Death

I worked as a nurse for fifteen years—the last seven of which were in cancer hospice care—so I feel it might be worthwhile if I spoke a little on the subject of death. One of the problems that can arise for people working in this area is that they disproportionately magnify the ‘physical death which comes at the end of life’. The modern mechanised world tends towards postponing physical death as long as possible. Death is seen as being far in the future for everyone, and the further away it is the more comfortable we feel about it. In this way we can hide away from death and live in the apparently full and happy knowledge that death only happens to ‘old people’ or to ‘other people’.

In the ‘stages of grieving’—which people endlessly discuss in hospice work—the early ‘stages’ include shock and disbelief. Considering how we hide from death throughout our lives – is it to be wondered at? Our reactions when someone close to us dies—or when we are given a diagnosis of a terminal illness—is almost always shock and disbelief. It will always seem too awful to take on board if our belief is that we are in some way inviolate. Even smokers—when they are diagnosed with lung cancer—experience shock and disbelief, as if they had no idea that they had been creating the causes of their deaths over a substantial period of their lives. We have a fantastic ability to hide from the reality of death.

A word often heard in hospice circles is ‘denial’. Patients deny that they have cancer. Patients deny that they are dying in the face of obvious physical deterioration. This can take many forms. For example: refusal to weigh so as not to discover weight loss; undressing in the dark so that one does not have to see a change in body image – the removal of a breast; the use of euphemisms to avoid the name of the disease. Even when someone faces up to death, their family may not have ‘reached the stage of acceptance’ and the family and loved person find themselves out of synch with each other.

Denial is a mechanism for coping with a situation which appears too harsh to bear. What is odd in relation to denial, however, is how hospice staff are apparently untroubled in discussing patients who are ‘in denial’. It never seems to occur to us that this is a mechanism in which we are expert – simply because we have been practising denial all our lives. We continually deny the reality of the moment because we are always either looking forwards or backwards. As Ngak’chang Rinpoche once said, Whether we call ourselves Buddhists, Jews, Christians, or Muslims – most of us practise the religion of Cleopatra, ‘The Queen of Denial’, and most of us are therefore up de Nile without a paddle.

We rarely exist in naked awareness of the moment – but as the moment is the only reality, we tend to be permanently lost. ‘Past’ and ‘future’ are not real in the moment – they are simply illusory ornaments of the moment. Only here and now is real.

We deny many things. We deny gaining weight – refusing to buy a larger size or else wearing trousers and skirts with elastic waists so we don’t feel so uncomfortable as they get tighter. We deny baldness – combing hair in particular ways to disguise it. We deny that we are in debt – waiting until we receive the summons to appear in court. People have been known to push their bills under the door mat so that they never see them. We deny that our relationships are starting to fail as we grow apart from one another. We deny that we are alcoholic. We deny heroin addiction on the basis that we are really ‘recreational users’. We deny killing our pets – euphemistically ‘putting them to sleep’. Then there are cosmetics, cosmetic surgery, tummy-tucks, liposuction, and ‘flattering’ clothes. I am not implying any value judgement here. I am not saying any of this is not permissible – if you can afford it – go for it, if you so desire. I am merely drawing attention to how we avoid reality.

We live our lives as if death were years away, and this is a denial of reality. Death might not be years away. I would like to quote from one of Ngak’chang Rinpoche’s poems. This is from ‘Fixing to Die Blues’:

Being appalled by death is the denial of the fact of death being the counterpart of birth. If anything is born it also dies. A couple’s state of being childless dies at the birth of their child. It is easy in this society to ignore physical death because it is so hidden away. The success of modern medicine has meant that we may not all have had close contact with death by the time we are adolescent. Our methods of sanitising death have encouraged our process of denial.

Part of a hospice course that I undertook was aimed at opening us up to the reality of death. We had to watch post mortems performed on patients who had been our charges. We made a visit to the local crematorium, arranged by an undertaker. First he took us to his business premises and we watched the process of embalming: the process of sanitising death, the corpse cosmetics. We went downstairs in the crematorium to see the ovens where they burned the bodies after the funeral service. He opened up one of the ovens which was cooling down after burning and showed us what was left. It was the body of a lady whom some of us had looked after during her last days. I remember looking at her white skull and femurs which were what was recognisable amongst the ashes, then they showed us the crenulator – the machine which grinds down the whole pieces of bone into powder. This was part of the reality of death. The nurses found the reality awful, even though they discussed denial as part of their everyday vocation.

