ESSENTIAL VEDIC PRINCIPLES GOVERNING PALLIATIVE CARE

Excerpted from the Lecture of HH Giriraj Swami, “ DEATH AND DYING IN KRSNA CONSCIOUSNESS’.On May 19, 2005, Giriraj Swami was invited to address the physicians and nurses of San Diego Hospice and Palliative Care. This extraordinary institution has a staff of six hundred and serves, at any one time, 850 to 900 patients. It is the only hospice in the US that boasts its own free-standing hospital, treating terminally ill patients' incidental maladies as well as offering relief for their pain. Dr. Parag Bharadwaj hosted the talk.Within the general category of Hindu there is a wide variety of practices, because the term Hindu itself is not indigenous. It is not found in the Vedic literature. It is actually a term that was coined later by Muslims to refer to the people across the Indus River, whom they called Sindus or Hindus. But seventy to seventy-five percent of Hindus are Vaisnavas, worshipers of Visnu, or Krsna. And another twenty percent are worshipers of Siva and Sakti. The worshipers of Sakti, called saktas, are related to the worshippers of Siva, called Saivites, because Lord Siva’s energy, or sakti, is called Durga. Saktas generally worship Durga, or Kali. Together, the Saivites and saktas comprise about twenty percent. And in the other five percent, there are different varieties.But on the existence of the soul, and the fact that our activities in our present lives--actions that are called karma--create reactions that we suffer in our future lives, all Hindus agree. In general, there are two categories of activities in the material world: prescribed, or pious activities done within the guidelines of scripture, within the laws of God, the laws of nature, and prohibited, or sinful activities, which violate the laws of God or nature. Sometimes people don’t like to hear the word “sin” because it is often used without any clear definition. But as we use it--and of course, we have actually translated the Sanskrit term vikarma--sinful activities are any acts that transgress the laws of God, just as crimes are any acts that violate the laws of the state. So vikarma is any action that violates the laws of God, specifically as they are recorded in Vedic literatures.So, on the one side we have forbidden, sinful activities, vikarma. And on the other we have pious activities. Now, everyone engages in a combination of pious and sinful activities. No one is all good, and no one is all bad. And according to one’s karma, one will enjoy and suffer the results. The result of a pious activity, an activity that is beneficial for oneself and for others, is material happiness, and the result of a sinful activity, or an activity that is harmful to oneself or to others, is pain and suffering. We all have engaged in a combination of pious and sinful activity, and so our present lives are composed of a combination of pleasurable and distressful situations.Now, the same act can have a pious aspect to it and a sinful aspect to it. For example, a man’s family is starving, so he steals some money or food for them. Under ordinary circumstances, bringing food for his family is his duty; that is what a husband and father is supposed to do. But stealing, obviously, is outside of his prescribed duty. His prescribed duty is to earn by honest means and provide for his family. And there are sins that are sort of accidental: you do something with a good intention, but it ends up producing a different result. Still, the consequences are there. As it is said, the road to hell is paved with good intentions. There are consequences, and therefore in the Vedic culture knowledge is considered important, so that you know the consequences of your deeds. In a way it is similar to medicine. In ordinary circumstances, if someone is sick we presume that he or she came in contact with a disease. We may not be able to trace exactly when and where, but the fact that he or she has the disease implies that he or she came in contact with it. For example, a tourist may go to India and get dysentery. Now, what exactly caused it? Was it this water? Was it that food? It may be hard to trace, but the fact that the person has dysentery suggests that the person came in contact with worms or amoebas or another microorganism in their food or drink.So karma is like that. We are suffering, and the fact that we are suffering suggests that we did something in the past that is giving rise to our suffering, although we may not be able to trace exactly when and where or what we did. But just as you can learn that you will pick up disease by drinking impure water or eating improperly cooked food or by coming in touch with other people who are infected, so too you can learn that if you do this there is that consequence, and if you want avoid the consequence you avoid the action or perform some other action that would counteract it.This knowledge of action and reaction is given in Vedic literatures such as the Bhagavad-gita and Srimad-Bhagavatam. And such information is very important. Vedic authorities