By John Harvey Negru
One of the more enchanting costumed Tibetan Buddhist dances involves a couple of jovial skeletons (citipati) who perform a jig that is, to me, vaguely reminiscent of Abbot and Costello in a vaudeville routine. Their grins are ear-to-ear, one holds a skull cup full of blood and the other holds a wand comprising a child’s spine and skull. Charming.
There are many images of these two clowns; it’s not a particularly obscure bit of tantric exotica. They’re just part of the entourage. They come on between the multi-octave throat singers and the more elaborately gowned Black Hat re-enactment or Yamantaka dance.
Clearly this is not an image of death that was part of the zeitgeist when and where I grew up as a nice Jewish boy, down the street from Leonard Cohen in Westmount, the English enclave in Montreal, Québec, a Canadian province still in the fading grip of the Catholic Church after the Quiet Revolution.
And yet, as I and my generation have grown older and older, we find ourselves with a ticket to the Greatest Show on Earth: our demise, like it or not. Leonard has already made his own curtain call.
These days, we have a cornucopia of narratives about how our end of life will go. And as you can imagine, each of us is pretty darn committed to finding the one that will bring the greatest peace of mind and no regrets.
As we have learned over the past year and a half, dying is a much more difficult passage than being dead. Tragically, many of us have found ourselves unprepared to deal with the passing of a loved one or recognizing that we ourselves are leaving lots of loose ends for those we love.
The end of life is not something folks like to talk about, but it is our ultimate mystery. On another plane, it is also a tricky logistical path across a gameboard, with pitfalls such as dealing with hospital bureaucracy, filling in forms, searching for hospice care, making advanced care plans, and so much more.
I know several Canadian Buddhists who have served as death doulas. A few months ago, I was approached by a Buddhist social worker from Toronto, Linda Hochstetler, who has specialized in death work for many years in a variety of capacities. She explained that she had written an end-of-life guide and asked if I would be interested in publishing it. The short answer was yes and the book will be out this autumn.
It seemed worth interviewing her because I wanted to learn more about her perspective on the end of life, and to explore some of the themes she raises in her book but which were subsumed to the need to keep it practical for its intended Canadian audience. Here is a portion of our conversation.
Buddhistdoor Global: When we talk about death and dying, reversing the order of things, we make death the focus of our attention at the expense of understanding and working with the process of dying. In the best of all possible worlds, how would you change that?
Linda Hochstetler: I would spend much more time teaching about the dying process. Everyone should know the death process intimately before they graduate high school. The dying process is not really understood or taught anywhere. Not to adults and certainly not to kids. I would love it to be a part of school curricula. It’s too often avoided at all ages. Switching the order within the phrase dying and death allows us to really look at dying up close and to spend much more time and interest here, understanding this before we try to move on to death.
BDG: The pandemic has transformed our awareness of the fragility of life, our interbeing, and our relationships with old and young. In offering spiritual care to frontline healthcare workers, what do you see and how do you respond?
LH: Frontline healthcare workers are called to do their work because it matters to them. They want to be a part of a system that they approve of and where they feel they can make a difference. The pandemic has been challenging because many of the policies in healthcare were not in line with healthcare workers’ priorities. Healthcare workers were asked to work without PPE initially, and there were often staff shortages when staff were sick themselves or just stressed out. These situations were unfortunate because they pitted the workers against families, and even when the healthcare workers wanted to work together with families to provide good care to sick family members, they were unable to do so. We have been hearing that we’re all in the pandemic together, but too often our needs have been competing and we have not been able to work together well. Under these conditions, spiritual support is often considered to be superfluous and the easiest part to cut out. This is unfortunate, because it is our spirituality that is the core of our common humanity.
BDG: What is “a good death” and is this a goal we need to strive toward?
LH: A good death will differ for everyone. It is one that is in line with one’s values. It is also one that is the best in those circumstances from the options available. It is helpful to aim for a good death but not to cling too tightly to the idea, because sometimes things come up that are a surprise. It’s easier to say what is not a good death than what is a good death. What is not a good death is hanging on and slowing down death with the idea that it can be prevented. Attached to this is the idea that resisting death increases interventions at the end. Interventions create activity and distraction from the dying process, and often require professionals and hospital rules to take precedence over the dying process, which belongs to the dying person and their loved ones.
