Accompanying the Dying: How I Prepare Myself for Hospice Work

John Hughes

The quieter you become the more able you are to hear.

My introductory essay to hospice and my involvement in it appeared in Eros & Kosmos on August 19, under the title “Accompanying the Dying: A Hospice Chaplain’s Perspective.” It was a thrill for me to be published in these pages.

In that piece I promised three forthcoming essays on accompanying the dying. I did not say what the topics of those essays would be, but they will be as follows: first, “My Preparation,” second, “The Work,” and third, “The Theory.”

Expanding those titles a little: what do I do to prepare myself each day and week to be the most resourceful and caring professional possible, and to grow into a person who can bring wisdom, compassion, and empathy to people who are at death’s door, and to their families? Second, what is it like in the room of a dying person, and how do I effectively respond to that environment, day in and day out? Third, about this “integral theory”: what is it, and how does it inform and nurture my work?

With this essay, I address the first question. If I did not prepare myself each day and week for this work, equipping myself with radiant energies of wisdom, compassion, and empathy, I would be exhausted in body, depleted in mind, and useless in spirit, probably fired from my job but certainly ineffective. The demands are too high and the situations too important, and all coming at such volume and speed, that I have to be alert and centered at all times, nimble with my receptivity, perceptive with my listening and responses, deep with my heart’s caring. People are going through momentous transitions which couldn’t be more real and heart-wrenching, and it is my job to accompany them through their experience. It is imperative that I be fully available to them.

Somewhere between nine and fourteen patients die each week under my care, as I serve two hospice residences housing ten and eleven patients, respectively, plus a huge Veterans Administration complex housing numerous dying soldiers and sailors at a time. Nine to fourteen patients die each week, and each experience is unique. Also, they leave family members behind, and in the wake of their loss these bereaved persons express everything from profound sadness to guilt to fear to nonchalance to anger to nothing at all.

Billy (all names used here are not real) has been a closeted gay man throughout his 50 years, and now as he dies from cirrhosis of the liver due to decades of alcoholic excess, with his religiously conservative family gathered around him, he just wants to be held by his long-term lover, whom none of his parents, sisters, or brothers knows anything about.

Fred wants to get something off his heart before he dies. During World War 2, he shot and killed an eight year old boy who had been loaded down with timed explosives by the German soldiers, and who was walking into the American encampment, presenting certain death to 40 men gathered, unless the boy was stopped from entering. Fred saved the 40 but not the boy, and has carried excruciating guilt and grief for 70 years and now is melting down with tears.

Sally is deeply frightened of dying. She is cognitively challenged and believes she will go to hell because of her “naughtiness” through the years. She puts on a happy front to her siblings and friends but in private is distraught, and no words of assurance I can offer make her feel any better.

Stephen is a millionaire surgeon and has two ex-wives sending contentious e-mails as he nears death, because they want the majority of the inheritance he will leave behind. Stephen has three sons, one of whom is estranged and out of contact, one of whom is sexually harassing the hospice nurses when he visits, and one of whom is the golden boy favorite son, but an obvious arrogant phony. All three want a large inheritance after his death. Stephen sits among citations and plaques honoring him for his medical achievements, but cries like a baby because he feels unloved by his family and utterly alone.

Mary is told by her pastor and father that if she dies it is due to her lack of faith, and therefore her guilt. She is not to give in to “the enemy” who “speaks the lie” of death, but to cling to Jesus, who wants her only to live. As she nears closer and closer to death, their prayers become louder and more insistent, and they become more and more excited about the “miracle” they expect to happen any moment, of her restoration to full health.

Samantha is extremely angry because she has been lying in her hospice bed for a full week and is still alive, not yet “gone home.”

Often, Billy, Fred, Sally, Stephen, Mary, and Samantha lie nearly side-by-side in adjoining rooms, their dramas unfolding simultaneously, their families rubbing elbows together out in the lounge area or at dining tables. I am spiritual care provider to all, working in a team with highly resourceful and brilliant nurses, nurses aides, social workers and doctors. It is my job to hold all the patients and all their family members, even the dysfunctional ones, in unconditional positive regard. I am to hold each person in the hospice unit in a forcefield of compassion. This is not always easy and often requires tricky footwork as I negotiate conflicts of interest (always prioritizing the well-being of the patients), and as grief provides an emotional humidity that makes many people irritable.

