Reflective practice

The image "Reflection" is by Claudia Markovitch.

Ms Marilyn Miller-Pietroni, adult psychotherapist and previously a lecturer at the University of Westminster says that in her personal journey from psychotherapy to meditation, she discovered that “reflection is a mind that watches itself. It is disciplined and not research-free."

She emphasises that each client encounter is a new one and recommended, “Every health practitioner needs a state of ‘calm receptiveness’ in order to avoid bias arising from the last session, past interaction or a desire for definitive outcome.”

Seaside Hospice

This is "Fair Havens" Hospice in Westcliff-on-Sea, near Southend-on-Sea in Essex. I suppose it could be called "my local Hospice" as it's the nearest to my home. It's also one of the first hospices to have been established in UK, as it was opened in 1983, its inspiration coming directly from the teachings and example of Dame Cicely Saunders.

The caring work of Fair Havens (and its partner children's facility Little Havens) is 77% funded by charitable donations, both private and corporate, and only the lesser fraction comes from Government. This is true of almost all hospices in the UK. It is also true that no more than 4% of those who die actually end their days in a hospice bed. This small percentage takes no account, however, of the many more who are supported by Day Services operated by the hospice, by short-term respite and palliative care options, and through family support e.g. bereavement counselling and specialist social work intervention.

Today I attended a "Multi-Faith" get-together hosted by the chaplaincy team, and joined a tour of the premises, escorted by various members of hospice staff who answered questions and offered information. As can be seen by the photographs, the hospice comprises two detached (former) family homes that have been modified and joined together. Another similar building on the same plot provides the premises for Day Care. Amazing ingenuity has been used to make optimum use of the limited space for eight bedrooms, all the necessary ancillary rooms, toilets, bathrooms, offices, a chapel, restaurant etc etc without ever seeming claustrophobic or cramped. The level of housekeeping and comfort achieved is, in my opinion, incomparable; and the provision for nursing and medical care would rival the best-equipped hospital.

I was accompanied on my tour by a Muslim G.P., Dr Pasha, who has practised family medicine in Southend-on-Sea for 50 years; before that he worked and trained at a hospital in Stourbridge in the West Midlands. He recounted to me his interview with Matron, who inducted him properly in what it was appropriate for a young and inexperienced doctor to do, and what he should not do, on pain of her displeasure. And he recollected being taught by a Ward Sister how to practise venepuncture to collect a specimen of blood, without causing the patient bruising or pain. In conversation with this man, one could not imagine a more gracious and delightful companion.

As it is the Muslim month of Ramadan, Dr Pasha eschewed the offer of tea and cake from his hosts. He told me that, at sundown when it is permissible to eat and drink, he is content to drink a little water and eat a morsel of food; then he allows his body to relax and prepare for a meal later in the evening. He told me that it is usual for younger people to fall hungrily on the food as soon as it is time to eat but, for the older man, a little restraint is more seemly and better for the constitution.

Dr Pasha was generous in his appreciation of the virtues of Christendom in practising love-in-action. He said that, with Islam, he thought Christianity was a religion that engaged with real-life suffering and deprivation where it found it. His view was that, in their belief in an after-life, Christians and Muslims invested this earthly life with a special meaning and significance for action by believers, not in the hope of reward or fear of punishment in the hereafter, but rather so as to help bring heaven closer to earth while they lived, for its own sake.

There wasn't much time to discuss the possible merits of dharma, nor did it seem the right place to do so, but it was an enjoyable and heart-warming experience overall, an opportunity to refresh friendships with colleagues, to meet new people, and to gain fresh knowledge and inspiration for the future.

The Buddha's Words on Kindness (Metta Sutta)

"Buddhist monks chanting the Metta Sutta marched the streets in Mandalay, Burma, in protest against the vile tyrrany of the ruling military junta, and their 20-year suppression of democracy".

Just over a year ago, I heard the Metta Sutta expounded by a monk at the
funeral of one of the Buddhist Hospice Trust's staunchest, most
generous, and most devout supporters. MK lived alone for many years
and was regarded by some as eccentric, as she was Austrian, of strikingly ascetic appearance, spoke
in very heavily accented English and, although she was almost totally deaf, frequented every Buddhist talk or exposition of the Dharma she could get to, usually sitting in the front row nearest the speaker.

