The first US hospice was established in 1974 and viewed as an alternative to current heathcare options for those at the end of life. Kim explained that, in many cases, traditional healthcare establishments were not welcoming, so hospice professionals had to fight for respect. The largest growth of hospice care providers in America occurred after Congress passed legislation in 1982 to create a Medicare hospice benefit allowing Medicare/Medicaid to fund hospice care. As of 2014, there were 6,100 hospices nationwide and more entering the market every year.

Most hospice care is not a non-profit endeavor but rather care provided by for-profit organizations and keenly attuned to demographics, networking, market shares and the competition. Ernie described that hospice organizations have changed significantly from the volunteer-based approach some of us may remember from the early days of hospice care and now have first-class marketing graphics and a business plan to match. The close personal relationship of a hospice care provider with surviving family members does not end with the patient’s death but can extend for more than a year after.

Ernie researched and reported many of the following statistics from the website of the National Hospice and Palliative Care Organization.

Hospice care providers are a very special, caring group of people. They are held in high regard by the families they serve. Their opinions and advice are trusted. They are passionate, dedicated, and tenacious. There is little turnover, and even those who do leave often move to another hospice.

No other healthcare professional actively talks to family about the end of a life and planning the way a hospice care provider does. Kim explained that they do whatever is in their power to reunite families and meet patients’ needs, they are flexible and open-minded, and they figure out how to provide the best end-of-life experience possible. Ernie recommends the chapter “The Power of Presence” in Doug Manning’s book, The Funeral, to appreciate the connection and relationship hospice care providers have with families.

Almost half of all deceased people in the US last year were under hospice care before they ever got to a funeral home, crematory, cemetery, or anatomical gift registry. That’s significant, because unless you have a great community engagement program, a family’s first contact about funeral plans is hospice staff. Social workers ask patients and families about their wishes and intentions long before you see them. Statistically, these caregivers have built a very personal relationship with almost half of these families immediately prior to the death of their loved ones. If that doesn’t motivate you to think about what you’re doing in your community and your hospice outreach, I don’t know what will.

The average length of hospice stay is about 70 days. That’s a long time to create a relationship with the family. 59% of hospice patients receive in-home care. Hospice staff go in, day after day, and build that relationship and gather the details of their lives and their family dynamics. It’s a very different situation – we get three days, they get almost three months to hold those really hard conversations about really hard parts of a patient’s life. In that role, they become trusted advisors and the go-to people for all things related to death and dying.

The average hospice caregiver, no matter how well-intentioned, only knows as much about funeral service as someone who goes to a lot of funerals. Most are invited, and attend, many patient’s services and thus see many local funeral homes. But, there’s no aspect of hospice training that goes into the ins and outs of funeral service.

We use a lot of trade-specific information and technical jargon that is confusing to families and just as confusing to those caregivers. And if these people go to a lot of funerals, it means they go to a lot of bad ones, too. What does that caregiver think after they leave? If the next family asks, “What should we do?” they might not recommend your funeral home because they remember that bad service.

Some funeral directors ask, “Why do they tell them to do the cheapest thing?” Kim reminds us that the social worker has seen their hospital bills, heard about maxed-out credit cards, and sat with the widow afraid of losing the house after losing her husband. That social worker is not concerned about whether the funeral home is interested in offering an upgraded casket. If the social worker sees you trying to sell the family anything, they might remind them that they don’t need it. It’s not right or wrong—it’s just the way it is. We can talk about “that’s not her role” or “the family might have wanted to do something nice and she took their choice away,” but you’re talking about a dynamic where she was protecting them. Hospice social workers and caregivers take their role as advocates very seriously. They value collaboration. That means if you can create a relationship and build trust, you can position yourself as an advocate of the family, and you can collaborate on the process. If they see you acting in the best interest of their families, they will support you.

By the time the hospice family comes to the funeral home, you need to understand what they’ve been through. You are professional and passionate members of funeral service, but terminal illness is different. In a hospice situation, the family often has the opportunity to come together and say goodbye. Sometimes, they’ve done it three or four times. They’ve done the first part of the grieving process. They've had a lot of time to talk about death, to think about death, and often have additional support via hospice resources to prepare and guide them. The family is often present at the time of death, and it’s not unusual for them to have a brief ceremony right then. Kim explains that, the presence of the family, the words of the chaplain, the goodbye to their loved one – after that, they may not need a traditional funeral to process their grief. And it’s important for funeral professionals to understand that.

That’s not to say that there isn’t need or opportunity for service and ceremony, but we must remember that those in hospice have declined for a long time. Their survivors often say “I don’t want people to see my loved one like that.” It’s hard for families to think about a visitation because of the change that illness has brought. They don’t want their friends and families to remember the deceased that way, or worse, not recognize their loved one anymore. But they don’t necessarily understand what you can do about that. They don't always understand how body preparation can make a big difference—whether they agree to full embalming (which can reduce swelling or return moisture) or merely a shave and a haircut (which can make them look like themselves again).

Lastly, you know that these families are spread out, so they’ve spent time and money on travel in addition to the financial costs of long-term care, lost time at work and time with their immediate families. They are exhausted physically, emotionally, and financially. And this stress has likely heightened any kind of disagreements about medical care and funeral planning.

