A Buddhist Approach to

A Buddhist Approach to Patient Care A Buddhist Approach to Patient Care Sabbadânam dhammadânam jinâti. The gift of Dhamma surpasses all other gifts....
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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

Sabbadânam dhammadânam jinâti. The gift of Dhamma surpasses all other gifts.

Dhamma Articles reprinted with kind permission from

A Buddhist Approach to Patient Care

Venerable Phra Paisal Visalo and Venerable Ajahn Jayasaro

Extracted with kind permission from the book compiled by Montira and Nissara Horayangura in memory of their beloved mother Maleewan Horayangura who passed away in 2006.

May this merit help her attain Nibbana.

Printed & distributed in loving memory of Mr. Arwin Fernando and Mrs. Tilda Fernando and Mr. Lakshi Alles and all other departed relatives.

May this merit help them attain Nibbana. Preminda and Dilrukshi Fernando

Printed by

# 306 Embuldeniya, Nugegoda, Sri Lanka.

E-mail: [email protected], Tel: 0718152131

Ranjith and Jeevani Pandithage

A Buddhist Approach to Patient Care

Introduction E

ver since we were young, Mom had taught us about the importance of preparing for death. In Buddhist belief, she explained, our state of mind in the last moment before death is extremely important as it would determine whether we would be reborn in a good way or indeed not be reborn at all. By frankly discussing death, she showed us that it was not some morbid topic to be avoided, but an integral, natural, and inescapable part of life. We found her advice to be pragmatic, spiritually-aware, and wise. When Mom was diagnosed with a terminal illness in late 2003, the reality of death’s inevitability hit home. Still, there was great uncertainty as to when it would occur, as the initial prognosis of months stretched into years, which served as a constant reminder of how death can come at any moment. While the situation was not easy, one positive aspect was that it provided time and impetus for Mom and us to learn more about, contemplate and prepare for her death; not everyone has the opportunity to do so. Over the course of her illness, we spent a great deal of time at the hospital and noticed how the bee-hive of activity there, especially in the ICU, focused mainly on tending to the physical

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A Buddhist Approach to Patient Care

well-being of patients. However, recollecting what Mom had taught us, we took care to also make her spiritual welfare a central concern, especially in helping her face death with a calm mind. In the end, she passed away peacefully on 6 April, 2008. As a tribute to Mom’s own long-held commitment to spiritual cultivation, we wish to offer in this book resources on nurturing spiritual well-being, particularly amidst serious illness. We hope that by compiling and sharing what we have learned and found helpful over the years, her long illness can serve in some way to help others. We conceived this section of the book as something like a kit for people taking care of their loved ones at the hospital or at home, or for people who are ill themselves. It can also be taken as food for thought for those who are still fit and well, so that they may take a closer look at death, and thereby become more prepared for it, instead of putting it far out of their heads. While our family approached it from a Buddhist context, we believe, as a Catholic friend of ours said, a peaceful death is considered a blessing for anyone. We hope the contents of this section can help those of any religion prepare their loved ones and themselves for a peaceful death. At the same time, we hope that it will also inspire readers to live life more meaningfully – and joyfully! By Montira and Nissara Horayangura

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

An overview of the three articles in this booklet: q

q

“Helping Dying Patients the Buddhist Way”* by Venerable Phra Paisal Visalo offers a clear and practical “how-to” guide to various things that can be done to help seriously ill persons in their final stages. “Embrace Death” by Venerable Phra Paisal Visalo offers different ways of contemplating death in daily life.

(These two articles encapsulate many major points addressed in the “Meeting Death Peacefully” workshops led by Venerable Phra Paisal Visalo and co-organized by the Spirit in Education Movement and PhutthikaBuddhist Network in Thailand. The workshop aims to help those who are seriously ill, their relatives, or any interested persons prepare for death. Nissara had attended the workshop and learned a great deal, which she shared with the family.) q

“Universal Charm”* by Venerable Ajahn Jayasaro.

(This is a transcription of the Dhamma talk Ajahn Jayasaro gave at Mrs. Horayangura’s funeral rites, giving teachings on dealing with the loss of a loved one. ) *Translated from Thai into English by Nissara, who takes full responsibility for, and humbly asks forgiveness, for any errors in translation.

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Helping Dying Patients the Buddhist Way By Venerable Phra Paisal Visalo

Illness not only affects the body, but also the mind. Thus, when most people fall ill, they must contend not only with physical pain, but also mental pain. Especially in the case of patients who are close to dying, mental anguish is no less a cause of suffering than physical pain, and indeed it can even be the greater cause. This is because what these patients face right in front of them is death, along with separation, and loss that is final. All this provokes feelings of fear, anxiety, and isolation to surge up very intensely, in a way they have never experienced before. For this reason, taking care of their spiritual well-being in fact becomes more important than looking after their physical well-being, specially in the case of final-stage patients, whom doctors have determined to have no hope of recovery or improvement. Because even though the body is irrevocably breaking down, the mind still has the opportunity to improve. It can cease its agitation and reach a state of peace, even in the last moments of life. For, although the body and mind are closely related, when the body suffers, the mind does not necessarily have to suffer too. One can take care of one’s mind in such a way that it does not suffer along with one’s body.

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

In the time of the Buddha, there were many occasions when the Buddha and his disciples helped those who were sick and close to dying. The kind of help they gave directly focused on treating the suffering of the mind. In the Tipitaka, there are several stories of people on the verge of death who were told by the Buddha to contemplate on their imminent death and the true nature of all conditioned things, whereupon they were able to realize high levels of spiritual attainment. Some even became fully enlightened.

Letting go of worries and all things, having seen with wisdom that there is nothing at all that one can hold on to.

From these stories, there are two major points to consider:

1. Extend Love and Sympathy

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2.

