Tibetan Buddhist Medicine: A Transcultural Nursing experience

S. S. Begley

J Holist Nurs

Vol. 12 No. 3



Copyright by J Holist Nurs

. A Transcultural Nursing Experience Tibetan medicine, at 2,500 years old, is considered the oldest surviving medical tradition. A combination of logical healing practices, spiritual methods, and mystical practice, this tradition has a holistic basis as one of its foundational theories. It is known as the earliest form of mind-body medicine and can lend much of its wisdom to holistic and psychosomatic medicine and nursing, as well as the emerging field of psychoneuroimmunology. A basic overview of Tibetan medicine, coupled with a Western-educated nurse's experience during the care of a Tibetan Buddhist monk, provided an expanded view of the riches inherent in transcultural holistic nursing. In the West, the field of Tibetan medicine has been a little known traditional medical system. Throughout Asia, however, for centuries it has been highly respected for its effectiveness. Tibetan medicine became known in the Western world with the exile of the Tibetan people from their homeland in Central Asia. With the Chinese invasion and occupation of the country of Tibet and the exile of more than 100,000 Tibetans to India in 1959, the Tibetan Medical Center in Dharamsala, India, was established by Tenzin Gyatso. Known as the 14th Dalai Lama of Tibet, the secular and religious leader of Tibetan Buddhists, he is perhaps more widely recognized as the Nobel Peace Prize winner of 1989. The medical center he created was meant to preserve the heritage of Tibetan medical practices and to maintain the ongoing study and practice of Tibetan medicine. The interest and practice of Tibetan medicine has also grown with the steady increase of interest in Eastern meditational, philosophical, and psychological methods and with their integration into Western culture. Despite these measures, the preservation of Tibetan medicine is imperiled by its inability to flourish in its own country as it had for centuries. Also, many Tibetan medical doctors were lost when "over one million Tibetans . . . died as a . . . result of the Chinese occupation" (Piburn, 1993, p. 12). This article presents my personal account of working with an individual who is a spiritual leader within the Tibetan medical tradition. As we trudged up the winding path to Kopan Monastery, sitting high on the old astrologer's hill behind Boudhanath Stupa,[1] we paused to catch our breath and view the remarkable snow-capped mountains that ring the Kathmandu Valley, where the capital city of Nepal resides. We remarked at our great fortune, and wishing that all our family could be with us to behold this beautiful sight on Christmas Day, we slowly continued on our way. Moments later, we arrived at the Christmas celebration, surrounded by young Tibetan boys, who lived and studied at the monastery. Westerners were among them, mostly young adults who had come for a month long course in Tibetan Buddhist meditation and philosophy. The course had ended the week before, and the next day a retreat would begin, to practice the methods in earnest. Yet before beginning, Christmas was to be celebrated! In the center of the group was the Spiritual Director of the monastery, a Tibetan Buddhist monk. Known simply to all as Lama Yeshe, whose name literally means teacher of wisdom, he greeted us warmly and handed me a bowl of yogurt. That the offering of yogurt was the first food offered to the historical Buddha, Shakyamuni, after he arose from under the Bodhi tree upon attaining enlightenment, had eluded me at the time. I now imagine that his gesture was a symbolic way of reminding me of my own Buddha nature. Looking back to that day, almost 18 years ago, I wonder if he knew then that I would nurse him for the last month of his life, seven years later and thousands of miles away, on the sunny coast of California. From what I was to learn in the intervening years of the profound abilities and wisdom of Lama Yeshe, I would not be surprised. (Author's personal journal, 1976, revised 1994) This article has been written to share an experience of transcultural nursing that increased my awareness of the importance of valuing, accommodating, and advocating for a client's cultural health care practices. Because of this transcultural perspective, not only did an expansion of my learning occur but also the provision of more client-centered and, therefore, more culturally appropriate and better nursing care was possible. The article also relates the integration of Western, complementary, and culturally specific therapies. It includes an overview of Tibetan Buddhist medicine and philosophy and provides an introduction to an ancient system of mind-body medicine still in practice today. Tibetan medicine, a system both complex and sophisticated, is based on logical assumptions yet includes a client's emotions, attitudes, habits, lifestyle, and spiritual beliefs. These key elements contribute to optimal health and wholeness; therefore, Tibetan medicine provides a perspective relevant for contemporary holistic health care. OVERVIEW OF TIBETAN MEDICINE As Clifford (1984) has explained, Tibetan Buddhist Medicine is a fascinating and complex interweaving of religion, mysticism, psychology, and rational medicine . . . . It is the product of an ancient culture very different from our own . . . and at first may seem . . . incomprehensible, especially to [one] unacquainted with Buddhism, with which it is so inseparably linked. The tradition includes a vast body of medical literature . . . enormous pharmacopoeia . . . and unusual methods of diagnosis and treatment. (p. 7) Its practice contains in-depth philosophical and psychological bases for diagnosis and treatment of illness, including physical, mental, and spiritual imbalances. Numerous ideas and concepts are combined to effect the healing process, and various medications and treatments are also used. Using a humanistic framework to treat the client with dignity and to assist in the alleviation