2000 Hilly Bol – Signa mortifera or Signs of Approaching Death. About the Phenomenology of the Dying Process, Prognostication, and the Relation to Music-Thanatology.pdf

SIGNAMORTIFERAorSIGNSOFAPPROACHING DEATH.
ABOUTTHEPHENOMENOLOGY OFTHEDYINGPROCESS,PROGNOSTICA nON,
ANDTHERELATIONTOMUSIC-THANATOLOGY.
HILLYBOL
Idedicatethispapertothedying;
Theyareourteachers..
Copyright©2000HilyBo1
AlRightsReserved

ACKNOWLEDGEMENTS
ForthepasttwoandahalfyearsIhavebeenastudentattheSchoolofMusic-Thanatology.
ThisgraduatelevelschoolformsapartoftheChaliceofReposeProject,apaliativeend-of
lifepatientcareprogramthatisaffiliatedwithSt.PatrickHospitalinMissoula,Montana.
Thefounderoftheschool,ThereseSchroeder-Sheker,describesmusic-thanatologyasa
contemplativeactivitywithclinicalapplications’,Withharpandvoicewedelivermusicthat
isprescriptiveanddynamictothedying.Prescriptiveanddynamicmeansthatthemusical
deliveryisuniquetoeachindividual,andcarefulyadjustedtotheneedsofthepatientfrom
momenttomoment. Itiswithintheworldofphenomenathatthisrelationshipbetween
patientandmusicisdeveloped.Themusic-thanatologisthasbeentrainedinworkingwitha
body-systemphenomenologyatthebedside.Comingfromamedicalbackground,andhaving
“read”thehumanbodyinmanydifferentwaysbefore,Ibecameinterestedinthemedical,
historical,religious,andspiritualaspectsofthephenomenologyofthedyingprocess.Ithank
ThereseSchroeder-Sheker,RobertSardelo,andKenThorpforthemanyinspiringwaysthey
presentedphenomenology-andsomuchmore-intheirclassroomlectures.
IhavespecialthanksforFredPaxton.Inhislecturesaboutthell”Cent. customaries’ofthe
monasteryofClunyinFrancehementionedtheservantintheinfirmaryofthemonastery.
Theroleofthisservantinreadingthesignamortifera,orsignsofapproachingdeathinorder
toprognosticatedeath, wasaddressedinhisscholarlypublication”.WhenIdeterminedthe
titleforthispaperItookthelibertyofparaphrasingthetitleofhisarticle.Theimageofthe
trainedservant,sittingatthedeathbedofadyingmonk,carefulywatchingthesignsof
approachingdeathbecameapowerfulguideandmodelformethatextendedbeyond
medievaltimeintothepresentworldofthemusic-thanatologist.
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ToSharonMurfin,JocelynBotkin,SileHarriss,LoisMandelko,LauraMoya,andLinda
Schneck,thankyouforinitiatingmeintotheworldofthephenomenaofmusic,foryour
musiclessons,andforyourteachingatthebedsideduringclinicalinternship.Youhelpedme
rediscoverandremembertheworldofmusicthatwasclosedoffearlyinmylife.
ToAliceReich,fordeepeningmyunderstandingoftheparticipantobserver,ofthe
significanceofrituals,andtheanthropologyofreligion,heartfeltthanks.
ToBarbara,Laurie,Suzanne,Sharilyn,Cynthia,Anna,Jane,Kely,Dolan,Andrea,Karla,
andMichael,thankyoualforouruniqueclassof2000community,forweavingthethreads
ofourindividuallivesintoaneverchangingandcolorfulwholethatwas-andstilis-so
muchmorethantheparts.Iloveyoual.
Last,butnotleast,toJan:althishasbeenmadepossiblebyLove.
Ifonewishesleadtobecomesierorsiergold,onemust
notseparateknowledge(gnosis)frominteriorexperience,
orintelectualactivityfromactiveimagination”.
INTRODUCTION
Birthanddeatharethetwogreattransitionsforhumanbeings,andofthesetwomuchmore
isknownabouttheprocessofbirththanabouttheprocessofdeathinWesternsociety.
Idealythedifferentstagesofbirtharecarefulyobservedand,ifnecessary,appropriate
measuresaretakentoprovidethebesttransitionpossibleforthechild.Ourdetailedindepth
knowledgeofthestagesofdeliveryalowsustoprovideexcelentcaretobothmotherand
child”,Whenitcomestothestagesofdying,however,Westernsocietyislargelyignorant.
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Infact,ifdeathisnothingmorethan”theendoflife”-thepurematerialisticview-ifwedo
notfindanymeaningindeath-thenwemightnotevendesiremoredetails.However,when
deathisunderstoodtobemeaningful,inseparablefromlife,andatransition,asitisinal
sacredtraditionsEastandWest,wewilwanttoreclaimwhatisactualyaknowledgeabout
deathanddyingoncepondered,butnowlost.Infact,asmusic-thanatologists,Ibelieveitis
essentialthatwedoso.
Myownsearchintotheworldofthesignamortifera,orthesignsofapproachingdeath,
beganwithasimplequestion:”Whathappenswhenapersondies?”Itisaquestionasoldas
humanityanditcontainsaweinthefaceofmystery.Ithasbeenraisedsincethebeginningof
consciousnessandawarenessoftheselfwasdawninginwo-/mankind.Ithasbeenraised
eversince,inavarietyofculturalsettings.Itisaquestionthatisattheforefrontofourwork
asmusic-thanatologists.
Therearemanydifferentlevelsonwhichwecanaddresstheabovequestion,andwecanalso
changeormodifyourperspective.Wecouldask:”Whicharethesymptomsorbodilysigns
ofapproachingdeath?”or”Whathappenswithconsciousness?”or”Whendoesaperson
actualydie?”
Wewilencounterseveraldefinitionsofdeath.Obviouslydeathisnotthesameforeveryone.
Aswewilsee,thesignsareexperienceddifferently indifferentcultures.Evenourown
culturehasdifferentdefinitionsofdeath.Deathisalsoaculturalconceptandcultural
conceptsdeeplyinfluencethewaywedealwithdeathanddyinginagivensociety,”
Prognosticationusedtobeagreatmedicaltoolthroughtheages,albeitfordifferentreasons,
anditpassedintodisusequiterecently.
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Whatexactlyisprognostication?Thewordprognosisisoriginally Greekanditconsistsof
twoelements:pro,meaning”beforeorforward”andgnosismeaning”knowledge”, fromthe
verbgignoskein, “toknow”. Wealsousethewordgnosisforknowledgeofspiritualthings,
especialywhatcomestousbyrevelation,andIwilcomebacktothatinthefinalchapter.
Prognosiscanbeadescriptionofwhatactualywilhappen, theactualprospectofadisease,
orthesubjectiveimpressionofwhatwilhappen, theanticipatedprognosis.Thisanticipated
prognosisisalsocaledprognostication.Prognosticationincludesforeseeing,asaninward
elementandforetelingasanoutwardelement. Prognosticationisaprofessionalperception
ofthepatient’s experienceofthedisease”,or-forthemusic-thanatologist-ofthedying
process.
Wecannotsimplyobservethesignsofapproachingdeath. Thereisalwaysarelationship
goingon.Whenwearelookingatsomeonewearewiththispersonatthesametime.”Ina
transpersonalwaywemayevenbethisperson.
Thephenomenologicalmethodpurportstobedescriptiveandpresuppositionless.but itis
probablynotpossibletoleavealpresuppositionsbehind.RobertSardelodescribes
phenomenologyasbeingpresenttothephenomena,lettingthemrevealthemsees,atthe
boundary, wheretheobjectiveandsubjectivemeeteachother.’?
Thequestion”Whathappenswhenapersondies?”transformsinto”Whatisthe
phenomenologyofthedyingprocess?”Dyingmeanstheactofdying,implyingthatdyingis
aprocessratherthananevent.”Death,beinganoun, referstoaneventinlineartime.
Iwildrawfromavarietyofdisciplines:medicine,nursing, history, anthropology,
thanatology, ethics,religiousandTibetanBuddhiststudies, inaninterdisciplinaryapproach.
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Thesedisciplinessharemuchmorecommongroundthanisoftenperceived.Inourtimewe
aresousedtospecialization,thatweoftenforgethowinterconnectedthesefieldsare.
