Awake at the Bedside: Contemplative Teachings on Palliative and End-of-Life Care

Somerville, Mass.: Wisdom, 2016. 347 pp., paper, $19.95.

Empty handed I entered
The world,
Barefoot I leave it.
My coming, my going—
Two simple happenings
That got entangled.
                               —Kozan Ichikyo

Recently a study was conducted at Massachusetts General Hospital on newly diagnosed lung cancer patients. The control group was given excellent medical care. The intervention group got medical care as well as palliative care, which is intended to provide relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.

It turned out that those who got both types of care had a better quality of life and fewer bouts of depression, were less likely to be hospitalized, and also lived on average 2.7 months longer. There is a belief among physicians that with palliative care, one may die better but one also may die sooner. This study suggests that this belief is incorrect.

The question is, then: what kind of care can not only prolong life, but can also provide one with the strength to understand, accept, and see what has gotten entangled in one’s life journey? The answer is, living with an enlightened perception. The care that provides such a perspective is called contemplative care, or spiritual care. But contemplative care does not have to be given only at the end of life. It is a lifetime lesson.

The essence of spiritual care is contemplating what is real and developing awareness of the present. The Theravada Buddhist teachings encourage people to prepare for the end-of-life journey. Why is meditation of any form such an important part of this journey? It is because people who meditate regularly will generally have less fear of death. The have developed an inner sense of balance and equanimity. Mindfulness brings a deep appreciation of moment to moment impermanence.

The editors of Awake at the Bedside have put together a profound collection of readings. These essays and poems introduce us to a deeply spiritual aspect of care. On a personal note, Awake at the Bedside came as a great gift for me. Inspired by Stephen Levine’s book A Year to Live, I am living this year as if it is the last year of my life. This book has become a new companion on my own journey.

Stephen and Ondrea Levine have a chapter in this book titled “Don’t Wait for Tomorrow,” which gives six meditations on death and dying. This is contemplative care for oneself and others, as the end-of-life journey will inevitably commence for everyone sooner or later. We listen to the one who is dying. A hand held sometimes brings better relief than strong medicines. We live with forgiveness in heart and resolved regrets. We mirror lovingkindness and compassion. We don’t wait for tomorrow but learn to live in the present.

In another article, Anyen Rinpoche talks about creating a “Dharma Vision.” We take great efforts in our everyday lives, and we should make similar efforts in our preparation for the end of life. Living with Dharma Vision means that there is no difference between our everyday spiritual practice and one that we engage in at the time of our approaching death. We create a Dharma Will, store it in a Dharma Box, and share it with our trusted Dharma Friends. This is the spiritual directive that we share with our core group. It provides a skillful means for navigating through the dying process. Anyen Rinpoche also provides guided meditations on contemplating impermanence as an integral element of our lives.

Larry Rosenberg offers three aspects of death awareness practices: awareness of the inevitability of death, awareness of the time of death, and awareness that only insight into Dharma can help us at the time of death. These reflections can be practiced daily. The caregiver can practice these with the dying person. It is not morbid; it brings peace in the face of pain and suffering.

No collection of readings on contemplative care could be complete without teachings by Elisabeth Kübler-Ross. “Dying patients are the best teachers in the whole world and they teach you not only about the process of dying, which is very easy to understand, but also about the process of living,” she says here. “To live fully means not being afraid of living and not being afraid of dying.” The caregiver should take care of the person’s physical needs first and then take care of the emotional needs—the unfinished business. This is the crux of contemplative care. It means letting what is natural take place, as well as allowing grief and anger to exist as natural phases and not to be suppressed. Dying is not the nightmare, she says; it is what we make for one another right here that is the nightmare.

This is not a book that is to be read once and put aside. It is a companion to be taken along wherever we go. Ultimately it is not about dying. It is about caring, both for ourselves and others. The pioneers of contemplative care offer us words of wisdom, stories that inspire, and poems that make us cry. Keep this book at your bedside. It is a presence that can inspire awakening.

Dhananjay Joshi

The reviewer, a professor of statistics, has studied Hindu, Zen, and vipassana meditation for the past forty-five years. He is a regular contributor to the Indian periodical Lokmat.

