“Pain is only intolerable when nobody cares. You matter because you are you. You matter to the last moment of your life, and we will do all we can to help you not only to die peacefully, but also to live until you die”. Dame Cicely Saunders, pioneer in the birth of the hospice movement. 

The VALOR unit provides Hospice care to those Veterans fighting their final battle.  Whether cancer, heart failure, kidney disease or a variety of other progressive disorders, the notion of entering a unit that you will probably not leave is overwhelming to most Veterans and care givers.  The unit staff are very aware of this mindset during every moment of every day.  The connection between physical and mental suffering is seen in most Veterans and caregivers and the VALOR staff recognize and address those needs simultaneously.  The blend of interventions and the recognition of individualism is a special skill set and requires knowledge of diseases, medications, cultural components of care, understanding of different "generational" issues, communication styles, the purpose of calm and the therapeutic benefit of intentional silence.  

Over the last several years, the VALOR unit staff has faced the COVID disruption we all have.  The inability to admit (or easily admit) from outside sites per Program Office guidance, the reduced census, and the floating of VALOR staff to other services created a sense of distress among the nursing staff.  The thoughts that there were Hospice Veterans needing their skilled and compassionate care somewhere else or not receiving needed care were sources of moral distress. 

The VALOR staff is known for their stellar care in the VISN and Nationally. They have consistently scored at the top of or in the top 5 % of the Hospice units when rated by those who have received services. The Bereaved Family Survey score indicates that VISN 6 scored the highest in the country in the latest published services, and Asheville led in the VISN.  The unit staff are frequent recipients of accolades – the following is a recent excerpt from a family member: 
 
“The staff here has been so very compassionate as my father transitions from this life to the next and I would like to recognize how amazing they have been, and it helps me as his daughter when this team has done their best to keep him comfortable, honor his wishes, maintain his integrity, and compassionately guide me as his daughter through the process. To come in here and be welcomed as a friend once you start coming in here every day—it means something. No question I have asked has gone unanswered with a “you just would not understand” and no one dumbed down the information or tried to use terms that would confuse me. I met Gabriel first, and his humility, compassion, and professionalism have been such a breath of fresh air to me. Today, I was having a really hard time as I seem to be going through the grieving process while he is still here. Gabriel offered me literature, which I read some of in the break area. While I was standing there refusing it though—he tried to tell me some things I really needed to know—and this was so helpful. I appreciate how even if the nurse is not tending to my father on a particular day, I am not invisible, and neither is he. The teamwork here is very noticeable and cohesive and it is apparent you respect one another. Thank you again for all you have done. May God bless you all for what you do.” 

Another example of the exemplary care includes the arrangement of a special visit. The VALOR staff learned about a request that a Veteran wanted to see his “special horses” one last time.  As a long-time volunteer at the community group, Horse Sense, the Veteran wanted the comfort and calming he experienced while working around his favorites.  In that one morning and with the help of several other services, the visit was arranged for that day and this property.  There was a sense of urgency with the request and the arrangements. He was able to see, pet, offer snacks and talk with his horses. It was an emotional time for all. 

These two examples have been from the last 2 weeks- the examples of the wonderful interactions and compassionate care are plentiful.  At times, the “thank-you” notes include heartwarming comments including praise for specific staff, particular actions completed comfortably like a much-needed shampoo, routinely showing up during a favorite TV show daily with a favorite snack without asking or reminding staff, offering and taking the Veteran outside in the bulky hospital bed for a breath of fresh air, finding suitable apparel for burial, and frequent mentions of anticipating the needs before the Veteran or family knew it was needed. I believe that these self-initiated actions are what all of us want and deserve. And, then there is the final salute- an honor and a privilege to participate in and always so appreciated by the family. 

The emotional attachment to the Veterans developed during the VALOR stay impacts the staff.  With worsening status and the eventual passing of the Veteran, the support system they have and ease with each other, demonstrates a Wellness model we all support for balance in life. 

As mentioned, the depth of care involves understanding a host of symptoms and a variety of progressive disease states. With that comes the responsibility of the staff to educate the Veteran and the family.  Providing education during and all around a crisis period requires patience and skill.  Reinforcements are given freely, and there is never scolding or reminders of the conversations that have happened before or those that have happened over and over again. 
   
Staff in VALOR have been asked to tell me why they chose to work on or gravitate toward this area for work.   The staff is varied in education, experience, and years in health care.  The team consists of registered nurses, nursing assistants, an energetic and thoughtful nurse practitioner, a Nurse Manager, and an Assistant Nurse Manager.  Others are pulled into routine meetings and care decisions without hesitation. Though the work is serious and at times “heavy”, there is a certain calm and light spirit on the unit. The friendly relationship among staff members and the collaboration between team members are a healthy example of teamwork.  Staff report feeling comfortable, though “work is work”, the” benefit of what I do brings me back every day” and feeling like “the unit is the first place in years of nursing where the work I do is felt to be truly helpful”, “my opinion is valued here”, and “our philosophy is that we do things for people and not to people”.  These comments, plus the observed actions and the demonstrated skills of all staff, totally speak to the values of the VA- the ICARE values seem to have been written with the faces of the VALOR staff in mind.   

And, in closing, I again quote Dame Saunders. “How people die remains in the memory of those who live on”.  I am confident that the lasting impression for those is immensely positive, and for that we should all be grateful.