Five Element Acupuncture For Terminal Patients:
A Powerful Intervention For Dying Well
Ron Puhky, M.D.
Five Element acupuncture with its particular emphasis on spirit and emotion, and its in depth focus on the specific qualities and functions of each Element as they apply during the dying process, is a particularly useful tool in understanding and aiding patients with terminal illness. The theoretical basis of treatment using this system is described, with discussion of specific groupings of useful points. Actual treatments are based on the individual clinical presentation and pulse diagnosis, with particular emphasis on using spirit level points; points to enhance the function of the Elements in easing the dying process; and points to promote the overall balance of the pulses.
Five Element acupuncture, dying process, terminal patients, pulse diagnosis, spirit level points.
Fearing death, I went to the mountains,
Over and over again I meditated on death's unpredictable coming,
And took the stronghold of the deathless unchanging nature.
Now I am completely beyond all fear of dying!
As physicians, we are intermittently and invariably, directly involved medically with our patients through most of their lives, from birth, almost until death. Unfortunately, the usual practice in non-acute patients at this last stage is to back away in some way. We have reached our professional end-point. Feeling our role is to basically prolong life, and to ease suffering, after the appropriate analgesics are prescribed, attending to the dying person is left to nursing and hospice staff, to family members and other third parties. Lacking further specific, time effective tools to help with this process, it is tacitly admitted that there is no further professional role to play. Yet even analgesics and sedatives, in excess can over sedate. Things may look better to the observer, but the patient goes on having to deal with their fear and psychic pain at a more unconscious level. In fact, we are in a bind, because if we intervene too much in this way, we may be depriving the patient of the faculties they need to move through the dying process. And there is the issue of dying well, of leaving this life in a conscious enough way: dealing with our major issues; saying our good-byes; making our peace.
As a further point, it might be said that at times we take the business of prolonging life too far, pushing palliative therapies, or even intense experimental ones, onto situations that are basically hopeless. And we do this because of a fear that is often shared with our patients- the fear of dying and of death. Yet at a certain point in time, we have to admit the inevitability of death, and this should involve us looking squarely at the issue. The cultural denial in this area should not be something with which we collude. The physicianís role should continue right to the end, giving presence, comfort and solace, all of which, if they are to be effective, involve having dealt with this issue personally.
The purpose of this paper is to demonstrate that there is also a very effective tool that we can use to ease the dying process, namely Five Element acupuncture. This system of medicine, with its particular knowledge of the workings of the energetic system, can allow us to access a personís deepest resources emotionally and spiritually at precisely the time they need it most. Through the use of acupuncture points that act at the spirit level, and of other points that calm disturbed emotions or activate specific elemental functions that ease dying, we can bring a powerful therapeutic effect to the dying patient. Treatments can help ease fear, and reduce physical, emotional and spiritual suffering. They can help the dying person gain more peace and a stronger connection with their spiritual essence, allowing them an easier acceptance of the dissolution of the body and physical life. Ultimately, the focus of acupuncture here is to connect the dying person to the subtle energies of their deepest spiritual resources- to their soul.
This paper will show how Five Element acupuncture has been applied in two cases that are typical of the fifteen cases of treating the dying process, that have been part of the authorís practice.
To properly do this work the physician needs to be in his ìobserverî or spirit center, to work on the spirit level in these people. This allows him to make the necessary level of connection with the patient, to develop appropriate ìintentionî, and to be present for the poignant and meaningful flow of events that occur in such situations. Finding some time for meditation, prayer, or centering preparation before treatment is thus very helpful. This helps provide the necessary focus from where we can choose the most effective points and then needle them with maximum effectiveness.
A. Using the Five Element model
Five Element theory has been part of Chinese Medicine from the 10th century B.C. These concepts first appeared in several books on philosophy such as the Shu Ching, the Li Chi and the Guan Dzu 2. The first medical writings on the Five Elements were found in the Nei Ching Su Wen 3 written around 200 B.C. Further discussion was found in the Ling Shu and the Nan Ching. The Five Element concepts4 are part of not only medical theory, but are an integral aspect of all ancient Chinese cosmology and philosophy.
