Ayurveda, Death & Dying by Renee Traub

 Introduction:

The intent of this research paper is to look at death and dying from an Ayurvedic perspective, specifically to assist those in the hospice and end­of­life caregiving field in learning to spiritualize the death process for themselves, their patients and patient families.  This paper will utilize Ayurvedic principles and introduce practices that caregivers, professionals and families can implement with patients in the process of dying.  My intention is to expand Ayurvedic practice into a field where it can be used to open the door to mindful, aware and compassionate dying. My interest in this topic stems from my professional experience as a neonatal ICU nurse for 28
years and a hospice nurse for 3 years, as well as my experience last year around my mother’s passing.  Oftentimes I have felt like a midwife to the soul.  I have experienced the sacredness of death and this is what I would like to share with the public. Research sources include ancient and modern Ayurvedic texts, allopathic medical journals, and alternative and complementary
texts relating to the topic.  To echo the work of Dr. Mits Aoki, I would like to “make death a work of art, a great achievement for the patient and a time of growth, understanding and closeness for family members.1 ”

Principles of Ayurveda

Ayurveda is a traditional Indian medical system with a scientific basis. It incorporates mind, body, and spirit in its understanding of the human being. Ayurvedic medicine complements Western medicine by focusing more on root causes rather than symptomatic treatment. Self­care practices are foundational for a healthy life. Examples of Ayurvedic practices are meditation and breathing techniques. Preventative medicine is emphasized as it is easier to put into effect than treating disease that has already manifested. Prevention means empowering patients to make positive lifestyle changes and behavior changes by educating and incorporating diet, spirituality, psychology, herbal medicine, and detoxification (known as pancha karma). Ayurveda reminds us that our true nature as human beings is spirit, and to connect to something greater than ourselves.
 
Ayurveda means “science of life.” It is a science because it contains systematically applied knowledge that has been proven in its effectiveness over thousands of years of continual application.  Ayurveda supports balance in all aspects of life ­ physical, mental and spiritual.  In the words of doctor and author Vivek Shanbhag, Ayurveda “respects the uniqueness of the individual, considers all the levels of the individual, emphasizes prevention, [and] empowers everyone to take responsibility for their own well­being.2 ”
  • 1 Aoki, Dr. Mitsuo.  www.livingyourdying.com “Helping Others Live with Dying.”
  • 2 Shanbhag, Vivek. A Beginner’s Introduction to Ayurvedic Medicine: The Science of Natural Healing and Prevention Through Individualized Therapies. Keats Publishing, Inc: CN, 1994. p. 9
According to Ayurveda, doshas are forces of nature that combine into the tapestry of life.  The human body is composed of the three doshas and operates based on their functioning,  If the doshas are out of balance with one another, there will be a disturbance in the function of the body and/or mind.  Often health or disease is discussed in terms of the balance existing
between the three doshas.  The three doshas are vata, pitta, and kapha.  On a cosmic level, one can say that vata relates to wind, pitta relates to the sun, and kapha relates to the moon and the earth.3 In short, doshas are forces that govern the physiology of the human being.4
 
Ayurveda “recognizes that each person is made up of a unique body type and a unique psychological personality.5 ”  We all have our own individual doshic combination from the moment of conception, and this is what accounts for our differences as people.  Vata dosha represents the forces of movement.  Vata is active and dynamic, like the wind.  Vata makes things happen in the body and mind, and is responsible for all movement, including the breath, the circulation, and movement of thoughts.  People who have a lot of vata can be energetic, vivacious social butterflies.  They can be very vibrant, enthusiastic and creative.  Every dosha has its balanced side, as well as its out of balance side.  When vata is out of balance, a person may be flighty, fickle, fearful and insecure.  Excess vata can manifest in worrying, a fragile nervous system, anxiety and exhaustion.  In order to heal, patients with vata imbalances will need a lot of hand holding, support, nurturing and a deep sense of connection with others.
 
The force of vata dosha is inherently dry, cold and light.  It is the dosha that governs depletion, destruction, decay, necrosis, debility, dissolution, and the process of wasting away and shutting down.  For these reasons it is especially correlated with the active dying process.  Signs of impending death such as a change in smell, bodily organs shutting down, core temperature instability, gurgling breathing (death rattle) and the mottling of the skin are all vata symptoms.
Terminal agitation, a dying patient’s behavior of responding unpredictably, is also linked to vata, and may include speaking to those who have already passed on, being spaced out or not present, non­responsiveness, outbursts of tears or yelling, and other behaviors displaying the movement and rapid dynamism of vata.  Vata dosha benefits especially from therapies involving calming, grounding and peaceful touch and sound.
 
Pitta dosha represents the forces of transformation and metabolism in the body and mind.  It is very active in the digestive system, the liver, eyes, and the rational aspect of the intellect.  Pitta dosha allows food to transform into energy and experiences to transform into opinions, analysis and evaluations.  Pitta is hot and fiery, and has rough, sharp, and clear qualities.  Individuals with a lot of pitta in their unique doshic combination can often be confident, organized, driven, bright, passionate and disciplined.  However, like fire, pitta can easily become uncontained.  This creates an excess of heat in body and mind, expressing itself in outbursts, anger, tantrums, criticism, resentment, jealousy and rage.
  • 3 Heyn, Birgit. Ayurvedic Medicine: The Gentle Strength of Indian Healing. Thorsons Publishing Group: Vermont, 1987. p. 13.
  • 4 Halpern, Dr. Marc. Principles of Ayurvedic Medicine. California College of Ayurveda: California, 1995. p. 53
  • 5 Shanbhag. p. 10.
 The process of dying is neither controlled nor precise.  This can be a challenge for pitta individuals who can be over­controlling and demanding, especially in times of stress. Strong­willed people who are used to being leaders and making things happen find that they have no control over the dying process, and this is difficult for pitta.  Sometimes pitta patients and/or family members are very direct and intense, and communicate in a way that is explosive and sharp due to their feelings of helplessness and powerlessness.  Strategies to support pitta patients and families in the dying process include cooling, relaxing and stress­diffusing forms of aromatherapy, breathing practices, yoga nidra and guided meditation.
 
