This article originally appeared in the ARH Journal, Homeopathy in Practice, Winter/Spring 2013. Courtesy ARH.
This piece is inspired by a long-standing patient whom I promised that when her death was imminent, circumstances permitting and provided that her family consented, I would be there for her at the time as her homeopath. Until researching this topic, only two remedies came immediately to mind for this time of transition: Arsenicum and Sandalwood. I felt most privileged by this request as well as rather startled and quite apprehensive.
It also occurred to me that whilst homeopaths are frequently called upon to assist with the grief of loved ones following a person’s death and perhaps to ease pain and discomfort of the terminally ill, there is a paucity of homeopathic literature on the actual dying process itself. This led me to speculate on possible reasons for these observations and my own mixed emotions, which then prompted a desire to attempt to wrap up what I could find in order to make some socio-cultural and homeopathic sense of our final stage of physical life. This article shares what I have found.
I would like to warmly thank those members of the ARH-Homeopathy e-group who so generously and supportively shared their experiences of being present at a death as well as their knowledge of remedies. I’m also very grateful to members of the LinkedIn.com e-group for doing likewise and to some members of the FHT network in Nottingham who also shared some of their wisdom with me. Most importantly, I remain grateful to my patient for broadening my outlook, increasing my knowledge and providing me with such a valuable and multi-layered opportunity.
LIFE AND DEATH
Death has been described as the last and greatest taboo in the western world, which lies somewhat at odds with the notion that it is the only certainty in life. Many people remain reluctantto talk about death and dying regarding it as a morbid topic of conversation, whereas in other cultures such as Mexico and in many eastern countries, death is regarded very much as part of life and the on-going cycle of life, death and regeneration. These philosophies also tend to be reflected in the way that funerals are conducted: in the northern hemisphere they tend to be very formal and restrained affairs with people trying to rein in their emotions in a very Nat-Mur sort of manner, whereas in other parts of the world funerals must be accompanied by much wailing and overt emotion to ensure that the deceased has a proper send-off from this realm and that the living can fully express their grief. Sometimes a lot of noise may accompany funeral ceremonies, often to chase away evil spirits or untoward influences. In some cultures funereal colours are usually black, in others mourners wear white or gold and sometimes it may be a wish of the deceased that mourners wear bright colours at their wake or funeral in order to detract from the misery of the circumstance.
It is said that part of the underlying caution and reluctance to talk about death and dying in this culture is that it has become very much a dehumanised and medicalised process, the domain of the elderly and the sick. In Victorian times, many people died at home and their body was laid out in the parlour of the family home so that loved ones could pay their respects. Nowadays, the elderly or sick usually die away from the rest of the population at largein hospitals or hospices and it is a legal requirement in the UK that a physician or a coroner (or sometimes a paramedic or police officer in the case of sudden deaths) ascertain the cause of death and sign a death certificate in order that a death can be registered and funeral arrangements can go ahead (Sidell 1993). Thus, death has become a medical event and a legal phenomenon, certified in terms of a physical cause and the aftermath dealt with in a somewhat sanitised manner. Moreover, as a result many of us are unsure of and uncomfortable about dealing with the needs of those actually dying, as well as with the grief of those left behind. Possibly this discomfort is partly because we are reminded of our own mortality as well as being largely unfamiliar with dying and death itself?
Another aspect to the shroud of reticence surrounding this stage of life I believe is the element of fear, or more specifically, fear and anticipation of the unknown. It is generally held that we always fear that which we do not understand, which by extension means not being able to understand that which we do not know: we simply do not know what it will be like for us when we draw our last breath and how it will feel to actually die. Nor do we necessarily know when and how it will happen for us and whether it will be sooner rather than later – we can only speculate upon the inevitable and hope for a peaceful transition.
The closest glimpses that we can get of any experiences of the inevitable are perhaps the various accounts of near-death experiences (NDEs) from people who have been close to death in some way and have then either recovered or been medically resuscitated. Reported sensations include those such as travelling down a dark tunnel towards bright light, looking down on their own body, visions of religious figures or dead relatives beckoning them forward and so on. Some have reported details of hospital wards or accident scenes that they could not have known about or seen physically seen whilst not (apparently) conscious. Conventional or material science explains away such phenomena by dismissing them as the result of chemical disorganization in the dying or failing brain (Waller 2010).Those of us who acknowledge a spiritual sphere would beg to differ, along with those who have had the actual NDE themselves. Also, of course, those individuals did not end up dead (this time around anyway) so there could well be a difference between almost dying and coming back and final, physical death.