In her last few years, confused, isolated, and resolutely adamant about remaining independent, she was treated like a wounded animal by local youth, teased and mocked, and her few possessions stolen by casual burglary.
In the weeks leading up to her death she was knocked over by someone on a
pavement bicycle, went to hospital with a broken hip, entered into
rapid decline with signs of agitated confusion (common after trauma in
old people), wouldn't eat or accept treatment, and had no visitors
except the hospital chaplain who contacted me, and Ananda Networker Netta Wills who took her vegetarian food to tempt her towards health, and comforted her.

By the time I made arrangements to visit her she had already died. There were only six people at
her funeral, as she had no family. I handed out some Swiss Ricola
Herbal Sweets to mourners, because she always carried them and pressed them on
everyone she met: they were almost her personal "signature". She used
to say something like "Zey are for children not suitable to be given"
every time.

Why am I recounting this anecdote? Well, mention of the Metta Sutta
brought the memory of MK to the front of my mind. And the mundane
circumstances of her death which were in every sense of the word
commonplace. But I am confident that she died as she had lived in a
state of Buddhist grace, of sublime abiding, fruit of her lifelong generosity and
devotion to Buddha, Dharma and Sangha.

The Buddha's Words on Kindness (Metta Sutta)

This is what should be done
By one who is skilled in goodness,
And who knows the path of peace:
Let them be able and upright,
Straightforward and gentle in speech.
Humble and not conceited,
Contented and easily satisfied.
Unburdened with duties and frugal in their ways.
Peaceful and calm, and wise and skillful,
Not proud and demanding in nature.
Let them not do the slightest thing
That the wise would later reprove.
Wishing: In gladness and in saftey,
May all beings be at ease.
Whatever living beings there may be;
Whether they are weak or strong, omitting none,
The great or the mighty, medium, short or small,
The seen and the unseen,
Those living near and far away,
Those born and to-be-born,
May all beings be at ease!
Let none deceive another,
Or despise any being in any state.
Let none through anger or ill-will
Wish harm upon another.
Even as a mother protects with her life
Her child, her only child,
So with a boundless heart
Should one cherish all living beings:
Radiating kindness over the entire world
Spreading upwards to the skies,
And downwards to the depths;
Outwards and unbounded,
Freed from hatred and ill-will.
Whether standing or walking, seated or lying down
Free from drowsiness,
One should sustain this recollection.
This is said to be the sublime abiding.
By not holding to fixed views,
The pure-hearted one, having clarity of vision,
Being freed from all sense desires,
Is not born again into this world.

Dedicated to the memory and to the merit of Marghareta Khan, lately supporter and generous benefactor of the Buddhist Hospice Trust and Inner Work School.

__._,_.___

Customer Service at your service....

You voted, I noted. And the software mis-toted (there were seven votes apparantly amounting to 113% of the poll). I didn't vote myself, honest!

Altogether, I am amazed at the response, as I had no idea (or not much idea) that anyone ever looked at the blog, and I'm gratified at the response, although I'm not about to beat my breast to announce how I feel otherwise.

But of course I can't help being influenced by the readership, and it remains to be seen how, doesn't it?

Thank you all for your input, and please keep visiting.

Positivity in Healthcare

Last Sunday I attended a whole-day workshop at the premises of the Brahma Kumaris Global Spirituality University in Pound Lane, Willesden, North-West London, my third visit to an event offered by the Janki Foundation.

At first acquaintance, the Brahma Kumaris (who offer their premises to Janki without charge) appear an other-worldly lot. They are all clad in white clothing, and look serene and approachable. Although I wore week-end jeans and a rugger shirt, and looked very much not a member of the congregation, who are mainly of Asian appearance, people met my eyes and smiled warm acknowledgement. The building is designed and fitted out as a modern conference center, but in a palpable way it seems to signal receptivity and calm. It's hard not to feel at ease there, despite its unfamiliarity to a newcomer.

The workshop was attended by about forty men and women, mainly health-care professionals, but with a sprinkling of business types including two financial analysts from Bloomberg. The facilitators were part of an established Janki team, volunteers who held down jobs outside the organisation. The workshop was a module from the extended VIHASA programme (Values In Healthcare - A Spiritual Approach) which, despite sounding rather esoteric, is culturally neutral and applicable to healthcare and its workers everywhere. Indeed, the full VIHASA programme has been trialled in Asia, Africa, the Carribean and in several European countries, with excellent evaluative reviews.

