Venerable Dr Mettanando, Bhikku of Wat Rajaorasaram, Bangkok, was ordained as a Buddhist monk on April 8, 1982 at Wat Paknam Bhasecharoen. He is a member of the Ethics Committee, Faculty of Medicine, Chulalongkorn University, and teaches Buddhist philosophy at Assumption University and Mahachulalongkorn Monastic University,Bangkok. He was the Initiator and Project Manager of the computerization of the Buddhist Pali Canon and production of the Pali CD-ROM for the Dhammakaya Foundation between 1982 – 1994. A popular speaker on Bangkok TV, he has written over 100 short TV programs for the promotion of social ethics. Venerable Mettanando has a number of academic qualifications ; B.Sc and M.D. from Chulalongkorn University, B.A and M.A. from Oxford University. , Th.M. from Harvard University, and Ph.D. from Hamburg University, Germany.

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"The topic of end of life care is very important. I would like to begin by addressing some basic fundamental questions concerning life and also leading towards Buddhist perspective and then appropriate Buddhist practice – what we should do for the end of life care. "

The topic of end of life care is very important. I would like to begin by addressing some basic fundamental questions concerning life and also leading towards Buddhist perspective and then appropriate Buddhist practice – what we should do for the end of life care.
There are five fundamental questions in the world which we all face from time to time. Every being in this world question him or herself:

· Who am I?
· What is this world?
· What is the meaning of my life?
· What will happen to me after I die?
· Why did this bad thing happen to me or my loved one?

Then we have a problem with this nature of human beings found in almost all of the cultures in the world. Now when I was in Oxford University, the first hour, there was a tutorial session with a Professor who asked every student to answer a question and that is: Can you give me the difference between modern society and traditional society? This notion is - I don’t know what the difference is very well but after years of teaching, that by understanding this notion the difference is- between modern society and traditional society which allowed me to understand more of the nature of human being.

In modern society, like in America and in Europe their perception is that the past was the worst, the present is better that the past, and the future is better than today. This is what people believe in modern society. And change is good - There are some societies where science is the authority. If you decide anything at all, you must have a scientific argument for it. Later, Egalitarian – where everyone is equal, shed challenging old ideas and they prefer simplified version – the simplest one is the best. The outcome is better. The outcome has priority over the process. Truth is only Mass and Energy – nothing else.

Traditional society on the other hand see the past as the golden age, and that today is worse and the future is even worst than today. Things are decaying; therefore change is bad, authority is in a sacred text. When you want to argue with someone you have to base your argument in a sacred text, not science. Hierarchy status prefers people in hierarchy and in many stratas of society they are many hierarchical indeed. Criticism of authority is bad. When you raise question to the master it seem to be a challenge, an intrusion, you see, more than a challenge. Respect to formality is very high. The process is more important than the outcome. This is traditional society. You have to go through all the process. The truth is the Mind and the Unseen, not the material.

In scientific world, our world began with Big Bang and then our ancestors were apes and there was a kind of evolution from primitive cells and then we become more sophisticated and complex beings inside and thus became human beings. Mind is a brain process, nothing else. Morality in social values – there is nothing sacred. Nothing exists after life. Life is procreation. The goal of life is procreation of species. Fortunate, misfortunate is just a coincidence. There is no meaning. Religion is based on trust in Genesis. In every religion, Buddhism included, there is story of Genesis; superiority of man over animals and plants. Morality is part of the natural law. Sacredness is the Unseen. There is something sacred which cannot be perceived by the eye. And the afterlife is sacred and real. Life, the purpose of life is the search of eternity. Fortune and misfortune there must be a reason behind it. You see these are the differences. Now why is this difference very important? It is because we are going through a twilight zone. Every religion provides two things – mono of and mono for? Mono-of is mino of reality, what is real and what is important; and mono-for, what is the duty, the goal of our life on earth.

In every religion there are five dimensions. Religion is like a huge single cell protozoa moving around, adapting itself to its settings, but it has five dimensions. The first is myth, every religion has its myth. And second from myth is ethics, and social institution, rituals and religious experience. Every religion has all these five dimensions. When we talk about religion we have to be aware which part of religion are we talking about – you see? And this is the thing that we can make use at the end when we bring religion into practice.

