Being with dying - Upaya Zen Center

Being with dying
Contemplative practices
for compassionate
end-of-life care
By Cynda Hylton Rushton, PhD, RN, FAAN,
Joan Halifax Roshi, PhD,
Barbara Dossey, PhD, RN, AHN-BC, FAAN
BEING
WITH DYING PEOPLE is an
integral part of nursing, yet many
nurses feel unprepared to accompany people through the process
of dying. Today’s fast-paced
healthcare environment conditions
us to view death as a physiologic
event, not as the sacred passage of
a life and as a failure not as part
of the human life cycle. To create
a safe passage for patients and
families, we need a holistic approach and skills that allow us to
witness the dying process with
compassion and strength.
The Professional Training Program in Compassionate End-of-Life
Care (CEOLC) explores how we
can create that safe passage for
our patients and ourselves. The
program, which started in 1994,
trains healthcare professionals in
the psycho-spiritual aspects of care
of the dying. This pioneering work
has transformed the care of dying
people across the United States
and the world.
The CEOLC program uses an
experiential, discovery model. The
foundation of the program is the
belief that the wisdom resides in
the participants. The learning model is based on mindful learning
that includes orientation in the
present, openness, flexibility, tolerance of ambiguity and uncertainty,
alertness to distinction, the opportunity to experience different contexts, and awareness of multiple
perspectives, options, and outcomes simultaneously. Let’s explore the key concepts of this program that helps nurses move
toward a more spiritual and compassionate end-of life-practice.
Who, me?
Denial of death is pervasive in our
culture. In the Hindu text, the Mahabharata, Yudhistara says, “The
most wondrous thing in the world
is that all around us people can be
dying, and we don’t believe it can
happen to us.” The idea that death
happens only to others allows us to
separate ourselves from the reality
that we will die. But to be present
at the death of another, we must
accept that we could be the person
on the other end of the stethoscope. This awareness connects us
to the fragility of our lives and the
lives of the patients we serve.
When our attention is diverted
from our shared humanity, we may
miss the gifts of our daily lives and
the service we are called to provide. Think about this in terms of
your own work and the gift that
may be embedded in your practice. How can we connect more
fully to our lives, our relationships,
our service, and ourselves? Without
contemplating our own life and
death, we are likely to miss opportunities to support patients and
families.
Search for meaning
Questions about what gives life
and death meaning are central to
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our ability to be present during the
dying process. What do pain and
suffering mean? Is there a gift that
people can experience through the
dying process? Do we live on after
our body functions cease? In asking such questions, we acknowledge that we have deep connections to each other, our work, and
something bigger than ourselves.
Reflective practices about the
meaning of our lives, relationships,
fears, and suffering allow us to
more fully respond to the fear and
suffering of others.
We discover the meaning of our
lives by the meaning we give to it.
Victor Frankl, who was imprisoned
in a Nazi concentration camp,
wrote, “Death gives life meaning.”
Recognizing the fragility of life and
the certainty of death liberates us
from the burden that we are in
control of our lives and allows us
to focus on living each moment to
its fullest. If you live every day to
the best of your ability, every day,
even your final one, is the best
day of your life.
Cultivating compassion
Compassionate care at the end of
life reflects an integration of these
three concepts: not knowing, bearing witness, and acting compassionately.
• Not knowing. Not knowing is a
state of mind that’s not attached
to ideas about self, others, the
world, or particular processes or
outcomes. Surrendering to the
limits of our minds and our ability to control events or outcomes
allows us to hear our inherent
wisdom and truth. The idea of
not knowing is contrary to traditional healthcare models that are
based on expertise, scientific data, and rationality. The space created by not knowing invites new
awareness and possibilities to
emerge, intuitions to be explored, and preconceptions and
assumptions to dissolve.
• Bearing witness. Bearing witness
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Practicing self-care
A guiding principle of compassionate end-of-life care is that you can’t care well
for others unless you care well for yourself. Self-care includes practices that we
perform on our own behalf to support, maintain, or improve our well-being.
Choosing various practices allows us to integrate body, mind, and spirit, so we
can care for others with compassion.
Developing a self-care plan involves approaching every moment of the day
mindfully. Seeking ways to restore your energy, health, and well-being helps develop greater resilience when challenges occur.
Start simply and practically. Think of three things that you would like to do
that would nurture you. Consider mindfulness practices, massage, imagery, play,
exercise, yoga, art, music, and other contemplative practices. Promise yourself
that you will do them faithfully. Working with others can provide the support you
need to integrate self-care practices into your daily life.
is a way of relating that’s linked
to the presence we extend to
others. It involves respecting the
truth of another person, suspending your judgment about it,
and remaining true to and respectful of what another has experienced. This means being
present with things as they are.
Being in the present moment
dissolves attention to the past or
future. It involves developing
the qualities of stillness, openness, and stability of mind that
allow you to be present for the
suffering and the sufferer—without fixing or controlling the
process or outcome.
• Compassionate action. The
foundation of all actions is compassion and service to others.
Compassion arises from an
open, gentle heart that can feel
another’s pain and your own
pain and allows you to be present in the face of suffering and
take action to relieve suffering
and pain. Through actions that
reflect integrity of mind and
spirit, healing is possible.
These three concepts help nurses work more skillfully with the
challenges of suffering, end-of-life
care, ethical conflicts, and interdisciplinary collaboration. They help
nurses cultivate greater insight,
depth, and understanding of the
interplay among compassion,
mindfulness, and presence and the
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interconnection between self and
others. (See Practicing self-care.)
