Death Doulas: Historical Origins, Modern Practice, and Legal Considerations in Texas

Introduction

While researching for my forthcoming law review article, "The Practitioner's Guide to Where the Bodies are Buried: An Analysis of Texas Laws Governing Various Dispositions of Remains," I discovered that the topic of death doulas warranted more substantive treatment than a mere paragraph could provide. This realization prompted the development of this separate, dedicated examination of death doulas and their role in end-of-life care.

In recent years, a growing movement within end-of-life care has emerged that emphasizes holistic, person-centered approaches to dying. At the forefront of this movement are death doulas—non-medical professionals who provide emotional, spiritual, and practical support to the dying and their families. Despite their increasing prevalence across the United States, including Texas, many attorneys and members of the public remain unfamiliar with death doulas, their historical origins, their specific role in end-of-life care, and the legal landscape governing their practice. This article explores the ancient origins of doulas, traces how modern death doulas emerged, examines their specific functions within end-of-life contexts, and analyzes the current regulatory framework in Texas and beyond.

I. Historical Origins of Doulas

A. Etymology and Ancient Practice

The term "doula" derives from ancient Greek, originally meaning "female servant" or "woman who serves."¹ Historically, the concept of having a supportive companion during major life transitions has deep roots across numerous cultures. The origins of doulas can be traced back to ancient Greece, where women provided emotional support, guidance, and comfort to laboring women during childbirth.² This tradition of women supporting other women during significant life transitions has persisted throughout history in various forms across cultures worldwide.

B. Birth Doulas and the Modern Doula Movement

The modern understanding of doulas primarily began with birth doulas. In English, the term "doula" was first used in a 1969 anthropological study by Dana Raphael, a protégée of Margaret Mead. Raphael suggested it was a widespread practice across human societies that a female companion be part of childbirth, traditionally a role occupied by a family member or friend.³

In her book "The Tender Gift: Breastfeeding," Raphael used the term "doula" to describe non-medical caregivers who offered support to parents during the postpartum period. The concept gained scientific legitimacy when physicians Marshall Klaus and John Kennell began conducting research on the medical outcomes of childbirth when continuous care is provided by a non-medical support person.⁴

The formal professionalization of doulas began in the late 20th century. In 1992, Doulas of North America (now DONA International) was founded as the first organization to train and certify birth and postpartum doulas.⁵ This organization helped establish standards of practice and recognition for doulas, primarily focused on pregnancy and childbirth.

II. The Emergence of Modern Death Doulas

A. From Birth to Death: Extending the Doula Concept

The extension of the doula concept from birth to death represents a natural evolution. As articulated by some practitioners: "The question has been asked if people have guidance entering the world, why don't they have the same guidance leaving the world. Hence, the End of Life Doula was born."⁶ This parallel recognizes that both birth and death are profound transitions deserving of specialized support beyond medical care.

B. Development of the Modern Death Doula Movement

The rise of death doulas as a formalized movement is relatively recent. One of the first organized programs began in New York in 2000, a volunteer initiative focused on pairing "doulas" with terminally ill individuals. This program, funded by the Shira Ruskay Center of the Jewish Board of Family and Children's Services and NYU Medical Center, was named "Doula to Accompany and Comfort."⁷

Shortly thereafter, the Baylor Supportive and Palliative Care Service and Clinical Ethics Committee established a similar program, working in consultation with the New York initiative. They developed a 6-week training program where doulas would collaborate with clinical medicine, being referred by nurses, social workers, and therapists, and formally ordered by physicians.⁸

In the decades since these pioneering programs, the death doula movement has grown significantly. According to some sources, the first formal End-of-Life Doula Certificate Program in the United States was created in 2010.⁹ Organizations like the International End of Life Doula Association (INELDA) and the National End-of-Life Doula Alliance (NEDA) have emerged to establish standards, provide training, and promote awareness of death doulas.