The Five Element system divides human experience into five distinct groupings or Elements. The Five Elements include Wood (liver and gall bladder), Fire (heart, small intestine, triple energizer, pericardium), Earth (spleen, stomach), Metal (lung, colon) and Water (kidney, bladder). These Elements act as maps within the body-mind continuum, which reflect all levels of human function, including but not limited to, the anatomic and physiologic functioning of the organ systems. The levels of function range from biochemical processes to the function of the organism as a whole, and includes behavior, psychological state, relationships and career choices. Using the Five Element 'map' dysfunction occurring on any of these levels can be placed in the appropriate context.
Five Element acupuncture has as its main method and focus that of finding and treating the causative or root factor (CF)5 of a personsí illness. The particular art of this system is in finding the Elemental essence of who the person is, and thus, why they are manifesting illness in a particular way.We need to know how they reacted to and interpreted traumatic events in their life, in such a way that only certain diseases and symptoms, and not others, appeared for them. The CF is where the person is most vulnerable to wounding, where a disturbance in the energetic pattern can first develop, and then lie at the root of their later pathology. Or, in other circumstances, if life and their adaptive abilities are positive, it can be more the deeper mark and essence of their personality. In either case, the CF is both a vulnerability and a growing edge for development and manifestation of oneís essence in life. It is how the Elements have configured themselves to provide the necessary vehicle for individuality to manifest, and for spiritual, emotional and intellectual evolution.
Although based on the Five Element acupuncture system, the treatments for the dying individual are not so much focused on the CF, as they are normally in this tradition. In this particular circumstance, we treat whatever Elements need support or need to be drawn on for their strengths and positive functional energies.
Let us first look at the Elements in terms of what they can each provide to the person in dealing with the dying process. The Elements each function in a specific way at physical, emotional, and spirit levels. (See Table I).
1. The Water Element6,7 is the system within that deals with fear and survival issues, including fear of death and the unknown. Fear is useful if it allows for action that helps to protect the individual and avoid danger. Too much of it paralyses and blocks the overall healing and adaptive energies, and strongly adds to physical and psychological pain. The Water Element also contains the antidote to excessive fear. It is found in the Zhi, which gives the will and the courage to face and deal with incredible odds, and in the Waterís big, general reservoirs of spirit: the Kidney points on the chest, and the outer Bladder line points on the back. This Element is also the storehouse of ancestral energies and wisdom, part of our inner knowing. It is the system that has been involved in the development of the hard wiring of our energetic structure and nervous system, and so connects to all the deeper inner capacities. These include not only the healing response, but also those natural embedded processes of letting go and dying with more ease and less pain.
2. The Wood Element6,7 deals with the emotion of anger and in this circumstance, allows a person to let go of the anger and the sense of the injustice they may feel when they face their death. It allows for forgiveness and self-forgiveness. It provides the sense of completion of oneís plans, that is part of its spiritual resource the Hun. The person has accomplished all that they can, so it is time to stop struggling, and to accept the completion of their outer work in this life, and move into the settling of their affairs. This requires dropping anger and resentments, forgiving others, and asking for forgiveness with all those they can. This brings the dying person peace and a sense of closure. Treating this Element can promote all of these emotional changes, actions and outcomes as well as allowing the person to effectively plan and carry out their death process.
3. The Metal Element6,7 is the Element of dying and letting go. It allows a person to be present in the time of good-byes and farewells, of tears, grief and loss. Treating this Element allows the patient to let go more easily. It softens and relaxes them. It helps when they are in denial and holding on too hard. It allows them to bow to and accept what is inevitable, including the time of death. Through the lung and the breath we are connected outwardly to heaven and inwardly to our spiritual essence. With our first breath it is our connection to physical life and form; and with our last, our soulís movement back to pure spirit and the formless. Often people die in the early morning hours of 3 ñ7AM, the time of Metal. Treating this Element has the benefit of allowing the patient to feel and acknowledge the richness and worth of their life and connects them more deeply to their spiritual essence. They can then let go with grace and few regrets.
