CE

Hindu End of Life

Death, Dying, Suffering, and Karma
Susan Thrane, MSN, RN, OCN

v Hindu suffering can be perplexing to Western K E Y W O R D S

thought. With almost 2.3 million Hindus
of Indian origin and an additional 1 million end of life
practicing American Hindus now in the Hinduism
United States, healthcare practitioners need to karma
know more about the tenets of Hinduism to reincarnation
provide culturally sensitive care. Family and
suffering
community interconnectedness, karma, and
reincarnation are major beliefs of Hinduism.

D
Healthcare decisions may be made by the eath is a universal experience. No matter what
most senior family member or the eldest son. our culture, our religion, our race, or our coun-
Karma is a combination of cosmic and moral try of origin, we will all die. How we approach
cause and effect that can cross lifetimes and death, how we think about suffering and grief, and
life lessons learned for spiritual growth. The what we believe happens after we die vary based on
belief in reincarnation gives great comfort to our culture, religion, and spiritual beliefs. Spiritual be-
the dying and their families because they know liefs ground our thinking about end-of-life concepts.
their loved one will be reborn into a new life Humanists, which include atheists and agnostics, be-
and that they are not gone forever. Enduring lieve that death is the end.1 Christians believe that death
physical suffering may lead to spiritual growth is the beginning of everlasting life with God.2 Hindus
and a more fortunate rebirth. believe that while death is the end of this life, it is also
the beginning of a new cycle.3
Several estimates of the number of Hindus in America
exist. According to the magazine Hinduism Today, there
are about 2.3 million Hindus of Indian origin and an-
other 1 million practicing American Hindus.4,5 Every
state in America has at least one Hindu temple, while
larger metropolitan centers have many.6 Historically, in
the West, there has been very little exposure to Hinduism.
With the exception of Hare Krishnas, one sect of

Author Affiliations: Susan Thrane, MSN, RN, OCN,

is Senior Research Specialist, City of Hope, Duarte, CA.
Address correspondence to Susan Thrane, MSN,
RN, OCN, City of Hope, 1500 E Duarte Rd, Duarte,
CA 91010 (sthrane@coh.org).
The author declare no conflict of interest.
DOI: 10.1097/NJH.0b013e3181f2ff11

JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010 337
Hinduism, Hindu people do not believe in proselytizing,
nor do they often talk to outsiders about their religion.7
T a b l e 1
With the population of Hindus growing in the United
States, healthcare practitioners need to know more about Key Issues for Culturally Sensitive Care
this faith to be able to provide culturally sensitive care. for Hindus
Highlights of Hinduism
v CASE STUDY 1 & Oldest known religion still in practice.
& Belief in one God with many forms.
Mrs S. is an 85-year-old Hindu woman brought to the & Spirituality is a way of life for Hindus.
emergency room by ambulance. She has a history of con- & Family is very important, and healthcare decisions are
gestive heart failure and hypertension. She has been in often made communally with the senior family member
the hospital three times this year. She is having trouble or eldest son as the final authority.
breathing and ‘‘lightheaded,’’ and her family is concerned.
& Karma is moral cause and effect of thoughts and
actions.
After diagnostic tests and physical examination, it is found & Reincarnation means being born into a new existence
that Mrs S. has symptoms of fluid overload, and her on earth to evolve spiritually.
ejection fraction is 12%. A urinary catheter is inserted, and & Adherence to traditional values depends largely on
she is given a diuretic. Mrs S. goes into shock, develops acculturation.
respiratory failure, and is put on a ventilator. The physician
has a discussion with the family about the seriousness be the most popular of Hindu sacred texts. According to
of Mrs S.’s condition. Mrs S. does not have an advance Jeste and Vahia,9 the Bhagavad-Gita is the most recent of
directive. Hindus rarely have advance directives because of the sacred texts and the most practical, giving devotees a
their belief in karma and reincarnation. After a discussion more practical guide to Vedic wisdom.
with Mrs S.’s husband and children, the decision was made One of the basic tenets of Hinduism is a belief in one
to extubate and give comfort measures only. This decision God called Brahman. Brahman can take many forms,
to shift the goals of care to palliation is in line with Hindu which means that there are literally thousands of gods
beliefs relating to karma. Being kept alive by machine is and goddesses in Hinduism that each contains a part, or
often viewed as interfering with karma and inhibiting the embodies a characteristic of Brahman. Many Hindus
natural course of death. Hindu people view death as a part choose one god or goddess as their principal representa-
of the natural cycle of life. Death is a transition to a new tion of Brahman, but may have many gods and goddesses
life. This case illustrates the importance of assessing cul- that they worship or celebrate. Daily worship called puja
tural factors in palliative care and good communication to includes lighting incense, prayer, and meditation and is
ensure optimum care. often performed as a family in the morning before every-
one starts their day.10 Puja can be performed anywhere,
v HINDUISM 101 but many families either have a room in their home ded-
icated to worship or at least an altar displaying statues or
Hinduism is the oldest known religion, having been pictures of their chosen deity.
practiced over 8000 years as evidenced by ancient Hindu
scriptures.8 Table 1 highlights some basic Hindu beliefs. Reincarnation and Karma
Several newer religions have roots in Hinduism includ-
ing Jainism, originating around 3000 BCE; Buddhism, Two important tenets of Hinduism that guide one’s ac-
originating around 600 BCE; Sikhism originating around tions and influence suffering are karma and reincarna-
the 16th century; and Brahmoism, originating in the 18th tion. Reincarnation essentially means to be born again.
century.8 Hinduism is unique in that it has no founder, The body is like a set of clothes that the soul removes be-
no beginning that we can point to, and no one holy book. fore putting on new clothing. From a Hindu viewpoint,
The most holy Hindu text is called the Veda: a word that one can be born as a human, an animal, an insect, or even
means wisdom. The Veda consists of four books and a plant.11 What form the next incarnation takes depends
more than 100,000 verses.3 Other holy texts are called on karma, and one can move up or down the hierarchy. If a
the Upanishads and the Puranas.8 The Bhagavad-Gita person has lived a good life and performed more good deeds
(song of God) is generally accepted by all and appears to than bad, they are born into a more fortunate existence.

