I'm responding to Gena's request about our the "passage quilt" that is used where I work, and I want to pose a question: do you have any EOL rituals at your place of work for the patients? for the staff? That you've developed for yourself?

The rituals we use where I work (VA)were adopted from other area hospices.

The first place I experienced this kind of thing was at Our House of Portland, which was started for a place for individuals with end-stage AIDS. When I first started to volunteer there it was pre-cocktail, so people mostly came to die. There were several rituals there. One was that the philosophy that "no one should die alone" and as these were mostly people with no family in their lives, so when a person started actively dying volunteers were called to come and sit with them.

When someone passed, their body was washed and a candle was lit in the room and they were covered with a passage quilt, hands and face left exposed. This was a quilt that was made by volunteers and was just a beautiful quilt. Anyone who was on the notify list was called (either when the person was actively dying or after they died) so that they could say "good-bye." When the undertakers came, they would put the person in the body bag, cover the bag with the quilt. The other residents would be informed that the body was going to be leaving the building so that they could either see them off or close their doors and anyone who wanted to (staff, volunteers, other residents) processed out with the body. The quilt was removed once they were placed in the van, and put back on their bed. Usually things that were important/symbolic of the person was put on the bed, the room was straightened up and there was a 24-48 hour period where people could come and say goodbye. Within a few weeks there'd be a circle for that person where anyone who wanted to (family, friends, and people associated with Our House) could come and tell stories about that person to celebrate their life. There were also quilts on the walls where people's names would be embroidered after they had passed.

Where I am now we have several of the same rituals, plus a few of our own. First of all, out side all of our hospice rooms there's a shadowbox where we encourage people to put pictures, medals, and other objects that help us get a better picture of who the person was when they were healthy -- lots of pictures from military service, but also things like newspaper clippings, wedding/family photos, etc. It really helps to keep the person in one's mind when caring for them.

When a person is actively dying, a butterfly is put on their door to let everyone know. When they pass, we use an electric candle, and the quilts (made by VFW -- Veterans of Foreign Wars -- women)all have red/white/blue themes. Generally, for the procession out it is only staff and sometimes family. The VA LTC facility where the hospice unit is has a outside area with a flag pole. The flag of the branch of the service they were in is flown at 1/2 mast, and a wreath with their name and the dates of their service is put in the dining room (this was at the request of the vets who said they it was very upsetting to have people die and they never hear about it). There is a quarterly memorial service at both the hospital and the LTC facility (they are in different locations) for the people that died during that time. In the hospital, it is the responsibility of the chaplain resident or chaplain fellow to design the service.

Surprisingly, I haven't developed any rituals outside of work. I do know a hospice nurse who planted a rose bush when a particularly memorable patient died.

So, anyone else?

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A Window For Your Home: Stories of dying and doctoral education

http://awfyh.blogspot.com/

magic is the deliberate manipulation of coincidence

Working at a Frail Care facility for the aged we have our fair share of residents who move on to the next plain.

The home as such does not have any set rituals but I firmly believe that no body should have to die alone.

If the resident has family present I pop in every 10-15 minutes to check on the resident and right near the end I will stay with them in the room and just place my hand on their shoulder.

For the resident without family present I spend the whole time in the room with the resident with my hand either holding their hand or resting on their shoulder. When I need to do rounds to the other residents I get one of the carers to take my place for that time.

The home them has a celebratery meal once a month to remember all those who have passed.

One of our local Undertakers will take any flowers in the residents room and place them on the shroud over the residents chest. A staff member will them escort the resident to the hearse.

Apeman, that's wonderful that you are so dedicated to your residents. 1,000 blessings on you for being so attentive and caring (and good on your employers for not blasting you for spending so much time with a resident!)

You know, the thing I've learned over time doing EOL work is that what you think you know for certain...isn't. For example, home is not always the best place to die. Another certainty I have had to question is the "no one should die alone." I'm not saying that dying people should be ignored (which, unfortunately was, and may still be in some places, the case in hospitals where staff weren't comfortable with dying and felt "well, there's nothing I can do for them now that we've withdrawn tx"), but I've come to learn that some people need to be left alone to die, at least at the very end.

For all the stories I have of people hanging on until person X arrived to say good-bye, I have an equal number of stories of people who lingered and lingered, and finally, the family left the room to get some fresh air, or a smoke, or whatever, and that is when the person passed. I think they sometimes are trying to protect their families from seeing them die.

My favorite line though was another hospice nurse who talked about an attentive family that was surrounding the bed, and the patient lingered and lingered. Her comment was that "they were blocking his exit." Sometimes we aren't aware of how fiercely we hang onto those who we love.

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A Window For Your Home: Stories of dying and doctoral education

http://awfyh.blogspot.com/

magic is the deliberate manipulation of coincidence

My aunt was dying in an ICU. She had been in V-Tach for over an hour (although only 64, there was virtually no chance of recovery so my uncle made her a "no code"). Then the doctor and the nurse came in and very gently went over the care plan and what we would have them do if "x" or "y" happened - short of a full arrest.

