Cultivating Presence

The Cancer Center and DHMC's Palliative Care Program lead the way in bringing mindfulness to patients and patient care.

Frank Ostaseski believes seriously ill patients and those in the end-stages of life have an enormous amount of wisdom to give to their caregivers and loved ones—indeed, to all those they leave behind.

Focus article photo

Frank Ostaseski

"I'm perpetually amazed by the inner wisdom of the dying," he says. "They have an innate knowledge of what the process of death is all about—and death, after all, is a process of life." Ostaseski is a world-renowned meditation teacher and end-of-life expert. Hosted by the Palliative Care Program, he came to Dartmouth Hitchcock Medical Center in the fall of 2010 to address clinicians and medical students, as well as the general public, about why caring for seriously ill people is an intense, intimate, yet "deeply alive experience" that can enrich a caregiver's life in a way no other experience can.

His presentation showcased the "mindfulness" approach to Palliative Care being taken by the program's director, Ira Byock, MD—an approach recently recognized by the American Hospital Association. AHA awarded the program its Citation of Honor, citing the "strong commitment to inpatient and outpatient palliative care, regional focus and end-of-life and palliative care research and education" made by the Palliative Care team.

"Mindfulness means paying attention to the here and now," says Byock. "It does not compete with any religious beliefs and traditions—an atheist can be as comfortable practicing mindfulness as a devout Jew or a fundamentalist Christian." Mindfulness, he adds, "enables clinician-patient time to be measured in depth more than in length."

Ira Byock, MD

Ira Byock, MD

Rethinking Palliative Care's Purpose

Across the country, palliative care and hospice programs are rethinking their purpose in order to create better pathways for patients and their caregivers to accept the unwanted reality of their illnesses while attaining some peace of mind and open heart. The Buddhist concept of mindfulness informs this approach, in which D-H's Palliative Care program is at the forefront of this transformation in care.

Person-centered care of this nature has significance for seriously ill patients, as well as their clinicians. "It means being focused on the person in front of you—even in the midst of incredible time pressures," describes Byock. "As one cultivates the ability to be fully present for the patient, awareness becomes compassion. That's the essence." He adds that authentic compassion is a hallmark of truly great doctors—the physicians we each want for ourselves and our family members: "Cultivating the ability to be fully present with another person, especially a patient who is seriously ill, is what distinguishes superb clinicians from those who are merely competent."

As Ostaseski puts it: "We listen with our minds, with our hearts, and with our bodies, and when we are with patients at the end of life we need to listen from all of these centers. Listening only from the heart or the mind isn't enough. We must use integrated listening." He points out that the mind listens intellectually and carries the baggage of memory. The heart is filled with emotion. The body, he says, "cultivates presence. It's always here. Being able to really sense our own bodies when we step in to be with a patient is essential to connecting with the patient, who, after all, is acutely attuned to what is happening with their own body."

Measuring the Mind-Body Connection
Jon Kabat-Zinn

Jon Kabat-Zinn, PhD

Lest this all sound a bit ethereal, Jon Kabat-Zinn's work at the University of Massachusetts involves measuring the tangible results of mindfulness in controlled studies. His findings, published in several peer-review journals, have formed the foundation for vigorous scientific inquiry into the ways the human mind can accept and come to terms with damage and illness in the body.  "The potential to ask interesting questions about the mind-body connection and mindfulness meditation's role in that connection has never been higher," he says. "It is an incredibly opportune time to do research into this."

Kabat-Zinn, a PhD who is founding Executive Director of the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School and founding director of that school's Stress Reduction Clinic as well as Professor of Medicine emeritus at the University of Massachusetts Medical School, came to DHMC in the spring of 2011 to build on the groundwork established by Ostaseski a few months earlier.

"Jon's brilliance lies in bringing the scientific method to measure the efficacy of mindfulness," says Byock. He adds that because of Kabat-Zinn's peer-reviewed, published research, "Resistance in the medical community to mindfulness has really disappeared. People have come to understand that it isn't religious. It's simply learning to make fuller use our human consciousness." While he was at DHMC, Kabat-Zinn presented at Medical Grand Rounds, defining mindfulness and discussing its relevance to stress, pain, and physical and mental health. He also discussed two specific clinical applications of MBSR (mindfulness-based stress reduction) and their reported outcomes as well as recent neuroscientific evidence of the effects of MBSR training on the brain and their potential medical significance. The fascinated, full-house audience of clinicians peppered him with questions.

In clinical settings, mindfulness meditation has proven to be an effective path for patients to be integrated into their treatment. "It draws on your own internal resources and offers great potential for learning, growing, and healing. It helps us live lives that are more authentic and accepting," comments Kabat-Zinn, adding that the National Institutes of Health is "really getting behind this. They have funded many, many studies that consistently show the power of healing that's within the mind-body connection."

"Compassionate Attunement"

Ostaseski, meanwhile, who helped form the Zen Hospice Project, the first Buddhist hospice in America, in 1987, is particularly interested in mindfulness as it connects the clinician and caregiver to the patient. What he calls "compassionate attunement" is the bond connecting care with the cared-for. "Compassion means to suffer with others—the important word there being 'with.' It creates an empathetic bridge," he says. "Without that true empathy, the patient will sniff out insincerity and won't trust you any longer and then all your work is for naught." But to bring compassionate attunement to a patient means "to become really familiar with our own suffering," Ostaseski comments, which can be a difficult process. Yet "it's the key to sincerity, to really understanding, in a truly compassionate way, the experience of the patient."

He adds: "I don't think we can underestimate the healing power of human presence. When we are compassionately present, we create with the patient a deep and abiding trust in the process of dying."

As a consultant and teacher of caregivers, "the most important thing is to understand our own capacity to be with suffering," he says. "We have separated ourselves from other people's pain, and when we think about dying, it's just that—a thought, a conceptualization. We've forgotten about our own capacity to know dying. Frankly, death has to come out of the closet."

In medicine in general and in palliative care programs especially, "We encounter people in the most difficult of times. It's easy for a doctor to be drawn off-center—either drawn in or repelled by the situation, it's so powerful and emotional," comments Byock. "Any practitioner ought to have some centering practice." While the Palliative Care Program at DHMC and the Cancer Center does not require the members of the clinical team to attend mindfulness training, presentations like Ostaseski's and Kabat-Zinn's have had a profound effect on how the program evolves its care.

Appreciating the Challenges

At the Cancer Center, Melissa Laverack, a chaplain in DHMC's ICU, led a six-week class, two hours each week, for cancer patients on how they can bring mindfulness into their lives and situation. She is also a member of a DHMC committee chaired by Robert McLellan, MD, that is "really exploring how mindfulness can be part of the institution," she says. "We'd like to see mindfulness grow out of this group into the broader DHMC community—into practicing mindfulness, not just talking about it. We're also working with the College to make mindfulness part of the Dartmouth philosophy of learning."

Laverack is perhaps the person at the Cancer Center and DHMC most familiar with mindfulness, or at least familiar with it for the longest time. Twenty years ago she read Kabat-Zinn's book Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness, which "just touched my soul," and soon she was studying with Kabat-Zinn ("this was before he got famous") in a small group in Cambridge, MA. She has followed the precepts of mindfulness through her studies in theology, art, and clinical counseling. "Mindfulness is my love. It informs me as I work in service to others. It has provided me with inner peace and the ability to appreciate what's in front of me—including the challenges," she observes. "It's not easy, but it can also be the easiest thing to do."

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September 19, 2011