of suffering, the profound wisdom embodied in the development of this medicine is seen clearly through the practical application of its deeper theories and its functional ability to effect cures. To a Tibetan medicine practitioner, removing symptoms without treating the whole being is to miss the opportunity to assist the client in true healing and would be considered neglect. One important aspect of Buddhism is its psychological belief system that addresses the many concerns of one who is seeking a deeper meaning in life. Its aim is to bring out the true self beyond the mask of personality, leading to meaningful life objectives and personal growth. Viewing personality as the learned complex of characteristics with which we identify our individuality, the purpose of Buddhist psychology and meditation is to go beyond these traits and recognize one's true nature or wholeness. Called "the truth body" or the unobstructed mind of enlightenment, one's true nature is considered to be "free of all coverings" (i.e., personality) (Landaw, 1987, p. 167). The Tibetan concept of personality is drawn from the two major branches of Buddhist texts. The first, the Maha Anuttara Yoga Tantra (Highest Yoga Tantra), deals with spiritual and emotional aspects of the mind in relationship with the body's various psychic energies. The second, the Abhidharma texts, contains a psychological theory derived from the study of observations of the mind's workings. Different levels within the branches can be studied, according to the level of mind and the ability of the student. Three distinct disciplines of practice lie within Tibetan medicine: dharmic, tantric, and somatic medicines. As Rapgay (1985) explains, "the Tibetan tradition contains a comprehensive theory of personality, a diagnostic system and theory of pathology derived from Tibetan medicine, systems of classification of psychopathology and a cosmology that allows for the intervention of non-human (or transpersonal) entities" (p. 52). As in contemporary holistic health practices, the essence of health in Tibetan medicine is holistic harmony. Yet theirs is a harmony of formless, subtle and manifest worlds, of mental, emotional and physical bodies, of spiritual, psychological and organic developments, of self, others and total environment. In the view of Tibetan medicine the microcosm of the body and the macrocosm of the universe are constantly dancing with each other. When they are out of step with each other or when they are out of tune with the spiritual reality that sets them moving, disease results. (Clifford, 1984, p. 89) As in contemporary holistic health practices, personal responsibility, coparticipation between client and practitioner, and prevention are stressed in Tibetan medicine. The need to assist in removing physical symptoms so that true healing can occur is accepted, and complementary therapies are often prescribed. Suggestions by the practitioner may be given as a means for helping a client effect positive changes in lifestyle behaviors. Caring, an attitude of kindness and compassion, is seen as an essential ingredient in assisting clients to mobilize their resources toward a state of wellness, and causative factors, the deeper meanings of illness, are explored with clients. The depth of the healer's wisdom and compassion is believed to be directly related to the ability to effect a cure. The Tibetan medical doctor aspires to emulate the Medicine Buddha, the form of Buddha nature that embodies the healing aspects to cure spiritual, psychological and physical disease. It is believed that "through the practice of meditation on the Medicine Buddha, one can generate enormous powers for self-healing and the healing of others" (Clifford, 1984, p. 33). This art of healing involves maintaining balance within the body and its functions, as well as between the person and the outer environment. Illness, therefore, is considered a lack of harmony within the mind-body complex or between it and the world at large. DHARMIC MEDICINE As the mind-to-body relationship is considered of foremost importance, control of the mind is the main key to this balance. Mind creates matter and therefore also illness and wellness. Meditation and yoga are used as therapeutic modalities to balance the mind-body complex. This is the realm of dharmic medicine. Dharma, from the Sanskrit literally meaning "that which holds one back from suffering," is the spiritual teaching of Buddhism (Landaw, 1987, p. 160). Meditation and the mind training practices (commonly called the practice of dharma) taught in dharmic medicine are considered means of learning how to control one's mind so that it can be trained to function in a balanced fashion with the body. The integration of this philosophy into daily life is an important element in the development of general health and well-being. This is akin to the holistic health model in nursing in which "in work, goals, relationships, the nexus of the body, mind-spirit connections [are] made and the search of these patterns and processes becomes a way of existence" (Dossey, 1981, pp. 37-38). The dharma is considered the "best medicine," and the purpose of dharma is "to cut the root of the mind's delusion," which is viewed from the Buddhist perspective as the true or ultimate cause of suffering. The primary aim of Buddhism is to understand the nature of mind and to develop compassion and greater awareness in one's life. Illness can encourage us to examine our lives and to learn what supports good health and what aspects and behaviors of our lives generate disease and suffering. Emotional, spiritual, and physical suffering that helps one develop compassion for oneself also provides a meaningful link with the outside world. All beings desire happiness and peace of mind. "Feeling somehow incomplete, insecure and unfulfilled, we look outside ourselves for something or someone that will make us feel whole," which we try to possess. When that attractive object does not fulfill our desires, we grasp after yet another object. As