Indriya Sthana Chapter 9. Signs and Symptoms useful for Palliative Care among Patients approaching Death
This chapter, (Yasyashyavanimitta), includes various signs and symptoms related to imminent death that start with changes in color of eyes and identified in a patient as well as in healthy individuals. It has been emphasized that physician should have knowledge of all Arishta Lakshana (near death signs) described in this chapter. Clinically only few of them manifest at a stage in an individual and hence the person must be examined properly. Certain features related with imminent death are described which when associated with any disease indicate grave prognosis. Complications which indicate the incurability of a disease are scientific and are seen till date. Description of eight grave diseases and symptoms of approaching death are other two important topics which add value to this chapter. These signs are important in palliative care. Therefore, knowledge of such predictive signs and symptoms is an integral part of medical science.
Keywords: Arishta, Vikara, Bala, Marana, Jivita, change in eye color, grave diseases, death.
|Section/Chapter||Indriya Sthana Chapter 9|
|Other Sections||Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana|
- 1 Introduction
- 2 Sanskrit text, Transliteration and English Translation
- 2.1 Signs of death due to Pitta disorders
- 2.2 Signs of death due to Rajayakshma and Shosha
- 2.3 Eight grave diseases leading to death
- 2.4 Death signs after Virechana (purgation)
- 2.5 Dryness as death sign
- 2.6 Feeble voice as death sign
- 2.7 Signs of death
- 2.8 Various assessment parameters for lifespan and death
- 2.9 Summary
- 3 Tattva Vimarsha / Fundamental Principles
- 4 Vidhi Vimarsha / Applied Inferences
- 5 Glossary
- 6 References
Yasyashyavanimitta refers to color changes in eyes. In the first four chapters of Indriya Sthana, conditions related to Indriya or five sense organs have been described. In those chapters, derangements in functional aspects of indriyas have been given importance and Atreya told to examine them by the help of Anumana Pramana. In this chapter certain anatomical changes or changes which can be examined by Pratyaksha Pramana(direct observation) are mentioned which are equally important indicators of life span. Nowadays, importance is given to the identification of approaching death. Educational and training programs are organized to educate family members/relatives/attendants so that patient care is not neglected near death and this specialized field is commonly known as Palliative care. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual'. The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families. Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care. When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as a strength in the doctor-patient relationship and helps to build trust. Charak also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death.
In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in this chapter. Presently to predict prognostic value few tools have been designed. Most widely-used prognostic tools is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are on going to develop tools for prognosis in other diseases also. Research can be done to develop a scale based on parameters described in Ayurvedic Arishta Vigyana and this chapter can also contribute a lot in making such kind of tool.
Sanskrit text, Transliteration and English Translation
यस्यश्यावनिमित्तेन्द्रियोपक्रमः अथातो यस्यश्यावनिमित्तीयमिन्द्रियं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||
athātō yasyaśyāvanimittīyamindriyaṁ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātrēyaḥ||2||
athAto yasyashyAvanimittIyamindriyaM vyAkhyAsyAmaH||1||
iti ha smAha bhagavAnAtreyaH||2||
We shall now expound the chapter entitled ‘The sensorial prognosis from the observation of the dark brown color of the eye of a man’. Thus said Lord Atreya. [1-2]
Signs of death due to Pitta disorders
यस्य श्यावे परिध्वस्ते हरिते चापि दर्शने| आपन्नो व्याधिरन्ताय ज्ञेयस्तस्य विजानता||३||
निःसञ्ज्ञः परिशुष्कास्यः समृद्धो व्याधिभिश्च यः| उपरुद्धायुषं ज्ञात्वा तं धीरः परिवर्जयेत्||४||
हरिताश्च सिरा यस्य लोमकूपाश्च संवृताः| सोऽम्लाभिलाषी पुरुषः पित्तान्मरणमश्नुते||५||
yasya śyāvē paridhvastē haritē cāpi darśanē| āpannō vyādhirantāya jñēyastasya vijānatā||3||
niḥsañjñaḥ pariśuṣkāsyaḥ samr̥ddhō vyādhibhiśca yaḥ| uparuddhāyuṣaṁ jñātvā taṁ dhīraḥ parivarjayēt||4||
haritāśca sirā yasya lōmakūpāśca saṁvr̥tāḥ| sō'mlābhilāṣī puruṣaḥ pittānmaraṇamaśnutē||5||
yasya shyAve paridhvaste harite cApi darshane| Apanno vyAdhirantAya j~jeyastasya vijAnatA||3||
niHsa~jj~jaH parishuShkAsyaH samRuddho vyAdhibhishca yaH| uparuddhAyuShaM j~jAtvA taM dhIraH parivarjayet||4||
haritAshca sirA yasya lomakUpAshca saMvRutAH| so~amlAbhilAShI puruShaH pittAnmaraNamashnute||5||
If patient eyes are brownish/blackish, distorted or displaced or greenish in color, then such condition indicates impending death. The patient who is unconscious, having dry mouth and is suffering from various diseases should be considered as having short life span and such patient should be discarded by the wise physician.
