Decedent Affairs Guidelines

Contact Numbers:

Decedent Affairs/Patient Relations Office 415-353-1729

UCSF Medical Center Policy Link: Death of a Patient

Staff Checklist (very helpful resource): EOL Checklist

Supervisor Role with Decedents

  • Release bodies to mortuary transporters on nights and weekends. During regular business hours, this is done by DA staff.
  • Assist nursing units and ED with Medical Examiner Cases
  • Assist families with viewing of decedents in the viewing room on nights and weekends
  • Interface with Donor Network representatives to release patients from nursing units for procurement/transport when needed
  • Assist nursing staff with accessing transport, morgue resources and decedent affairs when needed
  • UCSF Website for families of decedents

Morgue Tin

This is a closed metal clipboard which holds paperwork for decedents currently in the Mission Bay morgue. The tin is usually stored in a drawer in the ED workroom underneath the Reddinet computer. Patient relations usually brings the tin to the Nursing Supervisor office on Friday evening, and it stays in the office through the weekend. Any documentation for decedents should be stored in the tin. Patient Relations will prepare a packet of paperwork for each decedent in the morgue daily. The morgue log is also in the tin and maintained by Patient Relations; it can be updated by the supervisor by hand when necessary.

Releasing a Body:

On nights and weekends, BCH Supervisors are responsible for releasing bodies from the morgue to mortuary transporters. The standard policy is as follows:

  • A body may be released if an autopsy has been declined, and if the Donor Network has declined the case. Both of these items can be confirmed in the decedent’s medical record. If either of these items are in question, Decedent Affairs can be consulted 24/7.
  • Transport driver will call via the UC Operator. Instruct the driver to check in with security on arrival to Mission Bay. Ask the driver for the name of the decedent scheduled for pick up. Make sure to notify the driver that we do not schedule pick ups during the hours of 1600-2000.
  • Confirm the decedent is currently in the morgue and is appropriate for release.
    • Enter patient station and open the most recent admission
    • Select summary
    • Select Index Tab
    • Scroll down and select Post Mortem summary
    • Scroll down to view Provider Post Mortem Death Information
      • Confirm autopsy request is marked “no”. If “yes”, do not release body without discussing with patient relations and/or attending physician to verify.
      • Donor Network West must have been notified. If uncertain, discuss with attending physician and/or patient relations.
      • Medical Examiner must be marked “no”. If “yes” must contact patient relations before releasing.
  • Notify security that a mortuary pick up is planned and ask them to call the supervisor phone when the transporter arrives.
  • One morgue cooler key is kept in the Supervisor office on a red lanyard attached to the bulletin board.
  • On arrival, security will notify the Nursing Supervisor and instruct the mortuary transporter to drive to the loading dock. Security should meet the mortuary rep at the loading dock and escort them to the morgue. The Nursing Supervisor meets them at the morgue, completes all paperwork/logs (detailed below), unlocks the cooler, and verifies the identity of the decedent per policy.
  • Paperwork is returned to the Tin and kept in the Supervisor office or ED drawer.

Complete the Following Paperwork

  • Release of Body Form

    Confirm that family (legal Next of Kin) has signed a Release of Body form. This is sometimes a UCSF form, and sometimes a form that the family has completed at the funeral home. In either case, the form should be attached to the other paperwork in the morgue tin. If there is not a release of body form, the funeral home often will fax one on request. If the funeral home is unknown and the paperwork is missing from the tin, contact patient relations. The Release of Body form is not necessary for a ME case.

    • Sign this form and leave one copy in the tin, and give one copy to the mortuary transporter
  • Receipt of Remains Form

    Section one is completed by the mortuary transporter. Section two is completed by the BCH Supervisor.

    • Give the yellow copy to the transporter and leave the white copy in the tin with the decedent’s other paperwork.
  • Morgue Body Sign out Form (orange)

    Completed by Nursing Supervisor and signed by the transporter.

    • Must be left in the morgue in the plastic bin on the side of the podium closest to the cooler.
  • Morgue Log

    Large book located in the morgue. When releasing a body, find the decedent’s name in the log and record date/time of pick up and name of transporter.