Iwilhighlightsignsofapproachingdeathandprognosticationinfourdifferentsettings:
AntiquitywiththeaccentonHippocrates,theMiddleAgeswiththeaccentonCluny,the
TibetanBuddhistview,and”ourown”20thcentury.EventualyIwildiscusshowthemusic-
thanatologistmayrespondtothephenomenologyofthedyingprocess.Iwildiscusssome
aspectsofthedifferencebetweenso-caledprocessingandimminencyvigils,andIwil
addressthequestionofwhetherthereisaplaceforprognosticationinmusic-thanatology.
Thedeeperourinsightandimaginationofthedifferentstagesofthedyingprocessbecome,
thegreaterthesensitivityofourmusicalresponsewillbe.
InmanyrespectsIknowIwillbarelyscratchthesurface. Thesubjectisenormous.Imight
evenendupwithmorequestions thanIstartedwith.Themysteryoflifeanddeath isbigger
thanwe,humanbeings,are.Butitismyhopethatthispaperwilbeanexploration ofafield
inthanatology, whichgetssubstantialy neglected inmodemmedicine.
Humanbeingsarestorytelers.”Wetelaboutwhatitmeanstobehuman.SoIwiluse
somestoriesinthispaper.ThesearesomeofthepersonalexperiencesIhavehadwithdeath
anddying.Theyhaveinfluencedmyworldview.
A20thcenturystory: August27,1987. Iwasdoingmyworkasaradiologist
withaheightenedconsciousnessinthehospitalallmorning.IknewIhad
somehoursleftatwork. Iwantedtofinishmymorningscheduleofeighteen
patientsandtheirreportsassoonaspossible.Afterbeingwithmymotherand
lookingathereverysingledayduringaperiodofmorethansevenweeksI
knewshewoulddietoday.IalsoknewIwouldbeintimetobewithherafter
finishingmymorningtask.
HowcouldIknow?Andwhywasitsoimportanttoknow?
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SIGNSOFAPPROACIDNG DEATHANDPROGNOSTICATION INGREEKANTIQUITY
TheGreekmedicaldoctorHippocrateshasbeencaled”thefounderandfather”ofWestern
Medicineandhehasalwayssymbolizedtheidealofthecompassionate,discreet,andselfless
physician.HewasanapproximatecontemporaryofSocrates,andhelivedandworkedonthe
islandofCoscirca460BCE.BothCos,andCnidus,justoppositeitonthemainlandofAsia
Minor,developedflourishingmedicalschools,centresfortheteachingofmedicine.13
ThecolectionofmedicalwritingsknownastheCorpusHippocraticumconsistsofabout
sixtytreatises,mostofthemwrittenbetween430and330BCEbyalargenumberofmedical
writers.WhichoftheseworksiswrittenbyHippocrateshimselfisnotcertainatal,butthe
Hippocraticwritingsmarkthebeginningofthesystematicmedicalinquiryandcareful
observationthatwouldinfluencetheWesternworldduringmanyages.”
Inthechaptercaled”Prognosis”adescriptionofsignsofapproachingdeathisgiven,aswel
asdetailedinstructionsforameticulousexaminationofthepatient.
Thesignstowatchforinacutediseasesareasfolows.Firststudythepatient’s
facies(face);whetherithasahealthylookandinparticularwhetheritbeexactlyas
itnormalyis.Ifthepatient’snormalappearanceispreserved, thisisthebest;justas
themoreabnormalitis,theworseitis.Thelatterappearancemaybedescribedthus:
thenosesharp,theeyessunken,thetemplesfalenin,theearscoldanddrawninand
theirlobesdistorted,theskinofthefacehard,stretchedanddry,andthecolorofthe
facepaleor-dusky.”
Intheabsenceofinsomnia, severediarrheaorraveninghungerthesearethesignsthat
portenddeath. However:
Shouldtheilnesshavepassedthethirddaybeforethefaceassumesthisappearance
anexaminationofthewholebodyshouldbemade,payingparticularattentiontothe
eyes.Foriftheyavoidtheglareoflight,orweepinvoluntary,orsquint,ortheone
becomessmalerthantheother,orifthewhitesareredorlivid,orshowthe
presenceoftinydarkveins,orifblearinessappearsaroundtheeyes,oriftheeyes
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wander,orproject,oraredeeplysunken,orifthewholecomplexionofthefacebe
altered;althesethingsmustbeconsideredbadsignsandindicativeofdeath.
Theappearanceoftheeyesinsleepshouldalsobenoted, forifsomeofthewhite
showswhentheeyesareclosed,solongasitisnotduetodiarrhea,thetakingof
drugs,orthenormalhabitinsleep,itisabadsignandespecialyfata.Iftheeyelid
becomesswolenorlivid,orlikewisetheliporthenose,togetherwithoneofthe
othersigns,itmaybeknownthatdeathisathand.Itisalsoafatalsignifthelipsare
partedandhanglooseandbecomecoldandwhite.”
Thechapter”Prognosis”focusesonacutediseases,simplybecausepeopleusedtodiefrom
acutediseasesmuchmorefrequentlythanfromthechronicdiseaseswediefromtoday. The
onenotablesignabsentfromtheaboveobservationsispulsediagnosis.Thefirstinthe
WesternworldtorecognizethepulseasanindicatorofdiseasewasPraxagoras,aphysician
whopracticedatCosaround300BC.I7
Whydowefindthesignsofapproachingdeathinthechaptercaled”Prognosis”?The
answercanbefoundatthebeginningofthischapter:
Itseemshighlydesirablethataphysicianshouldpaymuchattentiontoprognosis.If
heisabletotelhispatientswhenhevisitsthemnotonlyabouttheirpastand
presentsymptoms,butalsototelthemwhatisgoingtohappen,aswelastofilin
thedetailstheyhaveomitted,hewilincreasehisreputationasamedical
practitionerandpeoplewillhavenoqualmsinputtingthemseesunderhiscare.is
Obviouslythereasonforprognosticationistoinspireconfidenceononehand,andtoprotect
one’sreputation ontheotherhand.
AnotherfamousGreekmedicalwriterwasGalenofPergamum(129-c.21O).His
commentariesonHippocratesbecamehighlyinfluential. Galenwasnotonlyfamousforhis
manydifferentwritings,butalsoforhisexpertiseinprognostication.19
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THEWEST:THEMEDIEVALWORLDOFCLUNY
ArichbodyoftextsonthesignsofapproachingdeathbecamewidespreadinWestern
Europebetweenthe8thand12thCentury,andmanyofthesetextswerebasedonorascribed
toHippocratesorGalen.”Medicaltextsaswelasliturgicaltextswerecolected,studied,
copied,andtransmittedinthesamemonasticscriptoria,andoftentherewasnoclear
distinctionbetweenthesetwO.21
Duringthatsameperiodoftimeanelaborateritualstructureforthedyingwascreated.
Initialythisritualwasconfinedtotheinfirmaryofmonasteries,butitmovedintothewider
worldoftheparisheslater.”
AmedievalstoryfromthecustomariesofCluny”:…Thenafterthebrotherhas
cometoastateofextremeweakness,aservantisbroughttohimwhohasnothingto
doexcepttowaituponthesickman.Andatnightaltheservantswhoareinthe
infirmarykeepwatchattentivelysothathisdeathcannothappenunexpectedly.The
crossislaiduponhisfaceandcandlesarekeptlituntilitisfuldaylight…
Servantswhoareweltrainedinsuchmatters, whentheyhaveseenthatnowthe
hourofhisdeathisimminent, spreadablanketonthegroundandsprinkleasheson
itintheshapeofacross…ThePrior. then.ifthesickmanisconscious.instructs
anotherbrothertoreadthepassiontohimoutloud.Ifheisnotconscious,twoor
fourareinstructedtosingthepsalmscontinuouslythere,untilitbenotedand
manifestthatthesoulisabouttodepartfromthebodywithoutlongdelay.Then
whenaservanthasseenitwhoisweltrainedandaccustomedtosuchduties,atlast
heseizesaboardandstrikesithardandveryquicklyinthecloisterandinfrontof
thedoortothedonnitorry…
Whoweretheseservantsintheinfirmary?Oneversionofthecustomariesspeaksofmultum
exertati,”highlytrained”, servantsandtheotherversionaddsthewordsmultumqueperiti,
“andwel-trained”,fortheseservants.”Apparentlytheseservantsknewwhendeathwasnear
bycarefulobservationandexperiencewiththedying. Apartfromtheirownexperienceand

