By Robert W. Ninker, CAE
It took us almost fifteen years to get a basic requirement for continuing education in many states. While the licensees may not have been all that enthusiastic about the idea, the Department of Professional Regulation was a long term opponent because of the added cost of regulation.

There are still many states which have yet to implement any form of continuing education either because of funeral director/embalmer resistance or opposition by regulatory authorities. Wherever the opposition lies, funeral service has an obligation to demonstrate its eagerness, not just a willingness, to keep itself competently informed.

Continuing education also has the effect of driving out the marginal licensees and that isn’t a bad idea either. For example, how can someone who worked in funeral service before the 1984 FTC Rule, ADA requirements, OSHA rules or a host of other regulatory requirements expect to leave their current occupation and drop right back into funeral service. No wonder the Federal Wage and Hour administrators don’t and won’t consider funeral service practitioners as professionals.

Until every state and the funeral service licensees they regulate are motivated to adopt even a minimal level of required continuing education, the profession will “get no respect.”

Let’s step away from funeral directing and embalming, just for a minute, and look at those who are writing preneed contracts for funeral services around the country. Not only is there no continuing education requirement for a preneed seller, there isn’t even an iota of preparation required by most states before an unlicensed person starts telemarketing or knocking on doors. In most states, there is no training or testing of competency for persons calling on the state’s citizens. Worse, in some states, an organization can sell preneed without even being affiliated with a provider! As a result, one man firms spring up which can go on a selling spree, using your General Price List, without either your knowledge or consent.

A number of state associations have addressed this matter, but there is bold opposition to requiring a sales person to prove they even understand their organization’s instructions, much less being required to know what the regulatory act says or means.

Ask yourself, could I, a non-licensed person, get a preneed permit in your state and sell preneed without any designated training? If so, how is the public being served or protected? You may be inclined to say or think, “Yes, but breaking our preneed act would constitute a felony.” In many states, people cannot be found guilty if they didn’t know they were breaking a law — believe it or not.

In summary, could we reasonably agree that any individual who is meeting the public, offering funeral services, should at least know the laws, regulations and administrative requirements? That is an ethical question you and your leaders need to answer. From the FUNERAL ETHICS ASSOCIATION’s perspective, you owe the public a competent representative!

Back now to continuing education. Does it matter whether you know about the laws and regulations in your state, the changing FTC rules, wage and hour rules and perhaps a half dozen legislative changes in your profession? Serving people, ever more competently, requires all of us to keep current.

Again, from an ethical practice perspective, continuing education is essential in the long run. In the short run, competency is at risk.

By Robert W. Ninker, CAE
The most challenging situations are those in which we seemingly have to put our own best interests aside in order to adequately serve a grieving family. Their interests, and those of the community, need to take precedence. No, I don’t think those two sentences are either enlightened or inspired. The key word is “seemingly,” because, in the long run, the wishes of the well served family are always our best interests.

Organ and Tissue Donations

We have long known that organ donations, autopsies or body donations have been a challenge for both funeral directors and embalmers. Because an organ or tissue donation can delay release of a remains, and involve additional preparation of the body, professionals have to struggle to put a proper perspective on the way families are counseled.

On the one hand, a family is entitled to know that there may be a delay of a day or more. At the same time, unless you put the best construction on the importance of allowing the greater community to benefit from the availability of organs and tissue, other dying patients will be denied desperately needed replacements for their heart, kidneys, skin or long bones.

The sad thing is that you, as a professional, can turn a donation, desired by the deceased and the family, into a routine funeral without saying one word! That is right, and it happens everyday, somewhere, with or without the knowledge of the licensee. Your leadership is respected by families you serve, more than you can ever believe. Lacking any experience in such matters, a family will look to you for whatever guidance they seek, or which you choose to offer.

Purse your lips, raise an eyebrow or simply hesitate before responding to an inquiry and you send a positive or negative perception to the family. You are that powerful, friend. The esteem in which you are held, in these matters, causes those you serve to react based upon the message you are perceived to be sending.

