Applications and benefits of Ho'oponopono?

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The ER television show, originally aired thirty years ago, has been revived in the HBO Max series "The Pitt" (Adarkwa & Lankwarden, 2025). Dr. Robinavitch, an ER attending physician, is portrayed by Noah Wyle, who is recognized as his younger role alongside George Clooney when the 90's sitcom first aired and brings back a familiar perspective on emergency room medicine. The setting is a modern-day trauma center in Pittsburgh, where Dr. Robinavitch demonstrates his medical expertise as a seasoned ER attending physician, leading a team of care team providers of nurses, medical students, residents, and other junior and tenured physicians, surgeons, and social workers. Each episode covers the life of the ER environment in just one hour of the shift per episode of the series.

Post Call Rounds: Horrible Night in the ED

In the first episode, the writers of the series Adarkwa & Lankwarden (2025) portray on screen the first hour of the morning shift. Dr. Robinavitch, the day shift oncoming doctor, receives a report from the night shift doctor as he hands the change of coverage to the incoming day doctor at the sign-out. In basic terms, communication occurs between ED doctors. It is the handoff and is a talk about what happened during the night, what needs to be completed, and what is currently happening so that the continuity of care for patients in the ER is seamless and continuous, all the while the next day shift brings new admissions, traumas and the peculiarities of the ER environment primarily as the waiting area becomes full.

The handoff and morning rounds take place in a somewhat nontraditional format—on the hospital's roof, where the night shift doctor is grappling with the aftermath of a horrific evening, taking care of a soldier and veteran of a recent deployment who survived two combat tours only to come home and pass away in the Pittsburgh emergency department. The ED physician is contemplating jumping off the roof as the morning discussion unfolds, and his colleague, Dr. Robinavitch, literally "talks him off the roof."

Patient from the SNF

In the most recent episode of The Pitt, Dr. Robinavitch has been grappling with the dilemma of a patient who was admitted from a skilled nursing facility with what appears to be an altered mental status and difficulty breathing. The patient's two surviving children are at odds with their father's POLST, or the document that defines how to proceed with medical therapy for those patients who have a grave illness and or are nearing death, such as whether or not to perform life-saving measures that could prolong the inevitable or incur more suffering than comfort during the last moments of life. The end-of-life process in the ED is never ideal for staff or the community.

The scene, filled with emotion from Dr. Robinavitch as he grapples with performing interventions to help a dying patient breathe and helping the surviving son and daughter understand what is at hand, that is, their father's active dying process, are also at odds with the decision to redact the instruction of the POLST and perform life-saving measures as they have yet to close the loop or come to terms with their father's relationship as his children.

The two grown adult siblings, both of whom appear to be middle-aged, debate whether to keep their father alive, not understanding the gravity of the dying process. For reference, during the dying process, Emanuel (2018) describes the experience of families and loved ones of shame, regret, and guilt at reversing the steps initiated, for instance, in the POLST. At the same time, Dr. Robinavitch tries to endear himself to them and, with a compassionate frame of mind, exercises empathy to help them understand what the dying process could look like, that is to say, peaceful and part of the human experience, or they could watch their father suffer more in the hours and days to come by keeping him alive with for instance a breathing machine impacting his current quality of life.

The scene unfolds into an experience that, at this point, is worth noting. It is often the case that professionals in the hospital environment frequently encounter and are sometimes faced with the fact that families are often not prepared or ready to have the conversation and accept the inevitable and the letting go process of loved ones. A concept that Dr. Atwul Gawande has described in his book Being Mortal (Gawande, 2014, p. 259) is that the reach of medicine has limits and that human biology will take its course at the end of life.

It is crucial here to acknowledge a concept that was highlighted during the most recent episode, where the adult children of a dying father were looking for an opportunity to find closure with their father as he is actively dying. Notably, the daughter's emotional response is visualized on-screen as her present anger, irritation, and unwillingness to let go of her dad. Elements of her and her father's past relationship indicate a rough history of trauma and discord, as evidenced by her on-screen emotional distress.

