Dr Brett Sutton writes on compassionate medical care in his article on Emergency Buddhism: Part II published earlier on the APLI website

Dr. Brett Sutton explores the connection between Buddhism and Emergency Medicine.

 

The historical Buddha first witnessed the suffering of the real world when he saw a birth, an old person, an ill person and a dying person. He realised that suffering arose out of those conditions and our response to them. He would spend many years leading a life of extreme deprivation and asceticism, only to discover that the suffering in his life had not been transformed or ameliorated. A point came in which he determined that he would sit and meditate and not cease until his enlightenment. And so, after many years of meditation, it came to be.

Given that we cannot change the reality of the existence of such life circumstances, we are left with our response to them. As doctors, we spend our working lives fighting the effects of an aging body, or aging mind. We identify illness, choose the most appropriate treatment, and institute it. We also have a real awareness of the inevitable march of time, of the inevitable effects of aging and disease progression. So hopefully this brings us a sense of proportion in the way that we treat patients’ conditions.

The twentieth century brought inconceivable advances in medicine, and public health, that almost doubled life expectancy. Infectious diseases and acute bacterial illnesses were a scourge of a century ago. That we have overcome many of them is a testament to modern medical knowledge and advances in living conditions. A consequence of such advances, however, is that chronic, degenerative and incurable conditions play a larger role in our lives, especially for the elderly.

Increasingly in Emergency Departments, I see patients with what amounts to a deterioration of a chronic condition, or multiple chronic conditions. I find myself treating the aggravating factors, but without any real expectation of improving quality of life. Of course, one is free to live with whatever quality of life one chooses, and medical outcomes are very difficult to predict, but many patients are not free to choose. Some deeply unconscious patients, or patients mute with dementia, have come to me in the Emergency Department, purportedly for life-saving treatment. Sometimes they arrive from nursing homes after years of incapacity. Often the nursing homes are simply responding to the requests of family or the patient’s local doctor. Sometimes, because there is no ‘living will,’ they are obliged to seek further treatment. Sometimes also, the intent is for patients to receive palliation and to die in hospital. I genuinely feel that emergency treatment or dying in hospital is sometimes appropriate; but that for many patients, transfer to an unfamiliar, sterile and strange environment does not serve their interests well.

Obviously we live in an era where the extended family is no longer the norm. We don’t care for our family members at home when they are very ill. And, by and large, they do not die with us at home. Death has become a distant event for us, institutionalised and hidden away. This makes it harder for us to feel comfortable dealing with such issues at home. And that is why, I feel, a societal shift in thinking needs to occur in which we see death as a natural event, and engage with it meaningfully. There is, I believe, a real alternative for the ill which has been little explored in this era of medical intervention, high technology and institutionalisation of the elderly. There could well be more support of residential care facilities to provide simple medical treatment or palliation where appropriate. This can be said of support to families also. Another great need is for living wills, or medical powers of attorney, to become widespread. This would help prevent unnecessary or unwanted transfer to hospital, or active treatment, or resuscitation. We should be more willing in Emergency Departments to discuss resuscitation issues very early with patients, even if not seriously unwell. It helps to normalise the issue, and often patients give vent to something they have wanted to discuss for a long time.

I often see great relief in patients who have the opportunity to talk about the issue of resuscitation, yet just as often see patients who are obviously thinking about it for the first time in their lives. The consequences of having no plan, I feel, are too great to simply ignore through one’s life. I tell my patients that, even at a mere 38 years of age and feeling perfectly fit and well, I myself have a living will. Simply because the issue is too important to leave to chance or to strangers who do not know my wishes with regards to resuscitation. Any one of us could die at any time, I tell them, and though unlikely to occur, serious illness demands very important decisions. A medical power of attorney allows one to specify treatment, thresholds for withdrawal of active treatment, resuscitation wishes, and even religious observances in one’s last hours or days. You might well ask yourself if you would be happy being allowed to die if in a persistent vegetative state, or on the contrary kept alive in the same situation. And if you were suffering a catastrophic stroke and unable to communicate but were aware of the world around you, would you want blood transfusions, antibiotics, surgery? The potential questions are endless but the general principles of care can, I believe, be readily clarified in most people’s minds.

 

Compassion

Compassion is often defined as the capacity to ‘feel with’ or ‘the heart that trembles in response to pain.’ Yet it would be a misconception to think of compassion in the Buddhist context as merely a feeling. It arises in knowing that one is part of a greater whole and is interdependent and connected to that whole. It derives from practiced meditation and requires transcendental wisdom. It is much more a profound intellectual realization than a feeling. It is far removed from grasping, self-seeking emotion. Indeed it may appear to lack passion or even warmth. It should perhaps then appeal to those of us – such as doctors – who enjoy evidence-based, scientific reasoning. Compassion arises from the transformative realization of others’ suffering and the need to transmogrify it. It is boundless in scope and given without expectation of reciprocity or reward. The evidence before us is the same as that which confronted the historical Buddha Gautama – suffering fills the world and we require a path of liberation. And the solution was evidence-based. Buddhism tells us that the worth of the teachings should not be accepted by reading, or even by the words of the wise, or a guru. The worth must be experiential – through our own practice and reflections on our transformation. It is in the transformation of our thinking, acting, motivation, and of our suffering. Compassion is both the means by which we can seek liberation from suffering for others, and for ourselves. It is the antidote to our own suffering. In that sense it is self-serving, yet not selfish. It helps fulfill our own wish to be happy whilst seeking the same for others. How fortunate that the world is thus!