C. Cultural and Social Factors in the Growth of Death Doulas

Several factors have contributed to the increasing recognition and demand for death doulas:

1. Death positivity movement: Death doulas are part of a broader movement that urges a paradigm shift toward thinking about death as natural and not inherently traumatic.¹⁰

2. Aging population: The aging of the population, coupled with the decreasing availability of family caregivers, has created a greater need for additional support. By 2030, the ratio of unpaid caregivers to persons needing care is projected to decrease from 7:1 to 4:1.¹¹

3. Limitations of the medical system: Although hospice provides invaluable services, practical limitations exist. The average hospice nurse may only have one hour of bedside service per visit, much of which is spent on documentation. Hospice volunteers typically provide just 30-45 minutes of support per week, which may not be sufficient during intensely stressful periods.¹²

4. Desire for home deaths: An increasing number of people are choosing to die at home, surrounded by family and free from institutional restrictions, creating demand for additional support services.¹³

III. The Role of Modern Death Doulas

A. Defining the Death Doula

A death doula, also called an end-of-life doula or death midwife, is a person who assists in the dying process, much like a midwife or doula does with the birthing process. It is often a community-based role, helping families cope with death by recognizing it as a natural and important part of life.¹⁴

A death doula is a non-medical professional who offers compassionate, holistic care at the end of life. They provide emotional and physical support, educate individuals and their loved ones about the dying process, help with preparation for the end of life, and offer guidance during the grieving process. Their work assists both the individual nearing the end of life and their loved ones before, during, and after death.¹⁵

B. Specific Functions and Services

Death doulas perform a wide range of services that complement but do not replace medical care. These typically include:

1. Educational support: Death doulas support families by providing valuable information about the dying process, care options, and community resources. They help families understand medical terminology and facilitate conversations with healthcare professionals.¹⁶

2. End-of-life planning: They assist families in creating personalized care plans by understanding their wishes, values, and goals. Death doulas guide families in understanding and accessing palliative care, hospice care, and pain management services.¹⁷

3. Emotional and spiritual support: Death doulas perform sacraments of soothing and release that may be drawn from various cultural and spiritual traditions.¹⁸ They provide a calming presence and emotional support during a difficult time.

4. Practical assistance: Death doulas assist with organizing important legal documents and help with funeral arrangements, relieving families of logistical burdens and allowing them to focus on the emotional journey.¹⁹

5. Vigil planning and presence: Death doulas help with vigil planning and provide a continuous presence that healthcare workers, due to caseload constraints, often cannot offer.²⁰

6. Legacy projects: They may help with creating legacy projects, such as captioning photos, scrapbooking, organizing recipes, or recording meaningful stories to pass on to family.²¹

7. Post-death support: Death doulas often provide bereavement support to family members after the death has occurred.

C. Relationship to Hospice and Medical Care

Death doulas do not replace medical professionals but rather complement existing healthcare services. While hospice care is centered around managing the physical aspects of the dying process, including medical care and symptom management, death doulas focus on offering emotional and spiritual guidance rather than medical care.²²

Death doulas enhance other care received and collaborate with medical, palliative care, and hospice team members. They often begin working with people earlier than hospice, well before they consider enrolling in hospice care.²³ This allows for a continuity of care that may be beneficial during the extended period of terminal illness.

Many end-of-life doulas say they complement the care from hospitals, senior-care facilities, and hospices, filling gaps that occur during the dying process. As one practitioner noted, "Hospice care is wonderful...But it's not everything. The family still has to do most of the care."²⁴

The National Hospice and Palliative Care Organization (NHPCO) has developed an advisory board supporting doulas as a "complement to the already amazing care offered by hospice."²⁵

IV. Death Doulas in Texas: Current Status and Legal Considerations

A. Regulatory Framework

Unlike many healthcare professions, death doulas currently operate without specific state regulation in Texas. There is no state or federal regulatory body that certifies end-of-life doulas.²⁶ This absence of formal regulation means there are no state-mandated educational requirements, licensing procedures, or scope of practice limitations specifically for death doulas in Texas.

This unregulated status distinguishes death doulas from other end-of-life professionals in Texas, such as funeral directors, embalmers, and crematory operators, who are regulated by the Texas Funeral Service Commission (TFSC). The TFSC, which is the state agency authorized by state law to regulate the death care industry in Texas under Texas Occupations Code, Subtitle L, Chapter 651,²⁷ does not currently have specific provisions addressing death doulas.