Now there are also several kinds of religions – Polytheism – For example, Egyptian religion and ancient Greek religion and some parts of Hinduism believe in many Gods. Monotheism – like Judaism, Christianity, Islam, and some part of Hinduism. Hinduism can be Polytheism and Monotheism at the same time; it depends who you talk to and in what context. And non-theistic religion like Jainism, Taoism, Confucianism, and Buddhism – these are non-theistic religions. There is no single authority which creates the world, heaven and earth.

Death - according to various religions. In the Egyptian Book of Death there was a judgment. As soon as a person dies, the soul is brought in front of Orisis, who is the God of Death, who judges the person. The person’s heart will be taken out and put on a scale the balance will be compared with a feather. If it is lighter than the feather the person will go to Heaven. If it is heavier, he will go to Hell. So in the Egyptian Book of Death there is a very famous painting of the Judgment Day, of the man who died, and probably it could be a part of the earliest thinking of Judgment. Then in Hinduism we have a sacred text, the Upanishad, we have black Ayurveda, and also the story of Nasikayta. There was a young man who somehow quarreled with his father and then found his way to Hell, to a kind of the underworld. He met face to face with God of Death and somehow he was able to please the God of Death who granted him three boons which he finally decided what he wanted to do. The three boons represent the goals of life-what people should have. In Chinese there is a belief in twin souls; when you die, for the Chinese, there are two souls, one is the soul of sin, and one is the soul of merit. The soul of sin go to Hell, the soul of merit go to Heaven. In geo – Christian, Islam tradition there are descriptions by Dante describing inferno. In Theravada Buddhism we have pribumi kata pramalai which describe journey to Hell and the underworld. Mahayana Buddhism there are several – Lotus Sutra Pure Land. Archarya also depicts different scenes of death. In Egyptoism they believe in spirits and death as a result of evil spirit.

Now when I was at Harvard I went to a library in a Divinity school and in a hall I was struck by a saying attached to a piece of paper – it says when “shit happens” in world religion – as a gentleman graduate, newly graduated from Oxford I did not know American slang, and it took me a while to understand what does “shit” means – and I found it was a rude word and the sentence was used in an Hollywood film promoted by Arnold Schwarzenegger and it means, well it explains many things. In Confucius, if you are a Confucian, when bad things happen, when “shit” happens, people in Confucian will say ‘Confucius say “shit’ happens’, because Confucians are naturalists. You don’t put yourself into interpretation. You take what it happened like that. You see, naturalist. You don’t give meaning to things, unnecessarily. Well Hindus, he will say, this “shit” has happened before. When you come across stories of bad things happening in Hinduism, suddenly in the scene there will be a sage, some holy man, a guru will appear, and there would be a sound, a gong or something and then the man appeared and he will reveal the story saying that this is not the first time. This has been known long ago that a story like this has happened and he will reveal it. Then Hindus are satisfied with that. This “shit” has happened before; therefore I am not the first victim. For Buddhists, Buddhists say this “shit” is your karma, so you blame your victims. For Catholics – “you deserve it.” It’s the prerequisite nature of God. For Muslims – this “shit” comes from Allah, you should be proud, nobody give it to you. For Protestants they will say - why did it not happen to other people? Protestants have different theology than Catholics because they feel they are the selected group, they are the elite, you see and they are proud to claim access to God directly. When bad things happen they say why it did not happen to other people, to you? Why “shit” always happen to us? And you notice that “us” is written with capital “U” not the small “u”. For females, all “shit” are from men. But what if you don’t believe in anything? Materialism.

You seek for something – death with dignity, right to die, final exit. Final Exit is a name of a book written by a British, his name is Derick umm…something…..and he wrote.. it’s a kind of manual for committing suicide - How to die, how to commit suicide, painless, there are several recipes to commit suicide. And the book gave birth to an organization in America and England called the Hemlock Society. Hemlock is the name of a plant. It is very poisonous and if you study Philosophy there is a story of Socrates. Socrates was sentenced to death and he chose to die by himself, by committing suicide. Although he can escape, he refused and he chose to take hemlock and so hemlock became a symbol – symbolism of death in dignity. So there are many people who are fighting for a right to die and also euthanasia. “ Eu” is a prefix in Greek language – it mean good. “ Thanas” mean death. – Good death. It means die by putting to death by somebody else, death with a mercy killing. And another thing is physician assisted suicide – it’s half way. You kill yourself, you take the pills into your mouth but the pills are prepared by doctors. So there are many people who believe they should have the right to die. And in the state of Oregon, in United States there is a law which allow patients who suffer from incurable disease, at terminal stage, to choose to have physician-assisted suicide. For people who don’t believe it is said you happen to be at the wrong place at the wrong time. They don’t think too much or that’s life, as simple as that.

