Extraordinary things happen in the cardiothoracic intensive care unit at Ronald Reagan UCLA Medical Center.

The sick rise from bed with new hearts and lungs. Machines valiantly take over for faltering kidneys, heart valves, bronchial tubes. All patients enter with grave health concerns, and the vast majority leave recovered, or at least on the road to healing.

The unit has 150 nurses, at least two dozen of whom are on the floor at any time. They are there for all of it: every intubation and needle stick, every setback, every odds-defying rebound. They bond with their patients and advocate hard for their best interests.

“Our business is living, surviving and getting whatever the patient needs to get there,” said Mojca Nemanic, a critical care registered nurse in the unit.

But sometimes, despite everyone’s best efforts, the most common thing in the world happens here, too. Heartbeats slow and then stop forever. Diaphragms release a final breath and do not contract again. People die.

And when there’s nothing left to fix, CCRN Lindsay Brant said, honoring a patient’s death can be life-affirming.

That’s the ethos behind Community, an initiative Brant proposed two years ago to support patients, their families and unit staff during the dying process.

Led by a 12-member committee of nurses, the initiative gives nurses the tools to care for a patient until, and even after, the moment of death. Community allows these caregivers to advocate as hard for the patient’s preferences at the end of life as they do during their treatment, and to process their own grief after a loss.

“Having somebody survive and recover is such a beautiful story,” said Brant, a 12-year veteran of the unit. “Why shouldn’t death and the transition also be just as momentous?”

The idea for Community began with Marbel, one of Brant’s first patients in her early years in the ICU.

The unit’s nurses speak of patients in broad outlines to preserve their privacy, but even the bare contours of Marbel’s story are haunting: a wound so grievous it nearly severed her body in two; grueling daily treatments that caused as much suffering as they relieved.

Marbel had had enough. Her surgeons wanted to press ahead. In frustration, Brant planted herself in front of the door to her hospital room, barring entry until doctors acknowledged what the patient wanted, which was palliative care and a peaceful death.

The experience sparked a realization, Brant said: A system set up with the noble goal of saving people could at times inadvertently overlook their humanity.

Brant took a course on care for the dying at Upaya Zen Center in Santa Fe, N.M. She became a certified death doula, a person who helps others prepare for life’s end and supports them during the process.

By 2023, she decided to approach her boss, unit director and CCRN Katrine Murray, with an idea for an initiative that would come to be called Community.

Molly Mayville, Allison Kirkegaard and Tony Estrada, from left, of the Threshold Choir prepare to enter a patient’s room to sing at their bedside in the cardiothoracic ICU at Ronald Reagan UCLA Medical Center.

(Juliana Yamada / Los Angeles Times)

Advertisement

Murray was immediately interested. The ICU was still reeling from the trauma of the COVID-19 crisis, in which staff cared for a seemingly endless wave of the pandemic’s sickest patients.

Studies have found critical care nurses to be at significant risk for anxiety, depression, post-traumatic stress disorder and burnout since the pandemic, thanks to the toxic combination of unrelenting work and the moral distress of watching patients suffer, and often die, without their loved ones present.

“People dying alone — that was one of the things we’ll never get over,” Murray said.

Even before the pandemic, intensive care nurses reported dissatisfaction and frustration with hospital procedures that failed to honor patients’ preferences at the end of life.

A 2018 study of intensive care nurses found no physical procedure or patient diagnosis that correlated with nurse distress. Witnessing a patient’s death, respondents said, was not in itself upsetting.

Brant, left, and Murray, right, discuss which patients the Threshold Choir will visit.

(Juliana Yamada / Los Angeles Times)

But they were three times as likely to report severe emotional distress if they felt that their patient died what they perceived as a “bad” death: afraid, unheard, their wishes and dignity overridden by those around them.

“The dying process is part of humanity, and therefore the process itself needs to be respected, just like the patients themselves need to be respected,” Brant said.

Starting in June 2023, Brant started surveying colleagues about their comfort and experiences with caring for dying patients. She started small group trainings and circulated “cheat sheets” of advice for supporting patients and their families.

Community officially launched in summer 2024. It encompasses a swath of programs intended to comfort patients and make meaning from death.

In the Goals of Care component, nurses talk with patients about their hopes for treatment and comfort with extreme measures, conversations that are documented and used to communicate patients’ wishes to their medical team.

The unit became an early adopter of UCLA Health’s 3 Wishes program, which helps caregivers carry out final requests for patients and their families: a hospital room wedding, a plaster mold of the entwined hands of a patient and their spouse, a last trip outdoors (no small feat, considering the armada of medical equipment that has to come along).

Brant cares for a patient in the unit.

(Al Seib / For The Times)

Advertisement

Brant connected with the Threshold Choir, a national network of volunteers who sing at the bedsides of the ill and dying. Members of the choir’s Westside chapter visit the unit every Thursday to sing soothing harmonies to patients in need of comfort, regardless of their prognosis.

There is the Moment of Silence, a ritual after a patient’s death in which nurses and doctors join the patient’s loved ones in the hospital room to honor their passing.

And for the staff, there is Show Up and Share, a quarterly session on Zoom and in person to debrief about challenging experiences on the unit. Some people vent. Some people cry. Some participants don’t say anything, but write in the chat how much it means to hear colleagues voice a similar emotion.

The hospital previously made social workers and counselors available to unit nurses, but uptake for their services was low, Murray said. In contrast, Show Up and Share “just works, because we’re doing it for each other as opposed to someone else,” she said.

In late 2024, CCRN Quentin Wetherholt was caring for a patient with a long-term illness when he sensed a subtle change in her demeanor. He initiated a Goals of Care conversation with the patient, her family and doctors that reviewed possible options for treatment, nearly all of which she had already tried. After hearing her choices, the patient spoke up: She no longer wanted life-prolonging measures.

From that point on, the patient’s attitude “was just nothing but joy, ironically. It caught me off guard. Normally, when people realize that they’re facing death, it’s a very sad environment to be in. But with her, it was freeing,” Wetherholt said.

“It was a very difficult road that she was on: lots of pain, lots of surgery. And so for her to have that just instantly be gone, and she could enjoy her time the way she wanted to enjoy it — it brought her back her sense of self.”

“The dying process is part of humanity, and therefore the process itself needs to be respected, just like the patients themselves need to be respected,” Brant said.

(Al Seib / For The Times )

Advertisement

The patient asked relatives to fly in from overseas. She asked for a milkshake. She died peacefully about a week later, with family around her bed.

After the patient’s death, the unit held a Show Up and Share session to grieve for her and for others who had recently passed in the unit.

“Before, it was almost like a point of pride — you know, ‘Death doesn’t affect me, this is what I do for a living,’” Wetherholt said. “But now it’s become such a nice thing to go through with your co-workers, to be able to have this forum to really heal and to not have to bottle it up.”

Early data are promising: In a survey of nursing staff five months after the Moment of Silence began, 92% felt more connected to their patients and families, and 80% felt closer to their teammates. Brant has applied for a grant to share the Community program with the hospital’s six other intensive care units.

“We are a family here, and we treat patients like they’re an extension of our family,” Brant said. “Nursing is the best excuse in the world to love on strangers, to treat all humanity as if it was your closest friend and loved one. And it’s such a gift to be able to do that.”