Posted By Administration,
Wednesday, March 4, 2020
Updated: Wednesday, May 13, 2020
At the end of February, CANA hosted our annual Cremation Symposium in Las Vegas. That’s right, we encouraged people to travel to meet up with more than one hundred people and network in a popular tourist destination — it was a different time. Unsurprisingly, the topic of discussion on the floor was the coronavirus pandemic, or the spread of COVID-19.
Fortunately, the US Center for Disease Control (CDC) has released guidelines with information on handling infected, or potentially infected, cases at your funeral home, crematory, prep room, etc. These preventative measures align with current best practices in the prep room or crematory (i.e. wear universal PPE, limit exposure to the disease, and clean all surfaces carefully) that protect you from everything from the common cold to tuberculosis.
Current estimates suggest that between 100,000 to 150,000 people will die from COVID-19 in the US. But your cases are not the only potential source of infection in your businesses. Of those that contract COVID-19, 80% are estimated to be mild which means they are more likely to transmit the disease. Experts are warning that the next two months, in particular, will be difficult depending on our response. Consider designating one staff member in your office as point person to monitor reports and updates from the CDC and your local jurisdictions, at least daily, to make sure your business is operating with the best information. As this post is updated, newest content will appear in gold to highlight latest information.
So what do you need to know to prepare your business when an outbreak hits?
Make a Business Plan
Since "workers performing mortuary services, including funeral homes, crematoriums, and cemetery workers" have been officially listed as Essential Critical Infrastructure Workers, it is even more important to make sure your business is prepared for this challenge. Inform, educate, and train your staff of the CDC recommendations.
Now that this post is getting so long, we've added a Table of Contents linking to information below:
- Caring for the Deceased
- Operating the Crematory
- Business Support
- Serving the Living
- Managing Staff
- Directing the Funeral
As a reminder, if there are federal and local orders/laws in conflict, follow the most restrictive to ensure that you comply with both, and ask for additional guidance and support as needed. Some resources to consider are: your state governor, local mayor, local health agency, as well as the Disaster Mortuary Operational Response Teams (D-MORT), Emergency Management Agencies (EMA) or Community Emergency Response Team (CERT) plus the Council of State and Territorial Epidemiologists (CSTE) and the National Association of County and City Health Officials (NACCHO). Be sure to check with health and government authorities any time you have questions to ensure safety and compliance for you, your staff, and your business. If you are designated an essential worker in an area under an enforced lockdown, consider carrying staff identification, state professional license, or some other information that demonstrates your status for ease of movement.
Caring for the Deceased
For any staff who handle the dead, the National Association of Funeral Directors (NFDA) and the Funeral Service Association of Canada (FSAC/ASFC) have useful resources for embalming, prep room, and removal staff in accordance with CDC guidelines (including specific guidelines for funeral homes) which clearly state recommendations for Personal Protective Equipment (PPE), transporting the deceased, and cleaning surfaces. Many authorities believe that cases and deaths are under-reported, so anyone coming in contact with the deceased should operate assuming that the case is positive. In the case of embalming, funeral homes are encouraged to follow families wishes assuming that the firm and embalmer have access to PPE and the time to embalm safely. Remember, as important as it is to wear PPE when handling the deceased, it is also important to follow the recommended sequence for putting on and removing the equipment.
Cremation is a sure way to destroy any contagion on a deceased body which is why it's preferred for Creutzfeldt-Jakob Disease and Ebola, but the WHO has stated that "people who have died from COVID-19 can be buried or cremated. Confirm national and local requirements that may dictate the handling and disposition of the remains." The CDC has not released definitive information on how long the coronavirus lives in a deceased body, but they do say that "there is currently no known risk associated with being in the same room at a funeral or visitation service with the body of someone who died of COVID-19." As always, families should do what's right for them. They can have funerals and burials as long as they follow their state and local mandates regarding the number of people and social distancing guidelines.
Operating the Crematory
Most guidelines that have been released do not specifically mention the crematory or operator. The following assumes that the crematory operator does not come into direct contact with the deceased, rather handles the container. If the operator in your business handles the deceased, see above.
CANA recommends the following:
- accept only cases in leak-proof, sturdy cremation containers per CANA Crematory Operations best practices
- the use of Standard Precautions should ensure safest possible work conditions. This includes PPE, as mentioned above, which is in short supply so follow optimize your use per CDC guidelines.