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 ❖ ❖ ❖ ❖ ❖

Karma guides how a Hindu lives, and each person’s dominated. The concept of karma conveys that suffering
deeds both in current and past lifetimes determine what is part of life. Suffering is a result of past thoughts and
sort of rebirth they attain. Karma is a combination of actions either in this life or a previous life. By enduring
cosmic and moral cause and effect that crosses lifetimes suffering, a Hindu ‘‘pays for’’ or cancels past negative ac-
and life lessons learned for spiritual growth. There are tions. ‘‘Suffering can be positive if it leads to progress on
three types of karma: karma from past lives that may or a spiritual path, Ito be tested and learn from a difficult
may not be experienced in the present lifetime, karma experience.’’16(p609) What may appear to be needless suf-
currently being created, and future karma or karmic ex- fering to Western minds may be, in fact, a striving to
periences saved for a future lifetime.12 A devout Hindu meet death in a clear and conscious state and may be an
will be non-violent on every level including the practice attempt to atone for karmic debt.
of vegetarianism. The ultimate goal after living many life- From a nursing perspective, karma and spiritual suffering
times is to be released from rebirth or to achieve moksha; can have several ramifications. Hindus who feel they need to
becoming one with Brahman.13 diminish or alleviate past karma may wish to endure
suffering. This may involve fasting, doing penance such as
intense prayer or worship, or enduring pain even when
Caste System
medication is available. Fasting can have several forms. The
patient may wish to avoid only certain foods or not eat
A discussion of Indian culture and Hinduism would be
certain meals or at certain times of the day. Other forms of
incomplete without a mention of the caste system. For
atoning for bad thoughts or deeds can include confession to
thousands of years, a strictly defined social structure ex-
a guru or priest, repentance either public or private, sacrifice
isted in India. Each group or caste performed certain
such as shaving the head, religious ceremonies, gift giving to
functions in society. The four main groups were the
the poor or to the temple, and pilgrimages to sacred spots.17
Brahman or priests; the kshatriyas, which were gover-
Obviously, participation in these activities depends on
nors and administrators; the vaisya, who were the mer-
whether the patient is at home or in a healthcare facility
chants and farmers; and the sudras, who performed
and whether he/she is ambulatory or near death. Assisting
menial tasks such as street sweeping and were considered
the patient and family to be able to complete religious
spiritually unclean. The caste system was abolished in
ceremonies, prayer, or penance may be very important to
1947, and while its influence is fading, some effects remain.
their spiritual well-being. Assisting the patient and family
does not necessarily mean participating; it can mean
Spiritual Suffering helping them find the materials or just assuring them that
they will not be disturbed. Allowing private time and space
Suffering for the Hindu is highly related to the concept of for these activities will be helpful.
karma, for example, ‘‘Belief in karma and reincarnation
are strong forces at work in the Hindu mind.’’14(p29) Any
good or bad thought or action leads to reward or pun- Suffering in Death and Dying Practices
ishment either in this life or a future existence. Hindus
believe that there are certain life lessons to be learned Fearing death is natural and results from a fear of the un-
before achieving moksha. Working through the karmic known. According to Hinduism Today, a person with a
situation will resolve that karmic issue resulting in a terminal illness should tell family and friends so they
lesson learned. can prepare for their loved one’s death and be happy for
A Hindu who is getting older or who has a terminal them.18 Death is the fulfillment of this life and a chance
illness will ‘‘tie up loose ends’’ by apologizing where for a better reincarnation, a chance to learn new karmic
needed, talking with family and friends to resolve con- lessons and to move closer to moksha.
flicts, and generally fulfilling all known responsibility.15 Hindus believe that death must come naturally at the
The goal of a well-lived lifetime therefore is to perform proper time. Life should not be prolonged by aggressive
good deeds, to practice devotion to God, and to learn the medical means unless it will result in a good quality of life.
karmic lessons encountered. Prolonging life artificially would result in the soul remain-
Spiritual suffering for a Hindu comes from knowing ing on earth past its natural time ‘‘tethered to a lower astral
at the end of life responsibilities are left undone, karmic region rather than being released into higher astral/mental
tasks are not completed, or bad thoughts and deeds pre- levels.’’14(p32) Hindus will often forgo aggressive treatment

JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010 339
when an illness is terminal or there is no hope of recovery. Ideally, a Hindu should die at home surrounded
If the patient is a parent of young children, more aggres- by family and friends who will sing sacred hymns and
sive treatments are often sought in the hope of prolonging say prayers or chant the dying person’s mantra in his/
life to provide for the children. Nor should life be cut short her right ear if he/she is unconscious. As death ap-
willfully. Speeding up death by artificial means would proaches, the bed should be turned so the head faces
result in a large karmic debt. Suicide would result in many east. Hindus with a terminal illness or certain other
lesser rebirths to ‘‘make up’’ for the karmic debt of ending disabling conditions are allowed to choose a ‘‘self-
one’s life unnaturally.19 Thoughts at the moment of death willed death by fasting’’19 but must tell their family and
will result in a greater or lesser rebirth. (See Table 2 for a community. This is an acceptable method of ending
summary of palliative and end-of-life issues.) suffering.
Hindus may endure pain or uncomfortable symptoms
to face death with a clear mind. They may use medication
Case Discussion Continued
to control symptoms, but may avoid using so much that it
reduces their consciousness. Rabindrnath Tagore,20 a
Mrs S. was extubated per her family’s wishes. Friends of
Hindu philosopher, once said ‘‘let me not beg for the
the family brought a CD player and played some tra-
stilling of my pain but for the heart to conquer it.’’ Hindus
ditional music. The temple priest was called and brought
will, if at all possible, be thinking of Brahman at the
Tulsi leaves and sacred water. Mrs S. was given medi-
moment of death and therefore experience a higher state
cation to relieve her pain and comfort measures includ-
of consciousness and a higher astral plane after death.
ing cool cloths, and positioning with pillows. Family,
Intentionally bringing all one’s attention and energy to the
friends, and the temple priest stayed with Mrs S., read-
top of the head and thinking thoughts of Brahman help
ing from holy texts and praying. Her youngest son
the soul leave the body in the highest possible state.
chanted her mantra into her right ear. The priest applied
holy ash to Mrs S.’s forehead and placed a few drops of
sacred water and a Tulsi leaf into her mouth for purity
T a b l e 2 and a peaceful death moments before she died.21,22
Nursing Care Issues for Palliative and
Hospice Care Postdeath Rituals
& Palliative care is aligned with Hindu values.
& Most Hindus are vegetarian. Assisting patients with After death, all the pictures of deities in the household
menu choices or having a dietary consult may help are turned to face the wall. The body is placed in the
Hindus receive acceptable food. Families may bring home’s entryway with the head facing south ‘‘reflecting
food from home. a return to the lap of Mother Earth.’’15(p170) If a patient
& Suffering is individualVsome may believe that suffering dies outside the home, the family may want to bring the
is beneficial for their Karma, some may not. body home for ritual bathing, dressing, and for friends
& Respect the choice patients make for the use of pain and family to say goodbye. If necessary, these rituals
medication: most will likely want a moderate amount to
relieve pain while maintaining awareness, but some may
can take place in a mortuary.
want little to no pain relief from medications, believing Bodies are always cremated, never embalmed, although
that suffering will ease karmic debt. they can be frozen for up to 3 days so relatives can attend
& The family may want to turn the bed so the head faces east. the funeral rites. The family may wish to witness the cre-
& End-of-life rituals such as chanting in the loved one’s mation and even start the cremation fire. The family may
right ear and putting Tulsi leaves and water from the return to collect the ashes directly from the crematorium.
Ganges River in the mouth are important for the soul’s After the family returns from the crematorium, everyone
purity and peaceful transition. bathes, and the entire house is cleaned. The ashes are
& Autopsy is not allowed unless required by law. scattered in an ocean or a river or are sent to India to be
& Organ donation is discouraged since it interferes with scattered in the Ganges River. Infants and young children
both the donor and the recipient’s karma and the
are the exception to the cremation rule: since they have
donor’s reincarnation.
& Above allVask about the family’s traditions and needs not accumulated bad karma and are considered pure,
before the last minute; everyone is unique. infants and young children may be buried.23 (See Table 3
for a summary of postdeath practices.)

