Gone But Not Forgotten: How VA Remembers

Caring for veterans at the end of their lives is a great honor. The US Department of Veterans Affairs (VA) health care professionals (HCPs) find meaning and take pride in providing this care. We are there to support the patient and their family and loved ones around the time of death. When our patients die, we feel the loss and grieve as well. VA health care providers look to our teams to set up rituals that pay tribute to the veteran and to show respect and gratitude for our role in these moments. It is important to recognize the bonds we share and the grief we feel when a veteran dies. The relationships we form, the recognition of loss, and the honoring of the veterans help nourish and maintain us.

Although the number of VA inpatient deaths nationwide has been declining steadily for years, internal reporting by the Palliative and Hospice Care Program Office has shown that the percentage of VA inpatient deaths that occur in hospice settings has steadily grown. Since 2013, more veterans die in VA inpatient hospice beds than in any other hospital setting. Therefore, it is useful to take stock of the way hospice and palliative care providers and staff process and provide support so that they can continue to provide service to veterans.

In the same way that all loss and grief are unique, there are many diverse rituals across VA facilities. This article highlights some of the unique traditions that hospice and palliative care teams have adopted to embrace this remembrance. We hope that by sharing these practices others will be inspired to find ways to reflect on their work and honor the lives of veterans.

The authors reached out to VA palliative care colleagues across the country via the Veterans Health Administration National Hospice and Palliative Care listserve to ask: How does your team practice remembrance? Palliative care providers responded and shared the unique ways they and their teams reflect on these losses.

There are many moments for reflection from the time of death to the weeks and months after, to the entire year of cumulative loss. Some observances start around the time of death. Susan MacDonald, RN, GEC, from Erie VA Medical Center (VAMC) in Pennsylvania reported that following the death of a veteran in the hospice unit, there is a bedside remembrance that includes the chaplain, care team, family, and other loved ones. At the John D. Dingell VAMC in Detroit, Michigan, the clinical chaplain leads a memorial service after a community living center (CLC) resident dies.

Several VAMCs, such as Detroit and Erie, have an Honors Escort or Final Salute. In these ceremonies, family, employees, residents, and other veterans line the hallways to honor the veteran on their departure from the building.¹ At the VA Maine Healthcare System, Kate MacFawn, nurse manager, Inpatient Hospice Unit, explained, “We debrief every death the day after it occurs. The doc[tor]s check in with the nursing staff on each shift, and the rest of the multidisciplinary team discusses [it] in our morning report.”

Palliative care providers consider the physical spaces where the veteran has spent those last moments and the void that is left. Karen Pickler, staff chaplain at Northport VAMC Hospice Unit recounts:

At the time of death, we decorate the tray table with the veteran’s picture, a flag, and an angel. In the CLC they will have a memorial service on Friday if a resident has died that week. This is for the unit and staff. In the past, other residents were not informed of the death. This way, the relationships between residents are honored as well as their natural families.

At VA Boston Healthcare System (VABHS) in Massachusetts in the Inpatient Hospice Unit-CLC, after a veteran dies, a flag, a strand of lights, and a rose in a vase are placed outside the veteran’s room to mark the absence. The VABHS remembrance practice has evolved over time based on input from the team. According to Noah Whiddon, LICSW, CLC complex case coordinator, at a weekly interdisciplinary team (IDT) meeting, the names of veterans who have died in the past week are read, and there is a commemorative ribbon cutting. “Any team member may write the last name of the deceased veteran on the ribbon and place it into a vase,” he said. “One of the nurse team members felt that a moment of silence would be appropriate, and we have added that.”

Every 6 months, VABHS holds a flag burning ceremony to appropriately dispose of worn out flags. Veterans and families are invited. The commemorative ribbons are packaged and burned at this ceremony with the following explanation of the ritual:

We’d like to take a moment to reflect on the lives of veterans we’ve lost in the last 6 months. Each week we remember the veterans for whom we have cared who have passed away. As part of this, we cut a ribbon and inscribe their name on it to commemorate their memory. We might have known these veterans for a few days or for a few years, but each of their lives had meaning for us. The courage that our veterans demonstrate at the end of their lives is an extension of the bravery they displayed in their service to our country. Today we will burn their commemorative ribbons with our country’s flag in tribute to and respect for their selflessness to our country. Please join us in a few moments of silence as their ribbons burn together with our flag.

