Coma Care - the patient as teacher
    Coma Care - the patient as teacher

    I am very grateful to my many teachers, most of whom are young unemployed men who engage in high-risk behaviours (such as violence, road accidents etc.) that have left them traumatised. Hardly teacher material one would think. Yet these teachers may be the very people to open up the bottleneck that is evident in medicine today – where solutions are sought from experts using generic tools for a condition, rather than empowering individuals to find inner solutions.


    My teachers are coma patients who have gone further than many of us into an altered state of consciousness to deal with pain and trauma. An altered state of consciousness is a different experience from day-to-day reality where we tend to agree on facts – a chair is a chair. Here we are discussing a consciousness continuum that includes more subjective experiences of reality, which others do not necessarily share in the same way. There are usual experiences such as day dreams, night dreams, trances, meditation, and, further along that continuum, less usual ones such as psychiatric breaks and the extreme altered state of consciousness known as coma. As we go along that continuum there is less understanding and tolerance on the part of society for that state, and often more projected shame. It seems that we have lost our curiosity about these potential healing spaces, yet they are regularly sensationalised in popular culture.

    So, propelled into this poorly tolerated state involuntarily, many of my teachers forget the experience – some are unable to remember anything, while others recall their experience and it changes their lives forever. It has changed mine to be able to accompany them even a little bit of the way.

    In observing dying coma patients I have noticed that if their feet are cold then usually we can ‘talk’ about the resolution of childhood dreams – completion of this cycle and their life task. If people have cold hands it seems that they need to deal more with unresolved issues such as forgiving others and asking to be forgiven. They will often wait until a family member shifts in attitude towards them before they die. If a mirage-type mist appears on their brow and later above their head they die within 24 hours. However, even when there are recurring experiences on the ward we use what we see only as a working hypothesis, checking feedback and staying ‘open minded’ to other possibilities.

    Recovering patients have other challenges. If we agree that we are all in a dream state full of sensations in this day-to-day reality then, of course, when people are coming out of an extreme altered state such as coma they will also talk about their experiences. One man was on a ship and the captain was Jesus, but he couldn’t set sail because the sails were knotted. We helped him unpack what in his day-to-day life stopped him sailing his own ship. One elderly woman’s mouth changed expression at the word ‘whisper’ and a conversation about family secrets had to take place. We catch the dream or essence of what they have been working on in their coma state and integrate it back into daily life.

    Coma is not a flat line or static state. We see consciousness come and go in the eyes of a coma patient. Sometimes it shoots back with such intensity we reel backwards as if caught in an eagle’s sight. Then we see it leaving the body and encourage it to travel as far as it needs to go – medical staff have another description for this phenomenon.


    A young unidentified Xhosa man lay in a coma. In medical terms that means a score of eight or less out of 15 made up of best verbal, eye and motor responses. He was called December 29th (his admission date) and had been badly beaten during a community attack. He lay in bed with elaborately painted finger nails. I asked the nurse if he might be gay and if we could perhaps try to trace his family through gay networks. At a loss, I sat down and said, ‘I apologise that you are not accepted for who you are. My name is Jan.’ He suddenly said, ‘My name is S’, and went back into a deep state. Over the next few days we worked on affirming his signals and consequently found his mother. He died a few hours after she arrived.


    In this world we tend to try to meditate or pray – to get a little closer to a state of oneness. In coma, people are already far along the road but sometimes still struggle with issues of duality that hold them back from release and death or make them afraid to fully return to this reality. Thus the issue would seem to be to surrender our perceived notion of duality. How can we work with this in real life with coma patients? And how could we change ourselves and therefore our society to make it more attractive for them to recover, if that is right for them?

    In every case the heart and spirit of the caregiver is paramount – it is those who can put their ego aside and step out of the framework of duality, the belief that we are separate from each other and the world around us, who can truly be in a healing relationship.


    We work at three levels. The first is the atmosphere or the field of the coma patient. We take note of world events, family arguments, moments of tenderness, noises. In our understanding the internal world is related to the external world and hence if we relieve external tension we also do so for the inner reality of the coma patient. In order to do this we have to ‘handle ourselves’ in a sometimes traumatised environment where people aren’t necessarily able to be kind or gentle. We try and see the people in the ward system as ourselves. A good method is to draw a picture of everyone in the field of a coma patient and then draw a circle around it and label this circle ‘me’ – this shifts your critical perception of the ‘other players’!

    Of course the ‘I’ is also part of that field and we take note of our own inner body signs and symptoms. We notice when our boundaries ‘melt’ and we feel the coma patient. This can take many forms from sudden emotions flooding through us to pounding headaches. We observe our inner processes and work to integrate them/their qualities and energies until the ‘disturbance’ is transformed.

    There are some days when we can’t work. On those days we blame the traffic or the nurses or our sore throats. Those could be days for reflecting on the edge I have reached in myself. Let me respect it and not force myself over it.

    The second level we work at is family systems therapy where we try and see what dream role the patient held in the family – ‘the quiet one, the trouble maker, the golden boy’. We notice how much is projected on to the ‘iden- tified patient’ and begin to work with the family to see more of who he is – not just the label they have put on him.

