TITLE PATIENT EXPIRATION, INCLUDING FETAL DEATH, PRONOUNCING OF PATIENT, AUTOPSY REQUESTS, POST-MORTEM CARE & MEDICAL EXAMINER CASES POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: PAGE: 01.PAT.16 4/81 02/26/15 Clinical Non-Clinical 1 of 14
Job Title of Responsible Owner: Medical Director of Laboratory Services
PURPOSE: To establish policy and procedures to be followed in the event of death.
POLICY STATEMENT:
It is the policy of Sarasota Memorial Health Care System (SMHCS) to maintain the individual’s dignity after death, to provide appropriate documentation of death and to prepare the body for expedient release to the funeral home.
EXCEPTIONS: Florida Statute 872.04 "Autopsies, consent required, exception, unless otherwise authorized by statute, no autopsy shall be performed without the written consent by the health-care surrogate, as provided in Florida Statute 765.202, if one has been designated. If a health care surrogate has not been designated, then written consent may be provided by the spouse, nearest relative or, if no such next of kin can be found, the person who has assumed custody of the body for purposes of burial. When two or more persons assume custody of the body for such purposes, then the consent of any one of them shall be sufficient to authorize the autopsy."
Refer to Exceptions Florida Statute 872.04. Sarasota Memorial Home Health.
PROCEDURE: PATIENT EXPIRATION AND PRONOUNCEMENT
1. When a patient has expired, the registered nurse (RN) will
notify the attending physician immediately.
2. When the attending physician is not on call:
a. a message will be left with the answering service.
b. the physician taking his/her calls will be notified immediately.
c. if the attending physician or on-call physician cannot be contacted, the SMHCS medical officer on-call will be notified.
3. When a patient expires, the physician in charge, or his/her
on-call physician, or two (2) RNs, must pronounce the patient dead.
4. The attending physician must make an entry in the chart
within 24 hours after death. In this situation, two (2) RNs will pronounce the patient and co-sign a statement of pronouncement in the nurse's notes and sign the expiration report (Form 023161).
5. The person(s) pronouncing death are responsible for
charting the absence of vital signs and the time of expiration along with any other pertinent facts.
6. Nursing personnel will notify Nursing Administration staff
on duty of the patient’s death and any other pertinent information.
7. If a family member is present, nursing personnel should
have the responsible family member sign the Consent for Disposition of Body of Deceased (Form 023161). This must be signed by the ranking family member in
accordance with the Rules of Descent as listed on (Form 023161). If, after notification, a family member is not present, MORGUE PERSONNEL WILL BE
RESPONSIBLE FOR OBTAINING SIGNATURES. IN ALL CASES. MORGUE PERSONNEL WILL CONTACT THE FUNERAL HOME TO REMOVE THE BODY. BODIES WILL ONLY BE RELEASED TO LICENSED FUNERAL HOMES AND/OR CREMATORIES, LIFELINK (Tissue donors) Refer to Organ Donor Policy 01.PAT.14
“ORGAN AND TISSUE DONOR PROCEDURE ) for those instances where the deceased is an organ donor for the correct procedure and consent forms to be completed.
8. The Consent for Disposition of Body of Deceased (Form
023161) will be sent to the Morgue to become a part of the patient’s medical record when the body is released. A copy will remain in the Morgue office for three (3) years.
NOTIFICATION OF FAMILY
1. The family will be notified of the patient’s expiration by the attending or the covering physician.
2. When the attending physician is not on call:
a. A message will be left with the answering service.
b. The covering physician will be notified. This
physician will be responsible for notifying the family. c. If the covering physician is not familiar with the
expired patient or family, or, in extenuating circumstances, does not wish to notify the family personally, he/she may request that nursing personnel be responsible for notification.
d. If the family is unable to be contacted, complete notification section on Expiration Report (p. 1 of 4) as to reason why no contact was made per attempts at notification.
e. It is the continued responsibility of the physician or nursing staff to contact the family of a deceased patient. MORGUE STAFF DOES NOT NOTIFY
FAMILIES OF EXPIRATIONS.
PERSONAL EFFECTS AND VALUABLES
1. It is the responsibility of the RN caring for the patient to ensure personal effects and valuables are inventoried and recorded on Expiration Report (Form 023161).
2. Dentures will be replaced if possible; if not, they must be put into a denture cup and placed with other personal effects.
3. Valuables include jewelry, watch, money, credit cards,
keys, etc.
a. All jewelry will be removed. If rings cannot be removed, please note on Expiration Report any jewelry that remains with the body.
b. Nursing unit may release valuables to next of kin
giving consent for the disposition of the body.
