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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Misc

Postmortem Care (Adult and Pediatric) (8.14)

Postmortem Care (Adult and Pediatric) (8.14) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Misc

8.14

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
April 28, 2017


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 8.14AP

Original
Revision

Page
1
of 6

Title: Postmortem Care (Adult & Pediatric)

I. PURPOSE

To provide guidance in the care of the body after death in a manner that maintains
dignity and ensures safe transfer of the body and belongings from the unit/care area.

II. POLICY

A. If a death occurs in an off-site clinic, it falls under Coroner jurisdiction. Clinic
staff should notify the Coroner and complete the paperwork provided by the
Coroner.
B. The physician is responsible for signing the Death Certificate. NOTE: Although
the physician is responsible for signing the death certificate, authorization for post
mortem examination (if applicable) and organ and tissue donation forms (if
applicable), he or she does not have to sign the other worksheets in the death
packet.

III. EQUIPMENT

A. Body bag
B. Patient gown
C. Underpad
D. Adhesive and/or adhesive solvent, if indicated
E. Dressings as needed
F. Transport cart
G. Paper forms for the patient’s clinical record

IV. FORMS USED

A. Postmortem Forms Packet for Inpatients: Call Nursing Coordinator for
postmortem paperwork.
1. Transfer of Human Remains to UWHC Morgue Form (301592-DT)
2. Notice of Removal of a Human Corpse from an Institution (DOH-5043)
3. Authorization For Postmortem Examination (Autopsy) (UWH #106)
4. UW Anatomical Gift Form (UWH #9013) (Request for Organ and Tissue
Donation)
5. Accounting of Disclosures (UWH #4004924)
6. Checklist for Postmortem Care
B. Radioactivity Tag, UWH #395, if indicated
C. Patient Valuables Form, UWH #220, if applicable

Page 2 of 6


V. PROCEDURE FOR UNIVERSITY HOSPITAL (UH) AND THE AMERICAN
FAMILY CHILDREN’S HOSPITAL (AFCH)

A. Record the patient's signs and symptoms observed prior to death. Be sure to note
specific time of events as they occur.
B. Notify appropriate physician. After 1700 hours on weekdays, and 1200 hours on
Saturdays, Sundays, and holidays, notify house officer on call.
1. Physician pronounces patient's death, determines time of death and enters
information on the clinical record.
2. UW Organ and Tissue Donation (UW OTD) is notified of all deaths and
imminent deaths according to UWHC Administrative Policy 4.31, Organ
& Tissue Donation.
3. Physician notifies the family and a UW Health designated requestor or
UW OTD coordinator and requests permission for autopsy/organ(s) and
tissue donation when needed if eligible for donation. Anatomical Gift
form is completed (UWH #9013) if indicated.
4. Staff offer family the opportunity to view the body on the unit.
5. Staff obtain the name of funeral home from the family and writes the
funeral home name on the Authorization form, UWH #106.
6. Physician or the Nursing Coordinator determines whether death is a
coroner's case.
C. Unit staff must notify the Nursing Coordinator (pager 7576), and other
departments as indicated, e.g. Admissions, Blood Bank. NOTE: Nursing
Coordinator must review paperwork before body is taken to the morgue. All
deceased bodies will be taken to the morgue. Consult Nursing Coordinator
regarding any exceptions.
1. Nursing Coordinator will notify the funeral home if the family has chosen
one. The following information will be given:
a. Name, age, and time of death of patient
b. Name of next of kin/guardian
c. Whether this is a coroner's case
d. If there is an autopsy
e. If an autopsy decision is pending
f. If there is consent for an anatomical gift donation
2. It is required by law that family be approached about an anatomical gift
for all deaths unless the person has previously provided first-person
consent or the person has been ruled out as a candidate for donation of
organs or tissue by the UW OTD. Screening for suitability to donate can
be done by calling the UW OTD at 866-894-2676 before impending death
or after death. See UWHC Administrative Policy 4.31 Organ & Tissue
Donation for details on anatomical gifts.
3. In instances of death of a patient admitted to the Veterans Administration
Hospital (VAH) who is undergoing temporary treatment at UW Health,
postmortem care is handled as a VAH death and administrative workload
associated will be responsibility of VAH. If VAH personnel have not
accompanied the patient, UW Health personnel (nurse, technologist, etc.)
will contact the VAH nurse to give notification of patient’s death.

