Psychological assistance to the dying. There are already mobile mobile brigades in the country

Sangye Khadro

Many people do not want to hear, talk or even think about death. Why is this happening? Whether we like it or not, sooner or later each of us will certainly leave this world. And before we face own death, we will most likely have to survive the death of other people: relatives, friends, colleagues, etc. Death is a reality, a fact of life, and therefore is it not better to accept its inevitability and approach it with openness than with fear and denial?

Perhaps thinking about death makes us uncomfortable because we think that death will be a terrible, painful, and depressing experience for us. However, it doesn't have to be exactly like that. Passing away can be a moment of learning and growth; the time when we can feel love more deeply, we realize that in our life it has the greatest value, we become stronger in faith and devotion to religion and spiritual practices. Death may even give us insight into our true nature and the nature of all things, and this insight will enable us to be freed from all suffering.

Let's take the example of Inta McKim, director of a Buddhist center in Brisbane, Australia.

Inta died of lung cancer in August 1997. Two months before her death, she wrote in a letter to her spiritual master Lama Zopa Rinpoche: “Although I am dying, this is the best time of my life! … For so long, life seemed so hard, so difficult. But when you really realize death, it turns out to be a great happiness. I would not want your death to go unnoticed for you, so that you miss the great happiness that is born from the awareness of impermanence and death. These experiences are surprising and unexpected and are accompanied by great joy. This is the greatest time of my life, the most exciting adventure, the best party!”

Inta spent the last few months of her life devoting herself to spiritual practice. At the time of death, her mind was calm, she was surrounded by relatives and friends who prayed for her. There are many similar stories about lamas, monks, nuns and spiritual practitioners who managed to meet death calmly, with dignity, and some of them even remained in meditation during and after death. With proper training and preparation, each of us can meet death with a positive and peaceful attitude.

It is very important to examine your thoughts, feelings and attitudes about death and dying to determine how realistic and constructive they are. How do you feel when you read or hear about the sudden and unforeseen death of a large number of people? How do you feel when you hear about the death of a relative or friend, or that they have been diagnosed with cancer? What do you feel when you see a hearse or drive past a cemetery? What does the verb "die" mean to you? Do you believe that there is something beyond this life, on the other side of death?

There are two unhealthy approaches to death. The first is fear, the thought that death is a terrible, painful experience, or complete disappearance. This fear leads to denial and a desire to avoid thinking or talking about death. But is it right, considering that one day we will have to go through this? Wouldn't it be better to accept the reality of death, learn to overcome your fears and prepare for the inevitable?

Another unhealthy attitude is careless and frivolous, leading us to say, “I am not afraid of death. I know that one day I will have to die, but everything will be fine, I can handle it. When I was young, I had the same attitude, but one day I was in an earthquake zone and for a few moments I was completely sure that I was on the verge of death. And then I realized how wrong I was: I was terribly scared and absolutely not ready to die! In The Tibetan Book of the Living and the Dead, Sogyal Rinpoche quotes a Tibetan teacher: “People often make the mistake of having a frivolous attitude towards death and thinking, “Death happens to everyone. It’s not a big deal, it’s a natural process, so I can handle it.” A wonderful theory, but it is true exactly until death approaches.

If you find yourself in one of these approaches, then perhaps you should continue your research on the topic of death. Expanding knowledge about death and dying will help us reduce the fear of death (because we have a tendency to be afraid of what we do not know, or what we cannot understand), and people who are frivolous about death will realize the importance of preparing for it.

First of all, let's look at the concept of death in the Buddhist tradition.

Death sometimes seems to people as a punishment for the atrocities they have committed, a collapse, a mistake, but none of these views is true. Death is a natural part of life. The sun rises and sets, the seasons come and go, beautiful flowers wither and lose color, people are born, live for a while, and then die.

One of the key truths that the Buddha revealed and taught us is the truth of impermanence: everything changes and ends. There are two levels of impermanence: gross and subtle. Gross impermanence boils down to the fact that everything generated and produced (whether people or other living beings, everything natural phenomena and everything created by human hands) cannot be eternal and will end its existence at some point in time. As the Buddha himself said:

What was born will die
What has been collected will be dispersed,
What has been accumulated will be depleted,
What was built will fall
And what was high will become low.

Our existence is as fleeting as autumn clouds.
Watching the death and birth of beings is like watching the movements in a dance.
Life is like a flash of lightning in the sky
She is like a stormy stream, swiftly rushing down a steep mountain.

Subtle impermanence is those changes that occur every moment in all living beings and inanimate objects. The Buddha said that objects and phenomena do not remain the same from one moment to the next, but are constantly changing. These words have been confirmed in modern physics, as Gary Zukav points out in The Dancing Masters of Wu Li:

“Each interaction of intraatomic particles consists in the complete annihilation of the original particles and the creation of new intraatomic particles. The intraatomic world is a continuous dance of creation and destruction, when matter passes into energy, and energy into matter. Transient forms flare up and go out, forming a never ending and always newly created reality.

The Buddha skillfully conveyed his teaching on the inevitability of death to one of his disciples, Kiza Gotami. Kiza Gotami was married and had a child very dear to her heart. When the child was about a year old, he fell ill and died. Overwhelmed with grief, unable to accept the death of a child, Kiza Gotami took him in her arms and went in search of someone who could bring him back to life. Finally, she met the Buddha and begged him to help her. The Buddha agreed, but asked for mustard seeds to be brought to him, from a house where no one had ever died.

Kiza Gotami walked through the village from house to house, and although everyone was ready to give her a handful of mustard seeds, it was impossible to find a house that would not be touched by death. Gradually she realized that death happens to everyone, returned to the Buddha, buried the child and became one of the followers of the Enlightened One. Following him, she reached Nirvana, complete freedom from the endless cycle of rebirth and death.

People sometimes fear that if they accept the reality of death and think about it, they will become mentally ill or lose the ability to enjoy the pleasures that life offers them. But, as it is not surprising, everything happens exactly the opposite. Denying death makes us tense, and accepting this given brings peace. With an eye on death, it is easier for us to realize what is really important for us in life. For example, be kind and love others, be honest and unselfish. Realizing this, we direct our energy to precisely such actions and avoid actions that would make us feel regret and fear in the face of death.

In the Great Nirvana Sutra, the Buddha says:

Of all plowing, the most important is autumn.
Of all the footprints, the largest are elephant footprints.
Of all the realizations, the most important is the remembrance of death.

The awareness and remembrance of death is very important in Buddhism for two main reasons:

1) Awareness of the transience of being is likely to push us to spend time wisely, doing positive, good, virtuous actions, abstaining from negative, non-virtuous ones. As a result, we will be able to die without regret, and in the next life we ​​will receive a favorable rebirth.

2) The remembrance of death creates an urgent need to prepare for death. There are various methods (e.g. prayer, meditation, mindwork) to overcome fear, attachment and other emotions that may arise at the time of death and cause worries, worries and even negative states of mind. Preparing for death gives us the opportunity to die peacefully, with a clear and positive state of mind.

The benefits of death awareness can be confirmed by the results of near-death experiences. Near-death experiences are experienced by people in literally on the verge of death, on the operating table or in a car accident. Later, when they come back to life, they are able to describe their experiences. As Songyal Rinpoche writes in The Tibetan Book of the Living and the Dead (p. 29):

“Perhaps one of the most striking discoveries is how it (near-death experience) transforms the lives of those who have gone through it. Researchers have noticed surprising consequences and changes: a person begins to be less afraid, more aware of the inevitability of death, he wants to take care of others more, he understands the important role of love better, loses interest in the material side of life and is filled with faith in the spiritual dimension and the spiritual meaning of life, and, of course, it is much easier for him to agree that everything does not end with death.

Each of us is made up of a body and a mind. The body is formed by the components of material nature: skin, bones, internal organs, etc., and the mind is formed by thoughts, perceptions, emotions, etc. The mind is an endless, ever-changing stream of experiences. It has no beginning and no end. When we die, our mind separates from the body and moves on to new life. If we are able to agree with this idea and continue to build on it, then this will help us overcome the fear of death and weaken the attachment to this life. In the Tibetan tradition, it is advised to look at life through the eyes of a traveler who has stayed in a hotel for a couple of days: he likes the room, likes the hotel, but does not become attached to them excessively, because he knows that all this does not belong to him, and he will soon leave.

Our next rebirth and the experiences that are prepared for us are determined by how we live our current life. Positive, wholesome, ethical actions will lead to a good rebirth and an experience of happiness, while negative, harmful actions will lead to an unwholesome rebirth and joyless experiences.

Another key factor in determining what our next birth will be like is the state of mind at the time of death. We must make it our goal to die in a positive, peaceful state of mind if we are to secure a good rebirth. Dying in anger, with attachment, or in any other negative state of mind can lead us to be reborn in adverse circumstances. This is another reason why it is important to prepare for death. If we want to maintain a positive mindset at the time of death, then we need to learn now to keep our mind from negative states and accustom ourselves to positive ones with all our might.

Death and rebirth are two symptoms of an ordinary, cyclic existence (samsara) in which we are constantly faced with problems, dissatisfaction and lack of freedom.

We are in this position because of the defilements that are present in our mind (the main ones are attachment, anger and ignorance), as well as because of the imprints of actions (karma) committed by us under the influence of these defilements.

Once the Buddha was just like us, a prisoner of samsara, but he found the path to liberation and achieved complete perfect Enlightenment. He did this not only for his own salvation, but also for the benefit of all other sentient beings, because he realized that all sentient beings have the potential to achieve Enlightenment. This potential is also called "Buddha nature" and it is in it that the true, pure nature of our mind lies.

The Buddha is filled with the most perfect, pure compassion and love for all of us sentient beings. He gave teachings on how to free ourselves from suffering and achieve Enlightenment. That is what his Teaching, Dharma, is about. The Dharma shows us how to free our mind from defilements and karma - the causes of death, rebirth and all other samsaric problems - and thus become free from samsara and achieve final Enlightenment. The mindfulness of death is one of the most powerful sources of the energy that we need in order to practice the Buddha's Teaching and achieve bliss with its help.

Now let's look at some methods that will help us start preparing for death.

Christine Longaker, an American with 20 years of experience working with the dying, has formulated four tips to help us prepare for death while making our lives full and meaningful at the same time. Here are the recommendations:

1) Recognize and transform suffering

We must accept that various problems, difficulties and painful experiences are an integral part of our lives and learn how to deal with them. If we learn to overcome the little suffering we face in our life path, then we will be better able to cope with the great suffering that we will face at the time of death.

It makes sense to ask yourself the following questions: How do I react when faced with physical or mental problems? Do I consider my reaction healthy, is it satisfying, or can it be improved? How can I learn to better deal with problems?

In this case, in the Tibetan tradition there are practices of developing patience, thinking about karma, cultivating compassion and tonglen (“giving and receiving”). An explanation of these practices can be found in Transforming Problems into Joy by Lama Zopa Rinpoche (Wisdom Publications, Boston, 1993).

2) Establish a heart connection with others, make relationships with them healthier, try to resolve old problems

This advice concerns our relationships with others, particularly family members and friends. The main points here are: to learn to be honest and compassionate in our interactions with others, to get rid of selfishness and try to resolve any long-standing problems that we have in relationships with others.

Reflect on your relationships with family, friends, co-workers, etc. Are there any unresolved issues in your relationship with them? What can be done to resolve them?

Tip: meditate on forgiveness, try to resolve problems.

3) Prepare for death with spiritual practices

Christine writes: “In any religious tradition, it is emphasized that in order to spiritually prepare for death, it is necessary to begin daily spiritual practice right now. It must enter so deeply into your consciousness in order to become your flesh and blood, a reflex reaction to any life situation, including the experience of suffering. The list of recommended spiritual practices of the Buddhist tradition is given below.

Try to imagine yourself at the moment of death: what thoughts and feelings are born in your mind? Do you know of any spiritual ideas or practices that would give you inner confidence and peace at the time of death? Have you studied them, have you started to apply them?

4) Try to determine what is the meaning of your life

Many of us go through life without a clear idea of ​​the purpose and meaning of our existence. This lack of clarity can become a problem for us as we age, as we gradually lose strength and become more dependent on others.

Therefore, it is very important to try to answer the following questions:

What is the purpose of my life? Why am I here? What is important and what is not important?

The painful or frightening experiences we experience at and after death are the result of negative actions or karma. To prevent these experiences, you need to refrain from negative actions and do as many positive actions as possible. For example, we can try our best to avoid the ten non-virtuous actions (killing, stealing, sexual misconduct, harsh speech, lying, slander, gossip, greed, malice, and wrong view) and practice the ten virtuous actions (consciously abstaining from killing, etc.). and doing the opposite of the ten non-virtuous actions). It is also good to take vows or commitments and perform cleansing practices on a daily basis.

Another aspect of Buddhist ethics is working with your mind to reduce the true causes of negative actions: defilements, or defilement emotions such as anger, greed, pride, etc., as well as awareness of death, which is one of the most effective antidotes for defilements. .