- clean all shared tools, equipment, and surfaces frequently - e.g. the cremation container, door or loader, refrigerator, door handles and light switches
- maintain social distancing between co-workers and other people who may enter the crematory
- Limit witnessed cremations to ten or fewer people total, including the funeral director and operator or other staff present.
Generally, viruses are killed above 200 degrees Fahrenheit, so the cremation process kills coronavirus. There is no concern about virus exiting the building via emissions through the stack or remaining in cremated remains, however the operator should wear PPE to ensure transmission from operator to urn does not occur.
When releasing cremated remains to the family, limit size of groups to ten or fewer, but also consider bringing the urn and paperwork to the client in his or her car.
Try to minimize physical paperwork with electronic documents and signatures, or providing gloves, to cut back on touching paper. Similarly, keeping clearly marked sanitized and used pens to take and return for cleaning will cut back on multiple use.
In this pandemic situation, some crematories are concerned about regulations which limit the cremations a business can perform. CANA is supporting state associations who are working with these regulators to address these permits in the hardest hit areas.
With the Families First Coronavirus Response Act (FFCRA), passed March 18 and effective April 1, businesses have new requirements for managing staff. All employers with 500 or fewer employees must provide paid Family Medical Leave Act (FMLA) leave and paid sick leave – this is new for those who manage companies with fewer than 50 employees who were previously exempt from such requirements. The Department of Labor, Wage and Hour Division has required posters and useful information to communicate with your staff.
As an employer who was previously exempt, this could be overwhelming, so it’s important to open lines of communication with your staff and establish a clear chain of command to address rapidly developing information. Don’t assume that all staff will immediately take advantage of these benefits and leave the business in a time of crises. Provide guidance and support in addition to addressing their concerns about what to do if they or a family member get sick. Don’t be afraid of questions or to admit that you don’t know. Importantly, communicate often to make sure staff are okay and keep lines of communication open.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed March 27 and retroactively effective to February 15, 2020, offers financial assistance to small businesses and large corporations alike. The US Senate Committee on Small Business & Entrepreneurship has provided the Small Business Owner’s Guide to the CARES Act resource. If your business is having financial difficulty, you can apply for relief through the Payment Protection Program (PPP) with the US Small Business Administration (SBA) and your current bank. Alternately, you can seek support from the Employee Retention Credit (ERC), however a business cannot receive both the PPP and the ERC.
To better understand how both resources effect your business, CANA recommends contacting services who manage and administer your payroll, business insurance, health insurance, preneed providers, and bank. These are groups carefully monitoring how these regulations and opportunities impact your work in your area, and know your business best.
For those in need of extra staff support, state associations in hard-hit areas and the NFDA have organized volunteer programs to help. Reach out to these associations with your need and availability.
Serving the Living
But don’t forget that the living are actually your primary audience, and the ones your staff come in to contact with every day. The CDC has more resources than just postmortem handling, and have special recommendations for the workplace in “Interim Guidance for Businesses and Employers to Plan and Respond.”
Many of the roles at a funeral home, like funeral directors, embalmers, crematory operators, don’t do the kind of jobs that let you work from home. We cannot access the prep room from our living room, or arrange with families from our beds. So encouraging proactive measures to keep employees well, then being flexible when people are ill is key to keeping your staff and the community safe in any outbreak.
By now, everyone knows the top four guidelines on personal safety:
- Wash your hands often, for at least 20 seconds.
Are you sick of singing the A, B, C’s while washing your hands? The good news is some other popular songs have 20-second choruses, including Landslide by Fleetwood Mac, Raspberry Beret by Prince, Jolene by Dolly Parton, Fever by Peggy Lee, Africa by Toto, Mr. Brightside by The Killers, and Truth Hurts by Lizzo. Mix it up and keep scrubbing.
- Avoid touching your eyes, nose, mouth, and ears.
- Cough and sneeze into a disposable tissue and discard it.
- Maintain at least six-feet (2-metres) around others, particularly sick persons.
When making arrangements or directing a funeral, these measures are important. The CDC now recommends "covering your mouth and nose with a cloth face cover when around others." Of course, the most vulnerable populations are typically older generations and those with pre-existing conditions (including smokers). If a staff member is concerned that they have been exposed, the CDC has issued guidelines for Safety Practices for Critical Workers which include frequent temperature readings, mask wearing, and frequent disinfecting of work spaces. Shared work spaces include break rooms, vehicles, and any shared equipment.