BDG: How is death work different from grief work?
LH: Death work is the honest seeing of the process of dying. It is witnessing the changes in the body, understanding how this affects the mind and ultimately our conversations and interactions with those remaining. Grief work is both the work of the dying person, who is letting go of this lifetime, and the work of the loved ones, who are releasing the dying person, and imaging a life without their loved one even while they are still alive. Very basically, death work has a greater focus on the body, while grief work has a greater focus on the mind and feelings. And both can happen both before and after the final breath.
BDG: The use of self is one of the benchmarks by which neophyte chaplains are evaluated in their CPE training. Yet the role of a spiritual caregiver demands the abandonment of self for the benefit of the patient or client. Since Buddhism negates the idea of a self, is there some special advantage a Buddhist approach can offer here?
LH: The use of self in a therapeutic sense begins with an awareness of self and an awareness of other. Buddhism negates the idea of a self—not in the sense that it doesn’t exist but that it is not inherently different from the other. Awareness training helps to hold this seeming dichotomy together. In this way, a Buddhist chaplain has the experience and training to see the patient or client as themselves and can more easily offer help from this perspective. They can go between their needs and their client’s needs seamlessly without needing to drop either side. Buddhist chaplains are way more comfortable with “both/and” situations.
BDG: When a loved one is dying, it is often the nexus for family conflict that can leave lasting scars. Of course, preventing such conflict is important, but when it has been unavoidable, what is the best way to repair the damage?
LH: Preventing family conflict around the death bed is so much easier than repairing it afterwards, so whenever possible, resources and time should be spent here. Making room for all loved ones to share in the dying process is best, even if that means making a schedule and taking turns in the care. However, when damage has occurred, it is best to find a neutral person—a chaplain or social worker—to speak with all sides individually and invite them to consider the wishes of the dying person. The dying person’s wishes should be of greatest importance, and ideally this priority can guide the overall decision-making.
BDG: How do Western Buddhist views of dying and death differ from those of Asian Buddhists? How are they the same?
LH: Buddhism is always a combined product of the scriptures/teaching and the local culture. As such, it is often hard to know what is influenced by Buddhism and what is influenced by culture. In many ways, there are fewer differences between Western and Asian Buddhists, and more differences between traditional Buddhist interpretations and modern options. For example, 50 years ago if someone was close to dying, they would be doing so at home and tended by family members into a natural death. Today, modern medicine presents many options for extending life and often these extensions are what is considered controversial. These options, which involve feeding and breathing tubes, are offered around the world. Taking someone off of life support, medical assistance in dying, or organ donations are all options that have come up in the last 50 years and were not even imaginable in the Buddhist scriptures or teaching, so much must be extrapolated from the culture on the rightness and wrongness of these choices. I think Western Buddhists and Asian Buddhists have much more in common than is often assumed and would do well to look at their similarities rather than their differences.
BDG: Briefly, what is the difference between palliative and hospice care, from a Buddhist perspective?
LH: There is no difference between palliative care and hospice care from a Buddhist perspective. In actuality, palliative care can involve a greater resistance when it includes death hidden from the community, but this doesn’t have to be so. Hospice care often occurs in locations—home or residential hospice—that allow for fewer rules regarding spiritual practices, but this is not inherently so.
BDG: What is the difference between spiritual care and psycho-spiritual therapy?
LH: Spiritual care emphasizes both the individual and the community aspect of spiritual practice. This might include formal practices such as prayer and chanting, with the support of spiritual leaders or lay chaplains or sangha members. Psycho-spiritual therapy often involves a relationship that works on individual ego work, often throughout one’s life. It includes explorations of where spiritual practices and aspirations fit into an individual’s life. Ideally, therapy is done long before the dying process so as to clear away energy for dying without also having the weight of previous relationships unresolved.
BDG: Is it possible to celebrate dying?
LH: Absolutely. Just like there are many challenges in one’s life, dying is a final one. Celebration comes from training for death and then completing it according to the training. As with many challenges, the focus doesn’t have to be on the exact result, but more in the effort in a particular direction. And the celebration of dying includes the celebration of living. Look at the whole life and see that dying is one more step of the life, and celebrate when it all hangs together consistently and as a whole.
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