ABSTRACT:
Buddhism in America is a complex and layered religion. There are two major branches of Buddhism: Mahayana, Theravada; each has many sects and subsects with distinctly different practices. Within each subsect, there is an origin country associated that also provides distinct cultural practice for the associated sect members, so a Zen practice from Vietnam may vary from Zen in Japan. Buddhists are a minority in America that account for 1%, compared to 62% of Christians. This creates a chasm of complexity when we further reflect on hospital staff chaplains where in larger institutions there may be only one part-time Buddhist chaplain on staff amid six Christians.[1] Thus, patients in need of care with specific Zen Buddhist accompaniment require healthcare staff to have a better understanding for their preferences for pain management and comfort. Pain at the end of life in Buddhist patients can be accompanied and mitigated with meditation, mind control, and minimal pain intervention. Accompanying Zen patients on this journey can provide a quality of life within death that allows for serenity and peacefulness for a transition respectful of their tradition. This paper will act as a reference guide for Buddhist patients in ill health or at the time of death. Additional examples of alternative interventions that were noted in case studies and Buddhist texts will be provided.
Goal: To help medical staff and families aid the dying person in an accompaniment that is in keeping with their faith practice while bearing witness to the pain they may be experiencing.
American Buddhism came from West to East, arriving to California and spreading throughout. There are two main branches, Mahayana and Theravada. Mahayana school believes in gaining enlightenment and then helping all others to achieve this as well. Theravada believe that each person attains their enlightenment to reach nirvana. Each school then branches out into many sects and subsects that have very specific practices as seen in Figure 1. Even within one specific lineage, you will see variations of practices and chants, so it is best to consult with each practitioner as needed.
Daniel Sulmasy, in Spiritual Issues in the Care of Dying Patients, said
“Dying persons want to know if there is any meaning in their suffering or in their dying. These questions are often framed in overtly religious terms, but qualitative research suggests that these are pressing questions for almost all dying patients. Despair is typically defined as the absence of hope, but another name for hopelessness may be meaninglessness.”[2]
In order to create meaning, we can accompany a person through their pain and hopelessness to provide spiritual accompaniment. For a Buddhist, this means to be reminded of our way of life and that death is a part of this impermanent existence. We strive to have very little medical interventions, with clarity of mind being important.
It is generally understood that well intended medical interventions at or near death, sought without communication or resources relating to a patients belief systems, produces a bad death. This could weigh heavily upon family survivors who could not give a voice to their family’s wishes if there was time to provide support. By having access to resources and a team that is open to community and family providing the religious tools for the dying patient, we can together produce a good death for the patient and family. By creating this resource, we can help family, practitioners and clinicians to have a reference a guide that can help bring comfort to a patient within a mysterious process.
Zen Buddhist Harada Roshi states that one of the Buddhist sutras provides the ideal Buddhist death: to have a premonition of death a week beforehand, in utter clarity and serenity, with little to no pain and free of attachments to the body.[3] However, this is rare and remarked by Harada Roshi in his commentary of letters with a dying young woman who was able to achieve this seemingly unattainable feat.[4] Within her final years of Tuberculosis and pneumonia she aspired to be enlightened before death, meditated in bed, and concentrated on the koan Mu with Harada Roshi to make this possible. This account can be read in full in Philip Kapleau Roshi’s book, The Three Pillars of Zen.[5]
Buddhist often reflect on living fully each moment, with awareness that each day is a gift in this precious life. Many will wear a skull on a mala (bracelet for chanting) to remind them of this transient and impermeant life. Shakyamuni Buddha taught to have no fear of death, and embraced his own death laying down. He had been ill while traveling and accepted a poisoned pork meal (sukara-maddava) in the village of Pava. It is said, that Buddha experienced severe abdominal pain, bloody diarrhea and acute weakness in his final moments. The Buddha is said to have then walked to Kushinagar, laid down between two sala trees, and gave his final instructions and ordination to his disciples and then passed into Parinirvana, or a deep meditative state, to which he transitioned from his body.[6] He had a serene expression that suggests he did not fear death. This acceptance and pure awareness is a model for Buddhists to let go of the body that is in pain, as it is not you. Buddhists are mindful of death within life, and often wear a mini skull to remind them that life is fleeting, and to not waste your time by night or day. Impermanence, the fact that change is ever present, is the truth we cannot avoid.