How do I care for myself and cultivate wisdom, love and effectiveness to meet these challenges five days a week plus during night-time and weekend on-call duties?

My self-preparation includes shadow work, meditation, and a rich intellectual life.

Shadow Work

I mention shadow work first here because it is so crucial. A person out of touch with their shadow is limited in their ability to truly see other people as they are, and a person doing shadow work is significantly liberated in ability to exude kindness.

Each of us has a part of ourselves which we have attempted to disown, which doesn’t fit with our self-image and which we have therefore consigned to the dungeon of our awareness. Maybe we think of ourselves as generous, and so we deny to ourselves awareness that at times we just want things for ourselves and don’t want to share. Perhaps we think of ourselves as humble, and so we don’t allow ourselves to feel pride in our accomplishments. A person might think of themselves as peaceful, and thus deny themselves of awareness that, in fact, they harbor a bad temper. These parts of ourselves, disowned and banished to the dungeon, do not go away, but instead fester down there, away from the light. They inevitably come up to interfere with our hearts and minds in the form of shadow.

No amount of repressive willpower, or spiritual meditation, will make the shadow go away. It has a life of its own and can play havoc with us in many ways. Have you ever known a person with a seemingly irrational temper? Or have you noticed that you have an unfounded fear of someone? Or do you have a colleague who carries an emotionally charged prejudice against a client or co-worker? Or are you aware of a nation-state which declares itself the guardian of liberty but at the same time has repressive features in its behavior? These may all be manifestations of the shadow, which create a burden of suffering.

The manner in which shadow wreaks havoc is with the phenomenon of “projection.” In other words, because you don’t want to admit something to be true of you, and that trait is down in the dungeon of your awareness as a festering power, it comes up when you project that trait onto someone else. You see the buried energy in another person. You give them blame for what is actually an energy inside of yourself.

As a hospice chaplain dealing with a public who are in the grips of grief, with all the rank emotions that entails, I have to be on top of my own shadow or I will be projecting blame onto people which they don’t deserve. I have to do shadow work, and I do it every Sunday night without fail, plus on an as-needed basis.

Shadow work means keeping a vigilant eye for those times when a person in my field of awareness irks me in a unique way. I become especially pissed at them, obsessed about their comments, frequently rankled by their presence, so that I want to either argue with or avoid them. Maybe I become intimidated by them for no apparent reason. They are in some small way mirroring to me something about myself which I am not admitting, and I would like to curse at them for that. I am blaming them for myself!

On Sunday nights each week, I reflect on the previous week of interactions in the hospice, and prepare for the new week. I think about the landscape of emotions that I have wandered through. Was there a person who pissed me off? Was there one whom I ignored totally after our first visit? Am I afraid of someone?

There always is. My shadow is active, and it usually takes me about two minutes of reflection before I remember being irrationally emotional about a patient or their family member. So, my next step is to think about why that is. What was it about the person who activated my shadow projection? That reflection process also happens fast. Bam! I was uniquely irked by Sally (above) because I think of myself as intelligent, and don’t like to admit to myself vast areas, enormous circumferences and vistas, of my ignorance about numerous matters in this universe. Sally is cognitively challenged and so her fears of hell are derived from lack of information, echoing my own lack of information.

I use this as an example. I wasn’t really irked by Sally, but you see how the process works. What is it about certain persons in the hospice unit that shuts down my compassion? I have to find out why. What shuts down my compassion is that they remind me of things I am not admitting about myself.  Once I become aware of that, I have to have a little talk with the shadow.

I did not come up with this process on my own, by the way. I saw it in a video put out by the Integral Institute, featuring Diane Musho Hamilton. I have been using it for about seven years since then.

After I have identified an area in which my shadow has been active, I describe the situation out loud, in a summarizing sentence.  Using the Sally example above, I speak the truth to myself: “Sally is irking me uniquely because she has fears due to ignorance, and I have fears due to ignorance too, while I prize an image of myself as intelligent, informed, and brave. She is showing me an aspect of myself which I don’t like, and so my compassion for her has shut down.”

Ahh! It feels so good to say it. The repression of my shadow lifts a little just from naming how it has functioned this week. It is out in the open.  I don’t shame myself for having a shadow—everyone does—and even take a little humorous delight in detecting how it has been working this past week.  “Whew! Poor Sally wouldn’t hurt a fly but I have been showering shadow on her for several days just because of my prized self-image.”

