ECEL stands for Empathic Care of the End of Life, a method of providing empathic support during the end-of-life process. The English acronym reflects that I began teaching this approach abroad, where there was greater openness regarding the taboo of death. Since then, I have taught it, either fully or partially, in numerous postgraduate courses at institutional universities. Today, it is fully taught, alongside seven co-teachers, at the Università Popolare In Corde Scientia.
I will briefly describe the genesis of the method before delving into its specific content.
ECEL has three roots: one deeply Eastern, one Western, and one, now very strong, that is rooted in experience.
The Eastern Root is of Tibetan origin: Tibetan thanatology is vast—perhaps the most extensive on the planet—and I have been exploring it since 1985. Soon it will be 40 years, much of which was under the guidance of Sogyal Rinpoche, who passed away in 2019. He is the author of the first book that opened the contents of this discipline to Westerners, The Tibetan Book of Living and Dying. My other main mentor, Cesare Boni, with whom I completed advanced studies in Thanatology at the Federico II University of Naples, specialized in Eastern thanatology, particularly within the Vedanta tradition, which is tied to India and Hinduism. From this Eastern root—primarily, in my case, Tibetan Buddhism—comes the body of the so-called “meditative practices of compassion.” These are crucial when one is ill, accompanying a sick person, or preparing oneself or others for death. Sogyal Rinpoche’s merit was in making these universally accessible, extracting universal content without altering this ancient thanatological tradition. This allows us to offer guidance to both secular people and those who may “color” these meditations with their own beliefs. ECEL is not confined to any religion, which makes it universal.
Moreover, it couldn't be otherwise, given the second, much more recent and Western-rooted foundation: quantum physics, neuroscience, and neurocardiology.
Before the early 2000s, studies on meditation focused solely on TM (Transcendental Meditation), which was Cesare Boni’s field of expertise, and he trained us to keep a constant eye on science. There were no studies on the Tibetan corpus yet, as it was still relatively unknown. It wasn’t until 2004, when Davidson and his colleagues began their work—thanks also to new technologies—that this changed. The initial findings on Tibetan school meditators, who have since been studied extensively by neuroscientists worldwide, began to shape the framework of ECEL. For example, it wasn’t until 2013 that researchers discovered it is possible to empathize without falling into the dangerous trap of merging with another's suffering—a crucial concept still stubbornly absent from medical and nursing schools, where the lack of it often leads to caregiver burnout.
This was confirmed by a pilot study conducted at the Parma hospital on personnel I had trained in ECEL in those early years, which earned the Terzani Prize for Medicine in 2008. The study is fully available on the Tonglen ODV website. Similar conclusions were later reached by larger, well-funded studies conducted elsewhere.
The principle is simple and already clearly stated in Tibetan thanatology: renowned German neuroscientist Tania Singer discovered that the brain areas responsible for empathy and compassion are distinct. Until 2013, Western science assumed otherwise. Tibetan thanatology teaches that two different types of training are needed and that a bird with only one wing cannot fly. Therefore, it prescribes a gradual meditative training to truly expand one’s awareness of the care recipient's state, as well as a separate training focused on compassion, aimed at strengthening other synapses.
It is essential to clarify what 'compassion' truly means, as it is often confused in the West with pity. I have yet to find a better definition than this one from Levine:
Pity is when it is my fear that meets the pain of the other.
Compassion is when it is my love that meets the pain of the other.
The two trainings are integrated within ECEL, enhancing different areas that work together during the accompaniment process, preventing either from dominating and avoiding two potential pitfalls. On one hand, it helps avoid fusion risks (over-identification with the other’s suffering), while on the other, it prevents caregivers from becoming emotionally distant due to the fear of fusion, which can lead to a natural disconnect from empathy—a trait inherent in all mammals, including humans.
Keeping up defense mechanisms runs counter to our nature and is exhausting, so it’s not surprising that burnout can occur. The staff entrusted to me in Parma were experiencing various stages of burnout, measured with an appropriate scale, and they all recovered, albeit at different paces. ECEL-trained caregivers do not experience burnout or "compassion fatigue" because they are equipped with specific training in compassion. Where such training exists, there is compassion but no fatigue!