Kapha dosha represents the forces of stability and structure in the body and mind.  It is the container for vata and pitta doshas.  Kapha dosha provides the physical form and material structure of the body.  Linked with the qualities of earth and water, kapha is wet, dense, heavy, slow and steady.  In the mind, kapha dosha describes qualities of gentleness, calm, consistency, and dependability.  Individuals with a lot of kapha in their unique doshic combination can often be nurturing, affectionate, compassionate and loyal.  However, when kapha is out of balance, these same qualities can become stubbornness, lethargy, withdrawal, depression, and issues of attachment and possessiveness.  Kaphic individuals, unlike vata and pitta, are slow to change, but once change is implemented, they are steady and enduring in new habits.
 
When working with kapha individuals in the death and dying journey, it is important to understand that they may experience a longer grieving process. Watery emotions such as tears may be present. Kaphas can also internalize emotions and not show them, even though they feel very deeply.  Honoring relationships is very important, as is self­care for caregivers and families who have created deep attachments to individuals who have passed on. 
 
In order to understand Ayurvedic psycho­spiritual healing, one must also understand the concept of gunas. Guna is a Sanskrit word meaning attribute or quality.6 It describes a person’s state of mind or state of consciousness.  The three gunas are sattva, rajas and tamas.  Sattva guna describes a state of consciousness that is peaceful, calm and balanced.  Rajas guna describes a state of mind that is full of movement and activity, constantly creating turbulence and drama. Tamas guna describes a state of consciousness that is inactive, dull and stuck.  A colleague has beautifully put this in terms that are understandable:
  • “A person who is a vegetarian, practices yoga daily, meditates daily, is emotionally stable and has a good work/life balance could be described as sattvic; a person working in the corporate field who is highly committed and driven, spends most of their waking hours at work, works hard and plays hard, is a competitive sportsperson, and eats meat every day could be described as rajasic; and a person who sits at home all day every day watching TV, eating microwaved food, and not exercising could be described as tamasic7 ”
  • 6 Klutznick, Karen.  http://www.kkayurveda.com/ayurvedabasics/thegunas.html 
The concept of chakras is important to understand when considering health from a mind/body/spirit perspective.  Chakras are energy centers in the body that “show how the life force...directs and guides the physical body through the nervous system.”8 Chakras are composed of energy that ranges from being more open, flowing and functioning to more closed and blocked.  Because chakras are not in the physical body, they can be worked with through energetic techniques such as meditation, mantra, color therapy and visualization. The seven major chakras correspond with the movement of energy through the spinal cord.
 
This paper will introduce two more concepts in Ayurveda that connect to the subject of death and dying.  These concepts are prana and ojas.  Prana is the lifeforce behind all creation that each person is linked to through the breath.  The process of breathing brings prana into the body. Individuals with healthy prana radiate a strong sense of aliveness, vibrancy, and sparkle.  They are full of life.
 
Ojas relates to the strength of the immune system.  Strong ojas creates physical and mental endurance and the capacity to get things done despite stress.  Individuals with strong ojas are centered and grounded, and less reactive than those with weak ojas.  Weak ojas creates hypersensitivity to the environment, as well as sensory overload and decreased immune system function.  Individuals with depleted ojas are often exhausted physically and emotionally.

Introduction to Hospice

Hospice is a care model that provides palliative care to individuals who are in the process of dying.  Hospice is a way to deal realistically and honestly with terminal disease.  It offers hope of dignity and comfort for patients and families.9 This model of care, focused on palliation rather than curative therapies, neither hastens nor prolongs death, allowing nature to take its course.10 Hospice care can take place at a dedicated hospice facility, nursing home, hospital, or at the patient’s home.  Patients are generally put on hospice towards the very end of life, generally no longer than six months.  The current model of hospice care centers around making the patient comfortable, managing patient pain, educating family members on the death and dying process, and helping the family organize and prepare for their loved one’s death.  Hospice describes an interdisciplinary team which may include doctors, nurses, social workers, assistants, chaplains and grief counselors.
Individuals in the process of dying undergo many changes physically, mentally and spiritually. Often they become drawn inward, sleeping more and showing disinterest in food, guests and other activities.  The body weakens, and the mind may become agitated and confused.  Fear and sadness may arise, as well as feelings of not wanting to be a burden.  The patient may wish to talk about the past and review her/his life.  Elizabeth Kubler­Ross, pioneer in the field of near­death studies, identified five stages of grieving for the imminent loss of one’s life: denial, anger, bargaining, depression and acceptance,11 The process of death has been studied forthousands of years, and is described in ancient texts in similar terms as today:
  • While approaching death, the process of destruction is initiated in the body.  Functions of various limbs and organs of the body get disturbed….drainage of strength from limbs, cessation of movement, destruction of sensory/tactile, impairment of consciousness, restlessness in the mind, affliction of the mind with fear, deprivation of memory and intellect….radical change in the conduct...wasting of muscle tissue and blood….morbid changes in the smell of the body...discoloration of the body, dryness in the orifices of the body.12
In my experience, hospice is all about being present with what is.  The practice of being unconditionally present and just listening, without having one’s own agenda, can be incredibly profound.  Caring for the dying can be a deep spiritual calling where one is open to whatever comes up, and willing to give whatever is needed.  In the words of spiritual teacher Ram Dass:
  • Whenever I tried to impose my model of a good death on a situation, or been attached to a particular outcome, it has backfired.  But when I meet the person with love, without wanting anything, I become a safe haven.  When I could remain conscious, aware of my own thoughts and feelings, waves of sadness or pity, aversion or fear, as well as my own temptation to react, I could bring soul quietness and a feeling that what was happening was alright.  This inner calm seemed rock­like it its stability.13
Hospice creates an attitude of service to the body, mind and spirit of the patient. Hospice has really made a difference in the lives and deaths of those it has touched, and by adding complementary Ayurvedic practices, opportunities are created to deepen compassion, mindfulness and integration.