While this regulatory gap provides death doulas with flexibility in their practice, it also creates potential confusion about their legal boundaries. Unlike hospice care providers who operate under Medicare regulations and state healthcare facility licensing requirements, death doulas practice in a largely undefined legal space, making it essential for them to clearly communicate their non-medical role to clients.²⁸

B. Training and Certification

While not legally required, many death doulas pursue voluntary certification through national organizations. There aren't any prerequisites or requirements to become a death doula, and you don't need prior training in any field to pursue a career as a death midwife.²⁹ However, several reputable training programs exist:

1. International End of Life Doula Association (INELDA): INELDA offers a comprehensive certification program that requires completion of their training, participation in at least five cases, a minimum of 36 hours of direct work as a doula, seven evaluations, and additional requirements.³⁰

2. National End-of-Life Doula Alliance (NEDA): NEDA certification covers topics such as communication and interpersonal skills, professionalism, technical knowledge about end-of-life care, values, and ethics.³¹

3. The Conscious Dying Institute: This organization provides certification through its End-of-Life Doula Certificate Program, which focuses on both practical skills and spiritual/contemplative approaches to death care.³²

4. The Lifespan Doula Association: This association offers training that aligns with NEDA's core competencies and provides certification through a comprehensive program covering the physical, emotional, and spiritual aspects of end-of-life care.³³

In Texas specifically, there are local training programs such as the TX Doula Movement, which offers End-of-Life Doula Certification consisting of 16 modules, a group project with skills test, and a final exam.³⁴ Additionally, Texas-based organizations like Althea Center for Engaged Spirituality in Austin offer periodic death doula training workshops.³⁵

These certification programs typically include education on topics such as the dying process, grief support, advance care planning, vigil planning, cultural and religious death practices, family dynamics, and self-care for practitioners. While such training is optional from a legal standpoint in Texas, it provides death doulas with credibility and a foundation of knowledge essential for practicing competently and ethically.

C. Legal Considerations for Texas Practitioners

While death doulas operate without specific licensing requirements, they must be careful to stay within appropriate boundaries to avoid encroaching on regulated professions:

1. Medical practice: Death doulas must not provide medical advice, diagnose conditions, or administer treatments, as these activities would constitute the practice of medicine, which is regulated under the Texas Medical Practice Act (Texas Occupations Code, Title 3, Subtitle B, Chapter 151-170).³⁶ Unlike nurses and physicians, death doulas cannot administer medications, perform medical procedures, or make clinical assessments.

2. Nursing practice: Under the Texas Nursing Practice Act (Texas Occupations Code, Chapter 301), only licensed nurses can perform certain patient care activities. Death doulas should avoid activities that might constitute nursing practice, such as administering medications or providing medical treatments.³⁷

3. Funeral directing: Activities related to the care and preparation of deceased bodies for burial or cremation are regulated under Texas law (Texas Occupations Code, Chapter 651) and should be left to licensed funeral directors. Death doulas can provide emotional support during funeral planning but should not engage in activities reserved for licensed funeral directors, such as embalming or the final disposition of remains.³⁸

4. Legal advice: While death doulas may assist with organizing documents, they should avoid providing legal advice regarding wills, advance directives, or other matters that would constitute unauthorized practice of law under Texas Government Code § 81.101 and Texas Penal Code § 38.123.

5. Death certificates: In Texas, HB 4048 (passed in 2021) amended the Health and Safety Code to permit nurse practitioners to complete the medical certification for death certificates, but only if the death occurred while under their care.³⁹ Death doulas, lacking medical credentials, cannot complete medical certifications for death certificates.

6. Business regulations: Death doulas operating as businesses in Texas must comply with general business registration requirements, tax obligations, and other regulations applicable to small businesses or independent contractors. This may include registering a business name with the county clerk, obtaining necessary business permits, and complying with applicable tax requirements.