The man whose veins are green and whose hair follicles are closed and who craves for sour things succumb to death due to pitta disorders. [3-5]
Signs of death due to Rajayakshma and Shosha
शरीरान्ताश्च शोभन्ते शरीरं चोपशुष्यति| बलं च हीयते यस्य राजयक्ष्मा हिनस्ति तम्||६||
अंसाभितापो हिक्का च छर्दनं शोणितस्य च| आनाहः पार्श्वशूलं च भवत्यन्ताय शोषिणः||७||
śarīrāntāśca śōbhantē śarīraṁ cōpaśuṣyati| balaṁ ca hīyatē yasya rājayakṣmā hinasti tam||6||
aṁsābhitāpō hikkā ca chardanaṁ śōṇitasya ca| ānāhaḥ pārśvaśūlaṁ ca bhavatyantāya śōṣiṇaḥ||7||
sharIrAntAshca shobhante sharIraM copashuShyati| balaM ca hIyate yasya rAjayakShmA hinasti tam||6||
aMsAbhitApo hikkA ca chardanaM shoNitasya ca| AnAhaH pArshvashUlaM ca bhavatyantAya shoShiNaH||7||
In a patient of rajyayakshma, waning strength, shining extremities and emaciated body parts denotes that patient will succumb to death soon.
The burning pain in the shoulder region, hiccup, hematemesis, distension of the stomach and pain in the flanks in patient of consumption will end the life of patient. [6-7]
Eight grave diseases leading to death
वातव्याधिरपस्मारी कुष्ठी शोफी तथोदरी| गुल्मी च मधुमेही च राजयक्ष्मी च यो नरः||८||
अचिकित्स्या भवन्त्येते बलमांसक्षये सति| अन्येष्वपि विकारेषु तान् भिषक् परिवर्जयेत्||९||
vātavyādhirapasmārī kuṣṭhī śōphī tathōdarī| gulmī ca madhumēhī ca rājayakṣmī ca yō naraḥ||8||
acikitsyā bhavantyētē balamāṁsakṣayē sati| anyēṣvapi vikārēṣu tān bhiṣak parivarjayēt||9||
vAtavyAdhirapasmArI kuShThI shophI tathodarI| gulmI ca madhumehI ca rAjayakShmI ca yo naraH||8||
acikitsyA bhavantyete balamAMsakShaye sati| anyeShvapi vikAreShu tAn bhiShak parivarjayet||9||
When diseases like Vatavyadhi (diseases due to vata), Apasmara (Epilepsy), Kushtha (Skin diseases), Shopha (Swellings), Udara (abdominal diseases including ascitis), Gulma (lumps and tumors), Madhumeha (urinary disorders including Diabetes) and Rajayakshama (Tuberculosis) are associated with loss of strength and muscle wasting then such patient should be discarded by the physician as patient will not recover and will succumb to death.
Patients suffering from other diseases too having above features should be avoided by the physician. [8-9]
Death signs after Virechana (purgation)
विरेचनहृतानाहो यस्तृष्णानुगतो नरः| विरिक्तः पुनराध्माति यथा प्रेतस्तथैव सः||१०||
virēcanahr̥tānāhō yastr̥ṣṇānugatō naraḥ| viriktaḥ punarādhmāti yathā prētastathaiva saḥ||10||
virecanahRutAnAho yastRuShNAnugato naraH| viriktaH punarAdhmAti yathA pretastathaiva saH||10||
If abdominal distension of a patient is relieved by purgation for short time and then patient develops thirst, distension of abdomen and severe pain again, then such patient should be considered as a ghost i.e. the patients will surely die soon. 
