Buddha's Teachings about Breathing

The Buddha's Sutra on the Full Awareness of Breathing is a reminder to bring breath, body and mind into harmony, with breathing serving as an anchor as well as a place to begin to go home and reconcile with oneself.

The Body

1.      Breathing in a long breath, I know I am breathing in a long breath. Breathing out a long breath, I know I am breathing out a long breath.

2.      Breathing in, my breath goes deep. Breathing out, my breath goes slow.

3.      Breathing in, I am aware of my whole body. Breathing out, I calm my body.

4.      Breathing in, I know I am alive. Breathing out, I smile.

Feelings

5.      Breathing in, I feel joyful. Breathing out, I feel joyful.

6.      Breathing in, I feel happy. Breathing out, I feel happy.

7.      Breathing in, I am aware of feelings present in my body and mind at this moment. Breathing out, I touch the feelings that are making me suffer.

8.      Breathing in, I calm those feelings leaving my body and mind peaceful. Breathing out, I am grateful.

The Mind

9.      Breathing in, I am aware of the activity present in my mind at this moment. Breathing out, I concentrate my mind and look deeply.

10.    Breathing in, I untie knots created by unhelpful thinking or imaginings. Breathing out, I embrace and quiet all of my thoughts.

11.    Breathing in, I gladden my mind. Breathing out, I water the seeds of loving kindness and compassion.

12.    Breathing in, I cultivate forgiveness. Breathing out, I liberate my mind.

The Objects of the Mind

13.    Breathing in, I observe all things transforming. Breathing out, I recognize their impermanent nature.

14.    Breathing in, I detect the disappearance of desire. Breathing out, I experience non-craving.

15.    Breathing in, I observe the cessation of erroneous ideas. Breathing out, I see suffering born from ignorance fading away.

16.    Breathing in, I let go of the idea that I did not exist before I was born. Breathing out, I let go of the idea that I will not exist after I die.

Reminders

Rituals

Rituals can transform a situation. At the end–of–life, they help a person die a peaceful death, and bring reconciliation and acceptance to loved ones. Rituals come in many forms addressing the physical world (body), thoughts and ideas (mind), and the realms of myth (soul) and spirit (energy); helping to heal the pain of letting go, while at the same time connecting those bearing witness with something beyond earthly concerns.
Many religions have in common:

Creating a peaceful, soothing atmosphere,

Appealing to the senses,

Helping the dying person and all present to sense a sacred presence 
Some tools:
Lighting: Soft incandescent lighting or burning candles to bring feelings of peace and tranquility.
Aromas: Burning sage, scented candles, essential oils, or incense to induce a calming effect.

Holy Objects: An altar arranged with spiritually meaningful articles, medallions, statues or pictures to offer a visual focus.

Music: To soothe and inspire. Certain instruments such as harps, drums or bells, are used in many traditions. Sounds of nature and the human voice can be very healing.
Prayer: Oral prayer in keeping with the dying person's tradition
Silence: An important sound. It is good to remember the value and necessity of simply sitting in silence with the dying person.

Self Compassion

Germer, Christopher K. The Mindful Path to Self-Compassion. New York: The Guildford Press. 2009

“A moment of self-compassion can change your entire day. A string of such moments can change the course of your life” - from the Introduction

This book was written to help readers develop and strengthen their capacity for self-compassion and loving-kindness. The author believes enhancing one’s skills in these areas reduces the isolation and inevitable personal suffering that results from self-judgment, self-doubt and self-condemnation: Extending kindness to oneself as a healing strategy boosts self-esteem, increasing the likelihood of being more fully able to extend these aspirations to others.

Germer travels the path to self-compassion from the perspectives of mindfulness and loving-kindness. His basic premise is that life is tough. It is just not possible to avoid feeling bad sometimes. He argues, since feeling bad is a fact of the human condition, then recognizing the common humanity in this experience bestows permission to treat oneself with the same kindness we afford to others.

Throughout the text, the author asks questions for the reader to ponder and introduces them in a step-by-step fashion to practical techniques and exercises that support the development of mindfulness, loving-kindness meditation and self-compassion skills. Practicing these techniques is encouraged as a means to strengthen and expand one’s repertoire for dealing with negative emotions.

Absence

I apologize to readers of this blog for ceasing to post without explanation. Amidst completing the requirements for the Palliative Medicine fellowship, moving from Ottawa to Winnipeg and starting two new positions, I lost one beloved relative to a COPD exacerbation and two very dear friends, one to cancer and the other unexpectedly but peacefully. Two other friends have been diagnosed with advanced cancer in the past few months. My world has become noticeably smaller and I am grieving these losses. I assumed the role of Executrix for the first time in yet another city, and experienced first hand the enormity of this task. Other responsibilities continue..... I cannot commit to regular posts, but I enjoyed blogging very much and miss this form of exploration and self expression. I will add to this site as I am able.