Landaw describes, "in this way we continue to circle around and around, changing this and that in our lives but never really getting any closer to our desired happiness and peace of mind" (pp. 35-37). Because all people are alike in wanting happiness and avoiding suffering, this awareness then becomes one of the primary bases for choosing compassion and compassionate action as "one wing of the bird" of personal growth. The other is skillful means or wisdom, the insight into emptiness (shunyata in Sanskrit meaning the absence of all false ideas about how things exist -- specifically, the lack of apparent independent self-existence of phenomena [Landaw, 1987, p. 161]). The opposite of emptiness is subject-object dualism. This dualistic view is considered an ignorant view characteristic of the unenlightened mind in which all things are falsely conceived to have concrete self-existence; to such a view, the appearance of an object is mixed with the false image of its being independent or self-existent thereby leading to further dualistic views concerning subject and object, self and other, this and that, etc. (Landaw, 1987, p. 161) Karma, the workings of cause and effect whereby positive actions produce happiness and negative actions produce suffering, are considered latent predispositions that exist at the subconscious level of the mind. When internal or external causes and conditions arise, an experience of positive or negative factors are activated. These factors are considered one significant cause of disease. An awareness of karma and the law of impermanence (a recognition that all things change) are essential to understanding suffering. Renunciation is the attitude of wishing to leave behind the suffering of life and death and their causes, and to attain instead the peace of full enlightenment of Buddhahood. The view of renunciation, the attitude of compassion, and the correct view of emptiness make up the three principle aspects of the path of dharma. Realization of Buddhahood, which all can attain, is the ultimate goal of Tibetan Buddhism and Tibetan medicine. Physical medicine can help the body but ultimately will not affect a spiritual disease. Spiritual diseases when diagnosed must be addressed by a qualified teacher, and the student guided in the appropriate dharmic or tantric healing practices. TRANSCULTURAL NURSING CARE: A PERSONAL EXPERIENCE It was in February 1984 that I was asked to accompany Lama Yeshe through a cardiac catheterization at a West Coast university medical center. Little did I know as I agreed to this request that I would nurse him during the final weeks of his life and thereby experience one of the most challenging and enriching experiences of my entire 25 years of nursing. Increased awareness of cultural similarities and differences (Leininger, 1979) and of the ways in which they play out when blending cultures and culturally derived health care practices, as well as religion, philosophy, and meditation practices added immeasurably to this richness. Although I am not academically trained in trans-cultural nursing,[2] 3 years of world travel, primarily in Third World countries of the southern hemisphere and the Asian subcontinent, provided me with a basis for broad transcultural experiences. This heightened awareness allowed a deeper appreciation for universal care patterns as well as cultural care diversities as they arose. Nursing theorist Madeleine Leininger (1985) defines universal care patterns as the care patterns, values, and behaviors common across cultures. Alternatively, she defines care diversities, the patterns and processes unique to individuals, their family, or their cultural group. She views health as being universal across cultures but defined within each culture in a manner that reflects the beliefs, values, and practices of that particular culture. "Thus," as George (1990) describes it, "health is also universal and diverse" (p. 339). Leininger (1988) defines health as "a state of well-being that is culturally defined, valued and practiced which reflects the ability of individuals . . . to perform their daily role activities in a culturally satisfactory way" (p. 156). This was the world I was entering, and it would cause me to question in the weeks to come much of what I did as a Western-educated nurse. Early on, I must have intuited the challenges ahead, for I wrote in a journal, "I feel as if I am 'stepping into a fire,' yet I don't know what those words really mean." Further enhancing this time of cross-cultural healing and nursing were the "world view, social structure and environmental context" (Leininger, 1988, p. 156) surrounding this prominent meditation master, author, and mentor to literally thousands of people in 17 countries around the world. As the spiritual director of an international Tibetan Buddhist organization, dedicated to preserving Tibetan Mahayana (Highest Vehicle) Buddhism as a practiced and living tradition, Lama Yeshe had a gregarious and warm personality. His genuine compassion and kindness, coupled with a keen sense of insight into the workings of both Eastern and Western minds, modeled the principles ofwhich his students aspired. His organization was composed of 62 centers worldwide and used for various functions: colleges, monasteries, publishing houses, retreat centers, and communities as well as hospices, and health care and healing facilities. To have realized all this within the 24 years since his exile from Tibet in 1959 is a remarkable tribute to him and the very large group of people who were in many ways directly related to this unique and engaging man. Accompanying him from a hospital in India to the United States was his main student, Zopa Rinpoche. Also a Buddhist monk, he was considered in the Tibetan Buddhist tradition as Lama Yeshe's "heart son," and in the Western view would also be considered his "next of kin." Zopa, called Rinpoche, daily carried out all the spiritual aspects of the ancient Tibetan medical practices during Lama Yeshe's illness. Rinpoche was recognized at an early