In January of this year, TVO.org ran three articles asking whether and what Canada had learned from the SARS outbreak of 2003. At the time, we had hoped that the novel coronavirus that had emerged in Wuhan, China, would be contained. That didn’t happen, and now Canada, alongside most countries in the world, is coping with what has quickly become the most serious threat to life and public safety this country has seen since the Second World War. With Ontario under a state of emergency, TVO.org is interviewing the front-line personnel we don’t often hear from, the ones keeping society functioning while millions of us stay safe at home. Today: how Ontario’s funeral homes are preparing for the grim possibility of a sudden massive surge in business.
Most of us will deal with the machinery of death only a few times in our lives. A loved one will die, and you will find yourself the person — the next of kin. And planning for what comes next will be your responsibility. Perhaps you’ll be prepared, emotionally and even logistically: your loved one has died, sadly but predictably, at the inevitable conclusion of a long illness, and you’ve already arranged a service. Or perhaps it’s sudden and completely unexpected — a young person, in good health, suddenly struck down. One of the first matters you’ll have to attend to is what happens to the body.
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As Canadians nervously eye COVID-19 crisis areas in Europe and the United States, it is not yet clear how severe the pandemic will become here. Canadians will die. Indeed, at time of writing, several dozen have died already. But we may just avoid the kind of mass deaths that have overwhelmed hospitals and funeral homes elsewhere.
Then again, we may not. And, at the risk of sounding crass, if the pandemic does reach crisis levels here, what will we do with the dead? Canada’s official pandemic plans include some guidance. The military could contribute personnel and vehicles; this is what’s happening in Italy. Skating rinks, with their powerful cooling systems and wide-open spaces, could be used as emergency morgues to store bodies of COVID-19 victims; this is what’s happening in Spain.
But using the armed forces, repurposing hockey venues, resorting to mass burials or cremations — these are last resorts. How far can we push the existing system before it breaks?
In an interview with TVO.org, leaders from Ontario’s funeral associations discussed the state of their preparations. Darren Denomme, executive director of the Ontario Association of Cemetery and Funeral Professionals, and Steve Reynolds, the organization’s president, were joined by Michael Sargent, president of the Ontario Funeral Services Association. The three men made clear that, while they hope for the best, they are aware that their professionals may soon be called upon to serve in tragic circumstances.
To provide context, they first described the typical process — how it would have worked as recently as a month ago. Though each stressed that every death is unique, the gentlemen all agreed that the process generally goes something like this: A person dies, and the death is reported to a coroner. The coroner records the death and makes a determination as to the necessity of a post-mortem (an autopsy is sometimes automatic — for instance, in the case of violent death; in other circumstances, such as a cancer patient dying in a hospital’s palliative-care unit, it would be rare). After a post-mortem examination is complete, or immediately after the death is recorded, should an autopsy be deemed unnecessary, the body of the deceased is collected by funeral-home personnel, using protective personal equipment, and removed from the scene of death, the institution where death occurred, or the place an autopsy was conducted. Sometimes, the funeral-home staff has previously been alerted that a death was expected. Other times, they deal with a shocked family grappling with a sudden loss.
When a death occurs in an institutional setting, or if a post-mortem exam has been conducted, the body will typically be wrapped in a “body enclosure” — a body bag. When the body arrives at a funeral facility, it is prepared in line with the family’s wishes and the religious traditions of the deceased. A funeral service can then be held (sometimes at the funeral home the body is prepared at, sometimes elsewhere), and burial or cremation then occur (cremation can also occur before a memorial, of course). Funeral-home staff take care of the logistics of the body’s handling and transportation, if necessary.
This is, of necessity, a brief and general overview. The details of a funeral can vary widely. A very simple scenario would involve receiving a body from home, after a natural death, transferring the remains to a crematorium, and then returning the ashes to the family, who then host their own private service. A more complicated, but still routine, scenario would involve embalming a body, dressing it for open-casket display, and transporting it to a house of worship for a service and then to a graveyard for burial.
Again, the scenario above is the normal way of doing things. But these are not normal times. Even though, at time of writing, the death toll in Ontario remains low, the impact of the pandemic is already being felt.
Funerals, for instance, are now subject to capacity limits and social-distancing requirements. Those wishing to pay respects to the family of the departed have to do so in small groups. Food and beverage service at memorial events has been disrupted by economic restrictions and in order to maintain high standards of hygiene. The physical layout of funeral venues has been altered: mourners must maintain two metres of separation. To date, the families whose funerals have thus far been affected are typically those mourning loved ones who didn’t die of the pandemic but during the pandemic — even as we prepare for the worst, people are still dying of non-coronavirus-related causes at a fairly standard rate. (We may eventually discover that the widespread disruption of routine economic and social life has depressed the death rate from some non-COVID-19 causes, while inflating it in others. Time will tell.)
But what if — God forbid — Canada doesn’t escape the kind of crises seen in Europe and the U.S.? What if it gets bad here?
