Chapter Seven

Giving Care

The Buddha’s instructions on how best to approach aging, illness, and death apply to everyone: not only in the sense that we all face these facts of life, but also in the sense that we will be called upon—even before we face these facts ourselves—to give care to those who are facing them in the present.

The Canon doesn’t depict a deva messenger who conveys this message. Caregivers do play a—literally—supporting role in the portrait of the ill deva messenger: picking him up and helping him lie down. But they come to the fore in the passage describing the Buddha and his closest attendant, Ven. Ānanda, caring for the monk with dysentery.

This story delivers a message phrased in strong terms: If you would tend to the Buddha himself, tend to the sick. This message was aimed directly at the monks—on the grounds that they had no family to attend to them, so they should care for one another—but it’s phrased in such a way that the message applies indirectly to lay people as well: When you belong to a family, you’re duty-bound to look after the aged, ill, or dying members of your family. After all, “tending to one another” implies that someday you will need someone to tend to you, too. We’re all in this together.

The Buddha lists the traits needed to be a good caregiver, whether you’re a relative or friend of the patient, or are a professional who wants to give care not only to the patient’s body but also to his or her mind. His comments on this topic were designed for situations in which both the patient and the caregiver are Buddhist and have shared views about what the true Dhamma teaches. The following discussion is also based on that assumption, but because this situation is still rare in the West, the advice given here should be adapted to the particular needs of the situation.

Some of the lessons—such as how to deal with pain or to develop the brahmavihāras—are more universal than others. And there’s one proviso: If you’re a Buddhist caregiver, it’s important that you observe the Buddha’s strictures about how to treat a patient in line with the precepts. For instance, you can’t lie to the patient—say, sugar-coating the doctor’s diagnosis by misrepresenting it—and you can’t do anything to speed up the patient’s death, even if the patient requests it, because those actions would harm you. Harming yourself through breaking the precepts is something the Buddha would never recommend, regardless of how other people might feel that they would benefit from your “helping” them in that way.

Of the Buddha’s stipulations for an ideal caregiver, two require special discussion: what it means to have goodwill for the patient, and how to teach the patient lessons in the Dhamma.

Goodwill. Everyone would agree that a caregiver should have goodwill and compassion toward a patient. However, there’s little agreement on how compassion translates into the major question of extending or shortening life. Because this issue sets the outside parameters for caring for a sick person, it’s best to discuss it up front.

For some people, compassion means extending life as long as possible; for others, it means terminating life—through assisted suicide or euthanasia—when quality of life falls below a certain level. Neither of these two groups sees the other as compassionate at all. The first sees the second as criminal; the second sees the first as heartless and cruel.

The Vinaya—the collection of the Buddha’s rules for governing monastic life—charts a middle course between these two extremes. The rules show how the Buddha himself worked out the practical details on how to apply the principles of goodwill and virtue to this specific issue.

On the one hand, he didn’t subscribe to the notion that medical treatment should try to extend life at all costs. He imposed only a minor penalty on a monk who totally abandons a sick monk before the latter recovers or dies. And there’s no penalty for withholding or discontinuing a specific medical treatment. So the rules convey no message that the failure to keep life going would count as murder. This is backed up by the Vinaya’s definition for killing: cutting off the other being’s life faculty. For this reason, the decision to discontinue life support—thus allowing the patient’s life faculty simply to run out on its own—would not break the precept against killing.

On the other hand, though, a monk who deliberately ends the life of a patient or deliberately speeds up the patient’s death, even from compassionate motives, is expelled from the monkhood and can never reordain in this life. After all, you don’t know where the patient is going to go after death—whether to a better place or to one with more suffering—so you can’t justify speeding up the patient’s death as an act of “putting the person out of his or her misery.” For this reason, there’s no room for euthanasia or assisted suicide.