anoraltransmissionthatisclosedtous,theseservantsmusthavehadaprofoundknowledge
ofmedievalprognostictexts.Anexampleofoneofthesetextsis:
Galenobserved:Thesearethesignsofapproachingdeathinthehumanbody.
Inthehumanbodytheforeheadbreaksout,theeyebrowsareskewed.The
lefteyeissmalerthantheright. Thebridgeofthenoseiswhite.Themind
fails.Thepulserunsahead.Thefeetarecold.Thebowelsemptythemsees.
Youngmenlieawakeandtheoldsleep.Thesearethesignsofapproaching
death.”
Theservantsalertedthecommunitybyclappingboardstogether,becausetheritualcarefor
thedyinginvoedthepresenceofthewholecommunity.Atthedeathbedtheysangthe
Credoandlitaniestoaidthesoultowardssaation, becausethetransitionofthesoulwas
consideredtobefarfromeasy.
Whyweremedievalpeoplesointerestedinthesignsofapproachingdeathandin
prognostication?Itisalconnectedtotheritualcareofthedying.Ifsomeone’sdeathcould
beforecast,therewouldbelesschanceofmissingtheopportunitytobringthewholeforceof
ritualskilandliturgicalpowerintoplaytodirectandaccompanytheprocessofdeathand
dying.”
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THEEAST:THEVIEWOFTIBETANBUDDIDSM
ThehistoryofTibetasaspiritualcivilizationisuniqueinthewaytheTibetansexploredthe
innerfrontiersofconsciousnessitself, inalitstransformationsinlifeandbeyonddeath.This
isespecialytrueafterBuddhismwasintroducedinTibetintheearlyThcenturyCE.27
TibetanBuddhismparticularlydevotedstudiestothephenomenologyofthedyingprocess,
includingthebodilysigns,inmoredepthanddetailthananyotherspirituality.Ordinary
fearsomedeathisseenasaforceclosetolife,andalsoasapowerfulimpulsetothegood,an
intensifierofpositiveattitudesandactions.”
The”BardoThodol”,alsoknownasthe”TibetanBookoftheDead”waswrittenbythegreat
masterPadmaSambhavainthe8thor9thcentury(soshortlybeforethefoundationofClunyin
theWestin910).Itremainedhiddenforages,andwasrediscoveredinthe14thCentury.It
wasintendedtobeamanualfortheordinaryTibetanlayperson. Thetitle’s correct
translationis”TheGreatBookofNaturalLiberationthroughtheUnderstandinginthe
Between”.””Bardo”meansthebetween,theperiodbetweendeathandrebirth.Y’The”Bardo
Thodol”isconnectedwithalargebodyofTibetanliteraturethatthoroughlyinvestigatesthe
phenomenaofdying.Itisofgreatsignificancethatwehavegoodteachingsandtranslations
ofthisliteratureavailablefortheWesternworld.Thefolowingdescriptionsdonotcome
fromtheBardoThodolitself,butfromthislargebodyofrelatedliterature.
I.SIGNSOFAPPROACHING DEATHINTIBETANTEACHINGg31
TheprocessofdyingaccordingtotheTibetanteachingsconsistsoftwophasesof
dissolution:anouterdissolution,whenthesensesandelementsdissoe,andaninner
dissolutionofthegrossandsubtlethoughtstatesandemotions.
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Theelementsearth,water,fire,air,andspacedetermineourphysicalexistence.Through
themourbodyisformedandsustained,andwhentheydissoewedie.Thepotentialandthe
qualityofthesefiveelementsalsoexistwithinourmind. Themind’sabilitytoserveasthe
groundforalexperienceisthequalityofearth;itscontinuityandadaptabilityiswater;its
clarityandcapacitytoperceiveisfire;itscontinuousmovementisair;anditsunlimited
emptinessisspace.
A.THEOUTERDISSOLUTION:THESENSESANDTHEELEMENTS.
Thefirstthingwemaybeawareofishowoursensesceasetofunction.Ifpeoplearoundour
bedaretalking,therewilcomeapointwherewecanhearthesoundoftheirvoicesbutwe
cannotmakeoutthewords.Whenwelookatanobjectweonlyseeitsoutline,notitsdetails.
Earandeyeconsciousnessisfailing.Thesamehappenswithsmel,tasteandtouch.Touch
beingthelastsensetofai.”Whenthesensesarenolongerfullyexperienced,itmarksthe
firstphaseofthedissolutionprocess.
Thenextfourphasesfolowthedissolutionoftheelements:
Earth.Ourbodybeginstolosealitsstrength.Wearedrainedofanyenergy.Wecannotget
up,stayupright,orholdanything. Wecannolongersupportourhead.Wefeelasthoughwe
arefaling,sinkingunderground orbeingcrushedbyagreatweight. Wefeelheavyand
uncomfortableinanyposition. Ourcomplexionfadesandapalorsetsin.Ourcheekssink,
anddarkstainsappearonourteeth.Itbecomeshardertoopenandcloseoureyes.Ourmind
isagitatedanddelirious,butthensinksintodrowsiness. Theearthelementiswithdrawing
andthewaterelementbecomesmoremanifest.Wecanexperiencethevisionofa
shimmeringmirage.
Water.Webegintolosecontrolofbodilyfluids.Ournosebeginstorun,andwedribble.
Therecanbeadischargefromtheeyes,andmaybewebecomeincontinent.Wecannotmove
ourtongue. Oureyesstarttofeeldryintheirsockets.Ourlipsaredrawnandbloodless,and
ourmouthandthroatstickyandclogged.Thenostrilscavein,andwebecomeverythirsty.
Wetrembleandtwitch. Thesmelofdeathbeginstohangoverus.Feelingisdissoing,
bodilysensationsdwindle,alternatingbetweenpainandpleasure,heatandcold.Ourmind
11

