Hindu End of Life - Death, Dying, Suffering, and Karma

Hindu End of Life

Death, Dying, Suffering, and Karma

Susan Thrane, MSN, RN, OCN

Hindu suffering can be perplexing to Western

thought. With almost 2.3 million Hindus

of Indian origin and an additional 1 million

practicing American Hindus now in the

United States, healthcare practitioners need to

know more about the tenets of Hinduism to

provide culturally sensitive care. Family and

community interconnectedness, karma, and

reincarnation are major beliefs of Hinduism.

Healthcare decisions may be made by the

most senior family member or the eldest son.

Karma is a combination of cosmic and moral

cause and effect that can cross lifetimes and

life lessons learned for spiritual growth. The

belief in reincarnation gives great comfort to

the dying and their families because they know

their loved one will be reborn into a new life

and that they are not gone forever. Enduring

physical suffering may lead to spiritual growth

and a more fortunate rebirth.

KEY WORDS

end of life

Hinduism

karma

reincarnation

suffering

eath is a universal experience. No matter what

our culture, our religion, our race, or our coun-

try of origin, we will all die. How we approach

death, how we think about suffering and grief, and

what we believe happens after we die vary based on

our culture, religion, and spiritual beliefs. Spiritual be-

liefs ground our thinking about end-of-life concepts.

Humanists, which include atheists and agnostics, be-

lieve that death is the end.

Christians believe that death

is the beginning of everlasting life with God.

Hindus

believe that while death is the end of this life, it is also

the beginning of a new cycle.

Several estimates of the number of Hindus in America

exist. According to the magazine Hinduism Today, there

are about 2.3 million Hindus of Indian origin and an-

other 1 million practicing American Hindus.

4,5

Every

state in America has at least one Hindu temple, while

larger metropolitan centers have many.

Historically, in

the West, there has been very little exposure to Hinduism.

With the exception of Hare Krishnas, one sect of

JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010 337

Author Affiliations: Susan Thrane, MSN, RN, OCN,

is Senior Research Specialist, City of Hope, Duarte, CA.

Address correspondence to Susan Thrane, MSN,

RN, OCN, City of Hope, 1500 E Duarte Rd, Duarte,

CA 91010 ([email protected]).

The author declare no conflict of interest.

DOI: 10.1097/NJH.0b013e3181f2ff11

Hinduism, Hindu people do not believe in proselytizing,

nor do they often talk to outsiders about their religion.

With the population of Hindus growing in the United

States, healthcare practitioners need to know more about

this faith to be able to provide culturally sensitive care.

CASE STUDY 1

Mrs S. is an 85-year-old Hindu woman brought to the

emergency room by ambulance. She has a history of con-

gestive heart failure and hypertension. She has been in

the hospital three times this year. She is having trouble

breathing and ‘‘lightheaded,’’ and her family is concerned.

After diagnostic tests and physical examination, it is found

that Mrs S. has symptoms of fluid overload, and her

ejection fraction is 12%. A urinary catheter is inserted, and

she is given a diuretic. Mrs S. goes into shock, develops

respiratory failure, and is put on a ventilator. The physician

has a discussion with the family about the seriousness

of Mrs S.’s condition. Mrs S. does not have an advance

directive. Hindus rarely have advance directives because of

their belief in karma and reincarnation. After a discussion

with Mrs S.’s husband and children, the decision was made

to extubate and give comfort measures only. This decision

to shift the goals of care to palliation is in line with Hindu

beliefs relating to karma. Being kept alive by machine is

often viewed as interfering with karma and inhibiting the

natural course of death. Hindu people view death as a part

of the natural cycle of life. Death is a transition to a new

life. This case illustrates the importance of assessing cul-

tural factors in palliative care and good communication to

ensure optimum care.

HINDUISM 101

Hinduism is the oldest known religion, having been

practiced over 8000 years as evidenced by ancient Hindu

scriptures.

Table 1 highlights some basic Hindu beliefs.

Several newer religions have roots in Hinduism includ-

ing Jainism, originating around 3000

BCE; Buddhism,

originating around 600

BCE; Sikhism originating around

the 16th century; and Brahmoism, originating in the 18th

century.

