Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Vaisnava Hindu and Ayurvedic Approaches to Caring for the Dying:
An Interview with Henry T. Dom, PhD (Hari-dhama)

Henry T. Dom is a practitioner of the ancient Vaisnava tradition of Hinduism. He earned his PhD in philosophy, writing a thesis on palliative and spiritual care in the Vaisnava-Hindu tradition at the Bhaktivedanta Research Institute for Vedic Studies, India and the University of Cape Town, South Africa. In 1995, after practicing Vaisnavism for 10 years, Mr. Dom was initiated into monkhood by a spiritual master of that movement in India. Before adopting Vaisnava culture and lifestyle, Mr. Dom worked as a professional actor in television, stage and film in South Africa, where he was born and raised in an Afrikaner, Christian family. His perspective on the place of spirituality in palliative care is rooted in his own multi-cultural, multi-lingual background, his practice of Vaisnava Hinduism and familiarity with the principles and practice of Ayurvedic medicine in India, in addition to his experience over the past ten years working in London, England, with the elderly and those dying from AIDS, cancer and other diseases in nursing homes, hospitals, and hospices.

With its large Hindu community, Great Britain is an ethnically and religiously diverse society. In his work as a spiritual care counselor and nurse's aide at St. Christopher's Hospice, London, Mr. Dom brings his multi-cultural perspective to bear in addressing the spiritual needs of patients and families with sometimes widely differing views about the meaning of life and death. In addition, he is involved in improving palliative care services in India, where he is helping to create a palliative care unit for the newly established Bhaktivedanta Hospital in Mumbai, and is one of the founders of a planned hospice and residential home in Vrndavan, a small village in northeast India.[Citation: Dom H. aisnava Hindu and Ayurvedic Approaches to Caring for the Dying: An interview with Henry Dom, by AL Romer and KS Heller, Innovations in End-of-Life Care, 1999;1(6), www.edc.org/lastacts]

How do you define spirituality?

Spirituality defies a single definition. It is not restricted only to those who belong to a religious denomination. Spirituality can do without religion, but the opposite is not true. I believe that spirituality is innately part of all living entities, and may be fostered through devotional practice of some kind.

How do you distinguish between religion and spirituality?

Religion refers to form, pattern, and a certain discipline to follow. Its dynamic moves from outwards in-it involves the objective application of certain practices which articulate certain externally formulated beliefs. Spirituality is more open and non-dogmatic, and involves learning and changing: its dynamic moves from inward out-in a process of subjective growth and connection. One can grow and express oneself spiritually through religious practice, but religious practice is not necessary to spiritual growth or expression. Spirituality can be expressed through loving and being lovable, having purpose and meaning in one's life, feeling connected or belonging, and in being authentically oneself.

What do you see as the central issues that health care professionals are grappling with in trying to address the spiritual needs of dying patients as part of palliative care?

I believe that there is a great lack of understanding about the difference between spiritual and religious (or pastoral) care. Spiritual care comes from the heart after the head has done its homework. Spiritual care is at the core of palliative care, yet health care professionals lack training in assessing patients' spiritual needs or in addressing them. To be able to provide effective spiritual care, the practitioner first needs to look inward to examine his or her own spirituality. Holding up a mirror to their own hearts and souls can sometimes be painful for those health care providers who hide behind impersonal roles and professional training. To provide spiritual care, one must have excellent interpersonal relationships with patients and good counseling skills. Patients often complain that health care providers are "too professional," and that they lack the human touch. Spiritual care is often neglected by health care providers, and is virtually absent in the medical and nursing care plans for the dying patient and bereaved family and friends.

What can be done to make the modern health care environment and personnel more responsive to the spiritual needs of patients and their families?

All health care professionals need training and education in the universal principles of spiritual care (as understood in both the West and the East), which lie at the heart of palliative care. According to Ayurvedic principles, palliative care is not only for those with a terminal diagnosis, but should form part of the care of all who are ill, mentally or physically.

Health care professionals owe it to their patients, especially those from non-Christian and non-religious denominations, to broaden their training horizons by being inclusive of what Eastern philosophy, religion and culture have to offer. Spiritual care is most profound and effective when it is not attached to one particular belief system. Distressed patients come forth with questions such as, "Why me?", "What have I done to deserve this?", or "Why am I being punished like this?" I believe that spiritual care that transcends pastoral care is the most effective means of alleviating this kind of suffering.

