A Treatise on EOLDs and Sliding Fee Scales
Dear End Of LifeDoula Tribe:
There have been a number of recent threads in our social media communities discussing what people charge, the nuance of sliding fee scales, and advice offered about approaching Hospice organizations with proposals for hiring doulas. I have been contemplating. What follows is not a one size fits all solution, just more food for thought.
Working on a sliding fee scale is not for every one, but it is certainly worth experimenting with. I have been working this way for decades, in EOL and other service work. In my experience, working on a sliding fee scale is an ethical decision, not a business decision. Offering clients a sliding fee scale requires that you stand centered in your commitment to provide the same level of care regardless of what people can pay. For me, this is a commitment to social justice and care-equity in a society that systemically punishes poor and working class people.
If you are considering a sliding fee scale, my best advice is to set your low end where you think it is genuinely affordable to your less wealthy clients and fair to you, so that you will not feel cheated by your own guidelines. Choices you make about your affordability and personal practice ethics regarding fees are going to influence your client profile and should be made conscientiously. Who do you want to work with?
Keep in mind that if your bottom rate is set where you'd be embarrassed when a group of people pass a hat to pay you, then your bottom may be too high. I am not sure your accountant is going to love you having a 'pass-the-hat' category in your business plan, so be prepared to justify this. Of course not every one's sliding scale will have this flexibility, but I speak from experience when I suggest you have an idea that hats will be passed, because this has actually happened to me.
Set the top of your sliding scale where it seems 'normal' to people with wealth, and do not expect to get paid this rate often. It is ok for the top to feel like a stretch. In my Celebrant practice consults, I quote clients an all-inclusive (rather than hourly) sliding fee scale, and then I add that “we can always make other arrangements if needed.” Sometimes this means barter, some times I work pro bono. I have never felt cheated by clients in these transactions and I have also on rare occasions been paid well above my top rate.
Is there a business plan that will make sense of work that ebbs and flows depending on who is dying, and for services that are billed on a sliding fee scale? A plan for a business that doesn't provide a reliable pay check and is arguably not supposed to? It took years to refine my own feelings about working this way and to come up with language about it that is honest and relatable to people. And to be abundantly clear, I have the privilege of a supportive spouse with more earning power than me. We are not wealthy but this gives me some leeway.
It is important to understand how rarely people are asked to make sliding fee decisions, or to give careful thought to how they value someone else's work. These value questions are sensitive especially when you are offering a service that has as much nuance as the EOL field. Are you asking people to pay more per hour than they make per hour themselves? It is so important that you communicate the range of your sliding fee scale in language that is generous and free of judgement. For me, it has taken maturity and lots of practice in the mirror to offer something as delicate as death care with any kind of fee attached.
This week I was visiting the first of my clients who has transitioned to residential hospice care during our relationship. The client paid me hourly for help with advance directives and other planning and then they became a pro bono client as I followed them first to the hospital after a bad fall and cognitive decline, and then to a skilled nursing facility. Their entire family is out of state. When the family was informed by a friend of their loved one that I continued visiting they chose to keep me on for continuity of care and began paying me again, near the middle of my scale, for two hours a week. I was able to assist the client's move to residential hospice after being asked, literally, to 'bust me out' of the nursing home. My visits average about three hours a week, effectively lowering my hourly rate but this is the level of need.
I had a conversation with a CNA at the residential hospice who has seven years of direct hospice experience as well as EOLD certification. They eventually intend to take on doula side gigs, if they can figure out how to charge for it. Sound familiar? Then I was thinking about the number of people already working in hospice who were in my UVM Doula cohort, and all the other doula cohorts too. Honestly, I have mixed feelings when I read the threads about approaching a local Hospice to pitch paid doula services.
Why are we, newly minted EOLDs, assuming we have something special and different to offer Hospice? Is it because this work is new and different to us? What kinds of expectations do we EOLDs have when trying to negotiate for paid work in hospice when there are already EOLDs on staff in other paid roles? Does the hospice care model already use volunteers to provide many of these un-billable services which are in the doula wheelhouse? I appreciate the enthusiasm I see to professionalize and segue into established care and billing models, yet it seems like some cautious humility is warranted here.
Every one deserves to be paid a living wage. But in some very real ways we are talking about a dying wage, and for work that is hard to put a price on. If you are planning to work on a sliding fee scale, you are making an ethical decision with business repercussions, prioritizing the connection of your services with your ethical values above your hoped-for income potential. In a culture that commodifies and commercializes everything, this means you are choosing an alternative paradigm that will sometimes be considered radical. Welcome to my world, Doula friends!
If you are considering work on a sliding fee scale then you may notice that I have left out the critical number advice in this treatise. I chose not to directly discuss here the dollar range I charge. The reason for this omission is that I think each of us has to come up with our own numbers. You have to factor in who you want to work with, what you offer, and how you make those offerings available. You have to factor in travel time and gas, advertising and meals on the road. Then stir in what people in your location are accustomed to paying. You have to know how much you are willing to give away, and to whom. You have to come to agreement with yourself about what is fair so that when you quote your scale to a potential client you are one hundred percent certain that it is offered in good faith. Coming up with the right sliding fee scale should cause you to pass through some uncomfortable interior terrain, but when your numbers are right you will be able to offer, with confidence, a range that meets your clients needs.
A year or so ago I asked 'Die Wise' author Stephen Jenkinson what he thought about the sudden intense grooviness and interest in end-of-life education and memento mori juju. He replied with some amusement, “Once the hullabaloo around the Death Biz blows over, those of us actually doing the work will still be here, doing the work.” There has been some deep thinking and writing recently in the end-of-life doula world about money and 'death positive' practice models. I hope that as we all find ways to do the work, whether or not we are trying to make a living with it, that we will remember that life is not a commodity. Neither is dying. And service offered from the Doula heart is priceless.
For more food for thought, here are links to the work of colleagues who have taken time to write on related topics and whose insight and integrity I respect, Danna Schmidt and Julie Keon.
The Angel of Death and the Sculptor, Daniel Chester French:
The memorial represents the moment when the Angel of Death interrupts the sculptor’s work, staying the chisel in his left hand. She also holds a bunch of poppies, symbolizing eternal sleep. The poetic content of the sculpture, as well as French’s successful integration of real and ideal elements, makes the memorial a profound statement on the creation of art and the cessation of life.
Milmore Memorial 1889–93, carved 1921–26 The Milmore Memorial was a funerary commission from the family of the Boston sculptor Martin Milmore (1844–1883) to honor his memory and that of his brother, Joseph (1841–1886). The original bronze was erected in Forest Hills Cemetery, Jamaica Plain, Massachusetts, in 1893; this marble version was commissioned by the Metropolitan.