Page 3 of 6

D. The nursing staff completes the postmortem paperwork packet. The physician is
responsible for signing the Death Certificate. NOTE: Although the physician is
responsible for signing the death certificate authorization for postmortem
examination (if applicable) and organ and tissue donation (if applicable) forms, he
or she does not have to sign the other worksheets in the death packet.
1. Transfer of Human Remains Form: The registered nurse (RN) completes
all upper sections of this form. The lower Receipt of Body at Morgue
section is completed upon arrival to the morgue by the UW Health
employee transporting the body to the morgue and the certificate of
removal portion is completed by funeral director when the body is
removed from the morgue.
2. Notice of Removal of a Human Corpse from an Institution: RN completes
items 1-31.
3. Authorization for Postmortem Exam: The RN may complete this form.
The physician must discuss postmortem exam with the family (when
applicable) and complete the “To be filled in by the requesting physician”
section on the bottom of the form.
4. Accounting of Disclosures form: Complete section II Nursing/Physicians,
III, IV, V, and VI. The RN or Nursing Coordinator prepares this form
depending on which disclosures are made (i.e., Coroner, funeral home,
etc.).
5. Checklist for Post Mortem Care: RN completes it and the Nursing
Coordinator reviews it for completeness and accuracy.
E. When patient’s death is a coroner's case, the Nursing Coordinator contacts the
coroner's office. Refer to UW Health Clinical Policy 3.3.9, Death Reports to the
Coroner. Give information and indications for possible coroner's case to the
coroner.
F. For patients with radioisotopes, follow instructions of Health Physicist if the
patient has expired within two weeks of the administration of a radioisotope.
After physician completes the information on the Radioactivity tag, UWH #395,
the tag is tied to patient's ankle.
1. Physician in attendance at time of death is to contact the Radiation Safety
Officer immediately at 890-2039. If not available, contact the Hospital
telephone operator and ask for radiation safety emergency assistance.
2. All patients who have received more than one millicurie of radioactive
isotope have a Patient Radioactivity Report, UWH #394, attached to their
chart.
3. The applicable portion of the Radioactivity Tag, UWH #395, must be
completed by the physician in attendance at time of death.
4. Indicate YES on the Transfer of Human Remains to UWHC Morgue form.
G. When preparing the body, observe standard precautions and any transmission
based precautions indicated.
H. If an autopsy is to be done, leave all tubes, catheters and invasive devices in
place. Cap or clamp all tubes and drains. NOTE: In an actual or suspected
coroner's case, do not cleanse the body or remove anything from the body that
might remove needed evidence.
I. If there will be no autopsy:
1. Remove and replace soiled dressings.
2. Remove urinary catheters.

Page 4 of 6

3. Remove peripheral lines and tubes.
4. Leave in place chest tubes (clamped), and ostomy bags.
5. All central lines should be capped and left in place.
6. ICP transducers are left in place.
7. Clamp IVs, coil NG and other tubes, and tape down.
a. Any plastic tubes with wires should be covered with tape. It is very
important to remove sharps (needles, scalpel blades, etc.) from the
body or sheets surrounding the body to avoid injury to personnel.
b. If tubes, catheters or invasive devices left on or in the body are to be
returned to the hospital or family, attach a note to the paperwork that
goes with the body. Refer to UWHC Administrative Policy 7.01,
Pathology Specimen Care and Handling.
c. If eye donation, elevate the head and place saline gauze and/or ice
packs over the eyes (see Instructions for Postmortem Eye Care
attachment in the “Related” section on U-Connect for complete
procedure).
8. Prior to family viewing, prepare the body so it is presentable for viewing
by cleaning the body with soap and water, as needed, and combing the
hair. Remove visible adhesive marks with adhesive remover; reapply
dressings over any draining area. Dress in clean patient gown. Place new
underpad under the patient.
a. Place the body in a position of rest with arms at side; close eyelids.
b. Place one pillow under the head so the head is level with the chest.
c. Close the mouth; place a rolled towel under the chin if needed.
d. Insert dentures. If dentures cannot be inserted, label and send them
with the body. Record this in the patient belongings in the clinical
record.
e. Lower the bed and side rails and place chairs close to the bed.
J. Whenever possible, family should be offered the option of spending time with the
deceased. Psychosocial support should be provided.
K. Patient Belongings:
1. Reconcile belongings at the time of death and document in the medical
record. Refer to UW Health Clinical Policy 2.1.22, Patient Belongings and
Valuables.
2. If patient representative/family is not available and an itemized list was
not prepared, two nursing personnel must itemize belongings/valuables
and document in the medical record. Patient belongings will be placed in a
labeled patient belongings bag and will be taken to environmental
services. Place valuables, including any jewelry removed, in a tamper-
proof envelope and store in unit lock box for Security to pick up on rounds
and take to safe in Admissions. If rings are unable to be removed, tape in
place. If family is returning to view the body in a timely manner, valuables
may be secured on the unit as families may wish to take valuables with
them.
3. Patient belongings/valuables which are released to patient
representative/family or Security Officer should be documented in the
patient’s clinical record, including to whom the belongings were released.