state that suffering is caused by sin and that sin is caused by ignorance. For example, if an ignorant child touches a flame he will be burned. Ignorance of the law is no excuse. The child can’t say, “Well, I was ignorant. I did not know I would be burned.” The fire won’t excuse you because you are ignorant of the law, although I may add that responsibility for karma begins only when the child is five years old. Until then the parents are responsible and they get the reactions for the child. But from the age of five the child enjoys and suffers according to his activities, and therefore knowledge is important. We want to remove the ignorance. Most people transgress the laws of nature unwittingly, but they still have to suffer, because ignorance is no excuse. Thus, knowledge is the real remedy. If someone gets dysentery, you may give the person some medicine and put the person on some diet and they will be cured. But if they don’t know the cause, if they remain in ignorance, they will go out and drink the same contaminated water or eat the same infected food and get sick again. So we can do things to temporarily mitigate the condition of distress, but unless the person has knowledge of what caused the sequence of events that led to the distress, he or she will continue the same pattern and continue to suffer.Question: Is there any way to gain release from such suffering?Giriraj Swami: Excellent question. As long as we are engaged in material activities, whether pious or sinful, we remain bound to the material world, and as long as we are in the material world and have a material body, we have to suffer--whether the majority of our actions are pious or sinful. There are four principles of suffering that everyone must endure, whoever they may be: disease, old age, death, and rebirth. So the real goal of human life or Vedic civilization is to be released from the cycle of birth and death. That is called liberation, in Sanskrit moksa or mukti. Now, how do we achieve that release from material bondage? By engaging in activities that do not bring any material result. Of course, in a general sense all of our activities are karma because in a generic sense karma just means activity. But in a more specific sense karma means activities performed within the laws of God, as opposed to vikarma, which are activities outside the laws of God, in the material sphere. And then there is the third category called akarma, and akarma does not bring any material result. Akarma releases one from material bondage altogether, and that is really the goal, because even if you are ninety-nine percent pious, you will still have to take birth again in a material body to enjoy the material happiness that is due to you. And as soon as you are in a material body, you must suffer disease, old age, and death.So the real solution is not to have to take birth in another material body but to go to our original home in the spiritual world, to go back to God.Question: Could you give some examples of actions that would be neutral? I’m not quite sure of this. I always thought they would be either good or bad.Giriraj Swami: In technical language those activities are called either yoga or bhakti, because the ultimate process to gain release is called bhakti-yoga. Yoga literally means to connect with God, and the astanga-yoga practice--which is not really practical today--but the astanga-yoga practice begins with yama and niyama, following rules and regulations. Any spiritual practice will begin with following rules and regulations. For example, in the Vaisnava tradition the rules and regulations are no eating meat, no gambling, no taking intoxicants, and no sex outside of marriage. So yoga begins with yama and niyama. Then there is asana. That is also a preliminary stage, and that is very popular in the West. And there is pranayama, breathing exercises. That is also popular. But the actual purpose of these preliminary practices is to reduce the pains of the body so that the yogi can meditate on God for long periods without being disturbed. That is the actual purpose. So to take the preliminary practices of yoga, which are beneficial to one’s health, as the end, so that one can be healthy and energetic to enjoy the material aspects of life--that is not the original intention.And the higher practices. There are pratyahara and dharana, which is meditation but at intervals. Then there is dhyana, a concentrated type of meditation. And the eighth or final stage is samadhi, complete absorption in God consciousness. That complete absorption in God consciousness is beyond material dualities. It is beyond material pious activities and material sinful activities, and it brings one to liberation.Now, in the present context, that type of yogic discipline that was performed in the Himalayas is very difficult. Therefore, for the modern age, the scriptures recommend the chanting of mantras, especially the maha-mantra: Hare Krsna, Hare Krsna, Krsna Krsna, Hare Hare/ Hare Rama, Hare Rama, Rama Rama, Hare Hare. And there are other mantras. But