In the VABHS acute care hospital, the palliative care IDT reserves 30 minutes, twice monthly for a chaplain-led remembrance. A large bowl-shaped shell is placed in the center of the table with smaller shells around it. Any team member can read the names of veterans who have died in prior weeks and share a memory of the patient or family, and then place a smaller shell into the larger bowl. This represents the transition from the smallest part of the universe back into the larger part. At the end, a moment of silence is observed or a poem is read. This tradition was brought to the team by the palliative care chaplain, Douglas Falls, MDiv.

Bimonthly bereavement meetings are held at the James A. Haley Veterans’ Hospital-Pasco County branch, and each veteran who has died is remembered. Whoever wants to share is welcome. “We conclude with a poem, usually shared by the physician, but it can be any team member,” explained Linda Falzetta-Gross, ARNP-BC. “This process is led by the team social worker. In the past, we used to ring a bell prior to each name.”

Bells also are used at the Greater West Los Angeles VAMC in California. At the weekly clinic, veterans who have died are remembered, and each team member has an opportunity to share memories. “We ring a Tibetan bell for a moment without words,” explains Geoffrey Tyrell, palliative care chaplain. “It is introduced with a few words to allow new staff members in our clinic to participate, as a moment of mindfulness to let go of our words and to go inside, to see what we might need for our own wellness.” Afterward the chaplain says a few words and wishes for peace for the veterans and their families. The team also has responded well to more participatory group activities, such as placing rocks in a bowl of water, to symbolize letting go of something that has been difficult.

Additionally, there are practices of a larger scope. Many VAMCs have established facility-wide memorial services annually, biannually, or quarterly. At this time, families and staff come together to remember and honor veterans who have died within the VAMC. These memorials might involve a variety of service lines, such as chaplaincy, voluntary services, nursing, and social work and may consist of an honor guard, music, and readings. In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and privacy regulations, only family members of deceased veterans may speak the names at the ceremony unless written consent is given. At the Tennessee Valley Healthcare System in Nashville, family members may stand and give the name of the person they are honoring. Balloons are released, stories are told, and a poem or appropriate passage is read. Families are given a book pinned with a flag, according to Jennifer C. Crenshaw, clinical staff chaplain. Family members are moved knowing that the VA remembers their loved ones even months after they are gone.

Due to the overwhelming positive feedback from veterans’ families who participated in these ceremonies, on January 24, 2018, Carolyn Clancy, MD, VHA Executive-in-Charge, Office of the Under Secretary for Health issued a memorandum requesting that all VAMCs immediately adopt this best practice: to host periodic ceremonies to publicly recognize and honor deceased veterans in the presence of their families, VA care providers, veterans service organizations and community members. Clancy recommended calling the ceremonies “The Last Roll Call Ceremony of Remembrance.”²

These rituals are a small sample of the rich diversity of practice in VAs across the country. What unifies VA palliative care providers is our mission to serve the veterans, honor their deaths, show respect and gratitude, and recognize that we, too, feel the pain of loss. We mark these moments with solemnity and beauty—a bell, a poem, a prayer—to honor our shared experience caring for veterans.

Caring for veterans at the end of their lives is a great honor. The US Department of Veterans Affairs (VA) health care professionals (HCPs) find meaning and take pride in providing this care. We are there to support the patient and their family and loved ones around the time of death. When our patients die, we feel the loss and grieve as well. VA health care providers look to our teams to set up rituals that pay tribute to the veteran and to show respect and gratitude for our role in these moments. It is important to recognize the bonds we share and the grief we feel when a veteran dies. The relationships we form, the recognition of loss, and the honoring of the veterans help nourish and maintain us.

Although the number of VA inpatient deaths nationwide has been declining steadily for years, internal reporting by the Palliative and Hospice Care Program Office has shown that the percentage of VA inpatient deaths that occur in hospice settings has steadily grown. Since 2013, more veterans die in VA inpatient hospice beds than in any other hospital setting. Therefore, it is useful to take stock of the way hospice and palliative care providers and staff process and provide support so that they can continue to provide service to veterans.

In the same way that all loss and grief are unique, there are many diverse rituals across VA facilities. This article highlights some of the unique traditions that hospice and palliative care teams have adopted to embrace this remembrance. We hope that by sharing these practices others will be inspired to find ways to reflect on their work and honor the lives of veterans.

The authors reached out to VA palliative care colleagues across the country via the Veterans Health Administration National Hospice and Palliative Care listserve to ask: How does your team practice remembrance? Palliative care providers responded and shared the unique ways they and their teams reflect on these losses.

