Mindfulness for a Good Death I

by Chelsea Reimer

Mindfulness in Dying: A Guide for Individuals and Families

As much as it may pain us to think of it, dying happens to every one of us. Contemplating death, our own or of those that we love, can bring up intense emotions. These feelings may be so powerful and overwhelming that we turn away from them. Perhaps, you were taught from a very young age that talking about death was taboo, or you feel as if the topic of death is simply too morbid or depressing to bring up with your loved ones. You are not alone – these feelings are very common within our culture.

So why are we so afraid to think about death? What if, by exploring some of the big questions as death nears, we could create space for the feelings that arise? What can we learn about ourselves and our relationships with those we love? We encourage you to use this guide to explore your own feelings about death and dying and to help discover what it means for you to have a good death.

What is mindfulness?

The word mindfulness is an English translation of the Pali word sati, a word that signifies awareness and attention. Pali was the language of Buddhist philosophy over 2500 years ago, and mindfulness is the core teaching of this tradition
(Germer, Siegel, & Fulton, 2013).

Mindfulness is a way of focusing our attention on the task at hand. It is a skill that allows us to be less reactive to what is happening in the moment. The goal is to direct your attention to your experience entirely in the moment, without judgement and without thoughts of the past or future.

Practicing mindfulness requires no specialized training or equipment, only the willingness to try. A mindful moment can be as simple as taking a moment to disengage from the activity at hand, taking a deep breath, and gathering your attention.

“Mindfulness can be defined as gently refocusing attention on what is happening in the present moment with a receptive, open attitude”
(Kashdan, 2011).

What are the benefits of mindfulness?

Research shows us that practicing mindfulness can have profound effects on improving quality of life and managing symptoms of illness or chronic pain. Mindfulness can reduce pain, tension and stress, it can increase joy and well-being, and it can improve the quality of interpersonal relationships (Kriegel, 2017; Niemiec et al., 2010; Schriener & Malcolm, 2008).

What does mindfulness have to do with dying?

“For someone who is dying, the past can be too complicated to contemplate, and the future is jarringly unknown. Focusing on the present… is where the potential for living most meaningfully – even while dying – exists”
(Martin, 2015).

Thoughts of death and dying, when unwanted or unwelcome, can be intrusive and distracting. Harnessing the practice of mindfulness in order to remain present in the moment is a powerful way to live every moment as wholly as possible. Mindfulness is a way to live our lives fully, all the way to the end.

When we begin to think about our own death, it is common to become caught up in regrets from the past, or concerns about the future. Mindful reflection and guided meditation are tools that can be used to focus on the experience at hand.

Mindfulness exercises are designed to slow us down and lead us to heightened sensitivity. Mindfulness may be a tool that gives you the freedom to explore what it means for you to have a good death. Perhaps there are specific rituals, ceremonies, or practices that are meaningful for you. Sharing these insights with your loved ones can help them to hold space for you in the ways that matter most. You have the power to shape your final moments.

“Death is not just happening to us at the end of a long road. It’s always with us. It’s in the marrow of every passing moment. I call it ‘the secret teacher that’s hiding in plain sight’ that helps us to discover what really matters most”
(Ostaseki, 2018).

Try this: Mindfulness Practice in the Shower

Adapted from Nancy O’Hara & David Gelles (2017)

A shower can be the perfect opportunity to try a mindfulness exercise for the first time. The quiet, secluded space is an ideal location for removing the distractions of day-to-day-life.

Start with removing all unnecessary distractions from the space. Leave any electronic devices in another room, far enough away so they cannot be heard.

Bring to your mind the idea that you are about to cleanse yourself as part of caring for your body and your mind.

Take a moment to be grateful for your access to warm water and clean towels.

Notice – do your thoughts turn to dwelling on the past or planning for the future? If so, do not judge yourself, merely bring your attention back to your awareness.

As the water touches your body, focus on this sensation. As you handle the soap, bring it to your nose and inhale its scent.

Wash your body slowly and methodically, staying present while focusing on the feelings of touch and smell.

When you turn off the water, take a long, deep breath before exiting the shower.

Bring your awareness directly to the moment at hand and thank yourself for taking time to practice this exercise for your health and well-being.