—-~–~————-,—————————
becomeshazy,irritable,andnervous. Thewaterelementisdissoingintofire.Wecan
experienceavisionofsmoke.
Fire.Ourmouthandnosedryupcompletely.Althewarmthofourbodybeginstoseep
away,usualyfromthefeetandthehandstowardtheheart. Perhapsasteamyheatrisesfrom
thecrownofourhead.Ourbreathiscoldasitpassesthroughourmouthandnose.Nolonger
canwedrinkordigestanything. Perceptiondissoes,andourmindswingsbetweenclarity
andconfusion.Wecannotrememberthenamesofourfamilyorfriends,orevenrecognize
whotheyare.Itbecomesmoreandmoredifficulttoperceiveanythingoutsideofusassound
andsightareconfused. Theinnerexperienceisofbeingconsumedinflames.Thefire
elementisdissoingintoair,andbecominglessabletofunctionasabaseforconsciousness,
whiletheabilityoftheairelementtodosoismoreapparent. Wecanexperiencethevisionof
shimmeringredsparksdancingaboveanopenfire,likefireflies.
Air.Itbecomesharderandhardertobreathe.Theairseemstobeescapingthroughour
throat.Webegintoraspandpant.Ourinbreathsbecomeshortandlabored,andour
outbreathsbecomelonger. Oureyesrolupward,andwearetotalyimmobile. Asthe
aggregateofintelectisdissoingthemindbecomesbewildered,unawareoftheoutside
world.Everythingbecomesablur.Ourlastfeelingofcontactwithourphysical environment
isslippingaway.Webegintohalucinateandhavevisions.Momentsofourlivesare
replayed.Theinnerexperienceislikeagreatwindsweepingawaythewholeworld.Theair
elementisdissoingintoconsciousness.Wecanexperiencethevisionofatorchorlamp
witharedglow.Ourinbreathscontinuetobemoreshalow,andouroutbreathslonger.At
thispointbloodgathersandentersthe”channeloflife”inthecenterofourheart.Three
dropsofbloodcolect,causingthreelongfinaloutbreaths.Then,suddenly,ourbreathing
ceases.
Justaslightwarmthremainsatourheart.Alvitalsignsaregone,andthisisthepointwhere
inamodernclinicalsituationwewouldbecertifiedas”dead”. ButTibetanmasterstalkofan
internalprocess,caledtheinnerrespirationthatstilcontinues.P
A20thcenturystory:Therewasagonyduringthelastdifficulthoursuntil
thefinalbreathwasreleased.Nothinginparticularhappenedatthattime.My
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motherwaslaidoutinthecasketandherbodywouldstayathome,whichis
notunusualintheNetherlands.WhenIwenttoseeheragain,herappearance
wastotalydifferentfromtheselasthoursbeforedeath.Therewasa
tremendouschange.Herfacewasyoungandpeaceful,asIhadneverseenit
before.Therewaslightaroundher.Howwasthispossible?Therewasan
obviouschangethatlastedforhoursafterwhatweintheWestwouldcalthe
momentofdeath.Whendowedie?
B.THEINNERDISSOLUTION.
Intheinnerdissolutionincreasinglysubtlelevelsofconsciousnessaretobeencountered.The
processofdeathmirrorsinreversethatofconception,becauseduringconception
consciousnessisdrawnin.Duringdeaththeso-caled”whiteessence”(inheritedfromour
father)descendsfromthecrownofourheadtowardtheheart.Ourawarenessbecomes
extremelyclearandalangercomestoanend.Theso-caled”redessence”(inheritedfrom
ourmother)risesfrombelowthenaveltotheheart.Thereisanexperienceofblissanddesire
comestoanend.Whentheessencesmeetattheheartweexperienceblackness,astateof
mindfreefromthoughts.Ignoranceanddelusionarebroughttoanend.Thenwebecome
slightlyconsciousagain,andtheGroundLuminositydawns,”themindofclearlightof
death”.Thisconsciousnessistheinnermostsubtlemind,theBuddhanature,therealsource
ofalconsciousness.”
Thisclearlightofdeathissomethingthateveryone,withoutexception,experiences.For
somepeopleitlastsonlyafewseconds,forsomeseveralhours,orevendaysorweeks.I
wonderifthisiswhatIsawwhenmymotherdied.Attheverymomentthattheconnection
betweentheverysubtleenergymindandthegrossphysicalbodysevers,thebodybeginsto
decay.ThisisthemomentofdeathfortheTibetans.”
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Tantricpractitionersprepareinlifeforthisprocessofdyingusingadvancedformsof
meditation.Theyalsotrainduringfalingasleep,asthestagesoffalingasleepresemblethe
stagesofdying.”
II.PROGNOSTICATION INTIBETANTEACHINGS
PrognosticationisalsopartoftheTibetanteachings. IntheBardoteachingsandTibetan
medicaltexts,wefinddescriptionsofsignswarningofimpendingdeathwithinyearsor
months,weeksordays.Theyincludephysicalsigns,certainspecifickindsofdreams,and
specialinvestigationsusingshadowimages.”
Ifoneisveryskiled, onecancarefulyscrutinizethebreathitself,eventhatofapersonthat
isingoodhealth,andbeabletodetectindicationsofdeaththatmaybeevenseveralyears
away.Differenttypesofpulsesmayalsoindicatedeath,beitdistantorproximate.”
MODERN TIME:THE20thCENTURY
I.INTRODUCTION
ThefamousWiliamOsler(1849-1919)wasaphysicianatJohnsHopkinsHospital,andalso
thefirstthanatologistofthe20thCentury. From1900to1904heconductedamostunusual
studyforthetimeentitled,”AStudyoftheActofDying”.Itwasneverpublished.Hewrites
inhisnotes:
Ihavecarefulrecordsofabout500deathbeds,studiedparticularlywith
referencetothemodesofdeathandthesensationsofthedying.Thelatter
aloneconcernushere.Ninetysufferedbodilypainordistressofonesortof
another…Thegreatmajoritygavenosignonewayortheother;liketheir
birththeirdeathwasasleepandaforgetting.”
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Peopleusualydiedathomesurroundedbytheirfamiliesatthebeginningofthe20thcentury.
Deathwasomnipresent;apartofdailylife,andchildmortalitywasstilhigh.Therewereno
antibioticstotreatinfectionsandtherewerenovaccinations.Manypeoplediedfrom
infectiousdiseasesthatweintheWestusualydonotdiefromanymore. The1918influenza
pandemiccausedmoredeathsthanWorldWarI.
Osler’sopponentMaeterlink(Belgiumessayist,poet,andNobelPrizewinner)disagreed
withOsler’soptimisticview,thatdeathwasmostlyasleepandaforgetting.Hewritesas
earlyas1912:”aldoctorsconsiderittheirfirstdutytoprotractaslongaspossibleeventhe
mostexcruciatingconvulsionsofthemosthopelessagony”.”.Thesetwoperceptionsof
deathanddyingareverydifferent.
ThelateFrenchhistorianAries,puttingdeathanddyinginabroadhistoricalandsociological
perspective,describes20thcenturydeathas”shamefulandforbidden”.”Dyingstartedtotake
placeinhospitalsandnursinghomesincreasingly.Deathbecameataboointhecourseofthat
century.Deathbecamehiddenandwasnotpartofdailylifeanymore.
Hardlyanystudiesondeathanddyingweredoneuntilthesixties.AtthattimeGlaserand
Strausswerethefirsttostudythecontextofawarenessofdyinginhospitalsettingsusinga
sociologicalapproach.IntheseventiesKubler-Rossattackedthetabooofdeathwithher
“stagetheory”,inwhichshefocusedonpsychosocialdynamics.f
Severaltheoriesaboutdeathanddyinghavedevelopedsince,butnoneofthemincorporates
thedyingbodyorbodilydying.Itistruethatamorerecenttheorypaysattentiontothebody
intheso-caled”readinesstodie”theory,butitdoesnotusedetailedbodyphenomenologyat
a.43
15