And don't forget your four-legged staff. Some animals have tested positive for coronavirus, though it's unclear whether the virus can spread from pets to humans. To protect your pets and your community, the CDC recommends limiting their interactions as well.
In the event that someone does get sick, encourage them to stay home. This is a difficult argument to make with the existing workforce shortage on top of a potentially growing caseload, because these jobs rely on you being in person to serve your families. But with the COVID-19 pandemics, you cannot serve your community while being sick yourself. Sick employees need to stay home to recuperate and be well, but also to prevent the spread of disease in the community. As the disease continues to spread, you may encounter employee shortages from illness, school closures, and caring for loved ones. Your business must have a plan for what you will do if you have too few staff.
Unless asked in writing to do so by OSHA, the Bureau of Labor Statistics (BLS), or a state agency operating under the authority of OSHA or the BLS, Death Care Services are deemed as a low risk sector, however CANA Member Regulatory Support Services recommends making a record of all work-related illnesses and injuries and placing that record in the affected employee’s medical file. For confirmed cases of COVID-19 or an employee that shows symptoms of COVID-19, this would include the employer’s directive to an ill employee that he or she does not return to work until cleared to do so by health care professional.
The challenge with COVID-19, or any infectious disease for that matter, is knowing with absolute certainty that an illness is a result of exposure in the workplace. Especially with the high communicability of the coronavirus, sources of exposure outside the workplace must be considered when assessing whether to report any fatality or hospitalization of an employee as a result of contracting COVID-19. However, some states are presuming that any essential worker who contracts the disease to have become infected at work thus making them eligible for worker compensation.
Directing the Funeral
And don’t forget that you also host community events with their own considerations. The CDC has special guidelines for “Mass Gatherings or Large Community Events” to help you plan and host safe services. Primarily, they recommend having supplies on hand to keep everyone healthy, namely hand sanitizer, soap, and tissues. Keep surfaces like door handles and light switches clean, and remember to talk to your community volunteers about being safe, too.
With increasing emphasis on mitigating the spread of COVID-19, in areas with active outbreaks, the CDC recommends community-based interventions including "event cancellations, social distancing, and creating employee plans to work remotely," careful planning and communications with your families is important. Social distancing, in particular, runs counter to the spirit of the funeral by discouraging gatherings of more than 10 people, encouraging vulnerable populations to stay away, and avoiding direct contact with others. Fortunately, you are professionals trained in talking to families with compassion and understanding.
Now that federal guidelines from the White House have sunset, state governors' and state and local health authorities are determining how businesses and communities can operate — you can find this list of resources above. In some areas, any visitation or service has been prohibited. White House guidelines to reopen businesses and services is recommended in multiple phases to keep employees healthy, prevent spread, and moderate hospital cases and is helping states set their own reopening procedures. These recommendations will require your business to develop plans and policies to accommodate your families' preference for service while maintaining the health of your community. New guidance from the CDC for consumers is written to help you educate your families on ways to hold services safely and the importance of taking social distance guidelines safely. Ceremony expert Glenda Stansbury provided a free resource to help you and your families find creative solutions, such as livestreamed services, to protect your business and the communities you serve. Grief expert Dr. Alan Wolfelt shared his suggestions on holding some form of ceremony at the Center for Loss blog.
Develop a plan with recommendations from the CDC including how to communicate with relevant parties. Mostly, be in touch with state and community partners to help respond to changing needs of your community. Working together facilitates communications, response planning, and organizing when the need arises. The Council of State and Territorial Epidemiologists (CSTE) has a list of who to contact at the state-level and the National Association of County and City Health Officials (NACCHO) is a good resource for local-level needs. These are great new additions to your connections with first responders, hospices, and other community leaders.
Keep Supplies Stocked
Social media is flooded with images of empty store shelves, so it’s a good idea to take stock of the goods you use frequently and make sure you have supplies. For those that are concerned about PPE supplies, the CDC has recommendations for Optimizing the Supply of PPE and information about Healthcare Supply of Personal Protective Equipment and OSHA has issued interim guidance which brings their enforcement more in line with CDC recommendations. The CDC has also provided a PPE Burn Rate Calculator to help facilities to plan and optimize the use of PPE. Also, reach out to suppliers, even those outside of mortuary supply, if your need is severe. As a final resort, reach out to your local health authority, coroner, or medical examiner to explain your need and ask for recommendations. One CANA Member suggested ordering smaller quantities to prevent large orders being flagged and redirected.
