'Will you stay with me?': The No One Dies Alone program
ANYONE WHO'S BEEN A NURSE for any length of time has known the feeling of being left with an an unpleasant, lingering memory from a patient case. It may be an error made, an innocent oversight, a decision that reflects lack of judgment, or something said—or even not said—by a patient. Whatever the circumstance, few nurses are ever granted the privilege of transforming this event into a vision that will blossom into one of the most extraordinary and rewarding experiences of a lifetime.
SACRED HEART MEDICAL CENTER, 1986 It was a rainy night in Eugene, OR, in 1986. Sandra Clarke, RN, was working as a staff nurse at Sacred Heart Medical Center. While making rounds at the beginning of her shift, she entered the room of a frail, elderly man with a DNR order on his chart. In a barely audible voice, he pleaded, "Will you stay with me?" Sandra promised him she would return as soon as she checked on her other six patients. After taking longer than she had anticipated, she returned to his room, ready to apologize for the delay. As she approached his bedside, she saw his pale, outstretched hand. He had died alone.
Sandra tried to rationalize the event. Her patient was elderly, had multisystem failure, and was going to die anyway. But his final moments were not supposed to be this way. It is unlikely that any human being would ever choose to die alone. Sometimes, however, circumstances are such that a person has no family or close friends, as was the case with this gentleman. Other times, someone may not have those who care living in close proximity to the healthcare facility. We live in a mobile society, and it could happen to anyone.
A PROGRAM IS BORN Sandra decided she would transfer to the intensive care unit, an environment in which patients are surrounded by personnel and technology. However, troubled by her broken promise, she was determined to find a way in which other patients at her hospital would never have to die alone. She envisioned a volunteer companion program. When she questioned other employees about being willing to sit with a stranger who was dying, she received mixed responses.
Fourteen years later, while working in ICU, Sandra still was harboring thoughts from the 1986 incident. She had volunteered to participate in a new pilot program at her hospital to develop an ethics resource team for staff members. During the training period, the Director of Pastoral Care, Bob Scheri, overheard Sandra discussing her concept. At his request, she outlined a proposal. PeaceHealth, the corporate organization of Sacred Heart Medical Center, endorsed her innovative idea. No One Dies Alone (NODA) became a reality in 2001, and the rest is a heartwarming history.
HOW IT WORKS No One Dies Alone is a simple and economical plan. It is basically a voluntary, unpaid phone-tree program in which volunteers sign up on an Internet site for a week, during which time they pledge to be available to stay with a dying patient. At PeaceHealth, a two-hour minimum bedside vigil assignment is preferred. The volunteers are comprised of hospital employees as well as existing unpaid volunteer staff. There is one part-time paid position of program coordinator, who oversees all functions of NODA and administers the program's advisory committee.
According to specific criteria on each nursing unit, either the chaplain or the nursing supervisor is notified when a patient is expected to die within 48 to 72 hours and there are no friends or family available to stay with them. The chaplain or supervisor reviews the request and contacts the phone coordinator, who then schedules coverage. The volunteers, who are called "Compassionate Companions," wear a special badge with an attached ribbon that identifies them. Upon arrival to the unit, they introduce themselves to the nursing staff, which supervises and assists them.
Every volunteer must sign a confidentiality agreement and have a background review, current tuberculosis testing, and at least six months' experience at PeaceHealth. They each complete an orientation program, are educated about their role, and receive the book The Art of Being a Healing Presence by Susan Cutshall and James E. Miller (Willowgreen, 2001). Compassionate Companions do not assist with patient care nor replace sitters, but they do provide comfort. During each vigil, they are provided with a bag that contains supplies such as inspirational, spiritual, and soothing CDs, along with a Bible, rosary, inspirational poems, hospital parking passes, and meal tickets. Note cards with NODA's logo are provided for the volunteers to communicate thoughts for patient's families. Sometimes several volunteers compile running comments. The cards and comments are left with the patient and given to the patient's family, if they have any, along with any personal belongings. Following a bedside vigil, the volunteer is sent a thank-you note. All volunteers are contacted before and after their assigned week to maintain a sense of connection and to make them feel part of the program. They have quarterly meetings and an annual luncheon, at which time they are presented with a small gift.
In 2003, PeaceHealth developed a guide to inspire other institutions to emulate its NODA program. Available by request for a minimal charge, the program has been distributed on an international level. More than 800 NODA programs have been implemented throughout the world, including at nursing homes and even one in a California prison. Clarke has received international recognition and several prestigious honors. Among them are the Circle of Excellence Award from the American Association of Critical-Care Nurses (AACN) for Excellence in Collaboration and the Recognition Award from the organization now called the Association of Healing Healthcare Advocates.