age as the reincarnation of a famous meditator, and his whole life, like Lama Yeshe's, had been dedicated to the development of his spiritual practices and the teaching of these methods. During this time, these practices would be Incorporated with Western medical and nursing care, and complementary therapies. Lama Yeshe would be treated with acupuncture and moxibustion[3] by a medical doctor who was also a licensed acupuncturist. For 10 years, Lama Yeshe had known about his severe rheumatic heart disease and years before had been advised to have surgery. At the hospital the day after his arrival from India, I first saw Lama Yeshe lying on a table in the cardiac catheterization lab. Looking through the plate glass window before entering the room, I noted how extremely thin he had become since I last saw him 6 months earlier. The last months of illness had clearly taken their toll, yet he looked quite youthful, as in earlier pictures, and he smiled warmly as I approached. "How are you, Lama?" I began. He answered, "I'm all right, dear"; I would come to know this response well during the next month, no matter how ill he appeared to me. This calmness of attitude and equanimity in the face of all adversity was the most amazing aspect and lesson in caring for this deeply spiritual man. Although he clearly suffered with physical illness, his continual calmness of mind and sense of peace set him apart from most clients for whom I had cared. Always very present with a sharpness of mind, there was no sense of denial or alienation. Despite pain and discomfort, he exhibited a sane, balanced approach, and a calmness and clarity pervaded his demeanor. The cardiac catheterization showed a progression of the disease, and surgery was recommended. However, he was given the option of leaving the hospital to rest and build his strength before surgery, especially because he had just arrived from India. He chose to return to a lovely home that had been arranged for him that overlooked Monterey Bay on the Northern California coast. I would remain to care for him with Rinpoche and a longtime student, who would cook for him. My memory of those first days is of Lama,[3] an avid gardener and flower lover, walking in the garden wearing a burgundy silk dressing robe, the color of his traditional monk's robes. His increasing strength and activity level were encouraging. His digestive system was delicate however, and the cook, Lama, and I worked to find foods that were nourishing, culturally familiar, appealing, and well tolerated. Altars were arranged by Rinpoche in both the living room and Lama's bedroom. They held images of the Buddhas, photos of teachers, flowers, candles, and traditional offering bowls. Above each altar hung a Tibetan thangka, or religious painting framed in silk brocade, of a meditational deity. Each afternoon, Lama took his usual time to rest and do his daily meditation and prayers. The level of nursing care at this point consisted primarily in assisting with activities of daily living and in being a liaison to and translator of the information provided by the Western medical doctors regarding blood work, X-rays, and so forth. Rinpoche spent much time performing ceremonies called pujas that included tantric healing practices and were performed to remove obstacles and to promote spiritual well-being and physical health. Various pujas may differ in content but generally consist of invocations, scriptural and mantra recitation, visualization, and recognition of oneself and others as whole and completely integrated beings or deities. A torma, a traditional offering made of barley flour and butter, was made in the shape of a body to protect Lama's psychic nervous system and was offered to the divinities by Rinpoche. TANTRIC MEDICINE AND HEALING In Tibetan Buddhism, religion and medicine are never truly separated from one another, and this blend in relation to health is called tantric healing or medicine. "A highly sophisticated and complex system, a sort of para-science of psychic and spiritual reality, and in terms of medicine, of psychic and spiritual healing" (Clifford, 1984, p. 66), this science of healing, similar to some forms of Oriental medicine, includes seasonal effects, astrological aspects, and spirit influences in addition to other measures. In tantric healing, visualization practices are performed during which one transforms oneself and the world around one into the body, speech, and mind of the Buddha, a completely whole, integrated being or deity. "These three bodies of the Buddha," Clifford (1984) explains, "represent the sacred trinity of the three levels of expression of the reality of Buddha nature" (p. 31). As in using positive affirmations, it is believed that what one focuses on is more readily created in one's life. Also, as is taught to practitioners of various forms of energetic healing modalities, the quality of intention and attention greatly affects the outcome of the session. In these tantric meditation practices, three aspects are held as most important: (a) to have the intention of doing the practice for the benefit of all beings and to assist in their liberation from suffering, (b) to remain unattached to the results of the meditation experience, and (c) to dedicate the benefit one may gain from the practice (which can include heightened awareness and other positive results) to the enlightenment of all beings. In this form of meditation, the "desirous energy that ordinarily propels us from one unsatisfactory situation to another is transmuted through the alchemy of tantra, into a transcendental experience of bliss and wisdom." This blissful wisdom is intensely focused so that it "cuts. . . through the false projections of this and that and pierces the very heart of reality. . . It destroys the very cause of our dissatisfaction: our fundamental ignorance of the nature of reality" (Landaw, 1987, p. 37). As in various healing modalities (e.g., acupuncture, Therapeutic Touch, etc.), in tantric healing, health and disease as well as mental disorders