To illustrate this point, I will give an example. I was told a story about a woman who had an argument with her son just before he went fishing with his father. During that trip, the son died. You can imagine the pain that the mother felt: she did not just lose her son - the last words she said to him were filled with anger.

It is impossible to predict when death will overtake us or someone else. Every time we part with someone for a short time, there is no certainty whether we will ever meet again. Realizing this can help us stop clinging to our negative emotions and resolve problems in relationships with others as quickly as possible. This will ensure that we leave life with a light heart and save ourselves from painful regrets in the event that the person with whom we had a quarrel dies before we have time to apologize to him and fix the problems.

Also, as you approach death, it is helpful to start gifting others your property, or at least making a will. This will help ease attachment and anxiety -What will happen to my possessions? Who will get what? - at the time of death.

Learning spiritual practices, such as those taught by the Buddha, will help us overcome defilements and negative behaviors and become more wise and compassionate. In addition, the deeper we comprehend reality, or Truth (the nature of our life, the universe, karma, our ability to develop spiritually and the methods for awakening this ability), the less we will be afraid of death.

At the time of death, we may experience physical discomfort or pain. In addition to this, we may be plagued by disturbing thoughts and emotions, such as regrets about the past, fears about the future, sadness from parting with loved ones and loss of property, anger because of the failures that haunt us. As mentioned above, it is very important to keep your mind away from such negative thoughts and instead focus on the positive at the time of death. Examples of positive thoughts:

Focus on the objects of faith: Buddha or God;

Calmly accept your death and its attendant problems;

Maintain non-attachment to your loved ones and property;

Be positive about how we have lived our lives, remembering the good things we have done;

To feel love, kindness and compassion towards others.

In order to be able to awaken such thoughts and feelings in yourself at the time of death, you need to accustom yourself to them. The degree of habituation to positive states of mind depends on how much time and how much effort we have devoted to spiritual practice during our lifetime. And it is best to start it now, because we cannot know when the hour of our death will come.

1) Going for Refuge

In Buddhism, going for refuge is believing in and relying on the Three Jewels: Buddha, Dharma, and Sangha, combined with a sincere attempt to study and practice the Buddhist teachings. Buddhist teachings say that going for Refuge at the time of death will ensure a good rebirth and help avoid an unfavorable rebirth in the next life. Faith in one's spiritual guides, in one or another Buddha or Bodhisattva, such as Amitabha or Kwan-Yin, will bring the same result and at the time of death will give a feeling of deep peace.

2) Practices aimed at achieving rebirth in the Pure Lands

A popular practice, particularly in the Mahayana tradition, is to pray for rebirth in a Pure Land, such as the Pure Blessed Land (Sukhavati) of Buddha Amitabha. Pure lands are manifested by the Buddhas in order to help those who wish to continue their spiritual practice in the next life, free themselves from all the distractions, difficulties and interferences inherent in the ordinary world.

Bokar Rinpoche mentions four basic conditions that must be met in order to be reborn in Amitabha's Pure Land:

1. Remember the image of the Pure Land and meditate on it;

2. Sincerely desire to be reborn there and constantly pray for such a rebirth;

3. Purify from negative actions and accumulate positive ones, as well as dedicate the merits from this practice to rebirth in the Pure Land;

4. In your desire to be reborn in the Pure Land, be guided by Bodhichitta - a strong desire to achieve Enlightenment (Buddhahood) in order to be able to help all beings.

3) Mindfulness

Mindfulness is a meditative practice that involves being aware of everything that is happening to our body and mind; it is accompanied by an equanimity, free from attachment to what is pleasant and aversion to what is unpleasant. A deep familiarity with this practice makes it possible to cope with pain and discomfort, keep the mind from disturbing emotions and remain calm during death.

4) Love and kindness

This practice includes the development of caring, participation and kindness towards others. When we face difficulties or pain, our strong attachment to the self increases our suffering. If we focus less on ourselves and more on others, we will reduce our suffering. At the time of death, thinking about other living beings and wishing them happiness and liberation from suffering will bring peace to our mind. Lama Zopa Rinpoche says that these are the thoughts and feelings that are best experienced before and during death. They not only help us die in peace, but also purify our negative potential and increase our positive potential, our merit, which guarantees a good rebirth in the next life.

For more information on how to cultivate love and kindness, see Sharon Salzburg Loving-kindness - The Revolutionary Art of Happiness.

People are afraid of death because they don't know what will happen to them. The Tibetan Buddhist tradition offers a clear and detailed explanation of the process of dying, which includes eight stages. The eight stages correspond to the gradual dissolution of various factors such as the four elements: earth, water, fire and air. When passing through the eight stages, various internal and external signs appear.

In the first four stages, the dissolution of the four elements occurs. In the first stage, the earth element dissolves. On the external level this is manifested in the fact that the body becomes thinner and weaker, and internally - in the fact that a person sees mirages. In the second stage, the elements of water dissolve, on the external level this manifests itself in the fact that the fluids of the body dry up, and on the internal level, in the fact that a person sees smoke. In the third stage, the element of fire dissolves. On the external level, this is manifested in the fact that the body temperature drops, and with it the ability to digest food, and on the internal level, in the fact that a person sees sparks. In the fourth stage, the air element dissolves. On the external level, this is manifested in the fact that breathing stops, and on the internal level, in the fact that a person sees flames ready to break out. This is the moment when they usually state clinical death. The gross physical elements have dissolved, breathing has stopped, and there is no more movement in the brain or circulatory system. However, according to Buddhism, death has not yet occurred because the mind or consciousness is still present in the body.

There is various levels consciousness: gross, subtle and subtle. The gross mind or consciousness includes six kinds of consciousness associated with the senses (consciousness associated with sight, hearing, smell, taste, touch, and mental consciousness) and eighty instinctive concepts. The six sense-consciousnesses dissolve in the first four stages of dying, and the eighty concepts in the fifth stage, after which the white vision appears. In the sixth stage, the white vision dissolves and the red vision appears. In the seventh stage, the red vision dissolves and the vision of darkness appears. White, red and black vision constitute the subtle level of consciousness.

Finally, in the eighth stage, the black vision dissolves and the stage of the most subtle mind of clear light enters. This is the most subtle and purest level of our mind or consciousness. Experienced meditators are able to engage the clear light mind in meditation, achieve the realization of absolute Truth, and even gain Enlightenment. That is why contemplatives are not afraid of death and even look forward to it, as if a holiday is approaching!

This is a brief explanation of the eight stages. More detailed explanations can be found in several books, such as The Tibetan Book of the Dead, translated by Robert Thurman.

Since we are understandably afraid of the unknown, becoming familiar with the stages of dying will help us overcome our fear of death to some extent. And if we begin to perform the meditation associated with the mental passage of the process of dying and the awakening of clear light, which is described in the Tibetan Vajrayana tradition, then it is quite possible that we will be able to achieve realizations at the time of death.

Here are just a few recommended spiritual practices that you can learn and practice on your own throughout your life and that will help you prepare for death. However, there are many other methods for people with different inclinations. When it comes to choosing the method that suits us best, we can rely on our own intuition and wisdom, or we can consult trustworthy spiritual teachers with whom we have a spiritual connection.

The Buddhist teaching says that helping another person to die in a peaceful, calm state of mind is one of the greatest virtuous deeds. This is because the moment of death is key to determining the next rebirth, which, in turn, will affect subsequent rebirths.

However, helping the dying is not an easy task. When people die, they go through many hardships and changes that naturally causes a restless state of mind as well as painful emotions. The dying have physical needs: they need to be relieved of pain and discomfort, they need help with the simplest activities, such as quenching their thirst, eating, defecation, bathing, etc. They also have emotional needs: they need to be treated with respect, kindness and love, to be listened to, to talk to them, and sometimes they want to be left alone and allowed to be in silence. They also have spiritual needs: they strive to find the meaning of life, to understand the cause of suffering, death; they want to find hope that after death there is some kind of continuation; to feel that they will be taken care of and beyond the threshold of death they will be guided by something wiser, more powerful than themselves.

Thus, one of the most important skills in helping a dying person is to learn to understand his needs and try to fulfill them as much as possible. The best thing to do when visiting a dying person is to put our own needs and desires aside and make up our minds that we are fully dedicated to this person and are ready to do everything to make him feel more comfortable, happy and calm.

There are so many excellent books out there on how to care for a dying person, taking into account their physical and emotional needs. In this book, we will focus on spiritual needs and how to try to meet them.

When people feel they are dying, they sometimes experience disturbing emotions such as fear, regret, sadness; they cling to people and things related to this life, and even become angry. It can be difficult for them to cope with their emotions that overwhelm them, and at times it may seem to them that they are literally drowning in their emotions. What can help them at this moment? One must be near them, listen to them with sympathy and find words of consolation in order to bring their minds into an even state.

But to cope with this task, you need to know how to deal with your own emotions. Being close to a dying person can cause exactly the same disturbing emotions in our mind: fear, sadness, attachment, feelings of helplessness, etc. Some of these emotions we may not have experienced before and, having found them in our mind, we We may be surprised and even confused. Therefore, we need to learn how to deal with our emotions if we want to provide real help to another person.

One of the best ways to deal with your emotions is through mindfulness meditation (see above). Another way is to remind ourselves of impermanence, that we ourselves, other people, our bodies and our minds, and everything around us is constantly changing from one moment to the next, never remaining the same. Awareness and acceptance of impermanence are the most powerful antidotes to clinging, attachment, and fear, which is often resistance to change. It is also extremely helpful to develop firm faith in the Three Jewels of Refuge (Buddha, Dharma and Sangha). It gives us the strength and courage we need when we are going through violent emotions.

If the dying person is a family member or friend, then it will be especially difficult for us to cope with the attachments and expectations associated with him. Although it is difficult, it is still best to mentally “let go” of the person. Attachment to him is unrealistic and will only create more suffering for both of you. Again, the most effective cure for attachment is mindfulness of impermanence.

Sogyal Rinpoche in The Tibetan Book of the Living and the Dead (pp. 212-213) says that when helping a dying person, it is very important to give him hope and receive forgiveness. When people die, many of them experience guilt, regret, depression, or feelings of helplessness. You can help them by letting them have their say, by listening with compassion and without judgment. But try to get them to remember good deeds committed during their lifetime and experienced positive feelings from the way they lived their lives. Focus on their successes and merit, not on their mistakes and misdeeds. If they are open to such information, then remind them that by nature they are pure and kind (in Buddhism we call this "Buddha nature"), and their transgressions and mistakes are transient and removable, like dirt on glass.

Some people are worried that their wrongdoings are so numerous and great that they will never find forgiveness. If they believe in God or Buddha, reassure them that the nature of God or Buddha is pure, their nature is unconditional love and compassion, so they will always forgive any mistake we make. If you have an unbeliever in front of you, then he needs to forgive himself. You can help him do this by encouraging him to be genuinely remorseful for his mistakes and willing to ask for forgiveness for what he has done. That is all that is required of him. Remind him that no matter what he did, he is in the past, and nothing can be changed, so it would be better not to cling to the past. However, you can start changing right now. If a person really feels regret about his mistakes and a desire to change, then he can always be forgiven. If there are people whom he has harmed before and they are still alive, then help him speak words of repentance and ask for forgiveness.

Sogyal Rinpoche writes (p. 213):

“All religions emphasize the power of forgiveness, and this power is especially needed and especially deeply experienced precisely at the moment of death. By forgiving and receiving forgiveness, we cleanse ourselves of the darkness of our transgressions and thoroughly prepare ourselves for the journey through death.”

If the dying person is a Buddhist, ask questions to find out how deep their knowledge and level of insight is. His answers will help you understand how to give him spiritual support. For example, if the dying person has a strong faith in Kwan-Yin (Tib. Chenrezig, Sanskrit Avalokiteshvara), then you should strengthen him in faith and advise him to pray to Avalokiteshvara as often as possible. Or, if he has been practicing mindfulness meditation, advise him to do this practice as often as possible. So, whatever doctrine or practice the dying person is familiar with, remind him of them and do everything to strengthen him in faith and inspire him to perform these practices. If he finds it difficult to do the practice on his own, because of pain, fatigue, or a confused state of mind, then do it with him.

If possible, place pictures of Buddha, Kuan Yin, Amitabha, and other deities where the dying person can see them. If he has spiritual mentors, put up their portraits as well. In addition, it is beneficial to recite the names of the Buddhas to the dying person, because the Buddhas promised to help living beings avoid bad rebirths.

Tell the dying person about impermanence and other Buddhist teachings, or read appropriate excerpts from books, but do this only if he is interested, do not be intrusive. Also be careful that your teachings do not cause confusion or anxiety in the mind of the dying person (for example, if the subject is too difficult to understand or if it is a new and unfamiliar teaching). Remember that the most important thing is to help the person achieve a calm and positive state of mind before and after death.

