This is what a good death could be

By Larry Beresford

Recently, a neighbor and friend of mine died. After her cancer was diagnosed as incurable, she was referred to hospice care, and family members traveled long distances to spend quality time with her during her last month of life.

Her neighbors in our condo building clamored for slots in her packed social calendar. Two days before her death, she held a socially distanced open house for people lined up six feet apart outside her door to come in for a few minutes, one and two at a time, to say their goodbyes. Then we received an email telling us she had gone, quietly, at home, in the presence of family. All in all, the kind of good death promised by hospice care at its best. And yet there’s something about how it unfolded that I’m having trouble wrapping my head around.

I had spoken with my friend a couple of weeks earlier, and she told me that she was going through the steps to obtain medical aid in dying – which became legal in California through the 2015 End-of-Life Option Act. It requires two oral and one written request to a physician for a lethal dose of medication, with a 15-day waiting period and confirmation of eligibility by a second physician. My neighbor complained to me about the bureaucratic hoops, knowing that I am a medical journalist who has written extensively about hospice and end-of-life care and trusting that I could listen non-judgmentally.

I told her that the regulatory hurdles, rightly or wrongly, were crafted to prevent the appearance of abuse for a procedure that continues to generate controversy in medical ethics. Advocates say terminally ill patients should have the right to choose the time of their deaths and to opt-out of the pain and suffering of living with an advanced illness. Opponents argue that good hospice and palliative care can obviate that pain and suffering and thus the need for patients to request a medical escape from this precious life. There is little room for compromise between those two views, but the option is now legal in California and eight other states.

Some hospices and hospitals will not participate in the end-of-life option, and it can be hard to find a doctor willing to sign the necessary forms. Very few terminally ill patients actually go through with obtaining and consuming the lethal medication. Only 551 Californians started the process in 2018, and 337 took the medication to hasten their deaths, according to state records. There are also questions about the choice of medication, which may include a combination of morphine, diazepam, and propranolol, a beta-blocker that slows the heart.

My parents died of cancer or cancer-related complications. I was present in my mother’s hospital room when death came to claim her. I was a hospice volunteer for more than 20 years and sat with a number of cancer patients in their final days. In other words, I feel familiar with the process by which cancer, which kills more than 600,000 Americans every year, makes its terminal advance.

Some patients may pursue oncologic treatments until the end, trying to stave off that advance. For others, hospice provides an option to step off the medical treadmill and receive care at home with the support of an interdisciplinary team of end-of-life experts who focus on comfort, symptom management, and maximizing opportunities for dignity and peace. Either way, terminal cancer is relentless.

With good palliative medical management, many – but not all – of the worst side effects and symptoms of terminal cancer can be managed. It can also be very messy, with incontinence, other bodily fluids, and unpleasant odors. All bodily functions will fail by the end. Most of the time, it unfolds on the disease’s timeline, as it has throughout human existence.

When someone dies of cancer, there is a retrospective sense of its inevitability, that this is what had to be. Those who witnessed its relentless advance can find comfort in that inevitability. It wasn’t a cosmic mistake that cancer has taken their loved one; it was part of the natural order of things. The loss and grief for those left behind are real, but the memories, hopefully, can be free of recriminations.

The end of life can also be a time to focus on expressing what Dr. Ira Byock calls “the four things that matter most” as one faces life’s end: please forgive me, I forgive you, I love you, thank you – plus a fifth, saying goodbye. Some have found that life becomes singularly precious when its ending looms, with opportunities for the most poignant kinds of resolutions.

To me, this is what a good death could be, one grounded in the reality that the cancer could not be denied but with doors opened for meaningful interactions along with the mess and pain. And there’s the ineffable profundity of a loved one’s final moment of transition from this world, such a huge, terrible mystery, yet guaranteed to everyone who lives. That should command our respect.

What happened to my friend? A peaceful, natural passing from the cancer? Or did she avail herself of the end-of-life option to make it happen a little sooner? If the latter, was it pain, or loss of control over the messy details, or an unwillingness to continue living with the existential awareness that death was lurking around the corner? Was she tired of living, that tiredness magnified by the cancer, or tired of talking about it? I’ll never know what she chose. It’s really none of my business. My admiration for her is unaffected, undiminished.