are often related to disruptions or blockages of the system's vital force or energy flow. Tantric medicine provides in-depth descriptions of the complex patterning of this energy and its movement. The energy is related with the breath, air, wind, or creative life force, and the channels and pathways through which it moves is the concern of much of Tibetan psychiatry and medicine, its diagnosis and treatment. It is said that the mind, or more correctly consciousness, requires a physical source for its base and rides on this flow of energy. Consciousness is defined as "that which cognizes objects and is by nature clarity itself and does not have a form" (Rapgay, 1985, p. 14). Simply expressed, if the body's subtle energies are in balance, the mind's balance will follow more readily, and vice versa. TRANS CULTURAL NURSING CARE: CHALLENGES A nursing perspective that was multicultural, rather than unicultural, was essential to plan, organize, and administer appropriate nursing care. I was familiar with certain aspects of the Tibetan culture, yet numerous aspects of the culture were unknown to me before this time. I made conscious attempts to remain sensitive and not impose Western cultural health care practices on the client. No doubt, culture shock and cultural imposition (Leininger, 1979) on my part occurred at times. Sometimes, due to a lack of knowledge of cultural mores, I made mistakes. I became aware (but only after delivering them to the bedside!) that red flowers are considered by Tibetans "inauspicious to one's health" during times of illness. Occasionally, discrepancies occurred regarding nursing care decisions and professional assessments that were essential components from my perspective for providing appropriate and ethically sound care. For example, a consulting physician was chosen through divination practices rather than through an analysis of qualifications or professional reputation. It was difficult to shift to this form of decision making and let go of my pattern of making informed professional judgments. During these times, an attitude of cooperation, communication, and respect for our differences allowed us to resolve these issues. This was where dear-headed thinking and decision making became most apparent, yet sometimes I and the nurses who were to join me began to second-guess our learned views. Knowing that the Buddhist perspective is that reality is composed of as many different views as number of people viewing the situation, one wondered at times what the nature of reality really was. Nevertheless, at all times, the foremost directive in our minds was to direct our actions clearly toward assisting and supporting the client's needs in whatever way possible while staying true to ourselves. Leininger (1988) calls this cultural care accommodation or repatterning (p. 156). While speaking with Rinpoche one night about these issues, we heard Lama's bell ring. Arriving at his room, we immediately saw that he had had a cerebral vascular accident (CVA). His left side was flaccid and his speech unintelligible. He was lying flat in bed. The bell, I noted, was not within his reach. How could this be? I clearly heard his bell ring, yet he could not have reached it in this condition. How had Lama called us? I had no answer. He was taken by ambulance to a nearby hospital. After the exam, the neurologist stated in front of Lama Yeshe that the CVA was severe and gave the prognosis of a persistent vegetative state. Rinpoche requested a room to do a puja. Finding no suitable room, he returned home to perform the ceremonies throughout the night. I remained with Lama at the hospital. The next morning after a battery of tests, Lama said, "I feel like a laboratory animal. Please take me home." It was stunning that he could speak, let alone that he wanted to go home! Arrangements for 24-hour nursing care was needed. My role had literally expanded overnight to include the coordination and supervision of a team of professional and attendant caregivers, as well as the delivery of more intensive nursing and rehabilitative care in the home setting. With the team's rapid expansion, an increased sensitivity to the provision of culturally based nursing care appeared to be "a critical factor for effective health promotion and maintenance, as well as recovery from illness and disability" (George, 1990, p. 336) or for facing death. Many aspects of care went beyond culture, were universal, like the shared sensitivity of human interaction between Lama and me during the times that I fed him. Another caregiver described this aspect of care as "like watching a lovely duet, accented by timing and grace." Nursing concerns for physical well-being included obtaining proper equipment and assistive devices. Attention to all aspects of care included vital signs checks, pulmonary and neurological checks, medication administration, nutrition/elimination, hygiene, skin integrity, mobility, and impaired function concerns, including safety measures, rehabilitation exercises, and so forth. Sleep and rest, as well as cognitive, sensory, and self-perception alterations were monitored. Lama's manner throughout was as previously described. No defensive or ineffective coping was demonstrated, no apparent self-esteem or body image disturbance was noted, and no sense of hopelessness, powerlessness, anxiety, or fear was exhibited. Each time I asked him about his emotional state, he always responded with the same calm response "I'm all right, dear" and looked me squarely in the eyes. I watched in awe as this man treated all who provided care to him with equanimity and kindness. During this time, Lama spoke little, yet he seemed to accept his own body and disease process without a sense of resignation or regret. His personal development and acceptance of life and death was apparent. As described earlier, the purpose of tantric practices is to generate a pure state of consciousness that allows one freedom from suffering. Lama Yeshe appeared to be a living example of the truth of this belief system. Rinpoche