Here to help! Some searching questions...

The following questions came to us from someone embarking on a research exercise into hospice development, and I attach my responses (for what they are worth). The questions were sincerely put, and I hope that my unvarnished responses have not dampened the enthusiasm of the researcher to enquire further.

What do you see as the most challenging aspect of your work with the dying?

Difficult question to answer.

Working with people in crisis is always something of a challenge to all involved. Dying is a crisis in the same way most of the rest of life throws up situations of challenging change, crises. Dying isn't qualitatively different, and Buddhism teaches us not to see death as something essentially different. The way people deal with dying is the way they deal with all crisis. We are creatures of habit. As we live, so we shall die. But perhaps Buddhists learn through their practice that they don't have to be challenged by change; indeed, Buddhism has acceptance at its heart. In acceptance nothing challenges, and there is no-one to be challenged.

Practice isn't easy, so perhaps that's the everyday challenge, to do what we can to practice, whatever we understand that to mean. And that's a challenge too, understanding what it means to practice. It isn't bowing, making obeisance to the Buddha, or sitting on the cushion.

What is - in your religion/spirituality - the most important aspect of the dying process?

It's important not to get hung up on 'the dying process', whatever that means. Dying is a normal physiological process and there's no part to which it is worth attaching symbolic importance, or thinking it is more important than another. The question arises out of the tendency on the part of many Buddhists to take teachings about the bardos too literally. One might quite as earnestly ask "What is the most important part of the process of evacuating the bowels?" Or, "what is the most important part of the process of digesting one's dinner?"

As a nurse I have attended the deathbeds of very many people, and death - you can rest assured - is always 100% successful. Every death is unique, and the process may be very drawn-out, or it may (of course) be instantaneous, as in a plane crash or 9/11. It doesn't matter how we die, what matters is how we live. I don't think the Buddha had a lot to say about deathbeds.


What are the most recurrent problems you are facing with dying people?

There are generally no problems to be faced with dying people except the usual ones such as "If I am visiting shall I find a place to park?" or, in my case, "Will my wife get irritated that I am not at home to help her with the household chores and domestic worries she has to face alone because I am attending to my "good works" with others?" You may have heard the Bible saying ascribed to Yeshwa (Jesus), "Leave the dead to bury their dead". It makes a lot of sense.

As the Chairman of a Buddhist charity, it is sometimes a problem fending off Buddhist volunteers who want to be "in on the act" at other people's deaths. If you ask them to address envelopes, wash up or serve tea they feel snubbed and hurt, that they have some special gift to impart, and you are standing in their way! Not all volunteers are like this, of course, but it is disheartening to find how many are.

Which are the situations in which you find yourself helpless?

Helplessness is a most desirable default mode to cultivate when being with the dying.

There is nothing to do, so the mind of helplessness is entirely congruent with that. "Doing less, being more" is the motto. If we can cultivate a heart of helplessness compassion will flow into it and, in that heart of compassion, 'helper' and 'helped' will encounter each other without distinction and in perfect reciprocity.

How supportive/unsupportive do you consider your society with death, religious approach to death, and religions in general?

Our own (British) society has been greatly shaped by Christendom including the tenets of Christian belief and doctrine, in their many vernacular forms, and there is no doubt in my mind that established religion in UK does provide a framework for many in helping them to find meaning and consolation in suffering and loss. Some individuals find it difficult to talk about death, to talk naturally to a person who has been bereaved and so on, and this reticence is part of the way people feel about death; it is not our part to judge them, or to characterise them as unsupportive. People have a right to their feelings, and there is nothing wrong with the way they behave.

I have deep admiration for Christian clergy and for many church-goers. I don't find that Buddhists are better at dying and death and supporting others than members of other faiths. Some are very good, some less so. I think that humans (regardless of their religious affiliations or lack of them) are on the whole infinitely capable of acceptance, equanimity, "courage", and of healing into their true nature.