CANA Member Bass-Mollett shared their hard work finding the answer on how to request N95 masks as it was explained to John Flowers, CEO of Bass-Mollett:
- All N95s in existing stock and those being manufactured now are sent to the Federal Emergency Management Agency (FEMA)
FEMA allocates supplies to each state’s Emergency Operations Center (EOC) based on need
Each EOC manages requests from entities within its respective state — including death care professionals
To place a request for N95s, you’ll need to contact your state’s EOC.
The National Institute for Occupational Safety and Health (NIOSH) has issued recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators which suggests that equipment be alternated and discarded when damaged or dirtied. Some recommendations suggest to avoid wearing cosmetics, which could dirty the mask and reduce its effectiveness faster.
Keep Calm and Wash Your Hands
Situations like this, in times of increased caseloads and illness, require flexibility, patience and planning which is why you need to have these discussions and plans now. Like the radiation case study in 2019, we want to help you plan, be safe, and prevent panic and misinformation. As information continues to change rapidly, the best resource for the most current information on your business operations is your local government and health authority.
Predictions say that "prolonged or intermittent social distancing may be necessary into 2022." Preparing now for the virus's resurgence in the Fall and Winter means you can protect yourself and your business with proactive plans and preventative measures.
Situations like this also require extra care for yourself and your colleagues. "Stress prevention and management is critical for responders to stay well and to continue to help in the situation." Use the support resources from the CDC available by both call and text, and work together to stay healthy. Jason Troyer, PhD., specializes in helping death care professionals serve their families better. He wrote a post for us about taking care of yourself in these ever-changing times. Additional resources unique to death care are available in his Finding Resilience program.
Thank you for the work you do.
For the next few weeks, CANA Members are invited to join us for weekly Open Forums to discuss how they're handling their response to COVID-19 and supporting their community. Check your inbox for instructions to join, or contact Membership Manager Brie Bingham for more information.
US Center for Disease Control (CDC)
US Occupational Safety and Health Administration (OSHA)
Barbara Kemmis is Executive Director of the Cremation Association of North America.
processes and procedures
Posted By Administration,
Wednesday, January 8, 2020
Updated: Thursday, January 2, 2020
After the celebrations are over, the beginning of each new year reminds us to refresh and improve our habits. It is not too late to resolve to accomplish the following items this year and establish a new routine for years to come.
- Update and review current governing laws and regulations.
Regardless of your role in the industry, it is important to understand the current laws and regulations that govern your work. Put aside the necessary time to review the federal, state, and local laws and regulations which affect your day to day operations. Right to control final disposition and cremation authorization issues dominate legal complaints against people and businesses in this industry. If you have difficulty finding the statutes and regulations, try searching the web sites for your state association or licensing board – they often have links available.
CANA Members: If you need further assistance, use your legal consultation benefit and give me a call.
- Educate and train staff on any new laws or regulations affecting your business.
Keeping yourself updated on new laws or regulations is just a first step. The next is to educate and train your staff and co-workers on what you have learned. Hold a “lunch and learn” with your team and give everyone the tools to succeed.
- Update your forms to bring them into compliance with any law changes.
Out of date, non-compliant forms are an easy target for regulators and plaintiffs’ attorneys alike. Confirm that your form documents include all the required notices, consents, and disclosures. Consult with an attorney if you have any questions regarding current legal requirements.
- Educate and train staff on the changes in your forms.
Compliant forms are important, but the persons who use them every day must understand how to utilize them to the fullest. Avoid the problems caused by improperly filled out forms. If done and utilized correctly, forms often provide the best documentation in defense of legal complaints.
- Review and update your operational policies and procedures.
OSHA compliance is critical to a successful operation. So, too, are human resource policies, and so much more. If you need assistance in your review, CANA has partnered with Cremation Strategies & Consulting to offer a program which will help you compile operational policies and procedures customized for your business. Learn more here.
- Review and update your employee handbook (including social media policy).
Employment issues are a prevalent headache across all industries and business models. Address common concerns in your employee handbook, so that everyone is on notice of the standards to which they will be held accountable. Implement clear, unambiguous policies on work hours, time off, sick leave, vacation time, and dress codes. Have appropriate sexual harassment policies in place. Communicate your expectations regarding social media use and restrictions on employee posts on business matters. Make sure employees are aware that social media is not for airing of workplace grievances or complaints.
