By the end you can
- Plan a vigil with a person and family, and fill in a written vigil plan that covers people, room, senses, safety and shifts.
- List the comfort measures a doula may offer, and name the ones that belong to the care team.
- Help a family call the hospice 24-hour line with four facts ready: who, what changed, since when, and what has been tried.
- Explain to a family what usually happens at and just after a death, who pronounces it, and why the "who do we call" decision must be made in advance.
- Keep yourself and the person safe when you are alone with them, and say when you would call 911.
Scope check for this module
A doula may
- Sit with the person, talk to them, read aloud, play music, and hold a hand when the person or family welcomes it.
- Help the person and family write a vigil plan and a rota of shifts.
- Offer a cool cloth, a warm hand, a blanket, softer light, a quieter room.
- Help the family phone the hospice 24-hour line, with the facts ready, and write down what the nurse says.
- At a death: sit quietly, note the time as the family saw it, and call the number the plan names when the family asks.
Hand to the care team
- Anything to do with medicine: giving it, timing it, questions about it, or disposing of it.
- Oxygen settings, feeding and fluids, and any tube, pump or line.
- Turning or moving someone who is in pain, and any lifting. You follow the team's instructions and the family's decisions.
- Any change in condition: new pain, distress, breathing changes, a fall, bleeding, a seizure, fever.
- Pronouncing death and the death paperwork. That is a clinician's job, and who may do it depends on the state.
What a vigil is, and what it is not
A vigil is the practice of staying close to a person who is dying, usually in the last days and hours. The National Institute on Aging (NIA) puts it simply: staying close to someone who is dying "is often called keeping a vigil." In the doula field, the International End of Life Doula Association (INELDA) describes the vigil as the time when the doula companions the dying person and loved ones "through the last days and hours of life," and it teaches doulas to help families write a vigil plan ahead of time: a written description of how the person and family would like those days to go.
A vigil is not a medical watch. The doula is not there to check breathing, count pulses, judge how close death is, or decide what the body needs. Those belong to the hospice or palliative team (see Module 2 for the usual changes, and when to call). The doula's part is the human part: the room, the people, the pace, the words, the quiet.
A vigil is also not a promise that someone will be present at the exact moment of death. You cannot promise that, and families should not be told it is expected of them. We come back to this below.
How long does it last?
No one can say exactly. NIA notes that "death can come suddenly, or a person may linger in a near-death state for days." That uncertainty is why a vigil needs shifts, a plan for rest, and a clear list of who to call.
When tradition asks for constant presence
Some religious and cultural traditions ask that the dying person never be left alone, or ask for particular prayers, readings, or people at the bedside. NIA's advice to families is: "Unless your cultural or religious traditions require it, do not feel that you must stay with the person all the time." Ask early what the person's tradition asks for, and build the plan around it. Module 8 goes deeper.
Planning the vigil with the person and the family
The best vigil plans are made early, while the person can still say what they want. If you did the values work in Module 5, you already know much of what matters to them. If the person can no longer speak, ask the family, "What would she say if she could join this conversation?" and look for anything she wrote down. If the family wants a place to put wishes in writing, caregoals.com/facing-the-end is one option; it says nothing is stored.
Go through the plan one element at a time. It is a working document the family owns.
| Element | Questions to ask | Watch-outs |
|---|---|---|
| Who | Who does the person want nearby? Anyone they do not want? Who should be called when things change, and in what order? | The person's wishes come first, even when relatives disagree. Write down phone numbers. |
| Where | Which room? Bed by a window? Can the person see the garden or the door? | Hospital beds and equipment set limits. Ask the hospice team before moving furniture that holds equipment. |
| When and shifts | Who sits when? Who sleeps when? Who covers nights? | No one should take more than one long shift in a row. Build in real sleep. |
| Things around them | Photos, a blanket, a rosary, a letter, a favourite shirt? | Keep the bed clear enough for the nurse and aide to work. |
| Music and sound | What music? Silence? Religious chant? Radio? | NIA suggests music "at a low volume." Have a plan to turn it off if the person seems unsettled. |
| Light | Daylight or dim? A lamp at night? | NIA suggests soft lighting. Keep enough light to see steps and cords. |
| Scent | A familiar soap, fresh air, flowers, no scent at all? | No candles, matches or any open flame near home oxygen. Battery candles are a common substitute. Ask the nurse which lotions or scented products are safe with oxygen. |
| Touch | Hand-holding? Stroking hair? Or does the person dislike being touched? | Ask the person if they can answer. Stop if they pull away or seem distressed. |
| Readings, prayers, words | A poem, scripture, a letter from a grandchild, a recording from someone far away? | Who will read? Who will bring the faith leader, if one is wanted? |
| Pets | Should the dog lie on the bed or nearby? | Pets near tubes and lines, allergies, and trip hazards. Ask the nurse. |
| Visitors | Open door or a short list? How long may people stay? | A kind sign on the door and one person to manage visits protect the person's rest. |
| Safety and quiet | Where is the hospice number? The POLST or DNR form, if there is one? The phone charger? | Clear paths, working smoke alarms, cords taped down. Keep it quiet but never locked in. |
Open flame and oxygen: the one safety rule to say out loud
Families often want candles. If the person uses medical oxygen, candles are a real danger. The U.S. Fire Administration says: "Never use a candle, match, lighter or other open flame near medical oxygen," and to keep oxygen tanks at least five feet from heat sources, open flames or electrical devices. Oregon's State Fire Marshal adds that "body oil and hand lotion can burn easily" around oxygen. Say this kindly and early, offer battery candles, and let the nurse answer any product question.
