The patient can’t stop coughing. Blood is coming out of his mouth, and each cough brings up more, until the front of his hospital gown is soaking wet.

Alan Bowden* sits next to him, frozen with fear. Bowden’s decision to be a volunteer came from a desire to get in touch with his emotions. But no amount of meditation could prepare him for this close-up view of suffering.

As the coughing continues, Bowden fights a war inside himself. He knows he should help this man, but his fear paralyzes him. All he wants to do is run away, get out, fling open the door, and escape down the hall.

Bowden pits all of his fear against all of his compassion. They twist and turn, pull and push, each trying to make him go in a certain direction. Then it becomes clear. All he has to do is what needs to be done. Bowden reaches over and picks up a clean gown. He begins to clean up the blood. The man’s coughing slows down, and then stops.

Hospice care began in London in 1967 at St. Christopher’s as an attempt to bring a more human element back into the dying process. The idea behind hospice care is that every person has the right to dignity and companionship as their life ends.

The Zen Hospice Project in San Francisco has over 130 volunteers who work at three different locations around the city, providing emotional and spiritual support for people with terminal illnesses. Volunteers are there to bear witness to people’s lives and to support them as they die. It is an intense process that attracts people who want to be present in this life and appreciate every moment. “People find themselves doing hospice,” says Eric Poche, volunteer coordinator for the Zen Hospice Project. “It puts things in perspective.”

Poche has the demeanor of a friendly librarian. He is a large African-American man who talks softly, moves slowly, and is calm in his work. His hair is going gray and he peers down at people through bifocal glasses. But he does not spend his days lost in old books or giving lectures to rowdy schoolchildren. He has spent 10 years working for the Zen Hospice Project.

The World Health Organization defines hospice care as, “total care of patients whose disease is not responsive to curative treatment. (The) control of pain and of psychological, social and spiritual problems is paramount.” Volunteers for Zen Hospice go through an application and screening process that Poche oversees. This sort of work is not something that can be taken on lightly. The hospice asks for a year-long commitment of five hours a week plus monthly meetings. Poche accepts roughly half of the 40 applicants he gets each year.

“I never believe people when they say they don’t have any fears,” Poche says.

Volunteers come to sit with the residents, talk to them, change sheets, clean up the common area, and generally help out. The volunteers need to have some sort of spiritual practice that they connect with, be it Buddhism or another tradition that incorporates awareness and compassion.

The Zen Hospice at Laguna Honda Hospital has 26 beds and all the patients here have a prognosis of less than three months to live. The walls are a soft peach color in the main area, giving the room a feeling of homey comfort. A grey and yellow cockatiel, Bing-Bing, hops around in a white cage that is near the door leading out to the garden. Outside, a fountain trickles past a purple Japanese maple and tufts of bamboo give the garden a tranquil splash of green.

Bowden became a volunteer three years ago because he was looking for “something for (his) heart.” He is a thin, pale man with a shaven head and dark, piercing eyes. Bowden practices Vipassana, a form of Buddhist meditation that focuses on mindfulness and, in turn, compassion and loving kindness.

The ability to cultivate mindfulness is what gives volunteers the ability to be open to and accepting of the changes the residents are going through. Buddha’s teachings describe life as being impermanent, full of suffering and ego-driven. The idea behind a meditation practice is to let go of desire, let go of your ego, and learn to live in the moment.

As his fears gradually disappear, Bowden thinks a lot about death and the way people die.

“It is as holy as birth is,” he says, raising his dark eyebrows. “Death is just another moment in life.”

Bowden has a theory about ego that he calls the “onion theory.” He feels that a person’s ego accumulates over time, like the layers of an onion. As life is ending, the person sheds those layers, working through the issues they held on to their whole life. At the very end the veil between the person and the wholeness of the universe is thin, the person is being drawn back into it. This is what he classifies as a “good death.”

Bowden sees death as a personal journey - as it unfolds it is absolutely unique for each person and perfect in its own way. People ride waves of consciousness as they come towards the end of their life. He sees it as “work” the residents are doing when they are in these states.

“It is a remarkable gift to be present with people as they go through this,” he says. “Their work is much harder than mine is. It’s not that I don’t feel sad. Sadness is a gift too.”

A bulletin board in the hallway holds photos of frail-looking people, some in wheelchairs, some sitting outside. In one of the photos an elderly woman with glasses sits at a table with a Dalmatian next to her. They are looking at each other quizzically; the woman’s face is one of calm beauty, her mouth hinting at a smile.

“We sometimes send these pictures to family members,” explains Poche. “So they can see that there were good times… that they didn’t just come here to die.”

* Last name was changed