Although I'm a Buddhist and it has worked for me, it's my point of departure in what I do, and I have no interest in or ambition to convert others to Buddhism. I lived and worked in Africa for many years, where Buddhism is just unknown. But the people there live richly-engaged dharma lives, and have no need of the teachings of Gotama to guide them away from what they know and do.

What do you think could be common ground for our different religions to expand our support in hospice work?

Our common humanity supplies enough ground, I think, for interfaith cooperation and mutual support in the face of suffering. Suffering feels and looks the same in all creeds. We don't need to wrestle with conceptual issues, indeed, they get in the way of collaboration.

There are certain principles of the hospice movement, and of the palliative and "end-of-life-care" movements, that are worth fostering because they have made a major difference to terminal care. Hospices as institutions where people go to die, however, are giving way (for various reasons including cost) to death at home, or in some other 'preferred place', as the spectrum of care-provision changes in line with popular choice, and improved technology.

How do you deal with mental and spiritual suffering in your work with dying people? What are the words and attitudes that seem to relieve anxiety, fears and agitation?

How do you, the questioner, distinguish mental and spiritual suffering? My question is intended to challenge you, the questioner, out of a state of mind that reduces life to a number of discrete compartments or categories that call out to be 'dealt with'. I don't intend to insult or attack you, and I know you are in a reflective situation, and just putting your toe in the water. But I think you are also robust enough to follow my drift.

Suffering does not call for formulaic responses, words, attitudes or theories. I can only be alongside the one who suffers, and dwell with her/him. In helplessness the words and actions may arise that are fitting, appropriate or 'helpful'; but they will be uncontrived, not 'mine', not to be held on to. Buddhism has nothing 'off the shelf' to offer, does it? The following true anecdote illustrates the folly of taking a 'cook-book' approach to death, however eminent the 'cook', and however well-intentioned the recipe.

I once met a very devout and kindly Buddhist woman who, when her old Glaswegian mother was dying, plucked up her courage to begin reading her Mam a few words from the Tibetan Book of Living and Dying. Her mother opened her eyes, gazed steadily at her daughter and said in a clear voice, "Aye, and ye can fuck off dearie, and tak' yer fucking book wi' ye!" That old dying woman was Buddha, and her daughter never forgot the lesson she was taught that day. Talk about enlightenment!

What has changed for you from your experience of dying people?

Well, I have never sentimentalised death, and I don't put dying on some sort of pedestal. I have come to understand that death takes care of itself and needs no facilitation. Death is good, death is kind, or so it seems to me. Dying may be difficult, and in some cases it presents difficulties for which there may be remedies, e.g. pain and symptom relief. People often need good nursing care. People largely prefer to die at home (if they can be adequately cared for at home), and this has affected the way hospices are funded and operated.

People who are dying appreciate the friendship and support of others who come with no helping agenda, no spiritual mouthings, no religious templates of belief or doctrine to pass on, no formulas, interpretations or solutions. Such people are rather rare, including amongst Buddhists.

And, to quote Christina Feldman, "We are always beginners in the art of compassion".

Is there any aspect of Buddhism that you feel may be particularly useful with dying
patients?

No, no agenda, no special tool in my tool box. Possibly I might remind myself often that Gotama said "No person can save another. Work out your own salvation, with diligence".

"Toxic Debt" and other lies...

The image is of Winter in Glen Etive, Glen Coe by courtesy of D W Roberston Gallery and is an illustration for Tales of Travel (see below)


As I write news is coming over the radio about the resue plan put together in the US to save international markets from melt down, or whatever other thermodynamic metaphor is appropriate for this jolt out of the consensus trance we've all been in for the last thirty or so years, or longer.

I have the powerful feeling that the explanations we're being given for what has happened to the 'markets', and what we need to patch things up, is another deliberately administered dose of anaesthetic. The problem, we're being told, is that banks are no longer willing to lend each other money, and this 'freeze' is the cause of the problem.