It may also happen that the dying person does not know how to meditate or pray. In this case, you can meditate, pray, or do other practices in his presence, dedicating merit to a calm state of mind at the time of death and a good rebirth of the dying person. You can also teach him to pray by saying Buddhist prayers or in your own words, from the heart. For example, he may pray to Buddha, Kuan Yin, or other Buddhas he knows, asking them not to leave him in difficult times, to help him find the strength and courage to cope with his suffering, keep his mind calm and find a path to good. rebirth.

Here is a simple meditation you can teach a dying person: ask them to visualize any Buddha they believe in in front of them, imagining that they embody all positive, pure qualities such as compassion, love, kindness, forgiveness, and wisdom. Light descends from the body of the Buddha, filling the body and mind of the dying person, cleansing him of all negative deeds and thoughts and blessing him to gain pure, positive thoughts. The mind of the dying person merges with the mind of the Buddha, which has perfect purity and goodness. If the dying person is unable to do this meditation (for example, they are very ill or unconscious), then you can do it for them by imagining the Buddha above the dying person's head.

In addition, help the dying person to release worry and anxiety, ask him not to worry about loved ones and possessions, assure that everything will be taken care of, and convince him not to be afraid of what lies ahead, but still believe in the Three Jewels. Try, to the best of your ability, to help him develop positive states of mind: faith, compassion, love, and kindness, and to avoid negative thoughts: anger and attachment.

If the dying person belongs to another religious denomination, try to understand their beliefs and beliefs and speak to them in that language. For example, if they believe in God and heaven, help them strengthen their faith, turn their prayers to God, and be filled with confidence that after death they will be in heaven with God. You must treat the dying person with due respect, his faith and spiritual practice. Remember that the most important thing is to help him tune in to positive thoughts that lie in the context of his religion and practice. No need to impose your own beliefs on him or convert him to your religion. This will be a manifestation of disrespect for the dying and a violation of ethical standards. Such behavior on our part can cause anxiety and anxiety in the dying person.

If the dying person is a non-believer, do not use religious terminology when talking to him. In simple words, help him get rid of negative thoughts such as anger and attachment and develop positive thoughts and a calm state of mind. If he shows interest in what you believe, then you can tell him about it, but be careful that your story does not turn into a sermon. It may be more effective to have a conversation in which you openly share your views with each other. For example, if a dying person asks you to talk about what happens after death, then instead of immediately jumping into a discussion about rebirth, it is better to say: “I'm not quite sure. And what do you think?" , and start the conversation from that point.

If the dying person really wants to learn about the Buddhist religion and practices, then of course one can start telling them about them. You can talk about the life of the Buddha and his Teachings, about the Four Noble Truths, about impermanence, about love and kindness, about compassion, etc. Be attentive and sensitive to the reaction of the dying person: do not push, otherwise he may fall into a negative state of mind.

Remember that the main goal is to help him get rid of any negative thoughts and be in a positive, calm state of mind.

If the dying person is not a Buddhist, he will be uncomfortable if you read Buddhist prayers or perform Buddhist practices in front of him, then you can do them silently, so that he does not know about it. For example, you can sit nearby and meditate on love and kindness, sending the energy of goodness born in your heart to the dying person to help him find peace. Or you can visualize a dying Buddha or Kuan Yin above your head and recite prayers or mantras silently, visualizing a stream of light pouring from the Buddha image onto the dying person. Mentally imagine that this light purifies him and helps his mind to find peace and purity. It is likely that a person will feel the power of these practices, even if he does not know that someone performed them on his behalf!

You can continue to meditate or recite prayers, mantras, the names of the Buddhas in the process of dying a person, as well as for as long as possible after breathing has stopped. Remember that, according to Buddhist teachings, the cessation of breathing is not considered the moment of cessation of life. This is only the fourth of the eight stages of the process of dying, and death, in fact, occurs at the moment when the consciousness leaves the body, that is, after the end of the eighth stage.

How long does it take to get to the eighth stage after stopping breathing? This cannot be said for certain. It all depends on various factors, such as the cause of death (for example, if a person's body was badly damaged in a car accident, then his consciousness can leave the body faster than in the case of a natural death) and the state of mind (experienced meditators can remain in the eighth stage, stage clear light, longer than someone who meditated little or no experience of meditation).

How can we know that a person is really dead? According to Tibetan tradition, there are several signs that consciousness has left the body: the temperature at the level of the heart center decreases, the body begins to smell, and a small amount of liquid is released from the nostrils or genitals. Until these signs appear, it is best to leave the body alone. Before they appear after stopping breathing, it can take from several hours to several days. You can do this if a person died at home, but it is difficult if he died in a hospital, because hospitals have rules governing the length of time the body is in the ward or in any hospital room. You can ask the hospital staff to move the body to another room and leave it there for a few more hours while the necessary prayers and mantras are recited.

It is better not to touch the body from the moment the breath stops until the moment when consciousness leaves it. However, if it becomes necessary to move the body, first pull out a few hairs from the top of the head (or touch the top of the head if there is no hair). This stimulates the person's consciousness to leave the body through the crown, which is the exit point for a favorable rebirth, for example, in the Pure Lands. After that, you can touch other parts of the body.

In Buddhist tradition, it is recommended not to cry in the presence of a dying person. It is not advised to cry even after he has stopped breathing. It is also better not to talk about a person's property and how it will be distributed. Such talk can disturb a person's mind. Family members and friends may go to another room to cry or discuss practical matters. For a person who has died, it will be more favorable to hear the sounds of prayers, mantras and spiritual instructions.

Among the practices that Lama Zopa Rinpoche recommends doing for the deceased are Medicine Buddha, Amitabha, Chenrezig, Giving Breath to the Unfortunate, and Prayer King. Copies of the texts of these and other practices for the dying and dead can be obtained by writing to: [email protected] If there is a lama or an ordained monk in your area who knows how to do the Phowa (mind transference) practice, then you can invite him. If there is no such person, then do those practices and recite those prayers that you yourself know, with all the faith, sincerity and compassion that your heart is capable of.

After a person has died, we can continue to help him accumulate merit by doing virtuous deeds: recite prayers (you can turn to monks or nuns for help), make offerings, free animals that are being led to the slaughter, and meditate, etc. All the merits from these actions can be dedicated to the good rebirth of the deceased, his speedy Liberation from samsara and the achievement of Enlightenment. It is recommended to dedicate merit regardless of whether the deceased was a Buddhist or a non-Buddhist.

It is very good to use the personal funds of the deceased for the accumulation of merit, for example, direct them to charitable purposes. It is important to know that the merits accumulated by family members (direct relatives of the deceased) are more powerful and effective. Performing virtuous deeds and dedicating merit to the deceased can help a person in the bardo (an intermediate state between death and the next life, which lasts up to 49 days). However, if the deceased finds the next rebirth quickly enough, then the merit that we dedicate to him, thinking that he is in the bardo, may not help him in this new birth, but may help him in subsequent rebirths, for example, shortening his life. being in an unfavorable birth.

I hope that the ideas in this booklet will help you come to terms with the inevitability of death and relieve your own and others' fears. Exists great amount materials drawn from ancient religious and spiritual traditions, as well as modern areas knowledge, such as psychology, sociology and palliative care, that helps you build your life so that you meet death with peace, calm and courage. And when people we love pass away, we can give them comfort, clarity of mind and hope. Let this little work inspire you in your own research on this important topic. And may all living beings be freed from the suffering associated with the termination of life, and achieve supreme peace and happiness beyond the cycle of birth and death.

The Book of Life and the Practice of Dying
Chapter XI
HEART ADVICE ON HOW TO HELP THE DYING

Sogyal Rinpoche

In one hospice I know, Emily, a woman in her seventies, was dying of breast cancer. Her daughter visited her daily and their relationship seemed to be very good. But when her daughter left, Emily almost always retired and cried. After a while, it became clear that the reason for this was her daughter's complete refusal to accept the inevitability of her death: she kept encouraging her mother to "think positively", hoping that this would cure her cancer. All she did was that Emily had to keep her thoughts, deep fears, panic and grief to herself, and there was no one to help her explore them, to help her understand her life, no one to help her find healing meaning. in her death.

The most essential thing in life is to establish fearless, sincere fellowship with others, but for the dying, as Emily has shown, this is the most important.

Often, when you first visit a dying person, they become withdrawn, unsafe, and unsure of your intentions. So don't expect anything out of the ordinary to happen, just be natural and relaxed, be yourself. Dying people often do not say what they would like to say or express, and their loved ones do not know what to say or do. It is difficult to find out what they would like to say, or even what they are hiding. Sometimes they don't even know it themselves. Therefore, the first, essential thing is to relieve any tension, in any way that comes to mind most easily and naturally.

Once trust and confidence is established, the atmosphere will be relaxed, and this will allow the dying person to mention what he really wants to say. Warmly encourage him to express as freely as possible thoughts, fears and emotions related to dying and death. This honest and direct exposure of emotion is at the heart of any transformation - coming to terms with life or dying a good death - and you must allow this person complete freedom of expression and allow him to say whatever he wants.

When the dying person finally confides his most personal feelings to you, do not interrupt him, do not deny or downplay what he is saying. A terminally ill or dying person is in the most vulnerable position of their entire life, and it will take all your skill and reserves of sensitivity, warmth, and loving compassion to allow him to open up. Learn to listen and learn to silently perceive: learn to open, calm silence, which will show the other person that he is accepted. Be most relaxed, unstressed: sit with your dying friend or relative as if you had no more important or pleasant thing to do.

I have found that in all serious life situations, two things are most helpful: a common sense approach and a sense of humor. Humor miraculously lightens the situation, helping to look at the process of dying in its true and universal perspective, destroying the excessive seriousness and tension of this situation. Therefore, use humor as skillfully and gently as possible.

I have also found, in my own experience, that it is essential not to take anything too personally. The dying may, at the moment you least expect it, make you the target of their anger and blame. As Elisabeth Kübler-Ross says, anger and guilt can be "displaced in any direction and projected onto their environment, sometimes almost randomly." Do not assume that this rage is really directed at you: knowing what fear and grief it comes from will allow you not to react to it in a way that could damage your relationship with the dying person.

At times you may be tempted to preach to the dying, or teach them the spiritual teachings that you yourself believe in. Never give in to this temptation, especially when you suspect that this is not what the dying person wants! Nobody wants to be "saved" by someone else's beliefs. Remember that your task is not to turn anyone into something, but to help this person in front of you get in touch with his own strength, confidence, faith and spirituality, whatever they may be. Of course, if this person is really open about spiritual matters and really wants to know what you think about them, don't refrain from discussing them.

Don't expect too much of yourself, don't expect your help to produce miraculous results or "save" the dying person. You will only be disappointed. People will die the way they lived, the same as they are. To establish real fellowship, you must make a deliberate effort to see this person as inseparable from his life, character, environment, and history, and accept him unconditionally. Also, do not be discouraged if it seems to you that your help is not very effective, and the dying person does not respond to it. We fail to know the deepest effects of our love and care.

How to show unconditional love

The dying person most needs expressions of unconditional love, free from any demands. Don't think that you have to exercise any special knowledge. Be natural, be yourself, be a true friend, and the dying person will be encouraged that you are really with him and interact with him simply as an equal, as one person with another.

I said, "show the dying unconditional love," but in some situations it's not so easy. We may have a long history of suffering associated with this person, we may feel guilty about what we have done to this person in the past, or we may feel anger and resentment about what this person has done to us.

So let me suggest two very simple ways with which you can release the love that is within you to this dying person. Both myself and my students who have worked with the dying have found that both of these methods are very powerful. The first is to look at a dying person and think that he is exactly like yourself, with the same needs, with the same fundamental desire to be happy and avoid suffering, with the same loneliness, the same fear of the unknown, the same secret sorrows, the same half-conscious feeling of helplessness. You will find that if you really do this, then your heart will open towards this person and love will be between you.

The second, and, as I have found, even more powerful way, is to place yourself, directly and directly, in the place of the dying person. Imagine that you yourself are lying on this bed in front of you, that it is you who are dying. Imagine that you are here, in pain and alone. Then really ask yourself: What do you most need? What do you need most right now? What do you really want from the friend in front of you?

If you do these two practices, I think you will find that what the dying person needs is the same thing that you would most like: to be truly loved and accepted.

I also often saw that the seriously ill longed to be touched, longed to be treated as if they were human beings and not as incarnations of the disease. A very great comfort can be given to the seriously ill simply by touching their hands, looking into their eyes, giving them a light massage or embracing them, or breathing softly in the same rhythm with them. The body has its own love language; apply it fearlessly, and you will find yourself bringing comfort and peace to the dying.

