Green burial: what it is, and why it faces challenges in Vermont

Here is a 10 minute piece about green burial in Vermont I had the good fortune to be featured in. I hope you find it informative. I had a lot of fun being “outstanding in my field” : Green Burials In Vermont?

Many thanks to Hoss Wuerslin of Greater Northshire Access Television for the opportunity to do an in-depth piece about green burial, why it wasn’t a viable option until June, 2017, and what obstacles need to be overcome before there are green cemeteries in Vermont (mainly that most cemetery by-laws require the use of vaults and their is confusion about the difference between burial at 3.5 versus 5 feet).

Also many, many thanks to the co-founders at Green Burial Vermont- Carl Anderson, Jeri Helen Belisle, Jim Holman, Kerstin Lipke, Diane Raza, Ron Slabaugh, and Jennifer Whitman. Without you guys, there would be no Green Burial Vermont!

(If there is a transcript available I’ll post it here in an update. For now, if you want to read more about the unique path of green burials in Vermont you can check out this post: Three and a Half Feet Under: Cemeteries Are Wary of Green Burials By Terri Hallenbeck @terrivt )

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Liminal Spaces: Reflections on Birth and Death

(Image: https://mikkolagerstedt.deviantart.com/art/Dawn-386046325)

I write this sitting in my living room in front of my wood-stove on a day with a windchill so low it threatens to break records. If I glance up I can see my dog curled against the drafty front door- one side exposed to the warm room, the other to the outside chill. In a few moment he will turn, changing one side for its opposite on the other.

It’s a remarkable illustration of the change that defined that last three weeks of 2017 for me, which were spent both in joyous anticipation (and later celebration) of my second greatnephew’s arrival and in intense crisis management with a family whose loved one had suddenly and dramatically turned towards what would become active dying.

I often tell people that I don’t believe that life and death are two sides of the same coin. Rather, together, they are the coin. And yet, this year, I saw just how differently that coin feels when life arrives compared to when it leaves.

This summer I had the privilege of being present for my first, complication-free, live birth. What struck me (beyond the absolute beauty of it), was the pause, just after the final push and just before the first breath. The air vibrated with love and anticipation, rewarded immediately with a deep inhale that broke the stillness.

In that pause I was reminded of the pause that occurs just after the dying have exhaled their final breath and just before the surrounding people become aware that it was final. The air vibrates then too, with many emotions, but the stillness will not be broken. No matter how much the people in the room move, the stillness of death is terrible in its finiteness.

After that first inhale, the midwives and the mother were busy welcoming the baby, checking health and wellness, bonding. Nothing felt rushed or hurried, and all felt imbued with the sense of contentment.

After the final exhale… well… One death I was present for this year was met with quiet resignation. Although surrounded by family and caressed by his wife of nearly 80 years as he died, when his death was confirmed she pulled her hands away. The room was filled with uncomfortable quiet until finally someone began a prayer. They seemed to fidget and cough as a way to mask the stillness and silence. No one touched him again before they left to make way for the funeral home.

My niece told me that after her first son was born she was so full of love and wonder that her heart felt bigger than she could hold. It wasn’t until a friend asked, days after his birth, if he had all of his fingers and toes that she even thought to do the cliched counting. She was simply immersed in the wholeness of this new life in the world.

Another death I was present for was sudden. Although he was clearly dying I had been on the verge of telling the family that it seemed likely he would live at least another day when all attention turned to his final breath. Without waiting for confirmation his family gathered around him- holding him in any way they could. The slight chaos formed a vortex around his still and silent body as everyone did what they needed to do to fill the room with love for every part of him- his eyes, his hands, his humor- before they were finally ready to say goodbye to the whole of him.

This December my niece gave birth to a healthy son. While I wasn’t able to be there with them, she kept me posted until she moved into active labor. And, knowing I was waiting, not long after the birth sent me a text with a picture of him telling me when he arrived, his height, and weight, and that he had arrived loud and indignant. She didn’t tell me how many fingers or toes he had, and I didn’t ask. Nor did I zoom in on the picture to count.