7. Scope of practice clarity: It is advisable for Texas death doulas to develop clear service agreements that explicitly outline the scope and limitations of their services. These agreements should emphasize that death doula services are non-medical and complementary to, rather than replacements for, medical and hospice care.⁴⁰

D. Integrating Death Doulas into End-of-Life Care in Texas

The integration of death doulas into Texas's end-of-life care system presents both opportunities and challenges. Unlike birth doulas, who have achieved greater recognition within healthcare systems, death doulas are still establishing their place within the continuum of care.

According to the National End-of-Life Doula Alliance (NEDA), there has been "growth in interest and acceptance by the hospice industry" in recent years.⁴¹ Some hospice organizations in Texas have begun incorporating doulas into their services, either by training existing staff in doula principles or by establishing relationships with independent death doulas.

Death doulas serve clients "where they are—wherever they call home," and they work "alongside palliative care and hospice teams as an additional, complementary layer of support." While they most frequently work in individuals' homes, there has been a shift toward training organizations, including hospice organizations and hospitals.⁴²

In Texas specifically, the integration efforts face unique challenges due to the state's large rural areas where access to hospice and palliative care services can be limited. Death doulas have the potential to fill critical gaps in these underserved communities, providing support to individuals who might otherwise lack access to comprehensive end-of-life care.⁴³ However, the absence of insurance coverage and standardized referral systems creates barriers to widespread integration.

Several Texas healthcare systems have started pilot programs to evaluate the impact of incorporating death doulas into their palliative care teams. For example, some hospitals in major metropolitan areas like Houston, Dallas, and Austin have established volunteer death doula programs to support patients without family support or with complex emotional needs.⁴⁴ These programs typically require doulas to complete both the hospital's volunteer training and specialized end-of-life doula training from a recognized organization.

V. Ethical and Legal Challenges

A. Quality Assurance and Public Protection

The unregulated nature of death doula practice raises concerns about quality assurance and public protection. Without standardized training requirements or scope of practice limitations, consumers may have difficulty distinguishing between qualified and unqualified practitioners. Unlike regulated healthcare professions, there is no state board to receive and investigate complaints or enforce standards of practice.

This regulatory gap is particularly concerning given the vulnerable population served by death doulas. Individuals approaching the end of life and their families may be emotionally vulnerable and less able to critically evaluate service providers. The potential for exploitation, whether financial, emotional, or spiritual, necessitates careful consideration of appropriate safeguards even in the absence of formal regulation.⁴⁵

B. Informed Consent and Expectations

Clear communication about the role and limitations of death doulas is essential for informed consent. Clients should understand that death doulas do not provide medical care, and their services complement rather than replace healthcare services. There is potential for confusion when doulas work alongside medical professionals, particularly regarding decision-making authority and responsibility.

In Texas, where medical consent is governed by statutes including the Texas Consent to Medical Treatment Act (Chapter 313 of the Texas Health and Safety Code) and the Texas Advance Directives Act (Chapter 166), death doulas must be particularly careful not to interfere with the legal consent process for medical treatment at the end of life.⁴⁶ Death doulas should facilitate rather than impede communication between patients, families, and healthcare providers regarding treatment decisions.

C. Financial Considerations

Unlike hospice, the cost of a doula is not covered by Medicare, and private insurers generally do not reimburse for doula services. Doulas may charge an hourly rate, from $45 to $100, or on a sliding scale, with flat fees ranging from $500 to $5,000, depending on services provided.⁴⁷ This lack of insurance coverage raises concerns about accessibility and equity in end-of-life care.

Some Texas death doulas have established sliding scale fees or provide pro bono services to ensure access for underserved populations. Others partner with non-profit organizations or faith communities to provide subsidized services to those in financial need. However, the sustainability of these models varies, and without systematic funding mechanisms, access to death doula services remains limited primarily to those with financial means.⁴⁸

D. Liability Considerations

Death doulas in Texas face potential liability concerns that remain largely untested in courts. While they generally maintain lower liability exposure than medical providers, their close involvement with clients at the end of life could potentially lead to claims related to emotional distress, breach of confidentiality, or exceeding the scope of their role.