We often forget that a dying person loses his whole world: his home, his job, his relationships, his body and his mind - he loses everything. All the losses that one can experience in life merge into one overwhelming loss when we die, so how can a dying person not feel sometimes sadness, sometimes panic, and sometimes anger? Elisabeth Kübler-Ross believes that the process of coming to terms with dying goes through five stages: denial, anger, argument, depression, and acceptance. Of course, not everyone goes through all of these stages, and not necessarily in that order; for some people, the path to acceptance may be extremely long and thorny, while others may not reach it at all. Our culture does not give people very much a true perspective in which to view their thoughts, emotions and experiences, and many who face death and its ultimate challenge feel deceived by their own ignorance and experience a sense of terrible failure and anger, especially because no one seems to want to understand them, and what they most need. As Cecily Saunders, the great pioneer of the hospice movement in the UK, writes: “I once asked a man who knew he was dying what he most needed from those who cared for him. He said, "For someone to show they're trying to understand me." Truly, it is impossible to fully understand another person, but I will never forget that he did not hope for success, but only that someone would be interested enough in him to try to do it.

It is essential that we are sufficiently motivated to try and reassure the dying person that, whatever their feelings of failure and anger may be, this is normal. Dying releases many repressed emotions: sadness or numbness or anger or even jealousy for those who are still healthy. Help him not to suppress these emotions when they arise. Be with him as the waves of pain and grief rise; if there is acceptance, time and patient understanding, then these emotions will slowly subside, and the dying person will return to that basis of peace, tranquility and sound mind, which is most deeply and truly embedded in him.

Don't try to be too wise: don't waste time saying something profound. You do not need to do or say anything to improve the situation. Just be here as fully as you can. And if you feel severe anxiety and fear and do not know what to do, directly admit this to the dying person and ask him for help. This kind of honesty will bring you and the dying person closer and lead to more free communication. Sometimes the dying know better than we do how to help them, and we need to know how to use their wisdom and let them pass on what they know. Cecily Saunders asks us to remember that when we are with the dying, we are not the only ones to give. “Sooner or later, but everyone who works with the dying realizes that they receive more than they give, meeting endurance, courage and often humor. It needs to be said…” The confirmation that we recognize courage in them can often inspire the dying.

I have also found that it helps me to remember that this dying person, always, somewhere inside, is good in himself. Whatever emotions and rage may arise, no matter how shocking or terrifying their manifestation in this moment, focusing on that - that he is intrinsically good - will give you the self-management and perspective you need to give him all the help you can. Just like in a fight with a good friend, you don't forget about best sides this person, do the same for the dying person. Don't judge them by the emotions that come up, whatever they are. This kind of acceptance on your part will free the dying person, allowing him not to suppress himself as much as he needs to. Treat the dying person as if they were still the way they sometimes were: open, loving, and generous.

On a deeper, spiritual level, it helps me a lot to understand that the dying person has the true nature of a Buddha, whether they realize it or not, and the potential for full enlightenment. As the dying person approaches death, this possibility increases in many ways. Therefore, they deserve even more loving care and respect.

To tell the truth

I am often asked: “Should I tell people that they are dying?” And I always answer: "Yes, with the greatest calmness, kindness, sensitivity, and as skillfully as possible." Based on my years of experience visiting the sick and dying, I agree with Elisabeth Kübler-Ross, who saw that “most, if not all, of these patients know this anyway. They feel it in the change of attention given to them, in the new, different approach with which others begin to treat them, in the lowering of their voices or the fact that they are especially trying not to make a noise, in the tear-stained face of a relative or an ominous shadow on the gloomy face of a relative. who can't hide his feelings."

I have often found that people know instinctively that they are dying, but rely on others - their doctor or loved ones - to confirm it. If they do not, then the dying person may feel that his family is not able to cope with such news. And then the dying person, all the more, he himself will not be able to master it. Such reticence, lack of honesty will only make him feel even more isolated and unsettled. I believe that it is essential to tell the dying man the truth: at least he deserves it. If the dying are not told the truth, how can they prepare for death? How can they bring the relationships of their lives to their true conclusion? How can they take care of the many practical cases that they have to decide? How can they help those who remain to live on?

From my point of view, as a spiritual practitioner, I believe that dying provides people with the greatest opportunity to come to terms with all their own life; and I have seen many people use this opportunity in the most inspiring way to transform themselves and get closer to their own deepest truth. So when we, with kindness and sensitivity, tell people as early as possible that they are dying, we are actually giving them the opportunity to prepare, to show their own strength and meaning in their lives.

Let me tell you a story that Sister Brigid, a Catholic nurse at the Irish Hospice, told me. Mr. Murphy was in his sixties and the doctor told him and his wife that he didn't have long to live. The next day, Mrs. Murphy came to her husband's hospice, and they talked and cried all day. Sister Brigid watched this old couple talking and crying every now and then, and when it went on for three days, she wondered if she should intervene. But the next day, the Murphys suddenly looked very at ease and calm, they sat holding hands and showing great tenderness to each other.

Sister Brigid stopped Mrs. Murphy in the corridor and asked what had happened between her and her husband to bring about such a great change in their behaviour. Mrs. Murphy told her that when they learned that her husband was dying, they together remembered all the years spent together, and many memories returned to them. They had been married for almost forty years, and it was natural that they were extremely sad to think and talk about all the things that they could never do together again. Mr. Murphy then wrote his will and farewell letters their adult children. It was all terribly sad, because it was very difficult to leave everything, but they endured it all, because Mr. Murphy wanted to end his life well.

Sister Brigid told me that for the next three weeks that Mr. Murphy lived, the couple radiated peace and a simple, wonderful feeling of love. Even after her husband's death, Mrs. Murphy continued to visit hospice patients and was an inspiration to all of them.

This story shows how important it is to tell people that they are dying prematurely, and also how great an advantage it is to be able to face the pain of loss. The Murphys knew they had a lot to lose, but by facing those losses and mourning together, they found what they couldn't lose - a deep love between them that survived Mr. Murphy's death.

Fear of death

I am sure that Mrs. Murphy's ability to face her own fear of death, hidden in herself, helped her to support her husband. You cannot help a dying person until you admit to yourself how much their fear of death bothers you and triggers your own most disturbing fears. Working with the dying is like holding a relentlessly accurate mirror in front of you that reflects your own reality. You see in it the distinct face of your own panic and your own horror of pain. If you don't look into it and accept that face of panic and fear in you, how can you bear it in the person in front of you? When you come to a dying person to try to help him, you need to examine your every reaction, as all of them will be reflected in the reactions of the dying person, and can largely help or hinder them.

Being honest with your own fears will also help you in your own journey towards maturity. Sometimes I think that there is hardly a more effective way to force our growth as human beings than to work with the dying. Caring for the dying is in itself a deep contemplation and reflection on our own death. It's a way to face it and work with it. When you work with the dying, you may come to some resolution, a clear understanding of what is most important in life. To learn how to really help the dying means to start becoming fearless and responsible for your own dying, and to find in yourself such beginnings of boundless compassion that we could never suspect.

Being aware of your own fears of death will immeasurably help you be aware of the fears of the dying person. Just really imagine what it could be: fear of ever-increasing, uncontrollable pain, fear of suffering, fear of loss of self-worth, fear of being dependent, fear that the life lived was meaningless, fear of being separated from everything we love, fear loss of control, fear of losing the respect of others; and perhaps the greatest of all our fears is the fear of fear itself, growing more and more the more we avoid it.

Usually, when you feel fear, you feel isolated, alone. But when someone is with you and talks about their own fears, then you realize that fear is universal, and then its sharpness, your personal pain, leaves it. Your fears return to the universal and universal environment. Then you are able to understand, feel more compassion, and deal with your own fears in a much more positive and empowering way.

As you face and accept your own fears, you become increasingly sensitive to the fears of the person in front of you and find that you develop the skill and insight you need to help that person bring them out. fears out, manifest them, cope with them and skillfully begin to dispel them. You will find that when you face your fears, it will not only make you more compassionate, brave, and intelligent; it will also make you more skillful, and this skill will open you all sorts of ways helping the dying to understand themselves and face themselves.

One of the most easily dissipated fears is the anxiety we all feel about the painful process of death. I would like to think that everyone in the world now knows that this is not necessary at all in our time. A study at St. Christopher's Hospice in London, which is well known to me and where my students died, showed that with proper care, 98 percent of patients can die a peaceful death. The hospice movement has developed a variety of ways to beat pain through various combinations of drugs, and not necessarily just drugs. Buddhist masters speak of the need to die in consciousness, with the most clear, unclouded and calm mental control. Controlling the pain without clouding the consciousness of the dying is paramount, and now this can be done. Every person has the right to such simple help at this most difficult moment of his departure.

unfinished business

Another concern of the dying person is often unfinished business. The masters tell us that we should die in peace, "without clinging, desire or attachment." It cannot be complete if the unfinished business in this life is not completed as far as possible. Sometimes you will find that people cling to life and are afraid to let it go and die because they have not come to terms with what they were and what they did. And when a person dies with guilt or bad feelings towards someone, those who remain alive suffer even more grief.

Sometimes people ask me: “Isn't it too late to make amends for the pain of the past? Isn't there too much suffering between me and my

dying friend or relative so that forgiveness may be possible?” I believe, and proved it to myself by experience, that it is never too late; even after great pain or abuse, people can find a way to forgive each other. There is a grandeur, seriousness, and finality in the moment of death that can make people reconsider all their relationships, become more open and ready to forgive, although they might not have been able to bear it before. Even at the very end of life, you can correct the mistakes of this life.

There is one way to help complete unfinished business that I and my students who work with the dying have found very helpful. It was developed from the Buddhist practice of equalizing and exchanging one's personality with others, and from the method of Gestalt psychology developed by Christina Longaker, one of my earliest students to address the realm of death and dying after her husband's death from leukemia. Usually, unfinished business is the result of blocked communication: when we are hurt, we usually defend ourselves by always speaking from the perspective of who is right and blindly refusing to see the other person's point of view. Not only does this not help anything, but it also blocks any possibility of a real exchange of opinions. So when you do this exercise, start with a strong urge to call out all your negative thoughts and feelings in order to try to understand them, work with them and resolve them, and finally let them go.

Then imagine in front of you the person with whom you have a problem. Visualize this person in front of your inner eye, exactly as you have always seen him.

Now imagine that he has really changed, so that he is now much more open and receptive to what you have to say to him, much more than before, willing to frankly discuss and resolve the problem between you. Vividly visualize this person in this new state of openness. It will also make you feel more open to him yourself. Then really, in the depths of your heart, feel that you need to tell this person. Tell him where you see this problem, tell this person everything about your feelings, your difficulties, how unpleasant it is for you, how sorry you are about it. Say anything you thought was risky or embarrassing enough to say to this person before.

Now take a piece of paper and write down everything you would say to him. After that, immediately start writing what this person could say to you in response. Don't dwell on remembering what this person used to say: remember that now, as you visualized, he really heard you and is much more open. So just write what you see that comes spontaneously and let that person in your mind fully express his view of the problem.

Search within yourself and find what else you need to say to this person - any other hurt feelings or regrets from the past that you have kept inside or never mentioned before. Again, after each time you express your feelings, write the other person's response in the way that comes to mind. Continue this dialogue until you really feel that there is nothing more to hide in yourself or that nothing more needs to be said.

To test if you are really ready to end this dialogue, ask yourself deep down if you can now wholeheartedly let go of the past, are you satisfied with the insight and healing that this written dialogue has brought you, and are you able to truly forgive this person, or whether you feel that this person would forgive you. If you feel like you've made it, be sure to express any last feeling of love or approval you might be holding back and say goodbye to it. Now visualize this person turning and walking away; and even though you must let him go, remember that you can always keep in your heart his love and fond memories of the best parts of your relationship.

To come to an even clearer reconciliation with the past, have a friend read this recorded dialogue aloud to you, or read it aloud to yourself at home. As soon as you read this dialogue aloud, you will be amazed at the change that will happen to you, as if you really communicated with this other person, and really cleared up all these problems of yours with him. Subsequently, it will be much easier for you to relieve tension and speak directly with this person about your difficulties. And when you truly let go of the tension, there will be a subtle shift in the unspoken relationship between you and that other person, and often the tension in your relationship that has lasted for so long will dissolve. Amazingly, sometimes you can even become best friends. Never forget that, as the famous Tibetan master Tsongkhapa once said, "a friend can turn into an enemy, and therefore an enemy can turn into a friend."

How to say goodbye

You need to learn to let go not only of tension, but also of the dying person. If you are attached to a dying person and cling to him, you can cause him a lot of unnecessary mental anguish and make it very difficult for him to let go of his own tensions and die peacefully.

Sometimes a dying person can live many months and weeks longer than doctors expected, while experiencing great physical suffering. As Christina Longacker discovered, in order for such a person to

let go of tension and die peacefully, he needs to get two precise assurances from those he loves. Firstly, they must give the person permission to die, and secondly, they must reassure him that they will be fine after he is gone and he does not need to worry about them.

