What role do Death Doulas play in end-of-life care? A systematic review

Experiences of engaging a death doula: qualitative interviews with bereaved family members

Background

There has been an emerging trend of adopting a death doula, a non-medical advocate and guide for people at the end of life and their families. While there has been growing empirical research regarding the work of death doulas, no studies have been undertaken with the families who have engaged them.

Objectives

To understand the experiences of families who used a death doula in terms of what they did for the patient and family; to understand the benefits and drawbacks of using a death doula; and to use family insight to determine cultural shifts towards death and dying, and what the death doula phenomenon tells us around our attitudes towards death and dying.

Methods

We recruited and interviewed 10 bereaved family members to learn about their experiences using a death doula. This qualitative research took an interpretive phenomenological approach, and thematic analysis was used to analyse the data.

Results

The most valuable attribute the families gained from death doulas was an increase in death literacy resulting in personal empowerment. Empowerment enabled positive end-of-life experiences for the family and personalised deaths for the patient. A novel finding was that the connections and knowledge shared between the death doula and family had a resonant effect, resulting in families being more comfortable with death and keen to share their knowledge with others. Therefore, family engagement of a death doula led to an increase in community awareness around death and dying.

Conclusion

Family members' experience with a death doula was overwhelmingly positive, empowering them practically and emotionally to deliver the best end-of-life care. Empathy and sharing of knowledge by death doulas were valued by families and resulted in an increase in death literacy which provided families with opportunities to 'pay it forward'. Furthermore, the relationships formed between doulas and families have the potential for a lasting, resonant effect.

Professional Roles, Services, and Quality of Life for End-of-Life Doulas in the United States

CONTEXT

End-of-life doulas provide support to the chronically ill, dying, and their families. However, little is known about the roles and services of doulas practicing in the United States.

OBJECTIVES

The purpose of the current study is to gain understanding of the roles and experiences of death doulas in the United States.

METHODS

The current study used concurrent triangulation mixed methods design combining survey data with video and audio file submissions from end-of-life doulas. The survey included demographics information, a questionnaire about the roles, services, and training of doulas, and the Professional Quality of Life Scale.

RESULTS

There were 74 (77.08%) complete responses from doulas practicing in the United States. Doulas shared about the types of services offered and professional roles they filled in work with the dying and their families. Many doulas offered hybrid or virtual services in addition to in-person care. Many worked at least partially on a volunteer basis. Professional Quality of Life Scales indicated a high level of compassion satisfaction, a low level of burnout, and a low level of secondary trauma.

CONCLUSION

In the complex healthcare system of the United States, end-of-life doulas offer valuable interpersonal services like legacy and grief work as well as practical services like financial and logistical end-of-life planning.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

End-of-life doulas: international reflections on a transnational movement

This review article summarizes the findings from the first virtual International End-of-Life Doula Symposium, held over 3 days on 25-27 April 2022. More than 40 people attended from seven countries, predominantly from Australia, Canada, the United States and the United Kingdom, and they were primarily experienced practitioners. In this article, we focus on participants' topics of conversations and experiences that were relevant across international boundaries, organized through the symposium themes of developments, disruptions, dilemmas and directions. All authors took de-identified handwritten notes across the 3 days of discussion, as well as reflexive notes about our own thoughts and perspectives on the topics discussed. We then collated our notes and abductively focussed our analysis on topics that generated significant conversation and/or came up repeatedly within the overall symposium themes, as well as trying to capture any unexpected issues and perspectives. We identify and summarize a wide range of interests and concerns within the development of the end-of-life doula (EOLD) role. We provide a model for integration pathways within existing health care systems, as well as an innovative conceptual framework synthesizing key intersecting developmental issues that are relevant across regional and national boundaries. The symposium was the first opportunity for EOLDs to collectively discuss their work and interests within an international context. Our findings indicate that there are fundamentally similar developmental issues across countries, along with some variations. As the first international event of its kind, our 'state of the field' summary review of the symposium holds significant insights relevant to both national and international contexts, and to a diversity of stakeholders interested in the development of this new care role and emerging transnational movement.

