Medical Acupuncture
A Journal For Physicians By Physicians

Spring / Summer 2000- Volume 12 / Number 1
"Aurum Nostrum Non Est Aurum Vulgi"

ARTICLE

SPIRIT-LEVEL POINTS

Five Element Acupuncture
For Terminal Patients: A Powerful Intervention For Dying Well
Ronald Puhky, MD

ABSTRACT
Background Five Element Acupuncture is a useful technique for understanding and aiding patients with terminal illness.
Objective To describe the theoretical basis of treatment using this technique as well as specific groupings of useful points.
Design, Setting, and Patients Two cases are described in which the author attended dying patients and performed Five Element acupuncture to alleviate their anxiety and express their good-byes.
Main Outcome Measures Patients' acceptance of death and their ability to make their peace.
Results Both patients died peacefully after saying their farewells.
Conclusions Five Element Acupuncture can be a powerful tool to help dying patients come to terms with inevitability and to die peacefully.

KEY WORDS
Five Element Acupuncture, Dying Process, Terminal Illness, Pulse Diagnosis, Spirit-Level Points

INTRODUCTION

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!

- Milarepa1

   Physicians are intermittently involved with their patients throughout most of their life cycle. Unfortunately, physicians often retreat in some manner at the last stage of a patient's life, having rationalized, then pronounced that our professional end point has been reached. With the belief that our basic role is to prolong life and ease suffering, the duties of attending the dying are left to nursing and hospice staffs or to family members and close friends. Lacking specific time-effective tools to facilitate this process, we may tacitly admit there is no further professional role to play. Analgesics and sedatives, when used in excess, can oversedate. The oversedated patient may appear in an improved status, but this patient must now deal with fear, and face psychic pain, at an increased unconscious level. We can further handicap the patient of the faculties needed to move through the dying process. The patient may be deprived of issues of dying "well," including saying good-byes and making peace with all concerns.
   Physicians may prolong life to the extreme, employing palliative or even intense experimental therapies in situations that are basically hopeless. And we do this because of a fear that is often shared with our patients, the fear of dying. One must admit the inevitability of death and look squarely at the issue of death. The cultural denial in end-of-life issues should not be something with which we collude. The physician's role should continue right to the end, giving presence, comfort, and solace.
   The purpose of this article is to demonstrate that Five Element Acupuncture can be used to help ease the dying process. This technique permits us to access a person's deepest emotional and spiritual resources at precisely the time it is needed most. We can bring a powerful therapeutic effect to the dying patient through the use of acupuncture points that act at the spirit level, and others that calm disturbed emotions or activate specific elemental functions that ease dying. Treatments can reduce fear, physical, emotional, and spiritual suffering. This may help the dying patient gain more peace and a stronger connection with spiritual essence, allowing an honest acceptance of the dissolution of the body and physical life. Ultimately, the focus of acupuncture is to connect the dying patient to the subtle energies of that person's deepest spiritual resources.
   I have applied Five Element Acupuncture to 15 patients to improve end-of-life care; this article discusses cases that are representative of situations common in most physicians' practices.

METHODS
   Basic to the approach that is required in Five Element Acupuncture is respect and reverence in a situation that is fundamentally one of awe and mystery. Finding 10 to 15 minutes a day for meditation, prayer, or some sort of centering preparation is most helpful. To accomplish this goal, the physician must be placed in an "observer" or spirit center and work on the spiritual level with patients. The physician can then make the necessary level of connection with the patient, develop appropriate "intention," and be present for the poignant and meaningful flow of events that may occur. It is much simpler in this state to choose the most effective acupuncture and effective treatment.
Using the Five Element Model
   Five Element theory has been part of Chinese Medicine from the 10th century BC. These concepts first appeared in 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 Wen3 written around 200 B.C. Further discussion was found in the Ling Shu and the Nan Ching. The Five Element concepts4 are not only part of medical theory, but also an integral aspect of all ancient Chinese cosmology and philosophy.
   The Five Element system divides human experience into 5 distinct groupings or Elements, including 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 that 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 include 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.
   The main focus of Five Element Acupuncture is finding and treating the causative or root factor5 of a person's illness. The particular art of this system is in finding the Elemental essence of who the person is, and thus why illness is manifesting in a particular way. We need to know how the patient reacted to and interpreted traumatic events in such a way that only certain diseases and symptoms and not others manifested. The causative factor is where the subject is most vulnerable to wounding, where a disturbance in the energetic pattern can first develop and then lie at the root of a later pathology. In another circumstance, if life and the person's adaptive abilities are positive, it can be more the profound signature and essence of the individual's personality. In either case, the causative factor is both a vulnerability and a growing edge for development and a manifestation of one's essence in life. It is how the Elements have configured themselves to provide the necessary vehicle for individuality and for the evolution of that which is spiritual, emotional, and/or intellectual.
   Although based on the Five Element Acupuncture system, treatments for the dying are not as focused on the causative factor as they normally would be. In this circumstance, the physician treats whatever Elements need support or need to be drawn upon for their strengths and positive functional energies.

