Gateway to Death

As a hospice volunteer Paramananda gave himself to caring for the dying. When he left he was no wiser about death but more aware of life.

It is 10am on a Tuesday morning. I am standing on the steps of an elegant Victorian house on Page Street in San Francisco. Tod is taking longer than normal to answer the doorbell. Just up the street on the opposite side of the road stands an impressive two-storey brick building. The majority of buildings around here are constructed from wood, so this one stands out. If you look closely you can see the Star of David in the wrought-ironwork of the balcony railings. This is the famous San Francisco Zen Center, which in former years was a hostel for young Jewish women. It is famous partly because of its founder Shunryu Suzuki, whose wonderful book Zen Mind Beginners Mind is regarded by many as a modern classic on meditation.

Zen Center is also famous for Richard Baker, the charismatic and controversial successor to Suzuki. Much of Zen Center’s success was due to Baker’s drive and leadership, although he is mostly remembered as the defendant in a Zen version of impeachment, which wrestled the leadership from him. It is famous because it was in the right place at the right time. Its history includes the Beats and the hippies, state governors and presidential hopefuls.

It is also an important part of the history of the hospice movement in the US. The house where I found myself every Tuesday morning for three years was the Zen Guest House – a four-bedded hospice that grew out of the Zen Center’s experience of caring for terminally ill members of its own community . It is a place to die.

Eight years ago I moved to San Francisco partly because I felt exhausted by a decade of Thatcherite Britain. Both the actual and the social climate of England seemed grey, without the promise of a brighter future. After 37 years of living in London, it was time for a change. I was invited to San Francisco to help establish a Buddhist center, in cooperation with a group of Americans who had, by various and unlikely coincidences, become interested in the teachings of Sangharakshita. I had been ordained by this remarkable Englishman in 1985.

For me, San Francisco was a city I had seen in movies; it was also the city of the Beats, and a new way of living: the city of love, where flower power first blossomed. San Francisco drew many who felt alienated from the mainstream values of America, and it became a refuge for those who felt their sexuality made them outcasts in the vastness of Middle America. By the time I arrived the flowers had long since wilted. Out of the radical soil of the 60s had grown a vibrant gay culture, but AIDS began to decimate this community.

To the city’s credit, and in particular thanks to its gay population, San Francisco responded to the ‘gay plague’ with courage, compassion and even humour. The city seems to understand that we all live on a fault line, regardless of our personal characteristics. After being in San Francisco for six months I wanted to play a part in the city’s response to AIDS, and I found myself applying to be a volunteer at the Zen hospice.

Although some of us will die suddenly, many of us will at some point require a place to die. A hospice is a place for the dying, an alternative to hospital when medical science has given up. To be admitted the client agrees that no further medical intervention will be administered, other than for the relief of avoidable suffering. Many of those who have occupied the beds behind this door for a few days, weeks or months might well have died on the streets if they had not found refuge here. Most of the guests are men dying of AIDS.

I hear Tod (the nurse with whom I shared my shift) coming down the stairs. He opens the door, welcomes me and explains that Keith has just died. It was strange coming each week to this house of death. Whenever I stood on those steps and rang the bell I felt a disruption in my guts as I wondered who would be left in the house. I tried to rationalise those feelings in a Buddhist way, as insights into impermanence, but fear would have been nearer the truth. It was good for me when I was drawn out of my fear of death into the intricate web of relationships that were forever forming and dissolving in the house.

Often I was unable to be in that state of grace. Most of the time I felt inadequate and clumsy. Sometimes I felt numb, as if my emotions had retreated. There is something frightening about caring for the dying. When I felt fearful I would try to remember how Frank, who was then the hospice director, replied to our anxious questions during our training: ‘What’s the worst that can happen – someone dies?’

The first time someone dies with whom you’ve made a connection is a rite of passage. You realise that the more you come into relationship with the terminally ill the more you will grieve at their passing.

In my time as a volunteer I never felt that I was up to the task of caring for the dying. I was not good at making small talk. I never found the right words. The platitudes you resort to when visiting a friend in hospital – ‘don’t worry, you’ll be back on your feet in no time’ – are inappropriate in a hospice. I was most comfortable with those very close to death. Between life and death, they existed in a twilight world, drifting in and out of consciousness. Sitting without words, holding an emaciated hand, listening to the rasping breath. I found this situation easy to stay with.

I would try to let go into my own breath, feeling that every time I breathed out I should not expect to breathe in again. I tried to hold a sense of loving kindness, accepting the person I was with completely. I felt that if I could breathe out completely it might somehow be a little easier for the person whose hand I was holding to die. When I sat with the dying in this way I also knew that my experience was highly subjective. It struck me again and again that even in such close proximity, death remains completely hidden. As the philosopher Martin Heiddeger said: ‘Death is not an experience’.

The morning of Keith’s death came in a brief period when I felt some confidence as a volunteer. Keith was a gay man in his early forties dying of AIDS, who had been in the house for some time, and I had formed something of a friendship with him. He was liked by all the staff and volunteers. To be admitted to the hospice the prognosis has to be six months or less. Sometimes (but not often) people survived longer, but most of those who came to us died within weeks. I went upstairs and into Keith’s room. Before the advent of the new drug cocktails, people with AIDS did not so much die as fade away. At some point the capacity or the will to eat would go, and the person slowly starved to death.

Keith had been unable to eat for a while and he had no body fat left. His once-handsome face had taken on the appearance of a famine victim. But because he was white his appearance evoked images of the Nazi death camps rather than a natural disaster. Mostly people here die in the small hours when the body is at its lowest ebb. It is as if the tide goes out and does not come back in.