"We are Human too.": The Challenges of Being an End-of-Life Doula

End-of-life (EOL) doulas are emerging professionals who provide an intimate approach to the death process by focusing on the psychological, social, spiritual, and emotional needs of dying individuals. EOL doula work is stressful; it exposes individuals to recurring stressors such as suffering and grief. Trained professionals are needed to help advocate for the dying individual and their families. Despite the growing literature on EOL doulas, information regarding the challenges of being an EOL doula is underrepresented in the literature. This paper is one of the first to address this concept. Twelve in-depth, semi-structured interviews regarding the EOL doula experience were conducted as a part of a larger exploratory study. Three overarching themes emerged from the larger project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only challenges of EOL are discussed, along with subsequent subordinate themes.

The StoryListening Project: Feasibility and Acceptability of a Remotely Delivered Intervention to Alleviate Grief during the COVID-19 Pandemic

Background: The events surrounding the COVID-19 pandemic have created heightened challenges to coping with loss and grief for family and friends of deceased individuals, as well as clinicians who experience loss of their patients. There is an urgent need for remotely delivered interventions to support those experiencing grief, particularly due to growing numbers of bereaved individuals during the COVID-19 pandemic. Objective: To determine the feasibility and acceptability of the brief, remotely delivered StoryListening storytelling intervention for individuals experiencing grief during the COVID pandemic. Setting/Subjects: A single-arm pilot study was conducted in the United States. Participants included adult English-speaking family members, friends, or clinicians of individuals who died during the COVID-19 pandemic. All participants engaged in a televideo StoryListening session with a trained StoryListening doula. Measurements: Participants completed a brief follow-up telephone interview two weeks after the StoryListening session. We describe enrollment and retention data to assess feasibility and conducted a deductive thematic analysis of the follow-up interview data to assess acceptability. Results: Sixteen clinicians and 48 friends/family members enrolled in the study (n = 64; 75% enrollment), 62 completed a StoryListening session; 60 completed the follow-up interview. Participants reported that the intervention was useful and offered a valuable opportunity to process their grief experience. Conclusions: The StoryListening intervention is feasible and acceptable for friends/family members and clinicians who have experienced grief during COVID. Our intervention may offer an accessible first-line option to address the increasing wave of bereavement-related distress and clinician burnout in the United States.

"I can be pro-abortion and pro-birth": Opportunities and challenges for full spectrum care among doulas in Georgia

Background

The work of full spectrum doulas (i.e., non-medically trained care workers offering support before, during, and after pregnancy including abortion)-is increasingly important as abortion access decreases across the U.S. Few studies have examined the work of community-based doulas in restrictive abortion settings or how they might further incorporate full spectrum care. As part of the community-engaged mixed methods Georgia Doula Study, this analysis examines the scope of work of community-based doulas regarding full spectrum and abortion services, doula opinions on full spectrum and abortion work, and potential barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia.

Methods

From October 2020 to February 2022, the team recruited 20 community-based doulas with 8 who provide full spectrum services including abortion. Surveys covered demographics, doula scope of work, family planning attitudes, and abortion stigma. Survey data were analyzed using descriptive and bivariate statistics. In-depth interviews further explored those topics. They were de-identified and thematically analyzed using a semi-deductive approach.

Results

The findings are organized around five themes: (1) doulas of all kinds center reproductive autonomy; (2) abortion doulas play important roles in reproductive autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4) abortion doulas provide diverse services carrying numerous benefits in a stigmatized environment; and (5) abortion doulas experience challenges including stigma but they offer solutions. All but two doulas in this study were interested in learning how to incorporate contraception and abortion services in their current scope of work, and most participants supported the role of full spectrum doulas.

Conclusion

This analysis highlights the experiences of abortion and full spectrum doulas, reactions of the larger doula community to those services, and facilitators and barriers to full spectrum doula care in a restrictive abortion setting. There are urgent needs and opportunities for full spectrum doulas to offer life-protecting services to pregnant people across the U.S. and globally. Coordination efforts for U.S. abortion care post-Roe v. Wade must include community-based doulas, who are largely open to aiding abortion clients through education, connection to care, and emotional support.

