“Nothing Lasts Forever”: A Reminder from the COVID-19 Pandemic

Abstract

“All compounded things are impermanent.

All emotions are pain.

All things have no inherent existence.

Nirvana is beyond concepts.”

           _ Buddha Sakyamuni

Suffering and cause

In Buddhism, suffering is a broad concept referring to pain, grief, misery or dissatisfaction, believed to be caused by ignorance, anger, and attachment, which are inherently an integral part of human beings. Heavily discussed in Buddhism, Karma (cause-effect) believes that every action, speech, intent/thought continuously produces a reaction that influences the future of the individual (1). Therefore, the COVID-19 pandemic that the entire humanity currently experiences too is a result of our Karma, determined by our behaviors and intentions. Nevertheless, the Buddhists principles of impermanence say that all phenomena are transitory and depend on the influence from other phenomena (2). Hence, COVID-19 too is a transitory and a passing thing.

The truth of impermanence helps us to understand that death and life are an unavoidable part of cyclic existence (3) and that everything is constantly changing (1) in this universe. In many Eastern cultures, including Bhutan, the world we live in is viewed more holistically, and death is perceived inextricably linked to life (4). Death is a natural part of life and the relationship between the living and the deceased continues (5).

Since the outbreak in Wuhan city, China, in late 2019, COVID-19 transcended global barriers, infected millions, and caused thousands of death (6) a scale previously unknown to humanity. COVID-19 continues to be a nuisance in every aspect of living. The current experience of the COVID-19 pandemic is not only a cause of healthcare crisis, but also rapidly becoming a social, economic, rights, and humanitarian crisis (7). Practices of safety measures including social distancing, wearing of face mask, frequent handwashing, have upset diverse societal conventions related to friendships, courtship, traditional delivery of end of life (EoL) care and funeral (8, 9). The practice of physical distancing and restrictive visits to healthcare centers parted away family and patient, often leading the latter to die in isolation deprived of care and support from the immediate loved ones. Many victims of COVID-19 have taken their final breathe through a ventilator in the health institutions, in the presence of doctors and nurses who witness the death pallor behind their facemasks and protective gear. The least these healthcare providers could do was to hold the hands of their patients, provide comfort, mitigate lonely death feelings, and be family in the final moments of their life (10). Fortunate are those who might have caught the last glimpse of their final departure through a smartphone screen, and exchange gratification and forgiveness. Such facilitation is critical and has influenced effective communication between families, parents, and healthcare providers, enabling quality of dying and bereavement (9). Currently, there is no greater than COVID-19 pandemic who teaches us that nothing is more valuable than love, family, community, socialization, communication, and togetherness.

Good and bad death

Dying with dignity recognizes the intrinsic, unconditional quality of human worth but also the importance of physical comfort, autonomy, meaningfulness, preparedness, and interpersonal connection. Maintaining dignity especially in the final moments of life is of paramount importance in most cultures (11), and can be preserved by applying caring attitudes and behaviors, compassion, and dialogue (12), facilitated by considering physical, emotional, social, religiosity, spirituality, and the cultural dimensions of the person (13, 14). This is, however, greatly affected during COVID-19 pandemic where the patient often dies alone in ICUs and hospital wards. Furthermore, the anguish, fear, depression and anxiety could challenge the preservation of the dignity of the patient and family, including the care provider. Death is generally considered good if met without fear (15), surrounded by close family members (3), happens at the place of choice such as at home (16), able to say goodbye (14). However, the attainability of good death, and how those lost their life to COVID-19 confronted dignified death is debatable. Whether the death during COVID-19 was ideal, honorable, peaceful, dignified, or a brave face often indicated good death (13) deserve further exploration to shed light on death preparation in adverse times. Nonetheless, Buddhists would argue that death preparation is not confined to EoL but in every fleeting moment of time (16).

On the other hand,  a “bad death” includes a long and painful dying process, death by suicide (17), dying in solitude as is the case during COVID-19 (16), or dying away from home (13). Unlike past, when death took place at home surrounded by family members and relatives, in a familiar environment, most people today die in the medical institutions surrounded by medical equipment, technology, and strangers, often is the case during COVID-19 pandemic. This has created a culturally incongruent situation for the patients and relatives which they have to accept this undesirable option with much ambiguity (18).

