3. Community Relationship-based care Communication around EOL issues Inter-professional relationships and team development Community development

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1 Being with Dying: Curriculum for the Professional Training Program in Compassionate End-of-Life Care Joan Halifax, PhD, Upaya Institute, Santa Fe, New Mexico Helping, fixing and serving represent three different ways of seeing life. When you help you see life as weak. When you fix you see life as broken. When you serve, you see life as whole. Dr. Rachel Naomi Remen Introduction The Being with Dying Professional Training Program in Compassionate End-of- Life Care (BWD) encompasses ethical, spiritual, psychological, existential, and social aspects of care of the dying. It includes mindful and compassionate approaches to end-of-life care, compassion-based ethics and communication strategies in EOLC, clinician self-care, and contemplative interventions appropriate for clinician/caregivers and dying people. The program builds on reflective practices that can regulate attention and emotion, cultivate compassion, aid in the development of a meta-cognitive perspective, promote calm and resilience, reduce stress, and foster emotional balance, embodiment, and compassion. The training also emphasizes basic neuroscience research in relation to the clinical, contemplative, and conceptual content of the training. The BWD faculty has learned in our decades of work in the end-of-life care field that cultivating stability of attention and affect enables clinicians to respond to others and themselves more compassionately and with greater clarity and ethical grounding. This fact is something that the training emphasizes through the progressive contemplative interventions that are taught during the course of the program. These contemplative interventions mirror the Halifax Compassion Model in training clinicians in attention, prosocial affect, the cognitive dimensions of intention and insight, and embodiment. These features can prime compassion and increase the capacity of clinicians to presence and work skillfully with suffering. The training also concentrates on the G.R.A.C.E. intervention a clinician/patient compassion-based approach as a way to give clinicians an attentional, affective, cognitive and somatic base for interactions with their patients. This eight-day residential program is structured to provide opportunities for participants to share insights with their peers as well as with the interdisciplinary team of facilitators that includes contemplative practitioners, clinicians, and educators. It is a deep dive into values and behaviors and utilizes many learning modalities, including didactic teaching, self-directed learning, inquiry, creative processes, council process, and contemplative practices to enhance awareness

2 of the importance of the inner life and professional responsibility. In the course of the training, there are frequent processes for participants to interact with each other in group debriefs, role playing, dyadic exercises, and council practice. Components of the BWD Training The BWD training has four components that center respectively on the transformation of the clinician, the patient, the community, and the institution: Four Dimensions of Training in Compassionate EOLC Transforming: 1. Clinician/Caregiver Clarifying worldview, values, priorities, knowledge Contemplative interventions, including the neuroscience of attention, insight, compassion Development of moral sensitivity Strategies supporting clinician/practitioner health 2. Patient Social, cultural, psycho-spiritual issues Addressing issues of pain/suffering/total pain Peri-death phenomena Dimensions of grief: anticipatory, acute, and chronic grief 3. Community Relationship-based care Communication around EOL issues Inter-professional relationships and team development Community development 4. Institution Ethical issues, process, and policies Implementation in clinician training Applications in clinical settings, with neuroscience rationale Research initiatives Faculty and Components of the BWD Training Program The training is taught by a renowned inter-professional faculty team modeling seven dimensions: collaboration, inclusiveness, respect, mutuality, compassion, and requisite diversity. The team includes: two contemplatives, from the Zen and Tibetan traditions (both of these contemplatives have a non-sectarian approach); two physicians: an oncologist who is a communications expert and a palliative care physician; two doctorally prepared nurses: one who specializes in clinical ethics and pediatric palliative care and the other in hospice care and PNI research; two

3 psychologists, one specializing in trauma and the other palliative care; a chaplain specializing in end-of-life care; and a yoga teacher. Six Core Contemplative Strategies Taught during the BWD Training: 1. Focused attention and concentration practices with an emphasis on equanimity and compassion, including mindfulness of breath, somatic awareness, body scan, walking meditation, yoga, stretching, qigong. 2. Cultivating investigative/discernment faculty that includes insight practices focusing on values and ethics, altruism, pain, suffering, death, priorities and the development of metacognitive capacities; these include insight meditation, Nine Contemplations, contemplation of priorities, writing practice on death, sandtray practice. 3. Presencing pain/suffering and practicing deep listening, including learning not to personalize or pity/console; practices include seeing purely/bearing witness, co-meditation, council process. 4. Cultivating prosocial mental qualities, including altruism, empathy, kindness, compassion, sympathetic joy, equanimity; practices include the G.R.A.C.E. intervention, the Boundless Abodes (Brahmaviharas), sending and receiving (Tonglen), exchanging self with other, 5. Subjective familiarization with psycho-physical aspects of sickness, dying, and death and practices utilizing visualization and imagination; practices include the practice of the dissolution of the psychophysical elements in the process of dying, dissolution of the body after death. 6. Open presence and the practice of panoramic, receptive, non-judgmental attention; the key practice is choiceless awareness. These practices, called contemplative interventions or reflective practices, are done each morning, and as well at various times during the day and evening. After each practice, participants work with a skilled practitioner to unpack their experiences and to explore how to apply the intervention in their work setting. Curriculum Components Covered by the BWD Training The design of the training builds logically from one day to the next, with the training initiated by a deep exploration of values and ethics. The logic of the training should be clear from the list that follows: Day 1: Orientation Day 2: View, Values, Ethics Day 3: Attention, Insight, Embodiment Day 4: Prosocial Communication Day 5: Compassion Day 6: Peri-death, Ethical discernment and action

