Editor’s Note: We are featuring a series of essays by Kate Crofton on anatomy lab. Her essays are based on 27 interviews with medical students, faculty, clinicians and donors. This is the fourth installment in the series. Read the final installment here. Read the third part in the series here.
My lab group is busily trying to dissect our donor’s forearms when the Anatomical Gift Program’s funeral director makes her rounds to our table. She is here to tell us our donor’s name, age, occupation and cause of death. This step of the curriculum is interjected at a calculated point in the semester when we are supposed to have acclimated to the more uncomfortable aspects of lab. The learning objective is a humanistic one: consider the person who donated their body. We have been cutting into this man for weeks, removing skin, separating muscles, lifting out organs and yet we do not know him. We ceaselessly wonder: what did he like to eat for dinner? What brought him joy? What obstacles did he overcome? Who did he love? Who loved him? Did he love his body? Did he suffer?
Why would someone choose to donate their body to medical education? We have a dishonorable history in medicine of illicitly sourcing cadavers for dissection: robbing corpses from graves, murdering people for their bodies and salvaging the unclaimed dead from city hospitals and morgues. Today, we call the bodies we learn from “donors” instead of “cadavers” to honor their autonomy and personhood, their choice to be in the room.
Weeks later in the course, my arms are up to my elbows in our donor’s abdomen, yanking on his intestines in an effort to identify the superior and inferior mesenteric arteries, when I find myself wondering: but how informed was his consent really? Did he know that we would saw his skull in half, detach his legs from his trunk, crack open his rib cage and cut out his heart? Did he want to know?
Professors have tried to help us come to terms with our questions and guilt. “[The donor is] not dying for the cause, but it’s brave. It’s selfless, and it’s trusting. They don’t know what the dissections are. For the most part the donors don’t know we’re going to bisect the pelvis. And I think that’s okay as long as we abide by the spirit of their intent — ‘learn from me.’ Anything that we do in that spirit to learn from them while maintaining respect for them is fine. If we were to do anything with another motivation, to try to mortify the remains or for the sake only of destruction that is not okay. Intent plays a major role.”
A palliative care physician compares the informed consent required for anatomical donation to that required for surgery, “If you’re consenting to surgery do you consent to: ‘We’re going to be cutting through arteries, bones, and muscles. Then we’re going to have to sew them back up, and it may bleed like crazy.’ Is that the level of detail people want to know? There are probably some people who do want to know that level of detail about it … the lead on how much detail you provide should be given to the patient or family.”
Another anatomy instructor reminds us that the donors’ selfless acts of sharing their bodies are now tied to the flow and progress of medicine, “Part of the reason that people donate their bodies is because they see this as a way for the next generation to learn medicine. [It is] also for their families so that health care for them is better than it is today. They’re done with their bodies, and this is their final stop along the way in their journey. They don’t need to do this. There are other ways they could have settled the end of their life, either by going directly to cremation or directly to burial. There was a reason that they wanted somebody to learn from them.”
But there’s another compelling reason to donate: relieving the surviving family members of some end-of-life expenses. Donated decedents are cremated by the medical school free of charge once the school is finished using the body for education. If the donor dies in a local hospital or nursing home, they are also transported for free from their place of death to the medical school. Did my donor want to help me learn, or did he just want to avoid being a burden to his family in death?
All of these lingering questions and preconceptions spring to mind when I get a call from a palliative care clinician announcing that she has a patient who is willing to talk to me about anatomical donation. I leap to action, clearing my schedule for the afternoon to make time for the hours-long heart-to-heart I expect we’re going to have. I want to ask the patient about his body, his life, his motivations for whole body donation and the extent to which he knows what we will do to his body postmortem. I presume that he’ll be curious to hear my perspective as a medical student who has taken anatomy and learned from a donor.
In the hospital, cheery acoustic jazz piano pounds away from a speaker near the patient’s bed. He sits upright, supported by pillows, with his knees bent, his ashen skin cloaked in white sheets. I feel as if I’ve run into an invisible wall, all my excitement and inertia dropping suddenly onto the cool tile floor. “Why do you want to donate?” I ask, trying to push through discomfort.
A drum riffs for a moment, and then the piano starts up again. He breathes heavily, a long pause. “I want someone to learn … I won’t need it.” His eyes tear up, and I’m not sure that I’ve correctly interpreted his muted, mumbled words. “If they can still learn …” I think I make out. The saxophone joins in, wailing on a solo. I try to wait patiently, hoping he will conjure the energy to give a more detailed explanation. His silence increases my discomfort. This man is closer to death than life, a stupid surprise. “I’d like to say thank you. I’m a medical student. I’m in my second year. I learned from anatomy, and I’m grateful. So thank you.”