When people ask me how best to give someone permission to die, I tell them to imagine themselves standing at the bedside of their loved one and saying to him with the deepest and most sincere tenderness: “I am here with you and I love you. You are dying and it is perfectly natural; it happens to everyone. I would like you to stay here with me, but I don't want you to suffer any more. The time we spent together was enough and I will always cherish it. Please don't cling to life anymore. Let go. I give you my full permission to die from the bottom of my heart. You are not alone now, and you never will be alone. All my love is with you."

One of my hospice students told me about an elderly Scottish woman, Maggie, whom she visited after her dying husband had already collapsed into unconsciousness. Maggie was inconsolable because she had not spoken to her husband about her love for him, and did not say goodbye to him, and now she felt that it was too late. The hospice worker encouraged her and told her that although he seemed unresponsive, he might still be able to hear her. She read that many of those who appear to be completely unconscious can actually perceive what is happening around them. She advised her wife to stay with her husband, telling him everything she wanted to say. Maggie wouldn't have thought of it herself, but she jumped at the idea and started telling him about all the good times they shared, how she would miss him, and how much she loved him. And in the end, saying goodbye to him, she said:

“It will be difficult for me without you, but I don’t want to see you suffer anymore, so it’s okay, you can let go.” As soon as she finished speaking, her husband let out a long sigh and died peacefully.

Not only the one who is dying, but their entire family needs to learn to let go. Keep in mind that each family member may have their own degree of acceptance. One of the greatest accomplishments of the hospice movement has been the realization of the importance of helping the entire family face their grief and uncertainty about the future. Some families resist letting go of a loved one, seeing it as a betrayal and a sign that they don't love them enough. Christina Longaker tells the members of such families to imagine themselves in the place of the dying. “Imagine that you are standing on the deck of an ocean liner ready to leave. You look at the shore and see that all your family and friends are seeing you off, waving their hands. You don't have the option to make a choice and decide not to leave, and the ship is already leaving. How would you like those you love to say goodbye to you? What would help you better on your journey?

Even an exercise as simple as this can go a long way in allowing each family member to deal with the sadness of goodbye in their own way.

Sometimes people ask me: “What should I tell my child about the death of a relative?” I say to be careful, but tell the truth. Don't let your child think that death is alien or terrifying. Let him touch the life of the dying person as fully as possible and answer honestly any questions the child may ask. The directness and innocence of a child can actually bring gentleness, enlightenment, sometimes even humor, into the pain of dying. Encourage the child to pray for the dying, and thereby feel that he is really doing something to help him. And after death has taken place, be sure to give the child special attention and affection.

To a peaceful death

When I look back at Tibet and the deaths I witnessed there, I am struck by the peaceful and harmonious environment in which many of them took place. Alas, such an environment often does not exist in the West, but my experience over the past twenty years has shown me that it can be created if you approach it with imagination. I believe that whenever possible, people should die at home, because most people feel most comfortable at home. And the peaceful death recommended by the Buddhist masters is most easily achieved in a familiar environment. But if someone has to die in a hospital, then you, those whom this person loves, can do a lot to make this death as easy and inspirational as possible. Bring houseplants, flowers, paintings, photographs of his loved ones, drawings of his children and grandchildren, or a cassette recorder of his favorite music, or food from home if possible. You can even get permission to bring the children to visit him or to stay overnight with his beloved relatives.

If the dying person belongs to the Buddhist or any other faith, then friends can build a small altar in his chamber with inspiring images. I remember my student named Reiner, who was dying in a private room in a Munich hospital. An altar was made for him with images of his masters. I was very touched by this and realized how deeply Reiner was helped by the atmosphere it created. Buddhist teachings tell us to build an altar with offerings when someone dies. Seeing Reiner's devotion and peace of mind made me realize how powerful it can be and how it can help inspire a person to turn their dying into a sacred act.

When a person is very close to death, I advise you to ask the hospital staff not to disturb him so often and stop taking tests from him, etc. I am often asked how I feel about death in the ward intensive care. We have to say that being there makes it very difficult to die peacefully, and hardly allows any spiritual practice at the time of death. There is no privacy for the dying: they are connected to monitors, and if they stop breathing or their heart stops, attempts will be made to revive them. There will be no way to leave the body after death alone for a while, as the masters advise.

If possible, you should arrange with the doctor to tell you when there is no longer a chance for the patient to survive, and then, if the dying person so wishes, arrange for him to be transferred to a separate room, without connecting monitors. Make sure hospital staff are aware of and respect the dying person's wishes, especially if they don't want to be revived, and make sure staff also know to leave the body as long as possible. Of course, in a modern hospital it is impossible to leave the body alone for three days, as was customary in Tibet, but all the support that peace and quiet gives must be given to the dead to help them begin their journey after death.

Also try to arrange that at the time when the dying person is in fact already in the last stages of dying, he will not be given any injections or any procedures related to the invasion of the body. They can cause anger, irritation and pain in him, and it is essential, as I will explain in detail below, that the mind of the dying person be as calm as possible in the moments before death.

Most people die unconscious. From near-death experiences, we have learned the fact that dying and comatose patients may be much more aware of their surroundings than we think. Many accounts of near-death experiences report out-of-body perceptions, on the basis of which these people are able to describe with amazing accuracy and detail their surroundings, and sometimes even other rooms in the same hospital. This clearly shows how important it is to speak often and kindly to someone who is dying or in a coma. Conscious, vigilant, and actively loving care for the dying must continue until the very last moments of his life and, as I will show below, even after.

One of my hopes for this book is that physicians around the world will take very seriously the need to allow the dying person to die in peace and quiet. I want to appeal to the goodwill of medical professionals and hope to inspire them to find ways to make this very difficult transition into death as easy, painless and peaceful as possible. In fact, a peaceful death is an essential human right, perhaps more essential than even the right to vote or the right to justice; it is a right on which, as all religious teachings tell us, very much depends for the well-being and spiritual future of a dying person.

You cannot do a greater good to a man than to help him die well.

AT recent times the themes of dying and death are discussed in numerous books, scientific papers, magazines, radio and television broadcasts. So in documentary"16 More Days..." is about one of London's five clinics for the dying, St Christopher's Hospice. Since its opening in 1967, 1600 patients have died in this clinic. The people who are brought here have only 16 days to live - hence the title of the film. These are patients who can no longer receive medical care. Doctors, sisters, clerics and voluntary assistants cooperating in the clinic strive to help the dying: make it easier for them to die, free them from the pain and fear of death. This difficult task requires great sacrifice, patience and love. The viewers of the film experience the peaceful death of a seriously ill person - not dying alone, but, on the contrary, surrounded by his wife and children. Family members give the dying person the feeling that he is not left alone; they help him to survive in this life situation. The film shows that help in dying is the last help in life: people live their lives together, just as they must accompany the dying person to his death. The dying person should be able to express his feelings; he must know that he was not left alone. If his family members and caregivers refuse to help him, understand him and overcome his anxiety and fear together with him, then they can leave the patient all alone. A dying person may notice with deep disappointment that he has been considered dead before he actually dies.
It is often not possible to help a dying person because even a person striving for this does not have the necessary prerequisites that would allow him to be near the dying person at this difficult stage of his life. Already at school and then in Christian communities, therefore, one should constantly strive to prepare people for the provision of such assistance. Important prerequisites for this are:
- the observation that the dying (other than those who die instantly) come to terms with the fact of their death at various stages of dying;
- the ability to penetrate into the world of feelings of the dying person and listen to him, as well as
- willingness to monitor their own behavior when communicating with the patient.
This chapter offers selected texts that provide guidance that may help in accompanying the dying.

Dying

An important contribution to the understanding of the dying person was made by the psychologist and physician E. Kübler-Ross with her book Interviews with the Dying. Based on her many years of experience with the dying in a Chicago clinic, she describes how the dying, at various stages of dying, come to terms with the fact of their imminent death. E. Kübler-Ross distinguishes five stages of dying, which in different people may vary in duration and intensity. "If we do not leave the dying alone, if we listen to their hopes, patients quickly go through all five stages ... Sometimes one of the stages can be skipped, sometimes the patient comes back" (Kübler-Ross 1971). Based on the experience of E. Kübler-Ross, W. Becker gives an impressive description of the long and difficult journey of the dying person and his companions through the various stages of dying.
1. Unwillingness of the patient and his relatives to recognize the proximity of death When a terminally ill person learns about his diagnosis or gradually realizes the truth about his situation, he goes through a stage of shock, which is characterized by unwillingness to accept reality. He reacts to the hard reality with the illusion of health and wellness: "No, no, this does not concern me! This is not happening to me, this cannot happen to me." Such a reaction helps the patient to dull the shock caused by the news of the impending end, and gradually get used to the current situation. At a later stage, the refusal to acknowledge reality is replaced by "isolation" of the senses. At this stage, the patient talks about his health and illness, about his death and immortality, as if emotionally it does not affect him at all.
The shock is experienced not only by the dying, but also by his relatives. They realize that their words mean little, their expectations are unrealistic, and that they themselves tend to close their eyes in the face of death. They are also involved in the patient's unwillingness to acknowledge reality, and this reinforces their need for detachment from reality. It often happens that the patient's relatives still cling to the denial of reality, while the patient himself is already beginning to prepare for it. The dying understand these needs of their loved ones and often pretend that they do not recognize reality, although in fact they are already beginning to consciously come to terms with it. Some are only able to endure meeting a dying person on the condition that they withdraw completely from him.
These observations show how important it is that anyone who wants to help a dying person clearly understands his own attitude towards dying and death.
2. Emotions, protest The stage of refusal to recognize reality is followed by the stage of emotions. The dying man is seized by a stormy stream of feelings. He comes into a state of anger and rage: "Why did this have to happen to me?" Anger can turn to loved one, a doctor, a nurse, a priest, and even God. It flares up on the most insignificant occasions and is often not provoked by those against whom it is directed. Often the dying person is not even able to express his anger, as he is hindered by the habit of external and internal control. External control is carried out by the persons accompanying the dying person, since they do not allow negative emotions, preferring to deal with friendly and obedient patients. Many also have strong inner control against negative emotions because they consider them unworthy of a Christian and hesitate to express their anger. At this stage, it is especially difficult for those accompanying people who perceive the outbursts of anger of the dying person too personally. If you are unable to accept the question "Why did this have to happen to me?" as an expression of the anguish and fear of the patient, you have to look for another answer that explains everything, and you cannot find it. The place of sympathetic perception of the patient is then replaced by numerous words that do not reach the patient in his suffering and prevent him from expressing his feelings. If, on the other hand, the accompanist is so deeply imbued with the feelings of the patient that he barely retains the ability to maintain a distance between him and himself, then the flow of the patient's feelings becomes even stronger until he drowns in it. At this stage, the dying need companions who are ready to listen to them and sometimes also endure their unreasonable anger, because they know that such an attitude helps the dying person in those moments when he cannot suppress his anger. If the caregiver understands the patient's feelings and his own, he can help the patient avoid depression.
3. Negotiations for the continuation of life After the stage of denial of reality and the subsequent stage of the explosion of emotions, the stage of negotiations follows. Just as a child, in response to a refusal to fulfill his request, first violently protests, and then tries to get around this refusal with the help of clever maneuvers, so the dying bargain for a delay - for example, with God. As payment, they may offer to give their lives to God, such as dedicating the remaining years of their lives to church service. In any case, such attempts at negotiations are very natural for a person and quite normal. Just as the negotiating stage can end in a spiritual and religious "sale" for a dying person, so many companions also feel their spiritual bankruptcy. The answers they give to the most important questions turn out to be unsuitable not only for the dying person, but also for themselves. If they participate in a trade initiated by a dying person, they are in danger of reinforcing the patient's illusions, while at the same time depriving him of an understanding listener. At the same time, the struggle with the hope of the dying person for some way out of the situation is useful to him only when it helps him to move on to the next stage.
4. Hope; negative and positive depression The negotiation phase rarely lasts long, as the progression of the disease and the nature of the treatment of the patient make it clear to him in what position he is. He may respond to this understanding with realistic hope or doubt. Hope in this case is associated not with the improvement or development of the existing situation, but with the process of dying and life after death. We are talking about such problems as the refusal to artificially prolong life at any cost, the hope of liberation from pain or the opportunity to feel a loved one next to you in your hour of death. If the dying person at the stage of negotiations realized himself bankrupt in the field of spirit and faith, then the only reaction left to him is despair, which can manifest itself either as the bitterness of a stoic, or as a depressive state. There are two forms of depression. The first form of depression is the patient's reaction to the losses he endures, namely, the changes that befell him as a result of the disease, the inability to correct the mistakes he made earlier, helplessness, and the inability to continue to fulfill his duties, for example, in relation to the family. Another form of depression is associated with the threat of loss of life and loved ones. It serves as a preparation for the final acceptance by the sick of their fate and is part of the dying work of the dying. This, the second, form of depression, unlike the first, usually proceeds very calmly, if the patient has something to tell, what to discuss and put in order.
If the companion manages to be with the sick person at this stage of his spiritual development, then various possibilities open up for him in the fight against depression. At the same time, it is necessary that the accompanist control his own depressive manifestations. At this stage, the dying person openly seeks the human closeness of the escort to make sure that neither now nor in the future will he be left alone. The dying man now faces critical issues about the past and the future. An escort can help him resolve family problems and settle economic and financial issues. He can think about the meaning of life and pray with the dying.
5. Acceptance and farewell At the last stage, the stage of agreement with one's fate, the dying person is extremely tired and weak. If he has managed to express his feelings and perform his dying work, then his need for peace and sleep increases. He has reached a certain degree of calm and composure, and the circle of his interests is narrowing. He can say with approval: "Yes, here comes my last hour". Intellectual penetration into death is combined with emotional readiness to accept death. If despair brought feelings of disappointment and helplessness to the dying person, then he welcomes his death as the end of despair and loneliness.

