HOSPICE TRAINING SESSION
Velandy Manohar, MD. FAPA
The traditions of Sanatana Dharma known all over the world as Hinduism requires me to offer invocation prayers to God before I offer my responses to the questions posed by Rev. Doyle.
Om! Om! Om!
Shuklambaram dharam Vishnum, Sashivarnam Chaturbhujam,
Prasanavadanam dhyayet, Sarva Vighnam opashantaye
Om Shanti, Shanti, Shantihi (Navagraha Sooktam)
I contemplate on the pleasant countenance of Almighty God and seek the amelioration of all hardships; May Peace pervade in the three spheres.
O God may we always hear that which is auspicious, may we always perceive with our eyes that which is auspicious. May we live the span of life allotted by Thee offering praises to Thee and be in harmony and health. May God save us from harm, bless us with the mental capacity to understand his revealed world and the resolute heart to walk with him in His path. (Revealed Word of God-Atharva Veda.)
Om! Saraswati Namastubhyam, Varade Kamarupini, Vidya arambaham Karishyami, Siddhir bhavati mey sada.
O Goddess of Learning, my humble prostration’s unto Thee, who are fulfiller of our supplications. As I commence my studies, I pray to Thee to invoke Thy blessings so that I may attain the highest goal.
Om. May God protect us both, the preceptor, and the pupil. May He nourish us both. May we work together with great energy. May our study be vigorous and fruitful. May we not experience animosity towards each other. May Peace pervade the three spheres.
Om. O God Supreme Would Thou deign to lead me from the state of Unknowing (ASAT) to Knowing Thee (SAT= Truth). From the darkness of ignorance to the illumination of Supreme knowledge and thus from Death to Immortality.
Q 1. What are the basic beliefs regarding death? What happens to the Soul Spirit or essence?
Every living being has a soul, plant animal or man. The visible body is not the whole reality. The reality within it an unseen essence whose existence one must apprehend and experience to live life to its fullest extent. The Soul must not be construed as a tangible or in tangible product of the brain. It is not Buddhi, Manas or Chittam mind, intellect, or consciousness. It is not Ahamkara that aspect of consciousness from which I-ness and Mine-ness are derived. These are all believed to be parts of the Subtle body or Sukshma Sarira. The Soul is not part of the Coarse tangible body called the Sthula Sarira. This is the material body, which is born, which exists for a period of time undergoes modifications in form, function and name and finally becomes dust or ashes and food for other creatures. In the Bhagvad Gita the Blessed Lord states” What so life form is born, whether it is fixed or mobile, know this well that it comes from the union of the physical body and the Soul.” xiii-26.
The Soul exists quite apart from these anatomical entities even though it pervades all nooks and crannies and influences all functions of the physical being. It is not located in any one part of the physical being. In the Bhagvad Gita xiii-33 The Blessed Lord says “As the one Sun irradiates the whole Earth the Soul irradiates the physical being” In the Kena Upanishad the Teacher gives this lesson,” The Soul is that by which the mind thinks; it is not one of the concepts that is generated by the mind, but it is that by which one is able to think through the mind. It is that which enables the mind to think, the eye to see, the ear to hear and the breath to move and sustain the body. Do not mistake the body that one has to feed, and which one day becomes the food of other creatures for the indwelling Spirit. This entity the subtlest of the subtle, the infinitesimal spark which is makes life as we experience it possible is called the Karana Sarira the inner most of the three components of physical beings.
The Soul (the Essence) is conditioned by the limitations that are imposed by fruits of actions and propensities from the previous births, which constitute the shroud of Avidya (darkness) then the conditioned embodied Soul, is called Jiva. The Soul is deemed to be in bondage when the conditioned self with its limitations experiences the material body and the world of objects as the True Self. When the indwelling Soul recognizes the misidentification of the coarse and subtle selves as the all-pervading reality and by claiming its birth right It reclaims its true identity as the changeless, indestructible Essence that pervades all living beings That Soul is ever free, forever unbound and resplendent with Gods grace. This realization is the basis of the final release and attainment of the Highest goal.