Even though being ill and close to dying is a time of crisis and physical disintegration, at the same time it can also be an opportunity to liberate the mind or elevate one’s state of mind. Being ill and close to dying are thus not conditions that are negative by themselves. If one knows how to use them well, they can be of great benefit to one. The Buddha’s teachings on illness and dying can be classified into two main parts: Inclining the mind to have faith in the Triple Gem (the Buddha, the Dhamma, and the Sangha) and confidence in the morality one has upheld or good deeds one has done in the past. In other words, inclining the mind to recollect good and wholesome deeds.

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These teachings of the Buddha provide an excellent model of how to give spiritual help to dying persons that can be applied to cases in the present day. This article will adopt the principles put forth by the Buddha and adapt them for use by doctors, nurses, family and friends in helping dying patients. Experiences from other real-life cases have also been drawn on to create the following guidelines. Dying persons not only have to contend with physical pain but also fear: such as fear of dying, of abandonment, of dying alone, of what will come after death, or of pain. The fear may cause even more suffering than the physical pain. Love and moral support from family members and friends is very important during this time because it can reduce the fear and help them feel secure. We should remember that patients in their final stages feel very vulnerable. They need someone they feel they can rely on, someone who is ready to be there for them during times of crisis. If they have someone who can give them unconditional love, they will have the strength of spirit to deal with all the various forms of suffering that converge on them at this time.

Being patient, forbearing, sympathetic, gentle, and forgiving are ways to show our love. Physical pain and a vulnerable state of mind can make patients act out in 6

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ill-tempered and abrasive ways. We can help them by patiently bearing with these outbursts and not reacting in negative ways. Try to forgive them and sympathize with them. If we are peaceful and gentle it will help them calm down more quickly. Pointing out their negativity may be something we ought to do sometimes, but always in a gentle and loving way. Family and friends need to have mindfulness at all times, which helps us not to lose control of ourselves and keeps our hearts filled with kindness, love, and restraint. Even if we don’t know what to say to make them feel better, just physically touching them in a gentle way will enable them to feel our love. We may hold their hand or touch their arm and squeeze it gently, embrace them, or touch their forehead or abdomen with our hands, while sending them our good wishes. For those who have some experience practicing meditation, you can bring your mind to rest in a peaceful state, while touching the patient. Loving-kindness (metta) that emanates from a mind that is peaceful and concentrated will have an energy that the patient will be able to feel.

A Buddhist Approach to Patient Care

them in the dark will leave such patients with less time to prepare themselves for death. Still, telling them the bad news without preparing them for it psychologically in some way before hand, may cause their condition to worsen. In general, doctors play the important role in telling the news, especially after they have built up close relationships with patients and earned their trust. Nonetheless, patients’ acceptance of their impending death involves a process that takes a long time. In addition to love and trust, doctors, nurses, family and friends need to have patience and forbearance and be ready to listen to the patient’s thoughts and feelings. Sometimes, however, it is up to the family to break the news. Many families tend to think that it is better to conceal the truth from the patient. But according to a survey done of patients, the majority responded that they would rather be told the truth than be kept in the dark. And even when relatives try to conceal it, ultimately the patient can discern the truth from the changed manner and behavior of family and friends, such as unsmiling faces, softer speaking voices, or greater effort made to please the patient.

If patients do not have long to live, letting them know so, will give them time to prepare themselves while they are still physically able to. But there are a great many patients who have no idea that they have a serious terminal illness and are in their final stages. To let time pass while keeping

Not all patients can accept the truth after they are told. But there could be several reasons for this besides the fear of death. They could have some unfinished business or other worries. Relatives ought to help them express their concerns. If they feel they have someone ready to listen to and understand them, they will feel safe to confide their inner thoughts. Posing appropriate questions can also help

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2. Help Patients Accept Impending Death

A Buddhist Approach to Patient Care

them identify what it is that is preventing them from accepting death or help them realize that death may not be so fearsome. What relatives can do is listen to them with an open nonjudgmental, and sympathetic heart. They should focus more on asking questions rather than lecturing or sermonizing. Helping patients lessen their worries about their children, grandchildren, spouse, or other loved ones may help them accept their death. Patients may become angry at doctors, nurses, and family for telling them the bad news, or concealing the bad news from them for a long time. Be understanding of these angry outbursts. If the patient is able to get past their anger and denial of death, they will be more able to accept the reality of their situation. When patients are told the bad news, they should at the same time be given moral support and reassurance that family, friends, doctors, and nurses will not abandon them, but will stay by their side and help them to the utmost of their abilities until the very end. Giving moral support during crisis points when a patient’s condition takes a turn for the worse is also very valuable. One useful benefit of telling patients the truth in a timely way is that it enables them to decide in advance what level of medical intervention they would like to receive when they reach crisis point or fall unconscious, i.e. whether they would like doctors to prolong their lives as long as possible using all technological means available such as CPR, respirator, feeding tube, etc., or whether they would like doctors to refrain from 9

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using these measures and just maintain their condition, letting them gradually pass away peacefully. Many times patients did not decide in advance because they did not know the real state of their condition. The result is that when they fall into a coma, relatives have no choice but to ask the doctors to utilize every possible measure to sustain the patient’s life. This often causes much suffering to the patient, with the only effect being to prolong the process of dying without helping to improve their quality of life at all, while costing a lot of money in medical expenses.

