Posted By Administration,
Wednesday, September 25, 2019
Updated: Wednesday, September 25, 2019
John Cassavetes once said “Film is, to me, just unimportant. But people are very important.” Gail Rubin’s article, first appearing in The Cremationist in 2015, shows us how we can use movies to get a glimpse into the human experience in all of its variety. The chance to see peoples’ journeys and the many ways they express grief provides us all useful perspective long before they sit at an arrangement table.
Lights! Camera! Action! Movies are a great way to teach, learn and tell stories that people remember. Studies indicate most humans are visual learners, so movies are a powerful medium to make a memorable educational impression – especially on touchy topics like death and grief.
Movies can be a great way to introduce funeral directors and cremationists, especially those new to the industry, to the diverse reactions that families may exhibit after a loved one dies.
When you look at examples from movies, coupled with background information from thanatology – the study of death, dying and bereavement – you can learn about the different ways people express or repress their grief. You can better understand grief responses without fear of offending a client family.
Consider these movie scenes and the types of grief they illustrate.
Elizabethtown — Instrumental Grief
Drew, a young man who lives in Oregon (Top 5 in cremation rate), has come to his father’s home town of Elizabethtown, Kentucky (Bottom 5 in cremation rate). Dad had unexpectedly died of a heart attack while visiting family there. Mom instructs Drew to have Dad’s body cremated and return with the remains to Oregon. The family in Kentucky wants to bury Dad in the centuries-old family plot.
In one scene, he’s having a phone conversation with Mom in Oregon about the cremation choice. She says, “Honey, I don’t know when I’m going to crash, but as of right now, we are learning about the car, and I’m learning organic cooking, I’m going to tap dance, and later on today, I am going to fix the toilet. It is five minutes at a time.”
Drew says, “Mom, I think you need to slow down.” She replies, “Look, everybody tells me that I should take sedatives, but hey, I am out here and I am making things happen. All forward motion counts.”
The instrumental grieving style focuses on practical matters and problem solving.
Mom is busy, busy, busy – that’s her way to deal with grief. This reaction is not determined by gender, as reported in the book Grieving Beyond Gender: Understanding the Ways Men and Women Mourn by Kenneth Doka and Terry Martin (2010).
You might think men are more inclined toward the practical approach, but Doka and Martin found it’s a pretty even split for men and women to experience an instrumental grief reaction. If you see a family member working a list of things to do prior to the funeral, understand that person is likely an instrumental griever.
A Single Man — Intuitive Grief
At the opening of A Single Man, George, a gay man mired in grief over the death of his partner, wakes up and gets ready for his day. He gets out of bed, showers, shaves, gets dressed, and goes into the kitchen. He narrates his thoughts in this monologue:
For the past eight months, waking up has actually hurt. The cold realization that I’m still here sets in. I was never terribly fond of waking up. I was never one to jump out of bed and greet the day with a smile like Jim was…. It takes time in the morning for me to become George…. Looking in the mirror, staring back at me, isn’t so much a face as the expression of a predicament. (Aloud) ‘Just get through the goddamn day.’ A bit melodramatic I guess. But then again, my heart has been broken. I feel as if I’m sinking, drowning, can’t breathe.
An intuitive grieving style emphasizes experiencing and expressing emotion. Rather than getting busy with activities that may distract or channel emotional pain and sadness, the intuitive griever is immersed in mourning. While we may think of women as emotional, men are just as likely to embrace this style of grieving, although they may retreat to the privacy of a “man cave” to mourn.
Overt sadness, tears and withdrawal in the arrangement conference or at the funeral/memorial service are signs of an intuitive griever.
In the film, George is experiencing profound sadness eight months after his partner’s death. While there is no timeline for grieving, at this point, he may be experiencing complicated grief – when deep mourning is unremitting. Addressing complicated grief is best handled by working with a trained grief therapist.
Because A Single Man illustrates mourning for a partner in a homosexual relationship, it’s the perfect segue to discuss disenfranchised grief. Disenfranchised grief is “the grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported.” (Kenneth Doka, 1989)
While people may be more understanding of mourning the death of a same sex partner now, A Single Man is set in 1962, well before homosexual relationships gained acceptance. Other examples of disenfranchised grief: a mistress unable to publicly mourn the death of or breakup with an illicit lover, mourning other losses, such as jobs, health or friends, or pet owners who are devastated by the loss of a beloved companion animal.