There are many moments for reflection from the time of death to the weeks and months after, to the entire year of cumulative loss. Some observances start around the time of death. Susan MacDonald, RN, GEC, from Erie VA Medical Center (VAMC) in Pennsylvania reported that following the death of a veteran in the hospice unit, there is a bedside remembrance that includes the chaplain, care team, family, and other loved ones. At the John D. Dingell VAMC in Detroit, Michigan, the clinical chaplain leads a memorial service after a community living center (CLC) resident dies.

Several VAMCs, such as Detroit and Erie, have an Honors Escort or Final Salute. In these ceremonies, family, employees, residents, and other veterans line the hallways to honor the veteran on their departure from the building.¹ At the VA Maine Healthcare System, Kate MacFawn, nurse manager, Inpatient Hospice Unit, explained, “We debrief every death the day after it occurs. The doc[tor]s check in with the nursing staff on each shift, and the rest of the multidisciplinary team discusses [it] in our morning report.”

Palliative care providers consider the physical spaces where the veteran has spent those last moments and the void that is left. Karen Pickler, staff chaplain at Northport VAMC Hospice Unit recounts:

At the time of death, we decorate the tray table with the veteran’s picture, a flag, and an angel. In the CLC they will have a memorial service on Friday if a resident has died that week. This is for the unit and staff. In the past, other residents were not informed of the death. This way, the relationships between residents are honored as well as their natural families.

At VA Boston Healthcare System (VABHS) in Massachusetts in the Inpatient Hospice Unit-CLC, after a veteran dies, a flag, a strand of lights, and a rose in a vase are placed outside the veteran’s room to mark the absence. The VABHS remembrance practice has evolved over time based on input from the team. According to Noah Whiddon, LICSW, CLC complex case coordinator, at a weekly interdisciplinary team (IDT) meeting, the names of veterans who have died in the past week are read, and there is a commemorative ribbon cutting. “Any team member may write the last name of the deceased veteran on the ribbon and place it into a vase,” he said. “One of the nurse team members felt that a moment of silence would be appropriate, and we have added that.”

Every 6 months, VABHS holds a flag burning ceremony to appropriately dispose of worn out flags. Veterans and families are invited. The commemorative ribbons are packaged and burned at this ceremony with the following explanation of the ritual:

We’d like to take a moment to reflect on the lives of veterans we’ve lost in the last 6 months. Each week we remember the veterans for whom we have cared who have passed away. As part of this, we cut a ribbon and inscribe their name on it to commemorate their memory. We might have known these veterans for a few days or for a few years, but each of their lives had meaning for us. The courage that our veterans demonstrate at the end of their lives is an extension of the bravery they displayed in their service to our country. Today we will burn their commemorative ribbons with our country’s flag in tribute to and respect for their selflessness to our country. Please join us in a few moments of silence as their ribbons burn together with our flag.

In the VABHS acute care hospital, the palliative care IDT reserves 30 minutes, twice monthly for a chaplain-led remembrance. A large bowl-shaped shell is placed in the center of the table with smaller shells around it. Any team member can read the names of veterans who have died in prior weeks and share a memory of the patient or family, and then place a smaller shell into the larger bowl. This represents the transition from the smallest part of the universe back into the larger part. At the end, a moment of silence is observed or a poem is read. This tradition was brought to the team by the palliative care chaplain, Douglas Falls, MDiv.

Bimonthly bereavement meetings are held at the James A. Haley Veterans’ Hospital-Pasco County branch, and each veteran who has died is remembered. Whoever wants to share is welcome. “We conclude with a poem, usually shared by the physician, but it can be any team member,” explained Linda Falzetta-Gross, ARNP-BC. “This process is led by the team social worker. In the past, we used to ring a bell prior to each name.”

Bells also are used at the Greater West Los Angeles VAMC in California. At the weekly clinic, veterans who have died are remembered, and each team member has an opportunity to share memories. “We ring a Tibetan bell for a moment without words,” explains Geoffrey Tyrell, palliative care chaplain. “It is introduced with a few words to allow new staff members in our clinic to participate, as a moment of mindfulness to let go of our words and to go inside, to see what we might need for our own wellness.” Afterward the chaplain says a few words and wishes for peace for the veterans and their families. The team also has responded well to more participatory group activities, such as placing rocks in a bowl of water, to symbolize letting go of something that has been difficult.

