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Posts Tagged ‘being with dying’

70. Hope is not a plan

Posted in Uncategorized, tagged , , , , on 28 October 2010| 3 Comments »

In “Letting Go,” an illuminating article on care for the dying, the surgeon and author Atul Gawande examines the choices that terminal patients and their families face at the end of life. Contrasting hospice with hospital care, he reports a remarkable finding:

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.*

Reflecting on this finding, Dr. Gawande concludes that the “lesson seems almost Zen: you live longer only when you stop trying to live longer.”

“Almost Zen” is an approximation, akin to the modifier “Zen-like,” which often obscures what it purports to describe. But in associating this particular “lesson” with Zen practice, Dr. Gawande comes close to the mark. Shunryu Suzuki Roshi, author of Zen Mind, Beginner’s Mind, often admonished his students to have “no gaining idea” when practicing Zen meditation. Other teachers have done the same.  Those Medicare patients who chose to forgo hospital treatment were indeed rejecting a gaining idea: that of a longer life at any cost. Ironically, by choosing hospice care, they not only improved the quality of their last days and avoided the debilitating side-effects of hospital treatments. They also lengthened their lives.

Yet it is one thing to know that you have a fatal illness and another to accept that you are dying. “I’d say only a quarter have accepted their fate when they come into hospice,” observes Sarah Creed, a hospice nurse quoted by Dr. Gawande. “Ninety-nine per cent understand they’re dying, but one hundred per cent hope they’re not. They still want to beat their disease.” Such hope is only human. Only a very cold observer would presume to judge it adversely. But to deny that one is dying, when that is in fact the case, is not a constructive way to prepare oneself or one’s loved ones for the inevitable. Nor is it the way of Zen.

The Zen teacher Charlotte Joko Beck, who is nothing if not tough-minded, once proclaimed that to practice Zen, we have to “give up hope.” When that statement angered some of her students, she explained what she had meant:

Sounds terrible, doesn’t it? Actually, it’s not terrible at all. A life lived with no hope is a peaceful, joyous, compassionate life . . . . [W]e are usually living in vain hope for something or someone that will make my life easier, more pleasant. We spend most of our time trying to set life up in a way so that will be true; when, contrariwise, the joy of our life is just in totally doing and bearing what must be borne, in just doing what has to be done. It’s not even what has to be done; it’s there to be done so we do it.**

Joko Beck’s tone is blunt, and her perspective may be difficult to accept. But that perspective accords with Dr. Gawande’s, insofar as it admonishes us to accept the harshest of realities and to act accordingly. Addressing the question of hope, Dr. Gawande recalls the example of Stephen Jay Gould, who survived a rare and lethal cancer for twenty years. “I think of Gould,” Dr. Gawande remarks, “every time I have a patient with terminal illness. There is almost always a long tail of possibility, however thin.” There is nothing wrong with looking for that tail, he acknowledges, “unless it means we have failed to prepare for the outcome that’s vastly more probable.”  What is wrong is that “we have created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets . . .  Hope is not a plan, but hope is our plan.” As a wiser alternative, he advocates open discussions, funded by medical insurance, between terminal patients, their families, and their doctors.  Conducted with patience and candor, discussions of this kind can clarify what is most important to the dying person. And having had such discussions, people are “far more likely to die at peace and in control of their situation, and to spare their family anguish.”

Reading Dr. Gawande’s prescription, I am reminded of the experience of Shinge Roko Sherry Chayat Roshi, Abbot of the Zen Center of Syracuse, whose mother recently passed away. During the days before her death, Shinge Roshi talked with her mother about books, art, and music. She edited her mother’s memoirs—and helped her write the ending. Her mother, in turn, saw to it that her affairs were in order. Accepting her imminent death, she gave her daughter a list of things to do, people to call, and last thoughts. For Shinge Roshi, the experience of being with her mother during and after her passing awakened feelings of profound gratitude.  It was, she said, as miraculous as birth.

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* Atul Gawande, “Letting Go,” The New Yorker, July 26, 2010 (http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande).

** Charlotte Joko Beck, Everyday Zen (HarperSanFrancisco, 1989), 66, 68.

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57. CB’s list

Posted in 1, tagged , , , , on 1 April 2010| 10 Comments »

“Death is certain,” Zen teachings remind us, “but the time of death is uncertain.” What truth could be more evident, one might say, what reality more apparent. Yet that truth and that reality are difficult to accept, even under the most auspicious conditions. And should we learn that our own death is imminent, the difficulty increases a hundredfold.

So it was with Carol Ruth Burdick (1928-2008), my friend of forty years, who learned on the evening of Friday, February 29, 2008 that she had advanced pancreatic cancer. Known to her community as “CB,” Carol was seventy-nine years old. Surgery, as she saw it, was out of the question, as was chemotherapy. The plain fact was that she was going to die, and soon. Rather than share that fact with friends or family, she spent the night facing it alone.

