Beloved San Francisco Zen Hospice Project Confronts Its Own End

It was late May when the body of the last person to die in the guest house of the Zen Hospice Project was carried down the stairs and through the back garden, then sprinkled with flower petals.

The San Francisco institution was founded during the height of the AIDS crisis, a time when sick men were left to die alone in the hallways of county hospitals because staff were afraid to touch them. Buddhist practitioners bought the Victorian on Page Street to create a place where men could get compassionate care and die with dignity.

Now, after 30 years of caring for people with all kinds of illnesses, the house is closing its doors. The organization no longer has enough money to keep the program going.

“It’s a little chaotic in here,” says George Kellar, the executive director of the last two and a half years, as we walk through the foyer of the house. “It’s in total transition.”

All the furniture is gone. The floors are covered with canvas tarps. Blue tape lines the perimeter of the living room. Men in jumpsuits and face masks are painting the fireplace, tearing up the carpet on the stairway and power washing the windows.

When the hospice issued its press release last week about this turn in the nonprofit’s fortunes, I noted the careful wording — that the guest house was “suspending” caregiving services, that they hoped they could “offer them again, at some point.” The implication was clear: Maybe a local tech billionaire could step in with a Hail Mary donation.

But this is a house that’s being primed for a realtor to stage it and put it up for sale.

“Five bedrooms, three bathrooms. It has a boarding house feel to it,” Kellar says as he gives me a tour of the upstairs. “It probably has that kind of history.”

Before the beds were cleared out, before all the nurses were laid off, the guest house had room for six residents. They called them “residents” not “patients.” This was their home, not a hospice. And they came here not to die, but to live fully until the end of their lives.

A corps of volunteers would sit with patients, sometimes for hours — just holding their hand, telling stories, singing songs. Kitchen staff prepared three meals a day to order for each resident, even when they could no longer eat.

“They can smell it, they can see it, if they want to taste that they can," Kellar says, adding that it's about letting the residents know "they’re not discarded and ignored and not important."

The organization became a pioneer in what it means to die well. It helped shape a national movement away from sterile hospital deaths — hooked up to machines — to a mindful, aesthetic end that emphasized being present with what was happening.

Donors loved the mission and they were generous. Until the 2016 election.

“We’ve been struggling through 2017,” Kellar says.

This year, they’re more than $1 million short on their $2 million annual budget. Donors have been telling Kellar they have to cut back on their gifts to the hospice because they need to support issues that have come under attack during the Trump administration.

“Voting rights, or women in politics, or immigration help,” Kellar lists the other causes drawing donations instead of his organization. “And homeless, there’s a lot of interest in helping the homeless situation.”

Nationally, philanthropy experts are waiting to see if this is a broader trend. The economy is strong right now and charitable giving has increased since the 2016 election, says Stacy Palmer, editor of the Chronicle of Philanthropy. But it’s unclear if people are giving more overall or shifting their dollars to issues that are in the news a lot.

“People really have to make choices about which charities they care about the most,” Palmer says, and in a time of shifting priorities, it can be harder to get people to open their wallets when it comes to end-of-life issues.

“People don’t really like to hear about death, even though what hospices do is really make death so much easier. It’s a tough conversation,” she says. “Sometimes really important causes are the ones that suffer just because they are dealing with difficult subjects.”

But some of the blame sits with the Zen Hospice Project itself. It relied too much on loyal donors, and didn’t cultivate enough new ones, Kellar says. And, for all these years, the hospice has declined to get licensed under the government’s Medicare and Medicaid programs, closing the door on a steady stream of reimbursement payments.

“We don’t want to compromise our commitment to this compassionate model,” Kellar explains. “And if that commitment is compromised by the reporting requirements or by the regulatory requirements, we don’t want to go there.”

But idealism doesn’t pay the bills. And that’s one of the reasons Kellar was brought in four years ago: to bring some business savvy to the nonprofit. He’s a Zen Buddhist, and he’s also a Silicon Valley guy — a software engineer with a background in sales and operations.

At first, he became right-hand man to the executive director at the time, BJ Miller, a doctor and a charismatic visionary who put the Zen Hospice Project in the national conscience through a high-profile New York Times interview and a TED talk that’s been viewed more than 7.5 million times. In it, Miller talks about the importance of “sensuous, aesthetic gratification” at the end of life and how the Zen Hospice Project wants to help people enjoy the last of their time by way of the five senses.

“Seriously, with all the heavy-duty stuff happening under our roof, one of the most tried and true interventions we know of is to bake cookies,” he said, the smell providing sustenance on so many levels. “As long as we have our senses — even just one — we have at least the possibility of accessing what makes us feel human, connected.”

Kellar, on the other hand, talks about marketing and distribution and “scaling” operations.

“I am using businesslike terms to talk about it, but I think you have to,” he says.

When he took over the executive director position, the budget troubles were officially his responsibility.

One strategy he pursued was negotiating a partnership with some private insurance companies to have them reimburse for some of the hospice’s services. It’s an appealing value proposition for insurers: It costs $850 a day to care for each patient at the hospice, compared to the thousands and thousands of dollars in daily costs for someone to die in an ICU.

But after 18 months, there was still no agreement.

“We could no longer wait,” Kellar says.

Kellar presented the numbers to the board of directors, and they agreed they could no longer afford to keep the guest house going.

“As difficult and sad as it is, which it is, we’re letting it go,” Kellar says. “And that will create another space for something else to present itself. And maybe that something else is this massive opportunity.”

That could be an opportunity presented by the 43 million informal caregivers in the U.S. — people taking care of their own ailing parents, spouses, or children — who need help. Kellar says if Zen Hospice Project sells the guest house, the organization can reinvest that money into its other programs: the volunteer program, which sends people to sit with the dying in the hospice floor of Laguna Honda Hospital, and theMindful Caregiver Education program, which emphasizes caregivers taking care of themselves so they can take better care of others.

“Our mission is to transform the experience of dying and caregiving,” Kellar says. “And while we started at the bedside and continue at the bedside at Laguna Honda, it is now a time to focus on helping other people at the bedside by training and education.”

But selling this iconic San Francisco institution to as a private residence for 5 or 6 million dollars?

“It’s not what I expected,” Kellar says, shifting from business guy to Zen guy. “I guess it’s a lesson in impermanence. And a lesson in ‘things change' and to not get as attached as we are because everybody here is very attached to this.”