goes down.

The Buddha’s instructions avoid these two extremes and follow a middle course whose outside parameters are provided by the precepts. On the one hand, the Buddha didn’t follow the idea that life should be extended at all costs. In the Vinaya, there’s only a minor penalty for abandoning a sick monk—i.e., you stop treating the patient—and there’s no penalty at all for withholding treatment.

Here we need to provide some context: Our training as monks is governed both by the Dhamma and by the Vinaya. Instructions in the Vinaya are expressed as rules; instructions in the Dhamma are expressed as general principles.

Now, the rules of the Vinaya cannot cover everything, because there are some sensitive areas that don’t lend themselves to clear-cut rules. This is where you bring in the teachings of the Dhamma: what it means to have compassion, for instance; what it means to have goodwill; what it means for you to follow what you think will be the most skillful course of action. When it comes to caring for a patient, the Buddha seems to have realized that this is an area too sensitive to be expressed in rules, aside from establishing some outside parameters. On the one hand, there’s the rule against killing, which is interpreted as cutting short the patient’s natural life span. On the other, there’s the rule that imposes only a slight penalty on abandoning a patient, and no rule at all against withholding treatment.

What this means in practice is that there’s nothing wrong with the decision to discontinue life support and to allow the patient’s life to run out on its own.

However, you cannot do anything to speed up the death faster than that, even if the patient asks for it. After all, you don’t really know where the patient is going to go after death. So there’s no excuse for “putting the person out of his misery.” The person could go someplace worse where there’s even more misery, so you don’t cut his or her life short. Here you have to watch out for the danger of following your own desire not to see the misery of others. You have to ask yourself, “Is your desire to speed up that person’s death for his or her sake, or for yours?”

Within these parameters, compassion and goodwill mean easing the patient’s physical and mental pain. This requires balancing two considerations: the patient’s ability to handle physical pain and the patient’s ability to stay mindful and alert. You have to balance these two considerations to figure out exactly how much painkiller the patient needs.

And don’t be surprised if the patient becomes difficult. This is where it’s important that you strengthen your own goodwill to make it resilient and enduring. The Buddha’s image is that you should make it like the great earth or like space: vast and deep. At the same time, you should adopt a daily practice of developing an attitude of goodwill for all, together with all of the other brahmavihāras.

Another way of showing goodwill is not giving in to displays of grief in the patient’s presence, because that would simply add to the patient’s burden. One of our monks went back home when his father was dying, and the problem was that the grandmother was still alive, and she would go every day to the hospital and cry and cry and cry. The monk said, “I wished I could have thrown her out of the room” because it was simply making the father more upset.

As for teaching the Dhamma, this will depend on the patient’s past beliefs. The primary consideration is helping to do away with the patient’s worries and anxieties. The traditional practice in Theravada countries is to get the patient to remember the past times when he or she was generous or virtuous. This can help lift the patient’s state of mind. Now, if you’re dealing with a patient with other views, try to figure out what, within the context of those views, the patient would find uplifting.

Once, when I was in Thailand, I was part of a group of monks who were invited to visit a man in a hospital who was dying of liver cancer. The man’s main concern was embarrassment about how ugly his body looked with the abdomen all swollen. He had lived most of his life being very proud of the fact that he kept himself fit and in good shape. Even when his friends were getting fat, he was staying slim and trim. So we told him, “At this point, it doesn’t really matter what you look like. Nobody leaves behind a beautiful corpse. Focus instead on the state of your mind.”

You may find that there will be cases where the patient doesn’t want to hear the Dhamma from you. The Canon talks about children teaching the Dhamma to their parents, but I’ve found this to be very difficult. So, if the person doesn’t want to listen to you, think of who the sick person would be willing to listen to, either in person or through recordings.

If the patient does listen to you, your primary role is to aid the patient’s mindfulness. In other words, keep reminding the person what was good in his or her practice and good in the virtuous qualities of his or her mind. Even people with dementia or who are in a coma can benefit from hearing the Dhamma in this way.

