The most critical skill for Hospice Comfort Care volunteers is the practice of presence. At its most basic, presence is the degree to which you, as a caregiver, can remain quietly focused on the patient. Undivided attention is great for any interpersonal interaction but is especially critical when trying to support those experiencing significant life transitions. This type of presence is much more than undistracted focus. For Hospice Volunteers, it is about facilitating a space where a patient can perform the "work" of processing and preparing for the end of their life. We must be entirely available for our patients while at the same time not interjecting our own opinions, beliefs, or selves into the death process. This preserves the sacred transition from life to death while supporting the person in transition.

The Merriam-Webster Dictionary defines presence as the state of being present, with "present" meaning at hand and available. 

In the context of our broader society, presence has a meaning that implies a goal of taking up space. When we encounter a person with a significant presence, such as a spiritual leader or a greatly admired politician, we often feel awestruck by the massive amount of mental, emotional, and spiritual space the person fills. Further confusion is sowed by business terms like Marketing Presence, which implies that being present is about being noticed and filling up a market space as much as possible. Neither of these conceptualizations is compatible with the kind of presence Hospice Comfort Caregivers practice.

As a Hospice Comfort Caregiver, I practice what I call silent, empty vessel, witness presence. I must be physically present but not take up mental, emotional, or spiritual space, allowing the person who is dying the room they need to process the end of their life. As a Hospice Volunteer, I have regular everyday conversations with my patients. I help some to eat, to move, to get comfortable, to stay clean, etc. Still, I also spend time in silence, only there to allow the patient to fill an empty vessel in my heart with their thoughts, feelings, fears, gratitude, regrets, triumphs, and joys. I am one of the last people to bear witness to that person's life and their embrace of the end of that life. 

By being silent at times, I allow the patient to enter into a conversation about their life and death that only they can lead. By allowing silence between myself and a patient, no matter how uncomfortable it might initially be, I am inviting the patient to fill that space with their own work of dying. The silence between us may go on for many minutes. The patient might fill that space with something else, but eventually, all patients talk about their life and, many times, their transition to death. 

I remember what I have learned from each patient because I am an empty vessel for both the parts of the story they recounted to me and their final journey toward death. Holding these parts of a patient means that after they are gone, they continue to be present in my life. We all live on in the hearts and minds of the people we interact with in our lives. Different people remember us in different ways. I remember my patients for the things they choose to recall from their lives in their final days. I am also holding their transition work on their journey toward their last breath, their final heartbeat. 

When a patient dies, I am sharply aware that I am one of their newest and final witnesses to their life and death. I see myself as one of their last connections to this life and a chaperone to the final threshold. As a Hospice volunteer, I bear witness to the patient's work processing their life and death. 

As Hospice Comfort Caregivers, we use our quiet presence to invite life reminiscence and death work. We are vessels that hold those moments for the departed. We bear witness to the precious parts of a person's life and final life journey. Our presence is quiet. It is patient. It does not call attention to itself or us. We can neither lead nor follow. There is only the patient on their final journey with us quietly by their side. 

The presence of the Hospice variety must be practiced. It does not come easy. For me, the most challenging aspect of starting out as a Hospice volunteer was stopping myself from filling the silences. Many volunteers initially struggle with this because we live in a society that tends not to value silence. We are used to calling attention to ourselves or watching others call attention to themselves. It takes a few visits with patients for a volunteer to get more comfortable with the silence and see the power of that silence.

When a patient is not responding, either because of their disease or because they are on the final days or hours of their journey, I spend more than half my time with them in silent reflection. I do this to let the patient process things in silence. When patients are in the final, silent stage of death, there is evidence that their minds are working to process the shutdown of the physical body and transition away from this world. These are the final sacred moments of life. It invites silent reflection. The lesser part of the time, I may read to them from their favorite books, be it poetry, the Bible, the Koran, or whatever moved them in life. Or I may pray beside them or speak to them about what is happening in the world while they prepare. 

As mentioned above, the presence needed if one is going to provide comfort care support to the dying person requires practice and, thus, conscious effort. It must be balanced with regular conversation. Furthermore, that balance is different for every patient. Some patients are ready to start reviewing their lives at the first meeting. Some patients want to engage in small talk and other activities for a few visits before discussing their history or personal topics, like their feelings or things they are proud of or regret. 

As to how I practice presence with patients, it mainly involves being in the space and time with the patient but taking up as little space and time as possible. It is about active listening, being a receiver, and, sometimes, a clarifier of information and feelings expressed in various ways by the patient. Sometimes this involves speaking, but most of the time, I participate in silence. I say as little as possible. That is the silent part of presence.

The following two components, being an empty vessel and bearing witness, are tightly coupled and rely on each other.

Being a vessel involves paying close attention and listening to remember what I am told, be it a personal history/life review or about the feelings surrounding impending death. My effort to remember also includes looking for lessons from the patient's life experiences as time diminishes. I ask questions to clarify anything I am unclear on. These questions also serve to demonstrate my intent to remember and bear witness. 

There are two parts to bearing witness. The first part involves showing the patient that I am an active witness to their life review and dying process. I ask questions when I need clarification and confirm with the patient what I have heard them say. In this active listening technique, what the patient says is sometimes parroted back to them to allow them to confirm I heard correctly or to restate their message. This reflection of their words enables them to elaborate, show that I am with them, and remember what they are telling me. (This technique was popularized by Carl Rogers, the therapist, and inventor of Client-Centered Therapy.) In short, I am comforting the patient by showing that I am a witness to their thoughts and memories in their final days; I invite them to elaborate, draw their own conclusions, and call out their own life learnings. 

The second part of bearing witness to each patient is remembering them after they are gone. I remember the patients to myself and to others. I tell stories of their lives and the lessons they taught me about living. I write (as here) about what each patient said and did that impacted me and helped me to change and grow as a person.  

The fact that I talk about the things I learned from patients and recount their stories to others, in a way, keeps them alive, at least in memory and imagination. In a sense, It is a reason for the recitation of the Mourner's Kaddish in the Jewish faith and for prayers for the deceased during Christian and Islamic services. David M. Eagleman, the famous neuroscientist, in his collection of poetic short stories, describes our third and final death as the moment we are recounted to others for the last time.

From my perspective, presence is not about attracting attention but rather about occupying a space and time with a patient in a way that facilitates their end-of-life work. This end-of-life work includes life review and reflection, expressions of pride and regret for things accomplished and not, shedding concerns in this life, and readying for whatever is next. As a volunteer, I conduct my presence with patients by occupying the space in silence when needed, by acting as a vessel for the patient's life recounting, and by bearing witness to their end-of-life preparations and transition across the final threshold. 

Our practice of presence is the primary tool that Hospice comfort care volunteers use to provide support and solace to the dying. It is an honor and a blessing to be part of a person's final journey. It is a sacred time that invites silent, empty vessel, witness presence.