Within those two parameters, compassionate care means easing the patient’s pain as is appropriate, balancing two considerations: the patient’s ability to handle pain and his/her ability to stay mindful and alert. You want to avoid leaving the patient in so much pain that he/she can’t stay focused and calm. At the same time, you don’t want to get the patient too blurry from painkillers to maintain any focus at all. Also, you ideally would want to provide a quiet environment so that the patient can attend to the work at hand: trying to comprehend the pains and other difficulties of illness while observing his/her own mind.

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. Adopt a daily practice of developing an attitude of goodwill for all, together with the other brahmavihāras, in line with the instructions in Chapter Three.

Another important way of showing goodwill for a patient is not giving in to any grief that you may feel as the patient’s condition deteriorates. The patient has enough burdens to bear as it is, so you don’t want to impose on him or her the burden of your own sense of loss. Instructions for how to handle grief are given in the next chapter.

Teaching the Dhamma. Here again, the don’ts mark off the territory for the do’s. The Vinaya cites cases where monks tell a sick person to focus his thoughts on dying, in the belief that death would be better than the miserable state of his life. The sick person does as they advise, he dies as a result, and the Buddha expels the monks from the monkhood. Thus, from the Buddha’s perspective, encouraging a sick person to relax his/her grip on life or to give up the will to live would not count as an act of compassion. Instead of trying to speed up the patient’s transition to death, the Buddha focused on speeding up his/her insight into suffering and its end. When you tell the patient to let go, it shouldn’t be with the intention of hastening the dying process. It should be with the intention of relieving the suffering of clinging in the present moment.

The Buddha’s attitude here derives from a point we discussed in Chapter Six: Every moment of life—every in-and-out breath, even the last—is an opportunity to practice and benefit from the Dhamma. A moment’s comprehension of the pain of the present is far more beneficial than viewing the present moment with disgust and placing one’s hopes on a better future.

As for the Dhamma you do teach the patient, this will depend on your relationship to the patient. In some cases, the patient will be willing to listen to the true Dhamma regardless of whoever speaks it. In other cases, he/she will be willing to listen to the Dhamma only from certain people. If that’s the case, find recordings made by those people, or—if possible—invite them to talk to the patient in person or via electronic means. Or read passages from the writings of authors the patient finds inspiring.

If the patient does show an interest in listening to what you have to say, remind yourself that your primary role is as an aid to the patient’s mindfulness, to give reminders of teachings that the patient has already heard and/or practiced but is now forgetting, whether from weakness, pain, fear, or cognitive impairment. There is some evidence that patients suffering from dementia or in a comatose state can still, on a subconscious level, benefit from hearing the Dhamma, so it’s not a waste of time or energy to read or speak Dhamma to them.

The focus should be on strengthening the patient in terms of the seven strengths that have formed the framework of the discussion in this book: conviction, shame, compunction, persistence, mindfulness, concentration, and discernment. For instance, if the patient is having trouble in dealing with pain, look at the discussion in Chapter Three on how to use these seven strengths in dealing with pain. If the patient is troubled by thoughts of worry and anxiety, look at the discussion of the hindrances in the section on Persistence (2) in Chapter Six.

Because your emphasis should be on strengthening the patient, then—as the Buddha recommends—the style of your talks should resemble the style of his: not simply instructing, but also urging, rousing, and encouraging your listener. You should try, as best as is possible, to encourage your patient in being strong in the face of pain, illness, and death.

Of the seven strengths, the most important ones to emphasize are those dealing with right view: conviction and discernment. Remember the lesson the Buddha learned on the night of his awakening, on the power of a person’s views at the moment of death to pull that person in a good or a bad direction. You don’t want your patient, under any circumstances, to abandon right view. Yet it’s precisely in the area of conviction and discernment that the pain and weakness of illness, along with fear of death, can wreak the most havoc in weakening the mind.

Even people who have been meditating a long time, if they haven’t really succeeded in perceiving pains as something separate from awareness, can get discouraged as they find themselves unequal to the task of facing the pains of their illness with discernment. Like King Koravya, they are alone with their 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 their cravings as something to be mastered.