The Jane Austen Book Club — Disenfranchised Grief
At the opening of the film, friends gather for a graveside funeral, complete with a celebrant, flowers and a photo of the deceased. It turns out the funeral is for a woman’s dog. One attendee checks her watch. Others roll their eyes.
At the reception afterward, a man says, “Let’s get some perspective here. I mean, do you think if Jocelyn was married with kids she’d be giving her dog a state funeral? This whole thing is warped.”
The love of a pet is intense, and with the loss, there is intense grief. Yet, grief over the loss of a pet often does not get the same level of public recognition given for the loss of a person. Mourners may turn to social media sites like Facebook to receive supportive comments from friends.
Savvy funeral homes are expanding their services to include sensitive death care to help pet parents. Such services can provide an opening and connection with families that leads to human death care business later on.
Other films cover the many faces of grief, including Grief and Past Trauma (The Big Lebowski), Grief and Talking and Repressed Grief (This Is Where I Leave You), Processing Grief (Walk The Line), You Can’t Tell Someone How To Grieve (Six Feet Under), Elisabeth Kübler-Ross’ Five Stages (All That Jazz), and Moving Beyond Grief (Gravity). I have a presentation called The Many Faces of Grief: Mourning in the Movies which offers two CEUs through the Academy of Professional Funeral Service Practice and looks into all of these films in-depth to help funeral professionals see different forms of grief on display.
Join Gail and CANA in Albuquerque on October 2-4, 2019 to discuss consumer insights she’s gleaned from the increasingly popular Death Cafes and consumer oriented Before I Die Festivals at the first-ever Green Funeral Conference. Learn more and register: goCANA.org/gfc2019
Gail Rubin is a Certified Thanatologist (a death educator) who teaches about pre-need funeral planning and end-of-life issues, using humor and funny films to reduce resistance to discussing death. An award-winning speaker, she “knocked ‘em dead” with A Good Goodbye, a TEDxABQ talk which provides a compelling online video supporting pre-need funeral planning. She’s the author of three books on end-of-life issues, one of the first people to hold a Death Café in the United States, and the coordinator of the Before I Die New Mexico Festival. Her website is www.AGoodGoodbye.com.
Posted By Administration,
Wednesday, June 12, 2019
Updated: Tuesday, June 11, 2019
Many funeral directors are facing more and more direct cremations with no services. They are at a loss as to how to overcome that trend. There are many ideas, theories, notions and educated guesses as to why families choose cremation. Cost. Environmental footprint. Control. Convenience. Lack of information. Religious affiliation, or lack thereof. All of those certainly are factors and can play a part in any one person’s decision. So we are going to look at the three Big C’s in Cremation.
I would like to go back in time to the early ‘60s when cremation first came on the profession’s radar, and find that first funeral director who said, “Well, I guess I shouldn’t charge as much for this since I’m not embalming or casketing” and take him out. I’m not a violent person by nature, but really?? That idea got started somewhere and we all just went along with it. Sure, let’s charge less for something that takes just as much time to accomplish, has much more liability, and requires just as much staff involvement. That makes perfect business sense.
Within that nonsense also was created the message to families that they were somehow lesser-thans or 2nd class funeral customers. I actually worked for an owner who said to families, “We bury our dead, we burn our trash.”
Because we didn’t take these families seriously and did not take their needs for a meaningful funeral service to heart, they left. Why would I pay $8,000 to someone who thinks I’m not as important as the people who buy the box? I can be ignored at the $695 box-and-burn immediate disposer who is more than willing to take my money and do nothing else for me.
Families are hiring us to perform a service. If I hire an orthopedist to perform surgery on my shoulder, his price is for the surgery. He doesn’t talk about which instruments he might have to use or the amount of time it might take or how many nurses will have to be in the room. He says, “This is my price to fix your shoulder.” Why can’t we have a price for body preparation? Yes, we’d have to figure out the correct GPL language but we could certainly have more productive conversations with our client families if we didn’t have an if/then/or approach to pricing.
Yes, for a small group of people the cremation choice is made based upon cost. But the large majority are choosing cremation based upon control. These people have attended bad services in their past and are determined that they are not going to go to another one. If I have a burial, then I’m beholden to the funeral director to get the casket from point A to point B and so I’m stuck with whatever service is offered to me. I can’t throw the casket in the back of my car and drive off and arrange a service that fits me. But I can walk out with an urn in my hand and have control over the type of service that I hold.