Support for the dying

When the death of a loved one enters a person's life, most people experience helplessness and despair. How can you help the dying? Is the help of a doctor and qualified nursing care enough? What role does faith play in this? How can a person who calls himself a Christian help another person to die with dignity? Information on these issues is contained in the book of Metropolitan Anthony of Surozh "Life, illness, death", M., 1995.

Help for the dying

One of the first forms of helping a dying person is to good care behind him. This means not only professional and technical side affairs.
Along with professionalism, we are talking about the human aspects of such care. We often hear from carers that they would like to devote more time and attention to this side of the matter, but they do not have enough time for this ... The human aspects of care are more often truly embodied when the patient is at home though home care may not be as professional. The lack of professionalism in this case is compensated: as E. Kübler-Ross (1970) noted, "a couple of spoons of a well-known homemade soup can be more useful for a patient than an injection in a hospital ..."
- The second way to help a dying person is to overcome physical suffering and pain.
With the help of medicines, the doctor can overcome or significantly reduce almost any pain, and this is very important for the patient ...
- Even more excruciating than physical pain can be emotional suffering caused by the upcoming farewell and parting with loved ones. Therefore, a very important form of helping a dying person is an attempt to capture and take on these sufferings to the greatest extent possible, creating an atmosphere of friendliness and cordiality around the dying person. Less correct is this form of helping a dying person, when he is "protected", hiding from him the sad truth about his condition.
- The fourth form of assistance consists in the appointment of psychotropic (sedative or stimulant) drugs by the doctor. Their use allows in the future to move on to a really deep, internal overcoming of the emotional problems that the patient faces at the last stage of his life. It happens that helping a dying person requires giving up trying to prolong his life for some more time. In some cases, the process of dying lasts a very long time, so long that there is a danger that the patient will no longer be able to cope with such a situation due to the tedious process. In such a situation, it may turn out to be quite ethical (moral) to take responsibility and refuse to fight one of the periodically arising fatal dangerous complications during the course of the disease, the consequence of which will be the approaching death of the patient. As we shall see, it may be permitted and even deemed necessary in the interest of the patient to allow the patient to die from one of these complications. The use of passive euthanasia (and we are talking about it) in certain cases can be considered one of the forms of assistance to the dying.

Psychological support for the dying as the best form of assistance is that:
1. talk to the patient about the fatal nature of his illness and the associated feelings of insecurity, fear, stubbornness, loneliness and grief;
2. such relationships are created with the patient, in which an honest, open conversation is conducted with him, thanks to which we are able to help the patient on a personal, first of all emotional level cope with your dying and die your own death;
Many are of the opinion that if the patient tries to get around the problem of his death, then his alienation and deep loneliness increase.
Such a view is developed in detail in Leo Tolstoy's Death of Ivan Ilyich. Patients often feel alienated from the family if the family does not tell them the truth - the truth that will give them courage. Physicians such as Weissman and Hackett of Harvard University believe that human closeness and warmth are the only cure for the dying, because dying is a solitary labor. By all this we do not at all want to say that the doctor must frankly declare to the patient that he is ill with a fatal, incurable disease and that he will be "liberated" within a month. Truth has many faces; each of them acts when it is needed. The truth under such circumstances should not deprive the patient of the last ray of hope. Hope for improvement never completely disappears, even when a cure is impossible ... Truth and hope are not mutually exclusive ... Weissman and Hackett believe that the patient, even without learning anything new, often notices that his family is insincere with him , as a result of which he has to spend a significant part of his energy protecting the feelings of his loved ones, instead of relying on their support. If the knowledge of death is completely removed from the patient, this deprives him of meaningful relationships with himself, with his family and other people who mean anything to him.
If the patient does not know the truth and does not share this knowledge with other people who visit him, he cannot develop a sense of community with them. Most of us have already experienced situations in which the dying patient did not know the truth about his condition and our relationship to him could only be superficial.
L. N. Tolstoy raised this problem in "The Death of Ivan Ilyich": "The main torment of Ivan Ilyich was a lie - ... that they did not want to admit that everyone knew and he knew, but they wanted to lie about him on the occasion of his terrible situation and he himself was forced to take part in this lie ... And he had to live like this on the edge of death alone, without one person who would understand and pity him.

Problem: The truth at the sick bed

H. Cr. Piper notes that the question of the truth at the bedside of the patient is not connected with the foundations and dogmas, but is a problem of communication, communication between the dying and those accompanying him. According to Piper, it is not about whether we have the right to say "this" to the patient, but about how we, together with him, can bear the burden of our fate (the fate of the dying person and our own associated with it). Such "communication" and such "solidarity" (closeness) with the sick doctor, nurse, confessor and relatives can also help him, according to M. K. Bowers, which is confirmed by the following example from his book. When a priest visited a seriously ill person, the following conversation took place: "Mr. priest, I know that I am seriously ill, but I must know how seriously. I cannot get any direct answer from anyone here. If I die, I must know about this. This fight with the shadows is just terrible. Would you lie to me, mister priest?"
The priest replied: "Yes, you are very seriously ill. But the question you have raised is a medical question that I am unable to answer. But I know how important it is for you to answer it. I will try to talk to Dr. V about it." ." The priest found a doctor in the hospital and told him about his conversation with the patient. The doctor thought for a while and said: "It will be better if we talk together with Mr. T. Let's go to him."
At the patient's bedside, Dr. V. openly referred to his conversation with the priest and to the patient's question. Then he said: “I did not talk to you in detail about the possible outcome of your illness because there are many things in your illness that are not clear to me. conventional means treatment. However, you have enough good blood, and the heart copes very well with the additional load. In such a situation, various unforeseen accidents can occur that will change the development of the disease in one direction or another. We are doing everything we can to solve these problems and fight infection in every way we know how. I have told you all I know and I promise to inform you immediately if there is any significant change in your condition. However, until then, you and your priest can also help us, we really need you. Always ask me anything you want and I will always give you as honest an answer as I can, okay? It's good that you addressed your question. I will visit you more often." After the doctor left, the patient said to the priest: "What a relief to know how things really are. It’s just terrible when you don’t know anything, but you just lie and think all the time. A person has a right to know what is happening to him, doesn't he?" Then the patient and the priest talked for some more time, after which the priest said short prayer for the doctor and for the release of all the healing forces of the patient. The patient fell asleep, and from that moment a gradual decrease in inflammation began. It is possible that this was facilitated by the release of the patient from fear after he learned the truth about his condition.

Death

A person's life path ends with his death. You need to be prepared for this, especially if there is a bed patient in the family. Signs before death will be different for each person. However, the practice of observations shows that it is still possible to identify a number of common symptoms that portend the imminence of death. What are these signs and what should be prepared for?

How does a dying person feel?

A bedridden patient before death, as a rule, experiences mental anguish. In sound consciousness there is an understanding of what is to be experienced. The body undergoes certain physical changes, this cannot be overlooked. On the other hand, the emotional background also changes: mood, mental and psychological balance.

Some lose interest in life, others completely close in on themselves, others may fall into a state of psychosis. Sooner or later, the condition worsens, the person feels that he is losing his own dignity, more often he thinks about a quick and easy death, asks for euthanasia. These changes are hard to observe, remaining indifferent. But you will have to come to terms with this or try to alleviate the situation with drugs.

With the approach of death, the patient sleeps more and more, showing apathy towards the outside world. In the last moments, a sharp improvement in the condition may occur, reaching the point that the patient who has been lying for a long time is eager to get out of bed. This phase is replaced by the subsequent relaxation of the body with an irreversible decrease in the activity of all body systems and the attenuation of its vital functions.

Bedridden patient: ten signs that death is near

At the end of the life cycle, an elderly person or a bedridden patient feels more and more weak and tired due to a lack of energy. As a result, he is increasingly in a state of sleep. It can be deep or drowsy, through which voices are heard and the surrounding reality is perceived.

A dying person can see, hear, feel and perceive things that do not actually exist, sounds. In order not to upset the patient, this should not be denied. It is also possible to lose orientation and the Patient is more and more immersed in himself and loses interest in the reality around him.

Urine due to kidney failure darkens to almost brown with a reddish tint. As a result, edema appears. The patient's breathing quickens, it becomes intermittent and unstable.

Under pale skin, as a result of a violation of blood circulation, dark “walking” venous spots appear, which change their location. They usually first appear on the feet. In the last moments, the limbs of a dying person become cold due to the fact that the blood, draining from them, is redirected to more important parts of the body.

Failure of life support systems

There are primary signs that appear at the initial stage in the body of a dying person, and secondary ones, indicating the development of irreversible processes. Symptoms may be external or hidden.

Disorders of the gastrointestinal tract

How does the bedridden patient react to this? Signs before death, associated with loss of appetite and a change in the nature and volume of food consumed, are manifested by problems with the stool. Most often, constipation develops against this background. A patient without a laxative or an enema finds it increasingly difficult to empty the bowels.

Patients spend the last days of their lives refusing food and water altogether. You shouldn't worry too much about this. It is believed that dehydration in the body increases the synthesis of endorphins and anesthetics, which to some extent improve overall well-being.

Functional disorders

How does the condition of patients change and how does the bed patient react to this? Signs before death, associated with the weakening of the sphincters, in the last few hours of a person's life are manifested by fecal and urinary incontinence. In such cases, it is necessary to be prepared to provide him hygiene conditions using absorbent underwear, diapers or diapers.

Even in the presence of appetite, there are situations when the patient loses the ability to swallow food, and soon water and saliva. This may lead to aspiration.

With severe exhaustion, when the eyeballs are very sunken, the patient is not able to completely close the eyelids. This has a depressing effect on those around you. If the eyes are constantly open, the conjunctiva must be moistened with special ointments or saline.

and thermoregulation

What are the symptoms of these changes if the patient is bedridden? Signs before death in a weakened person in an unconscious state are manifested by terminal tachypnea - against the background of frequent respiratory movements death rattles are heard. This is due to the movement of the mucous secretion in the large bronchi, trachea and pharynx. This condition is quite normal for a dying person and does not cause him suffering. If it is possible to lay the patient on his side, wheezing will be less pronounced.

The beginning of the death of the part of the brain responsible for thermoregulation is manifested by jumps in the patient's body temperature in a critical range. He can feel hot flashes and sudden cold. The extremities are cold, the perspiring skin changes color.

Road to death

Most patients die quietly: gradually losing consciousness, in a dream, falling into a coma. Sometimes it is said about such situations that the patient died on the “usual road”. It is generally accepted that in this case, irreversible neurological processes occur without significant deviations.

Another picture is observed in agonal delirium. The movement of the patient to death in this case will take place along the “difficult road”. Signs before death in a bedridden patient who embarked on this path: psychosis with excessive excitement, anxiety, disorientation in space and time against the background of confusion. If at the same time there is a clear inversion of the wakefulness and sleep cycles, then for the patient's family and relatives such a condition can be extremely difficult.

Delirium with agitation is complicated by a feeling of anxiety, fear, often turning into a need to go somewhere, to run. Sometimes this is speech anxiety, manifested by an unconscious flow of words. The patient in this state can perform only simple actions, not fully understanding what he is doing, how and why. The ability to reason logically is impossible for him. These phenomena are reversible if the cause of such changes is identified in time and stopped by medical intervention.

Pain

Before death, what symptoms and signs in a bedridden patient indicate physical suffering?

As a rule, uncontrolled pain in the last hours of a dying person's life rarely increases. However, it is still possible. An unconscious patient will not be able to let you know about this. Nevertheless, it is believed that pain in such cases also causes excruciating suffering. A sign of this is usually a tense forehead and deep wrinkles appearing on it.

If, during examination of an unconscious patient, there are assumptions about the presence of a developing pain syndrome, the doctor usually prescribes opiates. You should be careful, as they can accumulate and, over time, aggravate an already serious condition due to the development of excessive overexcitation and convulsions.

Giving help

A bedridden patient before death may experience significant suffering. Relief of symptoms of physiological pain can be achieved with drug therapy. Mental suffering and psychological discomfort of the patient, as a rule, become a problem for relatives and close family members of the dying.

