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JOURNAL OF PALLIATIVE MEDICINE
Volume X, Number X, 2009

Anthony L. Back, M.D.,1 Susan M. Bauer-Wu, Ph.D., R.N.,2
Cynda H. Rushton, Ph.D., R.N.,3 and Joan Halifax, Ph.D.4

Abstract
In trying to improve clinician communication skills, we have often heard clinicians at every level admonished to ‘‘use silence,’’ as if refraining from talking will improve dialogue. Yet we have also noticed that this ‘‘just do it,’’ behavior-focused ‘‘use’’ of silence creates a new, different problem: the clinician looks uncomfortable using silence, and worse, generates a palpable atmosphere of unease that feels burdensome to both the patient and clinician. We think that clinicians are largely responsible for the effect of silence in a clinical encounter, and in this article we discuss what makes silence enriching—enabling a kind of communication between clinician and patient that fosters healing. We describe a typology of silences, and describe a type of compassionate silence, derived from contemplative practice, and the mental qualities that make this type of silence possible.

May 21, 2010 — May 28, 2010

Instructors: Roshi Joan Halifax, PhD * Ben Daitz, MD * Cynda Hylton Rushton, PhD, RN, FAAN * Susan Benjamin, MA * Tony Back, MD and Mary Taylor
Description:

WAIT LIST ONLY

This revolutionary and practical training program for health care professionals gives essential tools for work with dying people and their families.  Designed for physicians, nurses, social workers, hospice workers, and clergy, the training covers core issues related to dying, death, and grieving; ethical issues in end-of-life care and training in communication of difficult news; community building around dying persons and relationship-centered care; cross-cultural and family concerns around religion and ethnicity; approaches to psychological and spiritual care of the dying; the relationship between pain and suffering; peri-death phenomena; and care of the caregiver.  Over the years, this program has been a key resource for hundreds of health care professionals in the U.S., Canada, and Europe who are dedicated to transforming the environment around dying.  The learning process is rich with seminars, direct teachings, exploratory processes and reflective practices.  The Professional Training Program in Contemplative End-of-Life Care has long been dedicated to fostering a revolution in care of the dying. This unique program provides clinicians with essential tools for taking care of dying people with skill and compassion, as well as sustaining resilience and dedication as they serve others.

This unparalleled program brings together, in a unique and powerful way, wisdom and practicality to the very sensitive and inevitable experience of encountering the end of life. The training program addresses the need for healthcare providers to develop knowledge and skills in the psycho-social, ethical, and spiritual aspects of dying; an approach to caregiving that is relationship-centered, including community development and cross-cultural issues; the development of skills related to care of the caregiver; and the means to implement these skills in traditional medical settings.
Much of this content is not addressed in the current training of physicians, nurses, psychologists, social workers, and other healthcare providers, and is essential in the care of dying people.

The training curriculum was developed in the early 1970’s by Dr. Joan Halifax, and has been taught since 1972 in hundreds of medical
and educational institutions around the world, including in Western and Eastern Europe, Canada, the Americas and Middle East, Asia, and the United States.

The training covers many important areas, including:

· Ethical, spiritual, psychological, and social aspects of care of the dying;

· The neuroscienti?c basis of contemplative interventions in care of the dying;

· Community-building around dying persons and relationship-centered care;

· Cross-cultural issues related to dying;

· Exploration of pain, suffering, and peri-death phenomena;

· Care of the caregiver;

· Strategies to support those who are grieving;

· Contemplative approaches to care of the dying and their families;

· Implementation of psycho-social and spiritual content into conventional

medical settings.

The training uses many learning modalities, including: didactic and self-directed learning, inquiry and creative processes, peer-to-peer learning and dialog, case study and council practice, re?ective practices, including mindfulness-based stress reduction techniques, yoga, tai chi, and practices enhancing the awareness and importance of the inner life and professional responsibility. The program is a means for personal and professional exploration and is not therapy. Participants also receive a comprehensive, 400-page training manual detailing every aspect of the training. The training is an important source of learning, inspiration, and information for healthcare professionals who are dedicated to transforming the environment around dying. This course includes 50 hours of CEUs for nurses and social workers provided by the New Mexico Nurses Association and  50 CEUs provided by the New Mexico Counseling and Therapy Practice Board. For the most updated information regarding Continuing Education Credits, please contact peggy@upaya.org.