The Doula Model in American Health Care in the 21st Century: A Narrative Literature Review

The doula model has been used in American health care for the past 50 years. The model dates back to biblical times-a woman who serves-the model that has passed the test of time. American women sought to improve the birthing experience in the mid-70s, and the doula model used in England was incorporated into American obstetrical care to respond to this need. With the turn of the 21st century, providing greater comfort to the dying became the focus. The birth doula model became the template. During the next 2 decades, other types of doulas-comfort doulas, delirium doulas, hospice doulas, end-of-life doulas, death doulas, and palliative care doulas-evolved. This model has provided companionship, comfort, support, advocacy, and education for many individuals and loved ones who are experiencing serious illnesses. Doulas have access to educational training and certification; however, standardization of registration, education, and/or certification has been sporadic and inconsistent. Many doulas are volunteers, and yet, many others are paid for their services. The variations in service, type, reimbursement, and roles make this model less attractive, and yet, the values of cost-effectiveness, care satisfaction, and guidance through the difficult medical experience justify further consideration in future research.

End-of-Life Doulas

Doula is a Greek word meaning "woman caregiver", and an "experienced woman who helps other women" [4].

New Faces at the Bedside: Death Doulas, Vigilers, and Companions

A growing number of nonmedical caregivers seek to improve dying in the United States. They call themselves end-of-life doulas, death midwives, soul guides, compassionate companions, and vigilers, among other names. These new faces at the bedside share a common goal of comforting the dying and their loved ones. Their work is both humanitarian and spiritual as they bring compassionate presence into the sacred space of dying. Thousands of individuals provide end-of-life caregiving through volunteer programs in hospitals, hospices, and community non-profits; hundreds more provide their services to clients for a fee. Using in-depth interviews and analysis of print and online materials, this article traces the development of nonmedical end-of-life caregiving from volunteer vigiling and companioning programs to the professionalization of end-of-life doulaing. Though professional doulas are in the media spotlight, this work began with volunteers who continue to provide most of the nonmedical end-of-life care support for the dying in the United States.

Death doulas as supportive companions in end-of-life care: A scoping review

BACKGROUND

Death doulas have gained greater attention recently by offering psychosocial, spiritual and other non-clinical support for patients with time-limiting diseases, including their families, with the potential to complement existing end-of-life care services. However, their roles, scope of practice and care impact remain poorly understood.

AIM

To describe existing knowledge on death doulas regarding their roles, care impact, training and regulation.

DESIGN

This scoping review utilised Levac et al.'s framework and textual narrative synthesis to summarise the findings.

DATA SOURCES

PubMed, Scopus, CINAHL, PsycINFO, ProQuest, Google Scholar were searched for relevant articles from inception to 20 May 2021. Empirical studies, narrative reports, unpublished theses and studies in English were included.

RESULTS

Thirteen articles were included. Death doulas take on diverse roles in end-of-life care. Their roles include providing psychosocial, spiritual, practical support, companionship and resource navigation. The positive impacts of engaging a death doula include continuous presence, holistic service and flexible payment regime. The negative aspects include role inconsistencies and confusion among healthcare professionals and the public.

CONCLUSIONS

Death doulas can augment existing end-of-life care services by providing holistic and personalised care services at home or hospital settings. Their roles are still evolving and remain mostly unregulated, with little evidence about their impact. There is a need for more rigorous studies to explore healthcare professionals' views about this role and examine the clinical outcomes among dying persons and their families.

"Would you like me to take your hand?": Introduction to End of Life Doulas

End-of-life (EOL) doulas are care providers and companions that offer spiritual, emotional, psychosocial, or psychological care to a person who is dying as well as their family and loved ones (Fukuzawa & Kondo, 2017). However, much like other options for EOL care (e.g., hospice, palliative care), their practice is often underutilized and misunderstood. There is limited research on EOL doulas, including who they are and what they do, leaving an opening for future studies to explore the topic (Krawczyk & Rush, 2020). As part of a larger investigation to gather information on EOL doulas, 12 in-depth, semi-structured interviews were conducted with certified doulas regarding their experiences. Three themes emerged from this project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only two themes, motivations to become an EOL doula and roles of an EOL doula are discussed.

