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Grave Words: Tools for Discussing End of Life Choices

Professor and Director Center for Ethics and Humanities in the Life Sciences C-208 E. Fee Michigan State University E. Lansing, MI 48824 517-355-1634

Grave Words: Tools for Discussing End of Life Choices. Video/1996/25 min. Directed and Produced by Maren Monson, MD. Co-Produced by Elizabeth Thompson. Distributed by Fanlight Productions, 4196 Washington St. Suite 2, Boston, MA 02131. 800-937-4113. Online: www.fanlight.com. E-mail: info{at}fanlight.com. Rental $50, Purchase $195.

This 25-minute video, produced in 1996, is intended to be used for training health care staff in discussing end-of-life options with patients and families. A short discussion guide is provided for facilitators, and includes a brief bibliography of some relevant research.

The video opens with Death knocking on a man's front door, to sing him the news, Rocky Horror style, that he is terminally ill, with only "six months to a year" to live. Other aspiring comedy sketches follow, scattered throughout. A patient (played by an actor in Monty Python drag) is befuddled by her doctor's devotion to $10 medical words, a problem addressed by a mock ad for a "Physician's Phrase Book," which unlocks the mystery of how to talk like a regular person. Later, the condemned man, Dan, meets with his doctor to have a jocular conversation about CPR, capped by the doctor's grotesque, frightening pantomime of what CPR is "really like." Later, we listen in as a patient tries to place his "order" at the Terminal Cafe, where they only serve what's on the menu—no à la carte. In the video's closing scene, Death is set upon by neighborhood dogs after the allegedly terminally ill Dan has slammed the door in his face. Interspersed among these sketches are snippets of information and advice regarding how such discussions should really go. These segments feature several physicians experienced with end-of-life care, including Bernard Lo of the University of California at San Francisco.

Most of these are useful. End-of-life discussions are too often short and dominated by physicians. Doctors don't inquire into what patients mean when they express concern about "poor quality of life." It's more important to focus on outcomes (the destination the patient hopes for) than particular interventions (how to get there). Physicians should be cautious in using generalizations about attitudes toward death within a patient's cultural or ethnic group. Some are dubious (one physician tells his patients that there is "no limit" to what he can do to relieve their pain) or too glibly echo a common platitudinous non sequitur ("Death is not a bad thing—death is inevitable!").

Easily the best part of the video is a generally well-conceived and acted portrayal of an "ideal" conversation between a physician and a patient terminally ill with breast cancer. There are elements even of this, however, which might raise some concern and would deserve discussion. The most serious of these is that after explaining the likely futility of any resuscitation attempt, the physician leaves the decision entirely in the patient's hands, declining to make any strong recommendation against CPR.

The facilitator's discussion guide is too lacking in background material to be of much help for anyone who lacks basic knowledge about legal, social, and ethical aspects of end-of-life decisions. Any facilitator with the requisite knowledge and experience would find it superfluous for running a discussion. The short bibliography, although it includes some key journal articles, was compiled circa 1996, and so is out of date.

As a whole, the video is of doubtful value, because of limitations both in content and in style. The content is lacking in two significant respects. The first is the almost exclusive focus on do-not-resuscitate (DNR) decisions. As important as these are, they are far from the only decisions that need to be made about the aggressiveness of care. Some of these other decisions can be more difficult than the DNR decision—in particular, decisions to withdraw interventions, like respirators or dialysis, which might quite literally be "keeping the patient alive." For an audience of residents, one might also worry about inadvertently reinforcing their common perception that "getting the DNR" is the primary objective of these conversations.

The second deficiency is the virtual lack of any information or guidance relevant to discussions with families. This is a serious omission. However ideal it might be to have had a conversation with the patient herself, the more frequent reality is that by the time the matter gets broached, the patient is no longer able to participate in the discussion. Conversation with families is often much more challenging, both ethically and psychologically, and staff need help in learning how to best meet these challenges.

The video's other problem concerns the comedic style used in the sketches, which consume at least a third of the tape. It's not that death and dying aren't fit subjects for humor, or that comedy can't be a valid educational tool. The problem is that broad lampooning is the style of comedy least likely to serve the educational objectives this video purports to communicate. There are two reasons for this objection. First, lampooning a behavior serves to make it so ridiculous as to be below serious consideration. It's great fun when directed against the truly moronic. But when a behavior is widespread, for what many people think are good reasons, it requires our serious consideration, not our facile dismissal. Is it really so silly to speak about CPR in blunt and graphic terms? It's not uncommon to hear physicians recommend just this approach, and they offer reasons in defense of it. Perhaps it's not the best strategy, but we won't convince them or others against it if all we do is make any such idea laughable.

Second, lampoons always feature buffoons, and none of us thinks we are one. The physician who uses medical jargon is not going to see himself in the sketch that lampoons what he does. Indeed, because the portrayal is so extreme, no one else will see him in it either. The character has stepped out of a play by Molière; he's not anyone we know. This treatment discourages, rather than encourages, self-examination. And because it bears so little resemblance to the real thing, it offers no effective critique of the real thing that will be heard by those in most need of the message.

Satire is humor for those already in the know. We shouldn't design our teaching strategies assuming our audience already understands what we want to teach them.

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