Timeline of Hospice Care14

1948: The term hospice, from the same linguistic root as hospitality, is first applied to specialized care for dying patients by physician Dame Cicely Saunders of the UK.
1963: The concept of hospice is introduced to the medical community of the US by Saunders.
1967: Saunders opens the first modern dedicated hospice facility in the UK.
  • 11 Kubler-Ross, Elizabeth. On Death and Dying. Scribner: New York, 1969.
  • 12 Caraka Samhita. Vol 2. Chapter 5. v. 90-91.
  • 13 Dass, Ram. Still Here: Embracing Aging, Changing and Dying. Berkeley Publishing Group: New York, 2000. p. 178.
  • 14 timeline information courtesy of National Hospice and Palliative Care Organization, Alexandria, VA.
1969: Elizabeth Kubler­Ross publishes On Death and Dying, a controversial book which sparks widespread public conversation on death and dying care in the US.
1974: Florence Wald of Yale University opens first hospice care facility in the US.
1982: Medicare begins to cover hospice benefits.
1984: Standardized hospice accreditation is initiated through the Joint Commission on Accreditation of Healthcare Organizations.
1986: Medicare hospice benefits are expanded and made permanent by US Congress.
2002: Department of Veterans Affairs launches program expanding hospice services to veterans and also providing continuing education in hospice and palliative care to clinicians.
2006: American Board of Medical Specialties recognizes hospice and palliative medicine as a medical specialty.
 
In recent years, research and policy work has been done in areas of hospice for HIV/AIDS patients in sub­Saharan Africa, pediatric hospice, expansion of hospice services for veterans and provision of hospice to individuals who are incarcerated.

Ayurvedic Aromatherapy

Aromatherapy is the use of the sense of smell for healing.  High quality essential oils distilled from plant sources can affect moods, balance the nervous system, and help calm and refresh the body and mind.  Aromatherapy works powerfully on the mind, and helps create sattva, allowing for greater peace and serenity in the final stages of life.15 The sense of smell is perceived through the evolutionarily oldest part of the brain, the limbic system, which responds to stimuli instantly, without thought.16  Scents have the ability to penetrate deeply into the brain, and chemically alter the functioning of the nervous and endocrine systems.  Studies have found that aromatherapy massage decreases anxiety, promotes relaxation, and stimulates autonomic nervous system function, especially in instances of palliative care.17
 
The application of aromatherapy in a hospice care setting can take many forms, all of which are user­friendly.  Essential oils can be purchased in health food stores or online, and many of the oils suggested here are inexpensive.  It is important that essential oils are pure and of good quality. “Fragrance oils” aren’t true essential oils ­ be aware of synthetic and adulterated oils used in the cosmetic and food industry. They do not have the therapeutic value of natural oils.18 Essential oils can be added to a tub of warm water for a foot or hand soak, added to a massage oil, or dripped into a spray bottle full of water.  Bear in mind that essential oils should generally not be placed directly on the skin.  One drop of an oil can be placed on a cotton ball to scent a room.  A spray bottle of rose water hydrosol can be used instead of rose essential oil, which is more cost effective.19
  • 15 Sushruta Samhita. Section 8, verse 10.
  • 16 Wall, Carly. Setting the Mood With: Aromatherapy. Sterling Publishing Company: New York, 1998. p. 12.
  • 17 American Journal of Hospice and Palliative Care. “The role of aromatherapy massage in reducing anxiety in patients with malignant brain tumours.” Downey et al. Aug/Sep 2009. 
 Excellent oils for reducing anxiety, stress and worry are lavender, chamomile, clary sage, lemon balm, rose geranium, rosemary and sandalwood.  Lavender creates a calm and positive attitude and stimulates brain secretions of serotonin, as well as calming and soothing the nervous system.20 21  Lemon balm, also known as melissa, is an excellent restorative of the nervous system.22 Rosemary is known to ease emotional tension.23 Sandalwood is known to relieve irritability that stems from anxiety.24 Chamomile is a nervine sedative specific to anxiety and stress.25 Clary sage is useful in cases of despair stemming from anxiety and stress.26 Feel free to make your own oil blends and remember that one drop goes a long way; only a few drops are needed in a foot bath or 4 oz spray bottle.
 
Many oils are helpful in aiding relaxation and supporting restful sleep.  This allows patients to respond to the stresses of living and dying from a more peaceful place.  Oils specific to this purpose are lavender, chamomile, frankincense, jatamamsi, lily, nutmeg, rose and sandalwood. Lily soothes the nerves and relieves irritability.27 Many of the oils listed in for anxiety, stress and worry are also helpful with stress relief and relaxation.
 