The Scriptures (sadhanas) for the cleansing of impurities (malla), progressive attenuation of distractions (vikshepa) and the lifting of the veil of Untruth (avarna) recommend three methods of self-discipline. These are Sravana (prayerful listening) Manana (Reflection) lifts one above the level of the mind –body stuff (upadhis) and Nidhidhysana (meditation) that will extinguish habitual errors (adhysa) and enable the seeker (sadhaka) to experience with feeling the essence of the Scriptures. (The Self alone is all this and I am that Self in my essence) Then the seeker is said to abide in the Truth. This is Samadhi. The seeker is who achieves this level of steadiness of the Spirit and enlightenment is believed to have attained the highest plane of consciousness (Brahma Stithi)
In the Brahma Sutra Bashya Srimad Adi Sankara describes the major concerns that condition the individual soul. When the soul is enmeshed by the attachment to one’s children and close friends and greatly motivated by their joys and sorrows the Soul so conditioned is termed the Gauna Atma. The attachment of the conditioned body to the Inner Self is stronger than the attachment to one’s spouse and children the Soul so distorted by misidentification is called Mithya Atma. When one reclaims one’s true identity with the Indwelling Soul in Spirit by transcending the knots and ties that bind then that self is called the Mukhya atma or the one True authentic Self. This individual can experience the Sat Chit Ananda state in this verse there is nothing further beyond this state for the embodied soul of Jivan mukta. The Yogi striving resolutely purified of talent, gradually gaining Perfection through many births, then reaches the highest goal. Such seekers acquire the wealth of discriminative knowledge of the unity of the self and the Supreme Self (Jiva-Brahma Aikhyam), dispassion (Vairagya) and capacity for reflection on the nature of the self (Atma vichara) The mind of such evolved souls have resolved all doubts about Truth asserted in the revealed word of God (PrameyaAsambhavana) and abides in a single unbroken chain of thought the Self alone is all this and therefore That Self I am. (Aham Brahmasmi iti Akhandakara vritti)
The Katha Upanishad and the Bhagvad Gita uses the metaphor that follows to illustrate the relationship of the components of physical being and the Soul. The God who presides over Death dispenses this wisdom to His persistent and brilliant youthful pupil.
“Know the soul to be the rider in the chariot which is the body. The discriminative intellect is the charioteer and the mind the reins. The sense organs are the horses, and the attractive objects are plentifully distributed along the way. If the charioteer (the individual person) is unwise and not vigilant and keep a firm grip on the reins which represent the mind the sense organs which represent the horses will bolt from this to that attractive object in an uncontrollable manner. If on the other hand a charioteer of wisdom keeps a firm hand on the reins (mind) then the senses are in good control and the chariot can be driven to its destination safely and successfully.
Just as the body undergoes modification from birth to childhood, adulthood, and old age so also the Soul moves from one body to another in its long sojourn in the Ocean of life, death and rebirth before liberation is experienced and attained to. (Bhagvad Gita ii-13) This Soul is uncleavable, It is incombustible, neither can it be made wet and dissolved or dried and powdered. It abides forever all pervasive, stables the immovable and most ancients. ii-24. The Soul does not die nor is it born, nor having been born with a body, does it ever cease to be at any time; it is unchanging ever abiding and primeval. It is not extinguished when the body is has taken its last breath. ii-20. Just as humans cast off worn garments and take on new apparel even so does the Soul cast off that which has come to the end of its time and enters new physical vessels that resume the Journey to the Self Effulgent light. After many lives of dedication to mindful performance of one’s duties based on Gods will people attain the Supreme
This verse from the great Sufi Seer Jalal ud din Rumi expresses his insight into the evolutionary transmigration of the Self)
“I died as a mineral and became a plant. I died as a plant and awoke in an animal, I died as an animal, and I found myself in a man. Why should I fear? When was I less by dying and be being born? Yet once more, I shall die as a man to soar with the blessed angels, but even from angelhood, I must pass on. All except God doth perish. To God I shall return.” This powerful urge for re-union with the Supreme Self is expressed thus in a Bengal Hymn,” Because Thou loves the burning ground, I have made the funeral pyre of my heart where I resides my desires, That Thou, O dark One, the hunter of the souls in the burial ground, Mayest dance Thy Cosmic eternal dance.”
The Chief goals and purpose of Sanatana Dharma is to prepare for the unbinding liberation of the self that precedes Self-Realization. It consists of four processes:
- Intuition derived from experience about the nature of the Self: This is called Brahmananubhava
- Insight based visualization of the Ultimate reality. This called Brahma Darsana.
- Contact through supra-sensory faculties with that which is Imperishable and Real. This is called Brahma sam sparsa.
- Direct Apprehension at the end of a pious and unselfish of the Supreme Reality. This is called Brahma sakshat kara.
The Mundaka Upanishad teaches us, As the spider draws its silk thread out of itself and is the Lord of the web it produces, as the shrubs and plants grow from the earth, as hair grows from the body of living beings, so has all this universe come out of the Imperishable cause. The Blessed Lord State,” Using nature, which is derived from Me, I create again and again all this multitude of beings, keeping them wholly dependent for their material needs on nature. In the scheme of My sovereignty, nature brings forth everything, the moving and the unmoving and in consequence this world evolves. ix-10.