For example, you can give the patient advice on goodwill. Remind the patient that it’s good to have goodwill even for people you don’t like. This lifts your mind above their level so that you don’t have to descend to theirs. Start with having the patient extend thoughts of goodwill for him or herself. If the patient feels that he or she doesn’t deserve to be happy, remind him or her that the question of “deserving” doesn’t count. Is this a problem in France? It certainly is in America, at least in my generation. This is something we suffer from because of our Christian upbringing. You have to remember, in the Buddha’s teaching the question of deserving doesn’t come in at all. What counts is that you aspire to do good—in this case, taming your mind, both for your own sake and for the sake of others. If the patient asks, “What can I do for other people in my state now?” you say, “If you can tame your mind, then you’ll be more likely to be able to withstand pain, and that will make life a lot easier for the people looking after you. Then you can extend thoughts of goodwill to others.” This doesn’t mean, “May they be happy doing whatever they want, good or bad.” Instead, it means, “May they understand the causes of true happiness and be willing and able to act on them.”

There are two ways of spreading goodwill. The first is what we’ve been doing in the morning meditations, starting with those who are dear to you and then going out step by step to those who are less dear. You start with yourself, then people you love, people you like, neutral people, people you don’t like, people you don’t know, all living beings, out to infinity.

The other way is to spread goodwill direction by direction: all beings to the east, all beings to the south, to the west, north, northeast, southeast, southwest, northwest, below, above. You can also spread goodwill classifying different types of beings if you want. There’s a very long goodwill chant that Ajaan Mun used to recite. First he would chant it, extending goodwill for all beings in the ten directions and then get more specific: all human beings to the east, human beings to the south, to the west, etc.; all devas in the ten directions, all the hungry ghosts, all the animals, all the hell beings, all the noble beings, all the non-noble beings, all the males, all the females. Breaking it down like that gives you something to do for quite a long time as you dwell with thoughts of mettā.

Another practice that’s universally good regardless of the patient’s background would be breath meditation. Another would be instructions in how to deal with pain.

Now, the style of talks that you give to this person should follow the style that the Buddha himself would have used. They say the Buddha would give talks using four styles: instructing, urging, rousing, and encouraging. You’ll notice that of these four verbs, only one is giving information; the other three are basically giving energy to the listener. Among the Thai ajaans, this is very common. Back when I was translating Dhamma from Thai to English, I noticed that about 80% of the Thai ajaans’ Dhamma talks would be what we would call pep talks. So, try to give those kinds of talks to your patients, with the emphasis on giving them strength.

In effect, you’re focusing on developing the patient’s strength of conviction, and then based on that, the cluster of strengths that come under mindfulness, concentration, and discernment. Now, in terms of discernment, note that you have to do your best to train the patient in the direction of right view at death. I’ve known some people who feel that it’s kinder to simply let the dying person die in peace, but that’s because they believe that there’s nothing more for the patient to do, so you should simply let the patient rest with no responsibilities. But from the Buddha’s point of view, the patient will be making some important decisions at the moment of death, so you want to encourage the patient to have the strength to make the right decisions.

Even people who have been meditating a long time, if they haven’t really succeeded in perceiving pains as something separate from their awareness, can get discouraged as they find themselves unequal to the task of facing pains with discernment. Like King Koravya, they’re alone with the pains, with no one to share the pains to make them less. On top of that, the body is beginning to escape whatever measure of control they used to have, and they face the prospect of leaving everything in this life behind. Like the king, they may revert to their enslavement to craving, rather than recognizing that the cravings are something they should master.

One of the worst things their cravings might tell them is that Dhamma practice doesn’t work after all. This may lead them to revert to the condition that the Buddha identified as our most primal reaction to pain: bewilderment on the one hand, and a search for someone, anyone, who will know how to put an end to the pain on the other. Pain, fear, and weakness are bad enough, but add bewilderment to the mix, and the mind can search for and grasp at anything. If people have to leave the body at that moment, the wind of craving can carry them anywhere at all. So it’s essential that you help your patient maintain right view in the midst of these challenges. This means believing that it’s really important to do what’s skillful and abandon whatever is unskillful. When you view your pains and weaknesses from a Dhamma perspective, that’s half the battle right there. In other words, right view in this case means that even though there may be bad things coming in from your past kamma, you can still do something skillful now.