Anger and resentment can arise at different stages of the dying process, especially in patients with high pitta.  Resistance to the dying process, asking “why me?”, loss of control over the body and one’s life, and family­ related dramas that come up during difficult times can all cause pitta to rise.  Spearmint, lemongrass, fir and cedar can all rebalance the body and cool hot feelings.28 Lavender, rose and sandalwood are excellent oils for relaxing and purifying a heated pitta mind. Rose increases love and compassion.29 Sandalwood deeply nourishes the heart.30 Jasmine is great for releasing anger, and purifying the mind and emotions.31 32 Lily calms the heart and soothes the nerves, reducing irritability and increasing faith and devotion.33
  • 18 Wall, Carly. p. 16.
  • 19 Edgar Cayce Rosewater is highly recommended and inexpensive.  Reputable brands of essential are Floracopeia, Simplers, Mountain Rose, Young Living and Doterra.
  • 20 Wall, Carly. Setting the Mood With: Aromatherapy.  
  • 21 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 22 Wall, Carly. Setting the Mood With: Aromatherapy.
  • 23 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 24 Ibid.
  • 25 Page, Linda. Healthy Healing. Quality Books Inc: 1985.
  • 26 Young, Gary. Aromatherapy: The Essential Beginnings. Essential Press Publishing, Salt Lake City,1996.
  • 27 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 28 Wall, Carly. Setting the Mood With: Aromatherapy.
  • 29 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 30 Ibid.
 Loss, sadness, depression and grief are often present in the dying process.  Patients may have regrets from the past, sadness at not being able to accomplish things they want to, and grief at saying goodbye to loved ones.  Gently uplifting oils can be beneficial in shifting the mind and increasing movement towards acceptance.  Coriander, pine and helichrysum are great for softening the grief process.34 Rose is a wonderful soothing oil for the mind and an anti­depressant, allowing for greater experience of love and increased self esteem.35 Rosemary, tulsi (holy basil), patchouli, cardamom and wintergreen also help alleviate depression.36 37 Citrus oils such as bergamot, lemon and orange are very uplifting.38 break through despondency.39 Cypress and eucalyptus can help break through despondency.39
 
Aromatherapy can bring about a sattvic state of consciousness, spiritualizing the death process and awakening higher awareness.  Scent has the power to bring us back into alignment with our authentic self.  Oils that have this property have been used in many of the world’s spiritual traditions.  Frankincense creates a space of purity in which higher virtues can come forth.40 Sandalwood and rose are other herbs that possess this sacred quality.  Essential oils can be selected for their therapeutic purposes and used not only in aromatherapy, but also in touch therapy or massage.

Massage and Gentle Touch

Massage has a long history as an integrative part of many healing traditions, including Ayurveda. Ayurvedic massage can feed the senses and nourish the body and mind through the application of therapeutic touch. It supports restful sleep and a calm, happy mind.41 A recent study of complementary practices in a hospice setting found that massage was not only beneficial to patient care, but reported by patients themselves as the most beneficial treatment they received. 42 Sharing massage with a patient or loved one can be a deep expression of love, care and compassion.  Especially while caring for those in hospice, it is important to maintain a sattvic touch, which is light, mild, gentle, balancing, harmonizing, warm, pleasant, sweet and nourishing.43 When massage is done with love, care, gentleness and sensitivity, it will increase sattva in the patient.  The massager must also have a sattvic quality in their attitude and manner of application.44 Healing benefits of massage and application of oils build up over time, and are also immediately beneficial to skin, muscles and the nervous system.45
  • 31 Halpern, Dr. Marc. p. 324.
  • 32 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 33 Ibid.
  • 34 Worwood, Valerie Ann. The Complete Book of Essential Oils and Aromatherapy. New World Library: San Rafael, CA, 1991.
  • 35 Wall, Carly. Setting the Mood With: Aromatherapy.
  • 36 Halpern, Dr. Marc.. p. 324.
  • 37 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 38 Page, Linda. Healthy Healing. Quality Books Inc: 1985.
  • 39 Young, Gary. Aromatherapy: The Essential Beginnings.
  • 40 Frawley, David. Ayurvedic Healing for Healthcare Professionals.
  • 41 Lad, Vasant. Complete Book of Ayurvedic Home Remedies. Three Rivers Press: New York, 1998. p. 60.
  • 42 American Journal of Hospice and Palliative Care. “Three lessons from a randomized trial of massage and meditation at end of life: patient benefit, outcome measure selection, and design of trials with terminally ill patients.” Downey, et al. Aug 2009.
 Massage is recommended for patients with high vata, pain and hypersensitivity, as well as any disturbance of the mind, emotions and nerves.46 Sesame oil and almond oil are recommended as they are softening to the tissues of the body.  Mild and sweet essential oils such as sandalwood, rose and lavender can be added.47 Incorporating aromatherapy into massage helps the mind and body prepare for a deeper opening.  Gentle massage of patients is recommended three times a week, or even daily.  Frequency of this practice allows oils and herbs to penetrate deep into the skin, creating permanent changes.48
 
Techniques and supplies for this practice are very simple.  Purchase cold pressed, organic sesame or almond oil at a health food store.  Pour some oil into a bottle and store the rest in a cool, dark place.  Add essential oils according to patient needs. Warm oil prior to application in a hot water bath in a sink or a pan.  Test temperature on wrist before use.  Pour oil in hand liberally, and use both hands to spread oil along body part.  Use long strokes for long parts, such as arms, legs, and torso, and use circular strokes around joints.  Rub the oil in and allow the body to soak it up.  Maximum absorption is important and may take 20 minutes or more.  Stress reducing or mindfulness practices such as meditation may be done while the oil is absorbing. After absorption, pat off excess with a cloth, and if necessary, some warm water.  Removing oil with soap is not recommended.49
 
If massaging the whole body is not available, a simple foot and scalp massage will have many of the same therapeutic benefits, and will assist in relieving sleeplessness and fatigue.50 Head massage can relax the entire body by relaxing the nervous system and relieving mental strain and stress.51 and scalp.52 Brahmi oil, available online, is especially recommended for the soles of the feet and scalp. 52

