‘It’s all about care after death. When someone dies do you stop caring? No, you don’t. We have to just, the way you’re still respectful, you still treat them with, you know, with respect and it’s a dignified approach but you just, it’s got a slightly different take on it. You’re not asking, “Are you comfortable? Are you embarrassed? Are you, is this, you know …” all those things you’re … you’re still providing all of those things but it’s in a slightly different format. So you still care, so I’m still here to care for people.'(APT 3)
On 19th January 2020, a report by BBC’s Clive Myrie was published (see https://www.bbc.co.uk/news/av/health-55724994). In it, Myrie discussed the work of mortuary staff in the response to the COVID19 pandemic in the UK. Myrie’s report reflected on a day spent with medical staff at the Royal London Hospital where, at the time, 12 out of 15 floors were occupied by COVID patients. As the death-toll increased, I often found myself wondering about how the anatomical pathology technicians (APTs) that I had spoken to were coping. As I write this, the UK has now passed an official death toll of 100,000 (https://www.bbc.co.uk/news/uk-55814751)
APTs have a varied role, the balance of which alters depending on location. APTs look after the day to day running of mortuaries, checking the bodies in, carrying out administration, and dealing with the undertakers that come to collect the deceased. The majority will do some work assisting pathologists in the post-mortem room as well as reconstructing bodies (either after a post mortem or because the body is disrupted for other reasons). Many also have contact with the bereaved, and may oversea viewings of a deceased body. You can find out more about their role here: http://www.aaptuk.org/ I carried out my interviews well before COVID19 hit, in times of ‘normal’ mortality rates. It was clear to me then that for many APTs, the emotional labour that they undertake on a daily basis was both motivating and burdensome. I was struck, and often moved, by the culture of care that I witnessed.
As Christmas approached 2020, I felt compelled to send them emails to check in. I feared that when people ‘clapped for carers’ they didn’t think of those dealing with the dead, but that the APTs must be having an awful time. Some of the responses I got confirmed my fears – they were over-stretched, had run out of space and were emotionally drained. Their business may be dealing with the dead, but the pandemic had pushed them to their limits. In this post, I want to add to Myrie’s report by expanding on the way in which APTs care for the dead. In later posts I will theorise this more deeply, but for now it seems urgent to locate my data within the current context – that is of a hidden workforce of APTs dealing with almost unprecedented death. First, a caveat – of course the APTs weren’t speaking about COVID patients when I saw them, but I have no reason to believe that what I found will not still be the case and as such my data can help us to understand the enormity and importance of the APTs during this period of excess death.
What does it mean to ‘care’ for the dead
Given that my initial interest was in death investigation, my interview schedule initially focussed on coronial autopsies. These were certainly a significant part of what the APTs did but, as I noted above, they were just one, often small, part of it. But I would say that the way the APTs approached their autopsy work can be situated as part of a general belief that it was their role to care for the dead. Indeed, as non-autopsy work forms such a significant element of many APTs day to day work, it was impossible to not talk about, and see the links with, the other aspects of their work.
When asked what it meant to care for the dead, I found a desire to look after the deceased body, for example APT 11 told me that to care for the dead meant to: ‘…make sure they’re safe and put them out for viewings, make sure no harm comes to them, similar as you would for a live person…'(APT 11)
So, there is a sense in which the APTs felt that it was their job to protect the dead from harm. They could do this in a range of sometimes surprising ways. Take APT 4, who told me that: ‘…we say to our nurses, “Nothing is a silly suggestion”. So, for example, we had one lady that said – she said, “I know it sounds strange but my husband is really scared of the dark” so we put a torch with him and just that one little thing, if it helped her that little bit then we will do things like that.’ (APT 4). This was just one of many examples – others included teddies with children and playing a deceased person’s favourite music for them. This recognition of the personality of the deceased in their care also extended to reconstruction, although the extent to which APTs were able, or willing, to devote time to personalising (as opposed to doing a good, professional job of) reconstruction was the subject of significant geographical variation.
Given my initial cartesian stance, I wondered why they felt it was so important to personalise the care of the dead. Given my previous work with forensic pathologists, I might have hypothesised that this was for the benefit of the bereaved. And I think that certainly was a factor: ‘I wouldn’t want someone who I loved or cared about who’d died kind of just to be put in a fridge, you kind of treat people how you want your relatives or loved ones to be treated.’ (APT 7)
But it was about more than that, as with the forensic pathologists, there was a sense of duty to the deceased person themselves. Unlike the forensic pathologists this was not because of how the person had died, but simply because of their humanity.
‘I think the care that we provide behind those doors is for the deceased and their dignity, you know, cleaning them, making sure their sheets are clean, that they’re shrouded, that before the post mortem they’re covered so that they’re not just laying there naked, that’s for the deceased but for the family I think it’s when we come through here and meet them, reassure them that their loved one’s being looked after and enable them to visit.’ (APT 5)
‘Just because they’re deceased doesn’t mean they’ve become something different, and I suppose it depends what some people believe different things, don’t they? But the end of the day we still have to care for them, we still have to care for the body, we still have to make sure they’re clean, we still have to make sure that they’re not in a terrible state, we have to make sure that they’re not damaged, just like you would a live patient. So you still have a care because that is somebody, do you know what I mean? I always think that person has a history, and you don’t know about that history.’ (APT 1)
In the last quote APT 1 introduced the analogy with live patients, but for many APTs the deceased are not analogous to patients, they are their patients.
As I have noted briefly in another post, and will explore more deeply elsewhere when time permits, the language used to describe deceased bodies is widely contentious. This is also the care amongst the APT community, whereby different mortuaries had very different occupational cultures around language and the dead. However, I was struck by the conviction that theirs was the morally correct position of those who did consider the dead to be their patients.
‘I mean we take a lot of care of the patients when they’re with us and we do call them patients, they are deceased patients they’re not cadavers, they’re not bodies they are patients and that is something we stress to the wards as well. So I get student nurses down and we do talks with them occasionally and what I will stress to them as well is just because a patient has died doesn’t mean the care stops so we will follow on that care throughout the entire state of the patient here so it’s just basically like a ward transfer so if we’ve done our job correctly you shouldn’t really be able to tell we’ve done anything at all.’ (APT 6)
Again, as so often is the case with the dead, the interests of the dead and the living are interwoven: ‘…we’re constantly thinking about the patient and the care of the patient and making sure that they’re going to be presentable for their family afterwards…we’re thinking about the bigger picture rather than the consultant that reports here, does what he’s got to do, down tools and is off.’ (APT 5)
But it seems to be that the language of patienthood invokes a kind of professionalisation that marks a clear sense that for these APTs the treatment of the treatment of the dead matters.
In the context of COVID19 and so much ‘excess’ death, I am struck by two things. The first is that whatever the numbers, the dead will have been cared for, by people who despite not knowing the person whilst alive, care about them. They will have been treated with dignity, respect and concern. This ought to reassure the bereaved but also is an important message about the value of the deceased body itself. Second, but directly as a consequence of the first, many APTs will be emotionally exhausted. Seeing so much death can never be easy, but to care so much and be confronted by resources meaning that you can’t give effect that care as you usually do will have been difficult at best. But it is because deceased bodies matter so much when we are connected to them that we ought to recognise the work done by the APTs during the pandemic. So, I leave it to the words of APT 4:
‘APTs are important because we are that link to that patient’s care rather than just being an autopsy or pathology.’ (APT4)