that is called the maha-mantra, “the great chant for deliverance.” Yet even though chanting, as a physical practice, is easier than meditating in a cave for hours or days on end, still it is hard, because we get restless. Therefore, in the practice of bhakti-yoga there are various activities, all connected with God. The idea is that somehow or other all of our activities throughout the day should be connected with God.Specifically, there are nine processes: sravanam kirtanam visnoh smaranam pada-sevanam/ arcanam vandanam dasyam sakhyam atma-nivedanam. There is hearing and chanting the name of God--or not just the name, but chanting about God in general, including His form, His qualities, and His pastimes. And hearing about God. In a way, that is what we are doing now; we are hearing about God. Then, remembering God (smaranam) and serving Him (pada-sevanam). Arcanam, worshiping in the temple or church, and vandanam, offering prayers. And these nine have been analyzed into sixty-four, and the sixty-four have been further analyzed. For example, in offering prayers there are two subdivisions. One is offering prayer that comes out of one’s own heart, and the other is reciting prayers from the scriptures or from sages and saintly persons of the past. So that is vandanam, offering prayers. Then dasyam, considering God to be your master or father, and sakhyam, considering God to be your best friend. And finally, atma-nivedanam, giving everything to God. The idea is that whatever we do should be done in relation to God. And activities done in relation to God are called bhakti-yoga, and they bring no material result. It may sound a bit theoretical, but it is practical.In Vedic civilization the time of death is considered the final test. In school we attend the lectures, do the assignments, take the quizzes, and write the mid-term, but whether we graduate or not really depends on whether we pass the final examination. So in life, the time of death is considered the final examination, and passing the final examination means thinking of God. That is why the whole focus at the time of death is to help the person remember God. And the other activities that we perform during our life, besides freeing us from activities that will bring results that will oblige us to take birth again, are practice for thinking of God. And we get little tests along the way. We get sick. Am I going to remember God, or am I just going to worry about the toothache? I am just going to frantically call the dentist and forget about God? So these are the tests along the way. Are we going to remember God or not? And then the final examination is the time of death, and if we can remember God then, we graduate. We are free: no more material bodies, no more repetition of birth and death.Question: In the work that we do we are often looking at physical pain. I was just curious in terms of the medication that we administer to alleviate physical pain and suffering, should those be discouraged? Would those be considered as interfering with consciousness at the time of death?Giriraj Swami: Very good question. How do we feel about medication to control the pain? Again, we come back to the goal. The goal is to remember God at the time of death. So our general approach is that we want to take enough of the medication so that the pain is not so excruciating that our consciousness is just absorbed in the pain. But at the same time, we do not want to take so much of the medication that it dulls us to the point that we cannot really think of God. That is the fine line that we look for.Question: If a foreign devotee or just a foreigner from another country would like to spend their last days in India and would like to be cremated there, is that difficult?Giriraj Swami: No. It is not. Are you talking about someone who goes to India to die or someone who . . .Question: Someone from another country who is ill and wants to spend their last days in India.Giriraj Swami: Yes. I will tell you exactly. I won’t burden you with all the details now, but the basic idea is that you need to make a living will that says that you want your body to be cremated in India. If you are American, you take that to the United States Embassy or Consulate so that they are included from the beginning. I think there is also another form where your immediate family sign their consent. You take that to the American Embassy or Consulate, get the necessary papers, and then when you actually do leave your body everyone knows what your desire was. No one has any objections and you will be cremated without any problem.Question: I have another question: if someone expires here and they want to bring their ashes to India?Giriraj Swami: Yes, that happens often.Question: I have two questions. Is Krsna the earthly manifestation of God and, according to the Hindu tradition, is there any benefit to suffering?Giriraj Swami: Very good questions. Krsna exists as Krsna in the spiritual world eternally. He comes to earth on occasion, but He is the same Krsna. He is like the president