Altars and Color Therapy

  • 43 Frawley, David. p. 502.
  • 44 Ibid.
  • 45 Halpern, Dr. Marc. Principles of Ayurvedic Medicine. p. 167.
  • 46 Sushruta Samhita. Section 5, verses 90-91
  • 47 Frawley, David. p. 506
  • 48  Ibid.
  • 49 massage technique from Halpern, Dr. Marc. Principles of Ayurvedic Medicine. p. 168.
  • 50 Johari, Harish. Ayurvedic Massage: Traditional Indian Techniques for Balancing Body and Mind. Healing Arts Press: Vermont, 1996. p. 4-5.
  • 51 Charaka Samhita.Vol 1. Section 5, verse 81-83.
  • 52 Lad, Vasant.p. 260.
The visual images that we take in through our sense of sight can bring pleasure or pain. The sense of sight can trigger memories, feelings and thoughts that are sattvic, rajasic or tamasic. The skillful use of color can add psychological harmony and peace of mind, and contribute positively to a patient’s emotional well­being during the dying process.53 This happens on a very subtle level and the psychological effects of color are not always consciously apparent to the viewer.  Color is vibrational energy that enters the eye and goes directly to the brain and mind.54
 
Color therapy can be applied in many ways.  Various methods include surrounding ourselves in therapeutic color choices through clothing, linens, window coverings, paint choices, colored light bulbs, flowers, candles, artwork and nature imagery.  Soft lights can be used instead of fluorescent or neon, and full spectrum light bulbs can be used in winter.55 Choosing decor with awareness of the specific effects of different colors can calm the mind and increase sattva.
 
The color gold is especially powerful in harmonizing the mind, strengthening the heart, and supporting ojas and immune and endocrine system health.56 Gold also provides stability, relieves anxiety, uplifts the spirit, and supports greater awareness and transformation of consciousness.57 For these reasons, gold is highly beneficial in hospice care settings.
 
The colors white and blue can also be used therapeutically.  White invokes purity, virtue and spirituality, and calms the heart, mind, nerves and emotions.58 It promotes meditation and spiritual awareness, and supports a state of mind that is expansive, flowing, clear and effortless. 59 Although these aspects are beneficial, white can increase vata and is not recommended in
excess.  Blue spiritualizes anger, antidotes the critical mind and reduces attachment and pitta, however, blue is very cold, light and dry and in excess, can increase vata.60
 
Another way to experience color is through creating an altar.  An altar creates a physical and tangible sacred space to facilitate mental and spiritual peace.61 Co­creating an altar with a patient allows for intimacy, connection, grounding and creativity.  Any objects can be used that have meaning and provide inspiration.

Mantras, Music and Affirmations

  • 53 Tirtha, Swami Sadashiva. Ayurvedic Encyclopedia: Natural Secrets to Healing, Prevention and Longevity. Ayurveda Holistic Center Press: New York, 1998. p. 319.
  • 54 Halpern, Dr. Marc. Healing Your Life: Lessons on the Path of Ayurveda. Lotus Press: Wisconsin, 2011. p. 126.
  • 55 Tirtha, Swami Sadashiva. p. 319.
  • 56 Ibid. p. 320.
  • 57 Halpern, Dr. Marc. Healing Your Life: Lessons on the Path of Ayurveda. p. 126.
  • 58 Tirtha, Swami Sadashiva. p. 321.
  • 59 Halpern, Dr. Marc. Healing Your Life: Lessons on the Path of Ayurveda. p. 126.
  • 60 Ibid.
  • 61 Simpson, Liz. The Book of Chakra Healing. Sterling Publishing Co: New York, 1999. p. 24.
The sense of hearing, like the sense of sight, can be used in ways that create harmony and peace, or in ways that agitate and disrupt the mind and body.  Hearing is the first sense that develops in utero.  The fetus reacts to its mother’s voice and external sounds as early as 4 ½ months.62  Hearing is the last sense to go as people transition into death.  Even unresponsive patients can often hear what is said to them.  Relaxing music, uplifting mantras such as ‘om,’ and affirmations are all sattvic tools that can be incorporated into patient care.
 
An affirmation is a positive, personally inspiring phrase that is a powerful tool to focus positive intention and counteract previous negative conditioning.63 Affirmations can be used to shift awareness and belief.  They can be played in the background, repeated aloud by patient or caregiver, written and placed around the space, or repeatedly mentally.  Patients and caregivers can develop their own affirmations, or use existing ones such as: May I be free from suffering, May I be at peace, May my heart flower.64 Other helpful affirmations are: I am at peace in this moment.  I release control; I embrace the unknown.65 Repeating affirmations creates the openness in mind and heart to receive what is longed for. If possible, repeat affirmations, or have them playing in the background, throughout the day.
 
Mantras are sound forms that create a shift in consciousness. Like affirmations, they can be chanted aloud or internally, or listened to in music.  To pacify vata, and create sattva, mantras need to be soft, warm, soothing, and calming.66 Patients should only chant out loud briefly, if at all, as this can deplete energy.  The mantra ‘om’ (rhymes with ‘home’) balances mind, body and spirit, promotes awareness, harmonizes the nervous system and clears the energy.67 The mantra ‘lum’ (rhymes with ‘chewing gum’) can be used to stabilize, ground, calm, and bring joy, happiness and contentment, and is especially useful when vata is high.68 Mantras resonate with the chakras and help to spiritualize the awareness on a subtle level.
 