When the exercise is complete, notice if you feel any new sensations. Perhaps you feel calmer, more grounded, or less anxious. Perhaps you are surprised at how intrusive your thoughts can be! These are all normal observations.

Try this: Mindfulness in Journaling

This may be a highly emotional process. We warn you only so that you give this exercise the space and time that it deserves and encourage you to reach out to others around you if you want to continue to process your feelings after you try this exercise.

Set aside a few minutes to sit in solitude with a pen and paper, removing as many distractions as possible. Leave electronic devices in another room, far enough away that they cannot be heard.

You may want to set yourself a timer, but you may enjoy letting your mind travel as far as it likes. The decision is yours.

Before you put pen to paper, take three long, deep breaths. Focus on being present in the moment, allowing your mind to let go of other distractions.

In your mind, imagine your death. What feelings come up for you?

Pick up your pen and begin to write. No one but you need ever read what is written – let your pen flow with your thoughts, avoiding self-judgement and criticism. This is an exercise in mindful exploration.

If you wish to push even deeper, consider the following prompts:

What does it mean to you to have a good death?
Where would you like to be when you die?
Who do you envision nearby?

When you are done, put down your pen, and without reading what you have written, take a moment to ground yourself in the present moment. Five deep, long breaths will help bring your awareness back to your body. Notice what feelings, emotions, and sensations have come up in your body and awareness during this exercise.

You may return to your writings at a later time, but it is not a requirement of the exercise.

If this was beneficial or informative for you, you may like to integrate journaling into your daily or weekly routine.

Mindful Families Grounding Exercise: The Hug

Video created by 
 Chelsea Reimer
 1:23 mins, November 2018

Resources for a Good Death

The following resources have been compiled to help you and your loved ones explore the uses of mindfulness as you prepare for your death, or the death of a loved one. Mindfulness is described by psychology researcher Todd Kashdan (2011) as “being open, receptive, and attentive to whatever is unfolding in the present moment” and has emerged as a powerful tool for self-reflection in preparation for dying. Although there are countless many other books, techniques, and experts that speak to the topic of mindfulness, these resources have been specifically chosen for their relevance in preparing for a death. The selected resources include written works, audio recordings, video presentations, and contact information for external organizations, in order to appeal to a broad range of learning preferences and styles.

10-Minute Guided Meditation on Death and Impermanence

This guided meditation, led by Bernadette Keogh, allows the participant to contemplate death from the Buddhist perspective. Many people find that guided meditation allows them to make space for the difficult emotions and bodily sensations that arise when thinking about death. You need no special training or equipment to try guided meditation – a quiet space and a few minutes of uninterrupted time is all that is required. Research demonstrates that mindful meditation is useful in reducing symptoms of depression, anxiety, and stress (Schreiner & Malcolm, 2008), helping us to free up valuable mental energy. This meditation can be downloaded or streamed on any Internet-connected device.

URL: https://www.youtube.com/watch?v=EWLB-jKOtvU

“Advice for Future Corpses (and Those Who Love Them): A Practical Perspective on Death and Dying” by Sallie Tisdale

Written by Buddhist practitioner, nurse, and end-of-life educator Sallie Tisdale, this book of essays is designed to help you prepare for your own death as well as the death of those closest to you. Described as a “travel guide to the end of life” (Scarles, 2018), this book has been widely praised for its authentic, fearless voice. Four appendices are included for those readers seeking advice on the practical tasks of preparing for death, including drafting a death plan, preparing advance directives, planning organ and tissue donation, and exploring the topic of assisted death. Tisdale blends empathetic understanding, spiritual guidance, and practical considerations, woven in with stories from her many years of experience as a registered nurse.

URL: http://www.simonandschuster.ca/books/Advice-for-Future-Corpses-(and-Those-Who-Love-Them)/Sallie-Tisdale/9781501182174

Meditations for Sick and Dying People: Helping the Dying

This article features meditation techniques and visualizations specifically tailored for those dying and those in pain and includes links to guided meditations for those who prefer audio recordings. This article is specifically helpful for those who are comforting their dying loved ones, as it offers step-by-step strategies for compassionate caregivers to help a dying person die with as calm and positive a mindset as possible. Simple, beginner-friendly breathing techniques are also offered, with additional tips for providing therapeutic touch and massage.