Natural Instincts

Wild Geese

~Mary Oliver

You do not have to be good.
You do not have to walk on your knees
for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body

love what it loves.                                      
Tell me about despair, yours, and I will tell you mine.
Meanwhile the world goes on.
Meanwhile the sun and the clear pebbles of the rain
are moving across the landscapes,
over the prairies and the deep trees,                      

the mountains and the rivers.
Meanwhile the wild geese, high in the clean blue air,
are heading home again.
Whoever you are, no matter how lonely, the world offers itself to your imagination,               calls to you like the wild geese, harsh and exciting —
over and over announcing your place
in the family of things.

May Grand Rounds

Here is the link to Palliative Care May Grand Rounds hosted by Thaddeus Pope.

Measures of Inner Peace

1. An increasing tendency to let things happen rather than make them happen.
2. An unmistakable ability to enjoy each moment.
3. A loss of interest in interpreting the actions of others.
4. A loss of interest in judging other people.
5. A loss of interest in judging self.
6. A loss of interest in conflict.
7. A loss of the ability to worry.
8. Frequent, overwhelming episodes of appreciation.
9. Contented feelings of connectedness with others and nature.
10. Frequent bouts of smiling.
11. A tendency to think and act spontaneously rather than on fears based on past experiences.
12. An increased susceptibility to the love extended by others as well as the uncontrollable urge to extend it. 

~Saskia Davis

La Neuvaine & La Donation: Film Review

To enlarge this article, click on the 'full' button in the toolbar underneath the article. To close the article after it has been opened, tap the escape button on the computer keyboard:

Defining Palliative Care

This blog post entitled, "Palliative care needs a simple and consistent message"  at KevinMD.com is worth reading.

Shell Shock

"Six weeks ago I felt fine". Today, I have two different kinds of cancer, one on my vocal cord making my voice hoarse and one in my lung pressing on my blood vessels, making me feel short of breath and causing my face and arms to swell. The lung cancer has already spread to my bones. My legs are weak. Now I need a brace and a walker to walk and my back hurts. If I try to walk, I get more short of breath. My pancreas is inflamed and they say I have diabetes. I can't sleep because I am worried. What happened??? 
I included the words "shell shock" on the Palliative Medicine consult today, amidst the obvious issues of pain, shortness of breath.... The term was first coined in WWI to describe the confused or nervous mental condition of people who had been under fire in a war. Today, "shell-shocked" is also used to describe someone in a state of stunned confusion or shock; someone who is dazed. The signs of shell shock are disorientation and inability to focus, with reactions like shaking, nightmares, twitching, headaches, fatigue, insomnia, dizziness, anxiety, and irritability. These are also signs experienced by patients with life-limiting illnesses who develop, for example, opioid neurotoxicity or delerium. In this case though, it was simply too much, too soon, too life-altering.

der Philosoph

The title of Haydn's Symphony #22, "The Philosopher", is thought to derive from the interplay in the first movement between the strings and English horns (melody and counterpoint), simulating a question followed by an answer. The composition evokes the image of a philosopher deep in thought while time passes (alluded to musically by the muted tick-tock effect). This symphony comes to mind every now and then when I find myself contemplating alternatives & having to make a decision .... trying to strike a balance between intuition (being/receiving) and reason (doing/thinking). Other balance images include the seal totem and the Third eye chakra
EMI Classics: Simon Rattle & The City of Birmingham Orchestra
I Adagio
II Presto
III Menuetto & TrioIV Finale (Presto)

Wordles & Endless Possibilities

This wonderful site offers endless possibilities for creative expression using words. The developer says: "Wordle is a toy for generating “word clouds” from text that you provide. The clouds give greater prominence to words that appear more frequently in the source text. You can tweak your clouds with different fonts, layouts, and color schemes".
This wordle was created from the blog post entitled, "Is there a difference between the soul and the spirit?", March 28th.

It would be interesting to monitor ongoing symptom burden in selected patients by teaching them how to use this tool. A visual ESAS! with choice of font, color scheme and layout. On the web site, under the Wordle 'advanced' tab, words can be weighted to increase their prominence. Here is an example using ESAS symptoms with weights arbitrarily assigned, giving anxiety the highest symptom burden and appetite, breathlessness and nausea the lowest: Pain:60, Depression:20, Nausea:10, Mood:20, Sleep:80, Tiredness:80, Anxiety:100, Well-being:50, Breathlessness:10, Appetite:10. It is easy to see that anxiety is the main issue confronting this fictitious patient, followed by tiredness and sleep.

