Death Doulas: Who They Are and How They Make Dying Easier

A pack of cigarettes. It was one of her client’s dying wishes, and one that Shelby Yaffe was happy to fulfill. Yaffe is a death doula, or an end-of-life caretaker, and making sure her clients get what they need for a peaceful transition to “the other side” is her top priority. 

“My biggest passion around death is that people should be able to have whatever they want (when they’re dying),” said Yaffe, who’s based in Arvada. “Anything that people want to be comfortable, any colors that they want, any music that they want. And it’s just so not like that out there, you know, it’s not personalized.”

Death doulas work with people who are facing the end of their lives, providing them and their loved ones with additional support beyond what hospice and palliative care offer. While hospice and palliative roles are medically oriented, doulas focus on providing emotional and spiritual support. This can cover everything from memorial and legacy planning to mapping out a client’s final moments to facilitating reconnection with estranged family members. 

Yaffe, who also works as a CNA, pointed out that the nature of the American healthcare system leaves a gap in emotional services for the dying, one that is increasingly being filled by doulas. Most of her job as a doula, she said, is companionship—listening to and being there for her clients.

“Providing truly whole-person, holistic care is not profitable as far as I have been able to see,” Yaffe said. “We have one CNA for 10 patients. We have one nurse for four patients. That’s a good, well-staffed day at the hospital. So just with the amount of work you have to do with each person, there’s no way to spend emotional support time at the bedside.”

America’s death problem

To Vanessa Johnston, a death doula based in Littleton, the effects of hospitals’ bottom lines on the dying are exacerbated by what she terms “deathphobia,” the reluctance of American culture to talk about or engage with death. 

“We used to deal with death and dying a lot better. 200 years ago, we used to see it a lot more often, and now it’s outsourced to hospitals and facilities, which is fine; I understand why, because there’s sadness and sorrow underneath,” Johnston said. “But in the meantime, we’ve done ourselves a disservice and we’ve lost those skills on how to process this loss.”

Stigma around death continues to be widespread. In the U.S., polling from Ethos in 2022 found that Americans would rather talk about money, mental health, sex, politics and religion (in that order) before death, which only 32% of respondents said they’d be willing to discuss. 

Just 25% of respondents had wills, and less than half had discussed end-of-life arrangements with their loved ones. Even so, what Johnston calls “the last great mystery” is still very much on people’s minds; 45% of respondents said they thought about death at least once a month, while 23% said they think about it daily.

“(Death) very quickly becomes freaky for people where, you know, only a hundred years and some change ago, people were taking care of their own family members after they were deceased,” Yaffe said. “People died in the home, and their family members were the ones who attended to the care of the body.”

Now, much of the end-of-life and post-death care has been taken over by hospitals and funeral homes. 

“The United States, especially, is so disconnected from death. People do not tend to their dead. People are afraid of dead bodies. People don’t want to touch their loved ones after they’ve passed,” Yaffe said. “I think that the fear of death was fueled by being separated from it, and the initial separation was because hospitals needed to make money. Death was just a part of life until we medicalized it as a society.”

Enter: Death doulas

Despite continued stigma around death, Americans are moving a little closer to confronting their mortality. In 2017, 31% of natural deaths occurred at home, while 21% took place at nursing homes, 30% at hospitals and 8% in hospice care centers. This marked the first year in decades where more deaths occurred at home than anywhere else, which, combined with increased awareness, helps explain why death doulas are on the rise. 

There are no legal requirements dictating who can call themselves a “death doula” in Colorado. While the Colorado state legislature passed a measure in 2023 expanding Medicare and Medicaid coverage to include birth doulas, death doulas are not reimbursed by state or private insurance and operate outside the purview of federal and state regulations. 

However, organizations like the International End of Life Doula Association and Going With Grace offer training courses and certificates in end-of-life care, which can be used as benchmarks for prospective clients. Johnston also co-founded the Colorado End of Life Collaborative in 2020, which currently has 22 members. To join the collaborative, doulas must be interviewed and vetted by the Collaborative leadership, have completed a reputable doula training and have a business license from the state of Colorado. 

Though Johnston saw the collaborative as a way to improve industry integrity, she also thought it was important to keep formal “gatekeeping” out of the field. 

“People have been doing this work for millennia, but it’s only now becoming a job. That’s also the reason why I don’t really want it to be weighed down by licensure,” Johnston said. “I’m interested in legitimizing this as a profession, but I also don’t want to gatekeep if somebody has been serving this role for 30 years in their community.”

As for legal oversight, Johnston was confident that the emotionally challenging nature of the work would weed out those with bad intentions. Even so, she emphasized the importance of researching multiple prospective doulas before seeking services. 

“Every death doula is different, so that’s why it’s important to interview them, find out what their other skills are,” Johnston said, adding that many people wait until it’s too late to thoroughly research their options.

Once they’re in business, doulas can take their own approach. Johnston, who is certified through INELDA, said she uses the three pillars she learned in INELDA training—life review, vigil planning and legacy projects—as a blueprint and adjusts based on the client’s needs. 

In the life review stage, she helps clients reflect on their proudest moments and most impactful relationships, eventually moving on to discuss any lasting regrets, unfinished business, guilt or shame. 

“If people have the opportunity to answer questions like that, they are more likely to see their life as a story and to experience more peace as they reach the ending of that story,” Johnston said. “They’re also able to prepare for the ending.”

In the vigil planning stage, Johnston and her clients plan their final hours and days of life—who will be in the room with them? How do they want their bed positioned? What do they want the environment to look like? Finally, Johnston works with families to process their clients’ deaths through legacy projects to honor and remember her clients (i.e., establishing traditions or creating a collection of memories). 

“I’m a supplemental support in a lot of different ways,” Johnston said. “What I do is not really medical. If I were to be on a hospice team, I would fit between the social worker and the chaplain.”

Though Johnston has no interest in working in healthcare, Yaffe is more open to combining her experience in the nursing and doula fields. She recognized that each role has its drawbacks.

“You’re not allowed to talk about certain things as a CNA; you’re not allowed to talk about religion or what happens after you die,” Yaffe said. “And I wanted to be able to do that. I wanted to be able to talk to family members about how they were feeling about the death and what they think might happen to people when they die.”

Yaffe hopes to one day open her own nursing facility specifically for the dying, where she can provide both medical and emotional support for her patients and clients and give them “whatever they want.” For now, though, she’s content to do both. Like Johnston, working so closely with death has reshaped the way she lives her own life. 

“I think that people forget how precious life is because they’re not thinking about the fact that it ends often enough,” Yaffe said. “I think about my death every single day, and I think that that has made my life a million times better than it was before because I appreciate everything so much more.”