Supporting the Deceased, Their Families, and Their Communities – Part 2: Practical Guidance for Building an Office of Decedent Affairs
Context.—
After-death care can be complicated and time-consuming for clinical staff, and frustrating for bereaved families. Delays and errors can have damaging legal and reputational consequences for hospitals. Offices of Decedent Affairs (ODAs) have been proposed as a solution, and their potential benefits have been described in several single institution reports. The literature lacks a contemporary and comprehensive review of existing ODAs and their approaches.
Objective.—
To describe the process of establishing a new ODA and to provide a snapshot of the spectrum of structure, function, and impact of existing ODAs in the United States.
Design.—
A survey was administered to 11 established ODAs spread across the continental United States. Programs were identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv.
Results.—
Eleven ODAs returned the survey, representing more than 190 cumulative years of experience in decedent care in the hospital setting (median, 10 years). There was a wide range in staffing (both staff size and background) as well as scope of services offered. The median ratio of hospital deaths to full-time equivalent (FTE) staffing was 360 deaths per FTE. Respondents reported that ODAs unburden clinical providers and facilitate decedent management. Some respondents reported a quicker turnover of hospital beds and shorter intervals between pronouncement of death and autopsy. ODAs increased autopsy rates when the autopsy services were part of the ODA.
Conclusions.—
This survey provides practical information for hospitals considering establishing a new ODA and useful benchmarks for existing ODA programs.
The death of a loved one is a major milestone associated with powerful emotions. It is the last point of in-person contact between the family and hospital staff. The events surrounding death can take on an enormous importance for the family. Miscommunications, delays, and frustrations in decedent care can undo an otherwise positive hospital experience. The tasks surrounding death invariably involve multiple hospital services including clinical staff, pastoral care, social work, security, patient transport, patient experience, and pathologists. Most of these services deal with death episodically and infrequently. Decedent affairs pull them away from their primary mission of patient care and place additional demands on their time.
Also see p. 1072.
Asking time-constrained staff to work on an area outside of their expertise contributes to the risk of miscommunication, delays, and potentially serious errors. Errors associated with decedent affairs are rare, but they have the potential to expose the hospital and staff to serious legal and reputational damage. Related miscommunications, delays, and frustrations can be misinterpreted as a lack of caring. Recent cases involving misplacement of decedents and confusion about consent have resulted in multimillion-dollar lawsuits.1,2
Part 1 of this 2-part series presented a literature review of Offices of Decedent Affairs (ODAs) and outlined the key points for the rationale for establishing an ODA. A review of the past 75 years of literature on ODAs reveals a significant gap in contemporary research and a complete lack of comparative data between programs. Part 2 of the series provides descriptive and numerical data on hospital ODAs, the sort of information that could be useful to hospitals trying to decide how to launch their own ODA. In brief, part 1 speaks to the “why” of starting an ODA, and part 2 speaks to the “how” of starting an ODA.
METHODS
To be considered an ODA, a program had to fulfill 3 requirements: (1) provide centrally coordinated, comprehensive decedent care; (2) be officially recognized by its hospital; and (3) have at least 1 employee with a predominant focus related to decedent affairs who served as a direct point of contact for decedent families.
A questionnaire was designed by the College of American Pathologists Autopsy Committee. It consisted 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 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 Medical Autopsy Listserv. Participants were given several months to complete the survey with data collection occurring between February 2023 and February 2024. All responding institutions participated in the manuscript editing process to ensure accurate representation of both individual and aggregate results.
RESULTS
Survey Respondents
Eleven programs participated, spanning the continental United States (Table 1). 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 (New Haven, Connecticut). No programs were screened out for not having met the definition of an ODA. 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 (>190 cumulative years of experience; median, 10 years/program).
Staffing and Oversight
The size of the staff varied significantly and ranged from a minimum of 1 full-time equivalent (FTE) to a maximum of 10 staff members across 8.5 FTEs (median, 4.6 FTEs) (Table 1). The number of deaths per year varied from 814 to 2579 (median, 1293 deaths/year). The number of deaths per FTE ranged from 134 to 1300 (median, 360 deaths/FTE). Institutions with higher death to FTE ratios tended to include fewer activities in their scope of practice (Table 2) and did not typically have 24-hour/365-day coverage (Figure 1).