But I find to my surprise, thinking it might have been the case, that something feels missing. It doesn’t seem final, or quite so real. With COVID, her memorial gathering was transferred to Zoom. To me, it just doesn’t feel like the same thing, death’s natural advance versus a medical intervention to check out early, even if the outcome is more or less the same.

What were the unmanaged issues to make ending it sooner seem the right answer? Could something have been done to make her more comfortable, more willing to stay for a natural end? Could there have been more poignant farewells, more reflections, more stories? Could I have had one more chance to talk with her about what she was seeing from her vantage on the rim of eternity? Could I have heard her laugh one more time? And am I selfish to want that? That’s what I can’t get my head around.

Complete Article HERE!

In pandemic era, the term palliative care is even more scary for some.

So specialists want to rename it.

By Haider J. Warraich

Palliative care has an image problem.

It’s a medical specialty that focuses on providing relief from the symptoms and stress of a serious illness to improve the quality of life for both patient and caregivers. But while the specialty’s goal is to help all patients with a serious, potentially life-threatening illness, palliative care specialists are almost always involved with patients approaching the end of life.

The result is that the very phrase “palliative care” has become frightening to many people with critical illnesses and their families, wrongly raising the idea that they are being sent to specialists who will help them die. Now a growing movement is advocating to rename palliative care so that patients — and doctors — won’t fear using it.

A recently published research study analyzing the general public’s perception of palliative care among more than 5,000 older Americans revealed that over 70 percent of participants did not even know what palliative care was.

Katy Butler, a health-care journalist who has written about her own experiences as a caregiver for her parents, wrote in an email: “Although I had a general sense of the meaning of palliative — to soften, to soothe — I didn’t understand anything about what it meant in medicine. People in crisis do not have the headspace to learn new vocabulary. It’s one of medicine’s major failings that it expects them to.”

Of those who are aware of palliative care, the same study shows almost two-thirds think it is the same as hospice, which is a service delivered at home or in a facility for someone with an expected survival of no more than six months.

Most physicians are likely to call palliative care specialists primarily when death is imminent — many worry that calling in a palliative-care consultation will increase anxiety and fear among patients. Diane Meier, a palliative care specialist who directs the Center to Advance Palliative Care, said “doctors are the group most fearful of death. We are people who like to achieve control over the uncontrollable. For our profession in particular, it is existentially threatening. Any acknowledgment that life is finite, that we don’t live forever, is like saying there is no God.”

Yet palliative care not only has been shown to repeatedly improve quality of life in patients with conditions such as cancer and heart failure, but also has been shown in some studies to help people live longer, perhaps through avoidance of potentially ineffective treatments, procedures and hospitalizations.

To increase the acceptability of palliative care for both patients and clinicians, as well as to delink it from death, palliative care practices around the country are substituting the name “palliative care” with “supportive care.”

There is evidence to suggest that this name change might reduce reluctance to engage palliative care specialists in the care of patients with advanced illness.

A study from MD Anderson Cancer Center in Houston showed that changing the name of the palliative care service to supportive care led to not only an increase in referrals by 41 percent but also earlier referrals: Patients seen by “supportive care” lived on average for 6.2 months, compared with 4.7 months among patients seen by “palliative care.” In a randomized trial, patients with advanced cancer viewed the term supportive care more favorably and were more likely to anticipate using supportive care rather than palliative care.

Words clearly matter and perhaps never more so than when life hangs in the balance. Yet even as evidence mounts, one study found that many palliative care specialists oppose a change of the specialty’s name. There are countless medical journals and organizations that have palliative care in their name.

“How do you identify as a tribe, as a field, as a subspecialty if you don’t know what your name is,” said Meier, a professor at the Icahn School of Medicine at Mount Sinai. Yet Meier also believes “we should call it whatever it takes to get it to the patients.”

The resistance to palliative care is ultimately rooted in our collective denial of our mortality. “Changing the name doesn’t change the underlying dynamic,” said Anthony Back, a palliative care physician and professor at the University of Washington in Seattle who was a co-author of the recent study on public perceptions. “Palliative care specialists are often used [late in the process] as the ‘brink of death consult.’ And if we don’t change ourselves, changing the name isn’t going to be enough.”

Even as the debate goes on, the use of “supportive care” is growing among those who treat patients, and instead of educating the public about what palliative care means, they want to focus on what palliative care does — what the benefits are not just to those at the very end of life.

