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Many models exist for integrating alternative and conventional medicine. Alternatives focuses on organizational structures and philosophical frameworks in which practitioners are achieving improved patient outcomes with alternative and cross-cultural therapies.

Nancy G Moore

In a culture that tries to keep death at arm's length, the Zen Hospice Project in San Francisco meets death face-to-face. This community-based project acts as a friend to indigent people facing the final months of their lives, and helps hospice volunteers to discover the innate generosity and compassion they never knew they had.

Patients who enter the hospice program are typically suffering from a chronic illness and are in the last 3 to 6 months of their lives. Often they're homeless or lack close, trusting relationships with friends and family members who could comfort them in their final hours.

The volunteers' main task is to form relationships with the patients. By being a friend who will not only listen but also assist with nausea and dean up after a bout of diarrhea, the volunteer says, in effect, "I am here for it all." This enables patients to develop a relationship of trust, which then can be extended to other unresolved relationships or even issues related to death and dying. 
Frank Ostaseski director of the Zen Hospice Project with hospice patient Dieudonne Benvenutto.

As volunteers develop an awareness of their own inclinations and emotions concerning death, they may become less reactive and more responsive to these states of mind in other people.

"As we cultivate this in our own lives, we tend to be more available to the needs and fears of patients," says Frank Ostaseski, founding director of the hospice project. The Zen Hospice Project recruits volunteers who want to explore their own spirituality and personal growth.

Volunteers and patients often come from very different worlds. Volunteers generally are white, middle class, well educated, and have some exposure to spiritual practice and complementary medicine. Through the hospice project they might meet, for example, a Hispanic person who is homeless or living in a single-occupancy hotel. Under normal circumstances the two might simply pass each other on the street, but now they find themselves in the most intimate contact. The hospice serves as a meeting place that goes beyond culture, and beyond the perceived differences that would have separated them in the past, says Ostaseski.

The conscious-dying movement can sometimes become "simply another agenda, another burden to place on the heart and mind of the patient," Ostaseski says. The Zen Hospice Project is designed to take people as they are, assisting them in closing out their lives without asking them to accept another person's belief system.

Though the project receives no government funding, it recently received a small grant from the Soros Foundation in New York, which has created the Project on Death in America to help reframe the way America deals with death. As part of that grant, the hospice project will broaden its public education program to reach more healthcare professionals or friends and family members who are caring for a loved one facing a life-threatening illness.

The tendency in the United States to deny death is all too common and can dramatically increase the suffering of the dying. Ostaseski recalls washing a patient whom he had turned over on his side. The patient looked back over his shoulder and said he never thought dying would be like this. Prompted by Ostaseski, the patient said he actually had never thought about what dying would be like.

"I realized in that moment that this suffering was more severe for him than his cancer-the fact that he found himself surprised at the end of his life with absolutely no preparation," he said.

A Buddhist, Ostaseski wants to see the experience of dying discussed more openly. "When we come into contact with how precarious things are, we begin to appreciate the preciousness of this life, and in my experience this causes us to hold our ideas and ourselves a little more lightly," he says. "We let go more easily, and that cultivates generosity and a kindness for one another."

The Zen Hospice Project has three central programs: its own residential program, a residential hospice unit in a public hospitaL and an education program. The two residential programs operate in a collaborative fashion. The Zen Hospice Project provides volunteers for the Laguna Honda Hospice, a 28-bed unit inside the nation's largest longterm care facility. The Zen Guest House Residence works with the local visiting nurses and hospice organization.

The Zen Guest House collaboration got started after volunteers were first seeing clients in hotels and on the street. Those clients were ending up at San Francisco General, the acute-care hospital, where they would either die or be transferred to a non-hospice unit of Laguna Honda Hospital. They could not stay home because the local visiting nurses required a primary caregiver. The patients often had no government entitlements because they had no address or the means to get those entitlements.
The Zen Guest House was created as a partial solution. By offering an address, the clients could begin receiving entitlements, and with the Zen Hospice Project becoming the primary caregiver, the patient could have access to the visiting nursing and hospice services. This arrangement meant that the visiting nurse and hospice organization could serve several people in one location, which in turn lowered their cow.

The Zen Hospice Project training for volunteers is comprehensive and certified by the California State Nurses Association. The hospice project values good listening skills and a willingness to roll up one's sleeves and go to work. The basis of the training, however, is mindfulness. "There are lots of nurses in hospitals who know how to turn a patient, but unfortunately they don't all do it with compassion," Ostaseski says.

Meditation practice by volunteers is taught and encouraged. Meditation helps us to examine our intentions moment to moment, Ostaseski notes. "Crossing the threshold of a room of someone who's dying is a remarkable time to pay very close attention."

Whereas volunteers are encouraged to have a regular spiritual practice, the Zen Hospice Project does not advocate any particular ideology. "People come to us because they need the care," says Ostaseski. "They don't care beans about Buddhism, and that's OK with us."

What patients do get from the hospice project is a safe environment - a place where it's warm and dry, the medical staff are caring; and a volunteer is ready to act as a nonjudgmental friend. "What often happens is that within this environment of kindness, people start to soften," explains Ostaseski. "They start to open a little bit and trust a little bit more, because they generally come from environments where there was not a lot of trust." And when that door of trust begins to open even slightly, they begin to think about who else they can trust and what else they need to resolve in their fives as they come towards the end.

Volunteers may ask patients if there is a family member or friend they want to talk with, but reconciliation is never pushed. Ostaseski has seen remarkable resolution of family issues, but he's also witnessed a situation in which a patient refused to contact his mother. After the patient's death, the mother was glad he hadn't.

Because hospice care is not limited to a therapeutic hour, but available 24 hours a day, Ostaseski says volunteers must be ready to listen whenever the patient is ready to talk. "That means we have to continually cultivate this openness in ourselves, this availability and readiness."

Volunteers keep a collective journal of each experience with a patient. Initially, one volunteer was assigned to one client, but the project has found that it's better to work in a community on a shift schedule, with the volunteer coming into contact with all the clients during that shift. "This makes a tremendous difference," says Ostaseski. No one person is carrying all the responsibility, so the volunteers can give themselves fully, and then they can let go.

Volunteers have always been available to hear clients tell their life stories in an informal way, but the Zen Hospice Project has some volunteers who are particularly adept at encouraging storytelling. Ostaseski recalls an English professor who would record oral storytelling sessions, then transcribe them into a booklet for the patient, who in turn could decide whether to give it to a loved one. "It's a powerful thing to give a person back their words," Ostaseski says.

The Zen Hospice Project's workshops and other educational programs are in great demand. Invitations have come from everywhere from New York to Montana to bring the project's work to those sites. "We're hoping to be able to slowly develop a program of teachers who can travel to some of those locations," Ostaseski says. In San Francisco, a meditation support group is being created for people with HIV, and retreats are planned at places like the Esalen Institute in Big Sur, Calif., for people facing life-threatening illness. "In that case, we'll be working with people much earlier on in their illness."

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