FORM 5012 must be completed for every death, including the Emergency Department.
It is UTMB policy that an autopsy to be requested on all non-medico-legal inpatient deaths (IHOP 9.15.2).
When there is a death, the pronouncing physician is responsible for obtaining the informed consent for autopsy and tissue donation. Every section of the FORM 5012 must be completed.
Key components that need to be documented in Epic:
- Written death note in Epic:
- Date and time of death
- Cause of death
FORM 5012 Authorization for Postmortem Procedures
Section 1 – Galveston County Medical Examiner Reporting
Determines whether the Galveston County Medical Examiner has jurisdiction over the death and if so contact the Galveston County Medical Examiner office at 409-772-4004. (See Reportable Death Section)
Section 2 – Texas Department of Criminal Justice (TDCJ) Inmate Death
If yes, notify the TDCJ Warden / Chaplain office 409-772-2691 or TDCJ Communications 409-772-6108 and proceed to Section 5.
If clinician wishes to speak to the family about autopsy consent do the following:
- Contact the chaplain to obtain the family’s contact information;
- Discuss Sections 3A & 3B of the FORM 5012 using the script in section 3B to obtain informed consent for autopsy procedure:
- Notify Autopsy Service and document in the note section of the FORM 5012 families wishes for an autopsy;
- Autopsy Service will follow-up with the witnessed telephone consent if family is not present to sign the FORM 5012.
Section 3A – Person Authorized to Consent to Postmortem Examination (Autopsy)
Determine the next-of-kin or authorized person to consent to the postmortem examination (autopsy). Check the appropriate check box. Proceed to Section 3B.
Section 3B – Authorization for Postmortem Examination (Autopsy)
The clinician is responsible for discussing and completing Section 3B of the autopsy consent. The clinician must read the paragraph sections to the next of kin or the authorizing person.
It is mandatory by the state that the clinician informs the person(s) of the following:
- They have the right to request that a physician not affiliated with UTMB review the finds of the postmortem examination (autopsy) performed at UTMB;
- Or perform the procedure at another hospital or institution; and
- Any cost associated with doing so will be the families responsibilities.
Section 3B must also be completed
A check box selection must be checked, signed and witness whether family consents or denies an autopsy.
Section 3C – Disposition of the body
Discuss funeral home release with the next of kin. If unavailable the physician may obtain telephone consent.
Section 4 – Disposition of organs, fluids, prosthetic devices and tissue after postmortem examination
This is a new mandatory section added to the FORM 5012. UTMB has a strong commitment to teaching and research so the request for organ, tissue retention or donation is a valuable anatomical gift. Section 4 of the FORM 5012 gives the family member(s) the opportunity to make an anatomical gift of the decedent’s body or organs for the purpose of research, education and medical science or potentially benefit future patients. The authorizing person who is reasonably available must check one of the boxes, sign and witnessed. If family is not present Autopsy Service will complete the form.
Section 5A – Physician Checklist
To be completed by the pronouncing physician.
The following sections 5A through 8 will be completed by Nursing, Autopsy Service and Transportation.