We’ve all been to “bad” services. The cookie-cutter, insert name here, hope someone says the name correctly, impersonal ritual that offers nothing about the person and what his death will mean to those mourning his loss. Every time one of these boring, hurtful or meaningless services occurs, another immediate disposition/no service is created. People say “When I die, don’t do that!”
Cremation offers a choice, a sense of control over what happens in a memorial service. Does that mean that most are held at someone’s house or at a bar or a restaurant with toasts and stories? Probably. Does that mean that the value of having a gathering that celebrates the life and explores the grief and provides a guidepost for mourning the loss is lost? Definitely.
Once I served as a Celebrant for an 80 year-old-man who died of suicide. It was a difficult service, but we honored his life and talked about the depression over health issues that caused him to make such a choice. We discussed what the grief journey was going to look like for those who were trying to make sense of the death. We encouraged the standing room only crowd to be an integral part of the family’s next steps as they turned tears into memories. It was a pretty good service.
That afternoon I received an email from a woman who was in attendance begging me for a copy of the service. This lady tracked me down and said she needed a copy of my words. So, I asked the family for permission and I sent her a copy.
Her backstory was this—her son died of a heroin overdose and her daughter, his twin, died of suicide four years before. They did not have funerals either time. They cremated, then met at a restaurant and told stories. They did not trust that someone could handle such delicate and hard situations, so they just avoided. She needed those words to help her on her own grief journey. This happens hundreds of times across the country to our Celebrants.
Because the celebrant is a ceremony expert, focused solely on the ceremony and often devoting much more time to the ceremony than funeral directors and clergy can, the celebrant can be a tremendous resource. What celebrants offer can even be attractive to those who initially think they don’t want a ceremony at all.
—Diane Gansauer, Director of Celebrant Services, SCI Colorado Funeral Services in Metro Denver
Until we change the service experience for those families, they will continue to walk away. Our pricing, our lovely chapels, our offers of assistance—they’ve been there and done that and don’t trust us to be able to do something that is meaningful.
Which brings us to the final C:
My bedrock message is “Celebrants can change your business, Celebrants can change your families, Celebrants can bring your cremation families back to your firm.”
The religious landscape of our country is changing. The percentage of people who identify as a “None”—not religiously affiliated, not engaged with a church—is rapidly growing. Statistics from the Pew Research report show that almost 25% of the overall population now considers themselves “nones” and over 35% of millennials are disenfranchised with religious experiences.
This has incredible implications for funeral service. Some funerals homes have stained glass windows, Bibles in the foyer, hymns on the speakers and scriptures on their websites. There is nothing wrong with having an ability to serve your religious families, but today anywhere from 25% to 80% of your community does not identify or resonate with those representations. If all you have to offer is a minister and a religious experience, they are going elsewhere.
High “nones” equal high cremation rates. It’s just that simple.
The greatest impact a Celebrant can have with a family is the one on one interview time, an opportunity to sit down and become part of the decedent’s family, by hearing and learning first-hand about the life of their loved one, and sharing a personal glimpse into the life of the decedent with friends and family at the funeral service. That is one of the greatest gifts you can ever give to the family. Out of that experience comes the most gracious of compliments that you will ever receive, which is to hear at the conclusion of the service how well you knew the loved one. The Celebrant experience gives you that opportunity to serve the family in ways you may have never dreamed possible.
—Kevin Hull, Vice President and Location Manager, Cook-Walden Davis Funeral Home
Celebrants are the answer for a majority of your cremation families. So many of them are not offered any options by their funeral professional. So, they either opt for the rent-a-minister or do nothing. Another immediate disposition walks out of the door.
When someone attends a service where every word of the service is focused on the life, on the family, and on the grief experience, their decisions can change significantly. “Oh. . .we can have this kind of service? Then I’m willing to talk to the funeral director about paying for THAT” Over 50% of the services I perform through referrals from funeral homes in my city come from someone who attended another service and came back and asked for that Celebrant. People pay for value. People pay for meaning. People pay for gatherings that heal.
My friend, Ernie Heffner from York, PA, ran numbers on his Celebrant services and found that cremation families who used a Celebrant spent 36% more on other goods and services. It’s not about the money. It’s about the value, the experience, the assurance that someone is going to hear their stories, to honor the life and work with them to put together a service that fits them. People pay for meaning.
I did a service for a man in his 40’s who drank himself to death. He left an estranged wife, a 19 year old daughter, 18 year old son, and a brother who was a recovering alcoholic himself. This meant two hours of slogging through a lot of baggage and feelings to get to the stories and to give them permission to say what was needed. But we put together a service that honored his life while being honest about his struggles and his demons.