When I am present at a death I stay with the body, usually even after the family is ready to move away. Even if the body will not be kept at home for a home funeral I tend to it. I brush hair and close eyelids. I arrange hands, and pillows behind the head. I straighten blankets. I move gently and talk softly while I work. It is my own ritual to say goodbye. In doing so, I try and honor the stillness and silence of death.

When I held my tiny and new greatnephew for the first time I marveled at his smallness, his warmth, his tiny heart so fiercely beating against my chest, his indignant (it may become a character trait) rooting and cry when he was hungry. Even when settled and sleeping he thrummed with life.

To me our work is not in overcoming our fear of death, but in coming into relationship with our own mortality. We begin and we end, and if we are lucky there are a great many years in between the two that are filled with love and wellness. Some end before they arrive in this world, others end long after they are ready to leave it.

The day is cold and the house is warm and my dog turns and turns to find a balance that suits him. I sit and write and think about living in balance with the fact that no matter how long we are alive for we thrum until we are still.

When end of life is difficult

A difficult end of life experience does not mean that the patient is experiencing a “bad death.” Depending on disease progression and patient choice end of life can be difficult. There is also a condition referred to as “terminal agitation/restlessness” which is not uncommon for any patient and is marked by restlessness, agitation, random body movements- from simply picking at the air to actual thrashing. All of these are a normal part of the dying process even though they can be very upsetting to the patient, their family, and the doula.

As a doula in a difficult end of life situation it is very important that you touch base with the patient, family, and hospice care team and make sure that there is not a need to change the care plan based on the symptoms you have observed. It is also important that you check in with yourself and adjust your self-care as needed.

Our work, even in difficult situations, is to be present and honor the patient’s own experience. However, in these difficult situations we do need to factor safety, both our own and our patient’s, into being present.

Safety: A patient’s safety will be dependent on them, but in very general terms it means that their experience does not have the possibility to re-traumatize, or traumatize them, cause them to harm themselves, or cause them to dissociate. Safe also means your own safety, both physical and mental.

Pain: When people are experiencing physical or emotional pain it can change their behavior. As doulas we simply meet them where they are and without judgement. It is also important to acknowledge and learn about the pain so as to honor the role of pain in the dying experience and do as little as possible to exacerbate it. Let the patient take the lead, and never turn away from bearing witness to their pain.

Traumatic visions/Flashbacks:  As a doula is almost never our role to contradict what a patient is experiencing, even if we can not see, hear, or experience it for ourselves. But when the experience is not a pleasant one we, as doulas, must be aware of whether or not our patient is safe. If patient is seeing violent or upsetting visions, validate what the patient is seeing and ask them how they feel- follow the patient’s lead in discussing it. But, if the patient is upset or become fixated on their experience of the image then they are no longer safe. It can help to ask the patient to describe mundane details of the vision, by refocusing the patient’s attention on the details rather than the whole, it may be possible help them feel calmer or more safe.

For someone who has experienced trauma, these experiences may be more pronounced. If the experience causes the patient to revisit that trauma it may actually become necessary to reorient them to the present in order to keep them safe. Using tactile information is often helpful to gently reorient them to the space around them.

Anxiety/Paranoia: Other patients may just simply not feel safe. Our best tool is our ability to be with the patient and honor their experience without judgement or contradiction. We are not seeking to alter the patient’s experience, rather we are trying to ensure they are safe while having the experience.

Terminal Agitation/Restlessness: Terminal agitation/restlessness can occur in the weeks, days, and hours leading up to active dying. It can present in an innocuous way, such as repeatedly reaching towards the air or picking at clothing, or in a more difficult way, such attempting to move when it is not safe for the patient to stand on their own, or thrashing. It is important to note the onset of such behavior, as it is an indicator that the patient is nearing active dying. Do what you can to make the environment the patient is in safe. Never, ever, restrain the patient. It is rarely possible to reorient a patient who is experiencing terminal agitation/restlessness. There are medical interventions that are possible that can help restore the patient to safety, but they should only be used if they are in accordance with how the patient wants medical treatment at the end of life.