Now I bring it to you a summary of the teachings of the Buddha. The Buddha said “All of my teachings concern with two things – dukkha and its solution. And the word dukkha has not been properly translated in many Buddhist countries. And they have used the term for a very long time. But when Buddhism got in touch with the Western country, in western culture they asked the question - what does dukkha means? And many people translate it as suffering, some people as pain some people says dissatisfaction. So I did some research on the word dukkha and I found that it gives a very good meaning if you understand the origin of the word. The origin is a Pali word. Pali is an ancient language in India and the word dukkha was a technical term used among craftsmen who worked with carts and tools and it applied to a situation. When two objects, two pieces of tool which is supposed to fit in with each other fail to do so, when they fail to do so - that situation is called dukkha. For example the wheel of a cart broke down and the hole of the wheel and the hub couldn’t fit in to the axis. One is bigger than the other; they are of different sizes; that is dukkha. And in English there is an idiom – to put a square peg into a round hole you see, or to put a round peg into a square hole, they won’t fit in. Now the more you try to put them forcefully the more dukkha you have. This is the nature. And the Buddha adopted the word into Buddhism as a theme for his teachings. So it describes many situations. Possibly the word pain, suffering, and dissatisfaction does not illustrate the deeper dimension of the word - it’s too far. Its philosophical meaning is deeper than that. It describe not only dukkha in your mind but also relationship, when relationship is broken, they do not fit in to each other any more, expectations of one party do not fit in with the rest, so that is dukkha. Or when you detect in a kind of management, in a corporation when there is conflict you can detect there is dukkha there too. Or it can be used for scientific discovery and many things else

Now what is life? When do we know when life ends, you see? There is no clear cut point which allows Buddhist to decide when life ends. There was no criteria used by physicist in those days –it doesn’t fit in very well. However in the commentary of vinayas sinayas it’s a kind of monastic discipline used by monks, Buddhist monks to describe that human life starts with awareness immediately after conception begins and ends, it last a hundred and twenty years. Now how can you use this definition, this definition cannot help much for us to diagnose the case of death, dying. Now I have to say my curiosity in social dimension of Buddhism started when I work with my thesis on death… on AIDS and Buddhism in Thailand. That was my thesis and I was very curious because in those days Thailand is called the Capital of AIDS. There are lots of problem inside – we have lots of prostitutes, we have a lot of brothels there. There was one woman there, an American woman there who spent two years studying Buddhism in Thailand and she came back and she wrote a paper and it amazed me. Because formerly I was interested in meditation and nothing else and she said that “It’s very interesting that Buddhist in Thailand, although Buddha said that this is not good, this is bad, prostitution is bad, gambling is bad, but there are a lot of this vice in Thailand. Some brothels are just next door to a temple and monks there they pay no attention to it; they accept it as fact. So when I came back to Thailand I had the opportunity to teach a very large gathering of Buddhists who have been practicing Buddhism for over ten years and I raised a question to them – “What will you do if you found that, one day you found that your neighbor has converted his or her house into a brothel.