Knowing nothing of her diagnosis, I called CB early the next morning to inquire after her health and to suggest that we meet for conversation, as we often did on Saturday mornings. When she told me her bad news, I  expressed my sympathy, but I didn’t know what to say. “What’s the prognosis?” I asked.

“About six weeks,” she replied.

A few hours later, CB and I sat at her dining-room table, looking out of her big picture window at her frozen pond. Her mood seemed preternaturally calm. “How are you feeling?” I asked. In response, she reported that during the night she had made a list of the ten “positive aspects” of her impending death. “You know how I hate positive thinking,” she declared—and then went on to read her list.

First, she would not be a burden to her grown children. Second, she would not suffer the humiliation of senile dementia. Third, she would not become destitute. Fourth, she would not have to endure a second knee replacement. Fifth, she would no longer need to worry about her internal pains, for now she knew their cause. Her list continued, each item detailing another benefit of her death—silver linings, if you like, in the darkest of clouds.

Exactly six weeks later, on another Saturday morning, CB passed away. Since then, I’ve often thought of her list. What prompted her to compose it, I’ve wondered, and what purpose did it serve?

To some, CB’s list might seem an elaborate form of denial, a rationalist’s defense against an implacable force. Perhaps it was, but I would prefer to see it as an expression of her literary sensibility and her practical outlook. CB was a published writer of poems and essays, articles and memoirs. It was natural that she would turn to language and literary form to articulate her situation. And CB was also an unsparing realist, who cast a cold eye on human folly and romantic self-deception. Void of such notions as a happy afterlife or a lasting legacy, her list acknowledged the concrete changes her death would bring, both for herself and her loved ones. It was not a wish list but a sober appraisal, reflective of both her stern Protestant upbringing and her literary education.

Yet CB’s list was more than a realist’s analysis. It was also, in its way, an affirmation of the wholeness of life. Positive/negative; good/bad; fortunate/unfortunate: by their very nature, such dualities divide the stream of being into artificial halves, favoring one over the other and falsifying the whole. Perhaps that’s why CB disliked “positive thinking,” which not only “accentuates the positive,” as the old show tune advises us to do, but also isolates half of our experience at the expense of the other. And perhaps that’s also why CB fashioned her list, which redressed the balance of darkness and light, sadness and happiness in her present experience. For her family and friends as well as herself, her list afforded honest consolation. Beyond that, it affirmed the unity of life and death, creation and destruction, even in the midst of loss. Sober though it was, her list was a hymn to life and death, a lapsed Protestant’s L’Chaim.

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Carol Burdick was Adjunct Professor of English at Alfred University and the author of Haps & Mishaps: Sketches from a Rural Life (Whitlock Publishing, 2008). For more information, see http://www.whitlockpublishing.com/local.htm.

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45. Closing doors

Posted in 1, tagged , , , , , , on 22 October 2009| 1 Comment »

DoorwaysThere are many ways to close a door. It can be done angrily or in haste. It can be done with infinite care. When Thich Nhat Hanh, then a young Vietnamese monk, visited the Trappist monk Thomas Merton at the Abbey of Gethsemani in Kentucky in 1966, Merton observed how his guest opened and closed the door. From that action alone, Merton later remarked, he could tell that Thich Nhat Hanh was “an authentic monk”.

Presumably, Thich Nhat Hanh closed the door quietly and with full attention, as his monastic training had taught him to do. In his book Zen Keys, he explains the purpose of that training:

The master can see if the student is or is not “awake.” If, for example, a student shuts the door noisily or carelessly, he is demonstrating a lack of mindfulness. Closing the door gently is not in itself a virtuous act, but awareness of the fact that you are closing the door is an expression of real practice. In this case, the master simply reminds the student to close the door gently, to be mindful. The master does this not only to respect the quiet of the monastery, but to point out to the student that he was not practicing mindfulness, that his actions were not majestic or subtle.*

Although he is articulating a general principle, Thich Nhat Hanh is also recalling a personal experience. As a sixteen-year-old novice, he closed a door with less than full attention, and his teacher called him back for a second try. That experience was, in his words, his “first lesson in the practice of mindfulness”.