or the governor who chooses to visit the prison. He is free to enter the prison whenever he wants and to leave whenever he wants. An ignorant prisoner might think, “Oh, he is another prisoner just like us.” But he is not. He is visiting the prison, but he is not bound by the laws of the prison. So when God or an incarnation of God descends from the spiritual world into the material world, he or she is called an avatara. The Sanskrit word avatara literally means one who descends. Within our line of Vaisnavaism we consider Jesus to be a saktyavesa-avatara. He is in that category of someone who descended from above to the world for some purpose. He delivered the message of Godhead.Question: Is Krsna an avatara? Or is Krsna just Krsna and others are avataras?Giriraj Swami: Technically, Krsna is called avatari, which means that He is the source of all avataras. But He can also be considered an avatara, because He also descends, like just Rama or any other incarnation. But He is called avatari because He is the original. They are all eternal. It is a little subtle, but He is considered the original, or the full manifestation.Now for the question of suffering. On the material platform, the value of suffering is that it burns up your bad karma. That is why many Hindus prefer to tolerate rather than protest, because they know that by tolerating the suffering they are exhausting their sinful reactions, and they feel that they would rather get it over with than try to postpone it by trying to counteract it, and then have to suffer it again later in another form. That is on the material platform. On the spiritual platform, the benefit is that it makes us more detached from the body and from the world. We are trying to become transcendentalists, but we still have material attachments. So when there is some upheaval or calamity we think, “Yes, actually the material world is not a happy place. I should not be spending my energy trying to make it happy, because by nature it is not a happy place. Lord Krsna confirms in the Bhagavad-gita, duhkhalayam asasvatam: ‘This material world is a place of misery, and it is temporary.’ I should be using my energy to realize God and get out of here.”Question: Can you expound a bit more about remembering God? Is it just saying the name or thinking the name of God, or is it coming back into a state of divine consciousness where one actually feels a connection with God?Giriraj Swami: What do we mean when we talk about remembering God? Now, God is a person. That is the first point. He is not a person like you and me, who have bodies made of flesh and bone. He is transcendental. But He is a person. The Bible says, “Man is made in the image of God.” We are persons, and so our supreme father or mother must also be a person. This is a difficult point, because we are so conditioned by the material concept of personality that when we hear about God’s personality we think in terms of our material conception. Sometimes people think, “If you say that God is a person you are limiting Him.” For example, I am sitting here. Because I am sitting here, I cannot be in the temple at Pacific Beach; I cannot be at my asrama in Santa Barbara. But God, He is a person, but He is in this room, He is in the temple in Pacific Beach, He is in Santa Barbara, He is in our hearts, He is in every molecule and every atom. But He is still a person.Here I would like to use an example of a person and who holds a high office, but the thing is, today’s politicians are all so controversial that it is hard to come up with a good example. [laughter] So let us make up a country [laughter], the president of a country. The term president describes his office. Or let us say the mayor. We hope the mayor is not controversial. [laughter] Oh, the mayor here is very controversial. All right, then let us take the mayor of some place we don’t know about. [laughter] Let us take the mayor of Davenport, Iowa. [laughter] So, “mayor” describes the office, but there is a person that occupies the office. And the person has a name; the person has an appearance; the person has personal qualities; the person has certain activities. Take the president--minus the controversy. He has a name: George W. Bush. He looks a certain way. If you see a picture of him you know, “There he is. There is President Bush.” And he has certain qualities. Some people like them more than others. But we know that he is bit of a cowboy, or that he is sort of religious and Christian. He has certain qualities, and he has certain activities. Apart from his official duties, he likes to go his ranch and walk around and ride around and whack weeds. So when we remember the president . . . Yes, there are things about the office that we consider, but to really remember the president means to know his name, his form, his features, his qualities, his activities, his associates. God, too, has a name; He has many names. He has a form; He has many forms. He has many qualities. He has many activities.And the real goal is to love God. “To know Him is to love