After the service, the brother handed me a thank you card with $300 in it. The funeral home had already given me a check for my Celebrant fee of $400. I said, “Oh, you’ve already paid me.” He said, “Please just take it.” The card read “Thank you for performing J’s service and I especially thank you for the time you spent with us Sunday evening. I’m hoping it provided as much healing to the others as it did for me. Thank you.” People pay for healing gatherings.
In today’s world, the most crucial element in helping a family lies in the ability of the Celebrant to actively listen and recreate what they have heard into something with meaning and value. Celebrant Training is funeral service’s best option to develop the skills to become an outstanding funeral professional. At our firm, all of our funeral directors must go through the Celebrant Training so they can understand the importance and value of working with our Celebrants to help the families have a truly outstanding experience. This is especially important for cremation families that are looking for something other than traditional services. Celebrant Services play a major role in making Krause Funeral Homes a place of exceptional funerals.
—Mark Krause, President
Krause Funeral Homes & Cremation Service
We’ve been saying this since 1999: Families need a service to begin their grief journey in a healthy and honest way. Unless we are willing to provide the professionals and the services that they are looking for, they are going to walk away. When families have options, funeral homes are going to lose every time unless their option is better, more appealing and soul touching.
Looking at everything we do when it comes to serving the cremation family—pricing, style of service, presentation of choices, availability to Celebrants who can do exactly what the family wants and needs – is the only way that full-service funeral professionals are going to stay in business. How we deal with all of the C words will determine how much farther down the road we get to travel.
CANA is partnering with Glenda Stansbury and the InSight Institute for the second time this July to offer Celebrant Training. Limited to 40 attendees, this course packs a lot of information, emotion, and training into three days but is increasingly considered a must for the most successful businesses in the US.
Learn more about this class coming to Louisville, Kentucky from July 29-31 and register online.
Glenda Stansbury joined InSight in 1996 as Marketing & Development Director. She has worked as an educator, teacher trainer, and seminar developer. She is a practicing Celebrant, adjunct professor at the University of Central Oklahoma Funeral Department and is a licensed funeral director/embalmer. Glenda is available for speaking to funeral professionals at state and national conventions or for private staff training. For more information, contact Glenda at email@example.com.
Posted By Administration,
Tuesday, May 21, 2019
Arguing. Fighting. Physical violence. Destruction of property. Extreme denial. When I ask funeral professionals about their most difficult challenges, I frequently hear about extreme behaviors in the arrangement room. Not only are the stories jaw-dropping, but they seem to be getting worse and more common over the years. In the face of anger and rudeness, it can be difficult to generate empathy for the bereaved. That’s why I think it is valuable to do our best to understand the source of these extreme behaviors. We may be able to be more patient and gracious if we understand what is causing these behaviors.
One way to make sense of these behaviors is through the lens of “defense mechanisms” – a concept originally developed by Freud. When you hear the name “Sigmund Freud,” you might immediately dismiss anything developed by a pipe-smoking, sex-obsessed, Viennese physician from the early 1900s. Even as a psychologist myself, Freud isn’t my favorite guy; I believe many of his perspectives are outdated, misogynistic, and outright wrong. However, some of his theories and perspectives have stood the test of time and can provide valuable insights into human motivation and behavior. I hope you will continue reading to discover if these 3 examples of defense mechanisms match your experiences in the arrangement room. I suspect you will discover that you actually agree with Freud on several of these concepts.
While I love giving a good lecture on Freud (seriously, just give this former college professor half a chance…), we don’t have the time or space for a full exploration of defense mechanisms. In a nutshell, Freud said all people use defense mechanisms to reduce anxiety or mental discomfort. Most of the time, these defense mechanisms are relatively normal and healthy; they only become problematic when they are used in extreme ways. For example, “denial” is one of the most commonly used defense mechanisms. A common experience of denial related to bereavement is when you reach for your phone to call a loved one, only to quickly remember they are deceased.
There’s absolutely nothing abnormal or pathological about this – our brains are simply used to them being alive and it takes a moment for that reality to reappear. On the other end of the continuum of denial is an extreme reaction. For example, when the police find that a family still has grandpa sitting at the dining room table – eight months after he died. All defense mechanisms can be viewed on a continuum; mild and common uses of reducing anxiety and pain or extreme situations when the individual’s reaction is much more dramatic and often pathological.