THE FIVE ELEMENTS
   Let us examine the Elements in terms of what each provides to the individual in dealing with the dying process. The Elements function in a specific way at physical, emotional, and spiritual levels.
   The Water Element deals with fear and survival issues, including fear of death and the unknown. Fear is useful if it prompts action to protect the individual by avoiding danger; it provides the fight-or-flight response in a positive adaptive way. However, too much fear can paralyze and thus block the overall healing and adaptive energies; it strongly adds to physical and psychological pain and has a potent nocebo effect.
   The Water Element also contains the antidotes to excessive fear. It is in Water that the courage of the warrior lies: the hero, the part of the person that can face and deal with incredible odds. It holds the spiritual resource of the Zhi, which is in part, will and determination, and is also part of this courage. One gains access to his/her deepest resources from the Water Element's big reservoirs of spirit. It encompasses the majority of the large, general spiritual resource points: the KI points on the chest, and the outer BL line points on the back. It also involves many other points that help deal with fear and overcoming obstacles.
   The Water Element is also the storehouse of ancestral energies and wisdom, part of our inner knowing. It is connected to the development of the "hard wiring" of our energetic structure and nervous system, and 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. The Water Element should be continually accessed when treating a dying person.
   The Wood Element deals with anger, and in this circumstance allows a person to release the anger and the sense of injustice individuals may feel when facing death. It allows for forgiveness and self-forgiveness. It provides the sense of completion of one's plans that is part of its spiritual resource. The individual has accomplished all that one can, so it is time to stop struggling and to accept the completion of the outer work in this life and move into the settling of one's affairs. This requires dropping anger and resentments, forgiving others, and asking for forgiveness. This accomplishment brings peace and a sense of closure to the dying person. Treating this Element can promote all of these emotional changes, actions, and outcomes, as well as allow the person to effectively plan and carry out the death process.
   The Metal Element is the Element of dying and letting go. It allows a person to be present in the time of farewells, tears, grief, and loss. Treating this Element facilitates the patient to "let go more easily." It softens and relaxes. It helps when the individual is in denial and holding on too hard. This Element allows acceptance to what is inevitable, including 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 soul's movement back to pure spirit and the formless. Often people die in the early morning hours, the time of Metal. Treating this Element allows the patient to feel and acknowledge the richness and worth of life and connects the person more deeply to spiritual essence. The dying person can then die with grace and few regrets.
   The Earth Element provides a 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. Earth also connects us to the solace of the internalized mother experience that 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 children's 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.
   The Fire Element 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 Fire, it naturally and joyfully can take one into the next stage of the journey. This is the joy at the homecoming that people report after near-death experiences, and why often they do not want to come back. In dying well, the connection with heart energy is very important as individuals say their good-byes and most importantly, let their loved ones and friends know that they hold them in their hearts. This is the real completion: resting in their Shen, ready to move on, appreciating the beauty, love, and joy of the world as they depart from it. The Table below outlines each element and its place in the dying process.
Point Selection and Treatment6
   Needle and moxa technique: The primary needle technique7 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 advance slowly into the prescribed depth of the point until Qi is obtained. This is done without lifting or thrusting or rotation; the point must be located accurately to obtain the Qi connection. Partial withdrawing of the needle and then re-inserting with slight changes in angulation is sometimes needed to obtain the connection. When Qi is felt, the needle is rotated clockwise 180°. There is usually an augmentation of the needle sensation. After 2 or 3 seconds, the needle is withdrawn and the point is sealed with a brief 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° counterclockwise and 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 3-5) of hand rolled, pea-sized moxa cones are applied one after the other directly to the point, and removed when the patient first feels the heat. This is usually followed with needle tonification as described above. Spirit points in particular are often first treated. Since the patient's 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 large 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 that ease fear as they bring calm and inner strength.
   Points for the Heart are also needed. Go directly 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 [or 39 F.E.] (Spirit Hall), and HT 1 (Utmost Source). HT 7 (Spirit Gate) can be used repeatedly to keep the gate to the Shen open.
2. Ancestor Points:
   Following a near-death experience, people often speak 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 designated in 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 an individual is still early in the dying process, this point brings peace, comfort, and stability to the mind and spirit so it can connect to departed loved ones and to the saints, sages, and holy ones to whom the person is connected.
   SI 11 (Heavenly Ancestor) is another such point; it is also linked to the Shen as the Heart's paired Yang Fu organ. TH 7 (Assembly of Ancestors) is also a link to these ancestral aspects since 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 to ease fear, especially KI, after using the large spirit points mentioned above. These points are tonified, with moxa added as needed. Useful body points 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 are BL 57 (Supporting Mountain), and
BL 61 (Servant's Aide), and also the Source point, BL 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 patient to surrender the tendency to cling and instead, relax 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), 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 is 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), GB 40 (Wilderness Mound), and occasionally LR 14 (Gate of Hope), usually done with sedation in these cases.