 

Dzogchen Practice

Our habitual ways of thinking, our conceptual frameworks, our automatic emotional responses – these are all deeply engrained in our way of being. If we seek to change them for the better, that change will not come through desire alone. No doubt determination and motivation are important, but a real transformation requires effective tools for such change. The Vajrayana lineage of Buddhism in Tibet has specific tools to help bring about such change. It is known as Dzogchen practice. When I first learnt of these practices, I did wonder to myself how an essentially intellectual process could be used to inculcate compassionate thought in us. Of course it is not merely an intellectual exercise. After all, one is attempting to alter the deeply ingrained ways of thinking and feeling that have had a short lifetime to take root; the antidote must both break down these mental habits and construct new ways of being. So it seems appropriate that there is an intellectual dimension to such practices.

I remember an awful day in ED when an eighteen year-old girl came in after a car accident. She was horribly injured and, despite everyone’s efforts, she died in surgery. I will never forget seeing her family with the surgeon to give them the news, and seeing the surgeon cry afterwards. I decided to go to the funeral the following week, for the family’s sake. I had only recently learned of Dzogchen teachings and so brought into my mind the practice at a time when a family was feeling such pain. I saw the father, consumed in grief, and visualised loving kindness pouring out to him and his family. One Dzogchen meditation asks us to make ourselves equal with others. This practice reminds us that we are all members of the human family, all sentient beings, all seeking happiness and avoiding suffering. In modern Western psychology, it is called ‘similarity’ and is our mechanism of finding empathy with others. Of course there is nothing magical about this practice but it is intended to make one always mindful of the need to empathise with others’ suffering. We all engage in similar actions often, but we can forget when we don’t naturally feel a kinship with others, or don’t identify with them by virtue of race or religion or background, when we don’t find that ‘similarity’.

Another meditation involves exchanging oneself with others, and so I exchanged myself with this brave father. The practice doesn’t evoke pity; it is an antidote to pity. For it is not pity we seek when we grieve, it is loving kindness. Of course, in a way, we all practice a kind of Dzogchen often. Yet there is a practical, straightforward method in Dzogchen which brings to the practitioner a means of cultivating compassion towards anyone, even our enemies. It is said that we should treasure our enemies for they, more than any others, teach us tolerance and forbearance.

 

Impermanence: Death and Dying

Buddhism states that there is much to be gained from contemplating our deaths; the nature and inevitability of dying, and becoming at ease with the idea of our transient existence. The idea of Impermanence is central in Buddhism – that all phenomena, all existent things are transient. A conception of anything as permanent is delusion, for nothing is immutable. Indeed, for Buddhists, nothing has an independent existence but rather is interrelated and contingent upon all other things. And so it is for us and our lives. This too must pass. So in Buddhism all things are seen to have no independent, objective reality. The phenomenology that we call the world is actually an illusion that our mind regards as real and independent and concrete. Buddhists are taught that all things are transitory, that all phenomena come, and go. In respect of our own lives, this too can be seen to be in a constant state of flux. Within our lives there are undoubtedly periods of enormous change. These are referred to as Bardos, and the most important of these is surely the Bardo of Dying. It is therefore seen not as an end, but as a time of enormous transition.

Think about this: If something were to come to each and every one of us, without exception, why would we not come to terms with it? Yet many of us either don’t contemplate it at all or conceive of it with fear and denial. Some have even planned to freeze themselves to attempt to cheat death. The Dalai Lama, when asked about this concept, called it the greatest folly we can engage in. Surely this kind of denial is the very worst response we can make to our own or others’ mortality.

It is a useful exercise to contemplate the possibility of the dying state of a patient as one in which we must be deeply cognisant of their needs and their vulnerability. If consciousness is extinguished in death and nothing survives beyond it, then it does not matter much what we do for the dying. If, however, something of us survives death (as most of us believe) then we must act to facilitate a good death.

The case for letting the very ill die, without the intervention of resuscitation, can be expressed thus: What if our dying is a profoundly critical, transformative time in our existence? What if our existence continued in a different form, the after-death state? What if that transition were negatively affected by the traumas (physical, mental and spiritual) of our interventions? The reality is that we cannot be sure, in an absolute sense, what occurs for the dying person – what they can feel, perceive, or experience. Yet asking the question “Are we doing more harm than good?” is surely an important one. And there is increasing evidence, that even for the deeply comatose and unresponsive states, that there can be a very lucid level of awareness. Our time of dying is potentially the most confusing and fearful, or most wondrous, serene and beautiful event that we will ever experience. It would be tragic, indeed, if in this most important transformative time that the only thing we brought to a patient was more pain, disorientation and fear.

There is a saying, in the spirit of Buddhism, which perhaps might apply at times to the question of resuscitation in hospital and to give pause to our desire always to intervene. It goes thus: Don’t just do something, sit there! So perhaps we should sometimes simply sit there – perhaps holding a hand, or making sure of comfort and tranquillity in an environment which is so often frenetic and impersonal.

 

Serenity

The Emergency Department may be filled with chaos, and indeed we are challenged by its highs and lows. Perhaps there are few workplaces where the ability to think calmly and clearly is so important. Indeed the stakes are often, literally, life or death. So I feel that the ability to remain undisturbed by the great dramas playing out before us is an essential quality of the Emergency Practitioner. It is a quality that most of us have engendered in our working lives through years in very challenging environments. Unfortunately for some, the quality of being undisturbed comes through being ‘shut off’ to the suffering around us. We become indifferent to what our patients go through, and simply go about our work with a sense of professional obligation, or self-righteous intellectual bravado, or defensiveness against litigation, or simply a kind of numbness. We have an alternative means of working with clarity and calmness of mind, without being indifferent to suffering. It is by being fully present in the moment, with open hearts and without judgement.

This article was originally published in Mandala, April-May 2008

Brett Sutton is an Australian doctor who is the Regional Disease Surveillance Coordinator for the International Rescue Committee, Kenya & Ethiopia.