CANA Members: Read up on what my office suggests for these policies as part of the Crematory Management Program.
- Educate and train staff on your policies and procedures.
Periodic training and review of operational and employment policies and procedures are critical. There cannot be compliance without your employees first understanding your expectations and standards to which they will be held accountable.
CANA Members: You can keep your standard operating procedures current and your staff informed with the Crematory Management Program and support from Cremation Strategies & Consulting.
- Meet with your insurance agent or broker.
Make sure your insurance agent or broker understands your business. Too often there are gaps in coverage discovered when you need insurance assistance or defense to a legal claim, when is too late to put the protections you need in place. Many gaps in coverage result from your agent or broker not understanding your daily work and operations sufficiently to make sure that what you actually do is covered. Just because you have “professional liability” insurance, you have no guarantee that all of your professional services are covered. Proactive insurance strategies will serve you best.
CANA Members: Have you looked over CANA’s newest benefit, a professional liability insurance program for crematories? Read what makes this policy different and how it covers businesses like yours.
- Meet with your tax planning professional.
Do not leave money on the table. A tax professional’s advice can add value to your business and improve its bottom line. Mitigate your tax risks and exposures prudently.
- Budget for and plan to attend meaningful continuing education opportunities.
Take some time to think about the education and assistance which will benefit you and your business most in the upcoming year. Then, search for continuing education opportunities that will assist in meeting your goals. There are in person and online resources available to address almost any concern as an industry professional or business owner. Some jurisdictions even allow you to get your crematory operator certification online. If you attend CANA’s convention in Seattle this year, please say hello. I look forward to seeing you!
CANA Members: Not sure how to get started developing a defined professional development plan for your employees? CANA Education Director Jennifer Werthman is here to help you achieve your goals – reach out any time.
Getting your new year off to a good start can jumpstart accomplishing your business’s New Year’s Resolutions. Best wishes for your success in 2020!
CANA Members: Your association is here to help! If you ever need these resources or anything else offered by CANA, reach out.
Excerpted from The Cremationist, Vol 53, Issue 1: “First Quarter 2019 Top Ten Legal Checklist” by Lara M. Price. Members can read this article and any other advice in The Cremationist archive. Not a member? Consider joining your business to access this and all archives of The Cremationist plus the many resources referenced here to help you find solutions for all aspects of your business – only $495
Lara M. Price is a shareholder at Sheehy, Ware & Pappas, PC, in Houston, in the products liability and professional liability sections of the firm. She has extensive experience in a number of substantive areas of trial practice, including products liability, professional liability, administrative law, commercial litigation, health care law, premises liability, and personal injury and wrongful death. She regularly represents corporations, other business entities, and individuals in complex litigation against claims for personal injuries, wrongful death, and economic loss in state courts throughout Texas and in federal courts in Texas and elsewhere. Ms. Price is General Counsel for CANA and Texas Funeral Directors Association.
processes and procedures
tips and tools
Posted By Administration,
Wednesday, October 9, 2019
Updated: Friday, September 27, 2019
Nobody likes paperwork. It’s a pain in the rear and a nuisance. Filling out forms and checking off boxes is a waste of valuable time for the crematory operator, am I right? That statement is as wrong as saying the earth is flat.
I like paperwork – I'm a weirdo – and documentation and record keeping policies, and following them consistently, are just as important as any other task performed in the crematory. This includes the safe and efficient operation of the cremation equipment. I have seen first-hand the effect of poor operating procedures on a business and on the community. I am on a mission to change this, but I am only one guy.
So, if you understand the reasoning behind all of this paperwork and documentation, you can better appreciate its importance. Even more important is understanding the impact of not following your company record-keeping and documentations policy consistently.
The Point of Paperwork
State laws dictate what paperwork is required for the cremation of the deceased, and it is important that you comply with these regulations. Because cremation is irreversible, it is crucial that you document each and every step of the process. Proper and consistent paperwork reduces the risk of litigation in the event you are accused of doing something wrong. When you make a mistake, it’s easy to deal with. Admit your error, make good on it, take your medicine and move on with your life. The hard part is when you are accused of doing something wrong that you did not do. Without proper documentation it can be difficult to prove your innocence.
So what’s the key to a successful cremation business? There are countless books about strategy, procedures, and processes, but this is one of my favorite quotes:
Strong businesses have strong policies.
