After the Last Note

“In the East the highest kind of music is that which sends the listener into samadhi. The silence which follows is an essential part of the music. The audience should be in the state of people who are watching the sun setting into the sea – they forget the circumstances which brought them there, they forget words like ‘sun’ and ‘sea’, they forget their own names and individualities. After the sun has gone, for a time there is no impulse to move – certainly not to clap or applaud.”

T.P Leggett, Zen and the Ways, 1978

In the West, without the meditative tradition that underlies much eastern music to guide us, our relationship to silence is less sure. In a society pre-programmed to move onto the next thing as quickly as possible silence has little currency. Often, when the last note of a musical performance ends we can’t wait to clap, stand up, whoop and walk out.

There are times, however, especially at the end of sad or quiet works, when the last note calls out to be followed by silence. Somehow, as listeners, we understand this need and allow ourselves to be part of it. In classical concerts, the conductor may assist by keeping his arms raised, holding the silence so that the audience can absorb with fullness what has gone before. The silence becomes essential for our appreciation.

When such pieces of music are performed in memory of someone who has died, the silence that follows the last note takes on a more reflective and healing quality. In those quiet moments, moved by music and memory, we are able to acknowledge the loss and take strength before moving on. We accept and feel the value of silence.

Elgar’s Nimrod – A performance in memory of the conductor Georg Solti.

In the hospital emergency room there is little time to pause and reflect – healthcare workers are expected to witness profound loss and then move on quickly to take care of the next patient. Unfortunately, this relentless rush can leave clinicians in a state of numbness, disengaged from the humanity in each individual encounter. Time pressure is the enemy of compassion, as the psychologists Darley and Batson knew only too well.

At the University of Virginia Medical Center, former ER Nurse Jonathan Bartels realised that in order to help healthcare staff acknowledge and accept the loss of patients without disconnecting emotionally, there needed to be a pause, there needed to be a silence.

“I noted that when people die after a traumatic instance, a code, often I would see surgeons and docs and nurses walk away with frustration, throw their gloves off in a defeatist attitude, not recognizing that the patient was a human being we worked on saving. So after these deaths I decided it would be a good thing to stop and pause and do a moment of silence. Just stopping. Honoring them in your own way, in silence.” says Bartels

Bartels’ invitation for members of the healthcare team to stop and honor the patient who had just died under their care was met with positive feedback. The practice that has come to be known as “The Pause”was born.

“Healthcare providers want a way to acknowledge death as a human rite of passage, a way to focus on the basic importance of human-to-human care” says Bartels

Approaching death from a scientific standpoint, a point of detachment, sterilizes the event for healthcare providers who are socialized to view death as a failure, he believes.

The 45 seconds to a minutes silence -“The Pause”- creates the space “to honor the human life that was lost, recognize the loss the family experienced, and acknowledge the medical team for their work and valiant effort.” says Dorrie K Fontaine, Dean of the School of Nursing at the University of Virginia.

Pause1.jpg (2450×1633)

“Maybe it’s a prayer, for those who pray; maybe it’s a time to close one’s eyes, clear one’s head and be still, for those who meditate; maybe it’s a time to take a series of breaths for those who need to settle their spirits; maybe it’s a reflective quiet to reflect and prepare for what’s next. …..But however it looks, this is a pause that marks a passage. Patients’ families often participate too, and feel its value.” concludes Fontaine

Introduction Video

“The Pause” seems to be resonating strongly with people. It has spread from the ER at the University of Virginia Medical Center to other departments, other hospitals, and, other countries. The practice is also being taught as part of the curriculum at the University of Virginia’s School of Nursing. The Dean, Fontaine, believes that it will help create more resilient professionals, who by taking better care of themselves can take care of others with more compassion and strength.”These are simple ideas that work”, she states.

In a society that has become uncomfortable with silence, sometimes we need a little assistance – a conductor holding his arms up, or an invitation to a practice. Maybe, if we can remind ourselves that the silence that follows the last note is an essential part of the music, we will be better placed to acknowledge what has been, and better prepared to accept what will follow. Sometimes there should be no impulse to move.












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