In discourse vii- 7 the blessed Lord says there is nothing that is beyond Me. All this Universe hangs together on Me, as pearls on a string.”
In the fifteenth Chapter v 7 and 8 the Blessed Lord states, A fragment of Mine own Self becomes in the world of living things an Immortal Soul. It attracts to Itself the five senses and the controlling intellect; all six are thus established in matter born from nature. The Soul, when it takes overlordship over a body or leaves it, takes these with it as the wind takes fragrances from bower to bower. (During the sojourn in the Ocean of life death and rebirth) Thus the embodied soul is contaminated with impurities (malla), distractions (vikshepa) and veiling (avarna). Worshipful performance of one’s duties without being devoted to the potential fruits of these actions (Nishkama Karma), total surrender to Gods will (Upasana) are the means (sadhana) to remove the Malla, Vikshepa and lift the shroud of avidya.
Finally, the destination of the Soul; the Blessed Lord Teaches us,” This is true; as from the flaming fire issue forth by the thousands, sparks of the same form, so from the Immortal Self proceeds diverse Jivas (individual souls) and they find their way back from whence it came (from the fire.) The Bhagvad Gita.ix-8.
Q 2. How is the body regarded after death? How should the body be cared for?
Several permutations and combinations of the Five major components of Creation viz., Ether, Wind, Fire, Water and Earth constitute the body. (The Pancha Maha Bhutas.) This physical nature that I have described is my inferior manifestation. My other and higher nature is the life principle by which the very universe is upheld. So said the Lord (Bhagvad Gita vii –5)
The Gross Body (Sthula Sarira) consists of elements of the five Mahabhutas and the residue of noble and ignoble deeds of the past lives. The seven material elements constitute the gross body; these are the skin, muscle, cartilage, fat, blood, bone and bone marrow. The gross body subjects the individual to the experience shame and pride, joy and sadness, heat and cold. The gross body is born it dies, it changes undergoes loss of its parts and it decays over the years. The gross body also enables one to have and to hold objects of affection and caring concern. Thus, it forms the matrix for the support of experiences that enable individuals to initiate, maintain or withdraw from relationships.
The Subtle body, (Sukshma sarira) The contributions of the five Mahabhutas are shaped by the prarabdhas (fruits of past actions.) when the following are formed:
The five organs of perception, the five organs of action, the five pranas (life sustaining processes), the mind with its doubts and the faculty of discriminative intelligence. The organs of perceptions are Ear, Tongue, Skin (touch), Nose and Eye.
The Organs of action are the faculty and muscles involved in speech, hands (involved in dexterous tasks), legs (ambulation), Organs of excretion and organs of reproduction.
The Causal body: This is the beginingless, Inexplicable Soul that is clouded by impurities and thus shrouded in Avarna (veil) of Ignorance about the imperishable and the perishable. It is the cause or the bhijam (seed of the subtle and gross bodies from birth to birth) The body is to be treated as gift of God and treated in accordance with specific rites that can be performed after the body is removed to the undertaker. Preferably the body has to be cremated at dusk of the same day. Different groups have different traditions. The rites may be offered to the Lord of Death who dispenses Justice based on the concept of dharma.
Q 3. What kind of Spiritual intervention is appropriate when the patient is dying?
Q 4. What kind of spiritual support is appropriate for the family during the process of dying and at the time of death of the patient?
In addition to satisfactions sought by the Gross body, the Subtle body and the Causal body we need to address the specific challenges that emerge during the process of dying and at the time of death during the interplay of the four personalities of all involved. These four are the physical, mental, intellectual, and Spiritual. All four of these personalities that influence both the dying process and responses to death per se are emanations or derivatives of the five sheaths of essential human psychobiological processes. The five sheaths are as follows:
- Annam maya Kosha. This sheath represents the food that we have consumed and incorporated into our being and is derived from food. This sheath when the soul sheds its mortal coil returns to mother earth and becomes food for myriad other creatures.
- Prana maya Kosha: This is the layer that includes all the magical processes that sustain life by converting food to energy and tissues.
- Manomaya Kosha: This sheath is the field of consciousness. Complex brain processes subserve the state of consciousness.
- Vijnana maya Kosha This is the faculty of reasoning and wisdom Its faculty is situated in the Frontal Cortex.
- Ananda maya Kosha this is the highest center of epiphany and abundant spiritual healing and joy. The Sat – Chit - Ananda State (a state of Bliss) can be achieved by virtue of being endowed with this component. The extremely peaceful state of dreamless deep slow wave sleep is similar to the experience available in this envelope to all creatures.