Hinduism is unique in that it has no founder,

no beginning that we can point to, and no one holy book.

The most holy Hindu text is called the Veda: a word that

means wisdom. The Veda consists of four books and

more than 100,000 verses.

Other holy texts are called

the Upanishads and the Puranas.

The Bhagavad-Gita

(song of God) is generally accepted by all and appears to

be the most popular of Hindu sacred texts. According to

Jeste and Vahia,

the Bhagavad-Gita is the most recent of

the sacred texts and the most practical, giving devotees a

more practical guide to Vedic wisdom.

One of the basic tenets of Hinduism is a belief in one

God called Brahman. Brahman can take many forms,

which means that there are literally thousands of gods

and goddesses in Hinduism that each contains a part, or

embodies a characteristic of Brahman. Many Hindus

choose one god or goddess as their principal representa-

tion of Brahman, but may have many gods and goddesses

that they worship or celebrate. Daily worship called puja

includes lighting incense, prayer, and meditation and is

often performed as a family in the morning before every-

one starts their day.

Puja can be performed anywhere,

but many families either have a room in their home ded-

icated to worship or at least an altar displaying statues or

pictures of their chosen deity.

Reincarnation and Karma

Two important tenets of Hinduism that guide one’s ac-

tions and influence suffering are karma and reincarna-

tion. Reincarnation essentially means to be born again.

The body is like a set of clothes that the soul removes be-

fore putting on new clothing. From a Hindu viewpoint,

one can be born as a human, an animal, an insect, or even

aplant.

What form the next incarnation takes depends

on karma, and one can move up or down the hierarchy. If a

person has lived a good life and performed more good deeds

than bad, they are born into a more fortunate existence.

Table 1

Key Issues for Culturally Sensitive Care

for Hindus

Highlights of Hinduism

& Oldest known religion still in practice.

& Belief in one God with many forms.

& Spirituality is a way of life for Hindus.

& Family is very important, and healthcare decisions are

often made communally with the senior family member

or eldest son as the final authority.

& Karma is moral cause and effect of thoughts and

actions.

& Reincarnation means being born into a new existence

on earth to evolve spiritually.

& Adherence to traditional values depends largely on

acculturation.

338 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010

Karma guides how a Hindu lives, and each person’s

deeds both in current and past lifetimes determine what

sort of rebirth they attain. Karma is a combination of

cosmic and moral cause and effect that crosses lifetimes

and life lessons learned for spiritual growth. There are

three types of karma: karma from past lives that may or

may not be experienced in the present lifetime, karma

currently being created, and future karma or karmic ex-

periences saved for a future lifetime.

A devout Hindu

will be non-violent on every level including the practice

of vegetarianism. The ultimate goal after living many life-

times is to be released from rebirth or to achieve moksha;

becoming one with Brahman.

Caste System

A discussion of Indian culture and Hinduism would be

incomplete without a mention of the caste system. For

thousands of years, a strictly defined social structure ex-

isted in India. Each group or caste performed certain

functions in society. The four main groups were the

Brahman or priests; the kshatriyas, which were gover-

nors and administrators; the vaisya, who were the mer-

chants and farmers; and the sudras, who performed

menial tasks such as street sweeping and were considered

spiritually unclean. The caste system was abolished in

1947, and while its influence is fading, some effects remain.

Spiritual Suffering

Suffering for the Hindu is highly related to the concept of

karma, for example, ‘‘Belief in karma and reincarnation

are strong forces at work in the Hindu mind.’’

14(p29)

Any

good or bad thought or action leads to reward or pun-

ishment either in this life or a future existence. Hindus

believe that there are certain life lessons to be learned

before achieving moksha. Working through the karmic

situation will resolve that karmic issue resulting in a

lesson learned.

A Hindu who is getting older or who has a terminal

illness will ‘‘tie up loose ends’’ by apologizing where

needed, talking with family and friends to resolve con-

flicts, and generally fulfilling all known responsibility.

The goal of a well-lived lifetime therefore is to perform

good deeds, to practice devotion to God, and to learn the

karmic lessons encountered.

Spiritual suffering for a Hindu comes from knowing

at the end of life responsibilities are left undone, karmic

tasks are not completed, or bad thoughts and deeds pre-

dominated. The concept of karma conveys that suffering

is part of life. Suffering is a result of past thoughts and

actions either in this life or a previous life. By enduring

suffering, a Hindu ‘‘pays for’’ or cancels past negative ac-

tions. ‘‘Suffering can be positive if it leads to progress on

a spiritual path, Ito be tested and learn from a difficult

experience.’’

16(p609)

What may appear to be needless suf-

fering to Western minds may be, in fact, a striving to

meet death in a clear and conscious state and may be an

attempt to atone for karmic debt.

From a nursing perspective, karma and spiritual suffering

can have several ramifications. Hindus who feel they need to

diminish or alleviate past karma may wish to endure

suffering. This may involve fasting, doing penance such as

intense prayer or worship, or enduring pain even when

medication is available. Fasting can have several forms. The

patient may wish to avoid only certain foods or not eat

certain meals or at certain times of the day. Other forms of

atoning for bad thoughts or deeds can include confession to

a guru or priest, repentance either public or private, sacrifice

such as shaving the head, religious ceremonies, gift giving to

the poor or to the temple, and pilgrimages to sacred spots.

Obviously, participation in these activities depends on

whether the patient is at home or in a healthcare facility

and whether he/she is ambulatory or near death. Assisting

the patient and family to be able to complete religious

ceremonies, prayer, or penance may be very important to

their spiritual well-being. Assisting the patient and family

does not necessarily mean participating; it can mean

helping them find the materials or just assuring them that

they will not be disturbed. Allowing private time and space

for these activities will be helpful.

Suffering in Death and Dying Pr actices

Fearing death is natural and results from a fear of the un-

known. According to Hinduism Today, a person with a

terminal illness should tell family and friends so they

can prepare for their loved one’s death and be happy for

them.

Death is the fulfillment of this life and a chance

for a better reincarnation, a chance to learn new karmic

lessons and to move closer to moksha.

Hindus believe that death must come naturally at the

proper time. Life should not be prolonged by aggressive

medical means unless it will result in a good quality of life.

Prolonging life artificially would result in the soul remain-

ing on earth past its natural time ‘‘tethered to a lower astral

region rather than being released into higher astral/mental

levels.’’

14(p32)

Hindus will often forgo aggressive treatment

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when an illness is terminal or there is no hope of recovery.

If the patient is a parent of young children, more aggres-

sive treatments are often sought in the hope of prolonging

life to provide for the children. Nor should life be cut short

willfully. Speeding up death by artificial means would

result in a large karmic debt. Suicide would result in many

lesser rebirths to ‘‘make up’’ for the karmic debt of ending

one’s life unnaturally.

Thoughts at the moment of death

will result in a greater or lesser rebirth. (See Table 2 for a

summary of palliative and end-of-life issues.)

Hindus may endure pain or uncomfortable symptoms

to face death with a clear mind. They may use medication

to control symptoms, but may avoid using so much that it

reduces their consciousness. Rabindrnath Tagore,

Hindu philosopher, once said ‘‘let me not beg for the

stilling of my pain but for the heart to conquer it.’’ Hindus

will, if at all possible, be thinking of Brahman at the

moment of death and therefore experience a higher state

of consciousness and a higher astral plane after death.

Intentionally bringing all one’s attention and energy to the

top of the head and thinking thoughts of Brahman help

the soul leave the body in the highest possible state.

Ideally, a Hindu should die at home surrounded

by family and friends who will sing sacred hymns and

say prayers or chant the dying person’s mantra in his/

her right ear if he/she is unconscious. As death ap-

proaches, the bed should be turned so the head faces

east. Hindus with a terminal illness or certain other

disabling conditions are allowed to choose a ‘‘self-

willed death by fasting’’

but must tell their family and

community. This is an acceptable method of ending

suffering.

Case Discussion Continued

Mrs S. was extubated per her family’s wishes. Friends of

the family brought a CD player and played some tra-

ditional music. The temple priest was called and brought

Tulsi leaves and sacred water. Mrs S. was given medi-

cation to relieve her pain and comfort measures includ-

ing cool cloths, and positioning with pillows. Family,

friends, and the temple priest stayed with Mrs S., read-

ing from holy texts and praying. Her youngest son

chanted her mantra into her right ear. The priest applied

holy ash to Mrs S.’s forehead and placed a few drops of

sacred water and a Tulsi leaf into her mouth for purity

and a peaceful death moments before she died.

21,22

Postdeath Rituals

After death, all the pictures of deities in the household

are turned to face the wall. The body is placed in the

home’s entryway with the head facing south ‘‘reflecting

a return to the lap of Mother Earth.’’

15(p170)

If a patient

dies outside the home, the family may want to bring the

body home for ritual bathing, dressing, and for friends

and family to say goodbye. If necessary, these rituals

can take place in a mortuary.

Bodies are always cremated, never embalmed, although

they can be frozen for up to 3 days so relatives can attend

the funeral rites. The family may wish to witness the cre-

mation and even start the cremation fire. The family may

return to collect the ashes directly from the crematorium.

After the family returns from the crematorium, everyone

bathes, and the entire house is cleaned. The ashes are

scattered in an ocean or a river or are sent to India to be

scattered in the Ganges River. Infants and young children

are the exception to the cremation rule: since they have

not accumulated bad karma and are considered pure,

infants and young children may be buried.

(See Table 3

for a summary of postdeath practices.)

Table 2

Nursing Care Issues for Palliative and

Hospice Care

& Palliative care is aligned with Hindu values.

& Most Hindus are vegetarian. Assisting patients with

menu choices or having a dietary consult may help

Hindus receive acceptable food. Families may bring

food from home.

& Suffering is individualVsome may believe that suffering

is beneficial for their Karma, some may not.

& Respect the choice patients make for the use of pain

medication: most will likely want a moderate amount to

relieve pain while maintaining awareness, but some may

want little to no pain relief from medications, believing

that suffering will ease karmic debt.

& The family may want to turn the bed so the head faces east.

& End-of-life rituals such as chanting in the loved one’s

right ear and putting Tulsi leaves and water from the

Ganges River in the mouth are important for the soul’s

purity and peaceful transition.

& Autopsy is not allowed unless required by law.

& Organ donation is discouraged since it interferes with

both the donor and the recipient’s karma and the

donor’s reincarnation.

& Above allVask about the family’s traditions and needs

before the last minute; everyone is unique.

340 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010

The period immediately following death is considered

a time of impurity. A pot of water is set in the entryway

and is changed every day for 31 days. On the third, fifth,

seventh, and ninth days, a meal of the deceased’s favorite

foods is prepared, and a portion is put in front of a

photograph of the deceased. The time of impurity can

last from several days to a year. The length of the time of

impurity is traditionally determined by caste: the lower

the caste, the longer the time of impurity.

During this

time, the family lives in seclusion and does not partici-

pate in festivals, celebrations, or temple observances.

PROFESSIONAL CARE ISSUES

Healthcare decisions in Hindu families will likely be made

by the most senior member of the patient’s family or the

eldest son.

Hindu culture believes in ‘‘human interde-

pendence and interconnectedness, which is understood to

be the foundation of well-being.’’

10(p28)

In other words,

Hindus do not have the same concept of individuality and

autonomy that Westerners prize so highly; family and

community are more important. Other cultural differ-

ences may or may not be relevant, depending on the

acculturation of the family, and are directly contradictory

to Western views. For example, addressing the head of the

family first shows respect in Indian culture, while main-

taining eye contact with a head of family or elder shows

disrespect. The best course is to tread lightly and be aware

until discernment can be made of individual preferences.

Accepting the end of life is part of Hindu philosophy.

Artificially prolonging life is generally thought of as in-

terfering with karma. Interventions such as intubation,

artificial feeding, or very aggressive care in the face of

a terminal illness would go against traditional Hindu

thinking. Palliative and comfort care are in line with Hindu

thoughts on karma and reincarnation, concepts that West-

ern caregivers need to be aware of.

Two other issues that relate to end of life include organ

donation and autopsy. Autopsy is avoided unless required

by law. Hindus believe that disturbing the body of the

deceased is disturbing to their soul and inhibits the soul

from moving onward.

Organ transplantation is another

practice that is conditionally discouraged. From the donor

perspective, a part of the body lives on and interferes with

reincarnation. From the recipient perspective, part of the

donor’s karma is transferred along with the organ espe-

cially a major organ such as the heart, liver, or kidney.

Depending on the views of the family, donation of an organ

other than the heart, liver, or kidney may be permissible.

Spirituality and culture go hand in hand for Hindus, and

Western medicine is beginning to acknowledge the im-

portance of spirituality in healthcare. Spiritual issues are

now being addressed for patients, especially at end of life.

In a study of 560 nurses who cared for dying patients in

Ethiopia, Kenya, India, and the United States, nurses from

all four countries identified spiritual interventions such as

praying with or praying for the patient and reading from

holy texts as helpful or important to patients and families.

The similarities between cultures speak more loudly than

the differences. Nurses from all four cultures stressed com-

passion, respect, and individualizing care based on patients’

needs. Specific culturally based interventions mentioned by

the nurses from India included allowing family member to

offer Tulsi leaves (a type of basil) for purity and water from

the Ganges River for a peaceful death.

21,22

CASE STUDY 2

Mr A. is a 73-year-old Hindu man with end-stage pan-

creatic cancer. He is cachectic, bed-bound, and unable to

eat. Mr A. rates his pain as 10 of 10 and is refusing pain

medication saying, ‘‘I want to be awake and need to

conquer my pain through meditation.’’

Case Discussion

It would be appropriate to gently question Mr A. and his

family regarding his beliefs surrounding both pain med-

ication and his spiritual values. It may be that Mr A.’s

spiritual beliefs lead him to suffer pain for the sake of

karma, or he may be unaware that pain medication can

be given that will not make him unconscious. He may

also feel spiritual distress because he cannot overcome

his pain with meditation and needs some counseling

Table 3

Care Concerns After Death

& Pictures and statues of deities are turned to face the wall.

& Allowing the family to bathe and care for the loved

one’s body may be an important ritual.

& Cremation occurs within 24 hours if possible.

& Family members attend the cremation and bathe after

returning home.

& A ritual time of impurity is observed.

& Ashes are scattered in an ocean or river or sent to India

to be scattered in the sacred Ganges River.

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JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010 341

from his spiritual advisor.

If Mr A. feels he must suffer

for his karma, his decision must be accepted.

CONCLUSION

Nurses who care for Hindus at the end of life whether at

home or in the hospital should remember that Hindus

are very family oriented and so may have many visitors at

one time. There may be singing, chanting, praying,

reading from holy books, and shared food. Healthcare

decisions will likely be made by a senior family member or

eldest son.

With a growing number of Hindus in the United States,

it is helpful to know something about Hinduism to pro-

vide culturally sensitive care. Some of the main beliefs of

Hinduism include the belief in one god named Brahman

andabeliefinkarmaandreincarnation.Karmaistheprin-

ciple of cause and effect that can continue over many life-

times. Any thought or action, good or bad, contributes to

karma. Reincarnation is being born into a new life to learn

spiritual lessons and to resolve karma from previous life-

times. Belief in reincarnation gives great comfort to the

dying and their families because they know their loved one

will be reborn into a new life, and they are not gone forever.

Palliative and hospice care are aligned with Hindu

values. Hindus believe that death should neither be

sought nor prolonged. Spiritual suffering is connected to

karma. Enduring physical suffering at the end of life may

reverse bad karma. Hindus would like to die at home

surrounded by family. Ideally, they would like to be con-

scious and be thinking of Brahman at the very moment

of death. If the person is not conscious, having the eldest

son or a senior family member chant the person’s mantra

(sacred phrase) in his/her right ear prior to death is help-

ful. Rituals such as placing Tulsi leaves in the mouth,

chanting, or washing the body may or may not be prac-

ticed by a particular Hindu family. Completing a spir-

itual assessment of the patient and family is essential to

facilitating appropriate spiritual care.

Acknowledgments

The author thanks Beverly Lunsford, PhD, RN, and all

the faculty at George Washington University Depart-

ment of Nursing for their inspiration and support.

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