Inside Knowledge: How to Activate the Radical New Vision of Reality of Tibetan Lama Tarthang Tulku
Berkeley, Calif.: Dharma Publishing, 2015. xxi + 225 pp., paper, $18.95

We often experience time and space as a cruel iron prison. They may be navigated, but they cannot be conquered. Knowledge can at best help us live more comfortably within them.

Or maybe not. Tarthang Tulku—one of very few Tibetan lamas in the West to try to go past the boundaries of Buddhist thought—has developed a vision, called Time, Space, and Knowledge (usually abbreviated as TSK), that enables us to see these primordial forces in fresh and revolutionary ways. His first book on the subject, Time, Space, and Knowledge: A New Vision of Reality appeared in 1977, and in the years since, he has added to his body of work with titles such as Love of Knowledge (1987) and Knowledge of Time and Space (1990). The latest offering, edited by Jack Petranker, a longtime student and teacher of TSK, is Inside Knowledge.

It’s hard to characterize the TSK vision, because, as Tarthang Tulku stresses, it is not a theory but a method of approach. In his preface to this book, Petranker writes, “the TSK Vision is not about ‘getting’ any specific result or ‘having’ any particular experience. In TSK it is the questions that matter.” It is perhaps best seen through adjectives rather than through axioms: the words “open,” “light,” “playful,” and “spontaneous” appear frequently.

“There is no solid self,” says Tarthang Tulku in an interview reprinted in this volume. “You are an open-ended expression of time, space and knowledge . . . By comparison, ordinary ‘human being,’ in which our Being is obscured, is a very mechanical process. Our reactions are practically of the ‘knee jerk’ variety, and we’re motivated by a small set of needs, predicated on insecurity and lack of fulfillment.”

The TSK vision frequently contrasts an ordinary experience of time, space, and knowledge—frozen, mechanical, and repetitive—with a fresher vision that can be explored experientially. “A zeroless dimensionality is available to us: grounded in uninterruptible openness,” Tarthang Tulku writes elsewhere in this volume.

Rather than pushing any further into the realm of concepts and definitions, it might be better to give a flavor of TSK through its exercises, a number of which appear at the back of this book. Here is one, “Space between Thoughts”: “As you observe your thoughts passing, watch very sensitively for the moment when one thought ends and another arises. This transition is very quick and subtle, but involves the momentary availability of a space which you can contact and even expand. This space has a quality of openness, free from the usual discursive and discriminative thinking.”

From my own experience, I would say that this exercise can shift and has shifted my awareness of time. Normally one thinks of time as a continuous flow: hence the common metaphors of a “stream” or “film” of consciousness. The exercise above suggests a new way of looking at time. One might call it atomistic: thoughts appear separately between the “space” that the exercise mentions, so that they are more like momentary flashes in a field of knowing than a never-ending and unstoppable stream.

I am in no way claiming that this experience, or any other, is the goal of the exercise: rather it is my observation of how things appear from a single given stance. The point is that there is an infinite number of such stances.

Here is part of another exercise: “Bring to mind the future, allowing it to be completely indeterminate. Instead of thinking about this or that coming event, let the unknown-ness of the future come to the foreground. As a gateway into this indeterminacy, reflect on the ongoing transformations through which living being evolves. Within the steady flow of linear time, there are movements we would consider favorable and others that are unfavorable. Yet if you welcome the future, you may become aware of a dynamic that unfolds naturally toward improvement.”

Again to speak from my own experience: doing this exercise, I am less aware of myself as attempting to shift an immovable future away from certain outcomes and toward others. Instead I am aware of the future as a large, dark, fluid, but dynamic presence that is to be absorbed and assimilated and transformed.

This, too, is only one response out of countless possible responses.

The TSK vision is subtle and elusive, and not easy to formulate in a language like English. But it is approachable, and of the several books in the TSK series, this is (as it is meant to be) perhaps the best and most accessible introduction to this “knowingness” of a very different kind. Someone who reads this book is likely to go away from it viewing time, space, and knowledge less as forbidding and impenetrable walls and more like an energy that is always present and available for dynamic creativity.

Richard Smoley