The next thing I do is put an empty chair beside me, and do a little role-playing with Sally, or whoever is the recipient of my shadow projection that week. I speak to the chair, out loud. “Sally, you are making me angry in a subtle way, or not so subtle, because you have a lack of information about life and death and Spirit and universal compassion and human nature. You think that because you have been ‘naughty’ in some way, you are going to hell. This is not bright. I like to think of myself as informed and effective, but I do have a side of myself which functions poorly in areas due to ignorance. I pretend that side doesn’t exist, but you are showing it to me while visiting here. I am pissed about that.”

After I say this to the empty chair, I allow “Sally” to speak for herself. It is amazing, if I just sit still and imagine Sally taking in my above comments, she will speak. I have never had a Sunday night in several years when the recipient of my projections did not speak from the empty chair.

“Sally” says “John, I don’t like that. You are my spiritual care provider and yet you are getting caught up in your personal drama. I am a bright person but suffering from cognitive deficiencies due to a long illness. I have a bad conscience about things I have done, actual real guilt, and so they lead to real fear for me because of my religious upbringing. You are intelligent, and an empowered white man. Give me a break. This is not about you but about me and my conscience and fear. Let your shadow projections go and see me and help me, please.”

I take in the reaction. I respond. “Thank you for that, Sally. I see how my shadow and projections has been undermining both of us. I see the ineffectiveness of my reaction to you, and hereby lift the shadow projections and embrace you as a real person. It is true that I am ignorant about vast swaths of human experience, but that is okay, and I don’t blame you for it. I am sorry I did that.”

The next day, when I walk into the hospice and see the real Sally, I see her in an entirely different light, with a softer energy inside myself. We can truly connect and talk about that “naughtiness” without my being dismissive.

There is much more to shadow work but this is the crux of how I approach it.


Traditional esoteric spiritual and philosophical wisdom, the collective wisdom tradition of humanity, teaches that there are three levels to human experience. Sure, there are many ways to slice this particular pie, from 12 Ox-Herding Pictures of Zen to Theresa of Avila’s levels of The Interior Castle and her ascent of the soul in four stages, to Dante’s different levels of The Inferno, but I find the three levels to be very effective in guiding my approach to meditation. The three levels are “gross,” “subtle” and “causal” domains of human experience. If I can spend discerning, open-hearted time in each level during meditation, I will be a much more effective spiritual care provider in hospice, and my presence among people will be calm, kind, and refreshing.  (The same goes for you in whatever your area of endeavor is!)

The “gross” domain of human experience is the one you’ve spent 99 percent of your time in. It is the bright light of everyday life, rational thought, and objective behaviors. It is our official cultural and social history together. It is the factual body, with its cellular structures, organs, and systems.  It is for many the template of reality, and for some misguided scholars the only realm or domain, the all-inclusive one level. It is the arena of communication and economics. You get it.

A higher domain of human experience is the “subtle” realm. Realize, I am talking about a higher level of you. You live and work and have your being in the “gross” level, but then you fall asleep and have a dream, a message from the subtle level of your mind, which is not rational but brings a penetrating wisdom. The subtle realm provides waking fantasies which can help you see the gross realm with better perspective. Acupuncture and chi gong and tai chi access the subtle realm of your body. Yoga sometimes does so, too. There are subtle yet powerful energies in your mind, your heart, and your body which you can harness to transform your being.

The “causal” domain of human experience is ignored by the majority of humanity, labeled in mythic terms, denied existence by some, neglected, but there. After you see that the gross level is not the only reality of your being, and you experience the subtle energies of your mind, heart and body, you can come to rest in the causal domain. This is the level of your existence which opens up to infinity, to timelessness. In the causal domain, you do not experience sights or sounds, but formless ecstasy. You see that you yourself are an infinite being, beyond space and time, beyond the grime and noise of the gross level, eclipsing the subtle energies, beyond the drama of your history. You are united with what Christian mystics call “Godhead,” what Hegel called “Spirit” and Einstein “First Cause,” what Taoists call “Tao” and Muslims call “Allah,” and what Hindus call “Self.” Such terminology is incinerated in the heat of your experience and you know only that you are participating in the Impenetrable Mystery, and thus feel bound in non-dual connection with everything that exists in all the domains.