Him.” The actual goal is to develop love for God, because when you love God then naturally you will think of Him. Anyone you love, you will naturally think of the person. So that is the goal--to develop love for God. And out of love you will be thinking of how beautiful His form is, how sublime His qualities are, how wonderful His activities are; you will like to repeat His name, just as one would repeat the name of a loved one; and you will think how best you can serve Him and please Him.So, one distinction between some of the Vedic literatures and other scriptures in that they give more details about the Personality of Godhead--not just that He is the supreme authority, the creator, the maintainer, the destroyer, and the protector, omniscient, omnipresent, and omnipotent, which He is, but in a more personal sense. And when we know Him in a more personal way and develop affection and attachment for Him in a personal relationship, then it will be very easy to think of Him all the time, and naturally we will think of Him at the time of death.Here I may mention that the fullest conception of God includes a male and a female form. This is not something we are making up to be politically correct, but this has been in the tradition for thousands of years. So although I have used the pronouns “He” and “Him,” in the highest conception there are actually two, male and female. Yet this is not polytheism either. It is really God and His energy, and together They comprise the complete form of the Supreme. In the Hare Krsna maha-mantra, Hare refers to the feminine feature and Krsna refers to the male aspect of God.Question: As workers in hospice we work with the families of patients and deal a lot with the grief, the loss of the soul in this body that they have enjoyed in the physical context. It seems that at the time of death--and I might not be saying this right--but a person could hear the name of God or think of the name of God, but we’re outside of that person, so in what ways can we can bring comfort and assurance to the family members? How can we be a comforter and supporter for them in their grief and the loss of their loved one?Giriraj Swami: That is another good question. The first instruction of the Bhagavad-gita, and I believe it is common to many other traditions, is that the person is not the body. The person is the soul living in the body. When the person leaves the body, we say that the person is dead, but actually the body was always dead; it was just animated by the presence of the soul. So at the moment that the soul leaves the body, all the elements of the body are still there, lying on the bed. You may lament: “Oh, my husband is gone.” “My wife is gone.” But why do you say they are gone? The body is lying on the bed. You might have thought that the body was your husband or your wife or your father or your mother, but when they pass away, you say, “Oh, my father is gone.” “My mother is gone.” But the body is still there. Why do you say they are gone? Intuitively, we know that the person was not the body. That loved one is something other than the body that he or she now has left; that person is the soul.When a person has led a good life, and even more so when he or she has tried to develop their relationship with God and hear the name of God and think of God at the time of death, we can be assured that the person will be going to a better destination. So there are many emotions. In part there is the sense of personal loss, that the person whom we loved and shared so many good times with is gone. In part, out of love, there is concern. Where is the person now? But if we know that the person has gone to a better place, we feel solace. And in painful illnesses such as cancer, we may also think, “All right. The soul has left this body, and this body had become very painful. It had become a painful place for the soul to inhabit, so it is actually better that the person has gone elsewhere.” The person, the soul, continues to exist. He or she has gone to live somewhere else, where there will be less pain and suffering.Still, we do not deny the sense of personal loss. Even among transcendentalists there are various emotions. When a perfect yogi leaves the body, we know that the person is qualified to enter the kingdom of God, so we are happy. We are both--happy and sad. We are happy because we know that the person has gone to God, to serve God, but we are sad because we will miss the person’s association. Still, the departed soul, we believe, can inspire and guide their loved ones who remain behind.Then there is also the idea that God is responsive to prayer. So if a loved one leaves the body, we know that the soul exists somewhere. We don’t know where, but we want to help the soul, because we love that person. So we can pray to God, “Wherever my mother is now”--or “my father” or whomever--”please be merciful. Please help that person come closer to You.” And I believe that those prayers will help the departed soul, and they will also give us a chance to continue our relationship with