Table. The Therapeutic Framework for the Use of the Five Elements in the Dying Process.

Principles of Treatment
   The first step is to use the Five Element model discussed above and understand which Elements are useful in treatment. The pulses are good indicators of the overall internal state of an individual and also, specifically, the state of each Element. Initially, the pulses provide extra diagnostic information; later, they provide feedback regarding how point choices and treatments are working. Successful treatments will result in balancing the pulses and improving the overall pulse qualities in each session.
   The treatments are not solely causative factor oriented. One must move around and do what is needed based on the patient's emotional state, Elemental needs, and pulse analysis. If the patient is very agitated, this will present in the pulses as an excess. This requires sedation 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 sometimes chaotic in other ways as the person nears death. There are often Husband/Wife8 (H/W) imbalances (where the right-hand pulses are stronger and more aggressive than the left). Usually these pulses are not corrected. The physician is not trying to bring the patient back to an enhanced healing state or in a state in which the patient is fighting death. Corrective treatment can actually upset the individual and at this stage, there is too much toxicity in the system to perform the strong energy transfers to correct the imbalance. Just using spirit points usually drops the degree of the imbalance and decreases any other chaotic, intense qualities in the pulses.
   In other cases when the person is less agitated, the pulses may be very weak. In those instances, the spirit points lift the pulses, balance them, and improve quality. In dying as in living, balanced pulses indicate and promote a "healthy" process. Where specific areas of weakness in the overall pulse picture remain, the physician needs to treat those areas; especially, the Elements involved. Regardless of the choice and order of points in a successful treatment, any approach should conclude with distal command points. At the end of each treatment, the physician should expect to see the pulses balanced and calmed. This is one of the immediate feedbacks of successful treatment. The patient may also communicate this 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. The pulses then are of special significance.
   At the beginning, daily treatments may be necessary rather than every 2 to 3 days. The patient or family should inform the physician when further treatment may be needed. This work definitely requires involvement of family and close friends. As these patients approach their death, they cannot always report accurately on their own process. Physicians 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 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 in communication with their spirit, opens their heart, their loved ones, and taps into the natural process of dying. This has its own flow, purpose, meaning, and solace. We have an innate natural process in us of "letting go" of the body, just as we have for the capacity for healing and for connecting with our spirit.