Such control potential makes it essential that you respond in a wholesome, informative and positive way.

Why wouldn’t you do that automatically? You may very well, unknowingly, convey a negative message even when you are attempting to give judicious counsel. Should a family at a hospital call you after being asked to allow a donation of their son’s organs as a result of an auto death, they may want to know the implications.

If you say, “Typically, the funeral is delayed and sometimes the securing of the maximum organ and tissue also results in further delay and increased cost,” you’ve essentially been honest. But, have you been ethically fair? You can state the facts and close with encouragement by saying, “Mr. and Mrs. Jones, even with these minor inconveniences, you should do what you feel would be best for your own personal satisfaction and the good that can come from your decision. I’ll handle the details, just let me know what you decide.”

You may be thinking that’s so much Pollyanna and that you are a funeral director and embalmer who cares for the dead and you know how some of the physicians, in their rush, don’t leave sufficient arteries so you can do your work effectively. That is true and calls for an educational process with regional organ banks, Red Cross and others. But, it doesn’t give you ethical license to indirectly deny a family or community the benefit of life extending organs or tissue.

Autopsy is Different, Though!

Yes, your influencing of an autopsy is a lot easier to achieve because you might not have the same level of guilt about informing a family that the autopsy will cause a delay, will cost more and, besides that, they should know the facts. It is “disclosure,” isn’t it, to say, “We know the hospital said it is just a small necessary incision but you should know what really takes place,” as you let your finger mark a large X across your chest.

At what point does a licensee cross the threshold of his or her ethical responsibility to balance fact versus the possible positive benefit of furthering medicine in the search for increased knowledge on how to prolong life by understanding what causes deaths? Ethically, you cross the bounds when you inject opinion, or fact, that has the effect of discouraging a family from authorizing an autopsy.

If you have read this far and we haven’t hurt your feelings or disturbed your conscience, congratulations. On the other hand, if you are thinking it’s easy for someone to be highfalutin ethical when they don’t have to deal with the arrogance or ineptness of a pathologist who ignores his responsibility to contain invasion of the scalp or other areas which will inhibit the proper presentation of the deceased for funeral visitation purposes.

Every funeral director has a war story about an ear being lacerated through pathologist carelessness and other more insensitive actions. However, that is a professional education problem and not justification for referring to pathologists as “butchers” as some have done in discussing autopsy decisions with a family.

The FUNERAL ETHICS ASSOCIATION’s manual of professional practices addresses the ethical issue with this policy:

Attitude Toward Autopsy

Post-mortem examination of the human body is an essential tool in the advancement of medical knowledge. Unwarranted discouragement of autopsy by funeral directors is to be considered unprofessional.

It is true that the performance of autopsies will frequently cause delay and inconvenience to the family and to the funeral director. Nevertheless, these difficulties can be minimized through cooperation between funeral directors and pathologists in understanding each others problems.

Questions relating to autopsy should be referred to the family physician, pathologist, coroner or medical examiner.

As Executive Director of the FUNERAL ETHICS ASSOCIATION, without a funeral director or embalmer’s license, where do I get the temerity to imply that funeral licensees may not be acting ethically? The answer is, from a professionally conducted survey of Illinois funeral directors, printed in the Archives of Pathology and Laboratory Medicine by Paul S. Heckerling, M.D. and Melissa Johnson Williams, LFD, LE, in November, 1992. It revealed that “Although 80.3% believed that autopsy served a useful purpose, 46.4% had counseled families not to permit autopsy, and 16.6% did so more than half the time.”

The article offers a detailed, analytical presentation of the reasons why funeral directors and particularly embalmers act in that way. For a copy, you may write to the FUNERAL ETHICS ASSOCIATION. The report is exceptionally enlightening.

As a follow-up to the published article, co-author Melissa Johnson Williams was asked if the article could be reproduced. In the discussion, she also confirmed that a number of medical journal articles have been published which accuse funeral directors or embalmers of being partly responsible for the decline in the percentage of autopsies which are being performed. That is a sad commentary we should reverse.

