“When confronted with a patient’s fatal illness,” says physician Friederike Boissevain, “we are expected to know what to do.” But Zen practice has taught her that being present with a mind of not knowing is sometimes the best medicine.
I leafed through the man’s medical file. A CT scan showed extensive disease, and the histology was unfavorable. He was younger than me, with two children, and worked in the ship industry. He lived in a middle-class neighborhood where the hedges were neatly cut. Symptoms of his illness had shown up a year ago, but he was against further investigation. As I shook his hand in the waiting area and felt his firm grip, I looked into his determined, suntanned face—and the fearful eyes of his wife. In my office, I started with my questions. Before I had finished the second one, he angrily grabbed his file and said, “Nothing in here is true. It is wrong, wrong. I am well and I have no idea why I am here.” His wife looked at me and I could see her secret tears. I smiled at her. Slowly, with the kindest voice I could muster, I started again.
In my work as a physician, I often have to break bad news—to initiate a conversation with someone who has just learned that they have cancer. The ideal opening to a conversation about terminal illness simply does not exist. Time is short, and a lot of facts have to be covered, a task often hindered by strong emotions, mostly anger and grief. More important, a container—a medical-treatment plan, as well as an emotional one for the next months—has to be created and put in place. This conversation is always an approximation. The process is similar to translating a poem or to the experience, midway in painting, when it becomes clear that we might not stay with our initial intention. The options then are either to stop, which is easier on paper than during a conversation, or to do my best with what we have. Even the most skillful opening statement is only the best one possible in that moment. Although I cannot deny a certain sense of routine after having had thousands of these conversations, I still have to start anew every time, by both seeing and unseeing the course of cancer I know all too well.
At the end of another long day, a patient’s husband and children appeared at my office door. I did what I could to explain to the two wide-eyed teenagers and their father why I thought pursuing further treatment was no longer a wise choice. She had endured so much. A complicated bone-marrow transplant almost took her life, then left her unable to find a job, which resulted in a period of severe depression. A brief sunrise of ease and enjoyment was soon followed by the cruel relapse of her illness. Now, not even forty, she was a paraplegic and bedridden. Day after day, cancer cells conquered the islands of independence she had once held so dear.
“When?” I was asked.
I looked into their three sobbing faces, and my voice seemed to echo forever. Finally her husband said, “I understand. Thank you.”
They simultaneously put on their sunglasses as they left, stepping into the sunlit hall. I sighed and released them from their sad movie as they headed into the warmth of a beautiful summer evening. Later, from afar, I saw them downtown standing closely side by side and enjoying ice cream. Life goes on. They would survive.
With Zen practice it is much harder to shrink back into habitual tendencies when faced with the reality of death. Because of my practice, I am grateful for every patient who gives me the opportunity to apply my understanding of mindfulness in this process.
As physicians, we are trained to know. That is our job. If we don’t know, who does? Even in times of “informed consent,” our influence in decision-making is necessarily greater than that of the family or spouse. Confronted with a patient’s fatal illness, we are expected to know what to do. Without challenging the trust placed in physicians, one of the things I am learning from my Zen practice is not-knowing.
How can this be applied to a science? Knowledge is good. I need knowledge to make an appropriate decision. But “knowing” the facts often impairs our ability to really listen to a patient.
Dogen has taught me to drop the information in the file, my proposal, and first ask my patients, “What brings you here?” There isn’t always a response right away, and it can be difficult to wait and not jump in.
Doing is easier than non-doing. In modern medicine, doing something, doing anything, can be so much more appealing than “doing nothing”—like sitting on a cushion and waiting for things to arise.
The silence might bring up a question I did not expect. Someone whom I’m sure asked to see me to talk about the side effects of treatment might actually want to inquire about the risks of going to a dentist or taking a long-planned weekend vacation during their medical regimen.
Occasionally, out of this silence, while discussing subjects that are mundane, intimacy arises: that unexplainable, unlearnable miracle when there is no gap, just confidence and trust. It sometimes feels like we’ve made a pact to go through this hand in hand. I have an unspoken obligation not to quit first, not to give up on the patient. This commitment reaches beyond personal preferences. The patient may have chain-smoked, tortured animals, mistreated a spouse, abused children—it does not matter. We are painting on a new easel—now. Our last chance in our dying moments should always be drawn on white paper. We bring in old colors, but we have a fresh white page to start with.