CASE HISTORIES
Patient 1
   Mary, a 48-year-old woman, had a 2-year history of 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, a palliative regimen of radiation therapy and tamoxifen began. She later developed liver metastases. The patient started a nutritional program and as a long-time Buddhist practitioner, used specific healing meditations and visualizations. She received psychotherapy and an adjunctive program of Five Element acupuncture treatments during the 2 years of her illness.
I was called by her family physician to attend her in the hospital where she was close to death, semi-conscious, and in respiratory distress with bilateral bronchopneumonia. At the bedside, a friend reported that Mary had been upset in recent days about leaving her children behind and had been in a lot of psychological pain and 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: chaotic, uneven, and barely palpable in the Metal and Water positions. During her previous therapy over the past 2 years, she had been treated primarily on the Fire Element as the causative factor.
   All points were treated bilaterally and tonified. Moxibustion was applied to certain spirit points. First treated was KI 25 (Spirit Storehouse), with 5 moxas, then needled to build up her reserves of spirit and ease fear. Next, LI 4 and LU 9 were needled to help the physical distress in the 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 reduced dyspnea. KI 3 was added for fear, and HT 7 to open the gate to the Shen. Since the patient was now more aware, a few words of counsel were added: suggestions to maintain her trust and connection with her deep inner resources, her spiritual teacher, and 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 causative factor. A further pulse check showed good balance, a slowing of the pulse rate, and an increase in strength. She was more peaceful and her breathing was easier.
   The following day, the family physician stated the patient had improved physically and psychologically. After the pneumonia resolved, she was seen for 2 more acupuncture visits in the hospital over the next 3 months before death. In those subsequent visits, it was obvious that her attitude and mood had greatly improved. She was able to resolve the issues regarding her children, and remained connected with her spiritual practice. Her close friends reported that she died peacefully.
Patient 2
   Gary, a 58-year-old man, was dying of disseminated prostatic cancer. He was referred for acupuncture. During a series of radiation treatments for an inoperable tumor, he was treated with Five Element acupuncture, as an Earth causative factor, and tolerated the radiation therapy. He remained in remission for 1 year, not requiring any medications. He continued acupuncture treatments every 6 to 8 weeks.
   Eight months prior to his death, his prostate-specific antigen levels started to increase, and he restarted antiandrogen therapy. Radiation therapy was prescribed for pelvic metastases. He received leuprolide acetate and bicalutamide. Acupuncture appeared effective during this period to reduce the adverse effects of these therapies, and also gave him emotional and spiritual support. Utilizing the Elements for their supportive functions and employing frequent spirit level points yielded the best results. The patient was realistic about his chances for survival. As liver metastases became evident, his oncologist began to consider gene therapy and enrolling him in an experimental drug program.
   At the conclusion of his last office visit, he said that he "knew he wasn't going to make it," and that he would ask for a home visit when needed. That call came 2 weeks later; his wife said that he wanted 1 more acupuncture session. When I arrived at the home, his wife and adult children were there, and the bed had been moved by the large window in the living room. He said that he had been in overall good spirits until that day and the pain was minimal.
   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, I used 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. I 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 gathered around, made small comments, and took pictures of the treatment. Everyone seemed to accept his approaching death. I asked if I should come back and he told me that it would not be necessary. He thanked me for my help during his illness and said a literal final good-bye. His wife called subsequently and informed me he died peacefully 2 days later.

DISCUSSION
   Through these cases, I demonstrate that acupuncture is a specific and effective way to aid the dying process. The positive comments of my dying patients and their loved ones have reinforced my experiences. No laboratory data or objective measurement for determining what transpires during dying is available. Obviously profound physiological and physical deterioration occurs, yet it appears that the subtle energies, emotions, and spirit can still be positively influenced. With acupuncture, a patient's subjective inner experience seems to improve while the physical distress is diminished. It is my opinion that Five Element Acupuncture helps the patient shift consciousness and achieve a state of acceptance and completion before death.

CONCLUSION
   Using acupuncture to aid in dying gives physicians an opportunity to be of service in an effective and compassionate way. As physicians, helping with the dying process brings an extra dimension to our work that is as much personal as professional. Physicians should be present with the patient and family, talking, counseling, and offering acupuncture expertise. This work places us into one of the most profound human experiences where, through the use of acupuncture techniques, we can start to develop new insights and understandings about the dying process.

REFERENCES
1. Chang GC. The Hundred Thousand Songs of Milarepa. Shambhala; 1989.
2. Matsumoto K, Birch S. Five Elements and Ten Stems. Higganum, Conn: Paradigm; 1987.
3. Ilza V. The Yellow Emperor's Classic of Internal Medicine. Berkeley: University of California Press; 1972.
4. Eckman P. In the Footsteps of the Yellow Emperor. San Francisco, Calif: Cypress Books; 1996.
5. Worsley JR. Traditional Acupuncture. Vol 2. Traditional Diagnosis. Royal Leamington Spa, England: College of Traditional Acupuncture; 1990.
6. Worsley JR. Traditional Chinese Acupuncture. Vol 1. Meridians and Points. 2nd ed. Dorset, England: Element Books; 1993.
7. Moss C, Puhky R. Five Element Acupuncture for Physicians [syllabus]. San Diego, Calif; September 1998.
8. Moss C. Five Element acupuncture for Husband-Wife imbalance and bipolar disorder. Medical Acupuncture. 1999;11(1):29-33.

AUTHOR INFORMATION
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.

Ronald Puhky, MD
Box 31, Fulford P.O.
Saltspring Island, British Columbia, Canada V8K 2P2
Phone: 250-653-4216
Fax: 250-653-4298
E-mail: puhky@saltspring.com

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