URL: https://www.thewayofmeditation.com.au/blog/meditations-for-sick-and-dying-people/

End of Life Doula Association of Canada

Just as birth doulas support parents during the labour process, death doulas support individuals through the process of dying in a way that is specific to the individual’s needs, beliefs and desires. Death doulas, alternately referred to as death coaches or death guides, can facilitate conversations, organize ceremonies and rituals, and help prepare bodies for burial or cremation. In previous years, death doulas were referred to as “death midwives”, but the term “midwife” is now protected by the College of Midwives of BC as a licensed term for healthcare providers offering maternity care. The services of death doulas are private (e.g.: not covered by Medical Services Premiums), but as with birth doulas, there may be sliding-scale options available for lower-income individuals. The End of Life Doula Association of Canada maintains a referral service and membership roster, and all of their doulas have been trained by a recognized end of life care program and have provided the Association with a recent criminal record check.

URL: https://endoflifedoulaassociation.org/

“Who Dies: An Investigation of Conscious Living and Conscious Dying” by Stephen & Ondrea Levine

Described as “the first book to show the reader how to open up to the immensity of living with death” (Penguin Random House, n.d.), this book was released in 1989 and continues to be considered a groundbreaking work in the application of Buddhist practices and guided meditation to the topic of death. Stephen Levine and his wife, Ondrea, drew on their experience in Vipassana meditation techniques to help thousands of individuals approach the idea of death with an open heart (Platek, 2009). Though Stephen has since passed, Ondrea continues to maintain their website, levinetalks.com, which hosts additional video and written resources.

URL: https://www.penguinrandomhouse.com/books/100574/who-dies-by-stephen-and-ondrea-levine/9780385262217/

References

All images were used courtesy of Pixabay, in alignment with CC0 Creative Commons licensing.

Gelles, D. (2017, May 10). How to be mindful while taking a shower. The New York Times. Retrieved from https://www.nytimes.com/2017/05/10/well/mind/how-to-be-mindful-while-taking-a-shower.html

Germer, C. K., Siegel, R. D., & Fulton, P. R. (2013).Mindfulness and psychotherapy(2^nded.). NY: The Guildford Press.

Kashdan, T. B. (2011). Confronting death with an open, mindful attitude. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/curious/201102/confronting-death-open-mindful-attitude

Kriegel, L. (2017, August 8). Mindfulness and its meaning in palliative care. Rutgers Cancer Institute of New Jersey. Retrieved from https://csupalliativecare.org/wp-content/uploads/mindfulness-ebook-08.08.2017.pdf

Martin, C. E. (2015, August 14). Zen and the art of dying well. The New York Times. Retrieved from https://opinionator.blogs.nytimes.com/2015/08/14/zen-and-the-art-of-dying-well/

Niemiec, C. P., Brown, K. W., Kashdan, T. B., Cozzolino, P. J., Breen, W. E. … & Ryan, R. M.

(2010). Being present in the face of existential threat: The role of trait mindfulness in reducing defensive responses to mortality salience. Journal of Personality and Social Psychology, 99(2): 344-365. doi:10.1037/a0019388

Ostaseki, F. As quoted by Illing, S. (2018, January 24). What the living can learn from the dying. Vox. Retrieved from https://www.vox.com/science-and-health/2017/12/7/16690024/buddhism-health-care-death-mindfulness-spirituality

Schriener, I., & Malcolm. J. P. (2008). The benefits of mindfulness meditation; Changes in emotional states of depression, anxiety, and stress. Behaviour Change, 25(3): 156-168. doi:10.1375.bech.25.3.156

November 25, 2018February 15, 2019

Mindfulness for a Good Death II

by Abbi Fowler and Hannah Roy

Using Mindfulness to contribute to a Good Death: A Guide for Families and their Loved Ones

As we age, the aspect of death may creep into our minds more often than we may like. In many cases death occurs suddenly with little to no indication, while others may receive a diagnosis terminal in nature that allow individuals and their families time to plan and organize the type of care they wish to receive when the time comes. Death can create feelings of worry, anxiety and fear, however there are strategies that can be used by both the individual and the family to prepare for the process of dying as well as death itself that will optimally support the individual to experience a “good death”.