Additionally, there are practices of a larger scope. Many VAMCs have established facility-wide memorial services annually, biannually, or quarterly. At this time, families and staff come together to remember and honor veterans who have died within the VAMC. These memorials might involve a variety of service lines, such as chaplaincy, voluntary services, nursing, and social work and may consist of an honor guard, music, and readings. In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and privacy regulations, only family members of deceased veterans may speak the names at the ceremony unless written consent is given. At the Tennessee Valley Healthcare System in Nashville, family members may stand and give the name of the person they are honoring. Balloons are released, stories are told, and a poem or appropriate passage is read. Families are given a book pinned with a flag, according to Jennifer C. Crenshaw, clinical staff chaplain. Family members are moved knowing that the VA remembers their loved ones even months after they are gone.

Due to the overwhelming positive feedback from veterans’ families who participated in these ceremonies, on January 24, 2018, Carolyn Clancy, MD, VHA Executive-in-Charge, Office of the Under Secretary for Health issued a memorandum requesting that all VAMCs immediately adopt this best practice: to host periodic ceremonies to publicly recognize and honor deceased veterans in the presence of their families, VA care providers, veterans service organizations and community members. Clancy recommended calling the ceremonies “The Last Roll Call Ceremony of Remembrance.”²

These rituals are a small sample of the rich diversity of practice in VAs across the country. What unifies VA palliative care providers is our mission to serve the veterans, honor their deaths, show respect and gratitude, and recognize that we, too, feel the pain of loss. We mark these moments with solemnity and beauty—a bell, a poem, a prayer—to honor our shared experience caring for veterans.

Caring for veterans at the end of their lives is a great honor. The US Department of Veterans Affairs (VA) health care professionals (HCPs) find meaning and take pride in providing this care. We are there to support the patient and their family and loved ones around the time of death. When our patients die, we feel the loss and grieve as well. VA health care providers look to our teams to set up rituals that pay tribute to the veteran and to show respect and gratitude for our role in these moments. It is important to recognize the bonds we share and the grief we feel when a veteran dies. The relationships we form, the recognition of loss, and the honoring of the veterans help nourish and maintain us.

Although the number of VA inpatient deaths nationwide has been declining steadily for years, internal reporting by the Palliative and Hospice Care Program Office has shown that the percentage of VA inpatient deaths that occur in hospice settings has steadily grown. Since 2013, more veterans die in VA inpatient hospice beds than in any other hospital setting. Therefore, it is useful to take stock of the way hospice and palliative care providers and staff process and provide support so that they can continue to provide service to veterans.

In the same way that all loss and grief are unique, there are many diverse rituals across VA facilities. This article highlights some of the unique traditions that hospice and palliative care teams have adopted to embrace this remembrance. We hope that by sharing these practices others will be inspired to find ways to reflect on their work and honor the lives of veterans.

The authors reached out to VA palliative care colleagues across the country via the Veterans Health Administration National Hospice and Palliative Care listserve to ask: How does your team practice remembrance? Palliative care providers responded and shared the unique ways they and their teams reflect on these losses.

There are many moments for reflection from the time of death to the weeks and months after, to the entire year of cumulative loss. Some observances start around the time of death. Susan MacDonald, RN, GEC, from Erie VA Medical Center (VAMC) in Pennsylvania reported that following the death of a veteran in the hospice unit, there is a bedside remembrance that includes the chaplain, care team, family, and other loved ones. At the John D. Dingell VAMC in Detroit, Michigan, the clinical chaplain leads a memorial service after a community living center (CLC) resident dies.

Several VAMCs, such as Detroit and Erie, have an Honors Escort or Final Salute. In these ceremonies, family, employees, residents, and other veterans line the hallways to honor the veteran on their departure from the building.¹ At the VA Maine Healthcare System, Kate MacFawn, nurse manager, Inpatient Hospice Unit, explained, “We debrief every death the day after it occurs. The doc[tor]s check in with the nursing staff on each shift, and the rest of the multidisciplinary team discusses [it] in our morning report.”

Palliative care providers consider the physical spaces where the veteran has spent those last moments and the void that is left. Karen Pickler, staff chaplain at Northport VAMC Hospice Unit recounts:

At the time of death, we decorate the tray table with the veteran’s picture, a flag, and an angel. In the CLC they will have a memorial service on Friday if a resident has died that week. This is for the unit and staff. In the past, other residents were not informed of the death. This way, the relationships between residents are honored as well as their natural families.