The piano takes it away. “Yeah” he grunts. I ask him, trying again at the conversation that I had imagined, “Do you have any questions for me about what might happen to your body, or what we might learn?” Jazzy piano chords mirror my tension as he exhaustedly mumbles: “I think I understand the process.” The saxophone picks back up, and so do I. “What have been some of the joys that you have lived in your body?” Nothing. “Or is there anything that you would want the students to know about you?” His breathing is increasingly jagged and raspy as his head tilts away from me.
The song ends, and in a moment of absolute silence, I realize that this man, very much like the donors my classmates dissected, will continue to be a mystery to me. I am not going to hear his life story during this interview, and furthermore my questions are completely irrelevant, and possibly offensive to him. This dying man doesn’t care to know the order of cuts that a group of students will make on his body as they navigate through his anatomy. I want to make him the protagonist of this story, but I know so little about him that he can only play a supporting role.
A new song begins, a jarring combination of bouncy piano chords and sultry saxophone, a wistful melody. Or maybe I’m just projecting. “Would you like me to let you get some rest?” I ask, and he startles. I thank him and return my grey plastic chair to a stack against the wall. I enter the elevator where a few nurses are joking with each other. Completely shaken, I check the time and see that the whole encounter lasted less than seven minutes.
His palliative care clinician tells me that the patient expressed a motivation to donate in order to contribute to science and future generations. She says that his children were initially upset when they learned that he’d preregistered with the Anatomical Gift Program, and they thought that he had done it to remove any financial burden that funeral expenses might impose upon the family. After talking more with him, they understood that he wanted to leave a legacy, and they supported his decision. “He went on to say how appreciative they were of all medical providers’ care and trusted if students were anything like the caregivers he’d had in the hospital then they didn’t have anything to worry about in terms of his body being treated with dignity and care.” She gives me his sons’ phone numbers, and I leave voicemails, thinking that this man’s story will continue to be unknown to me and to the students who would someday learn from him.
A week later, my cell phone buzzes aggressively on my kitchen table, the caller ID revealing an unfamiliar number. It’s one of the sons, returning my call, and now I can try again. “What brought your dad joy?” I begin. Well, he worked a lot, in construction, replies the son. When the caller’s mom died in 2005, his dad joined a bereavement group and then emerged enjoying a “second childhood” as a senior citizen. He went to college and discovered a love of singing karaoke. I ask about challenges too and start to construct a mental portrait of this man, something beyond the name, age, cause of death and occupation that we knew about our donors during the anatomy course. This man’s wife died of brain cancer, and within three weeks of her death he required a triple bypass. He was Catholic, “extremely intelligent,” and grew up in foster care. He served in the Marines right out of high school, and when he left the service he had three kids and “worked his butt off.”
I also start to understand the context behind my visit with the patient, his son describing his father in terms of “before” and “after” a massive stroke. The frail, emaciated man I met in the hospital bed, paralyzed on one side, was not the same man who had been active and self-sufficient, a 150-pound man shrunken into a 118-pound patient.
“How do you feel about your dad donating?” I ask. The son explains that shortly after his mom died, his dad initiated a conversation about his own end-of-life wishes, a topic the son was not yet ready to discuss. He acknowledges that whole body donation is not his first choice, but ultimately, it’s his dad’s decision. When his mom died, they were able to have an immediate service and burial, but when his dad dies, they won’t be able to do that. They’ll have a service, but then they’ll have to wait as long as two years to receive their dad’s ashes which they intend to bury at their mom’s plot.
It’s unclear how his dad learned about anatomical donation, maybe in his bereavement group, but at some point, he received a brochure and some letters in the mail from the Anatomical Gift Program at the University of Rochester, which the son digs out of a file folder and reads to me while we’re on the phone. He clarifies that it wasn’t a financial decision; his dad could have afforded a burial if he wanted one. He has struggled to understand why his dad is donating and remains unsure. He chuckles, laughter laced with grief, the motivation might be narcissistic he says, “maybe he just wants to live on for a bit,” or maybe he wants to help the medical profession.
I ask if there’s anything he would like to ask me, anything he would like to know about anatomy lab. “No,” he replies. He has a daughter who is a nutritionist and learned from cadavers in a kinesiology course, so he knows enough. She described it as “‘creepy,’” but “how else do you get to see that stuff?” he says, recognizing that anatomical models just aren’t the same.
His dad has recently been transferred from the palliative care floor of the hospital to outpatient hospice. He is no longer receiving treatment with curative intent, and his morphine dose has been increased to fend off pain. He is quiet, he is lethargic, and he is ready. “The son of a gun has seemed to survive everything” remarks the son. “He’s had a pretty full life, that’s the salvation.”