4 Day 7: Grief, Applications Day 8: Conclusion Details of the Curriculum Components Day 1: ORIENTATION (EDUCATION HRS 2.5) Late afternoon Session: Reflective practice: Intention, focused attention Evening Session: Orientation Introduction to CEOLC, Council: What will serve you in this training? Day 2: VIEWS, VALUES, ETHICS (EDUCATION HRS 8.5) Early Morning Session: Reflective Practice: Focused attention: emphasizing the relationship between equanimity and compassion Morning Session: View, values Debrief: Focused attention PPT: CEOLC Theory, Rationale: six edge states, four benefits, Halifax Compassion and G.R.A.C.E. models Inquiry practice: Attitudes toward dying: view, values related to dying Afternoon Session: Ethics Ethical base of BWD: Moral ground, moral sensitivity Exploring ethical foundation moral ground in care of the dying Reflective Practice: Mindfulness Practice Evening Session: Day s summary; Practices for building resilience Day 3: ATTENTION, INSIGHT, EMBODIMENT (EDUCATION HRS 8.5) Early Morning Session: Reflective Practice: Insight practice on inevitability of death Morning Session: Attention, insight Debrief: Inquiry practice (Nine Contemplations) PPT: Neuroscience of focused attention: Executive function, attentional blink, mind wandering Reflective practice: Presencing suffering Afternoon Session: Somatic approach to BWD Somatic approach to working with the challenges of EOLC Reflective Practice: Mindfulness practice Evening Session: Day s summary Body scan Day 4: PROSOCIAL COMMUNICATION (EDUCATION HRS 8.5) Early Morning Session: Reflective Practice: Boundless Abodes; prosociality Morning Session: Communication: Exploring the G.R.A.C.E. model

5 Debrief: Prosocial mental states G.R.A.C.E. model in communication: Role play Afternoon Session: Communication: Compassion PPT: Empathy, compassion, self-regulation: Application of Batson, Eisenberg Compassion-based communication (G.R.A.C.E.): Role play Reflective practice: Mindfulness Practice Evening Session: Day s summary Somatic practices for clinician self-care Day 5: COMPASSION (EDUCATION HRS 8.5) Early Morning Session: Reflective Practice: Compassion and transforming suffering Morning Session: Compassion Debrief: Compassion practice (Tonglen) Exploring role of interoceptivity in empathy/compassion: Reflective practice: Interoceptivity practice: Pulse, breath PPT: Neuroscience of empathy and compassion Afternoon Session: Pain/suffering Exploring pain/suffering Councils: When pain/suffering is unrelieved Reflective practice: Mindfulness Practice Evening Session: Day s summary Compassion exploration Day 6: PERI-DEATH, ETHICS (EDUCATION HRS 7.0) Early Morning Session: Reflective Practice: Exploring dying Morning Session: Peri-death Debrief: Dissolution of the body Exploring peri-death issues Councils: How do you mark the death of a patient? Afternoon Session: Ethics Ethical Issues at the end of Life: Ethical discernment, reasoning, action Walking reflective practice Public Talk: Being with Dying talk, with core faculty Evening Session: Summary of day s proceedings; Reflective practice: Sympathetic Joy Day 7: GRIEF, APPLICATIONS (EDUCATION HOURS 8.5) Early Morning Session: Reflective Practice: Contemplating Priorities

6 Morning Session: Grief Debrief: Contemplating priorities Reflective Practice Councils: Exploring grief: Patients, clinicians, family Afternoon Session Topics: Application of Training in Institutional Settings Exploring Applications: Using the four transformative areas of clinician, patient, community, institution Reflective practice: Mindfulness practice Evening Session: Councils: Completions and commitments Day 8: CONCLUSION: (EDUCATION HOURS 2.0) Early Morning Session: Reflective Practice: Open presence Morning Session: Large group council and concluding ritual, collecting evaluations, giving certificates. Conclusion The BWD training was initiated by the author of this chapter in 1996 in response to requests by a number of clinicians to be introduced to contemplative and compassionate approaches to end-of-life care. The training was originally funded by the Nathan Cummings Foundation and the George Soros Project on Death in America. As the training developed over the years, dedicated and skilled clinicians in the training became interns in the program, and then some moved into faculty positions. From there, several have become Core Faculty in the training and have made important contributions to the development of the curriculum. All of the current faculty in the BWD training were former participants in the program, and have established BWD training elements in their home institutions. A number of the faculty have collaborated on journal papers, and are moving BWD work into the mainstream through teaching, research, and writing. As of 2012, more than forty individuals from the University of Virginia Nursing and Medical Schools have been through the program. Groups of clinicians have been sent from Rockford Health Services, Duke University, San Diego Hospice, Johns Hopkins University, Zen Hospice, Maui Hospice, and various other institutions. The training is entering a new phase with the publication of the G.R.A.C.E intervention and Halifax Compassion Model, with research monies being now available to assess the efficacy of the training and its various interventions. As well, the core and associate faculty are developing new curricula to translate the training into all medical and nursing disciplines. (Gratitude to Drs. Tony Back, Cynda Rushton, Barbara Dossey, Susan Bauer- Wu, Donna Kwilosz, Gary Pasternak, Ted Heffernan, Charles Lewis. And to Mary Taylor and Tussi Kluge)

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