Facing death in a hospital

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I saw this by member @Mkoll writing on suttacentral and thought it well worth adding here:

Mkoll: I live in the USA, was an ICU nurse for 3 years, and administered IV morphine to many dying patients. A few points from my experience.

IV morphine is one of the standard drugs prescribed when a patient is put on “comfort measures” at the end of life. IV lorazepam (Ativan) is another standard drug—it’s in the benzodiazepine drug class and relieves anxiety, reduces agitation, and causes anterograde amnesia (you’re likely to forget what happens after receiving it and while it’s affecting you). They can be prescribed as PRN (“as needed”) boluses or as a continuous infusion.

“Comfort measures” means that the patient’s condition is terminal, death is close, and the decision has been made to stop trying to cure the condition and instead direct care toward keeping the patient comfortable.

At the point when comfort measured are ordered, some patients are unconscious or delirious and can no longer make decisions for themselves—someone else, whether family members or the physician, makes this decision. Others are fully conscious and aware—they may choose to be put on comfort measures of their own volition. We won’t have a choice about what group we fall in when we approach death since it depends on our condition and disease process. It’s a good Dhamma lesson, teaching us that these things are not under our control or subject to our wishes.

Not every patient is put on comfort measures. Some patients or families want the medical team to do everything to keep them alive. We do this, but eventually they will “code” which means their heart stops and we try to resuscitate them (CPR, drugs, etc.).
By default, patients in the hospital are a “full code” meaning we will try to resuscitate them if their heart stops. If a patient has a Do Not Resuscitate (DNR) order, we won’t do this. Anyone with decision-making capacity can request a DNR for themselves.

As a patient in the hospital with decision-making capacity (i.e. not intoxicated, psychotic, delirious, etc.), you have the right to refuse a treatment. This stems from the ethical principle of autonomy. If you don’t want morphine, just say so.

Personally, if I still have decision-making capacity at the end of life, I would be OK with IV morphine if I felt I needed to take the edge off pain to better maintain mindfulness. I would only ask for a dosage of just that much. But I would likely decline Ativan because I think it would reduce my awareness in a way that morphine in appropriate doses wouldn’t. And I would have a DNR in place.

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Why in particular IV morphine rather than an injection or pills?

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I’m no professional, but the patient will likely not be able to swallow. It is the ICU she is speaking of. IV drip will be a slow and steady dose to keep a steady level rather than a sudden “hit” from an injection.

I once spoke with an ICU nurse who works nights. The scary thing I heard from her is the harvesting of organs. The body is still physically kept alive when they harvest. I didn’t have the heart to tell her directly, but I think she got the message that she needs to be careful about this. Kamma is not always fair.

I’m not sure about the whole process. There was also a recent story about an anesthesiologist who “did what she was told” and intentionally killed a patient for harvesting purposes. I think the brain was dead but the body was functioning. It needed drugs to stop the body from functioning. She confessed it 20 years later, knowing it was wrong. You can google this. There are a few cases known or maybe the same lady when I fact checked this with gpt.

So the issue at hand, when I saw this title, made me click and wonder, what if there were issues about harvesting organs before there is “true” death? They go by “brain death,” but in Buddhism the heart is where the consciousness is, and that is kept functioning until harvest.

In contrast, the heart stopping is not always an indicator of real death either, since CPR can bring one back. That is what “code” is all about in the OP. As buddhist we do not believe in Near Death Experiences. They are “near” to death. One might get insight as to other realms with NDE, but it is “near” to death rather than death itself. (do not intentionally try this).

I got very frightened that I would make a mistake in my speech when I spoke with my cousin who was on his last days and on his last few IV morphine days. He was coherent but said he was comfortable and didn’t feel a thing. As monks we need to be careful not to praise death in any form or way. My first words to him were, “As monks we must encourage you to live as long as possible.” Then we had our normal chat about life. I definitely would not want to be a worker in a hospice even though it might sound “insightful”. It is a battle zone and easy for bad kamma to be made. There is no such thing as mercy killing in Buddhism. It is killing by kāyadvāra. It is killing a human.

So while I didn’t tell the ICU nurse directly about this, I told her about the dhammas and to be careful. The ICU nurse on suttacentral probably has no idea about this angle that I am bringing to light.

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Good lord. I hope not!

An interesting topic for discussion. I am hoping to be educated more. :slight_smile:

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This is correct. And if someone already has an iv, there is no reason to poke them with injections all day long.