Yes, palliative care specialists will be asked to see patients where other doctors find them of most value — when death is imminent — but the concept that really needs rebranding is death itself. As long as patients and doctors react to that fear by recoiling at its every mention, any new name reminding them of their mortality will quickly become tainted.

This seems important at this particular moment: the covid-19 pandemic has raised the specter of death for many people who hadn’t thought it would apply — yet — to them. People not only face a higher risk of premature death from the disease, they often have to do it in the worst circumstances possible — with a breathing tube down their throats and all by themselves.

Yet, because of the pandemic, palliative care doctors believe that they might have an opportunity to redefine what they do and demonstrate its value to patients in need.

“In New York, there was this urgency with which our colleagues sought our help, because they were under such extreme stress. It made me comment that covid-19 was the best marketing campaign palliative care could have asked for,” Meier said. “Our colleagues were looking to us to be the human side of medicine.”

In providing care to the sickest patients in the hospital, many of whom survived, palliative care specialists provided crucial supportive care not just to patients and their loved ones, but also the doctors struggling to take care of them.

The pandemic has given palliative care doctors more work than ever before and has added a new charge to palliative care, Anthony Back said, to fulfill our most human desire — to acknowledge the moment.

Complete Article HERE!

Patients with COVID-19 shouldn’t have to die alone.

Here’s how a loved one could be there at the end

By &

While the number of new COVID-19 cases in Victoria continues to trend downwards, we’re still seeing a significant number of deaths from the disease.

The ongoing outbreaks in aged care, and the fact community transmission is continuing to occur, mean it’s likely there will be many more deaths to come.

As a result of strict infection control measures restricting hospital visitors, tragically, many people who have died from COVID-19 have died alone. Family members have missed out on the opportunity to provide comfort to the dying person, to sit with them at their bedside, and to say goodbye.

But it doesn’t have to be this way. We have cause to consider whether perhaps we could do more to preserve the patient-family connection at the end of life.

Who can visit?

There’s some variation between Victorian health-care facilities in how visitor restrictions are applied. Some allow visitors to enter hospitals for compassionate reasons, such as when a person is dying. But visitors are not permitted for patients with suspected or confirmed COVID-19.

The latest figures show 20 Victorians are in an intensive care unit (ICU) with 13 on a ventilator. This indicates their situation is critical.

Despite hospitals, and particularly ICUs, being adequately prepared and resourced to provide high-level care for people diagnosed with COVID-19, patients will still die.

Family-centred care at the end of life in intensive care is a core feature of nursing care. So in the face of this unprecedented global pandemic, we realised we needed to navigate the rules and restrictions associated with infection prevention and control and find a way to allow families to say goodbye.

Our recommendations

We’ve published a set of practice recommendations to guide critical care nurses in facilitating next-of-kin visits to patients dying from COVID-19 in ICUs. The Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control have jointly endorsed this position statement.

The recommendations are evidence-based, reflecting current infection prevention and control directives, and provide step-by-step instructions for facilitating a family visit.

Some of the key recommendations include:

  • family visits should be limited to one person — the next-of-kin — and that person should be well
  • the visitor must be able to drive directly to and from the hospital to limit exposure to others
  • they should dress in single-layer clothing suitable for hot machine wash after the visit, remove jewellery, and carry as few valuables as possible
  • on arrival, staff should prepare the visitor for what they will see when they enter, what they may do, and what they may not do (for example, it would be OK to touch your loved one with a gloved hand)
  • a staff member trained in the use of personal protective equipment (PPE) should assist the visitor to put on PPE (a gown, surgical mask, goggles and gloves) and after the visit, to take it off, dispose of it safely and wash their hands
  • where possible, the visitor should be given time alone with their loved one, with instructions on how to seek staff assistance if necessary.

We also highlight the importance of intensive care staff ensuring emotional support is provided to the family member during and immediately after the visit.

Tailoring the guidance

It’s too early to know the full impact a loved one’s isolated death during COVID-19 may have on next-of-kin and extended family. But the effect is likely to be profound, extending beyond the immediate grief and complicating the bereavement process.

These recommendations are not meant to be prescriptive, nor can they be applied in every circumstance or intensive care setting.

We encourage intensive care teams to consider what will work for their unit and team. This may include considerations such as:

  • whether there are adequate facilities in which the visitor can be briefed and don PPE
  • whether social distancing is possible with current unit occupancy and staffing
  • whether an appropriately skilled clinician is available to coordinate and manage the family visit
  • each patient’s unique clinical and social situation.

