California state and local governments have been coordinating with the funeral industry to handle the excess deaths a pandemic might cause since about 2006. But the plan has never been stress-tested by anything like the coming coronavirus outbreak.
California's system of mutual aid is far more practiced in dealing with a handful or dozens of victims in a plane crash, fire or mass shooting, but it's never been used to cope with hundreds or even thousands of deaths that might occur over weeks in every part of the state.
When a catastrophe overwhelms the capacity of local funeral homes, the state can activate its Disaster Mortuary Operational Response Team. It would mobilize the broad category of licensed death care workers to safeguard and store the bodies, with federal funds picking up the cost.
The state's list of those workers is extensive: funeral directors, medical examiners, coroners, pathologists, forensic anthropologists, medical records technicians and transcribers, fingerprint specialists, forensic odontologists, dental assistants, x-ray technicians, mental health specialists, computer professionals, administrative support staff, and security and investigative personnel.
They are considered essential workers, and the kinds of problems they would confront are finding refrigerated places to store the remains (recommended between 39 and 46 degrees), identifying and keeping track of the dead and the relatives responsible for them, and making sure the right people receive and dispose of the bodies properly.
WHO'S IN CHARGE?
California's 58 county coroners are charged with dealing with an increased number of deaths. Some are elected by the public, some are appointed by their board of supervisors, and some simultaneously serve as county sheriffs.
In Los Angeles County, Coroner-Medical Examiner Jonathan Lucas has been preparing his office for an influx of cases, but has no firm idea what to expect.
"It's a difficult equivalence to make between what's happening in L.A. County and what's happening in Italy (and) China, because there are a lot of unknowns," Lucas said. "So we are simply just preparing for whatever we can try to prepare for."
That means stretching the office's limited supply of protective masks and other gear, and ramping up communications with the health care and funeral industries that will end up documenting, transporting and disposing of human remains.
Lucas is working to keep his workers healthy as well. He said he keeps his office door propped open so nobody has to touch a door handle.
THE ROLE OF PRIVATE MORTUARIES
Most of the people who will die of the disease caused by the new coronavirus will do so at home or at hospitals and other health care places. And when a person dies of a natural cause (like influenza or COVID-19) at home or the health care system, the body is removed to the private funeral home or mortuary for burial or cremation.
The California Association of Funeral Directors has helped the state plan for an increase in deaths.
"Part of that (process) was inventorying what's available within a county, for example, in terms of the number of funeral homes, how much refrigeration and storage capacity they had to deal with human remains and those kinds of things," said association Executive Director Bob Achermann.
State planners say a pandemic could generate six months' work for a local mortuary in about six to eight weeks. So the storage capacity of those businesses could be strained. Cemeteries and funeral homes are alreadly limiting the number of people who may be on their premises at one time, and many memorial services are being streamed or delayed to maintain social distancing.
Should the region need overflow storage, thousands of mausoleum vaults are available at Rose Hills Memorial Park and Mortuary in Whittier, said President and CEO Patrick Monroe.
It's the largest memorial park in North America, and it also has enough space to offer families room to temporarily entomb remains for the duration of the coronavirus outbreak, so they can be buried later when family and friends can attend ceremonies.
WHAT IF PRIVATE FUNERAL HOMES ARE OVERWHELMED?
If private or hospital morgues get overcrowded, the county coroner's office would step in.
"If any hospitals exceed their capacity, and hopefully we don't get there, but if hospitals exceed their capacity, then we would be able to sort of function as the county morgue," Lucas said.
The coroner's office will receive some of the bodies of COVID-19 victims, mostly those who die in places other than home or the health care system, and those who die under circumstances requiring investigation.
The county morgue has space for about 500 bodies, so the county has been working to clear up space by urging family members to accelerate transfers of those remains to private funeral homes and cemeteries.
California law permits bodies to be embalmed and stored in central locations, so that no one funeral home or hospital becomes overwhelmed or unsafe. Refrigerated trucks could be fitted out as temporary morgues, if necessary, Lucas said.
CALIFORNIA'S PLAN FOR PANDEMIC DEATHS
California state has been planning a public-private pandemic strategy since about 2006, and the latest version of The California Mass Fatality Management Guide was updated in September, long before the coronavirus appeared to be a threat to the state.
The 246-page plan includes some worst-case assumptions, for example, that between 25,000 to 59,000 Californians could die in a global pandemic influenza. Again, that is a worst-case scenario for an unknown pandemic, not specific to the coronavirus or COVID-19.
The plan proposes strategies to deal with some expected problems and shortages as disease reduces the labor force. For example, counties could re-assign some workers to the coroner's office to help issue death certificates. Cemeteries could put out a call for fill-in staff or volunteers to help dig graves.
If the need for help with bodies exceeds California's capacity, the plan says other states may step in to help. The state-to-state mutual aid system is overseen by the federal government. But the real unknown is the extent to which mutual aid agreements will work when every local government nationwide is facing a similar increase in deaths.
EXPECT THE BEST, PLAN FOR THE WORST
Nobody wants to think they or their loved ones might get ill with COVID-19 and die, but the experience in Italy and other countries is that the onset of symptoms and death can come quickly.
For that reason, in this calm before the onset of more illness and death, now is the time to speak with your loved ones and make your wishes known for the disposition of your remains and property.
It may feel like a dramatic step, but a hard conversation like that might have the added benefit of encouraging family members to be vigilant about social distancing as a prevention measure. And it's the grown-up thing to do in any case.
The National Institute on Aging has a guide for getting your affairs in order.
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