Despite these guiding words, we may find that in the final moments life may not go as we had planned. There are four major fears that Buddhist’s experience when they are very ill and approaching death: 1) fear of pain, 2) fear of pain medication, 3) fear of abandonment, and 4) fear of loss of self.[7],[8] For Buddhists, to have fear of death is irrational, as we know that we will be reborn in infinity to continue to serve all beings until Nirvana is attained, just as Buddha.[9] Rinzai Zen Master Yasutani Roshi states that we die when our karmic relations decree we die, and we are reborn when our karmic relations compel our births.[10] In Yasutani’s commentary on Mu, he states that we must understand the fundamental principle of growing old and aging:
“We are the manifestation of our karmic relations at any given moment, and upon their modification we change accordingly. What we call life is no more than a procession of transformation. If we do not change, we are lifeless. We grow and age because we are alive. The evidence of our having lived is the fact that we die. We die because we are alive. Living means birth and death. Creation and destruction signify life. When you truly understand this…you will not be anxious about your life or your death.”[11]
In Robert Bly’s book of poetry of death themes, he includes a poem by Rumi which really encapsulates the Buddhist experience.
I lived for hundreds of thousands of years as a mineral,
And then I died and was reborn as a plant.
I lived for hundreds of thousands of years as a plant,
And then I died and was reborn as an animal.
I lived for hundreds of thousands of years as an animal
And then I died and was reborn as a human being.
What have I ever lost by dying?[12]
Hindu-Buddhists are those who practice both aspects of Hinduism and Buddhism. They may lean more to one practice over the other and will have different Guru’s or deities within the Hindu faith that are preferred. The basis of this combined faith is to love and serve others.
Those who have Maharaji Neem Karoli Baba as their root guru will enjoy hearing the Hanuman Chalisa, or hearing the chant of “Ram, Ram, Ram, Ram…” or “Ram, Sita, Ram, Sita, Ram…” that is the lovers of Ramayana and Sita that Hanuman loved so dearly and held in his heart. Zen Buddhists who are also followers of Maharaji ji will appreciate hearing Krishna Das’s Hanuman Chalisa that is the Gate of Sweet Nectar and can be found on YouTube as Sri Hanuman Chalisa / Gate of Sweet Nectar.
For those who have Amma, also known as the hugging Saint, or Mata Amritanandamayi, followers are often referred to as the Amma’s children. The most common chant is “Ma, Ma, Ma, Ma, Ma, Ma, Ma…”
For Those Experiencing Pain:
Most Buddhist’s hold out as long as possible from taking pain medications, to stay clear and present. For those experiencing pain, we must balance the pain with joy. We can do this with recollecting on memories with our loved one and then with remembering our Buddhist practices.
Recollect on the wonderous nature of the Three Jewels in a guided meditation as recited by Shariputra to Anathapindika:[13]
- Breathing in, I see that this body is not me. Breathing out, I am not caught in this body. I am life without limit. I have never been born and I will never die.
- The element of Earth in me is not me. The fire element to keep warm and digest food is not me. I am not caught in the fire or warmth element.
- The water element in me is not me. There is water everywhere in and around me. I am free of the element of water.
- The air element in me is not me. I am life without boundaries
Meditation on Interdependent Origination:
- When conditions are sufficient, my body manifests itself.
- It does not come from anywhere, and after disintegration it does not go anywhere. When things manifest, we cannot really call them being.
- When things stop manifesting, we cannot really call them non-being.
- We are free from notions of coming, going, being, non-being, birth, death, same and different.
Eihei Dogen, twelfth century Zen Master, in the Shobogenzo fascicle, Heart of the Way, gives guidance for when we leave this life.[14] He says that between the death and rebirth, there is an intermediatory realm where we stay for seven days. We need to resolve to keep chanting the names of the Three Treasures without ceasing while in these intermediatory realms. After seven days, there is a transition to another realm where we stay for another seven days where we can see and hear without hindrance. After this we approach our parents to be conceived, resolve to maintain authentic wisdom and chant the three treasures in your mother’s womb and as you are being born.