What is meant by a good death? The term encompasses the preferences of an individual that support the way in which they would like to die. For example, dying at home, effective pain management, use of alternative therapies, surrounded by loved ones etc. (Repa, 2018). What constitutes a good death will be different for every individual as individual’s needs, preferences, ideas and perceptions of death vary significantly.

One way a good death can be viewed, is the way in which individuals would ideally like the process of death to be like for them and their family. Death not only involves the physical aspects of one’s body but also the emotional, social, mental and spiritual spheres of one’s overall wellbeing. However, when someone approaches death, mindful care should be provided in a holistic way that allows both the family and the individual to be as comfortable as possible.

Facing our own or a loved one’s mortality is possibly one of the hardest things that humans experience. In Canada, many of us choose to almost ignore death, which can make us fearful, unprepared, and closed off to death. Dying with dignity is possibly one of the most important factors in a ‘good death’. “Dignified dying” has been defined as maintaining personal comfort and control as the end of life approaches (Rankin, Donahue, Davis, Johnson, Maas, Wedig & Katseres, 1998).

Mindfulness and a Good Death

There are many different ways to help an individual have a dignified death and if the individual is open to using mindfulness it is a great tool to incorporate. Mindfulness is an exercise that allows and supports individuals to focus attention on their current feelings, emotions and internal body sensations (Stella, 2016). When an individual practices mindfulness they approach their current experiences of feelings, emotions and internal body sensations in a non-judgmental, accepting and compassionate manner (Stella, 2016).

Mindfulness practice gives insight into feelings that may be causing anxiety and fear and creates a healthy space to confront these emotions. Mindfulness of death supports an individual and family to prioritize what is important in their life. It helps us live our last days with purpose and intention and helps mitigate feelings of uncertainty and fear so, these feelings do not consume one’s final days of life (Shonin & Gordon, 2014).

It will take time to feel comfortable when practicing mindfulness as it requires a degree of attention and purpose that may have never been accessed before. Mindfulness practices can be used by both the individual who is approaching death as well as their family members and friends to address unpleasant and intrusive feelings surrounding death, grief and loss.

Mindfulness Exercises

When an individual has a strong fear of death it can lead to unbearable anxiety. When a dying individual has anxiety they feel that their pain is increased, discomfort is increased and no matter what interventions are tried to relieve all of those things the anxiety and fear still prevail. Using mindfulness to relieve some of the anxiety and fear for the individual can be beneficial. Here is a short exercise for individuals to realize the fear is present and to keep the fear and anxiety from controlling them.

When anxiety and fear creep in start paying close attention. Notice your heart pumping more, your chest tightening, your body stiffening, let an imaginary alarm go off in your head.

Take as many deep breaths as you need to slow your body down. Placing your hand over your heart may help.

Acknowledge to yourself, I’m fearful, I’m anxious, I’m worried. Name the fear so you can create a distance between yourself and the intensity of the emotional reaction.

Say a few phrases of well-wishing toward yourself.
‘May I see the source of my fear’?
‘May I be safe and free from fear’?
‘May I be happy and at ease?’

As fearful thoughts of dread and worry continue to arise, approach them with openness. Don’t treat them as a threat.

Be kind toward yourself for being afraid. See what happens when you hold your ground and let the fear rise in your mind. You may find comfort inside.

Mindfulness for Family Members

Family members and friends also experience waves of emotion when supporting their loved one through the dying process. It is not uncommon for family to not verbalize their feelings and/or emotions they are experiencing with others, as they do not want to burden anyone. If we keep these thoughts to ourselves they can manifest into negative self-talk and faulty thinking. Negative self-talk and even faulty thinking has the ability to perpetuate feelings of anxiety and fear surrounding death of a loved one. Below is a useful mindfulness exercise to address faulty thinking.

Remember thoughts are not necessarily facts.

Just because you are thinking something does not make it true.

Is it true?

Ask yourself, why this thought could be true? What information do you have would suggest that is true?

We often always believe what we tell ourselves regardless of factual information.
Ask yourself, why this thought could be true? What information do you have would suggest that is true?

Is it absolutely true?

Try to think of reasons and/or explanations of why this thought could not be accurate or true.

How does this thought make you feel?

