Care and consent: What’s the cost?
While the CMA Legal Order shines a spotlight on price transparency, is quality of care the real elephant in the room?
Silence can never be taken as implied consent. That’s the key finding of a new report, Care of the Body in Funeral Directing, co-authored by SAIF member Sarah Jones and Yorkshire University’s Dr Julie Rugg.
The research took place within a context of heightened understanding of the economics of the funerary industry following the Competitions & Market Authority’s (CMA) investigation; increasing interest in the concept of direct cremation providing a simpler funeral format; and the impact of the COVID-19 pandemic in focusing attention on what is valued in funeral practice.
More than 270 funeral directors were surveyed, along with qualitative interviews with people who had arranged a funeral. The findings highlight areas of concern around what families’ expectations are in terms of the preparation of the body and what constitutes first offices, and questions the wisdom of direct cremation and price transparency versus service transparency for bereaved families’ wellbeing.
The research found that there were five main ‘funeral factors’ which people consistently reported were important to them, and which had an impact on their funeral experience and satisfaction:
- Whether the wishes of the person who had died were known
- Whether funeral related decision-making was felt to be inclusive
- Whether the funeral directors had the right level of responsiveness to their needs
- Whether time spent with the body met their needs
- Whether the funeral service itself was deemed to be satisfactory.
“Many funeral directors are getting it right and clearly operating really sensitively with families,” says Julie. “However, the worst cases were where the funeral director was not engaged at all with any conversation, and sometimes did things that people found shocking.”
Respondents who were upset by something which had happened in the funeral process fell into two groups: those who had disagreed with their family about the funeral, and people who said that something had happened that they hadn’t agreed to, particularly embalming.
“Some said the body had been embalmed and they hadn’t given their permission,” says Julie. “They’d seen the body at the funeral director’s premises and they were aghast, shocked and horrified, and really upset because the whole procedure hadn’t been explained to them. They said, ‘If we’d known what was going to come, we wouldn’t have agreed to that’.”
A lack of clear communication – intentional or unintentional – would have led to this point, says Julie, and surprisingly, 3% of funeral directors surveyed did not seek permission prior to embalming.
“The families might have agreed to it, thinking it was hygiene preparation, as that’s what it’s often called, and in some people’s minds might just include cleaning the body. Nothing as invasive as embalming. That really indicated that the boundaries around action are really fluid.”
In her academic career, Julie has studied funeral practices around the world, and she had expected the deceased’s journey through the funeral process to be straightforward.
“I thought that when the deceased arrives at the funeral home there would be first offices, followed by preparation for viewing, then there might be embalming if people wanted that. However, everything was actually mushed up together. On the whole, first offices and preparation for viewing were pretty much the same package, and might include quite invasive procedures some people might be upset by. In particular, closing the eyes and suturing the mouth.
It was clear from funeral directors’ responses that many were presuming consent:
- ‘The family left us to do what we think was right’
- ‘It’s distressing for families to talk about’
- ‘They’ve left it in our hands, we’ll do what we think is right’.
“That, for me, is a little odd,” says Julie. “Because people not wanting to talk about something leaves quite a lot of open space where funeral directors feel that they can do what they want in terms of what they think is appropriate. It’s a bit frightening that in some instances the funeral director thought embalming was appropriate.
“Don’t take silence as consent. In every instance, the funeral director’s got to be satisfied that they have secured, as far as it’s possible, informed, explicit consent. That’s the key thing.”
The guidance produced is aiming to help funeral directors to think about the last time they dealt with a family and how much space they had given them to make a decision.
- Did they presume too much?
- Did they step in and say, ‘Can we talk about this a little bit?’
- Did they quite quickly say, ‘Oh, yes, I’ll do what’s necessary’ and take the whole issue out the family’s hands?
Visiting the deceased
Whether the family is engaged with the deceased or not, viewings can be problematic. Funeral directors also told the report authors that viewings occur more often than people might expect, and in some instances the bereaved are visiting many times.
“Funeral directors will know that some people really need a lot of time with the deceased,” adds Julie. “So how the funeral director thinks about the visits and how they frame that and prepare the family for a viewing is important.
“Some funeral directors were really good at getting that all ready, talking to the family about how the body should be presented, thinking about an appropriate context – that the room is right, that there’s a degree of privacy. The funeral director can judge whether the family is experienced in this or not, and then prepare people before they go in, particularly if the body’s not in a great condition.”
However, not all funeral directors are equal and families reported distressing viewings in rooms which ‘felt like back offices with filing cabinets around’, or where the deceased was screened off from other coffins by a curtain. Some respondents relived their distress up to five years after a viewing. Reflections on positive experiences indicated that families valued a funeral director who was on hand, but not being too directive, particularly if the family had experience with previous funerals.
Direct cremation, of course, precludes viewings, and one of the issues that throws up is it establishes a presumption that nobody’s going to want to view the deceased.
“I think that’s problematic for some people because families might not be prepared for the death,” says Julie. “It may be too sudden for them to deal with not viewing the body.
“It’s very difficult for someone who’s making a funeral plan to think about what their family might need, so that opens up a whole set of questions about what happens if what the deceased is saying they want in any pre-paid plan and what the family needs after the death are slightly different.
“I wonder whether there should be some flexibility around that, even if it’s not in the plan, so people could be allowed to attend a viewing. We haven’t talked to funeral planners about how they frame that conversation with people, and perhaps the conversation should be, ‘Well, what do you think your family will need?’, and ‘Have you talked to them about that?’ or ‘Do you think you might want to leave this little window open just in case you die very suddenly?’. If something happens that’s unexpected, the family really might need to spend some time with the deceased, so is direct cremation shutting too many doors there?”
In preparing the report, Julie and Sarah dealt with the CMA on two or three occasions and Julie has mixed views on how the final Legal Order protects families.
“It talks about transparency, but only price transparency, not service transparency. Despite how much data they collected, I’m not sure they really had a good view on how the industry works or how people buy funerals.
“The Standardised Price List guidance was a massively confused document. They had decided the behaviour change and applied it to the industry by saying, ‘Everybody wants to do a price comparison, this is how you do it’. The only thing that I’m quite pleased about is that they’ve indicated embalming as a separate service.
“It also looks at the bereaved as a victim, as vulnerable. Of course, some of them are, but that’s actually the minority. One of the findings from our original research [2019’s Funeral Experts by Experience: What Matters to Them] was that, actually, a lot of people were quite experienced about funerals, especially those over the age of 55. “It’s difficult because your sector is part retail, part service industry. For a funeral director to have lots of customers coming back to them, the CMA might say they have a captive audience, but actually, people come back for a reason – they know you’re good at your job. People are judging you by your service delivery, not about your pricing.”Tags: care, CMA, consent, Deceased, embalming, families, Full Circle Funerals, regulation, report, research, Sarah Jones