Citation: Archives of Pathology & Laboratory Medicine 149, 12; 10.5858/arpa.2025-0094-OA
Oversight for the offices was often provided by pathology departments (n = 6). In one of these cases, the ODA director is housed in pathology, while the remaining staff and the office budget are managed directly by the hospital (University of Washington). Remaining offices are housed in departments related to patient care services (Stanford Hospital), customer service (University of Utah)/patient relations (Yale New Haven Hospital), and social work/case management (University of Vermont, Michigan Health).
Directors of ODAs were predominantly board-certified pathologists (n = 5), followed by former funeral directors (Hershey Medical Center, University Hospitals, Stanford Hospital), chaplains (Stanford Hospital), and social workers (University of Vermont, Michigan Health). The background of the other ODA staff (when present) also varied. Some programs specifically employed former funeral home employees, who had extensive knowledge of the funeral process, transportation logistics, costs, and familiarity working with decedents. However, this was not the rule; across programs there was a mix of funeral workers, social workers, nurses, pathologists, pathology assistants/autopsy technicians, and hospital administrators.
Hours of Operation and Scope of Services
Six programs had all-day, every-day (24 hours, 365 days a year) call coverage for routine decedent care (Table 1). The other 5 programs had regular business hours with coverage from non-ODA staff weekends, holidays, and nights. Overnight coverage from non-ODA staff was provided by charge nurses (Cedars-Sinai), shift/hospital administrators (Yale New Haven Hospital), and social workers (University of Vermont, Michigan Health). The University of Utah’s program had patient transport deliver the bodies to the morgue after hours; the director was on call 24/7 for urgent matters only.
The scope of practice for the ODAs was broad and varied significantly from one respondent to the next. The only responsibility common to all 11 respondents was assisting families with questions after the death (which was a qualification for inclusion in the study). This included helping families with questions related to the death certificate, as well as other topics. Most respondents were not involved with signing death certificates, but they did ensure that they were completed accurately and in a timely manner. Most programs were also involved in family discussions pre death (n = 9), preparing educational materials for families (n = 8), managing body storage (n = 9), coordinating transportation (n = 9), reporting to the medical examiner’s office (n = 9), consenting for autopsies (n = 9), tissue donation coordination (n = 9), and ensuring paperwork is compliant with regulatory agencies (n = 9) (Table 2).
Programs were frequently part of hospital systems with more than 1 hospital campus (University of Vermont and Yale New Haven Hospital were the only 1-site programs); in most cases, the ODA covered the satellite locations as well (n = 7) and in other cases they did not (Cedars-Sinai, University Hospitals). Likewise, some institutions used their ODA to support their mission as a regional referral network for autopsies, taking autopsy cases from beyond their immediate hospital network (Mayo Clinic, Hershey Medical Center, University of Vermont, University of Alabama, University of Utah).
ODAs and Autopsies
All respondents performed hospital autopsies. Typical duties included educating families about options for an autopsy and the autopsy process, verifying information from the next of kin, providing a timeline for the autopsy, confirming consent, making arrangements with funeral homes, and following up with families and funeral homes when the autopsy was completed. Whether the ODA managed the logistics of the autopsy was a major area of divergence for programs. Five programs operated all autopsy activities through the ODA (University of Washington, University of Utah, University Hospitals, Mayo Clinic, and Hershey Medical Center). The University of Vermont was the only program that handled none of the autopsy activities through the ODA. The remaining 5 programs had a mix of duties related to autopsy. Typically, these programs had the ODA involved with some of the paperwork for the autopsy (for example, all 5 did consenting through the ODA) without performing the autopsy through the ODA.
Six programs (Stanford Hospital, University of Washington, Cedars-Sinai, Hershey Medical Center, University Hospitals, Michigan Health) had a universal consent policy that ensured the next of kin for every in-hospital death was offered an autopsy by a trained ODA employee (unless already consented by a clinician); Mayo Clinic also offered this at its main hospital (but not the satellite hospitals). Only 2 programs (Mayo Clinic and University of Alabama) also performed forensic autopsies. Half of the hospitals (n = 5) could also accept fee-for-service autopsies; 1 additional program accepted fee-for-service autopsies only from a prior contracted outside hospital (Michigan Health). Of note, 1 additional hospital did not offer “fee-for-service” autopsies but rather had an expanded policy of taking any autopsy from a state resident free of charge, regardless of whether they received prior care at the institution (University of Vermont).