Chanting/ continuous recitation:
| Buddhist Sect | Chant Relevance | Continuous Recitation |
| Nichiren | Devotion to the mystic law of the Lotus Sutra | Nam Myoho Renge Kyo |
| Obaku (Zen) | Nembutsu and concentrated focus; rhythmically chanting the name of Amida Buddha while inquiring into the reflection of our true nature. | Namu Amida Butsu or Namo Buddhaya; Namo Amitabhaya and ask “Who is the one reciting Buddhas name?”[15] |
| Pure Land | Nembutsu; I take refuge in Amida Buddha | Namo Amida Butsu or Namo Buddhaya; Namo Amitabhaya |
| Zen Soto/Rinzai | Three treasures or Three Jewels of Refuge | I take refuge in the Buddha, I take refuge in the Dharma, I take refuge in the Sangha. |
| Zen | Devotion to Quan Yin / Kanzeon – Bodhisattva of Compassion – The One who hears the cries – upon hearing her name chanted can relieve suffering | Chant Enmai Kannon Gyo (see full chant in appendix) or simply Namu Kanzeon Bosatsu[16] |
| Tibetan – All Use | Hail to the Jewel in the Lotus (QuanYin) | Om Mani Padme Hum |
“Our greatest fear, is that when we die we will become nothing.” Thich Nhat Hahn[17]
| Buddhist Sect | Major Areas of Study |
| Nichiren | The Lotus Sutra |
| Obaku | Concentration Samadhi |
| Pure Land | The Lotus Sutra |
| Zen Soto/Rinzai | Eihei Dogen’s Shobogenzo, Keizan Jokin’s Record of Transmitting the Light. Note: Rinzai followers study koans – recorded conversations between monastics that become riddles to help one discover their true nature. The Lotus Sutra, Chapter 25, The Universal Gate of Bodhisattva perceiver of the World’s Sounds. |
List of Buddhist Hospices (not comprehensive)
Shagged P’hande Ling (Maine, USA)
Chagdud P’hande Ling, an intergenerational Buddhist community dedicated to serving the elderly, ill, and dying, under the direction of H.E. Chagdud Tulku Rinpoche, is in Saco, Maine, USA.
Contact:
Marina Storper-Stretch, MHS, 8 Sugar Maple Lane, Keene, NH 03431, tel. (603) 358-5284, fax 357-3317, or Sally Ember, online: SALMBER@aol.com
https://www.chagdudgonpa.org/windhorse-articles/chagdud-phande-ling-place-of-temporary-and-ultimate-benefit
Insight Hospice & Healing Project (USA)
Hospice and Healing Volunteer Outreach project based in a Theravada Buddhist Tradition serving people of all religions.
Insight Hospice & Healing Project
335 27th Avenue, San Francisco CA. 94121
Tel: (415) 752-2436
Zen Caring Project / Zen Hospice Society
this pioneering organization evolved from the San Francisco Zen Center to offer residential care, mindful presence, and training in compassionate end-of-life service. https://www.zencaregiving.org/
phone: 1(314) 200-5727
San Francisco, CA
Tara Home (Land of Medicine Buddha)
this residential hospice provides around-the-clock compassionate care for terminally ill individuals in their final months. It relies completely on donations and prioritizes care for people who lack family support.
5800 Prescott Rd, Soquel, CA 95073
(831) 588-5850
info@tarahome.org | https://www.tarahome.org/
Pure Land of Amitabha Buddha Hospice
Adelaide, SA
https://purelandhomehospice.org/
After Our Loved One Has Left
For most all Buddhist traditions it is customary to attend to and stay with the body as long as an hour after the death. Medical staff are encouraged to remove as much medical equipment and medications. Fresh flowers are welcome with fresh cool air. Family and community members can continue to chant and remind their loved one that they have died now. This is especially important in cases of sudden death by overdose, surgery, and or neurological impairments. Some traditions may want to bathe the body, wash it down with warm soap clothes and dress in clean traditional clothes for the cremation. If they are a Zen Buddhist, it would be customary for them to wear their Rakusu as part of their final dress. Burial is rare, however if the requested or permitted some may request their body be fed to the wildlife. In Tibet this is called the charnel grounds.[18] The idea being that we have fed off of this world and now we are no longer our body, it is no longer of use to us, and can feed the endless cycles of life that need this to sustain their life.
Dependent origination, that whatever is born must die, is part of the cycle of life. However, people do tend to have attachment to people, and so suffering with grief is bound to occur at the time of death. Most all sects of Buddhists practice chanting during Bardo, after the death of the loved one until 49 days when the loved one journeys on. Zen Buddhist family members can chant the Maka Hana Paramita Heart Sutra daily in Japanese Sino or the English translation.
Memorial Service:
A large photo is placed at or near the altar of the Buddhist temple. Zen memorial service chants may include chanting The Heart Sutra, Enmai Juki Kannon Gyo, Daishin Darani. There is a moment in the service when loved ones take a moment to say a few kind words or memories. The service concludes with a dedication of chanting and closing ceremony chants and three bows. For Thai Buddhists, the monks at the Temple will do the chanting, there will be an offering of food and robes to the monks, people will make remarks and bows, and then a large meal will take place of traditional Thai dishes.