There are something like eighty different meditative disciplines, approaches to accessing the subtle and causal domains of experience while seeing the gross domain more clearly. I use three, and will describe one here.  There are vast arenas of meditative practice and experience of which I am ignorant. For instance, I know little of the Tibetan practices of mahamudra and dzogchen. However, I have been doing two of the three of my practices for 20 years.

I have a heart practice which I follow each morning in meditation for 30 minutes. The process goes like this: I petition Spirit for the grace to love in a special way on that day, for whomever needs it—patients, their families, and/or my colleagues. The petitioning is not casual, but quiet and prayerful and lingering. I then invite Love (a subtle energy) to come up into me from the ground and into my heart. I then invite Love to come down from the sky into my head and down into my heart. Love arrives to me each morning from below and above. I then sit in silence for about 25 minutes allowing Spirit to infiltrate me with Love. This receptivity gives way after awhile, and I enter the infinite causal realm. I experience the opening up into infinity which is the causal level of awareness. After a while, when I sense that the 25 minutes is up, I say out loud “yes to life” and hold that thought in my heart for a while. I then say “I commit myself to being love today, in all that I do.” I hold that thought in my heart for a while as well. I then say “thank you” for the morning, for my dear daughters and friends, for my family, and for what challenges will be presented to me that day in the gross domain of experience (some of it really will be “gross”). I sit for a couple minutes just holding gratitude in my heart. When I get off the meditation cushion and enter my day, I have a sense of the sacred honor that it is to be alive and going to my job, entering the rooms of people transitioning out of this particular gross realm and into the subtle and causal realms.  I carry on my person the fragrance of infinity, which is ample preparation.

Intellectual Stimulation

I find that intellectual stimulation is also a key preparation for hospice work because it makes me consistently thoughtful, not just accepting patients and situations on the surface, but slowing my mental process down to be receptive to their depths, and the intricacies of their experience. I am serious about deriving my intellectual stimulation from a life of reading, and divide my reading into two categories: “formally integral” and “pleasure.”

I will delve into integral theory in the third essay of this series, but in keeping with this discipline, I read in categories derived from it. I read phenomenology, which for me is the writings of Carl Jung, Edmund Husserl, and Martin Heidegger. I read cultural anthropology—Jean Gebser, and philosophy—Plato, and Michel Foucault. I read sociology—Talcott Parsons and Niklas Luhmann, and family systems theory, Edwin Friedman.  I regularly consult my nurses’ textbook on the medical aspects of the dying process. Of course, I read Ken Wilber, the foremost articulator of integral theory and practice for the 20th and 21st centuries.

Not that this group of readings is not pleasurable, but I also like to get away from the discipline of integral thought, and read novelists like Angela Carter, Clarice Lispector, Nadine Gordimer, John Kennedy Toole, Jim Harrison, and Philip Roth. I am a fan of Shakespeare, and love the recent translations of classics by Tolstoy and Dostoevsky.  I read the writings of spiritual and consciousness teachers such as Joan Halifax, Cynthia Bourgeault, Stanislav Grof, and Stuart Sovatsky. I read the four gospels of the New Testament, and the Bhagavad Gita. While just about every spiritually-oriented person in the West reads poets Mary Oliver, Rumi, and Michael Whyte, I rebel against that (conformity being for me a shadow projection, hahaha!), and read C.P. Cavafy and Rabindranath Tagore (I quoted Rumi at the top of this article because the saying was apt).  I view this reading as an escape into a transcendent mindset, and it clears away the cobwebs of my mind and activates my imagination, while inviting me into a higher and often funnier realm of spiritual experience, than the norm for me.  I carry this mindset into the rooms of patients.

Thus, having addressed my shadow and its nefarious projections onto my unwitting patients, having accessed the subtle and causal realms of reality through meditation, thus re-orienting myself towards the gross realm, and having fed my mind, I am refreshed and ready for hospice work, prepared to bring wisdom and compassion to the people I serve, and to their suffering families.

The next essay will take you with me onto the hospice floor, and into hospice rooms for “the work.”

About the Author

John Hughes - Джон ХьюсRev. John Hughes, MA in Theology/Theological Studies, founder of Integral Earth, ordained Episcopal priest, and Hospice Chaplain in Wisconsin, USA. Author of the book Crossing Rivers: Journal of an Integral Hospice Worker (2013).