End of Life Care Practices for Hindu Patients During COVID-19

With coronavirus disease 2019, the risk of death has increased in the general population. In these unprecedented times and even otherwise, it is important for the health care professionals caring for Hindu patients to be aware of the end of life practices in Hinduism. There is limited information in the medical literature about traditions and practices followed in Hinduism which is observed by 15% of the world population. Hinduism is currently the third largest religion following Christianity and Islam. Based on Hindu beliefs about life, death, and reincarnation, we propose 10 end of life best practices for Hindu patients.


Introduction
Over these past several years, the population in the developed countries has become more diverse resulting in a multicultural and multiethnic patient population. Along with patients' physical needs, it is equally important for us to understand their spiritual needs to provide holistic care. Lack of adequate knowledge of customs, traditions, and beliefs may hinder delivery of competent cultural care. Additionally, during coronavirus disease 2019 (COVID-19) pandemic, the risk of death has increased in the general population and patients who are COVID positive and are hospitalized remain in isolation and are unable to interact with their relatives in-person and their relatives are also unable to support the traditional end of life care (EOLC) for their dying family members. During such unprecedented times, health care professionals (HCPs) play a vital role in supporting dying patients' needs. In a recently published study exploring the relative's experiences and needs when a family member was dying during the COVID-19 pandemic, families mentioned that it was important to be able to say goodbye to the dying family member and that it was comforting knowing that there was a health or social care professional or chaplain with the dying family member. 1 Although this study was a good attempt to explore a patient's relatives' experiences, it lacked diversity in its sample size. It would therefore be helpful for HCPs to be aware of EOLC practices for different religions. There is limited information in medical literature about traditions and practices followed in Hinduism which is observed by 15% of world population. Hinduism is currently the third largest religion following Christianity and Islam. 2 About 95% of the world's Hindu population lives in India 2 but their population in other countries is increasing due to immigration. For example, the United States has about 2.23 million Hindus making it the seventh-largest Hindu population in the world. 3 There is widely published literature on EOLC practices predominantly limited to Caucasian ethnicity and those following Christianity. However, there is limited published direction on addressing EOLC for the Hindu population.
This lack of information for EOLC practices for Hindus strongly emphasizes the need for additional information, dialogue and direction for best practices as more and more HCPs care for Hindu patients, especially during COVID-19, in the absence of patients' close relatives who typically would be attending to EOLC practices for their dying family member. In these unprecedented times and even otherwise, it is therefore important for HCPs caring for Hindu patients to be aware of the EOLC practices in Hinduism and provide comfort to dying Hindu patients during their crucial last hours.

What is End of Life Care?
EOLC is defined as the care given to people who are near the end of life and have stopped treatment to cure or control their disease. 4 It includes physical, emotional, social, and spiritual support for patients and their families with the goal of controlling pain and other symptoms so the patient can be as comfortable as possible and may include palliative care, supportive care, and hospice care. 4 What is Hinduism?
After the European, especially British, influence due to the colonization of Indus Valley civilization, Hindu religion came to be called Hinduism. But the actual name of the religion is Sanatana Dharma, where "Sanatana" means eternal and "Dharma" means duty. The word "Hindu" is derived from the river Sindhu. It was a term given by Persians only a few centuries ago, to mean the people living beside the river Sindhu. We must understand that Hinduism is not a religion but is a way of life. There is no compulsion to follow a certain path. One cannot become a Hindu by following the paths described by Hinduism. One must be born a Hindu and will remain a Hindu even if one does not follow the beliefs.

Hindu Beliefs About Life
The purpose of life for Hindus is to achieve 4 aims called "Purusharthas." These are dharma (duty), kama (love), artha (prosperity), and moksha (salvation). These principles guide Hindus to act morally and ethically and lead a fulfilling life. Hindus worship deities instead of 1 single God. Each deity represents an energy that is unique to the follower. Different deities may be worshiped during various stages of life as per the follower's needs. Followers believe there are multiple paths to reaching their chosen deity and multiple paths to ultimately reaching the final goal of moksha. Hindus believe in the tenet of "sansar," the continuous cycle of life, death, and reincarnation; and karma, the universal law of cause and effect. One of the key thoughts of Hinduism is "atman," or the belief in soul.
Atman, the self or spiritual soul, is seen as a kernel that lies at the center of a large onion and is only revealed after the layers around it associated with the body, passions, and mental powers, are removed in a step-by-step fashion. The Taittiriya Upanishad, a Hindu scripture, defines 5 layers or sheaths (from the outer to the kernel): (1) the body (2) bio-energy, the equivalent of Chinese qi; (3) mental energy; (4) intuition and wisdom; (5) pure bliss achieved mainly through meditation. 5 These layers can be removed through self-actualization and the kernel of eternal bliss can ultimately be realized.