Experienced doctor at the evaluation stage general condition the patient can recognize in him the initial symptoms of irreversible pathological changes in cognitive processes. First of all, this is: absent-mindedness, perception and understanding of reality, the adequacy of thinking when making decisions. You can also notice violations of the affective function of consciousness: emotional and sensory perception, attitude to life, the relationship of the individual with society.

The choice of methods of alleviating suffering, the process of assessing the chances and possible outcomes in the presence of the patient in some cases, in itself can serve therapeutic agent. This approach gives the patient a chance to really realize that they sympathize with him, but they are perceived as a capable person with the right to vote and choose possible ways to solve the situation.

In some cases, a day or two before the expected death, it makes sense to stop taking certain medications: diuretics, antibiotics, vitamins, laxatives, hormonal and hypertonic drugs. They will only exacerbate suffering, cause inconvenience to the patient. Painkillers, anticonvulsants and antiemetics, tranquilizers should be left.

Communication with a dying person

How to behave relatives, in whose family there is a bed patient?

Signs of approaching death can be obvious or conditional. If there are the slightest prerequisites for a negative forecast, it is worth preparing in advance for the worst. Listening, asking, trying to understand the non-verbal language of the patient, you can determine the moment when changes in his emotional and physiological state indicate the imminent approach of death.

Whether the dying person will know about it is not so important. If he realizes and perceives, it alleviates the situation. False promises and vain hopes for his recovery should not be made. It must be made clear that his last will will be fulfilled.

The patient should not remain isolated from active affairs. It is bad if there is a feeling that something is being hidden from him. If a person wants to talk about the last moments of his life, then it is better to do it calmly than to hush up the topic or blame stupid thoughts. A dying person wants to understand that he will not be alone, that he will be taken care of, that suffering will not touch him.

At the same time, relatives and friends need to be ready to show patience and provide all possible assistance. It is also important to listen, let them talk and say words of comfort.

Medical assessment

Is it necessary to tell the whole truth to relatives in whose family there is a bed patient before death? What are the signs of this condition?

There are situations when the family of a terminally ill patient, being in the dark about his condition, literally spends his last savings in the hope of changing the situation. But even the best and most optimistic treatment plan can fail. It will happen that the patient will never get back on his feet, will not return to active life. All efforts will be in vain, spending will be useless.

Relatives and friends of the patient, in order to provide care in the hope of a speedy recovery, quit their jobs and lose their source of income. In an attempt to alleviate suffering, they put the family in a difficult financial situation. Relationship problems arise, unresolved conflicts due to lack of funds, legal issues - all this only aggravates the situation.

Knowing the symptoms of imminent death, seeing irreversible signs of physiological changes, an experienced doctor is obliged to inform the patient's family about this. Informed, understanding the inevitability of the outcome, they will be able to focus on providing him with psychological and spiritual support.

Palliative care

Do relatives who have a bed patient need help before death? What symptoms and signs of the patient suggest that she should be treated?

Palliative care for the patient is not aimed at prolonging or shortening his life. Its principles affirm the concept of death as a natural and regular process of the life cycle of any person. However, for patients with an incurable disease, especially in its progressive stage, when all treatment options have been exhausted, the question of medical and social assistance is raised.

First of all, you need to apply for it when the patient no longer has the opportunity to lead an active lifestyle or the family does not have the conditions to ensure this. In this case, attention is paid to alleviating the suffering of the patient. At this stage, not only the medical component is important, but also social adaptation, psychological balance, peace of mind of the patient and his family.

A dying patient needs not only attention, care and normal living conditions. Psychological relief is also important for him, relief of experiences associated, on the one hand, with the inability to self-service, and on the other hand, with the realization of the fact of an imminent imminent death. Trained nurses also know the subtleties of the art of alleviating such suffering and can provide significant assistance to terminally ill people.

Predictors of death according to scientists

What to expect for relatives who have a bed patient in the family?

Symptoms of the approaching death of a person "eaten" by a cancerous tumor were documented by the staff of palliative care clinics. According to observations, not all patients showed obvious changes in the physiological state. A third of them did not show symptoms or their recognition was conditional.

But in the majority of terminally ill patients, three days before death, a marked decrease in the response to verbal stimulation could be noted. They did not respond to simple gestures and did not recognize the facial expressions of the personnel communicating with them. The “smile line” in such patients was omitted, an unusual sounding of the voice (grunting of the ligaments) was observed.

Some patients also had hyperextension neck muscles(increased relaxation and mobility of the vertebrae), non-reactive pupils were observed, patients could not close their eyelids tightly. Of the obvious functional disorders, bleeding in gastrointestinal tract(in the upper sections).

According to scientists, the presence of half or more of these signs can highly likely testify to an unfavorable prognosis for the patient and his sudden death.

Signs and folk beliefs

In the old days, our ancestors paid attention to the behavior of a dying person before death. Symptoms (signs) in a bedridden patient could predict not only death, but also the future prosperity of his family. So, if the dying person asked for food (milk, honey, butter) in the last moments and relatives gave it, then this could affect the future of the family. There was a belief that the deceased could take wealth and good luck with him.

It was necessary to prepare for imminent death if the patient shuddered violently for no apparent reason. It was like looking into his eyes. Also a sign of close death was a cold and pointed nose. There was a belief that it was for him that death was holding the candidate in the last days before his death.

The ancestors were convinced that if a person turns away from the light and most of the time lies facing the wall, he is on the threshold of another world. If he suddenly felt relieved and asked to be transferred to his left side, then this is a sure sign of an imminent death. Such a person will die without pain if the windows and the door are opened in the room.

Bedridden patient: how to recognize the signs of impending death?

Relatives of a dying patient at home should be aware of what they may encounter in the last days, hours, moments of his life. It is impossible to accurately predict the moment of death and how everything will happen. Not all of the symptoms and symptoms described above may be present before the death of a bedridden patient.

The stages of dying, like the processes of the origin of life, are individual. No matter how hard it is for relatives, you need to remember that it is even more difficult for a dying person. Close people need to be patient and provide the dying person as much as possible. possible conditions, moral support and attention and care. Death is an inevitable outcome of the life cycle and it cannot be changed.

Psychological counseling. Handbook of practical psychologist Solovieva Svetlana Leonidovna

6.7. Psychological assistance to dying patients

The attitude towards death has a peculiar influence on the way of life of a person. According to the philosophical school of the Stoics, death is the most important event in the life of each of us. Since we habitually look at death as an absolute evil, we find it difficult to accept the idea that it can have a positive impact on life. Meanwhile, a similar point of view is presented in a number of works. Kociunas (1999), for example, says that life will immediately lose its intensity if you give up the thought of death even for a moment.

Each person inevitably meets with the death of relatives and loved ones. Medical workers, psychologists, psychotherapists most often face the problem of dying and death in contact with severely and long-term suffering patients. Thanatology (science of death) - new scientific field, which appeared in connection with the growing importance of this problem and is at the very beginning of its development. An incurable disease inevitably brings the reality of death closer. It significantly changes human life, and against this background, paradoxically, signs of “personal growth” often appear (Yalom I., 1980). When death approaches, a number of specific changes in the perception of life are observed (Kochyunas R., 1999), which primarily include the following:

The priorities of life are re-evaluated: trifles, insignificant details and details lose their meaning;

There is a feeling of liberation: what one does not want to do is not done; the categories of duty lose their force (“should”, “must”, “necessary”, etc.);

The momentary current sensation and experience of the process of life intensifies;

The significance of elementary life events is aggravated (rain, leaf fall, change of seasons, time of day, full moon in the sky);

Communication with loved ones becomes deeper, fuller, richer;

The fear of being rejected decreases, the desire and ability to take risks increases.

All these and similar changes indicate an increase in the sensitivity of a terminally ill person, which makes certain demands on those who are close to him - doctors, medical staff, relatives, friends, relatives. The patient has very important questions for him during this period, which he begins to ask the people around him: “Will I die soon?”, “How much longer do I have to live?” The only correct answer to such a question does not exist, despite the fact that one can speak of more or less universal principles. In particular, greater responsibility is recommended in talking with the patient about death. First of all, the patient is advised to put life's affairs in order, complete what he started, leave orders to relatives and friends. The patient has the right to know the truth about his real situation, and no one is allowed to usurp his right, but do not forget that right know is not the same responsibilities know. Often the knowledge that death will soon come does not alleviate the condition of the patient, sometimes it is even better if he knows less.

The onset of death, according to thanatology, can be greatly facilitated by a strong emotional and social crisis, it can be accelerated by the psychological reaction of surrender. It is known that before the age of six, as a rule, a child has an idea about the reversibility of death. Approximately in the pubertal period of life comes a complete understanding and awareness of the inevitability and irreversibility of death. Middle age, associated with a high degree of labor activity, with a rich and complex personal life, pushes thoughts of death to the very edge of consciousness. A real threat to life, occurring, for example, in patients with diseases of the circulatory system, malignant processes, severe injuries finds many victims psychologically unprepared. In old age, a person, as a rule, understands and realizes the proximity of death, but can hardly come to terms with it.

Psychological preparation for death involves the study of some of its philosophical aspects. Awareness of the inevitability of death, in particular, makes a person decide whether to spend the remaining time allotted by nature in anticipation of the inevitable tragic ending, or act against everything, live life to the fullest, realizing himself as much as possible in activities, in communication, investing his psychological potential in every moment of your existence.

Preventively, it is necessary to break the taboo on talking and thinking about death and begin to prepare for it while still in a state of full strength and health (Konechny R., Bowhal M., 1983). At the same time, an appeal to the altruism of each person can also be useful: you need to make your own dying bearable and acceptable, as less difficult as possible for others, leave the best memories of yourself, show resistance and courage.

The measure of the fear of death does not correspond to the actual danger in modern society. In a civilized world, in which the physical condition of people is clearly improving, the pathic fear of illness and death increases, first of all, the fear of diseases experienced as “fatal” (heart attacks, cancer, AIDS). In particular, people who are not too busy at work and are not associated with useful social activities, remaining alone in difficult moments, more and more often return to thoughts about what threatens their life and health.

Various religious systems, thus performing a psycho-prophylactic function, instill in people certain "antibodies" to suffering and death, resistance to dying and illness. The theme of suffering in rituals and prayers made the thought of death, illness and suffering an integral part of the mental equipment of a person. Suffering became a kind of "merit", which will be appreciated in the afterlife. Religious institutions have always provided a certain relief in this way in situations of real threat of dying and death. The atheistic worldview contains far fewer illusions.

There are a number of the most characteristic psychological reactions to the danger or proximity of death (Konechny R., Bowhal M., 1983):

Humility and calm acceptance of the inevitable;

Passive surrender, manifested in apathy and indifference;

Withdrawal into everyday everyday conversations and events;

Departure into the fantasy of immortality;

Constructive activities of the compensatory plan, useful (completion important work, permission family problems etc.) or problematic, which is in the nature of abuse (use toxic substances, overeating, abuse of erotic and sexual experiences), is observed with relatively preserved physical and mental abilities.

In relation to severe, dying patients, as a rule, the doctor takes a sparing position and, even reporting the presence incurable disease, does so in a way that keeps the patient hopeful by talking about the possibility of a long-term remission or about a recently proposed new drug that has a therapeutic effect that can slow the course of the disease and even lead to a complete cure. By doing this, the doctor does not deceive his patient, since with absolute certainty he cannot actually predict the course of the course and outcome of the disease. At the same time, the faith of the patient and his desire to survive can really activate defensive forces organism, delay the outcome, or, according to at least to give meaning to the last days of his life. “The requirement of veracity,” P.I. Sidorov and A.V. Parnyakov (2000) note, “also applies to a moment that is very important for the doctor - reporting the diagnosis to the patient.

At present, the prevailing trend is a dosed and accessible explanation to a seriously ill or dying person of the causes and characteristics of his condition. Simultaneously with the discovery of the diagnosis, hope should always be given in an acceptable form. If possible, a therapeutic proposal should also be made immediately. Thus, we promise the patient that we will not leave him alone. With regard to the moment of reporting the diagnosis, many consider the best option the earliest informing the patient - already in connection with the first suspicion or the first consultation.

Communication with a dying patient, practically devoid of meaning from a professional point of view, should not be interrupted, performing the function of psychological support for the patient. Sometimes medical workers, knowing that the patient is doomed, begin to avoid him, stop asking about his condition, make sure that he takes medication, performs hygiene procedures. The dying person is alone. When communicating with a dying patient, it is important not to break the usual ritual: continue to carry out appointments, ask the patient about how he is feeling, noting every, even the most insignificant, signs of improvement in his condition, listen to the patient’s complaints, try to facilitate his “care”, not leaving him face to face with death.