Dryness as death sign
पेयं पातुं न शक्नोति कण्ठस्य च मुखस्य च| उरसश्च विशुष्कत्वाद्यो नरो न स जीवति ||११||
pēyaṁ pātuṁ na śaknōti kaṇṭhasya ca mukhasya ca| urasaśca viśuṣkatvādyō narō na sa jīvati ||11||
peyaM pAtuM na shaknoti kaNThasya ca mukhasya ca| urasashca vishuShkatvAdyo naro na sa jIvati ||11||
One who, because of excessive dryness of throat, mouth and chest, is unable to drink anything does not survive.
Feeble voice as death sign
स्वरस्य दुर्बलीभावं हानिं च बलवर्णयोः| रोगवृद्धिमयुक्त्या च दृष्ट्वा मरणमादिशेत्||१२||
ऊर्ध्वश्वासं गतोष्माणं शूलोपहतवङ्क्षणम्| शर्म चानधिगच्छन्तं बुद्धिमान् परिवर्जयेत्||१३||
svarasya durbalībhāvaṁ hāniṁ ca balavarṇayōḥ| rōgavr̥ddhimayuktyā ca dr̥ṣṭvā maraṇamādiśēt||12||
ūrdhvaśvāsaṁ gatōṣmāṇaṁ śūlōpahatavaṅkṣaṇam| śarma cānadhigacchantaṁ buddhimān parivarjayēt||13||
svarasya durbalIbhAvaM hAniM ca balavarNayoH| rogavRuddhimayuktyA ca dRuShTvA maraNamAdishet||12||
UrdhvashvAsaM gatoShmANaM shUlopahatava~gkShaNam| sharma cAnadhigacchantaM buddhimAn parivarjayet||13||
If a patient develops weakness of voice, diminution of strength and complexion, and aggravation of disease without an apparent cause then such patient will die soon.
The person/ individual whose breathing has been shallow, has subnormal temperature and who feels piercing pains in the groins without experiencing a moment of comfort, should be discarded by the wise physician.[12-13]
Signs of death
अपस्वरं भाषमाणं प्राप्तं मरणमात्मनः| श्रोतारं चाप्यशब्दस्य दूरतः परिवर्जयेत्||१४||
यं नरं सहसा रोगो दुर्बलं परिमुञ्चति| संशयप्राप्तमात्रेयो जीवितं तस्य मन्यते||१५||
अथ चेज्ज्ञातयस्तस्य याचेरन् प्रणिपाततः| रसेनाद्यादिति ब्रूयान्नास्मै दद्याद्विशोधनम्||१६||
मासेन चेन्न दृश्येत विशेषस्तस्य शोभनः| रसैश्चान्यैर्बहुविधैर्दुर्लभं तस्य जीवितम्||१७||
apasvaraṁ bhāṣamāṇaṁ prāptaṁ maraṇamātmanaḥ| śrōtāraṁ cāpyaśabdasya dūrataḥ parivarjayēt||14||
yaṁ naraṁ sahasā rōgō durbalaṁ parimuñcati| saṁśayaprāptamātrēyō jīvitaṁ tasya manyatē||15||
atha cējjñātayastasya yācēran praṇipātataḥ| rasēnādyāditi brūyānnāsmai dadyādviśōdhanam||16||
māsēna cēnna dr̥śyēta viśēṣastasya śōbhanaḥ| rasaiścānyairbahuvidhairdurlabhaṁ tasya jīvitam||17||
apasvaraM bhAShamANaM prAptaM maraNamAtmanaH| shrotAraM cApyashabdasya dUrataH parivarjayet||14||
yaM naraM sahasA rogo durbalaM parimu~jcati| saMshayaprAptamAtreyo jIvitaM tasya manyate||15||
atha cejj~jAtayastasya yAceran praNipAtataH| rasenAdyAditi brUyAnnAsmai dadyAdvishodhanam||16||
mAsena cenna dRushyeta visheShastasya shobhanaH| rasaishcAnyairbahuvidhairdurlabhaM tasya jIvitam||17||
The man speaking irrelevantly about death or patient suffering from auditory hallucinations should not be treated. If in any disease, patient deteriorates all of a sudden, his survival is doubtful as told by Atreya. If the relatives of the patient request the physician begging for his life, the physician should prescribe the diet of soup prepared out of meat; but no Shodhana (purificatory therapy) should be done in such patient as it will further deteriorate the condition.