The first concern I raised was the issue of safely handling the bodies of COVID-19 victims. This is not expected to be a major problem — funeral staff must always approach human remains with caution. Sargent noted, for instance, that funeral-home staff may not realize, when receiving the body of an accident victim, that the victim had been infected with a blood-borne disease, such as HIV — the deceased themselves might not even have known. Funeral staff must therefore approach every body carefully, wearing full protective equipment (masks, face shields, gloves, gowns) to avoid any risk of infection. The process of preparing a body must similarly be done cautiously, in line with established protocols aimed at avoiding any risk to funeral staff. Asked whether anything is normally done at an institution by staff after a patient dies onsite, or by autopsy staff after a post-mortem, the gentlemen agreed that that was not the case. The body is simply enclosed and then stored until it can be retrieved.
Would funeral-home staff know whether they were handling the body of a COVID-19 victim? “We do receive a medical certificate of death,” Sargent explained. “That contains information about what’s known of the death’s circumstances. And if there is a contagious-disease issue that a hospital is aware of, and they believe it contributed to the death, we are informed when they tell us the person has passed away. We have that information, because it’s an asset to have — a requirement — so that we know what challenges we may face during an embalming process, for instance. And they are obligated to inform us if there is additional risk. And this is on top of our universal precautions.”
“Our concern isn’t pathogens on the body,” Reynolds explained. “We know that risk and are prepared for it. In this pandemic, our greater risk is families and mourners — the people we come in contact with while making funeral arrangements and during services. That’s the bigger concern for our staff. So we’ve adopted new sanitation practices in our funeral homes. We’ve had to limit the number of people who can come to arrange a funeral. Some funeral homes, with larger staff, are staggering their staff into teams so everyone isn’t in the building at the same time.”
“The real danger is the public not observing social distance,” Sargent agreed. (These words proved prophetic — public-health authorities in Newfoundland and Labrador announced Wednesday that dozens of cases have been linked to one sick individual who attended a funeral.)
What about protective equipment? Hospitals are already scrambling to make sure front-line personnel have the equipment they need. What about funeral-home staff who must directly interact with human remains?
“We are looking at that,” Sargent said. “We are actively working to make sure we have supply. Certainly, there may come a time when this is an issue. So far, we have enough. We are part of the front line for public health. Our job keeps the public safe. So we have to make sure we have the equipment. But we certainly understand that the first lines of defence are hospital personnel and hospital support workers. So this could be an issue. We’re looking at it.”
What about the really grim scenarios? What if our containment efforts fail, we don’t flatten the curve, and our hospitals are overwhelmed? What if the number of new dead each day soars dramatically? What is the upper limit of our existing funeral industry’s ability to process the dead?
There was no easy answer — although this is something the funeral profession is thinking about. “There have been directives from our governing bodies to funeral homes and cemeteries to look at that,” Reynolds said. “We are looking at surge-capacity issues. We would want to continue to provide prompt, dignified services for families.” I asked whether there exists an upper limit — a hard capacity beyond which bodies would accumulate faster than they could be handled. “We are having those discussions now,” Renyolds said. “We need to find that out.”
But there was one reason for, if not exactly hope, then at least guarded optimism — a surge of fatalities would not arrive instantly or evenly across any jurisdiction. “We are working across our organizations to coordinate a response. If this became extremely dire, we would turn to the government for directives and assistance,” he said, in reference to some of the bleaker parts of the above-mentioned official federal-pandemic plan. But they’d turn to one another first.
“Some of us remember SARS,” Reynolds added. “We have known since then that a pandemic was possible. We know the plans — we’re familiarizing ourselves with them again. And we’re encouraging all our professionals to get in touch with local authorities and be part of the conversation.” There has been a surge in the volume of questions the industry organizations are receiving from members, he granted, and there has been a strong push to provide good, consistent advice. “The Bereavement Authority of Ontario [which regulates the funeral industry] is in touch with us,” he said. “We’re bringing in experts in infectious disease to provide web-based updates for our members. We’re getting ready.”
“Funeral homes do sometimes have to deal with mass-casualty events, where local capacity is overwhelmed,” Reynolds said. “When we have had to ask for help, funeral professionals have stepped forward to help.” An example, he noted, came after the September 11 terror attacks on the U.S. Volunteers from Canada went south to help with the management of the thousands of funerals made necessary by that atrocity. And there is local emergency planning already in place — it varies by jurisdiction, but no funeral home would be expected to operate alone in a crisis.
The three men all took pains to note that, though the current emergency has already imposed some changes on funerals, for right now, it is business as almost usual — any surge in Canadian pandemic deaths is still weeks away and may never come at all. There is capacity in the system to handle an increase in the local death rate, and other jurisdictions could share material, resources, and personnel if one part of Ontario, but not others, were overwhelmed. More than 100,000 Ontarians die in any given year. It would take a massive surge in COVID-19 cases in the province to overwhelm a system that routinely handles that many bodies.
Meetings continue to be held to plan for a worst-case scenario. But, for now, the job remains the same: efficiently and considerately helping the families of the dead handle a difficult process.