Conclusion: If we are honoring the patient as a person and their wishes for end of life care, then these experiences are simply a part of their dying process. As doulas we must honor them as such.

 

Instructor for the UVM End of Doula Certificate program

I can finally let the word out! It was an honor to be able to contribute to this exciting course for End of Life Doulas, the first to be linked to a major medical school! Apply by August 15th to be a part of the first class! Read all about it here: https://learn.uvm.edu/program/end-of-life-doula-certificate/

Developed in association with the UVM Larner College of Medicine, the University of Vermont has partnered with Cabot Creamery to launch a fully online End of Life Doula Professional Certificate that will prepare you to meet the growing demand for end of life support as people live longer and the course of the average dying process continues to become increasingly gradual and anticipated.

Curriculum

The University of Vermont developed the online End of Life Doula Certificate curriculum to provide a comprehensive program covering the essential skills and knowledge to prepare you to embark on your new End of Life Doula role.  In association with the UVM Larner College of Medicine, we created an interactive and supportive online program that will prepare you to provide a holistic approach to your compassionate care work with your clients.

Learning Objectives

  • Understand how to best work in harmony with your client’s chosen care team, heightening a client’s feelings of empowerment and self-efficacy
  • Develop effective communication skills to have meaningful conversations with clients
  • Learn key ethical principles and patient rights
  • Understand common terminal conditions and diseases, pain management practices, the active dying process, and helpful interventions to ease pain and suffering
  • Learn how to practice Universal Safety Precautions while providing hands-on care
  • Understand the role and scope of an End of Life Doula and apply core skills to provide unconditional positive regard and non-judgmental support for your client
  • Recognize and support psychosocial development states and the stages of grief
  • Become familiar with a client’s network of organizations and professionals offering support to increase your ability to provide comfort to your client
  • Gain the skills to provide bereavement support to a client’s family and friends after death
  • Learn about meaningful activities for client visits and creating an environment of calm

Weekly Module Topics

Week 1: Introduction to End of Life Work, Hospice, and Palliative Care; Personal Death Awareness

Week 2: Introduction to the Grief Continuum; Commonalities in EOL Experiences, Dignity Therapy

Week 3: Understanding the Patient Experience; Terminal Illnesses/Diseases; Pain Assessment and Interventions, Active Dying Process; Introduction to Hands-on Care

Week 4: The Role and Scope of the End of Life Doula; Companioning and Serving; Appropriate Professional Boundaries; Holding Space and Honoring Sacred Space

Week 5: The Needs of Clients: Providing Comfort Care; Caregiving Considerations; “Turning Toward”

Week 6: Religious/Cultural Beliefs and Practices; After Death Options, Effective Referral Practices

Week 7: Preparing for Loss: Life Review, Completion Work, Legacy Projects and Grief Support

Week 8: Activities, Techniques, and Tools for Client Visits; Creating an Environment of Calm; Vigil Sitting; Personal EOL Wishes

 

 

Three and a Half Feet Under: Cemeteries Are Wary of Green Burials By Terri Hallenbeck @terrivt

It was an honor to be featured in this piece by Seven Days , Burlington Vermont’s weekly newsletter. Although the burial depth bill I wrote passed unanimously, I’m still hard at work making green burial accessible to ALL Vermonters. Public education is key. Look for a post about the non-profit I’ve founded, Green Burial Vermont, soon.

“Fred Cheyette plans to be buried in a hayfield next to his house in the town of Orange. His body will be wrapped in a simple cotton sheet and placed three and a half feet deep in the earth, with an oak sapling planted atop the grave.

“So my body feeds the tree,” said the 86-year-old retired engineer and psychotherapist, who is peppier and more youthful looking than his years suggest.