The workshop is a carefully balanced mixture of experiential and propositional work in small groups, in pairs, and as a full collective, with time for individual reflection and 'guided meditation'. The two facilitators were skilled and charismatic, never tipping over into 'facilitator-speak' or sententiousness. The workshop offered a taste of how the seven spiritual skills of VIHASA are nurtured and developed: these are described as "reflection, visualisation, meditation, appreciation, listening, creativity and play". At the heart of these activities is a powerful message of individual worth, of unique self-hood, and our capacity for compassion.

When returned home my wife commented on my looking "sun-kissed", as if I had been out in the sunshine. I knew that this glow was an inside-out manifestation. First I had been invited to choose a colour that would suffuse my day, and I had immediately known it should be "vibrant peach", though where that idea came from is anybody's guess! I am usually more a brown or blue man. Later, when invited to reflect on the meaning of positivity, my mind had delivered in quick and unambiguous succession the words "Energised", "Potent", "Open", "Sensitive" and "Whole". It is fair to say that on waking that morning I had felt anything but as I faced the long journey up across London to the venue. But that is what the workshop and its participants delivered to me, and - by all accounts - what it gave everyone who attended, and I am deeply appreciative of those gifts as I write. I hope very much to be able to offer some part of the VIHASA programme to Trust volunteers (and others) in future, and have booked to undergo facilitator training later this year, at Janki Foundation's generous invitation.

For more information on the Janki Foundation please use the links above and to the right of the posts, or contact me in person.

Difficult decisions

This Trust often gets requests for help, support and advice that give rise to difficult decisions. The Trust has defined charitable aims, set out in its founding charter. Broad in one sense of allowing for natural growth and diversification, the core 'business' of the Trust is that of supplying spiritual support for seriously ill, dying and bereaved people (notionally Buddhists), but in practice anyone who seeks help from a Buddhist perspective.

It is through this rather restrictive 'lens' that requests have to be examined. The Trust doesn't and can't offer a panacea for all ills, indeed it is hard-pressed enough to fulfil its supplementary objectives of teaching, promoting and developing the principles of hospice, and of encouraging personal openness to death and dying in the midst of life: "Hospice in the Heart".

So Paul King's combined invitation and enquiry posed a dilemma for me, as one of the Trust's representatives and a first-line of response via the website. Paul was tasked by the Five Buddha Shrine (in Las Vegas) to arrange an visit by Master Yu Tianjian, leading exponent of esoteric Hanmi (Chinese) Buddhism, to the United Kingdom in September of this year. An outline itinerary and background information is shown here. Paul thought that, as a hospice, we might know of individuals who might wish to avail themselves of opportunities for healing that Master Yu might bring. Paul offered attestations from people who had declared themselves healed in his presence, and Paul's reverence for, and faith in the Master was compelling. Paul affirms that he, Master Yu, comes with the most exalted recommendations and testimonials to his spiritual authority. Paul, as "his only English disciple", wishes fervently that others might experience, as he has experienced, the transforming power of the dharma as expressed by this "living Buddha".

I explained the Trust's un-afffiliated and disinterested stance re the many and various expressions of Buddhism, the so-called "many Buddhisms". We don't act for or on behalf of any sect or tradition, nor do we seek spiritual direction from a particular teacher or Master. In the eyes of many Buddhists this exposes a serious weakness in the Trust's legitimacy, but that is a non-healing wound we are willing to bear. I also explained that I could not, in conscience, exploit the vulnerability of individuals by holding out to them or their friends hopes of healing from any self-advertising source, however sincerely held his disciples' beliefs, or firmly established his own claims to esoteric powers.

Paul is a busy man, and our debate had to be curtailed for that reason. This post is a respectful compromise that I am sure, or at least I hope, Paul and Master Yu will acknowledge as fair both to their vocation and mission, and to the principles that guide our work. The links above are provided by Paul, and any further enquiries should be addressed to him via those. It goes without saying, I'm sure, that we wish Paul, Master Yu Tianjian and his retinue, and all who meet them, a safe and successful visit to our shores, and our best wishes for their endeavours while they are here.

"A small number of days..."

There's a new NHS protocol or procedure available increasingly to dying individuals in hospital, in residential care, hospices and in their own homes via Community Nurses. It's called the Integrated Pathway for End-of-Life Care, and I had my first professional dealings with it today.