Nowadays80%ofAmericansdieinahospitalorotherinstitution,anddeathisstil
substantialyhiddeninIntensiveCareUnits, CoronaryCareUnits,EmergencyRooms,
CancerFacilities,andNursinghomes.” Notonlylife,butalsodeathhasbeendeeplychanged
bytheuseofmedicaltechnology.
Scientificmedicineoftentutorsyoungphysicianstoseedeathasacorrectableaccident, and
thisisoneoftheobstaclestoapeacefuldeathinmodernmedicine.”CPR,cardiopulmonary
resuscitation,isconsideredtobeanormalprocedure, butitisnotapeacefulordignified
death.”
A20thCenturystory:January27,1997.Thepatient, unconsciousbecauseof
inadequatebloodflowtothebrain,rapidlygetsabreathingtubeinthe
tracheatoprovideoxygenunderpressure.Metalpaddlesareplacedonhis
chestand200joulesisfiredthroughhisheart.Thishasnoeffectanda
memberoftheteambeginsfirmmanualexternalcardiacmassage.Ribs
fracture.IV’sareinsertedfortheinfusionofcardiogenicdrugs, andcentral
linesintomajorveins, buthisheartresiststhesemeasures.Thebraindoesnot
getoxygen,andthepatient’spupilsbecomeunresponsivetolight. The
patientdiesaloneamongstrangers. Hewasmyfather, 78yearsold.Iknew
hewasfulypreparedtodie,butnotthisway.
Itwouldbetoosimpletoromanticizenaturaldeath,whichisasubtleformofdenial,andto
demonizetechnology.Thehistoryoftechnologyisaheroictaleononeside,anarrativeof
progress,accompaniedbyacounterdiscourseabouttechnologygonewild.”Technologyis
neithergoodnorbadperse.Theperceptionofthemeaningoftechnology,ratherthanit’s
presenceorabsencemightbeanimportantfactor.” Eveninpaliativecarethereisaplacefor
lowkeytechnology”,butgoodclinicalpracticecounselsdeath’s inevitabilityandnecessity.”
16

II.SIGNSOFAPPROACHINGDEATHIN20mCENTURYLITERATORE.
WhenIstartedlookingfor”signsofapproachingdeath”intoday’s literature,itwasdifficult
tofindusefulinformation.Arecentstudyconcludedthattop-selingtextbooksofferlittle
helpfulinformationonendoflifeissues.”Thesebooksreflectthisculture’sfocuson
extendinglife.Inmedicalarticlesandnursingtextbooksinformationondeathanddyingis
scarceandscatteredtoo.Iwonderifthisisjustanothersymptomofthedenialofthe
presenceofdeath?TheclassicaldescriptionofthefaceofthedyingbyHippocrates,the
faciesHippocratica,wellknownforsomanyages,isalmostnowheretobefound.Itisasif
deathhasnofaceanymore.
Signsofapproachingdeathareprimarily describedasthelossoffunctionofphysiological
subsystems.WhenIcomparethemodernapproachwiththeoldandverydetailedGreek
descriptionsitiseasiertogetaninnerimagefromthelatter,especialybecausetheGreeks
paidsomuchattentiontothefaceandtheeyes.Theincompletemoderndescriptionsarealso
incontrastwiththeverycompleteandrefinedTibetanphenomenologicaldescription.
Foracompilationofsignsofapproachingdeath fromrecentliterature:seeaddendum.
III.MEDICALTECHNOLOGY REDEFINESDEATH
Medicaltechnologynotonlyhashadahugeimpactonlifeanddeath;itevenmadeus
redefinedeath.Thetraditional viewintheWestwasthatdeathoccurredwiththelastbreath
oflife.52Thelastbreathisavisiblephenomenonthateitherfolowsorprecedesthecessation
oftheheartbeat. Irreversiblecessationofthefunctionofheartandlungsstildetermines
deathinmostsituations. Whentherewasdoubtaboutthiscessationbeingpermanent, the
onsetofrigormortisandthedecompositionofthebodycouldbereliedupon.”
17

Fromthesixtieson,techniquesweredevelopedtosupportvitalfunctionsincriticalyiland
injuredpatientsandthey”produce”thetraditionalvitalsignsofheartbeatandrespiration.
Usualythesepatientshadsufferedatraumatothehead,astrokeorcardiacarrest.
Evenwhenthefunctionofthebrainhasfulyandirreversiblyceased,thepatient,whenon
artificialsupport,breathes,issupple,andisperfusedwithblood.Usingtheterm”life
support”forthisartificialsupportofvitalfunctionshighlightsaparadox,becausethepatient
wildieassoonassupportiswithdrawn.”Asaconsequenceanawarenessofanewtypeof
deathwasaeadygrowing,butthefirsthearttransplant(1967)catapultedthisnewdefinition
ofdeathintothepublicarena.Howcouldthedonor,whoseheartwasbeating,bedead,while
therecipient,whoseownhearthadbeenremoved,wasconsideredalive?”Theanswerwas
braindeath:theirreversiblecessationofalfunctionsoftheentirebrainincludingthebrain
stem.
ItisfarbeyondthescopeofthispapertodiscussthemanydetailsthatledtotheUniform
DeterminationofDeathAct(UDDA),thatisnowlawinmorethanhalfoftheUS’s
jurisdictions,whilevirtualyaltheresthavesomeother,essentialysimilarstatute.An
individual,whohassustainedeither(1)irreversiblecessationofcirculatoryandrespiratory
functions,or(2)irreversiblecessationofalfunctionsoftheentirebrain,includingthebrain
stem,isdead..56Eithermeansofdeterminingdeathcanbeusedinappropriatecircumstances
tomeasurethesamephenomenon,namelydeathoftheorganismasanintegratedwhole.
Deathbecamelegalizedforthefirsttimeinhistory.
Twodifferentconditionsneedtobedistinguishedinclinicalpractice:withdrawinglife
supportinaseverelybrain-damaged personwileventualy,butnotimmediately,resultin
death.Converselythepersonsolelymaintainedbymachinesisaeadydeclared(brain)dead
18

andorgansmaybeusedfortransplantation.57Whilebothareonlife-supportonecannotsee
thedifferencebetweenthesetwopatientsfromtheoutside,butoneofthemis(declared)
dead.
Thephysicianisnotonlysupposedtocertifydeath,butalsotostateitscause.Acceptanceof
thenaturalnessofdying,especialyoftheelderly,directlyconflictswiththemedicalization
andlegalizationofdeathinmodernsociety.”Everybodyisrequiredtodieofanamedentity.
Everywhereintheworld,itisofficialyilegaltodiefromoldage.”
IV.PROGNOSTICATION INTHE20TIlCENTURY
PrognosticationhasbeenanimportantmedicaltoolfromHippocratictimesuntilOsler’sdays
atthebeginningofthe20thcentury. Anexaminationofentriesinsuccessiveeditionsof
WiliamOsler’stextbook”ThePrincipleandPracticeofMedicine”revealsthatintheperiod
from1892to1988thereisacomplementary, reciprocalrelationbetweenprognosticationand
therapy.Whentherapyisavailable,prognosticationisoftenavoided.”Besides,
prognosticationisalwayslinkedwithdeath.”Boththeomnipresenttherapeuticimperative
andthegeneraldenialofdeathleavescantroomforprognostication.
Nowadayscomputersarebeingusedforthemakingofaprognosis.Thecomputerized
prognosticmodelsuseanenormousamountofclinicalandbiochemicaldata,buttheydonot
improvethequalityofendoflifecare,orthecommunicationaboutthepatient’s
prognosis.6263Thoughthecultureofmodernmedicineavoidsprognosis,thepatientandthe
familythemseesarealwaysinterestedinit.Theymaybeevenmoreinterestedinprognosis
thanindetailsofdiagnosisandtherapy.
19