The other half of the battle depends on rousing and encouraging your patient’s defiant fighting spirit in the face of pain, physical weakness, and fear. After all, as you remember, the bodhisatta’s own fighting spirit, his audacious desire to come out victorious over death, was what enabled him to find the Dhamma of the deathless and teach it to other people to begin with. It’s only through inspiring that same undaunted attitude in one another that we can help one another find the Dhamma within ourselves in spite of the hardships of aging, illness, and death.

You may remember that story I told of the woman who went to practice the Dhamma with Ajaan Maha Boowa before she died. Even after she left the monastery, he continued to write letters to her. He kept saying: You can do it; you can do it.

I’ll end with a few stories. The first has to do with maintaining the patient’s right view. I have a student who’s a monk from Singapore. He was given an ecclesiastical title by the King of Thailand several years back. More recently, his father was on his deathbed, and it turns out that his sister is a Christian. I don’t know about France, but in Singapore, the Christians are very aggressive with dying people, trying to get them to convert. So the sister brought a minister to her father, but the mother stood in the way. She said, “My son has been recognized by the King of Thailand. Who’s recognized you?” In the end, the monk was with the father all the way to the end, helping him to meditate to his last breath.

Another story more directly involves me. When I was in Thailand, a very elderly man together with his daughter once came to spend a three-month Rains Retreat at our monastery. Toward the end of the Retreat, he developed pains in his jaw, which he dismissed as nothing more than a toothache. At the end of the Retreat, he went to the dentist, only to find out that he had a very advanced case of cancer. He returned to the monastery to bid farewell to Ajaan Fuang, saying that he planned to go home and die. Ajaan Fuang told him that if he went home, he would hear nothing but his nieces and nephews arguing over the inheritance. It wasn’t much, but it was enough to argue over.

So he told the old man, “Come, stay and die here.” We arranged a place for him to stay in the chedi, which is the spired monument we had built on the top of the hill. His daughter was his primary caregiver, but the monks helped as well. As the disease advanced, he got to the point where he couldn’t talk. We could see that he was in pain, but we had trouble getting adequate painkillers for him. He would plow his head back and forth on his pillow whenever the pain was getting to him. So I told the daughter that when that happened, she should whisper his meditation word, Buddho, into his ear. She did, and then the plowing would stop for about two hours. Then it would start up again. She would whisper the word into his ear again, and then he would stop.

This kept up for about seven days until late one night, when the daughter sensed that the end was coming. She chanted the Mahā Samaya Sutta to him and then put his hands together, saying, “May you please go to nibbāna.” He lifted his hands to touch his forehead and then he died, peacefully and alert.

The next morning, I helped build his coffin. We held funeral services for him for several days, and then the nieces and nephews came to pick up the body and take it back to the old man’s hometown for the cremation. Sure enough, as they were loading the coffin onto the truck, they were arguing among themselves about the inheritance.

Now, when you teach the Dhamma to a patient, there are going to be cases where the patient is too weak or delirious to understand what you’re saying. In cases like that, one of the best things you can do is to provide a quiet presence. But as I said before, speaking of good things that the person has done, telling him or her that he or she is loved, reading soothing Dhamma talks, chanting, etc., can help calm even an unconscious person, because there are a lot of things that come into the mind subconsciously.

There’s a lay Dhamma teacher I know in America whose mother was dying. As he was holding her hand, he said, “Let go, let go, let go,” but the more he said, “Let go,” the tighter she held on. Obviously, that was not the message she wanted to hear. He realized this was not working, so he said, “Mom, I love you,” and she relaxed her grip. The lesson: Give lessons that are appropriate to the patient. Be sensitive to his or her needs.

Remember: Eventually you as a caregiver will become a patient, too. So, use this opportunity as a caregiver to develop your own strengths of mind. The stronger you are in mind, the less of a burden you’ll be to others, and you’ll be able to face aging, illness, and death undaunted and unafraid.