PHILADELPHIA—Michelle Brassil, MD, had been warned when she began her fellowship at the Cpl. Michael J. Crescenz VA Medical Center’s Community Living Center in Philadelphia. “Don’t be surprised if you’re emotional,” her supervisor told her. “It’s not like anything you have seen before.”

Her supervisor was right.

Music began playing through the speakers. Activity in the building came to a halt. Patients and staff appeared in doorways as the body of a veteran who had passed away at the CLC’s hospice and palliative care unit earlier that day was wheeled on a covered stretcher draped with an American flag, taking one of his final journeys from the unit to the hospital’s morgue. Most importantly, he did not travel alone. He was accompanied by the unit’s veteran Honor Guard. They wore their special uniform—hat, gloves and vest—escorting the body through the hospital, paying tribute the best way they could to a fellow veteran.

As a fellow specializing in palliative care services, Brassil arrived at the Philadelphia VA’s CLC last year expecting to work on developing her communication skills and symptom management techniques. Passionate about making palliative care about more than just easing pain, Brassil was excited about the culture of VA.

Many times, hospice units outside VA have very strict criteria for who can be admitted. The hospice unit at the VA has a different approach, Brassil explained. The unit will take anyone with a prognosis of three months or less, as long as their goals are consistent with comfort-directed care.

“It can be a nice transition for patients who have a lot of needs that the family can’t support but who aren’t dying next week,” she said. “Patients and families have time to process what exactly is happening while still having excellent symptom management.”

At VA, palliative care is more than just simply providing healthcare to veterans at the end of their life, Brassil explained, It’s about managing patient and family expectations, creating an atmosphere where communication about deep-seated fears of dying is possible and about preserving dignity and a sense of community during a time when a veteran might feel the most alone.

When a patient passes away in hospice at the Philadelphia VA Medical Center the Resident Honor Guard is quick to respond.  In this photo, honors escorts practice the proper way to fold a U.S. flag. Photo from VA Healthcare-VISN 4

The Honor Guard—the development of which she is spending the last few months of her fellowship documenting—plays a significant role in preserving that dignity.

The Honor Guard was the brainchild of George “Gerry” Donlon, a U.S. Army veteran who served in Vietnam. A CLC resident himself, he approached the nurse manager of the hospice and palliative care unit, Bettyanne Corkery, with the idea.

There was some anxiety around the concept at first, Brassil said. “There was a fear that [deceased veterans] being escorted out of the building in front of other veterans getting care could be disturbing.”

Donlon impressed on the unit staff that the alternative—the bodies of veterans being wheeled out the back to the morgue—was worse.

“Prior to the Honor Guard, there was no kind of announcement when a veteran on the unit died,” Brassil said. “Friends just stopped showing up for meals.”

Donlon helped start a movement to not shy away from a veteran’s death in the hospice unit, believing that they should be honored up to and following their death.

With Corkery’s support, Donlon created the Honor Guard in 2014. It’s a 24-hour a day, veteran-run, all-volunteer position, the members of which take very seriously.

“A lot of them are very ill themselves, and it’s pretty impressive for them to be serving. These are men in electric wheelchairs, some with multiple missing limbs,” Brassil explained. “We had one patient who was in the hospice unit who was also in the guard. Up until he declined, he was still participating in the Honor Guard.”

As part of her documentation, Brassil has interviewed staff and is getting permission to interview residents and Honor Guard members. She’s also considering talking with residents who are not part of the Honor Guard to see how it affects the atmosphere of the facility and their own perceptions on death.

“I know there are Honor Guards at other VAs, but from my understanding this is the only one that’s completely veteran-led. We’re hoping this will become popular across the nation,” she said. “What I’ve always felt most moved by is that the family is so appreciative to see their loved ones respected. One last military goodbye in a very dignified way.”