At the heart of the crisis, allegedly, is "toxic debt", debts built up by poor people who were bamboozled into mortgages they couldn't afford, and can't repay. This level of "toxic debt" has "infected" the global financial system. I find it outrageous, but perfectly in keeping with the evil tenets of capitalism, that this language of poison and contagion should be used to define the heart of the problem; to denigrate and scapegoat the hapless undeserving poor, those who wanted to house their families, low-paid workers, single mothers, people from ethnic minorities.

The implication of what we're being told seems to be that banks actually have lots of money, but they don't trust anyone enough to lend it, including each other, because toxically infective "sub-prime" borrowers have contaminated the system, defaulted on loans, and infected the system like a type of rabies, paralysing it like 'lock-jaw'. So the banks are are sitting helplessly on the money they have left. The result is that no-one can borrow any more, so they have none to spend or 'invest'. There is, or soon will be, no money in circulation. Money has somehow congealed, clotted up.

The proposed solution seems to be that Governments will give a very large amount of money - "taxpayer's money" - to the banks. This is called "injecting liquidity" into the system to "lubricate it" or "free it up" or some other inane slogan borrowed from hydraulic engineering. This money will somehow, miraculously unblock the clogged-up system, and money will once again flow.

Presumably this borrowed money will be used to lend to other people, so that banks will "regain the confidence they need" to begin "lending money to each other", re-establish "confidence in the system" and everything will be AOK again. Except that you and I will be expected to pay for it through taxation, the privatisation of services, and the life-long indebtedness of our children.

Does anyone believe this anaesthetic nonsense? That the banks have money but are too mistrustful to lend it? That they need to be given money to steady their palsied nerves?

Well, I believe that in truth there is no money. The money that the banks and building societies have been lending to people doesn't exist, and never has. The money on your mortgage statement, or in your deposit account, the "equity" in your house, or the figure on your ISA certficate is just a mirage. Since the "Big Bang", money has just been an illusory row of noughts on the computer screen, from which people in the City and on Wall Street have been regularly helping themselves to huge tranches in currency bills, to buy or build mansions, Rolex watches, Maseratis and diamond encrusted crystal skulls as gee-gaws.

It seems to me that what is proposed is the launch of another illusory capitalist spree, a re-instatement of the status quo ante, business as usual in Wall Street and the square mile, a short term boom in the High Street as consumers "regain the confidence" they need to put a spring in their step in the long run-up to Christmas (expect the tinsel, toys and mince pies to greet you in Tescos, Wal-Mart and Sainsbury's soon enough). And the directors (and highly paid non-Execs like Tony Blair) will laugh all the way to their non-dom banks and off-shore Cayman Island havens.

What has this got to do with Buddhism? Well, as I said in an earlier post on the Social Care Green Paper, perhaps it's about seeing the world, or not seeing the world, from any perspective, but recognising that this is what we always do and recognising this, opening ourselves to the possible emergence of another way of being. As Ray Wills used to say "There must be another way". He didn't define what that other way might be because the Way doesn't have a destination in mind: it's a point of departure, an open road. What we can do (but it's hard and calls for energy and resolve) is to allow ourselves to open to another way of being, not adopting it or 'trying to' follow it, but rather becoming it.

A howl of outrage? An intemperate polemic? Well, yes, perhaps. But I'm human, and it's part of my way of opening up to another way being, and perhaps helping you, who knows. So I'll let it stand, and finish on a quieter note with the words The Vagabond, part of a song-cycle of verse (Songs of Travel) by R L Stevenson, set to music by a favourite composer, Ralph Vaughan Williams, and with the cool illustration of Glen Coe (above) as backdrop:

Give to me the life I love,
Let the lave go by me,
Give the jolly heaven above
And the byway nigh me.
Bed in the bush with stars to see,
Bread I dip in the river -
There's the life for a man like me,
There's the life for ever.

Let the blow fall soon or late,
Let what will be o'er me;
Give the face of earth around
And the road before me.
Wealth I seek not, hope nor love,
Nor a friend to know me;
All I seek, the heaven above
And the road below me.