Developing a meaningful relationship with hospice care providers in the community is not about dropping off cookies at Christmas. It is a commitment to education that can benefit all concerned, providing the families we mutually serve with seamless and meaningful end-of-life transition. Ernie provides three key strategies for starting your hospice relationship:

Dr. Alan Wolfelt, internationally acclaimed grief counselor, author and educator, has said “Education starts with understanding the people we serve.” To that point, it is helpful to review the demographic and societal statistics of your community, understand how these facts dramatically impact end-of-life service providers, and embrace the adaptations needed by the profession—including further education and training—in order to remain prospectively relevant to contemporary consumers.

Like Ernie says, life is about relationships and experiences. We are in the business of celebrating the life of the individual by recognizing how they touched the lives of others. Our mission is to orchestrate and direct a meaningful ceremony with compassion, flexibility and options and in way that is as unique as the person who died.

Trade shows make for a great opportunity to check out innovations in memorialization—scattering urns, the latest keepsake jewelry, contemporary stationery designs, and cemetery monuments. These products offer new ways for you to match the unique personalities of families and their loved ones.

But true personalization is so much more than products. From the moment you answer the phone, you have the chance to differentiate yourself from your competition and enhance that family’s experience. Then, once they walk in the door, you have the opportunity to infuse ceremony in each interaction and make a difficult process meaningful to the family.

Extracted from examples provided when Lindsey Ballard facilitated an interactive discussion on Best Practices in Personalization and Ceremony at CANA’s 2019 Cremation Symposium, we offer the following ideas as inspiration.

Transfers and removals offer a unique opportunity to gather helpful information about the family through observation of the home and the items of comfort that surround the deceased. Encourage your staff and removal technicians to take notice of décor, family photos, items on display that might reveal a passion or treasured activity, and even the colors that fill the space. Empower your staff to engage with the family—it’s here they can learn some of the stories behind these beloved objects and see what motivated people in life. These initial impressions can help start the conversation about ways to make a service personal and demonstrate that you care.

Symposium attendee Franklin Rainier, of Franklin J. Rainier, Jr. Funeral Home, shared a story about entering the home of a 95-year-old woman and finding it decorated with Pink Floyd memorabilia and album covers. When asked, the woman’s son confirmed that she had been a true fan. Back at the mortuary, Franklin and his staff played Pink Floyd and lit candles to honor her as they prepared her body.

For some families, such as those who make a direct cremation choice, the arrangement conference may be the only time they will be acknowledging their grief before moving on. Sometimes, a special window opens up during these conversations and it’s important to pay close attention. Attendee Rita Alexander, of the Cremation Society of Illinois, recommended being especially sensitive to the pauses in the conversation and allowing people as much time as they need to grieve in the safe space you’ve provided for them.

Attendees agreed that a primary strategy is to make the arrangement conference into a conversation, to put the pen down and get to know the family before filling out the forms. You can introduce yourself and your company and describe how the process will work, then invite them to converse and share. Ask them about themselves, the deceased, and family and friends—that’s the time to take notes. At Simon Dubé’s funeral home, a Dignity Memorial location, these notes are discussed in staff meetings to brainstorm how arrangers can make sure the family’s experience is special. Not everyone on staff is equally creative, but together they can design the meaningful service that each person deserves.

Attendee Keith Charles suggested keeping the acronym FORM (part of the word information) in mind to guide your questions: “F” is for family and their relationship to the deceased. Make sure to acknowledge every single person in the room. “O” is for the occupation of the deceased. What type of work did they do and what was its impact? “R” is for recreation. Where did they go on vacation as a family and are there photos to use during the ceremony? And lastly, “M” for motivation—what put meaning in their life? With this acronym to guide you, you’ll be sure to touch on the major aspects of someone’s life and gather valuable stories to create a meaningful service.

Attendees agreed that getting the family’s permission to personalize the service is the first step to providing a unique and memorable experience. Many attendees shared stories of services they’d performed that conveyed real meaning to the family they served. A signature purple door for a Friends fan, a dress carefully chosen and displayed with a tuxedo to re-create a meaningful dance memory, or the seemingly modest touch of preparing the body’s fingernails with a signature teal polish and passing it out to the family to wear, too. Never underestimate the power of the small gesture of service: accents of a favorite color, the gift of a small pin (such as an American flag pin in the case of a service for a U.S. veteran) distributed to each guest, and other touches go a long way to demonstrating you listen and care.

Simon Dubé explained that taking time to requires a lot of work, but staff that are motivated by family service are willing to make the extra effort. Word of mouth is your most powerful advertisement. When you create an unforgettable experience, the conversation keeps going and spreads the word about how your firm goes above and beyond for the families you serve. Simon had many useful tips, including the recommendation that you invite the family to view the set up of the room an hour ahead of the service to make sure that they are comfortable with what you’ve done. This leaves plenty of time to remove a display if the family disagrees, and also provides them an opportunity to grieve and remember with the memorabilia in private.

Facilitator Lindsey Ballard pointed out that every moment can be an opportunity to turn service into ceremony. Handing a flag to a veteran’s family can be more than a simple keepsake if you use it to bring the family together to reflect on the symbol the flag holds. Lindsey does this by inviting close relatives to lay a hand on the flag while she recites a few words about commitment: a veteran to his country and theirs to his memory. In this way, a service for the family is transformed into a ceremonial experience they will remember.

It’s important to stay in regular contact with families before, during, and after the services. Suggestions for accomplishing this goal include memorial service for donors, annual remembrance events, and mailing special cards to the family on the date of the deceased’s birthday or the anniversary of the death.