Your practice vigil plan
Fill this in for an invented person, or for yourself as if you were the one dying. It is saved only in this browser on this device, and it appears in your self-kept study record on the Capstone page. If you use this template with a real family, give them a paper copy and do not keep their identifying details in a browser (see Module 13).
Kept only in this browser. If this browser blocks storage, it will not be kept.
Comfort that is human, not clinical
Much of what comforts a dying person needs no training beyond attention. NIA lists simple things families can do: provide physical contact, "set a comforting mood," play music softly, involve the person in what they need, and "be present." It also says: "Your presence can be the greatest gift you can give to a dying person." That is the doula's ground.
The line is this: anything touching medication, oxygen, feeding or fluids, the technique of turning someone who is in pain, or a change in condition belongs to the team. The doula follows the team's instructions and the family's decisions, and never improvises around them.
| Comfort you may offer | How | When it becomes the team's |
|---|---|---|
| Presence | Sit where the person can see you. Say who you are when you come in. Silence is allowed. | Never; presence is always yours to give. |
| Talking and reading aloud | Talk to the person, not about them. Read a poem, a letter, a psalm, a sports page. | If the person seems distressed by sound, stop and tell the family and nurse. |
| Hand-warming and touch | Hold a hand, rest a hand on an arm, add a blanket if they seem cold. | NIA says hands and feet may become cool near death. Do not use electric blankets or heating pads; NIA advises against electric blankets because they can get too hot. |
| A cool cloth | If the person keeps pushing blankets away, NIA suggests removing the blanket and placing a cool cloth on the head. | Fever, shivering, sweating or a change in colour: tell the nurse. |
| Lips and mouth | Lip balm the nurse has approved. Mouth care with swabs only in the way the hospice nurse has shown the family. | If the family has not been shown, ask the nurse to show them. Do not put anything in the mouth of someone who cannot swallow unless the team has said how. |
| Positioning cushions | Tuck a pillow exactly as the team has shown the family. | Turning a person, moving someone in pain, or anything that needs lifting: team only. |
| The room | Soft light, lower noise, fresh air, phones silenced, a chair for the next person. | If breathing seems hard, a fan or open window may be part of what the team suggests; the breathing change itself goes to the nurse. |
Can they hear us?
NIA says "some doctors think that dying people can still hear even if they are not conscious," and advises families to talk to, not about, the person. A small 2020 study in Scientific Reports recorded brain responses to sound in a handful of hospice patients who had become unresponsive, and most showed responses similar to those of healthy young people. The authors concluded that hearing "may indeed be one of the last senses to lose function." The study was small, and it does not show that the person understood the words. A fair thing to say to a family is: "No one knows for sure, but there is some evidence hearing continues. It does no harm to speak as if she can hear you."
Things that look worrying and may be usual
NIA describes changes that often frighten families: breathing that alternates between deep and shallow or pauses, and noisy breathing near death, which NIA says "in most cases" does not upset the dying person. Your job is not to judge whether a particular change is normal. Your job is to stay calm, keep the family company, and help them tell the nurse. "That sounds hard to listen to. Let's call the nurse and describe it, so she can tell us what she thinks."
The hospice 24-hour line: helping a family call it
Every Medicare-certified hospice must be reachable at any hour. Federal rules say nursing services, physician services, and drugs "must be made routinely available on a 24-hour basis 7 days a week" (42 CFR 418.100). In practice that means a phone number, usually answered by a nurse or an answering service that pages one. Families who are new to hospice often do not realise they can call at 3 a.m., or feel they are bothering someone. Tell them plainly: the line exists for exactly this.
