Where do you want to die? A case for home deaths and funerals (Op-Ed)

So… where do you want to die? If you’re like four in five Americans, your first choice is to die at home, a figure which has remained unchanged since the 1970’s (Kalish & Reynolds, 1976; Henry J. Kaiser Family Foundation, 2016; Hine, 1979). Also unchanged is the fact that most Americans won’t die at home as they had hoped; in fact, the ratio is reversed, with most dying in an institutionalized atmosphere (Kalish & Reynolds, 1976; Henry J. Kaiser Family Foundation, 2016). How did we get here and how can we start to repair the disparity between what the dying want and what actually occurs? Integrating home death and funerary practices back into society is a place to start.

In the 19th century, families almost always cared for their dying and dead loved ones at home. The dead were commonly buried in family plots on the premises. This was practical, considering the limitations of travel at the time, but it had perhaps unintended purpose as well: many experts believe the proximity to death helped with healthy mourning via a phenomenon now recognized as continuing bonds, which acknowledges that both grief and connection to the deceased are ongoing (Hine, 1979; Klass, Silverman, & Nickman, 2014). It was only after the Civil War when the bodies of Abraham Lincoln and many others traveled long distances before burial that preservation of a body became of societal interest (Beard & Burger, 2017; Hine, 1979). The legitimization of the profession of funeral directing was accompanied by mortuary schools, licensing requirements, and escalating costs as status displays during death rituals became routine and desirable in American society. The modern funeral home became “the epicenter of the business of death” (Beard & Burger, 2017, p. 51). In the 20th century, embalming, casketing or cremating, displaying, and burying bodies at a cemetery became huge business.

And none of this is necessarily a problem — if it reflected the stated wishes of the dead and the bereaved. Studies show time and time again, however, that it does not: many critically ill people who die in hospitals receive unwanted, distressing treatments and have prolonged pain (Valente, 2018); hospice care is consulted late or not at all in the dying process (Henry J. Kaiser Family Foundation, 2016); conversations with physicians about wishes are focused on continued treatment instead of physical and emotional symptom management (Valente, 2018); modern funerals are often out of the financial reach of many deceased person’s family at an $8,508 median cost (Martin, 2016); and oftentimes families are simply not aware that they are allowed by law to pursue another option (Krupar, 2018). Additionally, in response to diversification of consumer’s purchasing options, funeral homes have developed “a seemingly endless menu of tangibles or services” to bolster profits (Beard & Burger, 2017, p. 55), making it stressful, complex, and downright expensive to bury a loved one or plan ahead for oneself.

Home funerals, in contrast, are a profound departure from the traditional American funeral, where mourners themselves take intimate care of the dead body (Hagerty, 2014). Home funerals engage with death as opposed to avoiding it. Instead of rapidly removing a body from sight, mourners spend extended amounts of time with their loved one. Despite what proponents of embalming might tell us, it’s not inherently gruesome or gross. Yes, dead bodies look dead. Yes, there are practicalities to take care of — but these are solved with dry ice or other refrigeration techniques and some self-education, leaving those who loved the person to focus on the realities of their bereavement. And then there’s the issue of agency, or the capacity to act and make free choices. While in a modern funeral the embalmer or funeral director is agentive, in a home funeral the bereaved act with agency as they care for the dead body. Home funerals further grant agency to the dead themselves, as their presence offers comfort to those they loved (Hagerty, 2014, p. 432). The home funeral frames friends and loved ones, not doctors or embalmers, as those with authority over the deceased, allowing them to navigate the end of life according to their own ethics and values.

Still not convinced? Then let’s consider what many are calling the healthcare cost crisis: hospice is a cheaper solution than hospitalization (Livine, 2014) and home funerals cost only a fraction of a modern funeral (Martin, 2016), even if the family or individual chooses to utilize some services such as cremation or burial, but skip embalming. Burial sans embalming is also a greener choice — there’s little matter that is more biodegradable than deceased carbon-based lifeforms — and better for the environment (Krupar, 2018). Next let us return to the concept of continued bonds, which have been found by many grief experts to be necessary for healthy grieving, as home funerals are one mechanism whereby mourners can stay connected to their loved ones and integrate grief-related behaviors and rituals (Klass et al., 2014). Behaviors once seen as pathological — perhaps like holding a home funeral, but certainly not limited to it — are now recognized as normal, natural aspects of bereavement. Last but not least, the practice of home funeral, of touching a dead body, is neither illegal nor dangerous. Home funerals are only contraindicated in the rare case of infectious disease. Eight states require some funeral director oversight (Beard & Burger, 2017), but home funerals are permitted in all fifty states, and hospice is covered by Medicare.

There are very good reasons why certain deaths and funerals don’t occur at home and that is not likely to change. Furthermore, the desires of the individual and their family trump every reason I have outlined above. However, the fact remains that there is a great gulf between those who wish they could die or mourn at home and those who actually do so, and that gulf could be significantly lessened with a mere change in thought. The question remains: where do you want to die? I hope to be at home.