– Vicente Falconi, management guru
Crematory Management Program
So my company and CANA have partnered to create the Crematory Management Program to develop a framework – a table of contents if you will – for standard operating procedures that can be customized to each business. This is a resource for CANA Members to help them develop their own SOP Manual -- with samples and examples (and a free consultation with me) to get your existing policies and procedures in one place, in order, and identify what your company is missing.
We based it on four overview categories that we will introduce here, with a focus just on the paperwork:
Core Policies and Procedures
These are the things that are at the 30,000-foot view, meaning the overarching and guiding policies for your business. On the paperwork side, Document Retention Policies and filing procedures are important. These are determined in part by your state/provincial regulators, and part your business practices. If you can’t find something, even if it was filled out perfectly, it doesn’t exist. No one likes to file paperwork, but an organized file system could save your job someday. I often recommend, when I’m helping firms who use electronic file systems, to keep records forever. Why not? A lot of cremation professionals are used to the paper, but electronic files are not only responsible environmentally, but easier to store and locate.
Equipment Operations Procedures
Equipment is my favorite part since I built them for so many years. Here, you need to document your equipment and how to run it and maintain it. You need written procedures for how cases move through your operation. Your firm should have a comprehensive written procedure guide outlining the steps in the process from receipt of the deceased to return of the cremated remains, and it should include the associated forms, verification, and documentation required. In the crematory, there are forms for the operator to fill out and forms that are already complete. The operator is responsible for verifying the presence, accuracy and validity of these already completed forms prior to each next step in the process.
Maintenance and inspection is one section that's completely populated in the CANA Member resource of the Crematory Management Program. Basically, your schedules and logs, maintenance records, outside/third-part inspection records are all there. I love the idea of the outside/third-party inspection -- that means if someone -- like a regulator or one of your families -- asks, you can pull that report that shows what an inspector found, how you addressed it, and what you're doing right. Plus, your maintenance records keep a clear list of your investment in your existing equipment and prepare for a future capital investment.
Forms and Authorizations
You likely know the necessary forms and authorizations to keep your business running, but all of the paperwork in the world is worthless without compliance and consistency. Be thorough and complete with every entry every time. If you leave a field blank it will raise a red flag. Was that field forgotten? Or was it really not applicable? If there is a space to record information, and you either do not have that information or it doesn’t apply to this individual, mark that fact down in the space. An incomplete form is worse than not having a form in the first place, when it comes to covering your backside.
Write legibly when filling out forms. A document that you cannot read is worthless. Never use whiteout if you make a mistake filling in a field. It’s better to cross out the mistake with a single line and put the correct information in next to the error. Initial and date the correction. Whiteout can make someone think you changed the document entry after the fact, to cover your mistake. Keeping a mistake transparent is always better when defending your actions.
What’s the importance of human resources? Your business can’t do anything without staff to run it. So think about roles-based operational procedures. The procedures should dictate what the results are – not the people doing them. The people doing them should fit the skill set and do them per your policy and procedures. Doing it the same way every time helps assure that mistakes are not made. If you never do it differently, you will do it right every time. Knowing and being able to say you do it right every time is a powerful statement to make.
Why We Do It
The most important reason to consistently follow all documentation and record keeping policies and procedures is the fact that doing so will virtually eliminate doing the wrong thing. It’s not just about the risk and the money. It’s the obligation to the families. A crematory operator is a vital part of the overall process of turning a dead body into a living memory for a family. It is absurd to think that any good operator would want to do anything less than a perfect job for the family of the deceased. After all, it’s more about the family than anything else, right?
A well-developed SOP Manual wrapped in a pretty bow is not the end-game. Once completed, it will not do you any good on the bookshelf, no matter how great the processes are. The final document, a customized and complete SOP Manual must be a continuous, living, breathing part of your day to day business. CANA's Crematory Management Program is a benefit to our members to help you ensure your policies and procedures are comprehensive, implemented and enforced.
Developed with Cremation Strategies & Consulting, this program provides step-by-step instructions to build a Standard Operating Procedures Manual to reduce liability, improve employee on-boarding and training, and ensure that operations are done correctly, efficiently, and consistently.
See more and get started: goCANA.org/crematorymanagement
This article is excerpted from "All Systems Go: The Importance of Paperwork and Record Keeping" by Larry Stuart, Jr. which first appeared in The Cremationist Vol. 54, Issue 1 — CANA Members can log in to see this and more articles from our quarterly publication. This is part of the recurring column All Systems Go! written specifically for the crematory operator and featuring an assortment of practical knowledge regarding operations, maintenance, and best practices for running an efficient, safe, and cost-effective crematory.