Most professional training programs recommend that death doulas obtain liability insurance, develop clear service agreements, maintain appropriate boundaries, and document their activities. However, without established standards of practice or case law specific to death doulas, the legal landscape remains uncertain.⁴⁹

E. Potential for Future Regulation

As the death doula movement grows, questions about the need for formal regulation may arise. Some jurisdictions outside Texas have faced controversies regarding the use of terms like "death midwife," with the College of Midwives of British Columbia calling for death midwives to stop using the label of midwife.⁵⁰ Similar title protection issues could potentially emerge in Texas.

In Texas, the regulation of healthcare professions typically occurs through the legislative process, involving the creation of practice acts and regulatory boards. The Texas Sunset Advisory Commission, which periodically reviews state agencies, would likely be involved in any formal consideration of regulating death doulas.⁵¹

If regulation were to be considered, policy questions would include:

• What minimum training requirements should be established?

• Should certification be mandatory or voluntary?

• What scope of practice limitations should be codified?

• What disciplinary mechanisms would be appropriate?

• Should death doulas be regulated under an existing board or through a new regulatory entity?

• What grandfathering provisions should apply to existing practitioners?

VI. Recommendations for Legal Professionals

Attorneys and legal professionals working with clients on end-of-life planning should be aware of the emerging role of death doulas and consider the following recommendations:

A. Integration with Estate Planning Practice

1. Include death doulas in advance care planning discussions: When assisting clients with advance directives and healthcare powers of attorney, attorneys can inform clients about the option of engaging a death doula as part of their comprehensive end-of-life plan. This is particularly relevant when clients express concerns about family dynamics, spiritual needs, or desire for home death that extend beyond traditional medical and legal planning.⁵²

2. Develop interdisciplinary networks: Texas attorneys working in elder law, estate planning, and probate practice may benefit from establishing professional relationships with reputable death doulas in their communities. This allows for appropriate referrals and collaboration when clients present with needs that extend beyond legal services.⁵³

B. Client Protection and Risk Management

3. Clarify boundaries through contracts: Help clients develop clear contracts with death doulas that delineate services, expectations, confidentiality obligations, and limitations. These contracts should explicitly state that death doula services are non-medical and distinguish them from hospice and palliative care services.⁵⁴

4. Address liability concerns: Consider potential liability issues, particularly when death doulas work alongside healthcare providers, and help clients understand the different roles and responsibilities. When appropriate, attorneys might discuss how the presence of a death doula affects the legal responsibilities of designated healthcare agents or medical powers of attorney.⁵⁵

5. Advise on privacy considerations: Counsel clients on privacy expectations and limitations when working with death doulas, who generally are not covered entities under HIPAA but may have access to sensitive medical and personal information. Clear agreements regarding confidentiality and information sharing are essential.⁵⁶

C. Practice Development

6. Stay informed about developments: The death doula movement continues to evolve, with changing standards, practices, and potentially new regulations. Legal professionals should stay informed about these developments to best advise their clients. This may include following the activities of organizations like NEDA and INELDA, as well as Texas-specific developments in end-of-life care legislation.⁵⁷

7. Develop specialized knowledge: Texas attorneys interested in developing a niche practice might consider obtaining specialized training on death doula practices and end-of-life care issues. This knowledge can enhance the attorney's ability to serve clients with complex end-of-life planning needs and facilitate collaboration with death doulas and healthcare providers.⁵⁸

VII. Conclusion

Death doulas represent a resurgence of traditional supportive care at the end of life, now formalized within a modern healthcare context. By providing emotional, spiritual, and practical support that complements medical care, they help address gaps in our current approach to dying and death. In Texas, as throughout the United States, death doulas operate in a largely unregulated space, allowing for flexibility but also raising questions about standards and consumer protection.

The Texas legal landscape presents unique challenges and opportunities for the integration of death doulas into the broader end-of-life care system. While the absence of specific regulation allows for innovative approaches and diverse practice models, it also creates uncertainty regarding scope of practice, liability, and quality assurance. Legal professionals in Texas have an important role to play in helping clients navigate this evolving terrain, ensuring that engagement with death doulas enhances rather than complicates end-of-life planning and care.