How do you assess a patient's spiritual needs?

I ask about their religious affiliation or denomination, whether they belong to a church, if there are clergy involved in their lives and if appropriate, how to contact them. I also ask about whether they want any religious input in their care now, whether they want to speak with a chaplain or to avoid them, whether they want to come to religious services. In terms of assessing their spiritual needs apart from religion, I try to assess whether they are feeling resigned or terrified about the prospect of dying, whether they feel isolated. I ask about what they hope for, what sense they make of their illness, what life means to them and what death holds for them, and (if appropriate) whether they believe in an after-life. I try to assess their self-esteem, and ask about whether they are happy with who they are and have become in their lives. I also ask whether we can talk about their body image.

How would you recommend that health care providers hold this kind of conversation with patients?

This is not an easy question to answer: there are as many "methods" as there are patients. These conversations between counselor and dying patient are spontaneous and intimate. Each individual patient is unique and there is no room for rigidity or inflexibility in the administering of spiritual care. The basic framework needs to be there, but how you color in the picture is very much dependent on time, place, circumstance and person. We need research to standardize and consolidate a framework for spiritual care, which is essential when drawing up an effective nursing and medical spiritual care plan. A key to successful spiritual care counseling is listening, touching, silence and sharing. As the Indian proverb goes: God gave us one mouth and two ears so that we can listen twice as much as speak!

In general, I would say the best way to hold this kind of conversation is by not "hiding" behind status, rank, qualification or professionalism, but rather by being equal, human, simple, honest, caring, non-judgmental and understanding. One needs to adopt excellent listening, speaking and presentation skills. You need to provide strategies to patients that will foster their hope, by being familiar with their belief system, if they have one and self-disclosing your own related experiences and belief systems, reactively to theirs. Your aim in this is not to give solutions or speculate, but rather, to evoke positive thoughts, experiences and memories. To do this well, you cannot be time-restricted.

In asking about religious matters, be matter of fact. They are objective questions with objective answers. You want to be open, non-judgmental and encouraging to people about their religious wants. In trying to get at spiritual needs and issues, listen more than talk. In particular, you are listening for expressions of hope, uselessness, meaning, purpose, losses, skill, aspects of life history, "who am I?", "why me?", and isolation or loneliness. Clues to a person's state of mind can be found in their body language (is there something hidden or painful here?) and other forms of expression, such as hesitation, deviation, and poor eye contact.

Dying patients often try to hide their desperation for spiritual comfort. It is up to the caregiver to provide the amount and type of information which the patient can absorb and benefit from. The comfort for patients does not initially always come in what you have to say or offer, but in establishing confidence and trust through your own sharing and self-disclosure. Of course, I do not pro-actively share Vaisnavism or Ayurveda with Western patients, but will do so only reactively. The opposite is true with Hindu patients.

For those unfamiliar with Vaisnava Hinduism and Ayurvedic principles, can you provide us with a brief overview of how they affect the spiritual care of Hindus?

Spiritual care, in the Hindu tradition, starts at the moment of conception and continues throughout life and into the next. In brief, the spiritual care of Hindus is focused around certain rituals and sacraments, or samskaras, which aim at securing the welfare of the practitioner and advancing his or her spirituality. The Bhagavad Gita, which is a fundamental religious text for Hindus, teaches that "for the soul there is never birth nor death" and "as the embodied soul continuously passes, in this body, from boyhood to youth to old age, the soul similarly passes into another body at death. A sober person is not bewildered by such a change." Thus, in performing the Antyesti, or funeral, which is the last sacrament in the life of a Hindu, survivors consecrate the death for the person's future happiness. Death is considered to be the biological event through which the soul separates from the material body in which it is temporarily trapped. Hindus believe that a person's next birth or destination is dependent on the sum total of their actions, desires, and thoughts in previous lives. Suffering is seen as the result of past misdeeds, or "karma," but it is also regarded as an unavoidable part of life which may be stoically endured. The quality of death is believed to be dependent on the quality of life, so the spiritual practices are important both to life, to death, and to the transmigration to a new body.