Cheyette has arranged what is known as a green, or natural, burial — rejecting the standard procedures of cemetery interments. There will be no embalming, no varnished coffin, no concrete vault, no polished headstone. He wants his body in the dirt and close to the surface.

Despite a state law that took effect this month to make it easier for Vermonters to choose a green burial, Cheyette’s arrangements are possible only because he will be buried on his own property. He received permission from his town’s Board of Health.

For others, planning a natural burial poses greater challenges: Advocates of green burials say they know of no cemeteries in Vermont that yet allow the green interments they envision.

Passing the new law — which allows burials at a mere three and a half feet, where a more active biological soil mix facilitates rapid and natural decomposition — appears to have been the easy part. Now, supporters of the practice have to persuade dozens of cemetery operators to change policies. Many Vermont cemeteries require a five-foot burial depth and that coffins be placed inside buried concrete vaults, rules that preclude the simpler burials.

But Michelle Acciavatti of Montpelier and a half dozen other green-burial advocates stand ready to convince cemetery operators to change their policies. They are forming a nonprofit organization, Green Burial Vermont, which will produce a manual of best practices.

“The goal of the nonprofit is promoting environmental and socially conscious burials in Vermont,” Acciavatti said.

The group’s efforts could change the traditional image of graveyards.

Carl Anderson of West Berkshire, a wildlife biologist who is a member of Green Burial Vermont, said he envisions existing cemeteries adding green sections, as well as new graveyards that will use proceeds from the sale of natural plots to conserve surrounding acres. The dead could share space with sugaring operations, tree farms or hayfields.

But first, the organization has to allay a host of fears: that coyotes would scavenge for shallower, unprotected bodies; that some types of soils would inhibit decomposition; and that changing the layout of a graveyard to something other than rows of mowed grass dotted with shiny headstones would pose logistical challenges.

“There are just unknowns,” said Patrick Healy, manager of Montpelier’s city cemeteries and president of the Vermont Cemetery Association. “We just want to know what the best practices are.”

“A lot of the pushback is coming from the cemetery operators,” said Acciavatti, who toured the state last fall and winter advocating for the legal change. “There are a lot of misconceptions.”

For Acciavatti, 34, dealing with death is a passion and a vocation. She runs a business called Ending Well, which offers end-of-life planning and counseling. She’s also a hospice volunteer and co-facilitates a monthly “death café” in Montpelier, where attendees sip tea and converse about mortality.

She set out to become a neuroscientist. Then two close friends died in accidents shortly after she graduated from college. A year later, she was in a close-call crash herself.

“The first thing the trooper said was, ‘You’re so lucky you didn’t die.’ That percolated inside me for a while,” Acciavatti said. Before she knew it, Acciavatti was making a business of the thing most people don’t want to talk about.

With a soothing, nonjudgmental manner, Acciavatti manages to make talking about death easy. She hopes to take such conversations out of the shadows and into living rooms and dining rooms. “I used to joke that I was constantly ruining holiday dinners,” she said. “Now I’m everybody’s death friend.”

On a beautiful Tuesday evening in June, a dozen like-minded people gathered at a Montpelier tea shop for the death café. Heavy at times, the conversation also focused on uplifting moments families share as a loved one approaches the end.

Cheyette is a regular attendee. He readily shared plans for his own burial. Having what he sees as an environmentally friendly afterlife plan is a comfort, he told the group.

He, too, wants to change the notion that death is a taboo topic. “It makes me feel alive,” he said later, of the death café discourse. “I feel really good when I leave there.”

Acciavatti said green burials pair well with her desire to open up discussion about death. “We’ve become so cut off from death,” she said. “It’s been medicalized. It’s been commercialized. It’s been taken out of the home.”

In a traditional burial, an embalmed corpse is placed in a casket, which is then lowered five feet deep into a concrete vault and covered. The body decomposes, but the lack of contact with soil slows the process, wildlife biologist Anderson said. In the meantime, water interacts with the casket’s metal, varnish and paint, which pose a risk of contaminating groundwater, he said.