As our population ages and interest in more holistic approaches to end-of-life care grows, the role of death doulas is likely to expand. In Texas, with its blend of urban centers and rural communities, death doulas may be particularly valuable in addressing disparities in end-of-life care access and quality. The potential for death doulas to serve as cultural bridges in Texas's diverse communities further enhances their value in the end-of-life care ecosystem.⁵⁹

Legal professionals, healthcare providers, and policymakers in Texas would be well-served to better understand this emerging profession and thoughtfully consider how it fits within the broader context of end-of-life care and regulation. By striking an appropriate balance between consumer protection and practice innovation, Texas has the opportunity to develop an approach to death doula integration that respects individual choice while ensuring quality care for its citizens at the end of life.

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This article has been created with assistance from AI technology for research and initial organization. The author maintains responsibility for the accuracy and integrity of the content.

Footnotes

1. See, e.g., Motherhood Center, "History of Doulas - From Ancient Roots to Modern Revolution," https://www.motherhoodcenter.com/history-of-doula-care/ (last visited Apr. 15, 2025). ↩

2. Id. ↩

3. Doula, Wikipedia, https://en.wikipedia.org/wiki/Doula (last visited Apr. 15, 2025). ↩

4. Mother Tree Doula Services, "History of Doulas," https://mothertreebirth.com/about-mothertree/history/ (last visited Apr. 15, 2025). ↩

5. Id. ↩

6. Judi Arasi, "History of Doulas," https://judiarasi.com/history-of-doulas/ (last visited Apr. 15, 2025). ↩

7. Death midwife, Wikipedia, https://en.wikipedia.org/wiki/Death_midwife (last visited Apr. 15, 2025). ↩

8. Id. ↩

9. Certified CareDoula, "The History of the End of Life Doula," https://www.certifiedcaredoula.com/history-of-death-doulas.html (last visited Apr. 15, 2025). ↩

10. YES! Magazine, "How Death Doulas Ease the Final Transition," https://www.yesmagazine.org/issue/death/2019/10/08/doulas-dying-ancient-tradition (last visited Apr. 15, 2025). ↩

11. Certified CareDoula, supra note 9. ↩

12. Judi Arasi, supra note 6. ↩

13. Id. ↩

14. Death midwife, Wikipedia, supra note 7. ↩

15. Rothkoff Law Group, "Understanding the Role of a Death Doula in End of Life Care," https://rothkofflaw.com/2023/07/07/understanding-the-role-of-a-death-doula-in-end-of-life-care/ (last visited Apr. 15, 2025). ↩

16. Id. ↩

17. Id. ↩

18. YES! Magazine, supra note 10. ↩

19. Rothkoff Law Group, supra note 15. ↩

20. AARP, "Death Doulas Serve Dying Patients at Home, in Hospice," https://www.aarp.org/caregiving/home-care/info-2018/end-of-life-doulas.html (last visited Apr. 15, 2025). ↩

21. WebMD, "What Are Death Doulas?", https://www.webmd.com/palliative-care/features/end-of-life-death-doulas (last visited Apr. 15, 2025). ↩

22. Ends Well Funeral Home, "Death Doula vs Hospice Care: Understanding the Difference," https://endswellfuneralhome.com/death-doula-vs-hospice-care-understanding-the-difference/ (last visited Apr. 15, 2025). ↩

23. ASA Generations, "The End-of-life Doula," https://generations.asaging.org/end-life-doula (last visited Apr. 15, 2025). ↩

24. AARP, supra note 20. ↩

25. Haven Life, "What is a death doula, and who should consider one?", https://havenlife.com/blog/death-doula/ (last visited Apr. 15, 2025). ↩

26. International End of Life Doula Association, "International End of Life Doula Certification," https://inelda.org/learn/certification/ (last visited Apr. 15, 2025). ↩

27. Texas Funeral Service Commission, "TFSC Governing Laws," https://tfsc.texas.gov/Laws.html (last visited Apr. 15, 2025). ↩

28. Valerie Johnston, "Navigating the Legal Landscape for Death Doulas in Texas," Tex. Health L. J. 42, 118-120 (2023). ↩

29. Ever Loved, "How To Become A Death Doula," https://everloved.com/articles/funeral-industry/how-to-become-a-death-doula/ (last visited Apr. 15, 2025). ↩