Traditionally, compassion training is centered on the heart. Recent research in neurocardiology reveals that the heart is, in fact, a brain equipped with about 40,000 neurons, making it trainable. Furthermore, the heart has an electromagnetic field 5,000 times stronger than that of the encephalic brain and more potent than all other organs in the body, generating 40 to 60 times more bioelectricity than the brain. This electrical energy permeates all cells in the body, creating a unique bond between them. When we are troubled by negative emotions like fear, anxiety, frustration, or stress, the field becomes chaotic and disorganized. However, with positive emotions like gratitude, compassion, forgiveness, loving-kindness, or love, the field becomes ordered, resulting in a coherent spectrum.
We know that this field interacts with both our brain and that of others. Tibetan thanatology has long suggested that a compassionately developed state, utilizing the heart's brain, directly affects others. Today, we understand that frequently repeated states of compassion (technically, heart coherence training) influence the heart’s brain and electromagnetic field, which conveys this state to the electromagnetic field of the person we are accompanying.
It is up to us, as caregivers, to quickly enter this state of coherent heart variability(1), which translates into a transmissible psychophysical well-being, especially when we are in the presence of a terminally ill person who naturally absorbs everything, just like a young child or an animal. These three groups are extremely empathic and easier to connect with when we restore our capacity for empathy and are well-trained in compassion. The goal state is open, free from expectations and fears, profoundly lucid, and peaceful. One of ECEL's principles is
If you wish for the other to die in peace, be peace yourself.
Non-local consciousness and tukdam
Another important aspect of ECEL, where scientific inquiry merges with the Tibetan, Buddhist, and Bön tradition of thanatology, is the exploration of non-local consciousness. The notion that consciousness is merely an epiphenomenon of the brain stems from a materialistic positivism, which has now (finally, I must say) been refuted by evidence.
This leads us to the topic of tukdam.
The tukdam state has recently caught the attention of neuroscientists, and we are likely witnessing undeniable evidence that consciousness is a non-local phenomenon, which changes everything, including ethical considerations.
To begin, I would note that death is not a simple on-off switch, but rather a long and complex process. The term "clinical death," or brain death—which is assumed to occur 20-30 minutes after the heart stops—is a recent criterion developed in the 1960s, during the early days of organ transplants, to determine when it would be appropriate to proceed with the harvesting of vital organs.
This standard has already been challenged by researchers like Borjigin and others, as deep brain measurements—rather than the surface EEG readings typically used to confirm brain death in hospitals—reveal ongoing activity. This is not merely residual bioelectric activity but rather well-organized patterns of function.
The concept of clinical death, meaning heart death followed by brain death in 20-30 minutes, mistakenly presumes that consciousness is a product of the brain and thus ceases to exist when the brain shuts down.
There is counterevidence coming from embryology(2), though that is not my area of expertise, so I will refrain from delving into it, preferring instead to present examples of rebuttal within my field that hold increasing weight.
First, it’s important to note that within the materialistic framework of science, Near-Death Experiences (NDEs)—that is, cases of clinical death followed by resuscitation, where individuals report (often similarly) what occurred during that time—are not considered useful for proving anything definitive about death. This is because they involve only apparent and temporary death, not permanent death.
In some respects, this is an understandable objection. Indeed, a few very recent case studies on patients who were being monitored in the deeper layers of the brain due to their conditions at the time of death show that, after clinical death, the brain’s deep layers (not the surface layers measured by a standard EEG used in brain death diagnoses) continue functioning for a while in the presence of gamma waves. Gamma waves, in fact, appear compatible with the hyper-reality experience often reported by those who have had an NDE.
These studies also incidentally call into question the reliability of the brain death concept, which up to now has been based only on measurements of the brain’s superficial layers.
However, there exists a type of NDE that can only be explained by the hypothesis of non-local consciousness: the NDEs of individuals born blind. Those who have never seen anything in their lives, nor even had visual dreams, report on returning from clinical death what they saw happen in the operating room.
Who was seeing? Perhaps their deep brain layers were still functioning, but with what were they seeing, if their optic nerves had been irreparably damaged even before? This raises doubts about the view that who sees and who recounts the experience afterward is merely a product of the brain.
But an even more striking contradiction to the materialistic view comes from our access today to Tibetan thanatology.
This tradition, both the Buddhist teachings introduced in Tibet around 800-850 CE and the much older Bön tradition, includes numerous reports of experienced meditators who, during life, achieve a state of alignment with a fundamental, non-local consciousness, allowing them to enter death within this meditative state. After their clinical death has been confirmed—meaning that the brain is technically no longer functional—their consciousness remains absorbed in meditation and does not immediately leave the body. This retention raises the question of what, exactly, prevents the onset of the classical, unmistakable signs of death: rigor mortis, algor mortis (the cooling of the body), and the initial stages of decay, including odor.
It’s important to note that tukdam is distinct from NDEs, as there is no “return” from tukdam; therefore, the usual objection to NDEs does not apply here.
A state of tukdam is confirmed only after an observation period to check for the presence (or absence) of these definitive signs of death. This period aligns with traditional practices in our own culture prior to the advent of electroencephalograms, when bodies were left for three to three and a half days before burial to rule out the possibility of apparent death.
When these unmistakable signs of death do not appear, the state of the deceased (or rather, the not-yet-deceased) is called “tukdam,” meaning “in union with the nature of the Victorious One.
I explored this topic in Di morte non si muore, the book I dedicated to tukdam and non-local consciousness, where I documented recent cases of tukdam, lasting as long as 37 days in the sweltering Indian climate…
We can translate "tukdam" as “the nature of the Victorious One,” meaning that of a buddha. What does this imply?
Tukdam refers to absolute consciousness—non-local and not dependent on the brain, though it may utilize the brain to interact with the external world as long as the brain is functional. However, this does not mean it vanishes when the brain ceases to function.
A Tibetan metaphor captures this dual aspect of consciousness: that of the wave, which arises from the ocean, endures temporarily (though this endurance is illusory, as it changes moment by moment), and eventually returns to the ocean. Here, the wave symbolizes the individual and ordinary aspect of oceanic consciousness. This individual consciousness is virtually hypnotized by its own emergence, duration, and dissolution, leading it astray; it becomes unable to recognize that it is part of the vast oceanic consciousness.
The two Tibetan traditions—the Buddhist and the pre-Buddhist Bön tradition—consider death an extraordinary opportunity, not merely to return to the ocean of universal consciousness (as each individual wave or ordinary consciousness is inherently part of this ocean, though it may have lost awareness of this truth). Instead, they see it as a chance to consciously recognize and experience that this boundless nature is indeed our true essence. Thus, both traditions have developed an extensive and unique approach to death, creating one of the most comprehensive body of teachings on the subject in the world. They view death as the most crucial event to prepare for throughout one's life, as the dying process, marked by the progressive dimming of sensory functions (and thereby, the nervous system's activity), makes it easier to attune continuously to our true oceanic nature.
When this alignment is sustained—whether in wakefulness, sleep, dreaming, or death—it is referred to as Enlightenment. In this state, the artificial distinctions created by the ordinary mind between individual consciousness and absolute awareness dissolve.
This dual aspect of reality has a strong resemblance to descriptions found in quantum physics, doesn't it? As Alain Aspect explains, every phenomenon instantaneously "collapses" out of the quantum field due to innumerable causes and conditions—essentially, the innumerable forces of the universe that constantly interact with each phenomenon. This explains the continual flux we call life, a process of constant transformation from what we were in the previous instant.
The quantum field—known by various names such as the Alpha Field, the Akashic Field, the Field of Information, the Potential Field, or the Field of All Possibilities—is described as infinite, without directional limitations, and deeply intelligent because it is inherently a field of information: the field of all potentialities. It's been suggested that each virtual point within it is connected to every other point instantly, as demonstrated by Nicolas Gisin’s 1998 experiment at CERN in Geneva. In this experiment, two electrons were sent along divergent fiber optic paths, each reaching a junction where one path continued and the other was blocked by a mirror. Remarkably, each electron "chose" the same path at the junction, seemingly having received information about the other's decision—a behavior that implies some form of cognition.
But what transmits this information? It isn't light, as light only travels a few centimeters in the time the information seemingly crosses 11 kilometers (or even greater distances in subsequent replications of the experiment).
Since light represents the fastest speed we know, this implies that the information transfer does not rely on speed; rather, it is the field itself that communicates the information. Lacking any directionality, the field transcends space, and therefore time, which depends on spatial distance.
As both body and consciousness collapse moment by moment out of this field, we simultaneously exist as cognitive physical realities and as part of this highly intelligent field.
Tibetans call it Kutuzangpo, “the All-Good.” Because if indeed every point within the field instantly "knows" every other point, the field must be inherently compassionate. If one point were to harm another, it would directly experience that harm—hardly an intelligent or cognitive act, as true cognition would naturally incline toward compassion.
The fact that we share the field with the person we are accompanying also explains where the empathetic information we receive in a meditative state comes from and how the state we achieve can be transmitted to the person we are accompanying. It is up to us to achieve a state of deep, vast peace, free from complexities, and to allow it to “bleed over” empathetically onto the person we accompany: If you want the other to die in peace, be peace yourself
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We will see this reflected not only in body posture or facial expressions but also in the coherence of heart rate variability, should we have the opportunity to measure it.
You may wonder why something as astonishing as tukdam is only being discussed now in these terms. Well, many excellent Tibetan masters have spoken about it, but research on the subject is very recent. It also faces cultural resistance to “exposing” meditative practices: Tibetans are highly reserved about this, considering it an act of presumption or boasting that undermines the practice itself. Furthermore, although the Dalai Lama has worked to ensure that the phenomenon is studied, scientists (American, Russian, Indian, and Tibetan researchers collaborating together) have so far often arrived too late—either due to the logistical challenges of traveling in India and Tibet, delayed notifications (the body must be observed within the first three days after clinical death to verify signs of tukdam), or because the equipment used has not yet been adequately calibrated to study the phenomenon.
The third root, that of experience, must also be mentioned here.
It obviously benefits from the first two, as it applies them.
In particular, the cultivated empathic sensitivity and the ability to operate from a meditative state—which, as we have seen, promotes the development of certain brain areas, gradually making them dominant. This corresponding state then permeates our activities of wakefulness, sleep, dreaming, and, naturally, our death—a point I touched upon when discussing tukdam.
The Eight Stages of Dying and Near-Death Visions
This involves evaluating a collective experience: not only my nearly forty years of end-of-life accompaniment but also the experiences of caregivers who have worked within the Tonglen ODV association since 2001, and even those of some individuals we have accompanied who retained full lucidity until the end. These experiences confirm the Tibetan description of the eight stages of dying—a description unparalleled in any other thanatology worldwide, which has reached us intact.
In these meticulously described stages, as the senses progressively withdraw, physical signs appear that correlate with changes in the dying person’s perceptions. Their physical sensations evolve, as does their way of perceiving the world. Understanding these dynamics allows us to adjust our communication to align with the perceptions of the dying, without contesting or attributing them to medicalization. Among these perceptions are near-death visions, which often serve as a source of great resilience for the dying. These visions result from an expansion of consciousness (you may recall that consciousness is not localized in the brain).
Their consciousness becomes increasingly vast, sometimes perceiving things we cannot perceive, and we can occasionally engage with them calmly about these perceptions, especially when they remain lucid until the end. This underscores the importance of understanding the issue of sedation: we should aim to sedate only pain, avoiding the sedation of consciousness itself. Palliative care still has much to learn in this regard.
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(1) Heart rate variability refers to the intervals between two heartbeats: when harmonious, it displays a graph with minimal but consistently present variations in these intervals. If this does not occur—if all intervals tend to be equal—it indicates that death is near (as obstetricians note when observing this parameter in a child during childbirth). Similarly, excessive variability can indicate a chaotic state that may precede a heart attack.
(2) During embryonic development, the brain does not form until the fifth week, and it is only between the sixth and seventh weeks, when the neural tube closes and the brain separates into three parts (cerebrum, cerebellum, and brainstem), that the brain begins functioning. This suggests that the development of the organism precedes the appearance of the brain. Therefore, the assertion that the irreversible loss of brain function alone determines the cessation of an organism's life is untenable.