Larry Stuart, Jr. is a graduate of Kent State University and is a past member of the Board of Directors of the Cremation Association of North America (CANA) as Supplier Liaison. Through his experience Larry has seen first-hand the negative impact that poor crematory maintenance and improper operating procedures can bring about. Larry has spoken at numerous industry events and has conducted crematory operator training classes across North America with a mission to advance the safety of cremation facilities and their employees and to more positively impact our community and our environment. For more information please visit larrystuartjr.com/about
processes and procedures
Posted By Administration,
Wednesday, June 26, 2019
Updated: Monday, June 24, 2019
This year at the CANA convention, I’m proud to cover a new topic on how we all serve our cremation families. As a group, we value the presence of the person and often encourage the family to see their loved one for not only identification purposes, but also because we know that the experience can be valuable in grief processing. We discuss this concept from a “front of the house” perspective often, but what does it mean to our prep room staff?
All of us who are in funeral service and caring for the dead are well aware that they come to us in various conditions. We also know that it is our job to observe these various conditions and prepare them in a way that is suitable for whatever disposition they are going to have. The industry term for preparation without embalming is “minimal care” however, that does not mean our efforts should be minimal. If we consider the most thorough method of preparation embalming, we can use it as our benchmark. However, not everyone gets embalmed, but that doesn’t mean that any preparation we do should not meet the highest level of care that embalming provides.
An Ethical Approach
Those of you who are reading this are likely embalmers (or know embalmers), so you are well aware that embalmers feel very strongly about giving the correct treatment to the deceased in their care. However, what does that actually mean, and how does it apply to preparing someone who is not going to be embalmed?
The first step of any thorough embalming is to bathe the person. Not only do we do this for safety reasons, but also to conduct case analysis (see the next section), and have a better understanding of what we are dealing with.
Embalmers are sometimes told by institutional care staff, death investigators, and even sometimes the family that the condition of the body is worse than it actually is, and a thorough bathing can actually create more of a peace of mind rather than reveal problems.
During this phase, all medical devices should be removed whether the person is going to be viewed by their family or no one other than the person placing them in the cremation container. We do this for safety in the crematory, because some implants can explode or melt, but also because used medical devices are trash and should be disposed of properly. A reasonable embalmer removes all of the medical devices they can from a person before presenting them, and if this is our ethical standard of care, then this should be done regardless. You wouldn’t expect a person to be buried with garbage, in fact the idea is repulsive.
One of the first things embalmers do when presented with a body is their case analysis. We observe the physical condition of the body in order to decide our strategy for fluid selection, feature setting, and dealing with any possible unknowns that may occur during the embalming such as swelling, purge, etc. But, if we are not embalming, what can we do? In this case, we still observe any pathological or other medical treatment outcomes this person may have. Medical devices should be removed and dealt with, and lesions should be treated appropriately with surface preservation (if allowed), sutured, or wrapped in bandages to prevent leakage.
By definition, embalming is always mutilation, which is one of the reasons we have to receive permission from the family before doing it. However, we embalmers bristle at this idea, because we are not in the business of mutilating people, we are preparing them for the most difficult event in a family’s life. We rectify this more negative perception by always minimizing the number of invasive procedures necessary, and we do so in a way that is careful and surgical.
Believe it or not, embalmers must have a bedside manner even though their patients have no idea how – or even that – they are being treated. We know how they are being treated. When we are preparing an individual who is not going to be embalmed, we always have to consider the technique we are using and recognize what is surgical and what is mutilation.
Further, perhaps one of the reasons a family is choosing not to have someone embalmed is because they do not recognize the care we put into it. Exceptional care of the deceased and proper bedside manner in any invasive procedure is not only ethical but respects the family’s wishes as well.
The Practical Approach
So now we have established three points on what to set our benchmark at when caring for an individual, but how do we apply this to a more practical manner? Presupposing compliance with all OSHA regulations and Universal and Standard Precautions, as well as observing the family’s wishes, providing minimal care does not mean compromising the quality of your care for their loved one.
To create a basis for our continued conversation on best practices of care, I have created an outline for you to consider. The outline described below is just that, an outline. This list is not meant to define limitations on best practices, but rather create marks on a spectrum.