The answer, the first answer that I received was “nothing” - because as soon as I realized the problems, I entered into Vippasanna meditation; impermanence, dukkha, no-self, the problem is gone. After seeing the nature is impermanent. Things by nature, suffering by dukkha, having no substance, I detach. The problem is gone. This is a very clear cut way to solve problem – as soon as it arises it is gone. But the brothels are still there. The problem is unattended. The second group of Buddhists said “We can’t do anything”. We know that the brothel is bad business, but you see, those prostitutes they were former playboys, adultress, they have affairs with women and they spend five hundred lifetimes in Hell. After spending five hundred times in Hell they were reborn again as animals being castrated five hundred times. After spending time like animals being castrated five hundred times they were reborn again as gays, homosexuals and spend another five hundred times as gays and homosexuals. After that they become prostitutes five hundred times. After five hundred times being prostitutes they become good women, housewives. Spending another five hundred times as housewives, finally they become men. Men are at the top. We can’t do anything because they are receiving the fruition of their karma. Although we know, we sympathize with them but we cannot help. No engagement. I detect that what is described fit in a book described by Melford Spiro. He is a social anthologist in America and he worked fourteen months in Burma and he wrote a systematic analysis. He found that there are several types of Buddhism. Buddhism is not a monolithic religion. It has several sub-sets inside. One, the first one we call Nibbanic Buddhism- religion of sabbatical salvation. Second, Kammatic Buddhism – religion of proximate salvation. These two groups are majorities in Myanmar. And Apotropaic Buddhism is a religion of magical protection and Esoteric Buddhism – religion of chiliastic expectation. Chiliastic means they expect the coming of the next Buddha. Now these are four major sub-sets, four sub-sets in Theraveda Buddhism in Myanmar. The upper two are the majorities.

You see, what I found from my investigation, is that it fits in with the Nibbanic, Kammadic Buddhism. And the Nibbanic people feel that there are three dominating principles – impermanence, suffering and no-self. The goal of life is to attain nirvana in life. The principle of practice is morality, mental concentration and wisdom. And merit or demerit should be detached. You shouldn’t live life to accumulate merit or demerit. They were all impediment. And the life of living a Nibbanic lifestyle is being a forest monk, unattached, nothing to do with materialism. For Kammatic Buddhist they see that Karma, the law of karma rules the world. For the Nibbanic Buddhism they feel that everything is suffering. Life is bad, and by nature. But Kammadic Buddhist see that justice rule the world, everything is just. Good things, you are rewarded and bad things leads to punishment. The goal is to maximize merit, attain rebirth. Again the principle is charity, morality and meditation. Monks are fields of merit. Merits are spiritual treasure, the real thing that one can take to next life. Ideal living is a rich virtuous businessman, a king or powerful person.

These are two extremes. Apotropaic Buddhism a smaller group, they say that the world is full of supernatural phenomena. The goal is for current living through rites and rituals. The practice is monks’ service in Pali chanting and to transform the life through merit or power of the Triple Gems. Ideal living is living in trouble-free world blessing, surrounded by good omens. Esoteric Buddhists on the other hand is such,that they wait for the visit of the fifth Buddha – Maitreya - to come so they can look for medication that will allow them to live for a long time. Now I found that there’s a different meaning. If your’re Nibbanic type, death is a natural process, life is painful and suffering, death is invincible. If your’re Kammadic Buddhist you see death as kammadic retribution. So what do you think? Either of them, they hardly pay attention to helping others, they see no dimension, no relationship with society whatever. So that is the problem of society. And Spiro concluded in his book that there is no social consciousness in Buddhism. So there are many problems unattended in Therevada world. Now I disagree with that.I found a lot of useful information given by Spiro. I found that there are ways to understand social dimension in Buddhism and that is through Manggala. Manggala is also a person with society and also with future and through adoption of Manggala we can help society and people with pain. So I found death and the justification of death in the first precept – Panatipata Veramani Sikkhapadam Samadiyami – abstain from taking life. Technically it said it is abstain FROM causing the falling away of lifeforce – panna.“Panna” – comes from Sanskrit word“ prajna “. It is a technical term used in a book called “ Charikasamitta”- it’s a manuscript of doctors there - where panna - lifeforce is situated in the heart muscles. The Panna empowers thinking, swallowing and breathing. We know that swallowing, and thinking and breathing were the works controlled by cerebro cortex and brain-stem functions. So when a patient dies, the brain becomes dead, justification - loss of panna. When the brain stops function the cordial function of the brain, and the brain stem stop functioning – that is also justification for dying, this is the dying according to Charikasamitta. So according to Nibannic Buddhism life is suffering, pain is an extension that is the nature, everyone for himself – you cannot help others. You have to help yourself. Equanimity is the highest virtue. Perception of problem of society confirm life is full of suffering and there is no society or individuals living together. For Kammatic also they see life as a process of karma in the past life, everyone has to do for himself, happiness of good merit done, suffering of demerit but what I agree with Nibbanic and Kammatic is that there is no society – you do for yourself.

