What will happen to me in my last weeks of life?
A Tibetan Buddhist Perspective 
The Buddha taught that dying and death is a very important transition to the next life, and that if we want the best chance to return with a happy human rebirth, that we should try to die peacefully and with virtuous thoughts, for example, feeling gratitude for the help your carers have given so selflessly in your last weeks.
Signs of approaching death can include one or more of the following: profoundly weak, essentially bed-bound, kidneys and liver deteriorate, toxins start to accumulate, no excretions, can’t swallow, disinterested in food or drink, drowsy for extended periods, disoriented with time, short attention span.
Terms you may hear used by the nurses and doctors, and how some palliative care nurses and Tibetan Buddhists interpret them, are the following: peripheral shutdown (extremities cold – not painful), terminal dehydration (actually creates euphoric feeling), terminal dyspnoea (frightening – may require morphine to help breathing), terminal restlessness (life review, spiritual struggle, extra morphine – terminal sedation – not necessary).
The Last Few Weeks of Life:
Reflections on the Personal Experiences of Jeffrey Hopkins 
 Excerpts from the Foreword by Jeffrey Hopkins to: Advice on Dying and Living a Better Life by His Holiness the Dalai Lama, translated and edited by Jeffrey Hopkins, Rider, 2002.
Questions and Conclusions composed by Len Warren and members of the Wheel of Life Palliative Care Support Group.
I gained many insights from the Dalai Lama’s teaching and learned much that later turned out to be very useful.
Death of Jeffrey’s father
My father had a stroke when he was 81. We were all very relieved when he rose from his comatose state and even returned home. However, by the time I arrived a few weeks later my father was back in hospital, comatose again. One day he was lying on his back and he opened his eyes. He turned and we began gently talking. At one point with a playful gleam in his eyes he said, “You wouldn’t believe what’s going on in this hospital.” Wondering what he meant, I happened to look up at the TV at the foot of his bed. A steamy hospital soap opera was on, and I noticed that the hospital had put a small speaker by his pillow. While in his coma he had heard all those shows! I later turned off the speaker, remembering that at the time of death it is most valuable to have someone remind you of virtuous thoughts. A few days later when he again regained consciousness, I turned off the TV that was blasting out a quiz show, and we went on to have a nice conversation. He died during the night. How relieved I was that before he died, he had come to his senses with his spirits restored. And that the TV was silent. I sat beside his body, and kept silent because I did not know his particular vocabulary of religious belief. Just by being there I felt I could support him on his journey.
- Did you know that near death, people can hear and know what’s going on, even though they may appear unconscious?
- Well before death, it is important to practise being peaceful from moment to moment; then there is a better chance of being peaceful at death.
- At death, it is important to try to recall virtuous actions. It would help to be clear about what is virtuous and to have created some virtue during your life.
- Did you know that a person who has just died can sense your thoughts and will be supported by silent prayer? You need first to believe in the power of prayer and it helps to know how to pray and what to pray for.
Death of Jeffrey’s mother
A year later my mother suffered what was probably a stroke. Mother rang my brother and said she felt terrible. Then her voice faded away. Subsequently the hospital brought her back from death’s door three times, leaving her struggling to communicate. Seeing her incoherent struggle, I remembered that the Dalai Lama had spoken of the need for friendly advice that could evoke a virtuous attitude, and approached her bedside. I knew that her special word was “spirit” so I said, “Mother, this is Jeff. Now is the time for the spirit.” She immediately settled down and stopped struggling. I gently repeated, “Now is the time for the spirit.” A few days later, she died peacefully.
- Have you ever noticed whether any of your close relatives or friends have special words, phrases, or sayings that are specially meaningful to them from an emotional or spiritual point of view?
- To be of any use after a stroke and before death, meaningful words, phrases, or mantras would preferably need to have been used and thought about for many years beforehand.
Death of Jeffrey’s cousin Bobby
When my cousin Bobby was diagnosed with brain cancer, he said that what he would like while he was still active was for all the cousins to gather and tell stories about grandpa. Most of us had hilarious stories to tell, which I videotaped. On Bobby’s next-to-last day, the family watched the videotape of the cousins’ gathering and put it away. The next day with everything kept simple and quiet, he died.
- It helps the dying person to let go if objects of attachment (sometimes this might also include family and friends), a day or so before death.
Death of Jeffrey’s friend Raymond
When my friend Raymond knew he was dying of AIDS, he and his partner asked me what they should do. Remembering my parents’ deaths and my own paralysis and near death from Lyme disease, I knew that long after we become unable to interact with others, we can have a strong, lucid, interior life. During my extreme illness, I internally repeated a mantra that I had recited over the course of almost thirty years. Bearing in mind my own experience, I suggested to Raymond that he choose a saying that he could repeat over and over again. Raymond had time to practise his mantra. His partner put it in a plastic frame by his bedside, so when Raymond turned his head, he saw it and was reminded to repeat it. After he lost the capacity to speak or to move at all, I sat on the floor beside his bed and gently repeated the words of his mantra, “May I be filled with loving-kindness.” Then his face lit up and his eyes moved underneath his closed eyelids. It had worked!
- Learn a simple mantra or prayer that can be remembered close to death
- To make the most of your own death, you need to become familiar with what will happen and how you should try to respond to the stages of dying.
- To help others who are dying, you need to have confronted your own death, studied the teachings, and tried to practise them over the years.
- To have the courage to suggest things for others to do at the time of death, you need to have thought deeply about dying beforehand yourself.
The Buddhist teachings contain all the steps you need to prepare for death, as well as detailed descriptions of the death process, the intermediate state and rebirth.