When to call
- Any change the family is worried about: pain, restlessness, breathing, a fall, bleeding, a fever, confusion, not waking.
- Any question about medicine, including "Is it time for the next dose?" and "Did I give the right one?"
- Before anyone reaches for 911, if the person is on hospice, unless there is an emergency such as a fire or violence.
- When the person has died.
Four facts to have ready
A simple way for families to pass on information has four parts. This is helping the family communicate, not a clinical assessment. You gather what the family has seen; you do not add your own judgment of what it means.
| Part | What to say | Example the family might use |
|---|---|---|
| Who | Caller's name, patient's name, address, that they are a hospice patient | "This is Ana, calling about my mother, Rosa Diaz, at 14 Elm Street. She's a hospice patient." |
| What changed | What the family sees or hears, in plain words | "She's moaning when we touch her legs, and she's pulling at the sheets." |
| Since when | When it started, and whether it is getting worse | "It started about an hour ago. It's getting louder." |
| What has been tried | What the family did, including any medicine they gave and when | "We gave the dose the nurse told us to give at 2 o'clock. We turned the light down." |
(The names and address in the example are invented.)
Your part in the call
- Help the family find the number. It should be on the vigil plan, on the fridge, and in their phones.
- The family member calls, or you dial and hand the phone over. If the family asks you to speak, say who you are: "I'm the family's doula. I'm not a nurse. I'm passing on what the family has seen."
- Write down what the nurse says, read it back, and note the time. If the nurse is coming, write the expected time.
- If the nurse gives instructions about medicine, those are for the family. You do not give, fetch, count or measure it.
Staying, leaving, and the "unaccompanied" death
Many families hope to be present when the person dies. Many are not, and some are out of the room for only a few minutes. NIA writes that many people want to be surrounded by family and friends, "but it's common for some to slip away while their loved ones aren't in the room." A hospice social worker writing on the palliative care blog Pallimed describes seeing this often, and suggests preparing families for it before it happens, so it is not later felt as a failure. Her account is drawn from her own practice, not from research; no one knows why it happens, and it should not be presented as a rule or as something the dying person chose.
What you can say, before and after, is simple and true:
- Example, before: "Sometimes people die in the few minutes when everyone has stepped out. Hospice staff see it. If it happens, it won't mean you did anything wrong."
- Example, after: "You were here for days. You were with her in every way that mattered. Stepping out to make coffee doesn't undo any of that."
Avoid telling a family what the dying person "wanted" or "chose." You do not know, and it can hurt as much as it helps.
Helping people rest
Family members often refuse to leave because they fear missing the moment. Help them make a clear agreement instead: "If anything changes, do you want to be woken? Even at 4 a.m.?" Then keep the agreement. Offer to sit while they sleep, shower or eat. Honour the person who needs to leave the room because they cannot bear it; staying is not the only form of love. Honour the person who must stay because their tradition asks it; plan shifts around them.
At the moment of death, and just after
When death comes, the most useful thing a doula brings is steadiness. There is almost never a reason to hurry. NIA notes that when someone dies at home, "there is no need to move the body right away," and that this is the time for any religious or cultural customs.
What to do
- Sit. Let the family take in what has happened. Do not rush to the phone unless they ask.
- Note the time as the family saw it. This helps them later. The official time is the one the clinician records.
- Call the number the plan names, when the family is ready. For a hospice patient, that is usually the hospice. The Hospice Foundation of America tells families to call their hospice provider's 24-hour number rather than emergency services when a hospice patient dies at home.
- The clinician pronounces death and tells the family what happens next. NIA says death must be officially pronounced by "someone in authority like a doctor in a hospital or nursing facility or a hospice nurse."
- Do not remove anything: no tubes, lines, pumps, catheters or dressings. Do not touch, count, move or dispose of medicines. The hospice handles these.
- Support the family's customs while they wait: washing, prayer, a candle only if there is no oxygen in use, calling the people on their list.
Who may pronounce death depends on the state
Rules differ, so never tell a family "the nurse will pronounce" as a general fact. Two examples show how much they vary. Tennessee's law lets a registered nurse determine and pronounce death for a hospice patient under listed conditions, including that the death was anticipated and the attending physician or hospice medical director agreed in writing to sign the death certificate. Pennsylvania extended the authority to pronounce death in home hospice settings to licensed practical nurses in 2024 (Act 137). Other states have their own rules. Ask the hospice how it works where the family lives.