It is important to note that defense mechanisms are largely unconscious responses. Or put another way, these are not deliberate or premeditated strategies. They still hurt if you are on the receiving end, but I don’t want you to think these are intentional efforts designed to attack others. They are the unconscious reactions of someone trying to deal with painful thoughts and emotions.
Although Freud and his daughter, Anna, described several dozen defense mechanisms, we are going to focus on three that you may see in the arrangement room: displacement, projection, and reaction formation.
Like denial, displacement is a very commonly used defense mechanism. Displacement is when we take the angry or aggressive impulses toward one person and “displace” them on another, usually safer, target. For example, let’s say your boss yells at you and it makes you angry. You realize that it isn’t smart to strike back at your boss, so you go home and yell at your spouse, yell at your kids, or kick the dog as a way to displace your anger onto a ‘safer’ target. (I fully realize that getting angry at your spouse may not be a “safer” target – this is just an example. Also, don’t kick dogs.)
A common example of displacement in funeral service is when the bereaved are angry at the deceased. Perhaps the deceased wasn’t a kind person. Perhaps the bereaved are angry that the deceased didn’t take better care of themselves or go to get a check-up when they suggested it. But even though they are angry, Western culture states that it is not acceptable to “speak ill of the dead.” So where does that anger and frustration go? Sometimes it goes to a “safe target” like the funeral professional. They may assume they won’t see you after the services conclude and therefore you are a safe target for their anger – even if you haven’t done a thing to deserve it. Have you had situations where the bereaved are angry at you for no apparent reason?
Have you ever had someone accuse you of only caring about money? A second defense mechanism, projection, might be a part of their response. Projection is the process of taking our own feelings and thoughts that make us uncomfortable and then dealing with them by projecting them onto someone else. A common example of projection is when we deal with our own self-hate by projecting that view onto others. Projection takes “I don’t like myself” and turns it into, “He/She hates me for no reason” or “Everybody hates me.” It reduces our anxiety and negative self-worth to suggest it is coming from others, not from oneself.
Here are some examples of what a person might be feeling and how they may project that onto the funeral professional:
Bereaved individual’s thought: “I’m curious about death and death-related procedures, but am worried about how others will judge my curiosity.”
Projected onto funeral professional: “Why are you so obsessed with death!”
Bereaved individual’s thought: “I’m so angry at my mother for not taking better care of my father and look what happened.”
Projected onto funeral professional: “Why are you treating my mother so badly!”
Bereaved individual’s thought: “I wonder how much this is going to cost. I could desperately use some extra money right now.”
Projected onto funeral professional: “You’re only obsessed with money!”
A third defense mechanism that may arise in funeral situations is the use of reaction formation. Reaction formation is when a person takes a thought or feeling that is uncomfortable and attempts to convince themselves (and others) that they don’t really have that view by making an extravagant display that is the opposite of their true feelings. For example, if a man found himself sexually attracted to his best friend’s wife, he might deal with the anxiety caused by those feelings by suggesting that he doesn’t like her at all. (We see an example of this exact scenario in the movie Love Actually: It’s a self-preservation thing, you see.).
In funeral scenarios, reaction formations arise when the bereaved hates the deceased yet acts as if they were perfect. The bereaved reacts by choosing extravagant funeral products and having an elaborate funeral. Freud would suggest this individual is attempting to convince themselves that their feelings of hate don’t exist. Of course, later the bereaved individual may resolve those feelings of hate and wonder why they spent so much on an elaborate funeral. I suspect this is when they unfairly turn the blame on the funeral professional and say things like, “You tricked me into spending a fortune on the funeral!”
In the Arrangement Room
While many other defense mechanisms come into play, these are three that appear frequently. After learning about these defense mechanisms a natural question is, “How does a funeral professional respond in these situations?” That is the focus of my presentation: “Defusing Conflict in the Arrangement Room: Strategies from Family Therapists” at the CANA’s 101st Annual Cremation Innovation Convention. I will be reviewing how funeral professionals can better understand the conflict that sometimes arises in the arrangement process as well as strategies funeral professionals can use to defuse these situations. I hope to see you there!
With a wide range of valuable networking and educational opportunities, the CANA Convention features sessions from presenters carefully chosen to make the most of your time away from the office and ensure you leave with practical takeaways.
We can’t wait to welcome Dr. Troyer to the CANA stage in Louisville this August. See what else CANA has planned for our 101st Cremation Innovation Convention: goCANA.org/CANA19.
Can’t join us? We’ll have recordings available so you don’t miss out on this amazing content.