How are these for end-of-life care? In the world people who die suddenly - of accidents, heart attack, of being killed average eight point nine percent ( 8.9 %) of people die suddenly, without warning. The rest ninety one point one percent ( 91.1 % ) die through slow causes of illness like cancer, aids, vital organ failure. But the problem at end-of-life care is who is going to decide – the doctor, the physician or the family? And who will decide when to stop. There are two forms, two forms of philosophy of treatment in medicine. One is called curative and the other is palliative. Curative is you go down to the cause and you try to uproot the cause of the illness. And then Palliative is to stop all the aggressive treatment and to take care of the patient – taking patient as the center, giving comfort as much as possible.

The process of death, this is a common process of death. It doesn’t always happen like this but the majority of people will die, will have this experience. It happen two to three months before dying the patient suffers from appetite loss, he or she starts to refuse food and drinks, this is the time when all the family got very upset, alert and worried and the patient spend more time sleeping, and start to withdraw. And then a very interesting thing is that he starts seeing dead people. Sometimes these images can interact or talk to them too. And then more and more withdrawn, more and more prolonged sleeping and start to disorientate and a few days before dying, one or two days, usually he or she gets better. Good orientation, remembers everyone correctly and start eating food that he or she loves. Then suddenly weaken and expire. This a natural process of dying.

In preparation of death, medically the doctors have to judge when to stop curative, when to say enough is enough. From curative to palliative, when to stop giving chemotherapy which will weaken the patient causing more trouble and then start giving morphine, treating pain, giving good oral care or to put or to discharge from hospital and allow the patient to stay at home. Most patients like to die at home. When there is a research done in the United States and around the world the preference of people would like to die at home – not at hospital. But the family would like to treat the patient in hospital for many reasons. Because first they think that they could be cured, they believe that, some family member who believe that life should be saved at all costs but some they are afraid of ghosts. They fear that if their father or mother die at home, their ghosts will be there and not good, bad luck and some just want to keep because they don’t know what to do –they were in frustration.

And we found in Thailand that the most problem is pain management. Most doctors didn’t want to given morphine, give very small dose and they say that the patient has only two months of survival, they’re afraid to give him morphine to make him addicted. There will be problem of morphine addiction. The patient has two months – why worry about addiction? You see? And simple question like oral care. The most common symptom after pain is oral care. Dry mouth is the most disturbing feeling of people who are dying and it can be simply treated by giving good oral care.. Home care is also good. Allow the patient to die at home – train members of family to be good nurse, caregiver. And the one we found in common in Thailand after 1997 we have the bubble burst of the economy.In 1997 in Thailand the rate of suicide is one suicide per hour throughout the country. It was so bad. And most common complaints that members of the family of the patient say is financial need is very important The second is psychological care. Most doctors look over this and never pay any attention. Social and family is very important. Many people before they die when they have broken relationship. It’s our duty to bring those relatives who have been away, left the patient, to come and say goodbye, to offer thanks and forgive each other.