Therapeutic Conflict Resolution

Scholars have studied and pointedly identified the existential connections of forgiveness as it relates to hurt and injury and is an ethical, moral conflict that all humans experience. Enright & Song (2022) describe the REACH module of forgiveness in their scholarly writing. The first therapeutic technique is to help others recollect the situation that caused feelings of hurt; second, try to practice empathy with the person who performed the hurt situation; third, with a spirit of altruism mindset, navigate a forgiveness path; fourth, make a pledge and commit to forgiving the offenses, and lastly hang on to the forgiving.

In the scene, Dr. Robinavitch incorporated the REACH model of therapeutic forgiveness (Enright & Song, 2022), an element of spirituality in healthcare, by asking open-ended questions about religion/spirituality and God and guiding the adult siblings towards the forgiveness closure experience as time seems to be running out in the scene. The on-screen performance evolves, demonstrating care withdrawal as the standard practice during end-of-life care. This is evidenced by the monitoring being turned off, the oxygen being removed, and the agonal breathing demonstrated by the dying father. In the show, the dying patient receives a scopolamine patch and frequent airway management with the Yankeur suction device to manage secretions. 

As the conversation erupted, the two surviving adult children were apt to reply that they did not have a God and were searching for a spiritual direction, as Dr. Robinavitch could sense they needed spiritual guidance or a hunch. Dr. Robinavitch helps the adult siblings navigate the forgiveness path. He refers to his mentor, who taught him a strategy using virtuosity for times such as these. The strategy uses tribal methodologies and practices from Hawaiian traditions: the concept of the Ho'oponopono.

The Ho'oponopono

According to Hurdle (2002), the native Pacific Islander technique has elementary roots in helping native tribal Hawaiian families resolve interpersonal conflict and was traditionally performed by the tribal leader. To perform ho'oponopono means to help individuals work through a process to correct wrongs done to each other in a structured style with open communication. The ultimate goal is to settle disputes, disarm and neutralize feelings of hurt, resolve words of distress, ill-temper, and rage, and finally cope with the challenges of relationships elsewhere (Hurdle, 2002).

In the scene, Dr. Robinavitch describes ho'oponopono and guides the two siblings to four concepts they can practice with their dying father. In his own words, he announces the following: The first is, "I love you." The next is, "Thank you." Then, "I am sorry, and I forgive you." Finally, he verbalizes, "Forgive me" (Adarkwa & Lankwarden, 2025). As the moment presses forward with their father leaning on his final breaths, the daughter and the son work through their process of those above, talking to first their father and then to each other, reopening old childhood wounds as each has experienced their father differently and in separate ways seated next to their father in his bed. The ho'oponopono technique appears to help the daughter and son find resolving life moments with their father as he nears death.

What can be learned from native Pacific Islander traditional practices of the ho'oponopono conflict resolution practice? These techniques can be applied to any situation where conflict resolution is needed in schools, churches, places of work, and the like. One does not need to wait until one's loved ones are nearing the end of life before one tells them what one needs to say, and that is communicating in a manner that demonstrates and expresses the love one has for another, being able to express hurts and injuries, having the opportunity to own and share in the hurts by accepting one another and forgiving one another that healing and resolution can take place. Although hard to practice, can the healing agency of the island of the Pacific of the ho'oponopono method heal relationships of all sorts, optimistically and faithfully? Yes.  

References:

Adarkwa, C., & Lankwarden, M. (2025). 10:00 A.M. The Pitt. Episode, HBO Max. Warner Media Direct LLC, https://www.play.max.com

Emanuel, Ezekiel J. (2018). Palliative and end-of-life care.  In J. Larry Jameson & Anthony S. Fauci & Dennis L. Kasper & Stephen L. Hauser & Dan L. Longo & Joseph Loscalzo (20th Eds., Vol. 1), Harrison's Principles of Internal Medicine (pp. 47-63). McGraw-Hill Education. 

Enright, R. D., & Song, Jacqueline Y. (2022). Forgiveness therapy. In Christopher C. H. Cook and Andrew Powell (2nd ed.), Spirituality and Psychiatry (pp. 281–292). Cambridge University Press.

Gawande, A. (2014). Being mortal: medicine and what matters in the end. Picador.

Hurdle, D. E. (2002). Native Hawaiian traditional healing: Culturally based interventions for Social Work Practice. Social Work, 47(2), 183–192. https://doi.org/10.1093/sw/47.2.183