Hospital takes on taboo subject: mistakes made after patients die

The woman’s death, one of almost a thousand every year at a major Boston teaching hospital, was nothing unusual, until her body was shipped to the wrong funeral home.

The mixup delayed the funeral, caused the family distress — and helped prompt Beth Israel Deaconess Medical Center to examine how it handles patients’ bodies and supports family members after a death.

The issue has received little attention nationally, though the National Center for Health Statistics has found that about one-third of deaths in the United States occur in general hospitals.

“We’re shedding a light on an area that has not been shed a light on,” said Dr. Lauge Sokol-Hessner, associate director of inpatient quality at Beth Israel Deaconess.

The hospital has created a 20-person working group to focus on the aftermath of a patient’s death. It’s part of a broader effort to reduce “insults to dignity” — mistakes that cause emotional harm, but haven’t traditionally been considered medical errors.

For example, after another woman died at the hospital, her family got to the funeral home and couldn’t find her pocketbook, said Patricia Folcarelli, senior director of patient safety. It turned out the pocketbook was still in the hospital morgue.

In another case, the hospital failed to complete an autopsy that a family had requested, she said.

These cases happen with low frequency, but have high impact, Folcarelli said.

“If something about the death doesn’t sit well with the family members, they’re at higher risk of complicated grief” — when grief gets “stuck” or turns into depression, added Kathleen Rimer, the hospital’s director of spiritual care.

The case of the misplaced body stemmed from a miscommunication between the hospital and the funeral home, which picked up the wrong body from the morgue, Sokol-Hessner said.

Hospitals have spent a lot of money studying patient “handoffs,” or transitions of care for living patients, but “this is one transition we hadn’t thought a lot about,” he said. His team has found no research on these post-mortem transitions.

“I don’t think anybody’s thought systematically about this process,” he said.

“It’s hard to talk about death,” Sokol-Hessner said. There are also no regulations for how hospitals handle dead patients, he added.

When a patient dies, a physician pronounces the death, nurses prepare the body, and a transport worker takes the body to the basement morgue, where a pathologist might conduct an autopsy. Other steps involve a wide range of staff.

“It’s not coordinated,” Folcarelli said. Families “get the runaround” and end up making lots of phone calls to track down documents and personal belongings. They feel “a sense that the death happens, and everybody else just moves on.”

The post-mortem process is so complex that Folcarelli and her colleagues created an intricate “death map” outlining dozens of steps that happen when a patient dies. As in any hospital process, an error can happen at any step.

For instance, staff have to report a death in an online state database. If they miss a field in the data entry, that could delay the death certificate — which could trip up family members who need that document to get discounted airline tickets for the funeral, explained Barbara Sarnoff Lee, the hospital’s director of social work and patient/family engagement.

Getting an autopsy report can be frustrating, too: Families may have to wait up to eight weeks between an autopsy and autopsy report. And sometimes they later find out they can’t see the report at all, because the hospital is barred by law from releasing it to anyone but the executor of the estate, Sarnoff Lee said. She said the hospital aims to communicate better with families about what to expect.

Randy Gonchar, who sits on the hospital’s Patient-Family Advisory Council, welcomed the effort to improve a process he’s too familiar with. His mother, father, brother, and nephew all died at Boston hospitals.

Hospitals “didn’t really do anything” to help his family when each person died, he said — except Beth Israel Deaconess did transfer his mother to a private room as the end drew near.

Gonchar said his mother died there six years ago on the Fourth of July, right after the fireworks stopped. He was at her bedside with his wife.

“At that point, all we did was walk out of the hospital,” he said.

After a death, that walk from hospital to parking lot can feel long and lonely, Gonchar said. He suggested the hospital offer to escort family members to their cars, especially if they are alone. He also supports an idea the hospital is considering — to assign a single point person, or perhaps create a new position called a “death navigator,” to help families cope with the emotional and logistical hurdles surrounding a death.

Meanwhile, hospital staff have been trying out the Pause, a practice started at the University of Virginia in which staff gather around the body for a moment of silence after a patient dies. The Pause aims to offer closure and “acknowledge the gravity of what just happened,” said Rimer, the spiritual care director.

Jennifer Manzo, a nurse in the medical intensive care unit, said staff there see at least two deaths per week. Patients arrive very sick, often with liver failure or other organs shutting down. Manzo said she tried the Pause a few weeks after Rimer explained the idea.

It was early in the morning, she said. Her pager went off: A patient’s heart had stopped. She ran to the room. After a flurry of chest compressions and beeping alarms, it became clear that the 10-person medical team wasn’t going to save the patient. He died before his family could get there.

“I think we should take a minute to pause and recognize this man’s life,” Manzo recalled saying.

Only later did Manzo realize that the dead man’s roommate had been sitting in the room the whole time.

“I felt horrible for him,” she said. Usually staff try to relocate the roommate if a patient is about to die.

Manzo said she apologized to the roommate. He wasn’t upset. Instead, he gave her a hug.

Rimer said she hopes to spread the “Pause” to more parts of the hospital. She also plans to enhance the “comfort cart” that delivers food to families of dying patients: She’d like to add muffins, sandwiches, and softer tissues.

“We want people to feel cared for in this very difficult time,” she said. “It’s a real gift to give a family a death about which they have no regrets.”

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