Spiritual care is often neglected in Thailand. Legal preparation and lastly bereavement. These are six factors of Holistic care for people who are dying. Bereavement is the care of the survival. Those people who lost their loved ones, suddenly, unexpectedly or violently still retain a scar in their mind, they are injured. If they are little children they grow up with a sense of emptiness. They lost trust in people and these people will have a bad time socializing, - they don’t want to give love to anyone because they felt they don’t know whether they will be betrayed. And if you share your love with other people what will happen? What will happen is that you trust no one so you cannot grow in society. In our society we need trust. To form a community we have to trust one another but here the relationship is injured from beginning. Then the child has a very dim future and if the bereavement process was not commenced correctly finally it will lead to a very bad future, bad omen for the person. So ethics at the twilight zone - we have to have a clear cut protocol - when to switch from palliative to curative, when to say that is enough Doctor, let our father, let our mother, let the patient stay in peace and be comfortable. And also truth-telling - who is going to tell? How? And what will happen if the patient could not cope with that news, or the family could not cope with that news. Whether to issue a 'Do Not Resuscitate' order – DNR, when do you say you don’t want any aggressive maneuver any more. And also problems with the medical team, whether they are trained to share a similar view, whether some doctors believe in palliative philosophy – that means to say I want to treat, I want to save life at all costs or just want to turn to palliative medicine or whether there’s problem with family that need to be helped. Whether you should use morphine or not. Some patients will say morphine will get me addicted so in my next life I will be addicted to morphine – they prefer not to have morphine and there are lots of pain. In Thailand many patients endure pain because they feel that endurance is good, forbearance is good. When the patient is in bad pain and when the doctor come and ask whether you are okay..'yes yes I’m okay. No problem.' But very painful. And many doctors prefer to give morphine at the time of pain. P-A-I-N for pain. So instead of painfree you have pain every four hours or six hours. So the ethic of giving morphine is very important. And who is going to decide all of these? That is the problem. Different face in different society. And who is going to take care of the survivor? And how far? Legal document is very important. In America they have law which advocate advanced directive. Advanced directive is a document the patient writes. The patient writes in exercise of a personal right of autonomy. He say I don’t want CPR or having DNR order issued and he describe when to let go, when to go to hospice. And in some disease for example the patient cannot decide for themselves, they pass the power of decision to another person. In some cases like Alzheimer - you lost your memory, you couldn’t even remember your wife or your husband, you don’t know what is happening to you, then who and how are you going to decide for yourself? So some people with history of Alzheimer pass this decision-making authority to a third person – to a loved one or to a physician.

I’d like to suggest you read a book called Tuesday with Morey. It’s a New York Times bestseller for many years. It has been produced into a movie by ABC – American Broadcasting Corporation – broadcast about three or four years ago. It has become a social movement for end-of-life care in United States. The story was that there was a professor, his name was Morey Schwarz. He was a professor at a University called Brandites, Boston, Massachusetts. He was diagnosed of ALS – amyotrophic lateral sclerosis. It’s very slow painful death – it’s motor neuron failure, the muscles fail to work starting from one point. It has different patterns but for him it start from his foot, spread upwards till he couldn’t breathe at all and he died. He died in peace but before he died he had a kind of session with his ex-students and he questioned many things. The story tell you how to treat the meaning of life. And Professor Morey faced death wisely, with delight and happiness. He was not at all demoral, he was strong and it seems that he has his own life philosophy and he felt that when you know how to die you know how to live. So this is a good movie and it’s a good book. In America patients who has six months prognosis will be allocated to hospice. Hospice is communal care, charity based. Eighty five percent of hospice staff are volunteers and eight to eight-five of them are home care, not institutionalized This is with holistic treatment, with cultural sensitivity. The goal is one – peaceful, painless death. And central is family with childcare and bereavement. So hospice staff not only pay attention to the qualify of life of the patient but how life is lived in the family who have lost the patient. At least for another year there will be someone to care for those who’ve lost their loved ones. Bereavement is done by first detection.Not after death has taken place but before, - in preparation for transition, such as healing of broken relationship and find ways to replace the loss, you see. Many people, many important people, well-known people, through bereavement they became new person, renew their life and got well. For example there was a famous pop-star, Paul McCartney – he became a great musician because he play the guitar after he lost his mother. It was a tragic feeling for the boy entering into teenage life, he lost his mother, he spend time, passing time practicing guitar, so he convert bad energy into creativity. And finally through it he became a very good guitarist and good musician and became a world famous rock star. So replacement of loss has to be planned, counseling.

Moral will is another one. I found that in preparation for dying, for bereavement, if the patient has some loved ones and it’s time to say goodbye, to offer thanks and to beg for forgiveness or something, better have it done before he or she die. May be in written document or videotape or in audiotape record. I have a case whom I attended, I treated the patient and she was fifty-two years old, a Christian woman who suffered from breast cancer and she found that she had a lump in her breast, about 1980 and she received a complete operation, mastectomy but she lost follow-up, never saw a doctor. A year later she got metastasis - so bad, the tumor metastasized in her lung, in her abdomen, in her intestine, spinal cord, bones. She was living a very miserable life. And she couldn’t sleep in a dark room and if when someone spoke some bad word or irritate her she get very moody, she threw things about, so her family became like Hell. When she came to see me I taught her meditation – only fifteen minutes. But she was very peaceful. And then she thanked me, she returned home and she meditated very dedicatedly. And the day after, I called her again, as follow-up phone call and she said “ I never experienced any happiness greater than this in my life. The most beautiful feeling I have.” And she was never afraid of death anymore. Before that she always dreamed of dead parents, dead friends who came to see her and persuade her to go with them and she will incline to go with them also. And after that no more nightmare. She told me “I know where I’m going to be after I die. I know that I’m going to have happy death and happy afterlife. I see myself where I’m going to be.” And I record her on video and I played the video in her funeral. And that was a very good bereavement for her little niece, for many members of her family. And I sensed there are many people crying, seeing her face – talking in her video and she said happily, confered everyone to lead a good life, she thanked me as she found happiness, true happiness in life through meditation. That was very useful.

