Supporting the Deceased, Their Families, and Their Communities – Part 1: Why Establish an Office of Decedent Affairs
Context.—
Decedent Affairs Offices and Programs can serve as an avenue to assist medical centers in facilitating efficient and comprehensive decedent management, despite a paucity of literature on their roles, establishment, and efficacy.
Objective.—
To characterize the motivations and rationales for establishing Decedent Affairs Offices.
Design.—
A survey was administered to 11 established Decedent Affairs Offices/Programs, identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. The questions comprehensively cover establishment, operations, and outcomes data available by institution.
Results.—
Survey respondents reported the rationale for starting their programs and the benefits such offices can have.
Conclusions.—
Decedent Affairs Offices and Programs provide a useful option to medical centers to navigate the increasingly complex task of comprehensive decedent management. The present survey helps to delineate the similarities and differences between these programs at 11 institutions, to aid nascent programs in their establishment and growth over time.
Despite the need of almost every hospital to have postmortem processes and procedures in effect to handle the care and disposition of decedents, there is limited information in the literature on the establishment and functionality of formal, centralized efforts at decedent care (Table). These Decedent Affairs Programs and Offices exist in a subset of hospitals, but the rationale for their existence, as well as their benefits, is not widely known.
Also see p. 1077.
One of, if not the first mention of a program in the literature is in 1958, when Military Medicine described the coordination of postmortem arrangements for service members conducted through the Department of the Navy.1 Subsequently, in 1986 and 1991 two articles from the University of Texas Medical Branch described how the establishment of such an office increased both autopsy rates and organ donation.2,3 They identified improved public relations with decedents’ families, compliance with state and federal laws, increased organ donations, and improved risk management as notable outcomes. Follow-up correspondence detailed a few other existing programs and posited that the hospital employment of morticians may provide the most cost-effective employees to staff such an office.4 Throughout the 1990s, additional journal articles were published, detailing how the formation of Decedent Affairs programs by institutions increased both autopsy rates and organ procurement.5,6 The literature then largely fell silent in these areas, plausibly due to hospital budgetary restrictions limiting the further expansion of such programs. The early 2000s saw only 1 publication on Offices of Decedent Affairs (ODAs) from Yale New Haven Hospital (New Haven, Connecticut), along with a poster abstract on Boston Medical Center’s ODA (Boston, Massachusetts).7,8 A 2017 article in Health and Social Work detailed the role for social workers working with ODAs.9 More recently, additional research has been published to demonstrate how ODAs increase autopsy rates, increase bereavement counseling to families, and improve practitioners’ attitudes toward hospital autopsies.10 A recent article in the Journal of Nursing Administration describes the formation of a Decedent Affairs Office at Emory University (Atlanta, Georgia), including the subsequent cost savings that have resulted from decreased off-site decedent storage and freeing up nursing staff from time-consuming postmortem care obligations in the clinical setting.11
This steady trickle of literature does little to compare strategies between institutions or to address the challenges of starting such an office. These programs have varied roles and responsibilities, are housed within different departments, consist of differing key stakeholders, and have widely varying functional and operational capacities, depending on the individual needs of the institution. The field of decedent care has also changed immensely over time and fresh literature on these programs is needed. As such, a survey of known ODAs in the United States was undertaken, with their varying functions and operational characteristics compared, in the hopes that institutions looking to implement such nascent programs at their own facilities can have a reference for comparison and assistance in structuring programs tailored to meet their own specific needs.
METHODS
A questionnaire was designed by the College of American Pathologists Autopsy Committee to survey US-based hospitals with centralized ODAs. To be an ODA, a program had to have an officially recognized, centrally coordinated effort related to decedent care. Offices were also required to have at least 1 employee whose predominant focus related to decedent affairs. This person should be readily available to family members of decedents for questions and assistance.
The questionnaire was composed of slightly fewer than 50 questions and included the following general topic headers: starting an ODA, the ODA’s current organizational structure, scope of practice, communication pathways and associated stakeholders, and the role of the ODA in specific duties such as autopsy, death certificates, and transportation. Additional free-text questions allowed for reflections on the benefits and challenges faced by the institution’s ODA.
US-based ODA offices were identified through the College of American Pathologists Autopsy Committee members and through a COVID-19/Medical Autopsy Listserv. Interested parties were given several months to complete the survey with data collection occurring between February 2023 and February 2024. The results are presented descriptively with the participation of all institutions in the manuscript editing process to ensure accurate representation of both individual and aggregate results.