This wordle uses 'duality' font, the 'mostly horizontal' layout and the 'kindled' color scheme. It is possible to select specific colors for each word if one understands how to use HTML color names. The wordle product changes every time you make a selection.....so, if you create something beautiful, open it in window (see tab on bottom left of the wordle), then save it as a screen shot.

Specialist Palliative Care Services

Teleman Suite in B flat major TWV 55:B10 

At rounds this week, members of our team were lamenting the confused response they sometimes encounter from patients when they announce they are from the Palliative Care team. 

"I must be dying"

"You mean there is no more hope"

"Have they given up on me?"

Similarly, we receive consults asking for "End of Life orders" when our presence earlier in the course of the patient's illness would have been helpful. 

The World Health Organization calls palliative care "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness." The illness might be cancer, but increasingly the term palliative care is used in regard to conditions such as renal disease, chronic heart failure, HIV/AIDS, progressive lung disorders and neurological conditions.  It is active holistic care. For this reason, the care team includes palliative medicine consultants and palliative care nurse specialists together with a range of expertise provided by social workers, physiotherapists, occupational therapists, dieticians, pharmacists and those able to give spiritual and psychological support. It is a sharing partnership between the person with the illness, their family and friends, the surrounding community and members of the health care team to re-frame hope, provide meticulous pain and symptom management and offer supportive care for the purpose of helping those involved cope with the condition and it's treatment, from diagnosis to cure or, through continuing illness to death and into bereavement.

The goal of palliative care is not dying, it is living each remaining day of life as fully as possible.

Gratitude

 









 
I see trees of green, red roses too
I see them bloom, for me and you
And I think to myself, what a wonderful world.
I see skies of blue, and clouds of white
The bright blessed day, the dark sacred night
And I think to myself, what a wonderful world.
The colors of the rainbow, so pretty in the sky
Are also on the faces, of people going by
I see friends shaking hands, saying how do you do
They're really saying, I love you.
I hear babies cry, I watch them grow
They'll learn much more, than I'll never know
And I think to myself, what a wonderful world
Yes I think to myself, what a wonderful world.
Oh yeah...

Are You at Peace?

"Are you at peace?" is an opening "probing" question used to gently broach the topic of existential distress. What is the comeback when the answer is a resounding NO!?

Care Search categorizes existential distress as relating to loss of control, burden on others, relationship related concerns, loss of continuity, uncompleted life task, hope / hopelessness, and acceptance / preparation. The Japanese Spiritual Care Task Force suggests psycho-existential suffering is caused by the loss of three essential components:

• Loss of relationships (with others) 
• Loss of autonomy (independence, control over future, continuity of self)
• Loss of temporality (the future)

Today I witnessed it as someone no longer able to touch/access that which used to ignite his internal spark. In this case it was math puzzles. Usual efforts to connect with what previously provided the dual power to energize and comfort failed and these had now become a source of distress, a reminder of the uninvited effects of disease and medication on the mind.

What "brings us to life", energizes & animates are the aspects of self that are precious to the individual. When you are sorrowful, look... in your heart and you shall see that... you are weeping for that which has been your delight. Kahlil Gabrin

Medicine and Society

Contemporary medicine in and of itself is complex: Trying to find a professional & personal "home" amidst the tethers and freedoms becomes an even more intricate task when an academic appointment is added to the clinical practice mix. This is on my mind recently, having passed the halfway mark of this Palliative Medicine fellowship. In earlier times, physicians were accountable primarily to their patients and their colleagues. Now they are accountable to governments, institutions and commercial organizations for their competence, performance and productivity, not to mention the cost-effectiveness of their activities.

 
The word cloud above was created from text in the article below. Food for thought: The authors explore relationships between health care's multiple stakeholders, particularly focusing on society's expectations of a physician and a physician's obligations toward society. Selected words have been assigned greater prominence to emphasize their significance in the source text. 

To enlarge this article, click on the 'full' button in the toolbar underneath the article. To close the article after it has been opened, tap the escape button on the computer keyboard:

Is There a Difference Between the Soul and the Spirit?