    Coma can help shift stuck relationships, but it is usually seen as a big disturber that must be fought against to ‘return to normal’. We do have to ask: ‘How good was the normal?’ ‘What could happen now that couldn’t happen before?’

    Working with the family we not only counsel them over the trauma of the accident but also to relieve them of the stuck roles they are all playing. Often there is a collective dream in the family that ‘This can’t go on’.

    Sometimes in our ward the family system is the prison system, where men come into the ward tattooed all over their bodies – even with a Nike tick on the nose. They are often treated judgmentally – yet these men are the most vulnerable within the prison system and in their coma state may be getting some relief from that reality.

    The third level of our work is directly with patients. We use a specific technique as a doorway to communication, but if the ‘metaskills’ (feeling sense/mood) is not there then true communication does not happen. We gave it the acronym A BIT OF CARE. See below.


    As more sophisticated neuro-imaging becomes available, it suggests that those declared ‘vegetative’ (a long-term coma state) may be having very rich inner lives. A study at the London school of neuro-disability showed that 42% of their vegetative patients had been misdiagnosed, which impacted on the care and treatment they received. Other studies of vegetative state patients have shown ‘normal brain activity’ to emotional stimulus. Therefore, we have to be so careful that a label does not prejudice our ability to observe every possibility.


    We are beginners in this field of coma work but we hope that if we continue to see our patients as teachers, we will learn from them as the real experts; we will begin to understand and accept all states of consciousness as normal.

    One of my teachers was a San man whose ethnic identity had meant he had experienced marginalisation all his life. As he lay dying he kept asking for his ID book. We discovered that he wanted to formally marry his common-law wife of 17 years. Some were a bit sceptical of his need for a wedding, and racial intolerance was also at play. We tried to arrange a wedding for him but he died before he could marry his wife. His dignity touched me deeply, so I wrote to friends overseas who wrote to their friends. Very soon choirs were singing, dancers were moving sensitively, candles were lit as his spirit was praised right round the world. He had lived his life under the banner of insignificance, but he was so powerful in his ‘death’ he seemed to become a star in the night sky.

    In hospitals the body is moved quickly into a room to be prepared. No rituals or blessings take place unless individual nurses are moved to do so. We wrote a memorial card for him with a San song.

    We can really only say to all those in altered states of consciousness, please forgive us for we know not what we do, and in turn, hope to become a little more aware that we may be the ones who are truly less conscious. Additionally, in acknowledging the present mystery of coma, let us not ascribe lesser or greater importance to it than to all other states of consciousness… aren’t they all dreams?



    Atmosphere – a coma patient can dictate an atmosphere just as much as a brooding partner or a sulky child. We also bring an energetic ‘mood’ into the relationship and these must harmonise before work can begin. We learn to surrender ourselves and follow the process – releasing ourselves of our hopes and dreams for the patient.


    Breathing – we know the person is in another time-space and we are not going to shock them out of it, but follow their chosen rhythm instead. So we match our breathing to their breathing. It helps us to enter their altered state.


    Introduction – saying our name helps them pick up our energy and if they have lost their autobiographical memory it helps them re-learn relationships.


    Touch – we begin by only touching the wrist as the least intrusive part of the body. We speak on their out breath and keep quiet on their in breath to allow them to absorb us either through hearing or sensing. Coma patients say they do not actually hear with their ears in a deep coma but they listen telepathically – knowing if we are angry, burnt out or genuinely loving. They feel encouraged to come to the surface when we are loving – even if only to check this reality out for the last time before moving towards death.


    Observation without interpretation – based on our own fears or wishes, it can be too easy to make assumptions about what we think a coma patient is going through. Instead, we try to catch the channel they are communicating in – it may be visual, auditory, verbal, movement, or proprioceptive (inner body feeling). We then look for tiny signs that may become repeated signals… a sound, shift in posture, a tiny movement of the hand. This is the presence of consciousness, however slight, and it can be acknowledged and followed.


    Feedback – communication will keep trying to happen in one channel or another until it is acknowledged. Imagine a young child jumping up and down in front of its mother (movement channel), and on being ignored starting to whine (verbal channel). Thus we give the coma patient encouragement to use any channel and acknowledge signs we see, hear, feel or smell. We say things like ‘I can see that!’, ‘Wow I heard that’.


    Copying – what do moms do when babies try and communicate? They reply in the same language! We move as the coma patient does, make their sounds, shake like them, etc.


    Amplifying – we help them to be aware and strengthen their signals and to use these signals to communicate. If they make a sound, we make the same sound but then may add a bit. If they move their arm, we will see how far it actually wants to go. In this way we re-establish a feedback loop that has been interrupted or lost when coma patients were seen to be ‘not there’.


    Resisting – often coma patients are depressed and out of touch with their own strength because of their injury. So when they move we resist the movement gently – it’s amazing when you feel that push back – juice in the tank!


    Enabling expression – we allow complete signals to take place. For example, if someone wants to grasp, we will let them grasp us; if they want to push, we will let them push us until somehow they feel ‘met’. Often people play with the tips of my fingers. I have no idea what that communication means to them but they usually die soon after.

    Coma Care - the patient as teacher

    Editor's note: There are a few articles that you may enjoy in our Mind, Body, Soul section such as The edges of the known and Crossing the Threshold.

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