Music can support the dying process in ways ranging from stress relief, to bedside support, to grief recovery.  Because music reaches a deep, non­rational part of the mind, it is ideally suited to shift feelings such as grief, fear, anxiety, sadness and anger that create rajas in the mind. Music can release blocked or painful feelings and can stimulate positive ones such as hope, love and gratitude. Sharing music together can lead to sharing of the emotions that the music brings up.69 70
  • 62 Gass, Robert. Chanting: Discovering Spirit and Sound. Broadway Books: New York, 1999. p. 23
  • 63 Simpson, Liz. p. 138.
  • 64 Levine, Stephan. Healing Into Life and Death.  Doubleday: New York, 1987. p. 23-24.
  • 65 Ibid. p. 27.
  • 66 Tirtha, Swami Sadashiva. p. 314.
  • 67 Ibid. p. 312.
  • 68 Ibid. p. 313.
  • 69 Levine, Stephan.. p. 25.
  • 70 http://www.growthhouse.org/music.html This website streams music that is intended to support the death process and patients in hospice and palliative care settings.
 Sound is a nutrient for the spirit as well as for the body.71 When the moment of transition into death arises, chants can be used to say goodbye. Stephan Levine suggests: Go in beauty. Peace be with you.  Til we meet again in the light.72 Another chant, made famous in Kundalini Yoga circles, that can be used comes from a popular song from the 1960s:
 
May the longtime sun shine upon you, May all love surround you,
And the pure light within you guide your way home.73

Meditation Practices for Hospice and Palliative Care

Meditation is a journey to the center of our own being.74 Meditation can be done anywhere, at any time, sitting, lying down, or walking.75 One can meditate with a mantra, a thought or feeling, by looking at nature, thinking about God, feeling pure love, or with any technique that doesn’t cause strain, anger or worry that one is not doing it properly.76  There are countless techniques for meditation, and they are all valid.  The technique introduced here is simple to learn and to practice.  Any other techniques can also be used.  The most important aspects to practice are devotion and sincerity.77
 
Meditation is an art of bringing harmony to body, mind and consciousness.78 It has been shown to be clinically beneficial in healing body and mind.79 It gives us a respite from the pressures of life.  As we relax, the heart beats more slowly and the blood pressure lowers. Meditation helps retrain response mechanisms so we don’t react as strongly or as negatively to adverse situations. It gives us the ability to be more centered, and more in control of our reactions.80 Meditation allows the mind to be healthy and sattvic, alert, positive and calm.81 When we meditate, we release rajasic mental states such as fear, worry and anger and replace them with positive attitudes.82 By practicing meditation as regularly as possible, we gradually gain control over the flow of our emotions and movement of our minds.  This allows us to turn awareness inward.83
  • 71 Levine, Stephan.. p. 25.
  • 72 Ibid. p. 27.
  • 73 lyrics written by Incredible String Band.
  • 74 Novak, John. Ananda Course in Self-Realization: Part 1: Lessons in Meditation. Ananda Church: USA, 1997. p. 13.
  • 75 Tirtha, Swami Sadashiva.. p. 595.
  • 76 Ibid.
  • 77 Ibid.
  • 78 Lad, Vasant..p. 76.
  • 79 International Journal of Palliative Nursing. “Mindfulness Based Cognitive Therapy.” Kabat-Zinn, Dr. Jon. June 2001.
  • 80 Novak, John. p. 15.
  • 81 Ibid.
  • 82 Ibid. p. 16.
  • 83 Ibid.
 One advantage of the form of meditation outlined below as a treatment method is that it is very safe, has no side effects, and is easy to teach and share.84 This form of practice creates the ability to look within and contact the deeper aspects of consciousness. In So Hum meditation we sit quietly and watch our breath.85 Patients can be in supine position or seated.  Keeping the spine straight is helpful. Patients can be supported with pillows to suit their comfort. Begin by allowing the mind to be present. Let go of stories in the mind and thoughts about what’s going on elsewhere.  Relax and be comfortable.  Take a few deep breaths in, if possible.  Inhale and
exhale through the nose, if possible.  As you inhale, mentally think ‘so’ (rhymes with ‘no’).  As you exhale, mentally think ‘hum’ (rhymes with ‘chewing gum’).  Continue this pattern of repeating ‘so­hum’ with the breath.  The syllable ‘so’ represents the life force entering the body through inhalation, and the syllable ‘hum’ represents the release of limitations through the exhalation.86 If the mind starts to wander, just bring it back to focus on the mantra and the breath.87 Breathe through whatever comes up.  In this practice, for most people, the breath naturally deepens.  You will very likely become distracted, just bring the mind back to focus on the breath and mantra, be gentle with yourself, and keep going.  When beginning this practice, 2­3 minutes of practice is suggested.  Practicing consistently brings benefit.  After the practice is finished, allow a few moments to bring the mind back to normal awareness.88
 
Another practice that supports deep relaxation and spiritualizing one’s awareness is yoga nidra. Yoga nidra begins with the patient in a supine position, supported with pillows for comfort.  This practice is guided by a soothing voice, and many good recordings are available.89 Yoga nidra takes the body through a total relaxation process, calms the mind and releases tension and stress.  Yoga nidra brings the mind to focus on different parts of the body, feeling them distinctly, and then fully relaxing.  It brings the mind to focus and creates intention.  Although it is not intended to cause one to fall asleep, one will receive benefit even if one is asleep.  If possible, keep the mind alert and focused.  When practiced effectively, this technique is as restorative as sleep.90