The fact is, until we as a profession can get beyond self-interest, animosity toward pathologists and personal bias, we lose respect as professionals.

As a way of encouraging each licensee to address autopsies professionally, following is the joint recommendation of the College of American Pathologists and the National Funeral Directors Association:

1. Encourage the performance of arterial embalming prior to autopsy except in those cases in which microbiological or toxicological studies are indicated.
2. Reduce procedural delays in an effort to minimize the time interval from death to release of the remains, preferably to a period of four to six hours.
3. Suggest and encourage the use of autopsy techniques which will eliminate technical difficulties for the embalmer.
4. Establish a joint CAP (College of American Pathologists)-NFDA Educational Program.
5. Seek legal permission for pathologists to sign death certificates following the completion of an autopsy.
6. Encourage the adoption of a simplified, non-technical autopsy consent form.
7. Encourage both professions to cooperate with and promote organ donor programs.

Perhaps it is time for the National Funeral Directors Association and others to assemble joint meetings of pathologists, organ banks and eye donor organizations for a candid, open dialogue on how licensees can act professionally and ethically in cooperation with physicians and pathologists. It is a two way street, friends.

The FUNERAL ETHICS ASSOCIATION receives complaints from around the country about perceived inappropriate demeanor of some funeral directors. You can avoid being the target of these types of complaints by the way you and your staff handle the arrangement conference.

Inevitably, when such a complaint is received by the FUNERAL ETHICS ASSOCIATION, the heart of the matter is that the complainant individually felt they were excluded from participation, by the inattention of the funeral director, to their specific wants and concerns.

You have a difficult task in arranging a funeral, especially when there may be 3, 5 or 7 actual participants. Large families who come together at the death of a parent may have flown in, from various parts of the country, under pressure circumstances, just so they could be together in the decision making process. They sometimes come with a level of expectation that only a very alert funeral director can adequately meet!

Take a minute and reflect on the last large family you served. Who got the attention? At the end of the arrangement, had you called each person by name at least once, and asked if he or she had any questions?

Whether or not you look to one or two persons who are accepting responsibility of the funeral expenses, everyone involved is looking to you, or your staff member, as a facilitator. You take on the role of what might be that of a committee chairman for a civic organization. You’ve done that and you know that volunteers need to be led, acknowledged, encouraged and sometimes even pampered if they need it.

A family, and each individual in it, brings that same level of expectation to your office, whether or not they are the decision maker or the financially responsible person.

You ignore them to your detriment. The unacknowledged attendee, during the arrangement conference, is the most likely person to bring a complaint about you, because he or she, feeling ignored, will be ultra sensitive about every facet of the funeral. In short, the non-responsible family member is more likely to find fault, and complain, than the individual(s) paying for the funeral.

So many times, the caller to the FUNERAL ETHICS ASSOCIATION starts off with, “I want to lodge a complaint against a funeral director.” Recently, we received such a call from West Virginia. The woman was one of four daughters of a deceased mother. But she flew in from Georgia to “participate”.

She acknowledged that the youngest daughter, who lived locally, had been appointed as probate administrator, but resented her boyfriend’s interference. It was one of the situations where there was little money immediately available. The boyfriend agreed to put up an initial deposit of $1,500 “to get things going.” The younger sister and he had agreed to sign the funeral arrangement. The caller said, “The rest of us never got the time of day.”

It turned out there was an estate. She had learned that a claim, from the boyfriend of her sister, was made to the estate, not only for the funeral, but included an $8,100 monument. She immediately concluded that the boyfriend and the funeral director had colluded to trick the estate into a false reimbursement because the statement for the $8,100 was on the funeral director’s letterhead. In her view, it was the funeral director’s fault.

When we pointed out that it would be pure folly for a funeral director to engage in such a scam, but that getting a copy of the firm’s letterhead might not be all that difficult, she still blamed the funeral director, not the sister’s boyfriend, who submitted the claim.

