In a hospital in California a line of doctors, oncologists, other medical specialists and nursing staff file into a brightly lit room and take their seats. The occasion is the screening of a film titled Extremis.
The footage is shot in the terminal ward of a large public hospital and depicts in stark close-up the dilemmas of patients and relatives (filmed with their permission), and the differing points of view of the treating doctors who confront death daily.
In the audience is the brother of a woman who was a patient in the terminal ward during the shooting of the film. Their story is a key focus in this hard-hitting, difficult to watch exposé of the complex processes of dying.
The “star” of Extremis, Dr Jessica Zitter, has worked for many years in emergency room medicine and is passionate about changing the way the system, doctors and other medical personnel manage terminal patients. Her book on the subject, Extreme Measures, will be published in February. The film has been widely viewed and won awards at Tribeca Film Festival.
The youngish director, understandably reluctant about the prospect of filming dying people, was persuaded to undertake the project by Zitter’s dedication and determination. He found the process harrowing.
The finished product, short, sharp and wrenchingly traumatic, reinforces with compelling immediacy the suffering of terminal patients being assisted to breathe with the aid of machines and the support of administering doctors and nurses.
Decisions about what is best for the patient, and the inculcated teachings and regulations of the system, are sometimes diametrically opposed. In its present form, the system largely dictates the decisions of those in the firing line, who are trained to save life at all costs, even if the chances of recovery are slim and may involve prolonged torment for the patient.
For doctors, the message of the film is unmistakable — become better educated and equipped to deal with the complicated issues of how long to sustain life when that life is dependent on machines and intubation. If the patient is too ill to make their own decision, it may be up to the treating doctor to end an unliveable life.
In the film, Joan, the sister of the man in the audience with us, is dying. Intubated, breathing with the aid of machines, there is little hope she will survive if the apparatus is removed. Joan is in and out of consciousness. During one of her lucid moments, her brother asks her what she wants to do. Zitter explains to Joan that if they remove the machines she may live for a short while, perhaps a day. Her brother becomes visibly distressed. Zitter removes the oxygen mask and Joan, with great presence of mind, addresses her brother and the doctor: “Everybody, stay calm,” she says softly. She opts for the machines to be removed and she dies a day later.
Zitter approaches a homeless patient and asks him what he would like them to do. He looks confused and lost and makes no reply.
Further away, a much younger woman, buried beneath mask and tubes, is shouting: “I don’t want to die, I’m too young, I don’t want to die.”
The film pans in on a dis-agreement between Zitter and another doctor. The latter objects to Zitter’s approach, advocating greater patience and longer use of equipment.
Another dramatic encounter takes place between doctors and the daughter of a dying woman. The daughter, distraught at the prospect of losing her mother, vehemently defends her mother’s right to continue her life on machines. The patient is clearly in bad shape and Zitter gently tells the daughter she needs to face the reality of her mother’s impending death. The machines remain in place. The mother dies a few days later.
Zitter’s zeal is admirable. Like the surgeon Atul Gawande, she is adamant that the patient should come first. “It is the system that needs to change, and the way we educate our doctors. We should never play God, but resources should be directed to those who need medical care and cannot afford it, rather than to patients with little chance of survival without expensive drugs and machines. As doctors we should take the responsibility, as hard as it is, to protect patients from pointless suffering, and to offer relatives the clearest choices we can.”
Extremis is not for the faint-hearted, although the issues it raises are inescapable and its message should not be ignored: hope for an easy death at an old age, but plan for the unexpected.
Zitter believes making one’s choices clear is imperative. “Do it in writing,” she urges. “It will make things much easier for relatives.”
Rosemund Handler has written four novels and is working on a fifth.