The last thing they brought up were the vasopressors she was on - and there were four of them. I softly told my uncle "that's all that is keeping her here...those drugs'.

He said, "Okay, it's time to stop them, but can we wait until my son gets here?"

The very second he said "it's time to stop them" my aunt went into asystole.

It was as if she hung on and on until she got "permission" to go.

********

On the professional side, there is no time for rituals in the ER and so often we are expected to "suck it up" and move on to the next patient with no time to process the fact that we just witnessed a death.

But I guess I have a personal ritual because I will continue to talk to my patients as I do their post-mortem care. Somehow I feel that somehow, somewhere they can hear me and the last thing I can do for them is care respectfully for their body after death.

And then I cry on the way home.

The day I stop crying will probably be the day I leave nursing.

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The ER is the only place where you are rewarded for efficiency by getting more patients!

Kim
http://www.emergiblog.com

KimRn
Your post brought me back to my first days on the wards as a young student. In those days we "laid out" our patients on the ward after death. my first death was an 8 months old baby boy (CHD). My ward sister told us " This is the last thing you will do for your patient before he leaves your care. Do it with pride, do it with care and do it with respect". Twenty years later, I have never forgotten her words and I still carry out her instructions every time. Even after a rookie Social Worker told me a couple of years ago "We prfer not to use the word died. we prefer end of life experience"

I have my own personal ritual I use in the ER. First I make sure the patient is clean and the clutter is out of the room. If the patient was an arrest, I generally leave the crash cart in the room so that the family will know that we did "try" to save their loved one. I raise the head of the bed to 45 degrees so that the face is not blue or mottled. I cover the patient with warm blankets, especially around the hands so the family feels warmth when they touch the patient, not a cold body. I place kleenex on the night stand and I dim the lights so the stark reality of how the patient looks doesn't appear so harsh. I put the side rails down so the family can caress or kiss the patient. It's a ritual for me, some think it's silly, others have adopted it.

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www.MyOwnWoman.blogspot.com

Thanks for the reminder about raising the bed and using warm blankies. I remember hearing someone mention that and thought it was a wonderful touch (nice when you have blanket warmers, but in the LTC unit we just used the dryer). Cleaning up the room is such an important thing. Besides all the medical related stuff, if people have been holding vigil so much stuff can accumulate. I would never have thought to leave the crash cart, truly subtle bit of sensitivity.

BTW, this all inspired me to write up why this is such an important thing for me to do --- and for once I wrote it on my blog instead of here.

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A Window For Your Home: Stories of dying and doctoral education

http://awfyh.blogspot.com/

magic is the deliberate manipulation of coincidence

huh, for some reason, a post of mine disappeared, and now my signature line is gone! So, if you want to see the post referenced, go to: http://awfyh.blogspot.com/

__________________
A Window For Your Home: Stories of dying and doctoral education

http://awfyh.blogspot.com/

magic is the deliberate manipulation of coincidence

Thanks for posting that, Marachne

As I said in another post, I am not fond of preparing bodies for the morgue. Maybe it's because we have to wrap them up naked in a smelly plastic bag. I've never liked doing that.

I always try to put a gown on them before putting them in the bag. Just makes me feel better.

There's a culture here who likes to keep the body in the place the patient died for 8 hours after death. That's not always easy to accomodate in a busy ICU, but we try our very hardest. I think we moved a patient to another floor once when we were absolutely getting slammed with patients. It's hard to justify using an ICU bed for a deceased patient when there are living patients who need ICU care.

It's nice to read about other's EOL rituals.

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code blog

My "end of life care" begins before the patient dies. As a house supervisor I have the privilege of receiving report on every patient. When I know that someone is in extremis, I sit with them if they have no friends or family in attendance. I hold his or her hand. I explain what is happening. I sing lullabies and songs of hope. I also tell them about the hope I have found in this life and in the one to follow. I invite him/her to join me in that hope. When I have to leave, I arrange for a staff member to sit with them until I return. I say goodbye each time I leave the room. And, finally, if the patient dies with me at the bedside, I tell him or her a last goodbye and a soft "See you soon."

If family or friends are present, I encourage them to tell stories - and they do. I listen to what they have to say about one another and about the loved one who is dying. I listen to them laugh, express anger, and tell of their hopes, fears and dreams. I laugh and cry with them. I witness their anger. I explain what is happening both to them and to their loved one. I ask them to consider talking to the one in the bed about the wouldas/couldas/shouldas. I then check on the family often during the night. Sometimes they want to talk. Sometimes they simply want me to sit with them for a while. Sometimes we pray together. Sometimes they ask me to pray for them all. And sometimes, when grief saturates the room leaving them without words, I simply lift them up in my heart to the One who loves us all.

What I do is not politically correct and is not approved by the leadership of my facility. But I do not care. I have seen too much death and dying to withhold love and support as death approaches.

Joy