Hindu Beliefs About Death
Krishna said in the Bhagavad Gita, "Like a man who has cast off his old clothes puts on others that are new, thus the embodied self casts off old bodies and moves on to others that are new." 6 Death is often viewed benevolently as an escape from 1 life enroute to a better place which is believed to be the ultimate destination; a place of ultimate salvation and peace. The human body and the universe consist of 5 elements in Hindu texts: air, water, fire, earth, and space. The last rite of passage returns the body to the 5 elements and their origins. The Vedas refer to 2 paths taken after death: (1) the path of the ancestors, where the deceased travels to heaven occupied by ancestors and is ultimately reborn and (2) the path of deities, where the deceased enters the kingdom of the Sun God and never returns. The latter is the equivalent of reaching salvation, the ultimate goal, and escaping reincarnation. There is also a reference to a hell-like "pit" where sinners are punished. At death, the sheaths separate successively eventually unveiling the soul which departs the body and goes on a path defined by an individual's karma. In most cases, the soul goes to a hollow in the cosmos occupied by the ancestors or to 1 of the 21 heavens and hells of Hindu cosmology and remains there for the duration defined by karma until the soul is reborn.

Hindu Beliefs About Reincarnation
Reincarnation is viewed as a never-ending set of cycles in which the soul repeatedly dies and rebirths. One may be reincarnated It is always best practice to ask the patient and the family if they require an interpreter before you approach the sensitive topic of EOLC. It is incorrect to assume that all Hindu patients speak the same language. Hinduism is not only practiced in India but also globally. Within India, according to the Eighth Schedule of the Constitution, there are a total of 22 spoken languages with more than 19 500 dialects. 7 Although it is an expectation that all Indian citizens know the national language-Hindi, there are still many who do not. Language barriers certainly contribute to hesitancy in requesting special considerations required for EOLC practices for Hindu patients. It is also a good idea to use certain specific Hindu terms mentioned in this article such as "Aatman" for soul or "Gangajal" for holy water to better connect with your Hindu patients and their family members during discussions pertaining to EOLC.

End of Life Care Best Practices For Hindus
Before we suggest EOLC best practices for Hindu patients, authors would like to share that they are both born Hindus, both practicing frontline physicians and both have sadly lost family, friends, and relatives to COVID-19 who did not receive appropriate EOLC during their hospitalization and subsequent unfortunate death, motivating the authors to write this article and lay the ground for discussing an appropriate approach to addressing EOLC support for Hindu patients. EOLC in Hinduism is broadly based on the Hindu belief that death should neither be desired nor lengthened and that spiritual suffering is connected to one's Karma. Undergoing physical suffering at the end of the life may reverse unpleasant karma and may make the subsequent life better, if at all the soul rebirths.
Based on earlier discussed Hindu beliefs about life, death and reincarnation, we propose 10 EOLC best practices for HCPs caring for Hindu patients (see Table 1). Although there are several well-described, elaborate practices performed after the death of a Hindu preparing the deceased for the funeral and thereafter, in this paper, we share only those practices that HCPs may be directly involved in offering while the patient is still alive and receiving care and seeks support in the preparation of death or immediately after death.