3. Help Patients Focus Their Minds on Goodness Thinking of goodness helps the mind become wholesome, peaceful, bright, less fearful, and better able to deal with pain. What the Buddha and his disciples often recommended to those on the verge of death was to recollect and have firm faith in the Triple Gem, i.e. the Buddha, the Dhamma, and the Sangha. Then, he had them establish themselves in morality (sila) as well as recollect the morality they had upheld in the past. The Triple Gem can be thought of as something virtuous or holy that the patient worships and sila as his or her good deeds. There are many ways to help incline patients to recollect these things. For example, you can: Place a Buddha statue or other sacred object or pictures of respected spiritual teachers in the patient’s room to serve as aids to recollection.

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q

Invite the patient to chant or pray together.

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Read out dhamma books loud to the patient.

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Play recordings of dhamma talks or chanting.

Invite monks, especially ones the patient has a connection with, to visit the patient and provide counseling; this will help greatly in raising the patient’s spirits. In applying these ideas, keep in mind patients’ cultural background and personal habits. For example, patients of Chinese background may respond best to pictures of Guan-Yin. If the patient is Christian or Muslim, one may use the appropriate symbols of these religions instead. Another way to incline the patient’s mind towards goodness is by encouraging them to do good deeds such as offering requisites to monks and making charitable donations. It is also essential to encourage the patient to think of the good deeds they have done in the past. This does not necessarily have to mean religious activities only, but also such actions as raising one’s children to be good people, taking care of one’s parents in a loving way, being faithful to one’s spouse, being helpful to one’s friends, or being dedicated in teaching one’s students. All of these are good deeds that can make patients feel happy, proud of themselves and confident that when they die, they will go to a good place.

A Buddhist Approach to Patient Care

clear to them that they can’t take any of their material wealth with them when they die. It is only the merit they have accrued that they can take with them. Everybody, no matter how rich or poor, or with whatever mistakes they have made in the past, has to have done some good deeds worth recollecting, to a greater or lesser extent. When they are close to dying, what we should do is help them recollect their good deeds, no matter how many terrible things they may have done in the past. If they are overwhelmed with feelings of guilt, they may not be able to see any of their good deeds. But any good deeds, even small ones, will be valuable to them if remembered during this time of crisis. At the same time, patients who have been doing good deeds all along should not let the remembrance of any unwholesome deeds (of which there are very few) overshadow all the goodness they have done, making them feel badly about themselves. In some cases, family and friends may need to list out their past good deeds as a way of confirming and reiterating them, giving patients confidence in the life they have led.

4. Help Patients Settle Unfinished Business

This pride in the good deeds they have done, and faith in the beneficial effect of such deeds, becomes very important for those close to dying for at this time it is becoming

One major cause of suffering that prevents people from dying peacefully is unfinished business. Such anxieties or other negative feelings need to be released as soon as possible. Otherwise it will cause the patient to suffer, feel heavy-hearted and push away death, and thus be unable to die peacefully, resulting in an unfortunate rebirth. Patients’ family and friends should be very concerned about these

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matters and be quick to act on them. Sometimes patients may not bring the matter up directly. Those who are around the patients should thus be very sensitive to it and ask them about it with genuine concern and kindness, not annoyance. If they have remaining work or responsibilities or a will that has not been settled yet, find a way to help bring these matters to a conclusion. If they wish to see someone for the last time, especially a loved one or someone they wish to ask forgiveness from, hurry and contact that person. If they are nursing an angry grudge against someone or have hurt feelings and grievances against a close intimate, advise them to forgive that person and let go of any anger. If they are feeling nagging guilt over some wrong they had done, now is not the time to judge or criticize them. Instead, one should help them release their feelings of guilt. We can help them open up and feel secure enough to ask forgiveness from someone while at the same time guiding the other party to accept the apology and forgive the person.

A Buddhist Approach to Patient Care

be some release of those feelings of guilt. If at some point they feel more ready to talk to that person directly, they may decide to do so on another occasion. Oftentimes the person that dying patients seek forgiveness from, is someone close, who may be right there by their bedside, such as a spouse or a child. In this case, it is easier if such a person initiates the conversation by offering her/his forgiveness first and telling the patient s/he does not bear any ill-will towards them for their past mistakes. But in order to do this, the person must first let go of any pride or anger s/he may feel. By making the first move, the person opens the channel for dying patients to ask for forgiveness more easily. Feelings of guilt, as long as they are not released, can greatly disturb the dying and make them unable to die peacefully. But once they have been able to say sorry and ask for forgiveness, they are able to die without distress.

Asking for forgiveness is not easy to do. One way to make it easier for dying patients is to have them write down their apology and everything they wish to say to the other person. They can have someone deliver it to that person or choose to keep it to themselves. The important thing is that by doing this exercise they begin to open their hearts. Even if no real communication has ensued with the other person, there will

In some cases, it is the child, relative, or friend of the dying patient who ought to ask for forgiveness. There is no other occasion where an apology is as important as it is at this point, but oftentimes children do not dare to open up to their parents even when they are about to die. Partly it could be because they may not be accustomed to talking to their parents openly. Partly it could be because they think their parents do not hold their misdeed against them or do not even know about it at all. This could be a serious and irreparable miscalculation.

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Actually, asking for forgiveness does not have to be done only with specific persons, because we all have probably done others harm without intending to or realizing it. As such, to have peace of mind and to avoid any lingering hostility with anyone, family and friends should advise dying patients to say sorry and ask for forgiveness from everyone they have ever had mutual hostility with or from everyone they have ever offended or harmed. Likewise, the family and friends of dying patients ought to ask for forgiveness from them while they are still conscious and able to understand. This provides the opportunity for dying patients to say they grant their forgiveness.

5. Help Patients Let Go of Everything A refusal to accept death and the reality of its imminence can be a great cause of suffering for people who are close to dying. And a reason for such refusal can be that they are still deeply attached to certain things and unable to part with them. This could be children or grandchildren, lovers, parents, work, or the entire world they are familiar with. A feeling of deep attachment can be experienced by people even if they do not have any lingering feelings of guilt in their hearts. Once attachment is felt, it leads to worry and fear of separation from that which they love. q

Family and friends as well as doctors and nurses should help dying persons let go of their attachments as much as possible by doing the following:

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q

Reassure them that their children and other descendants can take care of themselves.

q

Reassure them that their parents will be taken care of well.

