My Metta Institute Presentation

Improving the Experience of Dying Patients and their Families

 in the Emergency Setting

Hello, Aloha and Namaste – welcome to this training about how we, as caregivers and providers, can bring renewed and invigorated meaning to providing and caring in the seminal moments of our patients and their families lives. The dying process can often be less then peaceful and very difficult. My invitation to all of us is to make it our goal to improve the physical and spiritual treatment of the dying patient and their families in the hospital Emergency Room (ER).

For the purpose of this training we focus solely on patients who are expected to die and not the sudden, unexpected or traumatic death (however, some of what we will discuss is useful in all circumstances). We will discuss the purely physically based task first and then the manner in which we approach and carry out those task with an emphasis on the spiritual aspect. The integration of the heart, mind and body is paramount.

Part One

The Physical / Task Based Care of the Dying Patient and their Family.

The following points are largely task based. The mind / intellect approach is hugely important in the ER as it pertains to assessment and treatment options – all essential to quality patient care. However . . . our cognitive ability and listening skills are vital to feeling what is happening in our body to tap our deep intuition about what may be going on with our patient and their families – more on this in the second part of our training.

Pure task based ideas can include:

• move to a quieter room if possible and transferring out of the ER
• if possible go one to one with this patient (ask for help!)
• lower the lights, provide extra chairs for family (check in with the patient/family)
• page palliative care team & involve them as quickly as possible
• inform staff about this pt, use placards, disturb the patient/family as little as possible
• Create a 'spiritual crash-cart' (toolbox) that has electric candles, tissues, signs, CD player, tape for family pictures, etceteras
• work with kitchen to provide 'comfort food' (tea, coffee, water, cookies, etc.)
• provide the family with a booklet on what to expect during the dying process
• inquire / assist family in after-death care (rituals such as washing the body)
• Lets take five minutes and add to this list. What can we do better?

The pitfall of a task based approach alone is that it disallows for the spiritual care / needs of the dying patient and their family. Only focusing on task allows us, as providers, to protect ourself from the difficulties and/or pain inherent in dealing with the spiritual needs of the dying patient and their family. The takeaway lesson for all of us is to not just get caught up in task. Most of the essential task listed above can be accomplished fairly quickly. This is important so we can move on to what I consider our most important focus.

Part Two

An Inquiry into Spiritually Centered Care of the Dying Patient and their Family.

In Part One our focus was task based. But we know the dying process calls for much more than simply performing robotic task on a check off list. It is paramount for us to remain centered and present so we are better able to care for our patients and their families. So let us ask and inquire . . . how do we remain centered and present? How can we care for this patient and their family beyond just the physical task despite the busy demands of our environment?

• How we move through the room affects the mood and atmosphere and hence the experience of the patient and family. Don't rush, move slowly, deliberately.
• Don't focus on trying to 'fix' every single issue – just sit with it.
• We can stay present and focused on loving kindness as Ram Dass teaches us by repeating, 'I am loving kindness, I am loving kindness'. Don't just mindlessly repeat this – be sure to reflect and focus on each action performed with loving kindness.
• Integrate your heart, mind and body in your care. Listen to your intellect, feel what your body is telling you and let it speak through your heart.
• Create and envision the patients room as a sacred space. Be mindful that many of our prior task are carried out in the support and creation of this space.
• Pause before we enter that sacred space to acknowledge that another human being is dying. Pause to breath, honor this moment and patient, enter the room in a 'not knowing or doing' space. This is no matter what your task is – even if a simple 'to do'.
• Do enter the room to be present and available.
• Rather then doing each time you enter, focus more of a felt sense of listening and being.
• Once again, let us add to this list to improve our understanding.

Charlie Garfield brought this up in his April 2013 talk:

Listen from the heart.

Speak from the heart.

Act from the heart.

Summing it Up!

All too often in the emergency environment we become task focused. However, the dying patient provides us with a special and sacred opportunity to really nurture, respect the process and be deeply present. We must remember that we are all in the process of dying, it will be us someday and in this moment we have a unique opportunity to approach this patient and family in a different than usual way.

The challenges we face are how to do this within the demands of our respective workplaces. It is my hope and our goal to integrate both the doing and the 'being'. I hope that our time has been thought provoking and has laid out the beginnings of a road map for you and your patients to take that 'road less traveled by'. I invite and welcome any questions or thoughts that you would like to share.