Friends, when there is an arrangement conference, you are under greater scrutiny than at any time during the funeral process. The observers are the ones who can and will do you the most harm if you are not considerate of them, even if they are onlookers.

Take the time to sort out the decision makers while still attending to the psychic needs of each of the others who are present. It takes special strokes for all the folks.

There is an arrangements ethic. Polish yours and your future will sparkle, too!

By Robert W. Ninker, CAE
In many states, the legislation which provides for funeral director and embalmer licensure typically carries an introductory paragraph of intent. As we begin addressing ethical issues, let’s see what the legislators had in mind when they began requiring licensure.

Legislative Intent. The practice of funeral directing and embalming in the State is declared to be a practice affecting the public health, safety and welfare and subject to regulation and control in the public interest. It is further declared to be a matter of public interest and concern that the preparation, care and final disposal of a deceased human body be attended with appropriate observance, and understanding, having due regard and respect for spiritual dignity of man. It is further a matter of public interest, that the practice of funeral directing and embalming as defined in this Code, merit and receive the confidence of the public and, that only qualified persons be authorized to practice funeral directing and embalming in the State of Illinois. This Code shall be liberally construed to best carry out these subjects and purposes.

While your state’s legislation may contain different language, let’s examine the implications of the original intent. For example, is the practice of funeral directing and embalming truly a practice affecting the public health, safety and welfare?

Do you understand that language to include your responsibility for assuring that the death certificate is submitted, by the physician in a timely manner with accuracy and completeness? Do you understand your state law to require you to be diligent in assuring that the Department of Public Health has correct information so that researchers, seeking to determine ways to reduce disease and other causes of premature death, actually can count on your efforts to get it right.

When you see that the physician either is lax in revealing the true underlying cause of death, will you or your staff member dare to raise the issue, or do you send it along to Vital Records and let them decide whether a frequent cause from a particular physician may be nothing more than cardiac arrest? Does your staff take seriously the completion of every certificate so that it can truly serve its purpose in improving public health? That is indeed what the legislators expected when they gave that responsibility to licensees!

Next, is it really “a matter of public interest and concern that the preparation, care and final disposal of a deceased human body be attended with appropriate observance and understanding, having due regard and respect for the reverent care of the human body and for those bereaved and the overall spiritual dignity of man”?

What does that have to do with your removal practices? For example, in all instances, is one licensee capable of fulfilling the obligation by him or herself? How does your firm decide, based upon conditions, whether to send one licensee or two persons? Have you, or the owner, personally trained and periodically overseen the procedures used to assure “appropriate observance” is extended even when there is no nurse, physician or family member present when you or your staff prepare the remains for removal? Are universal precautions exercised on each removal rather than those which are marked in such a way as to raise questions whether the remains may have potential for infectious disease?

Are you or your licensees skilled in dealing with the increasing frequency of hospital apparatus being left in or on the deceased? Has your stamp of direction been taught to your licensees so they don’t have to guess on whether to remove bandages, IVs and other paraphernalia at the hospital or the funeral home?

Once the remains is in the preparation room, are all licensees trained not to smoke or eat in there and do you have a procedure for assuring the remains is treated in an ethical manner? The state ties that responsibility to licensees whether its in the laws, rules or is a matter of pure conscience!

It really is “a matter of public interest, that the practice of funeral directing and embalming as defined in the Code, merit and receive the confidence of the public and, that only qualified persons be authorized to practice funeral directing and embalming“.

Given this introduction, is there room, in your firm, for a procedural review to see that unlicensed persons are not making removals by themselves, and that they aren’t in the preparation room engaged in any direct contact with the body and have no casual access to it?

If your preparation room is not locked, others can have access to the remains and what does that have to do with your ethical “care” or sheltering of the deceased? In addition, what would the courts say about a situation where a remains, housed in your facility, was abused by another or afflicted by even a mouse?

When the legislators state their “code shall be liberally construed to best carry out these purposes,” they hold you to a very high standard. Can you feel comfortable with that obligation without a thoughtful reality check in your funeral home — this week!