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Remind them that all their material possessions are only theirs temporarily. When the time comes, they have to be given to others to be taken care of.

In giving spiritual guidance to the dying, the Buddha had advised that after helping them recollect and have faith in the Triple Gem and establishing them in goodness, the next step is to advise them to let go of all their concerns, such as their parents, children, spouses, material possessions and all other tangible and intangible things they are attached to. They are to let go even of any aspirations for rebirth in heavenly realms. If they are still attached to any of these things, it will hold their minds back and make them resist death, and be agitated until the end. Thus, when death approaches, there is nothing better than to let go of everything, even the notion of self. Of all attachments, there is none that is as deep and firmly rooted as attachment to self. In some people’s view, death means the annihilation of self, which is something they cannot tolerate and find very hard to come to terms with. Because deep down, we humans need to feel our self continues on. The belief that heaven exists helps satisfy this deep-seated need because it makes us feel reassured that we will live on after death. But for people who don’t believe in heaven or rebirth, death becomes the most terrifying thing. 16

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From the Buddhist point of view, there is actually no such thing as a self. It is something we have concocted ourselves out of ignorance. Those who have some grounding in Buddhism may understand this matter to some extent. But for those whose experience of Buddhism has been limited to rituals or basic forms of merit-making, it is probably not an easy matter to understand the concept of non-self (anatta). Nonetheless, in cases where family, friends, doctors, and nurses have an adequate understanding of this truth, they should advise dying patients to gradually let go of their attachment to self. Start with advising them to let go of the body, recognizing that we cannot control our bodies to be as we wish them to be. We have to accept their condition as they really are. One day, all our organs will have to deteriorate. The next step is to let go of feelings, to not identify with or attach to any feelings as being theirs. Doing this will help greatly to reduce their suffering and pain, because suffering tends to arise when one attaches to pain and identify with it as being ours. One holds that “I” am in pain instead of just seeing that the condition of pain has arisen.

A Buddhist Approach to Patient Care

of their identification with the pain as being theirs. It could be said that they used “spiritual medicine” to heal their minds.

6. Create a Peaceful Atmosphere For dying patients to be able to feel at peace and let go of all lingering concerns and attachments in a sustained manner, it is necessary for them to have the support of a peaceful atmosphere around them. If their room is swarming with people coming in and out, and filled with the sounds of people talking all the time or the sounds of the door opening and closing all day, it will naturally be difficult for them to maintain their mind in a wholesome and peaceful state. In taking care of patients’ spiritual well-being, the least that family, friends, doctors, and nurses can do is to help create a peaceful atmosphere for them. Avoid talk that disturbs the patient. Family members should refrain from arguing amongst themselves or crying. These things would only increase the anxiety and unease of the patient.

To be able to let go in this way requires considerable experience in training the mind. But it is not beyond the reach of ordinary people to do so, especially if one starts training the mind when one first becomes ill. There have been many cases of people with serious illnesses who have been able to deal with extreme pain without using any painkillers at all or only small doses. This is because they were able to let go

If family and friends just try to keep their minds in a healthy state - not sad or depressed – this will already be a great help to dying patients. This is because the states of mind of the people surrounding the dying patient can affect the atmosphere in the room and the person’s mind. The human mind is sensitive; it can sense the feelings of other people even if they don’t say anything out loud. People do not only have this sensitivity when they are normal and conscious. It is possible even for patients in comas to sense the mental energy of those around them.

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In addition, family and friends can create a peaceful environment by encouraging dying patients to practice meditation together with them. One form of meditation is anapanasati, or mindfulness of breathing. When breathing in, mentally recite “Bud”. When breathing out, mentally recite “Dho”. Alternatively, with each out-breath, count 1, 2, 3….10 and then start again. If it is not easy for them to be mindful of the breath, they can focus their awareness on the rising and falling of the abdomen as they breathe in and out by placing both hands on top of the abdomen. On the in-breath, as the abdomen rises, mentally recite, “rising”. On the out-breath, as the abdomen falls, mentally recite, “falling”. There have been reports of cancer patients who have dealt with physical pain using meditation. By keeping their minds focused on the breath or abdomen, they ended up needing to use very little pain medication. Moreover, their minds were clearer and more alert than patients who used a lot of pain- killers. Encouraging dying patients to do chanting together with family and friends in a room that has been set up to create an aura of serenity and sanctity (as mentioned earlier, such as by placing a Buddha statue or other objects of veneration in the room) is another way to bring about a peaceful atmosphere around dying patients and incline their mind in a wholesome way.

A Buddhist Approach to Patient Care

Even though a peaceful mind is important, from the Buddhist viewpoint it is wisdom that is considered the most important thing for a person close to dying (and indeed all humans, ill or otherwise). Wisdom means clear knowledge of the truths of life: impermanence (anicca), unsatisfactoriness (dukkha) and non-self (anatta). These three truths about all conditioned things show us that there is not a single thing that we can cling to. We will find death fearsome if we are still clinging to some things. But once we fully understand that there is actually nothing we can cling to, death will no longer be fearsome. Once we realize that everything by nature must change, that there is nothing that is permanent, death will become something that is natural. And once we realize that we really do not have such a thing as a “self,” then there will be no “me” that dies. There will be no-one that dies. Dying itself becomes just a change of state from one form to another, according to causes and conditions. Wisdom, the knowledge and understanding of these truths, is what makes death no longer fearsome or loathsome, and enables us to meet death peacefully.