Waterhouse painted "The Soul of a Rose" in 1908. I thought about this image the other day after seeing a patient with a reduced sense of smell. He breathed through a tracheostomy, bypassing the nose and the olfactory (sense of smell) apparatus because of prior total laryngectomy to remove vocal cord cancer.
The word soul brought to mind the quote "Nothing can cure the soul but the senses, just as nothing can cure the senses but the soul" Oscar Wilde  
That led to "You don't have a Soul. You are a Soul. You have a body" CS Lewis From there, I spent the remainder of the evening on an interesting Internet and eLibrary journey, reading and thinking about the soul and the spirit, how these words are defined and how they tend to be used in the Palliative Medicine literature.

Here is a sample of what I read:

• Our Spirit represents our true self, the spark of light. The Soul represents human/animal physical being. The Spirit is the life force that uses the soul (the body).
• Is there a difference between the Soul and the Spirit? The Greeks certainly thought so as they had different words, with completely different meanings, to describe each one. The Greek word for 'spirit' is pneumatos which means air, or wind. Wind/air (breath) is associated with the quality of having life, or being alive. The word 'Soul' derives from the Greek root psukios, which means mind, the seat of human consciousness, and cognition. Today, the soul and the spirit are mostly viewed as being the same thing, but the topic allows for an interesting exercise in describing the spirit as the expression of our soul while we are alive (with abilities and senses) in our bodies. Burke McKay 
• The human mind comprises the brain and all its workings — memory, perception, reason, emotions. It is, in other words, the “hardware” of human existence. The human soul is what governs the human hardware — the “software” of human existence, our very own “operating system,” unique to each of us. The human spirit is the “electricity” that animates us. 
• Our spirits are the expression of our souls in relation to how we feel, what we sense, and how well we are able to feel and sense. Our senses are gratified by movement, tasting food, breathing fresh air, seeing, smelling, touching and hearing. If we are in pain, our spirits may be more limited than when we feel well, how much more difficult it is to interact with and enjoy the world when pain is present. Sometimes our spirit is broken. Rarely is it ever said that the soul is broken. Perhaps the combination of body and spirit serve to develop our souls until we no longer have functioning bodies. Then life continues in the form of the soul and the spirit, in pure form, with no need for sensory inputs or for physical interaction with the world. Elizabeth M. Young
• The soul is the essence of humanity’s being; it is who we are. The spirit is the aspect of humanity that gives us the ability to connect with a higher power (God). The word “spirit” refers only to the immaterial facet of humanity. The word “soul” can refer to both the immaterial and material elements. Unlike human beings having a spirit, human beings are souls. In its most basic sense, the word soul means life.

It Really is This Simple

"The secret of the care of the patient, is in caring for the patient."

Francis Weld Peabody 1881-1927

Peabody F: The care of the patient. JAMA 1927;88:877-882.

"The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. What is spoken of as a 'clinical picture' is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears..."

From the Art Blog by Bob:
No other artist ever painted sickness and death quite like Edvard Munch. Munch, most famous for his iconic (and frequently stolen) 1893 painting The Scream, knew death intimately from a young age, watching siblings, family members, and friends all suffer through long illnesses against the backdrop of the cold, bleak winters of his native Norway. The Sick Child (above, 1885-1886) represents just one of his many depictions of illness.

It is Possible to Die Healed

"It is possible to die healed". I read this sentence in a Palliative Medicine text recently. The author, Balfour Mount, suggested the word 'healed' embraced the concept of human wholeness. As I was pondering my definition of healing, I was transported back to Epidavros, Greece, remembering a trip to commemorate medical school graduation and the profound impact of simply sitting on the amphitheatre steps contemplating the legacy of medicine.

The ancient Greeks were treated in Asclepions. These were healing sanctuaries named for the mythological god of medicine, Asclepius. When the philosopher-physician Hippocrates, a descendant of the asclepiad began his practice he introduced observation and study of the human body. His approach provided a physical & rational explanation for illness previously attributed to superstition, disfavor of the gods and evil spirits. He believed in the natural healing process of rest, a good diet, fresh air and cleanliness and ascribed to the philosophy of physician as "healer of the sick", rather than "curer of disease". Hippocrates believed the body must be treated as a whole and not just a series of parts.

When Thomas Egnew began his PhD studies on the meaning of healing, he was surprised to learn that despite references to the word healing since ancient times, medicine had no accepted definition of holistic healing. He hypothesized that ill persons undergo transformations in which they are unable to be the persons they once were. This threat to wholeness generates suffering that involves the physical, social, psychological and spiritual dimensions of personhood. He concluded by proposing that healing is the personal experience of the transcendence of suffering and is related to themes of wholeness, narrative and spirituality.  As an aside, the term medicine is derived from the Latin ars medicina meaning the art of healing.

To read Egnew's article, click on his name in this post, then select Full text (PDF) from the right column.