Beliefs related to the dying process and its impact on end - of - life care in the Marma community of Bangladesh: A qualitative study

Marma

Epidemiologist consisting of eight open-ended questions.Then a pilot study was done in the study area to check the feasibility and finalize the prepared questionnaire.Three in-depth interviews (IDIs) were conducted with a Buddhist monk, social activist, and cultural activist.The interviews covered the issues of experience of observing of dying process of near ones, care of the dying patient at the end of life, the concept of a good death and bad death, existing beliefs and customs related to the dying process, and death events.After piloting, the audio recorded interviews were transcribed from Marma language to Bangla language.The principal investigator checked the qualitative data and modified the questionnaire after consulting with experts, including Psychologists, Anthropologists, Buddhist spiritual leaders (Buddhist monks), Marma cultural leaders, Journalists, and Palliative Medicine experts.
The 26 interviews covered the experience of observing of dying process of near ones, care of the dying patient at the end of life, the concept of a good death and bad death, existing beliefs and customs related to the dying process, and death events.Each interview ranged from 30-75 minutes.
Participants' responses were transcribed verbatim in Bengali.Qualitative content analysis was employed, where manifest content involved describing the visible and apparent elements of the text, while latent content analyzed the underlying meaning, both requiring interpretation but differing in depth and abstraction.9 Meaningful phrases related to the study's aim were identified as the meaning units.These condensed meaning units were then coded and organized into subcategories.The subcategories were grouped into main categories.Finally, a theme was developed.

RESULTS
Among the participants, 16 were men and 10 were women, while 62% resided in urban areas and 30% were from rural areas, and the remaining individuals were from Buddhist monasteries.Their age ranged from 18-75 years.

Qualitative analysis
The theme emerged as 'reflection of previous Karma (the sum of a person's actions)' based on three categories 'state of body and mind', 'care of the dying person', and 'beliefs regarding the dying process' (TABLE 1).

State of body and mind
Interviewees witnessed various bodily expressions throughout the dying phase, especially at the time prior to death, such as restlessness, yelling, lack of breath, frothing and dribbling of saliva, tongue protrusion, and eyeball rolling.This category is further subdivided in three sub-categories irritation, tranquilty and hallucination.

Irritation
Before dying, some people develop larger protruding eyes, run or become restless, and ultimately collapse to death.Within the Marma community, there is a perception about mean (anyone who spent their life doing ill works) people that they are despised by all and they show angry expressions during the dying phase.An in providing care and comfort to the dying patient so that they can pass away peacefully.

Familial
Physical care is beneficial during the dying process.
Traditional techniques of care play an essential part most of the time.In explaining this process, an interviewee narrated, "I saw the granddaughter of a person sitting beside her and massaging the grandmother's chest.For some time, the dying person looked around and could sense our presence.
Eventually, she left us." A senior female citizen opined about end-of-life care as, A local leader expressed her beliefs on the care of the dying one as, "There were many aged people around her (my mother) and everyone started talking.We could sense that there was not much time for my mother.So, we immediately started sharing the good deeds done by her.Good deeds included making the novice ceremony of her sons, donating stairs for the temple, hoisting the flag, etc.While being reminded this way, she started mumbling Buddha Buddha and gave up his last breath." Most people and religious leaders have explained the importance of chanting.A Monk persuaded, "According to our Buddhist principles, since Buddha's accent, chanting (Maitrisutra) is recited to the dead pilgrims.The purpose of this work is to remember the words of religion and virtue before death."

Beliefs on the dying process
Multiple factors influence the beliefs of the Marma community about the dying process.It comprises the presentation of the dying, care of the dying, the presence of family, the lifestyle of one's entire life, environmental factors, and religious activities.

Terminal appearance
Work during life can shape the nature of the dying process as well as their life after death.Interviewees from various socioeconomic groups shared their opinions on a presentation during the dying process.
A female participant who had prior experience with caring for the dying shared her opinions as, "Some people stick out their tongues, while others often roll their eyes again and again.As a result, people typically say two things.Firstly, it is considered that the dying person deceived individuals while being alive and caused harm to others by telling lies, so their tongue protruded.Secondly, it is believed that if they killed animals or were engaged in slaughtering animals, they have their eyes turned upside down."Dying process and its impact on end-of-life care in the Marma community of Bangladesh leave with a satisfied and peaceful mind.A cultural activist explained, "'Muichongre' means guard in the Marma language.The person has to say final goodbyes.He is guarded when he dies so that he can die peacefully." Sometimes the dying person remains restless, so some special customs are practiced to calm the dying person.
The hair of the novice ceremony is considered sacred; an immediate novice ceremony is often arranged if the dying person's son has not accepted a monk's life.One respondent explains, "Many times, I have seen that no matter how much care is practiced, death does not happen easily.In such cases, someone from the family accepts the life of a monk as a more pious deed.This is observed according to the rituals of our Buddhist customs."

Rebirth
The dying phase is crucial in the Marma culture since it determines a person's rebirth implications.As a result, the care of a dying person is determined by their beliefs.
They are concerned about the nature of death and attempt to comfort the dying in a variety of ways.