Dr. Jason Troyer is a grief expert, author, former psychology professor, and therapist. He provides grief support newsletters, Facebook content, and informational videos at www.GriefPlan.com/funeral. He also provides community presentations, professional workshops, and trainings on behalf of funeral homes and cemeteries. Dr. Troyer can be reached at DrJasonTroyer@gmail.com.
tips and tools
Posted By Administration,
Tuesday, March 12, 2019
When CNN’s article regarding the JAMA radiation letter first hit the CANA newsfeed on February 26, 2019, we knew immediately it would be a big deal. And yes, the story has become a many-headed hydra of confusion, concern, and misinformation, accompanied by increasingly scary rumors.
We constantly field concerns from suppliers about cremated remains placed inside keepsakes, from crematory operators and embalmers about their cases, from families about their options, from regulators about all of the above, and from you — in the middle of it all — trying to serve your families, comply with regulations, and protect your staff.
CANA has curated several of the most useful questions in one place to counter some of the fear, anger, and rumors. And it’s all publicly available, so please share this resource far and wide, bookmark it for later reference, come back to check for updates, and, most of all, DON’T PANIC.
Where it started.
The radiation misinformation saga began with a research letter, titled Radiation Contamination Following Cremation of a Deceased Patient Treated With a Radiopharmaceutical and published on February 26, 2019 in the Journal of the American Medical Association (JAMA). In the letter, Dr. Nathan Yu (et. al) discussed a case study of a business in Arizona that cremated a 69-year-old man with pancreatic cancer in 2017. The deceased had been treated with an intravenous radiopharmaceutical for a pancreatic tumor and died five days later. When the medical staff became aware of the cremation, they notified the crematory and the cremation chamber, equipment, and staff were all tested for exposure to radiation. The equipment was found to have traces of contamination, as was a urine sample from one crematory operator (but it was a different isotope from the one used in the patient’s treatment). The contamination levels were below the limits set by the US Nuclear Regulatory Commission. In conclusion, because this is only one studied instance, researchers recommend further testing for more data and better understanding.
CNN was the first major media source we found to bring the letter to the general public awareness. To round out the story, the network solicited the opinion of Dr. Daniel Appelbaum, chief of nuclear medicine and PET Imaging at the University of Chicago Medical Center. He said, "If there are reasonable and fairly straightforward and simple things that we can do to minimize radioactivity, why not do that?” Applebaum also acknowledged the need for better understanding and regulations that keep workers safe. In the case of crematory operators, the doctor recommends "robust enforcement of mask and gloves and handling techniques."
Where it went.
Other media outlets picked up the story and it spread quickly, with information traveling like a game of telephone. My mother’s church group argued against cremation for spreading radiation in the community. One CANA member’s staff are expressing concerns about “the crematory operator who died from radiation” (when none have). Each of which are exaggerated concerns about what we know.
Because while the case study is new, the knowledge about radiopharmaceuticals and brachytherapy is not. And the medical community is quick to reassure that there is Low Risk of Radioactive Contamination from Cremation When Proper Safety Procedures Followed. CANA is aware that these concerns and fears are rooted in a lack of awareness and understanding, so we want to provide information to help.
What we know.
At CANA’s second Alkaline Hydrolysis Summit, we invited Jeff Brunette, Health Physicist and Manager of Radiation Safety at the Mayo Clinic, to talk about nuclear medicine and its impact on death care. His full presentation is available as a free, on-demand webinar for you, your staff, and anyone to access anytime on CANA’s Online Learning platform, but here are some highlights:
Nuclear medicine, as administered by a medical professional, is very different than a nuclear warhead. These treatments are administered at doses for safe and healthful diagnostic imaging and cures, not mass devastation.
- These treatments have known efficacy windows which range depending on the use. Diagnostic imaging (e.g. PET scans) can take 20 minutes to 67 hours to clear the system. Radiopharmaceuticals can take 3-12 days (this is where the case study falls). Radiation oncology, like brachytherapy, implants treatment into the body to deliver targeted doses over a treatment window and these isotopes can take weeks or months (or longer) to decay to acceptable exposure levels.
- The variations in the length of radiation are due to different materials (called isotopes) used in treatment and their half-lives (i.e. how long it takes the radiation to degrade to half its original mass).
- Safe levels are determined by federal regulation. For the US general public, this is anything up to 100mrem in a year (excepting medical treatment — a full-body CT scan provides approximately 1,000mrem), while for people who work with the substances it’s 5,000mrem each year. A fatal dose is more than 500,000mrem. And we are exposed to radiation by taking an airplane, using the microwave, and from nature (both Earth and space).