When the Patient is in a Coma or Has Lost Normal Brain Functioning

Even playing soft instrumental music has a beneficial effect on a patient’s mental state.

Many of these various ways of helping dying persons expounded on above can also be applied to those who are in comas or are unconscious. Even though such persons may not show any discernible signs of response, that does not mean they have lost all forms of awareness. There have been

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many cases of such patients who were able to hear or even see things happening around them. They were also able to feel the mental energy of people around them. There was one patient who reported that when she was in a coma, she was able to hear the doctors and nurses talking and the sound of chanting from recordings relatives played for her. There was another case where a person lost consciousness because his heart stopped beating. He was rushed to the hospital where the doctors revived him using electric shocks. Before attaching him to a respirator, one nurse took out his false teeth. In a short while, his condition improved. The following week, when he saw that nurse again, he was able to recognize her face immediately even though at the time that she removed his false teeth he was unconscious and on the brink of death. Dr Amara Milla told the story of one patient who had been in a serious accident. While that patient was lying unconscious in the ICU for a week, she felt like she was floating around. But at certain times she would feel there was a hand touching her body that was sending her energy. It would make her mind, which felt like it was adrift and about to be cut off at any moment, come together as one again. She would regain consciousness for a short time before drifting off once more. This happened everyday. Later, when she had recovered, she found out that there was a nurse who would come visit her every morning at the start of her shift. The nurse would hold her hand and send her loving-kindness (metta) to

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give her moral support. She would wish for the patient to have strength and regain consciousness. In the end, she did regain consciousness and recovered fully even though the doctors had predicted a very slim chance of recovery. This is another example of how even though someone may have lost consciousness, their mind is still able to feel and be aware of the energy of loving-kindness of those who are close by. For this reason, family and friends should not lose hope when their loved one falls into a coma or loses consciousness. There are still many things we can do for unconscious patients. T o review To review,, we can: q

Read dhamma books to them.

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Play recordings of dhamma teachings or chanting for them.

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Encourage them to recollect the holy things that they venerate and things that are wholesome, including their own good deeds in the past.

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Say things to ease their anxiety about their children or other attachments.

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Advise them to let go of everything.

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Create a peaceful atmosphere around them.

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Be careful of what you say and do at their bedside. One should not cry hysterically or argue or say anything that could trouble them. 22

A Buddhist Approach to Patient Care

Remember this principle: whatever we feel we should do for people when they are still conscious, we should keep on doing the same thing when they are no longer conscious.

7. Say Goodbye For those who would like to say what is in their hearts to the dying person, such as an apology or goodbye, it is not too late to do so. There was once an old woman who was sitting by her husband’s bedside feeling deeply grieved because she had never told him how much she loved him. Now he was in a coma and about to die. She thought it was too late to do anything now. But the nurse encouraged her, telling her that he may still be able to hear her even though he showed no sign of reaction. So she asked to be left alone with him, and then told him that she loved him from the bottom of her heart and was so happy to have lived life together with him. After that, she bade him goodbye by saying,

“It will be very difficult for me to live without you. But I don’t want to see you suffer any longer. So if you would like to go now, please go. I give you permission to die.” As soon as she finished speaking, her husband let out a long breath and passed away. As a person’s pulse weakens progressively and they approach the moment of death, if family and friends wish to say goodbye, they should first establish mindfulness, restrain their grief, then whisper their final words in the ear of the dying 23

A Buddhist Approach to Patient Care

person. They should talk of the good feelings they have towards the person, give her/him praise and thanks for all the good s/he has done, ask for forgiveness for any wrongs committed, then guide the person’s mind to ever more wholesome states by advising her/ him to let go of everything, drop all worries, recollect the Triple Gem or whatever s/he venerates. If the person has some grounding in Buddhist teachings, tell her/him to let go of the “self” and all conditioned things, incline the mind towards emptiness, and keep the mind focused on Nibbana. Then, say goodbye. Even if one has said goodbye to someone when they were still conscious, it is still useful to say goodbye again just before they die. The important thing to keep in mind is that being able to say goodbye and guide the dying person’s mind to a wholesome state can only be done well if the atmosphere surrounding the person is peaceful, and they are not disturbed by any attempts to perform invasive medical interventions. In most hospitals, if patients are in the ICU, and their pulse weakens to the point where they are close to dying, doctors and nurses will tend to do whatever it takes to keep them alive such as by stimulating the heart with electric shocks (defibrillation) or using all other available forms of medical technology. The atmosphere around patients will be chaotic and it will be difficult for family and friends to say anything to them. The only exceptions are cases where patients and

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

family members inform hospital personnel in advance of their wish that the patients be allowed to die peacefully, free of any medical interventions. For the most part, doctors and family members tend to think only about helping the patient in terms of their physical welfare, and neglect to think about their spiritual welfare. So they tend to support the use of all available forms of medical technology to prolong the patient’s life, even though when people are close to dying, what they actually need the most is spiritual help. Thus, if the patient’s condition worsens to the point where there is no hope of recovery, family members ought to give greater consideration to taking care of the patient’s state of mind, than of their body. This may mean asking others not to crowd around the patient and allowing her/him to die peacefully surrounded by close family and friends, who join together to create a wholesome and positive atmosphere that will help lead her/him to a good rebirth. In general, the place that is the most conducive to creating this kind of atmosphere tends to be the dying patient’s home. For this reason, many patients wish to die at home rather than in the hospital or in the ICU. If family and friends are ready to help meet the spiritual needs of dying patients, it will be easier for patients to decide to spend the last part of their life at home.