One of the worst things that their cravings might tell them is that Dhamma practice doesn’t work after all. This may lead them to revert to their pre-Buddhist views, or to the condition 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. 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 take them anywhere at all.

So it’s essential that you help your patient maintain right view in the midst of these challenges. This may have been one of the reasons why the monks in the time of the Buddha would question any fellow monk on his deathbed about his personal attainments: to bring that attainment back to mind, and to encourage him to devote all his energy to developing it further, if necessary, as best he can. That way, he could focus on viewing his pains and physical weakness from a Dhamma perspective, rather than a me-the-victim one. Viewing pains and weakness from a Dhamma perspective is half the battle right there.

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

Think of the two examples of Ven. Sāriputta giving instructions to men on their deathbed. In one case, he underestimated the patient’s capabilities (MN 97); in the other, he overestimated them (MN 143). The case to be regretted was the one where he underestimated what the dying person could do. This is a point that a caregiver teaching the Dhamma to a dying patient should always keep in mind.

Once you’ve been able to strengthen the patient’s conviction and discernment, it’s relatively easy to encourage the remaining five strengths. Given that we’ve discussed them so often in this book, I won’t detail them all again here. I’ll just focus on a couple of examples.

The first example deals with strengthening mindfulness and concentration. When I was in Thailand, a very elderly man, together with his daughter, once came to spend the 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 learn that he had an advanced case of cancer. He returned to the monastery to bid farewell to Ajaan Fuang, saying that he planned to go home to die. Ajaan Fuang told him that if he went home, he’d hear nothing but his nieces and nephews arguing over the inheritance—which wasn’t much, but it was enough to argue about. So he told the old man to continue staying at the monastery.

We arranged a place for him to stay in the chedi, the spired monument we had built on the top of the hill. His daughter was his primary caregiver, while the monks also helped look after him as the disease advanced. It got to the point where he wouldn’t talk, but we had trouble getting adequate painkillers, and we could see that he was in pain: He would plow his head back and forth on his pillow when it got overwhelming. I told the daughter that when that happened, she should whisper his meditation word, buddho, into his ear. She did, and the plowing would stop for two or three hours. When it began again, she whispered it into his ear again, and the plowing would stop again. This kept up for several days until, late one night, he died peacefully and alert.

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

The second example deals with strengthening shame. It might seem strange to appeal to a dying person’s sense of shame, but there have been cases where it has been helpful. The important proviso is that the patient respect the person making the appeal.

Years after the above incident—after Ajaan Fuang had died and I had returned to America—it was the daughter’s turn. She herself was on her deathbed at home. She proved to be a very difficult patient, cursing her husband and children, and complaining constantly of the pain. No matter how much they tried to get her to contemplate the pains from a Dhamma perspective, she wouldn’t listen to them, saying that they had no idea of how strong the pain was. A monk who had studied with Ajaan Fuang learned of what was happening, so he went to yell at her: “What kind of meditator are you? Didn’t Ajaan Fuang teach you how to deal with pain? Why aren’t you using the lessons you were so lucky to learn?”

Shocked, she came to her senses and, somewhat later, died peacefully.

This approach may not always be appropriate, but it sometimes can be effective, so it’s good to know that it can have its time and place in a caregiver’s repertoire.

Another lesson to take from these two stories, of course, is that eventually the caregiver will become a patient. So it’s important that you, as a caregiver, develop the seven strengths in yourself. This will benefit both you and your patient, now and into the future: The more experience you have in cultivating these strengths, the stronger you can be in dealing with whatever difficulties the patient throws your way, and the more authority you can bring to urging, rousing, and encouraging the patient to be strong as well. As for you, the more you develop them now, the more undaunted and audacious you can be when the time comes to face your own aging, illness, and death, and come out victorious.