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DYING AT GRACE: A DOCUMENTARY VIDEO

King's University College 266 Epworth Avenue London, Ontario N6A 2M3 dnichols{at}uwo.ca

Dying at Grace. Video/2003/147 min. Directed by Allan King. Produced by Allan King Associates Ltd. Distributed by Allan King Associates, Ltd., 965 Bay Street, Suite 2409, Toronto, ON Canada M5S 2A3, 416-964-7284. Online: www.allankingfilms.com. E-mail: mail{at}allankingfilms.com. Purchase $495 (institutional use), $45 (personal use).

Dying at Grace explores various issues related to palliative care by following five patients after their admission to the palliative care unit at Grace Hospital in Toronto, Ontario. The viewer is introduced to each patient in sequence through the lens of the camera; often viewers hear the nurses' report of the patient's diagnosis and condition and a general summary of the patient's status as the nurse records them for the charts. Unlike other films that attempt to highlight end-of-life issues and concerns, the director in this film was able to obtain permission from actual patients and families to document the realities of having a terminal illness and being a patient in a palliative care unit.

In the first section of this review, I will summarize the experiences of five patients that are featured in the video. In the second section I will analyze some of the themes that arise from the video and evaluate its overall strengths as a teaching tool in death education curricula. The first patient who is introduced to the viewer is Carmela, an elderly Italian woman with ovarian cancer. Most of Carmela's thoughts and experiences are seen through the eyes of her family as she does not speak much English. The viewer is also privy to the nurses' reports that are interspersed in the scenes that document her deterioration and the changes in her care that occur accordingly. When her family is notified that her death is imminent, the camera stays on the family members and on Carmela as the family gathers around her. Death is seen as a slow process with the body shutting down in small increments over what would appear to be an extended period of time. Time drags on painfully as the viewer observes Carmela's conscious awareness diminish and her breathing become more and more erratic. The camera stays on Carmela throughout this process and the viewer actually sees the moment of death of this patient in the very first sequence of the video.

The next patient that appears in the video is Joyce. She is also an elderly woman with metastatic bladder cancer. In one of the scenes, Joyce talks with the hospital chaplain and explores the difficulties that she faces as her debility increases. She experiences significant pain from her disease, yet she is reluctant to take more medication to control the pain because she is afraid of becoming mentally dull as a result. Fiercely independent, Joyce is seen at times sitting up straight and trying to remain alert when she is obviously falling asleep or unable to focus. She appears to be on a "vigil," fighting the loss of her bodily functions and her mental acuity. At one point, she describes the mental slowness she is experiencing as feeling "stupid." Although Joyce also describes feeling embarrassed by her urinary incontinence, she is reluctant to accept a urinary catheter because she sees it as another step down a path of no return.

In conversations between Joyce and the hospital chaplain, the dying woman poignantly relates events that happened in her life prior to her diagnosis and shares her views of life and death. Joyce appears on the surface to be a hardened, angry woman. As she talks more with the chaplain, the viewer becomes aware of how alone she has felt since the deaths of her husband and her children. At this point in her life she needs to protect herself from further losses. She has had only herself to rely upon for many years, and the idea of having to depend upon others falls outside of her frame of reference. When told of Carmela's death (they had been roommates), she responds with her own philosophy of life and death, and it is apparent that she gave up being able to hope for anything better for herself after suffering the many losses that she has experienced during her lifetime. The dichotomy is obvious: She needs to protect her independence and functioning while she also feels she has no reason to continue living.

Joyce leaves the unit briefly to attend a holiday party at her building and returns shortly afterwards in a greatly diminished state. The change in her mental status and condition are remarkable between her waving good-bye to the staff on the elevator and then being brought back almost unresponsive to the unit by the paramedics a day later. She dies the next day. The viewer is made aware of her death by seeing an image of Joyce in bed with her mouth open and a nurse checking for vital signs while the nurses' report plays in the background—giving the specifics of the death event.

Eda is the next patient introduced to the viewer. Eda was admitted to the unit with metastatic breast cancer. Once again, the theme of a patient's need for autonomy is placed in the foreground. Eda sees her condition as humiliating, and she is adamant that nobody other than her brother-in-law see her or have any contact with her. The viewer follows Eda through the highs and lows of her condition during her stay in the ward. After she is admitted to the palliative care unit, she begins to improve gradually; then she is reevaluated for possible further treatment, and finally the issue of discharge from the unit is discussed. At one point a nurse asks Eda what she expects will happen to her. Her response: she looks forward to going back into the world again. She even embarks on plans to find an apartment. In one scene, a staff person accompanies her in a van and assists her as she visits an available apartment. Although she recently entered the palliative care unit, and seemed to be preparing for her death, now she is entertaining thoughts of entering into life again.

Eda stays on the unit for several weeks, and she is aware when the deaths of the other patients occur. When asked about how their deaths affect her, she is philosophical and speaks of approaching things "day by day." Eventually, she agrees to try another round of chemotherapy. But the outcome of this regimen has devastating consequences: The treatment itself seems to take away her will to live, and she rapidly declines after receiving her first treatment. In one scene, Eda is shown curled up in her bed. She is in pain and appears to be disengaged from life. That image of Eda is in stark contrast to the woman who was looking at apartments and talking of reconnecting with old friends again in a previous scene. Her death occurs shortly afterwards and leaves viewers wondering if she simply chose to die or if her body could not withstand the ravages of further chemotherapy.