- Radiation treatments also vary in strength. Alpha waves are stopped by paper, or blocked by your skin. Beta waves are blocked by soft tissues and thin metal of aluminum. Gamma waves travel much farther. Distance from the radioactive material also changes exposure — the medical community measures the potency at one meter to determine when a patient can go into public spaces. In most of the cases described above, treatment is outpatient (even the implanted seeds) meaning the person can leave that day.
What's the risk?
The US Nuclear Regulatory Commission has set specific levels (mentioned above) to regulate emissions and uses. In the case of cremating a body treated with nuclear medicine, the Commission and medical community agrees that the potential exposure is too low to record. Though cremation volatilizes the radiation treatment, Brunette says even extreme cases are not likely to exceed the limits set for safe exposure due to the combination of medically accepted isotopes, their half-lives, and treatment use. He explains it with an analogy: taking a daily recommended dose of aspirin is fine (around 325 mg) but taking a year’s worth at once (118,625 mg or more than three bottles) is fatal.
Canadian Nuclear Safety Commission has their own rules and regulations and reviewed them extensively last year. CANA recommends their comprehensive Radiation Protection Guidelines for Safe Handling of Decedents as a great resource to learn more about the isotopes in question and safe handling procedures, even for non-Canadians.
Ultimately, Brunette argues that radiation is a limited concern because the levels you will encounter on the job are small, and not very common. Your bigger concerns are the activities that your staff do every day: musculoskeletal injury from lifting, exposure to disease during embalming (HIV; Hepatitis B & C; Tuberculosis; MRSA), and exposure to harsh conditions during cremation operations (heat, noise, dust or chemicals).
How can we operate safely?
CANA recommends asking all families for detailed medical information to properly understand and respond to potential risks. Just as you ask about the presence of pacemakers, ask about nuclear medicine treatments.
Paul Harris of Regulatory Support Services encourages all funeral home, crematory, and cemetery owners to ask the pertinent questions of their families. Cause of death is the first indicator that a case is at risk for radiation therapy, but all families should be asked in the case of death unrelated to their ailment. In many cases, families may be unaware or not understand the procedures the decedent has undergone. In these cases, you may need to ask for a Health Insurance Portability and Accountability Act (HIPAA) release form (in the US, rules in Canadian provinces vary) to contact the medical provider yourself. Asking the radiologist for information on the treatment and about the specific isotope and its half-life is the best way to determine when (or if) it is safe to cremate or embalm the body.
The medical community also recommends installing a simple radiation detector to quickly alert staff to the presence of radioactivity (some states require them in all morgues). Brunette recommends a pancake Geiger-Mueller counter which can be acquired cheaply (particularly if you have them left-over from the old nuclear-powered pacemaker days) and built into your case acceptance procedure. The Arizona Bureau of Radiation Control recommended a combination metal/radiation detector, such as the MetRad, which one school in considering adding to their intake process curriculum.
Mostly, Brunette recommends the following steps to reduce exposure:
Awareness: Talk to families, ask the radiologist, consider purchasing and/or installing detectors.
- Protection: Wear appropriate PPE when potential for contact with body fluids, cremated remains, or AH fluids.
- Disposal: Drain blood and body fluids during embalming directly into the sanitary sewer system and don’t aspirate unless necessary.
- Proximity: Maximize distance to the body and minimize time in close vicinity to the body.
What we do next.
The medical community should do what Drs. Yu and Applebaum say: research. Learn more about these situations so everyone can make informed choices about safety. In the long-term, this will serve us better than knee-jerk reactions and blanket rules to refuse all cases who have ever been treated.
Our professional community should continue to do what you do best: serve your communities safely and compliantly. Enforce PPE, add this to your list of questions for families, do your due diligence. You should review your existing policies, processes, and procedures to ensure that you are screening for the use of radiopharmaceuticals and staff are taking proper precautions. Inform yourself and staff with basic information about diseases that could indicate potential treatments and which isotopes are used. Know who to contact with questions like your local hospital’s radiology department (or the decedent’s doctor) or regulator.
Mostly, DON’T PANIC. Now that the public is aware of this issue, this is an opportunity to educate our communities and ourselves with good information from reliable sources. CANA will periodically update this post with new knowledge, so bookmark this for later.
Sources of information referenced in this article:
Barbara Kemmis is Executive Director of the Cremation Association of North America.