our loved one and to try and help our loved one even after he or she has left the body.Then there are the bereaved’s own spiritual practices--chanting or meditation or prayer or whatever. Yes, we are attached to our loved one and we are sorry because we will miss our loved one, but by chanting or prayer or meditation we come in contact with God. Of course, in the initial stage they may be too distraught. But then when we do engage in some practice that will bring us in touch with God, we feel, “God is there. It is all right. God is there. God is taking care. My real relationship is with God. By God’s grace I can gain His shelter in the future.”Question: We are almost out of time, but I just have to ask you this question. A lot of patients ask, “Why is this happening to me? Is God punishing me?” and this causes a lot of spiritual suffering. From your perspective in the Hindu tradition, how would you approach this question?Giriraj Swami: If someone is suffering from a terminal disease, I would not get into the idea that God is angry with them and is punishing them. I would rather say, “Anyone who takes birth in a material body has to die.” That is the point. “Birth, disease, old age, and death are inevitable for every conditioned soul. It may be this disease or that, it may be this symptom of old age or that, or it may be this or that way to death. But these factors are there for everyone. And now that you are in this position, you should use what time you have to develop your relationship with God, so that you do not have to take birth in another material body and suffer through the same cycle again.”Question: A lot of it is a fear that bad karma is causing it?Giriraj Swami: Well, it may have. Our teacher gave the example of someone drowning and another person coming along in a boat to rescue him. And the drowning person says, “Now wait a minute. How did I get here in the first place?” But that is not the point here. The rescuer would say, “Okay, we can talk about that later. [laughter] You are drowning. Just get in the boat! Don’t worry about the past.” So we are drowning in this body, in this samsara, this ocean of repeated births and deaths. Let us not worry how we got here. Let us try to get out. And it is never too late. That is power of God’s name and God’s mercy. It is never too late. There are stories in the Vedic literature of people who were very sinful but at the last moment chanted God’s name and were delivered. So it is never too late. That is the main point. So I would think, “Yes, let us not worry about that. Let us worry about how we can rectify the situation.”Question: A lot of our patients never made it to old age, and then it’s very difficult for everybody--the patient’s family and us--when they seem to not complete, in our perception, their life. What’s the approach to that?Giriraj Swami: Their destiny is caused by their activity, their karma. For whatever reason, they did something that is causing them to leave the body before the normal time. But the positive side--we always have to see the positive side, which is the spiritual side--the positive side is, depending on the circumstance, that a younger person may be better equipped to think of God at the time of death than an older one who has lost more of his or her faculties. In fact, there is a Sanskrit prayer:krsna tvadiya-pada-pankaja-panjarantamadyaiva me visatu manasa-raja-hamsahprana-prayana-samaye kapha-vata-pittaihkanthavarodhana-vidhau smaranam kutas teIt may seem contrary to our Western culture, our materialistic culture, which is so preoccupied with pampering and preserving the body, with staying in the body as long as possible, with squeezing out the last drop of pleasure from the body. [laughter] But this prayer, in opposition to that mad pursuit, offers a more philosophical perspective. In it the devotee prays to the Lord, “My dear Krsna, please let me die immediately so that the swan of my mind may be encircled by the stem of Your lotus feet. Otherwise, at the time of my final breath, when my throat is choked up, how will it be possible for me to remember You and chant Your holy name?” That is another perspective on dying before old age--one that is positive and spiritual.Hare Krsna.San Diego HospiceMay 19, 2005(Note: What is Palliative Care?"Palliative care is an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems."Objectives of Palliative care:-Provides relief from pain and other distressing symptoms;-Affirms life and regards dying as a normal process;-Intends neither to hasten nor postpone death;-Integrates the psychological and spiritual aspects of patient care;-Offers a support system to help patients live as actively as possible until death;-Offers a support system to help the family cope during the patient’s illness and in their own bereavement;-Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;-Will enhance quality of life, and may also positively influence the course of illness;Source: WORLD HEALTH ORGANISATION, GENEVA, 2002.)
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