4. The Earth Element6,7 provides us with our sense of place, home and comfort within our human community- our family, our friends, our tribe. We are connected members of the circle of humanity, rather than isolated individuals. The Earth also connects us to the solace of the internalized mother experience most of us have, and beyond that, to the universal Mother principle. The Earth allows us satisfaction with the works we have created in our life, along with gratitude for all the blessings we have received, not the least of which is the gift of life itself. It allows us to be grounded and centered in the flow of life, and is our connection with our children and our childrenís children- with the continuity of the life process, as life goes on from us. Experiencing the gifts of this Element within the dying process allows for a peaceful death and a sense of completion.
5. The Fire Element6,7 connects us to love, our consciousness, the God-within, and to the unity of all life. In our heart it holds our Shen, our immortal essence, our connection to the life principle. It is the part of us that is in deepest interrelation- both with our loved ones and also with the divine and the whole cosmos. It is where we connect with the Immortal Ancestors, the teachers, saints and sages. In this part of our energetic system lies our spiritual center and our ultimate spiritual resource- our deathless unchanging nature. It is an expansive place, one that functions well beyond the limitations of the physical body, even in the full of life. So, as death nears, when the person moves into it, it naturally and joyfully can take them onto the next stage of the journey. This is the joy at the homecoming that people report in after death experiences, and why often they donít want to come back. In dying well, the connection with their heart energy is very important as they say their good-byes and most importantly let their loved ones and friends know how they hold them in their hearts. This is the real completion- and resting in their Shen they are ready to move on, appreciating the beauty, love and joy of the world as they depart it.
Table I. The Therapeutic Framework for the Use of the Five Elements in the Dying Process
|ELEMENT||Issue Or Obstacle To Be Resolved||Elemental "Gift" Or Therapeutic Influence||Points To Be Used|
|WATER||Fear - terror of death and non-existence.||Courage. Will. Stillness. Calm. Reassurance.||KI-25, 24, 23, KI-21, 20. KI-3. BL-52(47),57,61,64|
|WOOD||Anger - sense of injustice, struggle, incompletion of life||Forgiveness, and Self-forgiveness. Relax. Completion.||LR-14, LR-13, LR-3, GB-40|
|FIRE||Despair-loneliness, isolation. Unlovability. Contracted spirit.||Opens to love and relationships, joy, beauty, unity, God. Self-confidence.||BL-44(39), CV-14, SI-11,TH-7, HT-1, HT-7|
|EARTH||Worry - obsession. Self-absorbed. Anxiety. Poor me, victim.||Comfort, sense of family, belonging. Contentment. Gratitude for life.||SP-21Great Enveloping. SP-3. ST-40 Abundant Splendor|
|METAL||Grief -loss. Denial, excess clinging. Spiritual emptiness. Many regrets.||Accepting of death and impermanence. Let go. Reconnect to Spirit, Big Mind.||LU-1 Middle Palace. LU-9. LI-18 Support and Rush Out. LI-4.|
B. Point Selection and Treatment
Needle and moxa technique: The primary needle technique(7) in Five Element acupuncture is tonification. Sedation is done much less frequently. The method of tonification is to needle the point with a simple insertion that is angled slightly in the direction of energetic flow in the meridian, and then advanced slowly into the prescribed depth of the point until Qi is obtained. This is done without lifting or thrusting or rotation. This means that the point must be located very accurately in order to obtain the Qi connection in this way. This is done by using light pressure with the tip of the index finger, and moving it over the indicated point location, until a small gap or ìmenî is felt in the fascial layer of the epidermis. Even then, partial withdrawing of the needle and then re-inserting with slight changes in angulation is sometimes needed to obtain this connection. When Qi is felt, the needle is rotated clockwise 180 degrees. There is usually an augmentation of the needle sensation. After 2 or 3 seconds the needle is withdrawn, and the point sealed with a momentís finger pressure.
Sedation is accomplished by locating the Qi in the same way, with a slight angulation against the direction of flow of the energy in the meridian, and then rotating the needle 180 degrees counterclockwise and then leaving the needle in for 15 to 20 minutes. The needle is then withdrawn without sealing the point.
The moxa technique used is that of direct moxibustion. A prescribed number (usually
3 to 5) of hand rolled, pea-sized moxa cones (Wakakusa grade loose moxa-source OMS) are applied one after the other directly to the point and removed when the patient first feels the heat. This is then usually followed with needle tonification as described above. Spirit points in particular, are often first given moxa. Since the patientís pain perception is often compromised in these cases, care must be taken not to burn the skin.