When options are exhausted pathogenetic treatment underlying disease, resort to symptomatic, palliative treatment to alleviate the suffering of the patient. Palliative care refers to the use of drugs, means and methods that bring temporary relief, but do not cure the disease. Its main goal is to create the maximum possible comfort for the patient, improve the quality of his life. This is especially important for doomed patients, slowly dying, for example, from cancer. The main thing at the same time is not only the extension of life, but also the creation of conditions for the remaining life for the patient to be more comfortable and meaningful.

A. V. Gnezdilov identifies 10 psychological (psychopathological) types of reactions in hopeless patients, which can be classified according to the following main syndromes: anxiety-depressive, anxiety-hypochondriacal, astheno-depressive, astheno-hypochondriac, obsessive-phobic, euphoric, dysphoric, apathetic , paranoid, depersonalization-derealization.

Most often observed anxiety-depressive syndrome, manifested by general anxiety, fear of a "hopeless" disease, depression, thoughts of hopelessness, imminent death, a painful end. AT clinical picture anxiety predominates more often in premorbid individuals, and depressive symptoms in asthenic individuals. Most patients show suicidal tendencies. Patients close to medicine can commit suicide.

Some patients, realizing their oncological diagnosis, imagining the consequences of a mutilation operation, disability and the absence of guarantees of recurrence, refuse the operation. Such refusal of treatment can be interpreted as passive suicide.

As you know, the position of the patient, given to him by the medical staff, is to "hold on with clenched teeth." And most patients behave this way, especially men. They keep themselves in control, not allowing emotional stress to spill out. As a result, in some patients taken for surgery, even before it begins, either cardiac arrest or a violation of cerebral circulation, which is caused by nothing more than emotional overload. Timely diagnosis of psychogenic reactions, which are usually suppressed and hidden by patients, can significantly affect the outcome.

In second place in terms of frequency is dysphoric syndrome with a melancholy-viciously gloomy coloring of experiences. Patients have irritability, dissatisfaction with others, search for the causes that led to the disease, and, as one of them, accusations against medical workers of insufficient efficiency. Often, these negative experiences are directed at relatives who allegedly “brought to illness”, “did not pay enough attention”, already “buried the patient to themselves”.

A feature of the dysphoric reaction is that suppressed anxiety and fear are often hidden behind aggressiveness, which to a certain extent makes this reaction compensatory.

Dysphoric syndrome is most often observed in individuals with a predominance of premorbid traits of excitability, explosiveness, and epileptoidness. Assessment of the severity of the dysphoric syndrome shows the presence of severe emotional tension.

Anxiety-hypochondriac syndrome consistently ranked third. With it, there is a lesser degree of tension than with the first two. In contrast to the dysphoric reaction, introversion, self-centeredness prevails here. The clinical picture reveals emotional tension with fixation of attention on one's health, fears of the operation, its consequences, complications, etc. The general background of mood is reduced.

obsessive phobic syndrome It manifests itself in the form of obsessions and fears and is observed in a group of patients with a predominance of anxious and suspicious, psychasthenic traits in the character. Patients experience disgust for their neighbors in the ward, obsessive fear pollution, contamination with "cancer germs", painful ideas of death during or after surgery, anxiety about the possibility of "gassing", feces, urinary incontinence, etc.

Apathetic syndrome indicates the depletion of compensatory mechanisms emotional sphere. Patients have lethargy, some lethargy, indifference, lack of any interests, even in relation to further prospects for treatment and life. In the postoperative period, as a rule, there is an increase in the frequency of manifestation of this syndrome, reflecting a reaction to the overstrain of all mental forces in the previous stages. Asthenic personalities have a more frequent manifestation of apathetic syndrome compared to sthenic ones.

I would also like to this case emphasize the importance of the doctor's orientation to the patient. Each organism has its own reserve of time and its own rhythm of life. Do not rush to stimulate nervous system patient by prescription of obvious drugs, even if he is out of the "time statistics" of a hospital bed day.

Apathetic syndrome is a stage in the dynamics of reactions that expediently adapt the patient to changing conditions. And here it is necessary to give the body to gain strength and recover.

Astheno-depressive syndrome. In the clinical picture of patients, depression, melancholy with feelings of hopelessness of their illness, early or late, but doomed, appear. This symptomatology is accompanied by a noticeable depressive background. It should be noted the prevailing connection of this syndrome with the group of the cycloid temperament.

Astheno-hypochondriac syndrome. The fear of complications, anxiety about the healing of the surgical wound, anxiety about the consequences of the mutilating operation come to the fore. The syndrome prevails in the postoperative period.

Depersonalization-derealization syndrome. Patients complain that they have lost their sense of reality, they do not feel either the environment or even their own body; require sleeping pills, although they fall asleep without them; mark the disappearance taste sensations, appetite, and at the same time satisfaction from the performance of certain physiological acts in general. We can note a certain relationship between the frequency of this syndrome and the group of so-called hysteroid-stigmatized patients.

paranoid syndrome is observed rarely and manifests itself in a certain delusional interpretation of the environment, accompanied by ideas of relationship, persecution, and even single deceptions of perception. The connection of this syndrome with schizoid personality traits in premorbid is characteristic. Common with dysphoric syndrome is aggressiveness directed at others. However, in the paranoid type, "intelligence", schematization, logic or paralogy of complaints are noted. When "dysphoria" is characterized by the emotional richness of the syndrome, the brutality of experiences, the chaotic nature of complaints and accusations.

euphoric syndrome. It is not difficult to imagine the mechanism of its occurrence: as a reaction of "hope", "relief", "success", euphoria appears at the postoperative stage. The euphoric syndrome manifests itself in an elevated mood, reassessment of one's condition and capabilities, and seemingly unmotivated joy. Its connection with the group of the cycloid series is undoubted.

Concluding the review of the psychological (pathopsychological) reactions of patients, it should be noted in particular the peculiar isolation syndrome at the catamnestic stage. This is the fear of recurrence of the disease and metastases, social maladjustment caused by disability, thoughts about the contagiousness of the disease, etc. Patients become depressed, experience a feeling of loneliness, hopelessness, lose their former interests, shun others, and lose activity. An interesting association with premorbid schizoid features among patients who have a syndrome of self-isolation. If it is present, the severity of the psychological state and the danger of suicide are undeniable.

Palliative care and radical medicine

The problem of dying is most acute for cancer patients, and it is solved within the framework of palliative medicine in hospices.

"Pallio" in Latin means enveloping, facilitating and, accordingly, a compromise way to solve a problem. Palliative care comes when the disease cannot be cured. A well-known expression of professional doctors says: “If you cannot cure, then at least ease the suffering of the patient, if you cannot alleviate, then undress them.”

One of the main objectives of palliative care is to take control of the symptoms of the disease, which means not a cure, but reducing the subjective severity of symptoms, minimizing the suffering of patients. The second significant point is organization of patient care. The third, leading and organizing principle of palliative medicine is creating quality of life for patients. Indeed, when does the problem of the quality of life arise, if not at the time when its quantitative potential becomes visibly limited?

Palliative medicine, based on the life time factor, becomes adequate not only in relation to incurable patients, but also to the elderly, because old age is a process that is difficult to slow down, and its treatment does not give real guarantees of success.

Radical medicine sets itself the task of curing the patient at all costs or prolonging his life as much as possible. Death is perceived as an absolute enemy. Life is the only and greatest value. According to this attitude, the knowledge of the disease and the ability to treat it is the highest goal of radical medicine. Prevention of diseases becomes a guarantee of success in the fight against them. Confidentiality in treatment is guaranteed by law. The secrecy of diagnosis is a rigorous principle that can be applied to the patients themselves. The stereotype of the culture of patient care should always follow the principle of optimism, which is regulated by medical deontology. The patient is taught how to live, how to behave. All responsibility for the disease lies with the doctor and medical staff. Extreme situations of suicide or refusal of help and treatment are interpreted not as the decision of the patient himself, but as an oversight by the doctor.

Relationships in radical medicine are built on the principles of a command system. The first person in charge of everything - chief physician. Behind him - the chief medical officer, the head of the department, the attending physician, the nurse, the nurse, and, finally, the patient himself. The treatment process is strictly regulated by numerous orders, guidelines, methodical letters, which guarantees compliance with a unified approach to treatment.

The principle of radical medicine "cure at all costs" contains in itself an extremely vulnerable position. We have to admit that someday the physical life of a person comes to an end, and this is a regularity that belongs to life itself. Considering death as an absolutely negative phenomenon is unjustified. Death is as natural as birth and is an inevitable attribute of life.

The simplest question asked to a departing person: “Is your death the most terrible thing?” opens up a whole treasure trove of other meanings, which crosses out the straightforward simplicity of the value scale of radical medicine. “Worse than my death is the death of children”, “Loss of an honest name”, “Loss of faith, love”, “Senselessness”. The meaninglessness, aimlessness of life is more terrible than death.

The establishment of the doctor's responsibility for the patient's illness grew out of an authoritarian system of society, where the people were a child in the care of a brilliant leader-father. This model of relationships was repeated in all state structures, but in medicine it looks extremely dramatic. The helplessness of the patient, relying entirely on doctors, blocks his own attitudes towards health. When the treatment is hopeless, the blame is felt, first of all, by the doctor and the nurse.

The principles of palliative medicine have long been used in various areas of human life. The very concept of "palliative" means an indirect solution of the issue, when the direct one is inaccessible. Radical medicine aims to cure the disease and uses all the means at its disposal as long as there is even the slightest hope of recovery. Palliative medicine replaces radical medicine from the moment when all means are exhausted, there is no effect, and the prospect of death arises before the patient.

The fundamental principle of palliative medicine is the recognition of the naturalness of death. The second postulate of palliative medicine is rather difficult for physicians brought up in the traditions of radical medicine. It sounds like this: the process of childbirth is most favorable for the child and the mother, if it proceeds naturally, according to the biological rhythms of both, when it is not interfered with from the outside. Exactly the same attitude is carried over in palliative care to the process of human dying. If the death program is running, then it is unacceptable to slow down dying or stimulate, accelerate it. It is here that the doctor's concern for the soul of the patient is important, which involves helping the patient to stand in the face of fatally inevitable suffering. It is about developing the ability to accept and endure suffering. Patient care is carried out comprehensively, in terms of four aspects of care: medical, psychological, social and spiritual. The creation of the quality of life should help the patient to "ripen" for death, passing various stages mental experiences. Up to the stage of acceptance of fate.

If the patient wants to know the truth, we are obliged to tell it without breaking his psyche. Serving, first of all, the patient himself, and not those whom he did not authorize to be his representative, should be a priority in all controversial issues.

The biggest test for a patient is his fear of the swift and inevitable end of life. One of the ways to debunk it is the technique of specifying fear: what exactly is frightening in death and why? Usually these are philosophical things: irrevocably flowing time and the disappearance of oneself in space without a trace. However, even an atheistic impasse gives rise to an alternative way out.

One of the aspects of time is the ability to experience it not as a succession of events, but as internal state, a moment connected only with the present. No past, no future, no comparisons, no need to choose - only the reality of the feelings of a person who is aware and reflects the world. And then, as the Epicureans said, it is senseless to fear death, because while you are, there is no death; when death comes, you are not.

The principle of humanity in its therapeutic position obliges to proceed from what the patient believes. Not imposing one's ideas, beliefs, beliefs, but respect for the freedom of each person to be the way he is. No matter how much the patient would like to shift the responsibility for the life he lived to someone else, and put the responsibility for the disease on the doctors, he has to reckon with the position of palliative medicine, which offers him, even if he does not consider the issue of personal participation in his fate, then , anyway, take responsibility for your life.

The drug-based, active, aggressive approach to managing patients, adopted in radical medicine, is giving way to a different trend. Start solutions from nature. Give priority to spiritual issues after pain relief. To try to ensure the maximum safety of the patient to the very end with the fullest possible satisfaction of his needs. Contribute to the growth of his soul, proceeding from the eternity of his existence. The acquisition of spiritual values ​​gives meaning even to premature death.

Hospices, specialized departments or centers for the treatment of AIDS patients, geriatric departments in multidisciplinary or psychiatric hospitals are the modern organizational form of palliative care. Hospice care is usually focused on helping incurable cancer patients and their families and loved ones. The program of activities in the hospice is designed primarily for palliative care for patients, pain relief, psychological support for them and their families. As a rule, a hospice includes a hospital and an outreach service that provides patronage to patients. Home care work is carried out by specially trained nurses. Psychological support of patients is carried out by a psychologist and a social worker.

Of great importance is the involvement of relatives in the emotional support of the patient. The physician must take into account the individual family system and family relations. Too much informing the family about the patient's condition with simultaneous insufficient provision of such information to the patient himself should be avoided. It is desirable that the patient and his relatives possess this information at approximately the same level. This contributes to greater consolidation of the family, mobilization of reserves, psychological resources of the family structure, assistance to the psychological processing of the work of grief in the patient himself and his family members. E. Kubler-Ross believes that the psychological reactions of relatives of patients in such situations are approximately the same as those of the patients themselves.