Death Positivity in America: The Movement-Its History and Literature

Western society is in an era of death awareness, its most recent salience: A Positive Death Movement. This article traces the evolution of American death culture by describing key periods of change, starting with the 1700s and going through the 21st century, and overviews contemporary movement scholarship. Experts suggest our current epoch is one in which a diffuse collection of individuals and organizations advocate for approaching death differently. Movement proponents aim to modify society's "conventional" death framework, which is characterized as medicalized, institutionalized, impersonal, and lacking psychosocial emotional preparation and engagement.

Bereavement and Support Experiences of Informal Caregivers of Persons with Amyotrophic Lateral Sclerosis: A Qualitative Study

Informal caregivers provide the major part of care for persons with amyotrophic lateral sclerosis (ALS), a terminal neurodegenerative disease. Apart from providing care, informal caregivers are themselves in need of support to fulfill the task of daily caregiving and to reduce their burden of caregiving. This need for support does not end with the death of the person cared for. In this study, we explore the themes of bereavement and support experience of informal caregivers of persons with ALS from interviews conducted with bereaved informal caregivers (n = 14) in Switzerland. Three key themes were salient in our data: Reacting to bereavement, finding support, and adjusting to life without the person with ALS. These themes are contrasted with themes from interviews (n = 11) with healthcare professionals (nurses, therapists, physicians) who care for patients and families with ALS. The themes described were offering support and identifying gaps in the support. We discuss support after bereavement for informal caregivers of persons with ALS in the established public health model of bereavement support. Bereavement support needs to be proactive from healthcare professionals; however, it requires the goodness of fit to address those in need and not those who are adequately supported by informal sources of support.

Compassionate community structure and function: a standardised micro-model for end-of-life doulas and community members supporting those who wish to die at home

Background:

End-of-life doulas are an emerging, non-medical support and advocacy role for the dying and their caregivers. As more and more people are dying at home, research shows end-of-life doulas are increasingly in demand as non-medical advocates and companions for the dying, and their friends and families. Compassionate communities are essential to those who wish to die at home by helping to avoid carer stress and burnout associated with physical and emotional labour when a person is at end of life. However, compassionate community models are top-down in nature as they focus on public policy, missing a domestic-scale, standardised design applicable when someone wishes to die at home. This gap affects care networks and communications and arguably hinders the work of end-of-life doulas.

Aim:

Findings from original qualitative research with end-of-life doulas in four countries demonstrated the importance of compassionate communities for death literacy and support for a person at end of life and their networks and that all practitioners were using ad hoc, variable approaches to compassionate community formation and maintenance. A micro-level standardised and replicable model for organising and maintaining compassionate communities for end-of-life doulas which completes the established compassionate community model was developed to fill this gap and provide a vital tool for end-of-life doulas and training programmes internationally.

Methods:

Thematic analysis of research data from qualitative semi-structured interviews with end-of-life doulas in four countries was undertaken and considered as a cohort as well as by country.

Conclusions:

A model was developed that addresses a gap in international approaches to practice, offering a standardised way to discuss, teach, and implement compassionate communities for end-of-life doulas in a variety of countries and languages. This article discusses the research and model in detail.

Being an end-of-life doula

This article describes what an end-of-life doula is, the training involved and how these individuals can help someone achieve the death they want, reflecting on a role that has existed traditionally in communities for centuries without formal recognition. How end-of-life doulas work holistically but also practically will be considered, outlining how keeping the dying person's preferences and wishes at the heart of their care is the primary aim. Recent issues such as advance care planning, digital legacy and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) will be reflected on through the lens of the end-of-life doula, with the aim of encouraging open discussion and death oracy as a life skill and creating a space to make choices about the end of life. Also explored is how an end-of-life doula works within an integrative model of healthcare, working in partnership with health professionals.