Or let autumn fall on me
Where afield I linger,
Silencing the bird on tree,
Biting the blue finger.
White as meal the frosty field -
Warm the fireside haven -
Not to autumn will I yield,
Not to winter even!

Let the blow fall soon or late,
Let what will be o'er me;
Give the face of earth around,
And the road before me.
Wealth I ask not, hope nor love,
Nor a friend to know me;
All I ask, the heaven above
And the road below me.

Tacit knowledge

It has been a pretty exhausting week at my place of work, with a spate of sickness affecting several of the carers, so that everyone unaffected has had to pitch in to cover for absent colleagues, work extra shifts, and generally 'burn the candle at both ends'. In the last weeks I have worked several back-to-back shifts of fourteen consecutive hours duty, mostly engaged in 'hands-on' care, interspersed with such activities as helping to cook and serve meals, wash up pots, pans and dishes, do laundry, and variety of administrative chores besides.

At such times nerves can get frayed, patience is strained, and mistakes and accidents are more likely to happen. This morning, arriving at work at about 0645, I looked in on the laundry room to find that one of our washing machines had been loaded with two sets of nightclothes, both of which sets had been subject to a hot wash while still containing incontinence pads, which ought to have been removed. These 'pads' are disposable adult garments like large 'nappies' made of cellulose padding inside a thin plastic envelope, designed - of course - to capture and contain human wastes.

Presumably the overworked and overtired careworker who did the washing had been too distracted to remember to separate out the pads from the garments so as to put them in the clinical waste bin. Of course, they had disintegrated in the machines, dispersing the contents throughout the wash, and liberally coating the inside of the drum with unpleasant emulsified pap. Not a bright start to the day, but not unusual either.

After work this evening I turned to an article in my daily paper, hoping to take my mind off things clinical, but my eye was caught by an article, a critique, about the training of young doctors. Not a lot has changed in the fifty or years I have been in a position to observe this happening except, perhaps, that doctors have grown unaccountably younger, like policemen. Training is still very much hospital-based, and possibly even more fragmented and modularised than ever, with more tick-box-type assessments, and less time at the bedside.

Patients are in hospital for much shorter periods than twenty years ago, so that doctors have less time to get to know their charges, less time to see changes in their patients over time, for getting a feel for how people respond over time to disease, and watching what happens as they get better. The wisdom that emerges from being able to witness such evolutionary change is called "tacit knowledge".

One of its characteristics is a growth in the necessary humility that a practitioner develops about her own part in the processes of recovery and 'cure', and a deeper respect for the adaptive potential of the human organism, in both the physical and the psychological domains. Medicine, after all, is just a set of interventions that help to put the patient into a condition that allows nature to take its healing course. The same is true of nursing and all 'healing arts'.

In this respect, I believe, nurses are at an advantage over doctors, and many doctors (certainly most senior or older doctors) acknowledge the wider and deeper clinical acumen of nurses in making a difficult diagnosis, and a more reliable prognosis, than less seasoned doctors. Nurses, unlike doctors, see their patients day-in-day out, are privy to their informal conversations and reflections, and see them in a far wider repertoire of activities than doctors, sleeping, eating, eliminating, attending to their own needs, in relation to their families etc. Unfortunately, changes in the way nurse training has been structured and delivered have made for a much less coherent and "wholistic" relationship between nurse and patient, less physical intimacy, less thorough-going trust and rapport, and less of a long view on events in the curriculum of health and illness.

There are times when I am attending to one of my own patients, that I am thrown back in my experience to an earlier time when I first began to learn to nurse, fifty years ago. It's not memory in the sense of a picture in the mind, it's a felt physical thing, a reassurance of close contact, warmth, the complex scent of a close-held body, the touch of skin, awareness of a tremor, of a small weakness, of effort, of courage that always springs up in the other to meet the challenge of the moment, and something eternal too about trust and vulnerability.