There are many things to do after a death at the hospice – both practical and ritualistic. First Tod and I have to wash carefully Keith’s pathetically frail body. We take our time; we are saying goodbye. I try my best to stay with it and after a few minutes I feel something within me relax. I feel a sense of tenderness. For a short while the rest of the world retreats and there is nothing else in my mind but this simple act of care. This is the first time I have washed a corpse.

Keith has left instructions on how he would like to be dressed – jeans, cowboy shirt and boots. There is something absurd and touching about the way Tod and I struggle to get the tooled high leather boots onto Keith’s body. After we have washed and dressed the body and Tod has attended to Keith’s hair, we sit for a while in the quiet room as the morning sun floods in.

Then I retire into the alcove on the landing, which acted as an office for the volunteers. I have a list of Guest House volunteers, and they all need to be phoned. There are perhaps 30 or so. It brings back memories of ringing family and friends after the death of my father all those years ago. Call after call is answered by message machines. It is a relief when halfway through the list I speak to a real person. ‘I am phoning to let you know that Keith died a little while ago, the body will be here until tonight, if you would like to come and say goodbye.’ The door bell rings, it is two friends of Keith come to see him. I can hear Tod explaining to them that Keith is dead. They come upstairs to sit with the body for a while. Throughout the day there is a steady trickle of visitors, and some remark on Keith’s outfit.

I often wondered how Tod manages to do this work day after day. To be honest, once a week was enough for me. Tod gave up a successful business to train as a nurse so that he could do something to help those suffering and dying from AIDS, a disease that had taken away many of his friends. I grew very fond of Tod over the years that I volunteered at the Guest House. He was kind and effective and never added to the feelings of inadequacy that I frequently suffered. He seemed unflappable in the face of death.

Only once do I remember him feeling overwhelmed by the task. A Native American man had been admitted since my last shift. Three out of the four beds were reserved for victims of AIDS, but I think this man was dying from cancer. Tod asked me to take breakfast up, and he was clearly reluctant to do this himself. He warned me that I should be prepared for a shock. I have never seen a face before or since like that Native American’s. The dark skin was drawn impossibly tight over the high cheek-bones, the black eyes where sunk so deep that they where nearly invisible and seemed to absorb the light in the room. The face seemed not the face of a dying man, which both Tod and I were used to, but the face of death itself. In the few days he had left, the man was surrounded by members of his family and tribe, who sat around his bed chanting and sometimes shaking rattles. I never got used to the face that seemed to proclaim the universality of death, rather than just the passing of a single man.

An important part of the hospice is the relationships between those who work there, whether paid or voluntary. To sustain this work it seems essential to have others who will give you a hug, listen to your fears and, perhaps most importantly, share a joke (even one that might seem in bad taste to an outsider). The Zen hospice project trains around 70 volunteers a year, most of whom work at the hospice ward of Laguna Honda hospital. Others, like myself, elect to work at the Guest House. The need for a feeling of community is always emphasised, so that a dying person enters, and for a short time becomes part of, a community.

For a hospice to function effectively attention must be given not only to the dying but to the carers as well. To become a volunteer one has to undergo a short but intensive training. All volunteers are expected to have some form of spiritual practice, although this need not be Buddhist. People come to hospice work for many different reasons, often as a result of having lost a friend or relative. When accepted onto the training people have to agree that at any point they might be asked to leave, and some people do not make it through the training. Sometimes potential volunteers are too raw with grief to support others.

I never felt completely at ease as a volunteer. What do you say to someone when they have moved closer to death every time you see them? And not just in the abstract sense that we all are moving in that same direction, but in the very immediate sense – that they are losing control of their body, and their life force is ebbing away day by day. Very few clients seemed to want to talk about death, at least to me. More often they wanted to talk about their lives. All too often they had bad feelings towards their families or others who they felt had let them down in one way or other.

It is true that some people become beautiful in death, they come to a place of what can only be termed grace – but this is not as common as some of the recent literature on dying and the hospice movement imply. Volunteers and members of staff felt a strong desire that the dying person should have the best possible death. In nearly all the cases I witnessed this was indeed true, as the hospice was a caring and warm place. However I did not often witness a spiritual transformation. It is hard to know what is going on with someone as they draw near to death: many are heavily medicated and confused. I was often amazed by the acceptance of those facing death, but I wonder if that was the result of a natural, in-built reaction to the process of dying.

Among the volunteers I saw a desire to ascribe this acceptance to some spiritual insight, but I think this had more to do with the needs of those attending than the experience of the dying person. I became increasingly uneasy about the New Age image of a good, even a redemptive death. We all need to make death seem OK.

A year after I finished working at the hospice I was asked to take part in a practice day for present and former volunteers. I was given a short slot to say a few words and lead a brief meditation. I was pleased to be asked, as I have great admiration for the volunteers and staff. I made two points. Firstly, no matter how closely one has been in contact with death, through the support and witnessing of others, death remains a mystery – something unknowable – and perhaps this remains true even at our own death. Secondly, and more importantly, even a ‘good’ death does not and should not be understood as making up for a life that has been unhappy or selfish. It does not put right the appalling neglect of society towards many of its less fortunate citizens (many of the people that came to the hospice were homeless or living in awful situations). Nor does it make up for a life that has not been well lived.

Looking back, I think I became a hospice volunteer because I wanted to face the reality of death, and the fact that I will die. I left the work no wiser about the nature of death, but perhaps with a little more resolution to try to live my life with kindness and courage.

Paramanada is working on a sequel to Change Your Mind, his introduction to Buddhist meditation