RESULTS
Eleven programs participated, spanning the continental United States. They included Cedars-Sinai Medical Center (Los Angeles, California), Hershey Medical Center (Hershey, Pennsylvania), Mayo Clinic (Rochester, Minnesota), Stanford Hospital (Palo Alto, California), University of Alabama at Birmingham (Birmingham), University Hospitals (Cleveland, Ohio), University of Michigan (Ann Arbor), University of Utah (Salt Lake City), University of Vermont (Burlington), University of Washington (Seattle), and Yale New Haven Hospital. Ten of the 11 programs were still in operation, while 1 program (Yale New Haven Hospital) had closed its office. Their duration in operation ranged from 3 years to more than 40 years.
Before the ODA
Programs were asked about their experiences in decedent care before having an ODA. They described several inherent problems with decentralized (non-ODA) models. Seven institutions noted inconsistent patient and family experiences, including negative experiences with decedent care before the ODA was created. Three institutions noted specifically that family experience was dependent on unit staff who were not given adequate training or resources to manage all the questions and concerns after a patient’s death. Two programs highlighted how stress and grief at the time of a loved one’s death could exacerbate these issues. Six programs described how frustration was also felt by staff who had complained of nonexistent policies, unclear oversight, and lack of division of labor for the numerous tasks required after a patient dies. At least 3 programs noted how these frustrations can extend to interactions between hospital staff and external organizations, such as funeral homes. One program noted that even with the creation of an ODA, it can be easy for hospital administrators to underestimate the amount of work and time needed to care for a given decedent and the decedent’s family.
Programs were also established not only to smooth out existing problems, but also to prevent potentially catastrophic issues, such as lawsuits and other forms of litigation, arising from misplaced personal items and other mistakes (n = 4 programs). While ODAs cannot completely prevent these events, the likelihood of their occurrence is higher when the chain of command is fragmented, policies are unclear or nonexistent, and there is no centralized subject matter expertise. ODA staff, often compassionate and skilled communicators, are better equipped to handle such issues. As noted by one program (Yale New Haven Hospital), “The office provides both the infrastructure to mediate the risk and the soft skills to help families in challenging times.” One program reported that before implementing the ODA, autopsy consisted of a higher-than-average number of adverse events, while they had not had any since the ODA was established.
ODAs do not have to be restricted to fixing existing problems; they can also increase the standard of care and bring added value to institutions. Two programs noted how ODAs improved hospital preparedness for unforeseen circumstances such as mass casualty situations and/or public health crises (such as COVID-19). These situations are easier to handle when policies and practices are well established, and specialized knowledge is centralized. Six institutions noted how a mix of new policies, staff with subject matter expertise, improved continuity of care, reliable means of communication, streamlined workloads, and systematic recordkeeping all improved patient care above the baseline.
Overall, there was a wide range of rationales listed for starting an ODA. These fell into 3 main categories: fixing existing problems, risk management, and raising the standard of care (Figure).
Citation: Archives of Pathology & Laboratory Medicine 149, 12; 10.5858/arpa.2025-0090-OA
Benefits of an ODA
As reported in the survey, the establishment of centralized ODA programs has brought about numerous benefits that significantly improve the handling of postmortem processes, enhance communication, and provide critical support to families and hospital staff. Below are several key advantages.
Subject Matter Expertise
ODAs provide specialized knowledge crucial for navigating complex situations. Questions related to decedent care can be surprisingly complex (Think: how quickly can a body cross international borders for religious services? Or what is the hospital’s policy for deaths occurring in off-site ambulatory clinics?). This expertise ensures that families and providers receive accurate and timely guidance.
Specialized Knowledge and Support
A core function of most responding ODAs is providing families with comprehensive knowledge about postdeath procedures, including funeral processes and costs (n = 11). They also offer direct communication about autopsy expectations and limitations (n = 10), appropriate handling of decedents (n = 11), and accurate completion of necessary documentation (n = 9). Coordination with organ/tissue procurement agencies can also be important (n = 9). These questions are specialized and best handled by people familiar with the facilities and government codes. Some programs specifically employ former funeral home directors/employees (n = 6), who have extensive knowledge of the funeral process as well as costs. Likewise, programs frequently have ODA staff who are directly involved in the autopsy process and can manage communication with families regarding expectations and limitations of an autopsy as it pertains specifically to their loved one (n = 10).
Clarity and Support for Families
ODAs often create and maintain informational resources, such as death booklets or autopsy informational folders (n = 8), providing better clarity for families about the steps following a loved one’s death. Maintenance and improvement of these family resources is best done by ODA staff, who will be aware of evolving best practices for these documents.