This leads inevitably to the question of what may happen at death and afterwards. It is fair to surmise that a person’s beliefs and personal philosophy may influence to some extent how a dying individual may feel about their impending death, as well as the grieving process.There are 3 key aspects involved here: religious and cultural factors, secular research and of course the actual transition or death process itself. A consideration of these follows so that we can have an idea how homeopathy (as well as some other CAM therapies) can play an active and beneficial role in dealing with what can be termed our final set of symptoms.
Knowing what sort of things to look for can help to provide some understanding of death and may sooth some anxieties. Although the natural or medical dying process can be conceived as happening on several dimensions – physical, mental and emotional, social and spiritual – pain and suffering, comfort and healing can occur on all these levels during the transition process. Physically however, there are changes that take place as the body shuts down, possibly to allow other spheres some room for final development and stock-taking?
The spirit, soul or animating force that keeps the heart beating and the lungs breathing (the two vital functions upon which all other functions depend) is generally believed to leave the body at death via the crown chakra. It is my belief that this could be the (homeopathic) vital force, for it is what one can clearly perceive to be absent in or around dead people (and animals). Waller (2010) reports that she was unable to find anything in conventional physiology books about death, presumably because physiology is the study of the living body, but outlines physical signs of dying evident in circulation and metabolism, breathing and elimination.
Sleep begins to take up an increasing proportion of the dying person’s time and it may seem as if they are unconscious. Approaching death, circulation slows down as blood pressure and heart rate drop, frequently resulting in cold hands and feet or bluish/grey fingers, earlobes, lips and nail beds. Vision may be impaired. When death is very close, feet and knees may be mottled or blotchy.With the need to produce much energy gone, the digestive system and appetite slow down and thirst decreases. The body becomes naturally dehydrated which allows the person to become sleepier and less aware of any pain and discomfort. Closer to death a fever often occurs, lung secretions thicken and gather in the trachea, causing breathing to sound moist and congested (known as the ‘death rattle’) or Cheyne-Stokes respiration may occur (alternating cycles of shallow and deep breathing or periods of not breathing at all for a while).
Digestion and elimination are among the first physical systems to cease. The bowel and kidneys slowly stop functioning and the body may prepare for death by a profuse amount of elimination. If the heart is struggling, this can result in swelling of the extremities or lung tissue. Shaking commonly occurs as a result of these organs shutting down.The final physical senses to go are hearing and touch. Even if the person is unable to respond and their main attention is turned inwards, it is most likely that they will still be able to hear others in close proximity and be reassured by touch, indicating an opportunity for and a likely need for continued comfort and reassurance ; Waller 2010).
RELIGIOUS & CULTURAL FACTORS
What follows is a mere summary of some of the major religious perspectives on death that for the context of this article have to brief, and I apologies in advance if I have unwittingly trivialized any aspects in this attempt to account for likely influences upon individual feelings about dying and death.
Buddhism is often described as a way of life and being, rather than a religion per se, and there are many different schools or perspectives. These have certain fundamental concepts about death in common however which involve regarding death as the breaking apart of the material of which we are made and a dying person’s state of mind is held in great importance. Following death, some may return to the human sphere, some may enter a pure world of light and bliss, others who have achieved enlightenment will merge with the ultimate nature of the mind. Many believe that Buddhism cannot be conceived by the intellect but by the instinct (Waller 2010).
Again, there are many Christian denominations but central to Christianity is the belief that if Jesus Christ is embraced as one’s saviour then your spiritual life will be eternal. Some fundamental sects hold that those who have not embraced Christ will go to hell rather than heaven. Representatives of many churches administer last rites to the dying in order to prepare their soul for death. Catholics administer absolution for sins by penance, sacramental grace and prayers for the relief of suffering through anointing and the final administration of the Eucharist. Protestants may also embrace a sacramental procedure or prayer that can be administered to a sick or dying person. (http://en.wikipedia.org/wiki/Last_Rites).