So essential to healthy eating is a healthy perspective that Zen Buddhist master and prolific author Nhat Hanh joins forces with nutritionist Cheung for a truly holistic approach. The duo pairs the latest nutritional information with the age-old Buddhist practice of mindfulness—that is, of being fully aware of all that is going on within ourselves and all that is happening around us—to draw attention to what and how we eat. Guidance is offered for recognizing what barriers—physical, psychological, cultural, and environmental—prevent us from controlling our weight, and readers are encouraged to savor food in order to fully nourish both the body and the mind. To that end, Nhat Hanh provides guided meditations on everything from eating an apple to coping with stressful situations, along with advice on selecting and preparing food, staying active, and avoiding self-criticism. Complete with a discussion of why healthy eating is also good for the environment, this is a uniquely insightful and positive program for wellness: a book of tested wisdom; practical action; and intellectual, emotional, and spiritual nutriments. –Donna Seaman

Review

“…Not your average healthy-eating guide. ‘Savor’ may have us rethinking every bite, but maybe that’s just what we need..” (Tricycle Magazine )

“Among Buddhist leaders influential in the West, Thich Nhat Hanh ranks second only to the Dalai Lama.” (New York Times )

“Authored by an eminent spiritual leader and a renowned nutritionist, this work infuses science into wisdom and wisdom into science. It is a practical guide to eating mindfully and points the way to attain a healthier weight and a more satisfying life.” (From the foreword by Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine )

“Even if you already have your weight under control, implementing the exercises in this book is bound to enhance the presence and sensuous pleasure of your eating.” (Basil & Spice )

“Hanh and Cheung explore the convergence of nutritional science with Buddhist teaching and find complementary insights. Together, they provide approaches that help to heal both the individual and societal illness that is being manifested as an epidemic of obesity. Everyone can learn from this book.” (Walter Willett, M.D., author of Eat, Drink, and Be Healthy and Chair, Department of Nutrition Harvard School of Public Health )

“In their new book, “Savor: Mindful Eating, Mindful Life,” Lilian Cheung, a nutritionist at Harvard, and Thich Nhat Hanh, a Buddhist teacher, give important advice to dieters about using Buddhist techniques of mindfulness to control overeating.” (New York Times )

“This is a uniquely insightful and positive program for wellness; a book of tested wisdom; practical action; and intellectual, emotional, and spiritual nutriments.” (Booklist )

“Zen Buddhist monk Thich Nhat Hanh and Dr. Lilian Cheung, in Savor, have brought us a profoundly beautiful and powerful guide to mindful eating and living. Please savor it.” (David S. Ludwig, MD, PhD, Director of the Optimal Weight for Life (OWL) Program, Children’s Hospital Boston and author, Ending the Food Fight: Guide your Child to a Healthy Weight in a Fast Food/Fake Food World. )

In Dharma in Hell, prison activist and meditation teacher Fleet Maull shares his journey of transformation and service amidst the anger, violence, darkness and despair of a maximum security federal prison. This collection of previously published and unpublished writings from his 14 years behind bars vibrates with kindness, hope and the triumph of the human spirit. It is a testament to the truth that all human beings possess basic goodness.

Fleet Maull, M.A., Ph.D. candidate, is a meditation teacher, prison activist and the founder of both Prison Dharma Network and the National Prison Hospice Association, which promote contemplative spirituality and compassionate end-of-life care in prisons and jails. He is also an adjunct faculty member teaching socially engaged spirituality at Naropa University and a management consultant who provides transformational training and coaching to business and nonprofit leaders and their organizations. He currently serves as the Director of the Colorado Peacemaker Institute.

Other papers  written by Fleet Maull include:
“The Prison Hospice Movement,” (Explore (NY). 2005 Nov;1(6):477-9.)
“Issues in Prison Hospice: Towards a Model for the Delivery of Hospice care in a correctional setting,” (Hosp J. 1998;13(4):57-82.)
“Dying in Prison: Sociocultural and Psychosocial Dynamics,” (Hosp J. 1991;7(1-2):127-42.)
“Hospice Care for Prisoners. Establishing an Inmate staffed hospice program in a prison medical facility,” (Hosp J. 1991;7(3):43-55.)

Qual Health Res. 2005 Dec;15(10):1329-44.

Bruce A, Davies B.

University of Victoria, British Columbia, Canada.

Abstract

In this interpretive study, the authors explore the experience of mindfulness among hospice caregivers who regularly practice mindfulness meditation at a Zen hospice. They explore meditative awareness constituted within themes of meditation-in-action, abiding in liminal spaces, seeing differently, and resting in groundlessness. By opening into nonconceptual, paradoxical, and uncertain dimensions of experience, hospice caregivers cultivate internal and external environments in which direct experience is increasingly held without judgment. This inquiry points to in-between spaces of human experience wherein mindfulness fosters openness and supports letting go, and creating spaces for whatever is happening in attending the living-and-dying process.

PMID: 16263915

Disabil Rehabil. 1997 Oct;19(10):442-51

Edwards M.