Today I was helping an old fellow off his commode, helping him hitch his underpants and trousers up, his head against my chest, his arms round me in a politically incorrect and improperly conducted lift by Health and Safety rules, telling him, when he said "You know how to help me", "Yes, we know how to work well together", and meaning it, and knowing it's meaning is not to be found in me, but in the way things are, in that tacit knowledge, that unspoken wisdom that pervades everything, and always. Help is not something I do to another, it's a resource two people in a relationship share, born of the relationship and its circumstances, and always in perfect reciprocity, whatever happens.

"Though the Path is vast and fathomless I vow to understand it.

Though enlightenment is beyond attainment I vow to embody it fully."

Social Care Green Paper

The diagram to the left is a representation of an aspect of the social care market, courtesy of Healthcare Economist Journal of the United States

Eminent Buddhist commentator and analyst Yann Lovelock has written to us inviting us to contribute to a discussion promoted by Government on the future of social care for old and very old people in our society. The link leads to a short introductory vox pop video in which a number of people offer views on the issue, framing the discussion, and linked to a site that presents the issues from the perspective of the working party preparing a Green Paper. The Green Paper is part of a process by which enabling legislation will be worked up, and services designed, to meet our social care needs in the years ahead.

As Yann reminds us, some of us will soon be facing questions of what care we need, what is available, what it is going to cost, and who will foot the bill. Some of us, of course, are facing these issues already.

These questions have been framed for us by the consultation document, and seem to me to have a very New Labour quality to them, in that they arise from a set of political assumptions about the meaning of care i.e. care as a commodity that individuals will want to buy, exercising choice over their purchases, purchases designed to support their independent living, a 'marketplace' for the setting out of care-wares, care-tariffs and so on (some of these terms are my own, I must confess).

Buddhists may want to challenge these assumptions, although they may not, of course. We are all used to viewing the world, its affairs, and our atomised part in those affairs, through a narrow slit of social and political conditioning. We constantly absorb through the media of TV, press, advertising and the Internet an insistent paradigm of existence that stresses individualism, consumer choice, competition, and the all-defining lifestyle.

I live my life mainly as a consumer; I can't help it. Although I make efforts to break out of consumerist samsara, it is deeply engrained, and I have no illusions about my intentionality or volition, which is weak and intermittent. My puny efforts are debilitating and discouraging, I often feel flaked out and hopeless.

But fettered as I am by the chains of my mind, I find that I must protest, even though I can't find the words to do so, except in the anguished cry,"There must be another way"!

I feel, I intuit, that there is another way to characterise care, a framework that expresses our interdependence, our shared vulnerability, our willingness to let go of the pride and intellectual arrogance that puts independence and individualism on a lofty pedestal, that "knows the price of everything and the value of nothing". I can not accept that care is, or should be, a commercial transaction, bound by contractual criteria, published as a menu of bite-sized interventions, packaged, audited, regulated, costed, 'branded', advertised, "starred", charter-marked and "visioned".

There must be another way.

N.B. I shall welcome your views, opinions and sugestions and, if you agree to my doing so, I will add them to views I am collating on behalf of the Network of Buddhist Organisations as a response to the Green Paper consultation. Or you can send them directly via the link given above.

De mortuis nil nisi bonum

Speak only well of the dead. This came to mind today as I read a quite lengthy broadsheet obituary which ended as follows: "At one time he owned a parrot with a penchant for fried eggs and Guinness. His wife Doris died in 1992, and he is survived by his son, Andrew."

That I should ever deserve such such an eloquent summation! "At one time he owned a small knife with a bone handle, a gift from his school-friend Roger, who had bought it on a holiday visit to Switzerland with his father, an industrial glass salesman."

I was at the second meeting recently of the reconstituted "Inner Work School" meeting, held on the second Saturday of each month in Friends House, Euston Road. It was good to meet old friends again under familiar circumstances, albeit a new venue, paid for by the Buddhist Hospice Trust. It was also good to meet up with newcomers, thanks to the efforts of Ben (Bodhiprem) Shapiro and Mick Lewin in publicising the event, and convening the meeting.