Breathing Practices for Hospice and Palliative Care

The breath is the primordial life force governing mental and physical function.  One’s breath is the essence of one’s life.  The first breath is taken shortly after arriving in the world, even before the umbilical cord is cut.  The breath continues, unbroken, until death. Breathing does not require conscious attention, but by choosing to bring awareness to the breath, one can influence the body and mind. Mindful breathing clears the mind, brings calm and allows individuals to connect their personal energy with the universal energy.91 
  • 84 Frawley, David. p. 517.
  • 85 Lad, Vasant..p. 79.
  • 86 Ibid.
  • 87 Chopra, Deepak and David Simon. The Seven Spiritual Laws of Yoga: A Practical Guide to Healing Body, Mind, and Spirit. John Wiley & Sons, Inc: New Jersey, 2004. p. 90-91.
  • 88 For different meditation techniques, consult the many books of Pema Chodron, as well as titles by Stephan Levine Who Dies? and Healing into Life and Death.
  • 89 Yoga nidra recordings are widely available on CD, iTunes and YouTube.  The recording of Dr. Marc Halpern guiding Yoga nidra is recommended.
  • 90 Feuerstein, Georg and Larry Payne. Yoga for Dummies. IDG Books Worldwide, Inc: California, 1999. p. 61.

To practice mindful breathing, sit or lie in a comfortable position.  Relax the shoulders.  Breathe deeply and slowly, allowing the breath to come from the abdomen.  Imagine that the belly is breathing, rather than the chest.  If possible, have the entire breathing movement come from the diaphragm.   After a few minutes, observe the effects of this practice on the body and mind.

Support for Caregivers

Caregivers for the dying often become distressed, depressed and drained of energy.  They often become the second patient.93 In times of stress it is easy to focus one’s attention outward, and forget one’s own needs.  There may seem to be no time for caregivers to focus on their own needs such as nourishing and healthy food, sleep, quiet time or meditation and time to unwind in nature or with loved ones.  For those who devote their time to caring for the ill and dying, it is especially important to prioritize self­care, ask for help and delegate responsibility to others.
Studies have shown that caregivers experience a rise in anxiety, depression and salivary cortisol, and that regular practice of yoga and meditation reduces all three of these symptoms.94 Caregivers can use all five of their senses to create harmony, peace and balance.95 The recommendations outlined in this paper can also apply to caregivers.  Massage nourishes the sense of touch, aromatherapy can influence the mind through the sense of smell, relaxing music and healing mantras can serve as sound therapy and color therapy can be applied through flowers and pleasant visual impressions.  Caregivers need to bring their attention to keeping ojas high, therefore, ojas building foods are recommended, such as nourishing soups, dates, almonds, and hearty grains such as basmati rice, quinoa and oatmeal with warming spices.
Helping others have a peaceful and dignified death, either as a professional or familial caregiver, is heart­centered work.  Caregivers in hospice situations extend themselves above and beyond usual boundaries.  Having a “good death” is important to people, and contributing to that end is a deep calling and not something that everyone is called to do.96 In order to be able to continue to give, one must avoid draining one’s self.  Ayurveda has profound wisdom to offer in this capacity.
 
Conclusion
  • 91 Chopra, Deepak and David Simon. p. 99-104
  • 92 Ibid.
  • 93 Berman, Claire. Caring for Yourself While Caring for Your Aging Parent: How to Help, How to Survive. Henry Holt: New York, 1996. p. 34.
  • 94 Evidence Based Complementary and Alternative Medicine. “A yoga and compassion meditation program reduces stress in familial caregivers of Alzheimer's disease patients.” Danucalov et al. April 2013.
  • 95 Sushruta Samhita. Section 8, verse 10.
  • 96 Sneesby and Mater. “Home is Where I Want to Die: Kelly’s Journey.” Contemporary Nurse. Aug 2013.
Ayurveda is an ancient system that can be used to offer ease and comfort to patients in hospice care settings, as well as their family and caregivers.  Techniques explored in this paper help support relaxation, manage stress and anxiety, and create feelings of peacefulness and upliftment.  These practices assist all who are involved in experiencing and being present to the sacredness of dying.  Through Ayurveda, we can explore the dimension of spirituality within us, unlocking greater capacity to love, care and be compassionate.

Bibliography

Berman, Claire. Caring for Yourself While Caring for Your Aging Parent: How to Help, How to Survive. Henry Holt: New York, 1996.
Charaka Samhita.
Chopra, Deepak and David Simon. The Seven Spiritual Laws of Yoga: A Practical Guide to Healing Body, Mind, and Spirit. John Wiley & Sons, Inc: New Jersey, 2004.
Danucalov et al. “A yoga and compassion meditation program reduces stress in familial caregivers of Alzheimer's disease patients.” Evidence Based Complementary and Alternative Medicine. April 2013.
Dass, Ram. Still Here: Embracing Aging, Changing and Dying. Berkeley Publishing Group: New York, 2000. Downey, et al.“Three lessons from a randomized trial of massage and meditation at end of life: patient benefit, outcome measure selection, and design of trials with terminally ill patients.” American Journal of Hospice and Palliative Care. Aug 2009.
Feuerstein, Georg and Larry Payne. Yoga for Dummies. IDG Books Worldwide, Inc: California, 1999.
Frawley, David. Ayurvedic Healing for Healthcare Professionals. California College of Ayurveda: Nevada City, CA, 1988.
Gass, Robert. Chanting: Discovering Spirit and Sound. Broadway Books: New York, 1999.
Halpern, Dr. Marc. Healing Your Life: Lessons on the Path of Ayurveda. Lotus Press: Wisconsin, 2011. Halpern, Dr. Marc. Principles of Ayurvedic Medicine. California College of Ayurveda: California, 1995. Heyn, Birgit. Ayurvedic Medicine: The Gentle Strength of Indian Healing. Thorsons Publishing Group: Vermont, 1987.
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Johari, Harish. Ayurvedic Massage: Traditional Indian Techniques for Balancing Body and Mind. Healing Arts Press: Vermont, 1996.
Kabat­ Zinn.  “Mindfulness Based Cognitive Therapy.” International Journal of Palliative Nursing. June 2001.
Kubler­Ross, Elizabeth. On Death and Dying. Scribner: New York, 1969.
Lad, Vasant. Complete Book of Ayurvedic Home Remedies. Three Rivers Press: New York, 1998.
Levine, Stephan. Healing Into Life and Death.  Doubleday: New York, 1987 livingyourdying.com
Novak, John. Ananda Course in Self­Realization: Part 1: Lessons in Meditation. Ananda Church: USA, 1997 Page, Linda. Healthy Healing. Quality Books Inc: 1985.
Shanbhag, Vivek. A Beginner’s Introduction to Ayurvedic Medicine: The Science of Natural Healing and Prevention Through Individualized Therapies. Keats Publishing, Inc: CN, 1994.
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Wall, Carly. Setting the Mood With: Aromatherapy. Sterling Publishing Company: New York, 1998.
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Abstracts

