SARASOTA MEMORIAL HOSPITAL POLICY

SARASOTA MEMORIAL HOSPITAL POLICY TITLE PATIENT EXPIRATION, INCLUDING FETAL DEATH, PRONOUNCING OF PATIENT, AUTOPSY REQUESTS, POST- MORTEM CARE & MEDICAL EXAMINER CASES EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 4/81 02/20/18 Clinical 1 of 15 Non-Clinical Job Title of Responsible Owner: Medical Director of Laboratory Services PURPOSE: POLICY STATEMENT: EXCEPTIONS: To establish policy and procedures to be followed in the event of death. 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. 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 of 15 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.

3 of 15 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 DO NOT NOTIFY FAMILY MEMBERS 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.

4 of 15 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 Services safe. 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.

5 of 15 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

6 of 15 is completed. 5. The Expiration Report will be completed by the RN, including type of isolation or precautions, NOT DIAGNOSIS. DELIVERY TO THE MORGUE 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

7 of 15 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. RELEASE OF BODY TO FUNERAL HOME AFTER MORGUE 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: a. Upon arrival, the Transport representative will provide the name of the deceased person being picked up. b. Morgue staff member will provide the exit paperwork for the deceased to the transport representative so the representative can match the transport company s documentation with SMHCS documentation. c. While the transport representative is reviewing the exit paperwork, the morgue staff member locates the deceased inside the cooler by the body bag tag identifier. d. At no time will the transport company representative be allowed into the cooler unless a morgue staff member is present and remains with the transport representative until the body is removed from the cooler. e. Once located, the morgue staff member lowers the deceased utilizing a body lift, and will keep the body on the lift for further identification. f. The deceased is then identified by the morgue staff member and the transport representative by matching the body bag tag, the toe tag, and picture identification on file taken at the time the body was initially delivered to the morgue. The body bag will be fully opened and directly visualized. The general appearance of the body including age, race, gender and manner of death will be verified by morgue staff for consistency with the individual to be released. g. Once the deceased s identification is confirmed, a

8 of 15 review is done to check for any personal valuables which may have been delivered with the deceased. h. Transport representative puts company s tag on the deceased ankle with name of the deceased. i. Deceased is then transferred from the lift to the transport company s cart. j. All exit/release forms are completed after the body is placed on the transport company s cart. Signature of the transport representative must be obtained on the Expiration Release Form (1553-7). k. The Body Identity Verification Form is completed by the transporter and the morgue staff member that performed the verification. FETAL DEATHS o KEY POINT All inconsistencies in the identification process must be resolved before the body is released from the morgue. 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

9 of 15 regarding the gestational age of the fetus. 5. Nursing personnel will document the crown-to-heel length, sex and weight of fetus. 6. If the gestational age in Procedure #4 and the nursing 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 adultsized 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 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;

10 of 15 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; i. criminal abortion; 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

11 of 15 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. 2) copies of the chart will be made for the ME to 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): REVIEWING AUTHOR (S): ATTACHMENTS: Peter Lindemann, Pearson Clack, M.D., Washington Hill, M.D. Thomas Reed, M.D., Medical Director Protocol for Adult Expiration Flowchart Protocol for Fetal Death or Termination <20 Weeks EGA Flowchart Protocol for Fetal Death >20 Weeks EGA Flowchart

12 of 15 Protocal for Adult Expiration 2003 Patient expires Physician or 2 RNs must pronounce RN notifies Physician - discusses autopsy and begin Expiration Report documentation Referred to Medical Examiner per criteria Autopsy desired for medical reasons per physician Autopsy not necessary per physician Family notified of death. Explained that death has been referred Medical Examiner. Medical Examiner's office will decide if autopsy is necessary. Family notified of death. Explain physician feels autopsy is necessary. Receives consent. If family refuses autopsy will not be performed. Family notified of death Continue Expiration Report documentation including disposition of the body Family request for Autopsy. Reason for Autopsy by Family. Notify Lifelink/Lions Eye Bank per Policy 1-800-64-DONOR Notify Nursing Admin personel Valuables to safe or released to family Nursing inventory for valuables and personal effects Complete Expiration Report Prepare body and send to Morgue

13 of 15 Protocal for Fetal Death or Termination <20 Weeks EGA If Dates Uncertain: Fetal Weight <500 GMS; Fetal Length <25 cm NO Signs of Life (Heart Rate, Pulsation of Cord, Respiratory Effort, Grimace, or Discrete Movement) YES Family wishes hospital disposition of remains Family wishes to arrange funeral, memorial service or cremation Physician Order Sheet Final Diagnosis Sheet Front Sheet (blue) Nurses Notes Footprint Sheet Birth Certificate Form Tissue Protocol Form#027017 Tissue Requisition Morgue Identification Card If baby expires, regardless of EGA, proceed same as "Fetal Death (stillbirth)" EXCEPT Fetal Death W orksheet Laboratory Log Book W rap body, attach "toe tag" to body. Attach "toe tag" to outside of wrap Expiration Report Family wishes "Memories To Hold" NO YES Notify Extension 2468 Photos Complete Purple Bereavement Packet Notify MTH Extension 2468 "Memories To Hold" checklist with updated fact sheet to Tube #46

14 of 15 Protocal for Fetal Death > 20 Weeks EGA If Dates Uncertain: Fetal Weight>500 GMS; Fetal Length>25 cm Family must make arrangements for Burial or Cremation with a licensed funeral home or crematorium NO Signs of Life (Heart Rate, Respiratory Effort, Grimace, or Discrete Movement) YES Fetal Death Worksheet Physician Order Sheet Final Diagnosis Sheet Front Sheet (blue) Nurses Notes Footprint Sheet Birth Certificate Form Expiration Report ID ankle bracelet Inquiry for Organ Donation Consent for Disposition of Body Consent for Next-of-Kin for removal or organ/tissue NO Family wishes "Memories To Hold" YES Notify Extension 2468 ID Baby "toe tag" outside wraps All forms to Morgue are white, EXCEPT fetal death worksheet, which is yellow Notify MTH Extension 2468 Photos (Identify Infant) Purple Bereavement Packet To Morgue Morgue Dispostion Form Fetal Death W orksheet or Expiration Report Consent for Dispostion/Autopsy Updated facesheet (mom) Organ/Tissue Donation Sheet "Memories To Hold" checklist with updated fact sheet to Tube #46

15 of 15 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: N/A Date Medical Director, POC Medical Director, North Port Laboratory Services Medical Director, SMH Laboratory Services Director/Responsible Owner: Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Medical Executive Committee: (if clinical and review requested by CMO and COS) Dr. Jason Tedesco, M.D. 1/17/18 Dr. Jeffrey Zacks, M.D. 1/16/18 Dr. Thomas Reed, M.D. 1/22/18 Harold Vore 1/9/18 Lorrie Liang 1/23/18 Dr. James Fiorica, M.D. 2/6/18 N/A N/A Chief Executive Officer: David Verinder, CEO 2/12/18