Green burials are intended to bring the body into closer contact with the soil. The unembalmed corpse is buried with no casket or in an unadorned wooden coffin. There is no concrete vault. Decomposition of soft tissue typically takes place within two years, depending on soil and hydrology, though bones take longer, Anderson said.

“With a green burial, you’re trying to put the body as close to active biological layers as you can without letting scavengers get at it,” he said. Hundreds of green-burial sites around the country do that at three and a half feet, without a scourge of scavengers, he noted. Vermont requires that deceased livestock be buried under two feet of soil.

But convincing cemetery operators to change their policies will take time, said Calais cemetery commissioner Jennifer Whitman. She joined the movement after hearing Acciavatti speak and would like her town to allow natural burials.

“This is a slow process,” Whitman said. “This is going to be the next 10 years.”

Just collecting contact information for the many cemetery operators throughout the state was a challenge, she said. Now, Green Burial Vermont’s goal is to help them work through logistical concerns.

People have many definitions of what constitutes a green burial, Whitman noted. Some want to be buried in the woods with no markers; others prefer a plain pine box in a shallow grave with a natural gravestone. Each cemetery’s operators have to figure out what they can accommodate, Whitman said.

Cemetery commissions would have to change long-standing policies, such as requirements for concrete vaults. Calais has such a rule, Whitman said.

That policy exists for good reason — to keep graves and caskets from collapsing, Healy said. When workers dig graves and mow cemetery grass, they often use heavy machinery, he noted.

Healy said that practice is one of the concerns he has about reserving part of a cemetery for green burials. He is not persuaded that wild animals won’t dig up natural graves, though advocates insist the fear is unfounded. And he wonders what the protocol would be for transporting a body to a gravesite without a casket.

“Will the public be able to handle seeing bodily fluids on shrouds?” he asked.

Nevertheless, Healy has had requests for green burials, and the Montpelier Cemetery Commission is considering what to do. One option is to phase in changes. “I think our first step may be pine boxes without vaults,” he said.

The Burlington Cemetery Commission is pondering the same questions.

“I would like to do more research and see if there’s a way to make it possible,” said cochair Allison Curran.

Burlington requires vaults and a five-foot grave depth at its two active cemeteries, Lakeview and Greenmount. Last week, Acciavatti asked the city commission for an exemption for a terminally ill client who wants a green burial. Commissioner Emma Swift expressed reservations about granting exemptions before setting a green burial policy, according to minutes of the meeting. The panel plans to consult the city’s attorney.

Meetinghouse Hill Cemetery in West Brattleboro may come closest to offering a green-burial option. The graveyard has a separate section where vaults and embalming are not required, manager Andrea Mitchell said. Three bodies have been buried there.

To the chagrin of green-burial advocates, however, the cemetery is unwilling to place bodies at depths of less than five feet. “The fella that digs our graves doesn’t want it, and I don’t want it. I think it’s too shallow,” Mitchell said. Asked why, she said, “I don’t know, but I don’t want to find out.”

Meetinghouse Hill charges $1,000 for a green plot, more than the $700 for a traditional one, because maintaining gravesites that are more prone to sinking is expected to be an additional challenge, Mitchell said.

If green burials gain traction in Vermont, the trend could give cemeteries a needed boost. Business is lagging, Healy conceded, as more Vermonters opt for cremation. Cemeteries are encouraging families to bury cremated remains, he said, but many choose to scatter or keep the ashes.

According to the Vermont Department of Health, slightly more than two-thirds of Vermont’s dead were cremated in 2014. Green burial advocates say cremation generates too much greenhouse gas.

Chris Palermo, owner of Perkins-Parker Funeral Home in Waterbury and president of the Vermont Funeral Directors Association, said that when he started in the business 40 years ago, about 15 percent of his customers chose cremation. Now, he said, 80 percent do.