Embrace Death By Venerable Phra Paisal Visalo

Life and death are actually one and the same matter. We will die in more or less the same fashion as how we live. If we live in ignorance, our final moment will likely be spent in agony, without any sense of peace and mindfulness. But if we constantly cultivate merits and self-awareness, we should be able to pass away peacefully, being in the state of mindfulness until our last breath. Life of the awakened one is to be aware of the prevalence of death all the time. There should be the ever readiness to confront death. And even when the mind does not yet feel ready, it can be further trained every day as the person performs his or her duty to the best, having accepted that uncertainty is but a fact of life.

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There are several methods to cultivate this contemplation on death, or Marana sati. Just a thought that we will all die sooner or later, so we should maximize wholesome use of the remaining time we have, is one example. However, for most people, such recollections may not be enough. They may be keen for a while, but eventually, their lives will fall back into the

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

same patterns of habits, indulging again in the work or entertainment at hand, while forgetting the most important thing to do in their lives.

Think of how every breath will dissolve as death arrives. The heart will stop beating. The body will no longer be able to move, and it will turn cold and stiff, not unlike a useless log.

One simple way to contemplate on death is to imagine what might happen to us if a death really took place – now. What would we lose? Whom would we miss? There might arise a feeling of pain for those who think they are not yet ready. But such an unpleasant situation might help him or her to be better prepared in the remaining time we still have, in order to deal with the suffering when the moment of loss actually comes.

Then think of how every valuable material we have acquired and kept will no longer be ours. They will belong to someone else. We cannot do anything with them. What we used to hold dear will be left unattended.

Here are some more ideas about how to contemplate on death and dying:

Practice dying at bedtime At the end of the day, the time to rest the mind and the body, is a good opportunity to reflect on the inevitability of death. Practice the process of dying as if we were facing it at this very moment. The suitable posture is to lie down and relax every part of the body from the head to the toes and especially the face. Breathe in and out freely. Feel the tip of your nose and the softness of the in- and out-breaths. Put down every thought, be it about the past or the future.

Moreover, we will no longer have another chance to talk with our children or our beloved. Everything we used to do with them will become the past. We will no longer be able to visit our parents or do anything more for them. There is not even time to say good-bye, or to make amends with those we have had grudges with. All the work has to be left behind too, even those that have not been finished. We can no longer make any further revision. However important that work is, it will have to be abandoned. It is the same with all the knowledge and experiences we have accumulated – they will all disappear with us. All the fame, power and supporters will leave our hands. No matter how powerful we are, we cannot take any of these things with us. Do not expect that people will continue to praise us after we die. Even our name will be finally forgotten.

As the mind calms down, think of how we are approaching death. We just don’t know when. Tonight might be the last night for us. Tomorrow might never come.

As we reflect on this, observe our feelings. Do we worry, regret, or have an attachment to any of these? Are we ready to accept these losses? If not, what makes us still agitated? Such

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

contemplation will help us realize that there are a few things that we should do but have not yet done (or done enough), as well as things that we still feel a strong attachment to. Such awareness will prompt us to do the important, but often overlooked matters, as well as practicing the art of letting go.

Attending a funeral service should also be the time to remind ourselves of the imminence of death. Once the deceased also walked and moved about like us. In the future, we would all have to lie down like him or her, not being able to take anything with us except the effects of our good or bad deeds.

Contemplation on death on various occasions

The best dharma teacher is the body in the coffin in front of us. He or she is trying to wake us up from indulgence and heedlessness in life. Whoever believes they still have a few more years to go will have to think again as they attend the funeral of a child or a teenager. Those engrossed in their power should realize that however “big’’ they may have been, everyone will end up being smaller than the coffin that would contain their body.

In fact, one can contemplate on death any time during the day. When travelling, by car, boat or plane, always be prepared. If there is something untoward happening in the next few seconds, how should we confront it? What would we think of first? Are we ready to give up everything we feel attached to at that point in time? When leaving the house, think if this could be our last trip and we may not be able to return to see our parents, beloved, or children again. Is there anything left that we may have regretted having not finishing them first? Are there any conflicts that we may wish we should have reconciled? Such awareness will urge us to try to treat our family better and not let certain issues to be resolved in the future – for such a day may never come. Reading newspapers, especially reports about accidents or disasters, is another opportune moment to contemplate on the uncertainty of life. Anything could happen without warning; people can die at any place and time. Try to think of how the same thing might happen to us, too. Will we be able to confront it? Are we prepared to die?

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Similarly, when visiting the sick person, we should remember that our body will one day be in a similar condition. Again, the patient, especially the terminally ill, is like our dharma teacher. Whatever their reactions – anxious, traumatic, desperate – they are teaching us how to prepare ourselves, so that when our turn comes, we may not suffer as much as they do. The sick person who seems to be in peace and able to maintain his or her composure despite the apparent physical pain, is also showing us examples on how we should likewise prepare ourselves, especially while we are still in good health. To keep our mind still in time of sickness is the same matter as to keep our mind still when facing death. So think

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A Buddhist Approach to Patient Care

of the period when we fall sick as an exercise to prepare ourselves for death. Sickness is like the first few lessons before we move on to the most difficult level – if we cannot deal with sickness, how then can we confront death?