Reincarnation is central to the Hindu religion and thus death is a natural progression of the soul, rather than a calamity. Depending on the deeds and actions of a person’s current life and whether correct funeral rites have been observed, a Hindu spirit may follow the path of the sun or the moon. Those that take the path of the sun will not return into another body but merge into the light whilst those that take the path of the moon will be reborn into a new body and its accompanying status and fortunes throughout the next life. There are many Hindu heavens and hells and many gods and goddess incarnations of the Divine (Waller 2010).
A Muslim family gather around the dying person to provide comfort and they prepare the deceased for washing, shrouding, prayer services and burial facing Mecca as soon as possible after death. The dead face judgement from Allah and only true believers can attain paradise. Muslims believe that death is a departure from the life of this world, but not the end of a person’s existence. The family of the deceased is obliged to settle debts as soon as possible and maintain a courteous, close relationship, for prayers and visiting graves are vital: the living must remember death and the day of judgement. Muslims are always buried rather than cremated according to Sharia law (Waller 2010; http://en.wikipedia.org/wiki/Islamic_funeral).
The Jewish tradition of being at the bedside of the dying is of immense value to both the dying person and to those about to be bereaved, for all must learn to face death. Death provides ultimate justice and the afterlife gives an opportunity for any perceived unfairness in life to be redressed. Hell is perceived as distance from the one single God and heaven or paradise is to be with God, whose judgement is based upon the dying individual’s personal ethics and adherence to religious custom and tenets in life (Waller 2010).
Sikhism also has the concept of reincarnation as a central tenet, but it is a monotheistic religion. Meditation upon the name of the Divine in order to attain salvation in death and liberation (complete unity with God) is essential in life. Death is considered to be a certain event that can only happen as a direct result of God’s will and Sikhs believe that birth and death are closely associated as integral parts of the cycle of human life. Death is constantly remembered so that the cycle can be broken and the diligent returned to God (http://en.wikipedia.org/wiki/Funeral). Both Sikhs and Hindus prefer the body to be cremated in order to help release the soul.
The extent of influence that religiosity and custom is likely to have upon any dying individual’s psychology is difficult to determine, but I would say that it could be a major consideration for many, whether it be a positive or negative impact. On the other hand, some of us have an eclectic outlook and philosophy regarding death, others may have no religious, cultural or spiritual beliefs at all and be glad to opt out of life, and many may simply be confused as to what happens when we die and regarding the hereafter, but dying is, without doubt, a complex and highly individual matter.
The classic work of psychiatrist Elizabeth Kübler-Ross is perhaps still the most influential research on reactions to dying and death. Her theory arose from interviews with over 200 dying patients in the mid-1960’s and was conceived as an attempt to reinstate the process of dying back into the full course of human life and offer some understanding of the process. Her book ‘On Death and Dying’ was published in 1969.
She describes 5 characteristic reactions to dying that she termed ‘stages’ with the intention that these 5 responses, although not necessarily manifested by a dying person in the same sequence and perhaps occurring simultaneously, would provide clues to help others understand not just their own death but also the grieving process itself. She observed that a person would always experience at least 2 of these stages: denial; anger; bargaining; depression; acceptance, but not necessarily in that (logical) sequence.
Table (i) below links these reactions to possible ways of expression and also to some suggestions for appropriate homeopathic remedies, should these stages be in evident in a patient approaching death:
Table (i) AKübler-Ross Framework
|STAGE OR REACTION||MAY BEEXPRESSED AS||REMEDY CONSIDERATIONS|
|1) DENIAL||“No, not me, there must be a mistake”||Chamomilla, Platina, Veratrum-Alb|
|2) ANGER||“Why me?” / “It’s not fair / someone’s fault”||Staphysagria, Nux–Vom, Tarentula|
|3) BARGAINING||“If I do ‘x’,’ y’ won’t happen” / “Let me live & I’ll do ‘z’ in return”||Lachesis, Pulsatilla, Sandalwood|
|4) DEPRESSION||Extreme sadness, loss, lack of motivation & desire to fight any more||Aurum, Ignatia, Phosphoric-Acid|
|5) ACCEPTANCE||“At last the right time” / “final rest before a long journey”||Arsenicum, (Constitutional as consolidation),Purple (crown chakra affiliation)|
Kübler-Ross’s theory has been generally criticised as being too simplistic, sanitised and homogenised (Kimmel 1990), but it is certainly worth reiterating because her work remains so influential. Further, it could indeed offer some comprehension about what some people may be going through when death is approaching and thus could be of some help in providing homeopathic help to the dying.