Close your eyes and take a few deep breaths, focus on the inhale and exhale of the breath.
Sit quietly, what feelings and emotions do you begin to experience?
Acknowledge these feelings, do not avoid them.
Repeat affirmations “ this feeling/emotion is not a threat”, “I can handle anything that comes my way”, “I am safe and loved”.
Open your eyes.

What would things be like if I did not hold this belief?

If I did not hold this thought or belief, what would happen good and bad?
Is this thought beneficial to myself or others?

Body Scan exercise for Pain Reduction Video

Video created by 
Hannah Roy and Abbi Fowler
1:50 mins, November 2018

Resources for a Good Death

Dying with Dignity Canada

This website is the platform for the national human-rights charity devoted to improving the quality of dying, protecting end-of-life rights and helping Canadians avoid unwanted suffering (Dying with Dignity, 2015). Much of the information shared on this website focuses on end-of-life options including information on medical assistance in dying (MAID). This websites offers support to the individual who is dying as well as their family and loved ones. There are three main tabs on the home web page including find support, education and our issues. Within these tabs you can find a wide variety of information including emotional support and bereavement counseling, navigating a request for MAID, a patient navigation booklet, finding palliative care resources where you live, and making an advance care plan etc. This website also shares two of their social media platforms including Facebook and Twitter as well as a blog that shares personal stories of individuals and families surrounding their experience of MAID.

URL: https://www.dyingwithdignity.ca/

The Art of Dying Well

This website offers an abundance of information and resources for individuals who are in the process of dying as well as their family and friends. Not only does this website offer written information there are also videos available to complement the information being shared. There are 6 main tabs at the top of the home web page which include what is dying well?, talking about death, facing death personally, losing a loved one, caring for the dying and about this site. If you click on one of these tabs it will further explore the topic into many subcategories. The website also shares their social media platforms in the top right
corner including Facebook, Twitter, YouTube and Instagram. A very interesting resource – this website also offers podcasts regarding all things related to death, which are free to access.

URL: http://www.artofdyingwell.org

The Sacred Dying Foundation

The Sacred Dying Foundation provides resources for individuals who are approaching death. The homepage displays five tabs including home, about us, events, contact, media and resources. The events page shares various events in the Vancouver area including workshops and meet and greets (death cafe) for individuals who are approaching death as well as their loved ones. The resource tab is extremely valuable as it shares a list of books and websites that can be beneficial for anyone impacted by the process of dying or death itself.

URL: http://dyingmatterscanada.com

The Conversation Project

The Conversation Project is a public engagement initiative with a goal to have every person’s wishes for end-of-life-care expressed and respected; too many people die in a manner they would not choose, and too many of their loved ones are left feeling bereaved, guilty, and uncertain (Institute for Healthcare Improvement, 2018). Starting the conversation about death can be very difficult for many and The Conversation project wants to help by offering tools, guidance, and resources to begin talking with those that are close to you about their wishes.

URL: http://www.theconversationproject.org/

Canadian Virtual Hospice

The Canadian Virtual Hospice provides support and personalized information about palliative and end-of-life care to patients, family members, health care providers, researchers and educators ). The Canadian Virtual Hospice started in 2004. At the Canadian Virtual Hospice, you can ask a professional any questions you have about your individualized experience. This is a safe place to sort through issues related to death and dying; the information and support they get helps make sense in times of confusion, offers compassion in times of isolation, and reassurance in times of anxiety.

URL: http://www.virtualhospice.ca

References

Goldstein, (2017). Mindfulness and Psychotherapy. Thoughts are not Facts (Practice). Retrieved from https://elishagoldstein.com/thoughts-are-not-facts/

Institute for Healthcare Improvement. (2018). The Conversation Project. Retrieved from http://www.theconversationproject.org/

Rankin, M., Donahue, M., Davis, K., Johnson, M., Maas, M., Wedig, J., & Katseres, J. (1998, January 01). Dignified dying as a nursing outcome. Outcomes Management for Nursing Practice [01 Jul 1998, 2(3):105-110.

Repa, B., (2018). What is a “Good Death”. Retrieved from https://www.caring.com/articles/a-good-death

Shonin, E., & Van Gordon, W. (2014). Mindfulness of death. Mindfulness, 5(4), 464-466.

Stella, M. (2016). Befriending death: A mindfulness-based approach to cultivating self-awareness in counseling students. Death Studies, 40(1), 32-39.