In Zen practice the closing of a door is only one of some ninety thousand “subtle gestures,” each an expression of mindfulness. Symbolically, however, the opening or closing of a door has special importance, insofar as it signifies a moment of transition.  In his poem “Men at Forty” the American poet Donald Justice employs that traditional symbol, as he observes that “Men at forty / Learn to close softly / The doors to rooms / They will not be coming back to”. As they stand “At rest on a stair landing,” these newly middle-aged men “feel it moving / Beneath them now like the deck of a ship, / Though the swell is gentle.”**

In her book Making Friends with Death, Judith Lief employs the same symbol to describe the transitions in our lives:

Transitions are like doorways. When we open a door, we think we know what we will find on the other side, but we can never be sure. We do not know with certainty whether we will find a friend or an enemy, an obstacle or an opportunity. Without actually opening the door and walking through, we have no way of knowing. When we face such a door, we feel uncertain, vulnerable, exposed. Our usual strategies do not hold. We are in no-man’s-land. Transitions make us uncomfortable, and they are often accompanied by some degree of pain, but at the same time, they open us to new possibilities.***

Acknowledging that each moment of experience is a transition, “bounded by its own birth and death,” Lief reminds us that transitions often engender fear. Like Justice’s forty-year-olds on their moving decks, we feel uncertain and insecure. As a counter-measure, Lief urges us to pay close attention to all the transitions in our lives, however small, and to abide, if we can, in uncertainty, rather than retreat to what we know.  By so doing, we “begin to loosen our habitual fear of the unknown and undefined”.

For many of us, that noble goal is not so easily attained. It is one thing to learn, as Thich Nhat Hanh did, how to close a door with full attention. It is another to learn how to witness and accept transitions, whether they be from youth to middle age, working life to retirement, robust health to chronic illness, a stable marriage to sudden widowhood. But, in truth, the two kinds of learning are of a piece, and the one is training for the other. By learning to be mindful of the “ninety thousand subtle gestures,” we cultivate an ability to cope with the not-so-subtle changes that befall us. By learning to close an actual door with full awareness, we strengthen our capacity to pass, with grace and affirmation, through the wider doorways that lie ahead.

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*Thich Nhat Hanh, Zen Keys (Thorsons 1995), 29

**Donald Justice, New and Selected Poems (Knopf 1995), 76

***Judith L. Lief, Making Friends with Death (Shambhala 2001), 15

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23. Being with dying

Posted in Previous columns, tagged , , , , , on 20 February 2009| Leave a Comment »

“Snow was general all over Ireland,” writes James Joyce at the end of his short story “The Dead.” In this celebrated story Gabriel Conroy, a middle-aged Dubliner, comes to terms with his own mortality. As often in Western literature, snow is a metaphor for death.

Today, what is general all over America—and indeed the world—is fear, whether its object be joblessness, a terrorist attack, or the more familiar specters of aging, sickness, and death. What have Zen teachings to say about fear? And what has Zen practice to offer?

One person who has confronted fear in general and the fear of death in particular is Joan Halifax Roshi, founder and Abbot of the Upaya Zen Center in Santa Fe, New Mexico. Trained as an anthropologist, Roshi Joan turned to Zen practice after the death of her grandmother. For the past four decades she has devoted her life to teaching Zen and caring for the dying.

In her new book, Being with Dying (Shambhala, 2008), Halifax presents the fruit of her life’s work. Observing that the fear of death causes many of us to avoid, ignore, or otherwise deny the “only certainty of our lives,” she reminds us that “to deny death is to deny life.” And to embrace death can be the ultimate form of liberation:

The sooner we can embrace death, the more time we have to live completely, and to live in reality. Our acceptance of death influences not only the experience of dying but also the experience of living; life and death lie along the same continuum. One cannot—as so many of us try to do—lead life fully and struggle to keep the inevitable at bay.

But how, exactly, are we to embrace death? To address our fear?

Halifax offer a wealth of “skillful means,” including zazen, walking meditation, reflection on one’s priorities, and the contemplation of nine perspectives on living and dying (“The human life span is ever-decreasing; each breath brings us closer to death”). But of her many strategems, two in particular stand out, the first of them a practical method, the second a matter of attitude.

Halifax calls her method “strong back, soft front.” By this she means the posture of meditation, in which we first straighten, then relax, our backs, feeling the strength and stability of an upright spine. Having established that stability, we soften the front of our bodies, opening our lungs to the air and our minds to things as they are. We bring our presence, strengthened but softened, to whatever suffering we encounter.

Simple though it sounds, this practice can bring immediate calm. And over time, it can engender a profound shift of attitude :

To meet suffering and bear witness to it without collapsing or withdrawing into alienation, first we must stabilize the mind and make friends with it. Next, we open the mind to life—the whole of life, within and around us, seeing it clearly and unconditionally from that stable inner base. And then we fearlessly open our hearts to the world, welcoming it inside no matter how wretched or full of pain it might be. I’ve come to call this the “threefold transparency”—us being transparent to ourselves, the world’s being transparent to us, and us being transparent to the world.

As Halifax readily acknowledges, this practice is anything but quick or easy. But with the necessary effort come eventual liberation and the capacity to be of genuine help to others. “It may take effort,” she observes, “to return our mind to practice. And it usually takes effort to bring energy and commitment to everything we do. Effort at its very core means letting go of fear.”

At a time when fear is as general as Joyce’s snow, such a perspective is as worthy as it is rare.

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