However,itisworthnotingthattwootherformsofprognosticationdoexistinourculture.
Prognosticationhasbeenusedforcardiacpatients, anditisbasedonheartratevariability, as
canbedemonstratedbytheuseofECG.Itsapplicabilitymightgrowinthenearfuture.”
Andpeopledream.Dreamscanrevealmanydifferentaspectsofdeathanddyingasa
transformationalprocess, buttheycanalsoannouncethenearnessofdeath.”
SIGNSOFAPPROACHING DEATH,PROGNOSTICATION, ANDMUSIC·THANATOLOGY.
Whatcanwelearnfromthisexplorationinthefieldofthanatology?Whatcanwelearnfrom
thesignsofapproachingdeathandthewaytheywereusedforprognostication?Whatcanwe
learnasmusic-thanatologists?
ThedetailedobservationstheGreeksoncemade,andthatwerecarriedthroughtotheMiddle
Ages,arenotalwaysconsciouslyusedinourtime,buttheyarecertainlyusefulindeepening
ourunderstandingofwhathappensatthebodilylevel. Especialythemanyminutechanges
ofthefaceandtheeyes,whentheybecomefamiliar, wiltelustheirstoryaboutthepatient.
PrognosticationinAntiquitywasatleastausefultooltoinspireconfidenceinthecare
provider,butitwasnotused,asfarasIknow,asguidanceforritualcare.However,itmay
havehelpedthefamilytostayclosetothedyingpatient,whichwasnormalfortheGreeks”,
asitisstilnormalformanyfamiliestoday, andconfidenceiscertainlyanimportantpartof
thepresenceofthemusic-thanatologistatthebedside.
TheroleofprognosticationatCluny, basedonthecarefulobservationsoftheinfirmary
servants,wasdifferent. Dependingonthebodilysignsitwasdecidedwhethertosingpsalms,
toreadthepassion,tosingtheCredo,ortosingthelitanies.FortheCluniaccommunity
20

deathwasanimportanttransition, andtheritualcare,includingthemusical choiceorthe
readingofthepassiondependedonthisprognostication.
TheTibetansstartreadingtheBardoThodolwhenthefinalprocessofdyingsetsin,andthey
continuereadinglongafterwhatweintheWest wouldcalthemomentofdeath.Reading
aloudthefamiliartextsremindsthedyingpersoncontinuouslyofwhatisgoingon,andthis
isaformofritualcare.
Inmusic-thanatologythemusicisprescriptiveanddynamic,andunliketheabovementioned
traditionalformsofcareforthedyingthemusicaldeliveryisindividualized.Iwonderifthis
reflectsadeepprocessofindividuation many people aregoingthroughinourculture.The
individualizedandpersonalapproachisbalancedbythemusicitself.Theinfirmarymusic-
mostofitisbasedonGregorianChant-hasalonghistory,anditisapersonal,asitbelongsto
thecommunity.Themusicmakesitpossibletomovebeyondthepersonal,individuallevel.
Howdomusic-thanatologists know howtochoosethemusicand/orvowelsortexttosing?
Anotherquestionrisesatthesametime: HowcanIwriteaboutthemusic, whentheessence
ofmusicisbeyondwords?
Musicgivesstructureandformtoournon-verbalworlds.Inthiswaywearealways
storytelers.Welookatthepatient, webreathewiththepatient, andwelistenwithourwhole
body, witheverysensingcapacity.Whenwelistenlikethisastoryistoldwithouttheuseof
anyliteralwords,astoryisrevealed,andthestorybecomestranslatedintomusic.
RobertSardelorelatesourbeing-intheworldtothetweesenses.Althoughweusethemal
inthevigilsettingIamconfiningmyselfheretothesenseofmovement.Thelivingbodyis
anopenfield, andbreathingtogether withthepatient isawayofsensingthepatient’sbody,
andawayofsensingmovement. Oursenseofmovementisabodilyfeelingofsensing
21

movementorstilnessinalourmuscles. Whenitisfulyexperienceditgivesafeelingof
freedom,butalsoafeelingofdestiny.”
Whichstorydowetel?Isitthestoryofthepastorarewefore-telingthestoryofthe
future?Isouractiveimaginationseeingthepastorisitfore-seeingthefuture?
Thepast,thepresent,andthefuturewereaeadymentionedtogetherintheveryfirstchapter
onPrognosisintheHippocraticWritings.Wecanplacetheminalinearsequence,likethe
linearwayofmovementinmusicintime.Placing theminhorizontaltime(thechronos)isan
essentialaspectofourlifeintheworld.Butmusicalsooffersthepossibilityofenteringthe
timeless(thekairos),wherepast,present,andfutureareone.SeveraltimesduringvigilsI
experiencedaclearsenseofknowing,thewayIknewthingswhenmymotherwasdying.
Iwonderifwereachthedeeperplaceofknowingatthecrossroadoftimes.
Themusic-thanatologisthasnotonlybeentrainedtoworkwiththebodilyphenomenaofthe
tweesenses. Thethree-foldimaginationofthebody-theuppernerve-sensesystem,the
middlerhythmicsystem,andthemetaboliclimbsystem-givesusanotherbasisformusical
choices.”Whichbodysystemseemsoutofbalance,toostrongortooweak?Dependingon
theanswerwemaychooseprimarilymelody, harmonyorrhythm.Therearecountlessother
choiceslikemajor,minor,oroneofthemodes,countermelody,repetitions,inversions,
specificintervals,longorshortphrasesetc.forfurtherrefinement,aldependingonwhat
revealsitselfinthemoment
Inmusic-thanatologywedistinguishbetweenprocessingandimminencyvigilsandweneed
prognosticationtomakethisdistinction.Althoughprognosticationseemstobealostartin
general,referringnurses-whohavealotofexperience,andprobablystilsomesortoforal
tradition-oftengiveaprognosticationinweeks,days,orhours.TheJewishtraditionevenhas
22

aspecialnameforthepatientwhoisimminent. Whenapatientisexpectedtodiewithin
threedaysorfewer,heistermeda”goses”.”Whydoesitoftenseemself-evidentwhethera
vigilwilbeaso-caledprocessingoranimminencyvigil,assoonasweentertheroom?We
mightcompareastrikingaspectoftheprocessofbirthwiththeprocessofdying.Atfirst
thereisstilinteractionpossiblewiththesurroundingordinarydailylife,butatsomepointa
shiftoccurs.Theprocessitselfseemstotakeover,andaltheenergyisspentintheprocess
ofgivingbirth.
Whenaltheavailableenergyofthepatientisspentintheprocessofdying,andwhenthe
pointofnoreturn-backtolife-isleftbehind,Icalapatientimminent. Withbirththefirst
gaspofairistheveryfirstactionofthenewbornbabyanditmarksitsbeingonearth.For
thedyingpersonthelastgaspofairmarksanimportantmomentofthebodyaswe.
Ibelievewecandeepenourunderstandingofthedistinctionbetweenprocessingand
imminencyvigils.Inaprocessingvigilwemaymeetapatientbeingdiagnosedwithacertain
disease,andoftenhavinganemotionalresponsetothedisease,and/oranxietyabout
impendingdeath.Ourknowledgeandimaginationofthediseaseprocess,andthewaythe
diseaseinterfereswiththethree-fold body-systeminfluencethemusicalprescription.
However,fromthemomentthepatientisactivelydying,theunderlyingdiseaseprocessitself
movestowardsthebackgroundmostofthetime.Duringimminencyvigilsanunderstanding
ofthephenomenologyofthedyingprocesscouldhelpinformourmusicalprescriptions.
ThereisprobablynodescriptionasdetailedandasrichinphenomenologyastheTibetan
wayofseeingthedissolutionofthebodyduringthisdyingprocess. Thedissolutionisthe
dissolutionoftheelements.Theelementsearth,water,fire,air,andspacedetermineour
physicalexistence.Throughthemourbodyisformedandsustained,andwhentheydissoe
23