Based on principles developed over many years in hospices and specialist palliative care services like Macmillan, it states that:

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Too many patients die an undignified death with uncontrolled symptoms (e.g. pain, breathlessness, nausea, agitation)*

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Transfer of best practice from a hospice setting to other care settings, including for non-cancer patients, is a major challenge (partly because death is regarded as a negative outcome and may be denied by professionals despite its being an obvious fact)

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Diagnosing dying is an important clinical skill (and central to the Pathway's successful implementation)

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One of the key aims of specialist palliative care is to empower generic healthcare workers to care for dying patients (by setting out the pathway in easy-to-follow/easy-to-document steps, allowing for individually- tailored alternative strategies and techniques where the situation calls for variation)

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Core education objectives related to the care of dying patients should be incorporated in the training of all relevant healthcare professionals (the plan constitutes a "core curriculum" that can be delivered in situ, in a real-life/real-death situation, and will be remembered by those who engage in it actively)

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Resources should be made available to enable patients to die with dignity in a setting of their choice (and the plan provides justification for making them available, with no redundancy of expenditure).

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National indicators for care of the dying patient should be identified and monitored (working to a consistent plan allows for reliable and valid audit across all agencies that use it).

*(The bits in brackets above are my own speculative comments, not those of the Plan's authors).

In actuality, the Pathway is a detailed plan involving the dying person, their friends and family, all key professionals who ought to be involved and who "sign up" to it, and it is triggered by a decision based on awareness that the individual has just a "small number of days to live", and will not recover.

In a nutshell, the plan draws on best evidence-based practice to deliver comfort, full symptom relief, remission from heroic and unnecessary treatments, psychological ease for patient and family, such spiritual support as may be wanted, full communication amongst all concerned, and all the components possible for "a good death".

Crucial to the plan is the consensual decision that only "a small number of days of life" remain, and it is an agreement on this that triggers the plan, and sets its integrated steps in motion.

Under discussion today with the family of our dying patient was, "how shall we recognise that death is only a small number of days distant"? Of course, there is always a certain unpredictability about death, and in an important sense "it knows its own time". It won't be hurried, that's for sure, any more than it will be unnecessarily delayed.

In my experience, and in the experience of many nurses and doctors, there is a variable period preceding death during which the person stops drinking, becomes bedbound, is very still and stuporose; and there is an unmistakable sense of recession, of withdrawal from involvement in the realm of life, hard to describe, but tangible and real to the sensitive or sensitised onlooker. Later there are physical signs, associated in some Buddhist traditions with dissolution of the elements: slight and/or sterterous, noisy breathing, pallor, coldness and sweatiness of hands and brow, a pinched appearance of the nose and face, episodes of restlessness and apparant agitation etc. These signs are possibly more distressing to the onlooker than they are experienced as distressing by the dying person.

Today, when our patient's GP visited her, she was bright, cheerful and anxious to know how he was doing himself. Although she is gravely ill, he thought it was not time to initiate her plan, and will visit another day when we reckon the number of days may be "small" enough to make the plan worthwhile, although it seems a rather cold-blooded business, if well-intentioned and humane.

Dachau, Bavaria

Last week my son and I were away for a few days in Bavaria, a trip we'd planned about a year ago as a treat. We stayed in a Munich Youth Hostel (very different from the Youth Hostels of my recollection from the 1950s) and walked miles around the city, dropping off at various watering-holes for a beer.

On our second day we took the train to Dachau, a small, pretty, pleasing and provincial town (see image on right), reminiscent of Hemel Hempstead or Bromsgrove, and the site of the concentration camp (image on left shows one of the camp watch-towers overlooking the roll-call assembly area).

It was a sombre experience, the moreso because of the nearness of the camp to the town: there is nothing isolated about the camp now, and there can have been nothing isolated about it in the 1940s. Indeed, prisoners were marched from the station to the camp entrance along suburban roads, past the same bus stops (presumably) as we stopped at on our short commute there.

It is a tribute to the German people that they have preserved the camp as a memorial, many of its original features being still intact, and with some sensitive reconstruction. There is a wealth of information on display, and several guided tours each day. My son and I spent just over three hours wandering round. The site is roughly the size of a small retail park, and housed 63,000 people in 38 barrack-rooms.

I imagine the question most foreign visitors ask themselves is, "Could it have happened at home?", and my own answer would almost certainly have to be "I don't know, but I think it might".