The process of dying
A dying individual and their family members experience physical and psychological distress during the dying process.The findings highlight two contrasting physical manifestations: irritation and tranquility.The terminal phase, characterized by an irreversible decline in functional status leading to death, can vary in duration, lasting from a few hours to days, and in rare cases, weeks. 10Pitorak also found that the worsening of specific symptoms indicates the onset of the terminal phase, including changes in breathing, profound weakness and fatigue, refractory delirium, and cold skin, among others.Recognizing the dying phase enables proactive planning for patient care, preparing the family, patient, and staff, and facilitating discussions about end-of-life preferences, location of death, and anticipated symptom management. 10,11 ng the signs and symptoms observed in dying individuals, as many as 70% of patients experience respiratory distress in the final six weeks of life.The prevalence, severity, and associated distress of respiratory distress increase as the time of death approaches. 12,13 awlor et al. discovered delirium in up to 88% of patients when carefully screened during their terminal phase. 14While witnessing the agitated delirium of a dying individual can be distressing for family members, caregivers, and healthcare professionals, the patient's distress associated with their thoughtdisordered states of hypoactive delirium should not be underestimated. 15,16 ing care of the dying patient and end-of-life care Most people worldwide suffer from symptoms of the final stages of their lives, either physically, psychologically, or spiritually, and sometimes even mixed.The Marma also have similar sufferings while caring for a dying patient besides their deep concerns with the religious components for a peaceful pass away.
Wairuatanga, which means spirituality, is a crucial element of the Māori community of New Zealand in coping.The challenges experienced during the end-oflife journey included diagnosis, treatment, dying process, funerals, bereavement, and unveilings. 17In addition, spiritual practices help solve issues and ease depression and anxiety. 17Hermann, in his study, also revealed the importance of spiritual care of the dying person, which included the need to experience nature, a positive outlook, and companionship. 18In another study, participants discussed visitors' choices, environmental preparation, and decisions for a dying family member before death.They also described the practice of calling a priest for the last rites when a loved one may be dying, although the dying person might hesitate because this sacrament might somehow assure the death. 19he beliefs on the process of dying and death Multiple factors influence the beliefs on the process of dying of the Marma community.The Marma community believes that their work shapes the nature of their death and life after death.communities around the world have various beliefs regarding how their death is shaped.Asian (Chinese) families feel they are assuring death if the loved one is in a room with the number "4" in it; since this number is associated with death in their culture. 19They also wary of having the ill person's feet facing the door because they believe the dead are carried out of the room with their feet first.In their culture, bad karma causes sickness and death. 19cording to the beliefs held by Catholics and Buddhists, it is considered unnatural for children to die before their parents.The Buddhist belief is associated with karma, where it is believed that children may pass away at an early age as a result of not having accumulated enough good deeds in their past life. 20ditionally, in Indian beliefs, there are specific favorable and unfavorable times for dying.Families from Eastern India may consult a pundit (priest) who consults a special book to determine an auspicious time for death. 21On the other hand, Native Hawaiians believe that every individual possesses mana (divine power) that resides in their iwi (bones) upon death.
They believe that the iwi must be buried in the ground to transmit their mana. 2ntal ethnic community in Bangladesh believes that deceased individuals will ascend to heaven in the afterlife. 22The Mro community also shares the belief that everyone's destination is heaven, although they acknowledge the presence of evil spirits that may obstruct their path. 22In contrast, the Marma community adheres to different beliefs, as they follow dogmas based on their past way of life and Karma, with their ultimate goal being the attainment of Nirvana.
Conversely, the Pankhua community in Bangladesh has a conviction that everything possesses a spirit and that everything is interconnected. 22On the other hand, the Marma community believes that their actions are enduring and remain intact, undergoing a transformation from one form to another.

Limitations
Due to the utilization of COVID-19 protective equipment, it was difficult to accurately observe sudden, brief facial expressions and body language.Although we focused on equal participation of both male and female, gender balance could not be achieved in the case of the interviewees as in the cultural perspective of the Marma community, women are not involved in death customs and sensitive religious activities.In rural areas, despite being a Marma, the investigator faced local Marma language problems while interviewing.Participants can only talk with their mother tongue (Marma language) and the local Marma language is difficult to understand.
This language barrier was solved with the help of two expert community people while conducting interviews.
Due to the COVID-19 pandemic, funeral ceremonies were arranged in more restricted ways with less participation of community people.So, the investigator did not get the opportunity to observe the death rituals which was done in the community.Short staying in the Marma community is also another limitation for which the dying process was not directly observed by the investigator.Only Bandarban Sadar Upazila of Bandarban district was selected purposively for the study, which does not represent the whole Marma community of three districts in Bangladesh.

Conclusion
Within the Marma community, the location and circumstances of death determine whether it is perceived as positive or negative.While passing away in one's own home is regarded as a desirable death, individuals may still endure difficulties during their final moments.In order to uphold traditional customs, providing palliative care in the form of end-of-life support can contribute to a peaceful and dignified transition.
We try to rub baked herbal medicine in various parts of the body in the traditional Marma ways in order to bring comfort in the last stages of a dying person."2.2.NeighborhoodTogetherness of family members and relatives plays an important role during the dying phase of a person.If a person can say goodbye to everyone, the person might leave with a satisfied and peaceful mind.A cultural activist explained, "All the family members and relatives visit the dying person.They spend as much time as they can with the moribund.They stay close so that the person is able to say final goodbye.It will be a good sign of death if he dies in front of his close ones."2.3.Religious/ spiritual careThe dying phase is crucial in the Marma community because it decides the rebirth.They are concerned about the nature of death and try to comfort the dying one in many ways.Buddhist chants before death, pious work in life, and donations in religious places are believed to make a peaceful exit.
Buddhist chants, pious work, and commemorating offerings at sacred places are said to bring about a tranquil departure.A person's professional life leads to rebirth.The previous employment of a person influences where they are born and what life they will have.According to one respondent, "Those of us who have faith in the afterlife believe that if the mind of the dying person can be kept calm, they will gain a good fortune.So, the family and relatives try to follow this ideology from the place of humanity."