Reminders on death We could apply anything we come across in our daily life to remind us about death. It depends on one’s circumstances and creativity. Some Tibetan meditation masters would pour all the water from their personal glasses and put them with the bottom up next to their beds. They do this because they were not certain if they would be able to wake up and use the glass again on the following day. The ritual thus served like a reminder for the masters that death could come to them at any given time. Later, a Thai writer has learned about this story and applied it to herself: Every night before she goes to bed, she always makes sure that every dish has been washed thoroughly. So if she happened to die in her sleep, there would be no dirty dishes left as burdens for others, she said. A 55-year-old man used marbles as his “death reminders’’. Each marble is equivalent to about a week of living. The man has calculated that if he were to reach the average life span, taken to be about 75 years old, he would have about 1,000 weeks left. So he bought 1,000 marbles and put them in a plastic box. Every week he would take out

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A Buddhist Approach to Patient Care

one marble from the box. The diminishing amount of the marbles reminds him that his days are numbered. It reminds him of the approaching death, which enables him to choose to do the most important thing, and not let himself drift away worrying over the inconsequential. Each person can choose different “reminders’’ – from the sunrise and sunset, or the flower that comes out in a bud, blooms and finally withers away, or a leaf that springs from a tree branch and finally falls down to the ground. They remind us of the transience of life. Lord Buddha once suggested one should view life not unlike the foamy top of the waves, or as a dew drop, a lightning flash – they are all transitory, and thus is our own existence.

Other activities to prepare for death We could try an exercise of “letting go’’ of our beloved people and belongings. Choose seven objects – it could be a person, a pet animal, or something we consider dear to us – and ask ourselves, if we were forced to give up one thing, which thing would it be? Continue with each of the remaining six objects. We could imagine ourselves being in an unpleasant situation – like facing a fire, an earthquake or an accident – that prompts us to lose each of our cherished items. What would we choose to keep? And what to give up? Such an exercise will teach us how to let go. It will help us review our own sets of attachments, to discover what we consider to be the most important in our lives. Some may find they love or worry about dogs more than their brothers 32

A Buddhist Approach to Patient Care

and sisters. Others may be willing to give up everything but not their favourite doll. Still others would choose their computer as the last item to give up. We may uncover something in ourselves that we have not been aware of before – and then we could try to adapt to the changing circumstances. All this is crucial in the preparation for death since ultimately we will have to lose everything one way or the other. Actually, even when we are still alive, we are bound to lose certain things or people, and often without the ability to make a choice of what we would like to keep and what we would like to lose.

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A Buddhist Approach to Patient Care

Universal Charm By Venerable Ajahn Jayasaro

Dhamma Talk Given at the Funeral Rites for Maleewan Horayangura. On 8 April 2008 at Wat That Thong, Bangkok, Thailand Today we have the opportunity to come and show our respect, love, and remembrance of Maleewan Horayangura. Whenever someone whom we love, respect, and feel gratitude towards passes away, it is natural that we will feel sad that another good person has left this world. But for Buddhists, in the face of such regret and sorrow, we still have our belief in and understanding of the law of karma to comfort us. Some people think that teachings about the law of karma, or indeed all religious teachings, merely serve the purpose of consolation. But what the Buddha discovered and realized was the truth about life, and from his vast knowledge he selectively chose to teach only those parts that would be useful to people. He unveiled only those parts that we can understand and make use of to bring happiness to our lives. The law of karma is one of those parts.

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A Buddhist Approach to Patient Care

The law of karma is the law of action. The Buddha said that all intentional actions, whether of body, speech, or mind, have meaning. The meaning is the effect they produce. Whatever we intentionally do, say, or think doesn’t just disappear from the world. It has a real effect. Whether other people are aware of our action or not, whether it’s widely known of or we keep it a secret, whether we believe in the law of karma or not, each of our actions has a force that produces an effect. So our belief in and understanding of the law of karma lets us rest assured and be at peace with everything that happens during our lifetime. We see and understand that all things happen according to causes and conditions. They don’t happen according to fate or determination by a divine power. They happen according to causes and conditions. It’s true that the web of causes and conditions shaping our lives is so complex that we can’t clearly point to this or that thing as the cause of this or that effect. It is a very intricate matter. But the bottom line is that whether our lives will be good or bad, whether we will progress or regress, depends on the quality of our actions. And we humans have the ability, the capacity, to take responsibility for our actions.

A Buddhist Approach to Patient Care

that that person has a lot of spiritual wealth which she can take with her. All the praiseworthy things that she has done, said, and thought haven’t disappeared or died. The only thing that has died is the material part of her life, what she has borrowed from this earth for temporary use: the elements of earth, water, wind, fire. This is what can die. But the merit (puñña), the power of goodness, that the deceased person has made doesn’t die. It is real and it is what will continue to nourish the flow of consciousness of that person. When we reach the last day of one life, it is like the closing of one scene in a play. Everything finishes, disappears, ends. But the effects of our karma, the good deeds and bad deeds we have done, don’t end there with it.

The Buddhist teachings emphasize actions or practices that will help us take on more and more responsibility for our lives, until we reach the point that’s called being our own refuge. If we remember the deceased, their good deeds and their virtues, with right view about the law of karma, even though part of us may still feel sad, mournful, and a sense of loss, another part of us will feel refreshed and uplifted knowing

In the case of Khun Maleewan, I believe she has accumulated a substantial store of provisions for her journey. I did not personally know Khun Maleewan herself, but I do know both of her daughters. I’ve learned that Khun Maleewan was a very kind and compassionate person. Wherever she went, she inspired affection. Even when she went abroad, such as when visiting her daughters in America, I’m told that whoever she met, even briefly, would feel she was a loveable person. What could this be the result of, if not her goodness and the meritorious deeds she had done in the past? At a worldly level, this may be called “charm” or whatever. But on the dhammic level, this is called the effect of a feeling of purity – when our minds are free of any thoughts of taking advantage of others, of taking revenge, or of causing harm, and are filled instead with thoughts of giving happiness and being useful