Death and Dying in Long-Term Care Facilities: The Perception of Occupational Therapists

End-of-life care in long-term care facilities for older adults requires numerous skills. However, many professionals, including occupational therapists, feel unprepared to deal with death and dyingand have difficulties to attend to the real needs of the older adults and their families.This is a qualitative study anchored in phenomenologywhich had the objective to understand the perception of occupational therapists regarding death and dying inlong-term care facilities. Data were collected through focus groups and analyzed by thematic content analysis. A total of 12 occupational therapists participated in this study, and two themeswere generated: "The Experience of Death and Dying" and "The Occupational Therapist's approach in Facing Death and Dying". These results may contribute to improvingthe care provided to older adults in the process of death and dying.

System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas

Background:

Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback.

Methods:

Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders.

Results:

The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas’ involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting.

Conclusions:

Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.

Describing the end-of-life doula role and practices of care: perspectives from four countries

Background:

End-of-life doulas are emerging as a potentially important new form of community-based caregiving in the global North, yet we know little about this form of care. The aim of our study was to solicit the perspective of key stakeholders and early innovators in community-based end-of-life care about the development and practices of end-of-life doulas.

Methods:

We conducted 22 semi-structured interviews with participants in four countries where end-of-life doulas are most active: Australia, Canada, the United States, and the United Kingdom.

Findings:

This article focuses on participants’ description of the end-of-life doula role and attendant practices, and our findings provide the first detailed taxonomy of the end-of-life doula role and specific services on the basis of the perspective of subject experts in four countries. We situate our findings within literature on the professionalization of caregiving, with particular attention to nomenclature, role flexibility and boundary blurring, and explicit versus tacit knowledge. We also discuss the importance of jurisdictional considerations as the end-of-life doula movement develops.

Discussion:

We speculate that the end-of-life doula role is potentially experiencing common developmental antecedents similar to other now-professionalized forms of caregiving. Our findings contribute substantial new information to the small body of empirical research about the end-of-life doula role and practices, provide critical firsthand insight as the movement develops, and are the first research to explore end-of-life doulas from a comparative international perspective.

'It's not what they were expecting': A systematic review and narrative synthesis of the role and experience of the hospital palliative care volunteer

BACKGROUND

Volunteers make a major contribution to palliative care but little is known specifically about hospital palliative care volunteers.

AIM

The aim of this study was to understand the role and experience of hospital palliative care volunteers.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

CINAHL, Embase, Medline, PsycINFO, PubMed and three dissertation databases were searched from inception to June 2019. A forward and backward search of included papers in key journals was also undertaken. Records were independently assessed against inclusion criteria by authors. Included papers were assessed for quality, but none were excluded.

RESULTS

In total, 14 papers were included. Hospital palliative care volunteers were mostly female, aged above 40 years, and training varied considerably. Volunteers faced unique challenges in supporting dying patients due to the nature of hospital care, rapid patient turnover and the once-off nature of support. Volunteer roles were diverse, with some providing hands-on care, but most focused on 'being with' the dying patient. Volunteers were appreciated for providing psychosocial support, seen as complementary to, rather than replacing the work of health professionals. Given volunteers were often required to work across multiple wards, establishing positive work relationships with health professionals was challenging. Divergent views about whether the volunteer was part of or external to the team impacted volunteers' experience and perceptions of the value of their contribution.

CONCLUSION

Hospital palliative care volunteers face unique challenges in supporting terminally ill patients. Volunteer support in hospital settings is possible and appropriate, if sufficient support is available to mitigate the challenges associated with complex, high-acuity care.

Whither a Welfare-Funded 'Sex Doula' Programme?

The sexual citizenship of disabled persons is an ethically contentious issue with important and broad-reaching ramifications. Awareness of the issue has risen considerably due to the increasingly public responses from charitable organisations which have recently sought to respond to the needs of disabled persons-yet this important debate still struggles for traction in academia. In response, this paper continues the debate raised in this journal between Appel and Di Nucci, concurring with Appel's proposals that sexual pleasure is a fundamental human right and that access to sexual citizenship for the severely disabled should be publicly funded. To that endeavour, this paper refutes Di Nucci's criticism of Appel's sex rights for the disabled and shows how Di Nucci's alternative solution is iniquitous. To advance the debate, I argue that a welfare-funded 'sex doula' programme would be uniquely positioned to respond to the sexual citizenship issues of disabled persons.