When death is imminent, Buddhists caring for the dying person focus on the patient’s state of mind at the moment of his/her death by reciting prayers around the dying person to aid the departing go in peace (19). Facilitation of such care is generally challenging during COVID-19 pandemic, however, every effort is made sure through the execution of standard operating procedures, so that, dignity in death and dying, funerals, rites and sensitivity are respected in Bhutan (20). Globally, new guidelines and policies related to the management of dead bodies, funerals and burials are implemented to contain COVID-19 spread (21). Guidelines issued included only immediate family members be allowed to participate in the funeral ceremonies provided social distancing are respected, numbers to not exceed 10 to 30, as well as ceremonies and rituals involving chanting, raising voice, or contact deceased through touching, hugging, cleansing, or packing the corpse per local practices be specifically avoided (22). Since the handling of mortal remains and processes involve emotions, sensitivity, and respect, the Ministry of Health (20) of Bhutan inform all the healthcare and EoL care providers inform family and relatives, explain the nature of the disease, risk of infection, funeral processes to be carried by trained personnel while respecting the religious and cultural values. To enable dignified cremation for the deceased, the team is composed of a healthcare provider to provide health and COVID-19 related information, a religious figure to explain the significance of rites and rituals, trained personnel (volunteers from the Red Cross Society, Bhutan) to handle dead bodies, and family members to goodbye the deceased for the final time. With limited testing capacity, shortage of trained health staff, inadequate ventilators and ICU facilities (needed in severe cases of COVID-19), and scarcity of funds, Bhutan’s choice of public health approach and prevention measures, along with the involvement of leaders, were proven effective in containing COVID-19 so far. However, Bhutan remain susceptible to the COVID-19 pandemic.

Stare at the sun

If we allow little time for ourselves and deeply contemplate death and dying, most of us would realize that living is dying (23). Whether we talk about it or not, death is everywhere, inescapable, and confront in an uncertain time. However, death and dying are subjects that evoke deep and disturbing emotions (24). Conceptually, we all have to agree that all born will one day die. But, somehow we have persuaded ourselves that 'all' does not include 'me‘, and have developed an attitude that death only happens to other people, indicating that we agree to death intellectually but deny it emotionally.

As Breitbart (10) rightly pointed out, COVID-19 pandemic forces us to “Stare at the Sun” too long and take us closer to the truth that death is part of life even though we try to look away from it. Although the death of dear ones are often punctuated by painful incidents of grief and sadness, it is also punctuated by the act of heroism, compassion, love, humanity, gratitude, and self-forgiveness (10). Death is a great teacher who clarifies that everything must pass. Death helps us realize life is worth a living, especially, when life lost to COVID-19 rings our ears. Those who understand the inseparability of life and death, and are willing to accept ‘nothing lasts forever’ wholeheartedly can ever hope to live totally, and only those who lived fully will be prepared to die gracefully. As death cannot be postponed forever, Buddhists encourage us to be mindful, psychologically prepared and accept impending death with calm and dignity (25).

What can be done more?

Besides COVID-19 vaccination, prevention measures including physical distancing, frequent handwashing, and use of face masks are proven effective, unavoidable to keep COVID-19 at bay. As the virus continues to mutate and variants of concern emerge, it is likely that the close relationships, care for EoL, death and dying would continue to be affected. Adequate counselling for the family and friends remains critical to dispel myths and misconceptions surrounding EoL, death and dying, and facilitate an informed decision. As the finitude of life is initiated at birth, the belief that there is no specific time, but every fleeting moment is a time to prepare for death (16) and its discourse is warranted both in and out of COVID-19 pandemic. Furthermore, exercising loving-kindness, compassion, rejoice, and equanimity through daily contemplation, meditation, and practices would foster gracious acceptance of death and dying to solace bereaved and deceased in times pandemic like COVID-19. Although death and dying are inescapable, being part of the prevention and adhering to COVID-19 prevention protocols would be the best help we can offer to self, family, community, and the nation. In doing so, life and death anxiety would be mitigated. As the frontline workers, especially healthcare providers are mandated to be on full personal protective gear, that often hides their facial expression, affects both the verbal and non-verbal communication and the doctor-patient-nurse relationship. Nonetheless, there are innovative ways and means to demonstrate genuine love and care. We are all left at the disposal to pray fervently that the COVID-19 pandemic becomes history and return to the pre-pandemic state of harmonious living and social conventions.   

While dignified funeral processes for the deceased are still inconsistent with tradition and culture, the COVID-19 mandates have restricted the social aspect of it. Where families and friends of the deceased gather and offer food and bade farewell to the deceased in a rather long mourning period (49 days), families have to now conduct rites and rituals limiting to immediate family members depriving extended family members and friends from participation. Sometimes these mandates and protocols could serve as the main barriers for people to come for testing. People would perform funeral rituals in secret and relatives gather breaching COVID-19 protocols. In the event of people especially elderly members of the family fall sick, they may not bring them to the hospital for fear of isolation but locally treat them at home, which fosters the gathering of people to see the sick. If this happens, the disease could spread uncontrollably and affect all sections of society. Rigorous advocacy on COVID-19 is therefore critical in reaching out the right information to the general public.