Being with suffering
Suffering is universal. Acknowledging that suffering is part of our lives
transforms it: We can see that suffering is inescapable, become aware of
how we contribute to our own suffering, and find acceptance and
more compassion for ourselves and
our suffering. This transformation allows us to be in pain but not suffer.
This means you can witness suffering but not be overwhelmed by
what you witness and experience.
Being able to be with suffering requires a certain stability of the mind.
Without it, the demands of being a
nurse can be overwhelming.
Equanimity, an integral companion to compassion, is the still, calm
part of us that keeps us centered
in the face of suffering and difficulty we witness. We are able to
walk through those crisis situations
and not be overwhelmed by them,
not be overcome by the experience, but remain competent, clear,
and compassionate.
Practicing mindfulness
Mindfulness involves bringing attention to what is happening in the
mind and body in the present. It
cultivates an awareness of feelings,
mental states, perceptions, and bodily functions. Mindfulness practices
help stabilize the mind through at-
Compassionate care at the end
of life reflects an integration of
these three concepts: not knowing,
bearing witness, and acting
compassionately.
tention and presence, develop insights, and cultivate kindness, compassion, and equanimity. In mindfulness practices, we learn to calm
ourselves and stabilize our minds
by developing greater concentration
and reducing reactivity.
Mindfulness helps us detach
ourselves from outcomes. When
we provide care for patients, the
intended outcome doesn’t always
occur, leaving us feeling disappointed, disillusioned, angry, or
depressed. But realizing that you’re
not in control of people and situations can be liberating. Your job is
to accept what is happening now,
not to try to change it. Developing
this ability to stabilize the mind
and release outcomes takes consistent, deliberate practice.
Mindfulness can create an environment in which it’s possible to
release your habitual responses
and guide thought and behavior
in accordance with your intentions. This provides the energy
and ability to pursue goals and
be more in control of the mind,
which allows you to be more
present. And that’s the very thing
that a dying person and family
members need most—your complete presence. When you calm
your mind, develop these practices, and create some spaciousness in yourself, your work becomes less burdensome because
you’re not so attached to everything being a particular way.
Another contemplative mindfulness practice involves acknowledging the suffering in the world and
our aspiration to be peaceful and
helpful to others and ourselves. By
directing positive thoughts and en-
ergy toward yourself, other people,
or all beings, you begin to shift
your inner environment and create
an intention of well-being and
peacefulness toward others and
your world. You can practice with
certain phrases, such as “May I see
my own limits with compassion,
just as I view the suffering of others.” This invites you to be compassionate toward the limits of
what you can do in the same way
that you are compassionate to other people’s suffering. Another
phrase might be, “May I offer my
care and presence unconditionally
knowing they may be met with
gratitude, indifference, anger, or
anguish.” This helps you understand that how the message is received doesn’t diminish your effort
or intention. As you reflect on
these phrases, you’ll give attention
to what is arising in the heart and
mind. This kind of intentional presence to our inner world can be a
kind of medicine for the suffering
that we witness and experience as
part of our caregiving roles.
A different way to learn—
and to be
To see things in a new way, nurses
need time to reflect and cultivate a
deeper awareness of themselves
and others. Learning happens
when we can create a space that
welcomes the diversity of each participant; invites open exploration,
safety, and solitude; and fosters
trustworthiness and respect. Our
most effective learning occurs
when we are actively involved and
able to deeply experience learning
in a personal way.
The essence of compassionate
end-of-life care is to come from a
place of authentic knowing and
bring that into your practice environment. Your most powerful message has nothing to do with words.
It’s your ability and willingness to
listen to someone who needs to be
heard. And if your words come
from that still place inside, they will
be the right words. When you
speak from the heart, you speak
from a place of compassion. Consider how this shift in awareness
could affect the health of your
work environment. And think about
the power of your presence for
yourself and those you serve.
✯
Selected resources
American Holistic Nurses Association, American Nurses Association. Holistic Nursing:
Scope and Standards of Practice. Silver
Spring, MD: Nursesbooks.org; 2007.
American Nurses Association. ANA Code of
Ethics and Human Rights. Available at:
http://nursingworld.org/ethics/code/protected.nwcoe303.htm. Accessed July 12, 2007.
Glassman B. Bearing Witness: A Zen Master’s
Lessons in Making Peace. New York, NY:
Bell Tower; 1999.
Halifax J. Being With Dying: A Guide to the
Great Matter. Boston, Mass: Shambhala; In
press.
Halifax J, Dossey BM Rushton CH. Being
with Dying: Compassionate End-of-Life
Training Guide. Santa Fe, NM: Prajna Mountain Press; 2007.
Langer EJ. The Power of Mindful Learning.
New York, NY: Perseus Books; 1998.
For a complete list of selected references, visit www.AmericanNurseToday.com.
Cynda Hylton Rushton, PhD, RN, FAAN, is Associate
Professor of Nursing at the Berman Institute of
Bioethics and Program Director at Harriet Lane
Compassionate Care Program of the Johns Hopkins
University and Children’s Center in Baltimore,
Maryland. Joan Halifax Roshi, PhD, is a Buddhist
teacher, Zen Priest, and the Founder, Abbot, and
Head Teacher of the Upaya Zen Center in Santa Fe,
New Mexico. Barbara Dossey, PhD, RN, AHN-BC,
FAAN, is Director of Holistic Nursing Consultants in
Santa Fe, New Mexico and International Co-Director
of the Nightingale Initiative for Global Health in
Ottawa, Canada, and Washington, DC.
The authors acknowledge the wisdom and support of
the team of interdisciplinary faculty colleagues, the staff,
and volunteers of the Upaya Zen Center and, most importantly, the patients and families we serve.
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