However, she does not appear to consider influences such as religion and custom, age and gender, not to mention circumstance of death, and her interviews were conducted only with young and middle-aged terminal cancer patients, which is a relatively narrow sample population. Further, to apply a similar model to the grieving process of loved ones who are left behind, alive and whose journey continues can be misleading, for grief, just like death, is unique to the individual.
It is also maintained that the Kübler-Ross model has been (mistakenly) perceived as an ideal and those whose grief and whose acceptance of death does not conform to it can be perceived as dysfunctional or abnormal. It would not seem appropriate in circumstances where death was unexpected, sudden or violent, as there simply would be no opportunity to deliberate for the individual concerned and the grieving of those left would also be different because of the greater element of shock involved.
But Kübler-Ross’s model may indeed fit well with some peoples’ circumstances and outlook nearing their own death. However, I would not personally be guided by these criteria for a grieving person and conjecture that the layers or ‘stages’ of grief are different to those of dying. (And besides, the focus of this article is on death and dying rather than grief).
More recently, the Hospice Concept of end-of-life care has come into beingas a practical model which may better account for actual needs than Kübler-Ross’s theories(Kimmel 1990), and it ishighly likely that this supportive framework would incorporate some of her concepts. The hospice model simply is the development of an individualised plan of care for the dying or terminally ill that is culturally and personally sensitive to the needs and wishes of both the patient and their family unit, and one that utilises the skills of an inter-disciplinary unit of paid staff as well as volunteers. This, refreshingly, indicates that there is a formal space for homeopaths and other CAM therapists to work alongside doctors and psychologists in palliative and integrative end-of-life care.
Indeed the most recent National Institute for Health and Clinical Excellence (NICE) Guidelines reflect this notion of sensitive, holistic care in their ‘End of Life Care for Adults Quality Standard’ mission statement, available at http://www.nice.org.uk/guidance/qualitystandards/endoflifecare/home.jsp. This NHS document sets out the UK criteria and procedures for dignified and culturally appropriate personal care for those approaching death and outlines certain requirements for afterwards. I would say, however, that the NICE guidelines seem to reflect Kimmel’s criticism of sanitation about the Elizabeth Kübler-Ross model and also makes a normative assumption of what might be termed a ’textbook death’. Nevertheless it can be useful to have some practical help as regards knowing what might be required, which leads on again to the contributions that homeopathy can provide.
PRACTITIONER EXPERIENCES, REFLECTIONS & FURTHER REMEDY SUGGESTIONS
One of my first reactions to my patient’s request was to wonder if anybody else had been present at a death and what it was like for them, as I have not actually been there with anyone (human) at the final moment of their life, only afterwards. I felt very honoured by her request but also apprehensive. Even though this patient’s death is not imminent health-wise, but chronologically likely to be sooner rather than later, she remains curious about the whole process – as I do.
I put an open question to practitioners to see what emerged as common experiences and so as not to pre-empt answers. The 25 unstructured responses I received from homeopaths were spontaneously and supportively given; many were touching personal experiences of being present at a loved one’s death and there were also responses from some who had been present during or close to a dying process in their role as a homeopath or therapist. Most mentioned remedies that they had either used themselves and/or offered suggestions. I received a further 7 replies from other holistic therapists who had been present during a client’s final moments.
There was one very prominent thread running through these experiences: actual transition to death was the most peaceful for those who had been already receiving homeopathy or other energy based therapy* and not necessarily treatment for the dying process. The other major factor that emerged from the answers was the need to match near-death remedies to both physical and emotional symptoms as they manifest and as often as necessary, because of the shifting and changing nature of the transition process. The majority of responses also underlined how each death is a different experience – just as we are individuals, our final set of symptoms will vary too.
* The 7 other therapists who replied are practitioners of aromatherapy, energy massage, reflexology, reiki, soul midwifery and sound therapy. Some are involved in end-of-life care schemes operated by local hospices.