from Contemp Nurse. 2013 Aug 4.
Home is where I want to die: Kelly's Journey.
Sneesby L, Mater C.
 
Abstract
The definition of a "good death" is centred on being peaceful, dignified and pain free. The preferred place of death has also been highlighted as an important concept in defining a good death (Cox, Almack, Pollack & Seymour, 2011) 70% of Australians express the desire to spend their last days at home. In reality only 16 % of people die at home (Preferred place of death, 2008). With 10% of Australians dying in residential aged care facilities and approximately 20% in hospices, the rest die in hospitals (Parish et al., 2006). Family support and the family's care giving ability play a major role in determining whether a person is able to die at home. Other factors include the availability of medical and nursing care.
 
from­Evid Based Complement Alternat Med. 2013 Apr 18.
 
A yoga and compassion meditation program reduces stress in familial caregivers of Alzheimer's disease patients.
Danucalov MA, Kozasa EH, Ribas KT, Galduróz JC, Garcia MC, Verreschi IT, Oliveira KC, Romani de Oliveira L, Leite JR.
 
Abstract
Familial caregivers of patients with Alzheimer's disease exhibit reduced quality of life and increased stress levels. The aim of this study was to investigate the effects of an 8­week yoga and compassion meditation program on the perceived stress, anxiety, depression, and salivary cortisol levels in familial caregivers. A total of 46 volunteers were randomly assigned to participate in a stress­reduction program for a 2­month period (yoga and compassion meditation program­YCMP group) (n = 25) or an untreated group for the same period of time (control group) (n = 21). The levels of stress, anxiety, depression, and morning salivary cortisol of the participants were measured before and after intervention. The groups were initially homogeneous; however, after intervention, the groups diverged significantly. The YCMP group exhibited a reduction of the stress (P < 0.05), anxiety (P < 0.000001), and depression (P < 0.00001) levels, as well as a reduction in the concentration of salivary cortisol (P < 0.05). Our study suggests that an 8­week yoga and compassion meditation program may offer an effective intervention for reducing perceived stress, anxiety, depression, and salivary cortisol in familial caregivers.
 
from Am J Hosp Palliat Care. 2009 Aug­Sep
 
Three lessons from a randomized trial of massage and meditation at end of life: patient benefit, outcome measure selection, and design of trials with terminally ill patients.
Downey L, Engelberg RA, Standish LJ, Kozak L, Lafferty WE.
 
Abstract
Improving end­of­life care is a priority in the United States, but assigning priorities for standard care services requires evaluations using appropriate study design and appropriate outcome indicators. A recent randomized controlled trial with terminally ill patients produced no evidence of benefit from massage or guided meditation, when evaluated with measures of global quality of life or pain distress over the course of patient participation. However, reanalysis using a more targeted outcome, surrogates' assessment of patients' benefit from the study intervention, suggested significant gains from massage­the treatment patients gave their highest preassignment preference ratings. The authors conclude that adding a menu of complementary therapies as part of standard end­of­life care may yield significant benefit, that patient preference is an important predictor of outcome, and that modifications in trial design may be appropriate for end­of­life studies.
 
from Am J Hosp Palliat Care. 2009 Aug­Sep
 
Three lessons from a randomized trial of massage and meditation at end of life: patient benefit, outcome measure selection, and design of trials with terminally ill patients.
Downey L, Engelberg RA, Standish LJ, Kozak L, Lafferty WE.
 
Abstract
Research suggests that aromatherapy massage (AM) is increasingly being used by cancer patients, especially in the palliative care setting, although few studies have assessed its effectiveness. I wanted to find out whether AM reduces anxiety in patients with a primary malignant brain tumour attending their first follow­up appointment after radiotherapy. Eight patients were recruited to the study, which comprised three methods of data collection: the measurement of physical parameters; the completion of Hospital Anxiety and Depression Scales (HADS); and semi­structured interviews. The results from HADS did not show any psychological benefit from AM. However, there was a statistically significant reduction in all four physical parameters, which suggests that AM affects the autonomic nervous system, inducing relaxation. This finding was supported by the patients themselves, all of whom stated during interview that they felt 'relaxed' after AM. Since these patients are faced with limited treatment options and a poor prognosis, this intervention appears to be a good way of offering support and improving quality of life.
 
from Int J Palliat Nurs. 2001 Jun;
 
The role of aromatherapy massage in reducing anxiety in patients with malignant brain tumours.
 
Abstract
 
Mindfulness is a lifetime engagement­­not to get somewhere else, but to be where and as we actually are in this very moment, whether the experience is pleasant, unpleasant, or neutral.Mindfulness is a lifetime engagement­­not to get somewhere else, but to be where and as we actually are in this very moment, whether the experience is pleasant, unpleasant, or neutral.