In Tibet far more children died of diseases which are curable in the West. In Tibet mothers died in childbirth far more frequently. Air burial there was a pragmatic solution to disposal of the body in an environment where wood is scarce, water too cold, and ground—which was not agricultural—was too rocky to consider burial. At the funeral, where the family and friends are present, the body is dismembered, the internal organs are cut out and the flesh is cut from the bones and fed to the vultures. The bones are then ground down and mixed with barley flour to make them palatable for the vultures. It is much harder to deny reality when this sort of ceremony is a commonplace occurrence.

The fact that we can now watch pictures of warfare on television—as it happens—has not helped in our process of denial of our own death. The trouble with televised death is that it is too distant and too often repeated to be of any real impact. Televised death seems merely to reinforce the idea that ‘death happens to others’.

Denial of this type occurs even more commonly with people who spend their working lives with ‘the dying’. It becomes much easier here to define a group of people for whom ‘death is happening’ and so distance oneself from being a person who began dying from the moment that they were born.

When I was working in hospice care I met many people who fondly imagined that it was helping them to ‘come to terms with their own deaths’. It reinforced the illusion that everyone except themselves was subject to ‘the dying phenomenon’. One could became more and more immortal, the longer one worked in such an institution. This may be what initially attracts some people into this type of work. Ngak’chang Rinpoche describes some of these people as vultures ‘. . . people who feed on death to create an illusion of immortality for themselves.’ When Ngak’chang Rinpoche first saw that I had a copy of Stephen Levine’s book Who Dies he asked whether I would allow him to alter the cover. Certainly, I replied. I did not like the book. When Rinpoche had completed his work on the cover he gave it back to me saying, I have always wanted to do that, but I have never owned a copy. When I looked at the cover it read ‘Who dies? You do, Stephen.’

My experience of observing the patients with whom I have worked led me to believe that the ones who seemed most undisturbed—who could look on death as the natural consequence of their having been born—were those who had lived with a spiritual aspect constantly present in their lives. By this I do not necessarily mean that they had strong religious belief. Many of these people did have strong religious beliefs – but others simply had some sort of understanding of how life cycles functioned within their own lives. They might not have come to this through religion – they could have come to it through deep pain or deep pleasure. What seemed significant was that they lived with a sense of death in each moment of their lives. Perhaps when you have had more than the average amount of pain or pleasure in your life it is not as easy to hide from death or to pretend.

There was one man who had married when he was very young. The lady was psychotic. He had a job where he worked nights, and when he came home his wife would not let him sleep. He described the process of water constantly dripping on a stone. She would constantly pick on him – eventually raising the pitch to such a degree that most days she spent screaming and shouting at him. He described how he developed a process of dying in her presence – that he ‘went somewhere else’. He was born in this ‘other place’. He said that if he had not managed this that he ‘. . . would have gone mad’. He eventually left her, as he was afraid that this was happening. At the time I visited him he had moved back to Wales, to the place where he was born – he had decided that he wanted to come home to die which he eventually did – peacefully. He said that he was grateful to his first wife as she had taught him ‘. . . how to die in life’.

People are—in the process of death—much as they are in life.

I used to feel that it was a shame that I had not known people before they got ill, but eventually I realised that how they coped with advanced disease and death was how they coped with life. If they were flexible and could change and adapt to life’s altering circumstances then they could also adapt to life-threatening illness. I am sad to say that some people merely manipulated their situation as a forum to play out their low levels of psychological health. People use the spiritual sphere to do much the same.

I remember one lady who was able to dominate her family and everyone else through her illness. It became the mechanism by which everyone around her failed her. The cancer specialist failed to diagnose her cancer. Then he failed to successfully treat it. Then the hospice failed to look after her adequately. Then the palliative care nurse and the doctor failed to relieve her pain. Then her minister of religion let her down in failing to visit her in the latter stages of her illness. Then her family failed to love and support her as she thought they should have done. Her daughter was under such pressure from her mother that she ran away from home and failed to make contact before she died. She succeeded in burning everybody out who had anything to do with her. I got to know her and her family quite well during the long course of her illness, and it seemed that this was precisely how her life had been.

It would seem that we all need to avoid becoming like this. So for anyone who agrees with me – the best time to start is right now and the best place is here. I wish you all the good death and the good birth that alternate to create a good life.