HCPs engaging in EOLC discussions with Hindus should
include routine core concepts of EOLC. 8 2. HCPs should talk about the dying person going to a better place. HCPs should comfort the family by saying that the soul never dies but simply disembodies a weathered body either to be reborn or to attain the ultimate goal of salvation. 5 3. Hindus believe that drinking the holy water of the river Ganges just before death facilitates the soul's liberation from the cycle of reincarnation and thus helps attain salvation. HCPs should therefore offer the family to allow the dying patient to sip on holy water. Most Hindu families keep holy water in a bottle in their houses or is available in Indian stores. Some families opt to offer sips of regular water symbolically. 4. One tulsi leaf, also called as the holy basil, is placed on the dying person's tongue. Hindus believe that this will help the dying attain Moksha. Tulsi plant is worshiped as the most sacred plant in Hinduism and is considered to be the earthly manifestation of Lord Vishnu's wife, Goddess Laxmi. Immediately after death, Tulsi leaves are also used to close all the body orifices so as to prevent the putrefying gases from polluting the environment. 5. HCPs should continue to offer pain relief but should be accommodative of patient's refusal which may appear irrational from the outskirts but has a deeper spiritual meaning for Hindus. Embracing physical suffering and pain just before death may help reverse the negative Karma of the dying person accrued in current life thus giving an opportunity for the departing soul to undergo lesser suffering in the next life, if the soul rebirths. 6. Hindus prefer to be rested in a certain position at the time of death. Hindus believe that the dying person should have the head in the North and the toes in the South direction. It is believed that the deity of death, Yama, has its waves moving in the North-South direction and forms a protective covering around the dead thus facilitating the journey of the departing soul and preventing negative forces from taking charge of the dead. HCPs should therefore offer the family to re-position the bed of the dying to the North-South direction. Families may feel nervous requesting repositioning of the bed, given the additional work for the staff to also change the position of the other attached equipment, but knowing that HCPs are culturally sensitive would encourage the families to perform their traditional customs without any procrastination. 7. It is also common practice for the Hindus to bring pictures of their deity and place them at the head end of the dying patient. This helps in creating a pious environment for the dying patient. 8. Patient and family members chant holy verses such as "Sri Gurudeva Dutta, "Jai Sri Ram", "Hari Om" from Hindu scriptures remembering the deities to create a positive environment and to facilitate the final journey of the dying. HCPs should be supportive of these traditions and should offer to allow additional visitors to chant mantras upon family's request, if feasible. 9. Immediately after death, family members may request to tie the big toes together with a string. This is traditionally performed based on the belief that by tying the big toes, the right and the left energies of the body come together and the energy remaining after death flows in a circle and forces the putrefying gases to get pushed upwards in to the mouth or the skull and prevents its accumulation in the lower void spaces of the body.
10. An earthen lamp with a single wick is traditionally lit facing South to ward off negative energies that seek the dying soul and attracts the energy of the Deity of Death called Yama. Prayers are offered to request Yama to seek the direction of the lit flame. Given the hospital requirement to prevent a fire hazard, this request is a challenge to fulfill and families are understanding of the safety concern and typically use electric candles symbolically.

Communicating About Death With Children
Although there is data demonstrating the presence of specific challenges perceived by parents in sharing about their terminal illness with their children such as parental lack of proper understanding of the dying parent's prognosis, denial and feeling ill equipped, this data is limited to Caucasian population and there is existing need to explore similar data on a broader diversified population. 9 Hindus traditionally do not hold back information about their terminal illness from their children. Neither do they traditionally prepare their children for the future after parental death. This is similar to what is seen in most other religions. However, Hindu scriptures such as Bhagavad Gita describe in detail how to conduct yourself in life and provide tools to handle grief after death. After a death in the family, traditionally, Hindus read a Sanskrit text referred to as The Garud Purana which is 1 of the 18 main scriptures in Hinduism which describes multiple highly diverse concepts including karma, rebirth, rites of passage, life after death and how to say the last goodbye to the deceased. 5 All family members including children are welcomed to listen to the recital of this scripture. Looking at this practice, in light of our modern era, of collectively reading The Garud Purana as a family after the death of a family member, it is evident that Hindus provide a platform and an opportunity for the family of the deceased including their children to ask questions and discuss about death, the ultimate truth of every living organism.
As seen in any culture or religion, it is always challenging to explain death age-appropriately to children. HCPs play a vital role in helping parents with life-limiting illnesses to communicate about their illness with their dependent children and conversely, helping children ask appropriate questions about their parent's illness and preparing them for the future. In this role, HCPs themselves find it challenging to have these difficult conversations indicating the need for support and training to carry out these conversations. 10 As HCPs, we need to be sensitive to child psychology and continue to involve children in an age-appropriate way in crucial discussions of their dying parents or relatives, especially during COVID-19. It is important for HCPs to themselves be transparent about the discussion surrounding death and to inquire and acknowledge the barriers faced by parents and children in sharing the bad news and provide support accordingly. Taking help from psychology and psychiatry teams to better support these discussions will also be helpful.
In summary, it is vital to provide empathetic EOLC to all patients including the Hindu population and better understand patients' cultural and spiritual needs. Hindu families when in minority may hesitate to discuss their EOLC needs. Hindu immigrants may be even more hesitant in discussing their needs. HCPs should be sensitive to patients' EOLC needs. They should be well-conversant and culturally sensitive to a diverse population such as those following Hinduism. Such well-rounded HCPs will make patients and families feel more comfortable discussing their needs knowing that there is an acceptance of their customs thus supporting traditional EOLC practices for their dying family member. This would further help HCPs in delivering compassionate and culturally sensitive care.

Future Research
There is an existing need to explore religion-specific challenges and experiences of patients and families receiving EOLC. We should facilitate better cultural understanding in the early years of medical education to foster appropriate support for a diverse patient population and thus develop culturally sensitive, compassionate, and empathetic HCPs.