There are specific chants that may be repeated in the ear of the dying person by priests or learned people that can reduce the fear that accompanies the last stages and absolve the indwelling spirit from the consequences of ignoble acts. For this to happen, the person who hears and repeats the sacred chants must do so with great devotion. Repeating the name of God by itself is extremely propitious before the breath finally leaves for the last time.
The guidelines on preparing for good death formulated by the Institute of Medicine helps us respond to these challenges that emerge when the five sheaths unfurl as the embodied soul reaches its final state. The principal components of what constitutes good end of life care according to IOM are as follows.
- Being free from Distress and Suffering (conditions experienced through the gross and subtle bodies, the annamaya, pranamaya and manomaya koshas.
- Care delivered is tailored to the wishes of the patient and the family (the vector of the interplay of the four personalities of individuals in the group).
- Care consistent with accepted Ethical and Best Practices standards and interventions that honor religious, spiritual, cultural traditions.
This includes discussions involving the individual who is dying and members of his family and the Physician of record with respect to a realistic appraisal of the quality of life that can be expected during the patients remaining days. This allows the family, the Clergy and Lay religious folks as well as friends and lovers to provide comfort for each other and to construct a supportive environment. This will be most conducive to good death by enabling solace, quiet reflection and peace.
The goals for a process that is designed to provide for a good death are:
1. Honor the patient’s life
2. Engagement and not abandonment of patients and those near and dear to the patients while they struggle with decisions to withdraw or withhold futile care,
3. Providing a stable and supportive environment that will engender the patience and forbearance that are sine qua non for the breath (the five pranas) to be stilled in its own time, for the spirit to unfold its wings and resume its sojourn through limitless spaces to Its Source, the Supreme Self or fulfil its destiny in another field of dreams and actions.
4. Monitor for high-risk bereavement. Offer support and make referrals as occasion demands for Mental health needs.
5. Follow - up with bereaved members.
6. Debriefing of staff and emotional support.
5 What kind of Spiritual Supports are available in the community?
For patients and families who follow the Hindu traditions support is available through the Priests and members of the temple Community. The main phone number of the CT Valley Hindu Temple Society is (860) 346 TMPL (346 8675). The names of the priests are available from the Temple staff. A few members have some experience in helping people through this process. These knowledgeable individuals are 1. A.V. Srinivasan, 2.Dr V. Srinivasan, 3 Dr T Seshan 4. Dr V. Manohar.
They can be contacted through the Temple. For those patients and their families who practice the Jain faith Dr P. Jain is someone who can be helpful. The current President of the Hindu Temple Society is Mr. Faqir Jain. Both of them can be contacted through the Temple too.
I will bring this presentation to a close with two verses from the one of the foremost philosophically treatises of Sanatana Dharma called the Isavasya Upanishad, one verse from the exquisite six stanza poem of Srimad Adi Shankara called Nirvana Shatakam that encapsulates the knowledge of the Supreme Self eloquently and finally two verses of benediction.
From the Isavasya Upanishad I offer these two verses.
- When a person understands that all beings are indeed pervaded by the universal Soul then he or she can realize the Oneness of all Beings and grief borne of Illusion and misunderstanding will vanish. (V 7)
- May the Divine wind enter the immortal breath. Then may my body be reduced to ashes and dust. Remember my deeds O Mind; remember what has been done O mind. (V 17). The Isavasya Upanishad is one of Mahatma Gandhi’s favorite texts besides the Bhagvad Gita, Bible and Koran.
The next verse is from Nirvana Shatakam (six verses on the subject of Liberation of the Soul)
The pre-eminent teacher Srimad Adi Shankara informs us
“I (the unblemished Soul) am free from the pairs of opposites from all dualities, As I have no form everything everywhere including the sense organs are pervaded by Me. Yet I am always beyond them. Therefore, to Me there is only Oneness to be experienced and equality among all (Samatvam)” As I have no bondage I am not in need of Liberation. We thought we were bound, but we understand with help of the great Seers we were ever liberated. Even when we misperceived ourselves to be bound, we truly were completely free (if we chose to believe).
The next two are verses of benediction:
“Om That Supreme Self is infinite and whole, and this the embodied Self is Infinite in its essence (Sat). This embodied soul emerges from the Supreme Self. Through the knowledge of the Supreme spirit as it pervades all created beings one can experience Oneness of embodied soul and the supreme Self. Thus, the wholeness alone remains for all time. Om Shanti, Shanti, Shantihi.
Om! May all beings experience auspiciousness, may all attain unto peace, may all achieve fullness of knowledge, May all be blessed by Thee. Om Shanti, Shanti, Shantihi.
May all humanity be blessed with the experience of comfort and joy.
I offer all this to the glory of our Creator.