1. Spirit points:
Start the treatment by choosing one of the big general spirit points of the Kidney: KI-24 (Spirit Burial Ground), KI-25 (Spirit Storehouse), and KI-23 (Spirit Seal). Direct moxa the points first, and then needle them. These are the big reservoirs of spirit and ease fear as they bring calm and inner strength.
Also needed are points for the Heart. Go right to the seat of the Shen and connect the person there. CV-14 (Great Deficiency)- the front Mu point, is very potent at this time. Also useful are BL-44 (Spirit Hall), and HT-1 (Utmost Source). HT-7 (Spirit Gate) is one we can use repeatedly in our treatments to keep the gate to the Shen open.
2. Ancestor points:
People speak in the near-death experience of being met by ancestors, both personal relations and spiritual figures. GV-20 (One Hundred Meetings) is an assembly of the ancestors point as well as the point of the crown chakra, the place felt by many ancient traditions to be where the soul leaves the body. This is a common theme, too, in modern accounts of the near-death experience. Tonify or sedate this point depending on the state of depletion or agitation of the person and the pulses. Even when they are still early on in the dying process, this point brings peace, comfort and stability to the mind and spirit of the person, as they can connect to departed loved ones and to the saints, sages and holy ones to which they are connected.
SI-11 (Heavenly Ancestor) is another ancestor point, and is also linked to the Shen as the Heartís paired yang Fu organ. TH-7 (Assembly of Ancestors) is another link to these aspects as the Three Heater itself has a major effect on calling up archetypal and ancestral energies as a part of its functioning in the Fire Element. This point can be used often.
3. Points for fear:
Choose points on the Water Element, especially the Kidney, to ease fear, after
using the big spirit points mentioned above. These points are tonified, with
moxa added as needed. Useful body points on the Kidney are KI-21 (Dark
Gate), often followed by CV-14, the Heart-Mu point, with which it has a
connection. Later, KI-20 (Through the Valley) can be used. The use of the
Source point, KI-3 (Greater Mountain Stream) is always added for fear, with
the above points. It can also be used alone. Points that have a beneficial effect
that are on the Bladder meridian are UB-57 (Supporting Mountain), and
UB-61(Servantís Aide), and also the Source point, UB-64.
4. Points for letting go:
This part of the treatment involves using points on the Metal and the Wood
Elements. The Metal Element points on the Colon and the Lung are for
promoting the smooth evolution of the dying process. They allow the
person to stop the tendency to cling on, and instead, relax more
into the dying process. Useful points are the Source points LI-4
(Joining of the Valleys), and LU-9 (Very Great Abyss). Other points
include LI-17 (Heavenly Vessel), and the Window points of Metal,
LI-18 (Support and Rush Out), and LU-3 (Heavenly Palace).
Points on the Wood are for letting go of anger, struggle and any sense of
unfairness or injustice that are disturbing the individual. They also serve to
relax the need for control. Useful points to accomplish this are the Source
points, LR-3 (Supreme Rushing), and GB-40 (Wilderness Mound), and
occasionally LR-14 (Gate of Hope), usually done with sedation technique
in these cases.
C. Principles of Treatment
We first evaluate our patient by using the Five Element model discussed above and seeing what Elements within them are in need of treating at that time. It is also necessary to monitor and balance the pulses. The pulses are great indicators of the internal state of the person as seen overall, and also, specifically, of the state of each Element. Initially, the pulses give us extra diagnostic information; later, they give us feedback as to how our point choices and treatments are working. Successful treatments will end up balancing the pulses and improving the overall pulse qualities in each session.
The treatments are not solely Causative Factor oriented. The practitioner must do what is needed based on the personís emotional state, and Elemental needs and what is showing up in the pulses. If the patient is very agitated, this will show up in the pulses as an excess. Here we need to sedate, and the points LI-4 and LR-3 (Four Gates) can be used, along with GV-20 if the agitation is extreme.