Rick is then admitted to the palliative care unit with metastatic lung cancer. Perhaps the most colorful of the patients that are followed in the film, Rick brings beer and his "social knife" as part of his belongings. He keeps a picture of a young woman that he once dated and talks about his inability to maintain the relationship with her. Some of the most poignant moments of his scenes show him reflecting upon his life and the choices that he made. The staff here is at its best in meeting Rick "where he is" with regard to his values and choices in life. Rick has no family members to care for him. Two good friends review his advanced directive with the social worker. The staff becomes his surrogate family over time. The staff makes no judgment of Rick's lifestyle or his request for high doses of pain medication. Rick has an episode of severe confusion at one point, requiring medication to calm him. After this event, Rick has difficulty communicating, and he begins to sleep more and more until he finally becomes unresponsive and dies in his sleep.

The last patient that the film documents is Lloyd, a young man with a form of brain cancer. Lloyd's disease progresses slowly and agonizingly, and the viewer watches his family—exhausted from long hours at his bedside—suffer alongside him. Lloyd becomes despondent and depressed over his condition and his inability to function. Gradually Lloyd and his family come to a place of letting go. In several scenes the family reads scripture with Lloyd and prays with him and with the chaplain, searching for peace in the midst of the anxiety over his impending death. The viewer easily becomes drawn into the family's painful realization that they must let Lloyd go while struggling with the permanence of his leaving.

Dying at Grace is a poignant, in-depth exploration of the process of dying. The viewer does not simply "watch" each patient's decline—the viewer becomes a part of the event, sharing the innermost thoughts and feelings of the patients and family members as well as the impact of these deaths upon staff members. The viewer develops a relationship with each patient through observation and vicarious participation in dialogues that speak of hopes and dreams, good times and regrets, and thoughts about life, death, and afterlife. The director's use of multiple close-ups of patients alone as they go through their day lends to a sense of intimacy between the viewer and the patients. No music plays in the background. There is no script. This is not a version of reality television. The reality of death itself is the subject matter. There is no voice-over narration explaining what the patients are going through; there is only the nurses' report that is interspersed with the actual dialogue that occurs with the patients, family members, and staff. The events as they are documented speak for themselves. Death is seen as an anticlimax—the end of struggling for breath, the end of pain or suffering, a time of quiet after much activity, and the notable absence of struggle often after a prolonged period of suffering. Viewers are not spared from seeing death itself in its stark reality; indeed, the opening scene is of a body being taken from a bed to the morgue in the hospital. The same patients who are introduced when they are living are each shown either at the moment of their last breath or when death has been discovered. Viewers begin to recognize the appearance of a "death mask" on the faces of the patients who are actively dying, and viewers come to realize that death is the great "equalizer" for all the patients whom they meet.

The majority of the patients express their need for control or autonomy, even in ways that may seem insignificant to others—for as long as that control is possible. Dying is seen as a gradual loss of control over both large and small concerns. Another theme that arises in the video is that each patient died as he or she lived. Carmela's close-knit family system is reflective of her culture and how she is described by those who are interviewed regarding her personality prior to her illness. Joyce's anger and independence remain intact until the day she dies. Rick laughs about how he has lived his life, and he continues to make choices in his dying that are congruent with his lifestyle when he was not ill. Lloyd and his family rely deeply upon their faith to comfort them throughout the death vigil and after Lloyd's death.

Each patient has the opportunity to discuss his or her thoughts about death and afterlife—with the exception of Carmela. When she requests the presence of a priest, and the two interact, they speak in Italian. During the interactions with the other patients, there is striking candor about how each person views his or her impending death and the possibility of life after death. What is perhaps most striking is the directness of the questions by the chaplain or staff members and the openness to answer these questions on the part of the patients and their family members. The patients appear to feel a sense of relief that these discussions occur and are part of the total care of the patients and their family members.

Dying At Grace was originally aired on our Provincial Public Television station, and several local and national newspapers acclaimed it as groundbreaking. It is not a film for those unwilling to see death squarely for what it is, and it is certainly not entertainment. However, it is a thought-provoking exploration on many fronts. I participate in a university-based death education program, and we showed the video in one of the introductory Thanatology classes last year after it was released. Partway through the showing, several students approached me and expressed a need to debrief what they were seeing, as they were profoundly affected by seeing death exposed so clearly. After a break with extensive discussion of the content of the film, the class agreed that although the film was valuable because it allows the viewer to come to grips with the reality of death, it would be advisable to prepare handouts ahead of time to alert viewers to the specific details of what they would see in the video as well as allow time for students—after viewing the video—to discuss ways in which it affected them emotionally. For instance, many of the students, some of whom were adult learners, found the film difficult to respond to because they had experienced recent deaths in their families; seeing patients die brought up personal issues regarding their own experiences.

The film would be a valuable teaching tool for all clinicians, especially those who work with aging populations and those with terminal illness. The film contains many excellent examples of the way staff members in a palliative care unit provide excellent supportive care to these patients in a respectful and caring way. Many of the scenes afford an opportunity to understand that palliative care is still active and compassionate care even though cure is not a possibility. The film is long—more than 2 hours. But it moves quickly because viewers are drawn into the context of the palliative care unit, identify with the staff members as they relate to the patients, empathize with patients as they go through the process of dying, and sympathize with families who participate in the "death vigil" that occurs for many of the patients. To make this documentary any shorter would leave out valuable components of the overall processes that patients undergo at the end of life.

The value of this film cannot be overestimated. It is a rare glimpse into the reality of dying and death, of human resilience and compassion, the possibilities for compassionate care to those who are dying, and respect for the grieving of the significant loved ones in their lives. It should be required in the education of those who will work with dying patients and their families. It will also give voice to those whose experiences resonate with the patients and families that are part of this excellent documentary.

Footnotes

Robert E. Yahnke, PhD, Audiovisual Editor

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