performed healing work, especially to Lama's affected side, that included energy modulation similar to Therapeutic Touch. Rinpoche also discovered in his Tibetan texts a complete outline of care for Lama's condition. This included methods of tantric medicine and contained a particular mantra, a special formula of syllables that uses the spiritual power of sound vibration. The nurses were requested to assist Lama Yeshe in the recitation of this mantra. The text also advised against allowing direct sunlight or sunlight reflecting on water from meeting the person's eyes, and as each day progressed, a gauze like curtain was hung over the window to avoid this reflected light. The curtain created a soft, shaded feeling in the room. This gentle lighting and the frequent repetition and rhythm of the mantra seemed to carry us to a state beyond ordinary place and time. Although much more attention was given to dharmic and tantric medicine than to somatic medicine in Lama Yeshe's care, an explanation of somatic medicine is included here to provide a more complete understanding of Tibetan medicine. SOMATIC MEDICINE The third discipline of Tibetan medicine is somatic medicine. The historical Buddha, Shakyamuni or Gautama Buddha (563 BCE), called "the Fully Awakened One," cited two reasons for disease. The first was the spiritual factors, or those brought from past life karma, and was called the distant cause. This included the three delusions of the mind: desire or attachment; close mindedness or ignorance; and hatred, anger, or aversion. These were the objects of the mind to be abandoned through the healing practices. The second reason for disease was the factors from this life and was called the proximate cause. Somatic medicine generally attends to the proximate causation of disease and ascribes to the humoral theory. This theory speaks in terms of the three humors of the body--wind, bile, and phlegm. Humor (nyes-pa in Tibetan; doshas in Sanskrit literally meaning "fault") generally means a "subtle principle of life energies." Although available, a literal translation of each humor is an in-depth undertaking, too lengthy for the scope of this article. In the Tibetan tradition, it is said that the 84,000 delusions cause 84,000 different disorders that lead to 404 diseases. Four main categories of proximate causes are seasonal changes, habitual tendencies and behaviors, poisons, and negative spirits. Although considered physical in nature, the three humors originate on a spiritual plane from the basic mental confusion that produces the subject-object dualism discussed earlier in this article. From this view comes the karmic force to manifest life and the universe. This subject-object dualism refers to the idea of holding to a permanent "self." Attachment to one's ego, or self, is the main cause of all three delusions. This is the main cause of suffering and the idea to be refuted to obtain a state of enlightenment and freedom from suffering. As Clifford has written, "the delusions, ignorance, desire and aversion evolve into the humors phlegm, wind, and bile respectively" (p. 90). Each delusion can cause the disturbance or imbalance of the three humors, and these imbalances cause physical disorders that lead to disease. They also affect one another: if one humor is imbalanced, the other two are affected as well. The main point of physical health is the balance of these three humors and their relationship to one another Each person has a primary humor relating to the individual's body type, personality, and so forth. The humoral theory and principles can be used as a guide for preventative care and for promoting wellness. One is encouraged to observe the effects of seasons, seasonal activities, diet, and environment, and behavior modification in these areas and numerous other treatments are often prescribed to attain optimal health (Clifford, 1984). The Buddhist medical system is also based on the five elements principle. According to this principle, all beings are composed of five elements--earth, air, fire, water, and space. The humors are also related to the elements: phlegm is composed of the earth and water elements; bile, the fire element; and wind, the element of air. Although the above explanations may appear theoretical and philosophical, one can find in medical texts very clear explanations with great detail of the processes by which these principles function. For example, the digestion of food products and their eventual breakdown into the regenerative fluids that nourish the physical body and support health are explained by the three humors and five elements principle. Herbal preparations made from a variety of herbs that grow naturally in Tibet are uniquely combined to provide desired therapeutic effects. It is said that over a thousand natural substances were available to the Tibetan physicians in their homeland. Besides herbs, rocks and minerals, earths and salts, fruits, twigs, roots, saps, and animals are included in the medicaments. As in the Native American tradition, the method of gathering and the state of the preparer's mind are very important to the medication's beneficial outcome. All the preparations of medicines begin with a prayer Besides oral ingestion, substances are burned as incense and inhaled, and herbal baths are prescribed. Dietary patterns, cleansing procedures, massage, exercise, and activities including physical yoga, meditation, and breath work are considered common treatments. Acupuncture, moxibustion, and lancing are viewed as stronger methods, and minor surgeries and cauterizations are rarely used and only when absolutely necessary. Based on the discussion thus far and judged by Western medical standards, Tibetan medicine may indeed appear to be a folk medicine based on cultural practices and religion. When studied in more depth, however, it is learned that it is a highly structured system of clinical medicine with 15 divisions of Clinical Pathology. They are: three pathophysiological processes (three humors), internal diseases, fever, diseases