For Hindus, a good death is achieved if one lives life in such a way that death does not take one unawares. Therefore, they emphasize the daily execution of sacraments, worship, fruitful activities and devotional service to God. They believe death should be entered voluntarily and peacefully, and in a sense, willed. One should leave the material body behind with the names of God on the lips and in the heart and mind of the dying. If the dying person is unable to do this, then the responsibility to chant or read from the scriptures lies with the relatives, friends, or spiritual master.

Thus, the belief that the spiritual identity of the individual is thought to continue even after physical death offers great relief and solace to a Hindu person faced with death.

How might a health care provider approach an elderly Hindu woman, for example, who is being cared for in a Western health care setting, to open a conversation about her spiritual needs or make it "permissible" for her to open it, on her own terms?

Before meeting the patient it would be imperative to know as much as possible about her social, psychological, religious/cultural and medical background. I also recommend some contact with the patient's extended family, since she will allow them to make many decisions on her behalf. Cultural factors need to be taken into consideration in all aspects of her care, i.e., what taboos she is constrained by; how strangers, especially men, relate to Hindu women; to which Hindu sect she belongs; her dietary needs, and so forth. The conversations need not be punctuated by the usual niceties as is often the case with non-Hindu patients. Hindus have a very open-hearted and minded approach to terminal illness and death.

The most important aspect for her is her preparation to depart from the body with her mind enshrined in thoughts of God. If this is not possible, due to illness, it would be important for others to engage her sense of hearing (the last sense to succumb to the dying process) so that she is conscious of God. This can be done through chanting, reading from the scriptures, or playing devotional music, which conveys transcendental sound vibrations. Other important activities include placing holy water on the forehead, and placing the sacred tulasi leaves in the mouth and tulasi beads around the neck. The Hindu lady would be far more concerned about her preparation for death in these ways, whereas a typical Westerner may be more concerned about being comfortable and pain-free during the dying process. The Hindu emphasis would likely be on the soul, rather than the usual emphasis in Western treatment settings on the body and the family, friends, and pets left behind.

By contrast, how might the spiritual needs of someone from a Western nation (a European or American), who may not believe in God, be addressed?

In my experience, atheists are not concerned with life after death. They are mainly concerned about being pain-free, sometimes requesting to be unconscious during the dying process, and are primarily interested in being at peace with themselves, the world and others. Speaking from my own Ayurvedic perspective, atheists seem to have the greatest difficulty in moving through the dying process, because it can be the occasion for a huge struggle between the "under-developed" spiritual intellect and the "developed" material intellect. It is the counselor's responsibility to facilitate a mental state in which the dying atheist can be comfortable and peaceful--often a huge challenge, since from my experience, atheists are very earthbound and attached to the material, which for them is the only reality.

At your hospice in India, a spiritual care plan is an integral part of the overall plan of care, on a par with the medical and nursing care plan. What does a spiritual care plan consist of, specifically?

The spiritual care plan is an independent plan, which is implemented interdependently with the nursing and medical care plans. It forms part of the holistic approach to patient care. The ultimate goal of this aspect of care is to elevate the spiritual consciousness of the patient through his or her own spiritual/religious/cultural affiliations and practices, under the guidance of a spiritual counselor, who is either a priest or brahman. Although the plan is coordinated by the spiritual care counselor, it is informed by multidisciplinary perspectives from the rest of the care team. The plan includes information taken from interviews with the patient, his/her relatives, community care professionals and spiritual/religious leader(s), relevant to the patient's religious, psycho-social and cultural needs. It will identify spiritual strengths and how these are fulfilled through various practices, worship, rituals, and sacraments and how it could contribute to the healing of the patient. The plan also will identify spiritual needs (weaknesses) and how the hospital's multi-disciplinary team can meet these needs through mutually agreed upon strategies, based on aims, objectives and outcomes. The plan is continuously assessed, reviewed, updated and adjusted according to the needs of the patient and his/her family members. The patient is greatly involved in developing and executing the content of this plan. If the patient is discharged to home, the aims and objectives of the care plan can be adjusted, with the patient's consent. We encourage contact with the patient long after discharge or with the family members should the patient have died.