The pulses are often chaotic in other ways as the person nears death. There are often Husband/Wife9 (H/W) imbalances (where the right hand pulses are stronger and more aggressive than the left). We donít usually correct them and try to reverse them in this situation, as here dissolution is the process, and we are not trying to bring them back to an enhanced healing state, or in a state where they are fighting their death. Treating this can actually upset them, and besides, at this stage there is too much toxicity in the system to perform the strong energy transfers done to correct the H/W. Just using spirit points usually drops the degree of the H/W, and decreases any other chaotic, intense qualities in the pulses.
In other cases, often when the person is less agitated, the pulses can be very weak. In those cases the spirit points lift the pulses, make them even and improve the quality. In dying, as in living, balanced pulses indicate and promote a ìhealthyî process. Where specific areas of weakness in the overall pulse picture remain, we need to go in and treat the particular Elements involved. Regardless of the choice and order of points in a successful treatment, any treatment should conclude with distal command points. At the end of each treatment we should expect to see the pulses balanced and of a reasonable, calm quality. This is one of the immediate feedbacks of a successful treatment. The patient may also communicate this to us indirectly, or directly, by relaxed breathing, a decrease in restless movement; or by mentioning a decrease in pain and anxiety. Still, in a dying person, the clinical signs may be subtle and the individual may not be able to communicate directly to us. The pulses then, are of particular significance.
Daily treatments may be necessary at the beginning, or every 2-3 days. As these patients approach their death, they cannot always report accurately on their own process. We need the observations of those attending the dying person: what is the degree of their pain or anxiety; the amount of confusion or restlessness; the quality of their interactions with their loved ones? Positive signs include attitudes of acceptance, and the clear understanding and communication of the reality of their dying. A deep sense of inner peace may appear. Humor and joking can be present, along with other qualities of happiness, leading to a deepening of final heartfelt communications.
At a certain point the dying person, in equilibrium and connection with their spirits, open to their hearts, their loved ones and to life, taps into the natural process of dying. This has its own flow, purpose, meaning and solace. We have wired into us this natural process of letting go of the body, just as we have for the capacity for healing and for connection with our spirit.
CASE HISTORY ONE
Mary was a 48 year old white woman, a divorced mother of two children aged 13 and 17. She had a two year history of metastatic breast cancer. At the time of diagnosis she had extensive axillary lymph node involvement and multiple bone metastases. After surgical removal of the breast mass, she was placed on a palliative regime of radiation therapy and Tamoxifen. She later developed liver metastases. She was on a nutritional program, and as a long-time Buddhist practitioner, was using specific healing meditations and visualizations. She was receiving psychotherapy. She had also been on an adjunctive program of Five Element acupuncture treatments over the two years of her illness.
I had been called by her family doctor to attend her in hospital, where she was very close to death, semi-conscious, in respiratory distress with bilateral bronchopneumonia. At the bedside, a friend reported that the patient had been very upset in recent days about leaving her children behind and had been in a lot of psychological pain, to the point of spiritual despair. When I was able to assess the patient, it was obvious that she was not only in respiratory distress, but agitated and afraid. Treatment was started immediately after pulse evaluation, where they were found to be chaotic, uneven, and barely palpable in the Metal and Water positions. During her previous treatments over the past two years she had been treated primarily on the Fire Element as the CF. In this near death circumstance, the approach to treatment was as outlined previously.
All points were treated in tonification, and bilaterally. Moxibustion was applied to certain spirit points. First treated was KI-25 (Spirit Storehouse), with 5 moxas then needle, to build up her reserves of spirit and ease her fear. Next, LI-4 and LU-9 were needled to help both with the physical distress in her respiratory system and the disconnection from her spiritual resources as an aspect of Metal. At this point, her pulses were calmer and more even, and the strength of the Metal and Water pulses was in balance with the others. At the same time, the patient showed a calming of her agitation and an easing of her dyspnea. Point KI-3 was added for fear, and Ht-7 to open the gate to the Shen. Since she was now more aware, a few words of counsel were added, suggesting she maintain her trust and connection with her deep inner resources, with her spiritual teacher and with the loving network of her family and friends. Next treated was CV-14, followed by TH-7, and PC-6, which as well as helping to put her in touch with her spirit and heart energy, were also points on her Fire CF. A further pulse check showed good balance of all the pulses, a slowing of the rate, and an increase overall in strength. She was more peaceful and her breathing was easier.