Multiple programs had a policy of performing autopsies for any patient of the hospital, current or former (Mayo Clinic—if within 10 years of the last visit; Hershey Medical Center—if within 3 years of last visit; Michigan Health—patients pay for transportation to/from the hospital but not for the autopsy; University of Washington—within 12 months and patients pay for transportation; University of Utah—within 1 year; Yale New Haven Hospital—at any time; and Stanford Hospital—at any time with free transportation if the body is within 60 miles of the hospital).
ODAs and Autopsy Rates
As consenting and performing the autopsy was in many cases a core duty for the ODA, data were collected on the rate of autopsy before the ODA and at the time of the survey (Table 3). All institutions reported their autopsy rate at the time of the survey. All programs were at or above the national average of approximately 6%3 of inpatient deaths (median, 10.7%; mean, 13.9%; range, 6.0%–29.3%).
Five programs were able to report on the rate of autopsy before the establishment of an ODA. Four programs reported an increase in autopsy rates since starting the ODA. Yale New Haven Hospital reported an initial increase in autopsy rates when the ODA started, which has not been maintained since it closed. The University of Vermont was the 1 program to report a decline in autopsy rates since the start of the ODA. As noted above, the University of Vermont’s ODA and autopsy services are separate, so the formation of the ODA may not have the same effect on autopsy as in other institutions.
Education
As 1 program noted, ODA staff “are experts in having conversations with families on postmortem care; they give families an idea of what the next steps are and things they could do” (Mayo Clinic). At least 3 programs had family-friendly web sites (Mayo Clinic: https://www.mayoclinic.org/office-decedent-affairs; Stanford Hospital: https://stanfordhealthcare.org/for-patients-visitors/decedent-care.html; and Michigan Health: https://www.uofmhealth.org/patient-visitor-guide/grief-support-following-death-loved-one). Multiple programs had educational materials for families relating to autopsies, funeral arrangements, and more. At some institutions, this educational mission extended beyond families to include resident teaching (pathology and other services), organ teaching sets for medical schools and/or high-school outreach programs (University of Washington), and maintaining a teaching organ repository (Stanford Hospital). University Hospitals noted their ODA created a death certification training model, which is required for all onboarding physicians/residents.
Quality Initiatives
All of the responding ODAs were involved in quality assurance activities. Through their core mission, they improved patient care by streamlining communication, closing gaps in care, and minimizing risk. They also ensured timely submission of relevant paperwork (such as death certificates) and were involved in various laboratory inspections. A subset of respondents specifically had roles on various committees, meetings, and regularly scheduled quality improvement initiatives such as auditing paperwork, participating in or hosting interdepartmental autopsy medicine conferences, morbidity and mortality rounds, and hospital quality improvement committees (Hershey Medical Center, University of Washington, Michigan Health).
Tissue Donation
Tissue donation was also part of the workflow for most ODAs (n = 9). This included cadaveric tissue donation for living donors (eg, long bones, corneas) but also coordination with various research groups for research-based tissue donation (n = 5). Mayo Clinic, for example, assists with research autopsies for their brain bank, including completing the consents, organizing transportation, and release of the body to the funeral home. They also answer off-hour calls and receive bodies for the whole-body donation program for the medical school anatomy department. The University of Washington noted that they had ad hoc oversight of the transportation of patient-derived tissue outside of the main campus.
Challenges
Most respondents described the same challenges to starting an ODA: budgeting, staffing, physical space, and organizational oversight. There was also emphasis on the groundwork required to generate hospital buy-in and to centralize resources that are often managed by a large group of stakeholders (eg, pathology, social work, security, spiritual care, customer service, nursing, hospital administration). Discussions of the merits of an ODA often took place for many months owing to the complex network of services involved in decedent affairs prior to centralization. Once programs decided the initial structure and core resources of the office, there was still the challenge of creating relevant policies, practices, and protocols.