of head and neck, diseases of solid and hollow organs, venereology, urology, miscellaneous diseases, hereditary diseases, pediatrics, gynecology, toxicology and sexology. (Rapgay, 1985, p. 8) In somatic medicine, the methods of diagnosis include 1,200 ways of examining disease. The three basic methods, however, are interrogation, sight, and touch. First, an in-depth interview is conducted about the client's life on all levels. Sight is then used for assessment, including urine and tongue diagnoses, and finally, touch is used for a pulse diagnosis. It is an analysis of 12 pulses on the fingers. Again, astrological and seasonal aspects are connected with the elements; therefore, they are also considered in the diagnosis. TRANSCULTURAL NURSING CARE: ENDINGS AND BEGINNINGS Lama Yeshe's own spiritual mentor, a highly respected and lively 80-year-old monk known as Song Rinpoche, arrived from Switzerland to see Lama Yeshe and to perform specific healing ceremonies. Often, parts of these ceremonies were done in Lama's room with either his active or passive participation. The recitation of Lama Yeshe's meditation practice was continued each day at his bedside by Zopa Rinpoche. The purpose of tantric meditation practices is to transform one's own psychological, emotional, spiritual, and physical energies. Due to the principles of reincarnation, death of the physical body in Buddhism is seen not as a finality but rather as a transmigration of consciousness from one life to the next. Dharmic medicine and tantric healing practices are meant to stabilize and increase the vitality of the subtle energy bodies so that the process of transmigration will be easily accomplished. The most advanced technology in the East is the ability to control one's mental continuum and to recognize the present consciousness in the past or future lives (Shakya Zangpo, 1993, p. 108). According to Tibetan Buddhism, enlightened beings can direct their consciousness to take rebirth so their future lives may be of benefit to others. Sometimes, meditation masters will predict the place where they will be reborn. When reborn, they are recognized as an incarnation of the former master and show signs of remembering their previous life. As is recognized in the contemporary hospice movement, the process of healing in Tibetan medicine is not always the outcome of the body's illness and the escape from death but the state of one's mind in facing this life's end. Despite all the methods employed, Lama's condition worsened and he was readmitted to the hospital. Explaining the legal procedures one needs to become aware of when one is very ill, including "Do Not Resuscitate" (DNR) and "Durable Power of Attorney for Health Care" orders, was an aspect of transcultural nursing that made the differences in our cultures very apparent. I explained to Rinpoche what would automatically occur if Lama Yeshe's breathing ceased or his heart arrested. I explained that this response to resuscitate was a hospital policy and would occur automatically. Knowing that peaceful circumstances are considered very important at the time of death, I further explained the choice to elect a DNR order, its use, and what it would mean if it were requested. Rinpoche listened carefully, asking clarifying questions, then called Song Rinpoche to discuss the matter. Their decision was to not request a DNR order and to attempt to resuscitate Lama if the situation arose. As I was saying goodbye to Lama Yeshe the last time that I saw him, he wrapped his hand around my long hair, pulled me close, and said, "I'll see you very soon, dear." Tears welled up in my eyes and his face blurred out of focus. I knew at that moment that Lama was saying goodbye for this lifetime, yet he wanted me to know we would see one another again. At dawn of the next morning, Tibetan New Year, March 3, 1984, after eating his favorite strawberry yogurt, his heart arrested. Attempts at resuscitation were made and abandoned after a lengthy period. He was 49 years old. A close student of Lama's later informed us that Lama had told him during this time that he would live only until the new year. He had said that it was now time to take a new body, his heart being too badly damaged for repair. In a traditional Tibetan ceremony with Song Rinpoche presiding, Lama Yeshe was cremated in his burgundy silk robe. Sometime later, Lama Zopa Rinpoche made a gift of the sash to me. On February 12, 1985, just under a year later, a boy was born to a Spanish couple with whom, as Lama Yeshe himself had said before, he shared a special relationship. . . . The child was named Osel, meaning Clear Light . . . and at fourteen months [according to ancient methods of prediction and spiritual tests] was recognized as the reincarnation of Lama Yeshe, not only by Zopa Rinpoche but by His Holiness the Dalai Lama as well. (Landaw, 1987, pp. 156-157) When Osel was 2 years old, we met one another. All he wanted to do was play with my long hair. Lama Osel Rinpoche is now 9 years old and is studying the tradition of his predecessor. SUMMARY As I look back on this time, I am incredibly grateful for the opportunities to learn of and experience cultures different from my own. Because the United States is steadily increasing in its population of foreign-born immigrants, the opportunities for those of us in the health care profession "to travel to foreign lands without leaving our soil" has also increased. The challenges of travel are inherent in any journey; the richness of opening our eyes, hearts, and minds goes with "the territory" if we are willing to remain available to new people, new places, new ideas, beliefs, and ways of being. Immeasurable growth can occur when our own views are seen alongside those of other cultures; we broaden our vision and perspective of what is "right and wrong," possible or impossible. Through a fuller understanding of other people and cultures, we are naturally led to a deeper understanding of ourselves. It has taken me literally years to assimilate the lessons from the experience of