How do Hindus explain the causes of disease?

Disease is explained by dysfunction in the family context as well as within the self. Therefore, as a first step in treating an Indian person, a health care provider needs to do a careful and systematic analysis of the family dynamics and how the individual perceives him/herself in relation to their God and all other living entities. In the Indian context, the individual would be asked questions about their own principles and values, based on his or her own scriptural injunctions, i.e., what/who is his or her true identity? What is the difference between matter and spirit? What does eternal life mean? What does he or she understand by karma? Who/what is God? Re-evaluation of their duties as individuals will then take place, and ultimately, through the practice of bhakti-yoga (devotional service), mantra meditation, and karma yoga (or service to the family and community)-all of these activities in combination with other therapies will restore balance and harmony into the patient's life.

In the Indian context, if the family dysfunction is repaired, yet the person still suffers pain and dies, how is that understood by the patient and family?

The explanation and acceptance of the disease, pain and physical death lies in a deep understanding of the law of karma- you reap what you sow, to put it simplistically. The law of karma (action-reaction) is extremely intricate and complicated. Repairing a dysfunction only alleviates spiritual pain and makes the dying process easier. Ayurvedic belief accepts that suffering and some degree of pain will always be there.

Is there an understanding of healing apart from cure in the Ayurvedic system?

Yes, spiritual healing. This happens when the dying patient's consciousness is actively engaged, through various means already mentioned earlier, in thoughts of God. Indian scriptures teach that if you think of God at the moment of death you will attain Him/Her. That is the ultimate goal of all Hindus. And if that is not achievable in this life, then a transmigration of the soul will give you another opportunity, wherein your next birth should be better than the one from which you have just departed. This attainment is dependent on the quality of the consciousness at the moment of death.

The body can temporarily be cured, but the spirit needs to be healed. To be healed spiritually means that the soul will return to its original destination: the spiritual world where there is no duality, through re-establishing a lost relationship with God. This return can only happen when a detachment from the material world takes place.

How does this understanding of healing comfort people at the end of life?

It happens when all the working senses of the patient are engaged in bhakti-yoga, devotional service to God through either chanting mantras, tasting sanctified foodstuff, seeing images of God and His/Her associates in the form of deities, hearing transcendental sound vibrations, touching religious paraphernalia, reading scriptures or being read to, smelling religious items offered to God, such as flowers. Being engaged in this way lessens physical, emotional and spiritual pain. The atmosphere in which the patient dies, therefore, must be spiritualized.

How would a Western hospital or hospice have to change to accommodate these beliefs and this kind of practice?

A Western hospital or hospice would need to be sensitive to the cultural/religious/spiritual needs of the non-Christian patients, by

• involving the family in the physical care of the patient;
• making the care environment homelike;
• accommodating dietary needs;
• allowing or encouraging patients and families to engage their own spiritual leaders in the spiritual care of the patient;
• adjusting the "chapel" in the institution to make it suitable for the spiritual practices of non-Christians; and
• making the care environment less institutionalized overall.

When health care professionals show visible interest in the faiths and cultures of others, for example, by visiting a Hindu temple, it can go a long way to building a respectful relationship.

Some other very simple modifications that would help include not using white sheets on the bed, personalizing the bed area and piping music from the patient's own religious or cultural traditions to the patient's bedside. Other things include making wards smaller and more personal, with fewer patients in each ward and providing overnight facilities for families and friends. The multi-disciplinary care team should be kept small, yet effective, and should cultivate a more personal, less professional (distant, superior) demeanor by wearing street clothes rather than uniforms. I believe it could be helpful to engage patients more in occupational therapies, complementary therapies, and to gradually introduce therapies from the East, such as ayurveda and pancha karma.

At St Christopher's Hospice, for example, the staff have a continuous liaison with spiritual leaders from different faiths in the community, attend inter-faith gatherings, make an effort to share in the celebrations of patients' religious holidays, and visit their places of worship. We request families to identify patients' special and specific needs regarding religious and spiritual practices. We allow spiritual leaders, family and patient to perform informal rituals at the bedside, and our chapel houses scriptures and icons of all the major faiths.