THE TEXAS MEDICAL CENTER, 2007 According to the NODA Guide, the program was not copyrighted so that other institutions could individualize it according to their specific needs. Such is the case at our facility, the Methodist Hospital in the Texas Medical Center, Houston. Following an 18-month pilot, the NODA program was implemented in March 2007. The hospital initially conducted two informative brunches for its employees in an effort to recruit volunteers. These brunches generated an overwhelming response, and some individuals outside the hospital had learned of the program and requested to participate. NODA at the Methodist Hospital is based on the concept of PeaceHealth, with some modifications. All volunteers must complete an application and an orientation program. As with all our employees and members of our unpaid volunteer staff, the volunteers are required to have TB and Joint Commission testing, and a drug screen. Continuing education opportunities are ongoing. Recently, an author and professional lecturer provided a luncheon series on the "Dynamics of Death" and "Taking Care of Yourself as a Volunteer." Our volunteers also have access to "Sharepoint," an Internet site that contains articles on topics such as grief and dying. After a vigil, they receive a telephone call and a handwritten note of appreciation.
Every nursing unit at the Methodist Hospital has the information specifying the three criteria for notification. The patient must be designated for comfort care or a full level-3 DNR classification, death is anticipated within 72 hours, and family is unable to provide sustained presence. Our companions do not provide respite care when family is intermittently present. If a patient meets the criteria, the Department of Spiritual Care and Education or on-call chaplain is contacted, and an e-mail is sent to all volunteers indicating that there is a need for a vigil. Volunteers then sign up for three-hour periods, except during the night shift, in which a six-hour time frame is allowable. Our hospital has a chaplain present on a 24-hour basis, and the clergy visits every Compassionate Companion during his or her vigil. Our volunteers also have a bag containing supplies similar to that at PeaceHealth. If any family is available, they are questioned about the patient's spiritual beliefs and what they would want. For example, one of our patients was a Native American. After communicating with a family member, the companion was able to obtain an appropriate Indian reading and icon for the patient. The volunteers also inquire about any special wishes from the family. Such was the situation when an elderly, disabled mother who lived outside Houston was unable to be with her dying son. She requested that Psalm 91 be read to him. The volunteer kept the mother on the phone during the reading.
Currently, at our hospital, about two to three vigils are held each month. The stories and situations related to our experiences are compelling and will forever remain in the hearts and minds of our staff and those who participated. The following are just a few of the situations in which the Compassionate Companions conducted vigils:
- A 26-year-old woman was transferred from another institution following complications of bariatric surgery. She was a single parent with two small children, both of whom were ill at the time. Her mother had to remain at home to care for her children, and her father's method of coping was emotional detachment. This was extremely disturbing for the staff, and a nurse notified the hospital chaplain. Once the vigil began, the companions remained in constant communication with her mother.
- A patient was visiting Houston when he was hospitalized and unexpectedly facing death. His son was overseas, and his daughter was in another state. Although neither of his children could arrive in time to be with him in his final moments, he was constantly attended. When his daughter did arrive, she asked to personally meet those who had been with him.
- A 51-year-old woman was admitted in an irreversible condition following cardiac complications related to a tooth infection. Her husband refused a DNR order and was so distraught he had to be escorted out of the hospital. Although he did not return, he called the nursing unit and requested life support to be terminated under the condition that someone be with her. His wishes were respected with the presence of a Compassionate Companion.
As with PeaceHealth, our volunteers keep a running narrative of comments, which are given to a patient's loved ones, if any. When a patient dies in the presence of a volunteer, a report is written to the Manager of Bereavement Services, who chooses some of the information to share with the family in a formal letter from the hospital.
It is amazing how intense the devotion and bonding to someone they just met can be. The following are just a few moving excerpts, written during a vigil, from the hearts of our volunteers:
"I arrived at 2 PM to sit with Tina. All her fingers are cold and discolored. She seems very comfortable, but she has rapid respirations. I introduced myself and took her hand. This assignment is a little difficult for me due to Tina's age. My daughter is also the mother of small children. I pray that Tina finds peace and is able to look down on her little ones from above."