When it comes to embalming, the word “clean” is often used interchangeably with the word “disinfected.” So how does that apply here? Closely observing and cleaning the person often uncovers medical outcomes such as bedsores or fluid pockets that are the result of the ante mortem or post mortem settling of fluids. Furthermore, moving the body from one side to another will reveal possible purge that may have not been otherwise apparent when the person was lying supine. There are different levels of cleanliness that may be available based on what the family wishes and what is possible based on the condition of the body.
- Basic disinfection: Basic disinfection procedures should be taken regardless of whether or not a family is planning to view their loved one. This would include the removal of all medical devices and bandages, surface disinfection using a spray, and removal from a soiled container into a clean one.
Mid-Level disinfection: This would include all of the above listed steps in addition to bathing the person, including washing their hair. Once the person has been thoroughly dried, it would also include the replacement of bandages over punctures from medical devices, and suturing of any surgical incisions. It would also include the draining of any fluid pockets that have formed. Orifices should be packed with cotton.
Thorough disinfection: Thorough disinfection includes all of the above steps, but it would also allow for some chemical preservation. While it may not call for vascular injection of embalming fluids, there is the possibility of surface embalming of any lesions, treatment of drained fluid pockets, the chemical cauterization of any surgical incisions, and the chemical treatment of any artifacts of medical device removal. Cotton for packing orifices can be coated in a topical preservative.
When preparing an individual at any level of service, we must consider the techniques we are using and ensure that they are appropriate based on family directions.
When caring for a loved one whose family has requested minimal care, we have to be sure not to be mired in our own hubris, but rather consider if our course of treatment is going to go well for our case. We must also consider our bedside manner matches the wishes of the family; are the procedures we are using in accordance with their wishes? If a family desires to view their loved one prior to disposition, but requests the least invasive techniques possible, do we understand what that means and are we able to execute that? For example, when closing the mouth in this situation, are you using a dental tie as opposed to a needle injector? Are you opting to use cotton to close the eyes as opposed to an eye cap? This is evaluated during case analysis and applied through bedside manner.
As funeral service purveyors, we are all very cognizant of the importance of the body and how it is honored. Just because a person has chosen not to be embalmed, does not mean we need to negate the philosophy of care that embalming entails. By observing these best practices, we can provide better customer service to our families in the assurance that their loved one will be cared for in a skilled and thoughtful manner.
Join embalmers and educators Damon de la Cruz, PhD and Ben Schmidt as they discuss best practices for preparing a decedent for identification, short term viewing, and cremation at CANA's 101st Cremation Innovation Convention. This lecture will include a discussion of safe handling procedures, the removal of medical devices, dressing, and cosmetizing deceased individuals. Ben and Damon will also differentiate between invasive and non-invasive procedures and the grey areas in between, sponsored by Ring Ring Marketing.
CANA's Annual Cremation Innovation Convention heads to Louisville, KY to bring together professionals across the funeral profession – funeral homes, cemeteries, crematories, cremation societies, and combos. Like CANA, Louisville celebrates a storied history even as it embraces its exhilarating future, making for the perfect pairing of location and association. Whether your thing is horse racing, whiskey, baseball, or shopping, you’ll find it in this charming city. Convention activities including social events, programming and exhibit time in the cremation innovation trade show merge seamlessly, keeping you on your toes and focused on the finish line.
Can’t join us? We’ll have recordings available so you don’t miss out on this amazing content.
Ben Schmidt is an instructor at Worsham College of Mortuary Science where he teaches Embalming Theory and Lab, Restorative Art Theory and Lab, Funeral Directing, and Funeral Service History. In addition to his duties there, he is the co-creator of MorTraqr, a web application for tracking embalming and funeral directing tasks. Furthermore, he is co-author of the textbook Creating Natural Form; Restorative Art Theory and Application. Follow the creation of the textbook, the further developments of Mortraqr, and the antics of his two year old son on Instagram @mortraqr.
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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.
- These implants are often the size of a grain of rice and inserted throughout the impacted area, thus impractical to be removed by a funeral or medical professional.
- 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).
- Recommendations from the Canadian Nuclear Safety Commission state that "if the therapeutic nuclear medicine procedure or manual brachytherapy procedure took place more than two years ago, the decedent can be treated in the usual manner. No precautions are necessary for autopsy, cremation, embalmment or alkaline hydrolysis."
- 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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