I called her family physician the following day, and was told she had improved physically and psychologically. In two days, the pneumonia resolved. She was seen every two weeks for acupuncture treatments over the next three months, when she finally died. In those subsequent visits it was obvious that her attitude and mood had greatly improved. She was able to resolve the issues around her children, and stayed connected with her spiritual practice. Her close friends, who were there at her death, reported to me that she had died peacefully.
CASE HISTORY TWO
Gary was a 58 year old white male who was dying of disseminated prostatic cancer. He was referred two years previously for acupuncture treatment, during a series of radiation treatments he was undergoing at the time for his inoperable tumor. He had been on both Flutamide and Zoladex. He was treated with Five Element acupuncture, as an Earth CF. He tolerated his radiation therapy well, and for a year was in good remission. He continued his acupuncture treatments every six to eight weeks during this time to maintain his energy level, appetite, and overall well-being.
Eight months prior to his death his PSA levels started to rise and he went back on anti-androgen therapy. Another course of radiation therapy was given for his pelvic metastases. He was placed on Lupron and Cassadex. Acupuncture was effective in helping him during this period with the side effects of nausea and decreased appetite, and also gave him emotional and spiritual support. Best results were obtained from using frequent spirit level points, and in working on the Elements for their supportive functions, as indicated previously in this article. He became realistic about his diminishing chances, after liver metastases became evident. His oncologist had begun talking about a gene therapy trial, and enrolling him in an experimental drug program.
At the end of his last office visit he said that he ìknewî he wasnít going to make it, and that he would call for a home visit when he needed it. That call came two weeks later, his wife saying that he wanted one more acupuncture session. When I arrived at his house, he told me that he had been in overall good spirits, but that he had begun to feel a bit uneasy over the last day. His pelvic pain, which had been effectively managed with Voltaren suppositories, had also begun to increase.
His pulses showed a wiry quality on the Wood and a deficiency in the Fire and Earth. Treatment started with tonification of points KI-25, with moxa, then KI-3. Next. we did TH-7, and HT-7. For pelvic pain, LR-3, in sedation, was added. The pulses became more even and the quality on the Wood pulse disappeared, but his Earth pulses remained weak. Then we tonified SP-21, SP-6, and finally, ST-40. As these last points were completed, he indicated that his pain was diminished and he felt calmer. During this process the family had been gathered around, making small comments and taking pictures of the treatment. Everyone seemed very accepting of his approaching death. I asked if I should come back and was told by my patient that it wouldnít be necessary. He thanked me for my help during his illness and said a literal, final good-bye. His wife called the office later and informed me he had died peacefully, two days after that visit.
In this paper, I have introduced the possibility that acupuncture is a specific and effective way to aid the dying process. The positive comments of my dying patients and their loved ones led to the development of this paper. There is no lab data, or objective measurement available at this time for determining what goes on in the experience of dying. There is obviously profound physiological and physical deterioration, yet it appears that the subtle energies, emotions and spirit can still be influenced in a positive way. With acupuncture, the patientsí subjective inner experience seems to be improved, while their physical distress is diminished.
In order to treat patients during the dying process, not only do we have to shift our roles from physician to healer, but perhaps we have to redefine the treatment of the dying patient from more than merely blocking their pain and anxiety. It is my experience that in using this acupuncture approach, we have the additional opportunity to help the patient shift their consciousness and achieve a state of acceptance and completion as they move into death.
To practice this form of acupuncture on the dying, gives us an opportunity to be of service in an effective and compassionate way. As physicians, helping with the dying process in our patients brings an extra dimension to our work that is as much personal as professional. We can be present with the patient and their family; talk to them; support them; and offer our acupuncture expertise. This work places us into one of the most profound human experiences, where, using acupuncture techniques, we can start to develop new insights and understandings about what may be happening in this most mysterious of lifeís processes.
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Dr. Ron Puhky is in private practice on Saltspring Island, British Columbia, doing general Complementary Medicine and specializing in Five Element acupuncture. Dr. Puhky is
Co-Director of the Five Element Acupuncture for Physicians Training Program, and a frequent lecturer in Five Element Acupuncture. He is a founding member of the AAMA.