At VA Boston Healthcare System (VABHS) in Massachusetts in the Inpatient Hospice Unit-CLC, after a veteran dies, a flag, a strand of lights, and a rose in a vase are placed outside the veteran’s room to mark the absence. The VABHS remembrance practice has evolved over time based on input from the team. According to Noah Whiddon, LICSW, CLC complex case coordinator, at a weekly interdisciplinary team (IDT) meeting, the names of veterans who have died in the past week are read, and there is a commemorative ribbon cutting. “Any team member may write the last name of the deceased veteran on the ribbon and place it into a vase,” he said. “One of the nurse team members felt that a moment of silence would be appropriate, and we have added that.”

Every 6 months, VABHS holds a flag burning ceremony to appropriately dispose of worn out flags. Veterans and families are invited. The commemorative ribbons are packaged and burned at this ceremony with the following explanation of the ritual:

We’d like to take a moment to reflect on the lives of veterans we’ve lost in the last 6 months. Each week we remember the veterans for whom we have cared who have passed away. As part of this, we cut a ribbon and inscribe their name on it to commemorate their memory. We might have known these veterans for a few days or for a few years, but each of their lives had meaning for us. The courage that our veterans demonstrate at the end of their lives is an extension of the bravery they displayed in their service to our country. Today we will burn their commemorative ribbons with our country’s flag in tribute to and respect for their selflessness to our country. Please join us in a few moments of silence as their ribbons burn together with our flag.

In the VABHS acute care hospital, the palliative care IDT reserves 30 minutes, twice monthly for a chaplain-led remembrance. A large bowl-shaped shell is placed in the center of the table with smaller shells around it. Any team member can read the names of veterans who have died in prior weeks and share a memory of the patient or family, and then place a smaller shell into the larger bowl. This represents the transition from the smallest part of the universe back into the larger part. At the end, a moment of silence is observed or a poem is read. This tradition was brought to the team by the palliative care chaplain, Douglas Falls, MDiv.

Bimonthly bereavement meetings are held at the James A. Haley Veterans’ Hospital-Pasco County branch, and each veteran who has died is remembered. Whoever wants to share is welcome. “We conclude with a poem, usually shared by the physician, but it can be any team member,” explained Linda Falzetta-Gross, ARNP-BC. “This process is led by the team social worker. In the past, we used to ring a bell prior to each name.”

Bells also are used at the Greater West Los Angeles VAMC in California. At the weekly clinic, veterans who have died are remembered, and each team member has an opportunity to share memories. “We ring a Tibetan bell for a moment without words,” explains Geoffrey Tyrell, palliative care chaplain. “It is introduced with a few words to allow new staff members in our clinic to participate, as a moment of mindfulness to let go of our words and to go inside, to see what we might need for our own wellness.” Afterward the chaplain says a few words and wishes for peace for the veterans and their families. The team also has responded well to more participatory group activities, such as placing rocks in a bowl of water, to symbolize letting go of something that has been difficult.

Additionally, there are practices of a larger scope. Many VAMCs have established facility-wide memorial services annually, biannually, or quarterly. At this time, families and staff come together to remember and honor veterans who have died within the VAMC. These memorials might involve a variety of service lines, such as chaplaincy, voluntary services, nursing, and social work and may consist of an honor guard, music, and readings. In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and privacy regulations, only family members of deceased veterans may speak the names at the ceremony unless written consent is given. At the Tennessee Valley Healthcare System in Nashville, family members may stand and give the name of the person they are honoring. Balloons are released, stories are told, and a poem or appropriate passage is read. Families are given a book pinned with a flag, according to Jennifer C. Crenshaw, clinical staff chaplain. Family members are moved knowing that the VA remembers their loved ones even months after they are gone.

Due to the overwhelming positive feedback from veterans’ families who participated in these ceremonies, on January 24, 2018, Carolyn Clancy, MD, VHA Executive-in-Charge, Office of the Under Secretary for Health issued a memorandum requesting that all VAMCs immediately adopt this best practice: to host periodic ceremonies to publicly recognize and honor deceased veterans in the presence of their families, VA care providers, veterans service organizations and community members. Clancy recommended calling the ceremonies “The Last Roll Call Ceremony of Remembrance.”²

These rituals are a small sample of the rich diversity of practice in VAs across the country. What unifies VA palliative care providers is our mission to serve the veterans, honor their deaths, show respect and gratitude, and recognize that we, too, feel the pain of loss. We mark these moments with solemnity and beauty—a bell, a poem, a prayer—to honor our shared experience caring for veterans.