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to those around us. This is how the effect of karma, of good karma, of wholesomeness, manifests. Goodness or meritorious deeds may not be as highly regarded these days as in the past. In today’s society, we worship financial success. We measure people according to things like wealth, position, adulation, and fame. This debased, superficial way of thinking is supplanting the old Buddhist culture, which held that what makes a person good, highly developed, and honorable is the store of meritorious deeds they have accumulated. I think we should try to maintain this old standard. After someone who has done many good deeds passes away, we may personally still miss that person. But if we view the situation with the eyes of Dhamma, with wisdom and the understanding of nature, we will consider that it is correct. It’s correct the way it is. If we view the situation with craving and expectations, in a worldly way, we may think that a person who is only sixty-something is not that old, and ought to have lived longer. But if we look at it in a truly Buddhist way, we will consider it correct. Death at sixty-two is correct according to the law of karma. That was all that that person’s store of merit afforded them. So it is correct according to their causes and conditions. That is how we consider it. If we are interested in studying our own life, observing the movements of our body and mind, observing our actions, their effects, and their impact on other people in the short term and long term, it will make us intelligent about actions and the workings of cause and effect. The more we observe 37

A Buddhist Approach to Patient Care

and study, the more we will see and realize, and the more we can become equanimous and accept things as being correct the way they are. Everything that happens is correct according to its causes and conditions. Someone who has done a lot of good deeds in the past is going to receive the fruits of that goodness. Those with refined minds will naturally be reborn in a refined place. Meanwhile, those with coarse minds will definitely be reborn in a coarse place. This is also likewise the fruit of their actions. In the case of a good person, who tried to do good and be a good daughter, a good mother, a good wife, who tried in all aspects of her life to do the best job she could, we need not have any doubt that her dedicated efforts will equip her with abundant provisions – perhaps we might call them “vitamins” – that will bring her much beneficial effect. When someone, perhaps a family member or a friend who was good to us, whom we love, respect, and were close to, passes away, it isn’t only that single individual’s affair, because she or he was a part of our lives as well. So when someone who is close to us dies, it is like a part of our own life also dies. Then let us observe the sadness that we feel, noticing that partly we are sad that that person has passed away. But in the case of a good person, we don’t have to be so sad because we believe that they have gone to a good place, and are probably enjoying even more happiness now. In feeling sad, it’s probably more that we are feeling sad for ourselves than anything else. It’s really more like self-pity. We

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will now have to be without that person. A part of our life is now dead and gone. Buddhism teaches us that anything can have power over our lives and can make us suffer at any time, as long as we do not see through its tricks. But, with all things, if we can fully comprehend them, if we don’t turn our backs on them or run away from them, if instead we dare to look them in the face, confront them, see through their tricks, we will rise above them. Those things won’t be able to control our minds and make us suffer anymore. We will not fall prey to them anymore. The Buddha thus taught us to contemplate frequently in our daily lives that we have aging as a natural part of our lives, that we cannot escape the experience of aging. We have sickness as a natural part of our lives; we cannot escape the experience of sickness. We have aging, sickness, death, separation from everything as natural parts of our lives. We have to think about this frequently, we have to contemplate this frequently in order to realise the truth as a direct experience. Observe it in your own life. Observe it in the lives of the people around you. Observe that even in each day, in each hour, in each minute, there is birth and death, there is separation from what we love, occurring all the time.

A Buddhist Approach to Patient Care

us to gradually become more familiar with what separation feels like. We can then make friends with that feeling. Once we are friends with that feeling, no longer fearing it or wanting to run away from it, we will be able to see that it is in fact a part of the world, a part of life. Our minds will feel, to lesser or greater extent, open and liberated. We will see that life is just like this. And we will see that separation does not necessarily have to make us depressed. It does not have to make our minds suffer. Because a mind that is one with nature, and accepts that all things happen according to causes and conditions, is a mind that is ready to act, ready to speak, ready to think in the correct way at all times. That correct-ness itself is Dhamma. How are we to practice dhamma? We practice with persistent effort, in every posture, in every minute of the day, to be with what is correct, whether in body, speech, or mind. We do not do things according to our heart’s desire. We try to incline our minds towards what is correct. We learn from every experience.

If we are interested in studying our life, both the aspects we like and the aspects we don’t like, and try to register and remember every instance wherein we have to separate, even just temporarily, from a person or thing that we like, it will help

So in this situation where we have experienced separation from a loved one, what is the correct thing to do? The correct thing for us to do is to come and perform funeral rites with our body, speech, and mind. If we are just going through the motions of attending funeral rites with our body, but our speech is not restrained or controlled, and our minds are left unguarded, free to proliferate thoughts about this or about that, this is not considered correct. This is not dhammic. This does not really produce much merit.

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

Holding ceremonial rites creates an opportunity for a lot of people to gather to do good deeds together and generate positive energy through the practice of restraining body, speech, and mind. It creates the foundation for goodness, beauty, and pure thoughts to arise in our minds. That goodness and beauty the Buddha called “puñña” (merit). Once merit has arisen in our minds, the correct thing to do next is to dedicate this merit to the deceased person. For even though this life of theirs has ended, their wandering through the wheel of rebirth, or samsara, has not. The way we can demonstrate our good feelings for the deceased person is to dedicate merit, which is something intangible, to them. Even though we can’t give them material things anymore, that doesn’t mean we can no longer give them anything or do anything for them at all. Because we have this intangible thing, merit, that we can still give the deceased as a gift for their journey ahead. So today, in sacrificing our time to come and join in these funeral rites, in sitting in a restrained and careful manner, and in listening attentively, we have done what is correct in body, speech, and mind. Our minds have experienced some peace and coolness. At this point, with a mind filled with respect, love, and remembrance of the departed one, may all of us dedicate the merit we have made to Maleewan Horayangura. If she is in a place or state in which she can receive this merit, may she receive it. If she is experiencing any suffering, may she be free of that suffering. If she is experiencing happiness, may she have greater and greater happiness from here on to the end of time.

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

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A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care

A Buddhist Approach to Patient Care