Arsenicum-Album overwhelmingly emerged as the most often used remedy (10 responses out of 25, or 40%) followed by Carbo-Vegetabilis (5 responses, 20%)) and SantalumAlbum (Sandalwood) (4 responses or 16%). These deserve further attention here, aside from what can be found in repertories:
Arsenicum is commonly known as ‘the friend of the dying’ for it has been traditionally used as a major fear remover in many contexts, including dying and separation and to soothe anxieties, anguish and restlessness.I find it surprising that the Kübler-Ross model omits a fear stage, as it appearsthat fear is one of the most common emotions involved at some point in the dying process (see earlier). Further, Arsenicum is indeed listed in black type in traditional repertories (e.g. Kent, Murphy, Phatak, Prisma) as well as in the more modern Complete Repertory. Interestingly, 3 respondents reported Arsenicum as giving a new lease of life for a while, in that individuals concerned outlived conventional prognostic expectations.
Also termed ‘the corpse-reviver’, Carbo-Veg is well known for all types of collapsed, cold states with stasis, which fits very aptly with the dying physiology described earlier. One comment I received describes how this remedy, upon the request of his relatives, was given to a patient whose both lungs had collapsed. Apparently they were the only ones who had not given up hope of this person’s recovery and the patient ended up reviving and surviving for a further three years, only collapsing again because he did not stop smoking and drinking (!) Carbo-Veg was also mentioned as being helpful to ease Cheyne-Stokes respiration.
Sandalwood has been traditionally used for centuries for anointing and embalming the dead and is mentioned in ancient Sanskrit and Chinese texts, so it would seem very appropriate as a remedy for the dying in modern times too. Also known to the ancient Egyptians, the oil and wood are very fragrant and have always commanded high prices commercially (Griffith 2007). Early homeopathic applications suggest an affinity to the urinary and sexual organs and hence a somewhat limited use for symptoms of gonorrhoea, but the meditative proving that Colin Griffith details highlights Sandalwood’s modern profile as a remedy noted for its ability to foster calm, peace and self-nurture during the transition to death. Joyce (200) mentions Sandalwood as facilitating the transition in cancerous states by helping to release any toxins trapped in the physical body just before death.
OTHER REMEDY SUGGESTIONS
We can see from the earlier description of the physical changes that can be expected close to death that remedies would be called for according to how and when they present and in line with the degree of discomfort they cause. For example, Ant-Tart or Pulsatilla as well as Carbo-Veg could be given to ease respiratory discomfort, Cuprum for cramps, spasms and jerking, Rhus-Tox if there was physical and internal restlessness especially at night, and so on. Remedies would be chosen just as one usually would to match any other individual, acute and shifting picture and in many instances could be given in water or applied to the dying person’s lips or inner wrists. I would be inclined to stick to low potencies such as 6C in order to target physical discomfort and to go for the gentle but thorough LM potency for more emotional priorities.
Several other remedies were afforded significance in the 6 repertories referred to and some of these were also mentioned in e-group responses. Before turning to these, it is also interesting to note that those repertories that feature the new remedies provide more specific and detailed rubric choices when it comes to death and dying than the older publications. The difference is principally in the physical versus emotional rubrics, as the older repertories seem to focus more on the physical agonies of death and in what seems rather a detached manner. Further, it is unclear whether the emotional rubrics and sub-rubrics such as “Mind, Fears, death”and “weary of life yet fearing death” (Murphy 2005) have general applications or are specific to dying time. However, since remedies are always individually selected, this may be immaterial. By contrast, the newer remedies are meditatively proven and thus almost always considered esoterically as well as physically and emotionally, which could account for much of these differences in focus.
Some homeopaths will also like to use Bach or Australian Bush Flower Essences, and since these are known for their balming emotional effects either alongside or instead of homeopathic remedies, they may provide a further soothing aid for those nearing death. One respondent drew my attention to the Australian Bush Flower ‘Transition Essence’ whilst a couple of others mentioned that they had used the Bach Rescue Remedy to promote calmness and acceptance of death. Individual flower essences could also be used to match a dying person’s mental pre-occupations and troubles.
The following tables give some brief examples of both traditional and meditatively proven homeopathic remedies and their possible applications. They are not intended as a comprehensive list but to provide a few suggestions and to show a difference in possible applications. In general terms, I usually tend to use both types of remedies to suit the personality and needs of the patient in question, and it is not my intention to imply that one type of remedy would be more appropriate than another for physical or emotional symptom pictures.
Table (ii) Some Older Remedies
Aconitum Another major fear remedy, may predict time of death
Crot.-H Septic states, haemorrhage, swellings
Latrodectus-M Screaming with pain, gasping breath, fear of asphyxiation
Opium Shocked states & terror, extreme pallor, comas & insensibility