Release of valuables is to be documented in nurse’s notes. Signature of next of kin is to be obtained on Expiration Report (Form 023161).
c. Valuables will be deposited in the Patient Financial
d. Once valuables are deposited in the Patient Financial Services safe, Corporate Policy 00.FIN.02,
“Receiving and Releasing Patient Valuables,” regarding release of patient valuables must be followed.
4. Personal effects may be released to the family by nursing.
This information will be documented and a family member will sign the Expiration Report (Form 023161), Personal Effects Section.
a. If personal effects are not released to a family member, they will be taken to the Morgue. Effects must be put in a bag and identified with a tag listing the deceased's name and hospital ID number. The Expiration Report is to be sent to the Morgue along with the bag of effects. Morgue or Security
personnel will verify items with the checklist.
b. Personal effects will be released to authorized
individuals or the funeral home. Person receiving personal effects will sign the Expiration Report. SIGNING AUTOPSY PERMIT
1. The attending physician is responsible for making the
request for an autopsy. He/she may delegate the signing and witnessing of the consent to nursing personnel.
a. Family Request - Nursing needs to ask physician
"reason for autopsy"
b. ECC - Nursing needs to ask physician "reason for autopsy"
2. Permits MAY NOT be signed prior to the death of a
patient.
3. A Power of Attorney granted by a patient to another,
ceases with the death of the patient.
4. Divorce terminates a legal relationship, leaving the
divorced party no authority to sign the Autopsy Permit and Consent for Disposition of Body of Deceased.
5. If the nearest next of kin is not available and will not be able to sign the release for autopsy, the pathologist will accept a telephone consent from the ranking family member according to Rules of Descent as listed in Form
023161, and witnessed by a two (2) nurses. The
telephone consent MUST be followed by a letter, FAX, or telegram with wording identical to that in the Hospital Autopsy Permit. Telephone consent requires two
witnesses. Refer to SMHCS Policy 00.RSK.14, "Informed Consent for Surgery and Other Special Procedures." POST-MORTEM CARE
1. In deaths where there is to be an autopsy by either
hospital or medical examiner (ME), the tubes and dressing should remain on the body and will be removed by the pathologist after the appropriate examination. For all other deaths, the body must be cleansed as needed, including the removal of all tubes and unnecessary dressings. In instances of suspected poisoning or drug overdose, it is essential that samples of blood, urine and gastric lavage, obtained at or about the time of admission to the hospital, be retained for appropriate chemical testing.
2. The wrist identification bracelet is to be checked for proper name and numbers ensuring that all information is
accurate.
3. The patient gown and excess linen will be removed.
a. Body or cadaver bags can be ordered from Central
Service via the PeopleSoft ordering system.
b. Body or cadaver bags will be used on all expirations.
c. The RN and transporter must verify ankle/wrist
identification (ID) bands with outside label for proper ID prior to closure of body/cadaver bag. Verification of proper ID will be documented on the Expiration Report (Form 023161).
4. The RN will be notified by the staff when post-mortem care
is completed.
5. The Expiration Report will be completed by the RN,
including type of isolation or precautions, NOT DIAGNOSIS.
1. Transport
a. Transport will be called to get recessed stretcher from the transport area. Morgue staff will be responsible for Morgue entry and exit between the hours of 0730 to 1800, seven (7) days a week. Remaining hours are to be handled by the Security department and nursing supervisor.
2. The completed paperwork will be taken with the body to
the Morgue by the transporter. Completed paperwork will include:
a. Expiration Report (Page 1)
b. Consent for Disposition of Body and Autopsy
Consent (Page 2)
3. The body will be transferred to a morgue stretcher. At
least two (2) employees will be used for each body transfer.
4. Two (2) employees will assist to lift each body into the rack, in the cooler, inserting headfirst.
5. A Morgue Disposition Form located in the Morgue area will
be completed. A second hospital employee must sign the Disposition Form, verifying the accuracy of label located on the foot of the body or cadaver bag.
6. Bodies brought to the Morgue refrigerator from the
Emergency Care Center (ECC) must be identified with wrist/ankle ID bracelets stating the patient’s name and ECC number.
7. Bodies brought to the Morgue from other institutions or by
the Medical Examiner Body Transport, must be properly labeled before being placed in the Morgue cooler or freezer. The outside of the body bag is labeled and the bag remains sealed until the ME arrives.