Compassionate Care
Appropriate and careful handling of decedents is a core hospital responsibility, which is frequently relegated to an afterthought when staff are also responsible for living patients. ODA staff are trained in respectful and appropriate handling of decedents; they put their patients first and understand decedent affairs must be attended to in a timely fashion. Examples of specific compassionate care projects at different institutions include an annual memorial service for fetal/neonatal deaths (University of Washington and University Hospitals). Michigan Health’s ODA offers grief awareness services for faculty and staff, in addition to numerous custom services for patients and families, including a bereavement folder with support and educational materials, bereavement snack program, bereavement food tray, legacy kits (such as hand mold, fingerprints), giving library for children impacted by death, memory boxes, Final Salute, Honor Walk, and creation of the purple sticker project to ensure proper disposition of products of conception when a family requests remains for burial.
Enhanced Interpersonal Skills
Staff in the ODA extend this sensitivity and compassion to the decedents’ families. At one institution (University of Washington), new staff do not take a call until they have worked and trained for 6 months to acquire the appropriate level of care and sensitivity toward grieving families. This ensures that families are met with kindness and understanding during difficult times.
Efficient Coordination and Documentation
Consistent and thorough documentation reviews by ODA staff ensure that all processes are streamlined and reliable. This includes coordinating with various stakeholders, such as medical examiners, organ/tissue procurement agencies, and funeral directors, to facilitate smooth operations. ODA staff are typically available for accurate identification of next of kin and appropriate completion of autopsy permits, coordination and follow-up on death certification, participation in laboratory accreditation exercises, and more. These efforts result in improved overall communication (n = 11), faster turnaround times (n = 3), and fewer errors (n = 2).
Centralized Management
Having a centralized office to manage deaths and coordinate postmortem activities ensures that decedents are treated with the same urgency and care as live patients. This centralization also supports hospital staff by relieving them of additional responsibilities and allowing them to focus on their primary duties. There is always somebody present to handle the situation or coordinate what happens next. As one ODA put it “we are really a middleman for everything. We often tell families that we are like a ‘concierge’ between the hospital, the family, the funeral home and other vendors because we are involved in all aspects [of decedent care]” (Hershey Medical Center).
System-wide Standardization
By standardizing decedent affairs across the system, ODAs ensure that best practices are uniformly applied, reducing variability and improving overall service quality. As one program noted, transferring a decedent to the funeral home used to take an hour or more, but with the ODA it typically takes just 5 to 10 minutes (University of Utah).
Community and Cross-Hospital Collaboration
ODAs are frequently responsible for multiple sites. Their role at satellite hospitals varies. This central role not only supports their hospital but also assists other hospitals and funeral homes in the region. This collaborative approach ensures that decedent-related questions and issues are addressed efficiently.
According to survey respondents, hospitals with ODAs manage bed turnover at a faster rate (Mayo Clinic meets with the families of the decedent within 1 hour of death in most cases), have faster consent for autopsy (Hershey Medical Center has a death to consent to autopsy interval of <6 hours), release bodies faster (Mayo Clinic aims to release bodies within 24–48 hours and University of Utah noted that the body-release process used to take ∼1 hour before the ODA but now takes 5–10 minutes), and minimize health care errors. One institution reported greater accuracy in reporting cases to the medical examiner’s office as well as decreased incidences of lost personal effects, while another has not had a decedent-related adverse incident report since the implementation of their ODA. In brief, the implementation of ODAs has transformed the management of decedent affairs, offering specialized expertise, improving turnaround times, enhancing communication, and providing compassionate support to families. These offices play a crucial role in ensuring that the final steps following a patient’s death are handled with dignity, efficiency, and care.
DISCUSSION
This survey highlights the significant impact ODAs have on improving decedent care, operational efficiency, and support for families and staff. By addressing systemic challenges, mitigating risks, and raising care standards, ODAs play a vital role in modern health care institutions. By centralizing and standardizing decedent-related processes, ODAs address long-standing systemic challenges, improve operational efficiency, and provide compassionate care during sensitive times.
In this survey, 3 main motivations for starting an ODA emerged: fixing systemic inefficiencies, managing risks, and enhancing care quality. ODAs stand in contrast to decentralized decedent care, which more often results in fragmented workflows, staff frustration, and poor family experiences. ODAs address these issues by centralizing processes, establishing clear policies, and ensuring consistent oversight. This structure minimizes risks such as misplaced personal effects or delays in documentation, which can lead to litigation or patient dissatisfaction. Additionally, ODAs help hospitals prepare for unforeseen crises, such as mass casualty events or public health emergencies, by providing centralized expertise and coordination.
The implementation of ODAs transforms the management of decedent affairs by streamlining operations, enhancing communication, and providing compassionate care. These offices address long-standing gaps in health care systems, ensuring decedent care is handled with dignity and efficiency. As hospitals increasingly recognize the value of ODAs, their role in supporting families, staff, and the broader community will continue to grow.
Contributor Notes
The authors have no relevant financial interest in the products or companies described in this article.