Page 5 of 6

4. For valuables taken to the safe, Admissions will work with Patient
Relations as needed to contact the authorized patient representative/family
member to pick up or have mailed.
L. Determine if patient identification band is in place (identification band serves as a
primary source of identification); if identification band is not in place, one is
prepared on the unit and placed on patient's wrist. (Patient's name, hospital
number, unit and service are included on identification band.) Do not tape
identification band on patient.
M. Transporting to the Morgue
1. Place body inside a body bag.
2. Record in clinical record the exact time of death, name of physician
pronouncing patient's death, and time and names of nursing personnel who
prepared the body for transfer to the morgue.
3. The clinical record is completed as soon as possible and placed with
discharge charts. However, if an autopsy is authorized, nursing will send
the clinical record with the body to the morgue. The mortician will obtain
the old record for the autopsy.
4. The Nursing Coordinator or designee will contact Security (pager 5050 or
call 890-5555) with estimated time of transport and patient room number.
Then the Nursing Coordinator will determine who will assist Security with
the body transport (i.e., Nursing Assistant, Autopsy Technician, or
Environmental Services).
5. Transfer body to the cart; If a unit does not have available help, call the
Nursing Coordinator.
6. The body needs to have a readable patient identification bracelet attached
and an identification tag on the body bag prior to removal to morgue.
7. UWHC staff transporting the body to the morgue will fill out the receipt of
body at morgue section on the Transfer of Human Remains to Morgue
Form for placement of the body in the morgue.
8. UWHC staff transporting the body to the morgue will place the body in
the refrigerated room. Clinical record/paperwork should be left on morgue
desk with the postmortem forms.

VI. PROCEDURE FOR THE AMERICAN CENTER (TAC)

A. Upon a patient expiring at TAC, the nursing associates will follow the same
process as outlined above at the UH, with the exception of the role of the Nursing
Coordinator, which will be fulfilled by the unit Care Team Leader (CTL) and the
securement of patient valuables.
1. TAC Security staff will scan and email the patient’s death packet to the
UH Mortician.
2. If the patient will be receiving an autopsy, the CTL will call the UH
Mortician at 263-8899 to arrange for transport from TAC to UH. In this
instance, the death packet will be sent with the body.
3. Transporting to the Body Hold Room:
a. Care Team Leader will contact the security office at 440-6666 to
inform of patient death.

Page 6 of 6

b. A security officer along with Patient Care Technician (PCT) will
transport the patient to the body hold room.
4. If the patient’s family has not designated a funeral home, the CTL will
contact the UH Mortician at 263-8899.
5. If the body has not been picked up within 48 hours of expiring, the UH
Mortician will arrange for the body to be transported from TAC to UH.
6. Security will be notified when the funeral home or transporting service
arrives to pick up the body from TAC. Security will escort the funeral
home to the body hold room and back to their vehicle at the loading dock.
7. Nursing associates will make every effort to send patient
belongings/valuables with family members if present upon patient death.
If family member is not present, patient belongings will be taken to
security, and all valuables will be placed in a sealed envelope to be placed
in the safe. Family will return to TAC to retrieve belongings and valuables
at their convenience.


VII. UWHC CROSS REFERENCES

A. UW Health Clinical Policy 2.1.22 Patient Belongings and Valuables
B. UW Health Clinical Policy 3.2.1, Patient Identification
C. UW Health Clinica Policy 3.3.8, Disposition of the Body After Death
D. UW Health Clinical Policy 3.3.9, Death Reports to Coroner
E. UWHC Administrative Policy 4.31, Organ & Tissue Donation
F. UWHC Administrative Policy 7.01 Pathology Specimen Care and Handling

VIII. REFERENCE

Instructions for Postmortem Eye Care (2009). Lions Eye Bank, Wisconsin (see
Related section on U-Connect)

IX. REVIEWED BY

Director, Organ Donation Transplant
Mortician, Clinical Labs Autopsy Services
Director, Nursing Operations Support
Nursing Coordinators, Nursing Operations Support
Director, Professional Services UW Health at The American Center
Nursing Patient Care Policy and Procedure Committee, April 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive