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.