Occasionally, solutions to constrained resources were discussed in terms of the graduated responsibility of the office, increasing its capacity, staffing, and scope of work slowly over time. This was particularly true with regard to staffing, with at least 3 programs describing a progressive move from part-time coverage to 24/7 call coverage. Additionally, there were instances of increases in the number of staff over time (even without additional call coverage), and transitioning services to the new office in a step-by-step fashion rather than all at once.
Of note, all programs that responded to the question “Were these goals met?” answered affirmatively; sometimes this was unequivocally, other times this was with the recognition that the office was still growing and continued to increase in scope and impact. Newer programs were more likely to note that it took time for policy changes to take effect and there was a learning curve for the rest of the hospital, which required concerted educational efforts. Specific outcomes noted by programs included saving floor staff 4 hours of work per decedent, a marked decrease in patient safety and quality assurance issues, as well as noting an unusually high level of preparedness and ability to maneuver challenges such as the COVID-19 pandemic. Overall, all programs felt that ODAs addressed the challenges they were intended to address.
DISCUSSION
Many resources, both physical and nonphysical, are required to make an ODA (Figure 2). This article explores a critical subset of these in detail, acting as a resource to directly compare many successful models of centralized decedent care. Prior literature has presented a small number of these programs but there has not been consistency in what is reported, or direct comparison between institutions.
Citation: Archives of Pathology & Laboratory Medicine 149, 12; 10.5858/arpa.2025-0094-OA
The survey, composed of ODAs from 11 academic centers across the United States, demonstrated broad satisfaction with the centralized structure of an ODA, with all programs endorsing improvements over pre-ODA workflows and outcomes. The scope of practice for these offices varied, with some covering all aspects of decedent care, and others acting as a hub to connect many independently existing hospital services. One area of significant heterogeneity was in the role of autopsy in the ODA. Some programs had ODA staff who were directly involved in the autopsy process and managed communication with families regarding expectations and limitations of an autopsy as it pertained specifically to their loved one. Strategies for what the ODA took responsibility for were reflected in various outcome measures. For example, ODAs that included autopsy services saw rises in autopsy performance (n = 3), while those that were independent of autopsy services saw declines in their autopsy rate (n = 1).
Despite concerns about institutional support for these programs, they appear robust over time. In the prior literature, most programs that published on their ODA have remained open.4–8 Some programs have been open continuously for 75 years.5 Still, a minority of programs have closed and these cases raise questions about what makes these programs sustainable.5,9 The reasons for programs closing are complex and include the challenges explored here: staffing, budgets, hospital buy-in, among others. Herein, we include the survey results of one of the programs that did not remain open over time (Yale New Haven Hospital); they report that key staff were reassigned, compromising the program, although they report that discussions are currently underway to reopen the ODA at their institution.
One of the most commonly reported challenges for an ODA was maintaining 24/7/365 call as well as hospital buy-in for the ODA over time. Filling these staffing challenges has been accomplished through the employment of a diverse set of individuals across many areas including funeral homes, social work, nursing, administration, and pathology. Of note, a prior publication reported significant cost gains by employing funeral home employees in their ODA.5
Future studies on the time and cost of the standard approach to managing decedent care, versus the ODA approach, are needed in order to expand on the findings here. Additionally, it is beneficial for other ODAs, particularly those not surveyed here, to publish on their experiences since programs vary widely based on institutional needs.
There are many challenges to coordinating after-death care at hospitals. And yet, it is a vital component of routine hospital activities. ODAs have been used as an organizational framework meant to streamline the various activities that must be undertaken on behalf of decedents and their next of kin. However, the literature on ODAs is limited, and their costs versus benefits are largely unpublished. This survey was meant to be a standardized tool for data collection for ODAs with the goal of making data about ODAs available to the broader community.
Ratio of in-hospital deaths (2022) to staffing (full-time equivalents). Institutions with 24/7 decedent care coverage are shown in blue; those without are in red.
Key characteristics shared across different ODAs. A visual representation of essential components including leadership, governance, infrastructure, policies, recordkeeping, external partnerships, and community support that contribute to the effective functioning of Offices of Decedent Affairs (ODAs).
Contributor Notes
The authors have no relevant financial interest in the products or companies described in this article.