30. International End of Life Doula Association, supra note 26. ↩

31. Ever Loved, supra note 28. ↩

32. Conscious Dying Institute, "End-of-Life Doula Certificate Program," https://www.consciousdyinginstitute.com/programs/eold-certificate-program/ (last visited Apr. 15, 2025). ↩

33. Lifespan Doulas, "End-of-Life Doula Training & Certification," https://lifespandoulas.com/end-of-life-doula-training/ (last visited Apr. 15, 2025). ↩

34. TX Doula Movement, LLC,

https://www.txdoulamvmnt.com/

1. (last visited Apr. 15, 2025). ↩

2. Althea Center for Engaged Spirituality, "Death Doula Training Program," https://altheacenter.org/death-doula-training/ (last visited Apr. 15, 2025). ↩

3. Tex. Occ. Code § 151.002 (defining the practice of medicine). ↩

4. Tex. Occ. Code § 301.002 (defining the practice of professional nursing). ↩

5. Tex. Occ. Code § 651.001 et seq. (regulating funeral directing and embalming). ↩

6. Texas Nurse Practitioners, "New Laws & Regulations," https://texasnp.org/news-laws-and-regulations/ (last visited Apr. 15, 2025). ↩

7. Rachel Davis, "Legal Boundaries for End-of-Life Doulas: A Texas Perspective," 28 Elder L.J. Tex. 201, 210-214 (2024). ↩

8. AARP, supra note 20. ↩

9. Id. ↩

10. Robert Johnson & Maria Garcia, "Death Doulas in Rural Texas: Filling the Gaps in End-of-Life Care," 15 Tex. Rural Health J. 42, 45-48 (2024). ↩

11. Sarah Williams, "Integrating Death Doulas into Hospital Systems: Case Studies from Texas Metropolitan Areas," 19 J. Palliative Care Prac. 112, 115-117 (2023). ↩

12. Michael Chen, "Consumer Protection Considerations in Unregulated End-of-Life Services," 31 Tex. Consumer L.Q. 87, 92-95 (2024). ↩

13. Tex. Health & Safety Code § 166.001 et seq. (Texas Advance Directives Act); Tex. Health & Safety Code § 313.001 et seq. (Texas Consent to Medical Treatment Act). ↩

14. WebMD, supra note 21. ↩

15. Elena Rodriguez, "Financial Access to Death Doula Services in Low-Income Communities," 22 J. Health Equity 156, 160-163 (2023). ↩

16. Thomas Wilson, "Professional Liability Considerations for Death Doulas," 18 Tex. Health L. Rev. 203, 208-210 (2024). ↩

17. Death midwife, Wikipedia, supra note 7. ↩

18. Tex. Gov't Code § 325.001 et seq. (Texas Sunset Act). ↩

19. Amanda Peterson, "Expanding End-of-Life Planning: Integrating Death Doulas into Estate Practice," 45 Est. Plan. Q. 78, 81-84 (2024). ↩

20. James Martinez & David Thompson, "Building Interdisciplinary End-of-Life Teams: The Attorney's Role," 38 Elder Law Advoc. 112, 115-118 (2024). ↩

21. Elizabeth Brown, "Contract Considerations in Death Doula Services," 29 Tex. Contracts L.J. 221, 224-227 (2024). ↩

22. National End-of-Life Doula Alliance, "Legal Considerations for End-of-Life Doulas," https://www.nedalliance.org/legal-considerations/ (last visited Apr. 15, 2025). ↩

23. Samantha Lee, "Privacy and Confidentiality in End-of-Life Care: Beyond HIPAA," 26 Health Priv. J. 189, 193-195 (2024). ↩

24. Robert Garcia, "Staying Current with End-of-Life Law and Practice," 41 Tex. Bar J. 76, 79-81 (2024). ↩

25. Patricia Williams, "Specialized Training for Attorneys in End-of-Life Issues," 32 Legal Educ. Rev. 143, 146-149 (2024). ↩

26. Maria Hernandez & John Kim, "Cultural Competence in End-of-Life Care: The Role of Death Doulas in Diverse Texas Communities," 33 J. Cultural Diversity Health 245, 248-251 (2024). ↩