It is morbid, but I want to know what will happen when he dies to turn his body into a cold, preserved, educational specimen. I schedule a meeting with the funeral director for the Anatomical Gift Program. I learn that within twenty-four hours after death he will be transported to the embalming room on the fifth floor of the school of medicine. The room is small, clean and sparse. There’s a sink on one end, a few counters, and a white ceramic table in the middle. The funeral director points my attention to a wooden door in the back, covered in rosaries and a child’s artwork. The mementos have been sent along with past decedents at the insistence of their families. Her eyes sparkle with tears, and I am moved, suddenly understanding that she has fashioned this makeshift memorial.
An anatomical embalming is distinctly different from a funeral home embalming. There is no viewing by the family, so beautifying the decedent is not the goal but rather, “We’re preparing for the decedent to last for eternity. If you would take care of the decedent and keep the decedent from drying out, you could keep the donor forever.” The body needs to be preserved, or it will decay upon the table over the course of the semester, and the students will no longer be able to learn from the anatomical structures.
Our meeting is interrupted when a gurney arrives at the door to the embalming room. I think at first that it is covered in a homemade quilt, and I am startled by the homey touch. I blink and see that it is a body bag subtly cloaked in a maroon and dark green quilted cover. “Is he clean?” asks the funeral director, making sure that the man isn’t wearing any jewelry or personal items. He is transferred to her worktable, a stiff corpse, his left foot peeking out from the thin white sheet. Papers are signed, and she gets to work.
What will happen next is not pretty, but it is necessary, and it is performed with respect. I am not permitted to observe the embalming, but the funeral director has already described the process to me back in her office. Before the embalming begins, the scrub-clad funeral director sprays the decedent down with disinfectant, removes his clothes, bathes him, and shaves his head. She works alone in the lab, gently preparing the body, apologizing out loud if she bumps his head.
Next, she makes a small incision in the carotid artery at the neck and inserts an arterial tube directing one canula up into the head and another down into the body. She injects a fluid to break up blood clots and lets it incubate in the body as she disinfects the eyes, nose, and throat with cotton and flushes the bowels with a water enema. Then she finds the jugular vein, adjacent to the carotid artery, and flushes out the blood. She will “tie the jugular vein shut [to make a] closed arterial and venous system; I don’t want anything coming out, I only want to keep pushing in. And that’s when I make a very strong anatomical solution and I just keep pumping tank after tank after tank so that the decedents at this time will be unrecognizable. They are blown to oblivion. They will look like the Michelin Man, that blown. And I will tie it off the best I can, everything shut, and they are so blown up that their arms and legs are in the air.”
She drills a small hole into the skull and injects more embalming fluid into the brain. Then she inserts a large needle into the sacrum and soles to pump more preservative under the skin of the buttocks and feet so that every part of the body will be preserved. Each hole is plugged with a small white plastic plug called a trocar, to keep the formaldehyde from spurting out.
When the embalming is done, she will give him another bath, but his body will continue to soil itself as his organs purge their remaining waste through all his orifices. She will leave him to cure on the table for several days before attaching him to a hoist and moving him to a storage room where he will hang in the air with other embalmed bodies, each identifiable by a wrist tag labeled with a donor number.
Over the span of the next three months, his distended body will reduce back to his size at death and then he will be assigned for use in medical education. He might go to the first-year medical school anatomy course, become a practice specimen for surgery fellows or be transported to another in-state school with a less robust anatomical donation program.
When the students are finished with him, he will return to the fifth floor of the medical school and be loaded into one of the two cremation chambers. A cremation cycle takes four hours, his body incinerated all alone in the chamber until nothing but ashes remains. The cremains cool overnight, and the next morning they’re packaged in a biodegradable paper bag with the donor number.
His family will be notified and arrange to meet with the administrator of the Anatomical Gift Program. She schedules a private room on the ground floor of the medical school, allotting thirty minutes to return the cremains, presented in bright blue paper gift bags. Most of her day is consumed by logistical tasks — taking calls from potential donors and families, completing preregistration paperwork and maintaining the accounting ledgers, but her favorite part of her job is being with the families. She is a source of support and consolation for their grief. “Sometimes they want to talk about little things or the positives … I let them talk as much as they want.”
Other families choose for the cremains to be sent to a communal burial plot. Twice a year, the program administrator and the funeral director drive the cremains to a private burial site in South Bristol. They bury the cremains by a reflecting pond overlooking Canandaigua Lake.
Funeral directors use a euphemistic phrase for the transfer of a dead body back to the earth: the final disposition. I struggle to classify the final disposition of the donors. It’s not burial, although the cremated remains could be buried. It is more than cremation though, because that ignores the intermediate steps in the anatomy lab. The donors’ anatomy will live on in our memory, a roadmap for treating our patients. We are entangled.
I imagine my donor’s ashes scattered by his family at a sentimental spot. The wind picks up and carries some of his carbon through the trees, over a hill and down a ravine. He meets his final disposition.
Image Credit: Courtesy of the National Library of Medicine. Image is in the public domain.