HOURS
1. From 0730-1800 - Morgue staff will be responsible for
release of the body to a funeral home.
2. Nursing Administration and Security will be responsible for
the release of bodies when Morgue staff is not on duty (1800 – 0730, 7 days a week).
3. To release the body to a funeral home, hospital staff must
obtain the signature of the representative from the funeral home and sign the Expiration Release Form (1553-7). FETAL DEATHS
1. If the fetus dies in utero and is less than twenty (20) weeks gestational age and no autopsy is done, the body is
handled as a tissue specimen. Upon special request, a tissue specimen may be returned to the Morgue from the Tissue Lab for funeral home pickup.
a. Death in utero is evidenced at delivery by lack of respiration, heartbeat, voluntary movement or pulse of the umbilical cord.
b. A 500 gm fetal weight or a 25 cm crown to heel body
length is considered equivalent to a twenty (20) week gestation.
2. Even if the fetus dies in utero and is less than twenty (20) weeks gestational age, an autopsy may be requested per autopsy permit protocol. The person signing the autopsy permit specifies how the body is to be handled after the autopsy, i.e., as a tissue specimen with disposition by the hospital, or as a burial or cremation by a funeral home. 3. If the fetus is born alive or if it is more than twenty (20)
weeks gestational age, the procedure for adults must be followed Florida Statute 382.071.
4. The attending physician must make an entry in the chart
regarding the gestational age of the fetus.
5. Nursing personnel will document the crown-to-heel length,
sex and weight of fetus.
documentation in Procedure #5 are not in agreement, the differences must be resolved by the attending physician and nursing if no autopsy is requested; by the attending physician and the pathologist if an autopsy is requested. If unresolved, the chief of staff must be notified and has the final authority.
7. The fetus will be cleansed, wrapped, identified and tagged
according to established procedure for adults.
8. If the fetus is twenty (20) weeks gestational age (or if autopsy is requested on fetus less than twenty (20) weeks gestational age), the fetus will be transported to the
Morgue and placed on a designated shelf in the Morgue refrigerator. A fetus will NEVER be placed on an adult-sized stretcher or morgue tray.
9. Completed paperwork is to include:
a. Expiration Report
b. Consent for Disposition of Body of Deceased
c. Consent for Autopsy (if requested)
10. Fetal Death Worksheet (if necessary) will be sent to the Morgue with the body.
MEDICAL EXAMINER CASES
1. The Florida Medical Examiner requires that deaths
occurring under the following circumstances be investigated by the ME:
a. Criminal violence of any type;
b. Accidental deaths of any type, deaths resulting from
medical complications following an accident; and delayed death, whose proximate cause if listed must be reported, even if the time of the actual death is months or years following the event which initiated the fatal sequence;
c. Suicides;
d. Suddenly, while in apparent good health;
e. Unattended by a practicing physician or other
recognized practitioner; f. in prison or penal institution;
g. in police custody;
h. suspicious or unusual circumstances;
j. poisons;
k. by disease, injury or toxic agent resulting from employment;
l. when a body is brought into the state without proper
medical certification; or
m. by disease, constituting a threat to public health.
2. The patient’s attending physician, or designee, is
responsible for notifying the ME in any of the above
circumstances. In addition, the RN assigned to the patient at the time of patient’s expiration will review the chart to ascertain if the death requires reporting to the ME.
3. If death has occurred under the previously mentioned
circumstances, or as a result of these circumstances, the RN will verify with the attending physician that the ME has been notified. If the ME has not been notified, the RN will place a call to the ME at 941-361-6909. This information will be documented on the Expiration Report and in the nurses’ notes.
4. Deaths in the ECC and EMS-transported Dead on Arrivals
(DOAs).
a. The ECC staff is responsible for completing the
following forms:
1) Expiration Report (Form 023161)
2) Consent for Disposition of Body of the
Deceased (Form 023161)
3) Morgue Disposition Form
b. All deaths from violence, unnatural, unexpected or
unexplained causes must be reported to the
appropriate law enforcement agency and the ME’s office.
c. The law enforcement personnel will conduct a
preliminary investigation, discuss the case with the ME and notify the ECC if the body is to be held for the ME. The name of the physician who has agreed to sign the death certificate will be noted on the Expiration Report.
d. If the private physician refuses to sign the death certificate, the ME’s office must be contacted. e. If the patient is a ME case:
1) all tubes, IVs dressings, etc. must remain
intact and will be removed by the pathologist.
include the EMS run report and ECC chart. 3) the original police report will be sent to the
Morgue.
f. If the patient’s death does not require investigation by the ME, the Expiration Report will reflect this information.