"I arrived a little before 5 PM. She is resting peacefully, breathing slowly. I have greeted her and introduced myself. As I hold her hand, I am praying for her family and her peaceful passing. I hope and pray that angels greet her and she is embraced with God's love. It is difficult for me to pray out loud, so my prayers are quiet and in my heart, but still I speak softly to her and reassure her of my presence."
"I arrived at 8:30 AM, and Tina was resting quietly. Her mom called and requested that she get her hair washed. The nurse washed her hair and then we combed it. Her hair looked so nice. It is short now because her hair was cut to make lockets for her children. What a wonderful keepsake. We prayed and read several of the Psalms. I sang 'Amazing Grace' and 'How Great Thou Art' to Tina. These are two of my favorite hymns. They always bring me comfort, and I hope they brought some comfort to Tina, also. I was so honored to be able to share some time with Tina."
Some of our Compassionate Companions schedule more than one vigil with the same patient. Following are a few poignant and eloquent words expressed by one of these volunteers describing the moment of death:
"At 2:30 PM this afternoon, I was praying the Lord's Prayer. John's vital signs continued to decrease and decrease, and I continued praying with John and letting him know how much he is loved. It was such a peaceful passing with no suffering that I was almost shocked that it was happening. Saying the Lord's Prayer must have been comforting to him. I was not nervous or scared, just overcome by the emotion of it all. Last night, when I sat with him, I was grateful that he had not died. But today, I am grateful that I was the one who was with him. ... This is the most beautiful program, and it is an honor to be part of it."
THE GIFTS No One Dies Alone has brought a tremendous gift to those who participate. Our volunteers range from senior management to employees from Transportation, Security, Laboratory Services, and Housekeeping. Interestingly, those who volunteer are primarily from the ancillary staff. Many have little or no patient contact, and they say this experience gives them the opportunity to be at the bedside. Sometimes, however, the ICU nurses sit with patients during their off-hours on the units in which they work. Some of the volunteers who are not hospital employees are real estate agents or are involved in the Houston oil industry.
No One Dies Alone is so simple, yet it encompasses palliative, emotional, spiritual, collaborative, and interdepartmental care. This program is the great equalizer. We see other employees from a different perspective. The person sitting for a vigil may be one of the top hospital administrators or the one who serves us in the hospital cafeteria. Yet at the bedside of a dying patient, everyone's role and purpose is the same. This entire program has enabled each person involved to be left with feelings of privilege and honor by providing peace and dignity to a stranger. This is such a contrast to leaving a dying patient isolated, alone, and frightened. For us as nursing professionals and human beings, when we witness this program in action, nothing can be more profound.
Following are the words of just a few of the volunteers that express the personal rewards of the No One Dies Alone program at the Methodist Hospital in the Texas Medical Center:
BEVERLY ALLEN, Executive Secretary to the VP of Operations: "You have to wonder what circumstances brought someone to the place of facing death alone, and no matter what their circumstances, my heart longs to fill that gap for them. To let them know there is a human presence, to hold their hand and assure them that they're not walking this path alone, is so very rewarding. ... All I can tell you is that these have been the most rewarding times of my life, and I will volunteer for this program as long as I am able. I love this hospital and the fact that they support such an awesome program."
CARMEN GOLDEN, Medical Technologist in Hematology: "The first time I sat with a patient, I knew that was God's plan for me. Everything became clear at that moment. ... I get so much more than they get from me. ... There is this indescribable presence and peace in the room. You can actually tell when they are 'ready' for their final walk. And when I walk out of their room for the last time, I gain a peacefulness and understanding that words cannot describe. It is as if God has followed me out of their room, holding my hand and walking beside me all day long. Volunteering is not about me. It is the message I wish to share."
AMANDA PILCHER, Major Gifts Officer with the hospital's foundation: "I had never before been in the presence of someone dying, and it was not at all what I expected. ... I was initially fearful of what was to come, but quickly felt a calm come over me as I shared the most beautiful final hours of a man's life with him as I held his hand and sang to him. I too was at peace, yet overwhelmed by the life experience taking place. It was truly an honor and privilege to share these final moments with him."
No One Dies Alone is a long overdue godsend to our nursing staff. It relieves the emotional burden, disheartening feelings, and guilt of having to leave a dying patient to attend other duties. According to Denice Foose, Program Manager of Bereavement Services and staff chaplain at our hospital, "Our nurses not only greet the Compassionate Companions when they arrive, they 'embrace' them."
JOY SHILLER is a nurse at the Methodist Hospital in the Texas Medical Center in Houston, TX.
STAFF EDITOR: STEVE MULLETT
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