Personal Meditation on the Last 48 Hours of Life
Based on the Observations of Denise Barham
 Denise Barham, Int. Journal of Palliative Nursing 2003, Vol 9, No 6, pages 245-251
Meditation composed by Len Warren September 2017
Denise Barham observed and recorded the behaviour of a practising Buddhist as she died, and published her findings (see reference above). Based on what she observed, I have composed a meditation that tries to capture the essence of the various physical and psychological events that will occur in the last 48 hours (or thereabouts, nothing is certain) of life.
“This is so frustrating. I want to meditate but I can’t. My concentration is no good anymore. Ten minutes is all I can manage. Sometimes. Can you help me please? Just read my favourite practices to me. The Six-Session Guru Yoga Prayer is a good one to start with. The Medicine Buddha Sadhana is a favourite. Also A Daily Meditation on Shakyamuni Buddha and the Overflowing Nectar of Bodhicitta. Thank you, thank you. You are so kind.”
“No, I don’t want anything to eat. Not a thing. It’s OK. No, I can’t drink either. It’s normal when you’re dying, didn’t you know? You mustn’t think I have to eat or drink. And don’t please don’t give a drip with saline in it. I’m actually feeling better now I’ve stopped trying to eat or drink. Oh, yes, that’s nice, just a few drops of water on my tongue. Thanks.”
“Arrggh! That really hurts when you move me. But no, I don’t want more morphine. I don’t want to be knocked out. I can hardly think but that’s better than not thinking at all. Just help me do some breathing meditation. Guide me through it please. I haven’t got the energy to do it myself. Teacher, I’m so glad you are here. Please say some more prayers. They calm me and I feel better. And they will help me have a happy rebirth, I am afraid of the lower realms, I don’t want to go there.”
“I can’t breathe properly anymore. It feels as I’m drowning. Give me some air! Ahhh, that’s nice, the gentle air from that little fan is good. Thank you. No, no, I don’t want the oxygen thing in my nose, it’s not as effective as the fan. More morphine? OK, just a little, it does make breathing easier.”
“I’m sorry but I can’t talk much anymore. I know I’m dehydrated but really it is OK. Actually it feels good. I don’t want water from a drip. I just want to die naturally. Talking is too hard but I am aware of all you say, I can hear everything very clearly. Sometimes it seems that I know what you are thinking. Oh, what was that terrible noise? The TV? It has really upset me; who made it? Can’t you be quiet? Oh, no, I’m getting angry and that is the last thing I want before I die. I do regret that outburst. Just play some chanting or prayers or say some prayers quietly, please. Ahh, that’s better, thank you.”
“They are coming to get me! Black, horrible. No! Go away! Don’t touch me! Yes, I did hurt others exactly as you say, but I’m sorry and I didn’t know what I was doing. Now I know better. Yes, the karma must ripen, but not now, please!”
“There’s a beautiful incandescent white light in front of me. What is it? I’m being enveloped in it, I feel peaceful at last. I can go now.”
The last 48 hours of life: a case study of symptom control for a patient taking a Buddhist approach to dying
Int. Journal of Palliative Nursing 2003, Vol 9, No 6, pages 245-251
Extracts from the Summary
Sarah died at 8:15 am on 12 June 2000, in Sydney, aged 39 years, survived by a husband and two children, aged 6 and 4 years. She had lived with breast cancer for four years, through operations, radiation and chemotherapy. Three weeks before her death, Sarah was admitted to a palliative care unit. Her goal was to die a peaceful death. At the time of her admission, extensive discussions were carried out between her, her family and the multidisciplinary team. Sarah prepared for her own death and expressed wishes that she hoped could be carried out in the last few days of her life.
Sarah practised Buddhism on a daily basis. She asked that she be allowed to be in charge of her death as much as possible.This was very important to her, in relation to her religious beliefs. She was not afraid to die, and as death became more imminent she welcomed it and longed for it.
Events in the Last Few Days
In the last week or so before her death, Sarah was distressed as a result of fatigue. She could not meditate more than 10 minutes. She often needed help to complete her practices.
Sarah became too weak to eat or drink. She knew this was a normal stage of dying. Her husband gave a few drops of water with a syringe every half hour.
Sarah had asked that morphine for pain control not be increased during the last 48 hours of life i.e. she had refused “terminal sedation”. At times, she moaned or cried out when being repositioned, but then settled. She relied on meditation and calm support from family and her Buddhist teacher to deal with pain.
Sarah started to become short of breath, and breathing became noisy and rapid (“terminal dyspnoea”). Sarah preferred a cool, gentle stream of air from a fan rather than oxygen via a nasal cannula. A low dose of morphine was given when she was distressed with not being able to breathe.
Sarah became dehydrated, with dry skin and membranes and thickened secretions. But she had refused “terminal rehydration”, as she knew that dehydration was a natural stage of dying.
In the evening, Sarah’s respirations became very moist with prominent “terminal death rattle”; she was semi-conscious and unable to swallow. She was lucid for about an hour.
Soon after midnight, Sarah became very restless (she had been calm up to this point). She started having hallucinations, and would toss and turn while moaning, reach out to something. Her family believed that she was experiencing blissful visions. This stage is called “terminal restlessness” and most dying people experience it; often they appear frightened, distressed and anxious.
At 8:15 am, Sarah died quietly, surrounded by her family and her Buddhist teacher.
 Contents of this web page prepared by Len Warren of Pure Land of the Indestructible Buddha, Hayagriva Buddhist Centre, 64 Banksia Terrace, Kensington 6151 Western Australia, September 2017.