Rather than just using a risk-minimisation approach to managing COVID-19, there’s scope for some flexibility and creativity in addressing family needs at the end of life.

Complete Article HERE!

Unpredictability of advanced heart failure complicates end-of-life care, doctors say

Some people with advanced heart failure live for a long time, while others don’t. That uncertain timeline poses challenges for doctors, their patients and families dealing with end-of-life care.

“We’ve had for cancer for many years, which have been used to make sure that end-of-life patients get high-quality care,” said Dr. Rebecca Hutchinson, a hospice and palliative medicine specialist at Maine Medical Center in Portland. “With , we don’t have those indicators.”

That discrepancy motivated Hutchinson and five colleagues to conduct in-depth interviews with 23 cardiologists and across Maine about treating people with advanced failure.

The study, published Monday in the Journal of the American Heart Association, found “prognostic uncertainty” of advanced heart failure complicates how doctors care for patients for several reasons.

“Heart failure is marked by frequent exacerbations where patients can get pretty sick and then recover back to baseline or pretty close back to baseline,” said Hutchinson, who led the study. “At some point, one of those exacerbations usually marks the beginning of end of life, but it’s not always easy to tell. Are you in one that’s close to end of life or are you in one where there’s going to be a recovery?”

That, she said, forces doctors to balance the desire to prolong life against the possibility that more treatment will do no good and cause unnecessary suffering. The uncertainty often makes it harder for patients to recognize the reality of their disease, and harder for doctors to discuss the situation with them, the study found.

“Doctors told us that patients with heart failure frequently don’t realize that this is a terminal disease,” she said. “That makes it harder to have the end-of-life conversations early to make sure we’re giving them care that’s consistent with their values.”

According to American Heart Association statistics, an estimated 6.2 million U.S. adults have heart failure, where the heart cannot pump enough blood to meet the body’s needs. About one-tenth of those are classified as advanced heart failure, where usual treatment is not effective but the remaining life span is hard to predict.

The study also examined differences in urban and rural areas, where patients may have less access to medical specialists and quality in-.

“That’s good and bad,” Hutchinson said. “Patients in tend to have less aggressive (unnecessary) interventions at the end of life, but it’s bad in that they may not have access to life-prolonging therapies.”

Hutchinson said the findings emphasize the need for better methods to calculate a patient’s prognosis and determine a patient’s values so that end-of-life care matches what the patient wants. Regardless, she said, —medical help to relieve the symptoms and stress of a serious illness—should be part of the plan.

“Palliative care really shouldn’t be tied to a prognosis,” Hutchinson said. “A lot of people associate palliative care with end-of-life care and hospice, but it’s really not.”

That point alone makes the study worthwhile, said Dr. Diane Meier, director of the Center to Advance Palliative Care and a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City.

While people choosing hospice must agree to relinquish insurance coverage for life-prolonging treatment, she said, “palliative care has no such restrictions. You can get it whether or not your disease can be cured, whether you’re going to live with it for 20 years or whether it’s progressive. Eligibility for palliative care is based on need—symptom distress, family exhaustion, uncertainty about what to expect—and not on prognosis.”

Meier, who was not involved with the new study, said changing the mindset is particularly important for heart patients, who may have years to live but face issues such as depression, anxiety and social withdrawal. She said all of that can be helped by palliative care, which research shows can improve quality of life and symptom control in people with heart failure.

“The important take-home message is we offer both life-prolonging treatment and palliative treatments meant to improve quality of life and day-to-day functioning—at the same time,” she said. “We need to replace our either/or mindset with a both/and model.”

Complete Article HERE!

How Death Doulas Have Adapted End-of-Life Care Amid COVID-19

By

Christy Marek, a certified end-of-life doula, has seen firsthand the added stress that terminally ill individuals have had to endure because of the pandemic. One client had been living at home but decided that her health was putting too much added stress on her family. “She had considered going into a facility just so that she could get the level of support that she needed as she was becoming bed-bound,” says Marek, who is based in Minnesota. But the client found herself at a crossroads: she had to choose between the possibility of dying alone in a facility (upon admission, patients were required to quarantine alone with no visitation for two weeks) or continuing to rely on family care while spending the rest of her time at home.