caring for Lama Yeshe; it has been like walking in a thick fog and only much later realizing that my clothes had become wet. In writing this article I realize the shift in my perceptions since that time. At the beginning of this experience, I feared I would not do my job well if I did not adhere to the way I had been educated from a Western health care perspective. I realize how easily I might have unknowingly adopted the view that Western scientific thought is the only valid intellectual mode. With this experience came the joy of remembering the part of me I knew well as a child and had almost allowed myself to be "educated out of": my intuitive knowing. I realize I have learned to look at circumstances from more than one perspective, from the perspective of another culture. I have learned to live more comfortably without knowing all the answers now. I have come to learn also that the outcome of a person's illness is seldom ha my hands, yet I can still be willing to give my very best in the ways I can make a difference. The experience deepened my awareness of my professional nursing skills and reinforced the value of caring interventions that include how attentively I care for a person, how fully present I am in the moment with another, how well I can listen and hear even without words, how comfortable I can make my clients, how best I can serve them with sensitivity and kindness. And I continue to discover over and again that inner peace and acceptance softens the heart, opens the mind, and moves us closer to others and to our own true nature. An expansion of my own spiritual beliefs has also occurred. I have come to believe there is order to our lives, often unknown but existent nonetheless; that life continues even after the death of the physical body and that death can be embraced as movement toward our deeper wholeness; and even that consciousness can move from one life to the next in a directed fashion and that we are all capable of this higher form of mind training. All this I feel was stirred within me from my experience of caring for Lama Yeshe. What a magnificent gift I have received. To become more whole, one must live a holistic life, whether one labels it that or not. One way to do this is to interact with people different than ourselves. At least we may learn that although we have different habits, patterns, and beliefs, we all are the same in wanting happiness and avoiding suffering. Lama Yeshe wrote, Dwelling deep within our heart and within the hearts of all beings without exception, is an inexhaustible source of love and wisdom. And the ultimate purpose of all spiritual practices, whether they are called buddhist or not, is to uncover and make contact with this essentially pure nature. (quoted in Landaw, 1987, p. 14) As holistic nurses, we have an awareness that each of our actions as individuals has repercussions on others, our society, our environment, and our universe. With an understanding of the concepts of wholeness, the interdependent effects of body and mind, and the primary role of consciousness, we may well identify with the Tibetan Buddhist medical tradition if only to remember our intention and motivation so that our lives may be of greater benefit to all. NOTES 1. A stupa is a Tibetan religious object symbolizing the enlightened mind of a Buddha. Often a large sculptural form of specified shape and size, it contains relics of holy beings. Boudhanath Stupa is a well-known Buddhist pilgrimage site outside Kathmandu, Nepal. 2. See Leininger (1979, 1985) for a discussion of transcultural nursing, cultural care diversity, and universality. 3. Moxibustion is an application of heat from certain burning substances at acupuncture points on the body, each point having a defined therapeutic action. 4. The term lama is the Tibetan word for teacher and is a title given to many Buddhist teaching monks. The author's personal relationship to Lama Yeshe caused her, like others around him, to refer to him as "Lama" both in and out of his presence. Therefore, in this article, the word lama will be treated as a first name and will refer only to Lama Yeshe. REFERENCES Clifford, T. (1984). Tibetan Buddhist medicine and psychiatry: The diamond healing. York Beach, ME: Samuel Weisner. Dossey, B. (1981, May). Holistic nursing: What is it? Texas Nursing, pp. 37-38. George, J. (1990). Nursing theories: The base of professional nursing practice (3rd ed.). Norwalk, CT: Appleton & Lange. Landaw, J. (1987). Introduction to Tantra, Lama Yeshe. London: Wisdom. Leininger, M. (1979). Transcultural nursing. New York: Masson. Leininger, M. (1985). Transcultural care diversity and universality: A theory of nursing. Nursing and Health Care, 6, 209-212. Leininger, M. (1988). Leininger's theory of nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1, 156-160. Piburn, S. (1993). The Dalai Lama: A policy of kindness. Ithaca, NY: Snow Lion. Rapgay, L. (1985). Tibetan medicine--A holistic approach to better health. Dharamsala, India: Author. Lama Shakya Zangpo. (1993). Psychospiritual healing. Unpublished manuscript. ~~~~~~~~ Shirley Spear Begley, R.N., B.F.A., C.C.H.T. Shirley Spear Begley, R.N., B.F.A., C.C.H.T., is a nurse with 25 years of experience, an educator, and a certified clinical hypnotherapist. A former director of nursing and director of community education in the home health field, her clinical skills were developed at Case-Western Reserve University Hospital of Cleveland. Postgraduate work and certifications in psychology, education, and group facilitation, as well as extensive training in mind-body awareness and Eastern thought, led to her development of Integrated Health Care Systems, a professional nursing organization. She is a nursing consultant and educator to individuals, organizations, colleges, and universities, and her areas of specialization are holistic health, holistic nursing, stress and pain management, and Therapeutic Touch. A summa cure laude graduate o fLake Erie College in Painesville, Ohio, she is also an artist and writer. -------------------