RESPONSIBILITY: It is the responsibility of the department directors of involved services to see that personnel are aware of, and adhere to, this policy and stated procedures.
REFERENCE(S): District Twelve Medical Examiner’s office (2003)
"Information from the District Twelve Medical Examiner’s Office"
Sarasota, Florida Manual Florida Statute 872.04 Florida Statute 765.202
AUTHOR(S): Peter Lindemann, Pearson Clack, M.D., Washington Hill, M.D.
ATTACHMENTS: Protocol for Adult Expiration Flowchart
Protocol for Fetal Death or Termination <20 Weeks EGA Flowchart
Physician or 2 RNs must pronounce
RN notifies Physician - discusses autopsy and begin Expiration Report
documentation
Autopsy desired for medical reasons per physician
Family notified of death. Explain physician feels autopsy is necessary. Receives consent. If family
refuses autopsy will not be performed.
Continue Expiration Report documentation including
disposition of the body Referred to Medical Examiner
per criteria
Family notified of death. Explained that death has been referred
Medical Examiner. Medical Examiner's office will decide if
autopsy is necessary.
Autopsy not necessary per physician
Family notified of death
Family request for Autopsy. Reason for Autopsy by
Family.
Notify Lifelink/Lions Eye Bank per Policy 1-800-64-DO NO R
Notify Nursing Admin personel
Nursing inventory for valuables and personal
effects Valuables to safe or
released to family
Complete Expiration Report
Prepare body and send to Morgue
Protocal for Adult Expiration 2003
Protocal for Fetal Death or T ermination <20 W eeks EG A If Dates Uncertain: Fetal W eight <500 G M S; Fetal Length <25 cm
Signs of Life (Heart Rate, Pulsation
of Cord, Respiratory Effort, G rimace, or Discrete Movement) Family wishes hospital disposition of remains Family wishes to arrange funeral, memorial service or cremation Tissue Protocol Form#027017 T issue Requisition Morgue Identification Card Laboratory Log Book
W rap body, attach "toe tag" to body. Attach "toe tag" to
outside of wrap
Physician O rder Sheet Final Diagnosis Sheet Front Sheet (blue) Nurses Notes Footprint Sheet Birth Certificate Form
If baby expires, regardless of EG A, proceed same as "Fetal Death (stillbirth)" EXCEPT
Fetal Death W orksheet
Expiration Report
Family wishes "M emories To Hold"
Notify Extension 2468
Photos
Complete Purple Bereavement Packet
Notify MT H Extension 2468
NO YES
YES NO
"Memories To Hold" checklist with updated fact sheet to T ube #46
Protocal for Fetal Death > 20 W eeks EG A
If Dates Uncertain: Fetal W eight>500 G M S; Fetal Length>25 cm
Family must make arrangements for Burial or Cremation with a licensed funeral home or crematorium
Signs of Life (Heart Rate, Respiratory
Effort, G rimace, or Discrete
Movement)
Fetal Death W orksheet
Physician O rder Sheet Final Diagnosis Sheet Front Sheet (blue) Nurses Notes Footprint Sheet Birth Certificate Form Expiration Report
ID ankle bracelet Inquiry for O rgan Donation Consent for Disposition of Body
Consent for Next-of-Kin for removal or organ/tissue
Family wishes "M emories T o Hold"
Notify Extension 2468
Notify MT H Extension 2468 Photos (Identify Infant) Purple Bereavement Packet
NO YES
YES NO
ID Baby "toe tag" outside wraps
All forms to M orgue are white, EXCEPT fetal death worksheet, which is yellow
T o M orgue
Morgue Dispostion Form
Fetal Death W orksheet or Expiration Report Consent for Dispostion/Autopsy
Updated facesheet (mom) O rgan/T issue Donation Sheet
"Memories T o Hold" checklist with updated fact sheet to T ube #46
APPROVALS:
Signatures indicate approval of the new or reviewed/revised policy. Date Committees/Sections/Departments:
Medical Director, Laboratory Services
Thomas J. Reed, M.D. 2/2/15
Administrative Director, Laboratory Services:
Charlene H. Harris 2/3/15
Vice President/Executive Director:
Chief of Medical Operations: (if clinical or appropriate)
R. Stephen Taylor, M.D. 2/6/15
Chief of Staff:
(if clinical or appropriate)
Medical Executive Committee: (if clinical and review requested by CMO AND COS)
Chief Executive Officer/ President:
David Verinder 2/7/15