Marek made several phone calls to facilities to advocate for her client. “I said, ‘What if she doesn’t have two weeks? What are you going to do?’” Marek recalls. Ultimately, her client ended up getting 24-hour home care, but it wasn’t her first choice. “People are then dying at home because the last thing they want is to go into a facility,” says Marek. “They don’t have time to quarantine for the amount of time that [facilities] need.”

For centuries, doulas have been assisting with childbirth, providing emotional, physical, and educational support during pregnancy, labor, and delivery. But there aren’t just doulas for the birthing process: over time, both officially and unofficially, end-of-life doulas have emerged to help individuals with palliative care and support their families through the grief that comes with losing someone. A 2017 study found that women who had continuous support during their labor—whether from a nurse, doula, or partner—reported a more positive birth experience. It seems likely that the same kind of constant emotional support from a death doula would have an equally positive effect on processing the grief around passing.

In a year when death and grief have become a constant, the palliative care process has reached a new level of complexity amid COVID-19. End-of-life doulas have always strived to be a support system for those who are terminally ill, but in 2020 the people who take on that responsibility have been challenged to think outside the box when it comes to caregiving. They’ve had to help their dying clients make unimaginable choices between risking virus exposure and spending their last days alone. They’ve also had their presence questioned at a time when their skills could be most valuable.

Alua Arthur, an end-of-life doula and founder of Going With Grace, has been trying to encourage clients to focus on what they do have control over, even when the world feels full of uncertainty. “Because they’re getting close to the end of life, I remind them that there are some things that are still firmly within our control,” says Alua. “[I have them] look at what it is that we’re trying to control and where the control actually exists. She has her clients work on “cultivating presence and practicing adaptability,” along with “exercises, like finding our feet and consistently planting our feet firmly on the ground [and] becoming present.”

Communication and connection have been the most challenging variables for doulas and their clients. Many in-person meetings with clients and their families have gone digital. For Arthur, FaceTime and Zoom have become essential for helping with clients’ health-related questions when she can’t physically be with them. “Family members [can] scan body parts through a video call, show me and say, ‘Does that look normal?’ Or, ‘She’s breathing like this, does that sound normal?’ And [they] hold the phone up [for me to hear] somebody’s breathing pattern.” That way, even if Arthur is not with the client, she can make an informed decision as to whether they should call the doctor. Arthur has also hosted webinars to help people experience grief and facilitate rituals for transitioning. She has helped coordinate with funeral homes to livestream funerals for clients so that more family members could participate.

For clients who are in assisted-living communities or the hospital, nurses often act as a bridge on behalf of doulas. Janie Rakow, a recently retired end-of-life doula and former president of the International End of Life Doula Association (INELDA), has been raising money for baby monitors for local hospitals so that doulas can keep in touch with their clients, talk to social workers and chaplains, and even play music. “Nurses and medical staff have been integral in helping doulas make sure they connect with families and play music until the end,” she says.

Omisade Burney-Scott, a full-spectrum doula based in North Carolina, has been encouraging her clients to “think about how you show up energetically when you can’t show up physically.”

“Because I’m a Southern Black woman, there’s so much ritual involved with death and dying in the South with Black folk,” says Burney-Scott. “It’s beautiful, it’s complex, but it’s highly ritualized.” Grieving has generally involved a lot of face-to-face interactions and “people coming to your house dropping off casserole after casserole,” so during the pandemic Burney-Scott has tried to help her clients try to find alternate activities that will create a similar feeling of closeness and community. One client with relatives spread throughout the United States and Europe had lost two family members and was looking to honor the deceased. “My question for this person was, ‘Where are they from? What are the things that are meaningful for your family? What are the things that you all love to do together?’ And one of the things that we talked about was food and how much food is a core part of their family culture.” Since their family already did a Zoom session every Sunday, Burney-Scott suggested that they make a dish that everybody in the family loves for their meeting. “Then, when you come to the Zoom call, y’all eat together and honor this person or these people who’ve made their transition,” Burney-Scott says.

End-of-life doulas also help their clients navigate and find support within a racist healthcare system. A 2017 study from Academic Emergency Medicine on implicit bias revealed that White patients were favored, especially by White doctors. Coronavirus has been two times as likely to kill Black and Latino people than White people. In June, Arthur was a panelist for a talk where she and other Black death doulas, along with grief and funeral professionals, discussed the implications of a “good death” in a racist society. More than 2,000 people signed up for the webinar, which touched on the “implicit bias that exists against Black workers, Black deceased and patrons of their families.” “I don’t know how many times I’ve heard people say that racism or race should not be a factor in how we care for people at the end of the day,” says Arthur. “But in order for us to effectively care for people in the afterlife, we have to honor the reality of their lived experience. That includes race, their physical ability, [their] ability to hear, color, sexual orientation, gender identity, and every little part of themselves. We’re honoring a life, so we have to look at the whole life.”

