In October 2016, a clinical nurse wanted to honor a patient and family who were choosing organ donation after a tragic accident. Over 4 days of discussion with the patient's family, she suggested something the hospital had never done before—lining the hallways with pediatric intensive care unit (PICU) staff in a moment of silence, as the patient went to the OR. The patient's father responded, “Absolutely, and I will stand with you.” Staff, with tears in their eyes, lined the hallway as the patient's father stood and saluted his son as he was transported to the OR. From that moment, the Honor Guard became a part of UC Davis Medical Center culture. It has grown from 15 to over 200 participants, across all disciplines.
A critical aspect of pediatric intensive care nursing is caring for families of dying children. These situations can contribute to moral distress.1 Although the circumstance of a patient's death cannot be changed, nurse empowerment and camaraderie can tremendously affect staff and patients' families.2 The Honor Guard impacts the lives of our patients and families, as well as provides staff with an avenue for closure. Implementing rituals honoring the lives that have passed and that function as a coping strategy for our community is imperative to change the culture of mourning.3
Methods and data
Although the Honor Guard was launched as an innovative part of nursing practice and care for an individual patient, the ritual was evaluated as a part of a broader project to assess staff satisfaction with resources within individual units and across the hospital. A voluntary survey was distributed to all nursing staff at UC Davis Medical Center in December 2017, asking questions such as:
- I have the ability to honor my patient after death.
- □ Yes □ No
- End-of-life tools I have used are...
Clinical nurses were asked to provide feedback regarding the Honor Guard along with other end-of-life care resources. Among PICU staff (N = 115), 63% responded. From a variety of resources identified across the institution, the Honor Guard was the highest rated resource with 90% “extremely satisfied” and 10% “somewhat satisfied.” Broader adaptation of the ritual across the institution will provide additional feedback regarding the practice and participant experience.
Since the first Honor Guard in 2016, there have been over 50 subsequent Honor Guards at UC Davis Medical Center. With hospital leadership support, the practice has been adopted hospital-wide. Staff are notified with a page activating the Honor Guard procession. Anyone available and interested in participating may line the hallways from unit of origin to the OR entrance. Perioperative services staff participate upon the patient's arrival at the OR. All participants stand in a moment of silence as the patient and family move from the unit to OR in a process that takes about 15 minutes. Education was provided to many teams and clinical areas regarding the ritual and its process. (See Education rollout.)
The implementation of the Honor Guard has continued during the COVID-19 pandemic with the support of executive management, social distancing during the ritual, and wearing of masks by all staff. UC Davis' executive team felt that the Honor Guard was a priority to provide a high level of care for staff, patients, and families during the pandemic.
Similar to the respect given to public and military service members who die in the line of duty, the Honor Guard ritual pays tribute to those patients and families who make the ultimate selfless decision in choosing organ donation. By implementing the Honor Guard in our institution, nurses have opened the discussion of how we cope with death in the medical community. Creating camaraderie during a time of mourning allows a community to develop a sense of kinship and strength, whether that community is a single unit or an entire hospital. The Honor Guard is now implemented hospital-wide at the author's facility.
- One-on-one education of department managers
- “All-Here Days” presentation (clinical resource nurses and assistant nurse managers)
- One-on-one education of nursing supervisors
- Meeting with executive directors for stakeholder engagement and to obtain adequate support
- Posting the educational tools and resources, such as the informational flyer below, on the End-of-Life Toolkit website.
1. Trotochaud K, Coleman JR, Krawiecki N, McCracken C. Moral distress in pediatric healthcare providers. J Pediatr Nurs
2. Crozier F, Hancock LE. Pediatric palliative care: beyond the end of life. Pediatr Nurs
3. Mullen JE, Reynolds MR, Larson JS. Caring for pediatric patients' families at the child's end of life. Crit Care Nurse