Counseling Warriors

I have met a lot of vets in my time at the San Francisco VA. I met a 27 year old a few months ago who had signed up at 18 years old with multiple tours in Iraq and Afghanistan.  He was a fire team leader with the 82nd Airborne, lots of action and loss and pain.  He's in school now, making himself into a productive member of society.

As with all 'my' guys I asked about his drinking and drug use.  He is using a lot.  My message to him was that we are here to help no matter what.  My message was that he has a responsibility to the name he wears on his wrist and in his heart to be responsible for what he does, that he must go forth into this nation and world and work toward helping society avoid the wars that cause us to wear the names of dead people on our wrist.

His friend and buddy would not want him to waste his time and life drinking or using.  We were both close to tears on this one.  But here he is at 27 heading toward a career in photojournalism in war zones. We miss the action when we are not there (and I never served in the military but from my ER and Fire experience). 

Remembering Sam


Aloha, my name is David McCullough. It was a death that took me from Hawai'i fourteen years ago and today a celebration of life well lived that returns me home, once again, once again to the people and place I love. There are many of you that have known him longer, more closely and intimately. I have felt so absent, yet still, even now . . . I marvel at the connection to Ohana resonating within my heart.  Sam and Patricia and so many of you make that possible. My eternal aloha and gratitude to you.


I met Sam when we performed in Taming of the Shrew at Diamond Head Theater over 15 years ago. He introduced me to his 'crew' at the Picasso in the Alana Hotel. The Picasso was not a nightclub . . . but it was. It was not a piano bar . . . but it was. It was one of the classiest joints I've ever had occasion to hang and the people made it so. Being welcomed into that circle has been one of the most wonderful experiences of my life – what an honor to be part of Sam's life and earn his trust and love.


So for Sam and I (and many of us) part of life was theater, having a drink or two, talking story and jazz, jazz, jazz. He taught me more about Jazz then I could ever imagine. That love lives on – just as Sam does. So wherever there's a musician or crooner singing a tune, whether under a bridge or beboppin at a jazz joint – Sam is there. Where ever a singer sings 'Spring Can Really Hang You up the Most' or 'Lush Life' I am with Sam . . . all over again. I'm married to a beautiful and very talented singer now and Sam got to meet her. Because of Sam's influence – some of the songs he taught me are the one's my wife performs. It is much of his style and sense of life, expressed through the soul of music that has been transmuted and lives on through all of us.


We all come from different worlds, cultures and times. All inseparably conjoined. I am an emergency room Nurse at the San Francisco VA hospital now but am also a hospice nurse. My father was a veteran and his death took me away from Hawaii nei.  Sam was a vet and our friend and his death reunites so we celebrate his life and how he lived it. There are such things as duty, honor, and commitment and Sam encapsulated all these values and more.  I work with veterans every day and some talk and others do not. Sam was a man's man – at least to me. In my experience he exemplified the archetype of a peaceful warrior through his strength and gentleness.


As many of you know he spent much his life with what I fondly and with great respect refer to as the War Corps. In contrast, Patrica was a Peace Corps Volunteer from 1966 - 1968 and I was a volunteer in Fiji from 1985 – 1987. That is how she and I became friends. In 1996 Jim Hesse and I started Shakespeare on Sundays and I invited Patricia to meet this cool, older and distinguished gentleman. I got busy with the group and of course Patricia introduced herself and the rest, well . . . you know the rest. I am proud, honored and deeply happy at my role in getting two of the most wonderful people I know to hang together.


So that's it. Few, if any of us will remember much of what is said today. These words are not as important as the energy Sam brought to this universe and its affect upon our hearts. I am proud and blessed to have become a better man because of Sam Polson.


Malama pono Sam . . . a hui hou.

Funeral in Hawai'i

I'm back in Honolulu for Sam's funeral. I'm struck by how lonely I am right now.  I also realized  that my ties here are dimming - I know fewer people now. For me it is the people that provide meaning and joy to a place. So I miss what was and naturally wonder at what shall be. 

It is late. 0120 for me but I do have some energy from being back to where I feel at home. One big change is I saw tents on main streets here with homeless people living right on the sidewalk. It's amazing. Not even in San Francisco would they allow that (Years later in reading this I bow to my own ignorance).

Just maybe I could come back. Or maybe at long last I realize I don't have to. Tough as it was being here with a divorce it was also some of the best years of my life. What was - cannot be again and really, I've never been one to live in the past. But this is true - the more past you have - the less future - so naturally it may hold sway. 

I grow tired and soon my thoughts turn nonsensical.