wedie.Theelementsearth,water,fire,andairarewel-knownintheWesternculturetoo.
TheGreekPresocraticphilosopherEmpedocles(c.495-c.435 BeE)describesthesefour
elements-hecalsthemroots-, earth, water, fireandair,andtheirunifyingforce,whichhe
calsLove.FromamusicalpointofviewitisinterestingthatinsteadofthewordLovehe
alsousesthewordharmoniaforthefifthelement.”GalenconsideredHippocratestobethe
originatorofthetheorybasedonthefourprimaryopposites(hot,cold,dry,andwet)inthe
bodyandthefourelements.”Eachoftheelementsmustreturntoitsoriginalnaturewhenthe
patientdies.Withoutthemanydetails,thisisthesameprincipleasfoundintheTibetan
view.Thefourelementswerebasicalyusedinphysicsfor2000years.Theelementsarestil
beingusedinalchemy.InAnthroposophicalMedicineeachmajororganisprimarilyrelated
tooneoftheelements;thehearttofire,thelungstoearth, thelivertowater,andthekidneys
toair.72Inalchemythefifthelement, thequintessence, isthepurestandthinnestsubstance.”
ThefifthelementintheTibetantradition, asaeadymentioned,isspace, unlimited
emptiness.
Becomingmorefamiliarwiththedissolutionoftheelementsduringthedyingprocessmight
beafirststepforthemusic-thanatologistinordertodevelopadifferentactiveimagination
forimminencyvigils.Theearthelementmightinspireustofindsolidityandgroundingin
music.Wemightthinkofbassnotes,drones,simplerepetitionsthatanchorthemusicetc.
Theclarityofwatermayleadustoclearmelodies,andthefluidityofwatertolegato,or
melisma’s.Thefireispureenergyandlight,whichmakesmethinkofharmonics,thebright
notesinthehigherregister,andclarityinmelody.Airmightinspiretowardsmore
movement. Iwonderifthefifthelementissilence.
24

However,therearesomedifficultiestobeexpectedtoo.Inthefirstplaceitisnotalwayseasy
toperceivetheseexternalsignsofdissolution,andtheycanhappenfast.Wewilhaveto
trainoursees,whichcouldtakemanyyears,andthereishardlyanyworkdonelikethisin
theWest. Inthesecondplacewemightnotseethesesignsofexternaldissolutionbecauseof
medication.”Modemdeathismedicalizedinmanyways.Theuseofmorphine,oxygen,and
intravenousfluidscaneasilymaskimportantphenomenology.Therearesomesoundreasons
tousemorphineandoxygen.”7677SometimesIgettheimpressionthatthiskindof
medicalizationtakesonanalmostritualdimensioninpaliativecare.
Themusic-thanatologisttriestoprovide anothermedicineatthebedsidewithmusic;music
asamedicinethataddressesbody,soul,andspirit. Thiskindofcareneedsfine-tuningwith
thepatient,thefamily, andtheothermembersthemusic-thanatologyteam.
Isthisfine-tuningthesameasusingthemaximum capacityofaloursenses?Whenweopen
uptoenterintotheun-known,weencountermomentsthatweknow.Whenourowninternal
cloudsvanish,informationaboutthepatientcanenterus.Thisknowledge,thisgnosis,feels
differentfromthecognitiveknowledgeweacquireintherationalandlogicalworld.Isit
revelation?Ismusicrevelation?
Whenweholdthepatientinourheartandthoughtsafterthevigil,wecontinuemeetingeach
otheratthesoullevel. Atthesoullevelthemusicstayswiththepatient,evenafterweare
gone,andthepatientstayswithus.Theservantstaysatthebedside, evenafterthemusic-
thanatogisthasleft.Thesoulprocesscontinuesandrevealsitself.
Canknowledgeeverbeagoalinitself?Thetreeofknowledge,notthetreeoflife,wasatthe
centerofthedramaofEden.AdamandEvewereexpeledfromthedivinepresence,because
25

theyaspireddivinewisdom.Godhadseenknowledgeasinseparablylinkedwithdeath…”in
thedaythatyoueatofityoushaldie”.78
Knowledgecanbeuseful,butitisneveragoalinitself.Inatruedialogue(betweenpatient
andmusic-thanatologist)thetrueconcernisnotgnosis,butdevotio.”
26

ADDENDUM
SIGNSOFIMPENDINGCUNICALDEATHINRECENTPUBUCATIONSSO 818283
LOSSOFMUSCLETONE:
Relaxationofthefacialmuscles(thejawmaysag);difficultyinspeakingandswalowing;
decreasedactivityofthegastrointestinaltract(nausea,flatus,abdominaldistension,and
retentionoffeces(esp.whennarcoticsortranquilizersareused));possibleurinaryandrectal
incontinenceduetodecreasedsphinctercontrol;diminishedbodymovement. Sometimes
restlessnessandagitationclosetodeath.
SLOWINGOFTHECIRCULATION:
Diminishedsensation;mottlingandcyanosisoftheextremities;coldskin,firstinthefeetand
laterinthehands,earsandnose(thepatientmayfeelwarmbecauseofelevatedtemperature).
Theheartratemaybe>lOO/min.whendeathisnear,beforeslowingdown.Theslowing
downofthecirculationcausesdiscolorationoftheskin,inparticulartheundersideofthe
bodywilbecomedarkerincolor.
CHANGESINVITALSIGNS:
Deceleratedandweakerpulse;decreasedbloodpressure;respirationsrapid,shalow,
irregularorabnormalyslow;Cheyne-Stokespattern;noisybreathingduetocolectingof
mucusinthethroat;mouthbreathing(drymouth).
SENSORYIMPAIRMENT:
Blurredvision,impairedsensesoftasteandsme.Hearingisoftenmentionedasthelast
sensetobelost,butIalsofoundadescriptionofhearinggonefirstandthenvision.”
Sometimesdisorientation.
MISCELLANEOUS:
Terminaldehydrationisnaturalandsomepeopleassumethatpatientsprobablydonot
experienceafeelingofthirst. Dehydrationreducespulmonarysecretions,thelikelihoodof
27

vomiting,theurinaryoutput,andthepossibilityofincontinence.Painoftendiminishesasthe
dyingprocessprogresses,eitherbecauseofdecreasingoxygensaturationlevelsinthetissues
and!orbecauseofdecreasingperceptionofpain.Thepatientmaybesleepingor
unconscious.Vision-likeexperiencesarequitecommon.
28