University Support Centre, University of Western Australia, Australia. medwards@cyllene.uwa.edu.au

Abstract

The Zen Buddhist contemplative tradition involves several meditation and instructional techniques that have strong phenomenological and theoretical connections with the experience of loss and the process of grief. From experiences which occurred during personal encounters with individuals (three of whom had a disability) in a grief counselling setting, several points of connection were identified. These included a heightened awareness of the embodied nature of experience, the importance of dialogue and relationship for both healing and transformation, the focus on process as opposed to outcome, the importance of the process of life review, a confrontation with the nature of absence and emptiness, and being present to what is experienced rather than focusing on the need for change. These findings are discussed in terms of Ken Wilber’s full-spectrum model of human development, as well as their implications for professional and non-professional support persons of people experiencing grief.

PMID: 9368096

Neurobiol Aging. 2007 Oct;28(10):1623-7

Pagnoni G, Cekic M.

Department of Psychiatry and Behavioral Sciences, Emory University, 101 Woodruff Circle, Suite 4000, Atlanta, GA 30322, USA. gpagnon@emory.edu

Abstract

Zen meditation, a Buddhist practice centered on attentional and postural self-regulation, has been speculated to bring about beneficial long-term effects for the individual, ranging from stress reduction to improvement of cognitive function. In this study, we examined how the regular practice of meditation may affect the normal age-related decline of cerebral gray matter volume and attentional performance observed in healthy individuals. Voxel-based morphometry for MRI anatomical brain images and a computerized sustained attention task were employed in 13 regular practitioners of Zen meditation and 13 matched controls. While control subjects displayed the expected negative correlation of both gray matter volume and attentional performance with age, meditators did not show a significant correlation of either measure with age. The effect of meditation on gray matter volume was most prominent in the putamen, a structure strongly implicated in attentional processing. These findings suggest that the regular practice of meditation may have neuroprotective effects and reduce the cognitive decline associated with normal aging.

PMID: 17655980

Neurology. 2008 Jun 10;70(24):2321-8.

Wahbeh H, Elsas SM, Oken BS.

Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code CR120, Portland, OR 97239, USA.

Abstract

OBJECTIVE: Half of the adults in the United States use complementary and alternative medicine with mind-body therapy being the most commonly used form. Neurology patients often turn to their physicians for insight into the effectiveness of the therapies and resources to integrate them into their care. The objective of this article is to give a clinical overview of mind-body interventions and their applications in neurology. METHODS: Medline and PsychInfo were searched on mind-body therapies and neurologic disease search terms for clinical trials and reviews and published evidence was graded. RESULTS: Meditation, relaxation, and breathing techniques, yoga, tai chi, and qigong, hypnosis, and biofeedback are described. Mind-body therapy application to general pain, back and neck pain, carpal tunnel syndrome, headaches, fibromyalgia, multiple sclerosis, epilepsy, muscular dysfunction, stroke, aging, Parkinson disease, stroke, and attention deficit-hyperactivity disorder are reviewed. CONCLUSIONS: There are several conditions where the evidence for mind-body therapies is quite strong such as migraine headache. Mind-body therapies for other neurology applications have limited evidence due mostly to small clinical trials and inadequate control groups.

PMID: 18541886

Pain Med. 2009 Nov;10(8):1395-407.

Morone NE, Rollman BL, Moore CG, Li Q, Weiner DK.

Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Abstract

OBJECTIVES: Determine the impact of an 8-week mindfulness meditation program on disability, psychological function, and pain severity in community-dwelling older adults with chronic low back pain, and to test the education control program for feasibility. DESIGN: Randomized controlled trial. Participants. Forty community-dwelling older adults with moderate low back pain or greater for at least the previous 3 months. Intervention. Participants were randomized to an 8-week meditation program or an 8-week education control program. OUTCOME MEASURES: Disability, psychological function, and pain severity were assessed. The same measures were obtained for both groups at baseline, at the end of the program, and 4 months after program completion. RESULTS: Sixteen participants (80%) completed the meditation program and 19 (95%) completed the education program. Both the meditation and control group improved on measures of disability, pain, and psychological function, both at program completion and 4-month follow-up. The differences between the two groups did not reach statistical significance. The meditation group practiced mindfulness meditation a mean of 5 days/week (range 1-7) and mean of 31 minutes/session (range 22-48). At 4 months follow-up 14/16 (88%) participants continued to meditate. CONCLUSION: Both the intervention group and the education control group improved on outcome measures suggesting both programs had a beneficial effect. Participants continued to meditate on 4-month follow-up. The control program was feasible but not inert. Piloting the control program in mind-body research can inform the design of larger clinical trials.

PMID: 20021599

JAMA. 2009 Sep 23;302(12):1284-93.

Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE.

Department of Internal Medicine, University of Rochester Medical Center, Rochester, New York, USA. michael_krasner@urmc.rochester.edu

Comment in:

Abstract

CONTEXT: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. OBJECTIVE: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians’ well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

PMID: 19773563

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