Burney-Scott has been helping members of the Black community process continued grief after the killings of George Floyd, Breonna Taylor, and Ahmaud Arbery and amid continued police brutality and the Black Lives Matter movement. “Grief is not an emotion that is mutually exclusive to physical death,” says Burney-Scott. “So what I have found is that there’s been an unrelenting nature to the grief that we’re all experiencing right now with the pandemic, with COVID-19, but also with racism and white supremacy.” Burney-Scott has been looking to her spiritual background to provide support for others. “My role in that has been to provide instructions and support around how to create your own altar, how to open your space and yourself up to either meditation, prayer, or conversation with your ancestors to ask for support for these families who have experienced the unimaginable,” she says.

More than ever, it’s been necessary for doulas to focus on possibility and opportunity as a way to keep their clients comforted and connected. Still, the challenges of limited physical interactions and restrictions due to COVID-19 have transformed their jobs. In the meantime, end-of-life doulas are doing everything they can to be there for their clients.“We support and empower,” Arthur says. “Why? Because we don’t want people to feel alone in the process. How? We show up.”

Complete Article HERE!

Dying in Your Mother’s Arms

A palliative care doctor on finding a “good death” for children in the worst situations.

A palliative care doctor on finding a “good death” for children in the worst situations.

by John Beder

If losing a child to an illness is one of the worst things that can happen to a family, Dr. Nadia Tremonti has made it her mission to make it better.

It’s not easy. But as a pediatric palliative care physician, she works to ensure that terminally ill children receive quality end-of-life care. Palliative care is sometimes misunderstood to shorten life expectancy, but it’s a method that increases quality of life, improves symptom burden and decreases medical costs. We follow Dr. Tremonti in the short documentary above as she works to make death less medical and more human. In the process she asks a critical question: When a child is terminally ill, how can we make the end of life a better one?

Complete Article HERE!

Sacred Crossings

– Reclaiming the Lost Art of Death Midwifery and Healing Ritual of the Home Funeral

Death Midwifery returns death to its sacred place in the beauty, mystery and celebration of life. A Sacred Crossings Death Midwife shepherds individuals toward a conscious dying experience; guides loved ones in after-death care of the body; and empowers families to reclaim the healing ritual of a vigil and funeral at home. They offer compassionate support to individuals and their families from terminal diagnosis to final disposition.

“As a culture, we deny the natural process of aging and death,” remarked Olivia Bareham, founder of Sacred Crossings. “Learning how to die consciously with grace and acceptance is the greatest gift we can give ourselves and those we love.”

Many people are unaware that they have the legal right to care for their dead at home before burial or cremation. Sacred Crossings offers education and guidance to families who wish to create meaningful funerals at home. We teach them the ancient ritual of bathing, anointing and dressing the body, laying the body in honor for a 3-day vigil and decorating the cremation casket. Inter-faith ministerial services include near-death prayer/meditation vigils, grief support and funeral celebrant services.

Sacred Crossings founder Olivia Bareham is a death midwife, home funeral guide, ordained inter-faith minister and funeral celebrant. She is a member of the National Home Funeral Alliance http://www.homefuneralalliance.org and serves on the board of the Center for Conscious Creativity. Sacred Crossings is owned and operated by certified death midwives.

About Sacred Crossings:
Sacred Crossings is changing the culture of death and dying – through death education and an alternative funeral home. We offer an environmentally friendly option to traditional funeral industry practices and the opportunity for families to have a vigil and funeral at home. The Sacred Crossings Institute offers workshops and classes in conscious dying, home funerals, end-of-life planning, and a certificate program in The Art of Death Midwifery. The Sacred Crossings Funeral Home, owned and operated by certified death midwives, offers a full range of services including home funerals, cremation, conventional burial, green burial and full-body deep sea burial. For more information, contact Annemarie Osborne, publicist at 949.237.2906 or by email annemarieosborne7@gmail.com or Olivia Bareham at 310.968.2763 or olivia@sacredcrossings.com or visit http://www.sacredcrossings.com.