So the irony is the doctor who took care of her died a few weeks before her. He committed suicide – undecided love affair, because he was a very young, good-looking doctor, he had many affairs with many nurses, couldn’t decide whom he should get married to. And suicide may seem to be an easy way out, you see. And he’s the one who told her that she has about two months. Life is full of impermanence. I learnt a lot of things from this case and it was a case that finally allowed me to go to Oxford,and to be the first Buddhist monk to study and graduate at Oxford University. The family was very happy for me and they wanted to do something in return., and one of their friends was a former Prime Minister of Thailand who wrote me a very strong recommendation and opened all the doors to Oxford – that was in 1985. And so when a person die you have to monitor the survivor, try to walk them through. In care giving, in giving care to people who are dying, to a family, is not an easy job. It require not only good philosophy, true dedication, it also is a work of sacrifice and also it’s a good lesson to learn. I benefit a lot from giving care to people who die and I think it is a very important part of society.

You see we care for newborns in the crib, in the nursery but we thought that people who are dying deserve the least care. This is wrong. People dying need even more care than new born babies. New born babies hardly have any broken relationship, hardly have any pain, twenty four hours trouble with sleeping, trouble with eating, trouble with talking, communication. Many people, majority people in America – more than eighty percent – die in misery. When our society becomes more and more materialized, more and more complex, then the care to the dying seem to be neglected. And in America and in the West they honor the young people and they see old people as useless. They worship the youth as the young generation. If your’re young and you’re successful, then you are great but not old people. They feel that old people cause trouble, dependency – it’s not true. If you have a meaning of life it will mean not afraid of getting old or death. Getting old means you are more mature. You gain more maturity and you learn more, understand the deeper meaning of life. So people who understand the meaning of life shouldn’t be getting frustrated or fear of old age. They should enjoy more.

Life gives you the opportunity to learn, you see. So personally I think we don’t know when we are going to die, nobody can tell. We may belong to the eight point nine percent of the world population who die without any warning, without any sign. But if you know how to live, means you know how to die. You know how to die, you’ll know how to live. In Buddhism a good death is not death in the sleep. How many of you want to die in sleep? That is escapism. A good death is a death surrounded by love, with time to say goodbye, with time to address your loved ones, with respect, with time to offer, with time to say “ I love you. I forgive you” and that is a good life that is closing a chapter in life. That is a good death. If you die unconscious that is not a good death in Buddhism, you see. So in preparation for this we should learn how to love other people. We should extend our love and forgive everyone, everyday, at all times.

Loving consciousness is precious and we have this loving consciousness at all the times. That means we are preparing to know how to die. If you do this then this is the way we should live our life. Society will be a much better place if everybody prepares to die wisely, you see. Not to look at Final Exit. When you die, you use any kind of poison, you use drugs, you use gun or you lock yourself in a garage being overwhelmed by carbon monoxide – that is not a good death. There is no dignity in doing so. A good death – death with love, compassion, care, forgiveness offered to everyone. So this address is core for holistic care for the dying and it is a very rewarding job which has been very much neglected in society, sad to say. In Thailand also the majority die badly – either in pain or in miserable condition, no time to say goodbye or express their love or forgiveness. So we think it’s time to make a change in society. You think it’s not good enough system in society to take care, we should set up one. If you set up a system you must have volunteers – this is not so difficult and does not require sophisticated machine. But what we require most is love, compassion, understanding, and time to listen to people, opportunity to allow the ill to express themselves, to say their mind and focus on them and treat them with our priority. That is very simple – care.

Sadhu.