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Posted By Administration,
Wednesday, February 27, 2019
Updated: Monday, February 25, 2019
There are a number of proactive measures we as a profession can take in pursuit of remaining relevant to contemporary consumers. Developed from ideas presented by Kim Medici Shelquist, Senior VP of Planning & Development for Homesteaders Life Company, and Ernie Heffner, President of Heffner Funeral Chapel & Crematory, this post focuses on the relationship between end-of-life care and death care and the family’s experience.
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.
Facts About Hospice Providers
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.
- Free standing hospice organizations not affiliated with a hospital are on the rise, 58.3% in 2013 increased to 72.2% in 2015.
- Not-for-profit hospices are decreasing, 34% non-profit in 2011 down to 31.9% in 2016.
- Of all US deaths, 44.6% in 2011 occurred under hospice care, 46.2% in 2015. 59% received in-home care.
- The average length of care decreased from 72.6 days in 2013 to 69.5 days in 2015. The median length of care decreased from 18.5 days in 2013 and to 17.4 days in 2014 and increased to 23 days in 2015.
- Aftercare: Few if any funeral homes have an aftercare program like hospice. 92% offer community bereavement support. Through ongoing bereavement activities by a “bereavement coordinator,” the hospice organization maintains a relationship with the family long past the time of the patient’s death, in fact monthly for 13 months after the death.
- Volunteers in Hospice Care: Statute requires that 5% of people hours are provided by volunteers. Many hospice organizations have a person dedicated to recruiting volunteers. In 2014, 430,000 volunteers provided 19 million hours of service.
- Spiritual Advisor: Hospice organizations are required to have a spiritual advisor on staff. Hospice chaplains are often very well-trained in non-denominational, non-religious approaches to the spiritual side of life and death.
The Role of the Hospice Worker
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.
Serving Hospice Families
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.
How to get started in developing a hospice outreach program
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:
Read all you can to learn about the hospice profession. Then research your state’s licensing requirements for Registered Nurses (RNs) specifically the continuing education (CE) requirements and what qualifies for program content.
- Build formal PowerPoint presentations
These need to be compliant with RN CE requirements. Include reporting, record-keeping system and handout material to be used. Then apply to get your program(s) certified by your state’s nurse licensing division.
- Recruit a hospice care provider as your outreach person
This could be a part-time position about 18 to 24 hours per week. Consider recruiting a retiring hospice social worker interested in a part-time position. Have this person be your representative to offer continuing education. This person should also attend monthly networking events relevant to serving seniors.
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.
Kim Medici Shelquist's remarks excerpted from her presentation at CANA's 2017 Cremation Symposium titled "Seek First to Understand: How will changing demographics and end-of-life care options impact the funeral profession?"
Ernie Heffner's full article is featured in The Cremationist, Vol 55, Issue 1, titled “Staying Relevant in a Changing World” featuring important discussion on the role of Celebrant services, the importance of minimum standards, hospice, and more. The Cremationist is an exclusive benefit of CANA Membership.
is President and Owner of Heffner Funeral Chapels & Crematory
, York, PA. After graduation from Pittsburgh Institute of Mortuary Science, he joined his father in a two-location firm serving about 100 families annually, with a cremation rate of about 4%. The firm grew to 22 locations in 2 states with 100 employees. That growth was during the acquisition mania of the 1990’s. Subsequent to strategic contraction, the firm today serves from six Pennsylvania locations, continuing as a “Mom & Pop” firm owned by Ernie & Laura Heffner and operated by Heffner and John Katora, V.P. and Heffner associate of 38 years. Ernie appreciates the truth of proverbs 22:10, which he paraphrases as, “Minimize the challenges in your life and your life will be better.” Focusing on organic growth and the pursuit of relevance to contemporary consumers has led to gratifying results.
Kim Medici Shelquist
in 2009 as Director of Marketing Communications after many years as Business Development and Communications Director of Hospice of Central Iowa. At Homesteaders, she added breadth and depth to the marketing department that resulted in the creation of several key B2C public relations and sales programs. Her efforts were also instrumental in helping Homesteaders become a recognized leader in preneed funding. Today, Kim oversees Homesteaders’ strategic planning and project management process as the Senior Vice President of Planning and Development. Her team is charged with identifying, evaluating and developing new opportunities that will help Homesteaders grow long into the future. Kim holds a bachelor’s degree in journalism and a master’s of business administration, and is a Fellow, Life Management Institute.
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