If after one month, no signs of improvement as the result of soup prepared out of meat and varied other nutritive agents are seen, then the patient’s survival is rare. [14-17]
Various assessment parameters for lifespan and death
निष्ठ्यूतं च पुरीषं च रेतश्चाम्भसि मज्जति| यस्य तस्यायुषः प्राप्तमन्तमाहुर्मनीषिणः||१८||
निष्ठ्यूते यस्य दृश्यन्ते वर्णा बहुविधाः पृथक्| तच्च सीदत्यपः प्राप्य न स जीवितुमर्हति ||१९||
पित्तमूष्मानुगं यस्य शङ्खौ प्राप्य विमूर्च्छति | स रोगः शङ्खको नाम्ना त्रिरात्राद्धन्ति जीवितम्||२०||
सफेनं रुधिरं यस्य मुहुरास्यात् प्रसिच्यते| शूलैश्च तुद्यते कुक्षिः प्रत्याख्येयस्तथाविधः||२१||
बलमांसक्षयस्तीव्रो रोगवृद्धिररोचकः| यस्यातुरस्य लक्ष्यन्ते त्रीन् पक्षान्न स जीवति||२२||
niṣṭhyūtaṁ ca purīṣaṁ ca rētaścāmbhasi majjati| yasya tasyāyuṣaḥ prāptamantamāhurmanīṣiṇaḥ||18||
niṣṭhyūtē yasya dr̥śyantē varṇā bahuvidhāḥ pr̥thak| tacca sīdatyapaḥ prāpya na sa jīvitumarhati ||19||
pittamūṣmānugaṁ yasya śaṅkhau prāpya vimūrcchati | sa rōgaḥ śaṅkhakō nāmnā trirātrāddhanti jīvitam||20||
saphēnaṁ rudhiraṁ yasya muhurāsyāt prasicyatē| śūlaiśca tudyatē kukṣiḥ pratyākhyēyastathāvidhaḥ||21||
balamāṁsakṣayastīvrō rōgavr̥ddhirarōcakaḥ| yasyāturasya lakṣyantē trīn pakṣānna sa jīvati||22||
niShThyUtaM ca purIShaM ca retashcAmbhasi majjati| yasya tasyAyuShaH prAptamantamAhurmanIShiNaH||18||
niShThyUte yasya dRushyante varNA bahuvidhAH pRuthak| tacca sIdatyapaH prApya na sa jIvitumarhati ||19||
pittamUShmAnugaM yasya sha~gkhau prApya vimUrcchati | sa rogaH sha~gkhako nAmnA trirAtrAddhanti jIvitam||20||
saphenaM rudhiraM yasya muhurAsyAt prasicyate| shUlaishca tudyate kukShiH pratyAkhyeyastathAvidhaH||21||
balamAMsakShayastIvro rogavRuddhirarocakaH| yasyAturasya lakShyante trIn pakShAnna sa jIvati||22||
If a man’s sputum, feces and semen sink into water, the wise physicians say that he has come to the end of his life. If the sputum has various color and sinks in water, the patient does not survive.
The morbid condition in which the pitta, reaches up to temporal area and accumulates there, is known by the name of Shankhaka. It kills the patient in three nights.
The man frequently spitting frothy blood and suffering from piercing pains in the stomach, should be refused for the treatment by the physician.
The patient, who suffers from rapid loss of strength and muscle wasting, aggravation of disease symptoms and anorexia, does not survive more than three fortnights. [18-22]
तत्र श्लोकौ- विज्ञानानि मनुष्याणां मरणे प्रत्युपस्थिते| भवन्त्येतानि सम्पश्येदन्यान्येवंविधानि च||२३||
तानि सर्वाणि लक्ष्यन्ते न तु सर्वाणि मानवम्| विशन्ति विनशिष्यन्तं तस्माद्बोध्यानि सर्वतः||२४||
tatra ślōkau- vijñānāni manuṣyāṇāṁ maraṇē pratyupasthitē| bhavantyētāni sampaśyēdanyānyēvaṁvidhāni ca||23||
tāni sarvāṇi lakṣyantē na tu sarvāṇi mānavam| viśanti vinaśiṣyantaṁ tasmādbōdhyāni sarvataḥ||24||
tatra shlokau- vij~jAnAni manuShyANAM maraNe pratyupasthite| bhavantyetAni sampashyedanyAnyevaMvidhAni ca||23||
tAni sarvANi lakShyante na tu sarvANi mAnavam| vishanti vinashiShyantaM tasmAdbodhyAni sarvataH||24||
These features in human beings denote impending death.
The physician should observe these and other similar features.
It is not necessarily that one founds them collectively in one person who is approaching death. Only few of them may appear in one person. Hence,the physician should know with all the signs and symptoms, prognosticative of death. [23-24]
Tattva Vimarsha / Fundamental Principles
Various biomarkers have been developed since the time of Charak and many diseases which were incurable can be controlled. Patient should be evaluated using these biomarkers, before communicating to the patient and family about remaining lifespan of patient.
The bala (strength and immunity) and mamsa (muscle mass) are important markers for assessment of health and death. Depletion of these two markers indicates near death signs. [8-9]
Change in eye color, voice, sputum, feces and semen are markers of near death.
Vidhi Vimarsha / Applied Inferences
General examination is important for assessing life span of any individual. Treatment should be planned after complete examination of disease and patient including the biomarkers.
Cravings for substances which increases vitiation of causative Dosha reflects grave prognosis of the disease. [Verse No. 3-5]
Patient with poor strength will die with consumption, as the patient will not be able to fight disease and will succumb to death. [Verse No. 6-7]
Ashta Mahagada , or eight grave diseases, are difficult to treat. They should not be treated if they are associated with loss of strength with muscle wasting.[8-9]
If patient suffers from an incurable disease and shows arishta signs, he should not be treated and physician should inform the relatives about the exact condition of the patient and suggest care to keep the patient comfortable. If the legal guardian of the patient requests the physician for treatment then only he should treat the patient. [Verse No. 14-17]
- (apasmAra,अपस्मार) - Seizures A neurological condition comprising episodes of fearful paroxysmal movements of the body which are produced by perversion of memory, intelligence and other mental functions along with loss of memory during the episode.
- ādhmāna (AdhmAna, आध्मान) The term signifies distention or inflation of a body part caused due to stagnation of the substances inside it; but generally is taken for distention of the abdomen associated with pain due to various reasons like obstruction to the urine and feces, accumulation of blood in abdomen etc.
- Ānāha आनाह Obstruction, Constipation Obstruction of the feces in the intestine is to be termed as constipation. The term also signifies obstruction to the flow or normal movements of any substance in any part of the body.
- chardi (chardi,छर्दि) - Vomiting A disease in which vomiting is the main symptom.
- gulma (gulma,गुल्म) - Lump in abdomen. A lump like formation occurring in the abdomen either mobile or static in nature, circular in shape and constantly increasing and decreasing in size.
- hikkā (hikkA,हिक्का) – Hiccoughs. A disease characterized by production of peculiar sound like hic-hic by mouth.
- jwara ( jvara,ज्वर) - Pyrexia / fever A sense of non well being in senses, mind and body along with raised body temperature and associated by obstruction to the skin.
- kushtha (kuShTha , कुष्ठ) - Multiple dermatological manifestation Chronic Dermatological diseases characterized by disfiguring and discoloration chronic non- suppurative skin disorders.
- lohitapitta (lohitapittaM,लोहितपित्त) - Hemorrhagic disorder A hemorrhagic disorder in which bleeding occurs through orifices of the body without any direct injury to the body tissues.
- madhumeha (madhumeha, मधुमेह) Diabetes mellitus. A stage of diabetes mellitus where in the urine and blood gets sweetened like honey.
- prameha (prameha,प्रमेह) Diabetes, The disease characterized by symptoms of frequent excessive and turbid urination.
- rajayakshma (rAjayakShmA- राजयक्ष्मा)- means “Roga” (disease) as well as a particular disease i.e. -Disease characterized by generalized wasting of the body tissues caused due to malnourishment as a result of obstruction in the channels.
- shankhak (sha~gkhak, शङ्खक) Intracranial growth, Saggital sinus thrombosis A fatal disease of head characterized by severe pain and swelling in the temporal area.
- shonita (shoNitA-शोणित)- 1. Synonym of Rakta. 2. Synonym of Ārtava
- shosha (shoSha,शोष) - A disease characterized by generalized emaciation.
- trishna (tRuShNA,तृष्णा) - Polydypsia The condition resembles to morbid thirst in which the person even after continuous water intake fails to quench his thirst.
- udara (udara, उदर) - Generalized abdominal enlargement.
- urdhvashvasa (UrdhvashvAsa, ऊर्ध्वश्वास) Stertorous breathing or failing respiration. Characterized by obstructed inspiration due to blockage of respiratory channels
- vatavyadhi(vAtavyAdhi, वातव्याधि) – Special category of diseases caused by vitiation of Vata Dosha
- virechana (virecanA- विरेचन) -Therapeutic purgation.
- Available from: http://www.who.int/hiv/topics/palliative/PalliativeCare/en/
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