BTW, MKoll is a man. Based on seeing their knowledge of Dhamma, I imagine they are aware of Dhamma implications in their work

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A post was split to a new topic: Brain Death?

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I hope he sees this thread and adds more :folded_hands:

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How interesting. Would there still be risk of getting bad kamma for the doctor if hte patient agreed to organ donation under those circumstances? I’d imagine the kamma is probably not bad or even good for the donor themselves. But the doctor is killing a person with thier permission to save someone else.

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About “going to die anyway”

We are all going to die for sure. So cutting off the lifeforce before that actual time has ended is a kammic crime. The same is true with one day or even 10 seconds. If I give a dhammatalk and I praise death to someone on his death bed. The person listening loses his will to live. It is a pārājika offense.

BMC I p 81-82

The Vinita-vatthu also includes under this type of act any statements that a nurse might make out of compassion to shorten the miseries of an illness by encouraging a patient to let go of life so as not to dawdle in the face of death. Thus, the Commentary notes, a bhikkhu talking to a dying patient should be very circumspect in how he chooses his words, focusing not on how to speed up the dying process but on how to inspire the patient with the following thoughts:

“The attainment of the paths and fruitions is not out of the ordinary for a virtuous person. So, having formed no attachment for such things as your dwelling, and establishing mindfulness in the Buddha, Dhamma, Saṅgha, or the body, you should be heedful in your attention.”

The Vinita-vatthu to Pārājika 4 contains a number of stories in which bhikkhus comfort a dying bhikkhu by asking him to reflect on what he has attained through the practice, which was apparently a common way of encouraging a dying bhikkhu to focus his thoughts on the best object possible. The suttas also contain advice on how to encourage patients facing death. See, for example, MN 143, SN 36.7, and AN 6.16. In all of these cases, the advice is aimed not at precipitating death but at inspiring calm and insight.

The Vibhaṅga notes that a statement describing the advantages of dying would fulfill the factor of effort regardless of whether delivered by gesture, by voice, by writing, or by means of a messenger. The same holds true for any statements under the next type of act.

About My Donor Status

Currently, I’m listed as a donor. I only learned about this last year. I will look into removing my donor status because of this.
However, I offered my kidney to Ven Pa-auk Sayadawgyi but he is too old and has too many complications for transplants. When I told my friend about this who was a doctor (before ordaining), he told me that I’m too old for donations anyway. (age 30 or below is best).

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Hmmm. Interesting. Good thing i didnt become a doctor :sweat_smile:

I think ill keep my organ donor status as i dont really care about dying prematurely when im in that kind of state and cant really accumulate merit anymore anyhow. As for the doctors kamma - i guess its just one of those unavoidable things that i shouldnt think too deeply into.

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I will probably make a video about this. This is something that only Westerners would actually bring up. Although the bodily warmth is very clear among those who know Abhidhamma, it is not really a topic due to the lack of machines and cultural norms that have this as a topic.

However, the issue for “killing” kamma is that one must perceive life in a living being.

  1. Perception of life
  2. Intention to kill
  3. Effort killing in bodily action or prompting with words or even praise, etc
  4. Result = death

Otherwise if one of the factors is missing, there is no completion of kamma. So, if I were to give a Dhamma talk about killing a brain dead person who is still “warm”, giving them wisdom to what defines life, then if they unplug the machines knowing this information, they will incur the kamma. All the factors will be there. If they don’t know this, they will not have the kamma. Perhaps the same could be said about abortion as well which is far worse.

So a famous monk in Australia who likes to say whatever he wants (not to mention names), also spoke about how he thinks there is no life in the early stages. If he believes this, then there is no kamma and no pārājika as some might guess otherwise. However, my guess is there is still some vipāka for spreading ignorance, disrespect of the elders etc. The result could be that he will be an embryo or even fetus and get his rare chance for human birth, only to have someone abort it thinking “it is not living”.

  1. When the mother has an abortion, the pain that arises in him through the cutting and rending in the place where the pain arises that is not fit to be seen even by friends and intimates and companions—this is the suffering rooted in abortion. (p. 512)
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As others have said, patients at the end of life will get to the point where they can’t swallow. Give them water to help swallow a pill and it could all end up in their airway, causing more problems. Also, as a general rule, drugs have a faster onset and stronger effect when given IV bolus versus PO (by mouth).

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