Why "who do we call?" must be decided in advance
Calling 911 starts an emergency response. POLST, the national organisation for portable medical orders, explains that without a POLST form, "the current standard of care during an emergency is for emergency medical services (EMS) to attempt everything reasonably possible to attempt to save a life." For a person who wanted a peaceful death at home, an unplanned 911 call can mean resuscitation attempts, a trip to hospital, or police involvement. That is why the plan matters. POLST programs have different names in different states.
| Situation | Who is usually called | The doula's part |
|---|---|---|
| Hospice patient, expected death, plan says call hospice | The hospice 24-hour line | Help the family call. Do not call 911 unless the family decides to. |
| Not on hospice, expected death, a plan was made with the doctor | Whoever the plan names: the doctor, the funeral home, or others. NIA advises talking in advance with the doctor, medical examiner, health department or a funeral home. | Follow the plan and the family's direction. |
| No plan at all | The family or the clinician decides | Do not tell the family not to call 911. Follow their direction or a clinician's. |
| Sudden or unexpected: a fall, an injury, violence, a fire | 911 | Call, or help the family call. |
What happens to the body, funeral homes and early grief are covered in Module 10.
When you are alone with a dying person
Families often ask a doula to sit so they can sleep or run an errand. That trust comes with preparation. Before your first solo shift, go through this with the family:
- Numbers. The hospice 24-hour line, two family members, and the home's full address to give to 911.
- The plan. Is the person on hospice? Is there a DNR order or POLST form, and where is it kept? What does the family want you to do if the person's condition changes, and if the person dies while they are out?
- The house. Exits, lights, where the oxygen is, pets, locks.
- Your limits. Say out loud: "I won't give any medicine, and I won't lift or turn her. If something changes, I'll call the hospice line and then you."
When to call 911
- Any emergency the family wants treated when there is no DNR, POLST or hospice plan that says otherwise.
- Fire, smoke, a gas smell, or anyone threatening harm.
- You are hurt or become unwell.
- You cannot reach the hospice line or the family and there is an emergency.
If the person is on hospice and something changes that is not an emergency of that kind, call the hospice line first, then the family. If the person falls, do not try to lift them; make them as comfortable as you can where they are and call. If you are not sure whether the person has died, call the hospice line if they are a hospice patient; otherwise call 911.
Your own safety
Tell someone where you are and when you expect to leave. If a visitor or household member makes you feel unsafe, leave, and call for help from outside. Module 13 covers home safety in more depth.
Case: a long vigil, a tired daughter, and a fight about turning
You have been with a family for four days. Their mother is on home hospice and has not spoken since yesterday. The daughter has barely slept in three nights. Her brother arrived this morning and says the aide showed them to turn their mother every two hours, and he intends to do it. When they turned her an hour ago, their mother groaned. The daughter says, "Stop. She's dying. It's hurting her. Tell him." The brother turns to you: "You're the expert. Help me turn her, or tell her I'm right."
What would you do first? Decide, write a sentence in the box below, then open the discussion.
Discussion: one reasonable path, and the traps
First move: name that both of them are trying to care for their mother, and that this is a question for the hospice nurse, now. "You both want her comfortable. Whether and how to turn her when it seems to hurt is a nursing question. Let's call the hospice line together." Then help them use the four facts: who; what changed ("she groans when we turn her"); since when; what has been tried (the turning schedule, any medicine the family has given, and when).
Why: turning technique for someone in pain, and whether to change the turning plan, belong to the team. The nurse may change the plan, suggest a different way to turn, or look at her pain. Those are not your decisions, and you should not predict them.
Next: after the call, turn to the daughter. She is exhausted, and exhaustion makes every disagreement sharper. Offer a shift plan: the brother sits for the next few hours, you stay, and she sleeps, with a clear agreement to wake her if anything changes.
The traps: (1) Helping to turn her. You do not turn or lift, and certainly not someone in pain. (2) Siding with the daughter by saying "turning doesn't matter now." That is a clinical judgment dressed as kindness. (3) Siding with the brother because "the aide said so." The aide's instruction may need updating; the nurse decides. (4) Staying out of it. The family asked for help; the help is getting them to the right person quickly.
This case is invented for teaching. It is not based on a real person.
Practice it out loud
Try the conversation “The 3 a.m. call”: A change in breathing, a medicine kit, and a family in conflict. An invented person speaks, you answer in your own words, and you see which of their needs you met. It runs in your browser and nothing is sent anywhere. Start this practice or see all six.
Check what you took in
Six questions. Answer, then check. The reasoning under each one is the real lesson.
Reflect
Only you can see this. It is saved in this browser on this device and is never sent anywhere. If this browser blocks storage, it will not be kept.