Comfort:
“If you have lost someone and you cried so very much, please accept the invitation of the Buddha. Look deeply and recognize that the nature of your beloved is the nature of no birth, no death; no coming, no going.” Thich Nhat Hahn[19]
Thich Nhat Hahn tells us that after your loved one has died, be on the look for signs of their continuation and new manifestations.[20] Pay close attention to the world, you may notice the leaves in the trees rustle a little more gently, birds fly close and stay near, flowers see you. Your loved one is always with you now.
Reading that may help the beloved who are grieving:
- Cacciatore, Joanne. 2017. Bearing the Unbearable : Love, Loss, and the Heartbreaking Path of Grief. Somerville, MA: Wisdom Publications.
- Newland, Guy. 2016. A Buddhist Grief Observed. Somerville, MA: Wisdom Publications.
- Ostaseski, Frank, Rachel Naomi, M.D. Remen, and OverDrive, Inc. 2017. The Five Invitations. [S.I.]: Flatiron Books.
Please be tender with yourself as you journey through this transition, accompanying a loved one, or while moving into the beyond yourself. Have no fear, this is a time of great faith as they have realized emptiness.
Gate, Gate, Paragate, Parasomgate, Bodhi Svaha.
Translation: Gone, gone, gone beyond, gone completely beyond, awakened enlightenment, So be it.
References:
[1] Pew Research. Religious Landscape Study. Accessed from: https://www.pewresearch.org/religious-landscape-study/
[2] Sulmasy DP. Spiritual Issues in the Care of Dying Patients: “ . . . It’s Okay Between Me and God.” JAMA : the journal of the American Medical Association. 2006;296(11):1385-1392. doi:10.1001/jama.296.11.1385
[3] Kapleau, Philip. 1980. pg 302. VI / Yaeko Iwasaki’s Enlightenment Letters to Harada-Roshi and his Comments
[4] Kapleau, Philip. 1980. The Three Pillars of Zen: Teaching, Practice, and Enlightenment. Anchor Books.
[5] Kapleau, Philip. 1980. pg. 284. VI / Yaeko Iwasaki’s Enlightenment Letters to Harada-Roshi and his Comments.
[6] Buddha’s Death, Buddha, What is Buddhism? Accessed October 27, 2026 from: https://tricycle.org/buddha/#death
[7] Ostaseski, Frank, Rachel Naomi, M.D. Remen, and OverDrive, Inc. 2017. The Five Invitations.
[8] San Francisco Zen Center, 2025. When Blossoms Fall: A Zen Guide for Death and Dying. California.
[9] Kapleau, Philip. 1980. pg. 79
[10] ibid.
[11] Kapleau, Philip. 1980. pg. 80
[12] Bly, Robert. 1992. What Have I Ever Lost by Dying? : Collected Prose Poems. 1st Harper Perennial ed. New York: Harper Perennial.
[13] Nhất Hạnh. 2002. No Death, No Fear : Comforting Wisdom for Life. First Riverhead trade paperback edition. New York: Riverhead Books.
[14] Tanahashi, Kazuaki. 2013. Treasury of the True Dharma Eye : Zen Master Dogen’s Shobo Genzo. Shambhala Publications, Incorporated.
[15] Obaku, Zen Buddhism, Huang-po. Britannica. https://www.britannica.com/topic/Obaku
[16] Uchiyam Howard Lazzarini, Shohaku Okumura, and Shoko Hayashi Lazzarini. New York, NY, USA: Wisdom Publications.a, Kōshō. 2025. The Sound That Perceives the World : Calling out to the Bodhisattva. . Translated by
[17] Nhất Hạnh, and Pritam Singh. 2004. Taming the Tiger within : Meditations on Transforming Difficult Emotions. 1st Riverhead trade pbk. ed. New York: Riverhead Books.
[18] Charnel ground, Wikipedia: https://en.wikipedia.org/wiki/Charnel_ground
[19] Nhất Hạnh, and Pritam Singh. 2004. Taming the Tiger within : Meditations on Transforming Difficult Emotions. 1st Riverhead trade pbk. ed. New York: Riverhead Books.
[20] Nhất Hạnh. 2014. Fear : Essential Wisdom for Getting through the Storm. First Harpercollins paperback edition. [New York]: HarperOne.