Special Situations

Immediate Mortuary Pick-Ups:

Occasionally a family will wish to arrange for the mortuary to pick up the decedent immediately after death to avoid the decedent spending any time in the hospital morgue. All of the same pick up processes should be followed, with the decedent staying in the inpatient room until the mortuary representative arrives at the hospital. At that time, standard procedure should be followed for the patient to be transported to the morgue. The Nursing Supervisor and mortuary rep should meet the hospital transporter when they arrive with the decedent to the morgue. The Nursing Supervisor then completes all paperwork as shown above. The patient is transferred directly from the transport gurney to the mortuary gurney. The Nursing Supervisor should log the patient into and out of the morgue, documenting the same time in and out, on both the orange morgue slip and in the morgue log. The decedent can then be released for transport to the mortuary.

Muslim Patients:

For those of the Muslim faith, it is often important that the decedent is transported by family to a mosque or funeral home for preparation and burial within 24 hours of death. It will be a benefit to the family to know what is involved in facilitating this in the State of CA. If possible, speak to the family as soon as possible once it is clear that the patient will be passing away.

  • Always contact Decedent Affairs on call as soon as possible to assist the family with arrangements
  • Ask the family to contact their mortuary of choice as soon as possible
  • The attending physician at the time of death must sign the death certificate. For deaths in the ED, the PCP will be asked to sign. Please obtain a cell phone number for the signing physician and provide this number to patient relations.
  • It may take multiple hours for a death certificate to be issued and is only done during business hours. Patient relations will discuss this process with the family.

Families are allowed to transport the decedent in a private car. They must contract directly with the mortuary, who will issue a “Permit for Disposition” or “Burial Permit”. This must be presented to patient relations before UCSF will release the body to the family.

Organ and Tissue Donation:

Patients accepted for organ or tissue donation by Donor Network West have special circumstances surrounding release and transport. It is always important to contact Decedent Affairs for these cases.

  • Donor Network West is contacted for any decedent over 36 weeks in age within an hour of the patient’s death. This should be done by the attending physician and documented in the post-mortem summary.
  • Donor Network West may request a copy of the CTDN Report, a condensed version of the patient’s chart. It can be printed from the Snapshot tab in ApEX. If not available in the menu at the top of the screen, it can be searched in the box on the upper right.
  • Typically, patients donating tissues will be transported from the morgue to an offsite procurement location by Donor Network West. The procedure is identical to releasing a body to a mortuary. The DNW rep will have a signed Release of Body form, or one will be completed in the tin. The Donor Network will usually arrange with the family to transport the patient to the funeral home following procurement.
  • Patients donating organs are transported to the Mission Bay OR from the ICU on life support. The patient’s organs are then harvested in the OR. Donor Network West will be on site working with the family in the ICU, sometimes for a full day prior to donation. The Nursing Supervisor will be asked to complete paperwork with the Donor Network rep to release the body prior to harvesting so that DNW can transport the patient directly from the OR to the mortuary when the case is complete.

Medical Examiner Cases:

  • All decedents are presented to the Medical Examiner by the attending physician. Some categories of decedents are always accepted by the ME, including patients who have died at home or in the ED. In these cases, the patient should not be moved or handled after the time of death, and all lines, tubes and devices must remain in place.
  • The Medical Examiner will indicate to the attending physician a timeline for arrival at the hospital. The ME will also state whether the decedent should be moved to the morgue or left on the unit prior to the ME’s arrival.
  • The Supervisor can assist the ME with the exam whether the patient is in the morgue or on the unit. The ME will ask for the ME Report which should be printed from APEX. This report can be run by clicking on “Summary” from the patient storyboard. Choose or search for “medical examiner report” from the menu at the top. If the ME requests more medical records (ie outpatient visit information), those can be provided by Medical Records through a separate request and should not be printed by the Supervisor.
  • The ME will sign the Receipt of Remains form and provide a “receipt”. These documents should be attached and left in the tin. A release of body is not required for ME cases.