Physicians committed to practicing mindfulness walk this path free of hesitation, without a need to reflect on what brought us to the profession. We are not doing this to help “them”—the poor patients. This is a common misunderstanding, especially in the health care world. We are doing this to help ourselves. And the only way to fully follow this path is to do it along with “them.” This is our path to enlightenment.
This path is all about the relationship with ourselves and the myriad dharmas—this great assembly of beings is one thusness. There is no hidden jewel outside or inside ourselves to discover. Living and practicing together in peace and harmony with other people is the jewel.
Recently, I greeted a long-term cancer patient who had just turned twenty-nine. His illness had progressed, and he had been in and out of hospital several times. The caretakers had decided we should meet and talk about whether to continue chemotherapy or move on to palliative care.
The patient arrived jaundiced and frail, using a walking aid. He had a shunt that drained his cerebral fluid and tubes to replace his bladder and bowel functions. While he prepared to sit down, I flashed back to a young, vital-looking father who talked enthusiastically about his work and was looking forward to his children entering their school-age years.
Now it was hard to imagine this was the same person. Yet, he emanated contentment. He did not bring up anything additional; there was no reproach, no wrestling with his condition, no attempts to explain.
In other words, I did not sense any separation between his expectations about his life and his current experience. There was no story. He simply told me, “I am fine. No nausea today. I slept well. I had an entire glass of tea.”
If this body does not exist, there is no pain. There is only dissolving pain on the spot. We have no choice but to face the moment right in front of us rather than the many stories we choose to add. No matter what happens to us in our life, we have to live it in the here and now.
It is easier to trust Dogen’s statement when things are running smoothly, but they seldom do. When we are faced with the loss of our home or the death of our child, or when we or a loved one develops a fatal illness, the jewel can be hard to find.
And yet we can trust it. By sitting down again and again, by “opening the hand of thought” during zazen, by practicing mindfulness in formal practices like chanting and oryoki, by staying with “one-thought, one-action” at a time during our daily activities, we can acquire the trust to respond to whatever situation life brings us.
If we do not just respond or react but live fully in that moment, even in the midst of so-called adverse circumstances, the jewel reappears. It takes on the most beautiful color it has to offer— the one that perfectly matches here and now.
Dying is not what we think it is or what it sometimes looks like.
After twenty-three years of caretaking, having witnessed countless brave ones enter a path from which no one ever returns, I am not sure I know more about life and death than I did in the beginning. There is a moment after death when everything—the deceased’s shoes, glasses, smell, the sound of his or her particular voice, the smile—is still there. And yet, what happens?
Dying is a precious experience that is deeply embedded in human existence, and as physicians we can try to cultivate an inviolable awe toward the grand miracle of death.
I hope to continue holding deep respect for death’s unstained integrity even amid the benefits and challenges of hi-tech Western medicine. And maybe, when the day comes, I too can bow to it with an attitude of calm and curiosity.
The entire body is radiant light even if it seemingly deserts us, which eventually it will. We might become too weak to walk. We might become morphine dependent. It might take us half a day just to get up and dress. We might be unable to leave our bed, with only a few days left.
Yet we can always heal.
We owe this healing to our humanness—the part of us that has been waiting so long to be invited in. We owe it to the ones who underwent much harder challenges and extremes than we face today to hand down this precious practice to us. Think about your spiritual heroes. How long ago did they live? Under what conditions? What did they have to risk to stick with their vows? Their flame is still burning. They consumed the wind of their lives so fully that their flame now reaches everywhere.
We owe this healing, plain and simple, to the ones who seek our help and whom we have vowed to care for.
Dogen is so modern in his understanding of my weakness. Looking at the many things happening in this world, it appears that there may be a way to avoid the dharma. Looking at myself, I see how many times during just one period of zazen I, more or less willingly, give myself permission to go astray and wander off into the land of dreams and worries.
This seemingly strict Zen master who led such a focused life says we might try to avoid awareness in the moment. Dogen thereby shows great sympathy for my countless weaknesses and habitual tendencies. Yet even with my worst conditioned patterns, in my darkest moments of entanglement, because I made it onto the cushion one time, I cannot get lost again. Looking back at my own crooked path of Zen practice, the most important thing I ever did was to sit down once. Everything else followed from there.
This experience can’t be erased. Whether or not it is continued and developed further, it sets something in motion that cannot be stopped. This is not because of trust in something but because of experience—an experience so many of us, now and then, have had. The snow of dharma covers everything, whether we see it or not.