340 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010
 ❖ ❖ ❖ ❖ ❖

The period immediately following death is considered thoughts on karma and reincarnation, concepts that West-
a time of impurity. A pot of water is set in the entryway ern caregivers need to be aware of.
and is changed every day for 31 days. On the third, fifth, Two other issues that relate to end of life include organ
seventh, and ninth days, a meal of the deceased’s favorite donation and autopsy. Autopsy is avoided unless required
foods is prepared, and a portion is put in front of a by law. Hindus believe that disturbing the body of the
photograph of the deceased. The time of impurity can deceased is disturbing to their soul and inhibits the soul
last from several days to a year. The length of the time of from moving onward.19 Organ transplantation is another
impurity is traditionally determined by caste: the lower practice that is conditionally discouraged. From the donor
the caste, the longer the time of impurity.24 During this perspective, a part of the body lives on and interferes with
time, the family lives in seclusion and does not partici- reincarnation. From the recipient perspective, part of the
pate in festivals, celebrations, or temple observances. donor’s karma is transferred along with the organ espe-
cially a major organ such as the heart, liver, or kidney.19
Depending on the views of the family, donation of an organ
v PROFESSIONAL CARE ISSUES other than the heart, liver, or kidney may be permissible.
Spirituality and culture go hand in hand for Hindus, and
Healthcare decisions in Hindu families will likely be made Western medicine is beginning to acknowledge the im-
by the most senior member of the patient’s family or the portance of spirituality in healthcare. Spiritual issues are
eldest son.25 Hindu culture believes in ‘‘human interde- now being addressed for patients, especially at end of life.
pendence and interconnectedness, which is understood to In a study of 560 nurses who cared for dying patients in
be the foundation of well-being.’’10(p28) In other words, Ethiopia, Kenya, India, and the United States, nurses from
Hindus do not have the same concept of individuality and all four countries identified spiritual interventions such as
autonomy that Westerners prize so highly; family and praying with or praying for the patient and reading from
community are more important. Other cultural differ- holy texts as helpful or important to patients and families.22
ences may or may not be relevant, depending on the The similarities between cultures speak more loudly than
acculturation of the family, and are directly contradictory the differences. Nurses from all four cultures stressed com-
to Western views. For example, addressing the head of the passion, respect, and individualizing care based on patients’
family first shows respect in Indian culture, while main- needs. Specific culturally based interventions mentioned by
taining eye contact with a head of family or elder shows the nurses from India included allowing family member to
disrespect. The best course is to tread lightly and be aware offer Tulsi leaves (a type of basil) for purity and water from
until discernment can be made of individual preferences. the Ganges River for a peaceful death.21,22
Accepting the end of life is part of Hindu philosophy.
Artificially prolonging life is generally thought of as in-
terfering with karma. Interventions such as intubation, v CASE STUDY 2
artificial feeding, or very aggressive care in the face of
a terminal illness would go against traditional Hindu Mr A. is a 73-year-old Hindu man with end-stage pan-
thinking. Palliative and comfort care are in line with Hindu creatic cancer. He is cachectic, bed-bound, and unable to
eat. Mr A. rates his pain as 10 of 10 and is refusing pain
medication saying, ‘‘I want to be awake and need to
conquer my pain through meditation.’’
T a b l e 3
Care Concerns After Death
Case Discussion
& Pictures and statues of deities are turned to face the wall.
& Allowing the family to bathe and care for the loved It would be appropriate to gently question Mr A. and his
one’s body may be an important ritual. family regarding his beliefs surrounding both pain med-
& Cremation occurs within 24 hours if possible. ication and his spiritual values. It may be that Mr A.’s
& Family members attend the cremation and bathe after spiritual beliefs lead him to suffer pain for the sake of
returning home.
karma, or he may be unaware that pain medication can
& A ritual time of impurity is observed.
& Ashes are scattered in an ocean or river or sent to India
be given that will not make him unconscious. He may
to be scattered in the sacred Ganges River. also feel spiritual distress because he cannot overcome
his pain with meditation and needs some counseling

JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 12, No. 6, November/December 2010 341
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