Notes
L’I’hereseSchroeder-Scheker’sarticlesgiveanin-depthdescriptionofMusic-Thanatology:
•Schroeder-Sheker,Therese.”MusicfortheDying:APersonalAccountoftheNewField
ofMusic-Thanatology-Histories,Theories,andClinicalNarratives.”JournalofHolistic
Nursing,Vol.12,No.1:83-99,March1994.
•Schroeder-Sheker,Therese.”MusicfortheDying:UsingPrescriptivemusicintheDeath-
BedVigil.” NoeticSciencesReview,No.31,Autumn1994:32-36.
•Schroeder-Sheker,Therese.”Musical-Sacramental-Midwifery:TheUseofMusicin
DeathandDying.”InMusicandMiracles,editedbyDonCampbe.Wheaton,n.Quest
books.
•Schroeder-Sheker,Therese.”AnointingtheDyingwithSound:Music-Thanatologyand
theCareoftheDying.”Caduceus,Issue40(Summer1999):21-26
2.AMedievalLatinDeathRitual.TheMonasticCustomariesofBernardandUlrichof
Cluny.FrederickS.Paxton,translatorandcommentator.St.Dunstan’sPress,Missoula,
Montana,1993.Asecondrevisededitionisinpreparation.
3.Paxton,FrederickS.”SignaMortifera:DeathandPrognosticationinEarlyMedieval
MonasticMedicine”.BulletinfortheHistoryofMedicine67(4):631-650,1993.
4.Modernesotericspirituality.Worldspirituality,Volume21.Crossroad,NewYork.1992.
IntroductionIbyAntoineFavre,p.xviii.
5.Imeannaturalbirth.Naturalbirth,midwives,andbirthathomearenotexceptionalatal
intheNetherlands.ThedifferencesbetweenobstetricsintheNetherlandsandtheU.S.are
huge.ThepercentageofCaesareansectionsforinstanceislowintheNetherlandscompared
totheU.S..
6.Lock,Margaret. “DisplacingSuffering:TheReconstructionofDeathinNorthAmerica
andJapan”.Daedalus125:207-244,1996.
7.Christakis,NicholasA.DeathForetold.ProphecyandPrognosisinMedicalCare.The
UniversityofChicagoPress,1999.Chapter1,pp.19-20.
8.”Beingwithandlookingat”isawel-knownprincipleinanthropologicstudies.The
historianCarolineWalkerBynumusesthisprincipleinchapter1ofherbookFragmentation
andRedemption,EssaysonGenderandtheHumanBodyinMedievalReligion.ZoneBooks,
NewYork,1991. ShealsoreferstoanthropologistVictorTurner.
29

9.RoutledgeEncyclopediaofPhilosophy,entry”Phenomenology,epistemicissuesin”,
editedbyEdwardGraig,London&NewYork,1998.
10.RobertSardelo.Classroomlectures.Autumn1998
11.Morison,RobertS.”Death:ProcessorEvent”.Science173:694-698, 1971,and
Kass,LeonR.”DeathasanEvent:ACommentaryonRobertMorrison.”
Science173:698-702, 1971.
12.AliceReich.ThinkingAnthropologically.PaperfortheChaliceofReposeProject.
Autumn1998.
13.Hippocraticwritings.EditedandintroducedbyG.E.R. Lloyd.ReprintedinPenguin
Classics1983.Introduction,pp.9-14.
14.Ibid.Introduction,pp.9-14
15.Ibid.,pp.170-171.
16.Ibid.,p.171.
17.Ibid.,p.31,p.359.
18.Ibid.,p.170.
19.Paxton.SignaMortifera,p.644,quotingfromGalen,OnPrognosis,ed.VivianNutton,
CorpusmedicorumGraecorum,Vo1.5 (BerlinAkademieverlag,1979),pp.59-61.
20.Ibid.,p.632.
21.Paxton,classroomlectures,Spring1999.
22.Paxton,SignaMortifera,p.647.
23.Paxton.AMedievalLatinDeathRitual,pp.75-6.ThecustomarywrittenbyBernardwas
forCluny.Theotherone,writtenbyUichwasforanewGermansettlement.
24.Ibid.,p.18.
25.Paxton.SignaMortifera,p.637,andnote24:Paris,BN,MS.lat.11219,fo1.170r.
26.Ibid.,p648.
27.TheTibetanBookoftheDead.TranslatedbyRobertA.F.Thurman. BantamBooks,New
York.ThisisthethirdtranslationoftheBardoThodolinEnglish;itismuchmoreaccessible
thantheEvans-Wenztranslation(1927),andhasscholarlycomments,p.lO.
28.Ibid.,p.20.
29.Ibid.,pp.xvii-xx,
30

30.Ibid.,p.246.”Between”isusedinatleastthreesenses:itsbasiccoloquialsenseofthe
wholeperiodbetweendeathandrebirth;itstechnicalsenseinthesetofthesixbetweens,the
life,dream,meditation,death-point,reality,andexistencebetweens;andinthesenseof
“phaseofabetween”,wheretheexperienceofaparticularperiodinoneofthesixbetweens
isitselfcaledabetween.
31.Rinpoche,Sogyal,TheTibetanBookofLivingandDying.Harper,SanFrancisco1992.
DutchTranslation: 1994.Iliberalyquotefromchapter15,pp.244-256, oftheAmerican
edition.Thedescriptionofthedissolutionoftheelementshassomanyinterestingdetailsthat
Iuseditalmostentirely.
32.Varela,FranciscoJ.Sleeping,DreamingandDying.AnExplorationofConsciousness
withtheDalaiLama.WisdomPublications,Boston,1997,pp.191-2.
33.RJnpoche,pp.251-253.
34.Ibid..p.254.
35.Varela,pp.163-4.
36.Ibid., pp.43-5.
37.Rinpoche,p.245.
38.Varela,p.161.
39.Golden,RichardL.”SirWiliamOsler:HumanisticThanatologist.”Omega36(3)241-
258,1997-98.
40.Ibid.,p.246.
41.Aries,Philippe.Westernattitudestowarddeath.TheJohnsHopkinsUniversityPress,
1974,p.85.
42.Copp,Gina.”AReviewofCurrent TheoriesofDeathandDying.”JournalofAdvanced
Nursing,28(2),382-390,1998.
43.Ibid.,pp.388-9
44.Nuland,SherwinB.Howwedie.ReflectionsonLife’sFinalChapter.VintageBooks,
NewYork,1994.
45.Calahan,Daniel. Chapter69″TheValueofAchievingaPeacefulDeath”. InGeriatric
Medicine,3rdedition,editedbyKristineCassel,eta.,NY,Springer,1996.
46.Nuland,pg39-41. IusedpartofhisdescriptionofCPR.
47.Lock,Margaret,p.208.
31

48.Seymour,JaneElisabeth.”RevisitingMedicalisationand’Natural’Death.”Social
Science&Medicine49(1999)691-704.
49.Jacobs,W.MJ.,eta.”TreatmentofRestlessnessinDyingPatients:morethanjust
Sedation.”NTVG142:433-6,1998. ArticleinDutch.AbstractinEnglish.
50.Calahan,pg1041.
51.Rabow,MichaelW.”EndofLifeCareContentin50TextbooksfromMultiple
Specialties”.lAMA.2000;283:771-778.
52.Lamb,David.Entry”Death,Medicalaspectsof.”InEncyclopediaofAppliedEthics,
AcademicPress1998.
53.Harris,John.RoutledgeEncyclopediaofPhilosophy, entry”LifeandDeath”,editedby
EdwardGraig,London&NewYork,1998.
54.Harris,John,RoutledgeEncyclopedia,p.626.
55.Capron,AlexanderMorgan.Entry”DefinitionofDeath.”InEncyclopediaofApplied
Ethics,AcademicPress1998,pp.718-9.
56.Ibid.,pg720-1.
57.McKhann, Guy.”TheModernMeaningofDeathandWhytheBrainisattheHeartofIt.”
TheWashingtonPost,Oct25,1998pC1col4.McKhannisdirectoroftheMindlBrain
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