By all accounts, the 'mood' of the first meeting was for open discussion to an emergent agenda, and the meeting I attended was carried on in this way too. It's hard to see how, with a fluctuating membership and no chairperson, an agenda could be developed that carried across meetings. But we shall see what emerges over time. For myself, I have enjoyed these gatherings, and got benefit from them, in ways hard to describe.

I know they have contributed to that softening of opinion in me that Buddhist practice produces, so that I can listen to the opinions of other people with something akin to empathy: it's like seeing the world from another point of view, through different eyes, and not in competition with one's own perspective. This is by no means my default position, I am almost if not fully as combative and confrontational and contraversial as I've always been; but there has been a change. Of course I am still always right, but other people have gradually much nearer to my position than they used to be, thus their expressions of dissent are more bearable.

"At one time around 1956 he owned a secondhand collarless Gieves shirt in a narrow blue stripe, which he wore with a white starched collar secured with a stud, loooking very much (as he thought) the fashionable young man-about -town, especially as he carried a rolled umbrella."

Am I alone in sensing a change in the temper of society since the "credit crunch" began? There seems to me to be a sense of sober expectancy amongst my fellows as I move about the town to do a bit of shopping or to pay bills. Do I also sense a "rabbit in the headlamps" paralysis in the unconvincing (and unconvinced) utterances of our national leaders? As if they understand the enormity of the show-down we face in the crisis of capitalism, the imminence of irreversible climate change, the here-and-now inescapability of 'peak oil', but lack the courage to do anything about it. The best thing would be to come clean, to spell out the situation, and to ask us to begin to develop ways of coping with a new reality. Offering structures that would mobilise our efforts for survival or, if we are not to survive, for a dignified extinction, worthy of a noble if flawed species. What might be our epitaph then?

"At one time he owned a portable Olivetti typewriter in a faux pig-skin carrying case, bought on Hire-Purchase terms from a door-to-door salesman who visited his rented flat in Moseley, Birmingham, in the autumnn of 1962."

The Buddhist Hospice Trust Blog: Mrs Waveney Miller

The Buddhist Hospice Trust Blog: Mrs Waveney Miller

Stephen Hodge, who was Waveney's first and much-loved teacher, has sent some kind and corrective comments on my earlier blog, and these can be read in full using this link. Thank you Stephen.

Lying low

I've been lying low, skulking (but not sulking).

My internet connection was lost for about six weeks, I overlooked a telephone bill, was disconnected, then the contract was cancelled, and I had to rebuild the connection all over again. It's a long boring story.

I have allowed my self to get into a situation where I felt pulled hither and thither. This was more a feeling than a fact, but it makes not much difference. I have taken time out, skulking, lying low and reconnecting with what seems important. I realise it's all relative anyway, but the part of me that that thrashes around in relative reality knew that I was losing touch with family, friends, responsibilities at work and at home, and needed to reconnect.

I missed the first of a series of Trust supporter meetings at Friends House, and it went ahead anyway. I've not had much feedback on it except that those who turned up took the view that they wanted a meeting that was 'open to the emergent' (as I think the saying goes) rather than something predesigned and overly structured. For those interested, the meetings are held on the second Saturday of each month (through May 2009) from 1330 at Friends House, Euston Road, almost opposite Euston station. Nothing to pay, no need to register or anything, just come along.

I read somewhere that the best-run and most effective organisations don't hold meetings, at least they don't hold meetings that work to an agenda and reach decisions. Mainly because the decisions taken at such meetings are pretty meaningless, and don't get implemented anyway. And nobody cares one way or another, except that everybody hates meetings, except the people that enjoy them, and everbody hates those chaps too (they are usually men).

The Trust recently received a donation of £1,000, and we are very grateful for it.

There will be more posts in due course, the blog is still alive.

The image above was delivered to you by courtsesy of Google images, and it is titled "skulking", and it says it better than words. Isn't Google fabulous?