He’s not yet had any customers ask for a green burial, but Palermo said he supports giving families the options they seek. Most importantly, he said, people should tell their families what they want, because, too often, they don’t.

“My sense is, people are becoming more comfortable with the discussion,” he said.

Cheyette is at ease talking about such matters. His wife, Sage Blue, who died in 2004, was cremated. Cheyette spread her ashes on their property, he said.

He hasn’t shared his burial plan with his three children but said he met with a group of close friends to explain what he wants. “It’s also posted on my refrigerator,” he said, next to his advance directive and do-not-resuscitate orders.

He explained why he wants his remains to nourish an oak tree. “I don’t want my body to be wasted,” he said.”

What living with a chronic illness has taught me about being with people at the end of life

(Image from Be Stigma Free )

I don’t think I’ve written about the fact that I have a traumatic brain injury, but I do. In my first semester of grad school, getting my degree in neuroscience, I was rear-ended in while stopped in traffic by a vehicle going somewhere between 50-70mph. Living with a TBI has helped me be better about being with people at the end of life. Because my illness is invisible I realize there are many symptoms people experience that are hard to explain, interpret, and/or predict due to the changes in brain function as people approach death.

Sensory input even in the form of loving touch can be incredibly overwhelming, painful, and overstimulating. If you are working with someone who can still communicate always ask before touching them (you should be asking because you should also never touch someone without their consent, but I digress). Ask every time because it may change. Even if the person can’t communicate verbally it is important to ask and look for body signals for clues as to whether or not touch is welcome or soothing. It can be both difficult for both patient and loved ones/caregivers to not use touch, but there are other ways to make someone feel loved and safe.

Sensory input goes beyond touch as well- auditory, olfactory, and visual stimulation can also be unpleasant. Again be sure to let your patient be your guide- they will either tell you or show you the safest and gentlest ways to interact with them. Understand this and help your patient and their families understand that there is nothing to be ashamed of in accommodating their stimulation responses.

Communication is often difficult. Finding the right mode of communication- speaking, writing, non-verbal communication- is essential for being a good end of life doula. Most of all, remember that patience is a crucial part of communication. Speak slowly, clearly, and directly. Don’t rush or mumble. Don’t shout. Watch to see how what you are saying is being received. Let your patient have the time they need to answer you and make a real effort to ensure you understand what they have said. (See my post on communicating with dementia patients for other tips on communicating.) Being heard is something that makes us feel like humans with value.

Never make assumptions. Both the most obvious and easiest to forget. Things that people may have relied on in the past to bring comfort may now serve as painful reminders of things they can no longer do or are leaving behind. Something that wasn’t an issue yesterday may be a major issue today. A big part of the mantra “meet your patient where they are” is allowing your patient to teach you about where they are in each moment.

Be not just willing, but truly able to settle in and be present with your patient. This ability to be fully present and aware of your patient and their needs is what will allow you to meet them in the most supportive and loving manner for them at that time. And that makes all the difference.

 

 

Planning and Preparing: Read about me in NY Magazine!

It has been a very busy year for me so far, but I am happy to report it’s also been very productive. The burial depth bill I wrote about in my last post passed and went into effect on July 1. Green burial is now fully legal in Vermont.

As I work with more people to plan for their end of life I am continually amazed and grateful for the privilege. It was a great honor to be interviewed and featured in NY Magazine’s “The Science of Us” series as an end of life planner.  “The Professionals who want to help you plan your death”

Please read and feel free to share. I love how Amy and I have such different approaches to advance care planning. I always try to find what is the best fit for my client, (even though I am attached to my own method), so don’t be surprised if I recommend Good to Go to you!

I have a bunch of exciting announcements that it’s hard not to share them all at once, but please keep checking back to see what else I’ve been up to. There is also a website re-design to reflect all the positive changes in the works!

If you have questions or want to be in touch there is a contact form on the blog, and you can follow me on Twitter and Facebook I’d love to hear from you!